From: Twomey, John K. Sent: 23 Feb 2017 15:14:10 +0000 To: Twomey, John K.;Agnew, Ann John Carla Wade (CTR);Kouzoukas, Demetrios Lance Matt Ryan Brian Randy Nina Kristin Paula Amanda Subject: Daily Health Care Reform Meeting 2017-?00001 From: Leggitt, Lance Sent: 10 Mar 2017 20:44:27 +0000 To: Leggitt, Lance Ann John Carla Wade (CTR);Keith Nahigian;Kouzoukas, Demetrios Matt Ryan Brian Caitlin B. Randy Nina Kristin Paula Amanda Subject: Daily Health Care Reform Meeting 2017--00002 From: Pate, Randy Sent: 8 Mar 2017 23:35:25 +0000 To: Pate, Randy Nina Marie Wade (CTR);Stannard, Paula Ann John Amanda Subject: Regulatory Huddle Attachments: Phase 2 Summary Chartdocx, ADMINISTRATIVE FLEXIBILITY ON KEY TOPICS (3-7-17) rp.docx, ACA regulations table.docx, ACA - -the Secretary Shall-.xlsx, Compilation of FAQs by subject area - 1 31 17.docx 331333] All, Thanks and looking forward to it. Randy 2017--00003 Page 0004 of 1535 Withheld pursuant to exemption of the Freedom of Information AC1 2017--00004 Page 0005 of 1535 Withheld pursuant to exemption of the Freedom of Information AC1 2017--00005 Page 0006 of 1535 Withheld pursuant to exemption of the Freedom of Information AC1 2017--00006 Page 0007 of 1535 Withheld pursuant to exemption of the Freedom of Information AC1 2017--00007 Page 0008 of 1535 Withheld pursuant to exemption of the Freedom of Information AC1 2017--00008 Page 0009 of 1535 Withheld pursuant to exemption of the Freedom of Information AC1 2017--00009 Page 0010 of 1535 Withheld pursuant to exemption of the Freedom of Information AC1 2017--00010 Page 0011 of 1535 Withheld pursuant to exemption of the Freedom of Information AC1 2017-?0001 1 Page 0012 of 1535 Withheld pursuant to exemption of the Freedom of Information AC1 2017-?00012 Page 0013 of 1535 Withheld pursuant to exemption of the Freedom of Information AC1 2017--00013 In five years from April of 2010 to May of 2015, the Department of HHS promulgated 314 regulations implementing the Affordable Care Act. These regulations occupy 13,208 pages in the Federal Register. 1 Premium Review Process; Request for Comments Regarding Section 2794 of the Public 4/14/2010 Health Service Act 2 Medical Loss Ratios; Request for Comments Regarding Section 2718 of the Public Health 4/14/2010 Service Act 3 Health Care Reform Insurance Web Portal Requirements (for Private Plans Data 5/5/2010 Template) 4 Early Retiree Reinsurance Program 5/5/2010 5 Medicare and Medicaid Programs; Changes in Provider and Supplier Enrollment, Ordering 5/5/2010 and Referring, and Documentation Requirements; and Changes in Provider Agreements 6 Designation of Medically Underserved Populations and Health Professions Shortage 5/11/2010 Areas; Intent To Form Negotiated Rulemaking Committee 7 Interim Final Rules for Group Health Plans and Health Insurance Issuers Relating to 5/13/2010 Dependent Coverage of Children to Age 26 Under the Patient Protection and Affordable Care Act 8 Medicare Program; Medicare Coverage Gap Discount Program Model Manufacturer 5/26/2010 Agreement and Announcement of the June 1, 2010 Public Meeting 9 Public Health Service Act, Rural Physician Training Grant Program, De?nition of 5/26/2010 ?Underserved Rural Community" 10 Public Health Service Act, Rural Physician Training Grant Program, Definition of 5/26/2010 "Underserved Rural Community" 11 Hospital IPPS for Acute Care Hospitals and Fiscal Year 2010 Rates and to the Long-Term 6/2/2010 Care Hospital PPS and Rate Year 2010 Rates: Final Fiscal Year 2010 Wage Indices and Payment Rates Implementing the Affordable Care Act 12 Changes to the Hospital Inpatient Prospective Payment System Resulting from 2011 6/2/2010 Health Care Reform Provisions 13 Discretionary Grant Program 6/9/2010 14 "Grandfathering? under Group Individual Insurance Market Reforms (Part 2) 6/17/2010 15 Medicare Program; Supplemental Proposed Changes to the Hospital Inpatient 6/17/2010 Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Supplemental Proposed Fiscal Year 2011 Rates; Corrections 16 Patient Protection and Affordable Care Act: Preexisting Condition Exclusions, Lifetime and 6/28/2010 Annual Limits, Rescissions, and Patient Protections (OCIIO-9994-IFC) 17 SEP: 8/23/10; Patient Protection and Affordable Care Act (PPACA), Emerging 7/7/2010 Infections Program (EIP), Enhancing Epidemiology and Laboratory Capacity 201 7--00014 18 Civil Money Penalty Reduction for Self-Reporting 7/12/2010 19 Revisions to Payment Policies Under the Physician Fee Schedule and Part for CY 2011 7/13/2010 20 Preventive Services (Part 4) 7/19/2010 21 Hospice Wage Index for FY 2011 7/22/2010 22 Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities? 7/22/2010 Update for FY 2011 23 The Negotiated Rulemaking Committee on the Designation of Medically Underserved 7/22/2010 Populations and Health Professions Shortage Areas 24 Home Health Prospective Payment System Refinements and Rate Update for CY 2011 7/23/2010 25 Claims, Appeals Review (Market Conduct) 7/23/2010 26 Maternal, Infant, and Early Childhood Home Visiting Program 7/23/2010 27 SEP: Cl10-003; CORRECT ION- DATE CHANGE 9/8/10; Patient Protection and Affordable 7/27/2010 Care Act (PPACA), Emerging Infections Program (EIP), Enhancing Epidemiology and Laboratory Capacity 28 High Risk Pools 7/30/2010 29 Communities Putting Prevention to Work 8/12/2010 30 Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care 8/16/2010 Hospitals and the Long-Term Care Hospital Prospective Payment System Changes and FY2011 Rates; Provider Agreements and Supplier Approvals; and Hospital Conditions of Participation for Rehabilitation and Respiratory Care Services; Medicaid Program: Accreditation for Providers of Inpatient Services 31 SEP: 9/21/10; Patient Protection and Affordable Care Act (PPACA), Emerging 9/14/2010 Infections Program (EIP), Enhancing Epidemiology and Laboratory Capacity 32 3408 Drug Pricing Program 9/20/2010 Manufacturer Civil Monetary Penalties 33 Proposed Information Collection Activity; Comment Request. Title: Affordable Care Act 10/22/2010 Tribal Maternal, Infant, and Early Childhood Home Visiting Program Needs Assessment and Plan for Responding to Identi?ed Needs 34 Medicaid Program; Withdrawal of Determination of Average Manufacturer Price, 11/15/2010 Multiple Source Drug Definition, and Upper Limits for Multiple Source Drugs 35 Grandfathering Amendment 11/17/2010 201 7--0001 5 36 Medicare Program; Home Health Prospective Payment System Rate Update for Calendar 11/17/2010 Year 2011; Changes in Certification Requirements for Home Health Agencies and Hospices 37 Medicare Program: Hospital Outpatient Prospective Payment System and CY 2011 11/24/2010 Payment Rates; Ambulatory Surgical Center Payment System and CY 2011 Payment Rates; Payments to Hospitals for Graduate Medical Education Costs; Physician Self- Referral Rules and Related Changes to Provider Agreement Regulations Payment for Certi?ed Registered Nurse Anesthetist Services Furnished in Rural Hospitals and Critical Access Hospitals 38 Medical Loss Ratio 12/1/2010 39 Adjustments for Disaster-Recovery States to the Fourth Quarter of Fiscal Year 2011 and 12/22/2010 Fiscal Year 2012 Federal Medical Assistance Percentage (FMAP) Rates for Federal Matching Shares for Medicaid and Title Foster Care, Adoption Assistance and Guardianship Assistance programs Disaster Relief 40 Premium Rate Review 12/23/2010 41 Request for Info?Value-Based Insurance Design 12/28/2010 42 Advisory Committee on Breast Cancer in Young Women Meeting 9/21/11- 1/6/2011 9/23/11 43 Medicare Program; Payment Policies Under the Physician Fee Schedule and Other 1/10/2011 Revisions to Part for CY 2011 44 The Consumer Operated and Oriented Plan Advisory Board, February 7, 2011 1/27/2011 45 Implementation, Systems and Outcome Evaluation of the Tribal and Low-Income Health 1/27/2011 Profession Opportunity Grants (HPOG) 46 Medicare, Medicaid, and Children's Health Insurance Programs; Additional Screening 2/2/2011 Requirements, Application Fees, Temporary Enrollment Moratoria, Payment Suspensions and Compliance Plans for Providers and Suppliers 47 Student Health Insurance Coverage 2/11/2011 48 Children's Health Insurance Program Allotment Methodology and States' Fiscal 2/17/2011 Years 2009 Through 2015 CHIP Allotments 49 Medicare and Medicaid Programs; Requirements for Long-Term Care (LTC) Facilities; 2/18/2011 Notice of Facility Closure 50 Waiver for State Innovation 3/14/11 51 Submission for OMB Review; Comment Request. Title: Affordable Care Act Tribal 3/17/11 Maternal, Infant, and Early Childhood Home Visiting Program Needs Assessment and Plan for Responding to Identified Needs 52 Medicare and Medicaid Programs; Civil Money Penalties for Nursing Homes 3/18/11 2017--00016 53 Agency Information Collection; Activities: Proposed Collection; Comment Request 3/29/2011 54 Early Retiree Reinsurance Program (ERRP) Notice 4/5/2011 55 Food Labeling; Nutrition Labeling of Standard Menu Items in Restaurants and Similar 4/6/2011 Retail Food Establishments 56 Food Labeling; Calorie Labeling of Articles of Food in Vending Machines 4/7/2011 57 NCEZID Notice of Intent to Award Affordable Care Act (ACA) Funding 4/12/2011 58 Notice of Intent to award supplemental Affordable Care Act funding to support 4/12/2011 FOA HM10-1001 59 Medicare Program; Changes to the Medicare Advantage and the Medicare Prescription 4/15/2011 Drug Bene?t Programs for Contract Year 2012 and Other Changes 60 Evaluation of Tribal Health Profession Opportunity Grants (HPOG) 4/18/2011 61 NCIRD Notice of Intent to Award Patient Protection Affordable Care Act funding 4/19/2011 62 Proposed Information Collection Activity; Comment Request 4/30/2011 63 Medicare Program; Inpatient Facilities Prospective Payment System-Update 5/6/2011 for Rate Year Beginning July 1, 2011 (RY 2012) 64 Medicaid Program; Methods for Assuring Access to Covered Medicaid Services 5/6/2011 65 SEP: 6/15/11; Affordable Care Act (ACA): Childhood Obesity Research Funding 5/17/2011 Opportunity Announcement (FOA) DP11-007, Panel 66 SEP: 6/7/11 6/9/11 Affordable Care Act (ACA): Childhood Obesity Research 5/18/2011 Funding Opportunity Announcement (FOA) DP11-OO7, Panel A 67 Exclusion of Orphan Drugs for Certain Covered Entities under 3408 Program 5/20/2011 68 Premium Rate Review 5/23/2011 69 Agency Information Collection; Activities: Proposed Collection: Comment Request 5/27/2011 70 Inpatient Facilities Prospective Payment System Update for Rate Year 6/3/2011 Beginning July 1, 2011 (RY 2012); Correction 71 Medicaid Program; Payment Adjustment for Provider-Preventable Conditions Including 6/6/2011 Health Care-Acquired Conditions 201 7--0001 7 72 Implementation, Systems and Outcome Evaluation of the Tribal and Low-Income Health 6/11/2011 Profession Opportunity Grants (HPOG) 73 Group Health Plans and Health Insurance Issuers: Rules Relating to Internal Claims and 6/24/2011 Appeals and External Review Processes 74 Evaluation of Tribal Health Profession Opportunity Grants (HPOG) 6/30/2011 75 Section 3113: The Treatment of Certain Complex Diagnostic Laboratory Tests 7/5/2011 Demonstration Submission for OMB Review; Comment Request 76 Administrative Simplification: Adoption of Operating Rules for Eligibility for a Health Plan 7/8/2011 and Health Care Claim Status Transactions 77 Testing and Evaluation of Tobacco Communication Activities 7/12/2011 78 NCEH ?Notice of Intent to award Affordable Care Act (ACA) funding to National 7/13/2011 Association for Health Data Organizations 79 NCEH "Notice of Intent to Award Affordable Care Act funding to ?National Association for 7/13/2011 Public Health Statistics and Information Systems 80 NCEH Notice of Intent to award Affordable Care Act (ACA) funding to seventeen states 7/13/2011 and local health departments to develop and implement tracking networks within their funded jurisdictions that is part of the National Tracking Network 81 Evaluation of Core Violence and Injury Prevention Program (Core VIPP) 7/15/2011 82 Establishing Exchanges Part I 7/15/2011 83 State Requirements for reinsurance, risk cooridors and risk adjustment 7/15/2011 84 Establishing CO-OP 7/20/2011 85 Announcement of Five Single Source Grant Awards. Award of five single source grants 7/27/2011 under the Tribal Home Visiting Program to the Eastern Band of Cherokee Indians, Cherokee, Native American Health Center, Inc., Oakland, Riverside-San Bernardino County Indian Health, Inc., Banning, Taos Pueblo, Taos, and United Indians of All Tribes Foundation, Seattle, WA. 86 Preventive Services 8/3/2011 87 Medicare Program; Hospice Wage Index for Fiscal Year 2012 8/4/2011 2017--00018 88 Meeting 9/21/11-9/23/11 8/5/2011 89 Medicare Program; Inpatient Rehabilitation Facility Prospective Payment System for 8/5/2011 Federal Fiscal Year 2012; Changes in Size and Square Footage of Inpatient Rehabilitation Units and Inpatient Units 90 Medicare Program; Prospective Payment System and Consolidated Billing for Skilled 8/8/2011 Nursing Facilities for FY 2012 91 Announcement of a Single Source Grant Award to the Tribal Law and Policy Institute. 8/12/2011 Notice to award a single source program expansion supplement grant to the Tribal Law and Policy Institute, located in West Hollywood, CA, to support activities of the National Resource Center for Tribes under the Tribal Maternal, Infant, Early Childhood Home Visiting Program. 92 Exchange Eligibility 8/17/11 93 Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care 8/18/11 Hospitals and the Long-Term Care Hospital Prospective Payment System and FY 2012 Rates; Hospitals' FTE Resident Caps for Graduate Medical Education Payment 94 Uniform Disclosure to Consumers 8/22/2011 95 Summary of Benefits and Coverage and Uniform Glossary-Templates, Instructions, and 8/22/2011 Related Materials Under the Public Health Service Act 96 Notice of Intent to Award Affordable Care Act (ACA) Funding 8/23/2011 97 Notice of Intent to Award Affordable Care Act (ACA) Funding 9/2/2011 98 Notice of Intent to Award Affordable Care Act (ACA) Funding 9/2/2011 99 Notice of Intent to Award Affordable Care Act (ACA) Funding 9/2/2011 100 Notice of Intent to Award Affordable Care Act (ACA) Funding 9/2/2011 101 Premium Rate Review?Amendment to the Final Rule 9/6/2011 201 7--0001 9 102 CDC Diabetes Prevention Recognition Program (DPRP) 9/9/2011 103 Request for Info?Basic Health Program 9/14/2011 104 Medicaid Recovery Audit Contractors 9/16/2011 105 OPHPR Notice of Intent to Award Affordable Care Act (ACA) Funding 9/27/2011 106 OPHPR Notice of Intent to Award Affordable Care Act (ACA) Funding 9/27/2011 107 Testing and Evaluation of Tobacco Communication Activities 9/29/2011 108 Patient Protection and Affordable Care Act; Establishment of Exchanges and Qualified 9/30/2011 Health Plans, and Standards Related to Reinsurance, Risk Corridors and Risk Adjustment; Extension of Comment Period 109 Delegation of Authority 10/6/2011 110 Statement of Organization, Functions and Delegations of Authority 10/19/2011 111 Proposed Information Collection Activity; Comment Request. Title: Affordable Care Act 10/26/2011 Tribal Maternal, Infant and Early Childhood Home Visiting Program Annual Report. 112 Advanced Payment Model Initiative 11/2/2011 113 Medicare Shared Savings Program: Accountable Care Organizations 11/2/2011 114 Final Waivers in Connection with the Medicare Shared Savings Program 11/2/2011 115 Home Health Prospective Payment System Rate Update for CY 2012 11/4/2011 116 National Ambulatory Medical Care Survey (NAMCS) 11/4/2011 117 Medicare Program; End-Stage Renal Disease Prospective Payment System and Quality 11/10/2011 Incentive Program; Ambulance Fee Schedule; Durable Medical Equipment; and Competitive Acquisition of Certain Durable Medical Equipment, Prosthetics, Orthotics and Supplies 118 Revisions to Payment Policies Under the Physician Fee Schedule and Part for CY 2012 11/28/2011 119 Evaluation of Core Violence and Injury Prevention Program (Core VIPP) 11/30/2011 120 Changes to Hospital OPPS and CY 2012 Payment Rates; ASC Payment System and CY 2012 11/30/2011 Payment Rates; Hospital Value-Based Purchasing Program; and Physician Self-Referral Rules 2017-?00020 121 Medical Loss Ratio: Non-Federal Gov Plans 12/7/2011 122 Availability of Medicare Data for Performance Measurement 12/7/2011 123 Medical Loss Ratio 12/7/2011 124 Community Transformation Grants: Use of System Dynamic Modeling and Economic 12/9/2011 Analysis in Select Communities 125 CO-OP 12/13/2011 126 ERRP Claims Announcement 12/13/2011 127 Transparency Reports and Reporting of Physician Ownership or Investment Interests 12/19/2011 128 Independence at Home Demonstration Program 12/21/2011 129 Proposed Information Collection Activity; Comment Request 12/28/2011 130 Adult Health Quality Measures 1/4/2012 131 Administrative Simpli?cation: Adoption of Standards for Electronic Funds Transfer (EFT) 1/10/2012 (CMS-0024-IFC) 132 Request for Information Regarding the Reinsurance Program under the Affordable Care 1/30/2012 Act 133 ACIP Meeting 2/22/12-2/23/12 2/1/2012 134 Covered Outpatient Drugs 2/2/2012 135 Summary of Benefits and Coverage and Uniform GIossary--Templates, Instructions, and 2/14/2012 Related Materials Under the Public Health Service Act; including template 136 Preventive Services 2/15/2012 137 Draft Guidance for Industry Scienti?c Considerations in Demonstrating Biosimilarity to a 2/15/2012 Reference Product; Availability 138 Draft Guidance for Industry on Quality Considerations in Demonstrating Biosimilarity to a 2/15/2012 Reference Product; Availability 139 National Practitioner Data Bank - Healthcare Integrity and Protection Data Bank Merger 2/15/2012 140 CDC National Healthy Worksite Program (NHWP) 2/15/2012 141 Reporting and Returning of Overpayments (CMS-6037-P) 2/16/2012 142 Application, Review, and Reporting Process for Waivers for State Innovation 2/27/2012 143 Draft Guidances Relating to the Development of Biosimilar Products; Public Hearing; 3/2/2012 Request for Comments 144 Meeting 4/18/12-4/20/12 3/20/2012 201 7--00021 145 Medicaid Eligibility Expansion under the Affordable Care Act of 2010 with Interim Policies 3/23/2012 146 State Requirements for Exchange--Reinsurance and Risk Adjustments 3/23/2012 147 Adoption, Health Impact and Cost 3/23/2012 148 Establishment of Exchanges, Exchange Eligibility, and Quali?ed Health Plans Part I with 3/27/2012 Interim Policies 149 Draft Guidances Relating to the Development of Biosimilar Products; Public Hearing; 4/2/2012 Request for Comments; Correction 150 Draft Guidance for Industry on Compliance Policy for Reporting Drug Sample Distribution 4/3/2012 151 National Quitline Data Warehouse 4/4/2012 152 Risk Adjustment Meeting--May 7, 2012 and May 8, 2012 4/11/2012 153 Meeting Cancellation for 4/20/12 4/17/2012 154 Targeted Surveillance and Biometric Studies for Enhanced Evaluation of Community 4/18/2012 Transformation Grants 155 Changes in Provider and Supplier Enrollment, Ordering and Referring, and 4/27/2012 Documentation Requirements; and Changes in Provider Agreements 156 Request for Information: Stop Loss Insurance 5/1/2012 157 Home and Community-Based State Plan Services Program and Provider Payment 5/3/2012 Reassignments 158 Home and Community-Based State Plan Services Program and Provider Payment 5/3/2012 Reassignments; Correction 159 Medicaid Program; Community First Choice Option 5/7/2012 160 Monitoring and Reporting for Community Transformation Grant Awardees 5/11/2012 161 Medicare Program; Proposed Changes to the Hospital Inpatient Prospective Payment 5/11/2012 Systems for Acute Care Hospitals and the Long Term Care Hospital Prospective Payment System and Fiscal Year 2013 Rates 162 Payments for Services Furnished by Certain Primary Care Physicians and Charges for 5/11/2012 Vaccine Administration 163 Notice of the Award of a Single-Source Program Expansion Supplement to Pima County 5/11/2012 Community College District in Tucson, AZ Under the Health Profession Opportunity Grants (HPOG) 164 Medical Loss Ratio Requirements: Notice Requirements for Issuers 5/16/2012 2017-?00022 165 Correcting Amendment: Health Insurance Issuers Implementing Medical Loss Ratio (MLR) 5/16/2012 under the Patient Protection and Affordable Care Act 166 Correction: Standards Related to Reinsurance, Risk Corridors, and Risk Adjustment 5/17/2012 167 Solicitation for Proposals for the Medicare Graduate Nurse Education Demonstration 5/18/2012 Program?Deadline Extension 168 ACIP Meeting 6/20/12 5/21/2012 169 Evaluation of the Communities Putting Prevention to Work National Media Initiative 5/23/2012 170 Medicaid and Children's Health insurance Program's; Disallowance of Claims for FFP and 5/29/2012 Technical Corrections 171 Correction: Establishment of Exchanges, Exchange Eligibility, and Quali?ed Health Plans 5/29/2012 Part I with Interim Policies 172 Patient Protection and Affordable Care Act; Data Collection to Support Standards Related 6/5/2012 to Essential Health Benefits; Recognition of Entities for the Accreditation of Qualified Health Plans; Accreditation Requirement in the Federally-facilitated Exchange 173 Community Transformation Grants: Evaluation of Nutrition, Physical Activity, and 6/6/2012 Obesity-related Television Media Campaigns 174 CDC National Healthy Worksite Program (NHWP) 6/12/2012 175 Submission for OMB Review; Comment Request. Title: Affordable Care Act Tribal 6/12/2012 Maternal, Infant and Early Childhood Home Visiting Program Annual Report. 176 School Environment Study: Evaluating the Effects of CT G-supported School-based 6/ 13/2012 Nurtrition, Physical Activity, and Obesity-related Television Media Campaigns 177 NCHM Notice of Intent to award Affordable Care Act (ACA) funding to the Association of 6/15/2012 Public Health Laboratories (APHL) to educate public health laboratories about the Environmental Public Tracking Network 178 Impact Studies of the Health Profession Opportunity Grants Submission for OMB Review; 6/18/2012 Comment Request 179 Request for Measures and Domains for Development of a Standardized Instrument for 6/21/2012 Use in Public Reporting of Enrollee Satisfaction with their Qualified Health Plan and Exchange 180 Announcement of a New Application Deadline for the Advanced Payment Model 6/26/2012 181 National Health Interview Survey (NHIS) 6/27/2012 2017-?00023 182 National Quitline Data Warehouse 7/9/2012 183 CY 2013 End-Stage Renal Disease Prospective Payment System, Quality Incentive 7/11/2012 Program, and Bad Debt Reductions for all Medicare Providers 184 Home Health Prospective Payment System Rate Update for Calendar Year 2013, Hospice 7/13/2012 Quality Reporting Requirements, and Survey and Enforcement Requirements for Home Health Agencies 185 Patient Protection and Affordable Care Act; Data Collection to Support Standards Related 7/20/2012 to Essential Health Bene?ts; Recognition of Entities for the Accreditation of Qualified Health Plans 186 Proposed Changes to the Hospital Outpatient Prospective Payment System (OPPS) and CY 7/30/2012 2013 Payment Rates; Proposed Changes to the Ambulatory Surgical Center (ASC) Payment System and CY 2013 Payment Rates 187 Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule, DME 7/30/2012 Face to Face Encounters, Elimination of the Requirement for Termination of Non-random Prepayment Complex Medical Review, and Other Revisions to Part for CY 2013 188 Targeted Surveillance and Biometric Studies for Enhanced Evaluation of Community 8/7/2012 Transformation Grants 189 Evaluation of the Communities Putting Prevention to Work National Media Initiative 8/7/2012 190 Adoption of Operating Rules for Electronic Funds Transfer (EFT) and Remittance Advice 8/10/2012 191 Office of Direct Service and Contracting Tribes; National Indian Health Outreach and 8/20/2012 Education Cooperative Agreement 192 Health Outreach and Education 8/31/2012 193 Cooperative Agreement 9/5/2012 194 Notice of the Award of Single-Source Program Expansion Supplements to Multiple 10/3/2012 Grantees Under the Health Profession Opportunity Grants (HPOG) 195 Smoke-Free Multi-Unit Housing 10/9/2012 196 Announcement of the Award of Four Single-Source Program Expansion Supplement 10/31/2012 Grants To Support Activities Associated With the Tribal Early Learning Initiative. Notice of award of four single- source program expansion supplement grants to Tribal Maternal, Infant, and Early Childhood Home Visiting (MIECHV) grantees to support their activities as participants in the Tribal Early Learning Initiative 2017-?00024 197 Payments for Services Furnished by Certain Primary Care Physicians and Charges for 11/6/2012 Vaccine Administration under the Vaccines for Children Program 198 CY 2013 Home Health Prospective Payment System Refinements and Rate Update, 11/8/2012 Hospice Quality Reporting Requirements, and Survey and Enforcement Requirements for Home Health Agencies 199 CY 2013 End-Stage Renal Disease Prospective Payment System, Quality Incentive 11/9/2012 Program, and Bad Debt Reductions for all Medicare Providers 200 Proposed Changes to Hospital Outpatient Prospective Payment System and CY 2013 11/15/2012 Payment Rates; Ambulatory Surgical Center Payment System and CY 2013 Payment Rates 201 Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to 11/ 16/2012 Medicare Part for CY 2013 202 Recognition of the National Committee for Quality Assurance (NCQA) and Utilization 11/23/2012 Review Accreditation Commission (URAC) for Accreditation of Qualified Health Plans (QHPs) 203 Exchanges Part Il--Standards Related to Essential Health Benefits; Health Insurance Issuer 11/26/2012 and Exchange Responsibilities with Respect to Actuarial Value, Quality, and Accreditation 204 Patient Protection and Affordable Care Act; Health Insurance Market Rules 11/26/2012 205 Incentives for Nondiscriminatory Wellness Programs in Group Health Plans 11/26/2012 206 Request for Information: Health Care Quality 11/27/2012 207 Request for Information to Aid in the Design and Development of a Survey Regarding 12/3/2012 Patient Experiences With Emergency Department Care 208 Notice of Bene?t and Payment Parameters 12/7/2012 209 Essential Health Bene?ts in Alternative Benefit Plans, Eligibility Notices, Fair Hearing and 1/22/2013 Appeal Processes for Medicaid and Exchange Eligibility Appeals and Other Provisions Related to Eligibility and Enrollment and Sharing 210 Request for Information for the Development of a Survey Regarding Patient Experiences 1/25/2013 with Hospital Outpatient Surgery Departments/Ambulatory Surgery Centers 211 Request for Information to Aid in the Design and Development of a Survey Regarding 1/25/2013 Experiences with Hospice Care 212 Modifications to the HIPAA Privacy, Security, Enforcement, and Breach Notification Rules 1/25/2013 under the Health Information Technology for Economic and Clinical Health Act and the Genetic Information Nondiscrimination Act; Other Modifications to the HIPAA Rules 2017--00025 213 ACIP Meeting 2/20/13-2/21/13 1/28/2013 214 Patient Protection and Affordable Care Act; Exchange Functions: Eligibility for Exemptions 2/1/2013 215 Certain Preventive Services Under the Affordable Care Act NPRM 2/6/2013 216 Comprehensive End-Stage Renal Disease Care Model Announcement 2/6/2013 217 Medicare, Medicaid, Children's Health Insurance Programs; Transparency Reports and 2/8/2013 Reporting of Physician Ownership or Investment Interests 218 Medicare Program; Medical Loss Ratio Requirements for the Medicare Advantage and 2/22/2013 the Medicare Prescription Drug Benefit Programs 219 Patient Protection and Affordable Care Act; Actuarial Value Calculator Methodology -- 2/25/2013 Essential Health Bene?t 220 Patient Protection and Affordable Care Act; Health Insurance Market Rules; Rate Review 2/27/2013 221 Solicitation for Nominations 3/8/2013 222 Patient Protection and Affordable Care Act; Establishment of Exchanges and Qualified 3/11/2013 Health Plans; Small Business Health Options Program (SHOP) 223 Patient Protection and Affordable Care Act; Amendments to the HHS Notice of Bene?t 3/11/2013 and Payment Parameters for 2014 224 Patient Protection and Affordable Care Act; Notice of Benefit and Payment Parameters 3/11/2013 225 Requirements for Long Term Care Facilities: Notification of Facility Closure 3/19/2013 226 Ninety-Day Waiting Period Limitation and Technical Amendments to Certain Health 3/21/2013 Coverage Requirements Under the Affordable Care Act 227 Federal Medical Assistance Percentages (FMAP) - Methodologies for Calculation of 4/2/2013 Enhanced Rate 228 Merger of the Healthcare Integrity and Protection Data Bank with the National 4/5/2013 Practitioner Data Bank (NPDB) 2017-?00026 229 Patient Protection and Affordable Care Act; Exchange Functions: Standards for Navigators 4/5/2013 and Non-Navigator Assistance Personnel 230 Early Retiree Reinsurance Program- Process Update 4/23/2013 231 Requirements for the Medicare Incentive Reward Program and Provider Enrollment 4/29/2013 232 Inpatient Rehabilitation Facility Prospective Payment System for Federal Fiscal Year 2014 5/8/2013 233 FY 2014 Hospice Wage Index and Payment Rate Update; Hospice Quality Reporting 5/10/2013 Requirements; and Updates on Payment Reform 234 State Disproportionate Share Hospital Allotment Reductions 5/15/2013 235 Bundled Payments for Care Improvement Model 1 Open Period 5/17/2013 236 Pre-Existing Condition Insurance Plan Program 5/22/2013 237 Medical Loss Ratio Requirements for the Medicare Advantage Medicare Prescription 5/23/2013 Drug Benefit Programs 238 HHS-Operated Risk Adjustment Data Validation (RADV) Stakeholder Meeting?June 25, 5/29/2013 2013 239 Noti?cation of Closure of Teaching Hospitals and Opportunity to Apply for Available Slots 5/31/2013 240 Increased Federal Medical Assistance Percentage Changes Under the Affordable Care Act 6/3/2013 of 2010; Correction 241 Incentives for Nondiscriminatory Wellness Programs in Group Health Plans 6/3/2013 242 Patient Protection and Affordable Care Act; Establishment of Exchanges and Qualified 6/4/2013 Health Plans: Small Business Health Options Program 243 Program Integrity:E xchange, SHOP, Premium Stabilization Programs, and Market 6/19/2013 Standards 244 Exchanges: Eligibility for Exemptions; Miscellaneous Minimum Essential Coverage 7/1/2013 Provisions 245 Certain Preventive Services under the Affordable Care Act 7/2/2013 246 CY 2014 Changes to the End-Stage Renal Disease Prospective Payment System, End-Stage 7/8/2013 Renal Disease Quality Incentive Program, and Durable Medical Equipment (DME) 247 Essential Health Bene?ts in Alternative Benefit Plans, Eligibility Notices, Fair Hearing and 7/15/2013 Appeals Processes, and Premiums and Cost Sharing; Exchanges: Eligibility and Enrollment 2017-?00027 248 Exchange Functions: Standards for Navigators and Non-Navigator Assistance Personnel; 7/17/2013 Consumer Assistance Tools and Programs of an Exchange and Certified Application Counselors 249 Medical Loss Ratio Requirements for the Medicare Advantage and the Medicare 7/22/2013 Prescription Drug Bene?t Programs; Corrections 250 Exclusion of Orphan Drugs for Certain Covered Entities Under 340B Program 7/23/2013 251 Medicare Provider Enrollment Notice 7/31/2013 252 FY 2014 Hospice Payment Rate Update, Hospice Quality Reporting Requirements, and 8/7/2013 Update on Payment Reform 253 Program Integrity: Exchange, SHOP, Premium Stabilization Programs, and Market 8/30/2013 Standards (Including Eligibility Appeals 254 Application by the Accreditation Association for Ambulatory Health Care for 9/13/2013 CMS Approval of its Federally Facilitated Exchange (FFE) Accreditation Program 255 Disproportionate Share Hospital Payment Reduction 9/18/2013 256 Prospective Payment System for Federally Qualified Health Centers; Changes to 9/23/2013 Contracting Policies for Rural Health Clinics; and Changes to Clinical Laboratory Improvement Amendments of 1988 Enforcement Actions for Proficiency Testing Referral 257 Establishment of the Basic Health Program 9/25/2013 258 Program Integrity: Exchange, Premium Stabilization Programs, Market Standards, and 10/30/2013 Cost-sharing Reduction Reconciliation; Amendments to the HHS Notice of Benefit and Payment Parameters for 2014 259 HHS Notice of Benefit and Payment Parameters for 2014; Technical Amendment 11/6/2013 260 Final Rules under the Paul Wellstone and Pete Domineici Mental Health Parity and 11/13/2013 Addiction Equity Act of 2008 261 Proposed Quality Rating System (QRS) Framework and Measures 11/19/2013 262 CY 2015 Notice of Benefit and Payment Parameters 12/2/2013 263 Patient Protection and Affordable Care Act; Maximizing January 1, 2014 Coverage 12/17/2013 Opportunities 264 Proposed Basic Health Program 2015 Funding Methodology 12/23/2013 265 Approval of an Application by the Accreditation Association for Ambulatory Health Care 12/23/2013 for Approval of its Federally Facilitated Exchange (FFE) Accreditation Program 266 Amendments to Excepted Benefits 12/24/2013 267 Patient Protection and Affordable Care Act; Program Integrity: Exchange, Premium 12/31/2013 Stabilization Programs, and Market Standards; Amendments to the Notice of Benefit and Payment Parameters for 2014; Correction 268 Certification of Compliance for Health Plans 1/2/2014 2017-?00028 269 Contract Year 2015 Policy and Technical Changes to the Medicare Advantage and the 1/10/2014 Medicare Prescription Drug Benefit Programs (Includes Appeals Process for Medicare Parts Recovery Audit Contractor (RAC) Determinations) 270 Home and Community-Based State Plan Services Program, Waivers, and Provider 1/16/2014 Payment Reassignments 271 Physician Compare Website: Town Hall Meeting February 24, 2014 1/29/2014 272 Frontier Community Health Integration Project 2/4/2014 273 Medicare Provider Enrollment Notice 2/4/2014 274 Bundled Payments for Care Improvement Models 2, 3, and 4 2014 Winter Open Period 2/14/2014 275 Ninety-Day Waiting Period Limitation-Orientation Period 2/24/2014 276 Ninety-Day Waiting Period Limitation and Technical Amendments to Certain Health 2/24/2014 Coverage Requirements under the Affordable Care Act 277 CY 2015 Notice of Benefit and Payment Parameters 3/11/2014 278 Request for Information Regarding Provider Non-Discrimination 3/12/2014 279 Basic Health Program; Final Federal Funding Methodology for Program Year 2015 3/12/2014 280 Establishment of the Basic Health Program 3/12/2014 281 Patient Protection and Affordable Care Act; Third Party Payment of Quali?ed Health Plan 3/19/2014 Premiums 282 Exchange and Insurance Market Standards for 2015 and 2016 3/21/2014 283 Prospective Payment System for Federally Quali?ed Health Centers; Changes to 5/2/2014 Contracting Policies for Rural Health Clinics; and Changes to Clinical Laboratory Improvement Amendments of 1988 Enforcement Actions for Pro?ciency Testing Referral Health Clinics; and Changes to Clinical Laboratory Improvement Amendments of 1988 Enforcement Actions for Proficiency Testing Referral 284 Policy and Technical Changes to the Medicare Advantage and the Medicare Prescription 5/23/2014 Drug Benefit Programs for Contract Year 2015 285 Exchange and Insurance Market Standards for 2015 and 2016 5/27/2014 286 Medicare Program; Additional Extension of the Payment Adjustment for Low-Volume 6/17/2014 Hospitals and the Medicare-dependent Hospital (MDH) Program Under the Hospital Inpatient Prospective Payment Systems (IPPS) for Acute Care Hospitals for Fiscal Year 2014 287 Ninety-Day Waiting Period Limitation?Orientation Period 6/25/2014 2017-?00029 288 Annual Eligibility Determinations for Exchange Participation and Insurance Affordability 7/1/2014 Programs; Health Insurance Issuer Standards Under the Affordable Care Act, Including Standards Related to Exchanges 289 Medicare and Medicaid Programs; CY 2015 Home Health Prospective Payment System 7/7/2014 Rate Update; Home Health Quality Reporting Requirements; and Survey and Enforcement Requirements for Home Health Agencies 290 Exchange and Insurance Market Standards for 2015 and 2016; Correction 7/24/2014 291 Medicare Provider Enrollment Phase 1 and 2 Update 8/1/2014 292 Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities for FY 8/5/2014 2015 293 Certain Preventive Services; Eligible Organizations 8/27/2014 294 Certain Preventive Services; Non-Profit Religiously Af?liated Organizations 8/27/2014 295 Annual Eligibility Determinations for Exchange Participation and Insurance Affordability 9/5/2014 Programs; Health Insurance Issuer Standards Under the Affordable Care Act, Including Standards Related to Exchanges 296 Amendments to Excepted Benefits 10/1/2014 297 Exchange and Insurance Market Standards for 2015 and 2016; Amendment 10/1/2014 298 Final Waivers in Connection with the Medicare Shared Savings Program; Continuation of 10/17/2014 Effectiveness and Extension of Timeline for Publication of Final Rule 299 Basic Health Program; Federal Funding Methodology for Program Year 2016 10/23/2014 300 Approval of Request for an Exception to the Prohibition on Expansion of Facility Capacity 10/31/2014 under the Hospital Ownership and Rural Provider Exceptions to the Physician Self- Referral Prohibition 301 CY 2015 Home Health Prospective Payment System Refinements and Rate Update 11/6/2014 302 CY 2016 Notice of Benefit and Payment Parameters 11/26/2014 303 Food Labeling; Nutrition Labeling of Standard Menu Items in Restaurants and Similar 12/1/2014 Retail Food Establishments; Calorie Labeling of Articles of Food in Vending Machines 304 Food Labeling; Calorie Labeling of Articles of Food in Vending Machines 12/1/2014 305 Provider Enrollment Application Fee Amount CY 2015 12/5/2014 306 Medicare Shared Savings Program: Accountable Care Organizations 12/8/2014 307 Amendments to Excepted Bene?ts 12/23/2014 308 Summary of Benefits and Coverage and Uniform Glossary 12/30/2014 309 Medicare Provider Enrollment Phase 1 and 2--2nd Update 2/2/2015 310 Contract Year 2016 Policy and Technical Changes to the Medicare Advantage and the 2/12/2015 Medicare Prescription Drug Benefit Programs 311 Reporting and Returning of Overpayments; Continuation Notice 2/17/2015 2017-?00030 312 CY 2016 Notice of Benefit and Payment Parameters 2/27/2015 313 Amendments to Excepted Bene?ts 3/18/2015 314 Medicare Program; Updates to the List of Durable Medical Equipment (DME) Specified 3/27/2015 Covered Items that Require a Face-to Face-Encounter and Written Order Prior to Delivery 201 7--00031 1001 1001 . 1001 . 1001 . 1001 . 1001 1001 1001 . 1M1 . 1001 . 1001 . 1001 .1008 .1003 .1008 Language deeabedin subsection (arrays issuedandthe planyeerwithrespectto such recomrnendellonorguideline VALLE-BASED NSURANCE Secretary may develop widehes to permit a group health plan aid a heath insurance Issuer ol'lemg group or NW1 heath nsurance coverage to utllze vain-based lrourance designs. appropmte penalties brnon?compliancewith sum requ'ements. devdoong the reporting reowements under paragraph (1 I. the Secretary may prov-3e for exceptions to war requirements forgroup hedh plats aid health hmnce issuers that subotmtially meet the gods of this section. Reguluons-TheSecrotaryehal promulgate regrleticnstodehethedepondents towarcoveraoeshalbemade under oubsedion inGenerd-Nothterthan the byagroupheelh such standards. the Secretary shal consult with the Nuonal Wit or nuance (reisrred to in thissectionashe Insurance-Wm edvocacyorgmzabons hedth'l'luanceissuers hedhcareprofesaiortals. General- Not later than 12 months after the date of enactment of the Patient Protection and Affordable Care Act. the Secretary strall develop standards for use by a group health plan and a health ?nsuranoe issuer offering group or individual health insurance coverage, in compiling and providing to enroliees a summary of bene?ts and coverage explanation that accurately describes the bene?ts and coverage under the applicable plan or coverage. developing such standards. the Secretary shall consult with the Nation! Association of Insurance Commissioners (referred to in this Periodic Review and Updating- The Secretary shall periodically review and rpdate as appropriate. the standards developed mderthis section. GENERAL- The Secretary shal, by regulation. provide for the development of standards for the definitions of terms used In health insurance coverage. including the insurance-related terms described in paragraph (2) and the medical terms described in paragraph (3). AVAILABILITY OF REPORTS- The Secretary shal make reports submitted under subparagraph (A) avaiable to the public ttlougr an Inwmet website. Regulations- Not later than 2 years after the date of enactment of the Patient Protection and Affordable Care Act. the Secretary shall promulgate regulations that provide criteria for determining whether a reimbursement structure Is described In subsection The Secretary shall make reports received under this section available to the public on the Internet website of the Department of Health and Human Services. lnGenerd-TheSeaetary shall States (orthe Exchanges operatingin such States) to eetabish. expand. or worm support for? of?ces of health consumer assistance: or healh insurance mm programs. Data Collection- As a condition of receiving a grant under subsection an office of health insurance consumer assistance or ombudsman program shal be required to collect and report data to the Secretary on the types of problems and inquiries encountered by consumers. The Secretary shall utilize such data to Identify areas where more enforcement action is necessary and shal share such Information with State insurance regulators. the Secretary of Labor. and the Secretary of the Treasury for use in the enforcement activities of such agendas. JUSTIFICATION AND DISCLOSURE- The process established under paragraph (1) shal require health 'nsurance issuers to submit to the Secretary and the relevant State a justification for an unreasonable premium increase prior to the implementation of the increase. Such issuers shal prominently post such information on their hternet websites. The Secretary shall ensure the public disclosure of information on sum increases and justi?cations for all health insurance issuers. PREMIUM REVIEW GRANTS 201?-The Secretary shall carryout a to mdgrants to States during the 5-year period with fiscal year 2010 to assist such States rn carrying out subsection ir'rdudlng? tieppropriaternderStatelaw. .7, lorheaII? coveram; ?(B?nprwiinginfanutionmd unseraion. Undersumformula? '(iltheSecratary shall coneidathemntrerolptanaofhedh immune State: and (1)shall receive less than 81.00031?. or morethm $5,000,000 Ioragrantyear.'. HHS--J une 2017--00032 MW MS MS ills. Labor. Treosuy l-I-iS Sec. 1101 Sec. 1101 See. 1101 Sec. 1101 Sec 1101 Sec. 1101 Sec. 1101 Sec. 1102 Sec. 1102 Sea 1102 Sec. 1102 Sec. 1102 Sec. 1102 Sec. 1103 Sec. 1103 See. 1103 Sec. 1104 Sec. 1104 MS Protection Agent Dunning Risk by Insurers- (1) GENERAL The Secrelery ehel criteria MIelha?hedlh mun-roe issuers and employmen-buedhealm plan hevedieceu'eged 'llivldud from remaining enrolled In prior based on than lnmduel's hailh stems. IN Secrelary may oomreclsloeligible entitles. (2) ELIGIBLE enenfnyeh?? (Mbeesmeor andomlelningsucn hlorrmlionas highnekpoolh'eigbleim sudreoverege; md(i)lhalhesmoutdpocketlimll MWhalmeSeaem ms inis His mskesuch mde?cll. ms INGEPERAL- lheSecreh'ysh?eleiehehenporuy enddependerlsol 2014. l-I-lS EMPLOYMENT-BASED PLANELIGBIUTY- Aperlicipefng mermloyment?baeed plenlhel? lheSecreleryenepplice?onl?or l-l-lS PROGRAM (?lm in mm claim that exceed subject 10 I119 limits in paw WIS USE OF PAYMENTS- Amounts paid to a employment-based plan under subsection shall be used to lower coals for the plan. Such payments may be used to reduce premium costs for an entity described in subsec?on or to reduce premium conlriau?ons, co- paymenls. deductibles. coinsurance. or char mn-ol-pockel costs for plan Such payments she! not be used as general revenues for an en?ty described in subsedion The Secretary shall develop a mechanism to monitor ihe appropriate use of such payments by such ms plerlalo endlB)prooe?reslo midweemderlheprogrem. ms by WIS INGEPERAL- starriimum. l-I-lS eriiliee. 1H8 USEOFFOMT-TheSecremer-eluullze IndersIDIreclionta) INGEPERAL- Seaeluyshd? (i)blheemnlfeasiale end ensbh? olen?? end orallhepolnlolcsre: (ill) pruvideler timely response. procees(lncluthg adju?mlionmdappeels): and (NJ describe all dale elements (lncluthgreaeonand addiiond conditions smorFederellew,ortoprmed ms (lndmiIg werendeleclmnic forms) and dale envy required by psllem and provldersf: and WIS HHS--J une 2017--00033 1104 .1104 .1104 .1104 .1104 .1104 .1104 .1104 .1104 . 1104 .1104 1104 1104 .1104 .1104 .1104 ,1104 1104 GENERAL- The Secretary shal adopt a single set of operating rules for each transaction relerted to under subsection with the goal oi creating as much uniformity In the implementation ot the electronic standards as possible. Such operating rules shall be consensus?based and re?ect the necessary business rules affecting health plans and health care providers and the manner in which they operate pursuant to standards issued under Health Insurance Portability and Accountability Act of 1996. ms OPERATING RULES DEVELOPMENT- In adopting operating rues mdet this subsection. the Secretary shal outsider agaaliftednonptol'lentity thattneetsthetollowhg regiement The andty touasee ita tntaalon on administrative sewii?cebon. The entity demonstrates a mum-stakeholder and process tor oi rules. Indudng Ispresentation by or particbalon from health andotherstanduddevelowientorga rizations (ClThe entity and supports nondiscnmimtion and con?ict cl interest pollcies that a commitment to open. fair. and ms GENERAL- The Secretary shal adopt operating rules under this subsection. by regulation In accordance with subpatagraph (C). following consideration of the operating rules developed by the non-pro?t entity described in paragraph (2) and the recomtnendation submitted by the National Committee on mm and Health Statistics under paragraph and having ensured consultation with providers. ms ELIGIBUTY FOR A HEALTH PLAN. PEALTH CLAIM STATUS. ELECTROMC FWDS TRANSFERS. PEALTH CARE AND later man Decanter 31. 2013. a health plan shal a statement mm theSacretuy. in are In compliancewiti any applicable standards tasdescthed wider, eligibiltyloraheaith plan heatt clarnetatua. respectively. I-EALTH CLAIMS a! EQUIVALENT ENCOUNTER NORMATION Em All) DISBIROLLMENT A I-EALTH PLAN. HEALTH PLAN PREMIUM PAYMENTS. CLAIMS ATTACHMENTS. REFERRAL CERTIFICATION Am than December 31. 2015. a man plan shal tile 3 statement with theSecretaty. in are In compliance win any applicable startdards and assoclated operahg rules for hedh claims or egnaient encounter Information. ervollmenl aid dlsenrotnent In a health plan. health plan premium payments. heath claims attad'l'nents ms insuchiotmastheSeaetatymay operating nlaedeea'bedunda cormilancevmhsuchstandavds. unless the healthpIan?? ?(AldemcnalralestotheSecretary mattheplan conducts Sacretzy: and? transactionswiththe'a partner's HHS (1M entities find rib by the Secretary under subsection (I) that? amends any standard cropetaing rule described mderparmrap?t (1)01thts subsection: or (I)eat?aheea?atdard (u deeated utdet?atbuchon naes(as ?under (Ixsnioranyotharilnencial and admirastratlvetransactlons I-HS EXPEDITED The Secretary shall promulgate an interim ?nal nIIe applying my standard or operating rule recommended by the National Committee on Vital and Health Statistics pursuant to paragraph (3). The Secretary shall accept and consider public comments on any interim final rule published under this subparagraph for 60 days after the date at such publication. I-HS EXPEDITED The Secretary shall promulgate an interim llnal rule applying any standard or operating rule recommended by the National Committee on Vital and Health Statistics pursuant to paragraph (3). The Secretary shall accept and consider public comments on any interim ?nal rule published under this subparagraph for 60 days alter the date of such publication. was AUDITS OF HEALTH PLANS- The Secretary shal conduct periodic audits to ensue that heath plans (including entities described under paragraph are in compliance with any standards and operating rules that are described under paragraph (1) or subsection ms ESTABLISHMENT- Not later than January 1. 2014. the Secretary shal establish a review committee (as described under paragraph ms PUBLIC COMMENT PERIOD- The Secretary shal accept and consider publlc cements on any interim ?nd nae published under this paragaph for 60 days after the date of such ms OPERATING RULES FOR OTHER STANDARDS ADOPTED BY THE SECRETARY- The Secretary shall adopt a single set of operating rules (pursuant to the process described under subsection for any transaction torwhich a standard had been adopted pursuant to subsection IN Not htar than Aprilt. 2014. and amually thereafter. the Secretary shall assess a penaly tea (as Mtnespectto ol Mitr- deemed meet malolsuch subsedion. and (Ilia standad (asdescrbed under subsection (a)(txanmd associated operating nlaa (as daectbad under mbeection it: any other fnmcial and admiritrativa tranaadiom. ms FEEAMOLNT- (D). and(E). certi?cattoniacornptete. DETERMINATION OF COVERED INDIVIDUALS- The Secretary shall determine the number of covered Eves mder a health plan based upon the most recent statements and ?lings that have been submitted by such plan to the Securities and Exchange Commission. was NOTICE AND DISPUTE PROCEDURE- The Secretary shall establish a procedure for assessth of penalty tees under this subsection that provides a health plan with reasonable notice and a dispute resolution procedure prior to provision ot a notice oi assessment by the Secretary at the Treasury (as described Mr paragraph ms. TIeasuy HHS--J une 2017--00034 Sac.1104 Sec.1104 Sec.1104 Sec.110l Sec 1201 Sec. 1201 Sec. 1201 Sec. 1201 Sec. 1201 Sec 1201 Sec. 1201 Sec. 1201 Sec. 1201 Sec. 1201 Sec.1302 506.1302 Sec. 1302 Sec. 1302 PENALTY FEE REPORT- Not later titan May 1. 2014. and annualy thereaher. the Secretary shall a reportidentifying those healthpiansthathave been assessed a penalty fee utderthis stbsection. UNIQUE HEALTH PLAN IDENTIFIER- The Secretary shall promulgate a final rule to establish a unique health plan identi?er (as described in section 1173(b) of the Social Security Act (42 U.S.C. based on the irtput of National Committee on Vital and Health Statistics. The Secretary may do so on an interim final basis and such rule shall be ettective not later than October 1, 2012. TRANSFER-MSecretarysh? turtdsoartsters (as described it section 1173(ax2XJ)otthe Soaal Security Act. as added by subsection (bx2XA)). The 1.2012. in amanner ensuring that such statdard ls ei'lectivertot laterthan Januuy t. 2014. startdardanda sirtglesat otassociatedoperating ruteslorhsatthcia?rns altactment?asdeecnbed in section 1173(a)(2)(8)otthe Social Sea-11y Act (42 use. ia outsietant w?dh I19 x12 Vernon 5010 ?mention stands-us. operulng ruteenotlalerthanmary 1. Juuaryt.2016. SECRETARIAL REVIEW. ?The Secret-yeti! reviewthe rating areas established by each State under meow reqtiementsoith istitle. Secretay may eelsbi?eh ratirtgareastorthatState. PERMISSIBLE AGE Seam. in oonadtuion wih the Natbnai Association Mice Comm. shall de?ne the age bands tor rating under paragraph Seoremy slid prornulm regbtions with reaped to emollient periods utder mphe (1) and (2t TheSecretartesotLabor. HeslharthumanServlces. ahalestmlishato-Statedemon ineurancecoveragelnthe individidrnaketirtsuchsme. Treasury mdtheSecretuyotLdtor States. CaeAct. the Secretayinconsulationwih "A()itte dwelneea (aade?lirtedlnaubsedlon Wyofmragetorw and" dsuch .?and '(D)the irttanationhrn indudirthtateandFederal egata'es. (1) IN GEtERAL.4ubteu to paragraph (2). the Secretary shall delrte the essential hastth bene?ts. except that such (A) Ambidatory paient services. (8) Emergency services. (0) Hoep?n?zdion. (D) Maternity artd nettbom care. (E) Mental haaItt and substance use asorder services. Including behavioru health treatment. (F) Prescription ratios. (6) Rdtabilltatlve and services and devices. (H) Laboratory services, (I) Prevents mil-teas services d'ImI-ic matagemarl. (J) Pedat?c services. indutitg oral and v'nion (are. bertelisutdermhmiseqmi typicaltyooveredbyernpioyera. irtduding hedthbene?tadeeatedinmu). andinreyisiythebsrte?a demoonhiritga Medlcala meettheimltation deecrtbedlnparagraph(2). Issuereguations HHS--J une 2017--00035 HHS l-I-iS MS l-I-lS. Labor. Treasuy ms. Labor. Treasury His. Labor. Treastty Hus. Labor. Treasuy ms. Labor. Treasuy Labor MS Sec. 1302 Sec. 1302 Sec. 1302 Sec. 1302 M1308 Sec. 1303 Sec. 1303 Sec. 1303 Sec. 1311 506.1311 Sec. 1311 Sec. 1311 Sec. 1311 Sec. 1311 See. 1311 Soc. 1311 Sec. 1311 Sec. 1311 the Secretary shall provrdenotlce comment. MS REQUIRED ELEMENTS FOR defining the eeaen?d health bene?u Indy paw (1). 1er Secretay EMPLOYER Secretary mayIssue INS ALLOWABLE Secretary MYERMNAW BY SECRETARY. ??l'he Seaetary maynotdatermine. that ,?neelh option requements. endgadenceoneccoun?ngol lakes all neceasuysupetnmurolhatme United Slates doesndli ms desabedln subperagmn (BXI) (ill SPECIAL RULES. ?For wpoees 01 clause (I)aplan shat beIreeIedas such mantel. ms IN Secretary estimate the basic per enrollee. per rnonl'I coat. an mural basis. coveragemderawellfled health ptenotthe seMceedesabed In WUXBXU- llIeindualonotsudImvarep services coveragem perarwclee.pormonth. year. he thatlhe Secretary rewient oteuch want? (I) re ruling ae determ'ned by the Secretary. mo? (l)eetabllahlng en Exdiange; and the relorms described in A and (and me amendmems made by such subtitles): and is meeting such char landmarks as he Secretary may catalish. I-HS ASSISTANCE TO FACILITATE PARTICPATION SHOP Secretary shall provile teclInIcal busmesses Insuch States Exmnges. ms lNGElERAL.?The5ecratary anal. byregulalicn.establish criteria lorlhecerti?cationolhedh piansaeq?itled requomenls. and not employ marketing practices or that navelne ellecl the enrollment olprovidus?nanurner consistent network adewecy proviaicne under eedion 2702(c) ofvie Public Hedlh Service Act). and provide-Widow n? and ontne (C) Include within heaIlh mnnce plan networks those essential community providers where avaiable. that serve ms WIS EWING PATIENT SAFETYW?BeglrvilngonJanu-y1 esdescrbed In pertCottille DtotllIoPubicHe?hServiceAct: Secretay may by raglation require. I-I-IS Secretary may eetabbh reaaonable exceptions to lie miememe deaaibed pamph (1). His Secretary may by moon adjust the runner otbeda deaabed in (1XA). ENROUEE SATISFACTION Seaalary shall davdcp an erlolee se?I'Itaction euway system that wild INTERPET Secretary shall? (A) contime to operate. InaInlaIn. and update the Internet porbl such aracliglblelopartimete?nan standardized (Midlng dually ral'mge) regarding qua?ied hedh pins olered an Endange to consumers In maklng easy beam Insurance cholces. WIS HHS--J une 2017--00036 Sec. 1311 Sec. 1311 Sec. 1311 Sec. 1311 Sec. 1311 See. 1311 Sec. 1312 Sec. 1313 Sec. 1313 Sea 1313 Sec. 1321 Sec. 1321 Sec. 1321 Sec. 1321 SOC. 1321 See. 1321 Sec. 132 Sec. 1322 Em Secreiuy slid Inquire an ee m. as deemed by the Seam loroslender years eiler me initial enrollmeni period; (CIspecIsI enrollment ami(D)epeddrnonihiy Act) HIS Secretay. in cuneil?iun wih experts in healih we mm and Widen. ehd develop Secreiery may eeiabhh reasonable exceptions lo reru'remenls desa'ibed in peregreph (1). HIS Secretary may by reghiiun adjust Ihe umber deeds desubed in (IXA). i-I-iS subsection. indudng prwin?msiu ms FAIR AM) WARM IIFORMATION AND Secretary. in winner-rim w'sh Suites. she! develop ms Em 0e Secreiary prooeduee under worn Stale premium In: creole and cost-ohm reducncreioruiane cold enough an Exchange. HIS Services. md IheSecreiary the procedure M?(AimeSeasierydeisrmInseIe ms IN Socreiery trial. a eoones practicable meme dais demumeni 01ml: Act. We WIS CONSULTATION. ?in Issuing me under (1). Ins SecreIery ehsl ooneuli win Ins Neeonsl CorIIrII?ssiunen mdiis hedhinsurmce usuere uunwrner hieresiedpeniee. I-HS to HIS 2010. Ihisseciion. CommerOpereIedendOriemed i-e-Is WIS HHS--J une 2017--00037 Sec 1322 Sec. 1322 Sec. 1322 Sec.1322 Se?1m Sec. 1322 Sec. 1322 Sec. 1323 Sec. 1323 Seo1323 Sec 1323 Sec. 1323 Sec 1323 Sec. 1323 Sec.1323 506.1323 Sec. 1323 Sec. 1323 dier wlullizehlegraledoaren'looels. commons FOR (Malia! anomaiullononly organlzmion has md A?ordebleCaeAcl. tolnlhenoeleglslallon. deIvllheorgarizae?ondoes IN issuance iasuermpieelo hwmmelseueerhlnaSlaleJhe Seaetarymyuseamoumwpropnued ofequ?lied undermls secuon lhe lamination of an issuer's lax-exempt slalus urderseob?on 501(c)(29)ol suoh Code. FOR AWARDING Secretary ahdnouamnhanJuyl. 2013.ewardlheloansand hedh Ineumoe ssuers(orawlvalepuohesimoomcl lesl??ished IndersIDseollon (d))andanyhe?h care facilities wWirldutlganmem. phannecy whoepi?: Seorelary mall eelahlishaeomrmriy hadhlneurmoeophonmo?u.mlhe ?section droiee. oompe?ion. aldslebilily rim. high qudily mmuuwsw. PREMIUMS SUFFIOENT To COVER COSTS. Secretary shall esubleh Wholly adjusled premlum rales In adniistraliveoosls) )usingmelhodsingenerduse by qudiied hem plans. 0F Seerelary shall select data as necessary to set premium rates under th (A) eelabiah'ng premium ralee unrhr erbperegeul (A). Ire SeaelaIy shall Include an approvals amoral for a contingency margin. heal?r lnsuranoe ophon. Secretary lobeapplled respeolloacomrwney Slate In which such community heellh hannoeope'on la dfered. the standard deserted under nbpaIagraph (A). the Seaelary shall rem hmrenoe oplim. in paragraph referred lo as the may promulgate We Io eslablish eddllonal requiremenls lor a oommunlty mum lneurmoe option) USE OF START-UP FUN) Seaelary use amounts contained In rho Sm-Up Fund to make payments (subledle ln.. ,7 (4))lorlhe desabedln mum). PASS THROUGH OF Secrelary may ealabl'nh procedures reducing the email 01 payments to contracting Mute lake lnlo any rebates or price oonoessrons HHS--J une 2017--00038 MS MS PMS. Treeslry MS H13 H15 H43 MS Sec 1323 Sec. 133 Sec. 1323 8991323 5311323 See. 1323 Sec. 1323 Sec. 1323 Sec. 1323 5&1323 Sec 1323 Sec. 1331 Sec 1331 Sec. 1331 SOC. 1331 See. 1331 Sec. 1332 Sec. 1332 Mikel-1W retetss WIS APPLICABIJTY 0F Seaetary may ep?y the recornmenhtioris de State Advisory Council to a cornmuniy new: insuMIoe option 'n that State. in any other State. or in all States. purpose at . functions ,stunction A ?ln (3X4)dsection187MoittIeSocisi contracts (sX1)ct such section. HHS "Secretary (ax1ieridmtoisecson 187Motlhe Soasl Security Actwimrespeatotitle otsudIAd. ms deception. waste. moipower. W. coders, ages: mismanagement ms IN Secretary pay the com-suing adminimtnra tee forthe monument. edmir'utruicn. end deltveryoims section. ms REQUIREMT FOR HIGH QUALITY ADMINISTRATKN Secretary may homes the teedesa'bed lrI Winerynotmoretnsn (Atbynotmaethenso edninisttetcr. nthedetaniIetionof theSecreta'anem In costs and low cost monuments provided that such requirements 8e consistent with section 1302 (it) Ream administrative costs and pmo?ig scrim simplification hr benetic'uies. Promothg high quality dinicel cue. (iv) Previtiig him qusity customer service to beneficiaries. l-I'iS NON-RENEWAL. ?The Secretary mynotremwa oontrsetiooitera community heeiitIIreurenos colon undermis subpaameBNuringhe coritisctpeiiod. the terms oi a contract under this subsection. the Secretary shall negotiate the reimbursement rates tor purposes oi subsection (bxe). WIS IN GENERAL?Ounerinusl boss. the Secretary shell community health ms IN Secretory ml basic health progemmeeting the requirementsoiihis section under Emme. ms MS SPECFIC Secretary shall mskeltie (?monuments ma ms pmg'un: plm.indvidu&snd premium tsii credits. cost-sharing reductions. orsrrial business otherwisebeeigible. mateunountolsudiaed?ls oipertiovenemhe?xaengss Wumt?is??ewme pisnmoeitnsuniver UieottiertsIes WIS HHS--J une 2017--00039 Sec 1332 Sec. 1332 Sec. 1332 Sec. 1332 M1332 Soc. 1332 Sec. 1332 Sec. 1332 Sac. 1332 5&1332 Sec 1333 Soc. 1333 Sec. 1333 Sec. 1333 See. 1341 Soc. 1341 Soc. 1342 Sec. 1342 muons WJWIMWNIC hear-I93. ("uproomlorlhesubvmlond speci?c diatlhammlbain ms appim?omiutwu?vamundanhla section. State may 2017 Such (B)ooniainsuch ?(Hia10-yearbudguplanio' mum/amour: subsection (bx2). COORDNATED WAIVER Sialawu?va?pmoaasaa amiable mprwin'ona. Secrelary (ax1)oniyi11he$eaalary deieimlnea (Blwipiovlde maidens! dim msiderlsasiha ms (31(2) granted to a Slam under subsection ms Iowan anyFadarilawumquimmerlMia notwiliinlha authovnyo?hoSmwy. I-HS FOR Sammy shall make a datarminaiion Mammalian not manna! 18) (3X1) moSocniaryshaIl underwboeclionuxnmie nammaefon. WIS lNGENERAL?NoilaiarihanJuw inoonaulation wihlhaNa?onalAaaociationof lmurancoComnissiom. nomkaaoqmcy momma promotion oxidant (inclo?lg ammonia Ialamg no rating) inuIding disputes a to ma parlonnmoa o?ha ms m? as lhemagede?ned in seaion 1312(1))mddiavadlfmigh Exd'iangea osmium mastitis Iille; cnlovounontollm In such canola. WIS mm naionwida qudiiadhaali planundar this suboodion shall indudaatlaasiihoasunha M1302. PAYMENT AMOUNT s.?Tho Savoury shall Include the following in lhe pm unou pawn} (A) DETERMNAWOF MGM-RISK IMJMDUALS ?Thomolhod by individualsme as high rial: Suhn'la?iodahall diagnostic ?Wooden that niximtivaofindividualnwim pro-exiting. hiniak conditions: or(ii) any other mbleobieciva method oiiden?ication racommendedby lheNnarimn AcedemyofAchJaries. (B) PAYMENT ms 2015 Sum SocialSowmyAci Seam subsection WIS HHS--J une 2017--00040 Sec 1342 Sec. 1343 Sec. 1401 Sec. 1401 M1402 Sec. 1402 Soc. 1402 Sec. 1402 Sec. 1402 5&1402 Sec 1402 Sec. 1402 Sec 1411 Sec. 1411 SOC. 1411 Sec1411 Sec. 1411 Sec. 1411 PAYLENTS IN. ?The Secretuy under subseaion thstii? (A)e thew amountouerlhemcoets; WIS Secretary. in consolationmh shelledustthe'nifnl sudeeriod. HHS this section. inclu?ig which provihfa? aedit slowed mderihis seciion with and used iardearrnining theMpeyment dthe credit". l-I-iS ms Any such system risk Iosucn ms INGEI?RAL.?TheSecretery hued hueddeeaibedhmhakamd (A) underm??fnecessarybermthet WIIMdOnotceuselherespedivem sduaridvelueeloexoeedthe leveisspediedinclsusem. WREDUCTION FOR LOWER INCOME TheSecreterysneil establish procedures mm 1Mperoentbu ms reunions. WIS Increase by reason oithls subsection. ms SECRETARIN. AUTHORITY. ?The Secretary. hoonsullsuonmmesmyolhe Treasury. snel preserve rules olth?n swsedian. i-HSJroecu?y Secretuy ehel edebliehaproganmeetinghe ManEmmo. and section 368(e)oilne mowed 196 man the 1402? ms deeabedinsubeection (4). Tmyforvuiialicnd mummiemilysizeforpurposad etigiblity. i-I'iSJ'msIly Security shelorovidcmeI verificelonsenddetorminetions urIdernls subsection shall Secretn'y. ms. Hernia-Id Secu'ity. Sou'el Security dodosurs. msintsnenoe?rweot infamlianwillbemet. "48.qu AMI) OOFtRECt?hthe case the inconsistency or 'ndility to veriy ie not resolved under WM). during2014 6103 Wu 0! Mar ms HHS--J une 2017--00041 Sec 1411 Sec. 1411 Sec. 1411 Sec. 1411 Sec. 1411 See. 1411 Soc. 1412 Sec. 1412 Sec. 1412 SOC. 1412 Sec 1412 Sec. 1413 Sec 1413 Sec. 1413 Sec. 1413 See. 1413 506.1421 Sec. 1501 IN GENERAL. ??och 9060" I0 whom the Seaelory Norm under subsection shoI now In the mm methodestobiished mderubseciion Wound MSeaetuy shall noefymeExdiengeofsudIIesIm. WIS ELIGIBIJTY FOR Em AM) PREMIUM TAX AND COST-SHARING infomIe?on padded by on onnbosm ?who (I). (2). (3). and (4)olsubseaion Is ven?ed uiderswsectiom and mm {Wimnot?y NSeoretaydiheTremuryudersedion benuide. ?'15me Secretuy eowrecyoilieinionneion.m bytekingsudi guidance. moyidentify. (I) ms lorenWyeIsMio-enoti?edmder deiennlnetioancluaIgeIMenoedm ?nimmd ms oosessedonemnloyero. "48.qu shidyoondInedunduEdpuwth). toihe FlienoeendHeelhjd ms IN Secrewymel helm ondtmonlhebeois me?hme smydIheTroosIuy. MSJ'IessuIy ?The Secretory shell omenmoedueslarnoking oovonoe muonsonlhe unemploymembenefns. ms nIovido). Treasury andoorli?nue nonioinolon In onnlWeStoteheolIi subsidy programs. shoil ensure motionlndeusl oreBgible intenrollmerl Indore Stale mdertilie )0001? wdi Act. the (IIJmoy befiedoniine. hnenon. by moll.or subeioy pvogrems: end ('Iv)isstruoiured tomexinine an applicant's io oompleh thefom setisieantily. tuting inio memomionshos We ms AGREEMENTS ?Sib]eol to section 1411 ond section 6103(lle)oi he RevenueCode 011988 and any other and enier'nioegveemenu. data ueediottheelewonic vedfnat?nmnie rmhewtie otherwie midiedond contents. mar fudala mm and other costs ond no value oidolo molding io ond undoi?ng forepniomle Skis hedh subsidy mm this section. lncluang their-notions entiuos?. 1 taxable year, WIS HHS--J une 2017--00042 Sec 1502 Sec. 1502 Sec. 1502 Sec. 1513 See 1513 See. 1513 Sec. 1513 Sec. 1513 Sec. 1514 SOC. 1514 Sec 1514 Sec. 1552 Sec 1567 Sec. 1561 SOC. 1561 See. 1561 See. 1561 Sec. 1561 IN who provides minimum essent'nt mist-agate 'I'Ierdud during a Myer shall. at may FORM AND MAMEROFRETURNP GENERAL?AmmIsdeecmedln this subsectionltsuch retum-? (A) presets.? (l)whelhercrnetlhe end CereAct. end '(Il)ln the case heelth plan. theanounl (lsnyiotsny sovmoepsymenl ms INFORMATION RELATING TO EMPLOYER-PROVIDED mlnr'mun assent-II coverage provided to an address. and erminyer bepaldoyhieemployer. snd? o?uedhoughmExchenge. HIS shslorsmsuohreolallons. rules. l-I-IS.stor rules. regulations. orguioenoelorthe HIS 11W FOR Secretary may prov's?ta for the payment at any assessable payment by this section on an annual, or other penodlc es the Secretary may ms wages? reducedby section). His. Labor M?timeemployees insubsectionai). snd? ?(2)oontsins? sndemployerioe Hmhcetionmmot employer. theopportuityloseenroll? emerge mdertheptan ms WITH OTIER may prmidethat? 6066. ms this Act). ms Secretary may premiums regulations to implement sealon, His standards Federalsnd Stale WHOOS. ?The Secretary shall enrotnent In such programs Worm methods determined memorials by the Secretay. ?bysucn' 'mdthee netifmtion eteii?ility aid wiimien deigibity Wed Ilidar?sudi me. His ends?mexlsting.hd1nology systemsto snd.? (ss deeobertln ELIGRE political ubdiv'eionetasma. in Includes?1 ) In tsot ,syslems; systems and ssrneState orlecellty: teoMologyln ms HHS--J une 2017--00043 Sec. 1561 Sec.2002 See 2101 Seem Sec. 2401 Sec. 2401 50(12402 Sec. 2501 Sec. 2501 Sec.2602 Sec.2602 See. 2701 Sec. 2701 Sec. 2701 Sec. 2701 WM). Committee lfiheSteteheseiectedtheophon State may elect to prwdee WW period (as deihed subsedion lo! who are elolbie tor medlcel assistance under clause (iXVIlI)oi subsection (ex10XA) or sec?on 1931 In the same nuns! es the State sh? establish} i-I-iS STATE 1902(e)oimeSocIel Security Act (420.50 as amendedoy subsection Is inserting". md?: md(C)by 'nsertingdierpaw?? beg?nning mnberoienroledmdnewtyemied pm. nonpregnni ms TRANSITION PLANNING AND OVERSIGHT. ..TheSecretery eiigibIlty threshoids goeshcomeend househoidirmme. will elig'ble for and: assistance. i-I-iS YEAR 2010 ALLOTILENTS FOR CHANGES INPROECTEDSPENDING FOR CERTAN PREVIOUSLY APPROVED EXPANSION purposes 01 receicutem the iiscel year line. ms determining unduthe pres-mun periodJnihe some es Slate options 1920. ms otihe iorrnentd" oran' camlacilityfor thementelly retarded. ms 2013 i-I'iS Iehr than??(i0 Mr 31. 2015. the Secreter shall submit to Congess and make evaluate to the PROJECTION OF NMER 0F 10 BE PROVIDED HOME AND StatesubmitstotheSecreury. hsucnionnendmenner. ms iambebpenodsbewning onoreiieremery?l. 2010. ms ms REPORTM?TheSecretaryshel ubmittoCongreesmmeiiepon endbeneiitstorwsleiigibleimis. ms 2010. the' i-I-iS DEVELOPMENT CAREOUALITYMEASURES FOR ADULTS ELIGBI.E FOR LNDER shell heuh queiity "Ieeulesmdersection 1139A. inducing with respecttoidentiiying exiting edil he?h beappio?etoMedia?d eii?aie acute. H-IS STANDARDIZED in consulationwih States. shu man are iorMedou'd eligible adults. REPORTS Iaterihan Jauary 1. 2014. and avery3 years ii'iereafhr. iheSeaetary shall 'ndude required underthet section. Meesurementhgemintheseme View mdvalidee'onoiemergingend Seam forgrents undersection 11mm?) ms HHS--J une 2017--00044 Sec. 2701 Sec. 2701 Sec. 2702 Sec. 2702 See. 2703 See. 2706 Sec. 2703 Sec. 2704 Sec. 2704 Sec. 2704 SOC. 2705 Sec. 2705 See. 2705 See 2706 REVISING. AND IMPROVNG OORE WASURES. ?8eg?mln9 not Her men 24 months Medcs'd mdannudyheredier. me Ihall re?ecltheresuitedlhe tesdng. valuation. and consensus process Ior the developmenl cl adul heelh quality measures. PlBUCATm.?Nollder celled. analyze,? i-I-lS HSeaelary'Hhal IderIinwnerIlSlalepraelices lhalprohlbil payrnerllorhethcereacqulred ccndilionsandshel incorporaielhe predicesidenli?ed oreiemenlsol suchpraciices.whidi Medicaid man in regulm Such regulations shall bee?eelive as olJuIy 1. 2011. and shell prohibit payment: to payment for heelh core-acquired conditions shall nol reed! In a loss deccees to are or services brMedlceld bene?ciaries WDICARE PROVISIONS. ?lrI carryingculmls section. the Secretary bymeSecreIary In such regulations. as wormiome Medicaid program. TheSecreIery-myexclwe certain HOME QUALIFICATION Secrelary ehal standards for Who as a WIS Meeco'on emergency roornvisils. lo skied nurshg lacillies. WIS EVALUATTON REPORT?NulusrmanJmuuy 1 2017. the Secretary shall evalumionand assessmenl com under saw (A). (2) SURVEY AM) INTERMREPORT IN mammary 1. 2014. I?eSeaelaryolHeuhendI-lumen Servicesshalwveysmesmel perineum?aimedmiseion roles; (ll) more: disease olcere Ior' chronic conditions: (Mama-en! oi impiemenialion: and leaned (as deecrbedn netbperegeph (Vi) assessment of quality iraovemenleuumlcal outcomes mdersuch option: and (vi)esl?lnelesofcoelsevl i-l'lS ASiale benellclanes. oene?c-erieemh panicular aagnoses. orpanioaar geogaohic regions ol the Slate buIIheSecreIary shellinsurelhateseM'Iole lhedenmnlionpmjeclis. lobegreeleslextenlposedii e.represerlaliveol ngeogreplic composition olMedicaid bene?ciaries nationally. mandamus-alien projed. PMS demonstraeon propel. Slates shal ensure Vial Medicaid berIefbianesarsnol liablelorany additional eosl DATA?EachSIaleselectedlo sectionshallprovidelome mderswsectiombxis). WAIVER OF sedion 1115(a) of he Soc?al Security Act (42 use. 1315(ai). lhe XIXXVII. and Xlo?helAcl eerneybeneceuaryloeccanplieh thegode cl Ina demraiion. ensure bene?ciary access to acule and post-acute care. and maintain quality a care. WIS shell. in Secully Ael. esaddedbysecnonml clIhIs Acl). Demonslaeon Propel mderMIIchepmlcipadm Stale shall equal the peymenlsmadelomeeglbie salely nel hospital syslemor agiobdcap?edpaymenimodel ?scal years 2010 MM 2012. TheSecreIary snel select In PW my,mlneSecrelary'sOserelIon Seaela'y' )shall Demalion ijealoalmmepedieipemg SIaIehoaliow organ?zallonlu purposesolreceivhgimenlive payments (as described mdersubseclion (til). '11 lhesanemrasanacoounuble mommizelionie 1&99diheSodalSeairllyAeltaa addedbysecnon3022). HHS--J une 2017--00045 Sec 2706 Sec. 27% Sec. 2707 Sec. 2707 Sec. 2707 Sec. 2707 See. 2707 Sec. 2707 Sec. 2707 SOC. 2951 Sec. 2951 See, 2951 Sec29$i State that deem to parti?me in the demenstrea'en project unda this section ehal submit to the Secretary an application at such time. In such manner. and eenteInIng such Narration as the Secretary may reeulre IW meetstheperiormaneegride?nee DEMONSTRATIGI Secretary el HealtiandHumanServicastln thla seatenrelerredloaslhe desabedrntubtectien (c))snelprovrdepaymenlmderthe State MedIceIdplenmdertItleMdIhe Social Security bothevenotattainedegess; mdersuchplan; and(3)raqure mediceleondition. In selecting State appscetiens tor the demonstration protect. the Secretary shall seek to achieve an appropriate national balance in he geegaptric dietrbmion if such projeda. State seett'mg to partlc?oate In the demonstration project mderthis section shall submit to the Secretary. at such time and In such tormat as the Secretary requires. an applcetlon that Includes such provident and atwrancet. as lhe Secretary may require. TO Secretary sheII pay to eech enable State. lrom n: ?ow under paragraph an amount each quarter equal to the Federal rnedIceI assistance peroentage oI expendituet 'n the grader Ior medical aaer'etnnce described it uheection As a coalition of readying payment a State ah? collect and report inert-ration. lerthepurpeaeedprovidng under tubsechon IN Secretary Ital velvet?! Imitation oteubdvlaien (B) blowing paw (28) 0' section 1MB) 0! the Social Security Act (42 U.S.C. 1396mm) (relat?ng to mutations on payments ler care or services ler Individuals under65yeare damMmpatients it an institution lermentd ofcerrying euthe demenetrelon prqea under this section. LIMITED WANER Secretary may me other requirements 0! titles Xtand )thot the Social Secuity Act (hcluding the requirements of sections 1902(a)(1) (relating to stalewidenest) and (reIating to MIN-MTG MAKE theSeeretery shall make eIlghIe entItIes to enaete theentliesto heme visitatirm school and the status etsuch and reductions abuse. neglect. and injuries. GRANT Secretary shal determrne the period at years a grant is nude to an etlgIbIe entity under paragraph (1). Secretary anal provide en ?la entity that receives a grant under paragraph (1) win lemtcal astIslance ln edrnIniuerIno programs or activities conduued in We or In pert with grant funds. mel providemeip?bleentity mderdauee (ii)withtedinical plan. assIstehce elewy er hreum gents. contracts. oreewerahve agreements. regardingthe ted'Inch assistance providedte entities in aeoerdancewith updates (I). NO IMPROVEMENT ORFALURE TOSUBMT Secretary deterniiesattera period ottime speciled bytheSecretarythat an eli?ila entity irwlernentingminprovement memended tonaprt?orgaizatient unawbmen CRITERIA FOR EVIDENCE OF EFFECTIVENESS OF Secretary the! establish criteria lerevldenee ct ellecttveness ensure that the process Ihecrlterte is Went and dthe eenmae needs assessments submitted Inder suesectIen and the grants made mder subsection": and (nxaxel. HHS--J une 2017--00046 Sec.2952 Seem-353 Sec29$3 Secretary shel some that the MaIemat and Child Heel: Bursar and the Administration and Famlies celaberatewtti reaped to out this section. incluaig with respect INDIAN TRIBES. TRIBAL ORGANIZATIONS. 0R URBAN INDIAN Secretary shal spedty Such requirements shall. tothegreetestexterit practicecle. requirements TIMOIganizntion Orwizmiorito. agrantmderthissection. theSecretarymeyuse Mia The Secretary shal spectty lie reowements la such crganizaeen to apply terand conduct the pregam which shall. to shall reap-e the organization herease aboutthe' and othernevtseing designs to the maximum extent Ieashle TheSecratary may carry out such activities directty. or through grants shaleriwcthet?' undipregramerpteject section shalubmitanappicationb insuch Including commiiniiea required under subsection (dx3XAithetIIe '(4JAstatementidentity'ng Secretary shal ensue ?at??(i0 the conduct at me: me maiden activities includes consultationwith iidependentreseumets. Sineo?idais. topics inclu?ig research design and mm dam matching. REPORT AND later than December 31. 2015. the Secretary shall submit a report to Corigressragsniigthe ?ierepottmieduiderttispuagaph shell inctuee? litcnnatlon reguorig he extent to which eligible entities grants under this sectIen tedtnical assistance provided indet- subsection inclutiig the type of any such assistance provided: aid recerrl'neridationa breach icgietahve ?We action as he determi'leea the erneunt appropriated uIderthIs subsection fer a ?scal year. the Secretary shall reserve? "(Al 3 percent at such amount br purposes at making wants to ellgete entities that are Inaari Trbes (or a consortium ct Imb't Tribes). Trbal Orgmizations. or Urban Indian Organizations; and 3 percent at such amount tor pu?poses 0t cmy'ng om subeections and (mm CERTAIN ACTIVITES. the extent Wle us! was the Seaetary shall ensure thu projects hided undermeection TheSecretary niayallowsum preieas to inciudelieblcwing: Deliva'lgerentmaigoubatientand home?baeedhe?h andsuppertaervices. including case mmagernent and cerwrehensve treatment servtcee Detivemg or Iipatient care the quality. avelleblty. aid erganr?zah?cn of health care and support services (incliaig tranuicrtahen serv-ces. Secretary shal estmtish reunions tor made under this section that include a limit on the amountotgrune may be used foraItn'eIistIatiorI. account'ng. andarequmementtereach loreechgrantperied. areporttotheSecretary Ihatdesu'bes howgantlundsmused Ian'ngsuch period. Secretary may pruride tedinical enhance to entities seeking a gent wider the section In order to assist such eritlies in certiptyino with the requirements at this section. PROGRAMS. ?Totheextent theSecretary may integrate the induti'lgthepregununder theSecretarymay Megrentsto eligible entities tor projects for the establishment. operation aid coordinationot etiective md cost-ef?cient systems hr the delivery of essential services to indvidude ash or at risk for postpartum condone aid the! families. condtiona. IN pupae described it attraction subject to the ?weeding provision: at this section. tor eppicettonotsucsection and ?(til the State yeah populeson percemge oeterminedmderperwa). PRO RATA Secratuy ahal adjuston a proratabesis the arnouritot the State allotments HHS--J une 2017--00047 .3001 IN Secretary shal solicit in each ot?soal years 2012. 2013. and 2014to local organizanonsendentitieeto conduct oons'ntentwithuanaection progmiaand activates In States utdilormdionandrepatingonotmm estheSecreteryahelspedty. GRANTS TO MEMENTIMIOVATIVE STRATEGES. (Dionne youthr and servheetohigh-nsk. M.mdoultur?y mder-represeraedyouth populanons. intangyorm In Instance homeleesyouth. youthwih pregnant wornonwhoaremdeth GRANTS FOR 1 in WW. RESERVATION OF Furies?me Secretary shall reserve to percent of such reminder for expendlues by the Secretary tor the activities described in clauses (ii) and paragraph research trump andted'rnicalesaiatance. i'Idudingdisaernitanonol madame praalcos. strategies. lndudlng mdother State. libel andoommu'tity In cany'l'tgorasuch tunaionaJhe lnthe otteen Hde sexualytrensm'ttodlntectlons. ?nma?aliteracy. allotments or grants under this secnon. IN Secretary shal amtinisier this section mm the Assistant Secretary for the Mn?mistration tor Diamond Fertilieswithinthe DQartmentott-le?iend HImmServicee. subsectionthe payments under, (altorlho INDEPENDENT purposes at the umber: uider swolausos (Ill) and (IV) of muse the Secretary shat have conducted an hdependent oi mat rumors are appropriate IN Secretary shal select muse torpurposee oflhe Progem. Soar measures shall be salaried from the measures spouted raider sIosoctton cssoota hospital that Is pardmdersedlon 1e1qu3). the Secretary may exempt sum hosprtal Secretxydeecrib?mghoweeimilar ediievesorsurpesees the unsealed resutts In terms otpetlent hedh outcomes andcost under this subsection. TILE Secretary may notselecte measure under paragraph measure has boonspeci?od under subsection onthe Hospital (A)ln atmoondlhetollontngeentenoe: "TheSocrolary may requirehospitalslosubmitdata onmeaaureethatuanotusedior thedatenn?l'laimof Winomivepaymenhu?aa . WANER Secretary may wave such requirermts Xlend XVI otlhe Sooel Security Act as programmderthis FOR FISCAL YEAR 2013.?For mound incentive payments made with respect to Gschages conning du?ng ?scd year 2013. the Secretary site! we the tellrm'ng: OMITIONS OR are selected under amperegreptt (A) that ooverat least the following 5 specific or We: "(eat Acme myooadlal l'tfm (AMI) ?(obj Heartiarre.? (oc)Pneu'noria' ?(dd)Surgeries. as Prefect (tomtertyretaned as Surg'icel IrIfeaion Prevention? beheJuly 2006) as bytho leloProvontt? (any HHS--J une 2017--00048 .3001 ,3001 3001 OF EFFICIENCY LEASURES. ?For inoenlve payments made with reaped Io diadlergee opening during ?scal year_ 2014 or Muenl heed year. the Secretary shall unsure than measures eeleded wider arbpaegraph (A)ind including spenaig per bene?dary' Such sex race aever'lyotineae delermlnes appropriate. Sea-etary liall establish peribmu'Iee eta-dude wilh reapect to males selected um underpaagaahun. CONSIDERATIONS ESTABLISHING In esleblahhg pe?crmanoe standards mm respeol lo under this paw. the Seaetay ahd tire imp apprertiete fem. such as? preaical perm-mane mm during previous penormmoe perlods. historical pertormenoe slendarus. lmprovemem rates: aid Try) the opportuniy brcorlimed immvernmt. PERFORMANCE PERIOD ?Forpurpoeesolrhe Program ?Secretary shellesiabeshmeperformaru periodlora fecalyea POSPITALPERFORMANCESCOREF perm-mace smmw?mespecrtome rrIethodeIogy. theSeaetayal? provideleraneasewnenttinmia wheeotiwrderredtoasme 'hoepits APPROPRIATE DISTRBUTION ?The Secretary shall eneurethat the niehodology developed meet pertamam scores largest vane-headlamp!? payments. NO PERFORMANCE Secretary shall not set a minimum performance etandad ii hoepeel. "new IheSecretaryehal amount (as de?ned lnpaagaphUxD? as paragraph(7)(8)(i) forehoepiallaeechdach REQUIREMENTS. ?In speaiylng the valuebaeed mauve paymenl percentage breach hospol fora fiscal year under the value-heaadhpentive paymentamdethisparagraphIoall MG paymemarrmmadefnedhaubpaagrqah fueudi?ecelyeaJ'heSeoratary peregrepMGHorsuehIIscelyea. AMOUNCBBIT OF NET RESULT OF Under the Program. Ihe Secretay shall. not later Ihar 80 days priorIothe?acai yeainvmed. In such fiscal year under persuade (6) and (max!) underlhe?opram. Ipihehospilai; Ihehoepital. OPPORTUNITY TO REVIEW AND SM Secretary shal ensure the! a hospital has me muae priorIo audi infer-mama behg made public. AGGREGATE NFORMATION ?The Secrelayshel penodlcally poslon Ihe WCompaemmbene ena' '6)th APPEALS. ?The Seaelary shell estabish a process by Mich howitals may eppeu the calculation 0! a hospIIaI?s perfunuiee wm reaped Iothe performance standarm eetd?iahed mder pang-um (SKA) aid Ihe hoepiu pHrformsoore ?warmth eppeus In a "may manor OMSULTATION WITH SMALL Seam aliel ooneull with emu rural and urban hoepiIaIs on the appecatlon the Program to such hospeaIs HHS--J une 2017--00049 .3001 PROMLGATION OF REGULATIONS ?The Secretary stall regulations to carry out the Program including hospieipaiormanceeccres. Unmarried-choiogy under 98W 001'0 the extent practicable. the Seaetery shell. wen Input lrom consensus 0mm aid other stakeholders. qudity meesIm woliai?e to? physiu?ans Indy section 184800: md aha pruviders otseI'vices md nappliere unethis title. ?mrl'heSeaetarysh?l clause es apprew'me. Such such as hospitals. patients. waters. seek stakeholders-I madly mm Io i-Iaviduas accessing it". undersecncn Such REPORT.?NotleterlthaeIuy1. 2016. (A) togetherwsh rewnrnendetionsioreudI Iegsletion and administrative actIon as the Secretary deierrmies A: theSecreteryoti-IeelhendHumen Services (In this subsection retened to es the ?Secretary") she! estebIIsh a demonstration program under which the Seculty Act mess hospitals (as defined In Induction 1361(mm1dsudI Act (42 U.S.C. with respect to inpatient cn?csl access hospital services (as dehed ?n paragraph (2)01 such section) In hoepdds. SITES. ?The Secretary shal conduct the demonsueeon progem under this peregepn at an mm (as deterniied bythe Secretay) at critical access hospitals. The Secretary shall ensue that such hospitals are BLDGETIEUTRALITYREQL theSeaetary Iaterthm 18 months a?ertheconvietion demonstration progmn underthis paragraph.? Secreta'yshel progrn accesehospitale with respect to Inpatient cancel access hoop-ts seMces; oherlegeletlonand admlnistrative action as the Secretary deterniies mpropr'nte. IN later Iran 2 years afar the date denaament otthle Act. the Secretary shall establish demonstreeon prewar? under the Secretary establishes a value-based purchasing man under the Medlcere mdertitle Social SecuityAct tor wpiceblehospitals (as de?ed-1 clause (ii))with respects) inpatient heap-'18 services (as de?ned In section ollhe Social Sewrly Act U. S. C. In orderto test INTEGRATIONOF PHYSICIAN QUALITY REPORTNGANDEI-R REPORTING?NoumerthenJannry 1. 2012.1he Secretary shall provide timer teem to eligible profewonds on the pedumance 01 the eligible preleesiomlmh respeatc INFORMAL APPEALS PROCESS ?The Seaetaryshell. by not hterthen Jemery1. 2011. est-blah end haveln phce Maw sibmit data qu?y measures unda? this REPORTS ON RESOURCES. ?The Secretary she! use claims due urns this title (aid may me other we) to provide con?deniel reports to physic'nns (end. as determined Web by he Secretary. to groups oi physia'ens) that IN GEIERAL. Secretary she! developmepisodegroupermet curbines separate but dInIcelly related Items and asepproprlete PLBLIC Secretary shell make the detais the ep'eode grower deeabed In ?pew (A) am to the public. HHS--J une 2017--00050 Secretary shall seek endorsement of the episode grouse described it subpaegrqih (A) by the wit! a control: under section 1890M REPORTS ON unuzmon 4m with 2012. the Secretary shal amide reports lo that corrmare 3%me patterns of other physicists. ANALYSIS OF Secretary shd, for purposes of preparing reports unrhr this M. estabish methodologies? W. suchasto?' '(I)attnoule epeodesotcsre. InMIclecrInpen. to physicians: appreprbh physicians for purposes at corrpenson Inder subpaagmh and moguls episodes care attributedtoaphysiusn mderclatee (I)htoacornposite measure perndividuel. DATA prepa'ng reports mda the m. the Seaetn'y shall make appropriate adustments. Includlno adjustments? to account lor ?forums In socloeccnornic and mm characteristics. and healh status at Indviduals (such as to recognlze that less heetthy Inaviduds may require more mm W), aid to airtime the etbct of geogwhic adjustments it payment rates (as deeabed in wheedion (an. MLIC AVAILABILITY OF METHODOLOGY. ?The Secretary sha make to the pubic? the methodologiesestebishedu ?(-0me adjustmentsmadetodahmder amperageph erd' aggregw reports respect to physicians. DEFINITION OF PHYSICIAN. ?In this peregeph: GENERAL ?The term 'physIcIan' has the given that term In section (I) VALUE-BASED PURCHASNG Secretary shal coordinate the Prevent with the veIua-baed payment modi?er established under ?section and. as the Sscretay appropriate. other sirnlar provisions cl this tItIe.". Intne reepedtosudiareteyel. mymual (3). shalbe reduced by 2 percentage points. peymentsmomtundetlis TILE later than October 1. 2012. the Secretary shall ptblish the hassles selected under abparegrephthatwl beappicailewith reepectloreleyear2014. MLIC AVAILABILITY OF DATA SUBMITTED Secretary shall establish (C)eveil?itetothepublic IN puposes year 2014 mdeech subsequent fecal year. In the case ole rehabitatton facility delenninlng lie increase tectadescribed in paragraph (3X6). and a?er'sppticeticnotparegreph (SXDJ. the Secretary TILE FRAME?Notlebrthanoaober I. 2012. the Seaetaryahall ptb?shthe msulected underthie TILE lebr than October 1. 2012. the Secretary shall ptblish the nreastires selected under this DOW MLIC AVAILABIUTY OF DATA SUBMITTED. ?The Seaetary shall establish procedures for data In section dale belng made pupils The Secretary site! report quallty "we: 0! procese. structure. outcome. penents? website otthe Centers for Medicare Medicaid Services.". mayspecll?yameesuelhatls endorsedoradopted Smy' )shall undartitle section 1819(a)olsuchAct (42U..SC 13966-3tam. underperagephm. theSecretary shaloore-outmtotlowtng Issues (A)The selection. aidmodlhcetion 18900Ithe Socid practicable. 2017--00051 ,3007 dmta the plat inder mh (1). the Seuetary chali? (A) consult with vetevant alleaed pettiee; aid (B) consider experience wih euch demonaratione ?at the Secretary determine: an inlay-mt to the vehe- baeed puchaeingp-wamdaecrtbedm peregraphtt) otthe Social Security Act torhome heuh agendas (as dethed in Act (42 U.S.C. 139mm? devaioping the plan under patagaph (1 the Secretaty ehal coneidat the following Issues: (A) The onoo'nodevelopmem. eelectlon.andmodllicetlon 18900100 Social predicable. (18! dimensions dquelity and ef?ciency in home healh agencies. (8)1'havepontn9. colection. and vddatton 01 quality data. (C) The structure at value-based payment adjustments. including the determination ot payments,? devetqa?ng the plan mdar (1). the eludi? (A) consult With iateyant at'leded parties; and (B) ooneldev ?penance With such commutation: tint the Secretary determines are veievani to the wane- based piadiaeing piooramdeeaibed in paragraph (1). IN GEIERAL. ??l'ha Secretai'y Ital eetetiIieh a payment moditiar that providaelordiflerantial payment to a physician or a gtoupol physicians underthe lee schedule establehed under subsection based upon the wally olcere Itan'ahed ,w (2)and(3). Such payment modifier and be separate from the geog'aphicam under eubeaction Such ot pumph (1). costs shall be evaluated. to the extent practicable. based on a ot appvopmte measureeotcoets eetablehed bythe Secretary(euch mdareibeecticn that eliminate the et'lea oi geogi'whic eduetmenta In payment rain (as andtakantoewouitneklactora diaractedshce. ethnicity no health status 01 (such as to reoomlae that lees healthy may require MICATION OF MEASURES. DATES OF IMPLEMENTATION. PERFORMANCE later than Jamary 1. 2012. the Secretary ehal ptblieh the lolow'ng: The ctqu?y ulcers and coats eetabl'shad under pareg?aphe (2) and (3). weatvely. The dates for implementatlon ot the payment moatler (as determhed under mm "(in The initial patient-lance penod (as speci?ed wider subpaeoraph (Bxlm. INITIAL .?Stbjact to the preceding piovia?one 0! this etbpatagraph. the Sectetary ehal imlementing the payment mot?areetmtlehed mderthis Situation though the ding 2013 for the physician lee schemle established under subsection IN Secretary dial epady an iniial pai'lotrnance period for appication ot the payment mod'rfu established indent-e with respect to 2015. PERFORMANCE the Secretary shd. to he extent practlceble. caeltmhedby deietniiedunderpamunmm Secretaiy ah? apply the payment modi?eteetabihed undathia eeMoeetinuehed??(nbegimmJatwy 1. 2015.Mhreepactio epedlc 1. 2017.wlhreepectlo al and SYSTEMS-BASED Secretary shall. as appvoprtaie. appty the payment media established under this ubeection in a manner that pvottiotee systems-based can. purposes of the initial ol he payment modi?er under this eubeection during proleseimaie (as de?ned In as the determines appropriate. COSTS?TheIeIm'coete? Whylie Inmak'ng the HHS--J une 2017--00052 .3011 .3011 3011 3011 .3011 .3011 3011 DONSDERATION OF SPECIAL CIRCUMSTANCES OF CERTAN PROVIDERS. ?In apply-In the payment rriodilier underthis subsection. the Seaetary stall as appropriate. take into account he specid circumstances of physicians or groups of physicians in rural areas and oIieruI-Iderserved communities. COORDINATKW WITH OTI-ER VALUE-BASED PURCHASNG REFORMS. ?The Secretary shal coordinate the value- baeed payment modi?er ostabhhed unda this subsection with the Physidan Feediack Progam mder std-reaction and. as the Secretary appropriate. other similar minions of this titie. RISK carrying out clause the Seaetery shell estabish and appry an appropriate risk edustment methodology. REPORTNG TO to ?scal year 2015 and each sincequent fiscal year. the Secretary shall armada confdeneal reports to mplicable hospitals wIth respect to hosplal soured conations or the ?pliable taspltal during the amicable period. IN ?1'he Secretary shal make nlurnation avenue to the public regadlng hospital acquired conditions at each appicebie hospital. TO REVIEW AND CORRECTIONS. ?The Secretn'y ahal enm that mpiicabie homitai hastiaopportmitytoreview. under stomach (A) prior to such Inlormaeon being made ptalic condiions policy under subsection of section 1866 of the Socid Security Act (42 0.5.0. 1395ww)to payments node to other iacitties wider theM eccereprogram raider title ot the Social Security Act. Including such payments tirade to 'ltpdiem rehdiilitatitm tadities. lam-term care hospitals [as desalted In at such sedan) hoep'dai outpatient depa'tments. I'll other hospitals enarded fun he inpatient prospea've system under such section. sk?led nursing facilities. ambulatory surycel centers. and health clinics. Such study shall inciude an aneiys'a cl how such policies could impact quality 01 pelent care. patient safety. and spenang wider the Medicue the case of a hospital that is paid Inder section 1814(bx3). the Secretary may exempt such hospital Secretay describ'ng hawe similar progem'n theState tore perticaeing hospitdarhoepiteh echievesor surpasses themeesued reams interrnaotpatienthedh mandcostsav?ngsestabhhed undermia subsection. later Iran January 1. 2012. the Secretary shal submit to Congress a report containing the results ot the study conducted under paw (1). together wih recemnendations tor such Ieg?sistion and administrative action as the Secretary deannines wooden. NATIONAL STRATEGY Secretary. ttrrorrgh a moment celeb-creme pm. shall euaclish a national strategy patienthealthoutcomes. andpopustionheaith. IN Secretary shel Identity naeonal priorities for Irvovement In developing the strategy mder paragraph (1) Secretary shal erisiaa that priorities identi?ed raider subpaaymh (A) wi?' rave the ?andw ctheeitrmiore populations. Including children and vulnerable popuabonsr Identity areas In the delvery at health care services that '(ii)addressgepsin quality. ef?ciency comparative etfedivaiese irttorrmtion.and health outcomes meantime and data aggregation ted-niquee: quality. elliciency. iraisparency. and outcomes; adttess the heelh care prwided to patients with high-cost chonic ideni'iying priorities Inder amperagraph (A). the Seaetary shai take into consideration the recorrlnendetions subriv?tied bytheentitywift econuectuaersedion1890(a)ofthe Sodai SecurityAct andother stakeholders. WITH STATE Secretary shall collaborate. coordhete. aid consult with State agendes responsible for adrrIIrIstering the Medicaid program under title the Sooai Security Act and the Children's Health Insurance Pagan under title )OOdsuch Act with respect to developing and disseminating stra)tegies. gods. models and timetables that are comment with the neionel priorities identi?ed was eubperquA) PERIODIC UPDATE OF NATIONAL Secretary update the naeonal strategy not less than annually. Any such upt?a shal Made a review dshort- and Iona-term goals. DEADLINE FOR MIAL SUBMISSION OF NATIONAL STRATEGY ?Not later than January 1. 2011 the Secretary shall submri stbsedron IN Secretary relevant oommitieesolCong?essan annuumteiohestrategy deedbed in paw SUBMITTED. ?Eedi upate submitted under ubperegeph (A) shell '(ii)an crladtotprogess. hfct'n?imreputadundasection I139AottheSoa?aiSemrityAct. section;end 201-1 thentormationreported mdersectlon 11mx4iclthe Social Security Act. rear-omens clsuch section. CARE QUALITY WEBSITE. ?Not later that Jeremy 1. 2011. the Secretary she! create an lntemet websitetomairepubiic intormationregrd'ng? ?[1)the estwlished Inder stbsecticn the agency-speci?c strategc puns ior hem care qudty described It subsection and char iniorrnaeon. as the Secretary determines to be appropriate". HHS--J une 2017--00053 3013 .3013 . 3013 . 3013 .3013 . 3013 . 3013 . 3014 3014 . 3014 . 3014 3014 3014 . 3014 . 3014 .3014 3014 3015 Secretary. in corisuiation with the Director at the Agency for Heatiicere Research and Quality Medicaid Services. ahalidentity. notieaa otlanthantrtennlaly. gaps where no cushy measures exist and existing oIIatIy measures that need improvement. updating or emanelon. consistent with the national strategy under section 3991M. to the extent "we. Ior use in Fedora health programs. it int: conaderetion?' the gaps Identltied by lie entity with a contract mdersectiori1890(a)ottne Social Security Act and other stakenoiders: cueiey measures identiled by the pedatric quality measures program wider section 1139A underperegreph (1Jendtiieprocees usedhomakesuchideritiicatton. IN ??l'he Secretary shal mdgrents. comrade. or 'liurgovemmentd eweernenu to eig'bie entities tor imprwing. wdatng. aexpanr?ig qudi?lymeaetresidentied unda subseaion (bJ. ELIGBLE subsection. mentity emit? '(A)hava ?r and otqudlty "(Elma-doctor! perfomuicewill be assessed bytha meesue; and ?Watcher parties use thequaity measures (sum as petients.consumers.endhedhcere andtest. Mereepplicebie. Secu-ityActcradoptedbyihe Secretary. ga..nucontrecuoregreenienu assessment oi? (AJheeilhoutcornesdeunceor-Iel status otpetients sett'nge. and he?h the experience. quality. aid me provided to and used by patients. OF Secretary shall me that gents orcontreda ended sedion are coordinated with grants and connects waded under sections and 1139(4xA) otlhe Social Security Act". MULTISTAKB-IOLDER GROUP SecretaI-yshelastabliaha descrbedlnsection 1890(bx7x8): 1390mm. 1890mellconveriem MLIC AVAILABILITY OF MEASURES CONSIDERED FOR luer man Deoembert at each year 1890(bx7xB) the! the Secretary is consider-i9 mder this titte. OF Secretary she! take into consideration the input from mlbetakehctder goupe deserted in pareg'epn in seleaing quaity nieasuree deserted ?n aadion that t890aridmeasures Ihatmnotbeenendorsedby sudi entity. RATIONALE FOR USE OF Semiary shell puttish ii the Federal Register the rationde lertheuseotarry qualityneesuedesaibed in section thIbJUXBHhat a contract under section 1890. ASSESSMENT OF later than Mandi 1. 2012. and at least once my three years thereatier. the Secretary shal? conduct an assessment quality 'lnpect oi the use deridorsed measures described 'Ii section 1590mm); and make such assessment evelwle to the public. IN Secretary stial establish a process for disseminating quality meesues used by the Secretary. Sucii process shall include the toliowtng: The Incorporation ot such measures. Miere applicable. In workforce pregame. tru'iig curricula. and any other meme determined wrists by the Secretary. The dissemination 399HHofIie Paulie Health SeMos Act. the extent practicaue. the Secretary shal utize and expand existing disseriination mettiode in disseminating qudity wider the process estabisiied under peregmh (t IN Secretary diali? "(Al (bu In no case less otten than once every 3 years) renew quest) measures deserted In section and with respect to each such measure. determine whether to? maintain the use otauch m: or phase out sum measure. ?(A)seekto avoiddupiceticndmeasuresused: ?(B)takeinioconsiderationamnt ?n'mativem methodotogiesandsirategiestcr Secretay. Mister. 1395- mdlheFederal Supplementary MedicalbmueTrustFund undersection 1395i). in ?proportionaatha Seamdaterniiasqipmpria. years 2010nw?i2014 IN Secrawy vial colect aid 399mm consistent this on quality aid resource use measures from infatuation systems used to support health care emery to Implement the public reporting oi pe?onnence irdormetion. asdesuibed in purpoeeJ'heSecremU sh?erisuethat sum collection. aggregation. and analyse systems spat an maeesingy broad wigs ot populations. providers. and mu areas over tine HHS--J une 2017--00054 3015 .3015 . 3015 . 3015 .3015 . 3015 . 3021 . 3021 3021 . 3021 3021 3021 . 3021 3021 3021 ,3022 3022 IN Secrewy may Md gents or contracts to sii?le entities to new. or inprave existing. eflorts to called and aggregate quality and resource use measures described wider subsection DATA AGGREGATION ?T'he Secretary may ewerdgrentsorcontrects Inderthis section only to entities TheSecreterysh amide sealantoen entity uniesstheentity latyevelueted. equeirnent. arservices DEVELOPMENT OF PERFORMANCE WEBSITES ?The Secrewy moire to the public. Mum slanderdizedhtunetm. SualI'I'Ifa'rrIetionshel physiciansmd other patients. policymakers. States. and other stakeholders. as the Secretary may specify. section. lheSecretuyshal consultwiththe 1890(e)ofthe Social SecurityAct. asappropmte todatenmthetypeofhfornuionma is use? inlemet websitesdescriied in subseaion (a)uIdlorpmlic report?ngofodter qtnlity messues Secretary. XVllofIheSocieI SecurityAct. The expendituesmderthe eppicabletitiesmle lnselect?ng gvetopetereru quality. utde?b'encyd thenJquary?l.2011. outcomes or polenlisty avoidable expendtures. Themodets selected Inder lhepreceding sentence may included-Is Secretary shall not relate. as a condition brleeting a model mderparegrwh (1). that the sppicuile title. increasing quaity of care; or improve the quality of cue and reduce spendng. IN Secretary shal conduct an evwdon of each model tested under this subseaion. Such shall include an analysis of? the quality of care kimishsd under the model. includ'Ig the of patient- Ievai outcomes and petierIl-cenleramess cn'teria detarm'eed appropriate by the Secretam and the changes spendingunderthseppiicebie titles byreesonofthemodel. Secretary shal unite the results of each evution under this peregsph mlable to the Milt: In a timely taslianmdmayestablish memnblarStetesuIdoIherentities partic'ostingin thetestingafmadels undeI this section is models. REPORT TO in 2012. and not less than once every odIer year theredter. the Secretary shel section. Eachsuch ?I'Idud?ng the rurbsr 'nd'rviduais described ii ?section and of indvidt? dseabed in sunsection puticipat?ng in such models and payments made LlIder applicable titles torservices on behdfof such individuals my models chosen for expulsion Inder swsection and the results from under absection(b)(4). lned?an. eedisuchreportshelpravidesuch apprapr'ntsfar Ispietiveactiontofacilitetethe paymentmodsief'. EXPANSION OF MODELS (PHASE II). ?Tuung into accomt the evaluation Inter eubsedion the Seaetaryrnay through expend one is beinglesied uIdersubesdion 18666 toheextenl deurmined epprapr? by the Secretuy determine that such expuision is expeaed to? radios without reducingthe qualityofcue; or' ermine wally ofcore and reduce spendng: and he Chief Actuary of the Centers for Medicare 5 Medicaid Services certifies that such experision would reduce program spend'ng unduappimle titles. WAIVER Secremry may museum requirernentsafmles 1902mm). testing models deecrIbed'eIsubsectiontb). underpaItsAerIdB. and end brnighquetltyend ef?denteerviaedeivery. Undersudipragrsm?' mighan essn and lorshued IN Secretary shal delerrn'ne Web menus to assess Ihe quality at care furnished by the A00. such as measures at? diriicsl processes and outcomes; ?00 patient utd, where practicable. cuegtvu overtones of care: and "felt utllzation (such as rates of hospital sari-solute for amtwlalory cue senseivs condtlons). HHS--J une 2017--00055 302 .302 . 302 . 302 .3022 .302 .3023 . 302 3023 .302 3023 3023 .302 . 302 .302 .3023 3023 OUALITY PERFORMANCE Semiary shall estabiish quaity pertcruaicestuiderds to assess the ASSIGNMENT OF MEDICARE FEE-FORSERVICE BEIEFICIARIES TO ACOS. ?The Secretary shall deteruilne eppropr?n'lethod services [raided Inderthis title by on ACO protessimel deeubed in (hxtXAI isetlewthe percent nthe toeccountlornormdvar?uliouin expendituresmderthistitle. ?1'0le AVOIDANCE OF the Seaetary determines that en ACO has taken steps to am sanction on the A00. inciuriig term'nae'on km the progeru. star-darts Secretary under subsection FOR SHARED SAVINGS ?Subiectho pertuuruicewithrespecttothe malty perforuwtcestanderds DOW. IN Secretary shel eslauish a pilot pruguu Ior integrebd care du'ng an episode olcare provided to en eppicwe bene?r'uy Hunt Is hospitalization ordu to inuuve the coordination. qualiy. u'Id ef?u'ency dheelth cere servrces title. APPLICABLE term condition means 1 or more of 8 conditons selected by the Secretxy In selecting conditions under the preceding serItence. the Seaetery shall take ins) consideration the following factors: Includeamixofaironic endeale conditions. includeeruixctsuvlcelend is orrelorwhich here Is evloertceclm opportuitylor otserv-ces emeritus Inder the title.? Whether condition ha signi?cant vu'ne'on the umber otreedrn'nsions: and he emouit olexpendltures iorpost-ewte care spending under this title. "(v)Whether a corrosion is an: DEAELINE FOR Secretary shall esteoish the pilot proguu not later that Juulry 1. 2013. DEIERMNATION OF PATIENT ASSESSMENT NSTRULBIT. ?The Secretary shel deternine Mich patient assessment Instrument (such as the Continmy Assessment Recent and Evaluator: (CARE) toot) she! be used under the pilot prmu to evahete the condom clan eppsceole bene?ciary Iorpurposes oldetenninlng the ciary. IN Secretary. in coneuletion wih the Agency for Hedthcue and Quality and the entity with 1390(s)ottheSocrel SecorityAct. program? tor episodes oIcere; end ?(Iii tor post-scute cere suppliers lore perioddehmined sppropnetebythe Seaetary. tithe Secretary dehrruines that such title. We COORDINAW WITH QUALITY MEASURE DEVELOP- MENT AND ENDORSEIIGNT measures donelne nonnerthetis consistent with the measues developedend endorsed under section 18) air! 1890A that are appicuzle to dl poetecute we settings. ?The Secretary shall develop requirements torentlties to psnlopsle In the pilot proguu under this section. Such requirements shall ensure that applicable bene?ciaries haven adequate choice otprovtders ol semces u'Id wpius tnder the plat program. ESTABLISHLENT OF PAYMENT Seaetery shell devasp payment methom for the pilot progun for entities participating 'n the pilot prowem. Such payment methods may Include Dundee payments and bids from entitles forepisodesotcue. TheSecretary shell section. FOR POST- ACUTE CARE SERVICES AFTER THE EPISODE OF Secretuy sh? est?lish pieced-es. in theeplsodeotcere. underwhich IN GEMRAL ??l'he Secretsry ml marsh quality measures (mm quality meesues ol process. outcome. and preceding sentence she! indude rrieeuns of the following? Functional status Reducing rates of awe hospisl rescuisslons' Rates of to the commonlty. ?(Ivi Rates to an emergency room after a hospitalization. 1v) of heuh cue acquired ?vi at petient-centerechess ct cue. Measures of patient peroepe'on at care. Other measures. inducing meuues 01 patient oucorues. determined Wrists by the Secretary HHS--J une 2017--00056 3023 .3023 . 3023 . 3023 .3023 3023 3024 . 3024 3024 . 3024 . 3024 3024 3024 . 3024 . 3024 . 3024 3024 3024 SUBMISSION OF DATA THROUGH ELECTRONIC the extent preciiceble. the Secretary she! defned 'n eedian 3000(13Jalihe Paulie Health Savice Act (42 use 30(5- in manna epea'fied by the Secretary. INDEPEMJQIT EVALUATION ?The Secretary shall conduct an Independent evebellon oi the pilot program. Inclualg the extent to which the phi prwern hes?1A) Improved quality Mares esishuhed under subsection (cx4)(A) (B) harmed health outcamee: in'praved apph?ile bene?ciary access in (are: and radioed spewing under this FINAL ollhe pilotmam. CONSULTATION ?The Secretary she! consult with represenuiives cl smel rural hospitals. critical access hoepiiale (as de?ned seclion1861(m)(1)). regarding their particbal'an in the platpragram .Such consolation ehdl include consideration of mm methods of implementing buidled payments in hospitals deeabed Inhe sentence. lekng Irloconsldereiionenydl?iculles In pravidedby sum hoepitds. INGENERAL?Netlaiertharrhuaryt 2016 lhequaily olpetIerrt cereend reducng spendlrig title. IN GEIERAL. ?The Secretary she! conducladernonstraticn program section relerredlo as the demonstration heme?bmed end servrces underthismie toepplceeie beneficiaries (as defined In subsection 'ndependenceai progurL OF TARGET SPENDING LEVEL ?The Secretary shell esleblnh estimated mnuet spendng besis.$uchwendn9 mots shell Includes risk corridor that takes Into account nonnel Won in eioendtures lerIterns and services PATIENT ELECTION TO PARTICPATE. ?TheSecreixyeheIdetennineen approprhiemethad cleneuhgthat pray-an. ?The term ?phyeicien' includes. excepi es the Seactary may other-win pravide. any individual Irma mm physiciens' servrcesend heethernedrcei rcledeecrbed In WIAXIJ- NO PHYSICIAN DLPLICATION IN DEMONSTRATION PARTICI- Secretary shall not pay an hdependence at home medical practice under this section that pertic'peles in sedion 1399. NO DUPLICATION DEMONSTRATION Secretary shal erisue that no independenceaiharmmedical inthe pregame under section 1899. preclicesthetere? md?(CJ use electrorricmedicdrecords. healrinlermalienlechnaiogy. endind'rviduelizedpianealcere. LIMITATION ON NUKBER OF PRACTICES. ?in select-rig cradled Independence at home rnedlcal practices Io participate programme Secretary limit the numberolsuch preclicessolheihe number nalenceedmm IN Secretary shel evaluate each independence at home meacel practice mder lhe demonetnlicn 'n subsection (3). REPORTS Secretary shel conduct at 'ndependent evduelion oi the md ubmit to Congress a ?nal report handing best practices wider the demonstration repai shall include an analysis at the demonstration program on coordinelon oi core. expendilues wider its title. applicable berre?cruy eccessloservices epplcebiebene HHS--J une 2017--00057 3024 . 302? . 3025 . 3025 .3025 .3025 .3025 . 3025 305 .3025 3026 3026 .3026 . 3026 .3026 .3026 3026 MANDATORY TERMNATION. ?T'he Secretary shall an withan? or' duringenyyearoi the program. PERMISSIVE Seaetary may terminate ageentant with an hdependenee at rune medical preane for such other reasons determined wopriate by the Secretary". 2012. .the and (desalted in paragwh (3XA))hthe inspitel iorthe ?scal year. Iotwhich lavebeenidemiiedby theMeacereP no as by the Secreiryshal seckihcctIdorsemcrItdeecrbedin (Axtixubutmayappiy suchmeesimwithoutsuch mmSecreietyforumichs HOSPITALS PAID UNDER SECTION tam?in the case oi a hospeal that is pod 1814mm. the Secreixy deecrib?etg hows similar program it the State fore par?walng hoapitd or hospitals achieves or surpasses eec?on. OPPORTLNITYTOREVIEW MD suam CORRECTIONS. ?The Secreiay shel cneurethataswsection (dlhospite heaiheopporhn'tytoleview. endeubt'nitoorrmtelu. such itlormelon being piblic CALCULATIONOF Secretary ah! cdulate reedniseion rateebr? patients (ea defnedin ph (D))iors speci?ed hospital In applicabiccondibon (asdcfincd In paragraph and other by the Secretary iorcn period (as richer! in POSTING OF HOSPITAL SPECIFIC ALL READMISSION RATES. ?The Secremry she! make iniortmti'on on all patient readmission rates calcuated under ?pew (A) available on the CMS Hospital Cortipcrc website In a iotmand 2 years ailerthedateoienaarnentoithia section. the make Ma program ior eligible hospitals to hm Ihc?e readmission rates migh the use oi patient salary organizalons (as clothed in sediort 921(0). RISK Seaetery shall utilize wproprlale risk adjustment measures to delen'rine eii?le hospitals. ?03) REORT TO TI-E determined wrists by the Secretary. eligible hospitals and patient esieti hospdalto hm rcadttiission rates and the oi such processes on madness-on rates} IN Secretary ehel establish a Cornrnunity?aeed Care Tm Program utder which the Seaetery promos iunang to eiigbic entities that Amish care transition services to high-risk Mcaccrc bene?ciaries. SELECTION. ?itI selecting eligible cntibcs to partlopcte in the prewar". the Secretary shal we priority to cegbic entities that?(Amar?matcina ptogramadminisicred by IlIeAdriIistraiion onAw?IgioprovidecorwretItcate transitions inierventionewnh "edible hospitals? practitioners: or (B) provide services to medically undercuved popuabons. smal communities. and rural areas. may lolheexterttdeermlned Services that suchexpmsionwoud title wil'toutteduaigqudity Ihc ptogremsheli Secretary at mtirne. irIeudIrnanna. Irmsicr. chaai Hosplai Truu Find 1817 oilhc Sooel Scwrity Act (42 aIdIhchderaI Supplementary MedicalheirmceTrust Fund undersection 184101on?42 U.S.C. 1M). in d5500.000..000 tomeCmtusfor MmreaMedicaid any other provision at law. the Secretary may implement the prorisions oi this section by ptoyam Instruction or otherwise. WANER ea HHS--J une 2017--00058 3102 .3102 . 3109 . 3109 .3110 . 3111 .3113 . 3113 3113 . 3113 . 3123 3123 3123 . 3125 . 3131 .3131 3131 3131 ANALYSIS .?The Secretary shall analyze alrent rnetl'iods of estabishing practice expense whit: adjustments dopersirge medical practice in the dlIerent lee screams areas Such analysis shall Include an evatiatlon ot the mung: The feasbilityolusing sctud dataorreimle Adoperat?nga medical practice. induding elfIce rents md non-physician etattwages. in riterantlee schedule ewenee portion dare practice expense in (All). lncluang the extent to which types olollce expenses are determ?ned In local markets Instead 01 national markets. The weights assigned REVISION FOR 2012 AM) SUBSEOLENT As a restlt 01 Ire analysis desa'bed in clause the Secretay shall. not later than Jaruery 1. 2012. make appropriate adjustments to the practice expense Whit: adjustment deserted In subperwwh to ensure actuate adjustments across lee schedule areas. Inciudng? "(It easing the elites rents component and its weight on ollioe expenses that vary among lee smedule areas;md non-pmfeea'onelpersornd ?bytheSeaetary iftheSecretary such ADMNISTRATION any otter provision at law. the Secretary may Implement the amendments made by ubsection by progun instruction or otherwise part. oltitle10.UriIedStatesCode. ing my other proulsion' at law. the Secretuy may Implement the amendments made by Paragraph (1) by program nstruetlon or otherwise. IN Secretary at Health and Hum SeMces (In this sectxm referred to as the "Secret-w") shall nude underwch patforcornplex ?gnoetic Wheat: provided to unmr such pat. Underthe demonstraeon meect. the Secretary shal establish appropriate payment rates lor such tests. DURATION.4tbjecttoswsectien shall conduct the derrionstrationprejedmderthis sedion lor the2-yeapenodbeginn?ngonJuty 1.2011. shell to Congress a report on the protect. Such report shall include? (1) an assessment oldie impact olthe demonstraeon prom: on access to care. quality olcare. health outcomes. and emendaures under title XVII at he Social Searity Act (including my savings mder such title). aid (2) such as the Secretary determines appropriate. IMPLEMENTATION purposes at administering this section (including preparing and submitting the report uider sibaection the Secretary shall provile forthe transfer. from the Federal Supplemental Medical Insurance Trust Fund under section 1841 olthe Social Security Act (42 U.S.C.1395t).to the Centers lorMeacere 5 Medicaid Sen/Ices Program Management Account. at 35.000000 Amotnts ransterred under the precedng sentence shall rerne?n availdile until expended. mderthissearonloranedditlonal 1- yearpertod section relerredto asthe '1'-yeareirtenslonperlod] that begins on the date Imaaleiylolowhg the last dayetthe inltlal 5-yearpenodmdersuoaection EXPANSIONOFDEMONSTRATION STATES. subsection extensionperted bythe Seaeteryundersuch silieectionto20. yearperiod. todiscontinuesuchpamwatlon". TEWORARY APPUCABLE PERCENTAGE NCREASE. For disdiergee occurring in ?scal years 2011 end 2012. the at (Musings hear sadlng scale ranging M25 percent larlovwotume hospitals wIIh 200alewadischargesolrndeuals entitled to. or IN to subclause (II). lor 2013 and sweequent years. the amount (or amounts) that would onerwler be relevant Inconduct?ng the analysis under the preceding sentence. the Secretary may between under madame (I). beinglully Irrptemented b20115 During each yeareteuch pmee?in theamuntcl HSeaetuyhhall payment benettclaryacoesstocere. midlng? (I) payment adjustmentslor servicesthatmaybemder- arm-wand: toprovirirghome conduceng the study underperewaphm. the Secretary shall considervmetheroenaln shoud access tours; (B)van'atieruin ?ndivimalewheere duaIyeigbleundathe Medicare and Medicaid programs; (Cltheprwenoeolsevereorcnronlc diseases. asevidencedby multlpie. discontinuous home SecletSectaityAct: (Ejtheebsence (?lm barriers; (G) atypical transportation costs; (H)secm?ty costs; and (netherlectors detenrmed appropmte by the Secretary. HHS--J une 2017--00059 3131 .3131 . 3132 . 3132 .3132 .3132 .3133 . 3133 3134 . 3134 . 3134 3134 3134 .3134 . 3134 .3134 ,3134 3134 the Secretary shal consultwiri? (A) statiehoiders rapreserit'nghomeheaim agencies. (3) groups represeniig Medicare bene?ciaries; (C)the Medicue AdvicryComn-iseion: (D)the InepedorGeneI-dd theDepa'tmerlofHeahh bytheSecretery. Sudirev'nioramaybe underswoaragraphm. Suchreveions may inctude adiustmentstoperdiem payments caremdservicee during The Secretary and consult with hospice pregame and the Medicare Payment Adveory Commission regardng the addlionaldataandintormalonto becoiiected payment reveionsundarswparagaoh archer as?ttie tebe_" EMPIRICALLY NSTFIED DSH fiscal year 2015 and each sibeequent ?scet year. instead at the amount of disproportiomte share hospital payment that wciId otherwise be made under subsection to a ?section year. the SeasiaryshalpaytothesubMon (d)hospital 25perceritotsuch amount (which represents the empiricaiiy jusa?ed amount for sud'I payment as deten-nined by the Medicare Payment Adveory Commission In its March 2007 Report to the Congress). ADDITIONAL adaion to the payment made to a subsection (6) how!? wider paragraph (1). Ior ?scal year2015end each year. the Secretaryshel peyto wen sibsection (Qhupd?smadditionel amountequal to the pre?x: otthetolom?ngtacm: FACTOR ?Abcnreqnitolie meme theaggragate amount 01 payments that woud be made to subsection hospitals under subeedlon it this payrrienta thetare nudetosubuction (d)hoep'lue uiderpaaguih (1)forauch ?scal yeertassoest'lriated) FACTOR FISCAL YEARS 2015. 2016, AM) 2017.?For each ot?scat years 2015. 2016. and 2017. a (rider IN ?The Secretary shall? periodically identity services as beeig potentia'y misvaiued using maria spedied?nciause?iizend? paragraphiorservicee idens'fied as beiig potentiuymievaieduidersibdause (I). (I)T'heSecretary may useeuistingprocessesto described in abuse Tie Secretary may conduct surveys. char data collection activities. studies. or other anatyses as the Secretary determines to be appropriae to imitate the review aid wpropr'ue adjustment deserted in clause (ixll). '(Ill) The Secretary may use analytic contractors to iden?y aid analyze services identi?ed u'iderdause comma silveysorcolectdete In clause (not). The Secretary may coordinate the review aid was adjustment deeabed in clause moi) wih lie periodic review deserted In suboeragraph (8). inciudirigwih respeato oodeswithlowrehive Varesdescited In clause the Secretary may make approcmte coding revisions (inclining using err-sting pm may inciudeconsoidetionolhdvidud servicesintoburidedcodeslor payment underthe feesdiedueuidersubsection misused)houyi(V)dsmpaawaph mpropr?ute. OF POTENTIALLY MSVALUED CODES ?For purposes at iden?yirig potantiely m'svdued services shalexarriietastheSecretary fariesdoodesasappropriah?or oodea(mdiamiliesotoodesas codesiunew newtedinoiogiesor orservices mulipte codesthatare bledin with? Secretary shal estauish a process subsection ADJUSTtENTS.?1he3ecretaryshali schedute wider supeection )The provisions ot (Bxiinl) shall appty to eaustments to reieive units nude pursumt to this sibpuagreph in the sarrie manna as such provisions qipiy to adjustments u'ider superegreph HHS--J une 2017--00060 3135 .3135 . 3137 . 3137 .3137 . 3137 .3138 . 3140 3140 . 3140 . 31.0 3140 3141 . 3142 . 3142 .3201 ADJUSTMENT PRACTICE EXPENSE TO HIGHER PRESUIIED with the tor compt?ng the runberd practice ewense relative value unis under subsection with reepet to advericoddiagnosoc Imaong services (as dstIrted In section Iumisned on ora?eranuery 1. 2010. the Secretarysheladjwsuch numbsrotuniis soil re?ects?1i) in Its 1. 2010. and beforeJanuey 1. 2013. 50 percent) presumed reteaiutilizstionot'msging equpment: Inthe ceseotservtces iumished on oratlerJenuary t. 2013. and betoreJanuaIy 1. 2014. a 70psrcent (rather than 50 percent) presumed rate at dilution oi imam equipment; and in the case otservtces furnished on ADJUSTMENT TECI-NCAL OOMDOIENT DISCOUNT ON SINGLEGESSION IMAGING INVOLVING CONSECUTIVE BODY services trashed on or July 1. 2010. the Secretary shall increase the reduaion in Federal RegisterenNovemtteth m5(part40501 aid (21in subacuon(c)(2)(a)(v). byeddngetthi ertd the blowing new ubdsuse: ADDITIONAL REDUCED PAYMENT FOR MLLTIPLE estabeshed Wit/4h 2010i!? notappiedlorservlcestumished prIc USE OFPARTIOULARWAGE 2009(74Fed. Reg. INGENERAL.?Notieterttm Secretaryotl-leatmandt'iunan section referrer Intersection 18$dheSociaISewrityAcL dwelopingthe plan underpsregephU). the Secretary shel take meccountthe goehforrefaming Promoting Greater Ef?dency irt Medicare". induding establish'ng a new hospitd index system that? (A uses Bueeu oistorStatistics date. orolterdsta orntettrodotogies. to calcuhte Naive wages for each geographic area halved; (B) matimlzes wage Index squstments between and with-t Inetmpolitan statistical areas aid stateveds rural areas; (C) includes methods to minimize the oi wage Itdex adyustments that resort Mom Implementation a NEW. while rnairlairitg budget neutrity in apply-19 sudt aciustmerrts: (D) takes into socomt the alter: that devetophg the pint utder pawn (1). the Secretary shall consun with retevara attected parties ?The Seastary shell comma a study to determine It. mdu Its system Inda this sibseaion. costs horned by Prospects described In section respect to ambtletcry payment classi?cation woups exceed those costs incurred by otter hospids lumishing eenricee under this subsection (as deterrn?ated by the Secretary). hcondningthestudyutda'thiamm. chips and blotoglcais incurred by such hospitals. HSeaetuyhhall estettlisha? Hospice0 Care programat hospice under which 15 Secretary shall proviso for the conduct of an independent evaistion of the prog'arn under this section. Sudt straitrslon shel Mtether the derrtonetrsu'on program has hvoved patient care. qualty oi lite. etd cost-etiecttveness for Medicare bene?ciaries participating in the demomtraion prewar-I. Secretary sin! submit to Congress a report containng the results at the evatuatlon conduaed under paragraph (1). together with such recommendations as the Secretary determines appropriate. respect to the 3-year pertodotthe demonstration pvogramunder this section. the 1. Budget Act of 1997 (42 note) paragraph (h)(4)oisection 412.64 ottitle 42. Code otFedersi RegutsttontheSecretary otHesItartdl-hunmServrcesshall minersuoseatonmdsuch section 4410and paragraph otsuch section 412.64 in the same master as he Seaetary administered such subsection atd paregraph(e)tordiechargse yearmul'oogh unbrm. seawege index). reterredtoasthe' Secretary" )shall mentloruman servicesutdersection 138601113 Souel SewntyAct (42USC Suchstudyehell Includemanatyusot? (A) tits Medicare Inpatient mau'ns of when Medueedepertdenl hospitals. as countered to other hospitah whidr reset?! 1 or more addiional paymts or saustments under such section (Including these payments or adjustments descrbed irt paragmth and (B) wheher payments to merino-dependent. small hospitals under subsection oi such section shalt! be applied to urban Medicsre?dqtendent hospitals recommendationslor as the Secretsy detsmites mproprm. iN hemat?usted MA (as detined In section 1854(b)(2)(E))Ioreach MA ptm?rtthe Ihenu-nberaverage nunberctbeneimiesemoledmder suchplaninthe 1858(1x4). exceptthet mappiytng such paragraph. meci?ed in unparegreph (A)atdother relevantpercentsgesmderthia part'). USE OF SIMPLE AVERAGE AMONG PLANS NOPLANS OFFEREDNPREVIOUS the the Seaetary shell unadjusted MAstatutory non-drug bidamwnt (assodefneaHor, ct ,theMA enountu $13an (A) DENIAL OF Secretary shal deny bid amounts submitted undu (A) that d: not meet the aauaml guidehtea and rules estwiished wider suoctause (I). HHS--J une 2017--00061 .3201 .3201 ,3201 3201 088A COVERING lhanoneStale. ?(ll)lhelclel condoning lathe year mdersush subpuawaph PERIODIC. Secretary shall povldelorthe ms! sualng slprograms described II Mapl- (C) WGenersl shall condtned under this QUALITY pertmekemonmly REFUSAL TO ACCEPT CERTAIN BIDS DLE To MSREPRESENTATIONS AND FAILURES TO ADEQUATELY MEET REQUIREMENTS ?ln lhe cese More lho lhel' ?enby uriderswpaegraph (A) sonla'ns sonsiehnl misrepresenlalions aid hilures be sdemalely meet requirements at the orgsriza?cn. shal. In hose aid hilues. repon lhose eslueries lo lhe Acluerial Board lorCounseling and Disa'pline." REFIKLENTS TOSERVICE AREAS. years. mwvioeutiza?onjie ruralarsumderubparsmlA)md(B). respec?valy. penemsolcere. MAKE UMTED TO SERVICE AREA FOR MA LOCAL Seaelary may. inaddilion bonny er?uslrmumderwbpuw (C).makelimiled exseplionslo plum". IMPROVED QUALITY years begim'ng with 2014. in be case dm MA plan that does not receive a paymenlsm?h mnllilypercspitasoelformeyesr. malesllon periods yesr,lhe$ecrelsry ml. In payments with In WW- RISK Secretary stall risk anus! performance bonus under subsection In the same mmner as the Secrelery risk adjusts benella'ery rebates described sealon Secretary. hmem?anMMsubeeinm (b)(1)(B)lor2014 and each umeeding yea. sh? notify lhe Medicare Advantage agenizationolsny perlomwisebonus (wading ssre eque?yper?onmmsebomsmm (2). lhiswbeedionwi?nsspedlomeyear. lhehfurmliondescnbedh APPLICATION OF PERFORMANCE BONUSES TOMAREGIONAL PLANS. ?For years the management. 0F Secretary shall ideally MA local uses in Midi. with respect to 2009. average bids submitted by an MAorganizabon mderseclion 1854(a)forMA local plans in mesreesrenolgrederlhan 7Spercenlol the adjusled average per smile coal for Ihe you rmlved. determined mdersesllon1876lax4).lor Ihe use lot individuals Mioare not enrolled in MA plan under lhis pm lor lhe year. but adjusted to ensbde souls manic lo paymem under section 1848(0), and 18601). RISK ??I'he Seaewy shell risk sausl reheleslo 0W under ml: subsectlon in me deecnbedl'lseclion 1854(bx1xC) IN yen was: 2012. the Secretary shell prume transitional rebelee under secllon 1854(b)(1)(C)lsr the pmv'slon olexlta bene?ts (as speci?ed by lhe Secreluy) lo enrolees dessrbed in (2). Fume?The Secretary shall Mfume memlhe Federal l-lospitu lneurame Trust Fund mdereec?on 1817end lhe Federal Sucplememary Medical Nuance Trust Fund esteblehed under section 1641. In such proporicn aslheSecrelary W2019forlhe purposedprmuammonel rebahs mderseaion HHS--J une 2017--00062 3210 .3301 .3301 FORMOFREBATE FOR PLAN YEAR Jmusryl. 2012 ("First mouse indud'ng ofsny? and cnxpeneesout-oiccdiete chemise accounts. RECURRENT TO APPLY IN 2011 THROUGH 2011?01 order to ensue payment secrecy. the Secretary shell omen an analysis dihe dibrences described it dauee The Seamuy shall emure that the results of such scores ?12011. 2012. snd2013. AUTT-ICRITY TOAPPLY IN 2014 AM) SUBSEOUENT YEARS. ?The Seaetary may. as mprocriate iiocrporete lhe results of such analysis into the risk scores for 2014 and subsequent years' Secretary mil provide for an encection to the transition described In mach for limited cItlme Iorinovldueisenroited undere specialzed MA phi Icrspectel needs ?4 de In Won Mn we no longer eigibie hr medic! am uirhr title XDC FOR NITIAL Seaetary shall ensure that accicmis 'lidiwdusls sriroled in a specialized MA ctsniuscecul needs subsection (016))Wto January 1. 2010. ?maimed to scan orihe pogram deserted in (A) by not later than Janusry1.2013.". TO REQUIRE SPECIAL NEEDS PLANS BE APPROVED ?For 2012 8rd subsequent years. the Secrmyehalrequ'leihataMeowe individuals be woved by the NetioneI Committee for Ouwy Aaeurmcs (based on standards established by the Secretary)". IMPROVEMENTS RISK ADJUSTMENT FOR SPECIAL NJMDUALS WITH CI-RONIC HEALTH IN ?For 2011 and years. for the under clause theSecretery defauitrisk lndiwdusls (es de?ned In section 1869mm?. EVALUATION. ?For 2011 pericdr?y heree?er. the SeweIHy shall and revbethe risk edjmm system underthis as associated win Irelity. Individuals wIth mullcte. chronIc wllhe or mental illness. coalitions. MICATION OF EVALUATION AND REVISIONS. ?Ths Secretory escmolmamounoemeremder absection a description army Minion ?inducted under subcleuse (linduring the preceding year aid my MedlceldSerwoes? ModlliceionoithezoosServlceNee plans. theSooeI Seatity Act (42 U.S.C. 1W7(i)(2)) aid that had er'lollment as of October 1. 2009. AUTHORITY TO DENY BIDS THAT PROPOSE SIGNIFICANT INCREASES IN 0051? SHARNG OR DECREASES Secretary may deriys bidsuormted clan lIlt crocosessimificsnt increases in cost shalt-gardeu'eases'n IN Secretaryl'ral reweetIheNationai Aseoc'ntion rev?ae servicesmdercerta. and rI'Iadeoonsistentwiththerules 1991 NAICModeIRegulstlon' Secretary shall establish a Medicare coverageer discount progam (in this section referred desabedinsubsection subsection notlatertimApri I. 2010. in ccnsultstIon mntleetuers. and allow forcomment on such model sweement. Secatary ?In (blwith (ext). 2010 in consultationwithmendechlers. sgeement. BY THE crowds. slleclivedmetobereceeledl IheSecreIry NOTICE IN Secretary shel monitor by a msnulecmrer with the terms agreement wider this section. IN to (2). the Secretary slid provide for tie implementation at this section. incluiig the or he dimes described Ii subsection I. HHS--J une 2017--00063 .3301 . 3310 .3311 .3311 .3311 COLLECTION OF DATAFROMPRESCRIPTION DRUG PLANS AID Secretary meyoolect menId?aoturers. determines eonroprists.? distribute. otmendaduars section. consistent PERFORMANCE REQURELENTS. ?The Secreter shel esteblish pertarmnoe Wernentstore third petty with Itidpertyunder Secretary may Implement the program under this section by program 'sIstmatton or otherwise. bene?ciaries discounts drugsalhe mandaatursrinaacordmoewith such mmawrarhedf?sdtoprovide: aid'Ti) 25 peroentai and amount WANEROFDE MINMIS Psalms?m Secretary iheSeuetaryshallnotreessim SPECIAL RULE FOR PLANS THAT WAIVE DE MNMS process established Indsr sum (A) mey eig'bie Individual (as detined in section brti'IaenIaIImentine 1WD?14tax5) Secretary shu erlailsudIen Nathinginlia premasentsnos FACUTATION OF not that Jerwy 1. 2011. the Secretary shd. In the case ate toenawprasariptiondugphn. wiIh?' ?(1)infannaiionan farmlaryd to the ?ndeai's avg regimensmid a atths Individuafs right to request a coverage determination. exception. arraaonsideretianmdersedon 1M)orresaivea grisveriasmderseatbnm?D-Am" SECRETARIAL AUTHORITY TO ENLIST SUPPORT ACTIVITIES. ?The enentitymey mimhratmor: eutharizal'anorutilizetion OF DRUGS IN CERTAN CATEGORIES AM) CLASSES. GENERAL Aubjeat to abuse dlnicst concern. CRITERIA ?The shall use criteria sstebIshed by the Secretary In M09 any detsmines'an under subateuse (I). Secretary and establish the criteria mar clause and any exceptions clause DISCLOSURE OF BASE BENEFICIARY Not later then 15 oteech year wen 2010. theSecretery bene?ciary premium under this psregeohwtm respect to the blow-I9 year. 2010. IotheCarmissioneratSocld '(I)Thamodiisd adjusted gross inoorne threshold applicable mm (2) ol section 18390) (handing aopiioetion or (5) 01de section). uI'IdsrpeI-egraph (3XC)otsecb?on 1839(i)( appicm'on atpuegaph (5) atsudI sedan). The Imnt?y edjutment amount spedied It th Anyothsr irlarmebonthe income-rotated REDUCING WASTEFUL DISPENSNG OF OUTPATENT PRESCRIPTION DRUGS LONG-TERM CARE FACLITIES Secretary shel reams PDP sponsors at prescription drug plans to utlize specific. uniform Iscrniquss. as determined by Its Semtery. i1 consultation with Mevmt stakeholders (including representativesot nursing fedlitias. residents atriusing teai?ias. pharmacists. he phen'nscy lIdustry (minding ratai md long-term care phermacy). prescription drug piano. plens. end eny amer stalrehaidsrs the Secretary determines approorms). deity.? Moose ,?Misn IN Secretary mel develop aid ample-It system. that is widely Imam aid easy to use. to tslsahons. e-ma?l. or any other means) by the Secretary. by a regional a'iIos at the Department al Heal' deurmServioss.? mda Medicare contractor undersection1874?iotthea Saul Seamly Act (42 U. S. C. 1399mm the date MODEL ELECTRONIC COMPLAINT FCRM Secretary sh?dwaicpernadeldectmnic aampiuitbn'nbbaued torreporlng Ombudsman. ANIMAL REPORTS BY THE Secretary shall submit to Congress annual reports on the system. Such reports shel maids Uielysis at the hunter and types at complains reported the system. geographic widow insuch complaints. andtha rasolmionat sum complaints. HHS--J une 2017--00064 3313 .3315 . 3315 . 3315 .3401 . 3401 3401 3501 Mcommontyused finenet'ldual ellwle In section 1935(cX6)otthe Social Security Act (42 US.C The Secretary and procedures which may Include a reconcilauon process. to Iully reimburse PDP sponsors bene?ciarycosterarhgassodated withtheqapicaionoteubpuagrwh (A) Mull-231100 and thancngend edmlnIstratIve costs and shall use such estlmate to adjust payments to planeunderpartc. TheSecretary aha eetmliah procaaireebrretroactive reimbusarnent ofpat Deigble worldbere'vrbureed dJanqu1.2010. Alter dehrmt?n'ng the mplicable desabed in clause aid atter application at clauses (vii). and (xi).theSecratary by 0.25 percenhge poem: and subIect to clause for each at ?scal years 2012 through 2019. by 0.2 percentage po?nt ADJUSMNT. ?For?scat yesr2012 andeach subsequent ?scal year. clause (I) IheSecretary shal reducesuch the facalyeer. tor the preoedlng fiscal year". PRODUCTIVITY AND OTI-ER the Increase tador described in clause (I) for a ?scal .bythe adjuahiant deeu'bed In aedion and (II) R: eedi d?eoal yam 2010 thouy'r 2019. by the other adjustrtient deserted In determmg the home healh market basket percentage Increase wider clause and after appacatton 01 clause the Secretary shall reduce such percentape? (or 2015 and each subsequent year. by the produuivity edjuetnent deeaised in section and [or each at 2011 aid 2012. by 1 percentage po'nt. After dehrmin?ng the rna?iret basket percentage license under dauee (ii)(Vll) or an appeale. wilt respect to theSecretary shallreducesuch percerrtage?? (I) 20133ideach ?sequent ?scal year by the produciviy adjustment desa'bed In section tmxaxexn?xux and subpct to muse (vtioreamd?scal year32013IIrouy12019. by0.5percerrta9epoint. For 2012 aid each ?sequent year. alter the Increase iactor described In subcleuse (I). the Secretary shat reduce such increase (actor by the productivity ariustrnent described in section 1WX3XBXIGXII). deteminiigm the CPD tee sd'tadule' Increase factor mder bythe WW adluslrient deserted In section and' tor each of 2010 2019. by the adiintment deserted In subparagraph (G). After dehrmin?ng the adjustment to the fee schedules mder clause 6). the Seaatary shall recline such a?uetment? for 2011 and each eubeerpent year. by the uodlnviy adjustment deacr'bed in section Imbxaxexu?m and loreech comment. TheBoerdshaI cormncan SECRETARIAL 0F PROPOSAL It. with respect to a proposal year. the Board Is requ'red. to but tale. to submit a propoed to the President by the deadline mpticdrle under paw the specific proposal that satis?es the requirements dswparagraphs (A)and(C) (and. to the extent ieaslbte. ct prawaph (2) and contains the information required paragwh By not later Iran Janury 25 ot the year. the Secretary shall transmit- (A) such propped to he President and (B) a copy of such proposal to the Mediate Payment Advisory Comrn'neion turite review INGEPERAL- except asprovidednperagraphm. sectiononAuguet INTERN FNAL Seaetary may use Intertm Mat Memek'm to molement any recommendwon desubed in paw (1). Federal Iegislattonisenacted inhayearwhidtindudesthemteol toCaigraae and 15.2017. LNKAGE TO HEALTH TECHNOLOGY- The Secretary shall ensure that research Metrics and resuls usedto htormtheactiv'liee ofthe hedh $12.aewelasany relevant standards. certification criteria. ?Implementation spea?catlons. HHS--J une 2017--00065 IN GENERAL-TIESecretuchting I'Irouyi the Patient diseasesiorta 2010. implementing MTM madedmderswsection the Secretary shall consutwih Federa. Stale. private. publoprivate. aridacademic entities. plumecyandphanneciet crgenizuicne. heeIl'Icarecrganizatione. ccnsuneredvouatee. chronic groups. and other stakeholders Involved with the research. desemtahon. and Implermntetion ct phenom-delivered delen'nlnas EVALUATION AND REPORT- TheSecretaryshal ascompaadlc usual care. resource use bytagetedindividuals; (3) (4) assess impea ofpetient-cost sharing requirements on medication edhaence aid recommendetione tormodificeticnez? (5) identity aid evaluate other that may Impact clinical and economic outcomes. My derriogrephic ELIGBLE be eligible to receive a grit or contract raider sweection an entity shall? provide a Secrateryaplentoraohievhg Iorigien'n tinmciai inslairiabIlIty: ('3)Mieraappicwie. ?(4)submit and Secreu'ymayreqke. GRANTS OR CONTRACTS TO FUND DEVELOPIENT OF PERFORMANCE Secretary may. mucua?y 931 ctthePubIcl?letherviceAct. awerdgranteor contracts to eligible entitiesiorthe purpose ital assess the use and elleciivanees cl medicationthera py management services." pilot prq?ect to deeigi. implement. aid evaluae emergency medical and trauma system coord'netee w?lh pubic health aid safely seMces. emergency medical services. madcai tacllitlas. trauma centers. and other entities In 'nduding9-1-1 Pluto Safety Arm-g Pains and ?urgency medical diepuch; includes a medianism war as regicnd medical Men to the medicaly approprime taciity (wirether aI facility or a hirer-level letiy) in a timely Pricrity- TheSeautaryshull giveprioritytor'the agents described hellieection (u)to any eligible entity that serves a poouation In a medlceey aidereerved area (as deiied In sedion 330(bx3?. IN eli?ile entity that seeks a contract orgmt described in subsection ahal submit to the such rnennerasthe Sea'etarynuyraqulre. APPLICATION IMORMATION ?Eech application shall Inciude? lrom the eligible entity that the proposed system? has been coordinated with the mpliceble Shta Oilice oi Emergency Medical Services (or equivdmt Slate clt'rce): includes consistent inched and Iiect medal overeigli prehcep'dal. hoep?dul. and Intertacility import throuwou?t the rayon: "(all prahoepltai treatment and triage. hospital destination. and Inlartecllity moon throuyrout the rayon. Includes a categorization or dasiyotton system tor special matted mimhmmamm diredicn. pellenttreclung. mdreecuceelomtion system iN ?The Secretary may not make a grant wider this section unless the State oi States) eudIgruritwaemede. (in kl'ld inderpaegwhm)mdeuch (A) In subsection 'wpraprtated'andal that blows rolovmg: Pall enIProtectionand AliordablaCareAct. _under such p_arts from the Mniietretorotthe i-ledth Reeoucea and Services Admin'etretion to lie ,Medrcd? The Instiniteeoti-ieuh. thei-iethesourceemdServims ticn. including? ?(1)the basic science otemergency niericine: ?(2)lhe model oleenrice delivaryend the components olsucl models thetcontriiutetoenhanced patient health hvoved practice: and the development 0' timely aid ef?cient delvery olheelth services. (btPedetric Emergency Medcei Federal proyans edmln'rsteradbyheNetionr pend in pedatnc emergency medical care systems and pediatric emergenq medicine. indudlrig? an examination oi the the role otpeciatric emergency services as an inbgrehd ctthe overall health system: system-wide pediatric emergency care planing. preparaaiess. coordination. and pediatric train'ng in InmaRasearui-TheSecrelary shaiisupportraseadilodebrmine lie estimated economic impaclot. andsav'ngs mdubmindiantraumacenters? (1)to assist In detruying Meteritiai Wmmoosts: '(2)lc inclu?ig byedaeseingcosts associaedwihpaiientslabization andtranster. meducaeonendcutraech. andolherllxedcosis. and with J, and": services; and (3H0 QUALIFICATION FOR SUBSTANTIAL UNCOWENSATED CARE COSTS- The Seaetary shall award substantial uncompensated caremundereubeedion (eXtiontytotraumaoenters meetlrig at lewtotthe criteria intolihe Atleest50percant oldie visits In (Interline Social SecuntyAc areaatolows: IN The Secretary shall establish an errant base tor each eagble mine center torgrarits under section to the percentage dasomad In program (2). subject to the requirements at sedlon 1241(bx3i. IN in awarding grants under section 1241(ex2). the Secrelay shall- leave 25 percent at the email allocated mission Level Ntreume centers: aid anount etiolated tor core miealcn awards ice large ubm Level I aid II tram cerium?1i) that have at least 1 yaduae medice education telowsh'o ?Ii mm or nume raided spec'nllies for which demand Is exceedng supply; ?00 IorMich??(n annud moompansated cue costs exceed 510300.000; cr'(li) at least 20 percent oternergency department visits are dierity or ael~pey or Merica'd patients: aid '(iil) tint me not eigbie la eubetentid uncompeneehd care ewerde uider sermon 12et(e)(1). HHS--J une 2017--00066 TRAUMA CENTERS IN 1115 WAIVER STATES Withstand-n9 paragraph the Secretary may Md a ?manual mmnvensated we grant to a trauma center under subsection (ax1) It Ire trauma center qud?ee for hard Poolor Social Security Act (42 U. S. 1315) Secreta'y may not and a gent to a numa center under subsection unless such trauma center? stbmits to the Secretary a plan satisfactory to the Secretary that demonstrates a to assist patients Mamet peylorpertoralolthecarelhey receive. inchdingeslid'ng feescale. endtoermteir billing and colechon practices.". OF FINANCIAL SUPPORT ?Tne Secretary may require a trauma center receiving a grant moor section 1241(e) to maintain access I) Iauma services at nonparabb levels to the prior year during the grad period. TRAUMA CARE Secretary may We the sauna center receiving a went under section 1241(a) ta to a rational and centralized registry dtraurna cases. In Woe With wideilnes developed by he American ColegeolSurgeons. andas the Secretary mayotherw?ee require". Secretary maynotauerdeorentloatmuma center under section contains such egeernente. neurancea. and ?orrnes?on as the Secretary detenr'meeto benecessarytocaryoutthit pen. LIMITATION ON DLRATION OF SUPPORT. ?The period dung Mich a teume center receives payments under a grar under section 1241(ax3ishail be tor 3 Ilscal years. except that the Secretary may msuch reoulremerl fora center RANT?Wratmding 1242(a). a gent mm 1241 may not be node an amount enceeding MAINTENANCE OF EFFORT. ?The Secretary may not provide Imding to a State under this part unless he State beueedto and coats dewted' In this pan. Emergency section 1241(a)(3). he Secreta'yshd? 'g've(1) and? ?Share? amount appropriated for substantlel moorroenseted care grants lore ?scal year. the Secretary shel? "(11m category trauma centergrantees: and 15 percentoleuch Clauma centergrantees; and beecheliglbletratmcenter. PARTICIPATION TRAUMA CARE SYSTEM OPERATING UNDER CERTAN PROFESSIONAL whsection unless he trauma center Is a participant In a trauma system that substanhs?y complies section 1213. 1241 endonthe mmutebllity oltraume centers: Establishment- Topromotemiversal access Iotraim cereservicee providedby trauma centers and trauma-related section. LESS THAN $10,000,000- lf the amount at moonstone ior this can in llscel year is less than 310000.000. the thathavet ormoretauma oenterseli?iefor wider section LESS THAN $20,000,000- llthe amount at aocropriesons It a ?scal year Is less the Secretary shal those States thethave1 mm (A) an: sedion 12t1(bx3) LESS THAN 830000.000- Ifthe amomt at mopria?one for this part It a ?scal year is less then 330000.000 the thathereI ormoretwma oentersellgbiefor mummy: 1241(bx3). $30,000,000 OR MORE- lithe amount 01 apprcoriaaons lor this on In a ?scal year Is 830000.000 or more. the Seamshelmidewchlimevenlyermel Slates Seculty Act. HHS--J une 2017--00067 See. 3510 Sec. 3510 50cm eecoonJmeSeaetuy underewparewepMA). aid patients otmairmei?cdtteatrnentop?onl. Reeourc Cutterurei'erredtointhis eubeedionas disseminate best implementation. andetledveuse ofpatient deceion aide and tiered PREFERENCE- orderto isolate the use dbeet practices. the Secretary shall pvunde a preterence 'li rridt'l'tg grant: under this subsection to heath care providers Imopareopate In training by Shared Decisonrnaklng Resource Camels or comparable training. Secretary may Issue gidance to eh?gibie wider the etheection on the use of patient decision aids. Wow and Commotion- In "Wig the determination under subeeulon the Secretary shall renew al aveilabie rmnutacitlera dini'xna. patienta and ooneurnen. experts In hedth itaracy. rec'd md ethnic marines. and experts in women's and pediatric mum. Reoort- undertyingthetdetemumton. Evaietron- The Secretary shall take such action as may be necessary to evaluate the proiecu tunded under this practicabie. Secretary may meganubei?ie eectiontocavryout demortetreeon projects to devebp and implement academic cirriwia that integrates quality ?I'nprwernent and patient safety in the clinical education of health prolecsionals, Such awards she! be nude on a motive basis and mm: to peer Mow unmittotheCmIIiteeor-IHeuh. Eduatim proiects EVALUATION AND The Secretary ehal directly or comrade with public and privae entities. providedmder dewtcoedasa resuloisucn prolects. andeverysecondyearthereafhr. the Establishment- TheSecreiary shal mshw?ilt lheOtlceotlhe Mmlnistralorol'ie Health ResourcesmdService Mien. monieshallbeheadedbyamm shall LIMITATIONS ON GRANT PERIOD- In carrying out this secoon. the Secretay shall ensure that the total period grarIdoea not amused 4 yeata. CORE PROFICIENGES- The Secreiay she! not mu a watt to an entity under this section urless such entity ptowaea aeaurencea that patient navigam reunited assigned. trained or employed using grant tuna meet minimum core pre?cieno?ee as de?ned by the entity that submits the application. that ave tailored tor the main tours or 'ntewentionoi the new imotmi Servicestoincreesetunding. torprogmauthonzedbyihePwlic HealthServbeAct. andhedhecreenhgs undiaethe Community Yrartetcrmalongrent program. the Education imrmnizatimprograms. evduatton. HHS--J une 2017--00068 Sec4004 Sec. 4101 Sec. 4101 Sec. 4101 Sec. 4101 See. 4101 Sec. 4101 Sec. 4101 Sec. 4101 See. 4101 Sec 4101 See 4102 Sec. 4102 See. 4102 Sec. 4102 See, 4102 Sec 4103 EVALUATm-TheSeaetaryshail ensure thatihecerwaign Implemented mderparegraph (tlis subjedtoan mainstay maidsmeetingscienceased metrics internetPortai- PREFERENCE- hawarding grants underthis section. the Seaetarysh dgive weferenceto My gents tor echoo based hedh centers that serve a large popuetion 01 chin eligible tor medical assistance Inder the State Medicaid pianundertitte XlXottheSocial health assistance was the State hedh plan Indertitle )0001that Act (42 US eligible foragant mderth?n sibeection. an entity shall? (A) be a ediool?bmed health cutter or md(3)submitan applicationataudi?ne. containing such intormuon as the Secretary may require incim at a minimum an assurance that tunds awarded oomrnen indicative oldie hedh statue dauch chhen and adolescents otan area. handing the otthe residents oteuch swaechon ?ne. nsuaimanner. andoonta?mlng?? (Bievldenoeoliocelneedtorthe State. andlocdtevI PREFERENCES AM) reviewing amications: Secretary may give piei'erence to '(A)Cornrnuitiesthat haveevitencadbarnerstoprimary more oreriroiiedln pubic health' entrance pm Populdions otchilaen and adolescents that tare hietorit?y demonstrated '(2)TheSeaetaryrm ?consideration to mther an ?pliant has received a grant under subsection (eiotsection 4101otthe Patient circumstances. mivathe app-national Mindwodceuse. CONSTRUCHON. ?T'he Secretary may award grants which may be used to pay the costs associated MII emanate and moderrizing existing builihgs tor use as an SBHC. 'nduding the puchau ottraie traders or Macaw to install on the adiool property. Authority To Award Grants? The Secretary shall award grants tor the costs 01 the operahon oi sd'Iool-besed health oenters(retenedtoi11hissection as sattCs'Hhatmeetthe requernentsotthis section. Emotion- The Secretary shall develop and imptement a nun torevdusting and monitoring oua?ty performanc- under the words made under this section. Requiremerls- In ?Wing campaign. the Secretary shall?- '(1)ensum that activities targeted towards speci?c popuetione such as chilaen. pregnm women. puents. the elderty. indvidua with I?abiities. aid ethnic mi racial minority populations. inctuding Alaska Natives and Native Hawaiians (as de?ned In sedion 4(c) ot the inrhl Hedh Cae humement Act) In a cuttIIaliy and linguistically Web maner: aid (2) utilize science-baeec butarenotlimitadto. oommuv?tywater floatation eSecretary shall conduct pinning activiieewithrespedtothe aarnpa'gn. hviemerm?ngthe pihiic educu?on canva?m mdersedion 3m. NATIONAL HEALTH AND EMATION SURVEY- TheSeaelary shall convonents that shall include in the Examination term ?toom-levet survelenoe' nieareactirvcei examination mere an examiner looks steedidentsisutsce.meech BEDICAL EXPENDITURES PANEL SURVEY- The Secretary ital that the Elm-James Panel Savoy by the Agency tor Hedhcare Research and Quality ?hides the verilcetion otdentai utlization. expenditure. aid coverage thongs throw conduct or a look-beck analysis. ORAL HEALTH SURVEIUANCE SYSTEM- (A) There is auIt'Iorized to be appropriate: such sumsas may the Nation: Oral Heaiih System from 16 States to all 50 States. territories. md District at Columbia. (B) The Seaemry shall enaure that the Naiorui Oral Health System We the measurement ot eerty childhood caries HHS--J une 2017--00069 Sec 4102 Sec. 4103 Sec. 0103 Sec. 4103 Sec. 4103 Sec. 4103 See. 4106 Sec. 4106 Sec. 4103 Sac. 4103 Sec. 41% Sec 4100 Sec 4100 Sec. 4108 See. 41% Sec. 4103 See, 4100 Sec 4100 Secrewy shal snails that he National Ora Hedh Suveillance System include the measurement ot earty childhood caries The Secretary may utilize anyhealirisli mm subsection. beused to (WA). The Sm may all-1e any heeli risk assessment asirelopeduidusection 4004(t)otthe Patient ProtectIcn and WW usedto The Secretary may coordinate with minimum entities (Inclumg State Heali MSW Programs. Area Agencies on Pg'ng. Aw'tg aid Disabiity Rescues Centers. aid the Adminittstion on Agog) to? snails that hedh risk assessments as maeibte to benefdaries: and "(lb provide approp?nte support for he compteticn otheetti risk assessments by bene?ciaries. TheSecroteryahdeamliah Totheextent lintegr?ionwith. thatis medicsiiecorssaidpersonai atatusotbene?cieries. The Secretary ahd esmliah procedures to metre beneficiaries were ofthe opaon to select an iniiei punitive uniservices first services; and approp'ahprovisionot such thereatm'. AUTHCRITY TO MODIFY 0R ELIMINATE COVERAGE OF CERTAN PREVENTIVE SERVICES. ?Notwithstaiding an) MWmesryt. 2010. unprepats. theSecretsr may?? ?aiytAtthecweregod punitvewvicedescrbedin lhaextentthat StatesPrevariveServicaeT Force: aid section: and no payment shall bemadeuruarthIs title toraprurentivaservtcedescmed in iN Secretary shal award grants to States to carry out ?natives to provide incentives to Medicaid bene?ciaries Mio? auccesatuly parii?wata ?n a program desabed in paw? (3): and (ii) upon completion of sudi participation. demonstrate dianges 'Ii health risk and ?Monies. incluriig the adops'on and main-arteries ot healhy behaviors by meeting specitic targets (as described in subsection OF Secretary shel awards gents to States beginning on January 1. 2011. the Secretaydeveicpepwancritena. whichever-s earlier. ThaSecretay Regisby ct EVIoencaBaseo Propane and Practices. STATE Seaetary shall candid at outreach and edimtion camaign to make States aware of th grants under this section. WANER Secretary may wars the requirements cl section 1902(ax1) (relaaig to siatewideness) ct Stale makes my prop-an described ii (A) sti?e aid scoessble to Mediaid bene?dsn'es. Secretary slid enter me a contract win an independent entity or organizetion ti contact an avaiiation and assessment oi the iratiatives carted out by States under this section. tor the pupose ct in the progan: (B) the extent to which special popthticm (Mtg adults win disabiitiee. edits with chronic illnesses. madam heuh care needs)aeabtelo participate in the program. (C)theteveiotsstielacoci1 otMsdicaidbenetia?aies progam; aid (D)the administrative costs insured by State agencies that as reapona?ble for otthe 2014. initiatives States c[Moogli mamm isseaionaid aalonreccmmend Jauaryt. 2016. FINALREPORTH?Nottatertthilyt 2016. muttcgetherm?th ationefcr such legislation aidadministretive action as the Secretaryomarrnnes appropute. HHS--J une 2017--00070 Sec 4201 5894202 Sec.l202 Sec.4202 Sec. 4202 Sec. 42% Sec. 4202 $ec.4202 Sec.4202 Sec. 4204 See. 4204 Sec4204 Sec4204 Seam Sec. 42% Sec, 4206 Sec4206 awadeompeileve mule aiddeveid meanings. mdwharenacaeaary. aneniity health manly-based piblicbeeithimavemionemnd (D)demmelraiethecepadty iIIundeII Iodeveiopihe relationships Win hedhca md'nuereiocary PILOT PROGRAM Seaelayehal contend an piIoI Molar-controlled IN Secretary anal conduct an evehacn oicomrrmity-based prevarmcri and wellness Mame and develop a den for promoting hedifry Heavies aid chronic disease eel-management lor Medicae bene?ciariee. IN GEIERAL ?The Secretary shel eveiuele preveniori end wehess programs including thoee that are beneficiaries (panicuia'y that haveemined 65 years afaga) reduce their risk dineblity. and inIury by making healthy Mylo choices. minding exercise diet. and eel management or chronic diseases EVIDENCE Secretary shall renew available evidence. harem. beet predicee. and that arr The whidiehalliruidaJtarnii'mm (I) physical activity. nutrition. and obesity; (ii) Ialle; (Illichronrc selvmanagement: and (IV) mental heeith. 2013. ?Secret-yam Includee? (A) recommendations Ior such and WM action as the Secretary determines topromoie (B)aryrdavent?idinmrelae?ngto theevidencereview under paragraph and (C) the reeds oi the wider Dawson eweeciion. Ihe Secretary and pruridebrlhe Iransfer. Iromthe Fedora Hospital Insurance Tmei Fund undereection 1817 dire Social Security Act (42 the Federal Suppiemenial Medical ineuanca True! Fund Indereeaicn 164101 such Act (42 use. 13950. In such as the Secretary dehnninee male. 01 $50,000,000 to the Ceniere for Medicare 5 Medicaid Services Program Amounts Ira-lured undarthe preceding mend! remain Mint] expanded. IN Secretary. ac?ig through the Diectoroltha Centers for Cartrol aid Prevention. ehall eetablieh demonelreiion program to ward grants Io States to lnprove lie provia'on cirecomrnended I'nrnunizeiione endeduile the use ?evidence-bend. contention-baud imerveniione Iorhigh-rieix popidaiions. IN Secreiary may Weanrereofvaccineelortne codi?na. ?l'IchdingaStaiepla'Ithat .r as withioceieuthontiee. awarding gratis under Ihia the Seaetary shall consider my reviaweor recommendations oi the Task Force on Commumy Prevertve Services. demonstrationprogrynes?iiehed mdarthil aubeaciionbgamarwih program. REGISTRATION ?\MhirI 120 days 01 enacirneni oi this clause. the Secreiery shall publish a notice In the Fedora Ragieiarepadyhg the lerme and con?rms brilpiamarlation diIern (I). penaig prorrugaiond raglaiiona. PROPOSED clause. IheSecreiery shell deuce recihiionmheSeereia' varniioreininyedlem. ?emulsi?ers. nutrieniconieni mderihis Secretary shall euhrrl?I to he Committee on Heath. Edmtion. Labor. aid Pertn'ona ofIhe Senail Secretay'e progress toward Mal regulations under this eubpaegreph, ADDITIONAL the Secretary deiervma that a nutrient. our than nutrient required under ubclauee Oixilli. should be disclosed Iorthe wooee oI prwidng to assist coneunere it maintaining hedhy dieiay practices. the Sea'eiary may require. by regulation. diadoeure deuch nIm?ant ii the Milan form required under eubclauee HHS--J une 2017--00071 Seem Sec. ?301 Sec. 4301 Seem $ec.4302 Sec.4302 Sec. 4302 Seem Sec.4302 896.4302 Sec. 4302 506.4302 Seem Secretary dial IOoornmn'tyhedthcenmil-Ided puoichealthservioesmdeyatema. onanannuatbasis. ?r?tgs Witt reaped to research upomd ureter oolledamdrepchotheextent practiodziie? duaonraoe. ethnicity. eex.pr?maylenwege.mddieabiity status torappticants. reopients.orpantooants; 18) data atihesrnallest geographiclevetsuohas State. Iocat.or reliable astimatasby raciaLethnic sexprirwylertwege it theSecretuyordeeigneesheli? (A) usi atamin'lnum. ?(B)devdopetandardet IhanIaasurementoisex. primary languege.anddsabitly status; end' Incapauated; treatmenttor Wmdisebitiesmdtoidentity? ms DATA ',data? A deitauth-tedh Horme?mTeohndogy di?? ?(A)devetopnlticnal strident forthe manwtentd?e collected: and devetcp interoperability and security systems tordata management. I-HS Disperiies: ?(C)theA9encyfa ReseudIH'Id Qualiiryz' ?(G)Iha OfficedRtheeIth: and [l)otherentities and' 'other(8)my report'ngor diesem'ndion "mm detemmedepproprietebythe Sedetery. PRIVACY AND OTI-ER Secmtery me) that? aldatacoladad pursuant to abaecticn Isprotactad??In section 264(c) otthe Heath lmurmoe Portabiity end Aocouttebity Act at 1996 [Ptuic Stat. 2033); stores. orreoetvesthedata. indudlnguseotsudt asde?ned bytheSecretayend? ardysisJid ms DATA Secretary shel eetebtilI procedues for sharing data ooleded pureumt to subsection measures relating to such data. and analyses at sudI data. watt other Federal and State agendas ?hiding the agendas. centers. and entities within the Department at Heath aid Human Services specified In subsection HIS DATAON I-HS Sacurhy. ms EVALUATNG DATA OGLECTION APPROACHES. ?TtIe Secretary shal avatuda monastarthaoclectionotdata accurate. endtimetyoolectionand andevduetionctdetaon ethnicity. sex. pan-vim. status. In conduct-1g such avaluee'm. he Secretaryshall considerthetolow'ngoopectzvas Protecting patient pnvecy. ?(ZImimizugthemuntive titiearIdtItIa race. ethnIdty. sex. ms AVAILABILITY OF Secretary may make data deserted In and avdecte tor additional research anatysas. and disserrIinaticn to other Federal agendas. non-governmentd entities. aid the public. it madame with any Federd agenoy?erdesdetauseregeem REORT ON 1B eneotmentotthin section the Secretay shall submit to Corvese a report on the evaluae'on conducted under subsection Such report shall. taking into? datInIng ?tor ethriciy sex primarylanginge. md stems title ?we mend ?(Butane reoommendeoonsmmemoet etiedtve strategies and approadtes to reporting HEDIS nual'ly measures as required under section 1352MB) and otter nebonely asmpropr'nte onsudibeses REPORTS ON DATA years after lhadataoitheanectmant section. andl years ectiededuidarsuosactiontc). IMPLEMENTING EFFECTIVE tater than 24 months at. the data at the enactment ct this section. the Secretay shal 'lnptementthe approadiesidanti?ed in the reporIMrrtittad underwbseotion (bxtHorthe ongohg. accurate. andtimetyoolection besisotreoe. ethnicity. sex. primary language. and status". ms HHS--J une 2017--00072 Seem Sec.4304 Seem Seam M4305 Seem Seem Sec. 5103 See 5103 Sea 5103 Soc. 5201 Seem Sec.5203 Sec.5203 506.5204 Soc.5204 $995204 WIS IheSeemary. e?ledaee Mommas? monllor ms maCedateneem Paln (in min HHS mdolherFedmIlegenu?eelhd relahhopain m. l-I-lS IN Secmury may make awardsefg?am, eoepawveegteememn. mdeetItramlo heelm Wuchoolt. ms ms EVALUATION OF PROGRAMS. ?The Secretary shall (chew er throng: wants oreonlreels) ptmidolorlhe Mn madman. lhe mmumeyralaebmangee InelmiIg swam?. ?magnum. manholmrmaoenjury byemployees. ?McMillan: indud'ngworkphee?lneu hedhyleed wmminmo FederalEmplayeeHetheoe?quo'em; Iepetteeneemingwehevelueien. which ms Seerehry shall eelahlish he Nallond Cedar la Noam Werldoree Analysis (rel-red to in this section as the National Oenler?). erenterlnloeontrectawim (A) no analysis.mdnpor?moldala. WIS IN Secretary the! mac the amount to In elm emlly uncle! We lot a amnion of lndviduds who have received Mm. raining. or funnel-l assistance hem mam: under this lille. LOAN Sectelardeeam-Iand wraqiepavernallhamlal In pediamwgieelspee?alty. needle-no. MS PROGRAM wasteland-nouns sodlon. lheSeerowy ms entering in!) centred: undu this subsection. lhe Seelelary Ihell y?ve ptienty to appieanla unawlbewomlng lna sehoelerolhermmanlememry. ?secondaryeduceuon selling; "(2)have ?1%th datum ?rm neecL Secretary mall ambush me Public Heum Wenderee Lem Repayment ngram (referred lo In this soclion as no ?Program?) to assume an adoquue snooty a! public mm mm? lo crlueal pubic mum Mime shortages i1 Fm. sum. Iced. me ulbd pubic hedh agencies. PAYLENTS FOR YEARS each year oloblw service the! an mm contracts Io an under ms ms HHS--J une 2017--00073 Sac.5204 Seem Seem 5315301 Sec. 5301 Sac.5302 Sec.5303 Seem Seam Sec.5304 Sec.5304 Sec.5305 Sec?!? 500.53? Sec.5305 Sac.5305 relmbusemanta fortax reaIIt?mg from payments under IN GEPERAL. ??lhe Secraiary may make gamete. orantermeomacts with, any allwla hedhandaIladheuh. erantermoenuacumm. hospital. acadanicaiyafhtee IN Secretary may make to arm hie comrade wIlh ecaedied sd'tooIe of medicine or osteopathic meda'riatoasmllah. maintain. orinvloye?' ?(Macadamia '(Bjmammallnwaeacaeanicmm units in ?elds de?ned' In subsection (a)(1j(A)Io enhance IacrulmanI. Irehing. and faculty deveieprnant HIS PREFERENCENMAKNG mdlorthepuposaof?' substanIIaIy wchunltserprograms. ms IhaSeaatary aaoldaoru?ve pdmarycere; maemepadent oentaradmadlceltome. ?(lemaa peroentegeelprovleevstreheom ms opportunlnee ?Wen?. assisted fediliae inermediate we fedtiee britdividuels with mental retavddion. home md community tamed settings. md erminecemactsw?h. aaof-oololeentletry. gremorconm? PRIORITIESNMAKNG AWARDS. maSaaetaryshellgNa projects depammtaolgenerel. pediatric. aplblichedhdantistry pedlatnc. orpuellchaalh dentistry. bedrquund. orirurn underrwlewhd minorities. Quali?ed Ihat aetioliah band relationah'ps wiIh ms PRELMNARY 1 yeranerlheemctmea section. the Secretary may disperse gm buedtpenmanuaivamd quailtetrvedaia. HIS IN SacraIary me! and grmta or contracts mdarthia sineedbn Io entI'Iies that warm a oer'utric aducdlon oanler mm to eubeection (ext). IN SecreIery mu grants oroonlreda utderlfas semen to indeuele described in paragraph lemme-Ia. and mm care management. I-HS TO midihdudeechoolaoimedbine. osteopatticmadc'ne. nursing. sodalwt. peyd'loiogy. darmy. andpharmaey. WIS HHS--J une 2017--00074 Sec15306 89cm 89cm Seam Sec 5307 Sec. 5307 Sec5309 Sec15309 Seam Sec15309 Seem Sec.5309 506.5309 Soc. 5311 Sec. 5311 maulunamoluadamfa. ('1)bewahuraala. Hunters. md doctoral inlemehip. implementatimol incluIiIg umoemuemmonamuewnemm'?) elm ms lhel?' (2) In selecting mega-nreduenb?nqaduab (3x2) MmaumuddaradmmwanMu will menhl dlsordeo. stress dloorden ouch as postlroumalic dressmand lraumolic brainimunes. WMWuds. chronically ill persons. mdlhai faIniiea. H13 3) oblitylocollec?ldalacnlhe ms he Secretary shall collabowhowih hodln societies. mdewamhniwiyhe?andculmral competency. wavemlon. mmcommunly-aned ovum. andolherommlunonses ms Secrolaty sh? Wilde lhe adoplion md lhe imiemenlalion culurd cum. ptevenlion. aid pluchaa?h. ?Mum oompelemy measures In quality muemenl syslems as tomato. OQLABORATICNFUI carrying out Man 1119 Sectalary shall collaha'aha win .10 anliiec dawibad '11 section 741M l-I'lS 741. RETENTION mum-um lo. will. ??le entitles lo by WIS nines. Icensedvoce?onolm num and' ms pmdahe?hcueladlly. gwepveleronceloappicmulhal ms Secretary shallmeke Mmbeyond lthecIelaIy Imam numeralamionorpatlam are. orenlerlmoconlrecuwllh. eligibleenll?eslo Each nursingwofklorce. IN Sectatary. acl'ng hough lhe Wm ollhe Hedlh Raeoucee and Sewicac Admin'nlralion. may enter Into an summon! wan elgble Inavlduah lot the repayment 01 education Icons. In In? this secnon. lo haease Ine numbev ol nursing lacully. WIS HHS--J une 2017--00075 Sec. 5311 Sec. 5313 Sec. 5313 Sec. 5313 Sea 5313 See. 5313 Sec. 5313 Sec. 5314 Sec. 5314 SOC. 5314 Sec. 5315 Sec. 5315 Sec. 5401 Sec. 5401 SOC. 5401 Seem Sec.5400 paragrapnt1).lheSecretary enlorcernentol WIS PRIORITY. ?ln md'nggrants under stbsec?on the Secretary shal g?ve priorityto ?pllcants that? totagetgeogreplimw? cornmun'ayhedhwkere. I-I-IS WITH ACADEMIC INSTITUTIONS AND THE DELNERY Secretary anal institutions? one-atop dalvery systems Inder sealer! '134(c) of the Act at 1990. Nothing" In this eecicn aha be corretrued to reqa?re such cda EVIDENCE-BASED INTERVENTIONS. ?TheSeaetxyeh?encourme I-I-IS QUALITY ASSURANCE AND COST Secretary ahel eetabliah guidelinea tor ensuing the oualltyotthe supervision ofcornmunay beam workeramderthe minnow undermle aecucn andior amino the costel'lectivenees cl soar pm HIS Secretary sh! n'Ior'l'tnr corrlnunity hear works prwama idmtiied in approved appirations underthia section under msection (9). ms Secretary may pruri?htedrnicel ass'stance to community hedh writerprograms thegrant ms IN GEIERAL. ?1'he Secretary may carryout activities Ioaddreae documented worklorce shortages In State malccel informatiaand meyexpendthe Epidemic lntelligenceServrce carrying out aubeectlon the Secretary aha! providelorthe moron olexletino fellowship OTHER Secrelty WIS toenauethemaxanum andtheneedaoltheunlted personnel. ms I-HS the Secretay and make $12.0w.0wtxm Mancunian (a)b health professions schools that meet the conditions described In ettaecticn ms and with mergrants me made with lmda Indu clam the Secetary ahell make em? 60 percent 01de (a)to paragraph (3) or (4) ol subsection Whig rneetlng the conditions under subeectlon and 40 percent cl Iorgrantsund meetlheoondilonsdescnbedin attraction I-I-IS FUPDNG IN EXCESS OF 330.000.0004 amounts approcneled under woeectlon (I) tor a ?ecal year exceed 312000.000? gran: under attraction to heuh proleeiona miracle that meet the conditions deacnbed stbeection ducted In (3) or (4) ol wheectlon (lncludng meet?ng conatlons Will to subsection not Ieesthan36.000.lor000 utuction and ahergranta so made wih fmda Indy clause: any remaining excess lncunt ms Fumue IN EXCESS OF 840.000.0004 amomte appropr?nhd unda tr ?ecal year are ?0.000.000 or more. the Secretary shall make malacle? not less than 316.000.000 tor grants Inder to health schools that meet the conditions deecrbed in sttsection not less than 316900.000 lor wants mderubeection (END hedh WWIWI that rrIeetIhecondiliorl deactibed l1 paragraph(3)or(4)d praaumtlo subsection to hedh prdees?ons schools that meet the conditions described at situation and (Iv) 1hr grmta ca nudewith ind: mdercbueea (I) ttrrorrgh any remaining ?InItiorg'antamdersttaection [e)to healI ms 0F Secretary shall make the lolowlnp 2 types cl awards In accordance win this sermon DEVELOPMENT Secretary mailmakemtoellglole entitiesloenable ms HHS--J une 2017--00076 Seem Seem 8995403 Seam Seem Seam Seem Sec. 5404 Sec5405 Sec.5406 Sec. 5601 Sec. 5501 Sec.5502 506.5502 Seasons $995502 SERVICE MANTENANCEAMDENHANCEMENT make eligible INS I-I-IS utthissemen semetheSecretuyehelensureIhe IoIowIng: INS Secretxy sh?dtemehveiyenm Ihet? "(i)henusins sdIocI contindsetbast 10 perceriofdire'ul edutxion and AREA EMCATION ensure Iheteech governance. Ihepaentimlitutiendhemdee; ms MS theSecretry HIS Isaitymembers. comma provide diseminetim and dIsserrInuion research ?nalssus'ng relevenreswrcee. I-HS AUTHOMY??TheSeaeterymey lolomngz? ma IN Secretary. mm the Director clthe Agency tor Heelhcere mo Quality. establish a Primary Cae Extension Progsm. ms Secretary shall cernoelilve grunts to States Iorlhe or primary as Primary Care Extension Picsrem Slate Hubs (retsned to 'n this section as ?Hube?). SECRETARY ?In cerryinsoutthissemen. IheSecretery shell ceruultwihlreheedsct suchesthe msHesllh HeaIIh commas appropriate. I-HS In lieu lepIyIns Ihebmet-neuniity emshnentsneqiedmdermuse (ixIlHe relmvevelueunisteeccounltor ms 1833011] by percent estlmetsd to be equal lo the Whores eshheted under the ?rst sentence at muselorsuchyeathells 332(ax1xA)ctIhe Mlle Heellh Sen/us Act) as hem pretesu'enel muse areas". I-I-IS IN GEIERAL. ??l?he Secretary shal mlepsprespeawepeymem system IorpeymentlorFedereIIy untied health Such appropriately Minimums; OCXLECTICN OF DATA AND Seaemy shell recite Ie submit codes. IN section the Iorcostreporhspe riodsbew'lms oncrellerOdeberI. 2014. brpeymentsfer Federelyq (1) ms INITIAL PAYMENTS. ?Ths amount WIS HHS--J une 2017--00077 Secssoo Sac.5503 Sac.5503 Sec.5503 Se?5508 Sec.5608 806.5503 Sec.55?5 Sec5506 Seem Seem Seem Sac. 5507 See. 5507 Sec. 5507 Soc. 5607 Soc. 5507 IN Secretaryshal hospital that WM) (es oolimled bythe Secretory). HIS I-I-IS REDISTRIBUTION OF POSITIONS IF NO LONGER MEETS CERTAIN the case subclauee or at such clause. the Secretary shall? reduce Iho olhorwloo applicable ioadonl ol the positions toauch ii 1 Isperagraph ll?lS IN increase'lilheotllerw'ee appicwla Ie-?lerllimil is lheSecratary allall Iakeim accoml? ?(i)Ihe domonstrelon IIkoIIhoodoIIho hooped thlo mum mm 3003! an soaediled mr? Iradi (n desctibsd ii mil Io Wurldoroxhparagephml. suoIocltoswpuegraphIEI. the Secretary oliel dlolribulotho Increase to IhaSacretxyI' atarritcryottha lemorlos. ol? orDislrictIlegInmaeeduignaleN mdornsuchsoclio 332(aXlXAIIasaha?I pawn Io ms IN lo dame he Seaatuy shall reserve the posiIions ava?ia lor (itiibulim Iaidarthis ragraph aa folows: 70 percent otauch positions Iordiatibutiori to hospitals deaabad In clans (1)de to? ?In subperegreph. WIS positionlo I-HS IN as I-IunanSoMcoosheIl Implomonlthe 1988. ms IN to the succeeding pin/alone olIhIs clause. the Secretary shell. by regulation. establsh wihthisclauss WIS ctauea.in witlineech closed hospital): ltatllticeluoeas. ms REQUIREIENT HOSPITAL TO FILL (:8le TE Secretary mayonly I-HS EFFECTON TEMPORARY FIE Sectetary otl-Ieali and I-lurImSorvicas shall ave FTE In: underseclion 42. OodooIFoderaI Roglblioris [as Act) in Such 1866mX4xHXVIdtho Social Security Act (Q U.S.C. IMMXHIM). HIS eligible emitiosloconductdomtretlon proIecls Inormonagaeorbainhigidallmd. FOR INDIAN iverm?y. H-lS:Labor ?Tho Secretary shall. bygraril. contract. orrlteregorlcyegieomonl. proIeds mderth I: Such Iranlng. cemllcellcn. IncIud'lig hedhcere w.Ilielae 'seneed l-l-lS:Labor oasodoritheenlmlonwidoclod MWISIJ holnpontoCowontho pioIocu ??uidorthis I-Hs;Lobor WIS HHS--J une 2017--00078 Sec 5507 Sec. 5507 Sec. 5507 See 5507 Soc. 5607 Seam Seam Seam Seem Seem Seam 506.55% Seam Sec.5608 We: inmdmoemme issuesapao?edinmaxmed?m) ensure humenumberolhotnd mama dernomtma?on projects mdu this I-I-IS Secretary and ?wage penIpretIng States to consult Mm colleges me respeatoacliviliee. ?mm. Miohmay Include oonn'derallond sudtoolegee ae pmnare In such Inplen'lenlation. SELECTION cm?l?ERlA?h States to parlIobale In the mam. the Secretary the! orIterIe Io ensure (If apoimle wilh moodlo Iolne adMIes ImoNed)?' and that Stan Medoa'd planz' exIn'ng traInIno standards tor personal or home (are aIdee In each par?opeflu SIate?" (I) are differed torn such standards In the other panlobalng States; 81d are dIllarenl turn no cure oornpetancles desorbod In paragrapMSXA); ?(N)Mpartioinhg requiredmdareme ms ASSISTANCE ?m Secmry shal crowds technical ??nance Io Sm: In developing written manna): and proboola for such oore training oorrpelenoiea. HIS Semryahudeyebpmmoedmeual oroomrolgrnuphasflu protocol In Mon win 51 Mependonl evaluahn contractor selaoled by Ina Secrelary. ms mlmW- H13 meSaoroIaryshalwmelIo reoorrlnendwombr you 2012. PROGRAM Secretary may underarm under his action Io leaonlng health ocular: lorlho purpose of establishing nun eoorodmad or awarded primary care resldancy programs. PREFERENCE FOR CERTAIN selecting redolent: forgrame mderthie section. the Secrem I-HS no ?1080an In. Secretary Ihal make payment mder Iris sedan for dlraol expenses Iponaenngim?mtiona bylherdevml ewedifmg bodyiarexpamion dexleling reaidencytalning prowarmr I-HS nacalyeermderswualonm). WIS DETERMNATIONOF OUALFIEDTEACI-NGHEALTH CENTER PER RESIDENT AMOUNT. ?Tho Secretary shall oormuialoreach applodmdersedlon 1806(dx3XE)ollha SodaISeertyAamul whoaappllahdaec?on MIOdIheBalanood BudgeIAcIof1997t42 U.S.C. 1395wwnoh))duringlhe praoetilg?aml yearbrmetaedilghedmm?amuud ?(Iii)by mdardause (II). I-I-IS oenteraadehemheda Seam. H18 FACTORS?hmlhoarnounl underparagrapn (1) theSeaetary snaII? '(A)evahatelndiect valuing oomda?veto ewporlhgaprimerym WOW. Secretary I-HS ahoepi?'n WIS HHS--J une 2017--00079 Sec.5500 Seem Seem Seam So?5509 Sec.5609 806.5509 Sec.5509 59cm Sec.5602 Sec.5602 Seem Sec.5602 Sec.5602 Sec.5602 506.5602 Sec. 5701 Basedmsuondetermlnedon. possible. ?Wwamepurpomol section 1078dthe Social Serenity Act sndehel Desmlecl to administrative reviewunderthetseaion In HIS TO PROVIDE AOCURATEAMJ MISSING line Seawtry and promuim reghtions I: carry on this section. IN Secreury we! eelsuish gredlm nurse eclacstion Indsr title oi the Socld Security Act (42 meoglble hospital my receive payment lorlhe hospital's reasonable costs (described i1 paragraph tor the provis?on 0' quali?ed clinical training to awenoe practice nurses. i-IlS WAIVER es WIS demonstration. desabed in (3)17Ieoosts to Ihe Mediate progrun uncieriitie XVII relevant Ioeligibie? underlhe exoeed$50H000000loreiiscai ensure that the scam payments do not amused such smoum WAIVER OF REOUREMENT HALF OF TRAINING BE PROVIDED iN NON-HOSPITAL WNW-BASED CARE SETTNG IN CERTAN Secretary may waive the requirement mder th wilh respect to eligible hospish looebd 'n rid or medically underesved arses. ?Seaetary'isneil outwith. I?sougieneoow cornprehenu?ve section 330(b)(3)ol Ihe Public Health SeMoe Act (42 U. S. C. )2540ibx3?: (8) neelh protessions shortage areas under section332 l-l-IS FACTORS TO OONSIDER. ?ln establishing the methodology) criteria mm (1). the Secretary? (A) shell Stetemd mdreglonsl Wmelbaedemties). Stsleheellhoflicesm munityorpanimions Monikemdothairmroshdpartiee; ?(Bishalltakeirb eccouit?(iHhetirnerlvdebilityw (siti'Iemoectot ms PLIIJCATION OF arry?ng on the miernsking process Indsr this attraction. the Secreury shel publish enecenentollhis Act. ms RILEMAKNG COMMUTE AND ole undereection United StalesCode. by sid(2)lhe Ihecomrnmee. WIS reports make ooneensusoris butissmieaho In sum deeigietions pursuemtoeudimies and coneietentwiththis section. ?is MICATION OF RULE AFTER PUBLIC cement. ?The Seaehry shall provide lor consideration at such comments PROGRAMWIZE) ?The Seaehry. acting the Administrator she! and grants and moperetive to eligible entities to enlish dsrnonlmion projects torthe proviicl'l otcoorrineted end integr?ed servIoesIospeosI mental and behavior! health settings. His Onenern?basis. mdtheetfedvenessofsucn MS HHS--J une 2017--00080 Sec. 5701 Sec. 6001 Sec.6001 Seam Sec.6002 Sac.6002 Seam Sec.6002 Sec.6002 Sec.6005 Soc. 6101 See. 6101 Soc. 6102 Soc 6102 Sec. 8102 msdeedhaMHunmSeMc-emaymn. rmdebymini?e WIS Sensury mall sun?sh and inplamait a process mm an Wis hoop? (as Much sum may applyiorm requiem mm Ihan Juiy1, 2011. ihoSecMaIy shall Wis regulations to mywlihepmcus under douse HHS OF FNAL later than 80 days diet a comma epoicelion moor Iris paragumAheSecmurysh? wbiiahinmaFedamlRamim?nd dmw'mmpacnowch ?nalisation i-I-iS couecnou OF OWNERSHIP mo Investmem Inroammu ?Fov ammonium W0) and (om ,?ana hoepilal. ms mm?dmbed In amnion (0(1)de 1877(1th Sodal SewrityAct. a: mammals. ms 2013. inauchelecimnicfovmanihe yeec 2011. iheSecveimy shaledaulsh W11)th mufaciumand gmuppudiuingolgmto abuc?on '(ij?meemylomakewchidorm?muQM Madman tolhepwlic. OGJSULTATIOM?hembilehngme pmoeduee minty mummwm.? lamina-Mod 1 010mm begimingmn 2013. me Seaman! ubmilno includes the i-l-iS Sepambaw. 2013mmJum30deedicalendaryaamm. Mansubeec?on). ms PROVISION OF bene?t plan or anyway that WW bene?t mangemenl Wmawmactwim? awpiliothAorualiz?wduingan MS men?ehedhmaFedemlRogim ihefadity'e shal assimtoSlaIes onhowloadoptlho ?Mixed unit! mm (A). ?is mderihiepaw, iha Such shell laud- chminqueliiy wrenchr 331m" Secretary and pmmuigu moons Io carry on this subsection. ms 2017--00081 Sec 6103 Sec. 6103 Sec. 6103 Sec. 6103 Sea 6108 Sec. 61% Soc. 510:; Sec. 6103 Sac. 6103 Sea 6103 Sea 6103 Sec. 61% Secu 5103 Sec. 6103 Sec. 6103 Soc. 6103 Soc. 6106 Sec. 8103 aspanudlhe ?M?igl-IarneCompare' Medicarembellenorasuocessor website). pram unmadonatimety basil. easily mai?y WIS IN GENERAL. ?Exoepi as mm dam neSeoreiavysmIl ensure Ihal vie WWH enmmofmlaauboedlon. Indudedonsuoh imlementad. INS darityof iimellneu. 8!!de onmnlolwssubsedlon: Iomodw l-I-lS ahd oonaquIIh?' msmlong- '(Iliiuowdumdungpe; and delerminesapproprialef'. HIS Mum man quarterly?. ms IN SecreIary shal conduct a spea'al focus ladliiy pmyam lorenloioemem oi moment for skilled nursing facilities that the Secretary has Iderli?ed as hav'ng whatanlialy failed to meet appieable Iaquiremerl of this Act. lees than orIoeevelySmonlha.? aspandlhe Modicarsbene?dailes(oom momnfuredloume Medlearewebelionorasuoousoi website]. no lolow?ng'Nonnaa'on In a manner dial is prom?nenl. upmaonalirnefy basis. easily accessible. ready IN as ptwidad In dauae he Seasiary troll ensure the inhalation dewlbed in MIMI: 1 ol Ihls subsection. WIS 'ndudedonauoh implemetmd. "(i)lomnewlheaoancy. darltyolpruen?lallon. I'lnalinesa. enau'nenlahhls hornodily I-HS CONSULTATION. ?In com the under Mann (All). the Seereiaiy consul wim?? Stale Iona- cave Mann slogans; omsumer advocacy grows: providu summer gmupe; skilled Inning Iadilyarmioyaasandmeirraprm; ?10?de Wmorgmwalhe determlnes W31 WIS mutat?'resgaalary haa idarli?adaa luring mm?ally?adbmealmplimble requirameruo?hiaAct. PERIODIC such program? Scotsman! oonw surveysoleach lecillry in me program not Secularyd?eolhmd his submie Mandtoaslhe mpowonnpommrawooesaorlumionme nursIng Iaolltiesand nursing bullies and In Seam anal. Ilpoeslble. Include such Inlame?onmNusIng Home Campus. DEVELOPMENT OF CONSUMER RIG-ITS PAGE ON HOME COMPARE Ieteim1yeeva?ammdenmmolwsm Medioarawabaitedwebpaand hcludesaoumnarighla Nonnuion pagemal contains links todaeu?mione and Intonation wlli respect lo. WIS HHS--J une 2017--00082 Sec. 6104 Sec. 61% Sec. 61% 8996111 Sec. 6111 Sec.6111 Sec. 6112 Sec. 6112 Sec. 6112 Sea6112 Sec. 6113 Sec. 6114 Sec. 6114 SOC.6114 Sec. 6121 Soc. 6121 See. 6201 AVNLABIUTY OF MORMATICW ??lhe Searetayshal establish proaedureela ilarmetian on lemi?ereatedpa meemanmmeetawledtam reqtlrernente as the Secretary may spedy underline procedures establlehed utderlhre paragwhf. INS compla'ntlormlorueebyuore I-I-IS SUBMISSION OF STAFFING IIFORMATION BASEDONPAYROLL DATANA WORM not ontuaman programs. aanlumeredvaceeygrawa. plurlderetelreMIder grows. employeeamd Searetaryln Mariam :uahpragrame. groupe. anapames). Sum specl?aatlane shallrequelhatthe ms WONOF CIVL MONEY PENALTIES NCERTAIN ubdauee (II). in I-I-IS COLLECTION OF CIVIL MONEY PENALTIES. ?In the case at a 0M money penatty "weed under clause. the Seam shal mregtletiansth HIS OCXJECHCN OF CIVIL MONEY the case :1 and my pendty inpaeed unda this cleue. the Secretay ms (?tam-I HIS Seaetuy shall aandu'a he prq?ect mder thie eedian fare 2-yeer perlad. WAIVER Secretary may such requirements at we: XVII and )0on the Social Act (42 seq.:1396et seq.)asmaybeneoeesary Iarlhe purpaeealaerrying outhe dean-union prajeat mderthie nation. Secretary and I year ms Secretary the! evaluate chem selected to partlelpale In the aernonwatlonproleat maerths ahaln that lncludeeamnrbero?aa?ea parttatpatng In the "Speclal Focus Faulty" program (ova I-HS WW 0F PAYMENTS RESIDENTS Secretary may. as Ihe Secretary delennlnee appropriate. reloceIea. IN Secretary the! conduct 2 demonetmlan pralects. 1 tarthe devetaprnerl dbest practloee In skied nure?ng facilities and nursing Iacllillee that are "mama it the GM Me muted (braiding Ihe developmental handingin atdertamdertakeadtued?nngennd Iarltedevdapmantafbeet practices In eklled and lathe use a! Irlarmaean technology to lnuove malaentaare. WIS theSecreIeryehalmdl or the? albest ?In (almreepectto Ihedemarmtianprojedim ?oatedintlurnp- eumpayment. I-I-IS legi?a?anamm?vaeatianas?n IN IsrquAme) atlhe Social Sammy Act (42 use. re attended by Inserting In be case at Inltlal tre'nlng and. II the Secretary delermlnee eppraorlete. In the case oI origohg lra'nlng. derner?la mm trairilg. ma patient muse pvm?lan Ming" bin I-HS IN GENERAL. ?Sectian IQIQUXZXAXIXIJ the Social Sewr?y Act U. S. C. I: amended by In he caee and. lithe Secretarydelermee appropriate. In the caee dorm below". I-HS IN GEIERALFTM Secretaryomeeltnend unmSen/ce?lnmeectlon IeIeneatoesthe ?Secular?. shall such prowemshall berelematoae me"netlamrlde program"). WIS HHS--J une 2017--00083 Sec. 6201 Sec. 6201 Sec. 6201 8996201 Sec.6201 Sec. 6301 Sec. 8301 Sec. 6301 Sec. 6301 See. 640? Sec. 6401 Sec. 6401 Sec. 6401 Sec. 6401 SOQMOI oond?imeslheplotme rmmeeaimJdeeMedIoaremmD'w humonLewModenmon AddM(Pubich1OB-173: 11731112217). Wynne ethorIzeeon dlhe of pmheebyemsme (b)(3)(A)u1d (111(6) Ieepee?vely. of mumnaar INS PARTICPATNG STATES. ?The Seereury ehellemellnto weemenuw?heech State? (I) 01.11138me has (cX1)o1wcheec1ion307 bedgound chedteu?uherl?au?demmemebeeisz I-I-IS CERTAIN PREVIOUSLY PARTICIPATING STATES ?The Seaem shell enter Imo WM and: Slalo? matineSecreIary unseat-on amuchonw?lmambesis; INS I-I-IS Resemmou o: FOR comuc?r OF Seam my man not more our. 9.000.000 ms Mthapprmeefwdsiuplm. esweles orpnmeenms. ms BULDNG DATA FOR RESEARCH ?'l'he Secrecely oonweheneive mm. haderiodeveiwa?nu?nhha wmdemMMeu?e?eaim?unmuluweme. I-HS IN Secmery Trust Fund under amounlequutoSI bene?emdetpenA. umledunder 2015 2016. 2017. 2018. end2019 an ms ae? wmm. LEVEL OF Secretary ehel the leveI demon-19 conduued under this mean prider 01 medical or oIher items or eervioee or euppier. ruse (I) for2010. $200: I-HS EXCEPTION. WAIVER FOR CERTAN REDICAID Seammey. on basis. reeulinehMJhe I-HS EXPEDITED Seventy may Win an Imenm final rule Io any out 1N: new. WIS Society may eeIebieh by plogrem ?nsimdkin oroiherwiee the procedures under his peregeph. I-HS mmpaegreph?). I-HS lNENEML?NmmenyoherpMmofmie?ue. ndu?ueebgorieed mdetheMedieeid Vegan. I-HS Immpeato lieWmm BWhenemounlequalIo? 101012010. yea. them United Slelee I:in mageHthen-monlh WIS HHS--J une 2017--00084 Sec. 6401 Sec.6402 Seem 8996402 5316402 Seem Seam Sec. 6402 Sec. 6402 Seam Snows Seem Seem 506.6403 Seam Seem mmuprovidensruppiele. WIS IN Secrelery .meSeaeteryshall HHS INCLUSW OF NAM PROVIDER Secretly shell undel l-I-lS may WIS such payments. ms Secleuly ehel consult with he lnspeasr Genelal the Depa?menl Health aid Human H18 PROMLGATION OF Secretly shell Wis regulations so any out this Mon and seam 1mix2xc331 ms shell evduee'sns cl eligible enti?ee Mich he Secretary soaked: with under Secretary shall conduct cl eligible entices Mich he Seclelery contracts will: undel i-l-lS Cue (42 U.S.C. 11101 ?ln ilwlemsnling Ihis eeaisn. ?Secretary shall plovidsluhemsximum mam. DISCLOSURE ?wnn meSecrelary mu? ?(A)plIMde slheelr?ythetielhesubjeuslme and' MS hedhwe FEES Seclerarymey sewsnlefelledtseuhe Secreuy' U.S.C. 11101 el ms Seam she. We 10 carry on the made by subsections and HHS--J une 2017--00085 Secslos Sec. 6407 Sec. 6410 Sea 6410 See. 6411 Sec.6504 Sec.6506 Sec. 6507 Sec.6507 5&8507 Sec. 6607 Sec. 6507 Sec.6603 Seam Seam Sece?os brapnysicianorewpller nadicacheni?c-?onsbr We. as seeded bylhe Secretavyf'. WIS Fm FACE TO FACE ENJOUNTER. ??lhe Seam and require lhatsuch maderbewtilen pureualioihephyeiu?an docunen?igihal apnyaiu?en. a phyaician auiatent. enuree practitioner oraciIical nine ao?wm?lehnelmneaadebrrnined btheSecIetaty.?. MW provide branyoflhetemecieadeaalbed'n oranyplomerov ?stapler Mm mowin?onJ-s WIS EXPANSION 06" ROWD 2 06" 11f DME OWETITIVE BIDDING the Secretary stall Include Ihe next 21 levgeel When sleuellcel areas by Intel populeilon (ear nose selected under (0) lot such round: and?. l-I-iS TO Ema? BID AREAS OR USE COMPETITIVE BID PRICES BY 'n 2016. Winclm?i)?. addincnalcoveledmaieohaeedinor infonmiion' Is iadaled as made wider section 1847 are reconaeied In accordance with seciion ms such magi-am Is called out accordance with such requiements as the Smy shal speclfy. ms IN GENERAL. ?Section In. Social Secunty Ad (42 u. s. 0 139mm mm is 20?, Insening diet lheiolouing: andinclading. 2010.deia pagan Wt and at such Mano] as the Secretary shall deem". CORRECTIVE Am. ??l'he Secretly piomulgale ?lotions Ila! ream Slates lo curred Federally daimeoveipeymerls. danonguacnedirringraun. eageudiis. orodierepptopnaeconediveedlm (1X8XivL?IeSeaetary shall clothe Wig: Notlderlhan Sedember 1. 2010: convalbleio claim ?ed under this title. l-l-iS 2010 reepedbiilieXVll. l-l-lS shall oi??(lnhemeladolooee ccdingmeliodclogles WEB) l-l-lS For of pelagraph Ihe Sodomy shall do the mbluwing: Molly States of? how Staten ale to Willem methodologies lnic dalme led under his 2011. submia ms u'Iibnn mpa?ngaiaidamhaudi referrals". wavering. orpmeedninghiduaabuee. adopitegihbty danderdeesubliehlng. ihelawad?iesm?heahwhidiaudi Mam fiwililnihe meaningollheienn ?muliiple enaioyerwelare mw?mder sedan 3(40 IN Secrelary may issue a cane aid desist (ex path) order uIderlh'a lilo were no he planer ?in ?Wiepubicin'ury. Liar (e)rnay seclon. inducing all related lniomlionaidevidence. beconduded in a con?dential manner. Labor HHS--J une 2017--00086 Seclesos 89cm Sec. 6607 Sec. 6703 5318708 Sec. 6708 Sec. 6100 Sec. 6703 Sac. 6703 SOOGTOS Soa?m Sec. em Seca 6103 Sec. 6703 506.6703 Soc.8703 Sec. 8703 anmunehnd?lyhawmm. ?(dlmewWeWNIWmm?eqmbn ?Whine any dMMen??eaormeiagm. consultants. or employees: "(IIASmeinaurmae "(2)Asmaalmmeygerwal Ineurenae Cumisslom ?(5)TIIeDepemIem dine Treasury "(6)de PROTECTION OF PRIVACY. Ana-1m nominee unde' mi: euinIIe the Seaewyshell eneurelne prolecnon of MTMUquJplicabla local privacyragla?one. SOLICITATIGI OF NOMNATIONS. ?The Secretary shall publish a notice In he Fedevai Mediating mm Seamy ahal promigah guidelinee to redeem-Iain waning In Ihe nee ol alder abme. mwepriu?on.mhlmeemwhmu?edpmm STATIONARY FORENSIC Secretary shall make 4 the want: deecribed ?l1 anaemia-I lo inetimb?one aimeducae?on wilhdemoneireied expertise in Io Mormeider shine. negieci. or exploudon. to when and operate stationery forensic calm. MOBILE perdierninlieuoleibeietenoe. Board. Mencken 13420lmle31 UnidelaIeeCode mendiyshailwmeneppiice?onblhe Secrelaryaisuchlime. Ineuchmannet. ar'doordairingmeh wbpcaorephmeligibieernityehal utmilan appialion ac?vitieeludedmderhegani STATE Emma?Each ubeac?on and ?section, be aliwa In moaiva a mdar lhie eubeaelion. a State shall aubmit wplica?on lo the Seam at such lime. In such manner. and oonieirlng such Infonmnon as the Secretary may require be ?le In mauve aaemanee Inlet (IXB), entity anal eubmil an applieawn to line Secretary at such time. In such manner. endoomlning was We: he Seam my require. mlnge pmpoedluhe mm. end? IN Secmuuy ma! early out aaivi?ee. lncluchg acIMliaa deserted In pangraphe (2) aid (3). I0 provide mamas Ior ?Mauls lo rain Ior. seek. and mainun empiwmenl pudding dlied are In long-lean care. HHS--J une 2017--00087 Labor Labor. Tneaeuy. Jueliee. ms I-HS MS WITH SECRETARY OF LABOR TO All) TRAN LONGTERM CARE ummla Sec 6703 Io train for and soak anuoymant providing dlnaoi one In long-lawn care. ms. Labor basadonobaaivaddhleai mhiavaoarli?caiion Sac.6703 moor-whom Sac. 6703 ladinioal ms Sacralary an" Io anaura that ha acthlas norm-clad using runes made available unoar subsaollon bonsai Indlviouals mo mdlnol can and Incraau Inn San 6703 may of he long-harm cam wkforoa. l-I-iS ACCOUNTABUTY MEASURES .?Tha shall davalq) measures to ensure that the aciivltiaa oonouaad uslngiunoarmoaavdauaunoarmls subaaollon halphiorovapananlsalaiyano maximum? $318708 rasull?ngfrommadcaionanors ms STANDARDS AND Sacratary shaI adopt electron-c standards Ior the exchange oldinloal data by long-lam oara laolliias. Inoluolng. whats available. standaros for massaging and nomanclalura Standards aoopiao bylhaSacrataryundu standarm aalabllahad mdar ubaaciiona and 0! section 1W. mndarda adopbd undar aaciion Sac. 8708 3004 oi ma PIblIc Haalih SaMoa Adana Whoa lili'niorma?on homology standards ms shal promulpb raglations lo carry on this subaadion. Such W8 Iaqulraa Stale. oolladlonandrapormgaa Soc. 6103 ma Secretary daiormlnao an my lo sallsiy Illa raqulramams of this subaaollon. nagoct Sac.6103 andawloitailonoi INGElERAL?ThaSacraiary ?(Blcolacuand aprila?on Sac.6703 ofJuIlioa." l-l-iS l-l-iS IN Secretary anal arm that ma Damnani oi Haailh and Human conducts Saq?m IN Saomiary ensue llIal Ilia Dapulmanl oi Haallh md Human Samoan??(B provides lachra'od lnclu?igihrough Soc. 6700 grams nude undar ansaouons and I-HS is mu 31 adult pmlad?wa sarvima grmi program mm Ilia Sammy shall annudly ward 9m to Slates in ma amounts calculaad undar puagraph (2) lorlha ofanhaio?ng achill Sacl6103 MS (m1 (Alforasmaluallsoaiyaarlslaas Sec.6703 PRO mmWralaradudionsbihamumdawbad In Sac.6703 ESTABUSMNT ?Tha Saorahry shall ward grants Io States for ma purpooas oioonouciing oamonsva?on prowams Sac 6703 in paragraph (2). IN Secretary ma! make grams Io algole Was with ralavani anaemia and amarlanoa In abuse and Sac 8703 new in long-Mn caIa ladlluas or long-lam oars ombudsman program and rasponslb?ias. lot Ina purpose oi? His Sac. em aldar abma. naglaoi. maxplolta?onlornam anomalous and Slala ms HHS--J une 2017--00088 Sec. 670:) Sec. 6703 Sec. 6703 Sec. 6703 M8708 Sec. 6708 Soc. 6103 Sec. 6703 Sec. 6703 Sec.7002 Seam Seam Seem Sec. 7002 Sec.7002 506.7002 M7002 Seem Ispon?. INS EVALUATIONS ptw'rhdin ma). the Secretarysh?? "(Mme potion (not less I-I-IS FoderalheelIoate pmgvamule His molem'undmpowianon' ?autism mayInmdo? '(?IJnoaland omnIc mlnotIIy unnamed beenusodspoddnoodum as language berm. disabii?ee. den statue. crepe). PENALTIES FOR a long-term are Won (A)or(8)oim(1)me facility HIS ms Sammy shall cowuct We? and: damn nude under ?coon 20410;). HIS Notlalermnoaobu 1. JusIIee Cowman W.wm00mmlmem?wofm86mmampm? I-HS omdwed umlerthia mu INGEIERAL. Secretary may. after ,forpquc Issue, mm. excepts 910mm ?mam. wIIhsodIon 7D1(h)oIlnoFodorII Food. Drug. mCosmeIIcActhIhmspecllolho Iowaureolabidog?celpmductmmis lam. l-l-IS Wotanappica?mbnimnse asptohdunmrmis mmdmaWMIaaquomeJmem subsodion. mama shall license he biological pmduc! muenhia subsection 3? the Seventy datum um the intimation minedn H-IS bIologo?pmnhaa anyoonaonduae IheSecIetaIthal bioeimilshobo?mlprodudbbe au?nInmaotIon inmned ?Guanine! the appIIoanth muted mo appiu?on lathe ?rst waved Imus bIoIogIooI or he wIln or ms WguIdmoe. I-I-IS ap?m?onsubni?edmdersoc?m 3510001810 PIblIc HealmServimAd mmredvomoygmwe: and MUG REVIEW OF RECOMMENDATIONS. -NIU monotone win the Industry. the Secretary mall? (I) WMJIOMWIMHWHIW mw; monsuch Wm; msucn manduiomasmeomy. RECMENDAHONS.?NollatarmanJamuy 15. 2012.1heSecteury?IalIruuniIlo Conga" Ute-wad mm under WW6). mummw 2010. lheSeaetuylel 3510001010 Pw?c MSoMooAcl (as Momma: penoa. MS HHS--J une 2017--00089 Seam Sec. 7002 Sec. 7002 8997002 Soc. 7101 Sec. 7101 Soc. 7102 Sec. 7102 Sac. 7102 Soc. 9001 Seem Sec. 9007 Seam 506.9009 Seam Soc. 3110 3510i} WIS mm. and Slabs Maaden 31 WSW lily. HHS ThoSooroiay paragrapMZXAi. (2x3). undor i-I-iS pieblamin (B). (L) (M) (NJ. er(0)eiwbaaden(ax4)ihaiia program mmuliipie options forourchaaingoworod dmoaiorinpoiionia. by uulizinoamwrohosm mino?moroihormmarrw pitchuing pmgram maimdy?unanmuladimr. and any char purchasing MS Fmamunbwepnabdmdarpuagraphm pricing mm speci?ed in ibis section. meniawep?aiodu?erpmrapbm mailprunlgab anddaimabyrnamfadirara. remedies Wartimddolonninm pumamiie EXCISE TAXON HIGH COST EMPLOYER-SPONSORED HEALTH COVERAGE- The Sammy snail mica web Trauuy raidivaioihai?minmd Treasury homer section. induaig ruloaio manila-?ve reporting Trio-wry mwmo?bia ubBaden indutiig ?Mia iodaiuniiaihaali?ailityofa patiam Truly Treaty-Ramadan Truly-Wm Tawny-Mam Treasury HHS--J une 2017--00090 Sec. 9010 eouroeo?nlomu?on walleblehomeSecretery. TheSeam end wbleh sec?on. lnduaig mama Sec.9010 Tremuy REGLLATORY such, rulee.or are In Sec.9014 mph". DISCLOSURE OF ALLOCATIONS. ?The Sunny smell. upon making a mum under this subsection. publicly Sec.m23 Treasuy meSecretaIy shell Issue Iegulelonehodetemme Seem Treasury APPLICATION paregm'uh? Sec.9023 Tm u'Idenhis Season swam. Treesuy Sec. 10101 he needed services 13 made evehble with 'lnpect on ptemiune. Sec. 10101 Depamndeedhandi-inmSem exceptmatmeSeaeterymayechh See 10101 mam-imam In euchSlate. H-IS Sembty may adjust the rates deserted In subsection If the Secretary decennlnee Sec. 10101 apprept'ah on accoum dine volatility dine market due no the Mme" of Slate Exchanges heureneeiewet. in eection. lo be In oompiimoewih the eppicd?e Sec. 10101 pm mderewsec?on as detemmed by the Secretary". ms Seam ehal plon'Iulgae regt?ione atoning he pavilions ofmie action md may Sec. 10101 {amide WW pemlhee. WIS ubmiuuch Sec. 10103 dcongeu. L?nr Sec. 10103 HIS.Labor RUES RELATNG TO PAYMENTS. ?The notice described l'l aim-arm (A). any Banning need by the iamerwith reepedlomeplan. Seaway See 10104 2013. Sec 10104 mmwweim?u Sm-lamdmmaaply. H15 mm We. Sec. 10104 and grain MS 2017--00091 Seci 10105 Sec. 101% Sec. 101% Sec. 101% Sec 101% Sec. 10109 Sec. 10109 Sec. 10109 Sec. 10109 See 10201 See 10201 Sec. 10202 Seci 10200 Sec. 10293 SOC. 10212 Sec. 1021 Sac. 10301 Sec. 10301 IN Secmary dial condudaeludy loexan'me hhabllitymd imlicalion dadiuefng me ?memtma?usMbm. edpetrnem. Treuuy IN Secreiery United We eheremderpemgwhuxCer). Treuuy euohperiod. WIS 2012. mdnotleu Mmammree?er. aduerminedwpropnuebvaeSecrewy; end' ms Sletie?oe. HeeIh lriorma?m Tedinoioqy Policy Committee. and he Heelh lriorma?m Tedwnology Slendude Comm: and "01) standard setting organizations and stakeholders. as detemrmed am by me Secretory! Jamar?. 2011. sWiMoheeMphne. Revuensoilhelnterneuonei 013390130de make reoommendetioneabout meSeormmalnronulgaeW andmnuliheSh-teievd. Mimpubicheainge. end' '(IiWIespecific ms fordemomtetion projecumderlhie section! TheSlaIe shall require?. SeouityAct.? MS iheSeoreiery shaloomwteasme allotmen?oreach yeaeefolova eh? MmitmiheSea?eterym admir?ta?ono?ndingrem?ved Inderihie pm. aidemerepi? 1395(0)) qud?y due. "(CHheeIrweure payment adjustments. inohding memoir-teacher ms HHS--J une 2017--00092 Secl 10301 Sec. 10301 Sec. 10303 89910303 See 10303 See. 10303 Sec. 10306 Sec. 103% SEC. 103% $96.10? Sea 103? Sec. 103% Sec 10306 Sec. 103% 891:. 10307 See. 10307 Soc. 10307 Sec. 103? end?(B) M-Ieveloummeureefor hoepiiabmd phyeidane. uwellaaomuuov?uaumw?uebymm HOSPITAL ACQUIRED CONDITIONS ?The Secretary emll. Io Ihe extent practicable publicly noon on mm 10! hoepluleoqulred mu ere ounenvy by me Centers Ior Medleere a Medicaid Senloee Io! Ihe MW "Seam Cleer'nghane Wm?: Wheelbmommln?ons. ?manna Imellneelov? r? dale data" manmmelhods. msmimugn wchcolealmandamme?mm me remnawaemance Ili?nlormalion IedInobgyeysIeme. MWlnoneuch bdindogy systems. and related ?manna. WmminWImedwolpe?entpopih?one undeIINssecIIon. aid eer?ig?hu whpaag'mhmy'ndude butaanotlirnitadb" :Id?)byiw?igahrh?mmlha Wrigneweentenoe: WIS hwemenl and palientcevleved we win the deemed In INVQVEMENT PRIVATE PAYER AND OTI-GR mm PARTY Secrelery may ?ve mm In A00: who I. pani?m?ng ln elmily mngememe wih other peyote. TREATIIENTOF PHYSICIAN Seamuymayminloan EXPANSION?TheSeaelermey. alenypolnlelermuyl. 2010 IoII'IeeIdamdehm'Iimd Secretary leewededlo? ov Sewinuoer??ae?utewhmeion muld mdwepmg'unlpu?ingu?a?eudi tide Individuds.": HHS--J une 2017--00093 I-HS Sect 10309 Sec. 10313 Sec. 10313 Sec. 10313 Soc 10313 See. 10315 Sec. 10315 Sec. 10315 Sac. 10315 See. 10315 Set; 10315 Sac. 10315 Sect 10317 Sec. 10317 SOC. 10317 506.10320 M10322 Sac. 10322 The Seam and nuke payments [in eddion to the paymam described '11 paragrapt'l (2Mxii)) for men a dimme to such hoepul under subsection (or section 1014(0x3). as the case may be) In an amount equd to the product at. WIS smeot to he sucoaeang pm subsection. the Secretary shall conduct thaaemonatratm program under aubudim(a)(2). w'ahlowpopibtiondemnbe Seaetaryu?ereumubeectiontom. HHS which Statutotndwe Insuon superman. theSeoretary shall meme same Saaotn'ymayspaaty bacont'luasuch portidpationmrd WIS auchaoma ms January 1. 2015 H18 ,lcalMod TrustF und ?under 8.500.000.0th period d?eml years 2015 mm 2018. urchaa?' (I)payrnent Warm hlmlevdeoleevedtyo?lheaa: ms ammtocaro; Medica reand (D).poaenyetatuo aru' Sm. IN GENERAL. ?Suh?act to (D). Iaklng into account the results at the study emanated under pprupriate. for de I-HS BemonAprlt. 2010. reclassi?cation. IhaSacretaryatI??nardetham redasdledwaoelmlex ms umpenodn. Boaroor ubaequentratayear. ms HHS--J une 2017--00094 Sec. 10322 Sec. 1032 Sac. 10323 Sec.10323 Sec 10323 See. 10323 Sec. 10323 Sec. 10323 Sec. 10323 596.10328 Sea 10326 Sec. 10327 Sec. 10327 Sec. 10329 Sec.10329 506.10330 Soc. 1031 Sec. 1031 ms DEEMNG. ?Fov waoses cl eligibility iar bene?ts under me. he Seam-y may deem an afbdad' A insubsedian I) meet Ihe aandians speded ll sedan 226(8). l-I-iS comprehensive. HHS MeaeallnsuranaeTvusI dumimmwumcamum l-I-iS mderihisii?e. ms The Secretary dam ellgbuity iar pilot pregame under subsection ms OPTIONAL PLOT PROGRAMS ?m5eaeurymy establish a mammogram. Inseam-mm this ubssdan. In each such eves. ms piiatpragsnnunder this subsedan mosm end sedanlamdte aompel?ivegmbhaeli?ble amines Ipsd'iedhubeedanmnarmepumased? Wheelhaanaans (esde?nedln subsedan end' '(AwIe ,d nae?muaganuruermiseedon "(8)1he (Medan. md? (C)iheavdabilityalMedwebene?Is aem'n individuals (?gmeed wiih environmental health aandiiane Indersectian 1381A WANER as l-l-iS unsedanJaiheextent mWeWby me.Seaetaryif? memqm MalnundeenMca?oanampI-eame assessment. I-HS Seau?yAct ms Natlmrihan 18mm? dudenadnendihis Act. IheSeaetary shall suhni'lbcangessarepan l-I-iS hedhinsuranae By Natlelermenhrmecyt 2013. 2012. the mm ?11mm. peandrfarnlmae sedaninemennatnet misgumomemecyaf ms HHS--J une 2017--00095 Sect 10331 Sec. 1031 Sec. 1031 Sac. 10331 Sec 1032 Sec. 103.12 Sec. 10333 Sec. 1033 Sec. 10333 Sec 10333 Sec. 10?07 Sec. 10407 Sec. 10407 Sec. 10.07 SOC. 10?07 506.10.? Sec. 10400 Sec. 10009 HIS I-HS FINANCIAL INCENTIVES CONSUMERS nothterthenJanuayL 2019. topmidelinancielincerliveslo Medicare bene?ciarieeberequredtopey Whose bene?clerieewtmom ms meeoneblemlo ?performing phyeiciureoraeeteiralidineq?ee uncbreuditi?e HIS ms IN ?1'he Secretary may magentebeiple entiieeto eupport commun?y-baeed ooilaboretivecae I-HS subsequent years. based on the the Secretuy may prune renewal grant: to prior year grant recipients. I-HS GRANT FUNDS To HRSA GRANTEES. matmaybesoenton HeamReecuces ?Services lnewerdinugrem. income indvidude. and 103 county or municipal otneeIIn. I-HS NATIONAL DIABETES REPORT (1) IN Secretary. in ochboration MII the manic State. I-HS (3) Secretary. In collaboration win the Diredor. eheil make eech Report Car: M. ms celeborntionw'lh Stetee. shell? Ideal enddeuhoerti?oetee; Iyeterneinordertoprwideooet- e?edlve. timely. and accurate ?at system: date. WIS INGEIERALW?TheSecreIeryehel oouncls. boadcerti?mtion. mdboerdrecer??cetim I-I-IS IbeSecreIeryeheleltereponontne Rq?neenl?iveeu? Fnenoe and Heell'r Educmion, L?'sor mdPeneionedlhe Serum. IHS ESTABUSMNT ?The Secretary shell mm grams to eligible endows to provide heir ?moms web access to comprehensive Woe prey-ans (as detached unar subsection amine Programs. I-HS mernberseopo'erted HHS--J une 2017--00096 Sec. 10409 Sec. 10409 Sac. 10409 Sac. 10410 See 10410 See. 10410 Sec. 10410 Sec. 10410 Sac. 10410 See. 10410 See 10410 Sec. 10410 Sec. 10410 Sec. 10410 SOC. 10410 See. 10411 Soc. 10411 Sec. 399NN IN Secrelary dial mpoinl ?ndiviauds Io lhe Baud based solely upon he established record ofdlel'nguiened IarvIoe one ollhe area demenlea described 'n mute Eadi 'nIivIdId apprinad lo the Board be Werner! and have Dread Inge dlsoldlnuy murals. INS ol? basic research: medicine: bioplmnaoeu?oale: (?owery md ddvery 0! medical product: blohfonmuosandgenemerapy; end"(gg products. ?equiv-twang. 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SECRETARIN. mummn?m Secretary shal mate the amoum 01 each mo entity's foe la any calendar year under ms In mlculding lud'I amout 1219 Summary shal Maud: Motility?: natpmmium: when with ms 2017--00100 Compilation of Frequently Asked Questions Regarding QHPs and the Offering of Coverage on Health Insurance Exchanges Issued through January 31, 2017 Legal Advice and Compliance Notice: This document compiles Frequently Asked Questions (FA 03) released by CMS (and selected FAQs form other agencies) related to the ACA. FA 03 continue to be issued and are sometimes modi?ed by subsequent guidance. The information provided is not intended to advise any company on how it may comply with any provisions of the referenced law or regulations, nor is it otherwise intended to impart any legal advice. If you have any questions about how to comply with this or any other law or regulation, we recommend that you consult with appropriate legal experts. Table of Contents ENROLLMENT 3 Applications 8 834 Enrollment File Processing 14 Direct Enrollment 29 Data Reconciliation 31 Special Enrollment Periods 37 Health Insurance Casework System 47 Grace Periods 65 Terminations and Cancellations 70 Renewals 76 NOTICE REQUIREMENTS 96 ELIGIBILITY CHANGES IN ELIGIBILITY 115 CSRs AND APTCs 134 Eligibility 134 CSR Plan Variations 146 Clarifications to 2/27/14 Bulletin on Retroactive APTCs and CSRs for Exceptional Circumstances. 147 ISSUER PAYMENTS 150 Member Billing and Payment 150 834 Enrollment File/820 Payment Data 153 Payments and Reconciliation - X12 HIX 820 165 Reconciliation of the CSR Component of Advance Payments for Bene?t Years 2014 2015 Issuer Payment Information] Establishing Payment Accounts 248 Initial Payment/Payment Redirect 255 Payment Cycle 260 Interim Issuer Payment Process 263 Discrepancy Reporting 278 REINSURANCE, RISK ADJUSTMENT, AND RISK CORRIDORS 290 Reconsiderations and Appeals 291 Risk Adjustment Implementation 298 Reinsurance 432 Risk Corridors 488 ESSENTIAL HEALTH BENEFITS (EHBs) 515 Substantially Similar 528 State Mandates 528 Cost-Sharing 532 Mental Health Parity 540 Dental 541 Prescription Drugs 564 Ancillary Products 567 ACTUARIAL VALUE 568 Actuarial Value Calculator 572 TEMPLATES 576 Accreditation Template 582 Administrative Template 583 1 Updated 1-31-17 2017--00101 Business Rules Template 585 Plans and Benefits Template 588 Prescription Drug Template 622 Uni?ed Rate Review Template (URRT) 637 Network Adequacy/ECP Templates 647 NETWORK ADEQUACY 653 Essential Community Providers (ECPs) 657 HIOS AND SERFF 677 QHP PROCESS 705 QHP Application 715 Marketing 720 State Review and Approval 720 Accreditation and Quality 723 Attestations 733 Plan Preview 737 775 FEDERALLY FACILITATED 807 FFM User Fees 809 SMALL GROUP MARKET AND FF-SHOP 816 Child-only Plans 833 Dependent Coverage 834 Eligibility 836 Small Business Employee Tax Credit 841 Employer/Employee Choice and Premium Aggregation 844 Agents Brokers 849 Rating 874 Minimum Participation Rates/Minimum Contribution 885 SHOP Enrollment/834 892 SHOP Renewal 937 Coverage Effective Dates 943 COBRA 949 SHOP Billing 951 SHOP Payments/820 Transactions 953 SHOP Terminations and Cancellations 1008 SHOP Reporting/Notices 1023 SHOP Logos 1028 SHOP Dental Coverage 1029 HEALTH INSURANCE MARKET RULES 1035 Rating 1038 Young Adults and the ACA 1047 Service Area 1053 Student Health Coverage 1056 Medical Loss Ratios 1061 Other 1085 CO-OP 1100 MEDICARE AND THE MARKETPLACE 1116 COMPLIANCE OVERSIGHT 1136 QUALITY 1144 OTHER 1151 CMS ENTERPRISE IDENTITY MANAGEMENT SYSTEM 1181 DOL FAQs about ACA Implementation 1192 SOURCE DOCUMENTS 1316 Note: Sec. 1557 FAQs (Non-discrimination) can be found on p. 1316 of this document; Source Documents are listed starting on p. 1349 ENROLLMENT Updated 1-31-17 2017--00102 Enrollment General 23. How will the Federally-Facilitated Exchange display qualified health plan options to consumers? Will consumers see all of their options or just those that are ?best? for them? Will the Federally-Facilitated Exchange allow individuals who are eligible for Medicaid or CHIP to purchase qualified health plans instead? A: Consumers will see all qualified health plans, including stand-alone dental plans, certified to be offered through the Federally-Facilitated Exchange, offered in their service area: HHS is developing ways for consumers to sort qualified health plan options based on their preferences. Quali?ed individuals who are Medicaid or CHIP eligible are allowed to purchase quali?ed health plans instead of receiving coverage through the Medicaid or CHIP programs. However, they are not eligible to receive advance payments of premium tax credits or cost-sharing reductions to help with the cost of purchasing quali?ed health plans through an Exchange. (FAQs on Exchanges, Market Reforms, and Medicaid (12/10/12)) Q9: Who is responsible for verifying a special enrollment period? Example: Marriage license, birth certificate. A9: In general, the FFE will accept self-attestation without further verification as it relates to eligibility for special enrollment periods. The exceptions are situations in which eligibility for the special enrollment period is tied to an eligibility event that will be determined through the application process. For example, if an applicant attests to having married in the past 60 days (a special enrollment period triggering event), the FFE may validate that there is a spouse included in the household. (Enrollment March 8th and 11th, 2013) Q10: Notifications: a) Do all notifications come from the b) Will Issuers have visibility into notifications sent/date? A10: The FFE will provide eligibility related notices to the enrollees. In 45 CFR 156, there are provisions describing the notices that will be sent by issuers; including noti?cation of effective date (45 CFR termination (45 CFR 156.270 non-payment (45 CFR 156.260 and non-renewal of recerti?cation (45 CFR We have not determined if issuers will have visibility into the noti?cations sent to enrollees, but we will provide additional information later this year. (Enrollment March 8th and 11th, 2013) Q12: What are the delinquent and termination speci?cations to determine if an individual terminates with an exchange? Updated 1-31-17 A12: If the Exchange initiates a termination, it will notify the issuer via an ASC X12 834 enrollment transaction. The technical specifications include the ASC X12 Version 5010 Implementation Guide (TR3), and the current version of the CMS authored Companion Guide which is posted on the CCIIO website: v1.pdf (Enrollment March 8th and 11th, 2013) 2017--00103 Q3: Are there values/definitions for the Special Enrollment Period (SEP) Reason Codes? A3: Within the ASC X12 834 enrollment transaction, every effort is being made to use existing Maintenance Reason Codes (INSO4) where applicable. In those instance where there is not an existing maintenance reason code that describes the Special Enrollment Reason, the FFM will include a loop in the 2750 and add a proprietary code. The SEP Reason codes are as follows: (1) Quali?ed Individual (Ql) or dependent loss of Minimum Essential Coverage 07-Termination of Benefits, located in the INSO4-Maintenance Reason Code. (2) 0 gains or becomes a dependent due to marriage, birth, adoption or placement of adoption; 32-Marriage, 02-Birth, 05-Adoption, located in the INSO4 Maintenance Reason Code. (3) An individual, who was not previously a citizen, national or lawfully present individual gain such status; NEWLY ELIGIBLE, located in the 2750 as SEP REASON. (4) A Ql enrollment or non-enrollment in a QHP is the result of an Exchange EXCHANGE ERROR, located in the 2750 as SEP REASON. (5) Quali?ed Health Plan (QHP) is in violation of material provision of its contract with the enrollee; AB/Dissatisfied with medical care/service rendered, located in the INSO4-Maintenance Reason Code. (6) Newly eligible for Advance Premium Tax Credit (APTC) or change in Cost Sharing Reduction FINANCIAL CHANGE, located in the 2750 as SEP REASON. (7) New QHPs available due to a permanent move; 43-Change of Location, located in the INSO4-Maintenance Reason Code. (8) Indian; NEWLY ELIGIBLE, located in the 2750 as SEP REASON. (9) Exceptional Circumstances; EXCEPTIONAL CIRCUMSTANCES, located in the 2750 as SEP REASON. (Enrollment FAQ #2 07/02/13) Q12: Will HHS be providing additional scenarios that show the process flow if a customer exits the process before selecting a plan? A12: To help issuers understand how the Federally-facilitated Market place will operate, CMS has prepared written scenarios which describe enrollment related events such as initial enrollments, terminations, changes, and cancellations. Each scenario includes a narrative of the event and speci?c information about data that will be included in the 834 enrollment transaction. The scenarios have been shared with issuers during training webinars and other meetings, and will be useful in their Requirements, Design, Development and Training activities. At this time, we are updating existing scenarios. If we identify an enrollment-related situation that has significant business, policy or transactional conditions, we will consider creating a scenario to share with the issuers. The example in this question will be considered accordingly. (Enrollment FAQ 04/24/13) Q12: How will carriers identify Tribal members if they are not enrolled in an American Indian] American Native plan variation? Updated 1-31-17 2017--00104 A12: There are no standard ways by which an issuer will be able to identify a tribal member, unless the individual self-identi?es in the application and therefore selects and enrolls in an plan. CMS will not provide a ?ag for tribal members. However, we would be interested in further discussion to understand if and why Issuers need to know if someone is a tribal member if they are not enrolled in an plan. (Enrollment FAQ #3 07/03/13) Q: When will Issuers receive further information on the prorating process? A: Thank you for your inquiry. Policy is currently being developed on the proration process. As soon as these instructions become available, we will release them to issuers.(REGTAP FAQ Database - FAQ #634 01/09/14) Q: What are the Exchange Operations Support Center (XOSC) steps to resolve issues surrounding the enrollment of individuals who are in need of urgent care beginning January 1? A: Please contact the Exchange Operations Support Center (XOSC) Help Desk at CMS FEPS@cms.hhs.qov or 855-CMS-1515 for questions about the XOSC issue. (REGTAP FAQ Database - #898 02/27/14) Q: Where have the Centers for Medicare Medicaid Services (CMS) posted Bulletins #001 through #006? A: At this time, Bulletin #001 and the memo containing Bulletins #002 through #006 are posted on the Center for Consumer Information Insurance Oversight (CCIIO) website, REGTAP and (REGTAP FAQ Database - FAQ #1325 4/1/14) Q: Where can Issuers access Bulletin #001, ?Amendments to draft Enrollment Operational Policy and Guidance Manual,? which CMS released on December 20, 2013? A: At this time, Bulletin #1 and the memo containing Bulletins #2 through #6 are posted on the Center for Consumer Information Insurance Oversight (CCIIO) website, REGTAP and the The following bulletins are located in the REGTAP Library: Bulletin 001- UpdateToEnrollmentManual.pdf Bulletin for Issuers 5CR 020714.pdf Revised Bulletin 50R 032614.pdf Bulletin IssuerAdiustedPremiums 50R 031314 ._p_df (REGTAP FAQ Database - #1543 05/08/14) Q: A consumer tells the Issuer slhe has reported an address change that does not affect her APTC or QHP eligibility to the Federally-facilitated Marketplace, but the Issuer has Updated 1-31-17 2017--00105 not received an updated 834 transaction. Should the Issuer update its system with information either provided from a consumer directly or in a HICS case? A: Yes. The Federally-facilitated Marketplace currently does not issue an 834 transaction in some situations, such as changes of address that do not affect enrollment, so it is important for Issuers to update their address records manually to ensure consumers receive key plan materials and invoices timely. CMS is working toward a system fix and will communicate with Issuers when it has been implemented. (REGTAP FAQ Database - FAQ #4935 09/18/14) Q: How is the term 'different product' defined in Bulletin 14, Section ii for effectuation? A: Product is de?ned in Bulletin 14 by the ?rst 10-digits of a 14-digit product ID for different products. (REGTAP FAQ Database - FAQ #10758 05/27/15) Q: What materials should issuers send Health Insurance Exchange (HIX) members upon enrollment? Can issuers send these materials electronically? A: Issuers should send HIX members a package that contains a summary of benefits (SBC), a coverage/member handbook, a prescription drugs benefits formulary, a provider directory, information about other coverage (if applicable) and a member identi?er (ID) card. Issuers may also provide members with an electronic copy of the prescription drugs benefits formulary and access to an electronic provider directory. Please refer to page 133 Appendix A - Sample Welcome Letter in the Federally- facilitated Marketplace (FFM) and Federally-facilitated Small Business Health Options Program (FF-SHOP) Enrollment Manual, located at: ENR Manual 093015 v2 5CR 10051 ip_df (REGTAP FAQ Database - FAQ #15236 03/23/16 Q: What are the dates for the 2017 Open Enrollment Period A: The 2017 OEP runs from November 1, 2016, through January 31, 2017. (REGTAP FAQ Database - FAQ #16394 06/14/16) Q: Can the Centers for Medicare Medicaid Services (CMS) provide the updated Enrollment Manual effective date? A: The Enrollment Manual published on July 19, 2016 is effective on the date of publishing, July 19, 2016. The majority of updated regulation coincides with the 2017 Payment Notice effective in May 2016. (REGTAP FAQ Database - FAQ #16872 07/26/16) Q: Where can issuers locate the presentation slides for the 2016 Enrollment Weekly Issuer Call Series webinars? A: Registered users in the Registration for Technical Assistance Portal (REGTAP) will be notified via an email announcement whenever new guidance is posted in the REGTAP Library. CMS has posted slides from 2016 webinars. These slides are listed in the Updated 1-31-17 2017--00106 Library under Enrollment. (REGTAP FAQ Database - FAQ #16838 09/09/16) What is approach to compliance for issuers affected by a substantial increase in enrollment in plan year 2017? The Centers for Medicare Medicaid Services (CMS) anticipates that some issuers of qualified health plans (QHPs) on Federally-facilitated Marketplaces (FFMs) may experience a substantial enrollment increase for the 2017 plan year. This may present temporary operational challenges that prevent these issuers from complying with certain FFM standards that have direct impact on consumers, including consumer casework. CMS intends to provide technical assistance to these issuers, including through account manager support and accelerated resolution of issues. Further, to address these concerns and recognize reasonable issuer efforts, CMS is providing a compliance safe harbor for issues attributable to a substantial increase in enrollment. Speci?cally, for the 2017 plan year, CMS will not use formal enforcement remedies for noncompliance with the casework standards under 45 CFR 156.1010 or other customer service standards when issuers that have experienced a substantial increase in enrollment make reasonable efforts to address concerns in an appropriate time frame. CMS will take into account the QHP issuer?s efforts to cooperate with CMS, address and resolve issues in a reasonable amount of time, and report on the progress of resolution. CMS always encourages issuers to work proactively with CMS to resolve potential issues, and appreciates all issuers' efforts to provide excellent service to all QHP enrollees on the FFMs. (CMS FAQs - FAQ on Compliance Safe Harbor for Issuers Affected by an Increase in Enrollment for the 2017 Plan Year 09/16/16) Does the September 16, 2016, Safe Harbor FAQ apply to issuers that experience temporary operational challenges as a result of the deadline extension to December 19, 2016, for coverage effective January 1, 2017? Updated 1-31-17 Yes. On September 16, 2016, the Centers for Medicare Medicaid Services (CMS) released an FAQ that described a compliance safe harbor for issues attributable to a substantial increase in enrollment for plan year 2017.1 The FAQ stated that CMS will not use formal enforcement remedies for non-compliance with the casework standards under 45 CFR 156.1010 or other customer service standards when quali?ed health plan (QHP) issuers that participate in the Federally-facilitated Marketplaces (FFMs) have experienced a substantial increase in enrollment and make reasonable efforts to address concerns in an appropriate time frame. The extension of the HealthCare.gov enrollment deadline to December 19, 2016, for coverage effective January 1, 2017, may have presented additional temporary operational challenges that have prevented QHP issuers participating in the FFMs from complying with certain FFM standards. To address this concern and recognize reasonable issuer efforts, CMS is extending the compliance safe harbor to cover issues attributable to any substantial increase in enrollment as a result of the December 19, 2016, extension. CMS will continue to provide technical assistance to QHP issuers participating in the FFMs experiencing operational challenges, including through account manager support and accelerated resolution of issues. FAQ on Compliance Safe Harbor 2017-?00107 for Issuers Affected by the Extension of the Enrollment Deadline to December 19, 2016 12/23/16) Applications 20. What information will consumers provide in the single streamlined application? What is the process/timeline for the approval of a state-specific single streamlined application? A: Section 1413 of the Affordable Care Act directs HHS to develop a single, streamlined application that will be used to apply for coverage through quali?ed health plans, Medicaid and CHIP. In addition, it can be used by persons seeking the advance payment of premium tax credits and cost sharing reductions available for quali?ed health plans through the Exchange. In consultation with states and other stakeholders, and with the benefit of extensive consumer testing, HHS has been developing an on-Iine and paper version of the single, streamlined application. We are releasing information on a rolling basis both to seek public comment and to support states in their eligibility system builds. In July 2012, HHS published a notice in the Federal Register outlining the initial data elements that will be included in the streamlined application for public comment. HHS received over 60 comments from states and other stakeholders that have helped inform our ongoing development work. These comments, coupled with ongoing consumer testing, have helped us re?ne and improve the application. Consumer testing and extensive consultation with states and consumer groups continues. HHS expects to provide the final version of the online and paper application in early 201Band will also work with states that seek Secretarial approval for their own application. (FAQs on Exchanges, Market Reforms, and Medicaid (12/10/12)) Q1: Will the FFE allow multiple simultaneous applications to be submitted? A1: The FFE will not prevent a Qualified Individual (Ql) from enrolling in more than one Quali?ed Health Plan (QHP), but an individual can only receive APTC and/or CSR in one QHP. To prevent multiple APTC payments, during the eligibility and enrollment process, Exchanges will check against the CMS data-store (by querying thru the HUB) to determine if there is an existing enrollment in the FFE or an SBE. If there is an existing enrollment, and the enrollee is receiving the HUB will return an indicator that the individual is not eligible for (Enrollment March 8th and 11th, 2013) Q7: Please provide the hours of FFE real-time operation (transactions on-Iine). What do consumers do during FFE downtime? A7: The FFE will be operational 24x7. There are limited hours during which certain verification services provided by other federal agencies will not be available each day. However, unavailability of such services will not interfere with the ability for an individual who has been determined eligible for coverage through the Exchange to compare plans or make a plan selection. (Enrollment March 8th and 11th, 2013) 09: Will the consumer be provided a confirmation email with additional plan information, such as a link to the issuer?s website, after plan selection? Updated 1-31-17 2017--00108 A9: Once an individual makes a QHP selection, slhe will be redirected to that website where additional information about how to make the initial month?s premium payment will be available. (Enrollment FAQ 04/24/13) QZ: What information is passed to issuers if the customer does not sign up in the same session? A2: If an individual does not make a selection of a QHP during a session on the Exchange, no information is provided to issuers. (Enrollment FAQ 04/24/13) QS: Issuers want to use the disability flag to indicate a disabled dependent; and would rather use that flag than the code for ?ward.? Will the Federally-facilitated Marketplace (FFM) use the disability flag in the ASC X12 834 enrollment transaction? A5: No, the Federally-facilitated Marketplace (FFM) is not using the disability ?ag in the enrollment transaction. Issuers will need to acknowledge the term ?ward" as the indicator of disabled dependent. (Enrollment FAQ #8 09/19/13; REGTAP FAQ Database - FAQ #184 09/19/13) Q6: Does the Federally-facilitated Marketplace (FFM) apply age limits on dependents when forming enrollment groups? A6: The Federally-facilitated Marketplace (FFM) applies the age limits submitted by issuers in the business rules section of the Qualified Health Plan (QHP) application for children of subscribers (the maximum age is at minimum 26, and higher for some states and issuers). The FFM does not apply age limits to dependents that are ?wards." (Enrollment FAQ #8 09/19/13; REGTAP FAQ Database - FAQ #185 09/19/13) 08: Does ?ward? (usage in the case of a disabled dependent) also apply to the SHOP market? A8: Yes, the Federally-facilitated Marketplace (FFM) use of ?ward" to identify disabled dependents applies to SHOP as well as the individual Marketplace. (Enrollment FAQ #8 09/19/13; REGTAP FAQ Database - FAQ #187 09/19/13) Q: Will Issuer customer service representatives be required to answer any Remote Identity Proofing questions when completing an enrollment on behalf of an enrollee? A: As indicated in the Pl Final Rule, the FFM does not intend to permit issuers to allow application assisters to perform the assistance functions set forth in 45 CFR 155.415 in the first year of Exchange operations. However, agents and brokers may still work for issuers, as many do today, but they must follow the standards set forth in 155.220. Agents and brokers can help the applicant answer RIDP questions prior to starting the application. Additionally, there are certain functions that issuers currently have their staff perform, such as answering general information about plans, and those individuals may continue to perform those functions. (REGTAP FAQ Database - FAQ #625 01/09/14) Q: Where and when will information about tobacco use be collected from applicants? Updated 1-31-17 2017--00109 A: During the consumer application process, applicants 18 and over will be asked if they regularly use tobacco, and the date of last use, so that any tobacco rating can be incorporated into plan premiums displayed on plan compare. (REGTAP FAQ Database - FAQ #1355 03/31/14) Q: If an issuer offers multiple Child-only Plans and some plans allow sibling relationships while other plans do not, will each plan display when the family enrolls separately or as a group? A: If the family group includes multiple children, the family will only be able to see plans that allow sibling relationships. If the family group is disaggregated so that only an individual child without siblings is part of the group, child-only plans that do not allow sibling relationships will also display. (REGTAP FAQ Database - FAQ #3534 08/07/14) Q: Will the Centers for Medicare Medicaid Services (CMS) provide an updated and consolidated list of guidance for the fields issuers can update on enrollees' applications? Specifically, does changing the agent on the application cause any problems for A: Please refer to the presentation slides titled ?Reporting Life Changes" which address the issue of updating enrollment fields, located here: ReportinqLifeChanqes 062915 5CR 0806 15.pdf Slide 4 features a list of life changes and where each change should be reported. These presentation slides can be located in the REGTAP Library by selecting Enrollment and Eligibility under the Program Area ?eld. (REGTAP FAQ Database - FAQ #15238 03/23/16) Q: Can dependents who are under 26 years of age, who are not on their parent's Federal tax return be covered under their parent's Marketplace coverage? Would this situation be an example of a multi-tax household? And would the 26-year-old consumer receive a separate tax credit? A: In this case, because the young adult is ?ling a separate Federal tax return, he or she would want to submit a separate application and would receive a separate tax credit. When the consumer is going through the application and is asked questions if he or she has an offer of coverage through his or her own employer or through a family member, the consumer is going to want to select 'Yes,? referring to the fact that he or she has an offer of coverage through a family member parent). (REGTAP FAQ Database - FAQ #16093 05/24/16) Q: An adult daughter has her under-age-65, non-disabled father living with her. Both file separate tax returns and have their own sources of income. Do they apply for Marketplace coverage together? A: In general, an application for Marketplace coverage should include the tax ?ler, spouse, and any tax dependents. For more information on who to include on your Marketplace application, visit FAQ Database - FAQ #16101 05/24/16) Q: How do we handle non-related people sharing the rent of a house or apartment? 10 Updated 1-31-17 2017--00110 A: In general, an application for Marketplace coverage should include the tax ?ler, spouse, and any tax dependents. The Marketplace counts the estimated income of the members of the tax household who are required to ?le a tax return. Individuals who share living expenses but file separate tax returns should ?le separate applications for Marketplace coverage. For more information, see and household-information/incomel. (REGTAP FAQ Database - FAQ #16104 05/24/16) Exemptions (Q1) Does the Marketplace process exemption applications? (A1) Depending on the type of exemption being requested, exemption applications are either processed through the Marketplace when a consumer submits an exemption application or through the Internal Revenue Service (IRS) when a consumer ?les their tax return. More information, including the exemptions applications, is available at: (CMS Technical Assistance Resources Shared Responsibility Payment and Exemptions Information FA 03 on Exemptions 09/30/14) (02) How long does it take the Marketplace to process an exemption application once it is submitted? (A2) The time it takes the Marketplace to process an exemption application will vary depending upon the complexity of the exemption requested, whether the application is missing any information, and whether additional supporting documentation is required. If additional information is needed, the processing could take longer. To process exemption applications most ef?ciently, we encourage consumers to submit the required documentation with their applications. Complete applications should take about 2 weeks. The consumer will receive an eligibility determination in the mail when the application has been processed. Completed and signed applications should be mailed to: Health Insurance Marketplace -- Exemption Processing 465 Industrial Blvd. London, KY 40741 (CMS Technical Assistance Resources Shared Responsibility Payment and Exemptions Information - FA 03 on Exemptions 09/30/14) (Q3) Does a consumer need to wait until he or she has been determined eligible for an exemption before applying for catastrophic coverage? Is it possible to request expedited processing to get an exemption certificate? Updated 1-31-17 (A3) There is no expedited processing, although in the case of a cancellation, a consumer does not have to wait for an eligibility determination by the Marketplace to purchase catastrophic coverage. If a consumer received a notice of cancellation from a health insurance company in the individual market and believes that individual market coverage options in the area are unaffordable, the consumers may enroll in catastrophic coverage without an eligibility determination. In order to get catastrophic coverage, a consumer should provide both the hardship exemption form and a copy of the notice of cancellation he or she received directly to the 11 2017-?00111 health insurance company that offers the catastrophic plan in which the consumer wants to enroll. For information, plan options and insurer contact numbers, please visit: or call 1-866-837-0677, a special phone number for people whose plans have been cancelled. (9 am. to 7 pm. EST Monday through Friday and 9 am. to 5 pm. Saturday and Sunday). Catastrophic plans are not available in all states. Consumers seeking catastrophic coverage based on eligibility for other hardship exemptions (not related to the cancellation of their individual insurance coverage) must wait until they receive an exemption eligibility notice from the Marketplace before they can apply for catastrophic coverage. In such a case, they should submit an exemption application to the Marketplace as soon as possible, as there is no ability to request expedited processing. (CMS Technical Assistance Resources Shared Responsibility Payment and Exemptions Information - FA 03 on Exemptions 09/30/14) (Q4) A consumer is offered employer sponsored coverage but it is not affordable for the consumer. Is the consumer eligible for a hardship exemption? (A4) If the consumer has an offer of coverage through his or her own job, the consumer may be eligible for an exemption if the premiums for the lowest-cost self only plan available would cost more than 8% of the consumer?s household income. If the consumer has an offer of coverage through another family member?s job (for example, as a spouse or dependent), the consumer may be eligible for an exemption if the premiums for the lowest-cost family plan available that would cover the employee and all other individuals who are included in the employee?s family who have not otherwise been granted an exemption through the Marketplace would cost more than 8% of the consumer?s household income. (CMS Technical Assistance Resources Shared Responsibility Payment and Exemptions Information FA 03 on Exemptions 09/30/14) (05) If a consumer is granted a hardship exemption, how long is it good for? Updated 1-31-17 (A5) For hardship exemptions granted to individuals experiencing circumstances that prevent them from obtaining coverage under a Quali?ed Health Plan (QHP), the exemption will be provided for the month before the hardship, the months of the hardship, and the month after the hardship. However, Marketplaces may provide the exemption for additional months after the hardship, including up to a full calendar year, if a consumer states that the hardship is still affecting them. These three exemptions are granted for a speci?c time period, however: . For the projected affordability hardship exemption applications in 2014, the exemption will be granted for the entire coverage year. Beginning in 2015, the exemption will be granted prospectively for the remaining months in the coverage yeah . For the hardship exemption for individuals ineligible for Medicaid solely based on a state?s decision not to expand coverage under the ACA, the hardship exemption will be granted for the entire calendar year. . The hardship exemption for individuals eligible for Indian Health Services will be granted on a continuing basis. This hardship exemption may be kept for future years without having the consumer submit another application as long as membership or 12 2017-?001 12 eligibility for services from an Indian health care provider remains unchanged. (CMS Technical Assistance Resources Shared Responsibility Payment and Exemptions Information FA 03 on Exemptions 09/30/14) (06) Can consumers apply for a hardship exemption any time throughout the year? (A6) Yes, consumers may apply for the hardship exemption throughout the year at the Marketplace. Hardship exemptions may not be claimed on a tax return with the Internal Revenue Service upon tax filing. Please visit for more information. (CMS Technical Assistance Resources Shared Responsibility Payment and Exemptions Information - FA 03 on Exemptions 09/30/14) (Q7) Will a consumer who received a special enrollment period for being ?in line? by March 31 and selected a plan within the limited amount of additional time provided still have to make a shared responsibility payment for the months prior to May 1, or whichever is the effective date of his or her coverage? (QT) No. Consumers who received a special enrollment period for being ?in line? by March 31 and selected coverage within the limited amount of additional time to enroll in coverage will be eligible to receive a hardship exemption for the months prior to the effective date of their coverage, because they will be treated as if they had enrolled in coverage by March 31. The exemption will be granted through the IRS when the consumer ?les taxes. The consumer does not need to submit an application to the Marketplace in order to receive this exemption. (CMS Technical Assistance Resources Shared Responsibility Payment and Exemptions Information FA 08 on Exemptions 09/30/14) (08) If a consumer submits an application and is below 100% of the federal poverty level (FPL) in a non-Medicaid expansion state, does the consumer have to do anything else to be exempt from the shared responsibility payment? (A8) When consumers in a non-Medicaid expansion state apply through the Federally- facilitated Marketplace and fall below 100% FPL, they will receive an eligibility determination that also provides an exemption from the shared responsibility payment. The consumers will see on their eligibility determination notice that they are eligible for the exemption. The consumers will also receive a follow-up notice from the Marketplace with their exemption certi?cate number (ECN) before tax filing in 2015. Note that the notices have not yet been sent at this time. If the consumer would like to enroll in a catastrophic plan, they may do so. A separate exemption application is not necessary. (CMS Technical Assistance Resources Shared Responsibility Payment and Exemptions Information FA 08 on Exemptions 09/30/14) (09) If a consumer completes and submits the wrong exemption form, does the consumer have to resubmit the correct form in order to be granted any exemption he or she may be eligible for? 13 Updated 1-31-17 2017--00113 (A10) Yes, the consumer must ?ll out the appropriate exemption form in order to be granted an exemption. The only exception is if the consumer indicated a different hardship type than their documentation showed, in which case the Marketplace will reach out to the consumer to con?rm their intent. (CMS Technical Assistance Resources Shared Responsibility Payment and Exemptions Information FAQs on Exemptions 09/30/14) (Q10) How long does it take to get an exemption certificate number (ECN) and how does a consumer get it? (A10) If the consumer qualifies for an exemption, he or she will receive an exemption eligibility determination notice in the mail that contains an ECN. An ECN will be provided for each consumer receiving an exemption. The length of time for issuing an exemption eligibility determination letter depends on several factors, including whether a consumer completed the exemption application form correctly. The Marketplace will follow up with the consumer if information submitted by the consumer is incomplete. (CMS Technical Assistance Resources Shared Responsibility Payment and Exemptions Information FAQs on Exemptions 09/30/14) 834 Enrollment File Processing Q2: What is the Issuer expected to validate? A2: Clari?cation was requested in order to fully understand the nature of the question. Based on clarification received, our understanding is that this question pertains to reporting and tracking of 834 transaction ?le errors. OIS is considering use of the ASC X12 824, which provides detailed reporting of data content errors. Meetings will be scheduled with issuers and SBEs to discuss the potential use of this transaction and any associated technical and operational issues. (Enrollment March 8th and 11th, 2013) Q3: What is the final decision regarding stacked enrollments? Will the FFE supply an end of day snapshot of enrollment, or do they intend to send an aggregation of multiple transactions for the same policy that was captured throughout the day? A3: The process that is currently being built entails sending all transactions from the FFE to the HUB throughout the day. Thus several transactions could be bundled and sent to issuers at the end of the day. We understand this is not the preferred approach for many issuers, and while the matter may be open for additional discussion, timing and budgetary considerations may make it dif?cult to change this approach. (Enrollment March 8th and 11th, 2013) Q8: Error Processing: a. What are the errors? b. What is the correction process? Updated 1-31-17 A8: understanding is that this question is related to validation of edits and acknowledgements. The Exchange will likely use three transactions for communicating transaction ?le errors: One transaction is called the TA1 for ?le level errors; another is the ASC X12 999 for functional group level errors (WEDI levels 1-6) and, we are considering the use of a third, called the ASC X12 834 Application Advice for other errors (business logic edit failure). The process for communicating transaction errors using this third transaction (the X12 834) will likely require a separate companion guide 14 2017-?001 14 for its use. CCIIO and OIS are actively working on development in this area. (Enrollment March 8th and 11th, 2013) Q3: Is there a list of definitions of all member and/or enrollment identi?ers assigned through the enrollment cycle with the respective business rules assumptions? A3: Information on the identi?ers used in the transaction is provided in the CMS Companion Guide, which is available on the CMS website at: transaction-v1.5.pdf. (Enrollment FAQ 04/24/13) Q14: How do issuers communicate the inbound 834 rejects due to a failure on the issuers? side? How should issuers respond back to the Exchange to the inbound 834?s with invalid email addresses? A14: The Exchange will be using several transactions to address 834 (enrollment transaction rejections). One transaction is the TA1 for ?le level errors; another is the ASC X12 999 for functional group level errors (WEDI levels 1-6). A third transaction under consideration is the ASC X12 834 Application Advice for other errors (business logic edit failure). The process for communicating transaction errors using this third transaction (the X12 834) will likely require a separate companion guide for its use. Instructions for how issuers should communicate and respond to rejections will be provided soon. If provided by the individual during the application process, the FFE will provide up to 3 communication contacts (home phone, work phone, cell phone, and email address) in the initial 834 enrollment transaction. If the issuer feels the email address provided by the enrollee is invalid, the issuer may obtain an updated email address from the enrollee, and should advise the enrollee to provide the FFE with the updated address by logging into ?My Account? on the FFE website. (Enrollment FAQ 04/24/13) Q1: What time of day will the ASC X12 834 transaction files be transmitted to Issuers? A1: The Federally-facilitated Marketplace has not ?nalized the decision about daily transmission times yet. (Enrollment FAQ #2 07/02/13) 05: In the Enrollment Transaction, is the 1000A N101 Plan Sponsor the alternate payer? A5: In the Federally-facilitated Marketplace, the subscriber is listed in 1000A. In the FF- SHOP, the Plan Sponsor is the employer group. We do not use the term alternate payer in the FFM. (Enrollment FAQ #2 07/02/13; REGTAP FAQ Database - FAQ #159 07/02/13) 06: In the Enrollment Transaction, in the field for 10008 N102 Payer, what information is pub?shed as the name? 15 Updated 1-31-17 2017--00115 A6: The Federally-facilitated Marketplace will insert the name of the issuer that was provided in HIOS for the Quali?ed Health Plan (QHP) application. (Enrollment FAQ #2 07/02/13) Q7: Does the 2320 Coordination of Benefits need to be included on the Issuer to Federally-facilitated Marketplace (FFM) 834 file? A7: No, the Federally-facilitated Marketplace is not sending Coordination of Benefits information to the Issuers, so there is no expectation for this information to be returned by the issuer to the FFM. (Enrollment FAQ #2 07/02/13) Q8: Are the 21006, 2100F Loops for Responsible Person and Custodial Parent required on the Issuer to FFM ASC X12 834 Enrollment file? A8: On daily files, the Federally-facilitated Marketplace (FFM) is requesting that Issuers return all of the data the FFM sent in the initial enrollment transaction, along with the new issuer assigned member identifier, issuer policy number etc. This does not apply to the audit files for which separate instructions will be provided. (Enrollment FAQ #2 07/02/13) Q9: What is the format/de?nition of rating areas to be used on the ASC X12 834? A9: The ASC X12 834 enrollment transaction will include the address for the enrollee and a location identi?er for that address within its county. The format of the location identi?er is 5 digits, alphanumeric. The ?rst two characters are the state abbreviation followed by 3 digits which identify the county based on the FIPS data base. For example, a county in Arizona would appear as: A2123. Additional information is provided in the Companion Guide, which is available at: (Enrollment FAQ #2 07/02/13) Q10: On the 834 audit file, how will historical data be structured in comparison to current data? Should the records be sent in a particular order? A10: Details about the requirements and structure of the reconciliation audit ?le and how the records should be sent will be ?nalized by the end of July. (Enrollment FAQ #2 07/02/13) Q17: Will CMS provide a machine-readable EDI implementation guideline for their particular implementation (SEF, for example), and if so, what standards format(s) will be available? A17: CMS is not planning to provide a machine-readable EDI implementation guideline for the implementation of any programming for the Federally-facilitated Marketplace. (Enrollment FAQ #2 07/02/13) Q21: For the member, will the 2100C loop or other address loops be sent to indicate the member's mailing address or will you send only 2100A loop for address? 16 Updated 1-31-17 2017-?001 16 A21: We will send the member mailing address in the 2100C loop if applicable. The ASC X12 834 Implementation Guide (TR3) requires that the mailing address be sent if it is different from the residential address (in 2100A) or when the dependent?s address is different from the Subscriber's address. The FFM will send the mailing address when these situations apply. (Enrollment FAQ #2 07/02/13) 022: The ASC X12 834 Enrollment Companion Guide indicates that Issuers need to provide back to the FFM the same information on the effectuation file as was passed to them on the ASC X12 834 enrollment inbound. However, Issuers may not necessarily store information sent on the file. Furthermore, there will be some codes that we would not be able to map back to the code that came in on the file. Will CMS expect to receive the exact codes that came in on the enrollment file in the effectuation and reconciliation files? Can CMS provide a policy on which relationship codes are irreversible (meaning, they need the same code that they sent in the 834 enrollment to the carrier)? One example: Relationship codes have many possible values based on the TR3 that may be mapped to a shortened list on the carrier side. "Sister-in-law", "Adopted Child" and many others may all be mapped to "Dependent" in carrier system. Will CMS require Issuers to reverse map back "Dependent" into "Sister-in-law" and "Adopted Child" and all others possible? A22: Yes, CMS expects the same codes that came in on the enrollment file to be returned on the effectuation and reconciliation files. With respect to a policy codes that are irreversible Adopted child mapped to Dependent and back to Adopted Child CMS will have further discussions with Issuers about this topic to determine this best options. (Enrollment FAQ #2 07/02/13) 05: For the State Based Marketplace (SBM), is the ASC X12 834 enrollment transaction sent to the FFM at the same time it is sent to the Issuer? Or does the SBM wait until the issuer has confirmed receipt of the 834 and ?effectuated? coverage before they send the 834 to the A5: SBMs have various business models. Some SBMs collect/aggregate the initial month's premium, and therefore may not require a "confirmation" (effectuation) transaction from Issuers. SBMs will determine the timing of their transactions to CMS. (Enrollment FAQ #3 07/03/13) Q7: Name Normalization: 0n the ASC X12 834 enrollment file, will the Federally-facilitated Marketplace (FFM) be performing any name normalization? If so, will an enhanced character set be used? Can the member name sent from the Marketplace be changed (based on name normalization on the issuer side)? A7: The Federally-facilitated Marketplace will not be performing name normalization, and no enhanced character set is planned for use with the ASC X12 834 enrollment transaction. The member?s name cannot be changed based on information obtained by name normalization on the issuer side; however, the issuer can report such information during reconciliation. An individual who wishes to correct personal information such as his or her name must do so through the FFM. (Enrollment FAQ #3 07/03/13) 08: Can multiple acknowledgement ?les (999) be sent back for one incoming enrollment file? 17 Updated 1-31-17 2017-?00117 A8: Yes, Issuers may send multiple acknowledgement files (999s) back for one incoming (physical) enrollment ?le. (Enrollment FAQ #3 07/03/13) Q9: Can the TA1 and 999 acknowledgements for the ASC X12 834 enrollment file be sent together? A9: Yes, Per the ASC X12 Implementation Guides, a TA1 can be included in an interchange with other functional groups and transactions. (Enrollment FAQ #3 07/03/13) Q11: On the initial enrollment file layout, as indicated in the most recent Enrollment Companion Guide (v 1.5 from March), the only date that is indicated is at the file/transaction level. There do not appear to be any member or coverage level dates in the initial enrollment 834 from the FFE, only the transaction date. Is this is intentional or an oversight? Shouldn?t the FFE be sending member (2000 loop) and coverage (2300 loop) dates in the initial enrollment 834? Is the FFE intentionally not sending dates - as the date is determined by receipt of payment and EARLIEST effectuation date within the carrier's system? If yes, are there any guidelines regarding whether the EARLIEST effectuation date is the beginning of the next month? Or the beginning of the month following the next month? A11: The CMS Enrollment Companion guide is to be used in conjunction with the applicable ASC X12 Implementation Guide TR3. A data element is included in the Companion Guide to provide unique or speci?c information about how the date would be used by the FFM. Dates will be included in transactions when applicable (required by the TR3). (Enrollment FAQ #3 07/03/13) Q13: Regarding the reporting of dollar amounts in the 2750 REF02 field, do dollar amounts always need to include two places to the right of the decimal? Also please confirm that a dollar sign does NOT need to precede the REF02 amounts. A13: Yes, the dollar amounts do need to include two places to the right of the decimal, and the 35 sign does not need to precede the REF02 amounts. CMS will not send the dollar sign in the enrollment transactions. This information has been updated in the CMS Enrollment Companion Guide. (Enrollment FAQ #3 07/03/13) Q1: With respect to the ASC X12 999 Acknowledgement transaction, CMS referenced the WEDI edit levels 1-6 in an early FAQ document (Enrollment March 8th and 11th, 2013, published April 16th on However, the CMS Enrollment Companion guide does not specify the WEDI syntax editing levels, nor does the ASC X12 Implementation Guide/TR3. Will WEDI levels 1-6 be required by the Issuers? A1: The six levels of the WEDI edits are not required per se, because the ASC X12 Acknowledgement standard is not an adopted standard by the Department of Health and Human Services (HHS). However, use of these edits by all parties assures a smoother transaction process between the QHP Issuers, vendors and the Federally-facilitated Marketplace. CMS did not include the edits in its Enrollment Companion Guide, but may include additional information about the edits in other guidance. The edits are not required, but the Federally-facilitated Marketplace will use them in processing transactions in order for all parties to be successful. We reiterate the six levels here: a) X12 Syntax integrity; b) implementation guide compliance; 0) balancing within the 18 Updated 1-31?17 2017?-00118 transaction; d) using the situational rules within the implementation guide and supplemented in the companion guide; e) use of external code sets; and f) Line of Service (SHOP vs. Individual) requirements. (Enrollment FAQ #5 07/12/13) 02: According to the CMS Enrollment Companion Guide, the Benefit status code in 2000- IN805 can have values: 1) Active; 2) 3) Surviving insured; and 4) TEFRA. Please explain when the FFM will send 'Surviving insured.? Will this be used when a spouse becomes the subscriber for a subscriber death scenario? A2: The CMS Enrollment Companion Guide does not reference these values for use in the Federal Marketplace Program System (FMPS) and we do not anticipate using surviving insured in the Federally-facilitated Marketplace (FFM). (Enrollment FAQ #5 07/12/13) Q3: 0n the initial enrollment file layout, as indicated in the most recent CMS Enrollment Companion Guide (v 1.5), the only enrollment date that is indicated is at the file/transaction level. There do not appear to be any member or coverage level dates in the initial enrollment from the Federally-facilitated Marketplace (FFM), only the transaction date. Shouldn?t the FFM be sending member (2000 loop) and coverage (2300 loop) dates in the initial ASC X12 834 enrollment transaction? Is the FFM intentionally not sending dates, e.g. as date is determined by receipt of payment and EARLIEST effectuation date within the carrier's system? If yes, are there any guidelines regarding whether EARLIEST is the beginning of the next month? Or beginning of the month following the next month? A3: The Federally-facilitated Marketplace (FFM) will send date information required by the ASC X12 Implementation Guide/TR3. The Implementation Guide requires the member level dates (DTP) segment in the 2300 - Health Coverage Loop to always be present. The CMS Enrollment Companion Guide does not have a different requirement for the presence of that segment, so the FFM will always send it on the Initial Enrollment transaction. Furthermore, as this is an Initial Transaction, the only applicable code value in the TR3 code list that can be used in DTPO1 is ?348 Benefit Begin.? (Enrollment FAQ #5 07/12/13) Q4: The test files from CMS contained county name in N406 for rating area. Will county name or county code be sent to the Issuer? The Companion Guide states the following for N406: Will transmit County of Residence. See 4.htm. A4: In production ?les, the location identi?er for the county of residence will be the FIPS 5 digit code and not the county name. (Enrollment FAQ #5 07/1213) Q: Each QHP ID (first 10 characters only) will be in its own GS segment, is this correct? Issuers have concerns about the file structure requirements from CMS, and the lack of details that have been provided. For example, the Federally-facilitated Marketplace will require the files back to have the same structure as those received. The CMS Enrollment 19 Updated 1-31-17 2017--00119 Companion Guide does not provide substantive detail because it follows the ASC X12 Implementation Guide/T R3 and expects Issuers to do the same. The GS segment is not referenced in the current Companion Guide other than to specify that multiple GS segments can be sent in one physical file and multiple segments can be in each segment. This requirement will require additional changes in our trading partner?s systems. Where do we obtain formal documentation to help our vendors make changes to their systems to meet the requirements? A5: In answer to the first question, the GS segment of the enrollment transaction will include the first 14 digits of the QHP identi?er (not just the ?rst 10 characters). In response to the second set of comments about technical concerns surrounding the use of the GS segment, Issuers should review Appendix of the ASC X12 Implementation Guide/TR3. If QHP Issuers feel additional training and/or technical assistance is still required for their staff or for their vendors, please submit speci?c concerns to issuer communications@cms.hhs.qov and reference: GS Segment Assistance or Technical Assistance in the subject line. (Enrollment FAQ #5 07/12/13) 06: Each Federally-facilitated Marketplace (FFM) has a different Exchange Identi?er in every state - for example, Ohio would be 0H1 and Texas would be TX1. The FFM identifier is not a single identifier such as FF1 for example. For State-based Marketplace (SBM) states, will CMS use the FFM ID and not the ID the state is using? For example, Colorado is sending on the 834, and Kentucky is sending us ?Kentucky This would be different from what we receive on the HIX 820 (C01 and KY1), correct? A6: The Data Services Hub (DSH) contractor will be using for all CMS outbound transactions in the Interchange Control Header segment ISAO6 Sender Identi?er element regardless of the transaction content. (Enrollment FAQ #5 07/12/13) Q5: According to the CMS Enrollment Companion Guide, three possible qualifiers for 2100G (Responsible Person Loop) are: 1) E1 Person or Other Entity Legally Responsible for a Child (QMCSO), 2) OD Responsible Person, and 3) S1 Parent. However, per the ASC X12 834 Implementation Guide, Power of Attorney should have a qualifier J6. What qualifier will be sent in 2100G for Power of Attorney data? A5: The CMS Enrollment Companion Guide explicitly uses only two of the 13 available qualifier codes from the ASC X12 834 Implementation Guide for use in the 2100G Segment. These two qualifiers are: QD for Responsible Person and S1 for Parent. These are the only two codes CMS plans to use in the Federally-facilitated Marketplace. If QHP Issuers feel that other qualifier codes such as Power of Attorney are necessary, recommendations may be submitted to Comment3834quide@cms.hhs.qov. The policy and technical team at CCIIO will consider the requests for future development schedules. (Enrollment FAQ #6 7/22/13) 06: Race and Ethnicity questions are asked separately, as two distinct questions on the Federally-facilitated Marketplace (FFM) enrollment application, but there is only one field in ASC X12 834 Enrollment transaction to represent both data elements (DMG05-01 in 2100A). What are the rules to combine the race/ethnicity into one data element? (AHIP 65) 20 Updated 1-31-17 2017--00120 A6: Federal law sees race and ethnicity as distinct, and that is why there are two separate questions on the Federally-facilitated Marketplace application. The ASC X12 834 Implementation Guide provides a situational ?eld for race or ethnicity, with the notation that the data ?is normally self-reported and under certain circumstances is collected for United States Government statistical purposes.? There are no other rules or regulatory guidance beyond the constraints of the ASC X12 834 Implementation Guide. (Enrollment FAQ #6 7/22/13) Q37: Will CMS publish further updates to the 834 Enrollment Companion Guide? A37: Yes. CMS released the Companion Guide for FFM enrollment transactions in January 2013, and CMS published several updates since then. The current version of the Companion Guide can be found at: transaction-v1.5.pdf. Updates typically will be made when a signi?cant technical change has been identi?ed or a business process is modified, resulting in a change to content in a Segment or Loop. Future updates may also be made if testing reveals the need for further clarification on any of the transactions contained in the Companion Guide. (QHP Webinar Series FAQ #10 05/09/13 updated 08/02/13; REG TAP FAQ Database - FAQ #150 and #1508 08/02/13; updated 08/27/14) 02: How should issuers handle over-aged disabled dependents who do not receive the proper health certification before choosing a Qualified Health Plan Some issuers have specific requirements for disabled dependents that were not captured by the business rules submitted during plan certification and plan preview. A2: The Federally-facilitated Marketplace (FFM) does not require health certi?cation for a disability as a condition of enrollment; therefore quali?ed individuals can be enrolled and designated as a disabled dependent without submitting documentation to the FFM. The QHP issuer should effectuate enrollment for all eligible individuals for whom the premium has been received. Any documentation required by issuers for certi?cation of disability may be requested after effectuation. (Enrollment FAQ #8 09/19/13; REG TAP FAQ Database - FAQ #2 09/19/13) Q3: Some enrollments that use the term "ward" to designate disabled dependent status, may not actually be disabled dependents. If an issuer is concerned that an enrollment is not accurate, how should the transaction be handled? How will issuers reconcile information with the Federally-facilitated Marketplace? A3: Generally, if a qualified individual has designated a dependent as a ward, the issuer may assume the individual is eligible to enroll, and that s/he is a disabled dependent. However, issuer specific verification activities following enrollment are permissible. More information on processing inconsistencies in enrollment transactions will be forthcoming. (Enrollment FAQ #8 09/19/13; REG TAP FAQ Database - FAQ #182 09/19/13) Q4: Generally, to be considered a disabled dependent, issuers require an individual to be disabled before age 26, have physician confirmation, and already be enrolled with a health plan. If an individual does not meet these requirements, they would not be on the same ?contract? as the primary subscriber. How should issuers process an enrollment transaction with a ?ward? enrollee who it (the issuer) determines does not meet their 21 Updated 1-31-17 2017-?00121 standard requirements for disabled dependent status? Should issuers process the enrollment transaction as a termination, cancellation or separate enrollment? A4: Issuers should process the initial enrollment transaction received for the individual as a ?ward," and if the premium payment is received timely, effectuate the enrollment. If after enrolling the quali?ed individual who has been designated with the relationship code ?ward,? the Quali?ed Health Plan (QHP) determines that the enrollee is not in fact a disabled dependent, then the QHP should follow the process that the Marketplace will put in place for resolving discrepant data, including disputed relationship codes or enrollment groups. (Enrollment FAQ #8 09/19/13; REGTAP FAQ Database - FAQ #183 09/19/13) Q1: How is the relationship code for "ward" to be used to designate dependent and/or disabled status? A1: Qualified individuals will select the term ?ward" to designate a dependent and/or disabled relationship (within the family) when completing the eligibility application. When selected, this relationship code will be sent to the Quali?ed Health Plan (QHP) on the ASC X12 834 enrollment transaction. Note: CMS requested that QHP issuers add ?ward" as an eligible dependent in their business rules to re?ect the Federally-facilitated Marketplace (FFM) definition of disabled dependent. (Enrollment FAQ #8 09/19/13 REGTAP FAQ Database - 09/19/131) Q7: Why can't the disabled loop be used in the ASC X12 enrollment transaction? A7: The Affordable Care Act limits the collection of information from applicants that is not directly related to determining eligibility. Detailed disability status questions such as those required to complete the disability information at in the 2200 Loop were not required to determine an applicant?s eligibility and are therefore not collected. (Enrollment FAQ #8 09/19/13; REGTAP FAQ Database - FAQ #186 09/19/13) Q: When a dependent is added to a subscriber's policy in a reporting period, the Enrollment Period Activity indicator is 021EC. What should the Enrollment Period Activity Indicator display in the next reporting period, if there is no additional changes for that policy 021 EC or 021028)? A: When a dependent is added to a subscriber's policy in a given reporting period, the dependent is assigned the indicator 021 EC. The 021 EC indicator code does not change for the dependent throughout the policy year unless some other activity occurred during the year that resulted in a new enrollment period with a new enrollment start date. NOTE: Each enrollment period consists of one 'span' of dates. The purpose of the Enrollment Period Activity code is to signify when an enrollment period has changed. Issuers must report all relevant and distinct enrollment periods for each enrollee. If an enrollee has two different date spans for enrollment within a reporting period, then each date span would be reported as a separate enrollment period for that enrollee. (REGTAP FAQ Database - FAQ #491 11/20/13) Q: If the FFM does not want a confirmation 834 on transactions like Change/Reinstate/ Terminate/Cancel and only wants the effectuation on initial enrollment if the initial enrollment was complete and the subscriber added one member, will the Marketplace 22 Updated 1-31-17 2017-?00122 treat the transaction as an initial enrollment for that member and therefore, require an effectuation 834 from the payer? A: Yes, a member add is considered initial enrollment and will require a confirmation transaction. (REGTAP FAQ Database - FAQ #400 11/21/13) Q: For relationship types on the 834, is the person filling out the application or the main person covered on the policy the relationship to for example, if mom fills out the application and lists her two children on the application and mom does not need coverage, will the children be identified as children or brother/sister? A: A non-applicant mother applying for coverage for her two children would yield an 834 with the youngest sibling identi?ed as the subscriber and the older sibling identified as the dependent. (REGTAP FAQ Database - FAQ #401 11/21/13) Q: Should Submitters still continue to send daily 834 files to A: Yes, Submitters should continue to send daily 834 transactions to CMS. CMS will reconcile the estimated payments made for the month of January to the actual confirmed enrollment data provided via 834 when available. (REGTAP FAQ Database - FAQ 527 12/06/13) Q: When referencing ?Start? and ?End? dates within the 834 transaction, is CMS looking for Issuers to provide coverage periods or invoice periods? A: The ?Start? and ?End? dates will reference the coverage periods. (REGTAP FAQ Database - #899 02/27/14) Q: Does CMS expect ?Start and ?End? dates for coverage associated with the 2700 Loop? A: For an active enrollee, there will be a start date. However, there will not always be an end date, unless it is for the future. (REGTAP FAQ Database - #900 02/27/14) Q: In the instance of Individual Relationship Codes, how will CMS identify erroneous relationship codes on the 834? A: If the issuer determines that the relationship code is incorrect and makes a correction based on guidance from CMS, the reconciliation process will capture these changes because they will show up as discrepancies. CMS may also release additional guidance related to this process in the future. (REGTAP FAQ Database - #902 02/27/14) Q: If an Issuer receives an add and a cancel for the same member in the same day, do the Centers for Medicare Medicaid Services (CMS) require that Issuers enroll the member for the purposes of sending the member's enrollment file as a cancellation on the outbound 834 or can Issuers not enroll the member in the first place? A: In this scenario, the issuer should create an add and cancel transaction. This will ensure the transaction are stacking correctly, and provides confirmation that the issuer 23 Updated 1-31-17 2017--00123 has received both transactions and taken the appropriate action. (REGTAP FAQ Database - #904 02/27/14) Q: Should Issuers expect any 834 files with prorated premium amounts in the event of a newborn? A: CMS is currently working on a proration policy. Further guidance is forthcoming. (REGTAP FAQ Database - #893 02/27/14) Q: Is there a version number associated with the EDI form? A: The version of the Centers for Medicare Medicaid Services Marketplace EDI Registration Form is Version 3.1 and is available in the CMS Issuers community at: (REGTAP FAQ Database - FAQ #1411 04/14/14) Q: Is there a timeline for when the EDI registration form is due and when connectivity testing will start? A: CMS contractors have been collecting information and testing the connection set up activities since June of 2013. Issuers can begin as soon as the issuer's organization is ready. (REGTAP FAQ Database - FAQ #1416 04/14/14) Q: How many 834 files will an issuer receive, if the issuer operates in multiple states in both the Federally-facilitated Small Business Health Options Program (SHOP) and Individual Marketplace? A: The FF-SHOP will send one ?le per Trading Partner, regardless of whether or not an issuer is operating in more than one state. The FF-SHOP will separate ?les by Marketplace, sending one ?le for the FF-SHOP and one file for the FFM Individual Marketplace. (REG TAP FAQ Database - FAQ #2571 07/03/14) Q: Can issuers add a primary care physician (PCP) number on the 834 Enrollment file? A: PCP data is not transmitted on the 834 transaction. (REGTAP FAQ Database - FAQ #3430 08/01/14) Q: If an Issuer receives reporting information in the 2750 Loop (premium amount, APTC, etc.), will the information have an associated date? If no date is provided in the 2750 Loop, what action should the Issuer take? A: Information transmitted in the 2750 Loop of the 834 enrollment transaction will not always include an associated date. The Draft 834 Companion Guide (FFM) Version 1.6 Pre-Clearance (08/30/13), available in the REGTAP Library at provides additional information about the 2750 Loop. (REGTAP FAQ Database - FAQ #3559 08/11/14) Q: When a newborn is added to an existing, already effectuated family, will issuers need to send a CONFIRM for the subscriber member to confirm the total premium for the family orjust the one 834 to CONFIRM the new member? 24 Updated 1-31-17 2017-?00124 A: Issuers need to send one 834 to con?rm the newborn enrollment. (REGTAP FAQ Database - FAQ #6056 10/22/14) Q: How does the Centers for Medicare Medicaid Services (CMS) define the term 'upper bound'? A: 'Upper bound' refers to an independent validation CMS conducts based upon all non- cancelled Federally-facilitated Marketplace (FFM) enrollments. CMS uses this information to check the validity of Manual Workbook submissions. (REGTAP FAQ Database - FAQ #15518 04/18/16) Q: If a family has a young adult child who is 24 or 25 years old without any income, can he or she be included on a parent's Marketplace application? A: In general, an application for Marketplace coverage with ?nancial assistance should include the tax filer, the tax filer's spouse, and any tax dependents. An application for Marketplace coverage without ?nancial assistance should include only those who are applying for coverage. Based on the facts presented, the family should include the young adult child on the family's application for Marketplace coverage if: (1) the young adult is a tax dependent and the family is applying for ?nancial assistance (regardless of whether the young adult is applying for coverage) or (2) the young adult is applying for coverage without ?nancial assistance (regardless of tax filing status). The young adult should submit a separate application for Marketplace coverage tax dependent and is seeking coverage with financial assistance. (REGTAP FAQ Database - FAQ #16091 05/24/16) 834 - Identifiers Q4: Transaction Identifiers - format and content: Please provide the final CMS decisions on format, length, and rules around use of Exchange assigned enrollee identifiers to allow plans to begin building the necessary fields and business rules into their systems as soon as possible. A4: We have compiled a chart with the parameters for each identi?er, including maximum length and format (alpha characters only, alpha/numeric mix, or numeric only). The chart includes a narrative description for each identifier. We provided the chart to issuers the week of 4/5/13. See Attachment 1. (Enrollment March 8th and 11th, 2013) Q5: Please provide a detailed understanding of the multiple identifiers used in the enrollment transaction, including enrollment tracking numbers (this was promised following the 3/8 issuer call but is TBD). a) Is Plan ID tied to the primary consumer or is it tied to the policy or is it tied to the eligibility? A5: The Plan Identi?er is tied to the subscriber who enrolls in the QHP. This identi?er is also tied to the other individuals in the enrollment group who are enrolled in that QHP. (Enrollment March 8th and 11 th, 2013) 25 Updated 1-31-17 2017--00125 06: Will the same FFE ID follow the member through the initial and any subsequent future enrollments? A6: The same FFE Identi?er (ID), which we call the Exchange Assigned Identifier, will follow a member through the initial and subsequent enrollments within the same Quali?ed Health Plan (QHP), but not through different QHPs. For example, if an individual in the FFE selects a QHP issuer (issuer the individual will be assigned an ID (1234) by the FFE. That ID will stay with the individual while he/she is enrolled with Issuer A. If the individual terminates with issuer A during annual open enrollment, and selects a different QHP issuer (issuer B) they will get a new ID (5678). Later, if for whatever reason, the individual terminates with issuer and enrolls again with issuer A, he/she will be reassigned the same ID (1234) given during their first enrollment with issuer A. (Enrollment March 8th and 11th, 2013) Q11: Will the same FFE identifier follow the member through the initial and any subsequent future enrollments? A11: The member identi?er will remain with an individual through the initial and subsequent enrollments as long as that individual remains in the same QHP. For example, an individual in an FFE selects a QHP issuer (issuer A). The individual is assigned an ID (1234) by the FFE. That ID will stay with the individual while he/she is enrolled with Issuer A. If the individual terminates with issuer A during annual open enrollment, and selects a different QHP issuer (issuer B) they will get a new ID (5678). Later, if for whatever reason, the individual terminates enrollment with issuer and enrolls again with issuer A, he/she will be reassigned the same ID (1234) given during their first enrollment with issuer A. (Enrollment FAQ 04/24/13) 02: The 834 Enrollment Companion Guide has only one ?eld for Agent ID, but it looks like an agent can log into the Federally-facilitated Marketplace (FFM) with both the Marketplace Assigned ID and/or the National Producer Number (NPN). We need to confirm that this is the case if Issuers are to receive both identifiers on the 834 transaction? A2: The Federally-facilitated Marketplace will send only one identifying number for the Broker or Agent on the ASC X12 834 Enrollment transaction, using the number that the individual has used to log in to the system. That number could be either the Marketplace Assigned ID or the National Producer Number (NPN). Within the information model CMS has designed, the enrollment transaction will only provide the one number. It is possible for an issuer to receive both the Broker and an Agent on one transaction, each with one NPN or one Marketplace ID as the identifier. (Enrollment FAQ #2 07/02/13) Q4: In the ASC X12 834 Enrollment Transaction, is the ISA06 Sender ID the same as the Source Exchange ID in Loop 2750 A4: Yes, both identi?ers will be the source exchange ID (identifier). (Enrollment FAQ #2 07/02/13) Q15: Policy Number: Issuers are to send the issuer?s assigned enrollee's policy number back to the Federally-facilitated Marketplace (FFM) in the confirmation transaction. Specifically, this is referring to loop 2300, REF02 Member Group or Policy Number - 26 Updated 1-31-17 2017--00126 Issuer assigned health coverage purchased policy number. How will the FFM use this policy number (an identifier, customer service, etc.) which is different than loop 2000 REF02 Member Supplemental Identifier (the issuer assigned subscriber A15: The Federally-facilitated Marketplace (FFM) will use the issuer?s assigned enrollee's policy number as one of multiple data elements to ensure an accurate enrollee match during reconciliation processing. There are also IRS reporting requirements for Issuers, and the FFM is considering sending the issuer?s assigned identifiers to the IRS. (Enrollment FAQ #2 07/02/13) Q19: Will the Federally-facilitated Marketplace Assigned ID for brokers be sent on the ASC X12 834 enrollment transaction along with the broker?s National Producer Number If yes, is the FFM ID going to be sent when the broker is using the FFM (sitting side by side with consumer) and they enter their A19: The Federally-facilitated Marketplace will send one identifier for the broker, either the Marketplace Assigned ID or the National Producer Number, depending on which identi?er the broker used to log in to the system. When the broker provides side by side assistance to the enrollee, the identi?er they use to log in to the system will be the identi?er sent on the enrollment transaction. (Enrollment FAQ #2 07/02/13) Q15: Does the payment transaction ID (2000, REF02 where REF01 60) need to be sent back on the 834 confirmation file? A15: Yes. In Section 10.2 Enrollment Confirmation/Effectuation Instructions, titled: Issuer to the Companion Guide states: Except where overruled by the usage requirements of the 005010X220 TR3, QHP Issuers must return all the information transmitted on the Initial Enrollment Transaction in addition to the information detailed below." (Enrollment FAQ #3 07/03/13) Q16: Policy Number - Issuers are to send the enrollee's policy number back to the Federally-facilitated Marketplace (FFM). How will the FFM use the policy number (an identifier, customer service, etc.)? This pertains to loop 2300, REF02 Member Group or Policy Number - Issuer assigned health coverage purchased policy number. The identifier is required on Confirmation Transactions. It is different than loop 2000 REF02 Member Supplemental Identifier which is the issuer assigned subscriber ID. A16: The term for policy number in the ASC X12 834 Implementation guide has the same meaning as the Issuer assigned health coverage purchased policy number, and is the same as the Issuer Assigned Policy number. This identifier will be returned to the issuer on subsequent transactions where appropriate, and it will also be used in IRS reporting when required. The Federally-facilitated Marketplace (FFM) is considering use of the issuer's assigned enrollee's policy number during reconciliation processing If the issuer uses the policy number as the Subscriber Number, it should be included in both member identifier data elements of the 834. (Enrollment FAQ #3 07/03/13) Q19: We understand the Exchange will send the National Producer Number (NPN) if available. However, since the Navigator and Broker use the same field on the application, will the Federally-facilitated Marketplace (FFM) only send the NPN or is it possible that Issuers will receive a code and information for brokers and a code and information for navigators in the same position? 27 Updated 1-31-1 7 2017-?00127 A19: The enrollment transaction will only carry the broker information in the N1 Segment, Loop the Federally-facilitated Marketplace will not send information for the Navigators, as this information was not mapped for the 834 transaction. (Enrollment FAQ #3 07/03/13) Q: What is the expected turnaround time for the Federally-facilitated Marketplace (FFM) to send us an 834 after we report a child being added? A: The FFM will not add the dependent child in the interim until Change in Circumstance (CIC) functionality is available later. The individual will be directed to update their information when the CIC process is available but in the meantime to contact their plan directly to include the child immediately on their existing policy. (REGTAP FAQ Database - FAQ #617 1/01/14) Q: Is State of Virginia one of 16 states this is currently able to receive Account Transfers from A: Virginia does follow the FFM Partnership Model, is an Assessment State and can receive Account Transfers from the FFM. Additional information can be found at: on Medicaid and CHIP marketplace interaction with the FFM, which also includes Account Transfers. (REGTAP FAQ Database - FAQ #1170 003/31/14) Q: If an issuer does not have an Issuer Assigned Member ID. Is it okay if the issuer leaves this field blank? A: If an issuer does not have an Issuer Assigned Member ID, please populate this field with the Subscriber ID. (REGTAP FAQ Database - #1585 05/13/14) Q: If a member has Individual Marketplace coverage and switches to Federally-facilitated Small Business Health Options Program (FF-SHOP) coverage, will the member retain the original Individual Marketplace A: The FF-SHOP will issue a new Marketplace-assigned Subscriber ID speci?c to SHOP. (REG TAP FAQ Database - FAQ #3432 08/01/14) Direct Enrollment Q: Can direct enrollment Issuers offer catastrophic plans to enrollees? A: At this time, the Direct Enrollment API does not support enrollments into catastrophic plans. Consumers seeking to enroll one or more members of their household in a catastrophic plan would need to enroll the entire household directly on the FFM. We are planning to make catastrophic part of direct enrollment at a later time. (REGTAP FAQ Database - FAQ #423 11/22/13) 28 Updated 1-31-17 2017--00128 Q: What are the demographic changes that a direct enrollment Issuer would be permitted to make for an enrollee? A: Enrollees can contact the QHP issuer to make changes and/or corrections to certain data that do not affect eligibility for coverage in a QHP or eligibility for QHP issuers are permitted to implement those changes within their own systems as necessary. For additional information please see the Changes to Enrollment Data Authorized for Issuers document located on REGTAP: Authorized for Issuers v4 5CR 0107 14.9df (REGTAP FAQ Database - FAQ 683 01/27/14) Q: If an Issuer is submitting a full active file that contains individuals effectuated through direct enrollment but the Federally-facilitated Marketplace (FFM) has not processed the enrollee yet, how will the Issuer submit the file without a Marketplace Assigned Subscriber A: The issuer cannot transmit an effectuation for an enrollment without receiving the enrollment from therefore it would have a Marketplace Assigned Subscriber ID. (REGTAP FAQ Database - #874 02/27/14) Q: For Issuers who offer direct enrollment, how will CMS ensure that all files between the Issuer and CMS are up to date? A: The Direct Enrollment process still goes through the FFM to transmit enrollments. The reconciliation process will capture any discrepancies. (REGTAP FAQ Database - #894 02/27/14) Q: Where do we find information on how issuers set up the Issuer based pathway on our website? A: Issuers seeking to obtain more information about direct enrollment should visit the Issuer community site on (REGTAP FAQ Database - FAQ #1348 03/31/14) Q1: Are Qualified Health Plan (QHP) issuer and web-broker Enrollment Partners required to display quality ratings on their respective websites for the 2017 open enrollment pe?od? A1: Qualified Health Plan (QHP) issuer and web-broker Enrollment Partners that use direct enrollment to facilitate enrollments through the Federally-facilitated Marketplaces (FFMs) and State-based Marketplaces on the Federal Platform (SBM-FPs) should adhere to CMS requirements for the display of QHP information in accordance with applicable requirements accordance with 45 CFR if a web- broker enrollment partner does not have access to the required comparative information for a QHP offered through the Marketplace, it must display the Plan Detail Disclaimer as detailed in the FFM and FF-SHOP Enrollment Manual. Specifically related to 2016 29 Updated 1-31-17 2017--00129 quality rating information, only Enrollment Partners that use direct enrollment in one of the quality ratings display pilot States are encouraged to display the quality ratings calculated by CMS for the 2017 open enrollment period for QHPs offered through the Marketplace in that State. Enrollment Partners that use direct enrollment in an SBM whose consumers do not use HealthCare.gov should confirm display requirements with the applicable SBM. QHP issuer and web-broker Enrollment Partners that use direct enrollment in a quality ratings display pilot State and that choose to display the quality ratings for the 2017 open enrollment period should contact the Exchange Operations Support Center (XOSC) Help Desk via email at CMS or via phone at 1-855-267-1515 to request the QHP quality rating information for display. QHP issuer and web-broker Enrollment Partners that are required to display the 2016 quality rating information for the pilot States on their websites should prominently display the following disclaimer language provided by CMS: Plan quality ratings and enro/Iee survey results are calculated by CMS using data provided by health plans in 2016. The ratings will be displayed for health plans for the 2017 plan year. CMS is testing the use of star ratings this year in 2 States and will use this test to improve the program. Learn more about these ratings. [Link to appropriate explanatory/Help text on HealthCare.gov.] For details related to the QHP issuer and web-broker Enrollment Partner requirements, reference Section 4.4 of the FFM and FF-SHOP Enrollment Manual. For more information related to the quality rating information, see Marketplace Quality Initiatives website. (REGTAP QHP Enrollment Partner FAQ 12/06/16) Data Reconciliation Q16: 834 Con?rmations for Enrollment Changes. This requirement is not in the ASC X12 834 Companion Guide but was mentioned in the annual letter to Issuers: chapter 5, SECTION 4. TRANSMISSION OF ENROLLMENT INFORMATION BETWEEN THE FFE AND QUALIFIED HEALTH PLANS, subsection ii: The letter also states that ?in response to the exchange sending a file to an issuer containing changes for multiple enrollees, once the issuer has made those changes or effectuated an enrollment, the issuer will send the exchange a full ASC X12 834 ?confirmation? record for each individual affected?. This requirement is not in the ASC X12 834 companion guide and does not have an ?issuer to transaction for ?changes?. We do not recommend confirmations for enrollment changes because it would create an unnecessary amount of files. 30 Updated 1-31-17 2017--00130 A16: The Federally-facilitated Marketplace does not require Issuers to send a confirmation transaction for changes. We will clarify this in the next version of the Enrollment Companion Guide as well as any future versions of the Issuer Letter/Annual Letter. (Enrollment FAQ #2 07/02/13) 020: When would a program level manual adjustment (APTC MADJ) be made? Is this only during reconciliation? Shouldn't adjustments always be tied to a subscriber? A20: During the payment approval process, CMS will perform a series of analytical checks to help identify any payment issues. These issues may be the result of improper system programming, bad data transfers from one system to another, rounding errors, ?le integrity issues, etc. A manual adjustment may take place when CMS has identi?ed a payment issue through these reviews. For example, an APTC Manual Adjustment (APTCMADJ) may occur when CMS is aware of an error in enrollment group data that has not yet been resolved. Due to a system error, an issuer cannot provide enrollment-related data to CMS. While the error is being resolved, CMS may choose to issue an APTC Manual Adjustment similar to a previous month?s APTC payment amount. This results in a manual adjustment amount being sent to the payee because enrollment group information is not yet available. When accurate enrollment group data becomes available, CMS can then correct the payment made using the updated information. (Enrollment FAQ #2 07/02/13) Q3: In the April, 2013 Letter to Issuers there is mention that QHP Issuer must report current and accurate information on the status of quali?ed individual and enrollee premium payments.? The letter says: Issuers will provide up-to-date information on the last premium payment date for every enrollee.? How are QHP Issuers to report this information? A3: Issuers must participate in a reconciliation process with the Federally-facilitated Marketplace (FFM). In the reconciliation audit ?le, Issuers will submit the ?premium paid through date" for every current enrollee. This will identify for the FFM, enrollees who are in a payment delinquency status, thus meeting the notification requirement for non-paying enrollees. (Enrollment FAQ #6 7/22/13) Q: Will testing be performed related to the reconciliation process? A: Yes, testing is expected to occur in November. Guidance will be provided at a future date related to the speci?cs and dates of the testing for reconciliation. (REGTAP FAQ Database - FAQ #628 01/09/14) Q: If generating a reconciliation the day that it is due, what is the time cut-off for when it must be submitted? Updated 1-31-17 A: CMS will designate a day that issuers will transmit files to the The will require all transactions received before the designated day be processed, prior to transferring the files to CMS. There will not likely be a specific time since we are looking at transactions from the end of the last audit period to the day before the cut-off 31 2017-?00131 date. Further guidance will be provided in the future. (REGTAP FAQ Database - FAQ #630 01/09/14) Q: What entities will be responsible for creating/sending the reconciliation and supplementary termination files? A: QHP and QDP Issuers, SHOPs and SBMs are responsible for creating and sending reconciliation/supplementary ?les to the The will also send full 'snapshot' and supplementary audit ?les to QHP and QDP issuers, SHOPS and SBMs. (REGTAP FAQ Database - FAQ #631 01/09/14) Q: When will the final guidance and timeline be released for 834 reconciliation process. Plans have only seen high level overview of the process. A: Further guidance is forthcoming. (REGTAP FAQ Database - FAQ #641 01/09/14) Q: Are reconciliation audit files case sensitive? A: No, the information provided on the reconciliation full 'snapshot' and supplementary audit files will not be case sensitive. (REG TAP FAQ Database - FAQ #642 01/09/14) Q: Will Issuers receive a production file that same day they receive a reconciliation file? A: The reconciliation ?le creation and transmission will not affect the daily 834 enrollment process. (REGTAP FAQ Database - FAQ #644 01/09/14) Q: When can Issuers expect to begin sending the first reconciliation files? A: CMS is currently developing the process for reconciliation and plans to initiate the reconciliation process in 2014. CMS is planning testing and will provide specific dates in future guidance. (REG TAP FAQ Database - FAQ 682 01/27/14) Q: Which reconciliation file does future termination dates appear on? A: If the termination is processed during the reconciliation period May 16 to June 15), it will show up on the supplementary file. All terminations that are processed during that period show up on the supplementary file even if the transaction is for a future date. The termination will show up on the full ?snapshot? audit ?le because it is an active record with a future term date. (REGTAP FAQ Database - #871 02/27/14) Q: What is the date of the first reconciliation that will take place? A: This is still being determined and further information will be provided in the future. (REGTAP FAQ Database - #872 02/27/14) Q: Out of the data elements presented during the November 25, 2013 Enrollment Webinar, which data elements do the Centers for Medicare Medicaid Services (CMS) expect on the supplemental termination file? A: CMS expects that all the data elements that are applicable to the specific enrollment are to be present in the supplementary ?le. In some instances, some of the elements 32 Updated 1-31-17 2017-?00132 may not be applicable due to the individual's circumstances. (REGTAP FAQ Database - #873 02/27/14) Q: When an Issuer receives an 834 audit ?le from the FFM, what is the expected turnaround time for Issuers to submit the associated 834 audit file backup? A: CMS expects that the Issuer will transmit the audit ?le the same day CMS transmits the audit file to the issuer. The Issuer should not wait to receive the CMS audit ?les prior to creating their audit files. CMS will provide specific dates of when the Issuers are required to transmit the Issuer's audit ?les to CMS and when CMS will transmit the audit files to the Issuer. Issuers should expect that these dates would be the same dates every month. Further guidance is forthcoming. (REGTAP FAQ Database - #877 02/27/14) Q: How will the reconciliation process help Issuers ?nd effectuated individuals if the Issuer never received an 834 ?le? A: For reconciliation, CMS will pull enrollment data in the FFM on a speci?c date and compare that information to the audit ?les the issuer transmitted to CMS for the same date. If there are enrollments in one system and not the other, it will create a discrepancy which will identify orphan records on both sides. (REGTAP FAQ Database - #878 02/27/14) Q: Will CMS send separate reconciliation ?les for SHOP and Individual Market policies or will CMS combine the files? A: Audit ?les for SHOP will be transmitted in separate ?les than the Individual Market audit files. (REGTAP FAQ Database - #879 02/27/14) Q: Is CMS the system of record when performing reconciliations? A: The FFM is the system of record for FFM enrollment and the SBM is the system of record for SBM States. (REGTAP FAQ Database - #880 02/27/14) Q: In the reconciliation file, does CMS require the inclusion of the Premium Paid-Through Date for A: Further guidance is forthcoming. (REGTAP FAQ Database - #881 02/27/14) Q: Does CMS require Issuers to use the same individual relationship codes that the Marketplace initially distributed to the Issuer? A: No. (REGTAP FAQ Database - #882 02/27/14) Q: Will CMS update the 834 Companion Guide to include audit and reconciliation file information? 33 Updated 1-31-17 2017--00133 A: CMS plans to release a separate technical guidance that covers the reconciliation process that will include naming conventions as well as where and when Issuers are to send files. (REGTAP FAQ Database - #883 02/27/14) Q: Is the fifteenth of each month still a potential date for when CMS will run reconciliation reports? A: All dates pertaining to the reconciliation process are estimates. CMS does anticipate that the cutoff date will be around the middle of the month, possibly the 15th. Further guidance is forthcoming. (REGTAP FAQ Database - #884 02/27/14) Q: In the case of an Advance Payments of the Premium Tax Credit (ATPC) change or a premium change, what is the most recent information that CMS expects the Issuers to return? For example, an individual has a premium of $500 and an APTC of $100 and there were changes to premium and APTC information during the May to June window of data processing. Does CMS require that Issuers send both iterations of the premium and APTC in the full audit file or just the most recent data? A: CMS expects to see the data that is in an Issuer's system as of the cut-off date on the full snapshot audit file. (REGTAP FAQ Database - #885 02/27/14) Q: In a supplementary file, does CMS expect to see old APTC values and new APTC values when the Issuer has made a change to a member's APTC amount? A: CMS expects to see the transaction that was changed. An Issuer should transmit the retroactive change made to the APTC on the supplementary ?le. This will notify CMS that the Issuer processed a change during that timeframe and that the change is retroactive. Issuers should not be making retroactive data changes to elements within the 2750 loop without receiving an 834 transaction advising them to do so. (REGTAP FAQ Database - #886 02/27/14) Q: Has CMS determined a deadline for Issuers to correct discrepancies in their systems? A: Further guidance is forthcoming. (REGTAP FAQ Database - #887 02/27/14) Q: Do the Centers for Medicare Medicaid Services require that Issuers include both old APTC values and new APTC values on the supplementary file that Issuers transmit to CMS wants to see the transaction that was changed. An Issuer should transmit the retroactive change made to the APTC information with the correct information on the supplementary ?le so that CMS knows that the Issuer processed a change during that timeframe and that the change is retroactive. Issuers should not be making retroactive data changes to elements within the 2750 loop without receiving an 834 transaction advising them to do so. (REGTAP FAQ Database - #888 02/27/14) Q: How should Issuers communicate retroactive data changes within the 2750 Loop to the Centers for Medicare Medicaid Services 34 Updated 1-31-17 2017--00134 A: Issuers should not be making retroactive data changes to elements within the 2750 loop without receiving an 834 transaction advising them to do so. (REGTAP FAQ Database - #889 02/27/14) Q: What reconciliation updates apply only to the Individual Market and what updates apply to both SHOP and the Individual Market? A: The data elements provided apply to both the Individual Market and SHOP. There are some elements that may not be applicable based on the individual circumstances and the issuer will need to make that determination when transmitting the information to the FFM. (REGTAP FAQ Database - #890 02/27/14) Q: What will happen if the Issuer sends more data elements than what the Marketplace requires for reconciliation? A: CMS is only comparing the required data elements. Providing additional data elements will not cause a discrepancy. However, depending what elements are provided, the file may not meet the business logic requirements and the issuer may receive an error or may be unable to transmit the file to the FFM. (REGTAP FAQ Database - #891 02/27/14) Q: How will reconciliation work for Qualified Health Plans (QHPs) versus Qualified Dental Plans A: Reconciliation will work the same. (REGTAP FAQ Database - #892 02/27/14) Q: Do the Centers for Medicare Medicaid Services (CMS) require Issuers to send non- Marketplace enrollment records for reconciliation? A: No. CMS is only reconciling FFM records with FFM enrollments. (REGTAP FAQ Database - #903 02/27/14) Q: If an Issuer has members who cancel before the actual coverage begins and the Issuer has not billed the employer for these members, will the Issuer include the member in the supplementary file if the cancellation was processed by the Issuer? If so, does it mean that the Issuer does not include the member on the supplementary ?le? A: Since the Issuer did not effectuate the enrollee and there was no active enrollment for the enrollee, the Issuer is not retroactively cancelling the individual. (REGTAP FAQ Database - #905 02/27/14) Q: Regarding enrollment reconciliations, will Issuers receive a reconciliation file at the end of a month for members enrolled during the same month? A: Guidance on reconciliation is forthcoming and will be released to issuers when available. (REGTAP FAQ Database - FAQ #1200 003/31/14) 35 Updated 1-31-17 2017--00135 Q: An issuer's reconciliation files have been rejected due to the use of a colon in the time stamp field. According to guidance, the time stamp is a minimum and a maximum of eight (8) characters. What is the correct format for the time stamp ?eld? A: The correct format for the timestamp field is The entire ?le name should appear in this format: For example, a file submitted for TPID 123456789 at 3PM on May 20, 2015, would have filename: (REGTAP FAQ Database - FAQ #15245 03/23/16) Q: If an issuer receives a member's request to change/update the member's address, can the issuer change the address in the issuer's system after the issuer directs the member to the Federally-facilitated Marketplace (FFM) to make the update? A: Issuer should direct members to report address changes/updates, particularly residential address; to the Federally-facilitated Marketplace (FFM). The issuer will receive the updated address in an 834 transaction, Pre-audit File, or in the Incremental Pre-Audit (IPA) ?le. Issuers should wait until they receive the member's updated address information from the FFM before updating their systems. (REGTAP FAQ Database - FAQ #15382 04/04/16) Q: From where does the Federally-facilitated Marketplace (FFM) pull data to populate Form 1095-As for 2015 Unaffiliated Issuer Enrollments A: The FFM uses data on the issuer's reconciliation ?les to populate Form 1095-As for 2015 UlEs. When the FFM receives a reconciliation ?le, it compares the records within the reconciliation file to the current data available in the FFM. If a record within the reconciliation file does not match any current data available in the FFM, the record is considered a UIE, and is ?agged with an Then, a Form 1095-A is automatically generated based on data in the reconciliation ?le and sent to the consumer. (REGTAP FAQ Database - FAQ #16022 05/17/16) Q: How should the Federally-facilitated Marketplace/Marketplace Qualified Health Plan (QHP) issuers direct Unaffiliated Issuer Enrollments (UIE) consumers who are missing their Form A: If a consumer is missing his or her Form 1095-A, QHP issuers should direct the consumer to call the Marketplace Call Center to request their form. When consumer call the Marketplace Call Center, the Call Center Representative (CCR) will open a Health Insurance Casework System (HICS) case, and triage it to Cognasante for research. When Cognasante has concluded research, the FFM will: 1. Update incorrect information, when appropriate 2. Print and mail a Form 1095-A to the consumer with a special UIE cover letter (REGTAP FAQ Database - FAQ #16023 05/17/16) Q: Can an issuer take an address update directly from the consumer that does not include relocation or a change in zip code or county report to the Federally facilitated 36 Updated 1-31-17 2017--00136 Marketplace (FFM) via the Reconciliation Inbound RCNI) file data? A: Issuers should direct enrollees to report address changes/updates, particularly residential address; to the Federally-facilitated Marketplace (FFM). The issuer will receive the updated address in an 834 transaction, Pre-audit File, or in the Incremental Pre-Audit (IPA) ?le. Issuers should wait until they receive the member's updated address information from the FFM before updating their systems. However, issuers may accept changes that relate to their internal system for marketing purposes or claims) without the consumer reporting through the FFM. Ultimately, any change that generates an 834 or that can be updated via the RCNO files must be reported by the consumer through the FFM. (REGTAP FAQ Database - FAQ #17840 10/18/16) Special Enrollment Periods Q14: What is the list of special enrollment period reasons, and how will these be used on the ASC X12 834 enrollment transaction? Will the CMS Enrollment Companion Guide list them in Table 12? A14: The Special Enrollment Reason codes that will appear on the 834 enrollment transaction include the items below. These codes will be used in the individual Member Reporting Category Loop (See page 57 of the Version 5010 Implementation Guide). The identi?er in the REF01 "17" says it is a Client Reporting Category, which points to the N102 segment containing a value for the REASON. This list will be included at the end of the updated version of the Companion Guide. The SEP Reason codes are as follows: (1) Qualified Individual (Ql) or dependent loss of Minimum Essential Coverage 07-Termination of Benefits, located in the INSO4-Maintenance Reason Code. (2) Ql gains or becomes a dependent due to marriage, birth, adoption or placement of adoption; 32-Marriage, 02-Birth, 05-Adoption, located in the INSO4 Maintenance Reason Code. (3) An individual, who was not previously a citizen, national or lawfully present individual gain such status; NEWLY ELIGIBLE, located in the 2750 as SEP REASON. (4) A Ql enrollment or non-enrollment in a QHP is the result of an Exchange EXCHANGE ERROR, located in the 2750 as SEP REASON. (5) Qualified Health Plan (QHP) is in violation of material provision of its contract with the enrollee; AB/Dissatisfied with medical care/service rendered, located in the INSO4-Maintenance Reason Code. (6) Newly eligible for Advance Premium Tax Credit (APTC) or change in Cost Sharing Reduction FINANCIAL CHANGE, located in the 2750 as SEP REASON. (7) New QHPs available due to a permanent move; 43-Change of Location, located in the INSO4-Maintenance Reason Code. (8) Indian; NEWLY ELIGIBLE, located in the 2750 as SEP REASON. (9) Exceptional Circumstances; EXCEPTIONAL CIRCUMSTANCES, located in the 2750 as SEP REASON. (Enrollment FAQ #3 07/03/13) Q: What is the purpose of this special enrollment period (SEP) process? A: Marketplace regulations at 45 CFR specify that the Marketplace will provide a special enrollment period when enrollment or non-enrollment in a Quali?ed 37 Updated 1-31-17 2017--00137 Health Plan (QHP) is unintentional, inadvertent, or erroneous and is the result of the error, misrepresentation, or inaction of the Marketplace. Marketplace regulations at 45 CFR specify that the Marketplace will provide a special enrollment period when an individual meets other exceptional circumstances as the Marketplace may provide. This process implements the special enrollment periods provided in Marketplace regulations at 45 CFR and (9), with a focus on situations in which system or process issues at the Federally-facilitated Marketplace (FFM) prevented the timely completion of an application, plan selection, or enrollment. (REGTAP FAQ Database - FAQ #603 1/01/14) Q: For marketplace error special enrollment periods (SEPs) requested after December 31, 2013, will Quali?ed Health Plan (QHP) Issuers have any involvement in the process of determining whether or not to grant the A: No. Determinations will be made by the Federally-facilitated Marketplace (FFM), and communicated to QHP Issuers through the Health Insurance Casework System (HICS). Issuers will not need to convey proof to the Centers for Medicare Medicaid Services (CMS) on behalf of a consumer. CMS will be responsible for determining whether a consumer qualifies for the SEP. Issuers should refer consumers who contact them first to the Marketplace Call Center. (REGTAP FAQ Database - FAQ #604 1/01/14) Q: How will Qualified Health Plan (QHP) Issuers know that a new enrollee has been granted a special enrollment period (SEP) with a January 1, 2014 coverage effective date, instead of the February 1, 2014 effective date received on the 834 file? A: A record will be posted on the Health Insurance Casework System (HICS) with speci?c information about the enrollee indicating Centers for Medicare Medicaid Services (CMS) approval to receive the January 1, 2014 effective date. QHP Issuers should regularly check HICS to determine enrollees who have been granted the SEP. QHP Issuers will adjust the coverage effective date in their systems. (REGTAP FAQ Database - FAQ #605 1/01/14) Q: For enrollees who have been granted a ?Marketplace error? Special Enrollment Period (SEP) granting a January 1, 2014 effective date, what effective date will be sent on the 834? A: The 834 will contain a coverage effective date of February 1, 2014. As discussed in #10, the FFM does not have the capability at this time to program the system to auto-assign a January 1, 2014 coverage effective date for only those individuals granted an SEP. The Issuer will need to send the 834 confirmation ?le to the FFM with a January 1 coverage effective date. (REGTAP FAQ Database - FAQ #606 1/01/14) Q: If a Quali?ed Health Plan (QHP) Issuer receives an enrollment that has granted the marketplace error special enrollment period (SEP) with a January 1, 2014 coverage effective date, and the enrollee does not pay the required premium by the due date, can the QHP Issuer default the enrollee to what would have been the regulatory required coverage effective date of February 1, 2014, and set a new payment due date? 38 Updated 1-31-17 2017--00138 A: Yes, but ultimately, if the enrollee does not pay the ?rst month's premium by the due date set for February 1, 2014 coverage, the QHP Issuer must cancel the enrollment for non-payment of premium. (REGTAP FAQ Database - FAQ #607 1/01/14) Q: If a Qualified Health Plan (QHP) Issuer receives an enrollment that has been granted the marketplace error special enrollment period (SEP) with a January 1, 2014 coverage effective date, and the enrollee contacts the QHP Issuer and states that he/she has changed their mind and would now like a February 1, 2014 effective date, can the QHP Issuer grant this? A: Yes, it is allowed but not required. The QHP Issuer must apply this policy consistently to all enrollees in the same set of circumstances. (REGTAP FAQ Database - FAQ #608 1/01/14) Q: Assuming the enrollee pays the first month's premium by the due date, what coverage effective date should a Qualified Health Plan (QHP) Issuer send back on the 834 Confirmation/Effectuation transaction? A: The QHP Issuer should send the 834 Con?rmation/Effectuation transaction indicating a January 1, 2014 coverage effective date, and when applicable, a January 1, 2014 Advanced Payment of the Premium Tax Credit (APTC) start date. (REGTAP FAQ Database - FAQ #609 1/01/14) Q: Why can't the Marketplace assign a January 1, 2014 effective date and transmit the 834 over with the correct effective date? A: The Federally-facilitated Marketplace (FFM) system automatically assigns the coverage effective date based on regulatory rules. Plan sections made on or before the 15th of the month will be assigned a coverage effective date of the ?rst of the next month. The FFM was able to alter this automatic assignment to accommodate the extra time granted for the month of December 2013. The system automatically assigns a coverage effective date of January 1, 2014 for plan selections made on or before December 24, 2013. Due to the rapid pace of implementing the marketplace error special enrollment period (SEP), the FFM does not have the capability to program the system to auto-assign a January 1, 2014 coverage effective date for only those enrollees granted the SEP. (REGTAP FAQ Database - FAQ #612 1/01/14) Q: What information will the Centers for Medicare Medicaid Services (CMS) provide to these members regarding first month's premium due date? A: Our instruction to the consumer is to wait a few days then contact their plan (this messaging has been in place throughout open enrollment). Regardless, they need to go ahead and pay their February premium to ensure their coverage starts on time. In addition we are instructing consumers that their plan will reach out to them and con?rm if they will receive January coverage, at which point they will be billed for January and need to work with their plan to pay their January premium. Issuers will need to conduct outreach to enrollees who are granted January 1 effective dates to con?rm they are getting January coverage need to pay their premium for January (directly to the plan). (REGTAP FAQ Database - FAQ #614 1/01/14) 39 Updated 1-31-17 2017--00139 Q: How long will this special enrollment period (SEP) process be in place, and can the Centers for Medicare Medicaid Services (CMS) provide any estimation around the number of members who may fall into this retroactive Effective Date change? A: The special enrollment periods described in #1 are not time-limited in regulation. We do expect to implement enhancements to the process used to execute these special enrollment periods in the future. We do not have any estimates of the numbers of individuals who will qualify under these special enrollment periods. (REGTAP FAQ Database - FAQ #615 1/01/14) Q: What guidance/rule is available on 'clear proof' and how we will convey that to the Centers for Medicare Medicaid Services If the enrollee contacts the Issuer, we need to be able to articulate to the enrollee what the requirements are. A: Issuers will not need to convey proof to CMS on behalf of a consumer. CMS will be responsible for determining what whether a consumer qualifies for the special enrollment period (SEP). Issuers should refer consumers who contact them first to the Marketplace call center. (REGTAP FAQ Database - FAQ #616 1/01/14) Q: Can an Issuer require additional documentation from a consumer or decline to enroll a consumer when the Federally-facilitated Marketplace has approved a Special Enrollment Period A: No. If a consumer completed an eligibility application and was determined eligible for enrollment during an SEP by the Federally-facilitated Marketplace, an Issuer must enroll the consumer. If notice of the SEP is transmitted via HICS, an Issuer must enroll the consumer in accordance with the instructions in HICS. Issuers are not permitted to alter or deny enrollment to a consumer because the Issuer disagrees with an SEP determination by the Federally-facilitated Marketplace. Issuers are also not permitted to require consumers to produce documentation to validate an SEP determination by the Federally-facilitated Marketplace. If a HICS case is unclear with regard to SEP effective dates, Issuers may contact the consumer to seek clari?cation/confirmation. (REGTAP FAQ Database - FAQ #4936 09/18/14) Q: During a grace period, if a member qualifies for a Special Enrollment Period (SEP) with a coverage effective date that is the day after the grace period ends, are issuers required to accept the 834 enrollment transaction from the Federally-facilitated Marketplace? A: Yes, when an 834 enrollment transaction indicates that an enrollee received an SEP, the issuer must accept the enrollment transaction, even if the member was previously terminated for non-payment of premiums. (REGTAP FAQ Database - FAQ #11224 07/06/15) Q: Does a Qualifying Event, such as the birth of a child, allow an enrollment group to add additional dependents other than the newborn for a newly selected or existing Qualified Health Plan 40 Updated 1-31-17 2017--00140 A: Anyone who gains a dependent or becomes a dependent is eligible for a special open enrollment window, which includes both the parents and the newborn, newly adopted, or fostered child. The Federally-facilitated Marketplace (FFM) also accepts applications for the entire family (including siblings) during the special open enrollment window. Consumers living in a state that is running its own exchange should check with the state exchange to see how the state interprets regulation. (REGTAP FAQ Database - FAQ #15237 03/23/16) 2016 Revisions to SEP Policies Q: What is the residency requirement for adults age 21 and over seeking Marketplace coverage? A: In order to be eligible for Marketplace coverage, an individual must meet certain residency requirements described in 45 C.F.R. In general, an adult age 21 or over is a resident of the ?service area of the Exchange? (1) where he or she is living; and (2) where he or she ?intends to reside" (including without a fixed address); or where he or she has entered into a job commitment or is looking for a job (whether or not currently employed). A separate Marketplace residency standard applies to individuals age 21 years or older who are living in an institution, incapable of indicating intent, or receiving an optional State supplementary payment. For more information, see 45 C.F.R. 155.305 and 42 C.F.R. 435.403. (REGTAP FAQ Database - FAQ #14651 01/19/16) Q: What does ?service area of the Exchange? mean? A: In general, ?service area of the Exchange" means the State in which the Exchange operates. The Marketplace uses the term "service area of the Exchange" in its regulations to account for Marketplaces that may not exist in an entire state or that exist across state lines. It also accounts for situations in which a Federally-facilitated Exchange operates in a State. Because all Marketplaces currently operate on a state- wide basis, and not across or within state lines, the Marketplace residency standard can be understood to create a state-based residency requirement. (REGTAP FAQ Database - FAQ #14652 01/19/16) Q: What does ?intends to reside? mean? Updated 1-31-17 A: For the purposes of to reside? means that an applicant has a present intent to reside where he or she is living, and intends to remain in the Exchange service area where he or she is seeking coverage. Individuals visiting an Exchange service area for a transitory purpose, for example, to attend to a business matter, obtain medical care, or for personal pleasure, do not have a present intent to reside, and do not meet the residency requirement for Marketplace coverage for the Marketplace service area they are visiting. Certain individuals who cannot indicate intent, such as children, can establish residency without showing intent to reside. For more information, see 45 C.F.R. and 42 C.F.R. 435.403. (REGTAP FAQ Database - FAQ #14653 01/19/16) 41 2017-?00141 Q: What is the residency requirement for children under age 21 seeking Marketplace coverage? A: For most individuals under the age of 21, the service area of the Exchange for the purposes of determining residency is: where the individual resides (including without a fixed address); or the residence of a parent or caretaker with whom the individual resides, consistent with the standard described in Question 1. A separate Marketplace residency standard applies to individuals under the age of 21 who are living in an institution, receiving Federal payments for foster care or adoption assistance under title of the Social Security Act, receiving an optional State supplementary payment, or are emancipated. More information on these standards can be found at 45 C.F.R. 155.305 and 42 C.F.R. 435.403. (REGTAP FAQ Database - FAQ #14654 01/19/16) Q: Does an individual over the age of 21 who is capable of indicating intent and is receiving medical treatment out of state at an inpatient hospital or similar medical facility meet the residency requirement in the Exchange service area where he or she is receiving care? A: No, such an individual does not meet the residency requirement by virtue of receiving inpatient medical treatment or similar medical treatment in the service area of an Exchange. (They may otherwise meet the residency requirement by meeting the residency standards) Individuals receiving inpatient medical treatment do not have the present intent to reside in the medical facility; they are visiting for the purposes of medical treatment and do not meet the Marketplace residency requirement by reason of their visit to receive treatment. (REGTAP FAQ Database - FAQ #14655 01/19/16) Q: Can Individuals residing in the U.S. Territories meet the residency requirements for Marketplace coverage? A: Although individuals from the territories are often US. Citizens or US. Nationals, a resident of a US. Territory does not meet Marketplace residency requirements while he or she is residing in the Territory. This is because, at the time of this publication, no US. Territories have opted to establish a Marketplace; instead, they have used specially designated funds to expand Medicaid to their residents. An individual from the US. Territories who is residing in a US. state or the District of Colombia may meet the Marketplace residency requirements. (REGTAP FAQ Database - FAQ #14656 01/19/16) Q: Is there a waiting period before an individual can become a resident? A: No, there is no waiting period associated with the residency requirement. (REGTAP FAQ Database - FAQ #14657 01/19/16) Q: If an individual moves, does his or her residence change for the purposes of Marketplace coverage? 42 Updated 1-31-17 2017-?00142 A: If an individual moves to a new Exchange service area state) and meets the requirements in 45 C.F.R. with respect to the new location, then the individual will meet the Marketplace residency requirement in the new location. Enrolled Marketplace consumers must report any and all moves to the Marketplace within 30 days by calling the Marketplace Call Center at 1-800-318-2596 889-4325) or by visiting HealthCare.gov, logging in, and selecting ?report a life change? from the menu on the left. The individual should provide his or her new address in the ?Get Started? section of the application. The Marketplace will determine if the move resulted in a change of residence for the purposes of Marketplace eligibility and whether the consumer is eligible for a Marketplace plan for the Exchange service area in which he or she is seeking coverage. (REGTAP FAQ Database - FAQ #14658 01/19/16) Q: Does an individual's residence change when he or she leaves an Exchange service area temporarily? A: No. An individual who leaves an Exchange service area temporarily with intent to return to the original Exchange service area continues to be a resident for the purposes of Marketplace coverage during the temporary absence. (REGTAP FAQ Database - FAQ #14659 01/19/16) Q: If an individual lives in one Exchange service area but works in another, where is the individual's residence for the purposes of Marketplace coverage? A: It depends. An individual can establish residency in more than one service area, as long at the appropriate residency standard is met. An individual, such as a seasonal farmworker, who lives and works in one service area but maintains a home in another service area where he or she lives other than during the seasonal employment, can establish residency in either or both services areas states). In contrast, an individual who does not live in the service area where he or she works (for example, an employee who crosses state lines daily for work) does not meet the residency requirement in the state of employment. An individual who establishes residency in more than one service area is eligible to enroll in a QHP through the Marketplace in either or both locations (if all other eligibility criteria are met). (REGTAP FAQ Database - FAQ #14660 01/19/16) Q: If an individual travels between homes in different Exchange services areas throughout the year, where is an individual's residence for the purposes of Marketplace coverage? Updated 1-31-17 A: If an individual leaves his or her primary home to visit a secondary home for a short duration, the departure will be considered a temporary absence, and the individual will remain a resident of the service area of the primary home. During that time, the individual will not have an ?intent to reside? in the location of the secondary home and will not meet the Marketplace residency standard for that location. In contrast, if an individual has two primary homes where he or she spends time for an entire season or other long period of time, then the individual may live and intend to reside in both locations. In such situations, the individual may establish residency in 43 2017-?00143 either or both locations. (REGTAP FAQ Database - FAQ #14661 01/19/16) Q: How does someone qualify for the Permanent Move SEP to enroll in a QHP or change their enrollment in a A: To qualify for the Permanent Move SEP under 45 C.F.R. a Ql or his or her dependent must gain access to new QHPs as a result of a permanent move. For the purposes of qualifying for this SEP, a move is considered permanent if a Ql (or his or her dependents) moves and meets the Marketplace residency requirement with respect to a new location. An individual who moves to a new location temporarily without an intent to reside there or otherwise meeting the Marketplace residency requirement, including for personal pleasure or to obtain medical care, does not qualify for the Permanent Move SEP. Similarly, an individual who moves permanently, but does not gain access to new QHPs as a result of the move, would not qualify for the Permanent Move SEP. For example, this may occur if an individual permanently moves within the same apartment building, neighborhood, town, or county, depending on the QHPs offered in the individual's service area. (REGTAP FAQ Database - FAQ #14662 01/19/16) Q: Can an individual who meets the residency requirement in more than one location qualify for the Permanent Move A: In limited circumstances an individual may meet the residency requirement in more than one location. Such individuals may qualify for the Permanent Move SEP to enroll in or change plans when they move between Marketplace residences, but they should consider whether they would bene?t more from enrolling in a QHP that offers a national provider network or out-of-network coverage instead. (REG TAP FAQ Database - FAQ #14663 01/19/16) Q: Can an individual who moves to an inpatient hospital or similar medical facility to receive medical treatment qualify for the Permanent Move A: No, an individual who moves to an inpatient hospital or similar medical facility to receive medical treatment is not eligible for the Permanent Move SEP because such an individual does not meet the Marketplace residency requirement with respect to the inpatient hospital or similar medical facility. (REGTAP FAQ Database - FAQ #14664 01/19/16) Q: How should individuals report a permanent move to the Marketplace? A: An individual who moves must report the move to the Marketplace within 30 days of the move by calling the Marketplace Call Center at 1-800-318-2596 4325) or by visiting HealthCare.gov, logging in, and selecting ?report a life change" from the menu on the left. The individual should provide his or her new address in the ?Get Started" section of the application. (REGTAP FAQ Database - FAQ #14665 01/19/16) Q: What instances of existing Special Enrollment Period authority will no longer be utilized by the Updated 1-31-17 44 2017-?00144 A: After a review of the SEP policies and associated operations of the Federally- facilitated Marketplaces (FFMs) and State-based Marketplaces using the Federal Platform (SBM-FPs), CMS has identified below seven SEPs that are no longer available to le through the FFM and SBM-FPs, effective January 1, 2016. This guidance only applies to FFMs and SBM-FPs. CMS will continue to monitor SEP usage and may make changes to SEP policy and operations in the future. In particular, CMS will continue to monitor SEPs related to Marketplace operations as Marketplace systems and operations continue to improve. CMS will continue to review SEPs and produce similar updates to clarify, streamline, gain ef?ciencies in, and provide more transparency around SEP policy and operations. As planned, the FFM and SBM-FPs no longer utilize the following instances of existing SEP authority to allow consumers to enroll in or change QHPs because the speci?ed time period has ended, the situation it addressed has been resolved, or needed system updates have been made: enrolled with surplus APTC as a result of a redundant or duplicate policy, tax dependents with a social security income error, incorrect APTC determination due to a system error for certain lawfully present non-citizens, certain lawfully present non-citizens below 100% FPL with cleared immigration status inconsistency, individuals eligible for or enrolled in COBRA, tax season and individuals losing coverage through the Pre-Existing Condition Health Insurance Program (PCIP). (REGTAP FAQ Database - FAQ #14666 01/19/16) Q: What actions is CMS pursuing regarding special enrollment periods? A: The CMS Center for Program Integrity will conduct an assessment of enrollments that came through certain SEPs to evaluate whether consumers properly accessed coverage. At a minimum, the assessment will include the two frequent SEPs utilized by Marketplace consumers: those related to loss of minimum essential coverage and permanent moves. CPI will sample consumer records nationally and may request additional information from consumers or take other actions to validate that they properly accessed coverage using those SEPs. The findings from the assessment will be used to inform future policy and business process improvements to enhance program integrity. We will announce further details in the coming weeks. Like all information provided by consumers, responses to questions that trigger a special enrollment period are made subject to penalty of perjury. We are reviewing HealthCare.gov and call center scripts to ensure that the existing language and attestation are appropriately clear to consumers, and will make any changes that are needed to further ensure that consumers understand that they may be subject to penalties under federal law if they intentionally provide false or untrue information as part of the enrollment process. (REGTAP FAQ Database - FAQ #14667 01/19/16) Q: An immigrant consumer who has recently been qualified as a lawful permanent resident is pregnant and has applied for a special enrollment period (SEP) so she can enroll in coverage. She recently got her identity verified, but the SEP is not allowing her to select a plan. What can she do? Updated 1-31-17 A: An individual may qualify for an SEP if he or she gained eligible immigration status within the past 60 days and the individual didn't have an eligible immigration status before. An individual is not eligible for an SEP if he or she changed eligible immigration statuses within the past 60 days. For example, the individual was a refugee or asylee and recently became a lawful permanent resident (got a ?Green Card?). A list of eligible 45 2017-?00145 immigration statuses is available here: FAQ Database - FAQ #16096 05/24/16) Q: Is loss of advance payments of the premium tax credit (APTC) or income-based cost- sharing reductions (CSR) a qualifying event for a special enrollment period (SEP) for consumers to change their Marketplace plan? A: A consumer may qualify for a Special Enrollment Period if he or she (or anyone in his or her household): - ls enrolled in Marketplace coverage and report a change that makes him or her: Newly eligible for help paying for coverage; Ineligible for help paying for coverage; Eligible for a different amount of help paying for out-of-pocket costs, like copayments. - Become newly eligible for Marketplace coverage because he or she has become a US. citizen, US. national, or lawfully present individual. - Become newly eligible for Marketplace coverage after being released from incarceration (detention, jail, or prison). - Gain or maintain status as a member of a federally recognized tribe or Alaska Native Claim Settlement Act (ANCSA) Corporation shareholders (he or she can change plans once per month). - Become newly eligible for help paying for Marketplace coverage because he or she had a change in household income or moved to a different state and he or she was previously both of these: Ineligible for Medicaid coverage because he or she lived in a state that hasn't expanded Medicaid; Ineligible for help paying for coverage because his or her household income was below 100% of the Federal Poverty Level (FPL). (REGTAP FAQ Database - FAQ #17684 09/30/16) Q: An individual currently has a plan through the Individual Marketplace, but will experience a significant increase to his or her plan premium upon renewal in the Individual Marketplace. This individual meets the eligibility criteria for SHOP (Small Business Health Options Program) Marketplace coverage, as an employee or as a dependent If that Individual chose to not renew his or her Marketplace coverage (allowing that coverage to terminate on 12/31), would it be considered a qualifying event for a special enrollment period (SEP) to enroll in his or her employer's SHOP Marketplace coverage? A: The individual would not qualify for a SHOP SEP and is able to sign up for SHOP coverage through normal processes when the group's plan renews. (REGTAP FAQ Database - FAQ #18322 12/06/16) Health Insurance Casework System (HICS) 46 Updated 1-31-17 2017--00146 Q: What is the format of the Health Insurance Casework System (HICS) record for these members? What information will be included? Will there be a standard Subject Line so Issuers can quickly identify a HICS record for a January 1, 2014 Effective Date? A: We understand the importance of standardized language in the HICS records. The Centers for Medicare Medicaid Services (CMS) is currently enhancing our operational processes for HICS January 1, 2014 special enrollment period (SEP) records to ensure HICS record contains suf?cient information so Issuers can match members to 834 records. While you may have seen some inconsistency in the HICS records thus far, we are working to improve the quality of the information. The goal is to provide the following data in the HICS record: the key phrase ?1/1/2014 the consumer's first and last name, zip code, and date of birth. This information may be found in different ?elds of the record. As we continue to roll-out the enhanced process, you may still see some HICS records with some but not all of the additional data elements. (REGTAP FAQ Database - FAQ #610 1/01/14) Q: Will Issuers receive any notification from the Centers for Medicare Medicaid Services (CMS) that a Health Insurance Casework System (HICS) record has been entered? A: No. Issuers will need to enter the HICS regularly to review their assigned cases. (REGTAP FAQ Database - FAQ #611 1/01/14) Q: How quickly will the Health Insurance Casework System (HICS) record he posted, in relation to the production of the daily 834 file containing that member's new enrollment? A: Cases from the Centers for Medicare Medicaid Services (CMS) Call Center are typically uploaded daily, with the exception of Sunday. They are usually uploaded in the morning (ET) and viewable by the Issuers. Cases recorded by CMS staff are viewable real-time, after they are saved in the HICS by CMS staff. Though possible, there should be very few instances where an 834 enrollment will be received after the HICS entry. (REGTAP FAQ Database - FAQ #613 1/01/14) Q: When will Health Insurance Casework System (HICS) training be provided or was last week's the only training we should expect? A: The Centers for Medicare Medicaid Services (CMS) provided HICS training on December 19. For those that missed the training, Issuers should carefully review the HICS user guide (located in HICS) for an overview. For Issuers who have experience with Medicare, they will ?nd HICS to be a system quite similar to Complaint Tracking Module (CTM). HICS is a web-based, intuitive system most people will ?nd very easy to use. In addition, CMS is planning on providing Issuers broader guidance for the handling of casework issues in HICS in mid/late January. (REGTAP FAQ Database - FAQ #6191/01/14) Q: How long do Issuers have to close these cases in Health Insurance Casework System 47 Updated 1-31-17 2017-?00147 A: All cases recorded in HICS as an Issue Level 1 are considered urgent and are required to be resolved the matter within 72 hours of receipt. At this time, we understand that this process is new and still under development. That being said, while CMS will not hold compliance with this requirement under close scrutiny, Centers for Medicare Medicaid Services (CMS) caseworkers and account managers will take note of those cases that become extreme instances of non-compliance, and will address each outlier with the Issuer who owns the case. All other HICS cases are considered Issue Level 2 and non-urgent; these cases are to be resolved within 15 calendar days of receipt of the case. (REGTAP FAQ Database - FAQ #620 1/01/14) Q: If a case is assigned to the incorrect Issuer, how should that be communicated back to Centers for Medicare Medicaid Services Should we close the case? A: Inform your CMS Lead Caseworker via email. Do not send only the Health Insurance Casework System (HICS) case FAQ Database - FAQ #621 1/01/14) Q: If a case is assigned to the wrong Issuer ID, but the correct parent company, how should that be handled? A: To ensure an expedient resolution for the consumer, Issuers should communicate internally within their organization (or subsidiary) to address the case. (REGTAP FAQ Database - FAQ #622 1/01/14) Q: What is the workaround for Issuers to receive cases if they do not have Health Insurance Casework System (HICS) access yet? A: If an Issuer does not have access to HICS, they should access the Centers for Medicare Medicaid Services (CMS) mailbox supplied to them on a recent Issuer call, hics access@cms.hhs.qov, to make their application. As an alternative, an Issuer can contact their CMS Account Manager for further information or instructions on how to get access. (REG TAP FAQ Database - FAQ #623 1/01/14) Q: Are issuers required to provide coverage on an expedited basis or with a retroactive effective date to QHP-eligible individuals who allege enrollment errors when CMS has not provided clear proof or validated that these individuals completed the steps to enroll in a Qualified Health Plan A: If othenivise appropriate, yes. If CMS instructs that the issuer is required to provide effective dates on an expedited or retroactive basis, the issuer is required to provide coverage without specific documentation or validation. If an issuer does not have an 834 transaction ?le, the issuer has the option to check the pre-audit file that is received after the enrollment was processed, which should contain the information necessary to enable the issuer to enroll the individual. Issuers unable to find the enrollment record in the pre- audit file should open a Remedy ticket by calling the Exchange Operations Support Center (XOSC) Help Desk, and leave the Health Insurance Casework System (HICS) case open with interim casework notes. (REGTAP FAQ Database - FAQ #1482 4/18/14 and CMS FAQs on Casework 06/17/2014 Q1 48 Updated 1-31-17 2017--00148 Q: Does the ?Caseworker Assignment Date? or ?Issuer Assignment Date? reflect when a case is actually assigned or reassigned to an issuer? A: The Issuer Assignment Date, not the Caseworker Assignment Date, re?ects when a case is actually assigned or reassigned to an issuer. We are aware that CMS may have assigned issuers cases in their queue with Issuer Assignment Dates earlier than the date on which the cases were added to the issuers' queues. It is our expectation that issuers will resolve those cases as quickly as possible. We are working on enhancements with HICS that will allow dates to be reset when needed. (REGTAP FAQ Database - FAQ #1483 4/18/14 and CMS FAQs on Casework 06/17/2014 02) Q: When does time begin to toll for backdated, reopened, and duplicate cases in HICS for issuers to be compliant with 45 C.F.R. 156.1010? A: The timeframe to resolve backdated cases runs from the date the case is actually placed in the issuer's queue, as opposed to when the case was logged into HICS. For reopened cases, the timeframe runs from the date of reopening (effectively, the reopening date serves as a new Issuer Assignment Date). For duplicate cases, the time runs from the date the new case is assigned to the issuer. Pursuant to QHP issuers in Federally-facilitated Marketplaces (FFMs) must resolve urgent cases no later than 72 hours after the case is received by the QHP issuer; a case is considered to have been received by a QHP issuer after it has been entered in HICS and assigned to the issuer (the Issuer Assignment Date). All other cases are assigned Issuer Level 2. Level 2 cases must be resolved within 15 calendar days of receipt of the case by the issuer, as established in Where applicable state laws and regulations establish timeframes for case resolution that are stricter than the standards contained in ?156.1010, issuers must adhere to those timelines. We are aware of a casework surge during the beginning of open enrollment and that there may have been some confusion around when the clock started. We have made some HICS system enhancements and released guidance earlier this year that clari?ed the process. For the remainder of this initial casework surge, issuers should resolve cases as quickly as possible. (REGTAP FAQ Database - FAQ #1484 4/18/14 and CMS FAQs on Casework 06/17/2014 Q3) Q: Can CMS notify issuers when it makes changes to cases, such as cases changed from level 2 to level 1 or reopening closed cases? A: When CMS reopens a case, it will show in the open queue in HICS and also in the HICS data extracts. Issuers should look at their open cases by using the data extracts as downloaded from the HICS data extracts tool to determine if CMS made changes to cases or reopened closed cases. CMS is considering future enhancements to HICS that will allow issuers to receive a noti?cation when any changes are made to a case, More information on using HICS is available in the HICS Quick Reference Guide for Marketplace Issuers, available at: Manua .pdf (REGTAP FAQ Database - FAQ #1485 4/18/14 and CMS FAQs on Casework 06/17/2014 QZ) Q: What should issuers do when they are assigned cases in HICS: What should issuers do when they are assigned cases in HICS: 49 Updated 1-31-17 2017--00149 1) That concern consumers' general customer service Qs that require providing education to the consumer but do not require the issuer to take any substantive actions based on CMS policy; or 2) That relate to eligibility for coverage through the Marketplace, Medicaid, or CHIP, or another issuer? A: Issuers should follow the following: 1) If issuers are assigned a case that does not require that they take any substantive action, CMS expects that issuers will nonetheless provide good customer service and educate consumers on any appropriate process or action that may be needed. 3) If issuers have cases that relate to eligibility for coverage through the Marketplace, Medicaid, or or another issuer, issuers should bring them to the attention of the lead CMS caseworker for reassignment, as applicable. We also note that although the claims appeals process is not handled through casework, issuers should be prepared to direct enrollees to the claims appeals process. (REGTAP FAQ Database - FAQ #1486 4/18/14 and CMS FAQs on Casework 06/17/2014 Q6) Q: How should issuers close change in circumstance (CIC) cases? A: CMS released guidance on CIC on February 6, 2014. We encourage issuers that have open cases predating this CIC guidance to reach out to enrollees and educate them on the new CIC process and may then close the cases. Enrollment, Termination, and Special Enrollment Periods (February 6, 2014), available at: Term SEP Guidance 020614 5CR 0207 14.pdf. (REGTAP FAQ Database - FAQ #1487 4/18/14 and CMS FAQs on Casework 06/17/2014 Q7) Q: What should issuers do with cases that they have referred to the XOSC Help Desk? A: Issuers should enter in the interim notes section in HICS that they have opened a Remedy ticket with the XOSC Help Desk. The case needs to remain open until the issuer knows that the issue has been resolved, to prevent duplicate cases. The XOSC Help Desk is diligently working to close Remedy tickets as quickly as possible. (REGTAP FAQ Database - FAQ #1488 4/18/14 and CMS FAQs on Casework 06/17/2014 Q8) Q: Guidance published on March 13, 2014 indicates that CMS will make HICS data available to the relevant state departments of insurance (DOls). Can CMS further explain this? A: At this time CMS has not released any HICS data to state DOIs. We understand that issuers have seen an in?ux in cases due to the backlog created after the temporary surge in cases after the open enrollment period began, so many current HICS cases do not appropriately re?ect issuer performance, and, furthermore, that additional guidance is needed for issuers. We will notify issuers before we release data to state DOls. However, as stated in the March 13, 2014 guidance, issuers are still required to comply with all applicable state laws and regulations that establish timeframes for case resolution that are stricter than the standards contained in 45 C.F.R. ?156.1010. (REGTAP FAQ Database - FAQ #1489 4/18/14 and CMS FAQs on Casework 06/17/2014 09) 50 Updated 1-31-17 2017--00150 Q: What should an issuer do if it has duplicate cases with different desired effective dates? A: The issuer should still close the oldest case (in accordance with previous but contact the consumer to determine which effective date he or she wants and annotate the HICS resolution accordingly. Casework Guidance for Issuers in Federally-facilitated Marketplaces, including State Partnership Marketplaces (March 13, 2014), available at: (REGTAP FAQ Database - FAQ #1490 4/18/14 and CMS FAQs on Casework 06/17/2014 Q10) Q: Will HICS records be used for enrollment reconciliation? A: CMS does not plan to use HICS records for reconciliation activities. (REGTAP FAQ Database - FAQ #1491 4/18/14 and CMS FAQs on Casework 06/17/2014 Q11) Q: Can an issuer process an enrollment solely using data from the pre-audit file? A: Yes. An issuer should not wait for an 834 transaction when the necessary information to process an enrollment can be found in the pre-audit ?le. (REGTAP FAQ Database - FAQ #1492 4/18/14 and CMS FAQs on Casework 06/17/2014 - Q12) Q: What should an issuer do when presented with an unclear HICS case summary? A: The issuer should contact the consumer to determine what his or her needs are and work to achieve a resolution. Issuers are encouraged to use that contact as an opportunity to invite the consumer to contact the issuer directly on any future issues/Os the consumer may have about his or her plan enrollment. Issuers may also choose to share with the Account Manager examples of case summaries that were not complete or clearly written, and CMS will follow up in an effort to provide clearer HICS case summaries in the future. (REGTAP FAQ Database - FAQ #1493 4/18/14 and CMS FAQs on Casework 06/17/2014 Q13) Q: What should an issuer do if a consumer no longer seeks assistance or action relating to their case? A: The issuer should close the HICS case with an appropriate case resolution notation. (REGTAP FAQ Database - FAQ #1494 4/18/14 and CMS FAQs on Casework 06/17/2014 Q14) Q: What is process for preventing duplicate cases? Updated 1-31-17 A: Once CMS receives a case, CMS conducts a search to con?rm that a duplicate case does not exist. If a duplicate case exists, CMS closes the older case and references the new case number in the notes. CMS makes every reasonable effort to prevent duplicative cases from being recorded in HICS. If a previous case exists, in most situations, a new entry will not be recorded. We recognize that issuers may have seen an increased number of duplicate cases in January and February during a time of exceptional workload. Issuers have received instructions on how to perform HICS 51 2017-?00151 extracts to help identify duplicate cases and are expected to close those cases as quickly as possible. (REGTAP FAQ Database - FAQ #1495 4/18/14 and CMS FAQs on Casework 06/17/2014 Q4) Q: If an Issuer receives a termination request through the Health Insurance Casework System (HICS), does the Issuer need to wait until the Federally-facilitated Marketplace (FFM) sends an 834 termination before the Issuer can actually terminate an enrollment? A: Please contact your Regional Of?ce Caseworker within regards to your specific case. (REGTAP FAQ Database - #1742 06/02/14) Q: Does voluntary termination occur when a consumer terminates their plan on Healthcare.gov and then the FFM sends an 834 termination to an Issuer? A: Yes, a voluntary termination occurs when a consumer terminates their plan on Healthcare.gov and then the FFM sends an 834 termination to an Issuer. Please see guidance on voluntary terminations in Bulletin for Issuers 5CR 020714.pdf (REGTAP FAQ Database - #1743 06/02/14) Q: Can consumers make multiple adds/terminations in the same ?le? A: Yes, consumers can make multiple adds/terminations in the same file. (REGTAP FAQ Database - #1744 06/02/14) Q: Do birth dates conflict with Individual Market rates when there is a termination and a new initial enrollment? A: Yes, birth dates con?ict with individual market rates when there is a termination and new initial enrollment. Further guidance is forthcoming. (REGTAP FAQ Database - #1745 06/02/14) Q: How should an Issuer process a enrollment add for a consumer who has enrolled a second time in the Marketplace and the Issuer has not received a cancellation for the consumer's initial enrollment? A: In this scenario, the Issuer should contact the consumer and verify their intent before canceling the consumer's policy. (REGTAP FAQ Database - #1746 06/02/14) Q: Are there limitations for Child Only enrollments in the IMP1A testing environment? A: Thank you for your question. Please contact the Exchange Operations Support Center (XOSC) Help Desk at CMS at CMS FEPS@cms.hhs.qov or 515 for support with this issue. (REGTAP FAQ Database - #1920 06/02/14) Q: Can an Issuer close a case it believes was an inappropriate referral? A: No. CMS expects Issuers to address all cases assigned to them for casework. CMS expects the Issuer to follow CMS instructions related to cases and to contact the consumer to further determine how the Issuer can assist the consumer. If an Issuer 52 Updated 1-31-17 2017-?00152 determines that the case was inappropriately referred, should be reassigned to another Issuer, or is a CMS issue, they should note the determination in HICS, leave the case open, and send an e-mail to the lead caseworker informing him/her that the case should be referred elsewhere. To expedite the process, the e-mail should include the HICS case number. (REGTAP FAQ Database - FAQ #4265 08/28/14; CMS FAQs on Casework 08/28/14) Q: A previous FAQ, Q9 located at Casework FAQs 061714 v1 5CR 061714.p d_f, indicated that an Issuer should change the effective date in their system when instructed to do so in a HICS case. However, HICS cases sometimes include several different effective date requests in the narrative based on what the consumer is requesting. In this case, what effective date should the Issuer apply to the consumer's poHcy? A: In cases in which an Issuer is asked to change the effective date in their system, either due to a type of SEP or an enrollment error, the Issuer should apply the effective date that is requested in the HICS case. If the correct effective date is still unclear to the Issuer after reading the HICS notes, the Issuer may contact the consumer to seek clari?cation/con?rmation. (REG TAP FAQ Database - FAQ #4937 09/18/14) Q1: A consumer tells the Issuer slhe has reported an address change that does not affect her APTC or QHP eligibility to the Federally-facilitated Marketplace, but the Issuer has not received an updated 834 transaction. Should the Issuer update its system with information either provided from a consumer directly or in a HICS case? A1: Yes. The Federally-facilitated Marketplace currently does not issue an 834 transaction in some situations, such as changes of address that do not affect enrollment, so it is important for Issuers to update their address records manually to ensure consumers receive key plan materials and invoices timely. CMS is working toward a system fix and will communicate with Issuers when it has been implemented. (REGTAP Casework FA Os #4 09/18/14) Q2: Can an Issuer require additional documentation from a consumer or decline to enroll a consumer when the Federally-facilitated Marketplace has approved a Special Enrollment Period A2: No. If a consumer completed an eligibility application and was determined eligible for enrollment during an SEP by the Federally-facilitated Marketplace, an Issuer must enroll the consumer. If notice of the SEP is transmitted via HICS, an Issuer must enroll the consumer in accordance with the instructions in HICS. Issuers are not permitted to alter or deny enrollment to a consumer because the Issuer disagrees with an SEP determination by the Federally-facilitated Marketplace. Issuers are also not permitted to require consumers to produce documentation to validate an SEP determination by the Federally-facilitated Marketplace. If a HICS case is unclear with regard to SEP effective dates, Issuers may contact the consumer to seek clari?cation/confirmation. (REGTAP Casework FA Os #4 09/18/14) Q3: A previous FAQ, Q9 located at Casework FAQs 061714 v1 5CR 0617 14.pdf indicated that an Issuer should change the effective date in their system when 53 Updated 1-31-17 2017--00153 instructed to do so in a HICS case. However, HICS cases sometimes include several different effective date requests in the narrative based on what the consumer is requesting. In this case, what effective date should the Issuer apply to the consumer?s poHcy? A3: In cases in which an Issuer is asked to change the effective date in their system, either due to a type of SEP or an enrollment error, the Issuer should apply the effective date that is requested in the HICS case. If the correct effective date is still unclear to the Issuer after reading the HICS notes, the Issuer may contact the consumer to seek clari?cation/con?rmation. (REGTAP Casework FAQs #4 09/18/14) Q4: Can an Issuer retroactively terminate a consumer?s enrollment when instructed to do so by the Federally-facilitated Marketplace? A4: Yes, if the Issuer receives a request from the Federally-facilitated Marketplace via HICS, it should retroactively terminate the consumer?s enrollment as requested. Consumers can also request retroactive disenrollments directly with an Issuer (see Issuer Bulletin If the Issuer has questions with the request, it can reach out to its Lead Caseworker for additional information. (REG TAP Casework FAQs #4 09/18/14) 1. Does an issuer need to refer a consumer to the Marketplace to create a HICS case when they have been provided enrollment policy or guidance from CMS that can resolve the consumer?s issue? No. CMS expects issuers to be consumer?s ?rst point of contact for issuer-related matters. As such, when CMS has promulgated policy or guidance, issuers can follow that policy to advise/assist the consumer as appropriate, and note the necessary changes in their internal contact management and/or enrollment systems. Consumers should only be directed to the Marketplace for matters the issuer is unable to or not permitted to address without Marketplace action. (FA 03 for Handling Health Insurance Casework System (HICS) Casework 4/21/15) 2. In the recent HICS update, issuers can now note when a case has been referred to the XOSC Help Desk. Is this required? No, issuers are not required to use these fields. However, doing so is strongly encouraged as it will help CMS monitor pending casework as a result of a Help Desk referral. (FAQs for Handling Health Insurance Casework System (HICS) Casework 4/21/15) 3. In a Marketplace presentation on March 13, 2015 (available on REGTAP at HHS EX SEPEffective Dates 040315 v1 5CR 040 715.9df it was mentioned that a new system functionality exists through which CMS is able to adjust effective dates for enrollments that meet qualifying circumstances. CMS indicated that this would reduce the amount of HICS cases requiring issuers to adjust effective dates. However we have not seen an appreciable decline in HICS cases yet. Is there a problem with this functionality? No. CMS will be working to phase in this functionality over the next several months into its customer service operation. Even when fully implemented, we still believe there will be situations where issuers will be directed via HICS to adjust enrollment effective dates 54 Updated 1-31-17 2017--00154 for an existing enrollment or after receiving a new enrollment transaction. All adjustments should be supported by existing policy and/or guidance. (FAQs for Handling Health Insurance Casework System (HICS) Casework 4/21/15) 4. We received a HICS request to reinstate a consumer?s enrollment into a Marketplace plan, but the consumer?s Marketplace coverage was terminated as a result of a data matching issue. What should we do? For HICS cases where you have not received a new enrollment transaction after the consumer experienced termination of Marketplace coverage as a result of a data matching issue, please advise the consumer to follow the directions in the latest communication he or she received from the Marketplace. After taking this step, the issuer may close the HICS case. The next step for the consumer may be to file an appeal with the Marketplace if he or she believes their Marketplace coverage was terminated in error. Consumers with expired data matching issues will need to contact the Marketplace to resolve their data matching issue in order to be eligible to update their enrollment. An issuer should not reinstate Marketplace coverage that has been terminated due to a data matching issue unless the issuer has a new enrollment transaction from the Marketplace. Additional information about data matching issues can be found in Bulletin #11. Note, the issuer may have a separate obligation under market-wide guaranteed availability and renewability rules to continue the consumer?s coverage outside the Marketplace. (FAQs for Handling Health Insurance Casework System (HICS) Casework 4/21/15) 5. What primary resources should issuers use for handling casework? In addition to the regulations in 45 C.F.R. 156.1010, CMS issued a memorandum providing guidance for handling casework on March 13, 2014 (available here: 03132014.pdf . Supplemental guidance is also available in the searchable FAQ database on REGTAP. (FAQs for Handling Health Insurance Casework System (HICS) Casework 4/21/15) 6. What should issuers do with repeat cases from the same consumer relating to the same issue? Issuers should follow the process outlined in the March 13, 2014 casework memorandum. In addition, generally, but not always, CMS will record another HICS case on an identical unresolved matter only after 30 days has passed since the previous case was opened. Exceptions to this rule could be related to a change in a consumer's health status a change resulting in a later case being coded urgent). Additionally, issuers are encouraged to contact consumers as soon as possible after receipt of a HICS case, and are required by 45 C.F.R. 156.1010(d) to contact consumers within 15 days of receipt of a HICS case. Issuers are also reminded that if a consumer has two cases in HICS that are unrelated issues, do not close one of the cases as a duplicate. (FAQs for Handling Health Insurance Casework System (HICS) Casework 4/21/15) 7. Can an issuer add a consumer to an existing enrollment group solely using information in No, unless CMS provides explicit guidance to do this in very limited instances newborn needs to be added to a group and the QHP is suppressed, meaning enrollment 55 Updated 1-31-17 2017--00155 capabilities have been suspended). (FAQs for Handling Health Insurance Casework System (HICS) Casework 4/21/15) 8. What should an issuer do if it receives a HICS case that relates to a 2014 1095-A issue? If the case is in the ?Plan and Issuer Concerns? category, advise your Lead Caseworker so the case can be reassigned. If the case is in the category, no issuer action is required. The case will be handled by CMS or its contractor. (FAQs for Handling Health Insurance Casework System (HICS) Casework 4/21/15). 9. If an issuer receives a request (inside or outside of HICS) to terminate a 2015 enrollment earlier than the date reflected on the 834, what should the issuer do? The earliest that CMS can approve a termination is no sooner than 14 days from the date the consumer requests the termination. The issuer may, at the consumer?s request and the issuer?s discretion, effectuate termination in fewer than 14 days, as indicated in 45 C.F.R. However, CMS expects that the issuer?s policy in this regard be applied uniformly to all enrollees. If an issuer is unable to accommodate the consumer?s request, they should communicate that information to the consumer accordingly. (FAQs for Handling Health Insurance Casework System (HICS) Casework 4/21/15) Q: What should an issuer do if it receives a Health Insurance Casework System (HICS) case with an unclear, incomplete, or contradictory narrative? A: Because most HICS cases are entered by the Marketplace Call Center only after a consumer indicates that he or she has contacted the issuer first, the issuer should check its internal communication records for additional information that could pertain to its consumer's case. The issuer should also contact the consumer to get a better understanding of the case. (REGTAP FAQ Database - FAQ #12257 08/31/15 and HICS FAQs 08/31/15) Q: If an issuer exits a particular service area at the end of a plan year the issuer will no longer be offering coverage in that service area for the following plan year), how much time does it have to address unresolved Health Insurance Casework System (HICS) cases from that service area? A: If a case arises during the original plan year and crosses over into the new plan year, the timeframes speci?ed in 45 C.F.R. 156.1010(d) still apply to the case. If a case related to a particular plan year arises after that plan year is over, issuers are expected to continue to review and resolve consumer issues after leaving the service area. Additionally, there may be state laws and/or regulations that also articulate an issuer's responsibility in such cases. (REGTAP FAQ Database - FAQ #12258 08/31/15 and HICS FAQs 08/31/15) Q: Does the Centers for Medicare Medicaid Services (CMS) have issuer call center service hour requirements for issuers participating in the Federally-facilitated Marketplace? A: No. However, issuers are required to satisfy any applicable state requirements. In the 56 Updated 1-31-17 2017--00156 absence of state requirements, issuers are encouraged to adhere to standard commercial practices in their geographical area or follow best practice recommendations used in the Medicare program. In the Medicare program, during and shortly after the Open Enrollment Period, Medicare Advantage plans operate a toll-free call center for both current and prospective enrollees seven days a week, from at least 8:00 AM. to 8:00 PM, according to the time zones for the regions in which they operate. During this time period, current and prospective enrollees are able to speak with a live customer service representative. More information can be found in the Medicare Marketing Guidelines (see Page 61): FAQ Database - FAQ #12259 08/31/15 and HICS FAQs 08/31/15) Q: Does the Marketplace Call Center provide consumers with their Health Insurance Casework System (HICS) case A: In instances in which a consumer contacts the Marketplace Call Center to inquire about a HICS case that has been opened but is unresolved, the Marketplace Call Center Representative may provide the HICS case ID. Because of the process utilized to create HICS cases, the Marketplace Call Center is unable to provide a HICS case ID to a consumer upon initial entry of the case. The case ID will begin with the letter and the last two numbers of the year in which the case was recorded. Issuer customer service representatives should be aware that consumers may be contacting them with follow-up questions regarding their HICS cases, and issuers should address consumer matters appropriately. Consumers have reported that some issuer call center representatives do not know about HICS or fail to recognize the case ID consumers provide, resulting in the consumer being unnecessarily referred back to the Marketplace Call Center. (REG TAP FAQ Database - FAQ #12260 08/31/15 and HICS FAQs 08/31/15) Q: Do the Centers for Medicare Medicaid Services (CMS) have some suggested best practices for recording Health Insurance Casework System (HICS) case resolution notes? Updated 1-31-17 A: Yes. Because HICS resolution notes are loaded into the interface used by Marketplace Call Center Representatives daily, and may be read directly to consumers making follow-up inquiries, issuers are encouraged whenever possible to provide complete and clear narratives in plain language that avoid acronyms or technical jargon. For example: Health Plan has located the consumer's enrollment into our bronze plan with an 8/1 effective date for the entire household, with a $600 per month tax credit being applied. The consumer will be receiving a welcome packet that includes his or her membership materials and ID card later this week. Resolution letter sent on 6/15/15." CMS plans to provide further examples of resolution notes for a variety of casework scenarios in the future. In general, issuers should provide clear resolution notes that provide enough detail to explain how the case was resolved. Simply indicating that the case has been resolved is not adequate. See 45 CPR. (REGTAP FAQ Database - FAQ #12261 57 2017-?00157 08/31/15 and HICS FAQS 08/31/15) Q: Does a Quali?ed Dental Plan (QDP) issuer need a Health Insurance Casework System (HICS) case to terminate a consumer's enrollment? A: No. Based on the Centers for Medicare Medicaid Services' (CMS) guidance issued on June 1, 2015, available at QDP issuers can process termination requests when contacted directly by a consumer without a HICS case. Consumers may also contact the Federally-facilitated Marketplace to terminate their QDP, which would result in the termination request coming to the issuer via a HICS case. The guidance is available at: QDPTerms 060115 50R 081815.pdf(RE GTAP FAQ Database - FAQ #12262 08/31/15 and HICS FAQs 08/31/15) Q: If an issuer receives a Health Insurance Casework System (HICS) case in which the member has lost eligibility for advance payments of the premium tax credit (APTC) due to an income data-matching issue, subsequently returns to the Marketplace and updates his or her household income information, which restores the member's eligibility for APTC prospectively, should the issuer provide a retroactive effective date for the restored APTC if the 834 enrollment transaction includes a prospective effective date? A: No. Consumers who lose eligibility for APTC due to an expired household income data-matching issue and subsequently update their household income information may qualify for a Special Enrollment Period (SEP) to enroll in, or change, coverage with APTC. However, that SEP will provide a prospective effective date. Consumers do not qualify for a retroactive effective date based only on updated household income information. The issuer should advise the consumer of his or her right to ?le an appeal of the ?nal eligibility determination notice with the Marketplace. If a consumer is granted retroactive application of the APTC amount based on an eligibility appeal, the request for retroactive application of the APTC amount will be communicated to the issuer via a HICS case. The HICS case will be recorded in the ?Plan and Issuer Concerns? category and the ?Eligibility Appeals OHI Related Use Only? subcategory with a narrative that includes the effective date that the issuer should apply. Where a request for retroactive application of the APTC amount is based on an eligibility appeal, the issuer should follow the instructions in the HICS case. (REGTAP FAQ Database - FAQ #12263 08/31/15 and HICS FA Qs 08/31/15) Q: Is it true, at this time, that a consumer can add a new email address to receive notifications, but they cannot change the email address that is associated with the Marketplace Account/sign-on? Updated 1-31-17 A: Yes. The Centers for Medicare Medicaid Services (CMS) is aware of some functionality issues that may prevent a consumer from updating his or her Marketplace account/sign-on email address if he or she is unable to access that email account due to a lost password, forgotten user name, etc. CMS is working to troubleshoot these situations. In the meantime, the issuer should advise a member in this type of situation that the issuer can update an email that is kept on file to be used for issuer alerts and notifications. The consumer should be advised that his or her Marketplace account is separate from the issuer's system and is linked to his or her originally-?led application. For information regarding updating that email address with the Marketplace, the consumer will need to work with the Marketplace Call Center and/or access his or her 58 2017--00158 My Account at HealthCare.gov. (REGTAP FAQ Database - FAQ #12264 08/31/15 and HICS FAQs 08/31/15) HICS - Enrollment Q1: What should an Issuer do if it has been assigned a case in which the consumer indicates s/he is enrolled with the Issuer, but the Issuer does not have the consumer?s enrollment information? A1: Issuers are expected to fully investigate these matters. The Issuer should: 1) Verify that the Issuer did not receive an 834 file, by ensuring that the 834 file was not rejected, or received. The Issuer should then determine whether the 834 was processed through the Issuer?s system. 2) If the 834 was not received or was rejected, review the corresponding pre-audit ?le(s) and any other supplemental files associated with the pre-audit files. The Issuer may need to wait for the pre-audit file that was extracted after the enrollment was processed, in order to verify enrollment. Pre-audit ?les are generally extracted once per month, so in some instances it may take as long as 30 days for the enrollment to appear in the pre-audit ?le. 3) The Issuer should attempt to contact the consumer, varying the time of day over the course of several attempts to increase the likelihood of reaching the consumer. We recommend that the Issuer attempt to make contact with consumers at least two times, with more attempts if the Issuer is unable to leave a message. If these attempts are unsuccessful, an Issuer should contact the consumer by mail. 4) Determine if the consumer still needs assistance and verify that the consumer appropriately completed plan selection. 5) If the Issuer does not ?nd the enrollment through the 834 ?le or the corresponding pre-audit file, and it has veri?ed with the consumer that the consumer received con?rmation of his/her enrollment into the plan either by a confirmation screen on healthcaregov or by con?rmation from a Marketplace Call Center Representative (CCR) -- the Issuer will need to contact the XOSC Help Desk at 1-855-CMS-1515 (855-267-1515) or CMS FEPS@cms.hhs.qov and: a. Open a ticket with the XOSC Help Desk. b. Please include the information when submitting any Help Desk ticket: 0 8-character Application QHP ID Zip Code (if available); Issuer representative contact information (e-mail and phone number); Issuer name and State; Issuer?s 5-character HIOS Issuer?s Trading Partner and Specific, detailed steps the Issuer representative took in attempting to resolve the case. 6) Update the Health Insurance Casework System (HICS) casework notes accordingly. (CMS FAQs Casework 06/17/2014; REG TAP FAQ Database - FAQ #2372 06/18/14 02: If an Issuer has not received an 834 file for a specific enrollment, but the enrollment transaction appears on the pre-audit file, can the Issuer process the enrollment solely using data from the pre-audit file? 59 Updated 1-31-17 2017--00159 A2. Yes. In cases in which an Issuer has not received an 834 ?le, but does have a pre- audit file reflecting the enrollment transaction, the Issuer should use the pre-audit ?le to process the enrollment. (CMS FAQs Casework 06/17/2014) Q3: Can an Issuer reinstate a consumer if the consumer?s enrollment in a plan was erroneously cancelled or terminated for non-payment of premiums? A3: Yes, an Issuer can reinstate the consumer. The Issuer should update its enrollment records accordingly until such time as reinstatement 834 transaction functionality is operational. Issuer and CMS records will be in reconciliation later this year. We expect to issue more guidance on this topic in the near future. (CMS FAQs Casework 06/17/2014) Q4: ls CMS approving special enrollment periods (SEPs) for consumers who seek earlier effective dates than those to which they are entitled, solely because they have a medical/drug need? A4. No. CMS does not have an SEP for medical/drug need. Consistent with 45 CFR a consumer may be determined eligible for a SEP if s/he missed the plan selection cut off as a result of a serious medical emergency. If CMS indicates that the consumer is eligible for an SEP in the HICS case narrative, the Issuer must process the SEP. (CMS FAQs Casework 06/17/2014) Q5: What should an Issuer do if it received an urgent case in which the consumer had a medical or drug need and despite the Issuer?s best efforts, it could not find an 834 file or pre-audit file documenting an enrollment for the consumer? A5. Issuers should thoroughly investigate such cases in accordance with the process outlined in Q1. (CMS FAQs Casework 06/17/2014) 06: Does an Issuer have an option to move the effective date upon consumer request (commonly referred to as ?Slide For example, this situation may arise where the Issuer receives an 834 file with a coverage effective date of 3/1/2014 but the Issuer does not send the welcome package or otherwise confirm the enrollment with the consumer until April, and the consumer requests a 4/1/2014 effective date instead of 3/1/2014. A6: Issuers cannot move the effective date upon consumer request in this circumstance and must implement the effective date re?ected in the 834 or pre-audit ?le. If the consumer thinks the effective date is incorrect for other reasons, s/he should contact the Marketplace Call Center. (CMS FAQs Casework 06/17/2014) Q7: For a family of four, an Issuer received an 834 enrollment file with instructions to enroll the husband and wife. The 834 does not contain instructions to enroll the two children, because they have been assessed as potentially eligible for Medicaid or CHIP. However, the children subsequently are determined ineligible for Medicaid and CHIP, and an 834 file with instructions to enroll them in the parents? QHP is sent to the issuer. What coverage effective date do the children receive? 60 Updated 1-31-1 7 2017--00160 A7: The Issuer should provide an effective date consistent with the date on the 834 transaction that adds the children to the policy, which will be a prospective date. If a consumer believes that s/he is entitled to a retroactive effective date, the consumer may request an eligibility appeal by contacting the Marketplace. More information about eligibility appeals can be found at marketplace-decisionl. (CMS FAQs Casework 06/17/2014) 08: What does CMS mean by ?defective enrollment? (as noted in HICS narratives or case notes) and why do some case notes instruct Issuers to make retroactive enrollment changes? A8: A defective enrollment typically describes the situation where a consumer has completed an enrollment through the Marketplace, yet the Issuer does not have a record of the enrollment in either an 834 ?le or a pre-audit ?le. Issuers are expected to address these situations by following the process outlined in Question 1. (CMS FAQs Casework 06/17/2014) 09: What can an Issuer do when duplicate HICS cases are received with different effective dates? For example, a HICS case was received in April and coverage was effectuated related to that case, but then another case for the same consumer is received in May with a different enrollment effective date specified? A9: The Issuer should reach out to the consumer to ascertain which HICS case re?ects the most recent information available. See Question 1 for recommendations regarding attempts to contact consumers. The Issuer can also contact the Account Manager to assist in such instances. (CMS FAQs Casework 06/17/2014) Q10: What is the expectation for Issuers when a HICS case narrative speci?es a coverage effective date? A10: CMS expects Issuers to implement effective dates as directed in the HICS case. (CMS FAQs Casework 06/17/2014) Advanced Premium Tax Credits (APTC) and Cost Sharing Reductions (CSR) Q11: What should an Issuer do if the consumer has an eligibility determination from the Marketplace showing the consumer is eligible for more APTC than is shown on the 834 file? A11: The Issuer should review the pre-audit ?le and any other ?les associated with the pre-audit ?le that CMS provided to confirm the APTC amount is correct. If the APTC amount on the 834 ?le is con?rmed by the pre-audit ?le or associated files, the Issuer should advise the consumer to go back to the Marketplace and change the amount of APTC s/he would like to use, as this may be a case where the consumer did not select the amount of APTC that s/he would like to apply. Issuers may only use data from an 834 ?le, the pre-audit ?le, or ?les associated with the pre-audit ?le for the purposes of applying APTC. If the consumer still disputes the amount of APTC and the Issuer believes there is a technical issue, the Issuer should open an XOSC Help Desk ticket and update the HICS casework notes accordingly. If, upon review, the Help Desk determines that the Issuer is applying the correct APTC amount, the Issuer should advise the consumer that s/he can obtain information about the right to appeal the 61 Updated 1-31-17 2017--00161 amount of APTC for which s/he has been determined eligible, subject to applicable timeframes and other requirements, at marketplace?decision/. The Issuer should also notify consumers that many states offer help to consumers with health insurance problems, including providing assistance with resolving problems with obtaining premium tax credits under section 368 of the Internal Revenue Code of 1986 and through Consumer Assistance Programs which can be found at (CMS FAQs Casework 06/17/2014) Q12: What is an Issuer to do if it has received an 834 file that does not indicate that a consumer is eligible for APTC or CSR, but the consumer states that s/he should have an APTC or Can the Issuer move forward without any APTC and/or CSR and disenroll the consumer if the consumer does not pay the whole premium when due? A12: The Issuer should act based on the information provided on the 834 ?le. If the consumer states that s/he should receive APTC and/or CSR, the Issuer should review the pre-audit ?le to verify that the information regarding matches that on the 834 ?le. If the 834 ?le does not re?ect eligibility for but the pre-audit ?le does, the Issuer should use data from the pre-audit ?le. If the pre-audit ?le also does not reflect eligibility for the Issuer should follow CMS regulations and guidance on non-payment of premiums if the consumer does not pay the whole premium when due. The Issuer should also notify the consumer that s/he can obtain information about the right to appeal the amount of APTC for which s/he has been determined eligible, subject to applicable timeframes and other requirements, at FAQs Casework 06/17/2014) General Customer Service Q13: What should an Issuer do if a HICS case narrative is not clear, and the Issuer is unable to reach the consumer because the contact number is invalid? A13: If, after checking through its own systems and information in the HICS case, the Issuer is unable to find accurate contact information for a consumer, the Issuer can close the HICS case with a narrative describing the steps taken to contact the consumer and note that the reason for case closure was the inability to contact the consumer. (CMS FA 08 Casework 06/17/2014) Q14: What should an Issuer do if they have a HICS case which includes an effective date that would seem to require a SEP, but for which there is no mention of a Updated 1-31-17 A14: The Issuer should review the HICS narrative to determine if the HICS case concerns a defective enrollment. The casework for defective enrollments will often not include a SEP as the consumer is requesting assistance to ?x a problem with the initial 62 2017-?00162 enrollment. The Issuer should use the HICS narrative to determine the appropriate action. (CMS FAQs Casework 06/17/2014) Q15: What should an Issuer do if it has submitted many XOSC tickets, some of which may be related to HICS cases but others which may be technical in nature, but has not received a response or acknowledgement? What happens after the Issuer receives a ticket number? A15: If you sent a ticket more than 60 days ago and have not yet received a response, your issue may have been resolved. Thus, if you sent a ticket more than 60 days ago and have not yet received a response, we ask that you: 1. Re-confirm that the issue still exists, and/or question has not been answered or resolved through subsequent actions taken by the consumer, Issuer, or 2. Re-confirm that the issue or question remains a priority for your organization; and 3. If the issue is still outstanding, please re-submit the ticket, and provide any additional information that has occurred since the original submission. Similarly, if your caseworker has requested that you contact the XOSC Help Desk regarding an open ticket, please re-submit the ticket. (CMS FAQs Casework 06/17/2014) Q16: What should an Issuer do with a case involving the Change in Circumstance process? Should these cases simply be handled by the Call Center? A16: CMS released guidance on on February 6, 2014. We encourage Issuers that have open cases predating the guidance to make at least two attempts to reach out to enrollees and educate them on the process, consistent with the February 6 guidance, and then close the cases. (CMS FAQs Casework 06/17/2014) Q17: What should an Issuer do with a case that requires action by the consumer through the Marketplace? Why was the consumer sent to the Issuer? A17: CMS is working through a backlog of aged cases. We believe that the majority of these aged cases can be addressed by the Issuer. For those cases that do not require any intervention or action by the Issuer, we encourage the Issuer to educate its customer about the Marketplace and steps s/he can take to address his or her issue. CMS expects Issuers will be familiar with general Marketplace rules and able to advise their customers accordingly. (CMS FAQs Casework 06/17/2014) Hand/inq of Casework Q18: What is an referral and how does that differ from our other HICS cases? A18: Advanced resolution center referrals are a select group of the most urgent cases received by our Call Center each day that are routed to our Regional Of?ces for action. Often these cases require immediate assistance from the Issuer. While the standard resolution time for urgent cases as de?ned in 45 CFR 156.1010 is 72 hours (unless an applicable state law provides for a stricter timeframe), we request that Issuers give these infrequent cases their prompt attention. (CMS FAQs Casework 06/17/2014) Q19: We have applied for additional HICS access for several of our staff but haven?t heard back. When will these applications be processed? 63 Updated 1-31-17 2017--00163 A19: Please allow up to 10 business days for processing. If a response still hasn?t been provided after 10 business days, please contact Bonita Porter at: Bonita.Porter@cms.hhs.qov. Please ensure that your requests for HICS access contain original signatures to ensure prompt processing. (CMS FAQs Casework 06/17/2014) 020: CMS has provided a great deal of guidance and training material. What materials does CMS recommend Issuers focus on the most for the purposes of helping consumers with most of their casework issues? A20: Issuers should be familiar with all CMS regulations and guidance applicable to them. In particular, CMS strongly recommends that Issuers understand the guidance issued in the Bulletins on Enrollment and Termination Policies and Processes for FFM and SPM Issuers located at for Issuers 50R 020714.pdf. Issuers should also be familiar with consumer-facing information developed for consumers and available on HealthCare.gov that relates to enrollment, SEPs, plan selection, premium payment, inconsistencies, Change in Circumstance, cancellations and terminations, and eligibility appeals. (CMS FAQs Casework 06/17/2014) Q: Should issuers expect to see Health Insurance Casework System (HICS) cases from employers and employees? A: CMS will be able to submit HICS tickets for both employers and employees, though CMS expects the vast majority will involve employees. (REGTAP FAQ Database - FAQ #8201 12/15/14) Q: When will the Centers for Medicare Medicaid Services (CMS) send guidance and regulations to issuers regarding how to respond to Small Business Health Options Program Insurance Casework System (HICS) cases? A: Issuers should follow the same established policies for handling SHOP HICS cases as other Marketplace cases. (REGTAP FAQ Database - FAQ #8202 12/15/14) Q: What are the Service Level Agreements (SLAs) for Small Business Health Options Program Insurance Casework System (HICS) complaints? A: 72 hours for Level 1 cases and 15 days for all other complaints. (REGTAP FAQ Database - FAQ #8204 12/15/14) Q: When does the Special Enrollment Period (SEP) for surplus Advance Payments of the Premium Tax Credit (APTC) end? Is this SEP still available for coverage effective dates retroactive to January 1, 2015? A: The Federally-facilitated Marketplace (FFM) Call Center offered a retroactive SEP to consumers who had surplus APTC. This SEP ran from February 26, 2015 through March 6, 2015, and provided consumers the option of receiving a January 1, 2015 effective date. (REGTAP FAQ Database - FAQ #10761 05/27/15) Grace Periods 64 Updated 1-31-17 2017--00164 Q42: 45 CFR 156.270(d) provides for a grace period of three consecutive months for QHP enrollees who receive APTC. Section states that an issuer must pay all appropriate claims for services in the first month of the grace period and may pend claims for services in the second and third months of the grace period. Under HIPAA regulations regarding administrative simplification requirements for electronic transactions and code sets, 45 CFR Part 162, providers are required to use the National Council for Prescription Drug Programs Telecommunications Standards, Version D, Release 0, when billing pharmacy claims. This standard does not contain a transaction allowing a claim to be pended. How should issuers handle pharmacy claims in months two and three of the grace period? A42: 45 CFR 156.270(d) does not require issuers to pay claims during months two and three of the grace period. Thus, issuers may pend these claims. However, issuers may not be able to pend pharmacy claims, only pay or deny such claims. In such instances, where it is not possible for the issuer to pend the claim, the issuer may deny the claim. If an enrollee pays for a drug out-of?pocket during the second or third months of the grace period due to an issuer?s denial of the claim and subsequently pays his or her share of the premium so as to no longer be in the grace period, that enrollee may submit a receipt, and the issuer must reimburse its share of the cost directly to the enrollee. Thus, the enrollee can be made whole even if a claim cannot technically be pended. (QHP Webinar Series FAQ #10 05/09/13) Q43: 45 CFR 156.270(d) provides for a grace period of three consecutive months for QHP enrollees who receive APTC. Section states that an issuer must pay all appropriate claims for services in the first month of the grace period and may pend claims for services in the second and third months of the grace period. If a QHP provides for the dispensing of a 90-day supply of drugs, does a QHP issuer have to provide the full 90-day supply if an enrollee is in the first month of the grace period? A43: Yes, the issuer should provide the full 90-day supply, pursuant to 45 CFR (QHP Webinar Series FAQ #10 05/09/13) Q20: In question 42 of the 05I09l13 FAQ document previously posted to REGTAP, you stated that if a pharmacy claim cannot be pended during months two and three of the grace period, an issuer may deny the claim. This FAQ further indicated that if the enrollee pays for prescriptions out-of-pocket and subsequently becomes up-to-date on premiums within the grace period, the issuer must reimburse its share of the cost of covered pharmacy benefits filled during the grace period, if the enrollee submits a receipt. In this 65 Updated 1-31-1 7 2017--00165 case, can the issuer have reasonable procedures to count only the cost-sharing amount towards the out-of-pocket maximum A20: Yes, where the issuer reimburses for a service to make the enrollee whole, the issuer should count applicable cost sharing towards to the MOOP. (QHP Webinar Series FAQ #12 06/28/13) Q1: Will subscribers who are eligible for the Advance Premium Tax Credits (APTC) but elect $0 APTC, still qualify for the 90 day grace period for non-payment of premiums? A1: No. Per 156.270(d) of the Exchange Final Rule, the enrollee must be receiving APTC to qualify for the 3-month grace period. (Enrollment FAQ #3 07/03/13) Q1: The April 2013 Annual Letter to Issuers indicated that Issuers must notify providers that may be affected by an enrollee entering a grace period for non-payment (providers who submit claims for services they have provided to individuals during the grace period and for which they risk not being reimbursed). When should the QHP Issuer send the notice to providers? Should it be sent as soon as the enrollee enters the grace period or in response to a submitted claim? If the latter, does notice need to be re-issued for each claim submitted by a single provider? Does the notice need to be sent at some regular interval each month of the grace period? A1: CMS does not intend to regulate on the timing or detailed procedures for the grace period notifications to providers. However, we are developing guidance regarding timing and content for this provider notification, as well as and recommendations for communication about claims processing or claim status for an enrollee in the three month grace period. (Enrollment FAQ #6 7/22/13) 02: As per 45 CFR when someone who receives APTC has fallen into the delinquency grace period, the Issuer must ?notify Health and Human Services (HHS) of such non-payment.? The regulation does not specify the means by which the Issuer is to provide the notification to HHS, but some Issuers would like to send the termination transaction to the Federally-facilitated Marketplace (FFM) at the conclusion of the grace period. Is this permissible? A2: If an enrollee fails to pay in full his or her portion of any premium due prior to the end of the applicable grace period, QHP Issuers must send an 834 termination transaction to the Marketplace. In addition, Issuers must participate in a reconciliation process with the Federally-facilitated Marketplace (FFM). Each month, Issuers will submit a reconciliation audit file with certain data elements for every current enrollee, including the ?premium paid through date.? This will identify the FFM enrollees who are in a payment delinquency status, thus meeting the notification requirement for non-paying enrollees. (Enrollment FAQ #6 7/22/13) Q7: An individual is eligible and takes Advance Premium Tax Credit (APTC) on his medical QHP plan. However, there is not enough APTC to also apply to their dental plan. 66 Updated 1-31-1 7 2017--00166 CCIIO indicated on a 6/17 enrollment technical call that that the enrollee would still be considered an APTC recipient and the 90 day grace period would apply to the dental plan. However, since the indicator on the dental plan would reflect how would the dental plan know the enrollee is APTC eligible to give them the 90 day grace on the dental plan, particularly if an individual has medical coverage with one Issuer and dental coverage with a Stand Alone Dental Plan? A7: Consistent with the policy regarding Advance Premium Tax Credit (APTC) and eligibility for the grace period for individuals on a standard medical plan, if no APTC is applied to the dental plan, the enrollee would not be eligible to receive a grace period for three consecutive months for that (dental) plan. (Enrollment FAQ #6 7/22/13) Q: Will there be a sample letter regarding notification to providers of the possibility for denied claims for services rendered during an APTC grace period? A: Issuers must notify providers of the possibility for denied claims when an enrollee is in the second and third months of the grace period as set forth in 45 CFR Issuers have flexibility in the wording and messaging of this notice. CMS does not intend to provide a sample letter regarding this notice. (REGTAP FAQ Database - FAQ #635 01/09/14) Q: What is the content, format and timing of a delinquency grace period notice or should Issuers just send CMS an 834 termination file for an enrollee who has not made their past due premium payment and is no longer in a grace period? A: In accordance with 45 CFR if an enrollee is receiving APTC and fails to make full payment (or payment within the optional premium payment threshold) of their portion of the premium by the due date, the QHP issuer must generate a notice for non-payment of premium to the enrollee. CMS provided an example of this notice in Appendix of the draft version of the Enrollment Operational Policy Guidance released on October 3rd. The speci?c wording and messages included in the example are included as recommendations. Further, 45 CFR ?156.270(d) requires QHP issuers to observe a 3 month grace period for enrollees receiving APTC and should not generate an 834 termination ?le until the grace period has expired and the enrollee has not paid their full premium during the grace period. Additional information can be found in Section 5.0 of the draft guidance. (REGTAP FAQ Database - FAQ #646 01/09/14) Q: Do provider grace period notice letters need to be generated for every one of a subscriber's claims or can a single letter be generated by a provider for all subscribers that have delinquent claims for that provider practice? A: It is required that the QHP Issuer inform each provider that an enrollment group is in a grace period, which may cause pended and/or denied claims. Guidance can be found in 45 CFR 45 and Letter to Issuers dated 03/01/2013. Please see link below: (REGTAP FAQ Database - FAQ 684 01/27/14) 67 Updated 1-31-17 2017--00167 Q: For a member to exit a 90-day grace period, the member must pay past due amounts. According to Marketplace regulations, these past due amounts do not include payments for months after the end of a member's 90-day grace period. Does this same standard apply to State Based Marketplaces (SBMs), in which Issuers (and not the Marketplace) collect premium payments? A: If an enrollee fails to pay in full his or her portion of any premium due prior to the end of the applicable grace period, QHP Issuers must send an 834 termination transaction to the Marketplace with an effective termination date of the last day of the ?rst month in the grace period. Please note, regulatory provisions in 45 CFR ?156.270 (1 on Grace Periods apply to the FFM and SBM's. (REGTAP FAQ Database - FAQ #2264 06/18/14) Q: If a member, who is eligible for the Advance Payment of the Premium Tax Credit (APTC), always pays late, will there be an advanced paid-through date on the member's 834? If yes, then the advanced paid-through date would relay that the member is still in month 1 of grace even though the member is in month 2 or 3. A: The ?paid through date" on the 834 will only show the initial month the 834 was sent. Enrollees effective date is Jan 1, and the enrollee has paid his/her premium for the month of June, the ?paid through date" is likely going to be January not June). However, issuers will participate with in a reconciliation process with the FFM. In the reconciliation audit ?le, issuers will provide the 'premium paid through date' for every current enrollee. This will provide to CMS all enrollees who are in a payment delinquency status. (REGTAP FAQ Database - FAQ #2265 06/18/14) Q: Are there any rules that prevent Issuers from effectuating a member until that member has paid past due balances from a non-Marketplace insurance plan November and December premium payments) and the member's initial premium payment for Marketplace coverage with a January 1, 2014 effective date? A: Past due premiums from a non-Marketplace environment may not be associated with Marketplace coverage. (REGTAP FAQ Database - FAQ #2268 06/18/14) Q: Issuers are aware that they are required to give consumers with advance payments of the premium tax credit (APTC) who have paid at least one month's premium in full a three-month grace period for payment of premium before terminating their enrollment. However, what should an Issuer do with a case in which the 834 file does not reflect that the consumer is receiving APTC, but the consumer who has not paid premiums claims s/he should have one? Can the Issuer terminate the consumer's enrollment without allowing the three-month grace period the consumer believes s/he is entitled to? A: The Issuer can terminate the consumer's enrollment without providing the three- month grace period if the information received from the Federally-facilitated Marketplace does not re?ect that the consumer is receiving APTC. The Issuer generally should act based on the information provided on the 834 ?le. However, if a question is raised regarding the consumer receiving APTC (and/or cost-sharing reductions the Issuer should review the pre-audit file to verify that the information regarding matches the information in the 834 file. If the 834 file does not reflect eligibility for but the pre-audit file does, the Issuer should use data from the pre-audit file. If the pre-audit file also does not re?ect eligibility for the Issuer should follow state law requirements, consistent with CMS regulations and guidance on non-payment 68 Updated 1-31?17 2017--00168 of premiums. The Issuer should notify the consumer that he or she can obtain information about the right to appeal his or her eligibility for at If through the Marketplace appeals process the consumer is found to be eligible for the APTC, the consumer may also qualify for a SEP. The Issuer should also ensure compliance with any applicable state laws or regulations regarding grace periods. (REGTAP FAQ Database - FAQ #4263 08/28/14; CMS FA 08 on Casework 08/28/14) Q: An issuer is attempting to access Revised Bulletin 10 on Grace Periods Related to Terminations for Non-Payment of Premiums and Enrollment through the Federally- facilitated Marketplace across Bene?t Years Grace Periods, via the following link: Bulletin1OGracePeriods 5CR 091214.p d_f, which was referenced in Frequently Asked Question (FAQ) 10760. The issuer has been unable to get the link to work and has unsuccessfully searched for the document in the Registration for Technical Assistance Portal (REGTAP) website. The issuer has also been unable to find the document on the Center for Consumer Information and Insurance Oversight (CCIIO) website and on Where is Revised Bulletin 10 located? A: The Centers for Medicare Medicaid Services (CMS) requires some materials to be archived due to being outdated. REGTAP maintains a record of the document in REGTAP, but eliminates public access since the information is no longer applicable or accurate. Revised Bulletin 10, along with many other bulletins, was archived due to the publication of the updated Federally-facilitated Marketplace (FFM) and Federally-facilitated Small Business Health Options Program (FF-SHOP) Enrollment Manual on October 5, 2015. The new guidance concerning grace periods spanning two (2) years can be found in Section 6.5.2 of the updated Enrollment Manual. CMS is currently planning to release the latest version of the Enrollment Manual this summer. (REGTAP FAQ Database - FAQ #16393 06/14/16) Q: Will consumers have a 90-day grace period when making a payment to an issuer, even if they lose the Advanced Premium Tax Credit A: No. If an enrollee who is receiving APTC enters a three-month grace period for non- payment of premium and, during months one or two of the grace period, becomes ineligible for APTC, the remaining length of the grace period is governed by state rules. For example, if an enrollee becomes ineligible for APTC during month two of the three- month grace period, and the termination of APTC takes effect on the first day of the third month of the grace period, the remaining grace period would be governed by state rules. If the same situation occurred during the third month of the APTC grace period, the APTC termination would take effect on the day after the APTC grace period expires and would not give rise to an additional state-rules grace period. (REGTAP FAQ Database - FAQ #17973 10/28/16) Terminations and Cancellations 69 Updated 1-31-17 2017--00169 Q10: Will issuers be provided an enrollment start date and a subsequent termination date only when the record terminates (per request, non-payment or other)? A10: When an individual enrolls with the QHP issuer, the enrollment transaction will include an enrollment effective date, but the initial transaction does not include a coverage end date. When an individual?s coverage ends, the coverage termination date will be indicated in the 834 termination transaction. For the most current guidance on the enrollment transactions please refer to the CMS Companion Guide, available at: transaction-v1.5.pdf. (Enrollment FAQ 04/24/13) Q12: The Exchange Final Rule requires that a QHP issuer provide notice to an enrollee if coverage is terminated at least 30 days prior to the last day of coverage and notify the Exchange of the effective date of termination and reason. We have not yet received written clarification on who will be responsible for rolling the over-age dependent off the policy, and who will provide notice to the individual. Please confirm the following for the FFM: a. Health plans will complete the termination and provide notice to the aged-off dependent and primary subscriber in a manner consistent with the Exchange Regulations and applicable state laws. CMS will be providing additional guidance on these processes in the near future. b. Following the receipt of the termination from the Issuer, an exchange eligibility determination will be triggered by the FFM to examine impact on premium, ATPC amount and CSR eligibility as a result of the enrollment change. c. The FFM is developing additional eligibility support and outreach approaches to ensure the consumer?s eligibility and enrollment information remain update date. d. For initial enrollments, the FFM is currently not programming to state specific rules like full-time student or veteran?s status). A12: The process for handling aging-off dependents is still under development. We are currently engaged in dialog with Issuers and we anticipate ?nalizing the policy and process by the end of July. (Enrollment FAQ #2 07/02/13) Q13: Enrollment File Indicator: States that permit coverage of dependents over age 26 may do so only for certain adult children, including veterans, full-time students, or persons with disabilities. The Federally-facilitated Marketplace does not obtain or provide this information as part of the eligibility determination process. However, health plans need a way to provide the reason for termination to the marketplace. For example, in Iowa (a State Partnership Exchange), Issuers must allow dependents to maintain their parent?s coverage if the child is a full-time student or has a disability. Will CMS be updating a list of termination reason codes to account for terminations other than non- payment of premium? If so, when? Currently the companion guide indicates that the disability indicator will not be sent on the 834? Will CMS consider revising the companion guide as this impacts whether individuals can remain on the policy after the maximum dependent age? 70 Updated 1-31-17 2017--00170 A13: The Federally-facilitated Marketplace will add several codes to the list of maintenance reason codes for communicating termination reasons to the Issuers, including codes for fraud, nonpayment of premium and minimum essential coverage. These codes will be listed in the next version of the Enrollment Companion Guide, expected to be published by mid-August. In addition, the testing process, which begins July 15th, is expected to generate additional information that will result in another version of the Companion Guide before October 1, 2013. CMS is discussing methods for providing disability status to Issuers based on relationship codes used on the application forms. (Enrollment FAQ #2 07/02/13) Q14: Aging off Pediatric Coverage: What will occur when an individual is enrolled in pediatric dental and they reach the age when Dental Pediatric coverage will end? Will the FFM manage the eligibility and send the issuer a termination 834 Transaction at the end of the plan year after the individual meets the age limit for pediatric dental coverage 19 years)? If the FFM does not send a termination transaction, then the individual will still be enrolled in the issuer?s system because the issuer cannot terminate individuals. The policies for ?dependent age out? on a family plan vary by State. If the family does not take any action during open enrollment wants to maintain current coverage), will the FFM be able to determine that the dependent is no longer eligible based on the age? If the FFM does not enroll an over age dependent, will it send a termination transaction, or just send an updated enrollment transaction for the entire family/enrollment group? A14: CMS is developing a process to address the topic of ?dependent age out," issuer options for action, and roles for the FFM and the Issuers. Information should be available by the end of July. (Enrollment FAQ #2 07/02/13) Q3: Will the FFM or the Issuer have the responsibility for terminating over-age dependents? Who will own the notice requirements related to determination? Given the policyholders Advance Premium Tax Credit (APTC) will be impacted, what is the requirement for the timing of a new Exchange eligibility determination? If the issuer owns such determinations, how should notice be provided to the FFM in the 834, and what is the process for maintaining coverage in the case of disability, or state law requiring maintaining of coverage full-time students, veteran's, etc.)? A3: We are developing guidance on the subject of terminations for over age dependents and will release that to Issuers soon. (Enrollment FAQ #3 07/03/13) Q4: In the final Exchange Rule, the provision at requires that a QHP Issuer provide an enrollee with a notice of termination of coverage that includes the reason for termination at least 30 days prior to the last day of coverage. Does the date of the notice dictate the date of termination, or does the notice simply give 30 days for the enrollee to make the payment? Which of the following scenarios would be in compliance with the above? 71 Updated 1-31-17 2017-?00171 Scenario 1: Premium payment for the month of March is due 3/1; enrollee does not pay by 3/31. Health Plan sends a termination of coverage notice to the enrollee on April 1st. Member does not pay premium. Health Plan terminates the enrollee effective 2/28. 2: As above, enrollee does not pay premium for month of March. Health Plan sends a termination of coverage notice to the enrollee on April 1st. Member does not pay premium. Health Plan terminates the enrollee effective 4/30. A4: On July 15, 2013, CMS published the Eligibility and Enrollment Final rule (CMS- 2334-F), which streamlines a number of provisions in the Affordable Care Act, including those related to termination. In this Final rule, the termination of coverage notice provision at ?156.270(b) states if the QHP Issuer terminates an enrollee?s coverage in accordance with or the Issuer must, and without undue delay: (1) Provide the enrollee with a notice of termination of coverage that includes the termination effective date and reason for termination. This regulatory clari?cation does not alter the rules for the effective date of termination for non-payment of premium. For enrollees receiving APTC, termination will continue to be the last day of the first month of the three-month grace period. For enrollees not receiving APTC, the effective date of termination must be in accordance with the standard policy established by the QHP Issuer in accordance with (Enrollment FAQ #6 7/22/13) Q: Scenario: There are no member level payments. There is an individual/family policy of 3 people (mom/father/son). The mother's premium is $100, father's premium is $200.00 and son's premium is $300.00 for a total of $600. The issuer receives a payment of only $400.00. The actual breakdown consists of mom and dad paid in full but they still owe $200.00 on the son. An issuer is not able to tell how a payment breaks down, so should the issuer terminate the entire plan or individuals within the plan? A: The premium must be paid in full (or at the threshold amount, at the issuer's option) for the entire enrollment group prior to the due date. An issuer should follow the termination process for the entire enrollment group if only partial payment is received. The scenario described would be impossible for a single enrollment group since using 2014 rating factors, there is no way a child could be rated more than his or her parents for the same plan. (REGTAP FAQ Database - FAQ #632 01/09/14) Q: CMS released guidance during the October 28, 2013 Issuer call stating that 'All enrollees that had terminations processed with the same effective date as the enrollment effective date (also known as retroactive cancellations).' Does this statement imply that Issuers are to include cancelled members on the reconciliation supplementary file? A: Issuers should include cancellations on the supplementary ?le if they were processed for effectuated enrollments. (REGTAP FAQ Database - FAQ #643 01/09/14) How do I know if I am eligible for this hardship exemption? If you have been noti?ed that your health insurance policy will be cancelled, and you believe that the individual market health plan options available in your area are unaffordable, you will be eligible for a hardship exemption and will be able to enroll in catastrophic coverage available in your area. on Options Available for Consumers with Cancel/ed Policies (01/13/14) 72 Updated 1-31-17 2017-?00172 What do I have to do to enroll in catastrophic coverage using this exemption? In order to receive a hardship exemption and be able to purchase catastrophic coverage, you must submit the hardship exemption form and should submit supporting documentation showing your health insurance policy was cancelled to an issuer offering catastrophic coverage in your area. If you do not submit supporting documentation with your hardship exemption form, CMS may contact you to let you know that you must submit supporting documentation of your policy?s cancellation, or your exemption may be revoked. on Options Available for Consumers with Cancelled Policies (01/13/14) Q: In reference to Appendix (nonpayment letter) of the Enrollment Operational Policy and Guidance module, does the member need to pay the September premium by September 1 to avoid termination? A: To avoid termination, enrollees must pay the full portion of the premium for which they are responsible prior to the end of the applicable grace period. In this example, if the enrollee paid the entire outstanding premium for which he or she is responsible on August 31 (premiums for June, July, August), the enrollee is no longer in the grace period. However, If the enrollee does not pay the entire outstanding amount on August 31st, the enrollee will be terminated. (REGTAP FAQ Database - FAQ 686 01/27/14) Q: Please provide guidance to the below EDI scenarios describing Issuers assumptions for inbound transactions and what Issuers are expected to provide for reconciliation. In the case of a deceased subscriber, will FFM send a full TERM for the entire policy? Would this transaction go on both the full file audit and supplemental file? A: Per 45 CFR termination due to death is effective on the date of death. If there are other family members on the policy receiving financial assistance, their eligibility will be redetermined. The reconciliation process is separate from the process for transmitting terminations. If a termination is transmitted and processed during the reconciliation period, it should be reported on the supplementary ?le for that reconciliation period. If the enrollee is not active as of the pull date of the audit files, the enrollee will not appear on the full 'snapshot' audit file.? (REGTAP FAQ Database - FAQ #681 01/27/14) Q: In the past you have used the term "cancel" for a member who doesn't make first payment and "term" for a member who doesn't make a subsequent payment. Is that distinction still going to be made? A: We will attempt to use consistent terminology moving forward, terminations apply for effectuated coverage while cancellations apply to coverage that has not yet been effectuated. (REGTAP FAQ Database - FAQ 833 02/21/14) Q: If an individual voluntarily terminates their coverage, will the individual be able to enroll in a new A: Upon termination, individuals will not be able to enroll in a new QHP unless they qualify for a SEP. (REGTAP FAQ Database - FAQ #1452 06/10/14) 73 Updated 1-31-17 2017-?00173 Q: What is the purpose of the Employment Status codes called out in Section 10.4 Individual Market Termination instructions in the 834 Companion Guide? A: The Individual Market will always send as the employment status code when terminating a member. The FF-SHOP, however, can send or for termination transactions. (REGTAP FAQ Database - FAQ #3428 08/01/14) Q: Can an individual terminate individual Federally-facilitated Marketplace (FFM) health insurance coverage if the individual becomes eligible for group health insurance coverage? A: Yes, an individual can voluntarily terminate coverage through the FFM if the individual obtains coverage elsewhere or obtains a new job with minimum essential coverage. Please see guidance in ?Bulletin Enrollee-Initiated Terminations? at for Issuers 5CR 020714.pdf in the REGTAP Library. (REGTAP FAQ Database - FAQ #3573a 08/11/14) Q: Will issuers initiate terminations directly with employees in the Federally-facilitated Small Business Health Options Program (FF-SHOP) as of the 2015 plan year? Or will the FF-SHOP initiate all terminations? A: As the enrollment system of record for the 2015 plan year, only the FF-SHOP will initiate cancellation and termination transactions. (REGTAP FAQ Database - FAQ #3763 08/14/14) Q: What should an Issuer do if it appropriately terminated/cancelled a consumer's policy for non-payment of premium and the consumer is dissatisfied? A: The Issuer should advise the consumer that s/he can re-enroll in the same quali?ed health plan (QHP) or a different one only if the consumer qualifies for a Special Enrollment Period (SEP). Otherwise the consumer will need to wait until the next Open Enrollment Period. Consumers do not have appeal rights through the Marketplace for disputing the termination/cancellation of their policies for failure to pay premiums. In some states, consumers may have recourse through the State Department of Insurance (DOI), so Issuers should also refer consumers to their State DOI for additional information and assistance. In cases in which a consumer's policy has been erroneously cancelled or terminated, the issuer should reinstate the policy by reactivating the enrollment as if it were never terminated or cancelled, and provide coverage based on the original effective date, reinstating all Out of Pocket (OOP) accumulators. The FFM will be updated through the baseline process until functionality is available for the issuer to notify the FFM of the reinstatement via an 834 transaction. (REGTAP FAQ Database - FAQ #4262 08/28/14; CMS FAQs on Casework 08/28/14) Q: Can an Issuer retroactively terminate a consumer's enrollment when instructed to do so by the Federally-facilitated Marketplace? A: Yes, if the Issuer receives a request from the Federally-facilitated Marketplace via HICS, it should retroactively terminate the consumer's enrollment as requested. Consumers can also request retroactive disenrollments directly with an Issuer (see Issuer Bulletin If the Issuer has questions with the request, it can reach out to its 74 Updated 1-31-17 2017-?00174 Lead Caseworker for additional information. (REGTAP FAQ Database - FAQ #4938 09/18/14) Q: How do the cancellation/termination reason codes discussed on a recent REGTAP call work with the codes listed in the 834 Companion Guide? A: The maintenance reason code reported in is used in conjunction with the ADDL MAINT REASON sent in the 2750 loop. The ADDL MAINT REASON code is used to provide clarifying and/or additional maintenance reason information not covered by the code reported in INSO4. For example, termination and cancellation transactions may report a maintenance reason code in INSO4, but will also include an ADDL MAINT REASON to specify whether the transaction is meant to be a cancellation (no period of coverage) versus a termination. (REGTAP FAQ Database - FAQ #6055 10/22/14) Q: What are considered appropriate actions for issuers to take under and, effective April 28, 2015, under to adjust claims from providers and pharmacies, if an enrollee's Marketplace coverage is terminated retroactively? A: If an enrollee's Marketplace coverage is terminated retroactively, in accordance with and and effective April 28, 2015 in accordance with the Marketplace will ensure that appropriate actions are taken to make necessary adjustments to advance payments of the premium tax credit, cost-sharing reductions, premiums, user fees, and claims. When a retroactive termination occurs, the issuer of the quali?ed health plan (QHP) under which coverage is being terminated is permitted to reverse all claims for services incurred after the retroactive termination date to the extent permitted by state law, and should refund to the enrollee all premiums paid back to the termination date. However, as an alternative, to the extent that state law permits the issuer to refund only paid premium amounts that exceed claims payments made by the issuer on the enrollee's behalf during the relevant period, an issuer may do so, provided it does so universally for all claims under all retroactive terminations. Nonetheless, recognizing the unique challenges of reversing pharmacy claims, if an issuer adopts a policy of only refunding premiums that exceed claims payments, as permitted by state law, it may adopt a policy of refunding only paid premium amounts that exceed pharmacy claims payments made by the issuer on the enrollee's behalf, while at the same time reversing medical claims. (REGTAP FAQ Database - FAQ #10017 04/21/15) Q: The state of Florida limits the eligibility of a newborn child who is a dependent of a non-subscriber once the dependent reaches 18 months of age. How should issuers terminate coverage for a child who has reached the state mandated age? (Reference Florida Statute ?627.641(1) at: Updated 1-31-17 A: An issuer may not terminate Marketplace coverage based on a dependent not meeting business rule criteria that was not provided to the FFM during Qualified Health Plan (QHP) certi?cation. The Federally-facilitated Marketplace (FFM) uses business rules submitted by issuers to determine eligible dependents (and thus enrollment 75 2017-?00175 groups) at the time of enrollment, and every quali?ed individual sent by the FFM on an enrollment remains eligible for Marketplace coverage and a portion of the family's advance payments of the premium tax credit (APTC) absent a subsequent transaction from the Marketplace, or non payment of premium. The FFM does not collect business rules related to the maximum age of a grandchild; therefore, should an issuer indicate that grandchildren are eligible dependents, and applicants identify a qualified dependent as a grandchild, the grandchild is an eligible dependent on the enrollment group, including at auto-reenrollment. (REGTAP FAQ Database - FAQ #10575 05/13/15) Q: If a member is terminated for non-payment, will the individual be eligible to re-enroll through the Marketplace? A: When a member's coverage is terminated for non-payment of premium, per 45 CFR the individual does not qualify for a Special Enrollment Period (SEP) for the resulting loss of minimum essential coverage (MEC). However, the individual may become eligible for an SEP based on other circumstances. See guidance in revised Bulletin 10 in REGTAP. Bulletin10GracePeriods 5CR 091214 p_df (REG TAP FAQ Database - FAQ #10760 05/27/15) Renewals Q: What is CMS's approach for auto renewals from 2014 to 2015 Updated 1-31-17 A: CMS is developing a template for issuers to complete that would cross walk 2014 Quali?ed Health Plan (QHP) plan ID and service area combinations Plan ID and County combinations) to a 2015 QHP plan ID. This data will facilitate 834 enrollment transactions from CMS to the issuer in December 2014 for those enrollees who have not actively selected a different QHP during open enrollment at that time. This Plan ID Cross Walk Template includes cases where consumers are renewed into a plan consistent with the uniform modi?cation of coverage standards described in 45 CFR It also includes cases where an issuer discontinues offering a particular health insurance product in the entire market, consistent with and selects for the individual a plan under a different product that is similar to the individual's previous plan. In all cases, issuers must comply with applicable federal and state law. The attached template is not the ?nal design but illustrates the concept CMS anticipates implementing for automatic renewals and enrollment for the 2015 benefit year. CMS anticipates releasing this template this summer and that issuers would submit this document to a specific email address. CMS expects that this template would allow an issuer to import their 2014 plan ID and service area information from last year's completed templates as a means for reducing the data entry burden and increase data accuracy. The issuer would then enter the 2015 HIOS Plan ID (standard component) to which consumers would be automatically enrolled into by the FFM. In the above example, CMS would expect that certain business rules would apply regarding which 2015 HIOS Plan IDs can be entered for a given 2014 plan ID and service area combination. The attached table highlights four examples: 76 2017-?00176 0 Example 1: If the plan continues to cover the same county and modi?cations to the plan design, if any, are consistent with the uniform modi?cation of coverage standards described in 45 CFR then the 2014 and 2015 HIOS Plan IDs would be identical. 0 Example 2: A given plan no longer covers a speci?c county. However, the issuer is offering another plan under that product line that does cover the county. In this case, CMS would expect that the 2014 and 2015 HIOS Plan IDs would be different but that the product ID component be the same. The HIOS Plan ID is a HIOS-generated 14-character plan ID number. The first ten characters of this 14-character Plan ID are the product ID component. . Example 3: An issuer is withdrawing a product from the market entirely and is not seeking QHP recerti?cation. In this case, the issuer would send the appropriate notice as required by 45 CFR 147.106, 156.290, and 155.1080 to the consumer. In this case, the issuer would be permitted to enter a 2015 HIOS Plan ID whose product ID component was not the same when compared to the 2014 HIOS Plan ID for the enrolled consumer. 0 Example 4: An issuer's product continues to cover a majority of the same counties in its service area but no longer offers any plans under the product that cover a speci?c county. The issuer identi?es another plan from a similar product in the service area of enrollees no longer served by the 2014 plan. CMS would expect that the 2014 and 2015 HIOS Plan IDs and Product IDs would be different. As previously stated, CMS will use the data submitted in this template to facilitate 834 enrollment transactions from CMS to the issuer in December 2014 for those enrollees who have not actively selected a different QHP during open enrollment at that time. A consumer can still make his or her own election at any time during Open Enrollment. For example, a consumer renewed into a plan in January will have the ability to replace it with a different plan in February. (REGTAP FAQ Database - FAQ #2070 06/11/14) Files: FAQ TemplateExampleAutoRenewals 5CR 0 61 O142070.pdf Q: If a health insurance issuer elects to discontinue offering a product (as defined in 45 CFR 144.103) in the group or individual market, may the issuer auto-enroll individuals covered under that product into a product of another licensed issuer? Updated 1-31-17 A: No. Section 2703(0) of the Public Health Service (PHS) Act and 45 CFR 147.106(c) provide that, in any case in which an issuer decides to discontinue offering a particular product offered in the group or individual market, that product may be discontinued by the issuer in accordance with applicable State law in the applicable market only if certain requirements are met. Among the requirements for product discontinuation is that the issuer must offer to each plan sponsor or individual provided that particular product the option to purchase, on a guaranteed availability basis, any other health insurance coverage offered by the issuer in that market. An issuer does not satisfy the requirement to offer other health insurance coverage currently being offered ?by the 77 2017-?00177 issuer" if it auto-enrolls consumers into a product of another issuer that is separately licensed to engage in the business of insurance in a State. Nothing in the PHS Act or the regulations under the PHS Act prevents an issuer that elects to discontinue offering all health insurance coverage in a market (market withdrawal under 45 CFR from auto-enrolling affected individuals into a product of another licensed issuer, to the extent permitted by applicable State law. Issuers are required to follow this guidance when completing the Plan ID Crosswalk template. As a reminder, this template will be used by the Federally-facilitated Marketplace (FFM) to automatically renew or re-enroll existing enrollees into 2015 coverage. As part of data integrity review of the Plan ID Crosswalk template, CMS will notify the issuer of any cases where a 2014 QHP or is crosswalked to a 2015 plan ID that uses a different issuer ID. In these cases, CMS will require evidence from the state, such as an email con?rmation, that the issuer is permitted to crosswalk plans in this manner. This evidence must include specific justification for the plans in question issuer has elected to discontinue offering all health insurance coverage in a market). *While stand-alone dental QHPs are excepted bene?ts and therefore not subject to the guaranteed renewability requirements, CMS will apply this guidance for operational purposes when performing data integrity review of the Plan ID Crosswalk template. (REGTAP FAQ Database - FAQ #3388 08/01/14) Q: When will the Centers for Medicare 8. Medicaid Services (CMS) finalize the Notice of Proposed Rulemaking (NPRM) for allowing individuals who want to renew coverage to make a Qualified Health Plan (QHP) election 60 days prior to a policy's renew date? A: CMS finalized the NPRM at the close of the comment period on April 21, 2014. (REGTAP FAQ Database - FAQ #3572a 08/11/14) 1. I like my current plan, and heard that I don?t need to do anything to keep it. Is that right, and what happens next? Updated 1-31-17 Most people enrolled in a health plan for 2014 through the Health Insurance Marketplace won?t need to take any action to stay enrolled in that current plan for 2015. You should have received a letter from your current health insurance company letting you know which of these situations applies to you for 2015: . If your current plan still will be available in 2015, you don?t need to do anything to stay enrolled. The letter you got showed your premium amount for 2015, after any Advance Payments of the Premium Tax Credit (APTC) that you are eligible for in 2015. If you were eligible for APTC in 2014 you may need to come back to the Marketplace, complete a 2015 application, and choose and enroll in a plan to remain eligible for APTC in 2015. If your current plan isn?t being offered in 2015, and you take no action on or before December 15, 2014, your health insurance company generally will place you in a different plan with bene?ts as similar as possible to your 2014 coverage. 0 You need to come back to the Marketplace to choose a new plan because the Marketplace and your health insurance company aren?t able to automatically enroll you in coverage through the Marketplace for 2015. 78 2017-?00178 However, even if your current plan will be available in 2015 and you choose to stay in it, you should come back to the Marketplace before December 15 to check the information on your application and make updates, such as to your income or address, and to compare plan options in your area. This will help ensure you?re getting the right amount of help paying for coverage, if applicable, and that you?re able to choose the plan that works best for you. The Marketplace will send an Enrollment Confirmation Message after December 15, 2015, to let you know if you were automatically re-enrolled for 2015. (CMS Technical Assistance Resources About Re-enro/Iment December 2014) 2. It?s past December 15 and I haven?t heard from my current insurance company about January coverage. I thought I didn?t have to do anything to keep my current plan. What should I do to make sure I stay covered? Contact your current insurance company right away. They can tell you if your current plan is still available and if you will be automatically re-enrolled for 2015. Your insurance company and the Marketplace can work with you to ensure that you pay your premium for January and avoid any gap in coverage. If you experience unexpected problems with your reenrollment, call the Marketplace Call Center at 1-800-318-2596 to see if you?re eligible for a Special Enrollment Period (SEP) with a January 1, 2015 effective date. If you aren?t eligible for a SEP, you can still make updates and enroll in a new health plan after December 15, 2014, but your coverage won?t start until the first of the next month if you make your selection by the 15th of the month; if you make your selection after the 15th, your coverage will begin on the first of the month that follows the next month. For example, if you choose a new plan on December 21, 2014, your new coverage won?t start until February 1, 2015. (CMS Technical Assistance Resources About Re-enroI/ment December 2014) 3. have gone to HealthCare.gov and have been exploring my plan options, because I know I have until December 15 to change plans for coverage to start on January 1. Yet, I just got a bill from my current insurance company for January coverage. Why did that happen and what should I do? Updated 1-31-17 The Marketplace wants to ensure that people who are covered now don't have a gap in coverage starting in January. You can still choose a new plan anytime on or before December 15, 2014 and still have coverage in the new plan effective January 1, 2015 even if you get a bill from your current insurance company before then. After that, if you haven?t taken action and your current plan or a similar one is available for 2015, generally you'll be automatically re-enrolled, to help you stay covered. If you already got a bill from your current insurance company for January, that?s part of their effort to make sure you don't have any gap in your health coverage in January. If you choose a new plan on or before December 15, 2014, coverage in your current plan will end on December 31, 2014, and you can ignore the bill you received. Your new plan will contact you about paying your January 2015 premium. 79 2017-?00179 You can still make updates and enroll in a new health plan after December 15, 2014, but your coverage won?t start until the ?rst of the following month. For example, if you choose a new plan on December 21, 2014, your new coverage won't start until February 1, 2015. (CMS Technical Assistance Resources - About Re-enro/Iment December 2014) 4. Even though I picked a more affordable health plan for January, my current insurance company just deducted a premium payment for January 2015 from my bank account. I can?t afford to pay two premiums. What should I do? If you changed plans for 2015, the Marketplace will notify your 2014 health plan that they shouldn?t collect premiums from you for 2015. If your current health insurance company already deducted a premium payment for January 2015, they should refund or return this payment as soon as they?re noti?ed that you?ve changed plans. You can call your 2014 insurance company to make sure their records are up to date and ask for a fast refund of any 2015 premiums that were deducted. (CMS Technical Assistance Resources About Re-enro/lment December 2014) 5. I keep getting reminders and bills from my current health insurance company even though I already switched plans and got a bill for January from my new insurance company. How do I stop this from happening? Starting December 2, the Marketplace is sending information to health plans to let them know who changed plans for 2015. However, your 2014 health plan may have billed you or contacted you before receiving and processing the information that you switched plans. You don?t need to pay any 2015 premiums for the 2014 plan that you?ve dropped. Just make sure to make your 2015 premium payments for the plan you chose for 2015. (CMS Technical Assistance Resources About Re-enrol/ment December 2014) 6. I don?t want to renew my coverage in the Marketplace for 2015 because my job now offers health insurance, yet I got a bill from my current insurance company. What should I do? You need to end your health coverage through the Marketplace when your new coverage from your employer begins. To do this, log in to your Marketplace account on HealthCare.gov or call the Marketplace Call Center at 1-800-318-2596. The effective date when your coverage will end can be as soon as 14 days from the day you make the request. This means if you end your current coverage on or before December 17th, you can avoid any overlap in coverage for 2015. You don?t need to pay the bill for January 2015 coverage from the 2014 plan that you?ve dropped. (CMS Technical Assistance Resources About Re-enrol/ment December 2014) 7. I wanted to keep my current plan through the Marketplace, so I didn?t shop or take any action on HealthCare.gov before December 15. I got a notice that was reenrolled in the same plan for 2015, but ljust got a premium bill with a higher 2015 premium that I can?t afford. Can I still switch plans and get a lower premium for January? Updated 1-31-17 If you missed the December 15, 2014 deadline to change plans for coverage beginning January 1, 2015, you can still enroll in a new plan through the Marketplace until February 15, 2015, but your coverage in the new plan won?t be effective until February 1, 2015 or March 1, 2015, depending on the date you make the change. For example, if 80 2017--00180 you choose a new plan on December 21, your new coverage won?t start until February 1. You MUST make the change by February 15, 2015 or you?ll likely have to wait until 2016 before you have another chance to change plans. As long as you pay your premiums for your current plan until your new one is effective, you can avoid a gap in health coverage. (CMS Technical Assistance Resources About Re-enro/lment December 2014) Q: Will members that are passively enrolled for the 2015 plan year be able to select a new plan by the end of open enrollment? A: Yes, members that are passively enrolled will be able to change plans. See guidance in Bulletin 14 (page 8) Reenrollment 120114 V1 5CR 1201 14.pdf (REGTAP FAQ Database - FAQ #8554 01/21/15) Q: Will passive re-enrollments reflect the Health Insurance Oversight System (HIOS) Plan ID and the information on the Electronic Data Interchange (EDI) Registration Form? A: Yes, passive re-enrollments will re?ect the HIOS Plan ID and the information on the EDI Registration Form. (REGTAP FAQ Database - FAQ #8555 01/21/15) Q: Will the Switched File include subscribers who have actively re-enrolled in Medicare or other State programs? A: No, the Switched File will include individuals who actively re-enrolled through Healthcaregov. (REGTAP FAQ Database - FAQ #8556 01/21/15) Q: Can Issuers send effectuations for all members, even when not required? A: Yes, Issuers can send effectuations for all members, even when effectuation is not required. (REGTAP FAQ Database - FAQ #8560 01/21/15) Q: Will passive renewals come on the daily files and will there be a different maintenance code? A: Yes, the passive renewals will be on daily ?les and have a different maintenance code in a separate file. Please see guidance in Bulletin 14(page 10) Reenrollment 120114 V1 5CR 1201 14.gdf (REGTAP FAQ Database - FAQ #8568 01/21/15) Q: When does 2015 Open Enrollment begin? A: Open Enrollment begins November 15, 2014 and ends February 15, 2015. (REGTAP FAQ Database - FAQ #8573 01/21/15) Q: Is there regulation that allows Issuers the authority to send baseline data to the Federally-facilitated Marketplace A: There are two (2) regulatory citations in the Code of Federal Regulations (CFR) Parts 81 Updated 1-31-17 2017--00181 155 and 156: Guidance/Downloads/508 These citations state that the Exchange must reconcile with the Issuer on a basis. (REGTAP FAQ Database - FAQ #8587 01/21/15) Q: Should Issuers include enrollees that have a future effective date in the Enrollment Base-Line File? A: Yes, Issuers should include enrollees that have a future effective date in the Enrollment Base-Line File. (REGTAP FAQ Database - FAQ #8600 01/22/15) Q: Does the Base-Line File include all enrollment details since January 1, 2014? A: Yes, the base-Line File includes the complete history of an individual's enrollment. CMS will match submitted QHP issuer records to FFM records and the Goal: 1 - 1 association of issuer and FFM records. The current versions of the Inbound and Outbound Data Baseline File speci?cations are available on CMS ZONE at: baseline-education-session (REGTAP FAQ Database - FAQ #8606 01/23/15) Q1: How often should issuers expect to receive Batch Auto-Reenrollment (BAR) files from Federally-facilitated Marketplaces A1: FFMs expects to send BAR ?les in two (2) waves. The first wave will begin around October 15, 2015. During this wave, issuers may receive BARS over a span of several days. Similarly, the second wave will begin around December 16, 2015, and may span several days. (Enrollment FAQs (10/18/15) and REGTAP FAQ #13832 10/28/15) 02: If an issuer terminates a member?s passive reenrollment into 2016 coverage based on the member?s presence on the Switch File, will the issuer receive an 834 enrollment transaction if the member does not appear on the Switch File later? A2: Yes, if a consumer who is enrolled in 2015 coverage with one issuer switches to a different issuer for 2016 Marketplace coverage and later switches back to the 2015 issuer for 2016 Marketplace coverage, the 2015 issuer will receive an 834 enrollment transaction for 2016 Marketplace coverage. (Enrollment FAQs (10/18/15) and REGTAP FAQ #13833 10/28/15)) Q3: Will the Centers for Medicare Medicaid Services (CMS) be sending any written communication to consumers that include their 2016 Advance Payments of the Premium Tax Credit (APTC) and Cost-Sharing Reduction (CSR) information? Updated 1-31-17 A3: The Eligibility Determination Notice (EDN) will include the updated 2016 APTC and CSR information, which will match the APTC and CSR information in the Batch Auto- Reenrollment (BAR) previously sent to the issuer. Federally-facilitated Marketplaces (Marketplaces) will provide an EDN and Enrollment Con?rmation Message (ECM) to enrollees via their Marketplace account as of December 16, 2015 (or later, if the BAR is sent after December 16, 2015); the EDN will also be mailed if the enrollee request to receive notifications via mail. The ECN displays the Quali?ed Health Plan (QHP), QHP ID, and any APTC applied to the premium. This is in contrast to the Marketplace Open 82 2017-?00182 Enrollment Notice (MOEN), which is sent to current 2015 enrollees (who do not have a future termination effective date on file) before November 1, 2015. The MOEN does not include the 2016 APTC, but instead is primarily to announce the Open Enrollment Period and explain the redetermination process. Should an enrollee who has been passively reenrolled subsequently report a life change Change in Circumstance, or to update eligibility, he or she will receive a new EDN (as with any but will not receive a new ECM. (Enrollment FAQs (10/18/15)and REGTAP FAQ #13834 10/28/15)) Q4: Are issuers allowed to enter two (2) billing addresses in the Health Insurance Oversight System (HIOS) Plan Finder? A4: Issuers should choose the billing address that would be the most appropriate for the consumer to enter in the HIOS Plan Finder. Issuers may need to reach out to the consumer to determine which address is most appropriate for billing purposes. (Enrollment FAQs (10/18/15) and REGTAP FAQ #13835 10/28/15)) Q5: How will the FFM communicate changes to 2016 enrollments to issuers after issuers receive a consumer?s 2016 Batch Auto-Reenrollment (BAR) or active 2016 enrollment, how will Federally-facilitated Marketplaces (Marketplaces) communicate changes to those 2016 enrollments? A5: Depending on when and whether the consumer is changing a current enrollment, switching to a different issuer, or terminating 2016 Marketplace coverage, changes to a 2016 BAR or active enrollment may come in the form of an 834 cancellation transaction, an 834 termination transaction, paired cancel Change in Circumstance and initial 834 transactions, paired termination and initial 834 transactions, or a cancellation reflected on the Cancel Incremental Pre-Audit (IPA) ?le. (Enrollment FAQs (10/18/15) and REGTAP FAQ #13836 10/28/15)) 06: Will the Switch File be cumulative? For example, if a member appears on the Switch File on November 4, 2015, if he or she does not switch back to the same issuer, will he or she appear on the Switch File on November 5, 2015, and November 6, 2015? A6: The Switch File is a point-in-time report that will identify current enrollees who have not yet been auto-reenrolled and have switched issuers as of their most recent plan selection on the day before the ?le was generated. However, if an enrollee who has switched issuers subsequently selects a plan offered by his or her original issuer, that enrollee will no longer be on the Switch File. In this scenario, Federally-facilitated Marketplaces will send an 834 enrollment transaction to the issuer. (Enrollment FAQs (10/18/15) and REGTAP FAQ #13837 10/28/15)) Q: What factors determine the effectuation of a passive renewal? Updated 1-31-17 A: The effectuation of a passive renewal is dependent on payment. The Centers for Medicare Medicaid Services (CMS) functionality will cancel the 2016 passive renewal policy for members who are received on the Batch Auto Reenrollment (BAR) File, but who were previously terminated for non-payment or subsequently terminated for non- payment after the BAR File is received. In 2014, issuers were given the choice of whether or not to accept or reject the enrollments for previously terminated members. If an issuer accepts that renewal transaction and requires a member to make a binder payment to keep his or her 2016 policy, CMS can accept an effectuation on a cancelled 83 2017--00183 policy. CMS does not require an effectuation if the policy is in the same product. If it is an enrollment going from 2015 coverage to 2016 coverage with the same issuer ID, and the Health Insurance Oversight System (HIOS) ID did not change, the issuer does not need to send CMS an effectuation confirmation if the policy is already effectuated. The IC 834 Effectuation Rules require an issuer to send a re-effectuation if a member's HIOS ID [the ?rst ?ve (5) digits of the Qualified Health Plan (QHP) changes. However, according to the regulatory requirement, if the member moves to another product, it does require a binder payment. The issuer must treat it as a new policy, get the binder payment and send the effectuation in. (REGTAP FAQ Database - FAQ #15243 03/23/16) Q: Where in the enrollment manual should issuers review guidance for reenrollment binder payments and effectuation confirmation requirements? A: For binder payment and effectuation con?rmation requirements, issuers should focus on Section 2.9.6. To summarize, a binder payment is not required for passive (auto) reenrollments into the same issuer (same issuer being signi?ed by the same 5 digit HIOS ID), while an active reenrollment into a new product does require a binder payment. Effectuation confirmations to the FFM, however, are only required when the enrollment group's HIOS or subscriber changes. (REGTAP FAQ Database - FAQ #17318 08/31/16) Q: If a consumer in the Individual Marketplace enrolled in coverage for plan year 2016 in September, will he or she need to re-enroll for plan year 2017 coverage? A: If a consumer in the Individual Marketplace enrolled in September 2016 for plan year 2016 coverage, he or she will be included in the auto re-enrollment group for plan year 2017 coverage. Once the consumer is re-enrolled, a 2017 application will prepopulate on the consumer's HealthCare.gov account. Agents and brokers can make changes to the consumer's prepopulated application by selecting ?Report a life change,? or direct consumers to update their information by logging into HealthCare.gov and clicking ?Start a New Application or Update an Existing One? and then ?Review My Application.? (REGTAP FAQ Database - FAQ #17974 10/28/16) Q: If a consumer is losing his or her current Marketplace plan for 2017, and enrolls in new plan prior to November 21, 2016, will the consumer's new plan selection be overwritten when the Marketplace does batch auto re-enrollment A: No. The Marketplace will send the consumer's plan selection forward for enrollment. All active plan selections made prior to the December 15, 2016 deadline will override BAR transactions. Certain consumers may qualify for an Special Enrollment Period (SEP) which would allow them to override BAR transactions through December 31, 2016. (REGTAP FAQ Database - FAQ #18310 12/02/16) Q: Does batch auto re-enrollment (BAR) apply to both subsidized and non-subsidized Marketplace plans? Updated 1-31-17 A: Yes. BAR applies to everyone enrolled in Individual Marketplace coverage. The Marketplace will automatically enroll a consumer in either his or her current plan or, if that plan is no longer available, in a new issuer's plan. All active plan selections made 84 2017-?00184 prior to the December 15, 2016 deadline will override BAR transactions. Certain consumers may qualify for an Special Enrollment Period (SEP) which would allow them to override BAR transactions through December 31, 2016. (REGTAP FAQ Database - FAQ #18311 12/02/16) Plan ID Crosswalk Temp/ate Q: When will CMS release the Plan ID Crosswalk Template for stand-alone dental plans A: The final version of the Plan ID Crosswalk template has been released. Issuers are able to access the Plan ID Crosswalk template and instructions on the CMS website in the QHP application templates section or on the National Association of Insurance Commissioners (NAIC) SERFF website in the 2015 QHP Templates section. To access the Plan ID Crosswalk template on CMS ?rst login to and paste the following link into the browser: (REGTAP FAQ Database - FAQ #2965 07/23/14) Q: If an issuer migrates beneficiaries to a plan with the same Plan ID in auto-renewal, must the issuer still complete the Plan ID Crosswalk Tab? A: Yes, individual market issuers must still complete the Plan ID Crosswalk Template. Specifically, all issuers that offered individual market QHPs or SADPs in 2014 through the FFM need to complete the Plan ID Crosswalk Template in order for the FFM to perform automatic re-enrollments. Please see the Plan ID Crosswalk Template instructions available on the Center for Consumer Information and Insurance Oversight (CCIIO) website for more information. (REGTAP FAQ Database - FAQ #2982 07/23/14) Q: If an issuer adjusts the cost-sharing for a 2014 Qualified Health Plan (QHP) to accommodate the increase in the 2015 Maximum Out-of-pocket (MOOP) limit, must the issuer also submit the Plan ID Crosswalk with the 2015 QHP Application submission? A: Yes, individual market issuers must still complete the Plan ID Crosswalk Template. Specially, all issuers that offered individual market QHPs or SADPs in 2014 through the FFM need to complete the Plan ID Crosswalk Template in order for the FFM to perform automatic re-enrollments. Please see the Plan ID Crosswalk Template instructions available on the Center for Consumer Information and Insurance Oversight (CCIIO) website for more information. (REGTAP FAQ Database - FAQ #2983 07/23/14) Q: The Plan ID Crosswalk template instructions indicate that overall data integrity review will include but is not limited to an evaluation for compliance with the proposed rule on Annual Eligibility Redeterminations for Exchange Participation and Insurance Affordability Programs as ?nalized. How should issuers complete the template given that the first submission is due to CMS by August 7, 2014 and that the final rule has not yet been published? Updated 1-31-17 A: Issuers should fill out the Plan ID Crosswalk template according to 45 CFR 155.335 as proposed. As indicated in the template instructions, submissions by August 7, 2014 85 2017--00185 will be used for the ?rst round of review by CMS. Issuers will have the opportunity to update their Plan ID Crosswalk template and resubmit by September 4, 2014. At that time, issuers can adjust their Plan ID Crosswalk template as needed based on the rule as ?nalized. (REGTAP FAQ Database - FAQ #3347 08/07/14) Q10: In regards to direct enforcement states, may issuers submit the Plan ID Crosswalk State Authorization Form to the Centers for Medicare Medicaid Services (CMS) Form Filing Team separately from the Plan ID Crosswalk Template once the state has provided approval? A10: All issuers offering individual market QHPs, including stand-alone dental plans (SADPs), should submit one or more Plan ID Crosswalk templates as part of their QHP Certification application. All FFM issuers, including those in states performing plan management functions, should submit the Plan ID Crosswalk template to QHP Applications@cms.hhs.qov. Issuers should schedule their Plan ID Crosswalk submissions to mirror the dates outlined in the 2016 Letter to Issuers. Issuers in Direct Enforcement states (Alabama, Missouri, Oklahoma, Texas, and Wyoming) should submit the authorization form to their state Department of Insurance and to Compliance and Enforcement Division to obtain the necessary authorization for submission. (QHP Certi?cation Process FAQs #4 (09/29/15)) Q11: Should issuers include a Health Insurance Oversight System ID (HIOS ID) in the subject line of the 2015 Plan ID Crosswalk email? A11: After completing the Plan ID Crosswalk template, issuers must save the finalized XML ?le and email it to QHP Applications@cms.hhs.qov with the subject title ?2015 Plan ID Crosswalk?. (QHP Certi?cation Process FAQs #4 {09/29/15) Q13: Must issuers submit to the Centers for Medicare Medicaid Services (CMS) justification as to why the State did not complete the Plan Crosswalk ID State Authorization form? A13: Yes, issuers must submit a justi?cation to CMS as to why the State did not complete the Plan Crosswalk ID State Authorization form. (QHP Certification Process FA 03 #5 (09/29/15) Q14: Must issuers in States performing plan management functions submit the Plan ID Crosswalk to the Centers for Medicare Medicaid Services (CMS) email address and through the System for Electronic Rate and Form Filing A14: All FFM issuers, including those in states performing plan management functions, should submit the Plan ID Crosswalk template to QHP Applications@cms.hhs.qov. CMS suggests that states also contact their state regulators for guidance regarding Plan ID Crosswalk submissions. Please refer to the ?Instructions for the Plan ID Crosswalk Template? for guidance on submitting Plan ID Crosswalk documents (located here: Marketplaces/th.html (QHP Certi?cation Process FAQs #5 {09/29/15) Q15: Must issuers complete the Plan ID Crosswalk Template for Small Business Health 86 Updated 1-31-17 2017--00186 Options Program (SHOP) plans? A15: For plan year 2016, CMS has deferred the Federally-facilitated Small Business Health Options Program?s (FF-SHOP) ability to auto renew employees. Therefore, issuers should not submit a Plan ID Crosswalk template for FF-SHOP plans. (QHP Certi?cation Process FAQs #5 {09/29/15) Auto Re-enro/lment for QHPs no longer available in the Marketplace Note: These FA Qs were first issued on 06/24/16; they were re-issued on 08/08/16. The new FAQs document is exactly the same but includes one additional FAQ that notes which states will direct auto-re- enro/lment vs. deferring auto-re-enrol/ment to CMS. Q. How has automatic re-enrollment changed in the FFMs and SBM-FPs for Plan Year 2017? A. For enrollees in QHPs no longer available in the Marketplace, the FFMs and SBM- FPs previously did not auto re-enroll them in another plan if the issuer no longer had QHPs available to the enrollee through the Marketplace. 45 CFR as amended by the 2017 Notice of Benefits and Payment Parameters (2017 Payment Notice) established, beginning in Plan Year 2017, that if no QHP from the same issuer is available through the Marketplace, then the Marketplace could automatically re-enroll such enrollees into a QHP from a different issuer. Such auto re-enrollments would be directed by the Marketplace unless the applicable State regulatory authority decides to act. (CMS FA Qs: Auto Re-enrollment for QHPs no longer available in the Marketplace: External FAQs (06/24/16); re-issued 08/08/16 no changes Q. Does this update apply to all enrollees in QHPs no longer available in the Marketplace for the upcoming 2017 Plan Year? A. No, this provision only applies to enrollees in QHPs where the issuer has no Marketplace enrollment option for the upcoming plan year with a service area that covers the enrollee?s location. For example, if an issuer?s QHP is no longer available through the Marketplace in a service area where that same issuer offers other QHPs, the issuer can crosswalk the applicable enrollees to QHPs in its other Marketplace QHP. However, if an issuer does not offer a QHP in that service area, the FFMs or SBM-FPs will automatically re-enroll the enrollees into another QHP offered by a different issuer in that service area. (CMS FA Qs: Auto Re-enro/lment for QHPs no longer available in the Marketplace: External FAQs (06/24/16) re-issued 08/08/16 no changes Q. What happens if an issuer no longer offers coverage in a service area that covers the enrollee?s location but still participates in the FFMs or SBM-FPs in the State? A. If an issuer still participates in the FFMs or SBM-FPs in the State, but it does not offer a QHP in a service area that cover?s the enrollee?s location, the Marketplace will automatically re-enroll the enrollees into another QHP offered by a different issuer. (CMS FA 08: Auto Re-enro/Iment for QHPs no longer available in the Marketplace: External FAQs (06/24/16) re-issued 08/08/16 no changes 87 Updated 1-31-17 2017--00187 Q. Who directs the automatic re-enrollment of enrollees into the A. 45 CFR as amended by the 2017 Notice of Bene?ts and Payment Parameters (2017 Payment Notice) authorizes the Marketplace to determine the auto re- enrollment of enrollees in QHPs where the issuer will have no Marketplace enrollment option for the upcoming plan year (PY), unless otherwise directed by the State regulatory authority. (CMS FAQs: Auto Re-enrollment for QHPs no longer available in the Marketplace: External FA 03 {06/24/16) re-issued 08/08/ 16 no changes Q. If the State regulatory authority does not direct the auto re-enrollment of an SPM and/or SBM-FP State, will the Marketplace determine the re-enrollment? A. Yes, the Marketplace will determine the automatic re-enrollment of enrollees in QHPs where the issuer will have no Marketplace enrollment option for the upcoming plan year, unless otherwise directed by the State regulatory authority, in all FFM States, including States performing plan management functions in an FFM (SPM), and in State-Based Marketplaces using the federal platform for eligibility and enrollment services (SBM- FPs). (CMS FAQs: Auto Re-enrol/ment for QHPs no longer available in the Marketplace: External FAQs {06/24/16) re-issued 08/08/16 no changes Q. How may the State let CMS know that it will execute the automatic re-enrollment of QHPs no longer available in the Marketplace? A. CMS will send a notice by email to all State regulatory authorities in States in which an FFM or SBM-FP is operating. The notice outlines the steps CMS expects State Regulatory Authorities in all FFM States (including SPMs) and in SBM-FPs to take if they wish to direct this auto re-enrollment activity for Plan Year 2017. If CMS does not receive notice from a State regarding its intent to direct the auto re-enrollment of QHPs no longer available in the Marketplace by 5:00 pm. ET on June 30, 2016, CMS will proceed to direct auto re-enrollment for applicable QHPs. (CMS FAQs: Auto Re-enro/lment for QHPs no longer available in the Marketplace: External FA 08 {06/24/16) re-issued 08/08/16 no changes Q. If a State elects to direct the re-enrollment of QHPs no longer available in the Marketplace, how does the State ensure that the FFMs will follow the State?s direction? A. If the State elects to direct this auto re-enrollment activity, the State should take the following actions to ensure that the FFMs can automatically re-enroll enrollees: 1) Please ?reply all" to the email notice from CMS by 5:00 pm. ET on June 30, 2016 con?rming the State Regulatory Authority will direct the auto reenrollment of enrollees in QHPs where an issuer will have no Marketplace enrollment option in an enrollee?s service area for the upcoming plan year. 2) Identify issuers and plans that will receive the enrollment of QHPs no longer available in the Marketplace. Issuers must offer at least one QHP in the same service area of QHPs no longer available in the Marketplace in order to be considered a receiving issuer. Please note that enrollees in each QHP no longer available in the Marketplace should be assigned to the same receiving plan in each county. If a plan that will no longer be in the Marketplace covers multiple service areas, the State can crosswalk the enrollees in each service area to a different plan, but cannot crosswalk enrollees in each zip code in that service area to a different plan. The State should also consider the capacity of the receiving issuers to absorb 88 Updated 1-31-17 2017--00188 the new enrollees. 3) Complete and submit Plan ID Crosswalk Templates to CMS for all QHPs no longer available in the Marketplace before the ?nal QHP data submission date of August 16, 2016. States should adhere to the hierarchy used by the Marketplace to crosswalk pertinent enrollees. The Plan ID Crosswalk Template and instructions can be found at Marketplaces/th.html 4) Notify receiving issuers of final auto re-enrollment decision in a manner determined by the State no later than November 1, 2016. 5) Coordinate and communicate with CMS as necessary with respect to this process. (CMS FA 03: Auto Re-enrol/ment for QHPs no longer available in the Marketplace: External FAQs {06/24/16) re?issued 08/08/16 no changes Q. If a State declines to direct the auto re-enrollment in the FFMs or SBM-FPs, will CMS provide the State with information regarding the final auto re-enrollment determination? A. Yes, CMS intends to provide States with final data for all enrollees in QHPs no longer available in the Marketplace that were re-enrolled by the FFMs and SBM-FPs. States may also request enrollment data for Plan Year 2017 from applicable issuers. (CMS FA 03: Auto Re-enro/Iment for QHPs no longer available in the Marketplace: External FAQs {06/24/16) re-issued 08/08/16 no changes Q. How do the FFMs or SBM-FPs determine which are the receiving Updated 1-31-17 A. If the enrollee's current QHP is not available through the Marketplace and no QHPs from the original issuer are available for auto re-enrollment in the Marketplace that cover a service area that includes the enrollee's location, and no direction is provided by the State?s regulatory authority, CMS, if feasible, will auto re-enroll affected enrollees in another QHP available through the Marketplace with a service area that covers the enrollee's location, taking into account the issuer?s ability to absorb new enrollment and the lowest premium plan, according to the following hierarchy: 1) The enrollee?s coverage will be auto re-enrolled in a QHP at the same metal level under the same product network type. 2) If there is no QHP available at the same metal level under the same product network type in the same service area, the enrollee will be auto re-enrolled in a QHP at the same metal level under a different, if possible similar, product network type. 3) If no QHP is available that is the same metal level under a different product network type in the same service area, the enrollee will be auto re?enrolled in a QHP that is one metal level lower than the enrollee?s current QHP under the same product network type. 4) If no QHP is available that is one metal level lower than the enrollee?s current QHP under the same product network type in the same service area, the enrollee will be auto re-enrolled in a QHP that is one metal level lower under a different, if possible similar, product network type. 5) If no QHP is available that is one metal level lower under a different product network type in the same service area, the enrollee will be auto re-enrolled in a QHP that is one metal level higher than the enrollee?s current QHP under the same product network type. 6) If no QHP is available that is one metal level higher than the enrollee?s current QHP under the same product network type in the same service area, the enrollee will be auto re-enrolled in a QHP that is one metal level higher under a different, if possible 89 2017--00189 similar, product network type. 7) If no QHP is available that is one metal level higher under a different product network type in the same service area, the enrollee will be auto re-enrolled in a QHP at any metal level under the same product network type. 8) If no QHP is available for enrollment at any metal level under the same product network type in the same service area, the enrollee will be auto re-enrolled in a QHP at any metal level under a different, if possible similar, product network type. (CMS FA Qs: Auto Re-enro/lment for QHPs no longer available in the Marketplace: External FAQs (06/24/16) re-issued 08/08/16 no changes Q. Does CMS provide guidelines to help States with SBMs other than SBM-FPs that elect to direct this re-enrollment? A. While SBMs other than SBM-FPs are not required to use it, they may use the decision hierarchy. (CMS FAQs: Auto Re-enrollment for QHPs no longer available in the Marketplace: External FAQs {06/24/16) re-issued 08/08/16 no changes Q. Which state regulatory authorities noti?ed CMS that they will direct auto re-enrollment for QHPs no longer available in the Marketplace in that state versus deferring automatic re-enrollment to A. According to responses from state regulatory authorities in the FFMs and SBM-FPs as of July 20, 2016, CMS will direct auto re-enrollment for QHPs no longer available in the Marketplace for 31 states. The remaining 7 states will direct auto re-enrollment for pertinent QHPs. The table below provides a list of responses for all FFM and SBM-FP states regarding this auto re-enrollment activity: State State Response Regarding Auto Re-enrollment AL Defer AK State will Direct AZ Defer AR State will Direct DE Defer FL State will Direct GA Defer HI Defer IL Defer IN Defer IA Defer KS Defer LA Defer ME Defer Ml Defer MS Defer MO Defer MT State will Direct NE Defer NV Defer 90 Updated 1-31-17 2017--00190 State State Response Regarding Auto Re-enrollment NH Defer NJ State will Direct N, State will Direct NC Defer ND Defer OH Defer OK Defer OR Defer PA Defer SC Defer SD State will Direct TN Defer TX Defer UT Defer VA Defer WV Defer Wl Defer WY Defer (CMS FAQs: Auto Re-enro/lment for QHPs no Longer Available in the Marketplace 08/08/16) Q: If a consumer decides to keep his or her existing plan (assuming the plan is still available), will his or her advance payments of the premium tax credit (APTC) be re- calculated during auto re-enrollment if the consumer does not update his or her financial information online? A: Yes assuming the consumer has previously authorized the Marketplace to check with the IRS for updated income information for the purposes of annual redetermination. Based on the plan year 2017 annual eligibility redetermination and re-enrollment guidance released by CMS on May 10, 2016, the amount of ?nancial assistance a consumer is eligible for will be recalculated based on the most recent income and family size information available to the Marketplace, updated federal poverty level tables, and 2017 plan premiums. A consumer will be auto re-enrolled in the same plan or, if the same plan is unavailable, a similar plan available to the consumer based on the 2017 plan crosswalk provided by the issuers or in a selected alternative plan from a different issuer. For more details, review the guidance at 2017-Guidance-051016-508.pdf (REGTAP FAQ Database - FAQ #17972 10/28/16) Other Q: Does an issuer need to refer a consumer to the Marketplace to create a HICS case 91 Updated 1-31-17 2017--00191 when they have been provided enrollment policy or guidance from CMS that can resolve the consumer's issue? A: No. CMS expects issuers to be consumer's first point of contact for issuer-related matters. As such, when CMS has promulgated policy or guidance, issuers can follow that policy to advise/assist the consumer as appropriate, and note the necessary changes in their internal contact management and/or enrollment systems. Consumers should only be directed to the Marketplace for matters the issuer is unable to or not permitted to address without Marketplace action. (REGTAP FAQ Database - FAQ #10023 04/22/15) Q: In the recent HICS update, issuers can now note when a case has been referred to the XOSC Help Desk. Is this required? A: No, issuers are not required to use these ?elds. However, doing so is strongly encouraged as it will help CMS monitor pending casework as a result of a Help Desk referral. (REGTAP FAQ Database - FAQ #10024 04/22/15) Q: In a Marketplace presentation on March 13, 2015 (available on REGTAP at HHS EX SEPEffective Dates 040315 v1 5 CR 040715.9df it was mentioned that a new system functionality exists through which CMS is able to adjust effective dates for enrollments that meet qualifying circumstances. CMS indicated that this would reduce the amount of HICS cases requiring issuers to adjust effective dates. However, we have not seen an appreciable decline in HICS cases yet. Is there a problem with this functionality? A: No. CMS will be working to phase in this functionality over the next several months into its customer service operation. Even when fully implemented, we still believe there will be situations where issuers will be directed via HICS to adjust enrollment effective dates for an existing enrollment or after receiving a new enrollment transaction. All adjustments should be supported by existing policy and/or guidance. (REGTAP FAQ Database - FAQ #10025 04/22/15) Q: We received a HICS request to reinstate a consumer's enrollment into a Marketplace plan, but the consumer's Marketplace coverage was terminated as a result of a data matching issue. What should we do A: For HICS cases where you have not received a new enrollment transaction after the consumer experienced termination of Marketplace coverage as a result of a data matching issue, please advise the consumer to follow the directions in the latest communication he or she received from the Marketplace. After taking this step, the issuer may close the HICS case. The next step for the consumer may be to ?le an appeal with the Marketplace if he or she believes their Marketplace coverage was terminated in error. Consumers with expired data matching issues will need to contact the Marketplace to resolve their data matching issue in order to be eligible to update their enrollment. An issuer should not reinstate Marketplace coverage that has been terminated due to a data matching issue unless the issuer has a new enrollment transaction from the Marketplace. Additional information about data matching issues can be found in Bulletin #11. Note, the issuer may have a separate obligation under market-wide guaranteed 92 Updated 1-31-17 2017--00192 availability and renewability rules to continue the consumer's coverage outside the Marketplace. (REGTAP FAQ Database - FAQ #10026 04/22/15) Q: What primary resources should issuers use for handling casework? A: In addition to the regulations in 45 C.F.R. 156.1010, CMS issued a memorandum providing guidance for handling casework on March 13, 2014 (available here: Supplemental guidance is also available in the searchable FAQ database on REGTAP. (REGTAP FAQ Database - FAQ #10027 04/22/15) Q: What should issuers do with repeat cases from the same consumer relating to the same issue? A: Issuers should follow the process outlined in the March 13, 2014 casework memorandum. In addition, generally, but not always, CMS will record another HICS case on an identical unresolved matter only after 30 days has passed since the previous case was opened. Exceptions to this rule could be related to a change in a consumer's health status a change resulting in a later case being coded urgent). Additionally, issuers are encouraged to contact consumers as soon as possible after receipt of a HICS case, and are required by 45 C.F.R. 156.1010(d) to contact consumers within 15 days of receipt of a HICS case. Issuers are also reminded that if a consumer has two cases in HICS that are unrelated issues, do not close one of the cases as a duplicate. (REGTAP FAQ Database - FAQ #10028 04/22/15 Q: Can an issuer add a consumer to an existing enrollment group solely using information in A: No, unless CMS provides explicit guidance to do this in very limited instances newborn needs to be added to a group and the QHP is suppressed, meaning enrollment capabilities have been suspended). (REGTAP FAQ Database - FAQ #10029 04/22/15) Q: What should an issuer do if it receives a HICS case that relates to a 2014 1095-A issue? A: If the case is in the ?Plan and Issuer Concerns? category, advise your Lead Caseworker so the case can be reassigned. If the case is in the category, no issuer action is required. The case will be handled by CMS or its contractor. (REGTAP FAQ Database - FAQ #10030 04/22/15) Q: If an issuer receives a request (inside or outside of HICS) to terminate a 2015 enrollment earlier than the date reflected on the 834, what should the issuer do? A: The earliest that CMS can approve a termination is no sooner than 14 days from the date the consumer requests the termination. The issuer may, at the consumer's request and the issuer's discretion, effectuate termination in fewer than 14 days, as indicated in 93 Updated 1-31-17 2017--00193 Other 45 C.F.R. However, CMS expects that the issuer's policy in this regard be applied uniformly to all enrollees. If an issuer is unable to accommodate the consumer's request, they should communicate that information to the consumer accordingly. (REGTAP FAQ Database - FAQ #10031 04/22/15) Incarceration Q1. What is the definition of incarcerated (other than incarcerated pending the disposition of charges) for enrolling in a qualified health plan (QHP) through the Marketplace? A. For purposes of eligibility for enrollment in a QHP through the Marketplace, the Federally-facilitated Marketplace (FFM) considers an individual incarcerated if the individual has been convicted of a crime and is sentenced to con?nement in an institution such as a correctional facility or inpatient mental health facility. An individual will also be considered incarcerated if the individual is currently an escapee from confinement or has had his or her parole and/or probation revoked and is sentenced to confinement in a correctional institution. The FFM will not consider an individual incarcerated if the individual: (1) has not been convicted of a crime, (2) has been convicted of a crime but is not currently sentenced to con?nement in an institution, or (3) has been convicted of a crime and is sentenced to a partial, limited, or alternative form of con?nement, but no government entity is required to provide the individual with medical care. For example, the Marketplace may ?nd that an individual in the following situations is considered not incarcerated: a. Living in the community after a sentence has been served; b. On probation or parole; or c. Any of the following if no county, city, state, or federal government is required to pay for or provide for the individual?s medical care: 0 Serving a sentence but allowed work release, 0 Under house arrest or home confinement, or Residing in a halfway house or other similar type of residential community supervision as a result of a conviction The precise application of these standards may vary by jurisdiction, because of differing terminology for these concepts across jurisdictions. (CMS FAQs Incarceration and Marketplace FA Qs 05/03/16) Former Kynect Enrol/ees Q: I am working with consumers who were previously enrolled in health coverage through the Kentucky State-based Marketplace (kynect). They are now receiving letters that they must enroll through HealthCare.gov. If they do not, will they be automatically enrolled in another plan? Updated 1-31-17 A: No. All Kentucky consumers must create Marketplace accounts, submit applications, and make active plan selections on HealthCare.gov during Open Enrollment for plan year 2017. Kentucky consumers can only gain 2017 Marketplace coverage outside of 94 2017-?00194 the Open Enrollment period if they experience a qualifying life event that would grant a Special Enrollment Period. (REGTAP FAQ Database - FAQ #18312 12/02/16) Q: The Kentucky State-based Marketplace (kynect) had a pre-screen tool that allowed consumers to view plans prior to enrollment. Does the Marketplace have that as well? A: Yes. The Marketplace has a tool that allows consumers to view plans prior to enrollment. (REG TAP FAQ Database - FAQ #18313 12/02/16) 02. What does ?incarceration pending the disposition of charges? mean? A. For purposes of eligibility for enrollment in a QHP through the Marketplace, the FFM considers an individual incarcerated pending disposition of charges if the individual has been charged with a crime but is waiting for the outcome of the charges to be determined. This includes situations in which an individual is: d. Arrested but not convicted of a crime; and e. Convicted of a crime but awaiting sentencing, whether con?ned to a correctional institution or released on bail, bond, or other conditional release. An individual who is incarcerated pending disposition of charges can enroll or continue existing enrollment in a QHP through the Marketplace and receive advance payments of the premium tax credit and cost-sharing reductions if he or she meets the other eligibility requirements. (CMS FA 03 Incarceration and Marketplace FAQs 05/03/16) Q3. Are probationers and parolees considered incarcerated if they are sent back to jail because their probation or parole has been revoked? A. Probationers and parolees can be eligible to enroll or stay enrolled in a QHP through the Marketplace if they are in a prison orjail pending the results of a hearing to determine if their probation or parole will be revoked. If they are sentenced to con?nement in an institution because their probation or parole has been revoked, they are no longer eligible to enroll in a QHP through the Marketplace, and, if already enrolled, must report the change in their status within 30 days so their QHP coverage through the Marketplace can be terminated. (CMS FA 03 Incarceration and Marketplace FA 03 05/03/16) Q4. If an individual enrolled in Marketplace coverage is sentenced to serve time in prison orjail, must the individual report that change to the Marketplace and terminate coverage through the Marketplace? Updated 1-31-17 A. Yes. Enrolled individuals have 30 days to report a change that affects their eligibility for enrollment in a QHP through the Marketplace, including incarceration (other than incarceration pending disposition of charges). In general, changes in eligibility can be reported by the enrollee or application filer, within 30 days, by contacting the Marketplace Call Center at 1-800-318-2596 (TTY: 1-855-889- 4325) or by visiting HealthCare.gov. Changes can also be reported through the Marketplace Call Center by (1) any adult age 18 or over who is on the application and applied for Marketplace coverage, or (2) an adult age 18 or over listed as a tax ?ler on the incarcerated individual?s application for Marketplace coverage, even if the tax ?ler 95 2017--00195 didn?t apply for coverage. Instructions on reporting a change and ending Marketplace coverage using HealthCare.gov are available at changes/canceI-planl. If neither the incarcerated individual nor any adult on the application is able to contact the Marketplace to report a change and end Marketplace coverage, then an individual authorized to contact the Marketplace on the incarcerated individual?s behalf can call the Marketplace Call Center at 1-800-318-2596 (TTY: 1-855-889-4325). Changes may not be reported by mail or through the paper application. (CMS FAQs - Incarceration and Marketplace FAQs 05/03/16) NOTICE REQUIREMENTS Summary of Benefits and Coverage (8805), Including Plan Compare Q11: What interaction will the FFE have with the Plan Summary of Benefits Coverage Will the Summary of Benefits and Coverage documents be linked the HealthCare.gov site today? Will the tool be re-purposed for the FFE to create an automatic link to the issuer websites? A11: For 2014, the federally facilitated marketplace will not automatically generate 880s, and issuers will be expected to provide links to those documents. At present, deeming of the SBC documents is limited to the healthcaregov data submission. The regulatory citation governing the deemed compliance for the electronic format requirements is 45 CFR 147.200. (Enrollment March 8th and 11th, 2013) Q33: Will specific examples that issuers are required to use in the SBC be provided? A33: The SBC coverage examples and link to the SBC URL are optional data ?elds in the Plans Benefits template. While the data fields for SBC coverage examples are optional, issuers are advised that the FFM may be using certain data elements from the SBC in Plan Compare. If this issuer does not provide this information, then Plan Compare will show ?not availableidentified as optional because we expect that issuers will be developing the SBC post submission; however, the URL will be required prior to open enrollment to display on plan compare. (Plan Management Webinar QHP FAQ #2 04/09/13) Q17: Will HHS be generating an A17: The FFM is not generating SBCs. (QHP Webinar Series FAQ #5 04/18/13) Q37: We have a question on an item on the Summary of Bene?ts and Coverage (SBC) template. Please explain what is meant by ?Abortion for Which Public Funding is Prohibited.? Is that intended for states that have passed legislation prohibiting abortion coverage in QHPs sold through the Marketplace, or other legislation related to abortion? 96 Updated 1-31-17 2017--00196 A37: As defined in the Marketplace regulation at 45 CFR ?abortions for which public funding is prohibited" includes those abortion services for which the expenditure of Federal funds appropriated for CMS is not permitted. More information on this topic is available at: (QHP Webinar Series FAQ #10 05/09/13) QZ: How does the Marketplace expect health plans to handle distribution of the Summary of Benefits and Coverage Regulation requires SBCs to be sent to applicants within 7 days of submitting the application. Will there be exceptions for Exchange enrollment? If yes, what are the exceptions? Will the Exchange be able to get enrollment to the carriers in time for carriers to make the 7 day requirement? A2: The Issuers are still expected to distribute the SBCs in accordance with current law; within seven days of QHP issuer receipt of the enrollment transaction from the FFM. The Federally-facilitated Marketplace (FFM) does not anticipate the need for exceptions because Issuers will receive the enrollment transaction within the same 24-hour period as the enrollee makes his/her selection of QHP or submission of the application. Thus, the FFM will be getting enrollment to the Issuers in time to meet the 7-day requirement. (Enrollment FAQ #3 07/03/13) Q: Will the Plan Compare tool have both the issuer and the plan name on the same line? A: Plan Compare will display the Issuer Marketing Name from HIOS and Plan Marketing Name from the Plans and Bene?ts Template. These names will be displayed on the initial plan results, side-by-side, details and con?rmation views. (REGTAP FAQ Database - FAQ #1351 03/31/14) Q: If a consumer clicks on the URLs, will that open up the website in a new window, or will it just take it to our website? A: Consumers who click on a URL will open a new window. (REGTAP FAQ Database - FAQ #1354 03/31/14) Q: Will CMS be generating a Summary of Benefits and Coverage (SBC A: The FFM does not generating SBCs. This is the responsibility of the issuer. (REGTAP FAQ Database - FAQ #2134 06/11/14) Q1. When must individual and group health insurance issuers make individual coverage policy and group certificate of coverage documents, respectively, accessible online under PHS Act section 2715 and final regulations? A1. Under PHS Act section 2715(b)(3)(i) and the ?nal rules published on June 16, 20151 health insurance issuers must include an Internet web address where the actual individual coverage policy or group certi?cate of coverage can be reviewed and obtained on the Summary of Bene?ts and Coverage The final rules apply as follows: 0 For disclosures with respect to participants and bene?ciaries who enroll or re-enroll in a group health plan through an open enrollment period (including re-enrollees and 97 Updated 1-31-17 2017--00197 Updated 1-31-17 late enrollees), beginning on the ?rst day of the first open enrollment period that begins on or after September 1, 2015; . For disclosures with respect to participants and bene?ciaries who enroll in group health plan coverage other than through an open enrollment period (including individuals who are newly eligible for coverage and special enrollees), beginning on the ?rst day of the ?rst plan year that begins on or after September 1, 2015; . For disclosures with respect to plans, beginning September 1, 2015; and . For disclosures with respect individuals and covered dependents in the individual market, beginning with respect to SBCs issued for coverage that begins on or after January 1, 2016. It has come to attention that some issuers have encountered certain dif?culties making these documents accessible online by these dates, given that this is the ?rst time for this process. For example, we understand that some issuers have several hundred documents that must be posted in compliance with this requirement for both individual coverage and group coverage. At the same time, 1 See 80 FR 34292CFR 147.200(g) these issuers are preparing various materials for Quali?ed Health Plan certi?cation for 2016 open enrollment in the Marketplaces. To the extent an issuer is unable to meet this requirement by the applicability dates listed above, HHSB will not take enforcement action against an issuer that makes the individual coverage policy or group certi?cate of coverage documents accessible online no later than November 1, 2015. This relief is limited to the requirement to post the individual coverage policy or group certi?cate of coverage. Issuers must still provide the SBC in accordance with the timeframes set forth in the final rules. Issuers must provide on the SBC the web address where the documents will be available by November 1, 2015, and must include language on the web page indicating the documents will be accessible on November 1, 2015. We clarify that under the applicability date provisions in the ?nal rule, with respect to individual market coverage, the requirements apply with respect to 8803 issued for coverage beginning on or after Jan. 1, 2016, therefore issuers are not expected to make an internet web address to access the individual coverage policy documents available for coverage that begins before Jan. 1, 2016. We further clarify that if a group health insurance issuer is required, in accordance with the June 12, 2015 SBC ?nal rule, to provide the internet web address on the SBC before October 31, 2015, HHS will not take enforcement action against that issuer if it provides an internet web address for group certificate of coverage documents no later than November 1, 2015. Beginning on November 1, 2015, as stated above, all group and individual health insurance issuers are expected to provide an internet web address for the group certi?cate of coverage or individual policy documents, respectively, by the date which the SBC is othenrvise required under the ?nal rules. As stated in the preamble to the June 16, 2015 ?nal rules, an issuer required to provide an internet web address is permitted to satisfy this requirement with respect to plan sponsors that are shopping for coverage by posting a sample group certi?cate of coverage for each applicable product. After the actual certificate of coverage is executed, it must be easily available to plan sponsors and participants and bene?ciaries via an internet web address. 98 2017--00198 This relief is only applicable with respect to the requirement to make individual coverage policy and group certi?cate of coverage documents accessible online, and does not apply to any other requirements of the June 16, 2015 final rules. (Summary of Bene?ts and Coverage Online Posting of Policy and Certi?cate of Coverage Documents (09/08/15)) 02. In the preamble to the June 16, 2015 final rules, the Departments of HHS, Labor, and the Treasury provided enforcement relief for coverage that is no longer being offered for purchase (closed blocks of business) provided that certain conditions are met.1 Closed blocks of business that satisfy the conditions are not required to provide an SBC. Are health insurance issuers required to provide an internet web address for individual coverage policy or group certi?cate of coverage documents with respect to closed blocks of business that do not satisfy the closed blocks safe harbor criteria? A2. Closed blocks of business that do not meet the conditions for enforcement relief must continue to comply with the SBC requirements, including providing the SBC to plan sponsors and individuals at the required timeframes in the SBC final rules. HHS recognizes a concern that consumers shopping for coverage might access the individual coverage policy or group certi?cate of coverage documents for a closed block of business in which they are not eligible to enroll; this could lead to consumer confusion and frustration. Therefore, HHS will not take enforcement action against an issuer of a closed block of business that does not satisfy the safe harbor criteria that limits access to the individual coverage policy or group certificate of coverage documents to plan sponsors that have already purchased and individuals who are currently enrolled in the coverage. Summary of Benefits and Coverage Online Posting of Policy and Certi?cate of Coverage Documents {09/08/15)} 1. A group health plan or health insurance issuer offers plans with an annual open enrollment period. When must it use the 2017 For a group health plan or health insurance issuer with an annual open enrollment period, applicability is based on the timing of the plan?s (or, in the individual market, the issuer's) open enrollment period. Health plans with an annual open enrollment period are required to use the April 2017 edition of the SBC template and associated documents (referred to in this document as the ?2017 beginning on the ?rst day of any open enrollment period that begins on or after April 1, 2017. Quali?ed Health Plans (QHPs) offered through the Health Insurance Marketplace must use the 2017 SBC during the 2018 open enrollment period, which runs from November 1, 2017 January 31, 2018. on the Summary of Bene?ts and Coverage Applicability Date 07/08/16) 2. A group health plan or health insurance issuer does not maintain an annual open enrollment period. When must it use the 2017 For group health plans or health insurance issuers without an open enrollment period, 1 The conditions for the closed block of business safe harbor are: (1) The insurance product is no longer being actively marketed; (2) the health insurance issuer stopped actively marketing the product prior to September 23, 2012, when the requirement to provide an SBC was ?rst applicable to health insurance issuers; and (3) the health insurance issuer has never provided an SBC with respect to such product 99 Updated 1-31-17 2017--00199 plans and issuers are required to provide the 2017 SBC beginning on the ?rst day of the first plan year (or, in the individual market, the policy year) that begins on or after April 1, 2017. on the Summary of Benefits and Coverage Applicability Date 07/08/16) 3. When are issuers required to begin using the 2017 SBC for form review in States in which HHS is doing direct enforcement? For direct enforcement States, 8803 are considered forms by HHS. SBCs based on the 2017 template should be submitted for review at least 60 days prior to use, similar to other forms. Because States differ in their review of SBCs some review them during form review, others may consider them to be marketing materials), issuers should follow applicable state guidelines for state enforcement activity with respect to SBCs where the State is enforcing SBC requirements. on the Summary of Bene?ts and Coverage Applicability Date 07/08/16) 4. What value should health plans and issuers enter on the Plans and Benefits template for ?Treatment of a Simple Fracture?? Until further notice, to satisfy template validation requirements, issuers should enter default values of on the Plans and Benefits template for each field under the third coverage example, ?Treatment of a Simple Fracture." Until further notice, health plans and issuers may continue to use the Coverage Example Calculator approved for Plan Year 2016 to calculate data for the SBC scenarios ?Having a Baby? and ?Managing Diabetes." on the Summary of Benefits and Coverage Applicability Date 07/08/16) FFM Notices Q: What is Form A: Form 1095-A is a tax form that will be sent to consumers that have been enrolled in health insurance through the Marketplace in the past year. Just like you get a W-2 from your employer, you'll be getting a form from the Marketplace - form 1095-A - you'll need it for your taxes. Keep it alongside your W-2 and other tax records. Similar to how households receive multiple W-2s if individuals have multiple jobs, some households will get multiple Form 1095-As if they were covered under different plans or changed plans during the year. If anyone in your household enrolled in a health plan through the Health Insurance Marketplace in 2014, you'll get a Form 1095-A Health Insurance Marketplace Statement. You'll get it in the mail by early February. Use it to ?le your 2014 federal income tax return. (REGTAP FAQ Database - FAQ #8451 01/12/15) Q: What is the purpose of Form A: Consumers receive Form 1095-A because they or their family member(s) enrolled in health insurance coverage through the Health Insurance Marketplace (Marketplace). Form 1095-A provides information that consumers need to complete Form 8962, 100 Updated 1-31-17 2017--00200 Premium Tax Credit (PTC). The Marketplace has also reported this information to the IRS. (REGTAP FAQ Database - FAQ #8452 01/12/15; reissued 02/09/15) Q: What do Lconsumers do with Form A: Consumers use the information included on Form 1095-A to complete Form 8962, Premium Tax Credit (PTC). Consumers ?le Form 8962 with their tax returns if they want to claim the premium tax credit or if they received premium assistance through advance credit payments made to their insurance provider (whether or not they otherwise are required to ?le a tax return) (APTC). (REGTAP FAQ Database - FAQ #8453 01/12/15; updated 02/09/15) Q: What information is on Form A: Form 1095-A includes: . Information about anyone in consumers' households who enrolled in a health plan through the Health Insurance Marketplace for 2014. 0 Information about the premiums for the Marketplace plan or plans consumers e_nrolled in. paid?te?thei-Fhealth-plane- The amount of any advance payments of the premium tax credit that were paid to consumers' health plan issuers on their behalves In 2014. These are the payments that lowered what consumers paid for the essential health benefits portion of their premiums. 0 The premium for eest?ef a 'benchmark' plan consumers use to calculate premium used?te?determine the amount of their consumers'?premium tax credit. (REGTAP FAQ Database - FAQ #8454 01/12/15; updated 02/09/15) Q: Who will receive Form A: The Marketplace will mail Form 1095-A to the tax ?ler?s or other relevant adult?s (primary application contact) pelieyheldee's last known address provided to the Marketplace and upload Form 1095-A to consumers' online account if they have one. All ta_x households who were enrolled in a Marketplace QHP, regardless of whether members of the household received ?nancial assistance, will receive Form 1095-A. Each member of a tax household, who is on the same policy, will be listed together on one Form 1095-A. The Marketplace will not provide Form 1095-As to consumers who were enrolled in only a catastrophic coverage or a stand-alone dental plan because they do not qualify for the Premium Tax Credit. (REGTAP FAQ Database - FAQ #8455 01/12/15; updated 02/09/15) Q: Who is included on Form Updated 1-31-17 A: Form 1095-A includes all members of a tax household who enrolled in a quali?ed health plan (QHP). Members of the ta_x household will be included on the form regardless of whether they received ?nancial assistance APTC). A separate Form 1095-A Is generated for each policy In which the household enrolled. Ihe?Marketplaee 101 2017-?00201 Q. Will consumers get a separate Form 1095-A for each policy they enrolled in? A. If consumers or their family members are enrolled in more than one QHP policy through the Marketplace, they will receive a Form for each policy. A separate Form 1095-A will be generated for each policy in which the tax household is enrolled. If consumers were enrolled in a health plan, reported a life change, and then were granted a special enrollment period (SEP), they will receive a Form 1095-A for the period of enrollment prior to reporting the life change and a separate Form 1095-A for the period of enrollment after reporting the life change (regardless of whether they change QHPs or stay enrolled in the same QHP). The Marketplace will not provide a Form 1095-A to consumers who were enrolled in only catastrophic coverage or a stand-alone dental plan (SADP) because those enrolled in these types of policies do not qualify for the Premium Tax Credit. If consumers or their family members were enrolled in both a QHP and a SADP, the Marketplace will adjust the Premium Amounts and APTC amounts, if applicable, on their Form accordingly (see questions below about how these values are calculated). (REGTAP FA 03 about Form 1095-A for Assisters(?rst issued 01/12/15; updated 02/09/15) Q: When will the FFM Form 1095-A be available? A: All Forms 1095-A will be postmarked by February 2, 2015. The FFM will print and mail Form 1095-As for coverage year 2014 to recipients and upload forms to their online HealthCare.gov accounts (if the consumer has one). Consumers' Forms 1095-A will be sent to the address they provided the Marketplace and posted to their online accounts. (REGTAP FAQ Database - FAQ #8457 01/12/15; updated 02/09/15) Q: Will Form 1095-A be available in languages other than English? A: Currently Form 1095-A will only be available in English; however, the envelope and the cover letter accompanying Form 1095-A will be available in English and Spanish. Each Form 1095-A will contain a notice tagline addendum that provides instructions in 15 additional languages for consumers to call 1-800-318-2596 if they need assistance interpreting or understanding Form 1095-A. (REGTAP FAQ Database - FAQ #8458 01/12/15; reissued 02/09/15) Q: What if I a consumer needs help understanding Form A: For more information about how your?Marketplace coverage will affect youac taxes, consumers should visit HealthCare.gov/taxes/ or call the Marketplace Call Center at 1-800-318-2596 (TTY: 1-855-889-4325) Consumers can get free assistance with filling out their taxes. This may include free access to tax software programs, or free in- person assistance. For more information, visit or RS.goleTA. If consumers you have additional questions about your taxes, need Form 8962, or want to learn more about the fee for not having health coverage, they should visit (REGTAP FAQ Database - FAQ #8459 01/12/15; updated 02/09/15) 102 Updated 1-31-17 2017-?00202 Q: How do consumers I print Form A: To print Form 1095-A, consumers should: 0 Log into their online accounts and navigate to the application-landing page by clicking on the appropriate application for the 2014 plan year. . Click on the tax form tab on the left navigation panel. Consumers can view and print their Form1095-A from the ?Tax Form? section. Form 1095-As will be posted to consumers' online accounts beginning January 9, 2015, but no later than February 2, 2015. All Form 1095-As mailed to consumers will be postmarked by February 2, 2015. The Marketplace will not begin generating corrected Forms 1095-A until the end of February 2015. Consumers with existing online accounts can also view the Form 1095-A in their online account from the ?Message" section on the global landing page, which is the same location where other notices are posted. If consumers do not have online accounts, they can create an online account to view and to print their Form 1095-A. When a new online account is created after Form 1095-A has been generated, the form will be available only in the ?Tax Form? section, and will not be posted to the ?Message? section Consumers will have to pass identity proofing to view their Form 1095-A electronically. (REGTAP FAQ Database - FAQ #8462 01/12/15; updated 02/09/15) 103 Updated 1-31-17 2017--00203 Q: What if I a consumer did not receive Form 1095-A from the A: Form 1095-A will not be generated for consumers: Enrolled only in a catastrophic plan, (since they are not eligible to receive APTC, nor can they claim the PTC on their tax return); 0 Who receive an exemption and were not enrolled in a QHP throughout the year at any point? Enrolled in a plan outside of the Marketplace. ?ou Consumers will not get a Form 1095-A if you th_eyhave health coverage from another source, like a job, a plan you th_eLbought outside the Marketplace, Medicaid, Medicare, or the Children's Health Insurance Program (CHIP). lfyou a consumer enrolled in 2014 coverage through your a state Marketplace instead of HealthCare.gov, your th_e Form 1095-A will come from your thit state Marketplace. If consumers were enrolled in a QHP through the Marketplace and do not receive a Form 1095-A, hard copy or electronically in their online account, then they should contact the Marketplace Call Center. In the process of mailing initial Form 1095-As to consumers, there may be situations when consumers' mailing addresses change, and they did not report the updated address to the FFM. Additionally, some Form 1095-As may not be printed and mailed if the mailing address the FFM has on ?le for the household is identi?ed as invalid based on an address validation the FFM performs. This could become a problem if the consumer, for one reason or another, is unable to access the electronic PDF of their 1095- A, or they do not have an online account. Most consumers do not have access to their Form 1095- A form In their online account, it?ean they should contact the Marketplace call center. (REGTAP FAQ Database - FAQ #8463 01/12/15, updated 02/09/15) Q: If 1 the consumer lose my Form 1095-A, how dog I th_econsumer get another copy? A: Consumers should access their Forms 1095-A from their online accounts in the Form? tax?form section. If consumers do not have online accounts, they can create one to view their Form 1095-A. If consumers experience issues when creating their online accounts or their Form 1095-A is not posted in their online accounts, they should contact the Marketplace Call Center. (REGTAP FAQ Database - FAQ #8464 01/12/15; updated 02/09/15) Q: How do I consumers get my their Form 1095-A mailed to meat?my a_ new address if! they recently moved? Updated 1-31-17 A: If consumers have online accounts, they should log into them their account and navigate to the application-landing page by clicking on the appropriate application for the 2014 coverage year. Consumers should then click on the ?Tax Forms? tab on the left navigation panel. Consumers can view and print their Form 1095-A from the ?Tax Forms? section. (Note: If the account is created after the 1095-A was initially generated, then they will only be able to view their form in the ?Tax Forms? tab and not in the ?Messages? section of their account.) 104 2017-?00204 If consumers do not have online accounts, inform them that they can create one to view and print their Form 1095- A. Consumers will have to pass identity proo?ng to view their Form 1095- A electronically. Consumers will then have to link their 2014 application to their account using the ??nd my application" functionality. If consumers do not have online accounts, do not want to create account, or have account creation issues, they should contact the Marketplace Call Center. If the consumer requests for a Form 1095-A to be mailed to a separate address from the one the FFM has on record, then a corrected Form 1095-A will be generated, and mailed to the updated address. The Form 1095-A PDF will have the ?corrected" check box marked, and a corrected record will also be sent to the IRS. This will occur even though no data elements on the Form1095-A (PDF and IRS submission) will have changed (Form contains only a permanent address, not a mailing address). Consumers will receive a ?Corrected" Form 1095-A to their updated mailing address in early March 2015. (REGTAP FAQ Database - FAQ #8465 01/12/15; updated 02/09/15) Q: What if the information on my Form 1095-A is incorrect because I the consumer didn't pay all of my?his or her premiums and my th_eissuer terminated my the enrollment? A: If the consumer received a grace period from their issuer and then was terminated due to nonpayment of premiums, the consumer may not have an accurate termination date on their Form 1095-A. It is expected that the issuer will provide CMS with the accurate termination date and CMS will send the consumer a corrected Form 1095-A in this scenario. The consumer's premium amounts for the months they were enrolled will show as the full premium amount, even though the consumer may not have paid the issuer that full amount. (REGTAP FAQ Database - FAQ #8466 01/12/15; updated 02/09/15) Q: If Form 1095-A is incorrect, will I consumers receive a corrected Form A- I: For enrollment related information that consumers believe may be incorrect on Form 1095- A, consumers should contact the Marketplace Call Center for research and resolution. The Marketplace will research the consumer reported inquiry, update incorrect information when appropriate, and mail and upload to a consumer's online account a corrected Form 1095-A starting in early March 2015. (REGTAP FAQ Database - FAQ #8467 01/12/15,? updated 02/09/15) Q: What is a corrected Form Updated 1-31-17 A. Corrected versions of Form 1095- A will be generated if certain data elements are updated by the FEM Marketplace Consumers will also receive a ?corrected? Form if they request that their Form 1095-A be mailed to an updated mailing address, although only the mailing address on the cover page will be updated since there is no mailing address included in the actual fForm 4095A. This will occur even though no data 105 2017--00205 elements on the Form1095-A (PDF and IRS submission) will have changed (Form 1095- A contains only a permanent address, not a mailing address). When data elements on Form 1095-A are corrected or consumers' mailing addresses are updated, the FEM Marketplace will mail consumers a corrected Form 1095-A and post the corrected form to consumers' online accounts if they have one. The corrected Form 1095-A PDF will have the ?corrected? check box marked and an updated record will also be sent to the IRS. The corrected Form 1095-A will not indicate which data element was corrected. When a corrected Form 1095-A is generated, consumers will also receive an electronic notification (depending on communication preferences) that the corrected Form 1095-A (including the cover page, Form 1095-A instructions, and language taglines) has been posted to their online accounts. (REGTAP FAQ Database - FAQ #8468 01/12/15; updated 02/09/15) Q: How long does it take to get a reprinted or corrected Form A: Beginning in early March 2015, corrected Forms 1095-A from the FFM will be mailed and uploaded to consumers' HealthCare.gov accounts. The updated Form 1095-A will have the ?corrected? check box marked. GMS The Marketplace will also report corrected information to the IRS. (REGTAP FAQ Database - FAQ #8469 01/12/15,? updated 02/09/15) Q: Will l?consumers receive Form 1095-A if 1 they enrolled in health coverage through my a_ state Marketplace instead of Healthcare.gov? A: Yes, consumers who enrolled in 2014 coverage through their state Marketplace instead of HealthCare.gov will receive a Form 1095-A directly from their state Marketplace. Consumers in these states should contact their state Marketplace directly for information and questions relating to their Form 1095-A. (REGTAP FAQ Database - FAQ #84 70 01/12/15; updated 02/09/15) Q: On November 21, 2014, HHS clarified that a plan benefit year could begin as late as March 31, 2014 for the purpose of establishing member months to meet the credibility threshold required by the cost-sharing reduction reconciliation simplified methodology. Does the new March 31, 2014 deadline include people who applied or tried to apply by March 31, 2014, but whose enrollments were not effectuated? Updated 1-31-17 A: Yes. A Qualified Health Plan issuer assessing whether enrollment meets the credibility threshold for the simpli?ed methodology may count members who applied or tried to apply by March 31, 2014, but whose enrollment did not become effective until later because of technology challenges. This includes members whose applications were not processed until after March 31, 2014, postponing their start date until May, and members who received a special enrollment period because Exchange issues prevented them from ?ling an application by March 31, 2014. The cost-sharing reduction reconciliation simplified methodology provided in 45 CFR allows issuers to develop a set of effective cost-sharing parameters based on the average experience of enrollees in a standard planminimum of 12,000 member months per benefit year in the standard plan to establish a credible claims data base on which to measure cost-sharing parameters. 106 2017--00206 Because of 2014 enrollment delays, we will consider this standard met if at least 12,000 member months are accumulated for enrollees, each of whom applied or tried to apply to the plan beginning no later than March 31, 2014 and remained in the plan until the end of the bene?t year on December 31, 2014. This includes members who received special enrollment periods that resulted in an effective date up to but not later than May 31, 2014. Issuers that selected the simplified methodology but do not meet the foregoing 12,000- member month credibility standard must use the Actuarial Value simpli?ed methodology described at 45 CFR 156.430 (REGTAP FAQ Database - FAQ #8472 01/13/15) Q. How many consumers got an incorrect Form 1095-A because of this issue? A. About 3 to 5 percent of taxpayers bene?ted from advance payments of tax credits to help lower the cost of their Marketplace premiums in 2014. Among those taxpayers, the overwhelming majority of Marketplace consumers received correct Form 1095-A?s. About 800,000 people got a Form 1095-A for coverage through the Federally Facilitated Marketplace that contained the incorrect premium amount of the second lowest cost Silver plan? in Part Column of the statement. The amount was for 2015, instead of for 2014. Some consumers may have gotten incorrect forms for other reasons, like wrong addresses or dates of coverage, and also will receive a corrected Form. (CMS Technical Assistance FAQs, February 2015) Q. Does this mean the tax credit the consumer received was incorrect? A. No, an incorrect form doesn?t mean that a taxpayer?s tax credit was calculated incorrectly this is an error in what was printed on the form. (CMS Technical Assistance FAQS, February 2015) Q. How will consumers know if they got an incorrect Form 1095-A because of this issue? A. Consumers can log into their Marketplace accounts on HealthCare.gov now to check the status of their forms. Once they log in, they should select their 2014 application, and then select ?Tax forms.? Consumers will see a message letting them know if their 1095-A form will be corrected. This is the best way for a consumer to check if they are impacted by this issue. If the 1095-A form that they received wasn?t impacted by this issue, the message will let them know that as well. The Marketplace account is also where consumers will ?nd their corrected forms when they are completed. All corrected forms should be available by early March. By the beginning of March, the Marketplace also will call and email consumers who got an incorrect Form 1095-A. The message will state that a Form 1095-A for the household is incorrect. Then, when the corrected form is ready, the Marketplace will send a message to the primary enrollee?s Marketplace account. (CMS Technical Assistance FAQs, February 2015) Q. Could consumers get an incorrect Form 1095-A as the result of a different issue? A. Yes, a small group of consumers may experience another issue that results in the Marketplace sending them a corrected Form 1095-A. If that happens, the Marketplace will notify the consumer household with an email and automated phone call. The process 107 Updated 1-31-17 2017--00207 of sending corrected forms is not unique to the Marketplace: it is common practice with all types of tax forms. (CMS Technical Assistance FAQs, February 2015) Q. What should consumers do if they got an incorrect Form A. Consumers who got an incorrect Form 1095-A are encouraged to wait until they get their corrected form before they fill out and ?le their 2014 federal income taxes. (CMS Technical Assistance FAQs, February 2015) Q. If a consumer doesn?t want to wait for a corrected Form 1095-A to file taxes, what can they do? A. Consumers are encouraged to wait to ?le until they get a corrected form. If they can?t wait, consumers can find the amount of the second lowest cost Silver plan that applied to their household in 2014 by: . Using the second lowest cost Silver plan Tax Tool at HealthCare.gov, or . Calling the Marketplace Call Center at 1-800-318-2596 (TTY: 1-855-889-4325) and working with a representative who will help them. (CMS Technical Assistance FA 03, February 2015) Q. What if a consumer got an incorrect Form 1095-A, but they already filed their taxes? A. If consumers ?led their taxes before February 25, they don?t need to file amended returns. The IRS won?t pursue the collection of any additional taxes based on updated information in the corrected forms. (CMS Technical Assistance FAQs, February 2015) Consumers may choose to file an amended return. Consumers may benefit from amending if the 2015 premium for their second lowest cost Silver plan (or ?benchmark? plan) is less than the 2014 premium. For example, if their original form lists a benchmark premium of $100 and their updated form lists a premium of $200, it may be in their interest to re?le. They may want to consult with a tax preparer to determine if they?d benefit from ?ling an amended return. (CMS Technical Assistance FA Qs, February 2015) Q. What should consumers do if their Form 1095-A wasn?t affected? A. If consumers don?t see a message in their Marketplace account or receive an automated call and email from the Marketplace about this or another issue, their Form 1095-A wasn?t affected. They can use their current Form 1095-A to ?ll out and ?le their 2014 federal income tax return, unless they?ll need a corrected form for another issue. When they log in to their Marketplace account, they?ll see a message that lets them know their form wasn?t affected. (CMS Technical Assistance FAQs, February 2015) Q: Which SBC template should issuers include in any ?lings with state regulators for the 2017 benefit year? A: Issuers should follow directions from state regulators. Generally, for the individual market, regulators should direct issuers to use the 2012 SBC template, as that is the template that is authorized for use for individual market coverage for the 2017 benefit 108 Updated 1-31-17 2017--00208 year which starts on January 1, 2017. (CMS FAQs SBCS Related to Rate Filing and QHP Certification 03/11/16) Q: How should FFM issuers complete the Plans and Bene?ts Template for 2017 plan year certification that is part of the 2017 QHP Application? A: For ?elds associated with the ?simple fracture" coverage example for the updated SBC template, issuers should enter default values of for all cost-sharing ?elds to satisfy validation requirements for this scenario. For 2017 coverage, fields associated only with the new SBC template (currently out for 30-day comment, which ends on March 28, 2016), including this coverage example, will not appear on Plan Compare or Window Shopping on HealthCare.gov. For the coverage examples that appear on the 2012 SBC template, issuers should continue to use the 2012 calculator. CMS will provide additional guidance on the Plan and Bene?ts template as the need arises. (CMS FAQs SBCS Related to Rate Filing and QHP Certi?cation 03/11/16) Language Access Requirements Q: When may entities subject to 45 C.F.R. and (B) aggregate limited English proficient populations across multiple states to determine the top 15 languages in which they must provide taglines on Web sites and critical documents? Updated 1-31-17 A: We intend to propose amendments to to provide more specificity about when entities subject to and (B) would be permitted to aggregate limited English pro?cient populations across states to determine the languages in which taglines must be provided, in light of questions that have arisen about this issue since and (B) were finalized. We intend to propose amendments to to specify that individuals, companies, or corporations that are agents or brokers subject to 45 C.F.R. (?web- brokers"), and that are licensed in and serving multiple states, would be permitted to aggregate the limited English pro?cient populations in the states they serve to determine the top 15 languages in which they must provide taglines under With respect to QHP issuers, we likewise intend to propose amendments to to specify that a QHP issuer would be permitted to aggregate the limited English pro?cient populations across all states served by the health insurance issuers within its issuer control group, whether or not those health insurance issuers offer plans through the Marketplace in each of those states, to determine the top 15 languages in which it must provide taglines. For example, a QHP issuer that is a subsidiary of a corporate entity or holding company whose subsidiary health insurance issuers serve multiple states would be permitted to meet the tagline requirement by including taglines on Web sites and critical documents in at least the top 15 languages spoken by the aggregated limited English pro?cient populations of all states served by the corporate entity?s or holding company?s subsidiary health insurance issuers, rather than in the top 15 languages spoken by the limited English pro?cient population of the individual QHP issuer?s state of licensure or state served. In the meanwhile, we will not take enforcement action against web-brokers or QHP issuers that comply with the rule by providing taglines in accordance with this FAQ. We also intend to propose amendments to to specify that Marketplaces would be permitted to aggregate the limited English proficient populations of multiple states to determine the top 15 languages in which taglines are required. In 109 2017--00209 this case, the applicable states would be those states in which an entity operates multiple Marketplaces or an eligibility or enrollment platform for multiple Marketplaces, including the Marketplace subject to the rule. For more information about language access requirements, see our Guidance and Population Data for Exchanges, Qualified Health Plan Issuers, and Web-Brokers to Ensure Meaningful Access by Limited-English Proficient Speakers Under 45 CFR ?155.205(c) and ?156.250. (CMS FAQs Language Access Tag/ine FAQs 08/10/16) Q: When providing the taglines required by 45 C.F.R. and (B) on Web site content, must Marketplaces, QHP issuers, and agents or brokers subject to 45 C.F.R. (?web-brokers?) provide taglines on each Web site page? A: 45 C.F.R. and (B) require Marketplaces, QHP issuers, and web-brokers to include taglines on Web site content and any document that is critical for obtaining health insurance coverage or access to health care services through a QHP for quali?ed individuals, applicants, qualified employers, qualified employees, or enrollees. 45 C.F.R. also applies to the Basic Health Program (BHP), in accordance with the BHP regulations at 42 C.F.R. CMS intends to propose amendments to and (B) that would specify that Marketplaces, QHP issuers, and web-brokers may satisfy tagline requirements with respect to Web site content if they post a Web link prominently on their home page that directs individuals to the full text of the taglines indicating how individuals may obtain language assistance services, and if they also include taglines on any standalone document linked to or embedded in the Web site, such as one in portable document format (PDF) or word processing software format, that is critical within the meaning of the rule. Thus, for example, if a QHP issuer included a link to a PDF of its provider directory or formulary drug list on its Web site, it would be required to provide a link to taglines on its Web site home page and to provide taglines on that PDF document. In the meanwhile, we will not take enforcement action against QHP issuers or web-brokers that comply with and (B) by providing taglines in accordance with this FAQ. (CMS FA 08 Language Access Tag/ine FAQs 08/10/16) FREQUENTLY ASKED QUESTIONS TO ACCOMPANY THE ESTIMATES OF AT LEAST THE TOP 15 LANGUAGES SPOKEN BY INDIVIDUALS WITH LIMITED ENGLISH PROFICIENCY UNDER SECTION 1557 OF THE AFFORDABLE CARE ACT (ACA) (09/14/16) 1557/1 HTML 1. Regulations implementing Section 1557 of the ACA require each covered entity to ?post taglines in at least the top 15 languages spoken by individuals with limited English proficiency of the relevant State or States.? 45 C.F.R. What are these languages in each State? Updated 1-31-17 As a resource for covered entities, OCR has made available a table displaying list of the top 15 languages spoken by individuals with limited English proficiency (LEP) in each State, the District of Columbia, Puerto Rico and each U.S. Territory. OCR created this list for covered entities? use in identifying languages in which to provide translated taglines in implementing list is organized ?rst by State with the US. Territories at the end of the table and then by language. 110 2017-?00210 Languages estimated to be spoken by the most individuals with LEP are ranked as number 1. Covered entities may use the information in this list to implement although nothing in the Section 1557 regulation requires covered entities to use OCR's particular resource in doing so. In implementing covered entities may refer to sources other than list if covered entities have a reasonable basis for relying on such sources when considering characteristics such as the currency, reliability, and stability of the data. Covered entities may use such sources even if the list of languages produced from those sources is different from list or has variations in the relative rank of the languages. As a reminder, nothing in the Section 1557 regulation bars a covered entity from including taglines in languages beyond those triggered by For instance, a covered entity may choose to include taglines in additional languages to maximize the breadth of national origin populations informed about the availability of language assistance services. Please be aware that providing taglines as requires does not fulfill the covered entity?s obligation for complying with the prohibition of national origin discrimination under Section 1557 and the rule. Under covered entities must also take reasonable steps to provide meaningful access to each individual with LEP eligible to be served or likely to be encountered in the entity?s health programs or activities. Independent of the tagline requirement at covered entities are responsible for providing timely and accurate language assistance services, such as oral interpretation and written translation, in non-English languages, even if the language is not shown on list, when doing so is a reasonable step to provide meaningful access to an individual with LEP. View the table created for OCR. - PDF - 2. What data did OCR use to compile its list of the top 15 languages spoken by individuals with LEP in each of the 50 States, the District of Columbia, and Puerto Rico? Updated 1-31-17 OCR used the U.S. Census Bureau?s (Bureau) American Community Survey?s (ACS) data set entitled ?Language Spoken at Home by Ability to Speak English for the Population 5 Years and Older.? The tables for this data set display, among other variables and geographic units, the estimated number of individuals, who speak non- English languages in each State,who speak English less than ?very well,? which OCR used as a proxy for the population with LEP OCR used the most recent State-based data set available to OCR during the development of the Section 1557 rule the 2014 ACS 5-year estimates, available as one of the Bureau?s American FactFinder tables.[i] The American FactFinder tables include estimates on a total of 39 individual languages and language groups. The language groups on the American FactFinder tables ?bundle? more than one language in the groups? estimates. For instance, the American FactFinder tables estimate the prevalence of individuals who speak English less than ?very well? who speak ?Other lndic 111 2017-?0021 1 languages, Other Paci?c Island Languages," ?African Languages,? and ?Other and unspecified languages," among other groups. For these groups where more detail was needed to identify the languages represented, OCR used the detailed State-based data set from the 2013 ACS 5-year estimates which were the most recent estimates available during the development of the Section 1557 The detailed tables display approximately 380 languages and language groups. On list, an asterisk after the language denotes that the estimate came from the Bureau?s detailed 2013 ACS 5-year estimates rather than from the 2014 ACS 5- year estimates. 3. Why did OCR rely on the ACS 5-year estimates rather than the 1-year estimates? OCR used the 5-year estimates (which average five years of data) rather than the 1-year estimates (which represent one year of data). This choice best balanced the currency of the estimates with their reliability and stability. In analyzing small populations, such as some LEP populations, a data source that averages ?ve years of data is more reliable and stable than a source that includes only one year of data.@ 4. What data did OCR use to compile its estimates of the top languages spoken by individuals with LEP for each of the U.S. Territories, other than Puerto Rico? For the U.S. Territories other than Puerto Rico, OCR used the data available from the U.S. Census Bureau, 2010 Census of Population and Housing.[iy1 OCR used this data source instead of the ACS because the ACS does not include data on the U.S. Territories, other than Puerto Rico. The language data available from the 2010 Census of Population and Housing for the U.S. Territories do not allow for a one-to-one comparison to the data available from the Bureau?s ACS for the 50 States, the District of Columbia, and Puerto Rico. In contrast to the Bureau's ACS data estimating the number of individuals who speak non-English languages who speak English less than ?very well,? the data available for Guam, the Commonwealth of Northern Mariana Islands, and American Samoa show the number of individuals who speak a non-English language. These estimates do not indicate how many individuals who speak a non-English language also speak English and whether that English-speaking ability is limited. The language estimates available for the U.S. Virgin Islands show individuals who speak a non-English language who speak English ?not well.? These estimates do not indicate how many individuals speak a particular non- English language who also speak English less than ?very well." 5. Did OCR make any technical adjustments to the data? For example, how did OCR address the fact that even the detailed 2013 ACS 5-year estimates by State contain information on language groups, as opposed to individual languages? Updated 1-31-17 In compiling its list for covered entities? use in implementing OCR made two main types of technical adjustments to the data OCR used. First, OCR omitted languages from the detailed language tables that still represented a language group rather than a single language or list of single languages for which covered entities could identify a speci?c language in which to provide a translated tagline in implementing 112 2017-?00212 This technical adjustment resulted in the omission of language groups, such as ?African" and ?Mayan language," from list. Second, OCR omitted any spoken languages that do not have a written equivalent in which a translated tagline could be provided. This technical adjustment resulted in the omission of speci?c languages, such as Crow, Dakota, and Inupik, from list. These technical adjustments made by OCR are limited to the provision of this particular resource. Consequently, the omission from this speci?c resource of language groups such as ?African? and ?Mayan language? does not relieve a covered entity from the separate obligation to take reasonable steps to provide meaningful access to an individual with LEP whose primary language for communication is a specific African or Mayan language. Similarly, the omission from this specific resource of spoken languages that do not have a written equivalent does not relieve a covered entity from the separate obligation to take reasonable steps to provide meaningful access to an individual with LEP whose primary language for communication is a spoken language that does not have a written equivalent. 6. Why do some of the States on list have more than 15 languages listed? Four States (Colorado, Maryland, Rhode Island, and Virginia) and the District of Columbia have 17 languages listed because the detailed 2013 ACS language tables identify an estimate of language speakers for a grouping of three languages Kru, Ibo, and Yoruba. The detailed ACS language estimates do not further disaggregate the number of individuals speaking English less than ?very well? who speak Kru, Ibo, and Yoruba, respectively. Although all three languages are grouped as one entry on the detailed 2013 ACS 5-year language tables with one combined estimate of language speakers, OCR counted each of these three languages separately because they are distinct languages. As a result, these four States and the District of Columbia have 15 estimates displayed but more than 15 languages listed. OCR recommends that covered entities that rely on list in implementing and that serve individuals in these States or the District of Columbia post taglines in 17 languages. This recommendation is informed by the purpose underlying the ACA to expand access to health care, reduce barriers, and address health disparities. 7. In list, why are there significantly fewer than 15 languages listed for each of the U.S. Territories other than Puerto Rico? For instance, only one language is listed for Guam. Updated 1-31-17 OCR has listed fewer than 15 languages for the U.S. Territories other than Puerto Rico because the data OCR used to estimate the languages spoken by individuals with LEP in the U.S. Territories other than Puerto Rico identify a mere handful of languages or language groups. Using Guam as an example, the table of estimates for ?Language Spoken at Home, Frequency of English Usage, and Sex by Ethnic Origin or Race? from the 2010 Census of Population and Housing provides data on the number of individuals in Guam who speak one language (Chamorro) and the four language groups: ?Philippine languages,? ?Other Paci?c Island languages," ?Asian languages," and ?Other Because the language groups listed are not further disaggregated to identify the specific 113 2017-?00213 languages into which a tagline or other materials could be translated, OCR made technical adjustments to omit the aggregated language groups. Consequently, the only individual language estimated to be spoken by individuals with LEP in Guam that OCR could identify for inclusion in this speci?c resource is Chamorro. Covered entities operating health programs or activities that serve individuals in the US. Territories may be in a better position to identify speci?c languages spoken by individuals with LEP in which to provide translated taglines to meet their obligations under The technical adjustments made by OCR are limited to the provision of this particular resource. Consequently, the omission from this speci?c resource of language groups, such as ?Philippine languages," ?Other Paci?c Islands languages," and ?Asian languages? for Guam, does not relieve a covered entity that serves individuals in Guam through a health program or activity from the separate obligation under ?92.201(a) to take reasonable steps to provide meaningful access to an individual with LEP whose primary language for communication is not shown on list. 8. Some languages listed in the table that OCR has made available have more than one spoken or written dialect, which means that the grammar, vocabulary, pronunciation, or usage may differ for the same language. For these languages, into which dialects did OCR translate its sample taglines and other materials? For the following languages with more than one dialect, OCR translated its sample taglines and other materials into the dialects as follows: For Spanish, materials are translated into neutral Spanish for the United States. For Chinese, materials are translated into traditional Chinese. For French Creole, materials are translated into Haitian Creole. For French, materials are translated into the European dialect. For Portuguese, materials are translated into the European dialect. For Persian, materials are translated into Farsi. For Cushite, materials are translated into Oromo. For Serbo-Croatian, materials are translated into Serbian. For Syriac, materials are translated into Assyria. For Kru, materials are translated into Bassa. For Micronesian, materials are translated into Pohnpeian. For Bantu, materials are translated into Kirundi. For Sudanic, materials are translated into Fulfulde. For Nilotic, materials are translated into Dinka. 9. The population with LEP may change in future years, affecting the languages spoken by individuals with LEP that are ranked within the top 15. Will OCR update its list of the top 15 languages in the future based on newer data? If so, will OCR release the sample tagline, sample notice of nondiscrimination, and sample nondiscrimination statement in languages not captured within the 64 languages in which OCR has already made such translated materials available? Updated 1-31-17 The Section 1557 rule does not specify when to revisit the languages triggered by the standard in As newer data from the Bureau's American Community Survey becomes available for the dataset entitled ?Language Spoken at Home by Ability to Speak English for the Population 5 Years and Older,? OCR will determine if and when the standard in triggers languages in addition to the 64 114 2017-?00214 already triggered by this standard. When additional languages are warranted, OCR will make available the sample tagline, nondiscrimination notice, and nondiscrimination statement in the additional non-English languages. ELIGIBILITY CHANGES IN ELIGIBILITY Q: Will the FFM handle all eligibility appeals rather than the Issuers? If that is the case, what would the process be for eligibility appeals received by the Issuer? A: Yes, in FFM states all eligibility appeals will be handled by HHS. If an issuer receives a misdirected eligibility appeal, they should inform the consumer that these appeals are handled by HHS and refer them to healthcaregov or the call center for more information on how to request an eligibility appeal. (REGTAP FAQ Database - FAQ #402 11/21/13) Q: If there are two unmarried individuals living in the same household, does CMS count both individuals' incomes if only one needs Individual Insurance? A: Unless one of the unmarried individuals is the tax dependent of the other, only the income of the person seeking insurance (and his or her tax dependents) is used to determine eligibility. If one of the unmarried individuals is claimed as a tax dependent of the other, than the income of both is used to determine eligibility. (REGTAP FAQ Database - FAQ #420 11/22/13) Q39: Clarify whether an issuer can or must allow children to enroll in catastrophic plans. The rules talk about these plans being available to ?young adults? and ?under 30? but they do not address enrollment of children. A39: There is no requirement to offer a child-only catastrophic plan. Section 1302(f) of the Affordable Care Act states that if a QHP is offered through the Exchange in any level of coverage speci?ed under subsection the issuer shall also offer that plan through the Exchange as a child-only plan. However, subsection only addresses bronze through platinum coverage, whereas catastrophic level of coverage is in subsection (QHP Webinar Series FAQ #4 04/16/13) Q: Are the Centers for Medicare 8. Medicaid Services (CMS) expecting Issuers to determine if dependents are eligible for Medicaid or Children's Health Insurance Program A: No. (REGTAP FAQ Database - FAQ #618 1/01/14) Q: Does the definition of a policy change mean a change in coverage, contract type, or anything else? A: Within the FFM, policy change can be a re-determination of a Ql's status that is triggered by an event or change in circumstance such as relocation, household income changes, household size changes, becoming qualified for other health coverage, changes in immigration status, becoming incarcerated, or any event that results in loss of MEC. Furthermore, some of these changes will result in a Special Enrollment Period. (REGTAP FAQ Database - FAQ #626 01/09/14) 115 Updated 1-31-17 2017--00215 Q: Can an illegal immigrant enroll in private health insurance? A: Per 45 CFR 155.305, only citizens, nationals of the United States, (US) or non- citizens who are lawfully present in the US are eligible to enroll in a QHP through the Marketplace. Per 45 CFR ?147.104 (Guaranteed availability of coverage), a health insurance issuer that offers health insurance coverage in the individual or group market in a state must offer to any individual or employer in the state all products that are approved for sale in the applicable market, and must accept any individual or employer that applies for any of those products. CMS has interpreted this rule to mean that health insurance issuers offering qualified health plans through the individual market Marketplace generally must accept individuals in the applicable market who apply for coverage under such plans both when the application is received through the Marketplace and when it is received outside the Marketplace. Additionally, while the law prohibits coverage through the Marketplace from being available to individuals who are not lawfully present in the US, the same plans offered inside the Marketplace must be offered outside the Marketplace to any individual seeking health insurance coverage regardless of whether the individual is lawfully present. Therefore, an individual who is not lawfully present in the US cannot obtain individual market health insurance coverage through the Marketplace, but generally can obtain such coverage outside the Marketplace. (REGTAP FAQ Database - FAQ 693 01/27/14) Q: Can individuals upload immigration veri?cation documents on and who reviews the documents that individuals upload on A: Yes, consumers can upload documents supporting their attestation of an eligible immigration status if asked to provide more information to the Marketplace. Consumers who attest to an eligible immigration status while completing the application for coverage will be asked to provide the Marketplace with information about the type of immigration document that they have supporting their status. The Marketplace will attempt to match the information provided with information contained in data sources used for eligibility verification. If any of the information provided does not match information contained in data sources used for eligibility veri?cation, it's called an application inconsistency. If there is an application inconsistency, the Marketplace will provide the consumer with eligibility while the inconsistency is being resolved based on the information provided on the application. The Marketplace may ask the consumer to provide additional information to the Marketplace to review in order to resolve the inconsistency. Consumers can either upload a copy of the requested document(s) showing their information to their My Account on Healthcaregov or mail in a copy of their document(s) to the Marketplace at: HEALTH INSURANCE MARKETPLACE 465 INDUSTRIAL BLVD LONDON, KY 40750-0001 (REGTAP FAQ Database - FAQ #1326 4/1/14) Q: What is the CMS guidance on consumer-reported changes? 116 Updated 1-31-17 2017--00216 A: Enrollees should be directed to to report changes that affect eligibility. (REG TAP FAQ Database - FAQ #2828 08/11/14) Q: If a member has a change in income, does the member have to go to the Federally- facilitated Marketplace (FFM) to report the change in income? Does the FFM re-determine the member's eligibility? A: Consumers should always report a change in income to the FFM. Once the member reports the change in income, the FFM will re-determine the member's eligibility. (REGTAP FAQ Database - FAQ #3052 08/11/14) Q: If consumers have recently amended their federal income tax returns, how long do they need to wait in to reapply for Marketplace coverage? A: The Internal Revenue Service (IRS) takes 3-10 weeks to process a tax return based on how it is ?led. Consumers should update their application, or reapply for coverage, during the Open Enrollment Period which begins November 1, 2016. After tax ?lers have filed their tax return, they can attest on the application to having ?led their taxes for all past years that they received advance payments of the premium tax credit (APTC). Consumers should update their application and select a plan by Dec 15, 2016 to have coverage effective Jan 1, 2017. (REGTAP FAQ Database - FAQ #17681 09/30/16) Q: Does a consumer's eligibility for Medicaid, in addition to actually being enrolled in Medicaid, disqualify a consumer from receiving advance payments of the premium tax credit A: Consumers who are determined eligible for or are enrolled in coverage through Medicaid or CHIP that qualifies as minimum essential coverage (MEC) are ineligible for APTC for themselves, and for income-based cost-sharing reductions (CSRs) to help pay for the cost of their Marketplace coverage. (REGTAP FAQ Database - FAQ #17685 09/30/16) Periodic Data Matching in the FFM Q1: What is Periodic Data Matching? A1: As described in Marketplace regulations at 45 CFR Periodic Data Matching (PDM) includes the process in which the Marketplace examines available data sources to determine whether consumers who are enrolled in Marketplace coverage with APTC or CSRs are alsedetermined eligible for the minimum essential coveraqe Medicaid or the Children? Health Insurance Program (CHIP. 1 117 Updated 1-31-17 2017-?00217 The Marketplace will notify these consumers that they may?be may no Ionqer be eliqible for financial help for a Marketplace plan if dually enrolled, and if so, that they should immediately end their Marketplace coverage with APTC or CSRs. meladed?m?wdated?gwdanee? (CMS FAQs Regarding Periodic Data Matching in the Federally-facilitated Marketplaces (09/18/15 updated by Spring 2016 Periodic Data Matching in the FFM FAQ 05/16/16)) 02: Why would consumers be enrolled in both Marketplace coverage with APTC or CSRs and Medicaid or CHIP coverage? A2: A consumer may experience a life change drop in income) making him or her eligible for Medicaid or CHIP but he or she may fail to tatminate end _Marketplace coverage with after being determined eliqible for Medicaid or CHIP Similarly, consumers who are enrolled in Marketplace coverage with may apply for Medicaid or CHIP directly with the state agency and be determined eligible, but fail to tetminate Marketplace coverage with While the Marketplace reinforces in many places the importance of reporting changes directly to the Marketplace and ending Marketplace coverage with after being determined eligible for or enrolling in other minimum essential coverage, this PDM notice is a reminder for to these consumers who may not have been aware that they need to terminate their Marketplace coverage with after being determined eligible for Medicaid or CHIP. (CMS FAQs Regarding Periodic Data Matching in the Federally-facilitated Marketplaces (09/18/15); updated by Spring 2016 Periodic Data Matching in the FFM FAQ 05/16/16)) Q3: What functionality is being used between the Marketplace and states to conduct A3: The PDM check verifies coverage usinq PDM?uses the existing Non- Employer Sponsored Insurance Coverage MEC service to check whether a consumer who is enrolled in Marketplace coverage with is also enrolled in Medicaid or CHIP coverage. Since the Marketplace is utilizing existing functionality to conduct the data match, there should be no additional burden on the state Medicaid or CHIP agency. (CMS FAQs Regarding Periodic Data Matching in the Federally-facilitated Marketplaces (09/18/15); updated by Spring 2016 Periodic Data Matching in the FFM FAQ 05/16/16)) Q4: How often will CMS conduct A4. CMS The Markketplace will be conducting periodic and?regulaFl-y?seheduled data matches a few times a year and will send _g notices accordingly. The future schedule of PDM will be determined based on various factors, including an evaluation of previous the??rst rounds of PDM. (CMS FAQs Regarding 118 Updated 1-31-17 2017--00218 Periodic Data Matching in the Federally-facilitated Marketplaces (09/18/15); updated by Spring 2016 Periodic Data Matching in the FFM FAQ 05/16/16)) Q5: What happens when a consumer is identified as being enrolled in both Marketplace coverage with APTC or CSRs and Medicaid or CHIP coverage? A5: GMS The Marketplace noti?es each state Medicaid or CHIP agency when the PDM technical execution is complete. Data about dually-enrolled consumers received by the Marketplace from the state Medicaid or CHIP agencies was iireviewed and analyzed prior to the release of notices to consumers. GMS The Marketplace mails paper notices to the household contact for consumers who are found to be are dually-enrolled in Marketplace coverage with and Medicaid or CHIP, with information including: . Names of consumers who are found to be dually-enrolled; 0 Instructions on how to end Marketplace coverage with A note that no action is needed at?the?Mar-ketplaee for consumers who aren?t dually-enrolled; and 0 Contact information for the state Medicaid or CHIP agency to con?rm if enrolled. (CMS FA Qs Regarding Periodic Data Matching in the Federally-facilitated Marketplaces (09/18/15); updated by Spring 2016 Periodic Data Matching in the FFM FAQ 05/16/16)) Q6: Who receives a PDM notice? Updated 1-31-17 A6: The Marketplace conductse_d a data match with state Medicaid and CHIP agencies to determine whether consumers who are enrolled in Marketplace coverage with CSRs are also enrolled in Medicaid or CHIP. The consumers for whom a data match was conducted included those who are enrolled in Marketplace coveraqe with and have validated Social Security numbers in FFM states and states using the FFM platform which have capacity to process requests throuqh the MEC check service. The Marketplace sent a notice to the household contact via mail for each application in which a consumer was identi?ed as being enrolled in both Marketplace covraqe with and Medicaid or CHIP. ?GMS?sends?a?PDM The names of the consumers who were identi?ed as enrolled In both were listed on the notice. Ihe?natiee?lists?the Note: For this Spring 2016 PDM round, the Marketplace was not able to send notices to dually-enrolled consumers in all states because some states were not able to fully participate in PDM or experienced technical issues. Consumers in the following states will not receive notices in this round of PDM: Georgia, Maine, New Hampshire, New Jersey, and Wyoming. {Consumers in these states should refer to Q10 and Q11 below for instructions.) CMS anticipates participation of these states in future rounds of PDM. 119 2017--00219 . future?reunds?ef?PDM (CMS FA 03 Regarding Periodic Data Matching in the Federally- facilitated Marketplaces (09/18/15); updated by Spring 2016 Periodic Data Matching in the FFM FAQ 05/16/16)) Q7: What should a consumer do upon receiving this notice? Updated 1-31-enrolled in Medicaid or CHIP, the consumer should end his/her Marketplace coveraqe with immediately. There are two ways consumers can do this: . Visit Follow the instructions for each person with Medicaid or CHIP. The link above also includes instructions on how to keep their Marketplace plan without premium tax credits and cost-sharinq reductions. . Call the Marketplace Call Center at 1-800-318-2596. TTY users should call 1-855- 889-4325. Once the consumer returns to the Marketplace to update his or her application via HealthCare.gov or the Marketplace Call Center, issuers will automatically be noti?ed to terminate the enrollee?s coverage going forward. Note: Consumers who receive a PDM notice but are no longer enrolled in Medicaid or CHIP do not need to take any further action, though they may wish to contact their state Medicaid or CHIP agency to confirm that they?re not enrolled. Also, consumers who have been determined eligible for Medicaid or CHIP but wish to pay full price to remain enrolled in their Marketplace plans may do so by following the instructions at or by calling the Marketplace Call Center at 1-800-318-2596. 120 2017-?00220 . (CMS FA Qs Regarding Periodic Data Matching in the Federally-facilitated Marketplaces (09/18/15); updated by Spring 2016 Periodic Data Matching in the FFM FAQ 05/16/16)) QB: What happens if a consumer takes no action after receiving the notice? A8: If a consumer is enrolled in Marketplace coverage with APTC or CSRs and is enrolled in Medicaid or CHIP, when the tax ?ler(s) ?le their tax return, they will likely have to pay back all or some of the APTC received for the months following the consumer?s eligibility determination for Medicaid or CHIP. Consumers may reduce the potential amount of APTC that the tax ?ler(s) will have to pay back when they file their tax return by taking steps to end Marketplace coverage with APTC or CSRs upon receiving the notice. Consumers who receive the notice but have more recently been denied eligibility for Medicaid or CHIP do not need to take any further action with the Marketplace, but may wish to contact their state Medicaid or CHIP agency to con?rm that they?re not enrolled. (CMS FA Qs Regarding Periodic Data Matching in the Federally-facilitated Marketplaces (09/18/15); this FAQ was not included in 05/16/16 update) 09: What is the impact on consumers who are enrolled in both Medicaid/CHIP and a Marketplace plan with Updated 1-31-17 A8: If a Marketplace confirms Medicaid or CHIP enrollment through a periodic data matching process, or a consumer who has APTC reports enrollment in Medicaid or CHIP during the coverage year, the Marketplace must accept the state's decision as a valid eligibility determination and the consumer?s eligibility for APTC must be updated to reflect that he or she has other MEC. Therefore, those consumers who are identi?ed as being enrolled in Medicaid or CHIP through the periodic data matching process should return to their application and either end their Marketplace coverage or end their APTC such that financial assistance is no longer being used to cover the consumer in the Marketplace. Generally consumers enrolled in Medicaid or CHIP have free or lower cost coverage compared to Marketplace coverage. In accordance with recent guidance from the Internal Revenue Service (IRS), if a Marketplace makes a determination or assessment that an individual is ineligible for Medicaid or CHIP and eligible for APTC when the individual enrolls in Marketplace coverage, the individual is treated as not eligible for Medicaid or CHIP for purposes of the premium tax credit while he or she is enrolled in Marketplace coverage for that year. Therefore, tax filers may be eligible for the premium tax credit for the months in which consumers in their tax household were enrolled in a Marketplace plan with APTC and Medicaid or CHIP. 121 2017--00221 statutGFy?eaps. (CMS FA Qs Regarding Periodic Data Matching in the Federally- facilitated Marketplaces (09/18/15) updated by Spring 2016 Periodic Data Matching in the FFM FAQ 05/16/16)) Q10: What if the consumer does not believe he or she is enrolled in Medicaid or A10: If a consumer doesn?t think that he or she is enrolled in Medicaid or CHIP, the consumer should contact the state Medicaid or CHIP agency as soon as possible to con?rm that he or she is not enrolledenrolled in Medicaid or CHIP. If a consumer believes that he or she was wrongly found to be enrolled in Medicaid or CHIP, he or she should contact the state Medicaid or CHIP agency as soon as possible, and ask to have his or her eligibility redetermined. (CMS FAQs Regarding Periodic Data Matching in the Federally-facilitated Marketplaces (09/18/15); updated by Spring 2016 Periodic Data Matching in the FFM FAQ 05/16/16)) Q11: What if a consumer was not notified of his or her enrollment in Medicaid or CHIP but believes he or she may be enrolled in Medicaid or CHIP and Marketplace coverage with A11: If a consumer did not receive a notice but believes he or she is enrolled in Medicaid or CHIP and enrolled in a Marketplace plan with he or she should contact the state Medicaid or CHIP agency and the Marketplace to confirm his or her enrollment statuses. If he or she is enrolled in Medicaid or CHIP and Marketplace coverage with APTC or CSRs, the consumer should visit or contact the Marketplace Call Center at 1-800-318? 2596 for instructions on how to end the Marketplace coverage with APTC If the consumer learns from the state Medicaid or CHIP agency that he or she has been determined eligible for Medicaid or CHIP but is not enrolled in that coverage, the state agency should help the consumer complete enrollment. (CMS FAQs Regarding Periodic Data Matching in the Federally-facilitated Marketplaces (09/18/15); updated by Spring 2016 Periodic Data Matching in the FFM FAQ 05/16/16)) Q12: What if the consumer is enrolled in Medicaid or CHIP but believes he or she is actually eligible to remain enrolled in Marketplace coverage with Updated 1-31-17 A12: A consumer may believe he or she Is eligible to remain enrolled in Marketplace coverage with - - if he or she ?experienced a household or income change that makes him or hern no longer eligible ineligible for Medicaid/CHIP. The consumer should contact his or her state Medicaid/CHIP agency to inform them of the change and receive a redetermination of eligibility for Medicaid/CHIP. If the consumer is found to no longerbe eligible for Medicaid or 122 2017-?00222 severage?will?end? the consumer can remain in his or her Marketplace coverage with if otherwise eligible. (CMS FAQs Regarding Periodic Data Matching in the Federally-facilitated Marketplaces (09/18/15); updated by Spring 2016 Periodic Data Matching in the FFM FAQ 05/16/16)) Q13: Is this the first time the PDM notice is being sent to consumers A13: Marketplace sent the PDM notices to consumers for the ?rst time beginning in September 2015, informing them that they were identified as being enrolled in a Marketplace plan with as well as Medicaid or CHIP and providing them with instructions to end their Marketplace plan with the-enline?appl-Ieat-Ien- (CMS FA Qs Regarding Periodic Data Matching in the Federally- facilitated Marketplaces (09/18/15) updated by Spring 2016 Periodic Data Matching in the FFM FAQ 05/16/16)) Q14: Do coordination of benefits and third party liability PL) apply during the time that the consumer was dually enrolled in Medicaid and Marketplace coverage with A14: State Medicaid or CHIP agencies should follow their normal PL practices for Medicaid. Medicaid should remain the payer of last resort. (CMS FAQs Regarding Periodic Data Matching in the Federally-facilitated Marketplaces (09/18/15) not updated Q15: Can State-based Marketplaces (SBMs) use this functionality? Do they have the same obligations regarding terminating A15: The periodic data matching functionality discussed here is a process used speci?cally with state Medicaid and CHIP agencies in states in which Medicaid and CHIP eligibility are determined or assessed by the Federail-y?faeilitated Marketplace. Heweven State-based Marketplaces are also required to conduct periodic data matching, as speci?ed in (CMS FAQs Regarding Periodic Data Matching in the Federally-facilitated Marketplaces (09/18/15); updated by Spring 2016 Periodic Data Matching in the FFM FAQ 05/16/16)) Q15: Will consumers who are notified that they are dually-enrolled be able to retroactively terminate their Marketplace coverage with A15: The Marketplace generally will not provide retroactive terminations for Marketplace coverage for dually-enrolled consumers. For this reason, we urge consumers who are determined eligible for or enrolled in Medicaid or CHIP to end their Marketplace 123 Updated 1-31-17 2017--00223 coveraqe with APTC immediately. (Spring 2016 Periodic Data Matching in the FFM FAQ 05/16/16) Q: An individual submitted an application through the Federally-facilitated Marketplace (FFM) and received the Eligibility results on April 15, 2015, stating that her children may be eligible for Health Connections (South Carolina's Medicaid). The client was informed that she would receive a final decision. However, after 10 weeks, the client's children are still without health insurance coverage. The client has contacted the state Medicaid office on several occasions, but no one is able to locate the application; the children's information; or verify the status of the children's eligibility. Please provide guidance on whether or not the client can make a change to her Health Insurance Marketplace application stating that the children were denied eligibility, so that they can get health insurance coverage while the state Medicaid office can figure out what is going on? A: The individual may choose to appeal if she believes the eligibility results to be wrong. The individual should go to decision/ to find and complete the appeal request form for her state. It should then be mailed to: Health Insurance Marketplace, 465 Industrial Blvd. ,London, KY 40750-0061. (REGTAP FAQ Database - FAQ #15235 03/23/16) What is an annual household income data matching issue? When consumers ?ll out a Marketplace application requesting ?nancial assistance, we check their eligibility for insurance affordability programs using trusted data sources. For most consumers, we are able to verify their household income information right away; however, sometimes consumers? household income information is not available from the trusted data sources, or their attested income is outside a set threshold when compared to these sources. In such instances, the Marketplace generates a ?data matching issue" that requires consumers to submit additional information through an alternate verification process. Consumers who do not provide income documents suf?cient to resolve their data matching issue can have their ?nancial assistance ended or modified. (CMS FAQs Annual Income Threshold Adjustment FAQ 07/21/16) How is the annual income threshold changing? Annual household income data matching issues are currently created whenever an applicant?s annual household income attestation is more than 10% less than the income data received from trusted data sources shows, or if no household income data is available from those sources. The HHS Notice of Benefit and Payment Parameters for 2017 granted authority to Marketplaces, subject to HHS approval, to set a reasonable threshold for the generation of annual household income data matching issues that would require additional verification. The regulation (45 C.F.R. stated that the threshold could not be less than 10% and that it could include a dollar threshold. HHS has determined that it is a reasonable threshold to generate an annual income data matching issue for a consumer if their attested income is more than 25% or $6,000 (whichever is greater) lower than data from our trusted data sources; we maintain the policy that a data matching issue is generated if no data is available from our trusted data sources. This threshold change, which we expect will simplify the process while maintaining program integrity, will be in place in the FFM prior to the start of open enrollment for plan year 2017. (CMS FAQs Annual Income Threshold Adjustment FAQ 124 Updated 1-31-17 2017-?00224 07/21/16) What does this mean for State-based Marketplaces? HHS has determined that it is a reasonable threshold to generate an annual income data matching issue for a consumer if their attested income is at least 25% or $6,000 lower than the data received from trusted data sources. Further, HHS has determined that it would be a reasonable threshold if State-based Marketplaces (SBMs) implemented a revised threshold that does not exceed the percentage and dollar thresholds of 25% and $6,000, but is not less than 10%. SBMs that would like to propose a threshold that goes beyond this guidance may submit a proposal to HHS for review and approval. The proposal should include the proposed threshold, an implementation timeline, and relevant research used to support the threshold. It should also include an explanation of why the proposed threshold better allows for normal variations in income while still protecting consumers against the possibility of large tax reconciliation payments in the event that IRS determines they were provided excess advance payments of the premium tax credit. Proposals should be submitted to the SBM's State Officer. While the FFM will be implementing this change for plan year 2017, States can implement or apply for a new threshold at any point during the plan year. (CMS FAQs Annual Income Threshold Adjustment FAQ 07/21/16) Q: Is it true that consumers in some states will not be receiving Medicaid/Children's Health Insurance Program (CHIP) Periodic Data Matching (PDM) notices? A: Due to technical limitations, dually-enrolled consumers in the following Marketplace states did not receive notices in this round of Medicaid/CHIP PDM: GA, NH, NJ, and WY. Consumers in these states will not be affected by this round of Medicaid/CHIP PDM. (REGTAP FAQ Database - FAQ #17677 09/30/16) Q: If a consumer received a final Medicaid/Children's Health Insurance Program (CHIP) Periodic Data Matching (Medicaid/CHIP PDM) notice, but is not enrolled in Medicaid or CHIP, can he or she appeal the Marketplace's decision to end advance payments of the premium tax credit (APTC) and income-based cost-sharing reductions A: A consumer can appeal the Marketplace's decision about his or her eligibility for health coverage, including eligibility for APTC and CSRs, within 90 days from the date of the notice. A consumer may appoint an Authorized Representative to help with his or her appeal, or may participate on his or her own. If a consumer requests an appeal, he or she may be able to maintain eligibility for coverage while the appeal is pending. Note that the outcome of an appeal could change the eligibility of other household members on the consumer's Marketplace account, even if they do not ask for an appeal. Information regarding a consumer's right to appeal and instructions on how to do so are included in the final notice. (REGTAP FAQ Database - FAQ #17680 09/30/16) Q: How would a consumer become enrolled in both Medicaid/Children's Health Insurance Program (CHIP) and a Marketplace plan with advance payments of the premium tax credit 125 Updated 1-31-17 2017--00225 (APTC) or income-based cost sharing reductions A: A consumer may experience a life change drop in income) making him or her eligible for Medicaid or CHIP, but he or she may fail to end Marketplace coverage with after being determined eligible for Medicaid or CHIP. Similarly, consumers who are enrolled in Marketplace coverage with may apply for Medicaid or CHIP directly with the state agency and be determined eligible, but fail to end Marketplace coverage with While the Marketplace reinforces in many places the importance of reporting changes directly to the Marketplace and ending Marketplace coverage with after being determined eligible for or enrolling in other minimum essential coverage, this notice is a reminder to these consumers who may not have been aware that they need to end their Marketplace coverage with after being determined eligible for Medicaid or CHIP. (REGTAP FAQ Database - FAQ #17683 09/30/16) General Questions about Periodic Data Matching Q1: What is Periodic Data Matching? A1: As described in Marketplace regulations at 45 CFR Periodic Data Matching (PDM) includes the process in which the Marketplace periodically examines available data sources to determine whether consumers who are enrolled in Marketplace coverage with are determined eligible for Minimum Essential Coverage (MEC) Medicaid or CHIP.2 The Marketplace will notify these consumers that they may no longer be eligible for ?nancial help for a Marketplace plan if dually-enrolled, and if so, that they should immediately end their Marketplace coverage with by the date indicated in the notice.3 As described in Marketplace regulations at 45 CFR if affected consumers fail to return to the Marketplace to update their Marketplace application to re?ect that they?re not dually-enrolled or end Marketplace coverage with the Marketplace will end any being paid on their behalf. The Marketplace will notify these consumers that their Marketplace coverage will continue without ?nancial help and they will need to end their Marketplace coverage if they no longer wish to be enrolled in that coverage. For unaffected household members, Marketplace coverage will continue, and the Marketplace will recalculate their eligibility for if applicable. (CMS FAQs on Summer/Fall 2016 Medicaid/CHIP Periodic Data Matching {08/01/16) 02: What functionality is being used between the Marketplace and states to conduct A2: The PDM check verifies coverage using the existing Non-Employer Sponsored Insurance MEC service to check whether a consumer who is enrolled in Marketplace coverage with is also enrolled in Medicaid or CHIP coverage. Since the Marketplace utilizes existing functionality to conduct the data match, 2 The Periodic Data Match checks to see if consumers are enrolled in Medicaid that qualifies as Minimum Essential Coverage (MEC). Most Medicaid or CHIP is considered some forms of Medicaid that cover limited benefits (like Medicaid that only covers emergency care, family planning or pregnancy-related services) are not considered MEC. For more information on what Medicaid programs are considered MEC, visit: 3The state data that is accessed through the PDM check includes Medicaid and CHIP enrollment data, not data regarding eligibility. Updated 1-31-17 126 2017-?00226 there should be no additional technological burden on the state Medicaid or CHIP agencies. (CMS FA 03 on Summer/Fall 2016 Medicaid/CHIP Periodic Data Matching {08/01/16) Q3: What is the impact on a consumers? eligibility for financial help when they enrolled in both Medicaid/CHIP and a Marketplace plan with A3: If a Marketplace confirms Medicaid or CHIP enrollment through a periodic data matching process, or a consumer on whose behalf APTC are being paid reports enrollment in Medicaid or CHIP during the coverage year, the Marketplace must accept the state's decision as a valid eligibility determination and the consumer?s eligibility for APTC must be updated to re?ect that he or she has other MEC. Therefore, those consumers who are identified as being enrolled in Medicaid or CHIP through the periodic data matching process should return to their application and either end their Marketplace coverage or end their such that ?nancial assistance is no longer being used to cover the consumer in the Marketplace. Generally consumers enrolled in Medicaid or CHIP have free or lower cost coverage compared to Marketplace coverage. In accordance with recent guidance from the Internal Revenue Service (IRS), if a Marketplace makes a determination or assessment that an individual is ineligible for Medicaid or CHIP and eligible for APTC when the individual enrolls in Marketplace coverage, the individual is treated as not eligible for Medicaid or CHIP for purposes of the premium tax credit while he or she is enrolled in Marketplace coverage for that year. Therefore, tax ?lers may be eligible for the premium tax credit for the months in which consumers in their tax household were enrolled in a Marketplace plan with APTC and Medicaid or CHIP. (CMS FAQs on Summer/Fall 2016 Medicaid/CHIP Periodic Data Matching {08/01/16) Q4: Is this the first time these PDM notices are being sent to consumers? A4: The Marketplace previously sent PDM notices to consumers in September 2015 and May 2016, informing them that they were identified as being enrolled in a Marketplace plan with as well as Medicaid or CHIP, and providing them with instructions to end their Marketplace plan with In summer/fall 2016, the Marketplace will implement new functionality to enable it to end when a consumer is found during a data match to be enrolled in Marketplace coverage with and Medicaid or CHIP. Dually-enrolled consumers will receive an initial warning notice and, if appropriate, a ?nal notice alerting them that their ?nancial help is ending. This summer/fall, the 2016 PDM process also includes new online support for consumers receiving PDM notices. Consumers will now be able to view their notices electronically on their Marketplace account, and access dynamic instructions and a user guide for next steps tailored to their particular circumstances. Those consumers who disagree with the notice and who are not enrolled in Medicaid or CHIP will be instructed to update their application information to confirm that they are not enrolled in Medicaid or CHIP. (CMS FA 03 on Summer/Fall 2016 Medicaid/CHIP Periodic Data Matching {08/01/16) 05: Are there other places besides these PDM notices that consumers are informed that 127 Updated 1-31-17 2017-?00227 they should end their Marketplace coverage with APTC if they are enrolled in Medicaid or A5: In addition to providing information on HealthCare.gov, the Marketplace has published content in a number of venues to help address issues related to enrollment in a Marketplace plan with once a consumer is determined eligible for Medicaid or CHIP. When selecting a Marketplace plan with APTC, consumers must attest that they understand their responsibility to end their Marketplace coverage with if they become eligible for other minimum essential coverage (including Medicaid and CHIP). The Marketplace eligibility determination notice (EDN) that consumers receive after submitting their application for coverage includes clear language regarding consumer responsibility to actively end Marketplace coverage with APTC upon becoming eligible for other minimum essential coverage. The initial warning notice regarding a consumer?s dual-enrollment will be available in the Application Details section of the dually-enrolled consumer?s Marketplace account, with a timer to notify them of the deadline to make updates to the application or end Marketplace coverage with APTC, before the Marketplace takes action to end financial assistance on the consumer?s behalf. (CMS FAQs on Summer/Fall 2016 Medicaid/CHIP Periodic Data Matching {08/01/16) 06: Can a consumer who is eligible for Medicaid or CHIP coverage that constitutes MEC keep their Marketplace plan? A6: Yes, if otherwise eligible for Marketplace coverage, such a consumer may keep his or her Marketplace plan. If a consumer still wants a Marketplace plan after being determined eligible for Medicaid or CHIP that quali?es as minimum essential coverage, they will not be eligible for any financial assistance to reduce the cost of their Marketplace plan. (CMS FA OS on Summer/Fall 2016 Medicaid/CHIP Periodic Data Matching (08/01/16) Q7: What if the consumer does not believe he or she is enrolled in Medicaid or CHIP after receiving the initial notice? Updated 1-31-17 A7: If a consumer doesn't think that he or she is enrolled in Medicaid or CHIP, the consumer should contact the state Medicaid or CHIP agency as soon as possible to con?rm his or her enrollment statuses If the consumer is not eligible for or enrolled in Medicaid or CHIP, the consumer should return to the Marketplace to update their application information to confirm that they are not enrolled in Medicaid or CHIP. As the consumer updates his or her application, the Marketplace will check again with the State Medicaid or CHIP agency in real time to confirm whether he or she is enrolled in Medicaid or CHIP. If the State Medicaid or CHIP agency tells us that he or she is enrolled in Medicaid or CHIP, a data matching issue will be generated and the consumer will be asked on their Eligibility Notice to send in documentation proving they are not enrolled in Medicaid or CHIP. This may include a Medicaid termination notice. They will have a period of 90 days to send in that documentation or risk losing During this time, they will remain eligible to enroll in a Marketplace plan with APTC or CSRs, if otherwise eligible. (CMS FAQs on Summer/Fall 2016 Medicaid/CHIP Periodic 128 2017-?00228 Data Matching {08/01/16) Q8: What if a consumer was not notified of his or her enrollment in Medicaid or CHIP because the state did not participate in PDM but believes that he or she may be enrolled in Medicaid or CHIP and Marketplace coverage with A8: If a consumer believes he or she is enrolled in Medicaid or CHIP and enrolled in a Marketplace plan with but did not receive a confirmation of Medicaid or CHIP enrollment or an initial warning notice, he or she should contact the state Medicaid or CHIP agency and the Marketplace. If he or she is enrolled in both Medicaid or CHIP and Marketplace coverage with the consumer should visit or contact the Marketplace call center at 1-800-318-2596 for instructions on how to end the Marketplace coverage with APTC. If the consumer learns from the state Medicaid or CHIP agency that he or she has been determined eligible for Medicaid or CHIP but is not enrolled in that coverage, the state agency will help the consumer complete enrollment. (CMS FAQs on Summer/Fall 2016 Medicaid/CHIP Periodic Data Matching (08/01/16 Q9: What if the consumer is enrolled in Medicaid or CHIP but believes he or she is actually eligible to remain enrolled in Marketplace coverage with A9: A consumer may believe he or she is eligible to remain enrolled in Marketplace coverage with if he or she experienced a change in household or income that makes him or her no longer eligible for Medicaid/CHIP. The consumer should contact the state Medicaid/CHIP agency to inform them of these circumstances. If the Medicaid or CHIP agency informs the consumer that longer eligible for Medicaid or CHIP, the consumer should return to the Marketplace and update his or her application to state that he or she is not enrolled in Medicaid or he or she can remain in his or her Marketplace coverage with if otherwise eligible. (CMS FAQs on Summer/Fall 2016 Medicaid/CHIP Periodic Data Matching {08/01/16 Q10: What is the difference between a Data Matching Issue (DMI) notice and a PDM no?ce? Updated 1-31-17 A10: A data matching issue, or DMI, occurs when a consumer completes a Marketplace application and the Marketplace cannot immediately verify information provided by the consumer or it ?nds that Marketplace data sources con?ict with information provided by the applicant. For example, a DMI is generated if the Marketplace ?nds that a consumer who is otherwise eligible for APTC and attests that he or she is not enrolled in other MEC is enrolled in Medicaid or CHIP. When a DMI is generated in this situation, the Marketplace requests that a consumer submit documentation within 90 days to prove that he or she is not enrolled in Medicaid or CHIP. During the 90 days, a consumer will be able to enroll (or remain enrolled) in Marketplace coverage with if otherwise eligible. If consumers do not submit suf?cient documentation to resolve their DMI within the timeframe, the Marketplace will end their and they will remain enrolled in coverage through the Marketplace without ?nancial help. PDM is a process the Marketplace uses periodically during the coverage year to identify and notify consumers who are enrolled in Marketplace coverage with and 129 2017-?00229 MEC Medicaid or CHIP. Consumers who receive a PDM initial warning notice and are enrolled in Medicaid or CHIP should immediately end their Marketplace coverage with APTC. If consumers do not take action by the date on the notice (within 30 days from the date of the notice), the Marketplace will end any being paid on their behalf for their share of a Marketplace plan premium, and re-determine eligibility for for remaining consumers on the application, as appropriate. (CMS FAQs on Summer/Fall 2016 Medicaid/CHIP Periodic Data Matching {08/01/16) Q11: Do coordination of benefits and third party liability PL) apply during the time that the consumer was dually enrolled in Medicaid and Marketplace coverage with A11: State Medicaid or CHIP agencies should follow their normal PL practices for Medicaid. Medicaid should remain the payer of last resort. (CMS FAQs on Summer/Fall 2016 Medicaid/CHIP Periodic Data Matching {08/01/16 Q12: Will consumers who are notified that they are dually-enrolled be able to retroactively terminate their Marketplace coverage with A12: The Marketplace generally will not provide retroactive terminations for Marketplace coverage for dually-enrolled consumers. For this reason, we urge consumers who are determined eligible for or enrolled in Medicaid or CHIP to end their Marketplace coverage with APTC immediately. (CMS FAQs on Summer/Fall 2016 Medicaid/CHIP Periodic Data Matching {08/01/16) Q13: What happens if a consumer takes no action after receiving the initial warning notice? Will the Marketplace automatically end his or her A13: Yes. Starting in summer/fall 2016, new functionality will allow the Marketplace to take action on consumers who do not respond to the initial warning notice. After the date on the notice, the Marketplace will end any being paid on behalf of those dually-enrolled consumers for their share of a Marketplace plan premium. For anyone in the same household who is not listed in the ?nal notice and still enrolled in a Marketplace plan, their Marketplace coverage will continue and the Marketplace will recalculate their eligibility for as applicable. The Marketplace will send a final notice and updated eligibility determination notice to inform consumers of changes to their ?nancial assistance. Note that for consumers who successfully responded to the initial warning notice by the date listed in the notice by either ending their Marketplace coverage with or updating their Marketplace application to re?ect the fact that they are not enrolled in or eligible for Medicaid/CHIP, the Marketplace will not end on their behalf and they will not receive a ?nal notice. (CMS FAQs on Summer/Fall 2016 Medicaid/CHIP Periodic Data Matching {08/01/16) Q14: What should a consumer do if they disagree with the decision of the Marketplace to end their APTC and A14: A consumer can appeal the Marketplace?s decision about his or her eligibility for health coverage, including eligibility for APTC and CSRs, within 90 days from the date of the notice. A consumer may appoint an Authorized Representative to help with his or her 130 Updated 1-31-17 2017--00230 appeal, or may participate on his or her own. If a consumer requests an appeal, he or she may be able to maintain eligibility for coverage while the appeal is pending. Note that the outcome of an appeal could change the eligibility of other household members on the consumer?s Marketplace account, even if they do not ask for an appeal. Information regarding a consumer?s right to appeal and instructions on how to do so are included in the final notice. (CMS FA 03 on Summer/Fall 2016 Medicaid/CHIP Periodic Data Matching (08/01/16) Q: What is the Medicaid/Children's Health Insurance Program (CHIP) Periodic Data Matching (Medicaid/CHIP PDM) process? A: Medicaid/CHIP PDM is a process the Marketplace uses periodically during the plan year to identify, notify, and reduce the number of consumers who are enrolled in Marketplace coverage with advance payments of the premium tax credit (APTC) or income-based cost-sharing reductions (CSR), and also in Medicaid or CHIP that qualifies as minimum essential coverage (MEC). Consumers who receive a PDM initial warning notice are informed that they should take one of the following actions: (1) update their online Marketplace application to indicate they are not enrolled in coverage with Medicaid and CHIP, or (2) end their FFM coverage with APTC if they're enrolled in Medicaid or CHIP. If consumers do not take action by the date on the notice (within 30 days from the date of the notice), the Marketplace will end any being paid on their behalf for their share of a Marketplace plan premium and covered services, and will redetermine eligibility for for remaining consumers other members of the household) on the application, as appropriate. The Marketplace will send a ?nal notice, as well as an updated Eligibility Determination Notice (EDN), to the household point of contact for an affected consumer's application to inform the household of the change in financial help. (REGTAP FAQ Database - FAQ #17303 08/29/16) Q: How often is Medicaid/Children's Health Insurance Program (CHIP) Periodic Data Matching (Medicaid/CHIP PDM) conducted? A: The Marketplace will be conducting Medicaid/CHIP PDM a few times a year and sending notices to affected consumers accordingly. The Marketplace does not anticipate performing another round of Medicaid/CHIP PDM in 2016. The future schedule of Medicaid/CHIP PDM will be determined based on various factors, including evaluations of previous rounds of Medicaid/CHIP PDM. (REGTAP FAQ Database - FAQ #17304 08/29/16) Q: How much time does a dually-enrolled consumer have to take appropriate action after being sent an initial warning notice about Medicaid/Children's Health Insurance Program (CHIP) Periodic Data Matching (Medicaid/CHIP Updated 1-31-17 A: If consumers do not take action by the date specified in the initial Medicaid/CHIP PDM warning notice (within 30 days from the date of the notice), the Marketplace will end any advance payments of the premium tax credit (APTC) or income-based cost- sharing reductions (CSR) for the affected consumers' covered services, and redetermine 131 2017-?00231 eligibility for for remaining consumers on the application, as appropriate. The Marketplace will send a ?nal notice, as well as an updated Eligibility Determination Notice (EDN), to the household point of contact for an affected consumer's application to inform the household of the change in ?nancial help. (REGTAP FAQ Database - FAQ #17305 08/29/16) Q: What if the consumer does not believe he or she is enrolled in Medicaid or the Children's Health Insurance Program (CHIP) after receiving the initial warning notice from CMS noting his or her dual enrollment in Marketplace coverage and Medicaid/CHIP? A: If a consumer doesn't think that he or she is enrolled in Medicaid or CHIP, the consumer should contact the state Medicaid or CHIP agency as soon as possible to confirm his or her enrollment status. If the consumer is not eligible for or enrolled in Medicaid or CHIP, the consumer should return to the Marketplace to update his or her application information to tell the Marketplace that he or she is not enrolled in Medicaid or CHIP. As the consumer updates his or her application, the Marketplace will check again with the state Medicaid or CHIP agency in real time to confirm whether the consumer is enrolled in Medicaid or CHIP. If the state Medicaid or CHIP agency tells the Marketplace that the consumer is enrolled in Medicaid or CHIP, a data matching issue (DMI) will be generated and the consumer will be asked on his or her Eligibility Determination Notice (EDN) to send in documentation proving he or she is not enrolled in Medicaid or CHIP. This documentation may include a Medicaid termination notice. The consumer will have a period of 90 days to send in that documentation or risk losing During this time, the consumer will remain eligible to enroll in a Marketplace plan with if otherwise eligible. (REGTAP FAQ Database - FAQ #17306 08/29/16) Q: How do consumers tell the Marketplace that they are not enrolled in Medicaid or the Children's Health Insurance Program (CHIP) after receiving a warning notice for Medicaid/CHIP Periodic Data Matching (Medicaid/CHIP Updated 1-31-17 A: Consumers who receive the initial warning notice and are NOT enrolled in Medicaid or CHIP should respond to the notice by updating their application to tell the Marketplace that they are not enrolled in Medicaid or CHIP. When they submit their updated application, their Eligibility Determination Notice (EDN) may say that they need to send in proof that they are no longer enrolled in Medicaid or CHIP. When the consumer is updating his or her application, the Marketplace checks, in real time, whether he or she is enrolled in Medicaid and CHIP. If the Marketplace ?nds that the consumer is enrolled in Medicaid or CHIP, he or she will get a Medicaid/CHIP data matching issue (DMI) and will have 90 days to upload or send proof that he or she is not enrolled in Medicaid or CHIP. Examples of proof to resolve a DMI include: a letter from health insurer including coverage termination date, statement of health bene?ts, or letter from the consumer's Medicaid or CHIP state agency stating they are not enrolled. 132 2017-?00232 If the consumer fails to provide adequate proof within the timeframe, the Marketplace will end any advance payments of the premium tax credit and cost-sharing reductions for the consumer with the DMI, and he or she will remain enrolled in Marketplace coverage at full cost. (REG TAP FAQ Database - FAQ #17307 08/29/16) Q: Can consumers end their Medicaid or Children's Health Insurance Program (CHIP) coverage if they want to keep their Marketplace plan with advance payments of the premium tax credit and cost-sharing reductions A: Consumers who are determined eligible for or are enrolled in coverage through Medicaid or CHIP that qualifies as MEC are ineligible for to help pay for the cost of their Marketplace plan premium and covered services. If a consumer still wants a Marketplace plan after having been determined eligible for MEC Medicaid or CHIP, he or she will have to pay full cost for his or her share of the Marketplace plan premium and covered services, if otherwise eligible. (REGTAP FAQ Database - FAQ #17308 08/29/16) Q: Which states are not participating in this round of Medicaid/Children's Health Insurance Program (CHIP) Periodic Data Matching (Medicaid/CHIP A: Due to technical limitations, dually-enrolled consumers in the following Marketplace states did not receive notices in this round of Medicaid/CHIP PDM: Georgia, New Hampshire, New Jersey, and Wyoming. Consumers in these states will not be affected by this round of Medicaid/CHIP PDM. (REGTAP FAQ Database - FAQ #17309 08/29/16) CSRS AND APTCS (COST-SHARING REDUCTIONS AND ADVANCE PAYMENT OF PREMIUM TAX CREDITS) Eligibility Q7: The Affordable Care Act prescribes a seamless, streamlined eligibility process for consumers to submit a single application and receive an eligibility determination for enrollment in a qualified health plan (QHP) through the Exchange, advance payments of the premium tax credit, cost-sharing reductions, Medicaid, CHIP, and the Basic Health Program, if applicable. . Under a Federally-facilitated Exchange, can a State retain authority over Medicaid eligibility determinations? 0 Under a State-based Exchange, can the Federal government perform activities related to advance payments of the premium tax credit and cost-sharing reductions, including the verification of employer-sponsored minimum essential coverage? Can the Federal government perform the eligibility process for exemptions from the individual responsibility requirement for State-based Exchanges? 133 Updated 1-31-17 2017--00233 Updated 1-31-17 A7: Section 155.305 of the proposed rule on Exchange Functions in the Individual Market: Eligibility Determinations; Exchange Standards for Employers (Exchange Eligibility NPRM available here) proposes that the Exchange will make eligibility determinations for advance payments of the premium tax credit, cost-sharing reductions, Medicaid, CHIP, and the Basic Health Program, where applicable, based on modi?ed adjusted gross income (MAGI). The Exchange Eligibility NPRM does not distinguish between a State-based Exchange and a Federally-facilitated Exchange in this regard. Based on comments to the Exchange Eligibility NPRM, however, we intend to modify this original proposal in the ?nal rule to permit additional options for determining eligibility under a State-based and Federally-facilitated Exchange. Federally Facilitated Exchange In response to comments to the Exchange Eligibility NPRM, we are planning to revise the options that are available for the responsibility for the determination of eligibility under a Federally-facilitated Exchange to include the following: 1. The Federally-facilitated Exchange will conduct initial assessments of applicants for Medicaid and CHIP eligibility based on MAGI, as part of the determination of eligibility for advance payments of the premium tax credit and cost-sharing reductions. However, the State Medicaid and CHIP agencies make ?nal Medicaid and CHIP determinations under this option. In order to ensure an optimal consumer experience, a State electing this option would agree to make these determinations consistent with general guidelines and the terms of an agreement established between the State and the Federally-facilitated Exchange to ensure that applicants are not required to submit redundant documentation and that timeliness standards are met. 2. Alternatively, if a State does not choose to retain Medicaid and CHIP eligibility determinations as set out in paragraph 1 above, the Federally-facilitated Exchange may determine Medicaid and CHIP eligibility using State eligibility rules and standards in conjunction with determining eligibility for advance payments of the premium tax credit and cost-sharing reductions. State-based Exchange Similarly, States that operate a State-based Exchange but do not wish to operate all eligibility functions as described in the Exchange Eligibility NPRM would have additional options under our intended revisions: 1. A State-based Exchange could be approved if it conducted all eligibility functions. 2. Alternatively, a State-based Exchange could be approved if it uses Federally- managed services to make determinations for advance payments of the premium tax credit, cost-sharing reductions and exemptions from the individual responsibility requirement. In all cases, a State could decide to have the Medicaid and CHIP agencies support the eligibility process by executing some or all functions under an agreement with the Exchange. Certi?cation as an Exchange would also require that procedures and systems are in place to ensure a simpli?ed, seamless consumer experience. In addition, for States that are interested in determining eligibility for all programs under the Affordable Care Act, we are exploring how the Federal government could manage services for 134 2017-?00234 veri?cation of employer-sponsored minimum essential coverage. Under these ?exible options, to ensure a strong consumer experience to applicants and enrollees and to minimize administrative burden and costs, it will be critical for States and the Federal government to work closely together. (State Exchange Implementation Questions and Answers (11/29/1 Q8: What data will IRS provide to support the eligibility verification process? A8: Section 6103(l)(21) of the Internal Revenue Code, as added by section 1414(a)(1) of the Affordable Care Act, permits the Secretary of the Treasury to disclose the following taxpayer information with taxpayer consent to support eligibility determinations for insurance affordability programs: taxpayer identity information with respect to such taxpayer, (ii) the ?ling status of such taxpayer, the number of individuals for whom a deduction is allowed under section 151 with respect to the taxpayer (including the taxpayer and the taxpayer?s spouse), (iv) the modi?ed adjusted gross income (as de?ned in section 368) of such taxpayer and each of the other individuals included under clause who are required to file a return of tax imposed by chapter 1 for the taxable year, such other information as prescribed by the Secretary by regulation to indicate whether the taxpayer is eligible for such credit or reduction (and the amount thereof), and (vi) the taxable year with respect to which the preceding information relates or, if applicable, the fact that such information is not available.? The IRS will provide modi?ed adjusted gross income (MAGI) for the parents or other head of household and for certain dependents who had enough income to have been required to ?le a tax return. Modi?ed adjusted gross income is the adjusted gross income shown on the Form 1040 with additional amounts added: any tax-exempt interest on State or local bonds, social security bene?ts that are excluded from gross income, and any amounts earned abroad that are othen/vise excluded from adjusted gross income. This information will be taken from the return that was last due to be filed. For example, during open enrollment in the last quarter of 2013, income information will be provided from 2012 income tax returns. The IRS will also provide information about the size of the household shown on the returns that were filed and coding to help the Exchange understand the information being provided and instances in which information may not be available. Where there has been a change in circumstance, the applicant will work with the Exchange to establish what changes should be re?ected in household income. Similarly, where there is no prior year tax return data on ?le, for example in the case of individuals with very low or no income who had not previously been required to ?le, the applicant will work with the Exchange to establish household income through alternate means. (State Exchange Implementation Questions and Answers (1 1/29/11)) 21. What will consumers be told if it appears they are not eligible for Medicaid, CHIP, or advance payments of premium tax credits? Updated 1-31-17 A: A qualified individual still will have the option to purchase a quali?ed health plan through the Exchange if he or she is not eligible for Medicaid. CHIP or an advance payment of a premium tax credit. As outlined in 45 C.F.R. section Exchanges will provide timely written notice to an applicant of any eligibility determination made by the Exchange.45 C.F.R. section 155.230(a) 135 2017--00235 provides further detail on the content of notices, including that notices contain contact information for available customer service resources and an explanation of appeal rights, if applicable. (FAQs on Exchanges, Market Reforms, Medicaid 12/10/12) 22. How will HHS help Exchanges with the eligibility process for exemptions from the shared responsibility payment for individuals? A: Section 1311(d)(4)(H) of the Affordable Care Act specifies that the Exchange will issue certificates of exemption from the shared responsibility payment described in section5000A of the Internal Revenue Code, which otherwise applies to individuals who do not maintain minimum essential coverage. In the ?State Exchange Implementation Questions and Answers" released on November 29, 2011, we indicated that a State-Based Exchange could either conduct this assessment itself or use a federally-managed service for exemptions from the shared responsibility payment. We included this option in the Exchange Blueprint. State-Based Exchanges can also choose to conduct this function independently. With this service, the Exchange will accept an application for an exemption, and then transfer the information contained on the application to HHS through a secure, electronic transaction. HHS will conduct relevant veri?cations and return an eligibility determination to the Exchange, which will then notify the individual who submitted the application. The Exchange and HHS will share responsibility for customer service. To the extent that an individual?s situation changes during the year, he or she would be required to submit an update to the Exchange, which will then transfer it to HHS to process. This con?guration limits the level of effort required on the part of the Exchange, while ensuring that the Exchange complies with the statutory direction to issue certificates of exemption. HHS will provide additional information regarding exemptions shortly, including technical speci?cations for the application and for the application transfer service. (FAQs on Exchanges, Market Reforms, and Medicaid (12/10/12)) 36. Will states still be required to convert their income counting methodology to Modified Adjusted Gross Income (MAGI) for purposes of determining eligibility regardless of whether they expand to the adult group? If so, how do states link the categorical eligibility criteria to the A: Yes, as required by law. Conversion to modi?ed adjusted gross income eligibility rules will apply to the nonelderly, nondisabled eligibility groups covered in each state, effective January 2014, without regard to whether a state expands coverage to the low-income adult group. The new modified adjusted gross income rules are aligned with the income rules that will be applied for determination of eligibility for premium tax credits and cost- sharing reductions through Exchanges; the application of modified adjusted gross income to Medicaid and CHIP will promote a simpli?ed, accurate, fair, and coordinated approach to enrollment for consumers. CMS has been working with states to move forward with implementation of the modi?ed adjusted gross income rules, and consolidation and simplification of Medicaid eligibility categories. (FAQs on Exchanges, Market Reforms, and Medicaid (12/10/12)) Q13: What notification will issuers receive when the FFE reduces or eliminates subsidy amounts? Will an 834 be sent? 1 36 Updated 1-31-17 2017--00236 (Enrollment March 8th and 11 th, 2013) A13: When the Exchange reduces or eliminates subsidy amounts for any reason, an ASC X12 834 transaction will be sent to the issuer containing the new information. also appears in the REG TAP FAQ Database as FAQ #300 10/2/13] Q1: Scenario - and decide to purchase an insurance policy together, but if they were to enroll in separate policies, they would be eligible for different cost sharing. If they purchase together, will they both have one SINGLE CSR or could each potentially have a different A1: In this scenario, if and apply for coverage in the Marketplace and would like to be enrolled in the same plan, they would be assigned to the most generous plan variation for which all members in the enrollment group are collectively eligible. For example, if is a member of a Federally recognized tribe and is eligible for a zero cost- sharing plan variation and is eligible for a 73% silver plan variation, if they enroll in the same plan they would both be collectively eligible for the 73% silver plan variation. However, if they chose to enroll in separate plans, they would both be assigned to what they are both individually eligible for. Please see of the HHS Notice of Bene?t and Payment Parameters for 2014; Final Rule published March 11, 2013. There will be one advance CSR payment amount for the entire enrollment group represented on the 834 at the subscriber level; there will be no individual level advance CSR payment amounts. (Enrollment and Payment Processing Webinar Series 02/27/13 updated 5/24/13) Q: Are CSRs available for the pediatric dental benefit? A: CSRs do not apply to stand-alone dental plans. If the pediatric dental bene?t is offered by a QHP, then CSRs do apply. See ?156.440(b) of the HHS Notice of Benefit and Payment Parameters for 2014; Final Rule published March 11, 2013. (REGTAP FAQ Database - FAQ #297 05/29/13) Q18: In one of the enrollment scenarios it talks about multiple tax filers who both qualify for APTC and CSR, and each of them have a child. The life partner has one child Updated 1-31-17 137 2017-?00237 and is listed as the responsible person for that child. Will the APTC and CSR amounts be combined and placed under the subscriber in this scenario? A18: Yes. If both partners are eligible for APTC, the amounts will be combined and placed under the subscriber in this scenario. (Enrollment FAQ #2 07/02/13) Q: Will Marketplaces be verifying the income of consumers as a part of the eligibility process for advance payments of the premium tax credit and cost-sharing reductions? Updated 1-31-17 A: Yes. According to 45 CFR Marketplaces will always use data from tax filings and Social Security data to verify household income information provided on an application, and in many cases, will also use current wage information that is available electronically. The multi-step process begins when an application ?ler applies for insurance affordability programs (including advance payments of the premium tax credit and cost-sharing reductions) through the Marketplace and af?rms or inputs their projected annual household income. The applicant?s inputted projected annual household income is then compared with information available from the Internal Revenue Service (IRS) and Social Security Administration (SSA). If the data submitted as part of the application cannot be veri?ed using IRS and SSA data, then the information is compared with wage information from employers provided by Equifax. If Equifax data does not substantiate the inputted information, the Marketplace will request an explanation or additional documentation to substantiate the applicant?s household Income. When documentation is requested, the Affordable Care Act and implementing regulations specify that if the applicant meets all other eligibility requirements, he or she will be provided with eligibility for advance payments of the premium tax credit and cost- sharing reductions based on the inputted projected annual household income for 90 days (which may be extended based on good faith), provided that the tax filer attests to the Marketplace that he or she understands that any advance payments of the premium tax credit paid on his or her behalf are subject to reconciliation. If documentation is requested and is not provided within the speci?ed timeframe, regulations specify that the Marketplace will base its eligibility determination on IRS and SSA data, unless IRS data is unavailable, in which case the Marketplace will discontinue any advance payments of the premium tax credit and cost-sharing reductions. For 2014 only, we recently indicated that HHS will exercise enforcement discretion such that a Marketplace may choose to request additional documentation from a statistically- significant sample of the group of individuals in only one speci?c situation: when the Marketplace has IRS data, the application ?ler inputs projected annual household income that is more than ten percent below IRS and SSA data, Equifax data is unavailable, and the individual does not provide a reasonable explanation for the inconsistency between the attestation and IRS and SSA data. In all other cases in which the data submitted by the individual cannot be veri?ed using IRS and SSA data or Equifax data, and the individual does not provide a reasonable explanation for any discrepancy identified between their attestation and electronic data, the Marketplace must request additional documentation. This includes, for example, all cases in which IRS data is not available for an individual, and the attestation to projected annual household income cannot be verified using Equifax data; and all cases in which there is both IRS data and Equifax data for an individual but the attestation to projected annual household income cannot be verified using that data. 138 2017--00238 We are clarifying that, for the Federally-facilitated Marketplace, CMS intends to set the initial size of the sample at 100 percent, such that everyone who is in the circumstance described above in which sampling may be used is asked to submit satisfactory documentation. Since publication of the ?nal rule, we have ascertained that there are suf?cient resources to ask every individual in this circumstance for such documentation with no exceptions. State-based Marketplaces may choose to use other sample sizes, provided that they are statistically significant for 2014. As described 45 CFR if satisfactory documentation is not submitted by the end of the resolution period, the Marketplace will determine eligibility based on the IRS and SSA data. We note that application ?lers must attest, under penalty of perjury, that they are not providing false or fraudulent information. In addition to the existing penalties for perjury, the Affordable Care Act applies penalties when an individual fails to provide correct information based on negligence or disregard of program rules, or knowingly and willfully provides false or fraudulent information. Moreover, the IRS will reconcile advance payments of the premium tax credit when consumers file their annual tax returns at the end of the year, and it will recoup overpayments and provide refunds when appropriate, subject to statutory limits. These safeguards all apply no matter which type of Marketplace is operating in a state. (CMS FAQs Health Insurance Marketplaces and Income Veri?cation 08/05/13) Q: How will the relationship between CMS and IRS work with A: In the individual market, the Exchange will make eligibility determinations for APTCs and HHS will pay APTCs to issuers on behalf of enrollees during the bene?t year. IRS will collect information from taxpayers and Exchanges in order to reconcile the APTCs against the ?nal premium tax credit amount, determined by IRS. (REGTAP FAQ Database - FAQ #295 10/2/13) Q: If an individual is eligible for a Cost-sharing Reduction (CSR) and not choosing a silver-level plan, do Issuer websites have to display the required CSR-eligibility notification in the same window of the plan selection or as a separate pop-up window? A: The issuer can provide the required CSR eligibility notification in the same window of the plan selection or as a separate pop up window. (REGTAP FAQ Database - FAQ 687 01/27/14) Q: What specific types of income W-2, Social Security, pensions) are factors for determining an individual's eligibility for Advance Payment of the Premium Tax Credit (APTC) or Cost Sharing Reduction (CSR) tax subsidies? A: The Marketplace will consider earned and unearned income when evaluating an individuals eligibility for subsidies, which include income such as Social Security, pensions and earned income from W-Zs. (REGTAP FAQ Database - FAQ #1175 003/31/14) Q: An Issuer has a fully subsidized member with a $100 premium and the full $100 is covered by an Advanced Payment Premium Tax Credit (APTC). If Federal subsidies cannot be used for abortion payments, will the Federally-facilitated Marketplace (FFM) 1 39 Updated 1-31-17 2017--00239 pay an Issuer $99 for the APTC and require an Issuer to collect $1 from the member, making the member's total premium equal $100? A: If an Issuer has a fully subsidized member with a $100 premium and the full $100 is covered by an Advanced Payment Premium Tax Credit (APTC), the Issuer cannot apply any portion of that Federal subsidy for an abortion payment. If permissible by an Issuer's State, the Issuer may opt to establish a separate allocation account for the collection of additional premium payments from a member who requires coverage for abortion services. However, an Issuer must comply with a State law that prohibits abortion coverage in Qualified Health Plans. (REGTAP FAQ Database - FAQ #22673 07/08/14) Q: Can you clarify 'affordability' for family coverage versus individual coverage, and how that relates to eligibility for the advance payments of the premium tax credit A: If an employee is eligible for employer sponsored coverage (ESC) that is ?affordable? and meets the ?minimum value" standard, then the employee is not eligible to receive APTC or cost-sharing reductions through the Marketplace. The same is true if an employee's spouse or dependent(s) are eligible for ESC through the employee that is affordable and meets the minimum value standard. To be deemed affordable for the employee or the employee's spouse or dependents, the employee's share of the annual premium must be less than 9.66% of annual household income for coverage year 2016. This calculated using the annual premium of the lowest-cost plan available to the employee only (not any spouse or dependents) that meets the minimum value standard. (REGTAP FAQ Database - FAQ #16092 05/24/16) Q: Can a consumer keep his or her premium tax credit (PTC) when also covered by Medicare? A: A consumer who is enrolled in Medicare is not eligible for advance payments of the premium tax credit (APTC) or PTC. The Internal Revenue Service (IRS) reporting process will show the IRS that a consumer enrolled in Medicare is also receiving APTC. That consumer may be required to pay back APTC received during the period he or she was dually enrolled, but that is ultimately the decision. (REGTAP FAQ Database - FAQ #16094 05/24/16) Q: If children are qualified for Medicaid or the Children's Health Insurance Program (CHIP), but their parents want them to enroll on the parents' quali?ed health plan (QHP), how do they do this online? A: If a child or an adult has been determined eligible for Medicaid or CHIP, they are generally not eligible to receive advance payments of the premium tax credit (APTC), but they are eligible to enroll in a QHP at full price. In this case -- in which a child is found eligible for Medicaid or CHIP, but the child's parents want to enroll him or her in a full- priced QHP -- the parents need to submit a separate application for their child in which they do not request ?nancial assistance, also called a non-?nancial assistance application. A separate application is required because the parents are receiving APTC. As an agent, you should remind them they would only be able to enroll their child in a QHP at full price when the child has been determined eligible for Medicaid or CHIP. (REGTAP FAQ Database - FAQ #16095 05/24/16) Q: What is the federal poverty level (FPL) range to qualify for the premium tax credit 140 Updated 1-31-17 2017--00240 The webinar slide indicated it is 100% to 400% of the FPL. Can you confirm that's accurate? A: Generally it is 100% to 400% of the FPL. However, individuals who are ineligible for Medicaid due to their immigration status may be eligible for APTC with annual household income below 100% FPL. (REGTAP FAQ Database - FAQ #16097 05/24/16) Q: What is the rare exception when subsidies are not available under 400% of the Federal Poverty Level A: In general, individuals with annual household income between 100% to 400% of the FPL meet the income eligibility requirements for advance payments of the premium tax credit (APTC). However, individuals who are ineligible for Medicaid due to their immigration status may be eligible for APTC with annual household income below 100% FPL. (REGTAP FAQ Database - FAQ #16099 05/24/16) Q: If a tax household takes care of and claims a consumer's elderly mother, is the mother's income included in the total family income reported to the Federally-facilitated Marketplaces even though she is on Medicare and does not need FFM coverage? A: In general, an application for Marketplace coverage should include the tax ?ler, spouse, and any tax dependents. These individuals should be included even if they aren't applying for health coverage. The Marketplace counts the estimated income of all members of the tax household who are required to ?le a tax return. For more information on who to include on your Marketplace application, visit and (REGTAP FAQ Database - FAQ #16101 05/24/16) Q: Will you clarify whether advance payments of the premium tax credit (APTC) are based on gross annual income or on adjusted gross annual income A: APTC is based on modi?ed adjusted gross income, or MAGI, which is de?ned as AGI, plus any tax-exempt Social Security Income, interest, or foreign income. Consumers should take their AGI from their tax return and use it to project income in the upcoming tax year, after adding any projected income in those three categories; tax exempt Social Security income, interest, and foreign income. (REGTAP FAQ Database - FAQ #16102 05/24/16) Q: When filling out the application at HealthCare.gov, how should we help a consumer define projected income, as we don't know at that time what the consumer's modified adjusted gross income (MAGI) will be? A: Advice on estimating expected income is available here: FAQ Database - FAQ #16103 05/24/16) Q: Does simply filing a 2014 federal income tax return automatically count as reconciling advance payments of the premium tax credit 141 Updated 1-31-17 2017-?00241 A: Tax ?lers must file their tax return with the Internal Revenue Service (IRS) Form 8962 to reconcile APTC. (REGTAP FAQ Database - FAQ #17678 09/30/16) Q: When were failure to reconcile (FTR) notices sent to consumers? A: FTR warning notices were sent in May 2016 letting affected consumers and members of their households know they were at risk of losing advance payments of the premium tax credit (APTC) because Internal Revenue Service (IRS) records indicated they did not have a 2014 federal income tax return on ?le. (REGTAP FAQ Database - FAQ #17679 09/30/16) Q: What if a consumer files his or her tax return without Form 8962? A: Tax ?lers must file their tax return with the IRS Form 8962 to reconcile advance payments of the premium tax credit (APTC). (REGTAP FAQ Database - FAQ #17686 09/30/16) 1. How do a rules about which family members may be covered together under a policy affect the determination? Updated 1-31-plan that supports the entire family on a single policy, or it may be a plan that requires the family to purchase multiple policies. For all states using the Federal platform for eligibility and enrollment (meaning Federally- facilitated Marketplaces, State Partnership Marketplaces, and State-based Marketplaces using the Federal Platform), the sum of rates from multiple policies generally equals the rate of a single policy, except for families with more than three covered children under age 21. Federal regulations at 45 CFR require that the rates for no more than three children under age 21 be taken into account in determining a total family premium in a single policy. Different plans have different business rules regarding the types of dependent relationships that can be placed on a single policy. For those plans that have relationship business rules that restrict the number of additional children under age 21 who can be placed on a single policy, the total family premium calculated will include the rates for covering all children on multiple policies. Note that almost all family plans allow children to enroll with their parents on a policy, although many do not allow siblings to enroll together without a parent. For example, consider a family which consists of four siblings age 0 to 20 seeking Marketplace coverage, and assume the following three silver plans are available in their zip code and county: - Plan A: does not allow sibling dependents, age 0 to 20 rate $25, total family premium $100 - Plan B: allows sibling dependents, age 0 to 20 rate $30, total family premium $90 - Plan C: allows sibling dependents, age 0 to 20 rate $40, total family premium $120 All four siblings would each need to be placed on their own policy if they enrolled in plan A, but all four would be able to enroll in a single policy for plans and that re?ects the 142 2017-?00242 cost of covering only three siblings (when age 0 to 20 siblings are placed on a single policy, no more than three of the siblings are rated). In the example above, the is plan A, with a $100 premium. (CMS FAQs: Second Lowest Cost Silver Plan Technical FAQs {12/16/16) 2. For states using the Federal platform for eligibility and enrollment, who is the subscriber for purposes of finding the The subscriber for purposes of finding the is the household contact the person who ?lls out the application) if he or she is eligible for an advance payment of premium tax credit (APTC) and seeking coverage. Othenivise, the subscriber is the oldest APTC eligible applicant if at least one APTC eligible family member is over age 20, or the youngest APTC eligible applicant if all APTC eligible applicants are age 0 to 20. The subscriber for purposes of determining the may differ from the subscriber identi?ed when a family selects a plan for enrollment. In determining the subscriber during enrollment, HealthCare.gov uses this same hierarchy but does not consider APTC eligibility. For example, consider a household with a taxpayer who is APTC ineligible because she can get affordable employer-sponsored coverage that provides minimum value, and dependents who are APTC eligible because they do not have access to the employer-sponsored plan. If the taxpayer applies for QHP coverage for herself and her dependents, she will be the subscriber when selecting plans for enrollment, but one of the dependents will be the subscriber when determining the When determining whether all relevant family members can enroll on a single policy, the Marketplace looks at each plan?s applicable business rules, which define which relationships are allowed on a single policy. All relationships are relative to the subscriber. Therefore, if a parent and four children are enrolling together and the parent is the household contact, the relevant relationship is ?child?, and Marketplace plans allow a child of the subscriber to be placed on the same policy. However, if the parent is not seeking coverage, or is not APTC-eligible for purposes of determination, one of the children will be the subscriber and the relevant relationship is ?sibling?, and many Marketplace plans do not allow siblings of the subscriber to be placed on the same policy. (CMS FAQs: Second Lowest Cost Silver Plan Technical FA 03 {12/16/16) 3. How are child-only and adult-only plans incorporated into the determination? Updated 1-31-17 Enrollment groups consist of all individuals enrolling in a single policy. Child-only plans are available to enrollment groups where all members are under age 21 and no dependent has a spouse, child, domestic partner, or parent relationship to the subscriber. Adult-only plans are available to enrollment groups where subscriber member is age 21 or over or enrollment groups where the subscriber is under age 21 and at least one dependent has a spouse, child, domestic partner, or parent relationship to the subscriber. Therefore, every enrollment group is eligible for either child-only plans or adult-only plans, but not both. Child-only and adult-only plans could be excluded in the determination, depending on the family makeup. Child-only plans will be excluded when the family includes individuals age 21 or older. Adult-only plans will be excluded if the family 143 2017-?00243 includes only individuals under age 21 with no spouse, child, domestic partner, or parent relationships. Adult-only plans will also be excluded if the family includes a dependent under age 21 who has a relationship to the subscriber that the adult-only plan does not allow. (CMS FAQs: Second Lowest Cost Silver Plan Technical FAQs {12/16/16) 4. At what geographic level is determined? Only plans that are available for sale in the subscriber?s zip code and county are included in the determination. Rating areas, de?ned in 45 CFR are collections of zip codes, counties, or metropolitan statistical areas and non-metropolitan statistical areas, as de?ned by the Of?ce of Management and Budget, in which each plan must have an identical premium for a given individual or family. Rating areas do not have to align with a plan?s service area, which de?nes where a plan is available for sale. If a plan?s service area does not cover an entire rating area, the plan is only included in the determination for families that reside in its service area. Once a plan is included in the determination, its premium is calculated using the rating area associated with the subscriber?s zip code and county. The rating areas for each state can be found at (CMS FAQs: Second Lowest Cost Silver Plan Technical FAQs (12/16/16) 5. If consumers meet the income, tax ?ling, and other coverage requirements for the premium tax credit, will they receive a premium tax credit (or advance payments)? Generally, yes. However, if a taxpayer's cost of the is equal to or less than the taxpayer?s expected contribution amount, the taxpayer?s premium tax credit (or advance payments) for the month is equal to This is true even if the taxpayer?s household income for the year is less than 400% of the Federal poverty level. The taxpayer?s expected contribution amount is the amount the taxpayer would have to pay toward the premium if the APTC-eligible members of the taxpayer?s household enrolled in the it is equal to the product of the applicable percentage and 1/12 of the taxpayer?s household income for the year. The applicable percentage is the percent of household income a taxpayer's household is required to contribute towards the cost of the The applicable percentage is higher for taxpayers with higher household incomes. The 2017 applicable percentages can be found at 18 RB/ar08.html . (CMS FAQs: Second Lowest Cost Silver Plan Technical FAQs {12/16/16) 6. How is essential health benefits (EHB) percent of premium used when determining Updated 1-31-17 Only the portion of the premium allocable to EHBs (the EHB premium) is considered when finding the and its premium. Silver plans are compared in terms of EHB premiums to determine which plan is the second lowest cost silver plan, and the premium tax credit is no greater than the difference between EHB premium of the and the taxpayer?s contribution amount. Some plans? premiums may exceed its EHB premiums, for example, because it provides services in addition to EHB, such as routine adult dental coverage. As a result, some families may have to pay more than the expected contribution amount to purchase the (CMS FAQs: Second Lowest Cost Silver Plan Technical FA 08 {12/16/16) 144 2017-?00244 7. At what point in time is the determined? 8. Can Updated 1-31-17 The is determined at the time of enrollment, and only plans that are available to the tax household are considered in the determination. As an example, a plan under an enrollment freeze, or in a ?suppressed" status, is only included in the determination for families to whom the plan is available, such as because they are renewing coverage in that plan. If the lowest cost silver plan or for a tax household becomes decertified or closed to new enrollment after a family enrolls, the for that tax household is not re-determined unless the tax household completes a new enrollment, such as during a Special Enrollment Period. Note that the eligibility determination notices generated upon application submission on HealthCare.gov include an amount of advance payments of the premium tax credit that is based on the plans available at the time of the application submission. The ?nal determination of advance payments of the premium tax credit takes place when applicants con?rm their plan selections and may differ from the amount displayed on the eligibility determination notice if the plan availability changes between when the application is submitted and when a plan selection is con?rmed. The premium of the determined at the time of enrollment is included on the 1095-A form consumers receive at the end of the year. If a consumer does not report a mid-year life change such as marriage, birth of a child, or a move to the Marketplace, the on the 1095-A may be incorrect, and the consumer will need to use the Marketplace tax tool to determine the premium. (CMS FAQs: Second Lowest Cost Silver Plan Technical FA 08 (12/16/16) I use the QHP landscape to determine You can use the landscape to find an estimate of the and the Marketplace Public Use Files (PUF) to ?nd a more precise estimate of the premium for an individual or family. The QHP landscape is a summary of the plan data and has a number of limitations, including that: - It does not include service area information at the zip code level. While most plans cover whole counties, a small number of plans cover only certain zip codes within a county. - It gives only one rate for each county. For states that define rating areas by three digit zip codes, a plan may have more than one rate for a county, depending on the zip code. Of the states using the Federal platform for eligibility and enrollment, Alaska and Nebraska are the only states that rate by three digit zip codes. Rating area definitions are available at - It does not include the rate for every age. While all plans should be following a state- speci?c or Federal age curve, the actual rates for a given age may vary depending on the issuer?s rounding methodology. - It does not include the business rules used for eligibility allowed relationships) and rating the number of children age 0 to 20 rated for various family types). 145 2017-?00245 The QHP landscape is available at and the Marketplace PUF at (CMS FAQs: Second Lowest Cost Silver Plan Technical FA Qs {12/16/16) CSR Plan Variations 027: For the zero cost sharing plan variation of a closed-panel HMO QHP, does the cost sharing for out-of-network services need to be eliminated? A27: A zero cost sharing plan variation, as defined at 45 CFR is a variation of a QHP with all cost sharing eliminated. However, cost sharing is de?ned at 45 CFR 155.20 to be any expenditure required by or on behalf of an enrollee with respect to Essential Health Bene?ts, including deductibles, coinsurance, copayments, or similar charges, but excluding premiums, balance billing amounts for non-network providers, and spending for non?covered services. Therefore, if the QHP is a closed- panel HMO that does not cover services furnished by a provider outside of the network cost sharing for services provided by an out-of-network provider is 100%), the spending, or cost sharing, for these non-covered services would not need to be eliminated for the zero cost sharing plan variation associated with this QHP, and should be entered as it would be for non-covered out-of-network services under the corresponding standard plan. For covered bene?ts that are not Essential Health Bene?ts, the coinsurance and copays must be the same as the associated standard plan (despite the template auto-populating them with 0's). For additional information, please consult the final HHS Notice of Bene?t and Payment Parameters, published March 11th 2013. (Plan Management Webinar QHP FAQ #3 04/11/13) Q: Do catastrophic plans need to have CSR plan variations (including the limited and zero cost sharing plan variations for American Indians/Alaska Natives)? A: CSRs and APTCs do not apply to catastrophic plans. See ?156.440(a) of the HHS Notice of Benefit and Payment Parameters for 2014; Final Rule. (REGTAP FAQ Database - FAQ #298 05/29/13) Clarifications to 2/27/14 Bulletin on Retroactive APTCs and CSRs for Exceptional Circumstances. Q: Does the February 27th bulletin apply to all Marketplaces or only State-based Marketplaces? Updated 1-31-17 A: While the concepts discussed in the February 27th bulletin apply to all individual market Marketplaces, the primary audiences for this guidance are State-based Marketplaces (SBMs) which, due to significant technical issues, have had dif?culty in providing timely eligibility determinations to individuals wishing to enroll in Quali?ed Health Plan (QHP) coverage through the Marketplace during open enrollment. The Federally-facilitated Marketplace (FFM) has already established a process for individuals that have experienced these types of exceptional circumstances while attempting to enroll in an FFM QHP. Guidance to issuers offering plans in the FFM on this process as included in a set of bulletins published by CMS on February 6, 2014. The February 6th 146 2017-?00246 bulletins provided detail on Enrollment and Termination Policies and Processes for the FFM and State Partnership Marketplace (SPM) Issuers. The February 27th bulletin does not apply to Small Business Health Options Programs (SHOPS). (CMS FAQ 03/14/14) Q: Are State-based Marketplaces required to implement the options discussed in the February 27th bulletin? A: No, SBMs are not required to implement either of the options discussed in the February 27th bulletin. SBMs that, due to technical dif?culties, have not been able to provide a timely eligibility determination or enrollment in a Quali?ed Health Plan (QHP) to individuals during open enrollment, have the option to establish retroactive coverage effective dates in either, or both, of the consumer coverage scenarios discussed in the bulletin. If an SBM chooses to establish retroactive coverage effective dates in either, or both, consumer situations, CMS will make advance payments of the premium tax credit (PTC) and cost sharing reductions (CSRs), as applicable, to the Marketplace QHP issuer on a retroactive basis based on the coverage effective date established by the Marketplace. As described in the bulletin, the QHP issuer will also be required to adjudicate or re-adjudicate, as applicable, the enrollee?s claims incurred during the retroactive period, and refund or credit to the enrollee any excess cost sharing or premium paid, and ensure the provision of refunds or credits of any excess payments made by or for the enrollee for covered bene?ts and services incurred during the retroactive coverage period. In electing to implement any of these options, a Marketplace must ensure it does not discriminate among issuers participating in the Marketplace, and is consistent in its treatment of issuers when applying effective date rules. The Marketplace must also treat enrollees in similar circumstances in a consistent manner and comply with 45 CFR 155.120(c) and 45 CFR (CMS FAQ 03/14/14) Q: Is the February 27th bulletin intended to apply to specific State-based Marketplaces, and if so, which? A: While some SBMs have experienced relatively more dif?culty than other SBMs in providing timely eligibility determinations and/or enrollments into QHPs, this guidance is applicable to all SBMs. Each SBM should consider the extent to which it has experienced (or is experiencing) technical dif?culties that prevent timely eligibility determinations and/or QHP enrollments by the SBM, and the nature of those technical difficulties. Each SBM must determine the extent to which the bulletin applies to its speci?c situation and, if applicable, how it wishes to implement retroactive coverage effective dates for the situations discussed in the bulletin. CMS does not intend to establish a formal process whereby SBMs request CMS approval to implement these options. CMS will work closely with, and provide consultation to, SBMs as they assess their individual situations and scope of their technical dif?culties, and as they make determinations on how they intend to implement these options should they choose to do so. (CMS FAQ 03/14/14) Q: When is the last date that a State-based Marketplace may retroactively enroll an individual in the Marketplace under the February 27th bulletin? A: Should an SBM elect to establish retroactive coverage effective dates for individuals in the exceptional circumstances discussed in the bulletin, the SBM must act no later 147 Updated 1-31-17 2017-?00247 than the last day prior to the start of the open enrollment period for plan year 2015 to establish retroactive coverage effective dates. It is expectation that the technical difficulties that prevent an SBM from providing a timely eligibility determination or enrollment into a QHP in the Marketplace in coverage year 2014 will be corrected by the time of the open enrollment period for coverage year 2015. Thus, an SBM must establish retroactive coverage effective dates for individuals in these exceptional circumstances by November 14, 2014. CMS will make advance payments of the premium tax credit (PTC) and cost sharing reductions (CSRs), as applicable, to the Marketplace QHP issuer on a retroactive basis based on the coverage effective date established by the Marketplace. (CMS FAQ 03/14/14) Q: If the QHP in which the individual was enrolled in outside of the Marketplace was not a silver metal level QHP, would the individual receive retroactive cost-sharing reductions upon being retroactively enrolled in the Marketplace? A: If the QHP in which an individual was enrolled in outside of the Marketplace was not a silver metal level QHP, the individual generally cannot receive retroactive cost-sharing reductions upon being retroactively enrolled in the Marketplace. However, special rules apply for eligible Indians. For non-Indians, if an individual was enrolled in a QHP outside of the Marketplace, and was later determined eligible to have enrolled in that QHP through the Marketplace, retroactive cost-sharing reductions would apply only to the a extent a cost-sharing reductions plan variation is available for that QHP. For example a non-Indian with household income at 200 percent of the FPL enrolled in a silver plan outside the Marketplace would be eligible for cost-sharing reductions under the 87 percent silver plan variation. If the QHP in which the individual was enrolled did not offer a cost- sharing reduction plan variation for which the individual was eligible (for example, because the QHP was not a silver metal level plan), retroactive cost-sharing reductions would not be available. For Indians, 45 CFR 156.420(b) requires a QHP issuer to submit a zero cost sharing plan and limited cost sharing plan variation for each of its health plans (at each level of coverage) an issuer offers, or intends to offer in the individual market on a Marketplace.3 Therefore, an Indian enrolled in a metal-level QHP outside the Marketplace would be eligible for retroactive cost-sharing reductions in a zero cost-sharing plan variation (if the QHP is offered as a zero cost-sharing plan variation) or limited cost-sharing plan variation of the metal-level QHP upon being determined eligible to enroll through the Marketplace in that plan variation. If an individual was enrolled in a QHP outside of the Marketplace, upon making an eligibility determination for the individual, the Marketplace will need to provide a special enrollment period (SEP) under 45 CFR or (9) to allow these individuals the opportunity to change QHPs prospectively. An individual determined by the Marketplace to be eligible for cost-sharing reductions may select, pursuant to that SEP, a QHP with a plan variation for which the individual is eligible in order to obtain cost-sharing reductions prospectively. (CMS FAQ 03/14/14) Q: Can an individual who enrolls outside of the Marketplace in a plan that is similar to a QHP later be determined eligible to have enrolled through the Marketplace? 148 Updated 1-31-17 2017--00248 A: In order for the Marketplace to deem an individual to have been enrolled in the QHP through the Marketplace retroactively, upon a determination of eligibility for coverage in the Marketplace for that individual, the plan offered outside of the Marketplace in which the individual is enrolled must be identical to the QHP offered through the Marketplace. (CMS FAQ 03/14/14) Q: What documentation standards, under the maintenance of records requirements in 45 CFR 156.480, apply for cost-sharing reductions for an item or service that has been furnished through referral from an Indian health program, including an urban Indian program, under contract health services? A: 45 CFR speci?es that issuers must provide cost-sharing reductions to eligible enrollees under 45 CFR 155.350(b) on any ?item or service that is an EHB furnished . . . through referral under contract health services.? 45 CFR 156.430 provides or payments to issuers for cost-sharing reductions. To document eligibility for reimbursement for cost-sharing reductions provided to an enrollee on an EHB provided through referral under contract health services, as de?ned in 25 U.S.C. 1603(5) and any implementing guidance, and to meet the standards set forth at 45 CFR 156.480, the issuer must retain documentation that includes the following information: 0 Identi?cation of the patient receiving the item or service (eg. name and date of birth); 0 The name and address of the provider delivering the item or service; 0 A description of the item or service furnished through referral under contract health services, including the date(s) the item or service was provided; and The name of the Indian health program issuing the referral under contract health services, contact information for the program, and the date of the referral. A copy of the referral. (We note that many of the required elements above may be contained in the referral itself, and recognize that often the referral will be obtained after the service has been provided.) (CMS FAQ: Cost-Sharing Reductions for Contract Health Services (05/09/14) ISSUER PAYMENTS Member Billing and Payment Q1: What happens when a cancellation occurs due to non-payment and the issuer receives the payment from the consumer after cancellation? Are issuers permitted to reinstate or will the enrollment need to come in again from A1: Issuers may choose to cancel coverage of any quali?ed individual who does not make timely payment of the initial premium. If the individual submits payment after the cancellation has occurred, the issuer cannot reinstate the individual. If the qualified individual is still in an enrollment period at the time the coverage is cancelled, he or she may go through the plan selection process again and may select the same or another QHP, on or before the end of the enrollment period. (Enrollment FAQ 04/24/13) Q4: Will issuers still send customers (consumers) premium invoices directly or will the Federal government collect premiums for individuals as well as SHOP business and send them to the health plan via the 820? 149 Updated 1-31-17 2017--00249 A4: In the ?rst year of the (2014), QHP issuers will be responsible for billing enrollees and employers to obtain required premium payments. The Federally-facilitated Exchange will not participate in the billing or collection of premiums. Beginning on or after January 1, 2015, the FF-SHOP will bill and collect premiums from the employer, and remit premiums to the appropriate issuers. The FF-SHOP will provide premium aggregation services to health plans via an electronic transaction, expected to be the ASC X12 Other Premium Payment 820 (Version 5010). (Enrollment FAQ 04/24/13; REG TAP FAQ Database - FAQ #155 04/24/13) 06: What are the requirements for how the (premium) payment is to be made (by check, credit card, etc.)? A6: There are no regulatory requirements for how enrollees are to make their premium payments eg. by paper, electronic or other means. However, in the April 2013 Letter to Issuers available on our website at: letter to issuers 04052013. p_df we state that QHP issuers should provide enrollees with information about how to make premium payments, and that they must be able to accept payment in ways that are not discriminatory. (Enrollment FAQ #1 04/24/13) Q13: In the individual Exchange, what details or data elements are issuers required to show on the premium billing invoice? A13: There are no regulatory requirements governing the content of an issuer?s premium billing invoice for enrollees of the individual exchange (Enrollment FAQ 04/24/13) 05: Are issuers required to allow individuals to make partial payments on the first premium, where the member is redirected to the issuer site once enrollment has been completed? Are issuers required to allow partial payments on subsequent payments following first premium? A5: Issuers may, but are not required to, allow individuals to make partial payments on the first month?s premium. However, prior to the effective date of coverage, if the enrollee does not ultimately make full payment for their applicable portion of the ?rst month's premium, the issuer must cancel coverage. An issuer may also accept partial payment for any subsequent month but if the enrollee does not make full payment of their applicable portion of all premiums due before the end of the applicable grace period, the Issuer must terminate coverage at?that?time? If an individual Is receiving APTC, he or she' Is only accountable for their portion of the premium for it to be considered a full payment. Therefore, if the individual has paid their share of the premium, the issuer may not wait until receiving the remainder from the federal government to maintain coverage. (Enrollment FAQ 04/24/13, revised in reissued Enrollment FAQ #1 09/04/13) Q: Are third party payors permitted to make premium payments to health insurance issuers for qualified health plans on behalf of enrolled individuals? 1 50 Updated 1-31-17 2017--00250 A: The Department of Health and Human Services (HHS) has broad authority to regulate the Federal and State Marketplaces section 1321(a) of the Affordable Care Act). It has been suggested that hospitals, other healthcare providers, and other commercial entities may be considering supporting premium payments and cost-sharing obligations with respect to quali?ed health plans purchased by patients in the Marketplaces. HHS has signi?cant concerns with this practice because it could skew the insurance risk pool and create an unlevel ?eld in the Marketplaces. HHS discourages this practice and encourages issuers to reject such third party payments. HHS intends to monitor this practice and to take appropriate action, if necessary. (CMS FAQs - Third Party Payment of Premiums for QHPs in the Marketplaces 11/04/13) Q: Can a provider, such as a hospital or a physician, pay a member's policy premium temporarily to assist the member in avoiding losing health insurance coverage? A: Please refer to the Third Party Payments of Premiums for Quali?ed Health Plans in the Marketplaces Guidance. (REGTAP FAQ Database - FAQ #815 02/20/14) Q1. Does the November 4, 2013 FAQ apply to QHP premium and cost sharing payments on behalf of QHP enrollees from Indian tribes, tribal organizations, urban Indian organizations, and state and federal government programs or grantees (such as the Ryan White Program)? A1. No. The November 4, 2013 FAQ does not apply to payments for premiums and cost sharing made on behalf of QHP enrollees by Indian tribes, tribal organizations, urban Indian organizations, and state and federal government programs or grantees (such as the Ryan White Program). QHP issuers and Marketplaces are encouraged to accept such payments. As CMS stated in its 2015 Draft Letter to Issuers on Federally-facilitated and State Partnership Exchanges pursuant to section 1312 of the Affordable Care Act, section 402 of the Indian Health Care Improvement Act, and 45 CFR a Marketplace may permit Indian tribes, tribal organizations, and urban Indian organizations to pay QHP premiums on behalf of members who are qualified individuals, subject to terms and conditions determined by the Marketplace. Indeed, Federal law specifically provides for this approach. In addition, guidance from the Health Resources Services Administration (HRSA) on the Ryan White Program specifically describes how grantees can use grant funds to pay premiums and cost sharing for eligible individuals enrolled in QHPs. (CMS FAQs - Third Party Payment of Premiums for QHPs in the Marketplaces 02/07/14) QZ. Does the November 4, 2013 FAQ apply to QHP premium and cost sharing payments on behalf of QHP enrollees from private, not-for-profit foundations? Updated 1-31-17 A2. No. The concerns addressed in the November 4, 2013 FAQ would not apply to payments from private, not-for-profit foundations if: they are described in Question 1, or if they are made on behalf of QHP enrollees who satisfy de?ned criteria that are based on ?nancial status and do not consider enrollees' health status. In situation 151 2017-?00251 CMS would expect that premium and any cost sharing payments cover the entire policy year. (CMS FA Qs - Third Party Payment of Premiums for QHPs in the Marketplaces 02/07/14) Q: Is the issuer option to set a premium payment threshold of 95% or more limited to the initial premium payment, or can it be applied to subsequent premium payments? A: Consistent with rating rules that must be standard and consistent, QHP issuers that choose to apply a payment threshold policy should apply them equally across all enrollees. Additionally, the policy may be applied to both the initial premium payment and/or any subsequent premium payments. When an enrollee has paid within the premium threshold but has not paid the full enrollee-responsible-portion of the premium, the enrollee still owes the balance. Should an enrollee's account fall below the threshold, it has become past-due and enrollees using Advance payments of the Premium Tax Credit (APTC) will be subject to the grace period for failure to pay premiums. (REGTAP FAQ Database - FAQ #636 01/09/14) Q: If an unpaid 2013 premium cannot impact a 2014 eligibility, can premiums for both 2013 and 2014 be billed on the same bill, assuming any payment goes first to the 2014 premium? A: A QHP issuer may not include non-Marketplace balances on an individual's Marketplace Quali?ed Health Plan balance. Unpaid balances from non-Marketplace plans cannot be considered in determining whether an enrollee has met the issuer's payment threshold. (REGTAP FAQ Database - FAQ #637 01/09/14) Q: Are Issuers required to accept prepaid debit card payments from all major card companies Visa, MasterCard, American Express, etc.)? A: As de?ned in 12 CFR ?235.2, we expect qualified health plan (QHP) issuers to accept all forms of pre-paid debit cards as legal tender for payment of plan premiums. This includes both commercial cards and those cards issued by government entities as payment for certain bene?t programs. Further, pursuant to 45 CFR the QHP issuer must present all payment method options equally for a quali?ed individual (Ql) to select his or her preferred payment method. We recommend that QHP issuers make available as many different credit/debit/check card companies as possible to members as valid forms of payment. We understand that your agreement with credit/debit/check card companies is such that there may only be certain brands of cards with whom you contract as acceptable for paying premiums. Additionally, ?Pre-paid' debit cards are also understood to be legal tenderjust as cash. (REGTAP FAQ Database - FAQ #639 01/09/14) Q: We are accepting prepaid debit cards using a pseudo DDA, initiating an ACH against the prepaid debit card using the routing and account number provided for the prepaid debit cardholder. If the card carrier blocks the debit transaction, have we completed our obligations? Certain prepaid debit card issuers do block these transactions. Updated 1-31-17 A: We would expect the issuer to follow their previously established practice for collecting premium payment. In the interest of the enrollee, we would expect you would 152 2017-?00252 employ robust means to contact the enrollee for premium payment issues. (REGTAP FAQ Database - FAQ #685 01/27/14) Q: Are members allowed to make multiple premium payments at one time? A: Yes, an enrollee does have the ability to make multiple premium payments at the Issuers discretion as long as the policy is applied equally across policy lines to all enrollees in the QHP. (REGTAP FAQ Database - FAQ #1172 003/31/14) Q: Are there any regulatory requirements governing the content of an Issuer's invoice for enrollees in the Individual Market? Do Issuers need to have Total Premium less Advance Payment of the Premium Tax Credit (APTC) amount on the invoices to members or just the amount that the members owe? A: CMS has not issued guidance on premium invoicing. Issuers may consult the draft Enrollment Operational Policy Guidance at OperationsPolicyandGuidance 5CR 1003 13.pdf (REGTAP FAQ Database - FAQ #2269 06/18/14) 834 Enrollment File/820 Payment Data Q5: What is the difference between PREAMT 9X on premium category and TOTRESAMT 9v on payment category? A5: Please see the Enrollment Transaction Companion Guide (834 - Version 5010). PRE AMT 1 is a member level amount that will be utilized for all members in an enrollment group in an individually rated state. It is the individual rate submitted by QHP issuers during QHP certification for the member that will sum to the total premium determined by the Marketplace for the enrollment group. TOT RES AMT is the amount owed by the enrollment group toward the total premium. This is a subscriber level amount for the entire enrollment group. (Enrollment and Payment Processing Webinar Series 02/27/13; REGTAP FAQ Database - FAQ #321 02/27/13) Q7: Will you be sending an enrollment transaction but no premium on What about premium tax subsidy? A7: Please see the Enrollment Transaction Companion Guide 834 (version 5010). The FFM will send an enrollment transaction which will include the premium amount due for each enrollment group. The FFM will not be aggregating enrollee premium payments for issuers. CMS will send a APTC payment for issuers for all con?rmed enrollments that are APTC eligible and enrolled. (Enrollment and Payment Processing Webinar Series 02/27/13; REG TAP FAQ Database - FAQ #322 02/27/13) Q12: If the consumer enrolls through the FFE, will the FFE collect the binder payment (the payment that binds the individual to the coverage)? If not, how will issuers be no??ed? A12: The FFE will not aggregate premiums for issuers in 2014. However, the FFE will generate an 834 enrollment transaction upon plan selection and send that initial enrollment transaction to the issuer to effectuate the enrollment and to collect the appropriate portion of the premium for which the individual is responsible. The 834 1 53 Updated 1-31-17 2017--00253 enrollment transaction will detail the enrollment information, including total premium amount, with a breakdown of the APTC amount and the remaining individual responsibility portion of the premium for the enrollment group. This will include a breakdown of the APTC amount and the remaining individual responsibility portion of the premium for the enrollment group. The issuer will be responsible for collecting the individual responsibility portion of the premium. This is depicted as the Total Responsibility Amount of the 2750 loop in the FFE 834 companion guide. (The companion guide can be found at (Plan Management Webinar QHP FAQ #1 04/08/13) 023: If subsidy payments will come to health plans via the 820, what about the remainder of the premium balance? A23: The 834 will contain the premium breakdown, it will show which entity should pay for which portion of the premium and the relevant effective dates. It will show the total premium, the Advanced Payment of Premium Tax Credit (APTC) amount, the amount that any other payers such as the state will pay, and what the member is responsible for at the subscriber level. Please see the 834 Companion Guide, available at v1.pdf, for more information. (Plan Management Webinar QHP FAQ #2 04/09/13) 06: Will we receive APTC and CSR at the Member level or at Subscriber level? Also, how would the Marketplace address the scenario where a person changes his/her APTC election during the year? A6: The APTC and CSR payment amounts will be at the subscriber level for the enrollment group. In a situation where an individual elects to change their actual APTC during the year, the FFM will generate an 834 change transaction which will be sent to the issuer with the new information. (Enrollment and Payment Processing Webinar Series 02/27/13; REG TAP FAQ Database - FAQ #29005/24/13) Q4. Prior to the proposed amendments to the SHOP program for the 2014 plan year, we understood that CMS would use the 5010 version (not HIX) for use in the SHOP. Since the FF-SHOP would not be providing premium activity to the Issuers, there will be no 820 activity other than for program-level payments. Will the Companion Guide be revised for the 2015 plan year when the employee choice model is implemented or would the 5010 version be used then? A4. CMS is evaluating how SHOP payments will be transmitted in 2015. Guidance will be released in 2014. (ASC X12 Exchange Related Payments (820) Implementation Guide 05/14/13) Q5. Request for clarification on how payments will be transmitted for child-only policies. Will the FFM transmit the Exchange Assigned Subscriber ID for the child subscriber, or will the FFM transmit the TIN or another identifier for the taxpayer/responsible person (example: parent of the child). A5. The Exchange Assigned Subscriber ID for child-only policies will be the child's Exchange Assigned Subscriber ID. (ASC X12 Exchange Related Payments (820) Implementation Guide 05/14/13) 1 54 Updated 1-31-17 2017--00254 QG. Will Issuers be able to tie the Risk Adjustment and Reinsurance credit/debits with the reports from the Edge Server for 3R's? A6. Issuers will have the information needed to tie credits debits to program reports (2300 Loop Ref 03: Exchange Report Document Control Number will be used to provide supporting documentation). Additional information about program reports will be shared in 2014. (ASC X12 Exchange Related Payments (820) Implementation Guide 05/14/13) Q7. Heath plans will need a way to "reconcile" the 820 information with CMS in the case that the information on the 820 doesn't match the funds sent via EFT from FMS and to address any other discrepancies between the 820 and 8345 as well as any other issues with the detailed payment information. A7. The enrollment reconciliation process is the primary method used to resolve discrepancies arising from 834 transactional processing, changes to enrollment data after the payment cycle begins). After enrollment discrepancies are resolved, payment adjustments will be shared on the next 820. A process will need to be established between CMS and Issuers to resolve any discrepancies in the payment or the 820. The process is not yet developed. CMS is exploring the use of a discrepancy report. Industry feedback on this approach is welcome. (ASC 12 Exchange Related Payments (820) Implementation Guide 05/14/13) Q10. Will APTC and or CSR refunds be shown in the next month?s 820 and deducted from the Funds Transfer? We are assuming health plans will not need to actually provide a separate refund? A10. Yes, when Issuers report enrollment terminations, CMS will process refunds of excess APTC and CSR payments and these adjustments will be reported on the 820. X12 Exchange Related Payments (820) Implementation Guide 05/14/13) Q11. For the APTC data field on the 820, is it a value at the subscriber level? A11. When an APTC payment is made, the RMR04 element amount in the 2300 Loop RMR segment is at the enrollment group level for a family, one APTC amount will be present in the RMRO4 element). (ASC X12 Exchange Related Payments (820) Implementation Guide 05/14/13) Q12. Will CMS conduct testing with QHP Issuers in all Marketplaces (SBMs, SPMs and FFMs) and all non QHP Issuers for the 3Rs information? A12. Yes, CMS will conduct testing with any Issuers or their designees receiving an 820 from CMS. (ASC X12 Exchange Related Payments (820) Implementation Guide 05/14/13) Q13. Will the 820 be issued on the 15th, or received on the 15th? Will there be a calendar for the expected dates for the effective year? More information needed. 1 55 Updated 1-31-17 2017--00255 A13. CMS will release further guidance related to timing and frequency of the 820. (ASC X12 Exchange Related Payments (820) Implementation Guide 05/14/13) Q14. Provide a definitive list of payment type codes along with the code format, structure and detail explanation of each code for the 2300 RMR Remittance Detail. This information is needed to develop backend systems of the Issuer. A14. CMS will expand the Exchange Payment Type Codes list and provide further clari?cations. (ASC X12 Exchange Related Payments (820) Implementation Guide 05/14/13) Q15. Add a section to address error handling between the FFM and Issuers. A15. CMS will be using the ASC X12 Standard Acknowledgement Reference Model for Syntax and Semantic note file error handling. The Application Advice level does not add much value when exchanging the Financial Transactions. (ASC X12 Exchange Related Payments (820) Implementation Guide 05/14/13) Q16. Plan translators may not be able to return acknowledgement files. Identify an alternate method to convey errors for Plans whose translators do not generate acknowledgements to test files other than a dummy test acknowledgement file. A16. Currently, there is no ability for the HUB to accept proprietary acknowledgements. (ASC X12 Exchange Related Payments (820) Implementation Guide 05/14/13) Q17. Revise the first sentence under ?Control Numbers? to ?The Marketplace is not establishing specific requirements for the ISA, GS and ST control numbers, other than a rule that at least one of the control numbers must increment from one day to the next or from one file to the next when multiple files are sent within one day.? A17. This language has been updated as suggested. (ASC 12 Exchange Related Payments (820) Implementation Guide 05/14/13) Q18. Revise the second sentence under ?Control Numbers? to ?However, since the ASC X12C 00501OX231 Implementation Acknowledgement for Health Care Insurance (999) transaction does not reflect the ISA control number, we strongly recommend that one or both of the GS and ST control numbers increment from day to day, or from one file to the next when multiple files are sent within one day.? A18. This language has been updated as suggested. (ASC 12 Exchange Related Payments (820) Implementation Guide 05/14/13) Q19. Revise the first bullet under ?Hub Processing Capabilities, The Hub can accept multiplez? to ?Files in one day.? A19. This language has been updated to read ?Physical Files in multiple submissions in one day". (ASC 12 Exchange Related Payments (820) Implementation Guide 05/14/13) Q20. Revise the lead in sentence under ?Hub Processing Capabilities, File Rejection Reasons:? to ?The entire file will be rejected in the following situations:? 1 56 Updated 1-31-1 7 2017--00256 A20. This language has been updated to read ?The entire logical structure contained within a physical submission will be rejected in the following situations.? (ASC X12 Exchange Related Payments (820) Implementation Guide 05/14/13) 021. Identify the value that will be sent in ISA11, e.g. While Section 4.1 Transmission Specifics indicates the FFM will not identify a requirement or preference for acknowledgement transactions, Issuers need to know what to expect on transactions from the FFM in terms of delimiters. A21. Delimiters are mutually agreed upon between Trading Partners and can be individually con?gured. (ASC 12 Exchange Related Payments (820) Implementation Guide 05/14/13) 022. Add TRN Reassociation Trace Number to the table and identify the relationship of the value in TRN02 to the EFT ACH to facilitate Issuers correctly reassociating the 820 remittance to the EFT payment. A22. If a payment is made, the TRN (Reassociation Trace Number) is a payer assigned reference number, to be passed through the EFT clearing system to the payment receiver. (ASC X12 Exchange Related Payments (820) Implementation Guide 05/14/13) 023. Please provide date of final transmission so that accounting decisions for QHP Issuers can be made to decide how to accurately reflect APTC amounts on individual billing statements. A23. CMS will release further guidance related to timing and frequency of the 820. (ASC X12 Exchange Related Payments (820) Implementation Guide 05/14/13) 024. Add a section to address the relationship and process timing between the enrollment data sent on the 834 and the payment remittance data sent on the 820. A24. CMS will address this topic in the future. (ASC X12 Exchange Related Payments (820) Implementation Guide 05/14/13) 025. Add a section to address the relationship and process timing between the payment remittance data sent on the 820 and the electronic funds transfer sent as an ACH transaction. A25. The 820 will be sent several days after the EFT ACH Transaction has occurred in order to allow CMS to include the EFT Trace number and EFT Effective Date on the 820. (ASC X12 Exchange Related Payments (820) Implementation Guide 05/14/13) 026. Provide the hours the Help Desk is staffed for Issuer support. A26. The help desk is available Monday through Friday to EST, and can be reached at 1-800-267-1515 or CMS FEPS@cms.hhs.qov. CMS will add Help Desk Hours to the Companion Guide. (ASC X12 Exchange Related Payments (820) Implementation Guide 05/14/13) 157 Updated 1-31-17 2017--00257 Q27. Add an appendix that will include examples in ASC X12 syntax format of FFM to Issuer transmissions. A27. CMS has added examples in ASCX12 syntax format to the Companion Guide. X12 Exchange Related Payments (820) Implementation Guide 05/14/13) Q: Will APTC and CSR payments be at the subscriber or the individual level? A: The APTC payment amount and the CSR advance payment amount on the 834 will be at the subscriber level for the enrollment group. (REGTAP FAQ Database - FAQ #292 05/29/13 Q: How will issuers receive information on subsidy amounts and cost-sharing reduction (CSR) plan variations? A: The 834 will indicate the plan variation or standard plan in which the enrollment group should be enrolled. This will be indicated by the QHP ID, which will include a 14-digit standard component ID with a 2-digit variation component. With this QHP ID, the issuer will know which CSR plan variation or standard plan to enroll the enrollment group. The advance CSR payment amount that will be paid to the issuer on behalf of that enrollment group per month will be included in the 2750 loop. The advance payment of the premium tax credit (APTC) amount for the enrollment group will also be captured in the 2750 oop. The 2-digit Variation Component has the following values and description: 00 - Non- Exchange variation 01 - Exchange variation (standard plan no CSR) 02 - Zero cost- sharing plan variation 03 - Limited cost-sharing plan variation 04 - 73% AV silver plan variation 05 - 87% AV silver plan variation 06 - 94% AV silver plan variation. The assigned Quali?ed Health Plan Identi?er is a concatenation of the 2. An example of both the Plan Id and Variant Component ID is as follows: 12345VA002002104 (REGTAP FAQ Database - FAQ #296 05/29/13) Q11: Where will adjustment reason codes be found on the HIX 820 premium payment report transaction? A11: The HIX 820 premium payment report transaction does not have a data ?eld for adjustment reason codes. The Centers for Medicare Medicaid Services (CMS) plans to issue a payment letter that will outline key adjustments made during the payment cycle. The 2300 Loop REFO3 ?Exchange-Related Report Type? element will provide report reference numbers. These referenced documents will provide additional information on manual adjustments. The format and method of distribution for these documents are still being evaluated and will be provided later in 2013. (Enrollment FAQ #2 07/02/13) Q: Given that pediatric dental claims are much different than medical claims does plan to revise the claim layout in order to reflect required fields and values associated with dental claims not currently captured in the medical claim layout? 1 58 Updated 1-31-17 2017--00258 A: Dental and vision claims included under major medical coverage will be accepted and, if submitted, must be submitted on the medical claim ?le. All dental and vision claims covered under major medical and submitted on the medical claim ?le require a valid diagnosis code. Claims without a valid diagnosis code cannot be submitted. CMS has conducted an analysis of the X12 formats for dental claims and our research suggests that the data elements we require on the medical claim ?le are available on the X12 dental claim ?le. (REGTAP FAQ Database - FAQ #521 12/03/13) Q: The recent Letter to Issuers released by CMS 3/1/2013 stated: Issuer must report current and accurate information on the status of qualified individual and enrollee premium payments. The QHP issuers will provide up-to-date information on the last premium payment date for every enrollee.? (Page 36). We are aware that the last payment data must be sent in the 834 Confirmation/ Effectuation file in the 2750 loop. Does this statement also mean that payment data also needs to be sent to the Marketplace on an ongoing basis for each premium payment? A: Yes, after the effectuation 834 transaction, the only way to capture this data would be by gathering it on the reconciliation snapshot ?le. (REGTAP FAQ Database - FAQ #624 01/09/14) Q: Horizon BCBS New Jersey would like to further discuss the establishment of cut-off dates for changes being incorporated into the following month's 820 file so the issuer can best reconcile financial systems and ensure that they are not reporting discrepancies multiple times when they are in fact queued up to be addressed in a subsequent months 820 file. A: CMS has posted a January payment process ?ow/time line and payment process FAQ's on the REGTAP library at Please refer to the REGTAP library for key dates relating to subsequent payment months. (REG TAP FAQ Database - #706 02/04/14) Q: Please provide information on the establishment of cut-off dates for changes being incorporated into the following month's 820 file, so issuers can best reconcile ?nancial systems and ensure there are not reporting discrepancies multiple times if a change is in queue to be addressed in a subsequent months 820 ?le. A: CMS has posted a January payment process ?ow/time line and payment process FAQ's on the REGTAP library at Please refer to the REGTAP library for key dates relating to subsequent payment months. (REGTAP FAQ Database - #707 02/04/14) Q: Will the HIX 820 include one Electronic Funds Transfer (EFT) trace number for the entire transaction, or unique EFT trace numbers for each subscriber? A: Each HIX 820 will include 1 EFT trace number. The Initial (Detailed) HIX 820 EFT Trace Number will be a unique trace number created by CMS for NON Payment Method Type Code HIX 8203. The Final (Summary) HIX 820 transaction will include one Treasury assigned EFT trace number for ACH Payment Method Type Code or a unique trace number created by CMS for NON Payment Method Type Code HIX 8203. The EFT 1 59 Updated 1-31-17 2017--00259 trace number is found in Table 1 of the HIX 820. (REGTAP FAQ Database - #708 02/04/14) Q: Under what circumstances is a TA1 Acknowledgement returned? A: CMS expects to receive a TA1 Acknowledgement for every outbound Interchange in which a (?nal) summary HIX 820 transaction set is sent. CMS expects to receive a 999 Acknowledgement for every functional group in every outbound final (summary) HIX 820 ?le sent. Since the initial (detailed) HIX 820 is optional, CMS does not require issuers to send TA1 or 999 acknowledgments. (REGTAP FAQ Database - #709 02/04/14) Q: Under What circumstances is a 999 Acknowledgement returned? A: CMS expects to receive a TA1 Acknowledgement for every outbound Interchange in which a (?nal) summary HIX 820 transaction set is sent. CMS expects to receive a 999 Acknowledgement for every functional group in every outbound final (summary) HIX 820 file sent. Since the initial (detailed) HIX 820 is optional, CMS does not require issuers to send TA1 or 999 acknowledgments. (REGTAP FAQ Database - #710 02/04/14) Q: What is the difference between the Summary and Detailed 820? A: The initial HIX 820 payment report will contain policy level payment-related information on Individual Marketplace APTC, CSR and FFM user fees as well as SHOP FFM user fees. The final payment report will contain the same policy level payment- related information, but will also include program-level payments and charges and the actual Treasury payment amount and EFT trace number. For more information, please see for the latest CMS HIX 820 Companion Guide and training documents. (REGTAP FAQ Database - #711 02/04/14) Q: Please con?rm that will send one 820 for the APTC, CSR, and User Fees that will provide detail for each category on the ACH wire transfer? A: The initial HIX 820 payment report will contain policy level payment-related information on Individual Marketplace APTC, CSR and FFM user fees as well as SHOP FFM user fees. The final payment report will contain the same policy level payment- related information, but will also include program-level payments and charges and the actual Treasury payment amount and EFT trace number. For more information, please see for the latest CMS HIX 820 Companion Guide and training documents. (REGTAP FAQ Database - #712 02/04/14) Q: Will the 820 ?le include State Based Marketplace (SBM) and the Federally-Facilitated Marketplace (FFM) data in one file? A: The initial HIX 820 payment report will contain policy level payment-related information on Individual Marketplace APTC, CSR and FFM user fees as well as SHOP FFM user fees. The final payment report will contain the same policy level payment- related information, but will also include program-level payments and charges and the actual Treasury payment amount and EFT trace number. For more information, please see for the latest CMS HIX 820 Companion Guide and training documents. (REGTAP FAQ Database - #713 02/04/14) Q: Will the Detailed HIX 820 match the Summary HIX 820? 160 Updated 1-31-17 2017--00260 A: The initial HIX 820 payment report will contain policy level payment-related information on Individual Marketplace APTC, CSR and FFM user fees as well as SHOP FFM user fees. The final payment report will contain the same policy level payment- related information, but will also include program-level payments and charges and the actual Treasury payment amount and EFT trace number. For more information, please see for the latest CMS HIX 820 Companion Guide and training documents. (REGTAP FAQ Database - #714 02/04/14) Q: Will the subscriber information in the 820 transaction be at the QHP level, since the QHP ID is included in the 2100 loop? A: All enrollment group (policy) level information for APTC, CSR, and FFM User Fees will be sent in the 2100 Loop including the subscriber name and associated identifiers. (REGTAP FAQ Database - #715 02/04/14) Q: Will the subscriber information in the 820 transaction be at the QHP level, since the QHP ID is included in the 2100 loop? A: All enrollment group (policy) level information for APTC, CSR, and FFM User Fees will be sent in the 2100 Loop including the subscriber name and associated identi?ers. (REGTAP FAQ Database - #716 02/04/14) Q: If subscriber information in the 820 transaction is at the QHP level, will subscriber records repeat for different plans in which they are enrolled health and dental)? A: All enrollment group (policy) level information for APTC, CSR, and FFM User Fees will be sent in the 2100 Loop including the subscriber name and associated identifiers. (REGTAP FAQ Database - #717 02/04/14) Q: Is plan information located in the 2100 Loop? A: All enrollment group (policy) level information for APTC, CSR, and FFM User Fees will be sent in the 2100 Loop including the subscriber name and associated identifiers. (REGTAP FAQ Database - #718 02/04/14) Q: Please confirm if the User Fee is based on the current enrollment and that it will not be pre-paid. A: FFM User Fees will be calculated each month based on current enrollments. Adjustments will be made for retroactive enrollments, terminations, changes and cancellations. (REGTAP FAQ Database - #719 02/04/14) Q: How will issuers receive FFM User Fee invoices and will there be an 820? A: FFM User Fees will be calculated each month based on current enrollments. Adjustments will be made for retroactive enrollments, terminations, changes and cancellations. (REGTAP FAQ Database - #720 02/04/14) Q: In the Companion Guide on page 17, Section 8 Examples in Scenario 1-Table 1, the decision to include this REF segment is under consideration, when will a final decision for this segment be made? 161 Updated 1-31-17 2017--00261 A: The HPID will not be included in the HIX 820 at this time. (REGTAP FAQ Database - #721 02/04/14) Q: Please clarify if the Contact Information in the Companion Guide for PROD support or only during the implementation? A: The XOC Contact Information is Telephone: 1-855-CMS-1515. Email: CMS FEPS@cms.hhs.qov. This will be the same contact for Test and PROD. (REGTAP FAQ Database - #722 02/04/14) Q: Under what circumstances (if any) will a carrier in a State-Based Marketplace (SBM) state be required to send an outbound 820? A: The CMS HIX 820 Companion Guide provides the supplemental instructions Issuers and SBMs will use when receiving HIX 820 transactions from CMS. For HIX 820 transactions between SBMs and their issuers, SBMs will work with their issuer community to establish their 820 procedures. CMS will not accept inbound 820$. (REGTAP FAQ Database - #724 02/04/14) Q: When will documentation on setup, testing, and overall 820 file exchange be made available to carriers in State-Based Marketplace (SBM) states? A: The CMS HIX 820 Companion Guide provides the supplemental instructions Issuers and SBMs will use when receiving HIX 820 transactions from CMS. For HIX 820 transactions between SBMs and their issuers, SBMs will work with their issuer community to establish their 820 procedures. CMS will not accept inbound 8205. (REGTAP FAQ Database - #725 02/04/14) Q: In the Companion Guide on page 16, there is a placeholder for 'Application to State- based Marketplaces.? Would it be possible for carriers to review this section before final publication of the Companion Guide and will carriers have an opportunity to comment on this section? A: The CMS HIX 820 Companion Guide provides the supplemental instructions Issuers and SBMs will use when receiving HIX 820 transactions from CMS. For HIX 820 transactions between SBMs and their issuers, SBMs will work with their issuer community to establish their 820 procedures. CMS will not accept inbound 8205. (REGTAP FAQ Database - #726 02/04/14) Q: Will CMS add a Payment Type Code for Premium or Premium Credit so Issuers can use the HIX 820 to send premium information to State-Based Marketplaces A: The CMS HIX 820 Companion Guide provides the supplemental instructions Issuers and SBMs will use when receiving HIX 820 transactions from CMS. For HIX 820 transactions between SBMs and their issuers, SBMs will work with their issuer community to establish their 820 procedures. CMS will not accept inbound 820$. (REGTAP FAQ Database - #727 02/04/14) Q: What are the dates for testing and production of the HIX 820 file? 162 Updated 1-31-17 2017--00262 A: The Centers for Medicare Medicaid Services (CMS) will provide additional information about the HIX 820 transaction testing and production process later in 2014. Visit for additional information. (REGTAP FAQ Database - #748 02/12/14) Q: Regarding Table 1 ASC X12 005010X306 Health Insurance Exchange Related Payments (820) Supplemental Instructions, Reference BPR04, will CMS be sending ACH or NON as a standard process? A: ACH will be sent when a payee is receiving an electronic funds transfer. NON will be sent for non-payments or information-only 8203. Please refer to the ASC X12 HIX 820 Implementation Guide for further guidance on Payment Method Types. (REGTAP FAQ Database - #731 02/07/14) Q: Regarding Table 1 ASC X12 005010X306 Health Insurance Exchange Related Payments (820) Supplemental Instructions, Loop 2100, Reference NM1 is the Individual Name the Subscriber Name or is this value adopted from the State Exchange? A: The NM1 will be the name of the subscriber for the enrollment group as reported on the FAQ Database - #732 02/07/14) Q: Regarding Table 1 ASC X12 005010X306 Health Insurance Exchange Related Payments (820) Supplemental Instructions, Loop 2100, REF Exchange Assigned Qualified Health Plan Identifier is the 14 or 16 digit QHP A: 2100 Loop REF 'Exchange Assigned Quali?ed Health Plan Identifier' is the 16-digit QHP ID. (REGTAP FAQ Database - #733 02/07/14) Q: For issuers who will be dealing with State Based Marketplaces, will they be receiving the CMS HIX 820 via the CMS Data Services Hub or the State Based Marketplace (who they will interact with for all other Marketplace transactions)? A: Issuers in State Based Marketplaces will receive the CMS HIX 820 via the CMS Data Services HUB. (REGTAP FAQ Database - #734 02/07/14) Q: Possible correction to Companion Guide, Section 8 Examples, Scenario 3 - APTC Adjustments on page 24. Jane Smith's APTC amount is listed as $500 in the table and on page 25, Table 2 sample for the APTC amount payment is and the text indicates that the APTC payment is $600. Should this be $500. A: The CMS HIX 820 Companion Guide has been updated to reflect this change. (REGTAP FAQ Database - #735 02/07/14) Q: When will CMS begin HIX 820 testing? A: CMS is in the process of developing the new issuer testing schedule and will reach out to issuers with more information regarding HIX 820 testing. (REGTAP FAQ Database - #854 02/25/14) Q: Where can issuers find the HIX 820 naming convention file? 163 Updated 1-31-1 7 2017--00263 A: The naming convention ?le can be found at naming-conventions (REGTAP FAQ Database - #855 02/25/14) Q: In the 834 file, how does CMS expect the Issuers to calculate the total premium amount? A: The premium amount total is the family rated total premium amount as determined by the Exchange. It is also the amount the QHP Issuer can expect to receive from all payment sources for the enrollment group. The premium amount total is sent in the 2750 loop of the 834. (REGTAP FAQ Database - #901 02/27/14) Q: When can issuers expect the CMS 820 Companion Guide to be published? A: CMS intends to release the SHOP Chapter of the CMS HIX 820 Companion Guide soon and it will be posted to REGTAP at that time with an e-mail announcement. (REGTAP FAQ Database - #1552 05/08/14) Q: Will the Payment Transaction (PTI) Identifier repeat after each RMR segment? A: Yes, the PTI will repeat after each RMR segment. For example: (REGTAP FAQ Database - FAQ #6054 10/22/14) Q: When will the Centers for Medicare Medicaid Services (CMS) release guidance relating to Enterprise File Transfer (EFT) onboarding for State Based Marketplaces (SBM) and SBM Issuers? A: Issuers can locate instructions and documentation regarding Electronic Data Interchange (EDI) Onboarding and the submission and receipt of materials via EFT in the presentation slides, Registration: Fundamentals Receipt of the ASC X12 HIX 820 (9/16/15)? and Payment Processing SBM Issuers EFT Onboarding available at in the Payments-Remittance Message (X12 HIX 820) section of the REGTAP Library. (REGTAP FAQ Database - FAQ #16849 09/09/16) Payments and Reconciliation - X12 HIX 820 Q4: This is a question about pro-ration. The subscriber, eligible for Advance Premium Tax Credits and/or Cost Sharing Reductions is cancelled mid-month due to death. The has already been paid to the issuer for the month. does the carrier have to refund the If yes, is the refund calculated on a pro-rated basis? Or is it refunded retro-actively to the beginning of the month? Does the policy apply to the Secondly, for the CSR, which will be reconciled annually, does the refund get 164 Updated 1-31-17 2017--00264 processed and paid throughout the year as events occur, or will it be part of the yearly reconciliation process that occurs after the calendar year and the claims run out period? A4: IRS just recently published proposed rulemaking on this topic. CMS is working with the IRS on the disposition of refunds for under various scenarios. We anticipate discussing this topic on an upcoming issuer engagement call. (Enrollment FAQ #3 07/03/13) Q: How will the maximum APTC vs. actual APTC work with Direct Enrollment? A: The maximum APTC is calculated by the Exchange and provided to the issuer for the individual plan selection process. The individual can choose their own plan and actual APTC amount on the issuer's website. The issuer must then provide the enrollment information to the Exchange so the Exchange can generate the 834. (REGTAP FAQ Database - FAQ #294 10/2/13) Q: If a consumer chooses a zero premium QHP by virtue of applying Advanced Premium Tax Credit (APTC) to 100% of the premium, will the Issuer receive payment from CMS if the issuer doesn't send an effectuation confirmation? A: Quali?ed health plan (QHP) issuers must send an effectuation transaction to CMS to effectuate the enrollment and receive payment regardless of the premium owed by the enrollee. (REGTAP FAQ Database - FAQ #645 01/09/14) Q: Are QHP issuers that choose to use the simplified methodology for cost-sharing reduction reconciliation (described in the Amendments to the HHS Notice of Benefit and Payment Parameters for 2014 Final Rule permitted to count both on and off-Marketplace members in a standard plan for purposes of determining whether the plan meets the credibility standard described in 45 CFR A: We clarify that QHP issuers that select the simplified methodology must count both on and off-Marketplace members of a standard plan (that is, enrollees in the standard plan that purchase the plan through the Marketplace or directly from the QHP Issuer) when determining whether the standard plan meets the criteria in any of subparagraphs (D) of 45 CFR If the standard plan meets the criteria in any of the subparagraphs (that is, it does not meet the minimum credibility standard), then the QHP issuer must calculate the amount that the enrollees in the plan variation would have paid under the standard plan without cost-sharing reductions using the actuarial value methodology, described in section (REGTAP FAQ Database - FAQ #492 11/20/13) Q. If a QHP issuer seeks to use the standard methodology for cost-sharing reduction reconciliation, but will not complete the necessary system upgrades prior to the start of the benefit year, can the QHP issuer notify HHS that it will use the simplified methodology, but then change their choice of methodologies mid-year once the system upgrades are complete? 165 Updated 1-31-17 2017--00265 A. We recognize that QHP issuers are working to make several modi?cations to their IT systems to be ready to participate in the Marketplaces. As a result, we will permit a QHP issuer to select the simplified methodology prior to the start of the 2014 bene?t year, and then change their selection to the standard methodology no later than July 15, 2014, by emailing CSRreview@cms.hhs.qov. Subject to 45 CFR an issuer must change its selection for all of its QHPs on a Marketplace (or none); the issuer may not make a different election for different QHPs. Similarly, if a QHP issuer merges with or acquires another issuer of QHPs, or acquires a QHP offered from another QHP issuer, as described in 45 CFR the methodology selected for the merging, acquired, or acquiring issuer (or for the acquired QHPs) may be switched to the standard methodology from the simpli?ed methodology no later than July 15, 2014. The same methodology must be selected for all of a merging, acquired, or acquiring issuer?s QHPs owned prior to the transaction (or for all of the QHPs acquired pursuant to the transaction). We note that if a QHP issuer changes its selection to the standard methodology after the start of the bene?t year, the QHP issuer must use the standard methodology to calculate the entire amount that enrollee(s) would have paid under the standard plan without cost- sharing reductions (not just the portion of the amount for the period of time after the QHP issuer changed its selection). (CMS FAQs - Choice of Methodology for CSR Reconciliation 102/13/13) Q: Is the CSR payment amount on the 834 at the member level and on the 820 at the policy level? A: The CSR payment amount identi?ed on the 834 will be calculated and reported on the 820 at the enrollment group (policy) level. (REGTAP FAQ Database #697 02/04/14) Q: Does CMS have a payment calendar and when can Issuers expect the first APTC payments? A: APTC and CSR payments will be made by Treasury to the banking information provided by the Issuer to CMS. For January coverage, Treasury will issue payments via electronic funds transfer (EFT) to SBM and FFM issuers between the 22nd and 24th of January. These payments are based on con?rmed enrollments received and successfully processed by CMS through December 16, 2013. (REGTAP FAQ Database - #702 02/04/14) Q: Is CMS sending the APTC and CSR payments directly to Qualified Health Plans A: APTC and CSR payments will be made by Treasury to the banking information provided by the Issuer to CMS. For January coverage, Treasury will issue payments via electronic funds transfer (EFT) to SBM and FFM issuers between the 22nd and 24th of January. These payments are based on con?rmed enrollments received and successfully processed by CMS through December 16, 2013. (REGTAP FAQ Database - #703 02/04/14) Q: Has a date been set by CMS to receive ACH payments? Updated 1-31-17 166 2017--00266 A: APTC and CSR payments will be made by Treasury to the banking information provided by the Issuer to CMS. For January coverage, Treasury will issue payments via electronic funds transfer (EFT) to SBM and FFM issuers between the 22nd and 24th of January. These payments are based on con?rmed enrollments received and successfully processed by CMS through December 16, 2013. (REGTAP FAQ Database - #705 02/04/14) Q: How will CSR payments be paid to Issuers? A: APTC and CSR payments will be made by Treasury to the banking information provided by the Issuer to CMS. For January coverage, Treasury will issue payments via electronic funds transfer (EFT) to SBM and FFM issuers between the 22nd and 24th of January. These payments are based on con?rmed enrollments received and successfully processed by CMS through December 16, 2013. (REGTAP FAQ Database - #699 02/04/14) Q: Will the process for CSR payments be different for State and Federal Marketplaces? A: APTC and CSR payments will be made by Treasury to the banking information provided by the Issuer to CMS. For January coverage, Treasury will issue payments via electronic funds transfer (EFT) to SBM and FFM issuers between the 22nd and 24th of January. These payments are based on con?rmed enrollments received and successfully processed by CMS through December 16, 2013. (REGTAP FAQ Database - #700 02/04/14) Q: What is the frequency of the CSR payments to Issuers and are billing required from the Issuer to collect A: APTC and CSR payments will be made by Treasury to the banking information provided by the Issuer to CMS. For January coverage, Treasury will issue payments via electronic funds transfer (EFT) to SBM and FFM issuers between the 22nd and 24th of January. These payments are based on con?rmed enrollments received and successfully processed by CMS through December 16, 2013. (REGTAP FAQ Database - #701 02/04/14) Q: Will actual payment of APTC be made to the Issuer prior to the month of coverage? A: APTC and CSR payments will be made by Treasury to the banking information provided by the Issuer to CMS. For January coverage, Treasury will issue payments via electronic funds transfer (EFT) to SBM and FFM issuers between the 22nd and 24th of January. These payments are based on con?rmed enrollments received and successfully processed by CMS through December 16, 2013. (REGTAP FAQ Database - #704 02/04/14) Q: Will CMS publish the scenarios for APTC retroactive adjustments in the near future? A: CMS plans to provide an Issuer call to discuss APTC retroactive adjustments. (REGTAP FAQ Database - #896 02/27/14) 167 Updated 1-31-17 2017--00267 Q: Will retroactive APTC adjustments only take place due to appeals? A: In addition to appeals, there are other scenarios, such as retroactive terminations, that could cause retroactive changes. Further guidance is forthcoming. (REGTAP FAQ Database - #895 02/27/14) Q: How will retroactive enrollment impact APTC, CSR and User Fees? A: Please refer to the CMS Bulletin to Marketplaces on Availability of Retroactive Advance Payments of the PTC and CSRs in 2014 Due to Exceptional Circumstances dated 2/27/14. (REGTAP FAQ Database - FAQ #1187 003/31/14) Q: Can you explain the process of Cost Share Reductions (CSR) from beginning to end? A: Sec. 1402 of the ACA requires Quali?ed Health Plan (QHP) Issuers to provide CSR to eligible low-income and Indian QHP enrollees and to offer plan variations that meet certain actuarial value and cost-sharing requirements. HHS will make advance payments to QHP Issuers to cover the cost of providing cost-sharing reductions offered under plan variations. CMS will reconcile advance CSR payments against actual CSR paid on behalf of enrollees at the end of the coverage year. For 2014, CMS will calculate a per member per month (PMPM) CSR advance payment rate for each silver plan variation and each zero cost-sharing plan variation. Issuers will receive the same amount for all CSR enrollees within a plan variation. For 2015, CMS will no longer calculate the advance PMPM amount for speci?c QHP IDs. Additionally, SBMs and FFM issuers will no longer review or validate advance CSR amounts. Instead, upon receiving a certified QHP enrollment, the SBM or Marketplace will calculate the CSR advance payment amount using a formula containing a CSR plan variation multiplier and the total premium amount of the enrollment group. Visit REGTAP at for more information on changes to the CSR advance payment calculation for 2015. (REGTAP FAQ Database - #1647 05/21/14) Q: What is the deadline for Qualified Health Plan issuers to submit cost-sharing reduction reconciliation data to Updated 1-31-17 A: Quali?ed Health Plan (QHP) issuers should submit cost-sharing reduction amounts provided to HHS by April 30, 2015 for the 2014 year. QHP issuers are required to submit reconciliation data under CFR In the 2014 Payment Notice we said we expected issuers to submit actual amounts of cost sharing provided through the cost-sharing reduction reconciliation process after the end of the benefit year. We are establishing an April 30 deadline for submission of CSR reconciliation data to be consistent with the data submission deadline previously established in CFR 153.730 for the risk adjustment and reinsurance programs. We anticipate providing issuers with a report on cost- sharing reduction reconciliation payments and charges for each bene?t year by June 30, when HHS also 168 2017--00268 expects to notify issuers of risk adjustment and reinsurance payments due and risk adjustment charges owed for the applicable benefit year. The claims run-out data for 2014 is March 31, 2015. Issuers will be reimbursed for 2014 cost- sharing reductions provided but not included in 2014 reconciliation in the 2015 year?s reconciliation process. For reconciliation of such claims, issuers would need to recalculate and restate 2014 claims. We will provide further guidance on this process at a later date. (REG TAP FA Qs Data Submission for CSR Reconciliation 10/02/14) Q: Can issuers count members enrolled after January 2014 when estimating whether a standard plan meets the credibility threshold required for the cost-sharing reductions reconciliation simplified methodology? A: Yes. A qualified health plan issuer may count members enrolled after January 2014 toward the 12,000-member month credibility threshold required for the simpli?ed method of cost-sharing reconciliation, as long as the members were in the plan for the entire bene?t year. Because of 2014 enrollment delays, we will consider this standard met if at least 12,000 member months are accumulated for enrollees, each of whom were in the plan beginning no later than March 31, 2014 until the end of the bene?t year on December 31, 2014. The CSR reconciliation simplified methodology provided in 45 CFR allows issuers to develop a set of effective cost-sharing parameters based on the average experience of enrollees in a standard planminimum of 12,000 member months per bene?t year in the standard plan to establish a credible claims data base on which to measure cost-sharing parameters. In HHS guidance issued March 11, 2014, ?Cost-Sharing Reductions Simplified Methodology Updated Examples," we interpreted adequate enrollment to be at least 1,000 enrollees, enrolled in the standard plan for the entire bene?t year. We stated that policies that only cover a portion of the bene?t year (either due to a mid-year special enrollment period, or a mid-year termination or reassignment,) should not be included. We did not intend to exclude those policies that because of technology challenges were accepted under special circumstances in January, February, and March 2014. In such circumstances, an issuer could have more than 1,000 enrollees per month, for a total of 12,000 member months during the year. Therefore, issuers that meet the credibility standard of at least 12,000 member months total, based on enrollees each of whom were in the plan beginning no later than March 31, 2014, until the end of the bene?t year on December 31, 2014, and who selected the simpli?ed methodology may, but are not required to, use the simpli?ed methodology described at 45 CFR Issuers that selected the simplified methodology but do not meet the foregoing 12,000-member month credibility standard must use the Actuarial Value simplified methodology described at 45 CFR 156.430 (REGTAP FA Qs Calculation of member months for the Cost-Sharing Reductions (CSRs) Reconciliation simplified methodology (11/21/14) Q: In guidance posted for issuers on February 13, 2015, HHS extended until April 30, 2016, the deadline for issuers to decide whether to use the standard methodology to reconcile 2014 benefit year cost-sharing reductions. May issuers make a similar election at that time for the 2015 benefit year? Updated 1-31-17 A: Yes. Although issuers must notify HHS of their choice of methodology for the 2015 169 2017--00269 bene?t year by March 31, 2015, under our recent guidance, issuers that previously selected the simpli?ed methodology may switch to the standard methodology up until the deadline for submitting cost-sharing reduction reconciliation data on April 30, 2016. As we noted in that guidance, issuers that previously selected the standard methodology may not switch back to the simplified methodology. (REGTAP FAQ Database - FAQ #9341 03/16/15) Q: HHS said issuers must notify HHS of the methodology they will use for the 2015 bene?t year by March 31, 2015. May the issuer elect to use the simplified methodology for the 2015 benefit year, but then use the standard methodology for 2014? A: No. Under 45 CFR 156.430 a QHP issuer may not select the simpli?ed methodology for a bene?t year if the QHP issuer did not select the simpli?ed methodology for the prior benefit year. (REGTAP FAQ Database - FAQ #9342 03/16/15) Q: Can issuers count members enrolled after February 15, 2015 when estimating whether a standard plan meets the credibility threshold required for the cost-sharing reduction reconciliation simplified methodology? A: Issuers using the simplified methodology for the 2015 bene?t year must have the equivalent of 12,000 member months in the standard plan, on or off the Exchange, or a particular subset of the standard plan, if applicable, for the entire bene?t year. For 2015, we will consider this standard met if at least 12,000 member months are accumulated for enrollees, each of whom applied to the plan no later than February 22, 2015 and remained in the plan until the end of the benefit year on December 31, 2015. This time period allows issuers to consider all those people who applied by the February 15, 2015 open enrollment deadline, but whose coverage may not have been effectuated until after February 15, 2015, postponing their start date until April 1, 2015, as long as the members were in the plan for the entire bene?t year. This also allows issuers to include members who received a special enrollment period allowing them to enroll through February 22, 2015, because Exchange issues prevented them from ?ling an application by February 15, 2015, with the result that their coverage start date was also postponed until April 1, 2015. Issuers that selected the simplified methodology but do not meet the foregoing 12,000- member month credibility standard must use the Actuarial Value simpli?ed methodology described at 45 CFR 156.430 (FAQs on CSR Reconciliation Simplified Methodology Member Month Credibility Threshold 04/02/15; also listed in REGTAP FAQ Database - FAQ #9485 04/03/15) Q: What is the credibility threshold that issuers must meet to reconcile cost-sharing reductions under the simplified methodology for the 2014 benefit year? A: Guidelines for meeting the member month threshold for the simplified methodology in the 2014 bene?t year have not changed. Issuers should assess credible enrollments using deadlines in the following guidance: FAQ CSRRecon SCR 01131 1 70 Updated 1-31-17 2017--00270 5.9df (FA OS on CSR Reconciliation Simpli?ed Methodology Member Month Credibility Threshold 04/02/15; also listed in REG TAP FAQ Database - FAQ #9486 04/03/15) Q: Can issuers count members enrolled after February 15, 2015 when estimating whether a standard plan meets the credibility threshold required for the cost-sharing reduction reconciliation simpli?ed methodology? A: Issuers using the simplified methodology for the 2015 bene?t year must have the equivalent of 12,000 member months in the standard plan, on or off the Exchange, or a particular subset of the standard plan, if applicable, for the entire bene?t year. For 2015, we will consider this standard met if at least 12,000 member months are accumulated for enrollees, each of whom applied to the plan no later than February 22, 2015 and remained in the plan until the end of the benefit year on December 31, 2015. This time period allows issuers to consider all those people who applied by the February 15, 2015 open enrollment deadline, but whose coverage may not have been effectuated until after February 15, 2015, postponing their start date until April 1, 2015, as long as the members were in the plan for the entire bene?t year. This also allows issuers to include members who received a special enrollment period allowing them to enroll through February 22, 2015, because Exchange issues prevented them from ?ling an application by February 15, 2015, with the result that their coverage start date was also postponed until April 1, 2015. Issuers that selected the simplified methodology but do not meet the foregoing 12,000- member month credibility standard must use the Actuarial Value simpli?ed methodology described at 45 CFR 156.430 (REGTAP FAQ Database - FAQ #9485 04/03/15) Q: What is the credibility threshold that issuers must meet to reconcile cost-sharing reductions under the simplified methodology for the 2014 benefit year? A: Guidelines for meeting the member month threshold for the simpli?ed methodology in the 2014 bene?t year have not changed. Issuers should assess credible enrollments using deadlines in the following guidance: FAQ CSRRecon 5CR O1 FAQ Database - FAQ #9486 04/03/15) Q: What is the transaction identi?cation name for the Centers for Medicare Medicaid Services (CMS) Health Insurance and Premium Stabilization Programs Payment Form? Updated 1-31-17 A: The transaction name for both the Health Insurance Marketplace and Premium Stabilization Programs (Advanced Payments of Premium Tax Credit Cost- sharing Reduction User Fee), and the Transitional Reinsurance Program is the same: US DEPT HHS CMS. The transactions are uniquely identi?ed by their 'Agency Location Codes', which are different for each program: - Marketplace and Premium Stabilization Agency Location Code: 7505008014 - Transitional Reinsurance Agency Location Code: 7505008015 (REGTAP FAQ Database - FAQ #10792 05/28/15) 171 2017-?00271 Q: Will Dunning Letters contain invoice amounts for all programs (Advanced Payments of the Premium Tax Credit Cost-sharing Reductions and User Fees) in one (1) Dunning Letter, or will Issuers receive separate Dunning Letters for each program? A: CMS will send a separate Dunning Letter for each program for which an insurance company owes a balance. (REGTAP FAQ Database - FAQ #10793 05/28/15) Q: Why are the Centers for Medicare Medicaid Services (CMS) invoicing Issuers rather than netting User Fees and subsidy overpayment against subsidy payments to Issuers? A: The Department of Health and Human Services (HHS) nets Federally-facilitated Marketplace (FFM) User Fee amounts from Advanced Payment of the Premium Tax Credit (APTC) and/or Cost-sharing Reductions (CSR) payments. If after netting there is a remaining balance or if no program payments were available to offset, Issuers will be invoiced for the remaining balance. (REGTAP FAQ Database - FAQ #10794 05/28/15) Q: Can the Centers for Medicare Medicaid Services (CMS) explain when an Issuer will receive a Dunning Letter for Advanced Payments of the Premium Tax Credit (APTCs) or Cost-sharing Reductions A: Issuers will receive an Initial Demand Letter (Invoice) if an Issuer owes FFM user fees that are not fully offset from APTC and CSR payments; or an Issuer received an overpayment of APTC and/or CSR funds based on restated data in a subsequent month's Enrollment Payment Data Workbook. (REGTAP FAQ Database - FAQ #10795 05/28/15) Q: If a consumer has received Advanced Payments of the Premium Tax Credit (APTC) because income was assumed to be 100% of the Federal Poverty Level (FPL) during enrollment, does the Centers for Medicare Medicaid Services (CMS) require the APTC be repaid if the consumer's actual income is less than the A: Issuer and State Based Marketplace (SBM) submitters are required to report current data as of the 15th of the month for enrollments effective on the 1st of the following month. For example, when reporting for the April cycle, submitters include enrollment data known through March 15th that is effective on April 1st. In this example, suppose the submitter reports an APTC amount for this member on the April tab of the submission. If the Issuer learns that the APTC amount should not have been reported, adjustments must be reported in a subsequent payment cycle. For example, during the May cycle the submitter would remove this amount from their reporting on the April restatement tab. In this way, CMS adjusts for the overpayment that was made during the April cycle. If amounts due exceed scheduled payments at the Payee Group level, CMS will invoice the issuer. (REGTAP FAQ Database - FAQ #10796 05/28/15) Q: Can CMS give issuers who pay providers under a capitated or delegated model some flexibility similar to what CMS has previously recognized in the reinsurance context and as alluded to in the 2014 Notice of Benefit and Payment Parameters, with regard to reporting data for CSR reporting purposes? 1 72 Updated 1-31-17 2017-?00272 A: Issuers that pay their providers under a capitated payment model must provide reductions in cost sharing to enrollees in cost sharing plan variations. Issuers, no matter the model for paying providers, must track and report those cost-sharing reductions in accordance with CMS's regulations. We note that the CSR Reconciliation simpli?ed methodology provides at CFR 156.430 for a simpli?ed calculation for plans in which 80 percent or more of costs are not subject to a deductible. (REGTAP FAQ Database - FAQ #11018 06/18/15) Q: capitation payment to the provider varies by plan design, specifically, member co-pay amount. The higher the co-pay the provider collects from the member visit, the lower capitation he gets from the plan. Is it correct that the CSR reconciliation methodology permits issuers to recoup only the difference in co-pays? A: Yes. Plans, including capitated plans, may only recoup the difference between what an enrollee paid in cost sharing for the plan variation and what he or she would have paid in cost sharing for the same services in the standard plan. (REGTAP FAQ Database - FAQ #11019 06/18/15) Q: What is the difference between policy-level and program-level information in the HIX 820 transaction? A: Policy-level information on the HIX 820 transaction refers to the 2100 loop where Issuers will ?nd subscriber information such as names and policy identifiers. Program- Ievel information is the 2300 which will indicate the program and the total payment. (REGTAP FAQ Database - FAQ #11212 07/01/15) Q: If a Payee has a net negative balance will the Payee receive a HIX 820 transaction? A: Payees with a net negative balance will not receive a HIX 820 transaction. Those Payees will receive Dunning Letters for amounts owed. (REGTAP FAQ Database - FAQ #11470 08/12/15) Q: Will the Centers for Medicare Medicaid Services (CMS) allow Issuers to submit additional Cost-sharing Reduction (CSR) Reconciliation data in subsequent benefit years? For example, will CMS allow Issuers to submit additional 2015 CSR Reconciliation data with 2016 or 2017 submissions? A: CMS expects that all claims from the 2014 bene?t year will be included in 2014 benefit year data submitted for CSR reconciliation on April 30, 2016. For the 2015 bene?t year, claims incurred during 2015 but which did not result in a ?nal payment by the issuer by the data submission deadline of April 30, 2016, may be submitted in the following reconciliation cycle, on April 30, 2017. CMS intends to provide guidance closer to the 2017 submission date on the process for reconciling 2015 bene?t year claims paid after April 30, 2016. (REGTAP FAQ Database - FAQ #11651 08/22/15) Q: What is a policy-based payment? A: Policy-based Payments are payment amounts that are calculated using effectuated subscriber-level data, which are then aggregated and paid out to Issuers at the policy level. Currently, the Centers for Medicare Medicaid Services (CMS) uses a Manual Payment Process using enrollment and payment data provided by Issuers and certain 1 73 Updated 1-31-17 2017--00273 State Based Marketplaces (SBMs) on behalf of their Issuers at the plan-level (16-digit Quali?ed Health Plan level). (REGTAP FAQ Database - FAQ #11867 08/24/15) Q: Will there be one (1) HIX 820 per Payee ID or one (1) per HIOS A: In most cases, one HIX 820 will be provided to each Payee ID per month and include all the Qualified Health Plans (QHPs) that correspond to that Payee. There are two (2) situations where a Payee would receive more than one (1) HIX 820 in a month: 1) if the total payment is $100 million or more, 2) if the total number of ENT loops in the HIX 820 are one million or more. (REGTAP FAQ Database - FAQ #11868 08/24/15) Q: Will 2015 data retroactivity be handled via the HIX 820 or through the current Manual Payment Process? A: 2015 retroactivity will be handled by the Marketplace Payment Team via the current Manual Payment Process. Policy-level payments will only apply to 2016 effectuated enrollments. However, payees will receive a program-level loop on the HIX 820 for their 2015 Advanced Payments of Premium Tax Credits (APTCs), Cost-Sharing Reductions (CSRs) and User Fee restated amounts. For a detailed example, please see 2.orq/00501 TAP FAQ Database - FAQ #11869 08/24/15) Q: Will HIX 820 files be generated for the payment months from January 2014 - December 2015? A: No, the HIX 820 will only apply to effectuated enrollments beginning in January 2016. (REGTAP FAQ Database - FAQ #11870 08/24/15) Q: If there are retroactive adjustments or retroactive payments spanning multiple months, will there be multiple loops for each month range or will the payment/adjustment be combined and the date range span the total appropriate coverage period? A: For retroactive adjustments that span multiple months, HIX 820 transactions will contain multiple loops, each corresponding to a coverage period within the same month. For example, if an Issuer has someone enroll in March that corresponds back to January, the HIX 820 for April will contain a separate loop for each coverage month January, February, March and April for that subscriber. (REGTAP FAQ Database - FAQ #11871 08/24/15) Q: Will the HIX 820 be used for Reinsurance, Risk Adjustment, and Risk Corridors (3Rs) transactions? A: Beginning in January 2016, all payments and charges going forward (including 3R3) will be re?ected on the HIX 820. For 2015, 3R5 program payments will be reflected on the Manual Process Payment Report. Training on this preliminary payment report was provided on July 29, 2015. Please refer to REGTAP for this presentation. Issuers may also refer to REGTAP for updates regarding future trainings. (REGTAP FAQ Database - FAQ #11872 08/24/15) Q: Will the Exchange Assigned Subscriber ID be sent on the HIX 820? A: Yes, the Exchange Assigned Subscriber ID will be sent on the HIX 820. (REGTAP FAQ Database - FAQ #11873 08/24/15) 1 74 Updated 1-31-17 2017-?00274 Q: When will the 820 will be available for use? A: CMS plans to implement the HIX 820 in January 2016. (REGTAP FAQ Database - FAQ #11874 08/24/15) Q: Will the Automated Clearing House (ACH) segment in the HIX 820 transaction reflect total payments and adjustments from the restatement of months in the 2015 and 2016 Plan Years? A: Beginning in January 2016, the HIX 820 transaction will re?ect policy-level details for the January coverage month as well as program-level information for any 2015 restatements that correspond to the January 2016 payment. The preliminary payment report will provide summary information of program-level information related to the total payment. It will also contain policy-level information including subscriber-level details. Additional training on this topic will be provided later in 2015. Issuers may refer to REGTAP for updates regarding future trainings. (REGTAP FAQ Database - FAQ #11875 08/24/15) Q: To what extent will the HIX 820 be similar to the versions proposed in 2013 and 2014? A: Changes to the HIX 820 have been logged in the revised Companion Guide, which has been posted on and The Centers for Medicare Medicaid Services (CMS) will eliminate and no longer send the initial (detailed) HIX 820. In addition, CMS will no longer send the Issuer Assigned Employer Group ID in the HIX 820. CMS has also eliminated the DEBTADJ Payment Type Code, removed the Report Type Code and added the RAD Payment Type Code. Please refer to the April 29, 2015 Financial Management Policy-based Payments Overview and HIX 820 Companion Guide Updates training slides at in the REGTAP Library for an outline of major changes. (REGTAP FAQ Database - FAQ #11878 08/24/15) Q: Will the Preliminary Payment Report (PPR) contain program-level payment information as well as policy-level payment information? A: The PPR will contain both program-level and policy-level payment information. (REGTAP FAQ Database - FAQ #11879 08/24/15) Q: Will the Centers for Medicare Medicaid Services (CMS) include Federally-facilitated Small Business Health Options Program (FF-SHOP) User Fees on the Preliminary Payment Report (PPR) and HIX 820 transaction? A: Yes, FF-SHOP User Fees will appear on both the PPR and HIX 820 transaction at the program level. However, SHOP-only Issuers will only receive the PPR and will not receive a HIX 820 from the Individual Market. (REGTAP FAQ Database - FAQ #11880 08/24/15) Q: How does the Centers for Medicare Medicaid Services (CMS) determine who receives Dunning Letters? A: CMS will send Dunning Letters to all Payee Groups with an outstanding balance. CMS sends Dunning Letters to the Financial Authority Contact (FAC) Issuers provided 175 Updated 1-31-17 2017-?00275 on the Payee Group's Financial Information Form (FIF) in the Financial Management Module of the Health Insurance Oversight System (HIOS). (REGTAP FAQ Database - FAQ #11881 08/24/15) Q: What is the cut-off date for HIX 820 connectivity testing? A: CMS needs all 2015 FFM Issuers to finish connectivity testing by August 15, 2015. (REGTAP FAQ Database - FAQ #11882 08/24/15) Q: What files can Issuers expect to receive from the Centers for Medicare Medicaid Services (CMS) as part of the Policy-based Payment Process? A: As part of the Policy-based Payment Process, Issuers will receive the Preliminary Payment Report (PPR) and the HIX 820 transactions ?le. (REG TAP FAQ Database - FAQ #11883 08/24/15) Q: What is a preliminary payment report, or an interim payment report? Is that part of the 820? Or is that the pipe 820? A: For 2015, 3Rs program payments will be re?ected on the Manual Financial Transaction Report. This was formerly known as the ?Interim Payment Process.? For more information of Preliminary Payment Reports, please see the REGTAP Training entitled ?Policy-based Payments: Preliminary Payment Reports, 2015 Pilot, and Discrepancy Reporting (REGTAP FAQ Database - FAQ #11885 08/24/15) Q: Do State Based Marketplace (SBM) Issuers need to prepare for the implementation of Policy-based Payments? A: The steps outlined during the July 29, 2015 FM Series II training Issuers to prepare for the implementation of Policy-based Payments do not apply to SBMs. The Centers for Medicare Medicaid Services (CMS) plans to onboard SBMs onto the Policy-based Payment Process after January 2016. To register, SBM Issuers will need to successfully complete and submit 820 registration forms to EDI by 10/15/2015. SBM Issuers will also need to set up folders by 11/30/2015. The con?guration to receive 820 ?les will either need to be via a SPOE folder (if EFT setup is configured to pull from CMS) or via a server folder (if EFT setup is configured for push mechanism). (REGTAP FAQ Database - FAQ #11886 08/24/15) Q: How will Issuers receive the Preliminary Payment Report A: Similar to the HIX 820 transaction, Issuers will receive the PPR through their 820 EDI onboarding setup via EFT. In a given month, Issuers can expect to receive PPRs around the 10th - 13th and the HIX 820 transaction between the 25th and 27th. Please refer to the REGTAP Webinar entitled ?Preliminary Payment Reports, 2015 Pilot, and Discrepancy Reporting,? dated July 29, 2015. (REGTAP FAQ Database - FAQ #11887 08/24/15) Q: What are the differences between the Preliminary Payment Report (PPR) and the final 1 76 Updated 1-31-17 2017--00276 HIX 820 transaction? A: The difference between PPR and the HIX 820 transaction is that only the HIX 820 transaction will contain the Electronic Funds Transfer (EFT) trace number and effective date in addition to policy-level enrollment and payment information. The PPR does not include an EFT trace number or an effective date. (REGTAP FAQ Database - FAQ #11888 08/24/15) Q: Should State Based Marketplace (SBM) Issuers request HIX 820 test files or wait until the Centers for Medicare Medicaid Services (CMS) outlines a specific process for SBMs to participate in pilot testing? A: SBM Issuers may request HIX 820 test ?les if they are ready to receive them by sending an email by August 1st to confirm readiness to FMCC@cms.hhs.qov with subject line 820 Testing: Con?rm Readiness.? Include all Payee IDs for which you are con?rming readiness in the email. (REGTAP FAQ Database - FAQ #11890 08/24/15) Q: How will the Centers for Medicare Medicaid Services (CMS) represent negative adjustments on the HIX 820 transaction? A: Retroactive and Prospective negative amounts in the HIX 820 transaction are visible in the RMR02 segments of the 2300 loop (details level). Each RMR02 element will contain a payment type code to specify the program for which the negative amount was charged. (REGTAP FAQ Database - FAQ #11891 08/24/15) Q: Will the HIX 820 transaction contain multiple ADJ codes if required? A: Yes, the Centers for Medicare Medicaid Services (CMS) include multiple ADJ codes in a HIX 820 transaction for retroactive adjustments to prior month's payments. (REGTAP FAQ Database - FAQ #11892 08/24/15) Q: Will the Centers for Medicare Medicaid Services (CMS) send policy records after the Change in Circumstance collapsing process? A: CMS will send policy records after the collapsing process so Issuers can determine which policies were collapsed after a non-?nancial occurs on the policy. (REGTAP FAQ Database - FAQ #11893 08/24/15) Q: What tasks should new Issuers complete in order to participate in the Policy-based Payments process? A: To participate in the Policy-based Payments Process, Issuers must email the Financial Management Coordinating Center (FMCC) to confirm readiness to receive a HIX 820 test ?le no later than August 1, 2015. Issuers should send responses to the HIX 820 test file no later than August 15, 2015. Issuers must have been submitting complete, current enrollment data to the Federally-facilitated Marketplace (FFM). (REGTAP FAQ Database - FAQ #11894 08/24/15) Q: Do the Centers for Medicare Medicaid Services (CMS) require Issuers to send a acknowledgement file for the Preliminary Payment Report 1 77 Updated 1-31-17 2017-?00277 A: No, CMS does not require an acknowledgement file for the PPR. (REGTAP FAQ Database - FAQ #11896 08/24/15) Q: In what order should a health insurance company with multiple third-party benefits managers (TPAs) re-adjudicate claims? After re-adjudicating medical and then pharmacy claims, is there a specific order for vision, dental, and chiropractic claims adjudicated by third-party vendors? A: As discussed in November 17, 2014 HHS guidance on the re-adjudication of claims, when readjudicating allowed costs for EHB against the standard plan, issuers using the standard methodology are required to ?rst set all accumulators to zero and then reprocess individual claims for each policy in their original order. Issuers using a third-party administrator that makes re-adjudication of claims in their natural order complex may, after setting claims to zero, adjudicate first all medical claims and then all pharmaceutical claims in a policy against the standard plan. Such issuers may not process claims within each category in any other order other than their original order. Further, the process described in the above guidance also applies to third-party administrators for other subsets of bene?ts, so that a TPA should first process medical claims, if any, followed by pharmaceutical, and then any other subset of benefits, for example vision, dental, or substance use disorder bene?ts, as applicable. These additional categories of claims should be re-adjudicated in the order that best approximates the natural order, so that, for example, if a preponderance of vision claims pre-date claims for dental care, the vision claims group should be re-adjudicated before the dental claims. HHS guidance on the re-adjudication of claims may be found at Claims Readiudication Guidance 11031 4 50R 111714. (FAQ: Re-adjudication of claims under the Cost-sharing Reduction Reconciliation Standard Methodology (08/25/15) and REG TAP FAQ Database - FAQ #11897 08/24/15) Q: In the case of a standard plan with separate annual limitations on cost sharing for in- network and out-of-network cost sharing, as permitted in the plan template, which should be used when calculating effective cost sharing parameters for the simplified methodology? A: Issuers reconciling what enrollees paid in cost-sharing reductions against standard plans that have separate in-network and out-of?network limitations on cost sharing must use the standard plan?s in-network annual limitation for the simplified methodology. However, issuers under certain circumstances may capture CSR amounts for enrollees who incur large out-of?network EHB claims amounts by electing to use the standard methodology. Under 45 CFR for plan variation policies with total EHB for the benefit year that are greater than the effective claims ceiling, the QHP issuer may elect, on a policy by policy basis, to calculate the amount pursuant to the standard methodology. (FA OS on Cost-Sharing Reduction Reconciliation Simpli?ed Methodology (08/25/15) and REG TAP FAQ Database - FAQ #11898 08/24/15)) Q1: Which off-Exchange plans should issuers include when determining whether a standard plan meets the enrollee member-month threshold required for the simplified methodology? Can issuers include a ?substantially similar? off-Exchange plan in the member-month threshold? 1 78 Updated 1-31-17 2017--00278 A1: As discussed in March11, 2014 guidance on the simpli?ed methodology, issuers should not consider member months in a substantially similar QHP when determining whether a plan or subgroup meets the threshold. Regardless of the HIOS plan ID number, QHP issuers that select the simpli?ed methodology must count all enrollees in a standard plan, including those enrolled in the QHP through the Exchange and those enrolled in the same plan as the QHP but offered outside the Exchange, as described in subparagraphs (1) and (2) of the de?nition of ?qualified health plan or at 45 CFR 153.500. QHP issuers should not include enrollees in a plan that is substantially the same as the standard QHP, as described in subparagraph (3) of the de?nition of ?quali?ed health plan or at 45 CFR 153.500. QHP issuers should not include enrollees in any other off-Exchange plans that differ from the QHP, including plans that differ due to network differences or service areas. For a full description of the simplified methodology see CSRSimpleMethodUpdate 5CR 031114. p_df (FAQs on Cost-Sharing Reduction Reconciliation Simpli?ed Methodology (08/25/15) and REGTAP FAQ Database - FAQ #11899 08/24/15)) 02: How is the credibility threshold applied for the simpli?ed methodology? CMS regulations require 12,000 member months for Individual/family and under/over effective deductible, but data collection template for cost sharing reduction reconciliation only refers to 12,000 member months for the standard silver plan. How should we treat a plan with more than 12,000 member months, but with fewer than 12,000 member months with claims under the effective deductible? A2: To meet the credibility threshold for the simpli?ed methodology, it is not necessary to have 12,000 member months with claims sets under the effective deductible. The credibility threshold is met when the standard plan and each of its subgroups, if any, have at least 12,000 member months with total allowed costs for EHB that are greater than the effective deductible but for which associated cost sharing is less than the annual limitation on cost sharing. If a standard plan's total enrollment exceeds 12,000 member months for the benefit year, but one or more of the subgroups described in CFR has fewer than 12,000 member months with total allowed costs for EHB that are greater than the effective deductible but for which associated cost sharing is less than the annual limitation on cost sharing, the issuer must use the simplified AV methodology. (FA 03 on Cost-Sharing Reduction Reconciliation Simpli?ed Methodology (08/25/15) and REGTAP FAQ Database - FAQ #11900 08/24/15)) Q: For a policy that switches from single to family (or vice-versa) during the year for reasons of marriage, adoption, or death, and stays on the same Qualified Health Plan ID, should the contract?s data be aggregated into one policy report when using the simplified methodology? Updated 1-31-17 A: If an issuer calculates separate effective cost-sharing parameters for self-only coverage and other than self-only coverage and the enrollees remain in the same QHP after a change in circumstance, an issuer may aggregate the two policies into one report. Specifically, when a plan variation policy is self-only for part of the year, and then becomes other than self-only (or vice versa), the issuer should apply the set of effective cost-sharing parameters (or the AV method, one minus the actuarial value of the standard plan) for the type of coverage for which the plan variation policy was for the greatest number of coverage months. If the type of coverage of the policy was evenly 179 2017-?00279 split, the QHP issuer should default to the other than self-only coverage effective cost- sharing parameters. We note that if the issuer of the QHPs is the same, the issuer is obligated under45 CFR 156.425(b) Continuity of deductible and out-of-pocket amounts, to ensure that any cost sharing paid by the applicable individual under previous plan variations (or standard plan without cost-sharing reductions) for that bene?t year is taken into account in the new plan variation (or standard plan without cost-sharing reductions) for purposes of calculating cost sharing based on aggregate spending by the individual, such as for deductibles or for the annual limitations on cost-sharing. (FAQs on Cost-Sharing Reduction Reconciliation Simpli?ed Methodology (08/25/15) and REG TAP FAQ Database - FAQ #11901 08/24/15)) Q: if an issuer offers two standard plans, one with embedded pediatric dental and vision benefits and a second plan without the pediatric dental benefits but offered with a separate pediatric dental plan, how does the issuer treat pediatric claims in this scenario, if at all? A: A standard plan with embedded pediatric dental bene?ts is different from a standard plan that offers companion dental coverage, even if all other bene?ts are the same. Therefore, for the simplified cost-sharing reduction reconciliation methodology, the issuer must calculate separate effective cost-sharing parameters for each standard plan and apply them to its associated cost-sharing reduction variant plan. Stand-alone pediatric dental plans do not qualify for cost-sharing reductions under the Affordable Care Act. (FAQs on Cost-Sharing Reduction Reconciliation Simpli?ed Methodology (08/25/15) and REG TAP FAQ Database - FAQ #11902 08/24/15)) Q: What do Qualified Health Plan (QHP) Issuers need to submit in order to conduct Cost- sharing Reduction (CSR) Reconciliation? Where can Issuers find more information on CSR Reconciliation? A: The data requirements for CSR reconciliation are available at 10526.html Additionally, the Center for Medicare Medicaid Services (CMS) will provide instructions and an electronic file later this year. To submit CSR Reconciliation data, Issuers must calculate the difference between the cost-sharing paid by enrollees in a QHP's variation policy and the cost-sharing that enrollees would pay under the standard version of the same QHP. Issuers calculate this difference using the Standard, Simplified or Actuarial Value (AV) Methodology. (REGTAP FAQ Database - FAQ #11652 08/24/15) Q: Should Issuers separate 2014 and 2015 payments for Advanced Premium Tax Credit (APTC) and Cost-sharing Reductions (CSRs) for purpose of CSR Reconciliation? A: Yes, Issuers should separate 2014 and 2015 payments for the purpose of CSR 180 Updated 1-31-17 2017--00280 Reconciliation. Issuers can use the informational Summary Payment Report to assist in separating 2014 and 2015 payments. CSR reconciliation for both years will take place in April 2016. See guidance on timing at CSR Recon timinq quidance 5CR 0213 FAQ Database - FAQ #11653 08/24/15) Q: When will Cost-sharing Reduction (CSR) Reconciliation for the 2014 benefit year occur? A: The Centers for Medicare Medicaid Services (CMS) will conduct CSR Reconciliation for the 2014 and 2015 bene?t years in April 2016. Please see CMS guidance on this topic at CSR Recon timinq guidance 5CR 0213 FAQ Database - FAQ #11654 08/24/15) Q: Does the 'Timing of Reconciliation of Cost-Sharing Reductions for the 2014 Benefit Year' announcement apply to self-funded medical plans, or will the announcement only apply to the Qualified Health Plans (QHP) in the Federally-facilitated Marketplace A: The 'Timing of Reconciliation of Cost-Sharing Reductions for the 2014 Bene?t Year' announcement applies only to QHP issuers. (REGTAP FAQ Database - FAQ #11655 08/24/15) Q: Will the Centers for Medicare Medicaid Services (CMS) provide additional training for Issuers regarding the final reconciliation and simplified method for Cost-sharing Reductions A: The reconciliation of 2014 and 2015 advance cost-sharing reduction payments will take place in April 2016. CMS will provide instructions and issuer training in advance of data submission. For information on the timing of CSR reconciliation, please see CSR Recon timinq quidance 5CR 021315.9df (REGTAP FAQ Database - FAQ #11656 08/24/15) Q: Is there a situation where the Preliminary Payment Report (PPR) and the HIX 820 transaction will not be identical? A: The only case in which the PPR and the HIX820 would not be identical would be if there were an offset stemming for an unpaid charge from a previous month. An offset occurs when the Department of the Treasury subtracts a debt owed from an Issuer's deposit. In such a situation, the amount deposited into an Issuer's account and the amount represented in the HIX 820 transaction would not be equal. An Issuer an use the addendum that comes with the HIX 820 transaction to check for Treasury offsets.(REGTAP FAQ Database - FAQ #12661 09/11/15) Q: Will the HIX 820 transaction contain information from the 2015 benefit year? A: For FFM issuers who participated in both 2015 and 2016, the HIX 820 will only include program-level amounts for 2015 Bene?t Year and policy-level amounts for the 2015 Bene?t Year. (REGTAP FAQ Database - FAQ #12667 09/11/15) 181 Updated 1-31-17 2017--00281 Q: What should Issuers do if they do not receive a Preliminary Payment Report (PPR) and a HIX 820 transaction? A: Issuers who do not receive PPR and HIX 820 transaction should submit a CMS Help Desk ticket to CMS FEPS@cms.hhs.qov for further assistance. (REGTAP FAQ Database - FAQ #12669 09/11/15) Q: Will Preliminary Payment Reports (PPR) contain the Manual Adjustments (MADJ) Payment Type Codes? A: Yes, the PPR will contain MADJ Payment Type Codes. (REGTAP FAQ Database - FAQ #12670 09/11/15) Q: Are Issuers that participate in both the State-based Marketplace (SBM) and Federally- facilitated Marketplace (FFM) considered FFM or SBM issuers? A: The Centers for Medicare Medicaid Services (CMS) considers these Issuers as part of the FFM for the Policy-based Payments process. (REGTAP FAQ Database - FAQ #12675 09/11/15) Q: When will the Centers for Medicare Medicaid Services (CMS) expect Issuers to provide reconciliation files? A: Issuers must currently submit reconciliation files as part of the Enrollment Reconciliation Process in order to establish readiness for the Policy-based Payments process. (REGTAP FAQ Database - FAQ #12682 09/11/15) Q: How will the Centers for Medicare Medicaid Services (CMS) log Issuer HIX 820 discrepancies? A: CMS will provide guidance at a later date. (REGTAP FAQ Database - FAQ #12696 09/11/15) Q: In FAQ 11651, the Centers for Medicare Medicaid Services (CMS) stated that any claims incurred during the 2015 benefit year that did not result in a final payment by the data submission deadline of April 30, 2016 may be submitted in the following year reconciliation cycle.1 Will CMS also permit issuers to carry over claims for the 2015 benefit year that were paid but were not able to be submitted in time for the April 30, 2016 dead?ne? A: Yes. Claims incurred in the 2015 bene?t year that were not able to be submitted in time for the April 30, 2016 deadline may be submitted in the following year reconciliation cycle, whether the reason for the non-submission was because they had not been paid in time or because the issuer was not able to reconcile the claim in time. CMS expects issuers to reconcile cost-sharing reductions under a permitted methodology following payment. (REGTAP FA Q: Claims run-out deadline for Cost-sharing Reduction Reconciliation (09/30/15)) 182 Updated 1-31-17 2017--00282 Q: Will Issuers have the option of receiving a paper-based remittance or must Issuers register for the electronic Policy-based Payments process? A: Issuers must complete Electronic Data Interchange (EDI) Registration in order to receive the automated HIX 820 transaction. The EDI Registration form is located on CMS at connectivity-testinq .CMS will not provide a paper-based remittance. Further guidance is available at in the Payments-Remittance Message (X12 HIX 820) section of the REGTAP Library in the presentation slides titled Registration: Fundamentals Receipt of the ASC X12 HIX 820 (REGTAP FAQ Database - FAQ #13871 11/04/15) Q: How does an Issuer access the CMS website? A: The website is An issuer will need a CALT User ID and Password to access the site. Once on the site go to the 'lssuer Community' and simply click on the 'Request Membership? to be made a member which will allow Issuers to access information and documents. (REG TAP FAQ Database - FAQ #13872 11/04/15) Q: How can an Issuer who is changing Electronic Data Interchange (EDI) vendors set up registration so that the Issuer's current vendor continues to handle current EDI production tasks and the new EDI vendor can participate in EDI connectivity testing? A: Issuers who are changing EDI vendors should complete an EDI Registration Form for the new vendor and indicate on the form the date that the change in vendors will be effective. (REGTAP FAQ Database - FAQ #13873 11/04/15) Q: Is it possible to have different Electronic Data Interchange (EDI) vendors for the HIX 820 and 834 transactions? A: Issuers can send different transactions to different EDI vendors. Those vendors must complete separate EDI Registration Forms using the Issuer's Trading Partner ID indicating what forms they will receive. (REGTAP FAQ Database - FAQ #13874 1 1/04/15) Q: Do Issuers who submitted Electronic Data Interchange (EDI) Registration Forms in January 2014 need to resubmit EDI Registration Forms? A: Yes, Issuers who submitted EDI forms in January 2014 need to resubmit due to the addition of the Payee ID ?eld. (REGTAP FAQ Database - FAQ #13875 11/04/15) Q: Is the term 'Payee equivalent to the term 'Payee Group Number' on the Electronic Data Interchange (EDI) Registration Form? A: Yes, the term 'Payee is equivalent to the term 'Payee Group Number'. (REGTAP FAQ Database - FAQ #13876 11/04/15) Q: Do health insurance companies need a separate Electronic Data Interchange (EDI) Registration Form for each Issuer? 183 Updated 1-31-17 2017--00283 A: All health insurance companies must complete one (1) EDI Registration Form for each Payee Group, which may contain multiple Issuers. (REGTAP FAQ Database - FAQ #13877 11/04/15) Q: Will the Centers of Medicare Medicaid Services (CMS) send the HIX 820 transaction directly to SBM Issuers? A: CMS will send the HIX 820 transaction directly to SBM Issuers. For further guidance Issuer should consult the supporting document titled, 820 Companion Guide, Version 3, April 29, 2015' located at in the Payments- Remittance Message (X12 HIX 820) section of the REGTAP Library. (REGTAP FAQ Database - FAQ #13878 11/04/15) Q: What should Issuers do if they experience difficulty in submitting the Electronic Data Interchange (EDI) Registration Form? A: Issuers can send an email to for technical assistance. (REGTAP FAQ Database - FAQ #13879 11/04/15) Q: How do Issuers proceed in the Policy-based Payment process if they have not received test HIX 820 transactions? A: In order to receive the HIX 820 transaction, Issuers must complete the following steps: 1) Complete a CMS Marketplace Electronic Data Interchange (EDI) Registration Form, 2) Provide Pro?le Information, 3) Establish and Complete Connectivity Testing using Pull Methodology. If Issuers have complete these steps and have not received a test HIX 820 transactions, please send an email to the Financial Management Coordination Center (FMCC) at FMCC@cms.hhs.qov for technical assistance. Issuers can find more information on EDI Registration at in the Payments-Remittance Message (X12 HIX 820) section of the REGTAP Library in the presentation slides titled Registration: Fundamentals Receipt of the ASC X12 HIX 820 (REGTAP FAQ Database - FAQ #13880 11/04/15) Q: Will State Based Marketplace (SBM) and Federally-facilitated Marketplace (FFM) Issuers receive the HIX 820 transaction before the Preliminary Payment Reports (PPRs) since the PPRs will be delayed until late October 2015? A: Issuers will not receive the HIX 820 transaction as a part of the Policy-based Payments Pilot. CMS will send only the PPR during the Pilot for enrollment reconciliation purposes. However in January 2016 Issuers will receive the HIX 820 transaction and a PPR. (REGTAP FAQ Database - FAQ #13881 11/04/15) Q: Since the Centers for Medicare Medicaid Services (CMS) will not distribute the Preliminary Payment Report (PPR) until late October 2015, does that mean that the Policy-based Payments (PBP) Pilot process will begin in November 2015? A: CMS will distribute the PPR at the end of October 2015 for the FFM Issuer Pilot. Policy-based Payments will not be in effect until January 2016. (REGTAP FAQ Database - FAQ #13882 11/04/15) Q: Is there a timeline for when the Centers for Medicare 8. Medicaid Services (CMS) will 184 Updated 1-31-17 2017--00284 begin testing HIX 820 transactions with State Based Marketplaces A: CMS has begun testing with SBM Issuers for the HIX 820 transaction. If SBM Issuer have not receive outreach, please email the FMCC@cms.hhs.qov. (REGTAP FAQ Database - FAQ #13883 11/04/15) Q: When an Issuer receives a payment corresponding to the HIX 820 transaction, is that payment for the current or previous payment month? A: Payments detailed for the HIX 820 transaction correspond to the current payment month. Issuers can find further guidance in the supporting document, 'Financial Management 2015 to 2016 Issuer Transition Guide Version 2.0 (9/28/15)? available in the REGTAP Library at under Payments-Remittance Message (X12 HIX 820). (REGTAP FAQ Database - FAQ #13884 11/04/15) Q: If an Issuer uses different Electronic Data Interchange (EDI) vendors for Federally- facilitated Small Business Health Options Program (FF-SHOP) Marketplace Issuers and Federally-facilitated Marketplace (FFM) Issuers, which EDI vendor will receive the Preliminary Payment Report A: Currently the HIX 820 for both SHOP and Individual Market can only be routed to the same vendor. (REGTAP FAQ Database - FAQ #13885 11/04/15) Q: Will Small Business Health Options Program (SHOP) only Issuers continue to receive HIX 820 transactions in 2016? A: SHOP-only Issuers will receive Preliminary Payment Reports (PPRs) only from the Individual market and will receive SHOP HIX 8205 from the SHOP Market. (REGTAP FAQ Database - FAQ #13886 11/04/15) Q: Do the Centers for Medicare Medicaid Services (CMS) expect Issuers to submit Reinsurance, Risk Adjustment and Risk Corridors (3R5) discrepancies based on the Preliminary Payment Report A: No, Issuers will only report discrepancies for Advanced Payment of the Premium Tax Credit (APTC), Cost-sharing Reduction (CSR) and User Fee (UF) amounts based on the PPR. (REGTAP FAQ Database - FAQ #13887 11/04/15) Q: Will the Centers for Medicare Medicaid Services (CMS) list the total policy amount as a separate line item in the Preliminary Payment Report (PPR) when prorating payment and enrollment data? A: Yes, CMS will list total policy amount as separate line items in the PPR when prorating payment and enrollment data. (REGTAP FAQ Database - FAQ #13888 11/04/15) Q: Will the HIX 820 transaction reflect historical payment data for a policy? A: No the HIX 820 transaction will not display historical payment data for a policy. The 185 Updated 1-31-17 2017--00285 HIX 820 transaction will only report the most recent payment data. (REGTAP FAQ Database - FAQ #13889 11/04/15) Q: When an adjustment is shown on the HIX 820, will the original amount be listed as a full reversal, and the restated amount also included in full? A: Yes, when an adjustment is shown on the HIX 820, the full original amount will be listed as a reversal. The restated (or new) amount will also be listed as the full amount. (REGTAP FAQ Database - FAQ #13890 11/04/15) Q: Will the Reinsurance, Risk Adjustment and Risk Corridors (3R5) payments come with a manual adjustment, or MADJ Marketplace Payment Type Code? A: No, 3Rs Payments will not have MADJ Marketplace Payment Type Codes. CMS will provide additional guidance for the 3R5 programs at a later date. (REGTAP FAQ Database - FAQ #13891 11/04/15) Q: If a subscriber changes their policy within the same Issuer, will the Federally- facilitated Marketplace (FFM) ID remain the same? A: In the event of a policy change, the Exchange Assigned Subscriber ID will remain the same and the Exchange Assigned Policy ID will change. (REGTAP FAQ Database - FAQ #13892 11/04/15) Q: Will the Centers for Medicare Medicaid (CMS) continue to follow the mid-month cutoff for payments given that the Preliminary Payment Report (PPR) will be created before the 15th and that it will match the HIX 820 transaction? A: The Centers for Medicare Medicaid Services (CMS) will continue to observe the mid-month cutoff. Current cutoff deadlines are available in the supporting document 'Financial Management 2015 to 2016 Issuer Transition Guide Version 2.0 (9/28/15)? located at in the Payments-Remittance Message (X12 HIX 820) section of the REGTAP Library. Please note that dates are subject to change. (REGTAP FAQ Database - FAQ #13893 11/04/15) Q: Will the Centers for Medicare Medicaid (CMS) distribute Pilot Preliminary Payment Reports (PPRs) for 2015 restatements along with the test HIX 820 transactions? A: Issuers will only receive text HIX 820 transactions as part of establishing connectivity to the Electronic Data Interchange (EDI). Additional HIX 8203 and PPRs will be distributed to Issuers in November 2015. (REGTAP FAQ Database - FAQ #13894 11/04/15) Q: How will the Centers for Medicare Medicaid Services (CMS) report a Change in Circumstance that results in a subscriber receiving a new Exchange Policy ID on the HIX 820 transaction? A: If a occurs and a subscriber changes the Exchange Policy ID, the ID represented on the HIX 820 will depend on the timing of the in relation to the cutoff date where CMS aggregates information to produce the HIX 820. If the occurs after the cutoff date, then the subscriber's former Exchange Policy ID will be on the HIX 820, and in the 186 Updated 1-31-17 2017--00286 following month, CMS will reverse the payment on the HIX 820 and correspond it to the current Exchange Policy ID. For further guidance Issuers should consult the supporting document, 820 Scenarios (10/5/2015)? available at in the Payments-Remittance Message (X12 HIX 820) section of the REGTAP Library. (REGTAP FAQ Database - FAQ #13895 11/04/15) Q: When a Health Insurance Casework System (HICS) case that has a rating defect or resolved rating defect appear on the Preliminary Payment Report (PPR) and HIX 820 transaction? A: Once the rating defect is resolved, the Centers for Medicare Medicaid Services (CMS) will reverse any incorrect payments and pay the proper amount. The reversal and payments will correspond to the relevant coverage months. (REGTAP FAQ Database - FAQ #13896 11/04/15) Q: Will retroactive Health Insurance Casework System (HICS) payments come with an ADJ or MADJ Marketplace Payment Type Code? A: Retroactive HICS payments will come with an ADJ Marketplace Payment Type Code. (REGTAP FAQ Database - FAQ #13897 11/04/15) Q: If an Issuer has 300 policies with rating defects that were resolved, will that Issuer see ADJ codes from each policy on the Preliminary Payment Report (PPR) and HIX 820 transaction simultaneously? A: If each rating defect was resolved at one time, the Issuer would receive an ADJ Marketplace Payment Type Code for each policy and for each coverage month. (REGTAP FAQ Database - FAQ #13898 11/04/15) Q: Will the HIX 820 transaction and Preliminary Payment Report (PPR) re?ect policy-level retroactive adjustments? A: Yes, the HIX 820 transaction and PPRs will re?ect policy-level retroactive adjustments. (REGTAP FAQ Database - FAQ #13899 11/04/15) Q: What process does the Centers for Medicare Medicaid Services (CMS) expect Issuers to follow with the User Fee (UF) amounts on the Preliminary Payment Report (PPR) and HIX 820 transactions? A: CMS expects Issuers to conduct discrepancy reporting by calculating UF amounts. (REGTAP FAQ Database - FAQ #13900 11/04/15) Q: Will the Preliminary Payment Report (PPR) or the HIX 820 contain policy-level information? A: Both the HIX 820 and PPR will contain policy-level information if the Issuer is a part of the Federally-facilitated Marketplace (FFM). Issuers should consult the supporting document, 'Financial Management 2015 to 2016 Issuer Transition Guide Version 2.0 (9/28/15)? for information related to what documentation each Issuer type will receive. 187 Updated 1-31-17 2017--00287 The document is available at in the Payments-Remittance Message (X12 HIX 820) section of the REGTAP Library. (REGTAP FAQ Database - FAQ #13901 11/04/15) Q: What naming convention will Issuers use to send acknowledgements to the Centers for Medicare Medicaid Services? A: For information on naming conventions for all files submitted to and from CMS, please refer to the Federal Data Services Hub (Federal DSH) Electronic Data Interchange (EDI) File Naming Conventions Guide at conventions-1 (REGTAP FAQ Database - FAQ #13945 11/09/15) Q: What element will connect the Preliminary Payment Reports (PPR) and the HIX 820 transaction? A: Currently, only the policy-level details link the PPR and HIX 820. However, Issuers will only receive one (1) preliminary payment report per month that will correspond to one (1) or more HIX 820 transactions. (REGTAP FAQ Database - FAQ #13977 11/10/15) Q: If a subscriber enrolls in January and experiences a non-financial Change in Circumstance in December, will the Issuer receive 10 reversals and reapplications for the same amounts with different Exchange Assigned Policy ID numbers? A: Yes, the subscriber who enrolls in January and experiences a non-?nancial in December will receive ten (10) reversals and reapplications with new Exchange Assigned Policy ID Number. (REGTAP FAQ Database - FAQ #13978 11/10/15) Q: Will the Issuer Assigned Policy and Issuer Assigned Subscriber IDs appear on the production versions of the Preliminary Payment Report A: Yes, Issuer Assigned Policy and Issuer Assigned Subscriber IDs appear on the production versions of the PPR. (REGTAP FAQ Database - FAQ #13979 11/10/15) Q: What is the deadline for Issuers to submit a acknowledgement after receipt of the HIX 820 transaction? A: Issuers should send the acknowledgement and response to the Centers for Medicare Medicaid Services (CMS) as soon as possible after the receipt of the HIX 820 transaction. If CMS does not receive a 999 from the Issuer acknowledging receipt of the transaction, the Electronic Data Interchange (EDI) team will contact the Issuer. (REGTAP FAQ Database - FAQ #13982 11/10/15) Q: How will the Preliminary Payment Report (PPR) and the HIX 820 transaction reflect the resolution of the Health Insurance Caseworker System (HICS) cases and rating defects? A: Resolved HIX cases will appear as policy-level retroactive adjustments on the HIX 820 transaction for each coverage month. (REGTAP FAQ Database - FAQ #13984 1 1/10/15) Q: How will the Pre-Audit file reflect retroactive adjustments to Advanced Payment of the 188 Updated 1-31-17 2017--00288 Premium Tax Credit A: When CMS makes a retroactive adjustment, the Pre-Audit ?le will re?ect that adjustment in that it will contain the new total amount. For example, the Pre-Audit ?le indicates a payment of $200 for January and CMS makes a retroactive adjustment crediting the Issuer $200 for January. The next Pre-audit ?le will re?ect this retroactive adjustment by displaying a total of $400 for the month of January. (REGTAP FAQ Database - FAQ #13985 11/10/15) Q: Will the production version of the HIX 820 transaction include Small Business Health Options Plan (SHOP) Enrollment data and include SHOP HIX 820 and Federally-facilitated Marketplace (FFM) HIX 820 information in the same transaction? A: SHOP Issuers participating in the SHOP Market will continue to receive separate HIX 820 transactions for premium aggregation. Issuers that belong to both the FFM and FF- SHOP Market will receive HIX 820 transactions from the Individual Market with program- level data regarding SHOP User Fees (UF) and policy-level details related to the Individual Market. Issuers can locate more information in the supporting document 'Financial Management 2015 to 2016 Issuer Transition Guide Version 2.0 (9/28/15)? located at in the Payments-Remittance Message section of the REGTAP Library. (REGTAP FAQ Database - FAQ #13987 11/10/15) Q: How do the Centers for Medicare Medicaid Services (CMS) calculate User Fees A: Federally-facilitated Marketplace (FFM) User Fees are calculated at 3.5 percent of total premium amounts. (REGTAP FAQ Database - FAQ #13988 11/10/15) Q: How will Issuers tell the difference between the Initial and Final HIX 820 transactions? A: The Centers for Medicare Medicaid Services (CMS) will not transmit initial HIX 820 transactions. Instead, Issuers will receive the Preliminary Payment Report (PPR) and a single HIX 820 transaction. An example of the PPR is available at in Payments-Remittance Message section of the REGTAP Library in the supporting document titled, 820 Pilot Materials'. Issuers can use the HIX 820 TRN02 Electronic Funds Transfer (EFT) Trace Number to differentiate between multiple HIX 820 transactions. (REGTAP FAQ Database - FAQ #13989 11/10/15) Q: Will State Based Marketplace (SBM) Issuers receive the Marketplace Payment Type Code to bring their total payments to zero A: SBM Issuers will not receive a Marketplace Payment Type Code. (REGTAP FAQ Database - FAQ #13990 11/10/15) Q: Will the Centers for Medicare Medicaid Services (CMS) use the document 'Payment Dispute Form for Pilot (Ver. 6 09/23/15) (FOR PILOT when the Policy-based Payment process begins production? A: Currently, the form only applies to the pilot process. After the pilot process is complete, CMS will update the Payment Dispute Form based on Issuer feedback. (REGTAP FAQ Database - FAQ #13991 11/10/15) 189 Updated 1-31-17 2017--00289 Q: How do the Centers for Medicare Medicaid Services (CMS) expect Issuers to use the HIX 820 Transaction? A: CMS expects Issuers to use the HIX 820 transaction as a remittance message for Electronic Funds Transfer (EFT) payments from the Department of the Treasury. Issuers will use the HIX 820 along with the Preliminary Payment Report (PPR) to identify and report payment discrepancies. Further guidance is available at in the Payments-Remittance Message (X12 HIX 820) section of the REGTAP library in the presentation slides titled '2015 Pilot and Discrepancy Reporting (08/26/15)? and Series 2015 Issuer Pilot and HIX 820 Testing (10/19/15)? as well as the supporting document 'Financial Management 2015 to 2016 Issuer Transition Guide Version 2.0 (REGTAP FAQ Database - FAQ #14103 11/30/15) Q: Can the Centers for Medicare Medicaid Services (CMS) clarify the file naming conventions for the Preliminary Payment Reports A: The ?le naming convention for the PPR is [Trading Partner for test. The ?le naming convention for the PPR is [Trading Partner for Production. (REGTAP FAQ Database - FAQ #14104 11/30/15) Q: Will the Centers for Medicare Medicaid Services (CMS) prorate premiums in the Pilot version of the Preliminary Payment Reports A: The Pilot versions of the PPR will not show prorated APTC, CSR, UF, or total premiums. Beginning in 2016, these amounts will be prorated. (REGTAP FAQ Database - FAQ #1410512/01/15) Q: Is the HIX 820 transaction more accurate than the Preliminary Payment Report (PPR) and how will it affect the resolution of payment discrepancies? A: The HIX 820 transaction and the PPR will contain the same policy-level information. Issuers will have the option of using the PPR or the HIX 820 transaction from which to report payment discrepancies. There are some instance in which the program-level amount in the HIX 820 will not be re?ected in the PPR. For further guidance on discrepancy reporting consult the supporting document 'Financial Management 2015 to 2016 Issuer Transition Guide Version 2.0' available at in the Payments-Remittance Message section of the REGTAP Library. (REGTAP FAQ Database - FAQ #14106 12/01/15) Q: Will Issuers be able to restate 2015 data using the Preliminary Payment Reports A: Issuer will continue to use the Manual Payment Process to restate 2015 data. These restatement will be re?ected as program level amounts on the PPR and HIX 820 190 Updated 1-31-17 2017--00290 transaction. The 2015 restatement amount will always be re?ected with a coverage period 12/1/15 to 12/31/15 on the PPR and HIX 820. For further guidance refer to Scenario 5 for 2015 restatements in the Financial Management 2015 to 2016 Issuer Transition Guide Version 2.0 available at in the Payments- Remittance Message (X12 HIX 820) section of the REGTAP Library. (REGTAP FAQ Database - FAQ #14109 12/01/15) Q: In what coverage period will Issuers receive 2015 restatements on the HIX 820 transaction? A: Currently, Issuer will receive 2015 Restatements on the December 1 to December 31, 2015 coverage period. 2016 program level amounts coverage period will re?ect the month in which the payment is made. For example, the January HIX 820 coverage period program level amount is January 1, 2016 to January 31, 2016. (REGTAP FAQ Database - FAQ #14110 12/01/15) Q: When will the Centers for Medicare Medicaid Services (CMS) distribute the new Preliminary Payment Reports (PPRs) and HIX 820 test files for additional Financial Management (FM) testing? A: CMS will distribute the new PPRs and HIX 820 test ?les for additional Financial Management (FM) testing the week of November 16, 2015. (REGTAP FAQ Database - FAQ #14111 12/01/15) Q: If a health insurance company has multiple Health Insurance Oversight System (HIOS) IDs and has not receive Preliminary Payment Reports (PPR) for all of their HIOS IDs, how do health insurance companies request that the Centers for Medicare Medicaid Services (CMS) send the missing A: Issuers should send an email to FMCC@cms.hhs.qov and provide a list of Issuer or Payee IDs for which the Issuer did not receive PPRs. (REGTAP FAQ Database - FAQ #1411212/01/15) Q: What are the dates for the All-Issuer End-to-End Testing? A: The Centers for Medicare Medicaid Services (CMS) projects additional FM testing to begin November 1, 2015 and end December 31, 2015. (REGTAP FAQ Database - FAQ #14113 12/01/15) Q: Will the Preliminary Payment Report (PPR) and the HIX 820 transaction be identical in how each reports negative payments? A: The Centers for Medicare Medicaid Services (CMS) will include an invoice loop in the HIX 820 transaction to report amounts owed. The PPR will not include an invoice and therefore will not report amounts owed. For further guidance Issuers should consult the supporting document, 'Financial Management 2015 to 2016 Issuer Transition Guide Version 2.0' available at in the Payments-Remittance Message (X12 HIX 820) section of the REGTAP Library. (REGTAP FAQ Database - FAQ #1411512/01/15) Q: Will payments in the HIX 820 Transaction have two decimal points? 191 Updated 1-31-17 2017--00291 A: Yes, the HIX 820 transaction will display two decimal points in payment information. If the payment is a whole number such as ten (10) dollars, the HIX 820 transaction will not display decimal points. (REGTAP FAQ Database - FAQ #14116 12/01/15) Q: Will the Pilot versions of the Preliminary Payment Reports (PPR) display payment adjustments? A: If an amount from a previous month was received and adjusted, then the PPR will reflect the adjusted amount with an ADJ suffix. (REGTAP FAQ Database - FAQ #14117 12/01/15) Q: Is the HIX 820 transaction equivalent to the 820 Remittance Advice? A: Yes, the HIX 820 Transaction is equivalent to the X306 version of the 820 Remittance Advice. (REGTAP FAQ Database - FAQ #14118 12/01/15) Q: Can the Centers for Medicare Medicaid Services (CMS) provide scenarios for health insurance companies with separate Payee Groups for the Federally-facilitated Marketplace (FFM) and State Based Marketplace? A: This scenario will be included in the FM additional testing schedule for mid-November 2015. (REGTAP FAQ Database - FAQ #14119 12/01/15) Q: If an Issuers receives two (2) HIX 820 transactions, will the Centers for Medicare Medicaid Services (CMS) send those HIX 820 transactions together? A: CMS will send the HIX 820 transactions separately. (REGTAP FAQ Database - FAQ #1412012/01/15) Q: Will the Electronic Funds Transfer (EFT) from the Centers for Medicare Medicaid Services (CMS) correspond to the previous or current payment months? A: The EFT will correspond to the current payment month. (REGTAP FAQ Database - FAQ #14121 12/01/15) Q: Which payment months will appear on the pilot versions of the Preliminary Payment Report A: Issuers will receive PPRs for the January 2015 - August 2015 and October 2015 payment months for a total of nine (9) ?les. Issuers will not receive a PPR for September 2015. (REGTAP FAQ Database - FAQ #14122 12/01/15) Q: For a health insurance company with Issuers in multiple States, how can the company determine program-level payment detail (APTC, CSR, UF, etc.) for each State? A: The document control number in the REF segment will contain the Issuer HIOS ID for each program-level payment on the HIX 820. (REGTAP FAQ Database - FAQ #14123 12/01/15) Q: During the end-to-end testing will the Centers for Medicare Medicaid Services (CMS) 192 Updated 1-31-17 2017-?00292 send the HIX 820 and Preliminary Payment Report (PPR) to Issuers? A: During the end-to-end testing process, Issuers will receive HIX 820 and PPRs through EFT. (REGTAP FAQ Database - FAQ #14124 12/01/15) Q: Do the Centers for Medicare Medicaid Services (CMS) anticipate any additional testing before the distribution of the production HIX 820 transactions in January 2016? A: CMS plans to conduct Additional FM testing in November 2015. (REGTAP FAQ Database - FAQ #14125 12/01/15) Q: On the HIX 820 transaction, will Issuers see an RMR segment for zero (0) dollars? A: No, HIX 820 transactions will not include RMR segments for zero (0) dollars due to the rules of the X12 HIX 820 transaction. (REGTAP FAQ Database - FAQ #14127 12/01/15) Q: Will the Centers for Medicare Medicaid Services (CMS) extract and validate the Preliminary Payment Report (PPR) and the Pre-audit File on the same day? A: CMS will extract and validate the PPR and Pre-audit file on the same day. Payments reflected on the PPR will be based on polices as they exist at the time the Pre-audit file is prepared. (REGTAP FAQ Database - FAQ #14128 12/01/15) Q: What will be the file naming convention for documents sent for FM additional testing? A: The file naming convention for the PPR is [Trading Partner The ?le naming convention for the HIX 820 is [Trading Partner (REGTAP FAQ Database - FAQ #14129 12/01/15) Q: Will Issuers receive the HIX 820 and Preliminary Payment Report (PPR) during FM Additional Testing? A: Yes, Issuers will receive the HIX 820 and PPR during FM additional Testing. (REGTAP FAQ Database - FAQ #14141 12/01/15) Q: What is the extract date for the January 2016 Preliminary Payment Report A: The extract date for the January 2016 PPR is December 16, 2015. (REGTAP FAQ Database - FAQ #14142 12/01/15) Q: Is FM Additional Testing the same as Testing? A: Testing refers to the FM Additional HIX 820 testing. During FM Additional Testing the Centers for Medicare Medicaid Services (CMS) will distribute additional HIX 820 test transactions. (REGTAP FAQ Database - FAQ #14143 12/01/15) Q: Can the Centers for Medicare Medicaid Services (CMS) confirm the values that will be sent in the Individual Market HIX 820 for the 1000 Loop in the field? 193 Updated 1-31-17 2017--00293 A: This will be the Payee Name, as established by the entity in the Vendor Management process. Further guidance on the Vendor Management Process is found in the presentations slides, '2015 Vendor Management Slides (10/27/2014)? available at in the Payments-Payee Groups section of the REGTAP Library. (REGTAP FAQ Database - FAQ #14144 12/01/15) Q: What are the instances where an Issuer would not receive the Issuer Assigned Subscriber ID in the Issuer's Preliminary Payment Reports A: The Issuer assigned Subscriber ID is only available in the PPR if provided by Issuer on Inbound 834 Con?rmation or through reconciliation. (REGTAP FAQ Database - FAQ #1414612/01/15) Q: What Issuers will receive the Advanced Premium Tax Credit (APTC), Cost-sharing Reductions (CSR), and User Fee (UF) Supplemental Report? A: Federally-facilitated Marketplace (FFM) and State Based Marketplace (SBM) Issuers will receive APTC, CSR and UF supplemental reports. Issuers who have not transitioned to Policy-based Payments and who continue to submit a Manual Payment Workbook will continue to receive APTC, CSR and UF supplemental reports. (REGTAP FAQ Database - FAQ #1414812/01/15) Q: When will the Centers for Medicare Medicaid Services (CMS) distribute the September Preliminary Payment Report (PPR) to Issuers? A: CMS will distribute January through November PPR during the week of November 16, 2015. (REGTAP FAQ Database - FAQ #14149 12/01/15) Q: Will State Based Marketplace (SBM) Issuers receive program-level HIX 820 transactions in January 2016 and transition to policy-level details later in 2016? A: SBM will receive program level payments. CMS will provide guidance regarding SBM transition to policy-based payments at a later date. (REGTAP FAQ Database - FAQ #1415012/01/15) Q: Why do the Pilot Preliminary Payment Reports (PPRs) contain only Marketplace Payment Type Codes and not regular Marketplace Payment Type Codes? A: Issuers will see an suf?x on the Marketplace Payment Type Code for any retroactive payment. Due to the timing of the PPR pilot, the payments January through August will all contain the suf?x. The Issuer will receive records without the suf?x in the October PPR. The suf?x will not appear for prospective payments going forward. (REGTAP FAQ Database - FAQ #14151 12/01/15) Q: What is the procedure if Issuers cannot identify all discrepancies in the Pilot Preliminary Payment Reports (PPR) by November 15, 2015? 194 Updated 1-31-17 2017--00294 A: Issuers can continue to submit discrepancies after November 15, 2015 as feedback on the overall FFM PPR Pilot. (REGTAP FAQ Database - FAQ #14152 12/01/15) Q: Can Issuers currently apply to participate in FM Additional Testing? A: Issuers will participate in FM Additional testing in which the Centers for Medicare Medicaid Services (CMS) will provide PPR and HIX 820 transactions. As part of the testing CMS will use test data in the PPRs and HIX 820 transactions. For further guidance Issuers should consult the presentation slides, '2016 FM Additional Testing HIX 820 Scenarios' available at in the Payment- Remittance Message (X12 HIX 820) section of the REGTAP Library. (REGTAP FAQ Database - FAQ #14153 12/01/15) Q: Will the Centers for Medicare Medicaid Services (CMS) include Reinsurance, Risk Corridors and Risk Adjustment (3Rs) data into HIX 820 scenarios? A: CMS will include all Marketplace-related payment information including any 3Rs information in the HIX 820 beginning in January 2016. (REGTAP FAQ Database - FAQ #14154 12/01/15) Q: Who do Issuers contact if they did not receive all Trading Partner IDs for Initial HIX 820 (X12) testing? A: Issuers should send an email to FMCC@cms.hhs.qov with a list of Issuer or Payee IDs that did not receive test HIX 820 transactions for all of their Issuer or Trading Partner IDs. (REGTAP FAQ Database - FAQ #14155 12/01/15) Q: Will the HIX 820 test files that the Centers for Medicare Medicaid Services (CMS) will distribute during additional Financial Management (FM) testing match the pilot version of the Preliminary Payment Reports A: The HIX 820 test files that Issuers will receive for additional FM testing will not re?ect the Pilot PPR. The HIX 820 ?les will re?ect scenarios that each speci?c category of Issuer will encounter when they receive production HIX 820 transactions in January 2016. For additional guidance, please consult the presentation slides titled, FM Series 2015 Issuer Pilot and HIX 820 Testing (10/19/15)? available at in the Payments-Remittance Message (X12 HIX 820) section of the REGTAP Library. (REGTAP FAQ Database - FAQ #14156 12/01/15) Q: Will the Marketplace Payment Type Code apply to Payee Groups that contain both Federally-facilitated Marketplace (FFM) and State Based Marketplace (SBM) Issuers? A: The Marketplace Payment Type Code applies to Payee Groups for Federally- facilitated Marketplace (FFM) Issuers only. (REGTAP FAQ Database - FAQ #14157 12/01/15) Q: What data will the Centers for Medicare Medicaid Services (CMS) use to generate the HIX 820 transaction for State-based Marketplace (SBM) Issuers? A: Transactions re?ected on the HIX 820 for SBM Issuers will continue to re?ect 195 Updated 1-31-17 2017--00295 payments as submitted through the Manual Payment Workbooks until CMS is able to process policy-based data from SBMs. (REG TAP FAQ Database - FAQ #14158 12/01/15) Q: Will the Centers for Medicare Medicaid Services (CMS) apply the proration methodology to Special Enrollment Period (SEP) subscribers? A: Yes, Issuers will see proration both on the termination of the first Exchange policy and the effectuation of the second policy in the middle of the month. (REGTAP FAQ Database - FAQ #14159 12/01/15) Q: Will the Centers for Medicare Medicaid Services (CMS) include 834 files as part of additional Financial Management (FM) testing? A: Issuers will not receive an 834 file; however, CMS will post a ?le to REGTAP with policy level characteristics that are re?ected in the FM additional testing Preliminary Payment Reports (PPRs) and HIX 820 transactions. (REGTAP FAQ Database - FAQ #1416012/01/15) Q: Will the Centers for Medicare Medicaid Services send bank deposits to Issuers on the same day every month? A: Bank deposit dates will vary from the 20th to the 23rd of the month each month. (REGTAP FAQ Database - FAQ #14161 12/01/15) Q: Will Issuers receive live data from the additional Financial Management (FM) Testing A: Issuers will receive mock policy-level data during additional FM testing. For further guidance Issuers should consult the supporting document, 'Financial Management 2015 to 2016 Issuer Transition Guide Version 2.0' available at in the Payments-Remittance Section of the REGTAP Library. (REGTAP FAQ Database - FAQ #1416212/01/15) Q: Can the Centers for Medicare Medicaid Services (CMS) explain the difference between the Pre-Audit File and the RCNO file and which file Issuers should use for reconciliation? A: The RCNO ?le combines what the Issuer sent on the RCNI ?le and the information on the Pre-audit ?le. The RCNO file contains responses regarding whether or not CMS will make updates to the FFM based upon the comparison between the two files. During Policy-based Payments reconciliation, Issuers should use the Pre-audit file. (REGTAP FAQ Database - FAQ #14163 12/01/15) Q: How long will it take the Centers for Medicare Medicaid Services (CMS) to process inbound confirmations, terminations, and cancellations after receiving the files from Issuers? A: Inbound confirmations, terminations, and cancellations can be processed in as little as one (1) day depending on the time in which they are received. (REGTAP FAQ Database - FAQ #14164 12/01/15) 196 Updated 1-31-17 2017--00296 Q: Will the Centers for Medicare Medicaid Services (CMS) include Risk Corridors (RC) Marketplace Payment Type codes in upcoming HIX 820 scenarios? A: Issuers can access HIX 820 scenarios with RC Marketplace Payment Type Codes in the supporting document titled, 'Financial Management 2015 to 2016 Issuer Transition Guide Version This document is available at in the Payments-Remittance Message (X12 HIX 820) section of the REGTAP Library. (REGTAP FAQ Database - FAQ #14165 12/01/15) Q: Is the User Fee (UF) Marketplace Payment Type code a program-level only code? A: The Centers for Medicare Medicaid Services (CMS) will use the User Fee (UF) Marketplace Payment Type Code at the policy level and program level based upon Issuer category. The HIX 820 transaction will re?ect UF retroactive adjustments at the policy-level using the Marketplace Payment Type Code UFADJ. For program level payments such as 2015 restatements the HIX 820 will use the payment type code MADJ. Issuers can ?nd further guidance in the supporting document, 'Financial Management 2015 to 2016 Issuer Transition Guide Version 2.0' available at in the Payment-Remittance Message (X12 HIX 820) section of the REGTAP Library. (REGTAP FAQ Database - FAQ #14166 12/01/15) Q: When will the HIX 820 support proration and will it only apply to plans after January 1, 2016? A: The HIX 820 transaction will support proration in January 2016 and will not be available for payment months prior to January 2016. Issuers should continue to use the guidance outlined in the Manual Process regarding proration in the 2015 restatements. (REGTAP FAQ Database - FAQ #14168 12/01/15) Q: Will the Header Total in the Preliminary Payment Report (PPR) contain Reinsurance, Risk Adjustment, and Risk Corridors (3Rs) payments? A: The total payment amount in the PPR header will include all Marketplace Payment in the transaction including the 3R3 program areas. The Payee and Issuer level totals will only re?ect APTC, CSR and UF totals. (REGTAP FAQ Database - FAQ #14169 12/01/15) Q: Will the Centers for Medicare Medicaid Services (CMS) include total premium amounts along with User Fee (UF), Advanced Payment Tax Credit (APTC), and Cost- sharing Reductions (CSR) amounts on the Preliminary Payment Report A: CMS include total premium amounts along with UF, APTC and CSR amounts. (REGTAP FAQ Database - FAQ #14170 12/01/15) Q: Will the Pilot Preliminary Payment Reports (PPRs) reflect what Issuers will receive during the Policy-based Payments (PBP) Process? A: The Centers for Medicare Medicaid Services (CMS) is currently updating the PPR format based upon stakeholder feedback. CMS will provide Issuers with updated examples prior to production in January 2016. For further guidance Issuers should consult the supporting document, 'Preliminary Payment Report (PPR) Schema 197 Updated 1-31-17 2017--00297 (11/17/15)? available at in the Payments-Remittance Message (X12 HIX 820) section of the REGTAP Library. (REGTAP FAQ Database - FAQ #14171 12/01/15) Q: Does the Preliminary Payment Report (PPR) replace the Initial HIX 820 transaction? A: The PPR will replace the Initial HIX 820 transaction. Issuer will use the PPR to aid in the discrepancy reporting to validate payment amounts. Issuers will receive the PPR through Electronic File Transfer (EFT) in a pipe separated format and will contain identical information. (REGTAP FAQ Database - FAQ #14172 12/01/15) Q: Will the Centers for Medicare Medicaid Services (CMS) include payments for members who are considered effectuated based on the rules in Bulletin 16? A: CMS will include payments for members who are effectuated based on the rules outlined in Bulletin 16. (REGTAP FAQ Database - FAQ #14173 12/01/15) Q: Can entities submit all medical, pharmacy, and pharmacy claims under one (1) claim for reimbursement? A: Yes. The Centers for Medicare Medicaid Services (CMS) does not make a distinction between medical services and pharmacy services for reimbursement purposes, so long as the services meet the de?nition of contraceptive services. (REGTAP FAQ Database - FAQ #14080 12/08/15) Q: Can an entity submit Forms for reimbursement on costs incurred on 2015 services? A: No, issuers and should not submit forms for reimbursement of services incurred in 2015 at this time. In this December 2015 reporting cycle, the Centers for Medicare Medicaid Services (CMS) is only accepting Forms for services incurred in the 2014 bene?t year. CMS will provide future guidance on the dates and process for submitting claims incurred in 2015. (REGTAP FAQ Database - FAQ #14223 12/08/15) Q: Can the Centers for Medicare Medicaid Services (CMS) clarify which entity the reimbursements apply to? A: The reimbursements only applies to payments made for a self-insured group health plan of an eligible organization. (REGTAP FAQ Database - FAQ #14226 12/08/15) Q: When will issuers be reimbursed for expenses incurred in the 2014 benefit year? A: Issuers will be reimbursed for expenses incurred in the 2014 in the early part of 2016 calendar year. CMS will provide future guidance on the dates and process for submitting claims expenses that have been incurred in 2015. (REGTAP FAQ Database - FAQ #14229 12/08/15) Q: What deadlines must Issuers meet to establish readiness for the Policy-based Payments Process? A: Issuers will be evaluated for the purpose of determining readiness based on data in the Federally-facilitated Marketplace (FFM) system in mid-November 2015. Issuer 198 Updated 1-31-17 2017--00298 readiness has already been determined and Issuers should have received noti?cation from the Financial Management Coordination Center (FMCC) on Friday December 11, 2015. If issuers have not received this notification please contact the FMCC at FMCC@cms.hhs.qov. (REGTAP FAQ Database - FAQ #14309 12/22/15) Q: Is the 10% variation between payments calculated using the Manual Payment Process and calculated using Policy-based Payments based upon Advanced Payment of the Premium Tax Credit (APTC), Cost-sharing Reduction (CSR) and User Fee (UF) payments after netting? A: For Medical Issuers the 10% variation is calculated using APTC CSR. For Dental Issuers the 10% variation is calculated based upon UFs. (REGTAP FAQ Database - FAQ #1431012/22/15) Q: Will all Issuers continue to use the Manual Payment Process in January 2016 or will the Centers for Medicare Medicaid Services (CMS) use the Manual Payment Process only for Issuers who do not establish readiness for Policy-based Payments? A: All Issuers will continue to submit data through the Manual Payment Process in January 2016. Data submitted through the Manual Payment Process will determine the payment amount. Issuers who are ready for Policy-based Payments will receive payments calculated based upon data drawn from the Federally-facilitated Marketplace and then adjusted by data submitted on the Enrollment Payment Data Workbook. (REGTAP FAQ Database - FAQ #14311 12/22/15) Q: What are the criteria for establishing readiness for Policy-based Payments? A: To establish readiness for Policy-based Payments, Issuers must be able to communicate new enrollments, changes in enrollment and reinstatements through IC 834. Issuers must successfully submit reconciliation files that pass basic validation checks for effectuations and cancellations in the most recent month, or if the most recent month did not pass these checks, the two (2) months prior to the most recent month. Finally, Issuers must have no more than 10% variation between the Issuer's data calculated in the Manual Payment Process and data calculated through the Policy-based Payments Process. (REGTAP FAQ Database - FAQ #14313 12/22/15) Q: If Issuers are not ready for Policy-based Payments, will those Issuers receive a Preliminary Payment Report (PPR) and HIX 820 transaction in January 2016 to aid in establishing readiness? A: Yes, Issuers who have not established readiness will receive PPRs and HIX 820 transactions. (REGTAP FAQ Database - FAQ #14314 12/22/15) Q: Will the Centers for Medicare Medicaid Services (CMS) in April 2016 adjust payments for January through March 2016? 199 Updated 1-31-17 2017--00299 A: During the temporary adjustment period CMS will completely reverse the previous months adjustments and provide a new adjustment for the current month. (REGTAP FAQ Database - FAQ #14315 12/22/15) Q: Is the full statistical validation of 834 files necessary for establishing readiness for Policy-based Payments? A: The Centers for Medicare Medicaid Services (CMS) does not require full statistical validation in order to establish Readiness for Policy-based Payments. CMS requires that Issuer send CMS IC 8345 so that enrollment data can process through the FFM. (REGTAP FAQ Database - FAQ #14316 12/22/15) Q: Will the Centers for Medicare Medicaid Services (CMS) display adjustments in April 2016 in one (1) payment loop? A: Adjustments will made by program on the HIX 820 which may correspond to one (1) or more 2300 loops. These adjustments will not be sent at the policy level. (REGTAP FAQ Database - FAQ #14317 12/22/15) Q: How do the Centers for Medicare Medicaid Services (CMS) calculate the 10% variance between the payments calculated in the Manual Payment Process and the payments calculated using the Policy-based Payments process? A: CMS calculates the 10% variance at the Health Insurance Oversight System (HIOS) ID level using the full year of payments based on a payment month cutoff date and time. (REGTAP FAQ Database - FAQ #14318 12/22/15) Q: Who will receive noti?cation regarding whether or not Issuers have met the criteria for Policy-based Payments? A: The Center for Medicare Medicaid Services (CMS) will notify the Issuer's CEO and the Financial Management Coordination Center (FMCC) contact through a letter. (REGTAP FAQ Database - FAQ #14319 12/22/15) Q: How do Issuers reconcile a manual adjustment if they are only reflected at the program-level? A: The Centers for Medicare Medicaid Services (CMS) will calculate the adjustment based upon the Marketplace Enrollment Payment Data Workbook submitted by the Issuer. CMS will assume this data is accurate. Issuers may email the marketplace payments mailbox with questions regarding payments. (REGTAP FAQ Database - FAQ #14320 12/22/15) Q: Will Issuers continue to receive a payment report during the Policy-based Payments Process? A: Issuers will receive a PPR in the middle of the month between the 13th through the 15th and HIX 820 at the end of the month on the 28th or 29th. For further guidance Issuers may consult Financial Management 2015 to 2016 Issuer Transition Guide Version 3.0 (1/11/16) available at in the Payments Remittance Message (X12 HIX 820) section of the REGTAP library. (REGTAP FAQ Database - FAQ 200 Updated 1-31-17 2017--00300 #14643 01/20/16) Q: What do the Centers for Medicare Medicaid Services (CMS) use for its member- matching logic? A: CMS uses Quatro Key which matches Subscriber ID, Member ID, Line of Business, and Health Insurance Oversight System (HIOS) ID. (REGTAP FAQ Database - FAQ #14645 01/20/16) Q: How do Stand Alone Dental Plans (SADPs) who not receive Advance Premium Tax Credit (APTC) payments provide enrollment data? A: SADPs in the FFM individual market provide enrollment data via 834 to CMS. SADPs should also submit Enrollment Payment Data Workbooks. (REGTAP FAQ Database - FAQ #14646 01/20/16) Q: Will the temporary payment adjustment have a unique Marketplace Payment Type Code? A: No, the temporary payment adjustment will have the payment type codes of APTC, CSR, and UF at the program level and will include a coverage period of January 1, 2016 to January 31, 2016 for the January payment cycle. Issuers may use the coverage period to distinguish the temporary adjustment from 2015 restatements. (REGTAP FAQ Database - FAQ #14648 01/20/16) Q: What kind of contact information do the Centers for Medicare Medicaid Services (CMS) collect for correspondence Dunning Letters)? A: CMS collects the following Financial Authority Contact information: name, title, phone number, and email address. Dunning Letters and other collections correspondence will be mailed to the billing address. If Issuers need to update Financial Authority Contact information, they may do so through the Financial Management Module in the Health Insurance Oversight System (HIOS). To ensure collections information is received on a timely basis, Issuers should verify that the billing address contains the complete street address where correspondence is delivered via the US. Postal Service. Additionally, Issuers should enter the name of the person who will be receiving the Dunning Letter in the Attn: ?eld. The Financial Management Module undergoes a blackout period between the 25th of each month through the 10th of the following month; therefore, all edits to Issuers' Vendor Records should be completed between the 11th and 24th of each month. (REGTAP FAQ Database - FAQ #14739 01/29/16) Q: How do Issuers verify charges sent in their Dunning Letters from data in the Enrollment and Payment Data Workbook that do not match the Issuer's system? A: Issuers should direct Enrollment and Payment Data Workbook inquiries, with their 5- digit issuer ID, to the Marketplace Payments inbox at The Centers for Medicare Medicaid Services 201 Updated 1-31-17 2017--00301 (CMS) will provide a response. (REGTAP FAQ Database - FAQ #14785 02/09/16) Q: How do Issuers verify charges sent in their Dunning Letters from data in the Enrollment and Payment Data Workbook that do not match the Issuer's system? A: Issuers should direct Enrollment and Payment Data Workbook inquiries, with their 5- digit issuer ID, to the Marketplace Payments inbox at The Centers for Medicare Medicaid Services (CMS) will provide a response. (REGTAP FAQ Database - FAQ #14785 02/09/16) Q: As an Issuer, we received a Dunning Letter an invoice) dated March 15, 2016 for the March payment cycle. However, we have since submitted data for the April payment cycle and we believe that our payment in April will exceed the amount of our March Dunning Letter. Instead of paying the amount in the Dunning Letter, can we wait for this amount to be netted from the April payment without incurring interest or administrative fees? A: The CMS netting process established pursuant to 45 CFR 156.1215 only occurs once every 30 calendar days at the time the payment amount is ?nalized for each Issuer and their af?liates under the same taxpayer identi?cation number. Additionally, the timing of netting varies based on the program type - Advance Payments of the Premium Tax Credit (APTC), Cost-sharing Reductions (CSR), Federally-facilitated Marketplace (FFM) User Fees, Risk Adjustment (RA) User Fees, RA, Reinsurance (RI), and Risk Corridors (RC). APTC, CSR, FFM user fee and RA User Fee charges are netted from payments 15 calendar days after the date of the Dunning Letter. RA and RC charges, as well as RI contribution amounts owed, are netted from payments 30 calendar days after the date of the Dunning Letter. For example, an APTC, CSR, FFM User Fee or RA User Fee amount included in a Dunning Letter dated March 15, 2016 that has not been paid by March 30, 2016 will be netted against any payments owed to the Issuer during the April payment cycle on April 15, 2016. An RA, RI or RC amount included on a Dunning Letter dated March 15, 2016 that has not been paid by April 15, 2016 will not be netted during the April payment cycle. Rather, because CMS permits Issuers 30 calendar days amounts re?ected in Dunning Letters, the netting of these amounts would not occur until the May payment cycle. CMS encourages Issuers to pay the amounts due as re?ected in the Dunning Letter, rather than waiting for the next month's netting process. If the full amount is not paid within 30 calendar days from the date of the Dunning Letter, the amount owed will be considered a debt, per 45 CFR At that point, pursuant to 45 CFR 30.18, CMS can assess interest, administrative costs and late payment penalties. To avoid these penalties, Issuers are encouraged to make timely payments of all Dunning Letters rather than waiting for amounts due to be netted from the following month's payment. In cases where Dunning Letter payments and CMS netting overlap, CMS will refund excess receipts as part of the following month's netting process. (REGTAP FAQ Database - FAQ #14818 02/18/16) Q: Can the Centers for Medicare Medicaid Services (CMS) explain when an Issuer will receive a Dunning Letter an invoice) for Federally-facilitated Marketplace (FFM) User Fees, Advanced Payments of the Premium Tax Credit (APTCs) or Cost-sharing Reductions 202 Updated 1-31-17 2017--00302 A: Issuers will receive a Dunning Letter if an Issuer owes FFM User Fees that are not fully netted from APTC and CSR payments; or an Issuer received an overpayment of APTC and/or CSR funds based on restated data in a subsequent month?s Enrollment Payment Data Workbook that is not fully netted by additional payments made in the current month. (REGTAP FAQ Database - FAQ #14819 02/18/16) Q: Will Issuers continue to submit manual workbooks for 2016 data after April? A: Yes, in addition to submitting any 2015 restatements in manual workbooks, all Issuers should continue submitting 2016 manual workbook in April and future months. CMS will notify Issuers when 2016 manual workbooks submissions are no longer required. (REGTAP FAQ Database - FAQ #14820 02/18/16) Q: What do the qualifiers and reference on the HIX 820 Transaction? A: On the HIX 820 Transaction, stands for administrative charges, stands for interest charges and stands for penalties. (REGTAP FAQ Database - FAQ #15511 04/18/16) Q: Should Issuers reject a HIX 820 transaction if the file does not contain a Federally- facilitated Marketplace (FFM) Policy ID for a payment? A: No. The Preliminary Payment Report (PPR) and HIX 820 transactions are generated anytime there are program or policy-level payments to the Issuer. Program-level payments will never include an FFM Policy ID. (REGTAP FAQ Database - FAQ #15514 04/18/16) Q: Will the Centers for Medicare Medicaid Services (CMS) calculate the 25 percent variance between the Manual Payment Process and Policy-based Payments (PBP) process for the year-to-date (YTD) or month by month? A: CMS will base the 25 percent cap on variation between the Payment Process and PBP process on the total Year-to-Date (YTD) payments. (REGTAP FAQ Database - FAQ #15517 04/18/16) Q: Will the macro that the Centers for Medicare Medicaid Services (CMS) will embed into the Dispute and Discrepancy Resolution Form generate .PSV files automatically? A: The macro is presently in development and is intended to be included in a future version of the Payment Dispute form. (REG TAP FAQ Database - FAQ #15464 05/18/16) Q: How do Issuers distinguish between Enrollment and Payment dispute response files? A: We are aware of the problem that this file naming convention is causing for issuers and are actively exploring a solution. (REGTAP FAQ Database - FAQ #15465 05/18/16) Q: Will the Centers for Medicare Medicaid Services (CMS) accept an Issuer's Payment Dispute Form if the Exchange Assigned Policy IDs do not match the Exchange Assigned Policy IDs reported in the Preliminary Payment Report 203 Updated 1-31-17 2017--00303 A: On the Payment Dispute form, Issuer Assigned Subscriber ID (F6) should align with the value submitted on the most recent RCNI. (REGTAP FAQ Database - FAQ #15466 05/18/16) Q: Can the Centers for Medicare Medicaid Services (CMS) confirm the maximum character limit for the payment cycle month on the disposition error code form? A: On the Payment Dispute form, Payment Cycle Month (F5) should be formatted as 201604) and should directly correspond to the field from either the PPR (Element B5 in the PPR schema) or the HIX 820 (Element BPR16) which is the basis for the dispute. (REGTAP FAQ Database - FAQ #15467 05/18/16) Q: Must Issuers compare the Health Insurance Caseworker System (HICS), the RCNO File and other items before conducting discrepancy reporting? A: The Centers for Medicare Medicaid Services (CMS) has not announced a deadline for Payment Dispute submissions at this time but will give advance notice of when the deadline will be enforced. Payment disputes should cite relevant HICS cases when known, and issuer values supplied on the Payment Dispute form should align with the values supplied on their most recent RCNI. (REGTAP FAQ Database - FAQ #15468 05/18/16) Q: How do Issuer ascertain the amounts deducted from their HIX 820 transaction by the Department of Treasury? A: When the Department of the Treasury subtracts a debt owed from an Issuer's deposit it is called a Treasury Offset. In such a situation, the amount deposited into an Issuer's account and the amount represented in the HIX 820 transaction would not be equal. Issuers should send an email to including their payee group number and name to request that CMS provide them with Treasury Offset information for the month in question. (REGTAP FAQ Database - FAQ #16455 06/20/16) Q: Can health insurance companies make requests regarding the order in which their Issuer receive reimbursements stemming from the Religious Accommodation User Fee Reimbursement? A: There is no process for issuers to directly request HHS to allocate the user fee adjustment to FFM issuers in a certain order. However, for FFM issuers in the same payee group, HHS allocates the adjustment across all FFM issuers in the payee group in a manner that maximizes the impact of the adjustment. As stated in a FAQ, available at: FFM issuers that qualify to receive the adjustment, and that have unpaid adjustment amounts, may enter into an agreement with another FFM issuer in order to more quickly realize the full effect of the adjustment. (REG TAP FAQ Database - FAQ #16456 06/20/16) Q: When will the Centers for Medicare Medicaid Services (CMS) no longer accept Enrollment Payment Data Workbooks through email? 204 Updated 1-31-17 2017--00304 A: The August 2016 Payment Cycle will be last time issuers may submit the Enrollment Payment Data Workbook to the marketplace mailbox. All SBMs and SBM issuers must be ready to submit their workbooks using Electronic File Transfer (EFT) for the September 2016 Payment cycle. (REGTAP FAQ Database - FAQ #16685 09/09/16) Reconciliation of the CSR Component of Advance Payments for Benefit Years 2014 2015 Q: Will CMS require issuers to provide data on premiums for the applicable benefit year during CMS's April 2016 data collection for reconciliation of the cost-sharing reduction portion of advance payments? A: No. Premium data is not required to calculate reconciled cost-sharing reduction amounts. Therefore, in recognition of issuers' system challenges this first year of operations, issuers are not required to provide information on premium as part of their data submission in April 2016 for reconciliation of the cost-sharing reduction portion of advance payments. CMS will update instructions to issuers to re?ect this change. (REGTAP FAQ Database - FAQ #14760 02/04/16) Q: What changes did CMS make to the final Manual for Reconciliation of the Cost-sharing Reduction (CSR) Component of Advance Payments for Bene?t Years 2014 and 2015? A: In the ?nal manual, CMS added material on reporting policies in the case of gaps in coverage and changes in plan, instructions on how to account for State subsidy wraps and coordinated bene?ts, and made minor clarifying changes throughout. The guidance expands on the claims run-out period and how issuers should handle 2014 claims remaining after the deadline for CSR reconciliation. The ?nal manual adds a REGTAP link to an Excel example of re-adjudication of claims for the simplified methodology, clari?es who may sign an attestation, and removes two (2) data elements - ?Total Annual Premium? and ?Total Premium", which are not needed for the calculation of CSR provided. We incorporated and provided links to FAQs published on REGTAP and final technical specifications. (REGTAP FAQ Database - FAQ #15268 03/24/16) Q: Please clarify 'natural order' for retroactively processed Cost-sharing Reduction (CSR) claims, since REGTAP FAQ 15458 and 15460 seem contradictory? A: The guidance from the Centers for Medicare Medicaid Services (CMS) on the re- adjudication of claims (November 17, 2014) applies to the retroactive adjustment of CSR amounts for enrollees who were not provided correct amounts of reduced cost-sharing. The purpose of retroactive re-adjudication is to correct accumulators and refund enrollees, if applicable. Therefore, when subsequently re-adjudicating re-processed claims for the purpose of CSR reconciliation, issuers must follow the corrected order of claims and accumulators, (when cost-sharing should have been incurred) and not the date when the issuer reprocessed the claims to correct errors. (REGTAP FAQ Database - FAQ #15813 05/03/16) Q: Pursuant issuer may file a request for reconsideration within 60 calendar days of the date of the notification of the Cost-sharing Reduction (CSR) reconciliation payment or charge to contest a processing error by the Department of Health and Human Services (HHS), HHS's incorrect 205 Updated 1-31-17 2017--00305 application of the relevant methodology, or HHS's mathematical error only with respect to the amount of a reconciliation payment or charge for CSRs for a benefit year. What is the date that the the Centers for Medicare Medicaid Services (CMS) will permit issuers to file a request for reconsideration? A: CMS will permit issuers to request reconsideration starting Thursday, June 30, 2016 related to the amount of a reconciliation payment or charge for CSRs for the 2014 and 2015 Bene?t Years. Issuers have 60 calendar days to file a request for reconsideration; as such, all requests must be submitted no later than 11:59pm. EST on Monday, August 29, 2016, and reconsideration requests after this deadline will not be considered. CMS will issue future guidance at a later date on how to ?le a request for reconsideration. Any issuer filing an appeal is strongly encouraged to file a discrepancy in order to permit CMS to work with the issuer to resolve the dispute outside the formal administrative appeals process. CMS issued FAQ 16488 regarding the CSR reconciliation discrepancy reporting process. If an issuer ?les a discrepancy and requests reconsideration on the same issue and the discrepancy process resolves the issue, we ask that the issuer withdraw its appeal by contacting (REGTAP FAQ Database - FAQ #16492 06/23/16) Q: The March 16, 2016, Manual for Reconciliation of the Cost-Sharing Reduction Component of Advance Payments for Benefit Years 2014 and 2015 states that recognizes that in this first year of reconciliation, a few issuers may not have fully anticipated the results of the reconciliation, and could be charged amounts they did not fully expect and cannot immediately pay. In such an event, if circumstances warrant, CMS is willing to work with the issuer on repayment (but would require that the full amount of these charges eventually be paid) consistent with applicable law.?1 How can an issuer request such an accommodation? A: CMS will consider providing flexibility on the payment schedule for reconciliation of the cost-sharing reduction component of advance payments to assist issuers with cash ?ow constraints, to ensure they may continue to provide coverage to enrollees through the end of the bene?t year. To request such ?exibility, an issuer must email CSRrepayment@cms.hhs.qov no later than 11:59 pm. ET on Tuesday, July 5, 2016. With that request, the issuer must provide CMS with detailed ?nancial statements and projections, and must inform its State Department of Insurance that it has requested this ?exibility. If the issuer meets the requirements for this flexibility, it must enter into a payment agreement re?ecting the terms of that payment schedule with CMS no later than 11:59 pm. ET on Tuesday, July 12, 2016. The payment schedule will require the payment of interest, in accordance with 45 CFR 30.18. (Alternative Schedule for Payment of Charges for Reconciliation of the Cost-sharing Reduction Portion of Advance Payments for the 2014 and 2015 Benefit Years (06/17/16)) Q: How can issuers file a discrepancy related to their Cost-sharing Reduction (CSR) reconciliation data submitted for the 2014 and 2015 Benefit Years? A: An issuer will be permitted to file a discrepancy beginning June 23, 2016 using the technical specifications on discrepancy submission published by the Centers for Medicare Medicaid Services (CMS), available at: 206 Updated 1-31-17 2017--00306 Issuers are encouraged to submit a discrepancy as soon as possible and prior to filing a request for reconsideration as explained in FAQ 16489. No discrepancy or request for reconsideration will be accepted after 11:59 pm. EST on Monday, August 29, 2016. Issuers who identify data discrepancies related to Quali?ed Health Plan (QHP) ID errors, Exchange Subscriber ID errors, or errors related to the amount of Cost-sharing Reductions (CSRs) that an issuer provided at the policy level, including, for example, ?awed issuer calculations or lost data, should submit data related to their discrepancy in a pipe-delimited file through electronic file transfer (EFT). CMS will only accept data discrepancies for data that directly impacts the calculation of the issuer's reconciled CSR amounts. At the same time as the discrepancy window is opened, CMS will publish a technical specification document outlining the format of the file, which generally will be similar to the file format used for submission of the 2014 and 2015 CSR reconciliation data ?le. We note that all issuers will be noti?ed of CSR reconciliation payments or charges by June 30, 2016, regardless of whether a discrepancy has been filed or resolved. If a discrepancy results in a payment or charge adjustment following the June 30, 2016 calculation, CMS will make this adjustment in a payment cycle following the decision. Any issuer that does not file a discrepancy will be deemed as accepting their ?nal data submission for CSR reconciliation for the 2014 and 2015 Benefit Years (as applicable) and CMS will use this ?nal data submission to calculate final CSR reconciliation payments or charges and will notify issuers by June 30, 2016 of their final CSR reconciliation payments or charges. We note that, pursuant to the Manual for Reconciliation of the CSR Component of Advance Payments for Bene?t Years 2014 and 2015, issuers also may submit additional 2015 data that becomes available after CSRs have been reconciled for the 2015 Bene?t Year, during the 2016 CSR reconciliation reporting year cycle, in the spring of 2017*. In rare circumstances, CMS may make limited exceptions to allow issuers to submit additional 2014 data during the same 2016 CSR reconciliation reporting cycle. CMS will issue guidance on the process for the 2016 CSR reconciliation cycle at a later date. See page 6 of the Manual for Reconciliation of the CSR Component of Advance Payments for Bene?t Years 2014 and 2015 and FAQs 14904, 14905, and 15457 available on (REGTAP FAQ Database - FAQ #16488 06/24/16) Q: What is the process for issuers to ?le a discrepancy related to their Cost-sharing Reduction (CSR) reconciliation data submitted for the 2014 and 2015 Benefit Years? Updated 1-31-17 A: An issuer will be permitted to ?le a discrepancy beginning June 23, 2016 using the technical specifications on discrepancy submission published by the Centers for Medicare Medicaid Services (CMS), available at: Issuers are encouraged to submit a discrepancy as soon as possible and prior to filing a request for reconsideration as explained in FAQ 16489. No discrepancy or request for reconsideration will be accepted after 11:59 pm. EST on Monday, August 29, 2016. 207 2017--00307 Issuers who identify data discrepancies related to Quali?ed Health Plan (QHP) ID errors, Exchange Subscriber ID errors, or errors related to the amount of Cost-sharing Reductions (CSRs) that an issuer provided at the policy level, including, for example, ?awed issuer calculations or lost data, should submit data related to their discrepancy in a pipe-delimited file through electronic file transfer (EFT). CMS will only accept data discrepancies for data that directly impacts the calculation of the issuer's reconciled CSR amounts. At the same time as the discrepancy window is opened, CMS will publish a technical specification document outlining the format of the file, which generally will be similar to the file format used for submission of the 2014 and 2015 CSR reconciliation data ?le. We note that all issuers will be noti?ed of CSR reconciliation payments or charges by June 30, 2016, regardless of whether a discrepancy has been filed or resolved. If a discrepancy results in a payment or charge adjustment following the June 30, 2016 calculation, CMS will make this adjustment in a payment cycle following the decision. Any issuer that does not ?le a discrepancy will be deemed as accepting their ?nal data submission for CSR reconciliation for the 2014 and 2015 Benefit Years (as applicable) and CMS will use this ?nal data submission to calculate final CSR reconciliation payments or charges and will notify issuers by June 30, 2016 of their ?nal CSR reconciliation payments or charges. We note that, pursuant to the Manual for Reconciliation of the CSR Component of Advance Payments for Bene?t Years 2014 and 2015, issuers also may submit additional 2015 data that becomes available after CSRs have been reconciled for the 2015 Bene?t Year, during the 2016 CSR reconciliation reporting year cycle, in the spring of 2017. In rare circumstances, CMS may make limited exceptions to allow issuers to submit additional 2014 data during the same 2016 CSR reconciliation reporting cycle. CMS will issue guidance on the process for the 2016 CSR reconciliation cycle at a later date. See page 6 of the Manual for Reconciliation of the CSR Component of Advance Payments for Benefit Years 2014 and 2015 and FAQS 14904, 14905, and 15457 available on (REGTAP FAQ Database - FAQ #16491 06/24/16) Q: Should issuers submit additional 2015 claims data that becomes available after the cost-sharing reductions portion of advance payments have been reconciled for the 2015 benefit year as part of the discrepancy reporting process in the summer of 2016? If additional claims data is available for 2014 benefit year claims, or the value of 2014 claims has changed due to re-adjudication, should issuers use the discrepancy reporting process in the summer of 2016 to submit additional 2014 benefit year claims data? Updated 1-31-17 A: Pursuant to the Manual for Reconciliation of the Cost-sharing Reduction (CSR) Component of Advanced Payments for Bene?t Years 2014 and 2015, issuers may submit additional 2015 data that becomes available after the cost-sharing reductions portion of advance payments have been reconciled for the 2015 Bene?t Year, during the 2016 cost-sharing reduction reconciliation reporting year cycle, in the spring of 2017. Issuers should not use the discrepancy reporting process to submit newly settled 2015 claims. Instead, issuers should submit these new or revised claims amounts in the 2016 cost-sharing reduction reconciliation cycle. 208 2017--00308 Issuers that have additional or revised 2014 bene?t year claims should use the discrepancy reporting process to re-adjudicate and submit policies with those new claims. CMS will not permit issuers to submit additional 2014 data during the 2016 cost- sharing reduction reconciliation reporting cycle, except in very limited circumstances. CMS will issue guidance on the data submission for the reconciliation of the cost-sharing reduction portion of advance payments for the 2016 benefit year at a later date. (REGTAP FAQ Database - FAQ #16720 07/15/16) Q: Under what circumstances will the Centers for Medicare Medicaid Services (CMS) permit issuers to submit additional reconciliation data for 2014 benefit year cost-sharing reductions A: Cost-sharing reduction reconciliation data submission for the 2014 bene?t year closed on June 3, 2016. Issuers should use the discrepancy process to report information the issuer believes affects the accuracy of its 2014 benefit year CSR reconciliation data submission. The deadline for ?ling discrepancy reports for the 2014 benefit year CSR reconciliation data is August 29, 2016. As stated in REGTAP FAQ 15396, CMS will permit issuers to restate 2014 CSR reconciliation data during the data submission cycle for the 2016 bene?t year (Spring 2017) only because of unusual circumstances, such as outstanding appeals or legal issues. CMS will not accept restatements of 2014 CSR data in Spring 2017 to correct for routine restatements or issuer error. Prior to submitting new data that modi?es the amount of CSRs provided for a policy, issuers must adjudicate the new claim and all other claims on the policy, as applicable, and re-adjudicate all such claims using CMS methodologies and re-adjudication guidelines to determine the accurate amount of CSR provided. See Guidance/Downloads/CMS Guidance on CSR Reconciliation- for 2014 and 2015 bene?t REGTAP FAQ Database - FAQ #17238 08/17/16; also released as a stand-alone FAQ titled ?Deadline for Restatements of CSRs Provided in the 2014 Bene?t Year, at reqtap.info/uploads/library/F FA 5CR 081716.pdf) Reporting of Cost-sharinq Reductions (CSRs) Q: Is there a de minimis for CSR reconciliation? A: Issuers who received advance payments must reconcile those amounts by submitting data to calculate what the issuer provided in cost-sharing reductions for enrollees as required under 45 CFR 156.430. There is no de minimis for CSR reconciliation. Pursuant to our regulations, HHS will reconcile CSRs provided against the CSR portion of advance payments for every issuer that received advance payments in the bene?t year (irrespective of the issuer?s enrollment or the amount of advance payment). (REGTAP FAQ Database - FAQ #14871 02/23/16) Q. If a CSR plan does not enroll any members during the benefit year, are issuers required to submit data for that plan? A: No, if an issuer did not have any enrollment in either a CSR plan variation in the 2014 or the 2015 benefit years, the issuer is not required to submit data for CSR 209 Updated 1-31-17 2017--00309 reconciliation. (REGTAP FAQ Database - FAQ #14872 02/23/16) Q: What do the marketplace payment type codes and represent in the HIX 820 transaction? A: The marketplace payment type code stands for administrative charges. The marketplace payment type code stands for interest charges. (REGTAP FAQ Database - FAQ #15169 03/17/16) Q: How will an issuer with de minimis enrollment in Cost-sharing Reduction (CSR) plans that elects not to submit reconciliation data repay the full amount to the Centers for Medicare Medicaid Services A: CMS will net the advance payment amount from the issuer in the August 2016 payment cycle and invoice the issuer for any remaining balance. (REGTAP FAQ Database - FAQ #15266 03/24/16) Q: For the data element, ?Total Number of Exchange Subscriber IDs in this Plan: Enter the total count of unique Exchange subscriber IDs in this plan variation for the benefit year,? should issuers include subscribers who did not have any claims or claims with Cost-sharing Reductions A: For this data element, issuers should only include Subscriber IDs for which the issuer is also submitting data. Likewise, if an issuer aggregates two (2) subscriber IDs into one (1) policy report, the issuer should report only one (1) Subscriber ID. The count of Subscriber IDs should equal the number of reports ?led in the policy (03) level report. (REGTAP FAQ Database - FAQ #15267 03/24/16) Q: Can issuers submit zero (0) dollars for Cost-sharing Reductions (CSR) provided for de minimis enrollment in certain plans (for example, American Indian/Alaska Native populations in bronze plans)? A: If an issuer has few enrollees or enrollees with few or no CSR claims in any plan variation including the zero (0) and limited cost-sharing plans during a bene?t year, the issuer may elect to reimburse the Centers for Medicare Medicaid Services (CMS) the full advance payment amount for those plans rather than re-adjudicate such claims. If an issuer elects to repay the entire CSR component of advance payments for a particular Qualified Health Plan (QHP), the issuer should email Failure to submit a report for a plan will not trigger an error; however, CMS will automatically calculate zero (0) for CSRs provided for the plan, and issuers will be charged the full amount of the advance payment they received for the applicable benefit year. Repayment of the full advance payment does not change the issuer's obligations under 45 CFR 156.480 to adhere to, and ensure that any relevant delegated entities and entities adhere to, the standards set forth in ?156.705 concerning maintenance of documents and records, whether paper, electronic, or in other media, by 210 Updated 1-31-17 2017--00310 issuers offering QHPs in a Federally-facilitated Exchange, in connection with the advance payment of cost-sharing reductions and premium tax credits. Additionally, as provided under issuers that offer a QHP in the individual market through an Exchange are subject to audit by the Department of Health and Human Services (HHS) or its designee to assess compliance with the relevant requirements regarding CSRs. (REGTAP FAQ Database - FAQ #15270 03/24/16) Actuarial Value Methodology Q: For plans with both family and single coverage, where family coverage has an internal out-of-pocket maximum for a member, do we apply the simplified actuarial value formula at the member or policy level? A: Issuers should apply the policy level annual limitation on cost sharing for the standard plan when using the simpli?ed actuarial value formula. For family coverage with embedded individual limits, the annual limitation on cost sharing for the standard plan is the family annual limitation. For single coverage, issuers should use the self-only annual limitation on cost sharing for the standard plan. (REGTAP FAQ Database - FAQ #14873 02/23/16) Q: What should issuers using the simplified AV method enter for CSRs provided for a policy when the result of the calculation is negative? A. In situations where the standard plan cost sharing is less than the cost-sharing reduction amount provided, issuers using the simplified AV method should enter a negative number. (REG TAP FAQ Database - FAQ #14874 02/23/16) Q: Are plans that elected to use the simplified AV method required to submit Attestation Form A: If the issuer is using the simpli?ed AV method exclusively for all plan variants and has no parameters to report, then, the issuer is not required to fill out Form C. If the issuer has parameters for any of its plan variants, it must submit Form C. (REGTAP FAQ Database - FAQ #14875 02/23/16) Q: Are plans that elected to use the simplified AV method required to submit Attestation Form A: If the issuer is using the simpli?ed AV method exclusively for all plan variants, the issuer must complete ?Attestation for AV Plans? - Tab 3 of Form C, which requires issuers using the AV method to list their QHPs. If the issuer has no parameters to report, the issuer is not required to ?ll out the other Form tabs for parameters and attestations. (REGTAP FAQ Database - FAQ #14875 03/21/16) Q: If an enrollee changes from a CSR-eligible plan to a non-CSR-eligible plan during the plan year and has claims under each plan, how do issuers apply the out of pocket maximum for the calculation for the simplified AV method? A: Issuers should only report claims for the time for which an enrollee was enrolled in a CSR-eligible plan. (REGTAP FAQ Database - FAQ #14876 02/23/16) 211 Updated 1-31-17 2017--00311 Q: Are issuers required to submit any additional materials if they selected the simplified AV method for benefit years 2014 and 2015? A: Yes. Issuers who selected the simplified AV method for the 2014 and 2015 bene?t years need to submit data files and attestation forms in accordance with the requirements documented in the CSR Reconciliation Issuer to MIDAS Inbound Specification documents. (REGTAP FAQ Database - FAQ #14877 02/23/16) Q: Are issuers required to submit data for the on-Exchange standard plan (01 plan variant) even though there are no CSRs provided for that plan variant? A: No. Claims for the associated standard plan are only used in estimating parameters for the simplified methodology, and are not used as a basis for reconciliation. (REGTAP FAQ Database - FAQ #14878 02/23/16) Q: In REGTAP FAQ 14874, CMS noted that issuers using the simplified Actuarial Value (AV) methodology should enter a negative number for CSR provided for a policy when the standard plan cost-sharing is less than what the enrollee paid. Should issuers also enter a negative amount when the standard plan cost-sharing is less than the amount the enrollee paid when using the standard methodology? A: For the standard methodology as well as for the simplified methodology, if the standard plan cost-sharing (312) is less than the cost-sharing paid by the enrollee, for example when the enrollee shifts to a more generous plan variation during the year, the issuer should enter the negative amount of CSR provided (313). (REGTAP FAQ Database - FAQ #15269 03/24/16 Q: When aggregating self-only and other than self-only policies after a change in circumstance, page 16 of the CMS reconciliation manual states that an issuer should aggregate the two (2) policies into one (1) report and calculate separate effective cost- sharing parameters for self-only coverage and other than self-only coverage for the plan variation. Does this also apply to the simplified actuarial value methodology? What if the issuer does not have separate effective cost sharing parameters for self-only and other- than-self? A: Yes, this does apply to the Simpli?ed Actuarial Value (AV) method. Issuers should aggregate policies that change from self to other than self-only in the same variation when using the simplified AV methodology, regardless of whether they calculate separate effective cost-sharing parameters for self-only coverage and other than self- only coverage. (REGTAP FAQ Database - FAQ #15390 04/05/16) Q: At what level should the Simplified Actuarial Value (AV) method formula apply for plans with embedded out-of-pocket limitations? A: The annual limitation used in the simplified AV methodology calculation is always the annual limitation of the policy level, (for example, other than self-only for the standard 212 Updated 1-31-1 7 2017--00312 plan). As discussed on p. 23 of the CSR reconciliation manual for 2014 and 2015 bene?t years, ?Issuers must use the other than self-only annual limitation on cost sharing for the standard plan for family plans with embedded individual limits." (REGTAP FAQ Database - FAQ #15391 04/05/16) Q: When standard plans have separate deductibles for Medical and Rx, but the annual out-of-pocket (OOP) maximums to Medical and RX is combined, how do you develop the separate parameters for Medical and Rx? A: When developing parameters for medical and pharmaceutical claims with separate OOPS but a combined deductible, issuers should develop effective parameters for the following subgroups: medical claims toward deductibles/combined medical pharmaceutical Maximum Out-of-pocket (MOOP) and pharmaceutical claims toward deductible/combined medical pharmaceutical MOOP. (REGTAP FAQ Database - FAQ #15392 04/05/16) Q: When using the Simpli?ed Actuarial Value (AV) method, should we pro-rate the annual limitation of cost sharing for members who are not active for the full plan year? For example, if a member is only active for 8 months should we multiply the out of pocket maximum by 8/12ths? A: Issuers must use the actual annual limitation on cost sharing for the plan in the equation for the AV methodology, regardless of whether a member is enrolled for less than the full bene?t year. (REGTAP FAQ Database - FAQ #15452 04/13/16) Q: What should issuers do if they wish to return advance payments? A: If an issuer wishes to return the entire Cost-sharing Reduction (CSR) portion of advance payments for all its Qualified Health Plans (QHPs), please email CMS as under the email subject line: RETURN ADVANCE PAYMENT FOR HIOS ID Please include your 5-digit HIOS issuer ID in the email subject line. In this event, you do not have to submit a cost-sharing reduction reconciliation report for that HIOS ID. If the issuer wishes to return advance payment for some but not all its QHPs, the issuer may simply omit the particular plan or policy information for plans and policies for which it will be returning advance payments when submitting its full CSR reconciliation data file. (REGTAP FAQ Database - FAQ #15575 04/19/16) Q: If a standard plan meets the membership credibility standard but has no claims subject to a deductible in its plan design, may the issuer use the Simplified Actuarial Value (AV) method instead? Updated 1-31-17 A: If a standard plan bene?t design does not require members to meet a deductible, meaning there are no claims in which the issuer can calculate the effective deductible and other parameters required for the simpli?ed methodology, the issuer may use the AV simpli?ed methodology. (REGTAP FAQ Database - FAQ #15809 05/03/16) 213 2017--00313 Q: Related to excluding claims that are 100% covered preventive care) from total allowed costs, does this guidance apply only to the Standard Methodology or does it also apply to the Simplified Actuarial Value (AV) Methodology? The AV re?ects preventive care covered at 100% and excluding these claims from the total allowed creates a disconnect between the AV and our understanding of the Simplified AV Methodology. A: Issuers using the Simplified AV Methodology should include claims that are 100% covered in total allowed costs for Essential Health Benefits (EHB) when determining standard plan cost, since the actuarial value of a plan is calculated based on cost sharing for all services. (REGTAP FAQ Database - FAQ #15876 05/10/16) Q: If an issuer that previously selected the Simplified Methodology told the Centers for Medicare Medicaid Services (CMS) it would try the Standard Methodology but ultimately is able only to use the Simplified Methodology, what should the issuer do? A: Please email CMS at by Monday, May 30, 2016 or as soon as possible prior to the June 3, 2016 data submission deadline, so that the issuer's file will not be rejected. (REGTAP FAQ Database - FAQ #15815 05/03/16) Accounting for Non-issuer Enrol/ee Subsidies Q: How should issuers handle the state subsidy portion of an enrollee?s claim? A: The amount paid by an enrollee should include any portion of the enrollee's cost that is being paid by a state on behalf of the enrollee for the purpose of calculating CSR provided. The subsidy part of the enrollee?s cost should be included in the amount the enrollee paid, but should be excluded from the value of CSRs provided by the issuer. (REGTAP FAQ Database - FAQ #14879 02/23/16) Q: How do issuers submit data for reconciliation of state subsidies from State-based Marketplaces (SBMs) like California and Washington? A: The CSR portion of the advance payments is provided by the Federal government, irrespective of whether the issuer participates on the FFM or on an SBM. Some states may provide additional subsidies beyond the Federal subsidy that is provided Marketplace (FFM and SBM) issuers for enrollees in CSR plan variations. A state wrap subsidy amount should be included when reporting the amount the enrollee paid, but should be excluded from the value of CSRs provided by the issuer. This reporting requirement is the same for SBM issuers and FFM issuers. (REGTAP FAQ Database - FAQ #14880 02/23/16) Q: Does the actual amount paid for essential health benefits (EHBs) by enrollees reflect payments by enrollees for both federal and state wrap subsidies? A: The amount paid by an enrollee should include any portion of the enrollee's cost that is being subsidized by a State through a state subsidy wrap, but should not include the amount paid by the Federal government on behalf of an enrollee in a CSR plan variation offer through the Marketplace (FFM and SBM). (REGTAP FAQ Database - FAQ #14881 02/23/16) 214 Updated 1-31-17 2017--00314 Q: What if a state provides subsidies for EHB that are not allowed EHB under a certain plan? A: Issuers may not seek reimbursement for cost-sharing reductions on services not considered EHB. State subsidies for EHB that are not allowed under the plan must be reconciled separately with the FAQ Database - FAQ #14882 02/23/16) Q1: What happens if we receive reimbursement from a third party after a claim is adjudicated? Should claims that are paid by the Veteran's Administration and subsequently sent to the issuer for secondary payment be included in CSR Reconciliation? A1: Third party payments for a claim must be netted from the total allowed costs that the issuer or enrollee paid for EHB prior to re-adjudication of claims for a policy. If the issuer receives a third-party payment after the re-adjudication of a policy, the issuer must re- state and recalculate CSR provided for the policy. Issuers expecting a third party payment should wait until the payment is received before calculating CSR for that claim. (REGTAP FAQ Database - FAQ #15101 03/11/16) Accounting for Newborn Coverage Q: States have different regulations around newborn coverage and how long issuers must pay for newborns before they are added to a policy. Should issuers include claims for those newborns that qualify for payment under state regulations? Alternatively, should issuers exclude those newborn claims if that newborn is not added to the CSR policy for that period of time? Updated 01/13/17: As discussed in CMS quidance, ?Issuer Guidance on Payments for Unaffiliated Issuer Enrollments (UlEs)," Dec. 9, 2016-1 CMS considers newborn coverage in states that require issuers to cover newborns for some period of time (most commonly a without additional premium under the mother?s (or other subscriber?s) policy to be an extension of the mother?s coveraqe. Therefore, in states that require newborns to be covered under their mother's (or other subscribei?s) policy at no additional premium for a 215 Updated 1-31-17 2017--00315 period of time, all CSRs provided to the newborn for that period of time under the mother?s (or other subscriber's) policy will be eliqible for reimbursement throuqh the CSR reconciliation process. To be reimbursed for CSRs related to the provision of care for newborns in states that require coveraqe, all CSRs provided to the newborn durinq the required coveraqe period must be reported under the Exchanqe-assiqned subscriber ID of the primary policyholder.2 After the expiration of the required coverage period in states that require newborn coveraqe under the mother?s (or other subscriber?s) policy, and upon birth in all other States, newborns must be determined eliqible for CSRs and added to the subscriber?spolicy in order for an issuer to seek reimbursement for CSRs provided to newborns. Under 45 CFR 156.410, issuers will not be reimbursed for CSRs provided in error or to ineliqible enrollees. The subscriber must ?le a chanqe-in-circumstance to request addition of the newborn onto the policy before the FFM can determine eligibility. Therefore, if an issuer provided CSRs for a newborn that had not received an eliqibility determination from the FFM, the issuer would not be reimbursed for CSRs provided on behalf of the newborn, and would not be permitted to include the newborn claims in CSR reconciliation. We note that when chanqe-in-circumstance requests are late and eliqibility determinations are delayed, if the issuer voluntarily covers the newborn at standard cost- sharinq levels, and the FFM subsequently ?nds the newborn eliqible for CSRs, eliqibility would beqin at birth or as provided under 45 CFR (or after the expiration of the required newborn coveraqe). In such a case, the issuer would be required to re- determine and provide CSRs on eliqible claims for the newborn. The issuer would include any such CSRs provided as the result of a re- determination for the newborn when submittinq information for CSR reconciliation. 2016U EManualPaymentProcess 50R 12 0816.pdf 7-See ?Reconciliation of Cost-Sharinq Reductions Provided in States that Require Immediate Health Insurance Coveraqe for Newborns Under Existinq Contracts,? at 5CR 011217.pdf (REGTAP FAQ Database - FAQ #14883 02/23/16; updated 01/13/17) Essential Health Bene?ts (EHBs) Q: Are CSRs only applicable to EHBs as defined by the federal government, such that any cost sharing reduced for state-mandated EHBs should not be included in CSR reconciliation? A: Issuers may seek reimbursement for CSRs only for EHBs. Bene?ts in an EHB category that were required prior to December 31, 2011 are eligible for CSR subsidies. (REGTAP FAQ Database - FAQ #14884 02/23/16) Q5: Are State-mandated benefits eligible for reimbursement if they are included in the Essential Health Bene?ts benchmark plan for that State? Updated 1-31-17 216 201 7--00316 A5: Only bene?ts mandated by a State before Dec. 31, 2011 are considered EHB for the purpose of cost-sharing reductions. If the State required coverage for certain bene?ts after Dec. 31, 2011, regardless of whether such benefits are included in the State- selected benchmark plan, such benefits generally are not considered covered EHB for the purpose of CSRs, and CMS will not reimburse issuers for any CSR provided for such bene?ts. However, in the EHB Rule (78 FR 12837 through 12838), bene?ts required by a State through action taking place after Dec. 31, 2011 that directly apply to the QHPs are not considered EHB, unless enactment is directly attributable to State compliance with Federal requirements. Examples of such Federal requirements include: requirements to provide benefits and services in each of the 10 categories of requirements to cover preventive services; requirements to comply with the Mental Health Parity and Addiction Equity Act; and the removal of discriminatory ag limits from existing bene?ts. Additionally, the 2016 Notice of Bene?ts and Payment Policy speci?ed that a State may need to supplement habilitative services if the base-benchmark plan does not cover such services. We noted that if a State supplements the base-benchmark plan, the bene?t(s) added is EHB. Finally, a bene?t required only in the large group market and re?ected in a large group base-benchmark plan is not an EHB for QHPs offered in the individual or small group markets because such a bene?t requirement does not apply directly to those plans, and to the extent it is included in the base-benchmark plan, it may be substituted for, in accordance with Plans subject to the EHB requirements offered in the individual and small group markets in those States would have to be substantially equal to the base-benchmark plan, and therefore may cover the State-required benefit as EHB since it is embedded in the base-benchmark plan. In such a case, the bene?t is an EHB because it is covered by the base-benchmark plan. Since each State defines EHB within the federal parameters, based on the base benchmark plan that they select, issuers may contact the State Based Exchange or the State Department of Insurance for a list of State EHBS. Additionally, the EHBs for each State are listed on the CMS website: resources/ehb.html (REGTAP FAQ Database - FAQ #15105 03/11/16) Q: Do Cost-sharing Reduction (CSR) subsidies only apply to in-network Essential Health Benefits A: Plans are permitted to provide cost-sharing reductions on covered out-of-network EHB bene?ts, for example to simplify plan design. In such cases, the issuer is permitted to include these out-of?network EHB claims when calculating cost-sharing reductions provided. Additionally, in the zero cost-sharing plan for American Indians/Alaska Natives, enrollees pay no cost sharing for EHBs, in-network or out-of?network, as long as the associated standard plan also covers EHB out of network. If the standard plan does not cover EHB out of network, then CMS will not reimburse issuers for any cost-sharing reduction provided to an enrollee for such non-covered services. See 78 FR 15481 (March 11, 2013) for discussion of under which a plan is not required to count out-of-network cost sharing toward the annual limitation or reduced annual limitation on cost sharing. (REGTAP FAQ Database - FAQ #15119 03/21/16) Q: Are non-formulary drugs considered Essential Health Benefits 217 Updated 1-31-17 2017--00317 A: As stated in the Standards Related to Essential Health Bene?ts, Actuarial Value, and Accreditation Final Rule (78 FR 12834; February 25, 2013), plans are permitted to go beyond the number of drugs offered by the benchmark without exceeding EHB. Specifically, as discussed in the HHS Notice of Bene?t and Payment Parameters for 2016 Final Rule (80 FR 10750; February 27, 2015) under 45 CFR a health plan providing essential health bene?ts must have processes in place that allow an enrollee to request and gain access to clinically appropriate drugs not otherwise covered by the health plan and in the event that an exception request is granted, the plan must treat the excepted drug(s) as an essential health bene?t, including by counting any cost- sharing towards the plan's annual limitation on cost-sharing. In such cases, non- formulary drugs are also eligible for cost-sharing reduction reimbursement. (REGTAP FAQ Database - FAQ #15264 03/24/16) Claims with Coordination of Benefits (COB) Q: How should issuers handle claims with How should issuers account for COB amounts and other amounts that aren?t part of the member cost-share or the plan cost- share? Are they summed up in the allowed amount or should the allowed amount always be the sum of member cost-share plus the plan cost-share? A: Issuers should include claims with COB, and should apply the COB amounts consistently to standard plans and plan variations. For either methodology, the issuer would apply or include, as applicable, any amount the outside insurer paid for the (effective) cost of the bene?t when calculating what the enrollee would pay in the standard plan. Issuers must include the COB portion of the claim when reporting total allowed cost. (REGTAP FAQ Database - FAQ #14885 02/23/16) 06: Can you please clarify what we should be using to calculate the allowed amount, since CMS has said both that the coordination of benefit (COB) should be included in a claim and also, in the CSR Reconciliation Issuer to MIDAS Inbound Specification document, that the amount the enrollee(s) paid is the difference between the total allowed costs for EHB and the amount the issuer paid. Updated 1-31-17 A6: Issuers should reflect adjustments for COB claims when reporting total allowed costs. However, the amount paid by the issuer or by the enrollee would be reduced, as applicable, in both the standard plan and the plan variation by any amounts that have been paid by a third party. For example, if a claim costs $500, and the auto insurer pays the issuer $250, the total allowed cost for the claim is $250 in both the standard plan and the CSR plan. If the auto issuer also pays the enrollee's $10 cost sharing, the total allowed cost remains the same at $250, of which the issuer pays $240 and the (auto insurer on behalf of the) enrollee paid $10. (REGTAP FAQ Database - FAQ #15106 03/11/16) 218 2017--00318 Changes in Circumstance Q: How should an issuer reconcile a policy that changes from self-only to other than self- only? A: Issuers can refer to pages 9 and 14 of the CSR Draft Manual on CSR reconciliation for 2014 and 2015. In order to reconcile for Standard Methodology, in the case of a policy that switches from self-only to other than self-only or vice versa after a change in circumstances, such as marriage or death, and remains in the same QHP plan variation, or in the case of other changes of circumstance that result in multiple policies for the same subscriber in the same plan variation during the benefit year, an issuer using the standard methodology may aggregate the policies into one (1) policy report as long as the issuer calculates cost-sharing reductions provided separately, as necessary, under the appropriate parameters for each policy for the period the policy was in effect. In order to reconcile for the Simpli?ed Methodology, in the case of a policy that switches from self-only to other than self-only or vice versa after a change in circumstances, such as marriage or death, and remains in the same QHP plan variation, an issuer may aggregate the two policies into one 1) report if the issuer calculates separate effective cost-sharing parameters for self-only coverage and other than self-only coverage for the plan variation. In such a case, when a plan variation policy is self-only for part of the year, and then becomes other than self-only (or vice versa), the issuer should apply the set of effective cost-sharing parameters (or the AV method, one (1) minus the actuarial value of the standard plan) for the type of coverage for which the plan variation policy was for the greatest number of coverage months. If the type of coverage of the policy was evenly split, the QHP issuer should default to the other than self-only coverage effective cost-sharing parameters. See FAQ 11901 (August 8, 2015): (REGTAP FAQ Database - FAQ #14886 02/23/16) Q: Is the issuer required to aggregate data when a policy changes from self-only to other than self-only, or can issuers submit two (2) separate records for this member? A: If an enrollee changes policies under the same plan variant, the issuer should aggregate the experience of the enrollee for under one (1) policy record, and should combine the start and end dates for the policy. If the enrollee?s change in circumstance results in the enrollee switching to another plan variation, then the issuer should submit separate policy records for that member. (REGTAP FAQ Database - FAQ #14887 02/23/16) Gaps in Coverage Q: How should issuers report multiple policies for a single subscriber in a benefit year, and which Plan Benefit Start and End dates should be used when there are gaps in coverage for the same policy? Updated 1-31-17 A: For subscribers with multiple policies in the same plan variation (Le, a gap in coverage), issuers should aggregate the policies and ?le one (1) report under the plan variation using the first and last dates for which the policy was in effect. In the case of a subscriber who changed plan variations during the year, issuers must 219 2017--00319 reconcile cost-sharing reductions provided to that subscriber separately for each plan variation, using the applicable Start and End dates for each plan variation. (REGTAP FAQ Database - FAQ #14888 02/23/16) Q: For example, how should issuers report a scenario where a subscriber moves from plan variant 04 to 05 and then back to 04 again? Should this be two records or three (3) records? A: In this scenario, issuers would report as two (2) records. Issuers would report the 04 variant as one (1) record. The O5 variant would be reported as a separate record. (REGTAP FAQ Database - FAQ #14889 02/23/16) Continuity of Accumulators Q: For those CSR-eligible consumers with multiple policies, does the issuer need to demonstrate continuity of deductible and GOP amounts (accumulation transfers) (in accordance with Moreover, is that continuity reflected in the data? A: Issuers must transfer accumulators and then calculate CSRs provided based on transferred accumulators in accord with The CSRs provided and submitted by the issuer for these policies should re?ect the transfer of accumulators. All data submitted for reimbursement for cost-sharing reductions is subject to audit. (REGTAP FAQ Database - FAQ #14890 02/23/16) Q: During the February 10, 2016 webinar presentation, CMS said accumulators would follow the enrollee back and forth between plans if the change is within the same standard (base) plan and same QHP. Does this mean that an enrollee should not be switching between different standard plans? A: No, under 45 CFR 156.425(b) and CMS guidance (78 FR 15486), published March 11, 2013, issuers are required to carry over accumulators when enrollees move back and forth through plan variations and between the issuer and Medicaid during a bene?t year. Except for a gap caused by assignment to Medicaid/CHIP coverage, issuers are not required to carry over accumulators for an enrollee who dropped coverage or was terminated and later re- enrolled in the same or different plan variation or standard plan. We note that although the QHP issuer is not required to extend the continuity of deductibles and annual limitations on cost sharing policy to situations in which the individual changes QHPs, the QHP issuer is permitted to extend this policy, if this extension of the policy is applied across all enrollees in a uniform manner. (REGTAP FAQ Database - FAQ #14891 02/23/16) Re-adjudication of Claims for the Standard Methodology Q: CMS guidance says, ?issuers using the standard methodology are required to first set all accumulators to zero and then reprocess individual claims.? What do we do in states that require us to carry over the accumulator from the prior year? A: Setting accumulators to zero is required when re-calculating claims from multiple sources as per our November 17, 2014 guidance; however, state laws that require issuers to carry over the policy holder?s accumulators, if any, would continue to apply. Example: Enrollee paid $500 toward a $1,000 deductible and, as required by state law, 220 Updated 1-31-17 2017--00320 starts a new bene?t year with $500 deductible rather than a $1,000 deductible. Issuers using third party administrators to re-adjudicate claims would still set accumulators to zero, but for this policy, the deductible would be met at $500 rather than the plan?s original $1,000. Carryovers also must be reflected at the non-subsidized level in the standard plan to accurately determine how much the enrollee would have paid in the standard plan. (REG TAP FAQ Database - FAQ #14892 02/23/16) Q: Do issuers have flexibility in the order and batching they apply for re-adjudication of claims? A: CMS expects issuers to re-adjudicate claims in a manner resulting in cost-sharing reduction calculations approximating the amounts that would result if the claims were- adjudicated in the order in which the claims arose. On November 17, 2014, HHS published guidance on the re-adjudication of claims, which stated that when issuers re- adjudicate allowed costs against the standard plan, issuers using the standard methodology are, required to first set all accumulators to zero and then reprocess individual claims for each policy in their original order. Issuers using a third-party administrator (TPA)?which makes re-adjudication of claims in their natural order complex?may, after setting claims to zero, ?rst adjudicate all medical claims and then all pharmaceutical claims in a policy against the standard plan. These issuers may not process claims in any other order other than their original order. The process described in CMS guidance also applies to TPAs for other subsets of benefits. As applicable, 3 TPA should ?rst process medical claims, followed by pharmaceutical claims, and then any other subset of benefits, for example vision, dental, and substance use disorder bene?ts. These additional categories of claims should be re- adjudicated in the order that best approximates the natural order in which they were incurred, so that, for example, if a preponderance of vision claims pre-date claims for dental care, the vision claims group should be re-adjudicated before the dental claims. Finally, consistent with our expectation that the cost-sharing reduction reconciliation re- adjudication process under the standard methodology approximate the experience of an enrollee in the standard plan without cost-sharing reductions, and to ensure consistency for all enrollees from the claims re-adjudication process, when re-adjudicating claims under the standard methodology, issuers must re-adjudicate all of the enrollee?s claims against a standard plan's total allowed costs and then determine the amount of cost sharing for EHB, rather than re?adjudicate cost sharing solely for EHB claims. Please see Claims Readiudication Guidance 11031 4 5CR 111714.pdf (REGTAP FAQ Database - FAQ #14893 02/23/16) Q: Can the issuer re-adjudicate medical and pharmacy claims in temporal order and then re-adjudicate mental health benefits at the end if vendor data issues make it dif?cult to re-adjudicate the claims? Updated 1-31-17 A: Yes, an issuer using a third-party vendor after setting all accumulators to zero may re- adjudicate medical claims and pharmacy claims in temporal order, then re-adjudicate other subsets of claims such as those associated with mental health, in the order that best approximates their natural order if more mental health claims occurred in the beginning of the year, they should be re-adjudicated ?rst.) (REGTAP FAQ Database - 221 2017-?00321 FAQ #14894 02/23/16) Q: Will CMS provide issuers with specific CSR reconciliation scenarios? A: CMS may update the ?nal CSR Reconciliation Manual to provide a few general examples. However, due to the number of specific scenarios that may apply to individual issuers, CMS will be unable to provide specific scenarios that apply in every circumstance. Issuers should re-adjudicate their claims using a reasonable method that applies consistently to claims groups. CSR reconciliation data submissions may be subject to future audit. Please also see guidance at CSRSimpleMethodUpdate 50R 031114. p_df CSRSimpleMethodExample 5CR 03111 4.xlsx and examples at CSRSimpleMethodExample 5CR O31 114.x sx (REGTAP FAQ Database - FAQ #14895 02/23/16) Q: Will issuers have the option to readjudicate claims in chronological order regardless of claim type? A: Issuers that do not use a third party administrator may reprocess claims in their original order but must first set accumulators to zero. Please see CMS guidance at Claims Readiudication Guidance 11031 4 5CR 111714.pdf (REGTAP FAQ Database - FAQ #14964 02/2616) Q18: Will issuers have the option to re-adjudicate claims in chronological order regardless of claim type? A18: Issuers that do not use a third party administrator may reprocess claims in their original order but must first set accumulators to zero. Please see CMS guidance at 1714.9df (REGTAP FAQ Database - FAQ #14964 03/11/16) Q: For the standard methodology, the natural order of claims was described as temporal order when claims are received). Which is it, the date of service or the date that the claim was processed/paidlpresented? A: Claims for services provided in a particular benefit year must be re-adjudicated in the bene?t year plan structure in which the cost sharing was incurred regardless of when they are presented for payment. Therefore, issuers should adjudicate and re-adjudicate claims in the order that best approximates their natural order, e. 9, when cost sharing was incurred for a particular medical service. This may or may not coincide with the actual dates of service, for example, when coinsurance is assessed on a total bill rather than on a per-diem basis. (REGTAP FAQ Database - FAQ #15458 04/13/16) Cost-sharing De?nition Q: The CSR Reconciliation draft manual, Methodologies section, page 7, talks about balance billing. Can you please provide the CMS de?nition of balance billing? A: The CSR Reconciliation Manual draft manual on page 7 indicates that balance billing 222 Updated 1-31-17 2017--00322 is excluded from any re-adjudication of claims to determine cost-sharing reductions. Balance billing is the practice by doctors to bill patients for amounts not covered by the patient?s insurance, usually for an out-of?network covered benefit. Cost sharing does not include balance billing. Therefore, CMS will not reimburse issuers for any cost-sharing reductions provided for balance billing. (REGTAP FAQ Database - FAQ #14896 02/23/16) Cap/tated Plans Q: May issuers of capitated plans use an alternative method to calculate total allowed costs for A: Issuers, including issuers of capitated plans, may use plan-specific percentage estimates of non-EHB claims submitted on the Uniform Rate Review Template (URRT) or any other reasonable method to determine total allowed costs for EHB. (REGTAP FAQ Database - FAQ #14897 02/23/16) Q7: Does the total amount the issuer paid for Essential Health Benefits (EHB) include per-member-per-month payments (PMPM) by issuers for capitated arrangements, e.g. full medical, pediatric, dental, and vision benefits) and that issuers using such arrangements may estimate reasonable allowed amounts for associated encounters using their internal pricing methodology for such encounters. A7: Yes, the total amount the issuer paid for EHB may include a PMPM payment, if applicable. Issuers may use their internal pricing methodology to establish a cost of a medical service in a capitated pay arrangement. (REGTAP FAQ Database - FAQ #15107 03/11/16) Q8: What is stance on plans' inability to re-adjudicate capitated claims for the purpose of creating the base shadow claim? Is it acceptable to exclude capitated services from the reconciliation? A8: No. How the issuer pays for services does not affect whether or not cost-sharing reductions were provided. Services that the issuer pays for in a capitated manner should be included in cost-sharing reduction reconciliation by measuring what the enrollee paid in cost sharing for the service under the plan variation against what the enrollee would have paid for the service under the standard plan. (REGTAP FAQ Database - FAQ #15108 03/11/16) Attestations Q: Who within an issuer's organization should sign the attestation forms? A: For Attestation Forms A, B, and C, the actuary or an authorized delegate of the actuary must sign. For Form D, the chief financial of?cer and the chief actuary must sign. (REGTAP FAQ Database - FAQ #14898 02/23/16) Q: The claims re-adjudication process does not seem to be an actuarial function. Why do Updated 1-31-17 223 2017--00323 issuers need an actuary to sign Attestation Forms A and A: Many aspects of the claims re-adjudication process involve actuarial estimation or results. The issuer?s actuary may delegate the signature to the chief executive of?cer or other senior company of?cial as an authorized representative. (REGTAP FAQ Database - FAQ #14899 02/23/16) Q: Must issuers submit, and have their attestation forms approved, before data submission? A: No, but issuers should submit attestation forms at the same time that data files are submitted (either immediately before or immediately after the ?les are submitted). Data submissions that cannot be linked to a valid attestation will be rejected. (REGTAP FAQ Database - FAQ #14900 02/23/16) Q: On the Risk Corridors (RC)/medical loss ratio (MLR) form for benefit year 2014, if an issuer included the cost-sharing reduction portion of advanced payments, will CMS require the issuer to submit Attestation Form A: No, if the issuer submitted the actual advance payment amount (rather than a certified estimate) then the issuer does not have to submit Attestation D. (REGTAP FAQ Database - FAQ #14901 02/23/16) Advance Payments Q: Is advance payment data (Data Element ID 109, ?Total CSR Amount Advanced to the Issuer by required to be reported as part of the CSR reconciliation process? A: No, data element ID 109, ?Total CSR Amount Advanced to the Issuer by will be made this?is optional. If issuers receive an error, they should simply input zero (REGTAP FAQ Database - FAQ #14902 02/23/16; updated 01/13/17) Q: Will issuers continue to receive the cost-sharing reduction portion of advance payments for adjustments to 2014 and 2015 benefits after CSR reconciliation is complete? A: Issuers will not receive any cost-sharing portion of advance payments after CSRs for the applicable bene?t year have been reconciled. CMS intends to provide guidance on reconciling CSRs provided but not re-adjudicated in time to be included in the regular annual reconciliation cycle. (REGTAP FAQ Database - FAQ #14903 02/23/16) Claims Run-out Date Q: Is there a specific cutoff date for claims to be submitted on the file to What final business date should be used, Feb 29, 2016, March 31, 2016? A: Not at this time. Issuers may include late claims from services provided in the benefit year as close to the April 30 data submission deadline as is practical, as long as the issuer recalculates and restates all claims for the associated policy as necessary prior to a final re-adjudication of such claims for reconciliation. Our guidance speci?es that if issuers are unable to re-adjudicate fully claims incurred during the bene?t year by the 224 Updated 1-31-17 2017--00324 April 30, 2016 submission deadline, issuers may submit these claims in the next CSR reconciliation reporting cycle in April 2017. (REGTAP FAQ Database - FAQ #14904 02/23/16) Re-submission of 2014 Bene?t Year Claims Q: In REGTAP FAQ 11651 (August 22, 2015)3,[ CMS expects that all claims from the 2014 benefit year will be included in 2014 benefit year data submitted for cost-sharing reduction reconciliation on April 30, 2016. If an issuer is unable to re-adjudicate and submit 2014 claims by April 30, 2016 because of appeals or other complex circumstances may the issuer submit these claims during the 2017 cost-sharing reduction reconciliation cycle? A: Yes. Although CMS expects most claims from the 2014 bene?t year to be included in 2014 benefit year data submitted for cost-sharing reduction reconciliation on April 30, 2016, we recognize there may be delays caused by appeals and unusual circumstances. Issuers may continue to re-adjudicate and submit claims from 2014 during the 2017 reconciliation cycle. For any 2014 claims submitted in 2017, the issuer must recalculate and restate all claims for the associated policy against the standard plan as necessary prior to a ?nal re-adjudication of such claims for reconciliation. Such claims may not be re-adjudicated outside the associated policy or added to 2015 bene?t year claims. CMS intends to provide additional guidance on the restatement of claims for a prior bene?t year. (REGTAP FAQ Database - FAQ #14905 02/23/16) Data Submission Deadline Q: What is the deadline for CSR data file submissions for the 2014 and 2015 benefit years? A: The deadline for data submission for bene?t years 2014 and 2015 is April 30, 2016. CMS can accept data on a Saturday, but since April 30, 2016 falls on a Saturday, we will allow issuers to submit their ?les until Monday, May 2, 2016 at 11:59 pm. (REGTAP FAQ Database - FAQ #14906 02/23/16) Q: Will issuers submit CSR reconciliation data files on a basis, or is this a one (1)-time submission? A: This is an annual process. CMS will provide guidance on CSRs re-adjudicated after the close of data submission at a later date. (REGTAP FAQ Database - FAQ #14907 02/23/16) Q: Is there a minimum date in 2016 through which paid claims must be included for the April 30, 2016 Cost-sharing Reduction (CSR) Reconciliation data submission deadline? If so, what is that date? A: There is no minimum paid through claims date. Issuers may include late claims from services provided in the benefit year as close to the April 30 data submission deadline as is practical, as long as the issuer recalculates and restates all claims for the associated policy as necessary prior to a final re-adjudication of such claims for 3 225 Updated 1-31-17 2017--00325 reconciliation. Our guidance speci?es that if issuers are unable to fully re-adjudicate claims incurred during the bene?t year by the April 30, 2016 submission deadline, issuers may submit these claims in the next CSR reconciliation reporting cycle in April 2017. Further guidance on 2017 submissions will be provided at a later date. (REGTAP FAQ Database - FAQ #15120 03/11/16) Specifications Q: To whom will CMS distribute automated emails? A: Emails with summary error information and file submission status information will be sent to the technical point of contact (POC) indicated on the issuer?s data submission. (REGTAP FAQ Database - FAQ #14908 02/23/16) Q: Can issuers use a designated technical vendor/third party administrator (TPA) to submit CSR files on the issuers? behalf? A: The TPA may submit the ?les/forms on behalf of the issuer. However, the TPA will need to reference the issuer's Health Insurance oversight System (HIOS) ID and TPID when submitting data files and attestation forms. (REGTAP FAQ Database - FAQ #14909 02/23/16) Q: Who will receive communications from CMS if an issuer decides to use a TPA to submit CSR reconciliation data on their behalf? A: CMS will send con?rmation emails to the technical point of contact (POC) that has been reported as part of the CSR data submission for the issuer. (REGTAP FAQ Database - FAQ #14910 02/23/16) Q: Should State-based Marketplace (SBM) issuers submit data through the A: Yes, SBM issuers will also submit CSR data ?les and attestation forms through EFT. (REGTAP FAQ Database - FAQ #14911 02/23/16) Q: Should issuers that sell only on SBMs use the SBM Exchange assigned Subscriber A: Yes, issuers should include the SBM Exchange assigned Subscriber ID. While SBM issuers are required to report this Subscriber ID, the SBM Subscriber ID will not be validated by CMS. CMS only validates Exchange Subscriber IDs for FFM issuers. (REGTAP FAQ Database - FAQ #14912 02/23/16) Q: Can SBM issuers leave the Exchange-assigned Subscriber ID blank? A: No. Issuers should report the SBM exchange assigned Subscriber ID. The Exchange- assigned Subscriber ID (ID 302) is a mandatory data element (see page 8 of the CSR Reconciliation Issuer to MIDAS Inbound Speci?cation). (REGTAP FAQ Database - FAQ #14913 02/23/16) Q: Will CMS provide a template EFT file for issuers to submit? 226 Updated 1-31-17 2017--00326 A: A pipe-delimited ?le must be submitted through EFT. The draft file specifications that are posted on the Centers for Consumer Insurance and Information Oversight (CCIIO) website include an example of the pipe-delimited format. (REGTAP FAQ Database - FAQ #14914 02/23/16) Q: How do issuers gain access to the EFT location? A: Issuers should already have their EFT set up because of the HIX 820 process. Issuers should reach out to their technical point of contact (POC) for the HIX 820 process. Specific access and login information was provided to these contacts when the EFT route was set up. (REGTAP FAQ Database - FAQ #14915 02/23/16) Q: Do issuers need to do a separate submission for each HIOS plan ID or can we do one (1) submission that covers all HIOS A: Each issuer (5-digit HIOS issuer ID) submits its own file. That single ?le will contain information for all of the issuer's CSR plan variations (16-digit HIOS QHP ID) and the policies under that plan variant. Issuers should submit one (1) submission for the 2014 benefit year, and a separate submission for the 2015 benefit year. (REGTAP FAQ Database - FAQ #14916 02/23/16) Q: Is there a requirement to list Issuer Summary Records, Plan Information Records and Policy Information Records in a specific order in the pipe-delimited file? A: Issuers may list the records in any order as long as the Record level code (?Record Code") is accurate. For example, issuers could list Issuer Summary Records, then all Plan records, then all Policy records. Alternatively, issuers could list the Issuer Summary Record, the Plan Records, and the Policy Records for that Plan under each Plan Record. (REGTAP FAQ Database - FAQ #14917 02/23/16) Q9: If a policy has no claims or no claims eligible for cost-sharing reductions, what should the issuer do? A9: The issuer does not need to submit a report for a policy with no claims or cost- sharing reductions. Failure to report CSR amounts for each subscriber will not trigger an error. CMS will automatically calculate zero for CSRs provided for this policy. (REGTAP FAQ Database - FAQ #15109 03/11/16) Q10: If a QHP issuer has acquired another issuer and subsumed the issuer's policies under its own HIOS ID, should the issuer indicate that it has acquired and is reconciling here another HIOS lD's policies? A10: If the QHP issuer has changed the subscriber IDs and replaced the HIOS ID of the acquired issuer's business with its own, then the QHP issuer should answer Yes to the question of whether it merged with or subsumed another issuer and list the former HIOS ID of that issuer. (REGTAP FAQ Database - FAQ #15110 03/11/16) Q11: On the Issuer Summary Record, one of the required ?elds is 'lssuer Extract Time.? Can you please tell me the format in which data should be entered in order to populate 227 Updated 1-31-17 2017--00327 this field? For instance, if the data is extracted at 1:25pm, how should this time be entered? A11: The valid format for the Issuer Extract Time is (Hour, Minutes, and Seconds). If the data is extracted at 1:25:20 the Issuer Extract Time should be populated as ?012520?. The requirements for the data element ID 106 ?Issuer Extract Time? can be found on page 3 of the CSR Reconciliation Issuer to MIDAS Inbound Specification document. (REGTAP FAQ Database - FAQ #15111 03/11/16) Q12: On the Issuer Summary Record, one of the required fields is 'Reconciliation Methodology.? If we are using the Simplified Actuarial Value method for the entire submission, what text should we enter for this data element? Should we simply enter 'Simplified Actuarial Value A12: Please enter if you are using the AV method exclusively for all plans being reported for CSR reconciliation. The requirements for the data element ID 110 'Reconciliation Methodology' can be found at the bottom of page 3 of the CSR Reconciliation Issuer to MIDAS Inbound Speci?cation document. (REGTAP FAQ Database - FAQ #15111 03/11/16) Q13: On the Policy Summary Record, one of the required ?elds is 'Self-Only/Other than self-only.' According to the Webinar from February 10th 12th, it looks like an should be entered for self-only policies. What should we enter for an Other than self-only poHcy? A13: For the Simpli?ed methodology and Simpli?ed Actuarial Value only, report whether coverage under this policy is self only, or other than self-only. This data element is required only if the methodology is SIMPLIFIED and SIMPLIFIED AV. Valid values are Self (S) or Other (0). The requirements for data element ID 306 ?Self Only/Other than self-only? can be found on page 8 of the CSR Reconciliation Issuer to MIDAS Inbound Specification document. (REGTAP FAQ Database - FAQ #15113 03/11/16) Q14: On the Policy Summary Record, one of the required ?elds is 'Actuarial value amount of the Standard Plan.? Can a percentage be entered for this variable? How many decimal places should be displayed? A14: Enter a decimal, not a percentage for this variable. In the ?nal version of the CSR reconciliation Issuer to MIDAS Inbound Speci?cation document that CMS will release, this data element will have a minimum of 4 characters and a maximum of 12 characters (Note: CMS counts the leading zero and the decimal point as characters). For example, if the issuer knows this value as 80%, they would enter that as 0.80. (REGTAP FAQ Database - FAQ #15114 03/11/16) Conditional or Optional Data Elements Q: Does CMS require issuers to include blank conditional or optional fields in the pipe- delimited CSR data files issuers to submit to CMS to maintain proper file length? A: Due to the pipe delimited nature of the data file, when the issuer is not populating 228 Updated 1-31-17 2017--00328 optional or conditionally required fields, the issuer should still include the preceding and following pipe delimiters. The issuer may include a space in between the pipe delimiters, but the space is not required. (REGTAP FAQ Database - FAQ #14918 02/23/16) Q: How should issuers using the standard methodology populate data elements 306, 307 and 308? A: Those data elements are not required for the standard methodology and should be left blank. Due to the pipe delimited nature of the data file, when the issuer is not populating optional or conditionally required ?elds, the issuer should still include the preceding and following pipe delimiters. (REGTAP FAQ Database - FAQ #14919 02/23/16) Q: Is the data in the file(s) the issuer submits supposed to be in the order as presented in the Data Elements? documentation or the order as presented in the Reconciliation Issuer to MIDAS Inbound Specification? documentation? A: Please refer to the CSR Reconciliation Issuer to MIDAS Inbound Specification documentation for the requirements related to the data submissions and speci?cally the ordering of data elements within each record each 01, 02, or 03 record) in the pipe- delimited file. Data elements must follow this order within each record level. (REGTAP FAQ Database - FAQ #14920 02/23/16) Q: For the field, Total Premium, it was stated on the February 10 webinar that this is not mandatory for our 2014/2015 submissions, should we default to 0.00 for each record? What is your expected value or do we leave it blank? A: The version of the CSR Reconciliation Issuer to MIDAS Inbound Specification available on the CCIIO website lists Total premium (in the Policy Detail Record) and Total Annual Premium (in the Plan Summary Record) as Mandatory data elements. Issuers that participate in beta testing in February should input 0.00 for these data elements. However, CMS plans to change these to optional data elements prior to full issuer testing in March and before the open data submission window in April. At that time, issuers may leave that data element blank. Since the data ?le is pipe delimited in nature, the issuer would still need to populate the preceding and proceeding pipes. (REGTAP FAQ Database - FAQ #14921 02/23/16) Q: Do advance payment amounts need to be provided at the subscriber or plan level? A: No, this data element is not required at the subscriber or plan level. (REGTAP FAQ Database - FAQ #14922 02/23/16) Validations Q: Can CMS provide examples of the enrollment validation edits that will be performed upon receipt of CSR data file by Would it be possible for CMS to share the specific details regarding enrollment validation edits that will be performed on file receipt so it might be incorporated as part of pre-submission testing? A: The CSR Reconciliation Inbound Specification document that is published on the CCIIO website includes a detailed description of the validations that apply to each data 229 Updated 1-31-17 2017--00329 element. CMS also expects to perform an outlier analysis on data submissions to identify anomalies. We expect to provide more details on the data validation process in a future FAQ. (REGTAP FAQ Database - FAQ #14923 02/23/16) Q: The document Reconciliation Issuer to MIDAS Inbound Specifications? has the following validation on page 13, ?Total number of Exchange Subscriber IDs for the Plan variation must match the Count of records listed in Policy details (03 records).? How would CMS prefer issuers to handle members with multiple enrollment spans 1/1/2014 3/31/2014 in Product A, and then 7/1/2014 12/31/2014 in Product A: For this validation, CMS is verifying that the Total number of Exchange Subscriber IDs for which the issuer is submittinq data in the plan variation matches the count of records listed in policy details (03 records). If a member has multiple Exchanqe Subscriber IDs but has remained in the same plan variant during the plan year, the issuer should only report one Exchanqe Subscriber ID. However, if the member was enrolled in different products and plan variants (indicated by the 16?diqit HIOS ID), during the benefit year, the issuer should report those products and subscriber IDs separately. In that case, the issuer should ensure that the coveraqe start and end dates for the member do not overlap. Issuers should ensure that the count of records reflects the count of unique Exchange subscribers in that plan variation for which the issuer is submittinq data. The information reported in each policy (03 record) must be unique for the time period in which the member was enrolled. Database - FAQ #14924 02/23/16; updated 01/13/17) Q: Will CMS reject the entire CSR reconciliation data file if a single Exchange-assigned Subscriber ID fails? A: Yes. If the Exchange-assigned Subscriber ID for the Federally-facilitated Marketplace (FFM) does not match FEPS enrollment data, the entire ?le will be rejected. (REGTAP FAQ Database - FAQ #14925 02/23/16) Q: If CMS has a record of a subscriber with CSRs, but the issuer does not submit a 03 record for that subscriber issuer orphan), will CMS identify this as an error when validating data? A: No, if an issuer has a subscriber for which it does not submit a policy level "03" record that will not trigger an error in the system. However, CMS notes that, if no data is submitted for that policy, any CSRs that the issuer provided for that policy will be counted as zero (0) when reconciled CSR amounts are calculated. (REGTAP FAQ Database - FAQ #14926 02/23/16) Q: Will CMS validate the Exchange-assigned Subscriber ID against the policy start and end dates? A: CMS will validate the Exchange-assigned Subscriber ID against FEPS enrollment data for policies offered through the Federally-facilitated Marketplace (FFM) only. The 230 Updated 1-31-17 2017--00330 validation will be performed to ensure the Subscriber ID is valid for that plan variation. Start and end dates will not be validated. (REGTAP FAQ Database - FAQ #14927 02/23/16) Q: What is the control source to ensure for each Health Insurance Oversight System (HIOS) Issuer ID, all HIOS Plan CSR variations requiring reconciliation, have in fact been included in the issuer?s file? A: CMS will compare the Quali?ed Health Plan (QHP) IDs in the issuer's CSR reconciliation data submission to record of the QHP IDs for which CMS paid the CSR portion of the advance payment. Following submission of its data, the issuer will receive an automatic email listing any QHPs for which advanced payments were made that were not included in the issuer's data submission for CSR reconciliation. (REGTAP FAQ Database - FAQ #14928 02/23/16) Q: How long will file validation take? A: Issuers should receive error reports on the status of system validations within 24 hours of data submission. (REG TAP FAQ Database - FAQ #14929 02/23/16) Q: Will the validation compare the policy-level Total Allowed Amount on CSR reconciliation data files to the Total Allowed Amount submitted for that policy via CMS EDGE Server? A: No, EDGE Server data is not involved in the CMS reconciliation calculation. (REGTAP FAQ Database - FAQ #14930 02/23/16) Date and Time Q: What should the Issuer Extract Date and Time data elements in the Issuer Summary information represent? A: The Issuer Extract Date and Time should represent the date and time that the data was pulled. Please note that the ?le naming convention that is required for attestation forms and data files also includes date and time stamp data elements, and these should be re?ective of when the ?le is being transferred. (REGTAP FAQ Database - FAQ #14931 02/23/16) Q: Should the date and time in the file naming convention for the attestation form mirror the transfer date and time? A: Yes, issuers should use the transfer date and time when submitting attestations. (REGTAP FAQ Database - FAQ #14932 02/23/16) Q: Will CMS consider expanding the maximum character length of dollar amounts? A: Based on feedback from issuers, CMS is expanding the maximum character length of the dollar amounts to 45 digits. (REGTAP FAQ Database - FAQ #14933 02/23/16; updated 01/13/17) 231 Updated 1-31-17 2017--00331 File Names and Error Logs Q: In the sample error logs, there are references to ?Difference between Allocated and submitted CSR amounts.? What are the allocated amounts? A: We will change this to reference ?allowed" amounts. (REGTAP FAQ Database - FAQ #14934 02/23/16) Q: In what format will issuers receive the error response files from The error report will be included within the summary report, which will be In plain text format with ASCII character encodinq. Issuers will receive the report in their EFT folder. (REGTAP FAQ Database - FAQ #14935 02/23/16; updated 01/13/17) Q: What will the summary and error file be named when it is dropped in our SFTP folder? A: CMS will use the following naming convention for the CSR Reconciliation summary and error report. TPID. CSRO OUT Error?File? (REGTAP FAQ Database- FAQ #14936; 14936a 02/23/16, updated 04/25/16) Q: Where can an issuer find a list of error codes and their corresponding data elements? A: CMS will post a list of the error codes that respond to each data element on REGTAP. (REGTAP FAQ Database - FAQ #14937 02/23/16) Q: What is the function code for the CSR Reconciliation Error Report? A: The function code for the CSR Reconciliation Error Report is CSRO. (REGTAP FAQ Database - FAQ #14938 02/23/16) Q: What is the function code for the CSR Reconciliation Attestation Forms? A: The function code for the CSR Reconciliation Attestation Forms is CSRATI. (REGTAP FAQ Database - FAQ #14939 02/23/16) Q: Where can issuers find more information regarding file naming conventions for CSR reconciliation data files and attestation forms? A: Please see pages 1?2 of the CSR Reconciliation Issuer to MIDAS Inbound Specification and pages 2-3 of the CSR Reconciliation Issuer to MIDAS Attestation Inbound Speci?cation for the ?le naming conventions. (REGTAP FAQ Database - FAQ #14940 02/23/16) Data Submission Q: Are issuers required to include plan variations with no membership in the count of plan variations reported on the Issuer Summary Record? 232 Updated 1-31-17 2017--00332 A: No, issuers do not need to count plan variations with no membership in the Issuer Summary Record. Plan level records records) do not need to be submitted for plan variants that did not have membership in the applicable bene?t year (2014 or 2015). (REGTAP FAQ Database - FAQ #14941 02/23/16) Q: Can issuers resubmit files that CMS has already accepted? A: Yes, issuers may resubmit the file at any point during the data submission period (April 1 30) even if the ?le was previously accepted. Reconciliation will be conducted on an issuer?s most recent, successful data submission. CMS will consider every resubmission as a new submission, so the ?lename for the resubmission must be unique and include a new date and time. Issuers must resubmit the entire file the full pipe- delimited file) when resubmitting data ?les. (REGTAP FAQ Database - FAQ #14942 02/23/16) Q: Will CMS require issuers to submit new attestation forms when resubmitting corrected CSR data files? A: Yes. A new attestation must be submitted with each new data ?le. (REG TAP FAQ Database - FAQ #14943 02/23/16) Q: Will CMS require an issuer to zip attestation forms if the issuer needs to submit only one (1) attestation form? A: Issuers should zip their attestation forms when submitting them via EFT. (Note: This does not apply to Attestation Form D, which should be submitted to a shared CMS mailbox). Even if an issuer is only submitting one (1) attestation form via EFT, the attestation form should still be zipped. Do not password-protect ZIP ?les. Data files should not be zipped. (REGTAP FAQ Database - FAQ #14944 02/23/16) Q: Should issuers zip data submission files? A: No. Data ?les should not be zipped. (REGTAP FAQ Database - FAQ #14945 02/23/16) Q: What course of action will CMS take if issuers are unable to correct all resubmissions before April 30, 2016? A: CMS will provide guidance at a later date. (REGTAP FAQ Database - FAQ #14946 02/23/16) Q: Are issuers required to resend attestation forms when resubmitting reports? A: Yes, issuers should resubmit attestation forms when resubmitting CSR data files. (REGTAP FAQ Database - FAQ #14947 02/23/16) Q: In what format will issuers receive the final CSR results from A: For 2014 and 2015, CMS will provide issuers with the calculated reconciled CSR amount as part of a ?nal report published on June 30, 2016. Issuer will also see payment or charge amounts that result from the CSR reconciliation process on their 820 233 Updated 1-31-17 2017--00333 statement following the July payment cycle. (REGTAP FAQ Database - FAQ #14948 02/23/16) Q: Which Subscriber ID should issuers use when aggregating policies in the same plan variation, for example as the result coverage? A: Issuers should use the last or current Subscriber ID when aggregating policies. (REGTAP FAQ Database - FAQ #15384 04/05/16) Q: What should the issuer do when filling two (2) policy records in different plan variations, each with a different Subscriber ID, for the same person? A: The issuer should report the policies under their respective plan variations, using the applicable Subscriber ID for the policy, and carry over accumulators, if applicable. (REGTAP FAQ Database - FAQ #15385 04/05/16) Q: In the case of multiple Subscriber IDs for an enrollee whose accumulators must be carried over, how can the issuer determine that the subscriber is the same? A: Issuers should compare the name and subscriber's Social Security Number (SSN) and other identi?ers, such as address or an issuer assigned member Identi?cation Number on the policies. (REGTAP FAQ Database - FAQ #15386 04/05/16) Q: CMS tells issuers to aggregate policies for one (1) person under one (1) subscriber. Does CMS object if an issuer wants to keep the subscribers separate so that they match enrollment data? A: Issuers should aggregate policies for the same subscriber in the plan variation, regardless of whether accumulators carry over. CMS instructs issuers to aggregate policies in a plan variation in the case of a change in circumstance or gap in coverage to avoid duplication of reporting and because in many cases, accumulators carry over. Even when not required to carry over accumulators, the issuer uses the same parameters to re-adjudicate these policies. When aggregating policies, report only one (1) Subscriber ID (for Data Element ID 302 ?Exchange Assigned Subscriber in the Policy Detail Record) and include only one (1) Subscriber ID in the count of ?Total number of Exchange Subscriber IDs in this plan variation for the bene?t year" in the Plan Summary level. If an issuer does not combine the policies into one (1) record and reports them separately, CMS will not reject the record or file. However, if the issuer submits multiple policy records under the same Exchange Subscriber ID, the issuer must ensure that cost-sharing information is not duplicated. Whether combining records or reporting them separately, the issuer must follow accumulator rules to determine CSR provided. (REGTAP FAQ Database - FAQ #15387 04/05/16) Q: If a member changes variant throughout the year, how do we report this? For instance, member was in same product the entire year but moved from Variant 04 (73 Actuarial Value) to 05 (87 Actuarial Value) halfway through the year. On the CSR submission, do we report the member aggregated as being Variant 05/1/1 to 12/31? Or, do we report the member twice, once in Variant 04 1/1 to 5/31 and once in Variant 05 6/1 to 12/31? Does the same rule apply when a member goes from Silver 70 to Silver 94 and vice versa? 234 Updated 1-31-17 2017--00334 A: You report the subscriber twice. Since these are two (2) different plan variations, whether or not they have one (1) or more Subscriber IDs, the issuer needs to adjudicate, re-adjudicate separately, and file two (2) separate reports, whether or not the issuer also is required to carry over accumulators. When the subscriber moves from the standard Silver Plan 70 (no CSRs) to the Silver 94 and then back to Silver 70, there would be one (1) policy report, for the Silver 94, since that is the only CSR plan. However, accumulators must transfer if there is no gap, or, if there is a gap, accumulators may transfer depending on issuer policy. (REGTAP FAQ Database - FAQ #15388 04/05/16) Q: Can issuers use their own internal policy IDs in place of Subscriber IDs assigned by State-Based Exchanges? How will this affect audits? A: For State-based Exchanges, issuers may report their internal Policy IDs instead of the ?Exchange Assigned Subscriber if the internal Policy ID is associated with a valid subscriber for the time period for which data is being submitted, and if the issuer believes that the internal Policy ID provides a more accurate means of identifying the policy and subscriber as compared to the ?Exchange Assigned Subscriber Issuers should be sure to still follow the format requirements for the ?Exchange Assigned Subscriber as outlined in the CSR Reconciliation Issuer to MIDAS Inbound Specification document. This will not cause an audit issue for data that is submitted in the 2016 cycle. (REGTAP FAQ Database - FAQ #15389 04/05/16) Q: For the 2014 Bene?t Year, issuers of zero (0) and limited cost-sharing plans were permitted to opt out of providing the data CMS required to estimate advance payments for CSRs provided. If an issuer did not submit data or receive advance payment in 2014, but provided CSRs to American Indians/Alaska Natives as required, should the issuer enter ?zero? for advance payment? A: Any issuer that did not receive advance payment from CMS but who provided CSR should enter zero (0) in the issuer summary record (109) ?Total CSR Amount Advanced to the Issuer by Such issuers should complete all other data ?elds like any other issuer, to substantiate CSRs provided. (REGTAP FAQ Database - FAQ #15393 04/05/16) Q: Do the attestations need both Chief Financial Officer (CFO) and Chief Actuary or can we choose which one A: You must include both signatures if you are submitting Attestation Form D. Attestation Form is the only form that requires both signatures. (REGTAP FAQ Database - FAQ #15394 04/05/16) Q: In my organization, the individual who oversees actuarial functions is not a lettered actuary. Would it be appropriate for this individual to sign the attestation? A: Yes, an individual that oversees actuarial functions, a delegate of the actuary, or a person that is capable of financially-binding the organization (for example, the issuer CFO or CEO) may sign the attestation. (REGTAP FAQ Database - FAQ #15395 04/05/16) 235 Updated 1-31-17 2017--00335 Q: Under what circumstances would an issuer not be allowed to re-submit Benefit Year 2014 CSR data in 2017 CSR filing? A: CMS expects issuers to reconcile all claims in a timely manner. Please see page 6 of the Manual for Reconciliation of the CSR Component of Advance Payments for Benefit Years 2014 and 2015. To the extent that issuers have late claims for 2014, for example due to appeals or unusual circumstances (to be determined by CMS), issuers may re- adjudicate and submit claims from the 2014 benefit year in the next CSR reconciliation reporting cycle in April of 2017. (REGTAP FAQ Database - FAQ #15396 04/05/16) Q: What are the consequences if submission files are not submitted by the 5/2 deadline? A: CMS will provide additional guidance; generally, however, if an issuer does not submit data as required, CMS will recoup advance payments paid to the issuer for the applicable bene?t year. (REGTAP FAQ Database - FAQ #15397 04/05/16) Q: Do total allowed costs for Essential Health Bene?ts (EHB) pertain only to claims that have an associated out-of-pocket subsidy, or do the Centers for Medicare Medicaid Services (CMS) want issuers to include all claims associated with Cost-sharing Reduction (CSR) members? A: Only claims with reduced cost sharing should be included in total allowed costs. Issuers do not need to include 100 percent covered EHB in the total allowed costs for EHB since claims without enrollee cost sharing are not re-adjudicated; therefore, do not report EHB cost for such claims in the (O3) record. Issuers should only include total allowed EHB costs for claims with reduced cost sharing up to the reduced annual limitation on cost sharing. (REGTAP FAQ Database - FAQ #15571 04/19/16) Q: If a subscriber in a Cost-sharing Reduction (CSR) plan variation has only claims that are 100 percent covered, should the issuer report claims for that subscriber? A: No. Issuers should not ?le an (03) record for subscribers with no claims or no claims with reduced cost sharing, and the issuer should not include this subscriber in the (02) record of ?Total number of Exchange Subscriber IDs in this plan variation for the bene?t year." (REGTAP FAQ Database - FAQ #15572 04/19/16) Q: We receive encounters from capitated providers and process them through our system just like fee-for-service claims. For example, if the hospital stay is capitated $1,200 for the member, the claim is processed through our system to show an allowed amount of $10,000 with a member pay of $100 on the CSR plan and a plan pay of $9,900. Since this is an encounter, we do not actually pay the $9,900. Should issuers report on the 03 record an allowed amount of $10,000, a plan pay of $9,900, a member pay of $100, a member would have paid (assume $5,000 in the standard plan) and then a CSR provided of $4,900? Or do issuers report an allowed amount of $1,300? Updated 1-31-17 2017--00336 In the case of capitated or discounted services, issuers should report a total allowed costs and plan paid amount using their internal pricinq system or a reasonable method for estimating these amounts. Total allowed costs should be the same in the plan variation and the standard plan. Of course, enrollee paid amounts should re?ect the amounts the enrollee did pay under the plan variation, and the amounts they would have paid under the standard plan. When using the simplified methodology, issuers must estimate a reasonable cost in the standard plan that Is consistent with the way they calculated simpli?ed methodology parameters. (REGTAP FAQ Database- FAQ #15573 04/19/16; updated 05/03/16) Q: How should issuers report claims where the DRG allowable is greater than the billed amount on a claim? For example, based on our provider contract, we will allow $7,787.34 per the DRG contract for a claim, but the billed amount is $5,785.23. The member cost share is $1,000 per Cost-sharing Reduction (CSR) plan, but changes to $6,000 - or more than the billed amount - under the standard plan. Will this be an issue in the CSR submission? A: The total allowed cost for Essential Health Bene?ts (EHB) is the actual allowed cost of the claim, not the DRG allowable. If you have a contract with a provider to offer the care at a discount from your DRG allowable then, for CRS reconciliation, the allowed EHB cost for this claim is the discounted rate, $5,785.23, of which the member paid $1,000. The cost of care in the standard plan must be reduced to the equivalent discounted ?billed? amount; so issuers cannot use the billed amount in the CSR plan and the DRG allowable in the standard plan when re-adjudicating this claim against the standard plan cost. The bene?ts and cost sharing structure of the standard plan must be identical to the benefits and cost sharing structure of the associated plan variation. If there is a discount in the CSR plan, there must be an equivalent discount in the standard plan. (REGTAP FAQ Database - FAQ #15574 04/19/16) Q: Are Negative Cost-sharing Reduction (CSR) amounts permitted on 02 records for plans with very low membership), or 03 records only? A4: Negative amounts are permitted for the "Total Actual Value of CSR provided" at the Plan Summary (02) record level, as well as for the "Actual CSR Provided" at the Policy Detail (03) record level. (REGTAP FAQ Database - FAQ #15576 04/19/16) 237 Updated 1-31-17 2017--00337 Q: During testing for Cost-sharing Reduction (CSR) reconciliation, the Centers for Medicare Medicaid Services (CMS) asked issuers using the Simplified Actuarial Value (AV) methodology exclusively to submit the third tab of Attestation Form C, so that issuer's files would not be rejected. Do issuers using the Simplified AV method exclusively still need to complete the third tab on Form A: Issuers using the Simplified AV method exclusively no longer need to complete Attestation Form to avoid ?le rejection. Such issuers must submit either Attestation A or B, as applicable, and D, if applicable. Attestation Form is only for issuers using the simpli?ed methodology or a combination of the simpli?ed methodology and the Simplified AV methodology. (REG TAP FAQ Database - FAQ #15810 05/03/16) Q: Please explain the financial impact of negative Cost-sharing Reduction (CSR) amounts to the issuer at each of the three record levels? A: Negative CSR amounts are not permitted at the issuer level. Negative CSR amounts at the policy level (03) will be subtracted from positive CSR amounts when CSR amounts are aggregated to the plan level. Negative CSR amounts at the Quali?ed Health Plan (QHP) level (02) will be equated to zero when CSR amounts are aggregated at the issuer level. Issuers with zero (0) CSR amounts (negative CSR provided for all plans) will be billed the amount of their advance payment. (REGTAP FAQ Database - FAQ #15811 05/03/16) Q: Since reporting on the plan level is optional, what will the Centers for Medicare Medicaid Services (CMS) do if issuers elect not to report a Quali?ed Health Plan (QHP) with a negative amount of Cost-sharing Reduction A: Issuers that do not report negative CSRs at the 02 level will receive a policy-level aggregation of the CSR provided (negative QHP amounts will be subtracted from their issuer-level advance payments.) In such a case, the amount issuers will see on their ?nal CSR report will be less than or equal to the amount they would be reimbursed. Although QHP-level reports are optional, CMS encourages issuers with negative CSRs at the QHP level to file 02 reports so that CMS may adjust CSR provided to zero (0) prior to aggregation. (REGTAP FAQ Database - FAQ #15812 05/03/16) Q: In the case of capitated services, what the issuer paid and what the enrollee paid does not always sum to the total allowed cost, since the issuer paid a capitated or discounted amount for the encounter. Will the Centers for Medicare Medicaid (CMS) reject the file if these amounts do not add up? A: No, files will not be rejected if the enrollee share and the amount paid by the issuer for a service do not equal the allowed cost. Issuers must use an internal pricing mechanism to determine the allowed cost of the capitated service as well as the cost of the member's share in both the Cost-sharing Reduction (CSR) plan and the standard plan. (REGTAP FAQ Database - FAQ #15814 05/03/16) Q: Please provide guidance on how to calculate the Cost-sharing Reduction (CSR) amount when a member's claims are being re-adjudicated under a standard plan with a Coordination of Benefits (COB) recovery and the actual COB recovery will not be adjusted? For example, for a $2,500 service, COB covered $1,500 and the enrollee paid 238 Updated 1-31-1 7 2017--00338 $1,000 in the CSR plan. The enrollee would have paid $1,500 in the standard plan, and since the issuer will not refund COB, the allowed cost would be more than in the plan variation. A: Issuers must reduce total allowed costs by the COB amount in both the plan variation and the standard plan (REGTAP FAQs 15101 and 15106) since amounts paid by third party insurers are not recoverable as CSR provided. Therefore, in this example for a $2,500 service, if COB in the plan variation is $1 ,500 and the enrollee share is $1,000, COB in the standard plan is also $1 ,500 and the enrollee share is $1,000, since the sum of what the issuer or COB paid and the enrollee paid for a service cannot exceed total allowed cost and total allowed cost must be the same in the variation and the standard plan. However, if the issuer pays part of the cost, the issuer may seek reimbursement CSR provided for up to that amount. For example, if the same $2,500 service covered in the cost-sharing plan variation, the COB paid $1 ,500, the plan paid $500, and the enrollee paid $500 (with costs in the associated standard plan of $1 ,500 paid by the COB, $0 paid by the plan, and $1,000 paid by the enrollee), the issuer would report $500 of CSR provided. (REGTAP FAQ Database - FAQ #15875 05/09/16) Q: With regard to REGTAP FAQ ID 15573, does this example only pertain to hospital stays or does this include primary care physician (PCP) visits as well? If it includes PCP visits, how are we to break up multiple PCP visits that occur in a single month to appropriately record the allowed amount if the Per Member Per Month (PMPM) rate is supposed to be included in the allowed amount for that claim? A: REGTAP FAQ 15573 applies to any encounter from a capitated provider. As stated in updated FAQ 15573 (May 3, 2016), and FAQ 15107, issuers should report a total allowed cost and plan paid amounts using their internal pricing system or a reasonable method for estimating these amounts, which may include per-member-per?month costs. In the case where the issuer charges a PMPM fee and the enrollee incurs cost-sharing for multiple services during multiple visits in a month, the issuer should not report total allowed costs equal to the PMPM amount. Instead, the issuer should apportion PMPM costs, if applicable and the costs of the services across visits using a reasonable method that is applied consistently for all members, regardless of their cost-sharing variation. (REGTAP FAQ Database - FAQ #15877 05/11/16) Q: Do the Centers for Medicare Medicaid Services (CMS) have guidance as to how the following claim amounts should be factored into the allowed amount for the Simplified Methodology? Updated 1-31-17 Capitation, i.e. prepaid amounts Coordination of Bene?ts (COB) Write-off amounts Network discounts for in-network providers A: For prepaid amounts, issuers should estimate a reasonable cost in the standard plan that is consistent with the way they calculated Simplified Methodology parameters (See REGTAP FAQ ID 15573). For COB, issuers must reduce total allowed costs and reduce what the issuer paid in both the plan variation and standard plan by the amount of the COB (FAQ ID 15101 and FAQ ID 15106). Issuers should treat write-off amounts and 239 2017--00339 network discounts for in-network providers consistent with the way they treat write-off amounts and network discounts when calculating simpli?ed methodology parameters (See REGTAP FAQ 15573). (REGTAP FAQ Database - FAQ #15878 05/12/16) Q: How will the Centers for Medicare Medicaid Services (CMS) validate Cost-sharing Reduction (CSR) data submitted for the purpose of reconciling the cost-sharing reduction portion of advance payments for 2014 and 2015 benefit years? A: CMS performs certain technical validations, for example to ensure file transfer, and that the issuer used the applicable methodology and submitted applicable attestations, prior to accepting data files for reconciliation of the cost-sharing reduction portion of advance payments for the 2014 and 2015 benefit years. In order to help ensure the integrity of the data submitted, CMS also compares the actual CSR provided, as reported by the issuer as part of its reconciliation data submission for the applicable bene?t year, to Risk Adjustment (RA) risk scores for the corresponding benefit year. identi?cation of outliers takes into account member-month differences, as reported by the issuer when it requested Advance Payments of the Premium Tax Credit (APTC) for cost-sharing plan variations, and state-level differences in advance payments and actual CSR provided. CMS contacted issuers identi?ed as outliers to request explanations for significant differences between actual CSR provided and RA risk scores, and to request that issuers review their data submissions to identify any reporting errors. Issuers that have identi?ed errors should contact CSRreconquestions@cms.hhs.qov as soon as possible. Issuers that are unresolved outliers and that are owed an additional payment from the Federal government, as calculated based on the issuer's most recent submitted data ?le for cost-sharing reduction reconciliation for the 2014 and 2015 bene?t years, will not receive a report of reconciled cost-sharing reduction amounts on June 30, 2016, and will not receive payment in August 2016. Additional cost-sharing reduction payments for these issuers will be withheld until the outlier issue is resolved. CMS will begin netting charges that result from cost-sharing reduction reconciliation from all issuers, including those that have been identified as outliers, in August 2016.* Any additional charges that the issuer may owe based on resubmissions to correct data errors will be collected in subsequent payment cycles. Additionally, an unresolved outlier may trigger a CMS audit under 45 CFR As set forth at 45 CFR CMS will net any cost-sharing reduction reconciliation charges owed by a QHP issuer to the Federal government from payments due to that issuer and its affiliates under the same taxpayer identification number in the applicable payment cycle. (REGTAP FAQ Database - FAQ #16490 06/23/16) Q: What is the process for issuers to file a discrepancy related to their Cost-sharing Reduction (CSR) reconciliation data submitted for the 2014 and 2015 Benefit Years? Updated 1-31-17 A: An issuer will be permitted to file a discrepancy beginning June 23, 2016 using the technical specifications on discrepancy submission published by the Centers for Medicare Medicaid Services (CMS), available at: Issuers are encouraged to submit a discrepancy as soon as possible and prior to filing a request for reconsideration as explained in FAQ 16489. No discrepancy or request for 240 2017--00340 reconsideration will be accepted after 11:59 pm. EST on Monday, August 29, 2016. Issuers who identify data discrepancies related to Quali?ed Health Plan (QHP) ID errors, Exchange Subscriber ID errors, or errors related to the amount of Cost-sharing Reductions (CSRs) that an issuer provided at the policy level, including, for example, ?awed issuer calculations or lost data, should submit data related to their discrepancy in a pipe-delimited file through electronic file transfer (EFT). CMS will only accept data discrepancies for data that directly impacts the calculation of the issuer's reconciled CSR amounts. At the same time as the discrepancy window is opened, CMS will publish a technical specification document outlining the format of the file, which generally will be similar to the file format used for submission of the 2014 and 2015 CSR reconciliation data ?le. We note that all issuers will be noti?ed of CSR reconciliation payments or charges by June 30, 2016, regardless of whether a discrepancy has been filed or resolved. If a discrepancy results in a payment or charge adjustment following the June 30, 2016 calculation, CMS will make this adjustment in a payment cycle following the decision. Any issuer that does not file a discrepancy will be deemed as accepting their final data submission for CSR reconciliation for the 2014 and 2015 Benefit Years (as applicable) and CMS will use this ?nal data submission to calculate final CSR reconciliation payments or charges and will notify issuers by June 30, 2016 of their ?nal CSR reconciliation payments or charges. We note that, pursuant to the Manual for Reconciliation of the CSR Component of Advance Payments for Bene?t Years 2014 and 2015, issuers also may submit additional 2015 data that becomes available after CSRs have been reconciled for the 2015 Benefit Year, during the 2016 CSR reconciliation reporting year cycle, in the spring of 2017. In rare circumstances, CMS may make limited exceptions to allow issuers to submit additional 2014 data during the same 2016 CSR reconciliation reporting cycle. CMS will issue guidance on the process for the 2016 CSR reconciliation cycle at a later date. See page 6 of the Manual for Reconciliation of the CSR Component of Advance Payments for Benefit Years 2014 and 2015 and FAQs 14904, 14905, and 15457 available on FAQ Database - FAQ #16491 06/24/16) Technical assistance Q: How do issuers contact technical support for Electronic File Transfers A: The technical support email address for the EFT process is EFT@cms.hhs.qov. (REGTAP FAQ Database - FAQ #14949 02/23/16) Q: Will CMS provide additional on technical submission or additional webinars? A: Yes, CMS will provide opportunities for weekly technical assistance to issuers. Dates and times will be announced shortly through REGTAP. (REGTAP FAQ Database - FAQ #14950 02/23/16) Q: How can issuers contact CMS with questions related to CSR reconciliation? 241 Updated 1-31-17 2017--00341 A: Issuers can email CSRreconquestions@cms.hhs.qov for technical issues and questions. Issuers can continue to submit policy-related questions through ITMS at (REGTAP FAQ Database - FAQ #14951 02/23/16) Q: Why is CMS conducting training on CSR reconciliation when the CSR Reconciliation Manual is still in draft form? A: CMS is conducting initial testing to help inform issuers about the standard data submission process in April. Issuers can expect the ?nal specifications to be very close to the draft speci?cations. (REGTAP FAQ Database - FAQ #14952 02/23/16) Q: How do issuers become beta testers? A: CMS is no longer accepting volunteers for beta testing. However, all issuers should be prepared to test with CMS in March of 2016. (REGTAP FAQ Database - FAQ #14953 02/23/16) Q: When does beta testing occur on CSR reconciliation timeline? A: Issuers that have volunteered for beta testing can begin working on their ?les and can submit their ?les immediately. CMS is conducting beta testing from now through February 26, 2016. (REGTAP FAQ Database - FAQ #14954 02/23/16) Q: When will the final CSR reconciliation manual be provided? A: The 30-day comment period closed February 15, 2016. CMS will publish final versions as soon as possible after that. CMS will also update technical specifications on the CCIIO website as applicable. (REGTAP FAQ Database - FAQ #14955 0223/16) Q: Does CMS have dummy data available for issuers to use? A: There is no required dummy data to use when testing. During the testing phase, issuers may submit real or dummy data. (REGTAP FAQ Database - FAQ #14956 02/23/16) Q: In REGTAP FAQ 15117, CMS said taxes and administrative fees are not Cost-sharing Reductions (CSR) eligible. Does that include dispensing fees and sales taxes on prescription drugs? Those amounts are included in the allowed amount for the drugs and often are covered by member co-pay. A: Additional costs such as dispensing fees and sales taxes for prescription drugs are considered cost sharing for Essential Health Benefits (EHB) (and therefore CSR eligible) and part of total allowed costs if they are included in a plan's benefit design for the standard plan and the plan variations. (REGTAP FAQ Database - FAQ #15453 04/13/16) Q: If a member enrolled in a Cost-sharing Reduction (CSR) plan for the 2014 benefit year goes into the hospital in December 2014 but is not discharged until January 2015, in 242 Updated 1-31-17 2017-?00342 which benefit year reconciliation cycle should the issuer report the claim and CSR paid? Is this a CSR provided in 2014, or in 2015? A: For a hospital stay that crosses bene?t years, the issuer should adjudicate CSRs based on the year for which accumulators for the CSRs applied, regardless of when the claim is presented for payment. For example, if cost sharing (co-pays, deductibles, coinsurance) for part of the hospital stay was incurred in 2014, that cost sharing and associated cost-sharing reductions should be adjudicated against 2014 benefit year plan designs, re-adjudicated with other 2014 benefit year claims, and reported as part of CSR reconciliation data for the 2014 bene?t year, regardless of whether further related services for the stay were provided in 2015. However, for example, if the enrollee's entire cost for hospital coinsurance related to the stay is not incurred until 2015, such claims and associated cost-sharing reductions should be adjudicated against 2015 bene?t year plan designs, re-adjudicated with other 2015 benefit year claims, and reported as part of CSR reconciliation data for the 2015 benefit year. The issuer must apply accumulators consistently for all enrollees in the standard plan and plan variations. The EDGE server data submission rules regarding discharge dates for claims that cross bene?t years do not apply to the CSR reconciliation data submission. (REGTAP FAQ Database - FAQ #15454 04/13/16) Q: What if the subscriber does not renew coverage in the second year of a bene?t that crosses plan years? A: Whether or not coverage is renewed for the second year, cost-sharing reductions should be calculated and reconciled based on the year for which the accumulators for the cost sharing would apply. (REGTAP FAQ Database - FAQ #15455 04/13/16) Q: If a member in a Cost-sharing Reduction (CSR) plan is admitted to the hospital prior to a grace period, and is discharged after the 30-day grace period date, how should issuers handle these claims? A: The issuer should pay, adjudicate, and re-adjudicate the portion of claims with cost sharing incurred during the period the enrollee was covered, regardless of when the claim is presented for payment. The Centers for Medicare Medicaid Services (CMS) will not reimburse issuers for cost-sharing reductions provided during the second and third months of a 90-day grace period after which the enrollee is retroactively terminated. See also REGTAP FAQ 15103. (REGTAP FAQ Database - FAQ #15456 04/13/16) Q: If claims involving coordinated benefits cannot be properly handled before submission, is it acceptable to filter out Coordination of Benefits (COB) claims and not include them for Cost-sharing Reduction (CSR) reconciliation? Updated 1-31-17 A: Issuers may wait to re-adjudicate complex claims until the complete cost of the bene?t has been accounted for; however, in such a case, the issuer must re-state claims for the entire policy, including the complete COB claim, reducing total allowed costs for EHB by the amount paid by another issuer, as applicable, in both the standard plan and the plan variation, to ensure correct re-adjudication of CSR provided for that policy. See also 243 2017--00343 REGTAP FAQ 15101 and 15106. (REGTAP FAQ Database - FAQ #15462 04/13/16) Q: I am an Federally-facilitated Marketplace (FFM) issuer who is receiving errors in my summary/error report for having reported invalid Exchange Assigned Subscriber IDs. Why might I be getting this error? A: For FFM plans, issuers need to report Exchange Assigned Subscriber IDs with any leading zeroes that the IDs originally had when generated by the FFM. Issuers will receive errors in their summary/error report if they report FFM generated Exchange Assigned Subscriber IDs without the leading zeroes. (REGTAP FAQ Database - FAQ #15463 04/13/16) Q: Is the Cost-Sharing Reduction (CSR) Reconciliation amount on error reports to issuers the final calculation for cost-sharing reductions provided? If not, how will issuers know the final amount? A: The difference between the advance payment (?2014 or 2015 CSR amount") and the CSR amount at the Policy Detail Level? listed on the issuer's data submission error report can be used as a preliminary calculation of the issuer's reconciled CSR amount. Amounts listed on error reports are not ?nal, since issuers may resubmit files through the June 3, 2016 data submission deadline, and may also be asked by the Centers for Medicare Medicaid Services (CMS) to resubmit after the data submission deadline in order to correct for missing or invalid data. CMS will also be conducting separate validation of the actual CSR amounts requested by issuers. This validation will occur after the June 3, 2016 ?nal submission date, and CMS will notify data outliers of next steps. CMS will send a ?nal report of reconciled CSR amounts beginning June 30, 2016 to those issuers who have successfully submitted data by June 3, 2016, and have not been ?agged as part of CMS's validation efforts. (REG TAP FAQ Database - FAQ #16214 05/31/16) Cost-sharing Reductions Provided During a Grace Period 02: How should issuers handle CSRs provided during a grace period? A2: Issuers that provide CSRs as allowed prior to the termination of coverage effective date (See 78 FR 15490 March 11, 2013) should seek reimbursement for CSR provided on services during the 30-day period that the enrollee was eligible for CSRs the same way it would seek reimbursement for any eligible enrollee, using the Subscriber ID and plan variation start and end dates for the period the enrollee was eligible. (REGTAP FAQ Database - FAQ #15102 03/11/16) Q3: May issuers seek reimbursement for CSRs provided during the 2nd and 3rd months of a grace period, for example on pharmacy claims that because of contractual arrangements between the issuer and supplier cannot be pended? A3: No. Issuers may not seek reimbursement for CSRs provided after the termination of coverage effective date with respect to a grace period, since the terminated enrollee is no longer eligible for tax credits in the 2nd and 3rd months of the grace period and therefore no longer eligible for cost-sharing reductions under Section 1402(f) of the Affordable Care Act. The only exception is provided under 45 CFR which permits issuers to seek reimbursement for CSRs provided during a retroactive 244 Updated 1-31-17 2017--00344 termination in which failure to terminate was not the fault of the QHP issuer, for example, when the QHP issuer receives a late termination notice from the Exchange. (REGTAP FAQ Database - FAQ #15103 03/11/16) Q4: Can the Centers for Medicare Medicaid Services (CMS) clarify how issuers should implement the Simplified Methodology if an issuer has a plan design where the percentage of Essential Health Benefits (EHB) not subject to a deductible falls between 20 percent and 80 percent? A4: If the percentage of EHB not subject to a deductible is less than 80 percent, the issuer should apply the parameters for the regular simpli?ed methodology. The parameters for HMO-like plans may only be used for plans or subgroups of plans with more than 80 percent of total allowed costs not subject to a deductible as discussed at 45 CFR (REGTAP FAQ Database - FAQ #15104 03/11/16) Exchange Subscriber IDs Q15: Please clarify Exchange Subscriber ID reporting requirements. A15: For the purpose of cost-sharing reduction reconciliation: If the issuer is aggregating policies in the same plan variation across a year, the issuer should report only one Subscriber ID associated with the member(for Data Element ID 302 ?Exchange Assigned Subscriber in the Policy Detail Record) and include only 1 Subscriber ID in the count of ?Total number of Exchange Subscriber IDs in this plan variation for the benefit year" in the Plan Summary level. (REGTAP FAQ Database - FAQ #15115 03/11/16) Q16: If the issuer submits an Exchange Subscriber ID that fails validation as a result of not matching FEPS records for the Federally-facilitated Marketplace (FFM), will the entire submission fail as a result of that single Exchange subscriber A16: No. If an FFM issuer's Exchange Subscriber ID fails validation, only the policy record level record) associated with that Exchange Subscriber ID will fail. The issuer will receive an error report indicating the failure, but the rest of the file will process. However, if 50% or more of an issuer's policy records fail, CMS will reject the entire ?le, including any valid policy records, and the submission will not be processed. Policy records that fail will not be included in the calculation of the issuer's reconciled CSR amount. We note that CMS will only validate Exchange Subscriber IDs for policies offered through the the validation will not apply to policies offered through a State- based Marketplace. (REGTAP FAQ Database - FAQ #15116 03/11/16) Claims Amounts Q17: Both the Plan Summary Record and the Policy Summary Record include claims information in the form of allowed costs and amount the issuer paid for EHB, etc. Should the claim amounts include both in and out of network claims? Should the claims amounts include or exclude certain fees such as pooling charges, access fees, HCRA surcharges, prompt pay interest, and provider incentive payments? A17: Out-of -network claims are generally not eligible for cost-sharing reductions and do not need to be included. However, if the plan variation provides cost-sharing reductions 245 Updated 1-31-17 2017--00345 on out-of?network services, they should be included (for example, with the zero cost- sharing plan variation, cost-sharing reductions are required because the enrollee pays no cost sharing for essential health bene?ts (EHBs), in-network or out-of?network, as long as the associated standard plan also covers EHB out of network).. If the standard plan does not cover EHB out of network, then CMS will not reimburse issuers for any cost sharing reduction provided to an enrollee for such non covered services. Total allowed costs for essential health benefits do not include fees, charges, interest or any other administrative costs for the issuer. (REG TAP FAQ Database - FAQ #15117 03/1 1/16) Other Q: When standard plans have separate deductibles for Medical and Prescription, but the annual Out-of-Pocket (OOP) maximums to Medical and Prescription is combined, how do you develop the separate parameters for Medical and Prescription? What subgroups should we use? A: For plans with separate medical and pharmaceutical deductibles but a combined annual limitation on cost sharing, issuers should develop separate effective cost sharing parameters for the medical and pharmaceutical claims. However, the total amount of cost sharing estimated under the standard plan for any policy must be limited to the combined annual limitation on cost sharing. (REGTAP FAQ Database - FAQ #15451 04/13/16) Q: If a service was provided in September 2015, but the claim is lost or not presented until June 2016, in which benefit year reconciliation cycle should the issuer report the Cost-sharing Reduction (CSR) provided? Is this a CSR provided in 2015, or in 2016? A: This is a CSR provided in 2015 but which could not be re-adjudicated and reconciled with other 2015 claims on the same policy because the issuer did not get the bill for service until after the data submission deadline. In such a case, the issuer would adjudicate and re-adjudicate all claims on the 2015 policy again, and restate 2015 CSRs for that policy during the 2016 reconciliation cycle (April 2017). The Centers for Medicare Medicaid Services (CMS) intends to provide guidance on the CSR restatement process for previous year claims. (REGTAP FAQ Database - FAQ #15457 04/13/16) Q: If claims are pended during the plan year, should those claims be re-adjudicated in the original order they occurred during the plan year, or when resolved? A: Pended claims should be re-adjudicated in the order that best approximates the initial adjudication of the claims. Thus, if the issuer's practice is to adjudicate a pended claim upon resolution (and not to retroactively adjudicate the pended claim as if it had occurred when originally incurred), the pended cost-sharing reduction reconciliation should similarly be re-adjudicated based on date of resolution. (REGTAP FAQ Database - FAQ #15459 04/13/16) Q: For the standard methodology, natural order - for claims from different sources, specifically pharmacy and medical claims - is there an order to processing for those received on the same day, or for those received on different days, or can they all be re- 246 Updated 1-31-17 2017--00346 adjudicated in the order received regardless of claim type/source? A: As discussed in November 2014 guidance from the Centers for Medicare Medicaid Services (CMS) on re-adjudication of claims for the purpose of cost-sharing reduction reconciliation, all issuers must set all accumulators to zero and, if using a third party administrator (TPA), first re-process all medical claims in their natural order and then all pharmacy claims in their natural order. If not using a TPA, claims for any type of EHB service should be processed in the order received. Claims Readiudication Guidance 11031 4 5CR 111714.pdf (REGTAP FAQ Database - FAQ #15460 04/13/16) Q: Can you provide clarification on whether understating the Cost-sharing Reductions (CSR) for a reported claim has any audit implications? We know that not reporting eligible claims doesn't have audit implications, but weren't sure about erring on the side of a conservative calculation. A: The Centers for Medicare Medicaid Services (CMS) expects issuers to submit accurate data on cost-sharing reductions provided, and all amounts are subject to audit. However, in remedying any inaccuracies in a submission, CMS will consider the financial impact of the inaccuracy.(REGTAP FAQ Database - FAQ #15461 04/13/16) Q: Should we include actual claims from the standard plan when an enrollee moves from the standard plan to a plan variation and accumulators must be transferred to the plan variation? Do the Centers for Medicare Medicaid (CMS) want to see the claims? A: For Cost-sharing Reductions (CSR) reconciliation, issuers should not include claims adjudicated under a standard plan when an enrollee switches to a plan variation of that standard plan and the accumulators must be transferred; however, when an enrollee moves to a plan variation of the same Quali?ed Health Plan (QHP) plan, issuers must carry over cost sharing amounts paid by the enrollee that accumulated to the Maximum Out of Pocket (MOOP) of the standard plan. This means the accumulator amount in the new CSR plan would be reduced by the amount that had accumulated to the standard plan MOOP from cost sharing paid by the enrollee on claims in the standard plan. The claims themselves are not carried over or reported. As discussed in REGTAP FAQ 14892, prior to re-adjudication of claims for the purpose of cost-sharing reduction reconciliation, if the issuer has reduced the plan variation MOOP amount by the amount accumulated from a previous standard plan or plan variation, the issuer must also reduce the associated standard plan's maximum out of pocket amount by the same amount, to accurately determine what the enrollee would have paid in the standard plan. (REGTAP FAQ Database - FAQ #15570 04/19/16) Issuer Payment Information/ Establishing Payment Accounts Q11: Is there any information available regarding how to register as a trading partner? Are hardware, software, or network requirements available for processing transactions timeframe for testing send and/or receive transactions? A11: Information about how to register as a trading partner and details about the network requirements for establishing connectivity, meeting security requirements, and processing transactions is forthcoming. We will also be providing information about the 247 Updated 1-31-17 2017--00347 testing schedule in the near future. This applies to issuers that will be approved to participate in the FFE as well as in SBEs. (QHP Web/nar Series FAQ #7 04/24/13 Q1. Add clari?cation that the 2100 REF Exchange Assigned Quali?ed Health Plan will be the identifier assigned by the Marketplace through which the enrollee submitted an application, i.e. FFM or SBM. A1. 2100 Loop REF02: Exchange Assigned Qualified Health Plan Identifier will be the identi?er assigned by the marketplace through which the enrollee submitted an application. (ASC X12 Exchange Related Payments (820) Implementation Guide 05/14/13) Q10: When we will be able to sign Trading Partner Agreements? A10: The Trading Partner Agreement process is under development. Background information and current updates about the Trading Partner Agreements can be found on the Issuer Community in the ZONE. (Enrollment FAQ #3 07/03/13) 05: How do issuers submit their banking information to CMS to receive payments? A5: Issuers who anticipate receiving payments for the Advance Premium Tax Credit and/or Advance Cost Sharing Reductions will provide CMS their ?nancial institution and banking information. More information and training on this process will be provided later this fall. (Payments FAQ #2 10/07/13) Q: Why do Issuers need to complete a new HIX 820 Trading Partner Agreement? A: All Issuers will need to complete new HIX 820 Trading Partner Agreements in order to align Payee Group financial information with the receipt of HIX 820 transactions. A Payee Group ID number is necessary for Payee Groups to complete HIX 820 Trading Partner Agreements. CMS will assign a Payee Group ID number to approved Payee Groups submitted in the Financial Information Template and will transmit the Payee Group ID to the Payee Group contact. The Payee Group contact should then provide the Payee Group ID to the Electronic Data Interchange (EDI) contact in order to complete the new HIX 820 Trading Partner Agreement. CMS will provide the Payee Group contact with the Payee Group ID as soon as possible. (REGTAP FAQ Database - FAQ #451 11/12/13) Q: For purposes of receiving Advance Premium Tax Credits (APTC) and Advance Cost Sharing Reductions (CSR), which Issuers should submit payee and banking information to CMS prior to December 1, 2013? Updated 1-31-17 A: Federally-facilitated Marketplace (FFM) and State Based Marketplace (SBM) Issuers, Issuers of Stand-alone Dental Plans (Pediatric) and Small Business Health Options Program (SHOP) Issuers that also provide Quali?ed Health Plans (QHPs) in the individual Marketplace should submit the requested documentation because they may be eligible to receive APTC and CSR payments on behalf of enrollees. (REGTAP FAQ Database - FAQ #452 11/12/13) 248 2017--00348 Q: How do issuers submit their banking information to CMS to receive payments? A: Issuers who anticipate receiving Advance Payments of Premium Tax Credits (APTCs) and/or Cost Sharing Reductions (CSRs) on behalf of enrollees will submit their financial institution and banking information to the Centers for Medicare Medicaid Services (CMS) on a Financial Information Template. A Financial Information Authorization Agreement will be submitted along with the Financial Information Template. Issuers must also request a Bank Veri?cation Letter for each ?nancial institution listed on the Financial Information Template. Copies of the Financial Information Template and the Financial Information Authorization Agreement can be found in the REGTAP Library at under ?Payments-Payee Groups.? The US. Department of Treasury will issue payments via Electronic Funds Transfer (EFT) to Federally-facilitated Marketplace (FFM) and State Based Marketplace (SBM) issuers. Upon receipt of con?rmed payments, CMS will send a Final (Summary) HIX 820 to issuers. (REGTAP FAQ Database - FAQ 463 11/19/13) Q: How would a Health Insurance company that has two (2) Issuers that share a Tax Identification Number (TIN), one (1) in the Federally Facilitated Marketplace (FFM) and one (1) in the State Based Marketplace (SBM), create Payee Groups in order to receive two (2) separate HIX 8205. A: The Health Insurance company should create two (2) separate Payee Groups, one (1) for each Issuer. (REGTAP FAQ Database FAQ #465 11/19/13) Q: Who receives notifications from the Centers for Medicare Medicaid Services (CMS) in response to documents submitted during the Vendor Management process: the individual contacts listed on the Financial Information Template, the Chief Financial Of?cer contact (CFO) or normal distribution recipients of Department of Health and Human Services (HHS) notices? A: Issuers will receive an automated email response when CMS receives the Financial Information Template and Financial Information Authorization Agreement email submission. If CMS has any questions about the Issuer's Payee Groups or Financial Information, CMS will contact the appropriate individual listed on the Financial Information Template, either the Payee Group or the Financial Authority contact. (REGTAP FAQ Database - FAQ 467 11/19/13) Q: What form does a Payee Group's Financial Institution provide directly to the Centers for Medicare Medicaid Services A: Financial Institutions must submit a Bank Verification Letter directly to CMS by facsimile at (301) 492-4746. Health Insurance Companies will submit the Financial Information Template and Financial Information Authorization Agreement to CMS via email at vendor manaqement@cms.hhs.qov. (REGTAP FAQ Database - FAQ 468 11/19/13) 249 Updated 1-31-17 2017--00349 Q: How and when do Health Insurance Companies provide the Centers for Medicare Medicaid Services (CMS) with Tax Identification Numbers (Tle)? A: Health Insurance Companies should submit updated Tax Identi?cation Number (TIN) information in the Health Information Oversight System (HIOS) no later than November 15, 2013. (REGTAP FAQ Database - FAQ #472 11/20/13) Q: Once Health Insurance Companies submit Financial Information Template, the Authorization Agreement and Bank Verification Letter, when will CMS provide Payee Group A: The amount of time it takes to provide Payee Groups with Payee Group IDs varies because it is dependent on the accuracy of the information submitted by Health Insurance companies. Once the submitted information has been validated, CMS will send the Payee Group ID to the Payee Group contact identified on the Financial Information Template. (REGTAP FAQ Database - FAQ 473 11/20/13) Q: What documents are due and when are the documents due in order for Issuers to receive payments? A: Health Insurance Companies must update Tax Identi?cation (TIN), Legal Business Name (LBN) and Chief Executive Of?cer (CEO) or Chief Financial Officer (CFO) information in HIOS by November 15, 2013. Financial Information Templates, Financial Information Authorization Agreements and Bank Verification Letters are all due to the Centers for Medicare Medicaid Services (CMS) no later than December 1, 2013. Health Insurance companies submit Financial Information Templates and Financial Information Authorization Agreements to CMS. The Payee Group's financial institution submits the Bank Verification Letter directly to CMS. Instructions for submitting the requested payee and banking information and copies of the Financial Information Template and the Financial Information Authorization Agreement can be found in the REGTAP library at under ?Payments-"Payee Groups." (REGTAP FAQ Database - FAQ #474 11/20/13) Q: Do Issuers in a State Based Marketplace (SBM) complete the Vendor Management process outlined in the November 4, 2013 Vendor Management webinar? Updated 1-31-17 A: FFM and SBM issuers, issuers of Stand Alone Dental Plans (Pediatric), and SHOP issuers that also provide qualified health plans in the individual marketplace should submit the requested documentation as you may be eligible to receive APTC and CSR payments on behalf of enrollees. Instructions for submitting the requested payee and banking information and copies of the Financial Information Template and the Financial Information Authorization Agreement can be found in the REGTAP library at under ?Payments-?Payee Groups.? (REGTAP FAQ Database - FAQ #475 11/20/13) 250 2017--00350 Q: Does the Centers for Medicare Medicaid Services (CMS) generate the Payee Group A: Yes, CMS will generate the Payee Group ID after validating the payee and banking information submitted to CMS by the Health Insurance Company. Once generated, CMS will send the Payee Group ID to the Payee Group contact identi?ed on the Financial Information Template. (REGTAP FAQ Database - FAQ #477 11/20/13) Q: If a Health Insurance Company includes three Qualified Health Plan Issuers that share the same Tax Identification Number (TIN), how should the company organize their Payee Groups? A: Health Insurance Companies organize Payee Groups according to the needs of the organization. In this example, the Health Insurance Company can create one (1) two (2) or three (3) Payee Groups for these Issuers. (REGTAP FAQ Database - FAQ #478 11/20/13) Q: Does the 'Not for Profit' status in the Financial Information Template refer to the company's state legal organization or the qualified federal tax-exempt status? A: The 'Not for Pro?t' status in the Financial Information Template refers to the company's quali?ed federal tax-exempt status. Enter for 'yes' to indicate the company has Not for Profit status and for 'no' to indicate the company is a For-Pro?t organization. (REG TAP FAQ Database - FAQ #479 1 1/20/13) Q: If a Health Insurance Company includes one (1) Qualified Health Plan (QHP) Issuer, how many Payee Groups will they have? A: A Health Insurance Company that has one (1) Issuer will create one (1) Payee Group. The Payee Group will contain the single Issuer. (REGTAP FAQ Database - FAQ #480 11/20/13) Q: In the Financial Information Template under the 'Not for Profit' status ?eld, does mean a company is not for profit? A: The 'Not for Pro?t' status in the Financial Information Template refers to the company's quali?ed federal tax-exempt status. Enter for 'yes' to indicate the company has Not for Profit status and for 'no' to indicate the company is a For-Pro?t organization. (REG TAP FAQ Database - FAQ #483 1 1/20/13) Q: Can Health Insurance Companies create a Payee Group that includes Issuers with different Tax Identification Numbers (Tle)? 251 Updated 1-31-17 2017-?00351 A: No, Payee Groups are sets of Issuers that share the same TIN. Health Insurance Companies must create separate Payee Groups for Issuers with different TINs. (REGTAP FAQ Database - FAQ #484 11/20/13) Q: Our Health Insurance company includes two Issuers that share one Tax Identification Number (TIN) how do we organize them so that we receive separate HIX 820 ?les for these Issuers? A: If a Health Insurance company would like to receive separate HIX 820 transactions for two Issuers that share one TIN, the Health Insurance Company will create a separate Payee Group for each Issuer. (REG TAP FAQ Database - FAQ #486 11/20/13) Q: Where and when will the Financial Information Template and Authorization Agreement be available and how do Issuers submit them? A: Health Insurance Companies will complete the Financial Information Template and Financial Information Authorization Agreement and submit them to the Centers for Medicare Medicaid Services (CMS) as an email attachment to vendor manaqement@cms.hhs.qov and fax CMS the code to (301) 492- 4746. Financial Institutions will submit the Bank Verification Letters directly to CMS by fax at (301)492-4746. Instructions for submitting the requested payee and banking information and copies of the Financial Information Template and the Financial Information Authorization Agreement can be found in the REGTAP library at under ?Payments-nPayee Groups.? REGTAP FAQ Database - FAQ #490 11/20/13) Q: The ABA routing number entry on the Financial Information Template is dependent on how the Centers for Medicare Medicaid Services (CMS) transmits funds. Will CMS send funds to Issuers through FedWire or Automated Clearing House A: Issuers will receive Advance Payments of Premium Tax Credits and Cost-Sharing Reductions through an Automated Clearing House from the US. Department of Treasury. (REGTAP FAQ Database - FAQ #500 11/21/13) Q: Please confirm that Issuers cannot use a PO. Box address in the Financial Information Template. A: Neither the 1099 Address nor the Billing Address in the Financial Information Template can be a PO. Box address unless the United States Post Office does not deliver mail to the street address and the company uses a PO. Box instead. (REGTAP FAQ Database - FAQ #501 11/22/13 11/21/13) Q: How can we obtain the Trading Partner Agreement A: The TPA is located on the Zone. The link is: The direct link is (REGTAP FAQ Database - FAQ #664 01/16/14) Q: Can Health Insurance Companies include the Financial Authorization Agreement and the Financial Information Template in one file? 252 Updated 1-31-17 2017--00352 A: Yes, Health Insurance companies can include the Financial Information Authorization Agreement and Financial Information Template in one (1) file. Files should be with a method such as SecureZip. (REG TAP FAQ Database - #762 02/12/14) Q: Does every issuer have to fill out the new Trading Partner Agreement? A: Yes. Issuers must complete a new Trading Partner Agreement in order to receive a HIX 820. This includes issuers who completed a previous partner agreement for the HIX 820. (REGTAP FAQ Database - #844 02/25/14) Q: Do I have to fill out a new 834 Trading Partner Agreement? A: No, issuers will only select the HIX 820 if they are only making updates to the HIX 820 Trading Partner Agreement. (REGTAP FAQ Database - #845 02/25/14) Q: If I already have a Trading Partner Agreement, do I need to submit a New Form or a Change Form? A: If you already completed a Trading Partner Agreement Form and are only updating the Form to include the HIX 820, you will select ?Change? at the top of the Form. You do not have to change the Trading Partner ID you have already created. If you have not completed a Trading Partner Agreement Form, then you will select ?New" at the top of the Form and create a new Trading Partner ID. Note: If you have multiple payee groups and need to create an additional trading partner agreement for an additional payee group, then you will select New and create a new unique Trading Partner ID. (REGTAP FAQ Database - #846 02/25/14) Q: Can I fill out the new Trading Partner Agreement if I don't have my CMS Assigned Payee Group A: No. Issuers must include their CMS assigned Payee Group ID when completing the new HIX 820 Trading Partner Agreement form. If you do not know your Payee Group ID please contact the CMS Help desk at CMS FEPS@cms.hhs.qov or at 1-855-267-1515. (REGTAP FAQ Database - #847 02/25/14) Q: What is the deadline to submit the new Trading Partner Agreement form? A: Currently there is no deadline to submit the new Trading Partner Agreement form. (REGTAP FAQ Database - #848 02/25/14) Q: If I have separate Payee Groups, do I have to fill out more than one Trading Partner Agreement? A: Yes, there will be a new HIX 820 Trading Partner Agreement for every payee group. (REGTAP FAQ Database - #849 02/25/14) 253 Updated 1-31-17 2017--00353 Q: If I have separate Payee Groups, how do I create a Trading Partner ID (TPID) for each payee group? A: For every Payee Group, a separate Trading Partner agreement should be created. Each Trading Partner agreement will have its own trading partner ID. The Trading Partner ID could be derived from one of the following; 1. NAIC value- 5 characters 2. NAIC 1 alpha character at the end. 3. Tax Payer ID -9 characters 4. Tax Payer ID 1 alpha character at the end. 5. HPID - 10 characters For example, if the company's TIN is 123456789 and they have two payee groups, one TPID will be 123456789 and the other TPID will be FAQ Database - #850 02/25/14) Q: Even if I have separate TPIDs, can all my files go to the same location? A: Yes, during onboarding, trading partners can establish a single point of entry id (SPOE ID) in which they can have all the HIX 820 transactions go to the same location. However, they will be in separate ISA-IEA envelopes. (REGTAP FAQ Database - #851 02/25/14) Q: What if I have a clearinghouse, how do I fill out the Trading Partner Agreement so that it is routed to the appropriate location? A: Clearinghouses (including Third Party Administrators) will need to ?rst complete the Trading Partner Agreement Form without a payee ID. Trading Partners who are then using the Clearinghouses will need to include the Clearinghouse TPID on their HIX 820 Trading Partner Form along with their Payee ID. (REGTAP FAQ Database - #852 02/25/14) Q: Can I have multiple Tax Identification Numbers on one Trading Partner Agreement? A: No, since Payee Groups requirements are constrained to one TIN, Trading Partner Agreements cannot cross multiple TINs. (REGTAP FAQ Database - #853 02/25/14) Q: How does an Issuer register as a Trading Partner with A: There are six (6) steps for an Issuer to register as a Trading Partner: Step 1: The Trading Partner downloads the HIX 820 Companion Guide and Trading Partner Enrollment package: registration-form Step 2: The Trading Partner completes and signs the Trading Partner Agreement and submits the signed agreement to the Hub team. Step 3: The Hub team coordinates the linkage between the Trading Partner Submitter Identi?er, User Logon Identi?er and password and notifies the Trading Partner. 254 Updated 1-31-17 2017--00354 Step 4: The Hub team will con?gure a test pro?le for one or more EDI interfaces with the Trading Partner. Step 5: The Hub team and the Trading Partner will conduct test transactions. Step 6: Once the EDI interface has been successfully tested, the Hub team will switch the Trading Partner Pro?le to a production status. Any Issuer experiencing difficulty accessing the ZONE or the Trading Partner Agreement should contact the XOSC Helpdesk at CMS FEPS@cms.hhs.qov or 1-855-267-1515 for assistance. (REGTAP FAQ Database - FAQ #1093 03/19/14) Q: Is the HIX 820 trading partner agreement separate from the trading partner agreement for the 834? A: Issuers complete one (1) Trading Partner Agreement, which includes information for both the HIX 820 and 834; however, if the endpoints for both transactions are different, organizations are encouraged to complete a separate Trading Partner Agreement for the HIX 820 in order to specify the proper destination for the transaction. Please note that as of January 2014, all Health Insurance Companies must complete new HIX 820 Trading Partner Agreements that align with their Payee Groups. The new Trading Partner Agreement is located at edi-reqistration-form on Any Issuer experiencing difficulty accessing the ZONE or the Trading Partner Agreement should contact the XOSC Helpdesk at CMS FEPS@cms.hhs.qov or 1-855-267?1515 for assistance. (REGTAP FAQ Database - FAQ #1094 03/19/14) Initial Payment/Payment Redirect Q3: What if the premium amount received on the 834 does not match the issuer's corresponding rates? A3: There will be a process established whereby the issuer can work out with the FFE any discrepancies in total premium as determined by the Exchange and depicted on the 834. The process is to be developed. (Enrollment Transaction and Companion Guide Webinar 02/13/13) Q7: What happens when the consumer is redirected to the issuer site to make the initial premium payment and then decides not to make that payment? Is the Exchange out of the process at that point and issuers would start their normal billing process? A7: After an individual has made a plan selection, and is redirected to the issuer?s website for instructions on how to make the ?rst month?s premium payment, there is no further role for the FFE. If an individual decides not to make the first month?s premium payment on the website, the issuer may choose to bill the individual through their standard billing process. (Enrollment FAQ 04/24/13) Q8: What would the consumer experience be if the consumer returned to the FFE website in an attempt to pay the initial premium? Updated 1-31-17 A8: If an enrollee returned to the FFE website in an attempt to pay the initial month?s premium, s/he would be re-directed to the QHP issuer site for instructions on making the 255 2017--00355 payment, as the Exchange does not accept or arrange any payment between the enrollees and issuers. (Enrollment FAQ 04/24/13) Q: If an individual forgoes using the payment redirect session with the Qualified Health Plan (QHP) before completing the payment process, does the ASC X12 834 enrollment transaction continue from the Federally-facilitated Marketplace (FFM) to the QHP issuer for that individual? A1: Yes, if an individual has con?rmed a Quali?ed Health Plan (QHP) selection on the Federally-facilitated Marketplace (FFM) site the FFM will always transmit the individual?s choice to the QHP in the daily enrollment transaction regardless of whether the individual did not complete the online payment process via the redirect process,. The issuer can use the enrollment transaction information to generate a premium bill for enrollees who have not yet made their ?rst premium payment. (Enrollment FAQ #7 Premium Payment Redirect 09/17/13; REG TAP FAQ Database - FAQ #188 09/09/13) Q2: If there are changes after the initial enrollment adding a dependent), will all the subsequent enrollment changes have the same Payment Transaction A2: Premium redirect only occurs for the initial premium payment. Therefore, any changes subsequent to the initial effectuated enrollment will not have a Payment Transaction ID because the payment redirect process will not be activated. The issuer will need to generate a new premium bill for the individual or family. (Enrollment FAQ #7 Premium Payment Redirect 09/17/13; REG TAP FAQ Database - FAQ #189 09/09/13) Q3: If the individual changes their mind and does not want to enroll in the Qualified Health Plan (QHP) they chose, even after they?ve taken all of the steps to enroll, can the QHP stop the enrollment? A3: No. The Qualified Health Plan (QHP) cannot ?stop" the enrollment. If the individual chooses to make a new selection during a valid enrollment period and before coverage for the original selection begins, slhe can make a new selection via the Federally- facilitated Marketplace (FFM). The FFM will send the new ASC X12 834 enrollment transaction to the new QHP issuer, and an ASC X12 834 cancellation to the original issuer. The new issuer will receive a transaction with a new Payment Transaction ID. (Enrollment FAQ #7 Premium Payment Redirect 09/17/13; REG TAP FAQ Database - FAQ #190 09/09/13) Q4: Can an individual be prevented from making changes to their initial selection until the first Qualified Health Plan (QHP) issuer has collected payment and sent the confirmation back to the Federally-facilitated Marketplace Updated 1-31-17 A4: No. Changes cannot be held until the issuer has collected payment. In a scenario where a qualified individual changes his/her original QHP selection during a valid enrollment period, the Federally-facilitated Marketplace (FFM) will provide the Ql the payment redirect URL for the new QHP and assign a new Payment Transaction ID. The FFM will send an ASC X12 cancellation transaction to the ?losing? QHP, and will create a new initial ASC X12 834 enrollment transaction for the new QHP selected. (Enrollment FAQ #7 Premium Payment Redirect 09/17/13; REGTAP FAQ Database - FAQ #191 09/09/13) 256 2017--00356 06: What if an issuer has two pathways for collection of the initial premium payment? For example, an issuer has contracted with a Third Party Administrator (TPA) to collect initial premium payments for the individual market, but for the SHOP, this service is out of scope. Some issuers are planning to collect the initial premium for SHOP using a different process. How will two different processes work with premium payment redirect? A6: In the scenario described, the issuers would have submitted their URL for payment redirect for individual products in the Qualified Health Plan (QHP) application but left the payment redirect question for SHOP products blank. When con?rming selections via the FFM, individuals who enroll in the individual market QHP will find the URL for the payment redirect process, and the SHOP employers will be informed that they will receive a bill from the issuer. (Enrollment FAQ #7 Premium Payment Redirect 09/17/13; REGTAP FAQ Database - FAQ #193 09/09/13) Q7: In the XML file that is sent to the issuer at the time of the payment redirect, what delimiter will be used to separate member names in the "Additional Information" field? A7: The XML file will include the semicolon as the delimiter used to separate member names in the Additional Information ?eld. (Enrollment FAQ #7 Premium Payment Redirect 09/17/13; RE GTAP FAQ Database - FAQ #194 09/09/13) Q8: Is the Payment Transaction ID being supplied for each payment instance? A8: Yes. The Payment Transaction ID is included for each payment instance for each enrollment group. For a detailed description, refer to the June 2013 updated Payment Redirect Business Service Description (BSD), which also includes several scenarios. The BSD is available on the zone and on the REGTAP site at (Enrollment FAQ #7 Premium Payment Redirect 09/17/13; REGTAP FAQ Database - FAQ #195 09/09/13) 09: If an individual selects a medical and dental QHP from the same issuer, and the information is on a different 2000 loop in the ASC X12 834 enrollment transaction, is the premium amount owed going to total up to one amount and we only enroll the individual if the total (premium) amount is received? A9: No. Each QHP selection medical and dental - will generate a separate enrollment and a separate payment Transaction ID. If a family selects a medical QHP and a separate dental QHP under the same issuer, the enrollments will be separate. The enrollee will be redirected once to the URL for the medical plan and then a separately to the URL for the dental plan. Issuers are expected to effectuate each enrollment independently once payment for the respective QHP selection is received. (Enrollment FAQ #7 Premium Payment Redirect 09/17/13; REGTAP FAQ Database - FAQ #196 09/09/13) Q10: How can there be two redirects - one for medical and one for dental? How will this process flow? A10: There will be a redirect for each type of plan selection. For example, if an individual selects a medical plan and a dental plan, they will be redirected to two different locations 257 Updated 1-31-17 2017--00357 on the issuer?s website. The consumer will access the payment redirect web links from the FFM website on the plan summary page presented after s/he has confirmed the plan selections. For each online payment, the consumer is redirected via a new window. (Enrollment FAQ #7 Premium Payment Redirect 09/17/13; REG TAP FAQ Database - FAQ #197 09/09/13) Q11: If an individual changes to a different Qualified Health Plans (QHP) before enrollment in one is effectuated, will they be redirected to the new QHP issuer?s website to make the first premium payment? A11: Yes. If an individual selects a new Qualified Health Plan (QHP) before their original selection has been effectuated, s/he would receive a new Payment Transaction ID and be redirected to the new quali?ed health plan's website through the payment redirect process. (Enrollment FAQ #7 Premium Payment Redirect 09/17/13; REG TAP FAQ Database - FAQ #198 09/09/13) Q12: How often will individuals be able to use the payment redirect process? Will they be redirected every time they make a change to a new Qualified Health Plan A12: Qualified Individuals will use the redirect function if they chose another QHP during an open enrollment or Special Enrollment Period. The payment redirect process is not used within the same QHP when other types of enrollment related changes are made after coverage has been effectuated. (Enrollment FAQ #7 Premium Payment Redirect 09/17/13; REGTAP FAQ Database - FAQ #199 09/09/13) Q13: Are there documents that provide examples of specific actions that will or will not trigger the payment redirect process? A13: Yes. The most current Payment Redirect Business Service Description (BSD), published in June 2013, provides several examples of triggers for the premium payment redirect processthe ZONE, the collaboration site for technical documents A copy is also available on the public facing site REGTAP, (Enrollment FAQ #7 Premium Payment Redirect 09/17/13; REGTAP FAQ Database - FAQ #200 09/09/13) Q14: If the qualified individual comes back to make a premium payment on the issuer?s website for a Qualified Health Plan (QHP) enrollment initiated on the FFM, what will happen to the Payment Transaction A14: If a qualified individual visits the Qualified Health Plan (QHP) website independently once enrollment is complete, the payment transaction ID is no longer relevant. Once the individual has been able to enroll in the QHP, makes the initial premium payment and has the enrollment confirmed, there is no further need for the payment transaction ID. (Enrollment FAQ #7 Premium Payment Redirect 09/17/13; REG TAP FAQ Database - FAQ #201 09/09/13) Q: How do Issuers obtain and provide the certificate needed for the SAML assertion regarding premium payment redirect? A: Issuers obtain and provide the SAML assertion for the premium payment redirect through a process specified by the Of?ce of Information Systems. The procedure and a 258 Updated 1-31-17 2017--00358 sample layout has been provided in the premium payment documents which are available on both RegTap and called: Payment Redirect SAML Assertion Format v2.pdf. All issuers should participate in the DIS Testing Webinars held every Tuesday and Thursday at 3:00 pm. Eastern Time. Call in numbers are available on the If additional assistance is needed, contact the DIS help desk at CMS feps@cms.hhs.qov. This response will be valid until further notice from OIS and CCIIO. (REGTAP FAQ Database - FAQ #208 11/21/13) Q: If an Issuer has submitted a URL for enrollment/payment during the QHP submission process but is not ready to support the Payment Redirect Process, how does the Issuer notify Hub that they do not want the Payment Redirect Process to occur for their A: Consistent with previous guidance, CMS is not accepting requests for changes to QHP data. CMS will provide guidance on the process for requesting critical corrections to QHP data and making administrative data changes after October 1. (REGTAP FAQ Database - FAQ #209 11/21/13) Q: In the instance a plan is selected on 10/15/13 for a family consisting of mom, dad and one child. The Subscriber logs onto FFM website 11l5/13 and wants to add another child. If the child is added to same policy, will the member be redirected to the premium payment redirect a second time if policy is changed? This may or may not result in a change of premium. 0 If the member is not redirected, will information be displayed to the member via the FFM website to instruct him/her to take next steps? 0 If member is redirected, will a new premium redirect transaction ID be assigned? A: In the scenario described of a child being added to an enrollment group prior to the beginning of coverage, the original group's selection is cancelled, and a new payment redirect link is offered for the new selection. More information on Premium Payment Redirect is available as a Business Service Description and FAQ on (REGTAP FAQ Database - FAQ 404 11/22/13) Q: What will be the FFM screen look like if an issuer does not offer premium payment redirect? A: The difference between the screen for an Issuer who offers payment redirect and those who do not is the that a QHP with online payment will display a button with the phrase 'Pay for Health Plan.' All QHPs will display this language: 'To activate your new health coverage, you must pay your first month's premium by your plan's due date. Your plan will contact you in the next few days with details on how to pay, or visit your plan online to make your payment now if your plan accepts online payment. Your payment must be received and processed by the effective date to be fully enrolled. Contact the health plan's customer service if you have any payment questions or issues.? (REGTAP FAQ Database - FAQ 633 01/27/14) 259 Updated 1-31-17 2017--00359 Payment Cycle Q4: Question: Slide 3 of the initial enrollment indicates a CSR AMT of 25.00. Can you confirm if this represents a dollar amount or percentage amount? A4: The CSR AMT represents a dollar amount. This is the advance CSR payment an issuer can expect to receive on behalf of the enrollment group. (Enrollment and Payment Processing Webinar Series 02/27/13; REG TAP FAQ Database - FAQ #320 02/27/13) 02: Will premium and subsidy level information be sent on a basis? How often can the subsidy level change or will it be an annual determination? A2: APTC and CSR information will be transmitted on the 834 from the Exchange to the issuer. The APTC and CSR amounts listed on the 834 will be amounts, but the 834 will not be resent unless there is a change in eligibility or a change in actual APTC made by the enrollee. There is no limit on the number of times that subsidy levels can change during a year. (Enrollment Transaction and Companion Guide Webinar 02/13/13; REGTAP FAQ Database - FAQ #299 04/18/13) 02: What does the CSR amount represent? Is that the amount CMS will pay each month for the family in A2: The 834 from the Federally-facilitated Marketplace (FFM) to the QHP issuer will include the advance CSR payment amount that the issuer can expect to receive from CMS each month on behalf of the enrollment group. This is the advance CSR payment and does not represent actual CSRs paid on behalf of eligible enrollees throughout the benefit year. CMS will reconcile advance CSR payments made with actual CSRs during the CSR reconciliation process, which will occur after the end of each benefit year. Please see of the HHS Notice of Bene?t and Payment Parameters for 2014; Final Rule published March 11, 2013. (Enrollment and Payment Processing Webinar Series 02/27/13; REG TAP FAQ Database - FAQ #28905/24/13) Q: How will discrepancies between issuer records and CMS records for payments for APTCs and CSRs be handled? A: A process will need to be established between CMS and issuers to work out any discrepancies in advance payments made for APTC and CSR. The process is under development. (REGTAP FAQ Database - FAQ #291 05/29/13) Q1: The IRS administers the premium tax credit program. In the Notice of Benefit and Payment Parameters for 2014, HHS sets forth that issuers will receive advance payment of the premium tax credit (APTC) on a basis. Which agency will make the APTC payments? A1: The IRS and CMS established a payment process to begin in January 2014. Payments will be processed using existing federal payment systems through the Department of the Treasury. CMS will reach out to Federally facilitated and State Based Marketplace issuers to provide additional information and receive financial account information starting in late summer 2013. (Payments FAQ #1 06/28/13) 260 Updated 1-31-17 2017--00360 Q: What system capabilities will an issuer need to account for premium payments and advance payments of the premium tax credit A: As required by 1412(c)(2)(A) of the Affordable Care Act, advance payment of the premium tax credit (APTC) will be made by Treasury to issuers of qualified health plans on a basis. An issuer receiving an APTC shall reduce the premium charged to the individual by the amount of the advance payment for the period This requirement, as well as the statutory requirement for the issuer to notify the consumer of the advance payment of the premium tax credit on each billing statement, is codified at 45 CFR Issuers, therefore, will need to be able to account for these two payment sources from the individual for premium and from Treasury for the APTC for the buildup of the full premium amount. There are existing programs that require an issuer to manage multiple funding streams for the full buildup of premium. The AIDS Drug Assistance Program (ADAP) Plus Insurance Continuation (APIC) can pay for commercial health insurance premiums for eligible individuals. ADAP is Federally funded through the Ryan White Comprehensive Treatment Extension Act of 2009, which is administered by the US. Department of Health and Human Services Heath Resources and Services Administration. (REGTAP FAQ Database - FAQ #293 10/2/13) Q1: What is the cut- off date for issuers to confirm enrollments (8345) to the Federally- facilitated Marketplace in order to get paid subsidies for January 2014? A1: In the Federally Facilitated Marketplace (FFM), confirmed enrollments must be successfully submitted by a QHP issuer to the FFM by December 16th to be included for payment in January. In State Based Marketplaces (SBMs), confirmed enrollments must be successfully submitted by the SBM to CMS by December 16th to be included for payment in January. CMS will run the payment calculation after December 16th. (Payments FAQ #2 10/07/13) 02: When can I expect to receive APTC and CSR payments for January? A2: Treasury will issue payments via electronic funds transfer (EFT) for the January coverage to SBM and FFM issuers between the 22nd and 24th of January. These payments are based on con?rmed enrollments received and successfully processed by CMS through December 16, 2013. (Payments FAQ #2 10/07/13) Q3: What is the regular payment cycle? Is the timeline for January payments the same as for future months? A3: CMS generally anticipates that the payment cycle will be roughly the same for future months. However, CMS may need to revise the timeline (Payments FAQ #2 10/07/13) Q4: When will I have information about my expected payments for January? Updated 1-31-17 A4: Issuers can expect to receive two HIX 820 payment reports: an initial, optional, report between January 8-10 and a final report between January 29-31. The initial payment report will contain policy level payment-related information on Individual Marketplace APTC, CSR and FFM user fees as well as SHOP FFM user fees. The final payment report will contain the same policy level payment-related information, but will also include program-level payments and charges and the actual Treasury payment 261 2017-?00361 amount and EFT trace number. For more information, please see for the latest CMS HIX 820 Companion Guide and training documents. (Payments FAQ #2 10/07/13) 06: How will issuers report any discrepancies identified on the HIX 820 for January? A6: CMS has developed a Payment Discrepancy Report (PDR) that will allow issuers to report discrepancies between what they believe they should be paid by CMS or what they owe CMS and what is reported on the HIX 820. This report will allow CMS to work with issuers on these discrepancies and resolve these concerns as quickly as possible. Issuers will receive an initial HIX 820 earlier in the month and a final HIX 820 later in the month following the Department of Treasury processing request for payment. While both the initial and ?nal HIX 820 transactions contain the same policy- level information, the initial HIX 820 is optional for issuers to process. Issuers are required to submit only one PDR per HIX 820 initial and final pairing for a payment cycle within 15 days of the receipt of the final HIX 820. If an issuer chooses to process the initial HIX 820, they are encouraged to submit discrepancies based on this report as soon as they are identified to allow for earlier processing. The Issuer is required to link reported payment discrepancies to the HIX 820 for which the PDR is being submitted by including the EFT Trace Number referenced on the HIX 820. More information and training on this process will be provided later this fall. (Payments FAQ #2 10/07/13) Q. Please describe the ACH transfer from Treasury to issuers such as whether the direct deposit will transfer from Treasury to issuer's bank account or there will be an ACH file sent to the issuer by the A: will send the approved payments to Treasury. Treasury will process the EFT and send the payments directly to the issuers bank account. Following con?rmation from Treasury, CMS will send a Final (Summary) HIX 820 to the issuer. (REGTAP FAQ Database - FAQ #4648 11/18/13) Q: Will Issuers submit 2016 Small Business Health Options Program (SHOP) data such as User Fees on the Enrollment Payment Data Workbooks? A: The FFM is the database that holds all enrollment information. EPS extracts (processes is a better word) effectuated enrollment data at the policy-level and rolls in up to the payee level for payments. (REGTAP FAQ Database - FAQ #12012 08/25/15) Q: CMS has instructed marketplace issuers and submitters to prorate financial data premium, APTC, CSR and FFM UFs) under the manual payment process for 2015 and 2016 data. This will take place via the Enrollment and Payment Data Workbook. CMS has also indicated that members and enrollment groups should not be prorated within the Workbook. How should we report members and enrollment groups such that they align to the prorated financial data? A: The Enrollment Payment Data Workbook does not collect data on ?member months? or ?enrollment group months?. As a result, there is no way to prorate a member or an enrollment group. Issuers and submitters are instructed to report member and enrollment group counts as of the 1st of the month. To the extent that changes occur over time, they should be re?ected on subsequent months? restated data. (REGTAP 262 Updated 1-31-17 2017--00362 FAQ Database - FAQ #14289 12/16/15) Q: How will prorating financial data premium, APTC, CSR and FFM UFs) but not enrollment groups and members impact the result of CSR formula? A: The CSR formula that is programmed into the Enrollment Payment Data Workbook is based on the total premium multiplied by the CSR plan variation multiplier. When the submitter prorates the premium amount and re?ects QHP-level premium totals in the Workbook, the corresponding prorated CSR amount will auto- populate. While the CSR calculation in the 2014 Enrollment Payment Data Workbook was member-dependent, the 2015 and 2016 CSR calculation is not. (REGTAP FAQ Database - FAQ #14290 12/16/15) Interim Issuer Payment Process Q: What do you mean by effectuated enrollment group and effectuated enrollment? A: For purposes of this interim payment process, ?effectuated enrollment group? is de?ned as any enrollment in which the amount the enrollment group is responsible to pay toward the total premium amount has been paid in full by the enrollment group. If using the CMS 834 Companion Guide, the amount the enrollment groups is responsible to pay is identi?ed as the REF02 value for TOT RES AMT as listed in the 2750 loop. (REGTAP FAQ Database - FAQ #524 12/06/13) Q: How does an effectuated enrollment differ from a con?rmed enrollment? A: For purposes of this interim manual payment process, CMS will consider effectuated enrollments as confirmed and make payments to issuers on behalf of all effectuated enrollments as indicated by the submitter. (REGTAP FAQ Database - FAQ #525 12/06/13) Q: CMS states that the deadline for Enrollment and Payment Data Template submission is no later than December 20th for payments to be made to issuers for January coverage effective dates. If an individual selected a plan on December 13th but didn't pay their premium until December 21st, should that individual's enrollment be included in the Template submission? A: No, since the individual did not yet pay their premium in full by the submission date, that individual would not be considered to be in an effectuated enrollment group for purposes of January payment. CMS would therefore pay for that individual's enrollment in the next payment month, assuming that effectuated enrollment data is submitted to CMS by the February payment cut-off date. In the above example, CMS would pay both the restated January payment amount and the February payment amount for that enrollment group in the February payment cycle. (REGTAP FAQ Database - FAQ #526 12/06/13) Q: Can CMS provide more details on the payment report issuers will receive in January? What will happen once the 820 process is implemented? Can we get a sample report prior to January 31 st? 263 Updated 1-31-17 2017--00363 A: CMS intends to provide issuers and SBMs with payee reports which will be summary level issuer level detail. These payment reports will show the APTC, CSR and User Fee amounts that were included in their ?nal payment along with any correction adjustments that were made to these program payments and charges. The Electronic Funds Transfer (EFT) trace number associated with the payment will also be included. CMS anticipates sharing a sample of this report later this month. (REGTAP FAQ Database - FAQ #528 12/06/13) Q: Does this template replace the 834 effectuation process? A: No, this template does not replace the normal 834 effectuation process. FFM issuers and SBMs should still continue to send daily 834 transactions to CMS. At a future date, CMS will reconcile the estimated payments made during the interim payment process to the actual con?rmed enrollment data provided via 834. Therefore, it is necessary that CMS still receive the actual 834 enrollment data. (REGTAP FAQ Database - FAQ #529 12/06/13) Q: How will we know that our data submission was accepted? A: CMS will acknowledge receipt of data submissions via return email as submissions are received. After data validation occurs, CMS will notify the point of contact designated for a submitter to inform them that the data submission passed all edit checks or that resubmission will be required. The point of contact for the submitter will be noti?ed of the errors that need to be corrected along with any resubmission request. (REGTAP FAQ Database - FAQ 530 12/06/13) Q: Are submitters required to submit a test file? What if submitters do not have any effectuated enrollments? A: All submitters should submit a test file under this process before submission of a production file will be accepted. If the submitter does not have any effectuated enrollments during the testing window, the submitter should populate the template using test data and submit it according to the schedule. If the submitter does not have any effectuated enrollments during the production data submission phase, CMS will accept an official statement from the CEO or CFO to that effect for that month's payment cycle. (REGTAP FAQ Database - FAQ #531 12/06/13) Q: Because coverage is not effectuated until the binder payment is due, the December 20th cutoff date for sending production templates to CMS seems premature. Many enrollment groups may not have made premium payments by that date. Should submitters include data for enrollment groups who have not made premium payments yet? Updated 1-31-17 A: No, CMS is asking for effectuated enrollment group information only. CMS understands that some enrollment groups may not have paid their premium by December 20th. CMS will therefore ask each submitter to resubmit data for January during the February template submission, allowing CMS to make any payments not 264 2017--00364 made for January during the February payment cycle. It is important to note that this is the same process that would have occurred under the normal payment process, that is, if a con?rmation 834 was not received by the December 15th cutoff date to receive enrollment transactions, CMS would not make a payment in January. Rather, it would receive the con?rmation 834 from the issuer once payment was collected from the enrollment group and make the payment during the February payment cycle. CMS would be unable to make payments in January if the template submission cutoff date was later than December 20th. (REG TAP FAQ Database - FAQ #532 12/06/13) Q: Please clarify who should be the point of contact for the submitter for this process. A: CMS will use the contact speci?ed by the issuer during the Financial Information Form (FIF) submission process under Vendor Management as the primary contact for the manual payment process. If the issuer has not submitted this information to CMS, please do so immediately. If you would like to designate an additional contact for this process, please send an email to with P00 in the subject line and the name of the additional contact in the body of the email. Please carbon copy (cc) that individual when you submit that email. CMS will send communications to both contacts throughout the payment processing cycle. If an SBM is the submitter on behalf of its issuers, the SBM must provide a point of contact to CMS. (REGTAP FAQ Database - FAQ #533 12/06/13) Q: Why is CMS requiring issuers to resend enrollment data and when CMS already has this information? A: The FFM does not have con?rmed 834 enrollment information available at this time. Therefore, CMS must rely on the issuers to provide information on effectuated enrollments. (REGTAP FAQ Database - FAQ 534 12/06/13) Q: If APTC covers the full cost of the premium for the enrollment group, doesn't CMS consider that enrollment effectuated since the enrollment group does not owe anything toward the cost of the total premium? If so, doesn't that mean CMS already has the effectuated enrollment data for these enrollment groups and therefore doesn't need it from issuers? A: CMS still requires a confirmation 834 from an issuer or SBM in the event the APTC covers the full cost of the premium. Under the normal payment process CMS will only make APTC and CSR payments for con?rmed enrollments, even if the APTC covers the full cost of the premium. In the interim payment process, CMS plans to utilize the same policy and requires that the issuer has effectuated the enrollment and, subsequently, included such policies in their data submission. (REGTAP FAQ Database - FAQ 535 12/06/13) Q: Is this process temporarily replacing the 820 process, the outbound 834 process, or both? A: This interim payment process will allow CMS to make payments even though the 834 and 820 processes are not yet in place. Daily 834 transaction development and 265 Updated 1-31-17 2017--00365 submission should still proceed as planned so that CMS can reconcile the payments made under the alternate payment process with actual 834 enrollment data. When full functionality is in place, CMS will send the HIX 820 payment report to issuers. (REGTAP FAQ Database - FAQ #536 12/06/13) Q: Once full functionality is in place, will CMS send issuer transactions on the 820 file for the January payments to provide the detail level or are issuers responsible for manually entering the detail during this interim period? A: CMS will provide more information on the recovery process at a later date. (REGTAP FAQ Database - FAQ #537 12/06/13) Q: Can the submitter send emails to CMS containing the Enrollment and Payment Data Template submissions? A: CMS does not have the ability to accept emails or obtain files from sources outside the federal government for this process. Submitters must follow the instructions provided by CMS which include populating the password protected Payment and Enrollment Data Template and submitting it to (REGTAP FAQ Database - FAQ #560 12/11/13) Q: How does CMS plan to reconcile these interim payments to actual enrollment data? A: After 834 transactions are received and processed by CMS at a later date, CMS will send detailed 820 transactions and corresponding payments that will retroactively adjust and reverse the estimated payments made during the interim payment process using the detailed enrollment group data from the 834 transactions. (REGTAP FAQ Database FAQ #585 12/17/13) Q: Can an issuer decide to opt-out of this interim payment process? What if an issuer is not able to submit the data in time to meet the December 20th deadline? A: All issuers are required to submit data under this interim payment process. CMS is committed to providing technical assistance to every submitter during this process. If an issuer is not able to meet the December 20th deadline to submit production data CMS will work with them to ensure the January data is included with the February data submission. (REGTAP FAQ Database FAQ #586 12/17/13) Q: How long does CMS plan to use the interim payment process? A: CMS anticipates running this interim payment process to make estimated payments to issuers for the January and February payment cycles. As soon as information is available for future months, CMS will issue guidance as appropriate. (REGTAP FAQ Database FAQ #587 12/17/13) Q: How does CMS plan to transition from this interim payment process to the full 834 approach that was originally designated? Specifically, how will CMS ensure that payments made during the full 834 approach do not duplicate payments already made during the interim payment process? 266 Updated 1-31-17 2017--00366 A: CMS is committed to ensuring that no duplicate payments are made on behalf of speci?c enrollment groups. That being said, the payments made during the interim payment process will be based on estimates of the best available data at that time. Payments made during the interim payment process are not made based on enrollment group level detail; rather, they will be made at the issuer level and are summary level payments. Once CMS is using full 834 functionality and is transitioning into the planned payment process, CMS will manually adjust the summary issuer level payments made with the actual enrollment group level payment amounts. That is, CMS will reverse the payments made during the interim process and replace those payments with the payments amounts based on specific enrollment group level data. CMS will detail this reversal in the detailed 820 transactions rather than including this information in summary payment reports so that issuers understand what was reversed and what was paid based on actual enrollment group level data. (REGTAP FAQ Database - FAQ #589 12/17/13) Q: How does this interim payment process align with the enrollment pre-audit process? A: The enrollment pre-audit work is being done to ensure that data in the FFM and issuer's enrollment databases align for the longer term. Any estimated payments made during the interim payment process will be manually adjusted at the enrollment group level after CMS is using full 834 functionality for payments. Correcting data in the FFM and issuer's enrollment databases will ensure long term, accurate payments. To the extent possible, issuers should adjust the data in your enrollment databases according to the pre-audit ?le process to help ensure the accuracy of the payments made during the interim payment process. However, it should be noted that once CMS is using full 834 functionality and the payment process is fully functional, estimated payments made during the interim payment process will be adjusted according to actual, valid enrollment group level data. (REGTAP FAQ Database - FAQ #590 12/17/13) Q: Which SBMs are submitting data for their issuers and which issuers in SBM States should submit the data themselves? A: The following SBMs are submitting data on behalf of their issuersand WA. Issuers in SBMs are submitting their own data. (REGTAP FAQ Database - FAQ 591 12/17/13) Q: We did not receive a con?rmation of our test template submission. Should we resubmit? A: If you did not receive a response regarding validation of your test ?le yet, please contact CMS at the immediately. (REGTAP FAQ Database - FAQ 592 12/17/13) Q: Does CMS require any information in addition to the enrollment and payment data template in order for an issuer to receive payment? A: Yes. CMS requires the submitter's financial authority CEO or CFO or authorized delegate) to attest that the information submitted on the January enrollment and payment data template(s) is accurate. CMS will issue detailed instructions on completion of this form on December 18, 2013. (REGTAP FAQ Database - FAQ 593 12/17/13) 267 Updated 1-31-17 2017--00367 Q: CMS has provided an alternative form that issuers and/or SBM submitters can use to certify the data submitted on the Enrollment and Payment Data submission. Does this form replace the certification form previously provided required to submit the new form if I have already submitted the prior version? A: CMS has provided an alternate Submission Accuracy Form which issuers and SBM submitters may use to certify their Enrollment and Payment Data Template submission. At their discretion, issuers or SBM submitters may use this form or the earlier version provided on 12/17/2013. If an organization (issuer or SBM submitter) has already submitted their certification no further action is required. If an organization chooses to submit this new form CMS will use the latest version submitted as the of?cial record of the organization's certi?cation. (REGTAP FAQ Database - FAQ #600 12/23/13) Q: If CMS is still utilizing the interim payment process in March and an issuer has a retroactive termination effective January 1, 2014, will the submitter refile January's template for the March submission? A: Yes, CMS intends to ask submitters to restate all prior months of enrollment during this interim payment process. If CMS is using the interim payment process in March 2014, CMS will ask submitters to restate January and February, submit updated information regarding each previous month's enrollment. This will capture all updated enrollment data through the March cutoff date and allow for adjustments to payments in March 2014. (REGTAP FAQ Database - FAQ #669 01/16/14) Q: When will issuers receive the payment report? Will the payment report show up after the EFT takes place or before? A: The Payment Report will be sent near the end of January, so it will be sent after the EFT occurs. (REGTAP FAQ Database - FAQ #670 01/16/14) Q: We submitted data for the January payment cycle. However, we understand that beginning with the February payment cycle, we will need to restate the prior month's data and also provide the current month's data. What does that mean? A: The enrollment and payment data template includes two tabs: 1. On the ?rst tab, submitters will include the full enrollment and payment pro?le for January all active enrollments for January effectuated through January 15th). The January restatement template should contain all enrollments effective during the month of January. It will capture what was already submitted to CMS in December (effectuated enrollments through 12/15) but will also capture enrollments effectuated after 12/15. It will also capture any retroactive adjustments to enrollment data in the month of January, including retroactive enrollments, terminations, cancellations, or changes. Submitters must submit a January restatement template even if data for January has not changed since the December submission. 2. On the second tab, submitters will include the full enrollment and payment profile for February all active enrollments for February effectuated through January 15th). It will include enrollments that were previously effectuated for January and that are still in place in February. (REGTAP FAQ Database - FAQ #671 01/16/14) Q: How will retroactive enrollment changes be reflected during this interim payment process? 268 Updated 1-31-17 2017--00368 A: To handle any retroactive enrollment, termination, cancelation, or change information, CMS will ask submitters to restate prior month's data during this interim payment process. This restatement of enrollment data for prior months will include the updated enrollment information. After CMS receives this information, it can adjust a previous payment made based on the updated data. (REG TAP FAQ Database - FAQ #672 01/16/14) Q: For the December template submission, an issuer reported $100 in APTC for an enrollment group effective 1/1. In January, the enrollment group's APTC retroactively changes effective 1/1 to $200. What amount does the issuer report for January and February for the January template submission? A: The issuer should report $200 in the January restatement template and $200 in the February template. CMS will therefore subtract what was already paid for January ($100) from the restated amount for January ($200) to get the January payment Summed with February, this issuer will receive $300 in February for this enrollment group. (REGTAP FAQ Database - FAQ #673 01/16/14) Q: Michael's coverage with issuer 21212 began on 1/1, but Michael thereafter terminated his plan on 1/10 retroactive back to 1/1. CMS already made payment of APTC and CSR for Michael's policy because it was included in issuer 21212's December template submission. How will CMS recover the payment already made for Michael's retroactively terminated policy? A: Issuer 21212 will restate January effectuated enrollment data in the January template submission. This restatement will include all enrollments effective in January as of 1/15, which will no longer include Michael's enrollment with issuer 21212. CMS will therefore subtract the payment already made for Michael from Issuer 21212?s February payment. (REGTAP FAQ Database - FAQ #674a 01/16/14) Q: John and Mary had a baby on 1/5, and the baby was added to John and Mary's QHP with issuer 56789 effective 1/5. With the addition of the baby to the family, the enrollment group is now eligible and therefore receives additional APTC and CSR. However, issuer 56789 was not paid this additional APTC and CSR in January because the data was not available in the December template submission to CMS. How will issuer 56789 receive the additional APTC and CSR for that enrollment group? A: Issuer 56789 will restate January effectuated enrollment data in the January template submission. The January restatement will include all enrollments effective in January as of 1/15, including the change to John and Mary's enrollment group data. Issuer 56789 will therefore be paid the additional full month January APTC and CSR amounts for the baby in February. (REGTAP FAQ Database - FAQ #675 01/16/14) Q: How will CMS determine which contacts at our organization receive the payment reports that will be sent out under this interim payment process? 269 Updated 1-31-1 7 2017--00369 A: CMS will use the contact information submitted in the vendor management process to determine the primary financial contact for the payee group and send the payment reports to payee groups. CMS will also send the payment report to any updated contacts provided to the interim payment process mail box marketplacepayments@cms.qov. CMS will work with SBMs who would also like to receive the summary payment data without EFT and banking information. (REGTAP FAQ Database - FAQ #676 01/16/14) Q: Which issuers are required to submit Enrollment and Payment Data Templates under this interim payment process? A: The A to this depends on a number of factors, critically whether the issuer is in a Federally Facilitated Marketplace (FFM) or a State Based Marketplace (SBM), and whether the plan offered is in the individual or the Small Business Health Options Program (SHOP) market. In the FFM, all QHP issuers offering plans in the individual and SHOP market should submit data under this process. In the SBMs, either an issuer or the SBM on behalf of its issuers should submit as described below. When an SBM is not submitting data on behalf of its issuers, all QHP issuers offering plans in the individual market should submit, although data elements for SHOP plans are optional. If an issuer is only offering SHOP plans in an SBM state (no individual market plans), that issuer may choose not to submit data. Please see the attached table for a list of required submitters. Files: FAQTableAttachment 50R 111713679.pdf (REGTAP FAQ Database - FAQ #679 01/16/14) Q. We are a Stand-alone Dental Plan (SADP) that does not have any enrollees that are eligible to receive the Advance Premium Tax Credit (APTC). Therefore, we do not expect to receive any APTC payments. Are we still required to submit under this interim payment process? We do have enrollees. How will we be charged for user fees owed to A. Stand-alone Dental Plans (SADPs) that do not expect to receive APTC payments are not required to submit under this interim payment process. If your organization is not going to submit a data template, please notify us by completing the Submission Certification Form we sent out on January 16, 2014. The form has been revised to accommodate Stand-alone Dental Plans that do not plan to submit because they do not expect to receive APTC payments from CMS. CMS is currently collecting user fees by netting these charges from payments when possible. We are still developing our process for invoicing issuers that do not have payments available to net from and will communicate that at a later date. (REGTAP FAQ Database - FAQ #680 01/21/14) Q: Under the interim payment process, the initial enrollment payment data submission window generally runs from the 16th to the 19th of the month. Can CMS extend the submission window? Additional time would allow submitters to conduct a more thorough review of the data and make corrections as needed. Updated 1-31-17 A: CMS created the submission window to accommodate the enrollment cutoff date on the 15th of the month. This allows for submitters to submit data for enrollments that will be effectuated as of the first day of the following month. CMS sends the enrollment 270 2017--00370 payment data workbook to submitters several days prior to opening the submission window. Submitters that need additional time to submit their data may decide to pull enrollment data from their systems prior to the 15th of the month for purposes of populating the enrollment payment data workbook and making timely submission. Enrollments that occur after the submitter has pulled the data would be re?ected in the restatement process during the following month. . (REGTAP FAQ Database - FAQ #814 02/19/14) Q: Do Issuers submit the HIX 820? A: Issuers do not submit the HIX 820. The HIX 820 is an outbound transaction from CMS. The Centers for Medicare Medicaid Services (CMS) has implemented an Interim Payment Process to facilitate timely Advance Payments of the Premium Tax Credit (APTC) and Cost Sharing Reduction (CSR) payments to Issuers on behalf of enrollees in the initial months of 2014. During this interim process, CMS will not utilize the HIX 820 ?le. CMS will provide additional guidance on HIX 820 ?les, processes and deadlines later in 2014. Visit for information about future trainings. (REGTAP FAQ Database - FAQ #1319 03/31/14) Q: Will the Manual Payment Process continue into 2016 for restatement purposes? A: Our intent is to continue the manual payment process into 2016 for restatement purposes. However, CMS will provide additional detail regarding the restatement of 2015 data going into 2016 as it becomes available. (REGTAP FAQ Database - FAQ #11370 07/31/15) 2015 Payment FAQs HIX 820, Policy-based Payment, Preliminary Payment Report, etc. Q: Will the Issuers receive one (1) HIX 820 transaction per Payee Group ID or one (1) per Health Insurance Oversight System (HIOS) A: In most cases, one HIX 820 will be provided to each Payee ID per month and include all the Quali?ed Health Plans (QHPs) that correspond to that Payee. There are two (2) situations where a Payee would receive more than one (1) HIX 820 in a month: 1) if the total payment is $100 million or more, 2) if the total number of ENT loops in the HIX 820 are one million or more. (REGTAP FAQ Database - FAQ #11166 07/01/15) Q: What is a Policy-based Payment? A: Policy-based Payments are payment amounts that are calculated using effectuated subscriber-level data, which are then aggregated and paid out to Issuers at the policy level. Currently, the Centers for Medicare Medicaid Services (CMS) uses a Manual Payment Process using enrollment and payment data provided by Issuers and certain State Based Marketplaces (SBMs) on behalf of their issuers at the plan-level (16-digit Quali?ed Health Plan level). (REGTAP FAQ Database - FAQ #11178 07/01/15) 271 Updated 1-31-17 2017--00371 Q: Will Issuers receive the Exchange-assigned Subscriber ID segment in the HIX 820 Transaction? Yes, the Exchange Assigned Subscriber ID will be sent on the HIX 820. (REGTAP FAQ Database - FAQ #11179 07/01/15) Q: Will the Centers for Medicare Medicaid Services (CMS) process 2015 data retroactivity through the HIX 820 or through the current Manual Payment Process? A: 2015 retroactivity will be handled by the Marketplace Payment Team via the current Manual Payment Process. Policy-level payments will only apply to 2016 effectuated enrollments. However, payees will receive a program-level loop on the HIX 820 for their 2015 Advanced Payments of Premium Tax Credits (APTCs), Cost Sharing Reductions (CSRs) and User Fee restated amounts. For a detailed example, please see (REGTAP FAQ Database - FAQ #11180 07/01/15) Q: Will HIX 820 files be generated for the payment months from January 2014 - December 2015? A: No, the HIX 820 will only apply to effectuated enrollments beginning in January 2016. (REGTAP FAQ Database - FAQ #11186 07/01/15) Q: Will the Automated Clearing House (ACH) segment in the HIX 820 transaction reflect total payments and adjustments from the restatement of months in the 2014, 2015 and 2016 Plan Years? A: Beginning in January 2016, the HIX 820 transaction will re?ect policy-level details for the January coverage month as well as program-level information for any 2015 restatements that correspond to the January 2016 payment. The preliminary payment report will provide summary information of program-level information related to the total payment. It will also contain policy-level information including subscriber-level details. Additional training on this topic will be provided later in 2015. Issuers may refer to REGTAP for updates regarding future trainings. (REGTAP FAQ Database - FAQ #11187 07/01/15) Q: Will the Preliminary Payment Report (PPR) contain program-level payment information as well as policy-level payment information? A: The PPR will contain both program-level and policy-level payment information. (REGTAP FAQ Database - FAQ #11879 09/01/15) Q: Will the Centers for Medicare Medicaid Services (CMS) include Federally-facilitated Small Business Health Options Program (FF-SHOP) User Fees on the Preliminary Payment Report (PPR) and HIX 820 transaction? A: Yes, FF-SHOP User Fees will appear on both the PPR and HIX 820 transaction at the 272 Updated 1-31-17 2017-?00372 program level. However, SHOP-only Issuers will only receive the PPR and will not receive a HIX 820 from the Individual Market. (REGTAP FAQ Database - FAQ #11880 09/01/15) Q: What is the cut-off date for HIX 820 connectivity testing? A: CMS needs all 2015 FFM Issuers to finish connectivity testing by August 15, 2015. (REGTAP FAQ Database - FAQ #11882 09/01/15) Q: What files can Issuers expect to receive from the Centers for Medicare 8. Medicaid Services (CMS) as part of the Policy-based Payment Process? A: As part of the Policy-based Payment Process, Issuers will receive the Preliminary Payment Report (PPR) and the HIX 820 transactions ?le. (REGTAP FAQ Database - FAQ #11883 09/01/15) Q: Do State Based Marketplace (SBM) Issuers need to prepare for the implementation of Policy-based Payments? A: The steps outlined during the July 29, 2015 FM Series II training Issuers to prepare for the implementation of Policy-based Payments do not apply to SBMs. The Centers for Medicare Medicaid Services (CMS) plans to onboard SBMs onto the Policy-based Payment Process after January 2016. To register, SBM Issuers will need to successfully complete and submit 820 registration forms to EDI by 10/15/2015. SBM Issuers will also need to set up folders by 11/30/2015. The con?guration to receive 820 ?les will either need to be via a SPOE folder (if EFT setup is configured to pull from CMS) or via a server folder (if EFT setup is configured for push mechanism). (REGTAP FAQ Database - FAQ #11886 09/01/15) Q: How will Issuers receive the Preliminary Payment Report A: Similar to the HIX 820 transaction, Issuers will receive the PPR through their 820 EDI onboarding setup via EFT. In a given month, Issuers can expect to receive PPRs around the 10th - 13th and the HIX 820 transaction between the 25th and 27th. Please refer to the REGTAP Webinar entitled ?Preliminary Payment Reports, 2015 Pilot, and Discrepancy Reporting,? dated July 29, 2015. (REGTAP FAQ Database - FAQ #11887 09/01/15) Q: What are the differences between the Preliminary Payment Report (PPR) and the final HIX 820 transaction? A: The difference between PPR and the HIX 820 transaction is that only the HIX 820 transaction will contain the Electronic Funds Transfer (EFT) trace number and effective date in addition to policy-level enrollment and payment information. The PPR does not include an EFT trace number or an effective date. (REGTAP FAQ Database - FAQ #11888 09/01/15) Q: Should State Based Marketplace (SBM) Issuers request HIX 820 test files or wait until the Centers for Medicare Medicaid Services (CMS) outlines a speci?c process for 273 Updated 1-31-17 2017--00373 SBMs to participate in pilot testing? A: SBM Issuers may request HIX 820 test files if they are ready to receive them by sending an email by August 1st to confirm readiness to FMCC@cms.hhs.qov with subject line 820 Testing: Con?rm Readiness." Include all Payee IDs for which you are con?rming readiness in the email. (REGTAP FAQ Database - FAQ #11890 09/01/15) Q: How will the Centers for Medicare Medicaid Services (CMS) represent negative adjustments on the HIX 820 transaction? A: Retroactive and Prospective negative amounts in the HIX 820 transaction are visible in the RMR02 segments of the 2300 loop (details level). Each RMR02 element will contain a payment type code to specify the program for which the negative amount was charged. (REGTAP FAQ Database - FAQ #11891 09/01/15) Q: Will the HIX 820 transaction contain multiple ADJ codes if required? A: Yes, the Centers for Medicare Medicaid Services (CMS) include multiple ADJ codes in a HIX 820 transaction for retroactive adjustments to prior month's payments. (REGTAP FAQ Database - FAQ #11892 09/01/15) Q: Will the Centers for Medicare Medicaid Services (CMS) send policy records after the Change in Circumstance collapsing process? A: CMS will send policy records after the collapsing process so Issuers can determine which policies were collapsed after a non-?nancial occurs on the policy. (REGTAP FAQ Database - FAQ #11893 09/01/15) Q: What tasks should new Issuers complete in order to participate in the Policy-based Payments process? A: To participate in the Policy-based Payments Process, Issuers must email the Financial Management Coordinating Center (FMCC) to confirm readiness to receive a HIX 820 test ?le no later than August 1, 2015. Issuers should send responses to the HIX 820 test file no later than August 15, 2015. Issuers must have been submitting complete, current enrollment data to the Federally-facilitated Marketplace (FFM). (REGTAP FAQ Database - FAQ #11894 09/01/15) Q: Do the Centers for Medicare Medicaid Services (CMS) require Issuers to send a TA1I999 acknowledgement ?le for the Preliminary Payment Report A: No, CMS does not require an acknowledgement file for the PPR. (REGTAP FAQ Database - FAQ #11896 09/01/15) Q: What is a preliminary payment report, or an interim payment report? Is that part of the 820? A: For 2015, 3Rs program payments will be re?ected on the Manual 274 Updated 1-31-17 2017--00374 Financial Transaction Report. This was formerly known as the ?Interim Payment Process." For more information of Preliminary Payment Reports, please see the REGTAP Training entitled ?Policy-based Payments: Preliminary Payment Reports, 2015 Pilot, and Discrepancy Reporting (REGTAP FAQ Database - FAQ #12490 09/03/15) Q: If there are terminations after the November cycle that are effective back to 2014, how do we return subsidy payments for them? A: These are the initial thoughts on 2014 restatements after the Nov cycle. We are just telling folks that we will share more information about post November cycle 2014 restatements as it becomes available. (REGTAP FAQ Database - FAQ #12491 09/03/15) Q: For any retro changes that occur, when can we expect those to show up on the 820 reports? A: Retroactive changes should show up on the next month's cycle's 820 as long as it has been processed through enrollment reconciliation. Any updates not processed through enrollment reconciliation will be re?ected on a future HIX 820. (REGTAP FAQ Database - FAQ #12492 09/03/15) Q: If there are no discrepancies to report between the 820 what we were expecting, what action should we be taking? A: If there are no payment discrepancies then there is no action for the issuer. Please continue to submit your enrollment discrepancies to the ER Contractor. (REGTAP FAQ Database - FAQ #12493 09/03/15) Q: For 2015, 3Rs program payments will be reflected on a preliminary payment report. A: For 2015, 3Rs program payments will be re?ected on the Manual (interim) Process Payment Report. (REGTAP FAQ Database - FAQ #12494 09/03/15) Q: How will a retro prorated midmonth adjustment be re?ected in the 820 when the issuer is paid $500 in Feb for Jan APTC and in Jan a CIC is also received to term coverage from 1/1/2016 on1/19/2016 and new effective is 1/20/2016 with a $800? Will the 820 end of Feb APTCADJ be 116.13 1/1 - 1/31 or do we get two 820 entries to re?ect each enrollment, we prefer it to be APTCADJ - 193.50 - 1/19 and APTCADJ +309.68 1/20 - 1/31 A: For the scenario you provided, you said on the February 820 an APTC for January was paid of $500 and then a term occurred on 1/19. If a term occurs on 1/19, it would be past the February cycle cutoff and not be reflected until the March 820. So, for the February 820, you will see APTCADJ $500 1/1-1/31. On the March 820, you will see APTCADJ -$500 1/1-1/31 (completely reverses the previous amount paid) and APTCADJ $309.68 1/20-1/31. Plus it will show APTCADJ $800 for 2/1-2/28 for the February coverage and APTC $800 for 3/1-3/31 for the March coverage. (REGTAP FAQ Database - FAQ #12495 09/03/15) Q: What is the function code for the Preliminary Payment Report 275 Updated 1-31-17 2017--00375 A: The function code for the PPR is l820. (REGTAP FAQ Database - FAQ #12496 09/03/15) Q: Where can Issuers find information on what the Centers for Medicare Medicaid Services (CMS) will include in the HIX 820 transaction and Preliminary Payment Report A: PPR will provide all the same details as the HIX 820 in regards to the 2100 and 2300 Loops, so it will provide subscriber level details (2100+2300) as well as program-level amounts (2300 only). Payees can find sample Preliminary Payment Reports (PPR) in the PPR Business Rules Schema located in the supporting document titled 820 Pilot Materials? at in the REGTAP Library under the Payments - Remittance Message (X12 HIX 820) program area. (REGTAP FAQ Database - FAQ #12497 09/03/15) Q: What Marketplace Payment Type Codes will the Centers for Medicare Medicaid Services (CMS) use in the Policy-based Payments Process? A: The Washington Publishing Company (WPC) website, displays Marketplace Payment Type Codes CMS will use in the Policy-based Payments process. (REGTAP FAQ Database - FAQ #12498 09/03/15) Q: Does the HIX 820 transaction reflect the sum of the policy- and program-level payments and adjustments matching the payments from the US. Department of Treasury? A: The HIX 820 transaction will contain policy- and program-level payments and adjustments for Federally-facilitated Marketplace Issuers. The policy- and program-level data will match deposits from the Department of Treasury. State-based Marketplace Issuers will receive program-level payment information only. (REGTAP FAQ Database - FAQ #12499 09/03/15) Q: Will the Centers for Medicare Medicaid Services (CMS) develop the Preliminary Payment Report (PPR) and the HIX 820 transaction from the same data sources as the Pre-Audit ?le? A: CMS will use data from the Enrollment Reconciliation Process to develop the PPR and HIX 820 transaction during the Policy-based Payments process. (REGTAP FAQ Database - FAQ #12500 09/03/15) Q: Where can Issuers obtain guidance on completing the Electronic Data Interchange (EDI) Registration? A: Issuers must access the following link on CMS ZONE to download the EDI registration form for 820 testing. The form will contain additional instructions on what information needs to be included on the form and how to submit: testing Please Note: The contact information provided on the form will be registered with EDI and will be the person who will receive all communications related to 820 testing, 276 Updated 1-31-17 2017--00376 including con?rmation that the 820 test ?le is sent. Please make sure the contact responsible for managing the 820 testing process is included on the registration form. All 2016 FFM issuers need to have their registration form submitted and approved by September 30. Please keep in mind that the approval of the registration form can take up to five business days from the time EDI receives it. Once the requested information is submitted, you will receive an email response from EDI to con?rm that form was correctly submitted and approved. (REGTAP FAQ Database - FAQ #12501 09/03/15) Q: How will the Financial Management Coordinating Center (FMCC) contact State Based Marketplace (SBM) Issuers to establish connectivity? A: The FMCC will use contacts established in the Vendor Management process to contact Issuers. (REGTAP FAQ Database - FAQ #12502 09/03/15) Q: When should Issuers expect to receive the HIX 820 transaction and Preliminary Payment Report on a basis once the Centers for Medicare Medicaid Services (CMS) fully implements the Policy-based Payments Process A: Issuers can expect to receive Preliminary Payment Reports around the 10th of a given month and the HIX 820 transaction between the 25th and 27th of a given month. (REGTAP FAQ Database - FAQ #12503 09/03/15) Q: How will the HIX 820 transaction list information for payments an Issuer receives only once or twice a year? A: Issuers will receive the HIX 820 transaction on a basis. The transaction will contain only payments received from a particular program in that month. If no payment is made from a speci?c program, it will not be present on the transaction. (REGTAP FAQ Database - FAQ #12504 09/03/15) Q: Will the Preliminary Payment Report (PPR) be delivered to the same folder as the 834 Enrollment File and HIX 820 Transaction? A: The Preliminary Payment Report (PPR) will be delivered to the same folder as the 834 Enrollment File and HIX 820 if the issuer has their folder structure set up to receive both the 834 and HIX 820 in the same folder. (REGTAP FAQ Database - FAQ #12506 09/03/15) Q: What documentation does an Issuer need to submit if the Issuer does not have any discrepancies to report? A: The Centers for Medicare Medicaid Services (CMS) does not expect Issuers to submit documentation if Issuers do not have discrepancies to report. (REGTAP FAQ Database - FAQ #12508 09/03/15) Q: Can Issuers conduct HIX 820 testing with a new Electronic Data Interchange (EDI) Vendor the Issuer plans to use in 2016? A: Issuers will not be able to test HIX 820 transactions with new EDI vendors for 2016 until the Centers for Medicare Medicaid Services begin testing for new 2016 Federally- 277 Updated 1-31-17 2017--00377 facilitated Marketplace Issuers and State Based Marketplace Issuers. (REGTAP FAQ Database - FAQ #12509 09/03/15) Q: When should Issuers expect to receive the pilot version of the Preliminary Payment Report A: The Centers for Medicare Medicaid Services (CMS) expects to send the pilot version of the PPR in September or October 2015. (REGTAP FAQ Database - FAQ #12513 09/03/15) Q: How do Issuers record the payments offset by User Fees made to organizations providing women's preventative services for religious organizations on the Enrollment Payment Data Workbook? A: Thank you for your question. We are still in the process of ?nalizing the process for reporting out user fee adjustment amounts to issuers. We expect to begin implementing the user fee adjustment in late winter 2015 or early winter 2016. Issuers and Third Party Administrators (TPAs) can ?nd additional information about the user fee adjustment, including the forms that must be submitted to HHS in order to receive the user fee adjustment, on the CCIIO website at: Stabilization Programs. CMS will hold a training session on REGTAP to provide FFM issuers, TPAs and Pharmaceutical Bene?t Managers (PBMs) with guidance on submitting the user fee adjustment forms during the week of November 9-13th. Further details on the training session will be announced through REGTAP. (REGTAP FAQ Database - FAQ #13870 11/03/15) Discrepancy Reporting Q8. What is the method of transmitting discrepancy reports from the Issuer to An electronic report form will be needed? How will plans indicate that excess funds received need to be returned? A8. A process will need to be established between CMS and Issuers to resolve any discrepancies in the payment or the 820. The process is not yet developed. CMS is exploring the use of a discrepancy report. Industry feedback on this approach is welcome. (ASC X12 Exchange Related Payments (820) Implementation Guide 05/14/13) Q9. What information is CMS expecting back from Issuers for each 820 they receive? A9. CMS expects to receive a 999 acknowledgment file from Issuers for each functional group. In addition, a payment discrepancy reporting process, in which an Issuer would report differences between expected payments and payments on the 820 it received from CMS is being considered. (ASC X12 Exchange Related Payments (820) Implementation Guide 05/14/13) Q: Has there been a timeframe determined as to when the CMS Contractor will produce the reconciliation report? A: The audit ?les from the FFM will be sent to the issuers on a speci?c day each month. CMS is still determining that date, but it will be a date in the middle of the month. The 278 Updated 1-31-17 2017--00378 discrepancy report will be provided within a few days after the audit ?les are received. CMS will provide speci?c dates in future guidance. (REGTAP FAQ Database - FAQ #408 11/22/13) Q: Will CMS expect a payment discrepancy report from issuers under this interim payment process? A: No, because the interim process involves issuers sending enrollment information directly to CMS, we do not expect to use the payment discrepancy report. Issuers will have the opportunity in subsequent months to restate their enrollments and any new enrollments, and changes or discrepancies can be incorporated in these restatements. (REGTAP FAQ Database - FAQ #538 12/06/13) Q: If an error is found during enrollment reconciliation "pre compare edits" what will be expected of the Issuer? A: Although the issuer is not required to reconcile the audit ?les or discrepancy reports received from the FFM with their internal system. The FFM strongly recommends that issuers reconcile to determine if there are internal systemic issues or trends in the discrepancies that can be resolved and prevented in future reconciliations. CMS is responsible for resolving discrepancies found within reconciliation. CMS has contracted with an contractor to resolve discrepancies. If the issuer identifies a discrepancy that is not on the discrepancy report provided by CMS, they should reach out to the contractor to ensure proper resolution. Guidance will be provided on a future date on this topic. (REGTAP FAQ Database - FAQ #629 01/09/14) Q: When will payment discrepancy reporting begin? A: CMS will not begin payment discrepancy resolution until the HIX 820 is being used. (REGTAP FAQ Database - FAQ #678 01/16/14) Q: The Centers for Medicare Medicaid Services (CMS) requires that Issuers submit effectuated enrollment data through December 15, 2013 for the December 20, 2013 Production Phase deadline for Interim Payments to occur in January 2014; however, the deadline for Enrollment has been delayed until December 23, 2013 for the January 1, 2014 enrollment period. Will Issuers be able to submit an additional file that includes effectuated enrollments that occur after the December 20, 2013 submission date? A: Yes, Issuers will restate January effectuated enrollments in February 2014 in order to receive payment for all January enrollments. CMS will provide additional training in early January 2014 about the restatement process. Please visit REGTAP at for additional information on the Marketplace Payment Process and to view upcoming trainings. (REGTAP FAQ Database - #745 02/12/14) Q: Has the layout and format of the discrepancy report been released yet? A: Please refer to the presentation for August 12, 2013 as there was more information regarding the elements on the discrepancy report. Additional guidance is forthcoming. (REGTAP FAQ Database - #876 02/27/14) 279 Updated 1-31-17 2017--00379 Q: Can issuers file a discrepancy report for bill type codes rejected due to ineligibility in the Risk Adjustment (RA) program? A: No, issuers should not file a discrepancy report for rejected bill type codes unless the issuer determines that an RA acceptable bill type was rejected in error. The acceptable bill type codes for RA are: 111, 117, 131, 137, 711, 717, 761, 767, 771, 777 and professional claims with at least one RA CPT code. The Centers for Medicare Medicaid Services (CMS) provided a list of acceptable bill type codes for RA on slide 34 of the November 19, 2014 webinar, available at SlidesTr2 111914 5CR 112114.pdf in the REGTAP Library. (REGTAP FAQ Database - FAQ #9072 02/19/15) Q: What is the timeline for the informal discrepancy reporting process and when is the deadline for submitting identified discrepancies? A: There is no timeline for the informal discrepancy reporting process; however, the Centers for Medicare Medicaid Services (CMS) suggest that issuers submit informal discrepancies as soon as the discrepancy is identi?ed. The formal discrepancy process begins in March and May. Issuers will have 30 days to submit a discrepancy report for interim reports and 15 days to submit a discrepancy report for ?nal reports. In order for an issuer to reserve appeal rights, the issuer must submit a formal discrepancy report. (REGTAP FAQ Database - FAQ #9071 02/19/15) Q: Can I submit a discrepancy report based on expected results in an outbound I haven't received in order to preserve appeal rights? A: Issuers should use the most recent outbound reports for discrepancy reporting. Issuers should not submit discrepancies based on outbound reports that are not available. The data in your actual outbound reports, as compared to the data you expected to be in outbound reports, are the basis for discrepancy reporting. Issuers can use the May discrepancy reporting window to report any discrepancies discovered after the current discrepancy reporting window closes. (REGTAP FAQ Database - FAQ #9878 04/13/15) Q: Can an issuer submit discrepancies based on issuer initiated Risk Adjustment (RA) or Reinsurance (RI) calculation runs? A: No, discrepancy reports should only be submitted for reports generated from runs originated by the Centers for Medicare and Medicaid Services (CMS). CMS cannot view nor therefore verify the outbound reports generated during issuer initiated RA or RI calculation runs. Please refer to the schedule provided by your account manager for future CMS report run dates. (REGTAP FAQ Database - FAQ #9879 04/13/15) Q: Can I use the formal discrepancy reporting templates for informal discrepancy reporting? Updated 1-31-17 A: Yes, issuers may use the formal discrepancy reporting templates for informal discrepancy reporting. Issuers must use the ?le and email naming convention for informal discrepancy reporting. Issuers should be sure to note the correct run dates and 280 2017--00380 that it is for the informal process in the discrepancy report header. (REGTAP FAQ Database - FAQ #9880 04/13/15) Q: Should I submit a discrepancy report for my Data Quality Analysis Report A: No, the discrepancy reporting process is only for outbound reports from the External Data Gathering Environment (EDGE) server. (REGTAP FAQ Database - FAQ #9881 04/13/15) Q: Should I report a formal discrepancy based on a Remedy ticket? A: Issuers may report discrepancies based on Remedy tickets. Issuers should include the Remedy ticket number in their discrepancy report in the appropriate column. Remember to include the ?Error Code" in the File Processing Discrepancy Template so that CMS can appropriately identify a system error. (REGTAP FAQ Database - FAQ #9882 04/13/15) Q: What if I am expecting a system fix after the end of the discrepancy reporting window, which will change or add outbound reports? How can I report my discrepancy? A: Issuers should use the informal discrepancy reporting process to report any discrepancies discovered outside of the formal reporting window so that CMS can resolve the discrepancy as soon as possible. If the discrepancy is still observed in the issuer's final outbound reports, the issuer may use the May formal discrepancy window to preserve appeal rights. (REGTAP FAQ Database - FAQ #9883 04/13/15) Q: Do Connecticut issuers, where Connecticut is operating the Reinsurance (RI) program, need to submit formal discrepancy reports on RI outbound reports to the Centers for Medicare Medicaid (CMS) or to the Connecticut applicable RI entity? A: Issuers in Connecticut should submit all formal discrepancy reports related to Rl to the CMS designated mailbox, (REGTAP FAQ Database - FAQ #9884 04/13/15) Q: Will the scope of discrepancy reporting include Advanced Payments of Premium Tax Credits (APTC), Cost-Sharing Reductions (CSR), and Marketplace User Fees? A: The Centers for Medicare Medicaid Services (CMS) is in the process of developing the HIX 820 discrepancy reporting process. CMS will provide training later in 2015. Issuers may refer to REGTAP for updates regarding future trainings. (REGTAP FAQ Database - FAQ #11215 07/01/15) Q: Will discrepancy reporting for HIX 820 transactions combine the Small Business Health Options Program (SHOP) HIX 820, Individual Marketplace, and Risk Adjustment, Reinsurance and Risk Corridors (3Rs) HIX 820 discrepancies? A: No, discrepancy reporting for SHOP, Individual Marketplace and 3Rs will be separate processes. (REGTAP FAQ Database - FAQ #11220 07/01/15) 281 Updated 1-31-17 2017--00381 Q: Will discrepancy reporting for HIX 820 transactions combine the Small Business Health Options Program (SHOP) HIX 820, Individual Marketplace, and Risk Adjustment, Reinsurance and Risk Corridors (3Rs) HIX 820 discrepancies? A: No, discrepancy reporting for SHOP, Individual Marketplace and 3R3 will be separate processes. (REGTAP FAQ Database - FAQ #11876 08/24/15) Q: Will the scope of discrepancy reporting include Advanced Payments of Premium Tax Credits (APTC), Cost-Sharing Reductions (CSR), and Marketplace User Fees? A: Yes, the Centers for Medicare Medicaid Services (CMS) is in the process of developing the HIX 820 discrepancy reporting process which will include APTC, CSR, and User Fees. Please refer to REGTAP training materials entitled ?Policy-based Payments: Preliminary Payment Reports, 2015 Pilot, and Discrepancy Reporting" from July 29, 2015. (REGTAP FAQ Database - FAQ #11877 08/24/15) Q: Should Issuers report discrepancies found in the Preliminary Payment Report (PPR) as well as discrepancies found in the HIX 820 transaction? A: Yes, Issuers should report any discrepancies found in the PPR as well as the HIX 820 transaction through email in the Discrepancy Reporting Excel Template. Basically, the PPR and the HIX 820 will be duplicate information at the policy-level so Issuers only need to report the discrepancy once. CMS will provide further guidance at a later date. (REGTAP FAQ Database - FAQ #11884 08/24/15) Q: How will Issuers submit payment discrepancy reports? A: When an Issuer identi?es a discrepancy, the Issuer will use an Excel template to submit the discrepancy information by electronic ?le transfer to the Enrollment Reconciliation Resolution Contractor. For more details, please see REGTAP Training entitled ?Policy-based Payments: Preliminary Payment Reports, 2015 Pilot, and Discrepancy Reporting (REGTAP FAQ Database - FAQ #11889 08/24/15) Q: If an Issuer finds discrepancies on HIX 820 transactions for different Payee Groups, do the Centers for Medicare Medicaid Services (CMS) expect to the receive one (1) discrepancy template per HIX 820? A: Yes, if there are discrepancies with multiple Payee Groups, CMS expects to receive one (1) discrepancy report per HIX 820 transaction. (REGTAP FAQ Database - FAQ #11895 08/24/15) Q: Should Issuers report discrepancies found in the Preliminary Payment Report (PPR) as well as discrepancies found in the HIX 820 transaction? A: Yes, Issuers should report any discrepancies found in the PPR as well as the HIX 820 transaction through email in the Discrepancy Reporting Excel Template. Basically, the PPR and the HIX 820 will be duplicate information at the policy-level so Issuers only need to report the discrepancy once. CMS will provide further guidance at a later date. (REGTAP FAQ Database - FAQ #11884 09/01/15) Q: How will Issuers submit payment discrepancy reports? 282 Updated 1-31-17 2017--00382 A: When an Issuer identi?es a discrepancy, the Issuer will use an Excel template to submit the discrepancy information by electronic ?le transfer to the Enrollment Reconciliation Resolution Contractor. For more details, please see REGTAP Training entitled ?Policy-based Payments: Preliminary Payment Reports, 2015 Pilot, and Discrepancy Reporting (REGTAP FAQ Database - FAQ #11889 09/01/15) Q: If an Issuer finds discrepancies on HIX 820 transactions for different Payee Groups, do the Centers for Medicare Medicaid Services (CMS) expect to the receive one (1) discrepancy template per HIX 820? A: Yes, if there are discrepancies with multiple Payee Groups, CMS expects to receive one (1) discrepancy report per HIX 820 transaction. (REGTAP FAQ Database - FAQ #11895 09/01/15) Q: When is the deadline for Issuers to submit discrepancy reports? A: The Centers for Medicare Medicaid Services (CMS) will provide further guidance at a later date. (REGTAP FAQ Database - FAQ #12505 09/03/15) Q: How will the Centers for Medicare Medicaid Services (CMS) handle rating defects in the Policy-based Payments discrepancy reporting process? A: As part of the payment discrepancy process, Issuers will report rating defects as payment discrepancies. (REGTAP FAQ Database - FAQ #12507 09/03/15) Q: Is it an enrollment discrepancy if an Issuer recognizes that the Preliminary Payment Report (PPR) and the Issuer's enrollment information do not match and the Issuer received an overpayment? A: Yes, if the Pre-audit File, the PPR and the Issuer's enrollment information do not match and the Issuer received an overpayment, the Issuer should report this event as an enrollment discrepancy. (REGTAP FAQ Database - FAQ #12510 09/03/15) Q: If after comparing the Pre-Audit file with enrollment information, an Issuer finds they are due a payment that does not match the amount listed on the Preliminary Payment Report (PPR), should the Issuer submit a payment discrepancy report? A: Yes, if the Pre-audit ?le and the Issuer's enrollment information do not match the amount received in the PPR, the Issuer should report this event as a payment discrepancy. (REGTAP FAQ Database - FAQ #12511 09/03/15) Q: Should Issuers submit issues stemming from enrollment discrepancies on the payment discrepancy reports? A: No, Issuers should not report discrepancies stemming from enrollment issues on the payment discrepancy reports. (REGTAP FAQ Database - FAQ #12512 09/03/15) 283 Updated 1-31-17 2017--00383 Q: Can the Centers for Medicare Medicaid Services confirm that the format for the payment discrepancy report is identical to the enrollment discrepancy report? A: The format for the payment discrepancy report differs from the format for the enrollment discrepancy report. Issuers can find further guidance on the payment discrepancy report format at in the Payments-Remittance Message (X12 HIX 820) section of the REGTAP Library in the August 26, 2015 presentation slides entitled '2015 Pilot and Discrepancy Reporting (REGTAP FAQ Database - FAQ #12514 09/03/15) Q: Can the Centers for Medicare Medicaid Services (CMS) outline the discrepancy reporting process? A: Issuers begin discrepancy reporting for Policy-Based Payments after receiving the Preliminary Payment Report (PPR) between the 7th and 10th of a given month. CMS expects Issuers to compare the PPR to the Pre-Audit file that Issuers received around the 28th of the previous payment month to begin reporting enrollment and payment discrepancies. Issuers may use the HIX 820 transaction when Issuers receive the transaction between the 22nd and 24th of a given month. Issuers can find further guidance at in the Payments-Remittance Message (X12 HIX 820) section of the REGTAP Library in the August 26, 2015 presentation slides entitled '2015 Pilot and Discrepancy Reporting (REGTAP FAQ Database - FAQ #12515 09/03/15) Q: What effect will continuing the Manual Payment Process for the 2016 Benefit Year have on discrepancy reporting for the Policy-based Payments Process? A: If Issuers report based on enrollments then Issuers should not experience payment discrepancies. The Centers for Medicare Medicaid Services expects most discrepancies to be Enrollment discrepancies. (REGTAP FAQ Database - FAQ #12660 09/1 1/15) Q: Will Issuers have access to a RCNO file for discrepancy reporting in January 2016? A: Issuers will receive the first RCNO16 ?le on January 26, 2016. Issuers will receive 2016 Pre Audit files on December 10, December 23, and January 26. The Centers for Medicare and Medicare Services (CMS) suggests that Issuers use the Pre-Audit ?les as well as the Preliminary Payment Report (PPR) and HIX 820 transaction to conduct discrepancy reporting. (REGTAP FAQ Database - FAQ #13993 11/11/15) Q: Can Issuers use the Preliminary Payment Report (PPR) to conduct discrepancy reporting if they are not prepared to receive this HIX 820 transaction? A: Issuers can use the PPR to conduct discrepancy reporting but in order to receive the PPR, Issuers must complete the EFT setup process. (REGTAP FAQ Database - FAQ #1410712/01/15) Q: When must Issuers complete pilot discrepancy reporting? A: CMS would like for Issuers to report payment discrepancies by November 15, 2015. 284 Updated 1-31-17 2017--00384 (REGTAP FAQ Database - FAQ #14108 12/01/15) Q: Can the Centers for Medicare Medicaid Services (CMS) provide more information regarding comparing payment information to the Pre-Audit file for the purpose of discrepancy reporting? A: Further information on the Discrepancy Reporting Process is available at in the Payments-Remittance Message (X12 HIX 820) section of the REGTAP Library in the presentation slides entitled '2015 Pilot and Discrepancy Reporting (08/26/15)? and Series 2015 Issuer Pilot and HIX 820 Testing (REGTAP FAQ Database - FAQ #14114 12/01/15) Q: Is it possible for Issuers to conduct discrepancy reporting though system logic? A: Issuer can use system logic at their own discretion to compare payment reports, Issuer records and the pre audit ?le. (REGTAP FAQ Database - FAQ #14126 12/01/15) Q: How should an Issuer report a scenario in which the Issuer receives a policy on the Preliminary Payment Report (PPR) but did not find that policy in the Issuer's enrollment system and Pre-audit File? A: In a scenario where the Issuer receives a policy on the PPR bud did not ?nd that policy in the Issuer's enrollment system and Pre-audit File the Issuer will process the discrepancy as an enrollment dispute. (REGTAP FAQ Database - FAQ #14145 12/01/15) Q: Do Issuers use the HIX 820 Transaction to conduct discrepancy reporting as well as sending TA1I999 acknowledgements? A: Yes, the Centers for Medicare Medicaid Services (CMS) expects to receive acknowledgements for the HIX 820 transaction. However the Issuers may use either the HIX 820 or Preliminary Payment Report (PPR) for discrepancy reporting. (REGTAP FAQ Database - FAQ #1414712/01/15) Q: Will the Centers for Medicare Medicaid Services (CMS) indicate proration expectations in the discrepancy reporting documentation? A: For further information on proration expectations and discrepancy reporting documentation please reference the supporting document, 'Financial Management 2015 to 2016 Issuer Transition Guide Version 2.0' available at in the Payments-Remittance (X12 HIX 820) Section of the REGTAP Library. (REGTAP FAQ Database - FAQ #14167 12/01/15) Q: Will the formal interim discrepancy process requirements under 45 CFR 153.710(d) for the Reinsurance (RI) and Risk Adjustment (RA) programs apply to the 2015 Benefit Year? A: No. Issuers will not be required to con?rm to the Centers for Medicare Medicaid Services (CMS) that the information in the interim report accurately reflects the 2015 Bene?t Year RI and RA data to which the issuer has provided access to CMS through its dedicated distributed data environment [that is, an issuer's External Data Gathering Environment (EDGE) server]; or describe to CMS any discrepancy an issuer identifies in the interim report (1). However, CMS will continue to make reports available to issuers 285 Updated 1-31-17 2017--00385 Updated 1-31-17 on their EDGE servers to assist with the identification of data submission errors or problems before the April 30, 2016 deadline for the 2015 Benefit Year reporting cycle (2). In addition, CMS will maintain a help desk and provide technical assistance to assist issuers with the 2015 Benefit Year data submission process. Even though CMS will not require issuers to formally con?rm to CMS that the information in the interim report accurately re?ects the 2015 Bene?t Year RI and RA data to which the issuer has provided access to CMS through the issuer's EDGE server; or describe to CMS any discrepancy it identi?es in the interim report. Issuers should contact their Financial Management Command Center (FMCC) Service Representatives for Distributed Data Collection (EDGE) technical assistance throughout the 2015 Bene?t Year data submission window. CMS encourages issuers to report any problems experienced during the data submission process as soon as possible so that, to the extent feasible, CMS can provide assistance to resolve those problems before the ?nal data submission deadline. CMS also asks that issuers always review their data and the EDGE reports generated during the data submission process. Issuers must provide access to accurate and complete RI and RA data for the 2015 Bene?t Year through their respective EDGE servers by the April 30, 2016 data submission deadline. Issuers will also be required to submit responses as part of the formal ?nal discrepancy process for the 2015 Bene?t Year, pursuant to 45 CFR Within 15 calendar days of the date of the final report from CMS, the issuer must confirm through an attestation that the information in the final report accurately re?ects the 2015 Bene?t Year data to which the issuer has provided access to CMS through its EGDE server in accordance with ?153.700(a) or if applicable, qualify that attestation by describing to CMS any discrepancies identi?ed in the ?nal report. As a reminder, the discrepancy reporting process is the mechanism through which issuers can notify CMS, and CMS can assist with the identification and resolution of problems that are causing discrepancies between the data an issuer made accessible on its EDGE server and the EDGE report(s) on that data. The discrepancy reporting process does not afford issuers an opportunity to submit or correct data on EDGE servers after the applicable data submission deadline; and the ?ling of a discrepancy report does not change the deadline for issuers to timely submit accurate and complete data. As stated in the ?Adjustment of Risk Adjustment Transfers due to Submission of Incorrect Data Guidance,? (3) where CMS is made aware that an issuer has submitted incorrect EDGE server claims or diagnosis data that will have the effect of understating an issuer's plan average risk score for the RA program, and thus negatively affecting the issuer without having a negative effect on other issuers within the market, CMS will not permit the issuer to submit supplementary data after the data submission deadline. Citations: 1. We proposed in the HHS Notice of Bene?t and Payment Parameters for 2017 Proposed Rule (80 FR 75488) to remove the interim discrepancy reporting process requirements in 45 CFR 153.710(d) beginning with the 2016 benefit year. 2. See, 45 CFR 153.730. 3. See, Center for Consumer Information Insurance Oversight, CMS, Adjustment of Risk Adjustment Transfers due to Submission of Incorrect Data Guidance, (September 2, 2015) available at: (REGTAP FAQ Database - FAQ #14247 12/15/15) 286 2017--00386 Q: What is a persistent discrepancy? A: The Centers for Medicare Medicaid Services (CMS) de?nes a persistent discrepancy as a discrepancy that is identified in multiple months. Issuers have the option to report a persistent discrepancy every payment month it occurs or report it once and allow time for correction before reporting the discrepancy again. (REGTAP FAQ Database - FAQ #14312 12/22/15) Q: If there are multiple duplicate rows for a subscriber, should the Issuer report that as a single discrepancy? A: If there are multiple policies for a subscriber the issuer should report all policies that are not active. If there are multiple payments for the same policy the Issuer should report the duplicate payments as a single discrepancy. (REGTAP FAQ Database - FAQ #14644 01/20/16) Q: Should Issuers use the Pre-Audit file received on December 23, 2015 to conduct discrepancy reporting for the January 2016 payment to eliminate timing related discrepancies? A: Yes Issuers should use the pre-audit file distributed on December 23, 2015 to conduct discrepancy reporting for the January 2016 payment cycle. Issuers should also refer to the PDNS ISUIPAs received on January 6, 2016. The ?le provided policies that were cancelled after the payments were made. (REGTAP FAQ Database - FAQ #14647 01/20/16) Q: How should Issuers report an incorrect Exchange-assigned Policy ID on the Dispute and Discrepancy Resolution form? A: In this instance, issuers should not report this as a payment dispute. For a given subscriber, the exchange assigned policy ID reported on the is the correct policy ID and should be used by the issuer. If an issuer is maintaining a different exchange assigned policy ID for a subscriber than what the Preliminary Payment Report (PPR) and HIX 820 are reporting payments for, issuers will need to work internally to align the subscriber to the correct exchange assigned policy ID as reported in the (REGTAP FAQ Database - FAQ #15403 04/08/16) Issuer Payments - Other Q: What is the difference between the Initial and Final Dunning Letters? Updated 1-31-17 A: The Marketplace Payment Submission Process uses Dunning Letters to invoice Issuers. The Initial Demand Letter provides Issuers with 15 calendar days to submit payment without accruing additional charges. The Final Dunning Letter (also called the Intent to Refer (ITR) letter), is generated 60 calendar days after the initial demand date and includes accrued interest. The ITR letter also signals the intent of the Department of Health and Human Services (HHS) to refer the Issuer's debt to the Department of the Treasury in 90 calendar days if left unpaid. (REGTAP FAQ Database - FAQ #9201 287 2017--00387 03/04/15) Q: When will an Issuer receive a Demand Letter? A: As part of the interim payment process, the Centers for Medicare Medicaid Services (CMS) nets charges against available Advance Premium Tax Credit (APTC) and Cost-sharing Reduction (CSR) payments for each Issuer. If charges exceed APTC and CSR payments, the Issuer will receive a Demand letter requesting the balance of the amount owed. (REGTAP FAQ Database - FAQ #9202 03/04/15) Q: How do Issuers register with Pay.gov? A: To register an account on Pay.gov: (1) Click the Register hyperlink in the upper right hand corner of the Pay.gov homepage; the Registration screen will appear. (2) On the Registration screen, enter account information including the contact name, username, email, address and phone number. Additionally, provide a secret question and answer and a shared challenge question and answer. (3) When all registration ?elds are complete, check the marked box to agree to the Pay.gov ?Rules of Behavior? and then click the Register Account button. For additional information, refer to the Marketplace Payment Submission Process (1/30/15) slides at in the REGTAP Library. (REGTAP FAQ Database - FAQ #9203 03/04/15) Q: How do issuers access the CMS Health Insurance Marketplace and Premium Stabilization Programs Payment Form or ?Marketplace Payments Form?? A: To access the Marketplace Payments Form at Pay.gov, Issuers must: (1) Select ?Make a Payment? on the Pay.gov homepage. (2) Then either search for the form directly in the Pay.gov archive by typing in Health Insurance and Premium Stabilization Programs Payment Form," or click the ?Search by Agency" link. (2a) When searching for the form directly: enter the full name of the payment form in order to access the appropriate form. (2b) When searching for the form by Agency: first select from the A-Z Index. Then click the ?Health and Human Services (HHS) Centers for Medicare Medicaid Services link from the list provided. To reach the Marketplace Payment Form, select the ?rst link for CMS that appears on the list. (3) Click the ?Continue to the Form? button under the Health Insurance and Premium Stabilization Programs Payment Form." For additional information, refer to the Marketplace Payment Submission Process (1/30/15) slides at in the REGTAP Library. (REGTAP FAQ Database - FAQ #9204 03/04/15) Q: How do Issuers complete the Marketplace Payment Form? A: Issuers must complete all ?elds including company, contact, and program and invoice information in order to submit payment. To complete the form, Issuers should: 288 Updated 1-31-17 2017--00388 (1) Enter company and contact information ?elds, and then select the appropriate Marketplace program. (2) Complete the invoice information ?elds by providing the Entity ID, Invoice Number and the total amount due. Refer to the header fields of the most recent Dunning Letter for this data. (3) To go to the next screen, click the continue button, or click the PDF Preview button to see and review the completed form. Issuers that owe payments for multiple programs must submit these payments on separate Marketplace Payment Forms. For additional information, refer to the Marketplace Payment Submission Process (1/30/15) slides at in the REGTAP Library. (REGTAP FAQ Database - FAQ #9205 03/04/15) Q: How do Issuers submit the Marketplace Payment Form? A: Once Issuers complete the Marketplace Payment Form, the Payment Information screen will display. To submit the form, Issuers should: (1) Click the ?Review and Submit Payment" button. (2) Check the box labeled would like to receive an email con?rmation of this transaction? to receive an email confirmation the transaction. Save this email as proof of payment. (3) Click the appropriate box to agree with Pay.gov's Authorization and Disclosure Statement. (4) Click the submit payment button once. Multiple clicks will submit multiple payments. Once the transaction is complete, the confirmation screen will display and the con?rmation email will generate. For additional information, refer to the Marketplace Payment Submission Process (1/30/15) slides at in the REGTAP Library. (REGTAP FAQ Database - FAQ #9206 03/04/15) Q: When is the Intent to Refer (ITR) letter sent out? A: An Intent to Refer (ITR) letter (?nal letter) is generated 60 days after the date of the initial Demand Letter. (REGTAP FAQ Database - FAQ #9207 03/04/15) Q: Will I be charged any interest or administrative fees? A: Yes, the Intent to Refer (ITR) letter reflects administrative charges and accrued interest in addition to the original balance owed. (REGTAP FAQ Database - FAQ #9208 03/04/15) Q: What happens if I am unable to pay my debt within 90 days? Updated 1-31-17 A: Debts that remain unpaid 90 days from the date of the initial demand date will be referred to the Department of Treasury's Debt Management Services for Cross Servicing and Offset of Federal Payments. Treasury will collect all required penalty charges and fees. (REGTAP FAQ Database - 289 2017--00389 FAQ #9209 03/04/15) Q: How much interest will I be charged? A: HHS updates the interest rate on a quarterly basis. The current HHS-established interest rate is 10.5 percent per year. (REGTAP FAQ Database - FAQ #9210 03/04/15) Q: Do I have the right to inspect my records? A: Yes, you have the right to inspect and copy all records pertaining to your debt. In order to review the HHS records, you must submit a written request to Your request must be received within 60 calendar days from the date of the Initial Demand Letter. (REGTAP FAQ Database - FAQ #9211 03/04/15) Q: What happens to my debt while a review is pending? A: Interest charges and penalties will continue to accrue during the review period. Therefore, while review is pending, an issuer will be liable for interest and related payment charges on amounts not paid by the due date identified in your Initial Demand Letter. (REGTAP FAQ Database - FAQ #9212 03/04/15) Q: What happens if I have to petition for Bankruptcy? A: If you have to file for a petition for bankruptcy, please notify CMS by e-mail at CMS ?nancial obligations will be resolved in accordance with the applicable bankruptcy process. (REGTAP FAQ Database - FAQ #9213 03/04/15) Documentation supporting your bankruptcy status, along with a copy of your notice, must be submitted. When notifying CMS about the bankruptcy, please include the name the bankruptcy is filed under and the district court where the bankruptcy is ?led. (REGTAP FAQ Database - FAQ #9213 03/04/15) REINSURANCE, RISK ADJUSTMENT, AND RISK CORRIDORS General What is risk adjustment? To whom does it apply? Updated 1-31-17 To minimize the negative effects of adverse selection and foster a stable marketplace from year one, the Affordable Care Act establishes transitional reinsurance and temporary risk corridor programs, and a permanent risk adjustment program to provide payments to health insurance issuers that cover higher-risk populations and to more evenly spread the financial risk borne by issuers. The risk adjustment program is designed to protect issuers that attract a high-risk population, such as those with chronic conditions. Under this program, money is 290 2017--00390 transferred from issuers with lower risk enrollees to issuers with higher risk enrollees. This is a State-based program that applies to non-grandfathered plans in the individual and small group markets, inside and outside of Exchanges. The risk adjustment program is intended to reduce or eliminate premium differences between plans based solely on expectations of favorable or unfavorable risk selection, or choices by higher risk enrollees in the individual and small group markets. The risk adjustment program also serves to level the playing ?eld inside and outside of the Exchange, reducing the potential for excessive premium growth or instability in markets inside or outside of the Exchange. (CMS FAQs - Risk Adjustment Implementation Issues (not dated)) What is included in the Standards Related to Reinsurance, Risk Corridors and Risk Adjustment The NPRM proposes standards related to the risk adjustment program. The NPRM proposes that a uniform set of data for risk adjustment be considered. This reduces burden on health insurers that offer quali?ed health plans in different States by creating uniform reporting standards. It proposes that risk adjustment calculations occur at the State, rather than plan or Federal level, given States? role in the system. And while a Federal risk adjustment methodology would be developed, States electing to run their own risk adjustment program could use an approved alternative methodology. This white paper is intended to provide context for comments in response to the NPRM. (CMS FAQs - Risk Adjustment Implementation Issues (not dated)) Q: Where is the 2014 Final Payment Notice located? A: summary of the HHS Notice of Benefit and Payment Parameters for 2014 (45 CFR Parts 153, 155, 156, 157 and 158) is available on the CCIIO website at 2013.html. The full document can be found here: 11/pdf/2013-04902pdf (REGTAP FAQ Database - FAQ #175 11/18/13) Reconsiderations and Appeals Q: When must a company file a request for reconsideration (that is, the first level of administrative appeal) for the Risk Adjustment (RA) and Reinsurance (RI) programs for the 2014 program year? A: For an RA payment or charge (including an assessment of RA user fees), an RA default charge, or an RI payment, a company must ?le a request for reconsideration within 60 calendar days of the June 30, 2015 notification. Therefore, if a company/issuer would like to ?le an administrative appeal for the risk adjustment and reinsurance programs for the 2014 program year, it must complete the ACA Financial Appeals - Request for Reconsideration (Risk Adjustment and Reinsurance) Web-based Form by August 29, 2015. (REGTAP FAQ Database - FAQ #11331 07/22/15) Q: Which market should a company select when appealing certain Risk Adjustment (RA) transfer amounts on page 4 (Reconsideration Request Details) of the ACA Financial Appeals Request for Reconsideration (Risk Adjustment and Reinsurance) Web-based Form? Updated 1-31-17 291 2017-?00391 A: If a company is appealing the Department of Health and Human Services (HHS) RA transfer amount for an Individual market, including catastrophic, the company should select the ?Individual? market in the drop down for that HIOS ID. If a company is appealing the HHS RA transfer amount for a Small Group market, the company should select the ?Small Group" market in the drop down for that HIOS ID. If a company is appealing the HHS RA transfer amount for a merged market (Individual and Small Group markets), the company should select the ?Merged" market in the drop down for that HIOS ID. If a company is appealing the HHS RA transfer amount for a non-merged catastrophic market, the company should select the ?Catastrophic? market in the drop down for that HIOS ID. (REGTAP FAQ Database - FAQ #11332 07/22/15) Note: REG TAP mistaken/y dates this FAQ as 07/22/2051. Q: Is there more than one basis for an administrative appeal? A: Pursuant to 45 CFR 156.1220, an issuer may ?le an administrative appeal to contest a processing error by the Department of Health and Human Services (HHS), HHS's incorrect application of the relevant methodology, or HHS's mathematical error only with respect to: The amount of advance payments of the premium tax credit (APTC), advance Cost- Sharing Reduction (CSR) payments, or Federally-facilitated Marketplace (FFM) user fee charges for a benefit year; The amount of a reconciliation payment or charge for CSRs for a benefit year; The amount of a Risk Adjustment (RA) payment or charge for a benefit year, including an assessment of RA user fees; The amount of an RA default charge for a bene?t year; The amount of a Reinsurance (RI) payment for a benefit year; or The amount of a Risk Corridors (RC) payment or charge for a benefit year. (REGTAP FAQ Database - FAQ #11333 07/22/15) Q: How can an issuer make a request for reconsideration for the Risk Adjustment (RA) and Reinsurance (RI) programs for the 2015 Benefit Year? Updated 1-31-17 A: An issuer must complete an ACA Financial Appeals Request for Reconsideration (Risk Adjustment and Reinsurance) Web-based Form for the 2015 Benefit Year. The Web form is completed at the company level and issuers have the ability to select the applicable Health Insurance Oversight System (HIOS) for which they are appealing. Issuers will select the appropriate markets and contested amount for each HIOS For more information, see the Request for Reconsideration Form for Risk Adjustment and Reinsurance Quick Start Guide for the 2015 Benefit Year in the REGTAP Library at under the ACA Financial Appeals proqram area to assist in the completion of the ACA Financial Appeals Request for Reconsideration (Risk Adjustment and Reinsurance) Web Form. 292 2017--00392 (REGTAP FAQ Database - FAQ #11334; 11334a 07/22/15; updated 06/07/16) Note: REG TAP mistaken/y dated this FAQ as 07/22/2051. Q: What occurs if an issuer's request for reconsideration is unsuccessful? A: A reconsideration decision is final and binding for decisions regarding the advance payments of the premium tax credit, advance Cost-sharing Reconciliation (CSR) payments, or Federally-facilitated Marketplace FFM user fees. A reconsideration decision with respect to other matters is eligible for, and then subject to the outcome of a request for informal hearing filed in accordance with 45 CFR (REGTAP FAQ Database - FAQ #11335; 11335a 07/22/15; updated 06/07/16) Q: When must a company file a request for reconsideration (that is, the first level of administrative appeal) for the Risk Adjustment (RA) and Reinsurance (RI) programs for the 2015 Benefit Year? A: For a RA payment or charge (including an assessment of RA user fees), a RA default charge, or a RI payment, a company must file a request for reconsideration within 30 calendar days of the June 30, 2016 notification. Therefore, if a company/issuer would like to ?le an administrative appeal for the RA and RI programs for the 2015 Bene?t Year, it must complete the ACA Financial Appeals - Request for Reconsideration (Risk Adjustment and Reinsurance) Web Form by Monday, August 1, 2016. (REGTAP FAQ Database - FAQ #16308 06/08/16) Q: How can issuers file a discrepancy related to their Cost-sharing Reduction (CSR) reconciliation data submitted for the 2014 and 2015 Benefit Years? Updated 1-31-17 A: An issuer will be permitted to file a discrepancy beginning June 23, 2016 using the technical specifications on discrepancy submission published by the Centers for Medicare Medicaid Services (CMS), available at: Issuers are encouraged to submit a discrepancy as soon as possible and prior to filing a request for reconsideration as explained in FAQ 16489. No discrepancy or request for reconsideration will be accepted after 11:59 pm. EST on Monday, August 29, 2016. Issuers who identify data discrepancies related to Quali?ed Health Plan (QHP) ID errors, Exchange Subscriber ID errors, or errors related to the amount of Cost-sharing Reductions (CSRs) that an issuer provided at the policy level, including, for example, ?awed issuer calculations or lost data, should submit data related to their discrepancy in a pipe-delimited file through electronic file transfer (EFT). CMS will only accept data discrepancies for data that directly impacts the calculation of the issuer's reconciled CSR amounts. At the same time as the discrepancy window is opened, CMS will publish a technical specification document outlining the format of the file, which generally will be similar to the file format used for submission of the 2014 and 2015 CSR reconciliation data ?le. We note that all issuers will be noti?ed of CSR reconciliation payments or charges by 293 2017--00393 June 30, 2016, regardless of whether a discrepancy has been filed or resolved. If a discrepancy results in a payment or charge adjustment following the June 30, 2016 calculation, CMS will make this adjustment in a payment cycle following the decision. Any issuer that does not file a discrepancy will be deemed as accepting their final data submission for CSR reconciliation for the 2014 and 2015 Benefit Years (as applicable) and CMS will use this ?nal data submission to calculate final CSR reconciliation payments or charges and will notify issuers by June 30, 2016 of their ?nal CSR reconciliation payments or charges. We note that, pursuant to the Manual for Reconciliation of the CSR Component of Advance Payments for Bene?t Years 2014 and 2015, issuers also may submit additional 2015 data that becomes available after CSRs have been reconciled for the 2015 Benefit Year, during the 2016 CSR reconciliation reporting year cycle, in the spring of 2017*. In rare circumstances, CMS may make limited exceptions to allow issuers to submit additional 2014 data during the same 2016 CSR reconciliation reporting cycle. CMS will issue guidance on the process for the 2016 CSR reconciliation cycle at a later date. See page 6 of the Manual for Reconciliation of the CSR Component of Advance Payments for Bene?t Years 2014 and 2015 and FAQs 14904, 14905, and 15457 available on FAQ Database - FAQ #16488 06/24/16) Q: Pursuant issuer may file a request for reconsideration within 60 calendar days of the date of the notification of the Cost-sharing Reduction (CSR) reconciliation payment or charge to contest a processing error by the Department of Health and Human Services (HHS), HHS's incorrect application of the relevant methodology, or HHS's mathematical error only with respect to the amount of a reconciliation payment or charge for CSRs for a benefit year. By what date will the Centers for Medicare Medicaid Services (CMS) permit issuers to file a request for reconsideration? A: CMS will permit issuers to request reconsideration starting Thursday, June 30, 2016 related to the amount of a reconciliation payment or charge for CSRs for the 2014 and 2015 Benefit Years. Issuers have 60 calendar days to file a request for reconsideration; as such, all requests must be submitted no later than 11:59 pm. EST on Monday, August 29, 2016, and reconsideration requests after this deadline will not be considered. CMS will issue future guidance at a later date on how to ?le a request for reconsideration. Any issuer filing an appeal is strongly encouraged to file a discrepancy in order to permit CMS to work with the issuer to resolve the dispute outside the formal administrative appeals process. CMS issued FAQ 16488 regarding the CSR reconciliation discrepancy reporting process. If an issuer ?les a discrepancy and requests reconsideration on the same issue and the discrepancy process resolves the issue, we ask that the issuer withdraw its appeal by contacting (REGTAP FAQ Database - FAQ #16489 06/23/16) Q: Are all issuers required to file a request for reconsideration related to the 2015 Benefit Year Risk Adjustment (RA) and Reinsurance (RI) programs? 294 Updated 1-31-17 2017--00394 A: No. Unlike the attestation and discrepancy reporting process, which required every issuer to submit an attestation (or attest and qualify that attestation with a discrepancy), issuers only need to request reconsideration if an issuer wishes to contest: (1) a processing error by the Department of Health Human Services (HHS), (2) HHS's incorrect application of the relevant methodology, or (3) HHS's mathematical error related to the final risk adjustment transfers and reinsurance payment amounts. The Centers for Medicare Medicaid Services (CMS) notes that if an issue was identifiable at the time, issuers must have ?led a discrepancy to later request reconsideration on the same issue. For more information on the reconsideration process, please visit the Registration for Technical Assistance Portal (REGTAP) Library, under the Financial Appeals? program area, and review the training titled ?2015 Administrative Appeals Process for RA Transfers RI Payments (06/29/16 07/06/16)? and the ?Request for Reconsideration (RA RI) Quick Start Guide for the 2015 Bene?t Year." (REGTAP FAQ Database - FAQ #16621 07/07/16) Q: As 2014 risk adjustment appeals are resolved, will the Centers for Medicare Medicaid Services (CMS) release payment amounts held back for appeals and sequestration in States that no longer have a pending risk adjustment appeal? A: Yes. As CMS indicated in FAQ 13869 (published 11/3/15), FAQ 14753 (published 2/1/16), FAQ 15276 (published 3/26/16), and FAQ 16057 (published 5/23/16), CMS will release the 10 percent holdback from the 2014 benefit year risk adjustment payments in the payment cycle following final resolution of all 2014 bene?t year risk adjustment appeals in that State. The administrative appeal process and timeline are contained in 45 CFR 156.1220. The release of holdback amounts will not be sequestered. See the July 15, 2015, and July 29, 2015, ,,Payments, Invoicing and Collections Process for the Risk Adjustment and Reinsurance Programs?/oo webinar presentation (available at: under the Payments- Remitting Amounts Due program area) for more information. Based on the current status of risk adjustment administrative appeals as of March 14, 2016, CMS will release payment amounts held back for 2014 benefit year risk adjustment appeals and ?scal year 2015 sequestration in the following State and markets in the August 2016 payment cycle: 1. Hawaii 2. Florida Small Group Market Only (pending 2014 benefit year risk adjustment appeal in the individual market) 3. New York Small Group Market Only (pending 2014 bene?t year risk adjustment appeal in the individual market) Note: CMS already released the payment amounts held back for 2014 bene?t year risk adjustment appeals and sequestration in 46 States and the District of Columbia. Please see FAQs 13869, 14753, 15276, and 16057 for the full listing of these States. (REGTAP FAQ Database - FAQ #16819 07/21/16) Q: What is the holdback percentage for the 2015 bene?t year Risk Adjustment and Reinsurance programs? 295 Updated 1-31-17 2017--00395 A: The holdback percentage and sequestration rate are determined based on when the payments are made. For the 2015 Benefit Year, reinsurance and risk adjustment payments made during the 2016 Fiscal Year (FY) (October 1, 2015 through September 30, 2016), the Centers for Medicare Medicaid Services (CMS) will holdback 6.8% for reinsurance and 7.0% for risk adjustment. See the HHS Notice of Bene?t and Payment Parameters for 2017 Final Rule (81 FR 12204, 12216). This holdback amount includes the 2015 Benefit Year appeals and 2016 FY sequestration holdback amounts. Holdback amounts in FY 2016 from the Reinsurance and Risk Adjustment programs will become available for payment to issuers in FY 2017 (October 1, 2016 through September 30, 2017), unless a reinsurance or risk adjustment appeal is pending. In other words, CMS will release: 1- The FY 2016 risk adjustment holdback after the end of FY 2016 (September 30, 2016) or when all risk adjustment appeals for the 2015 Bene?t Year are resolved in a State, whichever is later; and 2- The FY 2016 reinsurance holdback after the end of FY 2016 (September 30, 2016) or when all appeals for the 2015 Benefit Year are resolved, whichever is later. If any portion of reinsurance or risk adjustment payments for the 2015 Bene?t Year are made during FY 2017, CMS will holdback 6.9% of reinsurance payments and 7.1% of risk adjustment payments to account for FY 2017 sequestration. These holdback amounts will become available for payment to issuers in FY 2018 (October 1, 2017 through September 30, 2018), unless a reinsurance or risk adjustment appeal is pending. When holdback amounts are released, they are not subject to further holdback for appeals or sequestration. For more information on holdback and sequestration, please see the July 27, 2016, Payments, Invoicing and Collections Process for the Risk Adjustment, Reinsurance and Reconciliation of the Cost-Sharing Reduction Portion of Advance Payments Programs webinar presentation, located in the REGTAP Library at (REGTAP FAQ Database - FAQ #17161 08/08/16) Q: What is the holdback percentage for the 2015 Benefit Year Risk Adjustment (RA) and Reinsurance (RI) programs? A: The holdback percentage and sequestration rate are determined based on when the payments are made. For the 2015 Benefit Year, reinsurance and risk adjustment payments made during the 2016 Fiscal Year (FY) (October 1, 2015 through September 30, 2016), the Centers for Medicare Medicaid Services (CMS) will holdback 6.8% for reinsurance and 7.0% for risk adjustment. See the HHS Notice of Bene?t and Payment Parameters for 2017 Final Rule (81 FR 12204, 12216). This holdback amount includes the 2015 Benefit Year appeals and 2016 FY sequestration holdback amounts. Holdback amounts in FY 2016 from the Reinsurance and Risk Adjustment programs will become available for payment to issuers in FY 2017 (October 1, 2016 through September 30, 2017), unless a reinsurance or risk adjustment appeal is pending. In other words, CMS will release: 296 Updated 1-31-17 2017--00396 1. The FY 2016 risk adjustment holdback after the end of FY 2016 (September 30, 2016) or when all risk adjustment appeals for the 2015 Bene?t Year are resolved in a State, whichever is later; and 2. The FY 2016 reinsurance holdback after the end of FY 2016 (September 30, 2016) or when all appeals for the 2015 Benefit Year are resolved, whichever is later. If any portion of reinsurance or risk adjustment payments for the 2015 Bene?t Year are made during FY 2017, CMS will holdback 6.9% of reinsurance payments and 7.1% of risk adjustment payments to account for FY 2017 sequestration. These holdback amounts will become available for payment to issuers in FY 2018 (October 1, 2017 through September 30, 2018), unless a reinsurance or risk adjustment appeal is pending. When holdback amounts are released, they are not subject to further holdback for appeals or sequestration. For more information on holdback and sequestration, please see the July 27, 2016, Payments, Invoicing and Collections Process for the Risk Adjustment, Reinsurance and Reconciliation of the Cost-Sharing Reduction Portion of Advance Payments Programs webinar presentation, located in the REGTAP Library at (REGTAP FAQ Database - FAQ #17162 08/08/16) Q: What is the holdback percentage for the 2015 Benefit Year (BY) Risk Adjustment and Reinsurance programs? Updated 1-31-17 A: The holdback percentage and sequestration rate are determined based on when the payments are made. For the 2015 Benefit Year, reinsurance and risk adjustment payments made during the 2016 Fiscal Year (FY) (October 1, 2015 through September 30, 2016), the Centers for Medicare Medicaid Services (CMS) will holdback 6.8% for reinsurance and 7.0% for risk adjustment. See the HHS Notice of Bene?t and Payment Parameters for 2017 Final Rule (81 FR 12204, 12216). This holdback amount includes the 2015 Benefit Year appeals and 2016 FY sequestration holdback amounts. Holdback amounts in FY 2016 from the Reinsurance and Risk Adjustment programs will become available for payment to issuers in FY 2017 (October 1, 2016 through September 30, 2017), unless a reinsurance or risk adjustment appeal is pending. In other words, CMS will release: 1) The FY 2016 risk adjustment holdback after the end of FY 2016 (September 30, 2016) or when all risk adjustment appeals for the 2015 Bene?t Year are resolved in a State, whichever is later; and 2) The FY 2016 reinsurance holdback after the end of FY 2016 (September 30, 2016) or when all appeals for the 2015 Benefit Year are resolved, whichever is later. If any portion of reinsurance or risk adjustment payments for the 2015 Bene?t Year are made during FY 2017, CMS will holdback 6.9% of reinsurance payments and 7.1% of risk adjustment payments to account for FY 2017 sequestration. These holdback amounts will become available for payment to issuers in FY 2018 (October 1, 2017 297 2017--00397 through September 30, 2018), unless a reinsurance or risk adjustment appeal is pending. When holdback amounts are released, they are not subject to further holdback for appeals or sequestration. For more information on holdback and sequestration, please see the July 27, 2016, Payments, Invoicing and Collections Process for the Risk Adjustment, Reinsurance and Reconciliation of the Cost-Sharing Reduction Portion of Advance Payments Programs webinar presentation, located in the REGTAP. (REGTAP FAQ Database - FAQ #17167 08/08/16) Risk Adjustment Implementation HHS is releasing a draft white paper discussing implementation issues and questions related to the State-based risk adjustment program for the individual and small group markets established by the Affordable Care Act. This white paper serves both to begin the consultation process around the development of the federally-certi?ed risk adjustment methodology developed by HHS and to provide context for individuals to submit comments in response to the Standards Related to Reinsurance, Risk Corridors and Risk Adjustment Notice of Proposed Rulemaking (45 CFR Part 153) released in July 2011 (76 Fed. Reg. 41930). Comments are due by September 28, 2011. Comments sent in direct response to the white paper will inform the HHS-developed federally- certified risk adjustment methodology, which will be released as part of a Federal Payment Notice that will appear in the Federal Register, and will include a draft notice and a comment period before the notice (and methodology) are finalized. Responses to the white paper may be submitted on an ongoing basis in advance of the draft notice, slated for Fall 2012. (CMS FAQs - Risk Adjustment Implementation Issues (not dated)) Why is this paper being announced now? This paper is being released to coincide with the Standards Related to Reinsurance, Risk Corridors and Risk Adjustment NPRM comment window, which closes on September 28, 2011, because it provides context for individuals wishing to submit comments in response to the NPRM. Importantly, this white paper provides a more detailed technical discussion of several elements of the NPRM. In addition, HHS is beginning the development of a Federal risk adjustment methodology, and comments received in response to this white paper will assist HHS in this effort. (CMS FAQs - Risk Adjustment Implementation Issues (not dated)) How does this paper relate to the recently released Standards Related to Reinsurance, Risk Corridors and Risk Adjustment This white paper provides a more technical description and analysis of issues related to the development of a federally-certi?ed risk adjustment methodology than was contemplated in the NPRM. This paper is a draft meant for discussion purposes only and does not represent ?nal policy. (CMS FAQs - Risk Adjustment Implementation Issues (not dated? What is included in this white paper? 298 Updated 1-31-17 2017--00398 This white paper provides a more detailed technical discussion of several elements of the NPRM. In particular, this paper discusses methodological choices in developing a Federal risk adjustment model, describes potential approaches to calculate payments and charges, and addresses permissible rating variation. The paper places emphasis on payments and charges and permissible rating variation because these topics are particular to the Affordable Care Act and provides further detail on preliminary approaches to examine the implications for premiums of various payment and charges alternatives. (CMS FAQs - Risk Adjustment Implementation Issues (not dated)) Is there opportunity for comment or feedback on this paper, and if so, how? Yes. Comments in response to this white paper may be submitted to the email address There is no deadline to submit comments to this white paper; we see this as a part of an ongoing consultation process. However, these comments will not become part of the administrative record that will be the basis of the ?nal risk adjustment proposed rule. Comments in response to the white paper will be used by HHS in developing the first annual Federal payment notice that will appear in the Federal Register and will include a draft notice and a comment period before the notice (and methodology) is ?nalized. While this white paper should serve to inform comments to the NPRM, comments in response to questions raised in the NPRM should be submitted at the regulations.gov website, where they will become part of the administrative record for the NPRM. (CMS FAQs - Risk Adjustment Implementation Issues (not dated)) Did any public input 90 into the drafting? This paper was drafted as part of an ongoing consultation process with States, issuers, risk adjustment experts and other stakeholders. In keeping with the commitment to transparency, this white paper is intended as the first in a series of consultations that will include meetings and other opportunities for feedback. HHS is seeking comments on this white paper to inform the development of a federally-certified risk adjustment methodology. The methodology will be released as part of a Federal Payment Notice that will appear in the Federal Register. Before ?nalizing the Payment Notice and the federally-certi?ed methodology, HHS will issue a draft notice and take public comment. (CMS FA 03 - Risk Adjustment Implementation Issues (not dated) What are the next steps? Updated 1-31-17 Comments in response to this white paper will be considered as HHS begins the process of developing a federally-certi?ed risk adjustment model. Comments will inform the HHS-developed federally-certi?ed risk adjustment methodology, which will be released as part of a Federal Payment Notice that will appear in the Federal Register and will include a draft notice and a comment period before the notice (and methodology) is finalized. Comments in response to the NPRM will be addressed in the rule making process. (CMS FAQs - Risk Adjustment Implementation Issues (not dated)) 299 2017--00399 024: Do issuers need to be QHP certi?ed if they only offer off-Exchange products, but still want to be able to receive the 3Rs (reinsurance, risk adjustment and risk corridor)? A24: The reinsurance program applies to all applicable individual market issuers inside and outside of the Exchange, and the risk adjustment program applies to applicable individual and small group market issuers inside and outside of the Exchange. Products outside of the Exchanges do not need to be QHPs in order to take part in these programs. The risk corridor program is only applicable to QHPs. (Plan Management Webinar QHP FAQ #3 04/11/13) Q12: Which issuer should submit reinsurance contributions for enrollees in point-of- service plans when the plan provides health insurance coverage through two affiliated issuers? A12: When a point-of-service enrollee is covered by two affiliated issuers, the enrollee need only be counted once for reinsurance contribution purposes. The issuers should coordinate to ensure the total reported is an unduplicated aggregate enrollment count for all enrollees. Reinsurance contributions should be made for the point-of-service enrollees by the issuer of the plan through which the enrollees would receive the majority of bene?ts, as reasonably determined by the issuers. The issuers must submit to HHS documentation substantiating the enrollment count pursuant to 45 CFR including references to the issuer that counted the point-of?service enrollee in their annual enrollment count, and the issuer that did not. As an example, assume that Comprehensive Health Insurance Company, Inc. offers a point-of?service product in the individual market in State X. The point-of?service product includes a PPO option written by Comprehensive Health Insurance Company, Inc. (Comprehensive Health) and an HMO product written by Comprehensive Health Insurance HMO, Inc. (Comprehensive HMO), which offers HMO products in the individual market in State X. Assume that there are 1,000 enrollees in State in the point-of?service product, and therefore, both Comprehensive Health and Comprehensive HMO, which are under common control, have the same 1,000 individuals as enrollees. The 1,000 enrollees receive the majority of their benefits from Comprehensive HMO. In this scenario, Comprehensive HMO would make reinsurance contributions with respect to the 1,000 enrollees, whereas Comprehensive Health would omit these 1,000 enrollees from their enrollment count. (QHP Webinar Series FAQ #7 04/24/13) Q13: For purposes of reinsurance payments, how will claims covered by a point-of- service plan be allocated when the plan provides health insurance coverage through two affiliated issuers? A13: HHS is in the process of working through the payment processes that would apply to point-of-service plans provided through two affiliated issuers. We will provide further guidance specifying how claims for point-of?service products will be aggregated for reinsurance payment purposes in those cases. (QHP Webinar Series FAQ #7 04/24/13) Q: When must a contributing entity submit its enrollment count for the purposes of making reinsurance contributions? Updated 1-31-17 A: Pursuant to 45 CFR a contributing entity must submit to HHS its annual enrollment count for the transitional reinsurance program no later than November 15 of 300 2017--00400 bene?t year 2014, 2015, or 2016, as applicable. Therefore, for the 2014 benefit year, a contributing entity must submit its annual enrollment count by November 15, 2014. The count must identify the number of covered lives of reinsurance contribution enrollees during the applicable bene?t year for all of the contributing entity?s plans and coverage described in 45 CFR (CMS FAQs Reinsurance Enrollment Count 11/08/13) Q: Optical and dental benefits for children under age 19 are ?essential health benefits.? If a plan does not provide major medical coverage, but provides pediatric dental and optical benefits, is the plan obligated to pay reinsurance contributions simply because the pediatric benefits are essential health benefits? A: No. Under 45 CFR plans that do not provide major medical bene?ts are exempt from making reinsurance contributions. Plans that provide only pediatric dental and optical bene?ts do not provide major medical coverage. A plan is not required to make reinsurance contributions on behalf of its enrollees merely because it offers certain bene?ts that are essential health benefits. (REGTAP FAQ Database - FAQ #552 12/06/13) Q: A fully insured plan offering medical coverage has a December 31 plan year, and a self-insured group health plan providing only prescription drug coverage has a January 31 plan year. All full-time employees are enrolled in the medical and prescription plans at the same time. Retirees, however, can elect to enroll in either or both plans. Does the prescription drug plan need to make reinsurance contributions? A: Applicable to All Reinsurance Contribution Benefit Years No. Pursuant to 45 CFR a contributing entity is not required to make contributions on behalf of a self-insured group health plan or health insurance coverage that consists solely of benefits for prescription drugs. (REGTAP FAQ Database - FAQ #553 12/06/13; updated 09/13/16) Q: A self-insured supplemental health plan, whose participants are simultaneously enrolled in insured major medical coverage offered by a different plan sponsor, provides a modest (several hundred dollars) maximum dollar of coverage per year per policy for medical expenses that have not already been paid for by the major medical plan. Is the supplemental plan required to make reinsurance contributions on behalf of its enrollees? A: No. The self-insured supplemental health plan is not required to make reinsurance contributions on behalf of its enrollees because the plan does not provide major medical coverage (see 45 CFR We note that because the supplemental plan and the fully-insured major medical plan have different sponsors, the aggregation rules at 45 CFR 153.405(g) do not apply. Also, since the supplemental and major medical plans are structured as separate plans, the aggregation rules at 45 CFR 153.405(f) do not apply. (REGTAP FAQ Database - FAQ 554 12/06/13) Q: A self-insured supplemental health plan, whose participants are simultaneously enrolled in insured major medical coverage offered by a different sponsor, reimburses a 301 Updated 1-31-17 2017--00401 portion of an enrollee's out-of-pocket expenses when the enrollee sees an out-of-network doctor under the major medical plan. Is the supplemental plan required to make reinsurance contributions on behalf of its enrollees? A: No. The self-insured health plan would not be required to make reinsurance contributions because the plan does not provide major medical coverage because it is designed to be supplemental to a major medical plan (see 45 CFR We note that because the supplemental plan and the fully insured major medical plan have different sponsors, the aggregation rules at 45 CFR 153.405(g) do not apply. Also, since the supplemental and major medical plans are structured as separate plans, the aggregation rules at 45 CFR 153.405(f) do not apply. (REG TAP FAQ Database - FAQ #555 12/06/13) Q: Is a retiree-only health reimbursement account that covers fewer than two participants who are current employees required to make reinsurance contributions? A: A retiree-only health reimbursement account will reimburse medical expenses only until the account balance is exhausted. In general, we do not consider plans with a dollar limitation on bene?ts to provide major medical coverage. Therefore, we do not consider a retiree-only health reimbursement account to provide major medical coverage. Under 45 CFR plans that do not provide major medical coverage are exempt from making reinsurance contributions. (REGTAP FAQ Database - FAQ #596 12/19/13) Q: Under the exception set forth in 45 CFR can an employer exclude from reinsurance contributions any contributions payable with respect to employees who are eligible for primary Medicare under the Medicare Secondary Payer (MSP) Rules under section 1862(b) of the Act and requlations issued thereunder? A: An employee actually receivinq primary coverage from Medicare pursuant to the MSP Rules does not need to be counted when the employer is calculating its Annual Enrollment Count for the purposes of reinsurance contributions. In 45 CFR we provide that a contributing entity must make reinsurance contributions for its self-insured group health plans and health insurance coverage except to the extent that, in the case of employer-provided health coverage, such coverage applies to individuals with respect to which bene?ts under Medicare are primary under Medicare Secondary Payor. rules under section 18629b) of the Social Security Act . . . Database- FAQ #597; #597a 12/19/13, updated 09/18/15) Distributed Data Collection Q10: Could HHS collect encounter data and let States perform risk adjustment? Updated 1-31-17 A10: The Affordable Care Act calls for a risk adjustment program to reduce incentives for health insurance plans to avoid covering people with pre-existing conditions or those in poor health. Risk adjustment ensures that health insurance plans have a financial incentive to provide services to the people who need them most by adjusting premiums to provide more funds to plans enrolling a higher proportion of people with high health costs. This mechanism ensures that insurance plans compete on the basis of quality and service, and not on the basis of avoiding sick, high-cost people. 302 2017-?00402 HHS issued a proposed rule on Standards Related to Reinsurance, Risk Corridors and Risk Adjustment (published on July 15, 2011). HHS did not propose and will not implement any proposal that calls for States or the Federal government to collect personal data such as name, social security number or address for the risk adjustment program. Protecting the privacy and confidentiality of an individual?s personal health information continues to be among HHS's highest priorities. HHS will not require States to collect medical record or information that identifies an individual?s doctor; nor would the Federal government collect this information. (State Exchange Implementation Questions and Answers (11/29/1 Q20: The recent Proposed Notice of Benefit and Payment Parameters for 2014 de?nes some requirements for a distributed data environment for collecting risk adjustment and reinsurance data. Can you provide more details? A20: HHS has provided a list of required data for the HHS-operated distributed data approach in the PRA package approved under OMB Control Number 0938-1155. After release of the ?nal payment notice, HHS is conducting a short series of educational webinars focused on details of the distributed data approach. You can register for these sessions at The next session will be held on April 10, 2013. During these sessions, HHS will make available the data formats, definitions, and technical standards applicable to the HHS-operated distributed data approach in future guidance. This summer HHS plans to conduct followed by user group sessions and additional operational policy guidance. (Plan Management Webinar QHP FAQ #2 04/09/13) Q1. Does HHS want the HIOS plan ID used in the Plan ID field in the Edge Server Enrollment Submission (ESES) for the Edge Server? A1. The enrollment submission for the Edge Server uses the HIOS ID to identify the issuer and the corresponding HIOS standard component ID for the plan. This information will be provided in the Edge Server ICD (interface control document). (Distributed data collection for Reinsurance and Risk Adjustment FAQ #1 05/09/13; REG TAP FAQ Database - FAQ #259 05/09/13) Q2. Issuers have heard that they would be receiving and sending 834 files for enrollment transactions. Are issuers now using both the 834 and XML files? A2. The Edge Server accepts XML ?les only and is strictly for the purpose of Risk Adjustment and Reinsurance data collection. The 834 transaction referenced is unique to Exchange enrollments. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #1 05/09/13) Q3. Could HHS provide more guidance on the masked enrollee ID numbers? For instance, if issuers assign a unique ID number today that is not the member's SSN, are issuers required to map their current ID number to another unique ID number solely for the Edge Server? Updated 1-31-17 A3. In the HHS Notice of Bene?t and Payment Parameters for 2014, Final Rule, regulation text ?153.720 states that an issuer may not include personally identifiable information in the masked enrollee identi?cation number or use the same masked enrollee identi?cation number for different enrollees enrolled with the issuer. If the 303 2017--00403 current enrollee ID number does not violate one of these requirements, then the current ID may be used as the masked enrollee identification number. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #1 05/09/13) Q4. Reinsurance only impacts the Individual market. Risk Adjustment impacts both the Individual and Small Group markets. Based on this, does HHS anticipate different record layouts or 'uploads' for Reinsurance vs. Risk Adjustment? A4. In Distributed Data Collection there are submissions based on enrollment, medical claims, and pharmacy claims. The record layouts for each of these transaction types includes the data elements to address both reinsurance and risk adjustment as appropriate. Additional details will be provided during the May 8th and May 22nd webinars. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #1 05/09/13) Q5. What is the data frequency of data submission? Is it quarterly or can issuers submit or twice A5. As stated in the preamble of the HHS Notice of Bene?t and Payment Parameters for 2014, Final Rule (Section HHS recommends issuers submit data at least quarterly throughout the bene?t year. Issuers have the ?exibility to submit more frequently bi-weekly, HHS recommends file submissions or more frequent submissions based on Issuer file size and processing time. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #1 05/09/13) 06. How should issuers treat claims from capitated arrangements on the Edge Server Medical Claim Submission? A6. The Edge Server will accept claims that have a $0 allowed amount. For capitated services, Issuers will need to derive (or estimate) a paid amount for these services. In addition, the inbound claim ?le layout contains a ?eld to indicate a derived amount has been computed for capitated arrangements Further information and speci?c ?le layouts pertaining to capitated arrangements will be covered in the May 22nd Distributed Data Collection (Edge Server) webinar. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #1 05/09/13) Q7. Has a decision been made as to whether or not additional diagnosis code information can be submitted from chart reviews (similar to the RAPS file process for Medicare Advantage)? If it is allowed, would issuers use the Medical Claim format to submit? A7. Guidance on the use of chart reviews as a source of diagnosis codes for risk adjustment will be provided by HHS prior to January 1, 2014. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #1 05/09/13) 09: What is the deadline for submitting enrollment files, claim files? What is the deadline for any adjustments/updates to enrollment or claims files on the Edge Server? A9: All claims, for the bene?t year 2014, must be submitted ongoing by April 30, 2015 for services with a from and to date of service or statement covers from and through date between January 1, 2014 and December 31, 2014. Issuers should still submit 304 Updated 1-31-17 2017--00404 replacement data claims as frequently as necessary to ensure stored claims data are accurate and includes all claims to be considered for risk adjustment and reinsurance. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #3 07/23/13) Q10: Please explain the use of service from and to dates for professional and institutional claims. A10: Dates of service are primarily used to determine for which bene?t year the services should be considered for reinsurance and/or risk adjustment. Dates of service, either represented as statement covers from and through or date of service from and to, are used in duplicate checks and overlapping stay logic as outlined in the Business Rules document published in the REGTAP library. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #3 07/23/13; REGTAP FAQ Database - FAQ #221 07/23/13) Q11: Do you consider the Date paid [Date the claim was paid or the encounter was processed by the Issuer] as the bank paid date or check date? A11: The date paid means the date a check or electronic funds transfer was issued for paid claims. For encounters, the date paid means the date of claim adjudication. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #3 07/23/13; REG TAP FAQ Database - FAQ #222 07/23/13) Q12: Are claim files edited against stored enrollment records? A12: During the initial file load process, medical and pharmacy claim files are not compared to the enrollment files or stored enrollment records. Enrollment and claim files are processed independent of each other. Therefore, an enrollee does not need to be present in the enrollment data table for a claim to be accepted. The process of cross referencing the enrollee and claim data tables for identifying claims eligible for reinsurance and risk adjustment is performed during program specific processing. Issuers will receive outbound data ?les indicating which stored enrollees do not have corresponding claims and which claims do not have a corresponding enrollee/enrollment period record. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #3 07/23/13; REGTAP FAQ Database - FAQ #223 07/23/13) Q13: If a claim is finalized and adjusted within the same reporting period, do issuers send the original claim, void and replace, or only submit the replacement record? A13: Issuers can either submit each claim transaction or submit a ?nal claim transaction based on the business need. If an issuer chooses to submit each claim transaction, then they will need to ensure that the proper void/replace indicators and date/time stamps are included in the file submission. If an issuer chooses to submit a ?nal claim transaction, they will need to ensure that all relevant data, such as full paid amounts and all diagnoses, are included in the file submission. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #3 07/23/13; REG TAP FAQ Database - FAQ #271 07/23/13) Q14: Will the Edge Server determine whether a duplicate claim contains the same data or will it simply reject as duplicate any claims with the same Claim ID being submitted? 305 Updated 1-31-17 2017--00405 A14: For medical claims there are two duplicate checks performed: one at the claim header level, where the Issuer ID and Claim ID are used to match against the stored claim table, and the second at the claim line level, where a multi-key system is used. For pharmacy claims, there is a single duplicate check performed where a multiple-key system is used. The duplicate logic is described in the Business Rules document available in the REGTAP Library at (Distributed data collection for Reinsurance and Risk Adjustment FAQ #3 07/23/13; REGTAP FAQ Database - FAQ #224 07/23/13) Q15: Should claims submissions only reflect essential health benefits (EHBs) or should all claims be submitted to the Edge Server? A15: All major medical claims and pharmacy claims, where an issuer incurred a cost, should be submitted to the Edge Server for consideration. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #3 07/23/13; REG TAP FAQ Database - FAQ #210 07/23/13) Q16: Should women's contraceptive claims be submitted under the same masked enrollee ID as other medical claims to the Edge Server? A16: Contraceptive claims covered under a non-grandfathered, individual or small group plan should be submitted on a pharmacy or medical claim ?le, as appropriate. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #3 07/23/13; REG TAP FAQ Database - FAQ #211 07/23/13) 02. If a medical claim has multiple lines and one of the paid amounts is derived, how is that reported at the header level? A2. If a medical claim includes both derived and paid amounts, then the header should include the derived indicator value of At the line level, each line should include the appropriate value which indicates whether the value is derived. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #4 08/16/13) Q: Regarding the edge server Medical claim submission file, should the Total Amount Paid XML element 'policyPaidTotalAmount') business data element at the Claim Header level equal the sum of the Amount Paid XML element 'policyPaidAmount') business data elements at the Claim Service Line level? A: Yes. A Medical claim can consists of multiple 'Medical Claim Service Line' items each having a 'policyPaidAmount'. The 'Total Amount Paid' (policyPaidTotalAmount' at the claim header level equals the sum of the Amount Paid? (policyPaidAmount) for each 'Medical Claim Service Line.? (REGTAP FAQ Database - FAQ #517 12/03/13) Q: Do outbound files, sent from the edge server, contain a naming convention explaining the file name and type header, details, etc.)? A: The type of outbound ?le could be determined through the 'FileTypeCode', which is described in Section 6 of the Interface Control Document (ICD). The 'FileTypeCode' will indicate whether the ?le type is an accept/reject report for enrollees or claims (pharmacy 306 Updated 1-31-17 2017--00406 or medical), and whether the ?le is a detailed or summary error report. Please refer to the ICD located at for specific information on the file naming convention. (REGTAP FAQ Database - FAQ #518 12/03/13) Q: What should an issuer do when reporting Claim Q: Since voided/replaced claims are only at the header level for Medical claims, should issuers only submit a void/replace for the entire claim or is there a way to void/replace at the service line level of a Medical claim? A: Claims that need to be voided or replaced should be submitted in their entirety. Medical claim files include both a claim header and the claim lines associated with the claim header. Since every medical claim submitted requires both a header level and claim line detail level, any void or replacement of a claim must also include both the header and line level components. All claim lines associated with the claim header should be resubmitted even if only one claim line associated with the claim header is adjusted. For more information on voiding and replacing claims, please see the user group presentation materials from November 6, 2013 posted in the REGTAP library at (REGTAP FAQ Database - FAQ #522 12/05/13) Q: What should an issuer do when reporting Claim Paid Date if the issuer the Paid Date at the service line level, but the Medical Claim submission format includes this field at the header level? A: The claim paid date is only reported at the header level of the claim ?le submission. If an issuer captures the date paid at the line level, the date paid at the line level should be reported at the header level. (REGTAP FAQ Database - FAQ 572 12/12/13) Q: Will HHS use the edge server to collect claims and reimburse issuers for contraceptive benefits paid on behalf of group health plans established or maintained by eligible organizations under the accommodation established in 45 CFR 147.131? A: We have not yet speci?ed the manner in which the data will be submitted, and will provide that information in future guidance. The ?nal rule ?Coverage of Certain Preventive Services Under the Affordable Care Act? published by the Departments of Health and Human Services (HHS), Treasury, and Labor on July 2, 2013, set forth requirements regarding coverage for certain preventive services under section 2713 of the Public Health Service Act. Section 2713 of the Public Health Service Act requires coverage without cost sharing of certain preventive health services, including certain contraceptive services, by non-exempt, non-grandfathered group health plans and health insurance coverage. This ?nal rule provides an accommodation for group health plans established or maintained by eligible organizations. The ?nal rules provide that a group health insurance issuer that would othewvise provide contraceptive coverage for these group health plans must exclude the coverage from the group health insurance coverage, and provide separate payments for the contraceptive services. The ?nal rules also establish processes and standards to fund the payments for the contraceptive services that are provided for participants and bene?ciaries in self-insured plans of eligible organizations under this accommodation, through an adjustment in the 307 Updated 1-31-17 2017--00407 Federally-facilitated Exchange (FFE) user fee payable by an issuer participating in an FFE. In order to facilitate the FFE user fee adjustment, and ensure that these user fee adjustments reflect payments for contraceptive services provided under this accommodation and that the adjustment is applied to the appropriate participating issuer in an FFE, the final rule requires certain information be collected from applicable participating issuers and third party administrators. Please refer to the ?Coverage of Certain Preventive Services under the Affordable Care Act? ?nal rule for further information on these submission standards (See (REGTAP FAQ Database - FAQ #577 102/13/13) Q8. Will the submission process be similar to the Medicare Part data reporting? A8. No. All claims and enrollment ?les will reside on the issuer's edge server. There is no centralized data collection by as is the case with Medicare Part D. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #1 05/09/13; REG TAP FAQ Database - FAQ #275 05/09/13) Q17: Is it correct to populate the highest cost or primary ingredient in the Product/Service ID field for compound claims multiple NDC codes)? A17: Issuers may populate the Product/Service ID field for compound claims with the highest cost ingredient. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #2 07/15/13) Q17: Is it correct to populate the highest cost or primary ingredient in the Product! Service ID field for compound claims multiple NDC codes)? A17: Issuers may populate the Product/Service ID field for compound claims with the highest cost ingredient. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #3 07/23/13; REG TAP FAQ Database - FAQ #225 07/23/13) Q: What are issuers' responsibilities for establishing and updating dedicated distributed data environments, prior to publication of HHS guidance? A: HHS intends to provide technical guidance to support issuers in establishing dedicated distributed data environments. Until such guidance is provided, issuers will not be deemed to be out of compliance with any of the data requirements set forth in 45 CFR 153.700 through 153.730; 153.420; or We also note that, in the preamble to 45 CFR 153.740(a) published in the Program Integrity: Exchange, Premium Stabilization Programs, and Market Standards Final Rule (78 FR 65060), we stated that we would not impose civil money penalties on an issuer for non-compliance during the 2014 calendar year, if the issuer has made good faith efforts to comply with these requirements. (REGTAP FAQ Database - FAQ #1212 03/28/14) Q: Are issuers required to submit terminated members, as well as current enrollments on a basis? A: In accordance with the general enrollment file submission rules, the initial enrollment file will be a cumulative file of all of the issuer's enrollees and enrollment periods. Subsequent enrollment file_s_uvbmj_s.s_i.orls__m_ust be a COMPLETE REPLACEMENT FILE 308 Updated 1-31-17 2017--00408 inclusive of all enrollees and enrollment periods. Issuers should continue to submit prior year enrollment data, each year, until the Centers for Medicare Medicaid Services (CMS) notifies issuers to cease such submissions. In reqard to terminated enrollees, the EDGE Server Business Rules (ESBR) state, an enrollee or associated enrollment period that is no longer included on a newly submitted ?le will be inactivated. Inactivated enrollee records and the associated enrollment periods will no lonqer be eliqible for consideration in the RA or RI proqrams. In addition, any claims associated with that enrollee or enrollment periods will be orphaned and not included in RA or RI calculations. For more information, please refer to the EDGE Server Business Rules (ESBR), located under the Distributed Data Collection (DDC) Proqram Area at in the Reqistration for Technical Assistance Portal (REGTAP) Library. Q: In reference to the membership ?le, if a member was active and subsequently had a claim that has been paid, however the member was retroactively cancelled back to the initial effective date, should this member be included on the enrollee file? A: If an issuer has submitted the enrollee once, each subsequent enrollment file submission should also include the enrollee. If an enrollee is retroactively terminated the issuer must update the 'Coverage End Date' of the enrollee. The only claims that will be considered for risk adjustment and reinsurance are those claims that are associated with an active enrollment period. (REGTAP FAQ Database - FAQ #4659 11/26/14) Q: What format should issuers use for the masked Unique Enrollee A: The requirements for enrollee IDs submitted to the EDGE server are de?ned in 45 CFR 153.720. This regulation states the issuer must establish a unique masked enrollee identi?cation number for each enrollee. The Interface Control Document (ICD) further clari?es that this number cannot be a medical record number or cardholder ID number. Issuers must establish their own method of de-identifying an enrollee ID. Also, please note that issuers must use the same Unique Enrollee ID if the enrollee switches plans within the issuer. Issuers may use an existing internal ID provided the ID was not used for exchange enrollment transaction or on the enrollee membership cards. Additionally, the ID should not include other knowable IDs such as the Social Security Number (SSN) and driver's license number. (REGTAP FAQ Database - FAQ #5057 11/26/14) Q: Can the Centers for Medicare Medicaid Services (CMS) identify the differences between the 2014 Benefit Year and the 2015 Bene?t Year External Data Gathering Environment (EDGE) server registration and provisioning process? A: There are no differences between the EDGE server registration and provisioning process in the 2015 Bene?t Year compared to the 2014 Bene?t Year. For further 309 Updated 1-31-17 2017--00409 guidance, refer to the EDGE Server Pre-Registration and Registration (8/20/15) and EDGE Server Provisioning (8/27/15) presentation slides, located in the Distributed Data Collection for RI and Server Program Area of the Registration for Technical Assistance Portal (REGTAP) Library. (REGTAP FAQ Database - FAQ #12450a 09/02/15) Q: How can issuers determine who is the organization's assigned Financial Management (FM) Service Representative? A: Issuers should request the organization's FM Service Representative by contacting and including the organization's Health Insurance Oversight System (HIOS) ID. (REGTAP FAQ Database - FAQ #12453a 09/02/15 Q: Should issuers contact their Financial Management (FM) Service Representative for issues related entirely to Amazon Web Services (AWS), such as increasing server size? A: Yes. Issuers with AWS servers must contact their FM Service Representative prior to modifying anything related to their server and contacting AWS support. Once a ticket has been opened by an FM Service Representative, issuers can contact AWS. Issuers must ensure that the FM Service Representative is included on all communications, including calls, with AWS. (REGTAP FAQ Database - FAQ #13127 09/21/15) 2015 Archive Questions On Tuesday, July 12, 2016, several issuers had questions related to the pre-archive instructions provided by the Centers for Medicare Medicaid Services (CMS). CMS is providing responses to those questions below. Issuers who have additional questions related to the pre-archive instructions should email EDGE Server Data@cms.hhs.qov. Granting Access to Non-Existent Schemas Q: How do we grant access to 2015 schemas and tables that do not currently exist on the External Data Gathering Environment (EDGE) server? A: The schema and tables do not need to physically exist when granting permissions. The schemas and tables will be loaded to the server as part of the July 22, 2016 maintenance release. In order for the schema and tables to be loaded successfully, permissions need to be present. Issuers will need to have DBA User or Root Access to create the permissions. It is important to verify the accuracy of the permissions granted, as a typo would result in a failure of the schema and table deployment. (REGTAP - DDC for RI 8. RA Edge Server? 2015 Archive Questions 07/14/16) Space Needed: Q1: Part of the pre-archive steps indicate to run a command to check the space available. How much extra space should I have available? 310 Updated 1-31-17 2017--00410 A1: It would be ideal if the server had three (3) times the current database capacity. At a minimum, twice the current database size will be necessary. (REGTAP DDC for RI RA Edge Server 2015 Archive Questions 07/14/16) Q2: Can CMS advise how much space the DB backup files will take in the [opt/edge directory? A2: Database storage for is different than the storage required for backup ?les on IoptIedge. The Iopt/edge directory contains database backup ?les for every remote command issued by CMS. We recommend at least three (3) times the size of the current active schemas and be available. (REGTAP DDC for RI RA Edge Server? 2015 Archive Questions 07/14/16) No Command Prompt Returned Q: I ran a command to view the EDGE properties but it never returned to the command prompt. Is this expected behavior? A: No, this is not expected behavior. If no command prompt is returned after running a command, issuers should contact their Financial Management Coordination Center (FMCC) representative by sending an email to EDGE Server Data@cms.hhs.qov and include any screen shots associated with the activity performed and the returned results. (REGTAP - DDC for RI RA Edge Server- 2015 Archive Questions 07/14/16) Count of Tables Q: When running the command to check the count of common tables, the result was 74 tables instead of the 75 schema listed in the EDGE Server Annual Archive Job Aid. Is the result an errorerror. The current table count is 74. After the maintenance release (17.0) on July 22, 2016, there will be 75 tables. Issuers should con?rm the table count after the maintenance release. DDC for RI RA Edge Server? 2015 Archive Questions 07/14/16) Data Compression Q: During the archive process, will the 2015 archived data be compressed? A: No. The archived data will not be compressed and will consume the same amount of space it currently consumes. (REGTAP DDC for RI RA Edge Server? 2015 Archive Questions 07/14/16) Transactions/Edge Server Note: Includes some FA OS on Reinsurance Q11: Have specifications on the Edge Servers required by issuers been released yet? A11: HHS has provided a list of required data for the HHS-operated distributed data approach in the PRA package approved under OMB Control Number 0938-1155. After release of the final payment notice, we HHS is conducting a short series of educational 311 Updated 1-31-17 2017-?00411 webinars focused on details of the distributed data approach. You can register for these sessions at The next session will be held on April 10, 2013. During these sessions, HHS will make available the data formats, definitions, and technical standards applicable to the HHS-operated distributed data approach in future guidance. This summer we plan to conduct followed by user group sessions and additional operational policy guidance. (Plan Management Webinar QHP FAQ #1 04/08/13) 021: Will issuers need to submit a subset of the QHP template data for off-Exchange plans to support reinsurance and risk adjustment? Will there be functionality added to the current templates or a subset of templates created for these off-exchange plans to require only the information needed for this the reinsurance and risk adjustment calculations? A21: HHS plans to create templates specific for the data pertinent for the reinsurance and risk adjustment program operations. This will provide a streamlined approach for non-QHP data submission. (Plan Management Webinar QHP FAQ #2 04/09/13) 022: How will the banking data and edge server provisioning be submitted? A22: HHS is currently working on the submission process for banking data and provisioning process for the edge server. HIOS will be utilized where possible to reduce burden to issuers. Further guidance will be provided as these processes are ?nalized. (Plan Management Webinar QHP FAQ #2 04/09/13) 025: Is the data submission process for Medicare applicable to the Edge Server? A25: The data and submission process on the Edge Server is speci?c to the reinsurance and risk adjustment programs speci?ed in the ACA private insurance and not Medicare). Medicare data should not be submitted to the Edge Server. (Plan Management Webinar QHP FAQ #3 04/11/13) 026: Per the final Payment Notice, the initial Risk Adjustment model will exclude prescription drug data. However, the final Payment Notice states that claims and encounter data for prescription drugs are required to be submitted on the Edge Server. Why is this? A26: The transitional reinsurance program considers pharmacy claims as reinsurance- eligible claims. All reinsurance-eligible claims will be included during the payment calculation process on the Edge Server for the HHS-operated reinsurance program. (Plan Management Webinar QHP FAQ #3 04/11/13) 045: If the issuer has a capitated plan, does the issuer need to submit the claims from the These claims will have a $0 Allowed Cost amount because the provider receives a set payment; will these claims pass the Edge Server Edit? A45: The Edge Server will accept claims that have a $0 allowed amount. For capitated services, Issuers will need to derive (or estimate) a paid amount for these services in order for them to be considered for reinsurance. In addition, the inbound claim file layout contains a ?eld to indicate a derived amount has been computed for capitated arrangements. Further information and specific ?le layouts pertaining to capitated 312 Updated 1-31-17 2017-?00412 arrangements will be covered in the May 8th Distributed Data Collection (Edge Server) webinar. You can register for this webinar at (QHP webinar series FAQ #9 05/03/13) Q: What is the deadline for submitting full replacement enrollment claims data on the Edge Server? A: Issuers have the ?exibility to submit claim and enrollment data at any time for a given benefit year as long as that data is submitted at least quarterly and all data for consideration in reinsurance or risk adjustment is submitted by April 30th following the bene?t year. (REGTAP FAQ Database - FAQ #454 11/13/13) 05. Will the UNIX system on the Edge Server support Secure File Transfer Protocol A: There are two methods for submitting a file for processing on an edge server - user interface (UI) and secure ?le transfer protocol (SFTP). Issuers have the option of using either method (Ul or SFTP) however, any file that exceeds 10MB must be uploaded via SFTP. (REGTAP FAQ Database - FAQ 455 11/13/13) Q: Where is information on how the software application and databases are installed on the Edge Server (specifically a description of the naming conventions used during the install), so that Issuers can determine a methodology to separate each legal entity running on a single Edge Server while preserving confidentiality? A: Data is not stored separately on the edge server. If two legal entities have data on the same server, the host must serve as the firewall between those entities and the server. All data must pass through the host when submitted to the server and when reported back to the entities whose data resides on the server. The host is responsible for ensuring the appropriate routing of data back to the entities. The host needs to ensure 313 Updated 1-31-17 2017--00413 that data submitted to the edge server pertains to a single legal entity in order to be able to route submission results back to the issuers. (REGTAP FAQ Database - FAQ #456 11/13/13) Q: Will there be penalties for Issuers submitting data after the quarter or annual dead?nes? A: CMS has established the rules for failure to comply with HHS-operated risk adjustment and reinsurance data requirements in the Program Integrity Final Rule under 45 CFR You can find the Program Integrity Final Rule at Pl.pdf. (REGTAP FAQ Database - FAQ #45711/13/13) Q: Regarding the Medical submission file, do Issuers void original claims containing an adjusted claim value with a new 'Claim Line Sequence Number'? A: Claims that need to be resubmitted due to changes that result from adjusted claims should be submitted in their entirety. All claim lines associated with the original claim should be resubmitted even if only one claim line associated with the entire claim is adjusted. Adjusted claims are resubmitted using the replace indicator and in doing so the claim lines that are unchanged are not rejected as duplicates and the claim lines that are changed replace the previously submitted data. For more information on replacing claims, please see the Edge Server Business Rules in the REGTAP library at (REGTAP FAQ Database - FAQ #458 11/13/13) Q: When sending member data to the edge server, should issuers send the Rating Area used for premium rating purposes or based on the location of the member? A: Issuers should use the same plan rating area that was used for premium rating purposes as established by Program Integrity Rule at 45 CFR (REGTAP FAQ Database - FAQ #462 11/15/13) Q: Will the outbound files available in 2014 contain the results of the reinsurance and risk adjustment algorithms? A: Issuers will receive various outbound files/reports on the Edge Server. The first group of reports to be produced will provide file processing results rather than risk score or reinsurance information. A subset of outbound ?les/reports will be generated when processes the stored data on issuers Edge Servers and generates reinsurance and risk adjustment speci?c ?les/reports. Information regarding timing of reports and details on the speci?cations will continue to be communicated through the Release Management process. (REGTAP FAQ Database - FAQ #173 11/18/13) Q: How should issuers populate fields in the submission files when the data is fewer characters than the field allows left or right justified, or filled with A: The restrictions on data field size are maximum limits. If a submitter value is less than the maximum allowable no ?ller elements need to be included. 314 Updated 1-31-17 2017-?00414 Where the restriction column of the ICD indicates a length and no enumeration value is provided, the length may be interpreted to mean a maximum value. For example, File ID has a restriction indicating a length 12. The File ID can be up to 12 characters in length. In contrast, the restriction for the Plan ID indicates a length 16 and speci?cally provides the format required which is a value equal to exactly 16 characters. (REGTAP FAQ Database - FAQ #174 11/18/13) Q: Can issuers resubmit corrected data after the quarter if unsuccessfully submitted during the quarter and is before the April 30, 2015 deadline? A: Issuers should submit replacement data claims as frequently as necessary to ensure stored claims data is accurate and includes all claims to be considered for risk adjustment and reinsurance by the submission deadline. Issuers may submit data quarterly for enrollee data, with the caveat, that issuers must ensure that the last submission for 2014 (in April 2015) is done in a timely manner and provides an accurate listing of all relevant 2014 enrollment periods. (REGTAP FAQ Database - FAQ #428 11/18/13) Q: Will Issuers be required to report claim data with ICD-9 or ICD-10 diagnoses for risk adjustment and reinsurance following the ICD-10 implementation in 2014? A: In developing the Edge Server software, CMS has considered ICD-10 coding. As we approach the implementation date of ICD-10, issuers will be provided with any changes that may be necessary when submitting claims containing ICD-1O information. (REGTAP FAQ Database - FAQ #429 11/18/13) Q: Can issuers install the Intrusion Detection System (IDS) and monitoring software NetlQ and Tripwire) directly to the edge server, or will be responsible for this task? A: The edge server software is hardened to prevent malicious attacks and malicious code that may disrupt operations. Issuers should follow their corporate data security standards when installing Intrusion Detection Systems and Anti-Virus applications. (REGTAP FAQ Database - FAQ #433 11/18/13) Q: Will publish an updated Welcome Packet to REGTAP that would replace the current version from March 2013? A: The Welcome Packet previously published is no longer current. We are streamlining the edge server provisioning process. In the upcoming months, CMS will provide additional materials on a new automated provisioning process along with information on registering issuer edge servers. (REGTAP FAQ Database - FAQ 436 11/18/13) Q: After the hardware specification and connectivity configuration process has been completed, what are the next steps for the issuer? Updated 1-31-17 A: CMS is changing our implementation process in order to incorporate lessons learned from the beta test provisioning process. The Welcome Packet previously published is no longer current. In the upcoming months, CMS will provide additional materials on a new automated provisioning process along with information on registering issuer edge servers. 315 2017-?00415 This adjustment will not affect the schedule for program operations reinsurance payments and risk adjustment payment transfers will still take place in mid-2015. You will receive notification of upcoming events and additional information through the REGTAP system. (REGTAP FAQ Database - FAQ 437 11/18/13) Q: Please provide specific examples of the content that will be displayed in the Detail Error Reports from the edge server. A: The following resources are provided and include information on outbound file layouts which are produced after ?le processing occurs on an Edge Server. Interface Control Document (ICD), Error Code List and XML (eXtensible Markup Language). The ICD specifies the interface requirements for the transmission of required information between CMS and an Edge Server. Inbound and outbound files are created using eXtensibIe Markup Language (XML). Detail and summary report speci?cations are provided in the latest version of the Interface Control Document (ICD). XML Schema De?nitions (XSDs), the ICD and the June 26th webinar documents are provided in the REGTAP Library at (REGTAP FAQ Database - FAQ 441 11/18/13) Q: Can the yearly amount Issuers pay providers, under capitated plans, he submitted to the Edge Server for the purpose of risk adjustment and reinsurance? A: Capitated claims are acceptable for submission to the edge server. Issuers will need to derive (or estimate) a paid amount for these services as outlined in 45 CFR 153.710. As indicated in the Edge Server Business Rules, the Derived Amount Indicator is a data element that allows issuers to identify claims that have capitated provider arrangements instead of fee-for-service arrangements and to re?ect the derived costs associated with the capitated services in the Derived Amount Field. If a medical claim includes both derived and paid amounts, then the header should include the derived indicator value of At the line level, each line should include the appropriate value which indicates whether the value is derived. (REGTAP FAQ Database - FAQ #494 11/20/13) Q: What is Jabber being used for? A: The jabber ports will be used during the provisioning process and will not be used after the provisioning is completed. This port is used to communicate to the management server on the CMS Network. Once the provisioning is complete the ports can be closed. (REGTAP FAQ Database - FAQ #496 11/20/13) Q: In order to replace a previously submitted claim with an incorrect enrollee ID number, can the issuer resubmit the claim with the same claim number and an 'R=Rep acement' indicator? Updated 1-31-17 A: As noted in the Edge Server Business Rules (available in the REGTAP Library at in order to replace a previously submitted medical or 316 2017-?00416 pharmacy claim, the claim must be resubmitted with the original claim number and the replace indicator (R) in the Void/Replace indicator data ?eld. If multiple claims exist on the stored medical claim table, either in an active or inactive status, any claim ID may be used as the Original Claim ID to replace the most current active version of a claim. The Edge Server searches the database for a claim that matches the original claim number. If a match is found, the original claim is made inactive and the replacement claim is added as the new active version of that claim. (REGTAP FAQ Database - FAQ #516 12/03/13) Q: Is a plan that provides prescription drug, optical, and dental or a combination of these coverages, but that does not provide major medical coverage, required to remit reinsurance contributions on behalf of the individuals enrolled in the supplemental plan? A: No. Under 45 CFR plans that do not provide major medical bene?ts are exempt from making reinsurance contributions. A plan that provides only prescription drug, optical, dental, or a combination of these benefits does not provide major medical coverage, and therefore would not be required to make reinsurance contributions on behalf of their enrollees. (REGTAP FAQ Database - FAQ #551 12/06/13) Q: How should prescription drug rebates be accounted for when reporting prescription drug costs for the reinsurance program? A: When submitting pharmacy claims to the edge server, the reported paid amount does not need to be adjusted to re?ect manufacturer rebates. Pharmacy rebates will not be considered in the calculation of reinsurance payments. (REGTAP FAQ Database - FAQ #556 12/06/13) Q: Is there a process for tracking the percentage of reinsurance funds issuers may receive if HHS is unable to collect the entire $10 billion allocated for reinsurance payments for 2014? A: Because reinsurance contributions for 2014 will not be collected until early in 2015, we will not be able to provide information regarding any pro rata adjustment that may apply to requests for reinsurance payment during 2014. However, information on the total contributions collected and total payment requests made are required for HHS to calculate whether any pro rata adjustment to reinsurance payments is required. Therefore, the June 30th report discussed in 45 CFR 153.240(b) will provide information regarding any pro rata adjustment, if applicable. (REGTAP FAQ Database - FAQ 557 12/06/13) Q: How should mother and infant claims costs be treated for the purposes of the reinsurance program? Updated 1-31-17 A: In the preamble to the 2014 HHS Notice of Bene?t and Payment Parameters (78 FR 15420), we stated that ?in operation, issuers will separate infant and mother claims when possible. If an infant claim cannot be separated, HHS will assign the infant to the lowest severity category and the ?term' maturity category. We note that HHS does not intend to unbundle claims in operation.? For reinsurance purposes, issuers should similarly unbundle claims whenever practicable - that is to say, whenever it is legally and operationally practicable for an issuer to do so. If an issuer cannot practicably unbundle 317 2017-?00417 all infant and mother claims, the issuer must adopt and adhere to a consistent policy for the bundling and unbundling of those claims for purposes of uploading to the Edge Server (for example, a policy providing that claims within 30 days of birth are to be bundled, and claims after that period unbundled). Claims costs that remain bundled will count as the mother's claims costs under the reinsurance program. (REGTAP FAQ Database - FAQ #558 12/06/13) Q: How should subrogation claims be presented to the Edge Server for purposes of reinsurance? A: Issuers must submit paid claims net of any reduction in liability due to subrogation payments made with respect to those claims (whether or not received directly by the issuer) as of April 30 of the year following the applicable benefit year. We recognize that at the time a claim is ?rst loaded to the edge server it may be difficult to know whether future subrogation payments will reduce an issuer's liability for that claim. Therefore, if an issuer's liability is reduced due to a subrogation payment that is received prior to the end of the data collection period, an issuer must submit a new version of the claim to adjust for the subrogation payment. The void and replace process should be used to submit these changes to the edge server, just as it should be used to report adjustments for a change to diagnosis, services or issuer's paid amount. Consider an issuer that pays $1,500 for a claim from March, 2014. The issuer would submit this paid claim to the Edge Server. If the issuer receives a $500 subrogation payment in September, 2014, then the issuer would submit a replacement claim to the edge server with the new version of the claim with a paid amount of $1,000. If the issuer later receives another $1,000 subrogation payment on this claim in January, 2015, the issuer would submit a void of the $1,000 claim to the edge server, reversing the entire claim, resulting in a $0 claims paid amount. (REGTAP FAQ Database - FAQ #559 12/06/13) Q: For the transitional reinsurance program and permanent risk adjustment program, can an issuer submit claims costs or diagnosis for an enrollee who is admitted in the 2013 bene?t year but discharged in the 2014 benefit year or who is admitted under a plan not subject to the market reforms rules but discharged under a plan subject to the market reform rules? Updated 1-31-17 A: No. Pursuant to 45 CFR 153.234, a reinsurance-eligible plan's covered claims costs for an enrollee incurred prior to the application of the insurance market reforms at ?147.102 (fair health insurance premiums), ?147.104 (guaranteed availability of coverage, subject to the student health insurance provisions at ?147.145), ?147.106 (guaranteed renewability of coverage, subject to the student health insurance provisions at ?147.145), ?156.80 (single risk pool), and subpart of part 156 (essential health benefits package) to that plan do not count towards the reinsurance payments parameters. Pursuant to the preamble to the HHS Notice of Bene?t and Payment Parameters for 2014 (78 FR 15418), plans not subject to the market reform rules are treated separately, such that these plans would not be subject to risk adjustment charges and would not receive risk adjustment payments. Therefore, if an enrollee's date of admission is prior to January 1, 2014 or under a plan not subject to the market reform rules, then the claims costs incurred for this enrollee cannot count towards the attachment point for reinsurance payments, nor can the enrollee's diagnoses be used because plans not subject to market reforms are not 318 2017-?00418 subject to incurring risk adjustment charges or receiving risk adjustment payments. (REGTAP FAQ Database - FAQ #598 12/19/13) Q: Is it optional to submit a supplemental file? A: If a diagnosis is missed or omitted during claim or encounter submission, a supplemental diagnosis ?le should be submitted in accordance with the submission of the EDGE Server Supplemental Diagnosis File Submission (ESSFS) ?le as detailed in the EDGE Server ICD and EDGE Server Business Rules (ESBR) Version 3.0 dated 08/12/2014 SCR 081114.pdf) located in the REGTAP library. (REGTAP FAQ Database - FAQ #6525 10/31/14) Q: Will any of the EDGE server output provide individual risk scores for issuers to review? A: Risk scores will be calculated on the issuer's EDGE server. Issuers will receive individual risk scores and Plan Liability Risk Scores (PLRS) while CMS will receive only Plan Liability Risk Score. (REGTAP FAQ Database - FAQ #6530 10/31/14) retired 06/0 \v Q: Is there a duplicate check performed for supplemental diagnosis records? A: As stated in the EDGE Server Business Rules (ESBR) Version 3.0 dated 08/12/2014, to ensure that only one version of an active supplemental diagnosis detail record is stored on the EDGE server, duplicate checks will be performed. The duplicate checks are located in the Duplicate Supplemental Diagnosis Code Detail Records section 5CR 081114.pdf). (REGTAP FAQ Database - FAQ #6532 10/31/14) Q: Can issuers use health assessments as a source of risk adjustment diagnosis codes? A: Diagnosis codes from health assessments may be submitted in accordance with the medical claim submission process (if a claim for a paid service or accepted encounter was not previously submitted and accepted) or may be submitted in accordance with the 319 Updated 1-31-17 2017--00419 supplemental diagnosis code submission process (if a claim was previously submitted and accepted on the EDGE server). For more information on the requirements, please review the REGTAP library for the EDGE Server Business Rules (ESBR) Version 3.0 dated 08/12/2014 5CR O81114.pdf). (REGTAP FAQ Database - FAQ #6533 10/31/14) Q: For the risk adjustment program, can issuers submit encounter claims for services provided by registered nurses and physicians assistants instead of medical doctors? A: Encounters and claims from registered nurses are not allowed. Since each State determines licensing requirements for medical providers, please check with your State. Our business rules require a medical claim; therefore, medical providers licensed by the State to practice medicine and can bill for services that generate a medical claim or encounter would be appropriate. For guidance on the business rules that CMS applies to enrollment files and claims files submitted to an issuer's EDGE server, please visit the EDGE Server Business Rules document 50R 081114.pdf). (REGTAP FAQ Database - FAQ #6534 10/31/14) Q: What is the definition of a Third-Party Administrator Are there additional steps necessary for registration when using a A: A TPA-hosted EDGE server request must be submitted in cases where a third party contractor purchases and provisions a server on behalf of an issuer. In other words, the designations of TPA-hosted and issuer-hosted must be based on the organization that has primary ownership of a server the organization that owns the physical server or has a contract with a virtual server provider). An issuer-hosted request may be submitted in cases where an issuer owns the server, but grants contractors user access to the server to perform tasks related to EDGE server operations. In cases where an issuer has granted their contractors access to the Health Insurance Oversight System (HIOS) as an issuer user (Le, a TPA or other contractor user is able to log into HIOS as an issuer user), TPAs must still set-up HIOS accounts for their own organizations and register in HIOS as an EDGE TPA (TPAs may not submit an issuer-hosted EDGE server request on behalf of an issuer even if the TPA is theyare currently registered as an issuer user in HIOS). The Centers for Medicare Medicaid Services (CMS) requires all issuers and TPAs to sign an EDGE Server License Agreement for all TPA hosted servers. Thus, TPAs must be appropriately identi?ed in EDGE server requests. (REGTAP FAQ Database - FAQ #7229; 7229a 11/14/14; updated 12/11/15) Q: How can issuers manually run the Risk Adjustment (RA) risk score calculation and Reinsurance (RI) processes on the External Data Gathering Environment (EDGE) server? Updated 1-31-17 A: The RA command to run locally is: edge report RA_RS_Transfer_Pre im 2014. Please refer to page 8 of the March 3, 2015 EDGE Server Maintenance Release Notes at ESReleaseNotes 030315 50R 030615.p d_f in the REGTAP Library. (REGTAP FAQ Database - FAQ #9439 03/626/15) 320 2017-?00420 Q: Will the External Data Gathering Environment (EDGE) server accept claims with acceptable bill types such as 111 or 131 and a discharge code of 30 for Risk Adjustment (RA) claims selection? A: The exclusion of claims with discharge status code 30 (still a patient) only applies to hospital inpatient bill types (111 or 117) for RA claims selection. (REGTAP FAQ Database - FAQ #9440 03/26/15) Q: When can the Premium Amount for a subscriber equal zero A: The EDGE server will only process a $0 premium for a subscriber enrollment period for a partial month. A partial month is less than the calendar month of 28, 30, or 31 days. Issuers must not submit $0 premiums for whole month enrollment periods. Please refer to the EDGE Server Business Rules and example 8 in the EPAI Operational Rules document posted in the DDC Regtap Library on October 2, 2014. (REGTAP FAQ Database - FAQ #9484 04/02/15) Q: Section 5.5 of the EDGE Server Business Rules (ESBR) states: Overlapping Coverage in a Federally-facilitated Marketplace (FFM) or State based Marketplace (SBM) Plan Individuals enrolled in a plan offered on the Marketplace, either FFM or SBM, cannot be enrolled in the same plan for the same period of time. Issuers who have received 834 transactions where an individual has overlapping coverage must resolve the discrepancy. Overlapping Coverage in an Off-Marketplace Plan Individuals enrolled in plans offered outside of the Marketplace may be enrolled in the same plan for the same period of time. In such instances, issuers will need to create a separate enrollment period for the time of overlap and report the appropriate premiums charged for the non-overlapping and overlapping periods.? What is the definition of an Off-Marketplace plan? Is this a non-Exchange plan? Is it anything other than Health Insurance Marketplace plan? Medicare? Medicaid? Commercial? A: An ?off-Exchange plan? or ?off-Marketplace plan" refers to a health insurance policy that is not available for purchase within a Federal or state exchange (a government-run Marketplace of health insurance plans). It is purchased directly from the carrier or through an agent or broker. Both off and on-Exchange health plans in the individual and small group markets must satisfy Essential Health Bene?ts (EHB) coverage requirements and utilize one of the metal plan (Bronze, Silver, Gold and Platinum) designs for medical out-of?pocket (OOP) costs. (REG TAP FAQ Database - FAQ #15248 03/23/16) Edge Server Operations/Edge Server Speci?cations 09. If an organization has two licensed entities (with two separate HIOS IDs), can the organization submit all of its data to one Edge Server? 321 Updated 1-31-1 7 2017-?00421 A9. A single Edge Server may be used to submit data for multiple plans or multiple issuers. Issuers can submit all of their data to one Edge Server as long as they are under one insurance company that is one legal entity. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #1 05/09/13) Q10. Will the HHS Software create the data repositories or are there database components that must be built on the Edge Server A10. The software that HHS pushes to the Edge Server will create the data repositories necessary for processing. Issuers will load the submissions to the Edge Server and the Edge Server will provide response reports. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #1 05/09/13; REG TAP FAQ Database - FAQ #609 05/09/13) Q11. Who are some third party vendors providing an Edge server environment? A11. HHS does not make recommendations regarding third party vendors. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #1 05/09/13; REG TAP FAQ Database - FAQ #276 05/09/13) Q12. Why was a new methodology chosen instead of leveraging Medicare's encounter reporting process? A12. Concerns were expressed by stakeholders about HHS having access to proprietary data and storing in a centralized repository. To respond to the concerns, HHS adopted a distributed data approach that eliminates the need for centralized data collection and helps ensure privacy through the application of masked enrollee identi?ers. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #1 05/09/13; REG TAP FAQ Database - FAQ #261 05/09/13) Q20. Are Edge Servers required for issuers in states that are not Federally-Facilitated Exchanges (FFEs), but rather State-Based Exchanges (SBEs) such as New York? A20. The Edge Server supports the reinsurance and risk adjustment programs which are both inside and outside of the Exchange (now referred to as the Marketplace). If operates either the risk adjustment or reinsurance programs, or both for a state, then an Edge Server is required. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #2 07/15/13) Data Elements Q1. Should only paid claims be submitted to the Edge Server? Or are administratively denied claims allowed as well? A1. Denied claims are not acceptable for submission to the Edge Server. The Edge Server will not accept claims that have a $0 allowed amount at the claim header. A $0 allowed amount at the line level, on institutional claims, is acceptable for services that are covered under a more inclusive reimbursement such as DRG or case rate. For capitated services, Issuers will need to derive (or estimate) a paid amount for these services. In addition, the inbound claim file layout contains a field to indicate a derived 322 Updated 1-31-17 2017-?00422 amount has been computed for capitated arrangements (45 CFR Please note that this derived amount field does not apply to denied claims in full or partial fee- for-service payment arrangements. Further information and speci?c file layouts pertaining to capitated arrangements were covered in the May 8, 2013 Distributed Data Collection (Edge Server) webinar (webinar materials are available in the REGTAP Library at (Distributed data collection for Reinsurance and Risk Adjustment FAQ #4 08/16/13) Q3. Do issuers submit zero paid claims, such as scenarios where the entire allowed amount went to the deductible? A3. At the claim header, a medical claim may be submitted with a $0.00 paid amount, for example, if a deductible covered the full cost, as long as the header allowable amount is greater than $0.00. In the case of an inpatient stay, where a case rate or DRG was paid, the paid and allowable amounts at the line level may both be equal to or greater than $0.00. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #4 08/16/13) Q: Would denied procedure codes at the claim level be used for risk scores and should denied claims line diagnoses be included in the EDGE Server Medical Claim Submission (ESMCS) Extensible Markup Language (XML) header? A: If the procedure is denied because it is part of a more inclusive service, then it should be submitted to the EDGE server for consideration in the Risk Adjustment (RA) and Reinsurance (RI) programs. If the procedure is denied because it is not covered or authorized, then it is not eligible for consideration and must not be submitted. (REGTAP FAQ Database - FAQ #7267 11/14/14) Q: When will the Centers for Medicare Medicaid Services (CMS) provide issuers with the X803 (XML Schema Definition) for the EDGE server Outbound Reports files? A: Updated Extensible Markup Language (XML) and XSDs for all outbound ?le types have been posted to the REGTAP Library. (REGTAP FAQ Database - FAQ #7379 11/18/14) Q: Does the Date Timestamp stamp in the EDGE server inbound file name have to match the Run Date in the submission file header? A: The Centers for Medicare Medicaid Services (CMS) will not provide a validation check between the Date/Time stamp in the EDGE server inbound ?le name and Run Date header. (REGTAP FAQ Database - FAQ #7390 11/18/14) Q: The Interface Control Document (ICD) states the File ID data element should be a string no longer than 12 characters long; however, the Extensible Markup Language (XML) example, posted in the REGTAP Library, has a value of 'medfile03', which is less than 12 characters. Can the Centers for Medicare Medicaid Services (CMS) confirm the format for the File ID data element? A: CMS apologizes for the confusion. The File ID data element must be a string equal to 12 letters and/or numbers. (REGTAP FAQ Database - FAQ #7393 11/18/14) 323 Updated 1-31-17 2017--00423 Data Maintenance Q13. How long does the data for reinsurance and risk adjustment need to be retained for on the Edge Server? A13. Although we have not finalized our policy, we anticipate that an issuer Edge Server will need to store 3 years? worth of enrollment and claims data. However, it is important to note that in accordance with Section 153.620 of the Federal Regulations, Issuers are required to retain any information requested to support risk adjustment data validation for a period of at least 10 years after the date the data are reported. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #1 05/09/13; REG TAP FAQ Database - FAQ #214 05/09/13) 022. What is the expected SLA for the Edge Server, the OLA for the combined software and hardware stack, and does CMS have guidelines around response times and potential down time escalations? A22. Requirements regarding maintenance windows have not been determined at this time. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #2 07/15/13; REGTAP FAQ Database - FAQ #256 07/15/13) Documentation Q14. When will XML extract guides be made available? server interface control document (ICD) is available in the RegTap Library at (Distributed data collection for Reinsurance and Risk Adjustment FAQ #1 05/09/13; REG TAP FAQ Database - FAQ #262 05/09/13 edits reflect REG TAP database version) Q15. Are Distributed Data Collection webinar presentation slides available to issuers? A15. Yes, the presentation slides from the webinar are available on REGTAP in the library. They are listed in the library as Distributed Data Collection for Reinsurance and Risk Adjustment Overview (03/20/13). (Distributed data collection for Reinsurance and Risk Adjustment FAQ #1 05/09/13; REG TAP FAQ Database - FAQ #270 05/09/13) Q16. What is the rationale for not releasing the ICD now? A16. HHS is incrementally releasing the ICD to provide an opportunity for questions related to each ?le layout. The entire ICD will be available after the completion of the May 22nd webinar. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #1 05/09/13) 324 Updated 1-31-17 2017-?00424 Q17. Is there an Edge Server template along with the SERFF templates and where does it reside? A17. No, the Edge Server interface control document is not part of the SERFF templates. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #1 05/09/13) Q18. Will there be a Companion Guide claims data like the Companion Guide for Enrollment and if so, when will it be available? A18. No, the Enrollment Companion Guide, currently available, is for enrollment submissions to the Federally-Facilitated Marketplace. This is a different enrollment transaction than that for the Edge Server. For the Edge Server, HHS will release an Interface Control Document (ICD) that details the rules and formats for Edge Server submissions, including enrollment, medical claims, and pharmacy claims. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #1 05/09/13) Q19. When will the open source code be available for download for use outside of deployment to an Edge Server? A19. Software allowing Issuers to replicate the Edge Server process will be provided on or before January 1, 2014. The software code for Risk Adjustment and Reinsurance payment calculations will be available in 2014. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #1 05/09/13) 020. For the Edge Server are there any file specification for the data collection currently available? A20. As documentation becomes available, such as the Interface Control Document (ICD) and Welcome Packet, they will be placed in the REGTAP library. In addition, the ?le layouts (speci?cations) for enrollment will be addressed in the webinar on May 8 and for Pharmacy and Medical claims on May 22. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #1 05/09/13) 021. We have heard that the edge server information is not required for submission with the QHP application for April 30, 2013. We heard that this information, the information from Appendix D, would not be required until the issuer actually had the edge server in place. Could you please confirm if this is factual or if this information is needed by April 30? A21. Your understanding is correct. Edge Server information is not required with the QHP application by April 30, 2013. Edge Server information is not needed until an issuer has an Edge Server. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #1 05/09/13) 023. Does HHS plan to conduct a webinar to demonstrate how the Edge Server application works and how it will be managed? 325 Updated 1-31-17 2017--00425 A23. During provisioning, set-up and during submission of test data, the issuer will have the opportunity to better understand how the software operates. is not planning a separate demo at this time. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #2 07/15/13) 024. Are the questions documented during the webinars available with other materials? A24. Yes, questions and answers are being documented. You may find the documented questions and associated responses in the REGTAP Library. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #2 07/15/13) 025. How will the operating system be distributed? A25. The operating system will be distributed as part of the provisioning process. As indicated in the Welcome Packet on page 2 (available in the REGTAP Library), provisioning is the process of overlaying the server operating system and deploying software, database tables, reference tables and proper server con?gurations. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #2 07/15/13) Q26. Will there be any further guidance or instructions on the Edge Server Storage Calculator or can additional questions be submitted? A26. At this time, does not plan to provide additional instructions on the Edge Server Storage Calculator. Questions can be submitted to reqistrar@REGTAP.info. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #2 07/15/13; REGTAP FAQ Database - FAQ #257 07/15/13) Q13. How will information about the data stored in the reference tables be communicated? A13. The Edge Server software code includes reference tables. Updates to software or reference tables will be communicated through the release management process. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #4 08/16/13) Q9. Where can issuers find the full list of error codes for rejected records? A9. Outbound report error messages are available in the REGTAP library available at (posted on June 26, 2013). (Distributed data collection for Reinsurance and Risk Adjustment FAQ #5 09/23/13; REG TAP FAQ Database - FAQ #384 09/23/13) Q10. Where are the XSD and XML examples for the inbound and outbound files posted? A10. Both inbound and outbound XSD and XML file examples are available in the REGTAP library available at (Distributed data collection for Reinsurance and Risk Adjustment FAQ #5 09/23/13; REG TAP FAQ Database - FAQ #385 09/23/13) Q: Where can issuers find the database schema? 326 Updated 1-31-17 2017--00426 A: The schema is posted in the REGTAP Library. (REGTAP FAQ Database - FAQ #7413 11/18/14) Q: Hello. Today attended the EDGE Server Webinar Series Announcement for (5/10/16) can you tell me where I can get the handouts for the presentation please? A: Thank you for your question. The weekly announcements that we provide on our Tuesday Edge Server call are published Every Friday in a document called: EDGE Server Updates 2015 Data Submission. This document can be found in the REGTAP library under Distributed Data Collection for Edge Server and then Supporting Documents. Since this is a cumulative document it will have historical announcements from prior sessions. (REGTAP FAQ Database - FAQ #16314 06/10/16) Edqe Server Operations Technical - Provisioning/Set-up 022. Will there be any delays in the timeline considering no data specifications have been released but testing is expected to begin in March 2013? A22. While the timeline is tentative, provisioning and testing are currently scheduled to begin in September 2013, not March 2013. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #1 05/09/13) 023. Can HHS please provide more details regarding partner testing? What are the objectives? Can HHS provide volume requirements? What level of data quality is expected? A23. As part of the provisioning process in the fall of 2013, HHS will provide more details about testing your edge server. Information about Edge Server hardware specifications will be provided during the April 24th webinar. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #1 05/09/13) 024. To what email address should issuers send questions during analysis? A24. Questions may be sent to reqistrar@REGTAP.info. Technical questions may be sent FEPS@cms.hhs.qov. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #1 05/09/13) 025. How will HHS connect to the Edge Server to pull the data SFTP, web services, VPN, etc.? A25. All communication between the Edge Server and the CMS Management Console will use Secure Sockets Layer (SSL), namely and (Distributed data collection for Reinsurance and Risk Adjustment FAQ #1 05/09/13) 026. Will participants from the beta test have their Edge Server reprovisioned in total or will they just be 'pushed' an update? A26. Beta testers will not have to be reprovisioned if they continue using the same Edge Server. These issuers will simply have their tables truncated. Beta testers who upgrade their Edge Server will need to be reprovisioned. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #1 05/09/13) 327 Updated 1-31-17 2017-?00427 Q28: Will be installed by CMS during provisioning? A28: Yes. CMS installs all Edge Server software during the provisioning process and pushes updates to the software when necessary. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #3 07/23/13; REG TAP FAQ Database - FAQ #272 07/23/13) 029: Can a TPA/support vendor provision an Edge Server without an issuer? A29: No. In order for an Edge Server to be provisioned, the TPA must have an issuer for whom they are running an Edge Server. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #3 07/23/13; REG TAP FAQ Database - FAQ #233 07/23/13) Q: Can CMS please provide details regarding the testing process for the edge server? A: There is no requirement that the issuer community conduct testing at a speci?c time. Issuers can use the test zone at any time after provisioning is complete. CMS is revising the provisioning process in order to incorporate lessons learned from beta testing. CMS will be providing updated information on this process through REGTAP. Issuers will determine the type of data and ?les that they would like to test on their Edge Server. CMS will not require an Issuer to have a formal test plan. Issuers should thoroughly test their extract, transform and load (ETL) process and review the outbound error ?le reports to identify any issues in their submission process. (REGTAP FAQ DATABASE FAQ #435 11/18/13) Q: What is the timeline for testing and provisioning the edge server? A: CMS is changing our implementation process in order to incorporate lessons learned from the beta test provisioning process. We will continue to work with issuers to ensure their hardware is in place in time for software provisioning. This adjustment will not affect the schedule for program operations reinsurance payments and risk adjustment payment transfers will still take place in mid-2015. CMS plans to provide additional training and education regarding enhancements to the edge server provisioning process in the upcoming months. We are also working to streamline the process to submit provisioning forms through an automated process. Thus, please do not submit provisioning forms until CMS has provided additional information. You will receive noti?cation of upcoming events and additional information through the REGTAP system. (REGTAP FAQ DATABASE FAQ #438 11/18/13) Q: Are there edge server Provisioning Request forms available to fill in electronically or should issuers use the screen shots in the Welcome Packet and write all the information? Updated 1-31-17 A: The Welcome Packet previously published is no longer current. We are streamlining the edge server provisioning process. In the upcoming months, CMS will provide additional materials on a new automated provisioning process along with information on registering issuer edge servers. (REGTAP FAQ DATABASE FAQ #446 11/18/13) 328 2017-?00428 Q: How does the On-Premise EDGE server provisioning process differ from the Amazon EDGE server provisioning process? A: For Amazon EDGE servers, the Centers for Medicare Medicaid Services (CMS) will initiate an automated provisioning process to install the EDGE server software stack and configure the server. For On-Premise servers, issuers will have?to initiate a manual provisioning process. Prior to provisioning, issuers will have?ta load Red Hat Enterprise Linux (RHEL), JAVA and Following EDGE server registration, On-Premise issuers will haveJee run a provisioning script provided by CMS to set-up their servers. For more information about the differences between the On-Premise and the Amazon EDGE provisioning processes please refer to the On-Premise and the Amazon EDGE Provisioning Job Aids posted in the REGTAP library (REGTAP FAQ Database - FAQ #7222; 7222a 11/14/14; updated 12/11/15) Q: Are issuers able to install two (2) separate instances of the EDGE server, one (1) each in the testing and production environments? A: Yes, issuers will be able to set-up a test server in addition to their production server. Issuers will receive a provision script as part of the registration process and this script can be run on multiple servers. Issuers must only submit files on their test server to the test zone. All production data must be submitted on the production server. (REGTAP FAQ Database - FAQ #7225 11/14/14) Q: When issuers with multiple EDGE servers register the first server in the Health Insurance Oversight System (HIOS), will the Centers for Medicare Medicaid Services (CMS) provide issuers with the link to the ZIP file for the installation software, or only upon registering all servers? A: CMS will provide issuers a separate ZIP ?le for the On-Premise EDGE server installation software for each EDGE server that is registered. (REGTAP FAQ Database - FAQ #7226 11/14/14) Q: How can issuers find more information on the costs associated with setting up and maintaining an Amazon EDGE server? A: The Amazon Web Services (AWS) website contains information on the storage, processing, and support costs associated Issuers can also develop a cost estimate based on their speci?c processing needs by using the AWS Simple calculator tool Issuers may also email Amazon for more information on Amazon pricing. (REGTAP FAQ Database - FAQ #7232 11/14/14) Q: Is the only database supported by the EDGE server or can issuers use an Oracle/SQL server? A: On-Premise issuers will be required to use (REGTAP FAQ Database - FAQ #7418 11/18/14) 329 Updated 1-31-17 2017--00429 Edqe Server Speci?cations Technical - Hardware 028. Can HHS please provide issuers with Edge Server hardware specifications? A28. Details about Edge Server hardware speci?cations will be made available on the April 24th webinar. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #1 05/09/13) 029. Does HHS have guidelines based on membership or claims volume on the size of the server, and required memory, space, etc.? A29. Details about Edge Server hardware speci?cations will be made available on the April 24th webinar. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #1 05/09/13) Q30. Can the Edge Server run in a virtual environment? A30. The Edge Server must be a physical server. At this time the Edge Server does not support Blade, virtual machines, or SAN. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #1 05/09/13; REG TAP FAQ Database - FAQ #277 05/09/13) Q31. Do issuers need separate Edge Server for each plan? A31. No, issuers do not need a separate Edge Sever for each plan. A single Edge Server may be used to submit data for multiple plans or multiple issuers. Issuers can submit all of their data to one Edge Server as long as they are under one insurance company that is one legal entity. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #1 05/09/13) Q32. Will vendors servicing multiple issuers be able to submit the Risk Adjustment and Reinsurance data through one Edge server as indicated in the 'Third Party Administrator' scena?o? A32. A single Edge Server may be used to submit data for multiple plans or multiple issuers. Issuers can submit all of their data to one Edge Server as long as they are under one insurance company that is one legal entity. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #1 05/09/13) Q33. If states are implementing risk adjustment in the future using the distributed approach, shall the states use a different physical server? A33. A state that chooses to operate reinsurance and/or risk adjustment will decide how to collect the necessary data. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #1 05/09/13) 021. Is it required to use Red Hat Enterprise Linux, or can an issuer use a Microsoft Windows Server? 330 Updated 1-31-17 2017--00430 A21. Currently, the Edge Server only supports Red Hat Enterprise Linux. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #2 07/15/13) 021: How many Edge Servers will an issuer or TPA need to acquire? A21: has updated our policy related to the number of Edge Servers an issuer would need to acquire. We published a new definition for Edge Server group and additional information that issuers and TPAs can use to determine the number of Edge Servers appropriate for their business. Please refer to the presentation provided during the June 5, 2013 Webinar available at The new group definition allows for multiple issuers to exist on a single Edge Server regardless of legal af?liation. Issuers and TPAs should carefully review the new information and adopt the appropriate security procedures to protect co-located data. Issuers should also utilize the Edge Server Storage Calculator to determine appropriate size requirements. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #3 07/23/13) Q30: Are issuers required to use a specific hardware vendor for their Edge Server Dell)? A30: No. The servers listed in the Edge Server Welcome Packet are examples only. CMS does not require the use of any specific vendor for the Edge Server hardware. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #3 07/23/13; REG TAP FAQ Database - FAQ #234 07/23/13) Q15. Have the edge server hardware specifications been released? A15. Materials related to edge server hardware speci?cations are available I the REGTAP Library available at (Distributed data collection for Reinsurance and Risk Adjustment FAQ #5 09/23/13; REGTAP FAQ Database - FAQ #389 09/23/13) Q: Are Issuers responsible for maintenance or patch activities for Red Hat Enterprise Linux (RHEL) on the Edge Server after provisioning? A: CMS will use the CMS Management Console to provide software updates to the CMS software on the Edge Server. This will include software and security updates to the Red Hat Enterprise Linux (RHEL) operating system. The Edge Server is designed to ping the CMS Management Console to see if updates are available. (REGTAP FAQ Database FAQ #427 11/18/13) Q: Will the Centers for Medicare Medicaid Services (CMS) process data differently for the On-Premise EDGE server and the Amazon Web Services (AWS) EDGE server; will output be the same regardless of instance type? A: Regardless of which instance an issuer chooses (AWS or On-Premise) CMS will process all data on issuers' EDGE servers the same way both servers will have the same ?le processing application). (REGTAP FAQ Database - FAQ #7220 11/14/14) 331 Updated 1-31-17 2017--00431 Edqe Server Speci?cations ?Technical - Software Q27. Are there specific anti-virus and anti-intrusion software requirements? A27. Issuers should follow their corporate data security standards. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #1 05/09/13; REG TAP FAQ Database - FAQ #215 05/09/13) Q31: Who will schedule and deploy software updates to the Edge Servers? A31: will use the CMS Management Console to provide software updates to the CMS software on the Edge Server. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #3 07/23/13; REG TAP FAQ Database - FAQ #273 07/23/13) Q32: Are operating systems (OS) other than Red Hat Enterprise Linux allowed for Edge Server provisioning? A32: No. The operating system that will be used on issuers? Edge Servers will be Red Hat Enterprise Linux. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #3 7/23/1; REG TAP FAQ Database - FAQ #235 07/23/133) Q19. What version of Red Hat Enterprise Linux (RHEL) should we load to the edge server prior to provisioning? A19. Red Hat Enterprise Linux version 6 is the supported Linux distribution for the edge server. Prior to provisioning, issuers will have two (2) options for installing the operating system. The first option is to install an evaluation copy of Red Hat Enterprise Linux (RHEL) to allow CMS to access the edge server for provisioning. The second option is to obtain a link, which will be provided by CMS, to download the software image prior to provisioning. Once an issuer is ready to provision, CMS will then apply a licensed version of RHEL to the edge server. Maintenance of the operating system software will be the responsibility of CMS. Information on obtaining an image of the RHEL and maintenance of RHEL will be provided in future guidance. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #5 09/23/13; REG TAP FAQ Database - FAQ #392 09/23/13) Q20. How will update the edge server software and Red Hat? A20. CMS will use the CMS Management Console to provide software updates to the CMS software on the edge server. This will include software and security updates to the Red Hat Enterprise Linux (RHEL) operating system. The edge server is designed to ping the CMS Management Console to see if updates are available. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #5 09/23/13; REG TAP FAQ Database - FAQ #393 09/23/13) Q21. ls Firefox the only supported web browser? When will additional web browsers be available? 332 Updated 1-31-17 2017--00432 A21. plans to support multiple browsers. Additional information about supported browsers will be available prior to provisioning. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #5 09/23/13; REG TAP FAQ Database - FAQ #394 09/23/13) Q16. What service level agreements (SLAs) does have in place for the edge server? A16. Requirements regarding service level agreements and maintenance windows will be included in future guidance. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #5 09/23/13; REG TAP FAQ Database - FAQ #398 09/23/13) Q17. Can you provide more details about the CMS Management Console and how to navigate the server? A17. More information about the management console will be provided in the future. For the most current information about the edge server, please visit the REGTAP Library at (Distributed data collection for Reinsurance and Risk Adjustment FAQ #5 09/23/13; REG TAP FAQ Database - FAQ #390 09/23/13) Q18. Where are edge server technical questions to be submitted? A18. CMS is working to ensure that issuers and TPAs are well supported once provisioning and file submission begins. CMS will have a help desk available to help with troubleshooting any technical issues or to respond to questions related to ?le processing and the outbound ?les that are generated as a result. CMS will provide additional information regarding help desk support in the future. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #5 09/23/13; REG TAP FAQ Database - FAQ #391 09/23/13) Q22. What is the difference between the Primary Administrator and the Secondary Administrator? A22. There are two (2) administrator roles: 1) Group Administrator - created by CMS, the group administrator has access to individual edge servers within the group to manage user roles; 2) Business Administrator created by CMS, has root access to the edge server and will be able to add users without the users being removed during updates. Also, please review the materials in the REGTAP Library available at (Distributed data collection for Reinsurance and Risk Adjustment FAQ #5 09/23/13; REG TAP FAQ Database - FAQ #399 09/23/13) Q: Can issuers create their own patch program for the third party software applications RHEL, Java) or do issuers have to use the Centers for Medicare Medicaid Services (CMS) patch program? A: Issuers will receive the scripts automatically via the "phone home" service. Issuers must have a system administrator log in to the EDGE server to manually execute these scripts as directed by the release notes. CMS recommends that issuers stay current with CMS-provided updates. CMS will publish supported versions of EDGE server software. 333 Updated 1-31-17 2017--00433 CMS may not be able to provide technical support to issuers using non CMS supported EDGE server software versions. (REGTAP FAQ Database - FAQ #7414 11/18/14) Q: Where can issuers find information on the Centers for Medicare Medicaid Services (CMS) supported versions of the third party software? A: Information on the supported versions of each third party application is available in the Pre-Registration Job Aid posted in the REGTAP Library. (REGTAP FAQ Database - FAQ #7415 11/18/14) Q: How can issuers ensure database and operating system updates will not affect EDGE server application functionality? A: The Centers for Medicare Medicaid Services (CMS) has a full system development life cycle where it applies the patches and application updates using the same processes that will be used 'in the ?eld' by issuers with their EDGE servers. When infrastructure patches are applied, we will also go through vulnerability testing and hardening reviews in order to continue with the same level of security standards that we prepared with the initial deployment of the EDGE server. CMS recommends that issuers follow industry best practices and backup and the operating system (08) prior to applying patches. (REGTAP FAQ Database - FAQ #7419 11/18/14) Q: Has the Centers for Medicare Medicaid Services (CMS) released a list of the age and sex claim edits? A: Information on age and sex edits can be found in the Risk Adjustment (RA) Model Algorithm Software Instructions located at Stabilization Programs (June 4, 2014) and on the CMS website. (REGTAP FAQ Database - FAQ #8146 12/1 1/14) Q: Can the Centers for Medicare Medicaid Services (CMS) publish a list of reason codes for claims exclusion, including reason codes related to the Risk Adjustment (RA) program? Updated 1-31-17 A: There are eight (8) reason codes used to identify whey a claim is excluded from RA, listed below: R01: Unacceptable bill type for an RA institutional claim R02: Inpatient institutional claims cannot have a Statement Covers From date prior to 2014 R03: Professional and institutional outpatient claims must have at least one RA eliqible service code R04: Unacceptable discharge status code for an institutional inpatient claim 334 2017-?00434 R05: Active plan record does not exist for the year of the claim coveraqe from date Updated (04/16/15) R06: Claim not associated to an active enrollment period of an enrollee R07: Claim Statement Covers Throuqh date does not fall within the payment year R08: Outpatient or professional cross year claim excluded from RA because the enrollee has no issuer submitted enrollment coveraqe in the payment year Updated (03/28/15) Q: How will the Risk Adjustment (RA) program manage orphaned claims? A: The External Data Gathering Environment (EDGE) server will accept all orphaned claims, but the RA program will not utilize any orphaned claim data for RA calculations. In order for RA to calculate individual risk scores, claims must be matched to an active enrollee. For more information on EDGE server file processing rules, please refer to the EDGE Server Business Rules located in the REGTAP Library. (REGTAP FAQ Database - FAQ #8480 01/14/15) Q: When will the Centers for Medicare Medicaid Services (CMS) publish the International Classification of Disease 10 (ICD-10) Hierarchical Condition Categories (HCC) diagnosis crosswalk tables? A: The Model Algorithm Software Instructions state that issuers are required to use 10 codes by October 2015. CMS will release the HCC diagnosis crosswalk tables at a later date. (REGTAP FAQ Database - FAQ #9977 04/17/15) Q: Is the generation of the Risk Adjustment (RA) Risk Score Detail (RARSD) and RA Risk Score Summary (RARSS) reports included in the Do-lt-Yourself (DIY) software? A: No, the DIY software's purpose is to give issuers an understanding of the risk score calculation process. The RARSD and RARSS reports are not part of the DIY software or any of the DIY software's outputs. (REGTAP FAQ Database - FAQ #11623 08/19/15) Edqe Server Speci?cations Technical Security and Inteqrity Q: How is auditing of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) data accomplished in the Amazon Web Services (AWS) cloud? A: The EDGE server application tracks all the activity with the data. All data is and stored in an S3 bucket. Similarly, outbound data will not be stored if not The database is deployed in an elastic block storage volume. All data is transported over 860F so data in transit is also (REGTAP FAQ Database - FAQ #7233 11/14/14) Q: What is the version of Transport Layer Security (TLS) and the cyphers used in Hypertext Transfer Protocol Secure on the Amazon Web Services (AWS) side? A: The S3 Object Storage Service is where the objects will be stored. Amazon currently supports TLS Version 1.0, 1.1, 1.2, and Secure Sockets Layer (SSL) Version 3.0. There are also five (5) different cyphers that are currently being utilized. These could possibly change over time as Amazon needs to meet internal and external compliance requirements. However, currently Amazon uses a combination of AES 256128, along with several other options. (REG TAP FAQ Database - FAQ #7237 11/14/14) 335 Updated 1-31-17 2017--00435 Q: Why is the security and monitoring of antivirus programs the responsibility of the issuers and not the responsibility of Amazon? A: Amazon uses a Shared Security model, which means Amazon has certain responsibility to the underlying infrastructure to a certain point and then everything that is put on top of that infrastructure is the responsibility of the issuer. Specifically, Amazon is responsible for all hardware and infrastructure up to the hypervisor level and then everything that resides on top of the hypervisor is the issuer's responsibility. More information on Amazon's Shared Security model can be found at (REGTAP FAQ Database - FAQ #7238 11/14/14) Q: To what extent can issuers modify the Amazon Web Services (AWS) ?rewall? A: Each Amazon instance will be provisioned with ?rewall rules. Users will be able to ?lter all access to only allow certain traffic that is explicitly allowed to that software. Issuers will define the port and protocols which will be allowed to their instances. Additionally, issuers can put their own host-based ?rewall or Internet Protocol (IP) tables in Red Hat to the security groups at the infrastructure level. It will be up to the issuer to determine the level of security that the issuer they wants to implement on their virtual machine. More information on the Amazon firewall can be found in the Amazon Security webinar slide deck and Amazon set-up videos posted in the REGTAP library and on Amazon's security website (REGTAP FAQ Database - FAQ #7239 11/14/14) Q: Is there an Intrusion Prevention System (IPS) and/or Intrusion Detection System (IDS) wrapped around the Amazon Web Services (AWS) server and monitoring that would take place 24/7 or is it expected that that log monitoring for activity would go to the customer? A: There is no additional monitoring at the individual server level that is prepackaged as a part of the EDGE server. It is up to the issuer to determine if the issuer they wants to put a software-based Intrusion Prevention Firewall (IPF) or Intrusion Defense Firewall (IDF) in place. Amazon has deeshave an auditing solution that will monitor the infrastructure changes - called Cloud Trail (documentation on Cloud Trail can be found at (REGTAP FAQ Database - FAQ #7240; 7240a 11/14/14; updated 12/11/15) Q: Does the EDGE instance need to be placed in the demilitarized zone A: Under the original EDGE server design from 2012, the Centers for Medicare Medicaid Services (CMS) proposed that issuers should submit servers in the DMZ. However, this is no longer the case with the updated EDGE server speci?cations. Issuers should secure the EDGE server application as they would any other application in the network (CMS recommends issuers do not place the EDGE application in the DMZ). (REGTAP FAQ Database - FAQ #7412 11/18/14) Q: Does Centers for Medicare Medicaid Services (CMS) require issuers to install an Anti-Intrusion system for the On-Premise EDGE server? 336 Updated 1-31-17 2017--00436 A: CMS expects issuers to follow industry best practices for securing their servers. Issuers will be responsible for the complete suite of security support and controls. For the updated EDGE server design, CMS has not issued speci?c security requirements that issuers must follow. (REGTAP FAQ Database - FAQ #7421 11/18/14) Edqe Server Speci?cations Technical ?Storaqe, Data Retention, Data Transfer Q: Will all Amazon data stay within the United States? A: All Amazon data is stored within the United States. (REGTAP FAQ Database - FAQ #7234 11/14/14) Q: Can issuers purge all data from the production tables in the EDGE server? A: The Centers for Medicare Medicaid Services (CMS) will allow issuers to purge their data in the test zone of the server in order for their test zone data tables to mirror the production data tables. A script will be provided to issuers to run through command line interface that will purge their test zone data. Issuers do not need CMS approval to purge test data. With regards to the production zone, in general, all issuers are expected to resolve issues with their stored claims data by submitting void and replacement claims. Issuers must resolve enrollment data issues by submitting full, updated replacement enrollment ?les. On a case-by-case basis, CMS may approve requests from issuers to purge all of their production zone data. Issuers will have to demonstrate that they have widespread systemic errors in their stored claims data that require complete purging of all their tables. Issuers must submit data purging requests to the CMS Help Desk and get approval from CMS prior to purging production data. In order to maintain the integrity and traceability of the data collection process, issuers will not be allowed to delete or make modifications to individual stored records in the data tables. CMS will check for changes to the tables as part of the Reinsurance (RI) and Risk Adjustment (RA) audit process. (REGTAP FAQ Database - FAQ #7398 11/18/14) Q: During file processing, what happens if the server goes of?ine in the middle of a job? A: Data is stored incrementally on the tables during ?le processing. It a server went offline in the middle of processing a ?le, some records from that submission could be stored in the tables. Data is stored incrementally in batches of 2500 records. No outbound reports will be generated if the server goes of?ine before file processing is completed. If the server goes of?ine in the middle of file processing the Centers for Medicare Medicaid Services (CMS) recommends that the issuer submit a new ?le with all the same records as the original ?le. Records successfully processed during the ?rst ?le would show up as duplicate errors in the processing of the second file. (REGTAP FAQ Database - FAQ #7399 11/18/14) Q: For EDGE server processing of Risk Adjustment (RA) and Reinsurance (RI) data, will the Centers for Medicare Medicaid Services (CMS) pull the data, or does the issuer push the data to A: When CMS runs an estimate report, a script is sent to initiate the generation of the report. The report will generate on the issuer's EDGE server, and CMS will receive a 337 Updated 1-31-17 2017--00437 summary report detailing plan-level information necessary for the calculation of RA and RI. CMS does not pull data for the purpose of running or generating risk scores or RI estimates. (REGTAP FAQ Database - FAQ #7410 11/18/14) Q: Do the tables need to be located within each EDGE Instance? A: Issuers must set up a separate EDGE server instance for every Health Insurance Oversight System (HIOS) ID. The EDGE server storage folders and tables do not need to be in the same location as EDGE server instance (issuers can modify the provisioning properties ?le to specify the location of the EDGE server folders and database). (REGTAP FAQ Database - FAQ #7417 11/18/14) Q: Is the Hypertext Transfer Protocol Secure connection to the Simple Storage Service (S3) bucket to manually upload files into the S3 bucket or can issuers externally automate the upload? A: A manual upload from the console is recommended. However, Amazon Web Services (AWS) offers application programming interfaces (APIs) and command line interfaces. The issuer can automate this process. (REGTAP FAQ Database - FAQ #3544 11/26/14) Edqe Server Speci?cations Technical User Roles/Registration Q: When an organization registers an On-Premise EDGE server, who will receive the script for provisioning? A: The individual within the organization with the submitter? user role will be able to access the ZIP ?le with the script on the registration site after the Centers for Medicare Medicaid Services (CMS) approves the request. (REGTAP FAQ Database - FAQ #7227 11/14/14) Q: What is the difference between an Issuer Submitter and Issuer Approver? A: Issuers are required to set-up both the Issuer Submitter and Issuer Approver roles. The Centers for Medicare Medicaid Services (CMS) does not have speci?c requirements about the type of staff within an organization that must complete these roles. The Issuer Submitter submits the EDGE server request and the Issuer Approver reviews the request and either approves or rejects it. If the request is approved, it goes to CMS for review. The roles for requesting and approving the registration request are separate from the roles that issuers will set-up for EDGE server users the people that an issuer designates for submitting and approving the EDGE request do not necessarily have to be the same people within an organization that will have access to the server). The Issuer Submitter cannot also be the Issuer Approver. (REGTAP FAQ Database - FAQ #7228 11/14/14) Q: Does the Centers for Medicare Medicaid Services (CMS) permit issuers to have multiple servers for a single issuer ID so that issuers could use one (1) Third Party Administrator (TPA) to submit and reconcile pharmacy claims and a separate TPA to submit and reconcile medical and supplemental claims? A: Organizations cannot set up multiple EDGE servers for the same issuer ID. All four (4) file types must have?to be loaded onto the same server in order for the Risk 338 Updated 1-31-17 2017--00438 Adjustment (RA) and Reinsurance (RI) calculations to run correctly. (REGTAP FAQ Database - FAQ #7230; 7230a 11/14/14; updated 12/11/15) Q: What should issuers do if they are encountering problems with setting up their EDGE registration site user roles? A: The Centers for Medicare Medicaid Services (CMS) recommends that issuers contact the Health Insurance Oversight System (HIOS) Help Desk for information pertaining to user roles. The telephone number is 1-855-267-1515. (REGTAP FAQ Database - FAQ #7231 11/14/14) Q: Can Amazon issuers set-up multiple EDGE server instances with one (1) Amazon Web Services (AWS) account? A: Issuers can set-up multiple instances in a single AWS account. The AWS storage S3 bucket associated with the count will be subdivided with folders for every issuer ID. (REGTAP FAQ Database - FAQ #7242 11/14/14) Q: Can a data submission file contain more than one (1) Health Insurance Oversight System (HIOS) five(5) digit issuer A: Issuers must set-up one (1) EDGE server instance for each HIOS issuer ID and accordingly all ?le submissions must only contain one (1) issuer ID. (REGTAP FAQ Database - FAQ #7244 11/14/14) Q: Who is responsible for signing the license agreement? A: Organizations may determine the appropriate individual to sign the license agreement at their own discretion. (REG TAP FAQ Database - FAQ #7403 11/18/14) Q: Can issuers provide one (1) license agreement for all Health Insurance Oversight System (HIOS) IDs or do issuers need separate agreements for each HIOS A: Issuers must upload a separate agreement for each issuer request and only one (1) HIOS ID can be entered on each agreement. (REGTAP FAQ Database - FAQ #7404 11/18/14) Q: How does the EDGE server determine whether a Health Insurance Oversight System (HIOS) ID is linked to the EDGE server; what will happen if an issuer loads two (2) separate EDGE Server Enrollment Submission (ESES) files with unique HIOS IDs to the same EDGE server? A: Issuers are required to set-up a separate EDGE server for each HIOS issuer ID. Issuers will only submit ?les with data for a single issuer ID to each EDGE server. The EDGE application for each issuer-speci?c EDGE server instance will have a reference file with all of the Plan IDs associated with the particular Issuer ID. The data will be rejected if the plan IDs in the ?le do not match any of the Plan IDs in the issuer-specific plan reference file stored in the application. (REGTAP FAQ Database - FAQ #7405 11/18/14) 339 Updated 1-31-17 2017--00439 Q: Will every issuer receive a single EDGE server or if an organization has two (2) issuers, will there be two (2) servers needed? A: Issuers must set-up a separate EDGE server instance for each 5-digit Health Insurance Oversight System (HIOS) issuer ID. Issuers that select the On-Premise option can choose to virtualize their physical servers to accommodate multiple virtual instances on a single physical server. (REGTAP FAQ Database - FAQ #7406 11/18/14) Q: Issuers would like to set up a server for testing and another server for production. Does it matter what Issuer ID issuers use when registering the server issuers will use for test? A: On-Premise issuers who wish to install an entirely separate test server can use the credentials they receive in the EDGE server registration process to install additional EDGE servers. Because they share a common credential, issuers must take care to use the appropriate installation for processing production data. Othen~ise, some of the production data may be on a different server from other data, and will not aggregate correctly in the Risk Adjustment (RA) and Reinsurance (RI) calculations. (REGTAP FAQ Database - FAQ #7411 11/18/14) Q: When using Red Hat Enterprise Linux (RHEL), are issuers required to account for a designated number of guests? A: For each EDGE server, issuers are required to have one (1) guest operating system for each Health Insurance Oversight System (HIOS) ID. (REGTAP FAQ Database - FAQ #7420 11/18/14) Q: Can the Centers for Medicare Medicaid Services (CMS) elaborate on the Database Administrator (DBA) role? A: The DBA will be responsible for the administration of the database. This includes applying patches, monitoring performance of the database, running backups, and other administrative duties. (REGTAP FAQ Database - FAQ #3504 1 1/26/14) Edqe Server Specifications Technical - Other Q: Can Amazon servers be stopped frequently, so that the issuer does not incur more charges? A: Amazon servers eambe should be turned on and?eff by issuers when the servers are not in use. Issuers will incur processing charges when their servers are turned on. Please refer to the Amazon set-up videos in REGTAP for a demo of how to turn the servers on and off. (REGTAP FAQ Database - FAQ #7235; 7235a 11/14/14; updated 12/11/15) Q: What is between the Amazon East and West availability zones? A: There is no difference in availability between the different zones in terms of 340 Updated 1-31-17 2017--00440 performance. (REGTAP FAQ Database - FAQ #7236 11/14/14) Q: How can issuers get more information on Amazon's Business Associate Agreement A: Issuers should contact Amazon directly with any questions that they have regarding Amazon's BAA at (REGTAP FAQ Database - FAQ #7243 1 1/14/14) Q: Will carriers run EDGE server calculations when data is posted or will calculations be automatically triggered? A: The initial release of the EDGE software will only include the ?le processing application. The file processing application will run all of the submitted data through a series of edit checks and will provide issuers with detailed reports on the accept/reject status of each record. For issuers using the Amazon EDGE server, file processing will be initiated automatically on the server each time an issuer uploads a file on the server. For issuers using an On-Premise EDGE server, ?le processing can be manually triggered by running an ingest command or may be automated by creating a CRON job. By the end of 2014, the Centers for Medicare Medicaid Services (CMS) will release an updated version of the EDGE application that includes the Reinsurance (RI) and Risk Adjustment (RA) software to perform program speci?c calculations. The RA and RI calculations will be initiated by CMS via command scripts. (REGTAP FAQ Database - FAQ #7408 11/18/14) Q: Can issuers resubmit a Test Zone file after ?xing errors? A: When a File ID has been accepted in either the test or production zone, the same File ID cannot be resubmitted to the same zone where it was accepted. In terms of submitting the same data in multiple files, duplicate record errors may occur if error-free data is submitted in both version of the medical, pharmacy or supplemental ?le submissions (similar to the production zone, the edit checks in the test zone will reference the stored test data from prior test ?le submissions as part of the ?le processing edit checks). In order to resubmit previously accepted test records, you would have to submit a void or replacement claim. (REGTAP FAQ Database - FAQ #3508 11/26/14) Q:l am an issuer that is exiting the Individual and/or Small Group market and I have not reported this through the External Data Gathering Environment (EDGE) Server Status Web Form. How do I inactivate (decommission/ deactivate) my EDGE Servers? Updated 1-31-17 A: Requests to inactivate EDGE servers must be sent to the Financial Management Coordination Center (FMCC) (edqe server data@cms.hhs.qov) by the current Chief Executive Officer (CEO) Designate or Alternate CEO Designate and they must include a PDF attachment on company letterhead that contains the following information: 1. Health Insurance Oversight System (HIOS) IDs for those affected by the EDGE server inac?va?on 2. EDGE server IDs Note: This is the ?edgeserver? parameter in the ?edge.properties" file in the ?/opt/edge/con?g? directory. If your server was never provisioned, please omit this ?eld. 341 2017-?00441 3. Reason for the EDGE server inactivation request acquisition, bankruptcy, exiting market(s), etc.) 4. Benefit years that may be effected by the EDGE server inactivation 5. Signature of someone with the authority to legally and financially bind the company The FMCC will process your request and send you a con?rmation once your server request status has been updated to ?Canceled? in the EDGE Server Management (ESM) Console. (REGTAP FAQ Database - FAQ #17689 10/03/16) Q: How often do the External Data Gathering Environment (EDGE) server Keys expire and what actions do issuers need to take if they expire? Updated 1-31-17 A: The ?edge.keys" ?le that connects EDGE servers to the Centers for Medicare Medicaid Services (CMS) Amazon Web Services (AWS) instance expires every 90 days for access security. The ?Server Last Key Rotation? ?eld in the EDGE Server Management Console (EMC) can be referenced to determine the date when an issuer's keys were last rotated. On the 80th day after the date of the ?Server Last Key Rotation? ?eld, a ?Key Change? remote command is released to an issuer's EDGE server at 11:59 pm. Eastern Time (ET) that will be valid until 90 days after the date of the ?Server Last Key Rotation? date time. CMS recommends that issuers run an EDGE command at least every nine (9) days with a Cron job to ensure that issuers receive the remote command. If an issuer does not pick up the remote command, the issuer will receive an Access Key error when attempting to run any EDGE command. To resolve this, issuers will need to download a new set of ?edge.keys" from the EDGE Server Management Console (EMC), which inactivates the keys in the ?Key Change? remote command, install them, run an EDGE command (ex. ?edge version"), reinstall the keys downloaded since the key change remote command will install inactive keys and then run an EDGE command once more. Example: ?Server Last Key Rotation" date time: 04/01/2016 12:00:00 1. 06/20/2016 23:59:00 ET: ?Key Change? remote command is staged 80 days after 04/01/2016 2. 06/30/2016 12:00:00 ET: Keys on server expire 90 days after ?Server Last Key Rotation? date 3. 7/1/2016 09:00:00 ET: Run EDGE command and receive Access Key error - Download ?edge.keys? from the ESM Console. The ?Server Last Key Rotation? date time is now approximately 7/1/2016 09:00:00 ET. - Install the ?edge.keys" ?le in the ?/opt/edge/config? directory. - Run an EDGE command (the Access Key error is not expected) - Reinstall the ?edgekeys? that you downloaded from ESM because the ?Key Change" job likely installed the expired keys. - Run an EDGE command again and con?rm that no Access Key error is thrown. (REGTAP FAQ Database - FAQ #17806 10/13/16) 342 2017-?00442 Edqe Server Operations - Testing 022: How do issuers submit data to the test zone of the Edge Server as opposed to the production zone? A22: As indicated in the Interface Control Document (ICD), each submission file format for the Edge Server contains an Execution Zone Code. This ?eld is populated with a for files that are to be loaded to the test zone and a for files that are to be loaded to the production zone. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #3 07/23/13; REG TAP FAQ Database - FAQ #229 07/23/13) 023: What is the availability of the test zone, what can we submit and what will we receive? A23: The Edge Server test zone will be available as soon as the software is available and will remain available as long as an Edge Server is operational. The test zone will support inbound ?le processing and will create outbound file processing detail and summary reports. Issuers will determine the type of data and files that they would like to test on their Edge Server. There is no formal test plan that CMS will require an issuer to perform. Issuers should thoroughly test their ETL process and review the outbound error ?le reports to identify any issues in their submission process. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #3 07/23/13; REG TAP FAQ Database - FAQ #230 07/23/13) 024: What will be the availability of the Edge Server test zone? A24: The test zone is part of the Edge Server software. Once the software is released and an issuer is provisioned, they can submit ?les to the test zone. The test zone is a permanent zone on the Edge Server that will support ongoing testing needs, and therefore will be available for issuers to utilize prior to submitting ?les to the production zone. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #3 07/23/13) 025: Are the test and production zones identical? A25: Yes. The test and production zones mirror each other in the software and table information that is available on each. In this way, issuers can submit ?les to the test zone to see the processing results prior to submission to the production zone. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #3 07/23/13; REG TAP FAQ Database - FAQ #231 07/23/13) 026: Can CMS provide guidance for Edge Server testing? Updated 1-31-17 A26: Issuers will determine the type of data and files that they would like to test on their Edge Server. There is no formal test plan that CMS will require an issuer to perform. Issuers should thoroughly test their ETL process and review the outbound error ?le reports to identify any issues in their submission process. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #3 07/23/13) 343 2017-?00443 027: Will CMS provision two separate servers for an issuer, one for production and one for test? A27: The production and test zones are available on a single Edge Server. CMS does not envision a need for an issuer to procure and provision multiple Edge Servers to access these zones independently. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #3 07/23/13; REG TAP FAQ Database - FAQ #232 07/23/13) Q: If issuers can submit the same File ID to both execution zones test and production), would separate error reports need to be generated by each zone? A: The test and production zones mirror each other in the software and table information that is available on each. The test and production zones will support inbound ?le processing and both will create outbound ?le processing detail and summary reports. (REGTAP FAQ Database - FAQ #599 12/23/13) Q: Table 3, page 5 of the EDGE Server Business Rules (ESBR) states 'the test zone mirrors the tables and software used in the production zone.? Will the data in the test zone mirror the data used in the production zone? A: The test and production zones are independent and store information from ?les that are submitted to each zone independently. The table structures and software in the test zone mirror the table structures and software in the production zone. allowing issuers to test their Extract, Transform and Load (ETL) processes. Data submitted in the test zone will only mirror the production zone if all ?les that are submitted to the test zone are also submitted to the production zone. (REGTAP FAQ Database - FAQ #7401 11/18/14) Q: What files will issuers be able to test after they provision their EDGE servers? A: Issuers will be able to test all file types in the EDGE server test zone after they complete the provisioning process. Data submission in the test zone will mirror data submission formats in the production zone, allowing issuers to test their Extract, Transform and Load (ETL) processes. (REGTAP FAQ Database - FAQ #7422 11/18/14) Q: How do issuers distinguish between test zone and production zone data; will each region have its own database tables? A: The test and production zones will each have their own data tables. The Centers for Medicare Medicaid Services (CMS) will provide issuers with more information on the database structure for the test and production zones in future guidance. There are no differences in the inbound ?le format requirements for ?le submitted to the test and production zone (in order to allow issuers to be able to run comprehensive ?le processing tests of their data in the test zone). All inbound file headers contain a ?eld that allows issuers to specify whether a given file should be processed in the test or production zone (the application will use this ?eld to route the data to the appropriate zone as part of the file ingest process). (REGTAP FAQ Database - FAQ #7423 1 1/18/14) 344 Updated 1-31-17 2017-?00444 Q: Can issuers correct and resubmit rejected EDGE server test zone data or do the files need to be voided and replaced? A: The test zone mirrors the tables and software used in the production zone and is available for issuers to test ?les prior to submission to the production zone. The test zone allows issuers to validate that their data extract and submission process works, prior to actual submission of their XML files to the production zone. Similar to the production zone, the only way to change the claims status of a stored claim in the test zone from active to inactive is by submitting a void or replacement claim. Submitting the same claim in the test zone without submitting a void or replacement claim will result in a duplicate claim error in the test zone. (REGTAP FAQ Database - FAQ #2904 11/26/14) Q: Will there be separate EDGE server applications for test and production regions on the EDGE server? Errors A: The same file processing application will run on ?les submitted to test and production zones. (REGTAP FAQ Database - FAQ #2916 11/26/14) Q34: What's the timeline for resubmitting after the errors have been ?xed? A34: To be considered for risk adjustment and reinsurance, errors must be corrected by the April 30, 2015 deadline for benefit year 2014. Please consider resolving errors and resubmitting corrected data in a timely manner. If errors are not corrected, then risk scores and/or reinsurance payments could be affected. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #3 07/23/13; REGTAP FAQ Database - FAQ #237 07/23/13) Q35: How are corrected errors submitted to the Edge Server? A35: The same format used for initial submission of enrollment, pharmacy claims, and medical claims ?les is used to submit corrected data. Enrollment ?les require full replacement ?les with the corrected records included, whereas Pharmacy and Medical claims files are not full replacement files and only the corrected records need to be resubmitted. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #3 07/23/13) Q36: Will all error codes associated with a record be reported or only the first error encountered? Updated 1-31-17 A36: For each record that processes, there is a hierarchy of veri?cations that occur. Required and Face validity must pass before reference and logical veri?cations can occur. Where possible, all errors associated with a record will be reported on the detail error report. However, if a required or face validity element fails, the record cannot proceed to reference and logical edits and therefore, an acceptance or reject on those verifications could not be provided during the initial processing. For example, if there are three (3) errors at the reference or logical edit steps, all three (3) errors would be reported. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #3 07/23/13; REGTAP FAQ Database - FAQ #238 07/23/13) 345 2017-?00445 Q: What market-level information will the Centers for Medicare Medicaid Services (CMS) include in the Risk Adjustment (RA) payment transfer reports? A: When CMS runs RA payment transfer reports in June 2015, CMS intends to report the state average premium and state average risk score for each risk pool/market in a state. More details regarding the RA payment transfer report will be provided in the future. (REGTAP FAQ Database - FAQ #8481 01/14/15) Data Submission Enrollment Data Q1. When will CMS provide the ?le layouts and speci?cations for the inbound enrollment, medical claim, and pharmacy claim files? A1. The webinar scheduled for May 8 included information on the enrollment submission file layout and specifications, while the webinar held on May 22 included information on the medical and pharmacy submission layouts. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #2 07/15/13; REG TAP FAQ Database - FAQ #275 07/15/13) 02. If there are any rejected records in Enrollee, Medical Claims, or Pharmacy claims files, does the whole file reject or only those records reject? A2. In accordance with Interface Control Document, an entire ?le will be rejected only if the header fails or if all issuer level sections fail. If a single record fails verification, then only that record would be rejected. For further clari?cation on rejections, see the Business Rules document related to hierarchical rules (available in the REGTAP library). (Distributed data collection for Reinsurance and Risk Adjustment FAQ #2 07/15/13; REGTAP FAQ Database - FAQ #246 07/15/13) Q3. Please describe the Plan ID used for Edge Server submissions? Updated 1-31-17 A3. Both a HIOS (Health Insurance Oversight System) ID and Plan ID are required Edge Server data elements. The HIOS ID identi?es the issuer and the Plan ID is an enumerator for each plan that is tied to the HIOS ID. Plan IDs will be assigned in HIOS. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #2 07/15/13; REGTAP FAQ Database - FAQ #247 07/15/13) 346 2017-?00446 Q4. For members with Cost Sharing Reductions (CSRs) that change month-to-month, how is that reflected in the Edge Server submission? A4. Only the CSR level will be captured in the Edge Server data collection. CSR amount is not a data element. A change in CSR level is re?ected in the Plan ID. Therefore, if the Plan ID changes, then an update to the enrollment file must be submitted. Remember, the enrollment ?le is a full replacement. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #2 07/15/13; REGTAP FAQ Database - FAQ #248 07/15/13) Q5. Is the Rating Area an enrollee-level attribute? A5. The Rating Area Identi?er is included in the enrollment period category of the Edge Server Enrollment Submission. [Referencez Interface Control Document (ICD), Enrollment Section (Table (Distributed data collection for Reinsurance and Risk Adjustment FAQ #2 07/15/13; REGTAP FAQ Database - FAQ #249 07/15/13) 06. When sending the same enrollee information with no modifications (no adds/drops/changes), what is expected on the enrollment period activity column? A6. Enrollment ?les are complete replacement files. Therefore, all information needs to appear each time the ?le is submitted regardless of modi?cations, or the record will be inactivated and will not be included for risk adjustment and reinsurance. If there is no change to the enrollment from the original submission, then the enrollment period activity indicator would remain consistent with the original submission along with all the other data elements. If there is a change to the enrollee, and thereby the enrollment status, a new enrollment period would need to be included on the enrollment ?le. For example: In January, an enrollee is submitted with enrollment period activity indicator 021028 (initial issuance of policy). In February, if there was no change to the enrollee, the same enrollment period information would be submitted, including the enrollment period indicator 021028. If in July, a dependent was added, a second enrollment period would be added to the subscriber enrollee and would include the enrollment activity indicator 021 EC (addition of member to existing plan). (Distributed data collection for Reinsurance and Risk Adjustment FAQ #2 07/15/13) Q7. Can you provide more information on the 'rating area' data element? A7. States determine the number of rating areas. Therefore, the rating area data element must be consistent with the rating area assigned for the Plan ID within a State. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #2 07/15/13) Q8. Please provide additional clarification regarding the Premium Amount such as is this the amount the member pays per month or the amount the plan collects per month (including any subsidy)? A8. The premium amount is the total premium for the policy, including the amount of premium charged to the enrollee or other responsible party and the APTC amount. If the premium amount changes, then a new enrollment period should be included when the next replacement enrollment file is submitted. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #2 07/15/13) 347 Updated 1-31-17 2017-?00447 QQ. Does the order of the Enrollee coverage segment matter (for instance, must 1/1/14 - 03/31/14 be submitted before 4/1/14 - 5/31/14)? A9. No. The order in which the enrollment periods appear on the ?le is not signi?cant. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #2 07/15/13; REG TAP FAQ Database - FAQ #250 07/15/13) Q10. How will CMS determine that a member is enrolled in a plan on the individual or SHOP market versus some other non-exchange (marketplace) health plan? A10. The plan ID identifies the plan in which an individual is enrolled. The last two positions of that identi?er will indicate whether the plan is offered on or off the Exchange (marketplace). In either case, the plan must be registered in HIOS and have a HIOS- assigned ID. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #2 07/15/13; REGTAP FAQ Database - FAQ #251 07/15/13) Q11. During the April 8 webinar on Slide 29, is the unique issuer ID assigned by HIOS referring to the Health Plan ID A11. No, HPID is a Health Plan Identi?er and is different than the HIOS (Health Insurance Oversight System) ID. HIOS IDs and Plan IDs are required Edge Server data elements. The HIOS ID identi?es the issuer and the Plan ID is an enumerator for each plan that is tied to the HIOS ID. Plan IDs will be assigned in HIOS. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #2 07/15/13) Q12. Regarding the enrollee file, what is the time period for enrollment data and do issuers reset every January and stop submitting the previous year's enrollment periods, or does the file keep growing year after year? A12. plans to evaluate the cutoff period for submission of enrollment period data related to each calendar year. does anticipate that, at least through the data submission deadline in 2015, 2014 enrollments will be required to be submitted. We will determine whether further submission of that data would be necessary after that deadline. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #2 07/15/13) Q13. Can an enrollee be the subscriber for the first half of the year and then a member under their spouse's plan for the remainder of the year under the same masked enrollee identifier? A13. Yes. The change for the enrollee would be at the enrollment period level. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #2 07/15/13; REGTAP FAQ Database - FAQ #269 07/15/13) Q14. In previous webinars that discussed Edge Server performance, HHS indicated that large issuers should upload files more frequently than quarterly. What is the performance concern with the enrollment file since this is a full replacement file? A14. Issuers may wish to maintain the most current statement of enrollment on their Edge Servers, and therefore may wish to use a submission. Regardless of the enrollment file decision, good data management would suggest that large issuers should 348 Updated 1-31-17 2017--00448 submit claims data more frequently. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #2 07/15/13; REGTAP FAQ Database - FAQ #252 07/15/13) Q15. Will the enrollment period activity definitions change over time (additional values added)? A15. There is currently no plan to change the definitions of these values. If the de?nitions of the Enrollment Period Activity values change, then guidance will be provided to issuers. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #2 07/15/13) Q16. What coverage end date should issuers use for enrollees who have not terminated? A16. In accordance with the Edge Server Business Rules, Section 5.5 (available in the REGTAP library), the Edge Server will accept open ended enrollment periods. However, CMS recommends using the last date a premium rate is effective for a policy when developing enrollment period end dates. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #2 07/15/13; REGTAP FAQ Database - FAQ #253 07/15/13) Q17. Do issuers include null enrollments where Effective Date equals Termination Date in Edge Server Enrollment Submissions? A17. Issuers do not need to include null enrollments where the start and end dates of enrollment are equal. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #2 07/15/13; REGTAP FAQ Database - FAQ #254 07/15/13) Q18. Can an individual be enrolled in a small group plan and an individual plan at the same time? A18. Yes. Enrollment in a small group plan and an individual plan at the same time is a condition in which enrollment periods could overlap. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #2 07/15/13; REG TAP FAQ Database - FAQ #255 07/15/13) Q19. Do issuers exclude enrollees who are age 65 or over who are covered by Medicare? A19. There is no requirement to exclude enrollees from Edge Server data submission who are age 65 or over. Medicare eligible individuals may choose to have coverage in either the individual or small group market. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #2 07/15/13) Q1: Why is HHS using the XML format for Edge Server submissions rather than an 834? A1: As of a result of the type of data we are collecting, the minimum amount of data we are collecting, and the nature of the Edge Server design, CMS determined that X12 transactions would not be utilized and elected the XML format consistent with all other custom ?le transmissions related to the new Marketplaces. A compliant 834 would contain far more data than what is required for ES processing. In addition, use of an 834 would require deployment and management of translators on every Edge Server. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #3 07/23/13; REGTAP FAQ Database - FAQ #216 07/23/13) 349 Updated 1-31-17 2017--00449 Q2: Will the Edge Server Enrollment Submission process allow for per member per month records, regardless of changes could one member enrolled for the complete 2014 year, with no membership changes, have 12 separate records with start and end dates respective to each individual month)? A2: Yes. It would be possible to have 12 separate enrollment periods under a single enrollee section of the Edge Server Enrollment Submission. However, this is not recommended as this would increase the ?le size and required storage capacity. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #3 07/23/13; REG TAP FAQ Database - FAQ #217 07/23/13) Q3: Who assigns the unique enrollee A3: In accordance with 45 CFR ?153.720, the issuer must establish a unique masked enrollee identi?cation number for each enrollee, in accordance with HHS/CMS-defined requirements. The Interface Control Document (ICD) further clari?es this number cannot be a medical record number or cardholder ID. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #3 07/23/13; REG TAP FAQ Database - FAQ #218 07/23/13) Q4: What is the format of the Rating Area data element? A4: The rating area is determined by the State where the issuer provides the health plan a 1, 2, or 3 digit number. Issuers should contact their State for designated rating areas. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #3 07/23/13) Q5: How would an issuer report enrollment period and premium data to the Edge Server for mid-month premium increase/decrease due to the addition or removal of a dependent? A5: The Edge Server enrollment submission includes one premium amount per enrollment period record. Therefore, in a month with two different premium amounts, an issuer would generate a separate enrollment period for each portion of the month with a unique premium amount. In addition, the enrollment activity indicator would be updated to identify the reason for the change. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #3 07/23/13) Q6: What is included in the premium amount on the enrollment file? A6: The premium amount is the total premium for the policy, including the amount of premium charged to the enrollee or other responsible party, and the APTC amount. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #3 07/23/13) Q7: Is the field in the Edge Server enrollment submission generated by the health insurance plan/insurer? A7: Yes. This ?eld is generated by the issuer in order to track submission ?les. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #3 07/23/13) 350 Updated 1-31-17 2017--00450 08: Should issuers handle data across two years in the NUMBER OF ENROLLEE ?eld in the Edge Server enrollment submission using one file where the data are accumulated together 2014 and 2015) in a record, as separate records within a file, or as two separate ?les? A8: Enrollment data for multiple years is included on a single file. The Total Number of Enrollee Records includes all Enrollee Records on the file. Therefore, this field would include all records for all years submitted. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #3 07/23/13; REG TAP FAQ Database - FAQ #219 07/23/13) 09: What is the deadline for submitting enrollment files, claim files? What is the deadline for any adjustments/updates to enrollment or claims files on the Edge Server? . All claims' dates of service and enrollment periods for 2014 benefit year January 1, 2014 through December 31, 2014) must be submitted by April 30, 2015. Adjustments and updates to enrollment and claims files may be made onqoinq through the submission deadline. Issuers should still submit replacement data claims as frequently as necessary to ensure stored claims data are accurate and includes all claims to be considered for risk adjustment and reinsurance. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #3 07/23/13; REGTAP FAQ Database - FAQ #220 07/23/13 - edits reflect REG TAP database version) Q4. If an issuer receives only partial payment for a premium, what should they report on the enrollment file? A4. The premium amount is the total premium charged for the policy, per month, to the enrollee or other responsible party and includes the APTC amount. It does not represent the amount paid. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #4 08/16/1313; REGTAP FAQ Database - FAQ #263 08/16/13) Q5. For the Enrollment Period Activity field on the Edge Server Enrollment Submission, what value do issuers use to report enrollment period change because of reduction in the number of dependents? A5. According to the Interface Control Document (ICD) Table 9 (Business Data Element 'Enrollment Period Activity'), a change in the number of dependents would be communicated with value 001, 'Modi?cation of existing policy.? (Distributed data collection for Reinsurance and Risk Adjustment FAQ #4 08/16/13) 06. How frequently should claim and enrollment ?les be submitted to the Edge Server? A6. As stated in the preamble of the HHS Notice of Bene?t and Payment Parameters for 2014, Final Rule (Section HHS requests that issuers submit data at least quarterly throughout the bene?t year. Issuers have the ?exibility to submit more frequently bi-weekly, HHS recommends ?le submissions or more frequent submissions based on Issuer ?le size and processing time. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #4 08/16/13) 351 Updated 1-31-17 2017--00451 Q1. How are non-subscribers reported? A1. As outlined in the Edge Server Business Rules, to link a non-subscriber to a subscriber, the Subscriber ID (also known as the unique enrollee ID) must be populated on the enrollment period record of the non-subscriber. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #5 09/23/13; REG TAP FAQ Database - FAQ #379 09/23/13) Q: In the data element field, Enrollment Period Activity in the Enrollment file, will removal of a member be categorized as 001 Modification of Existing Policy or 021 EC Addition of Member to an Existing Plan? A: If an enrollee is enrolled for any period of time and is then terminated, the enrollee must continue to be submitted on the enrollment ?le with an enrollment period that reflects the actual start and end dates of enrollment. Upon termination, the enrollment period must be submitted with the actual date of termination and with no change to the original activity indicator. The enrollment activity indicator shows the reason for the start of the enrollment period and is never impacted by a later termination. (REGTAP FAQ Database - FAQ 493 11/20/13) Q: Regarding the Enrollment submission file on the edge server, does the data element 'RecordlD' have to match the eXtensible Markup Language (XML) output in exact sequential order or can the Record IDs be in any order as long as they are unique within the column? A: The Record ID data element needs to be contiguous and sequential in every ?le submission but the ?rst record does not need to be Record ID 1. The validation of reported totals can still be accomplished if the record IDs are contiguous and sequential. (REGTAP FAQ Database - FAQ #595 12/18/13) Q: Will an EDGE Server Enrollment Submission (ESES) with an error be considered 'not confirmed' and become inactive? A: If enrollment record is stored as active in the system and an updated enrollment ?le is submitted with an error in enrollment record X, then the new enrollment record will be rejected and the status of the stored version of enrollment record will be changed to inactive (since the new enrollment ?le did not contain an accepted version of enrollment record X). Issuers will receive outbound ?les listing all enrollees and enrollment periods that were changed to an inactive status. (REGTAP FAQ Database - FAQ #7252 11/14/14) Q: The membership that issuers submit through the inbound files, does that include all members, or is that the Affordable Care Act (ACA)-related members only? In other words, it does not include people who are being renewed in grandfathered or transitional release products, correct? A: Only enrollees that are enrolled in a Small Group or Individual Market Plan, whether on or off the Exchange. Plans renewed in grandfathered or transitional products are excluded. (REGTAP FAQ Database - FAQ #7253 11/14/14) 352 Updated 1-31-17 2017-?00452 Q: If an issuer includes an enrollee on the EDGE Server Enrollment Submission (ESES) file for a claim that was identified as orphaned, will that claim be considered during Reinsurance (RI) and Risk Adjustment (RA) calculations? A: Yes. If issuers receive a list of orphaned claims and then submit the enrollment information the claims will be selected for consideration in RI and RA calculations. (REGTAP FAQ Database - FAQ #7254 11/14/14) Q: How should enrollment data be submitted for a child when the parent is the subscriber, but not an enrollee in the plan? A: The subscriber is determined by the enrollee to whom the premium is applied. If the parent is not enrolled, the premium would apply to the child, so the child would be reported as the subscriber. (REGTAP FAQ Database - FAQ #7257 11/14/14) Q: When submitting per member per month (PMPM) enrollment records, which Enrollment Period Activity Indicator (EPAI) code should issuers use for all subsequent months (after the ?rst month of initial enrollment) if there were no other changes to the subscriber's plan? A: When submitting PMPM enrollment records, if the premium amount for the subscriber's plan did not change, issuers should continue to use the initial EPAI code for subsequent enrollment months. For more information, see the EPAI guidance located at 5CR 100314.pdf in the REGTAP Library. (REG TAP FAQ Database - FAQ #8892 02/09/15) Data Submission Diagnosis Codes Q: Will HHS accept supplemental diagnosis codes for consideration in calculating enrollee risk scores when HHS operates risk adjustment on behalf of a State? What sources are permitted for supplemental diagnosis codes; and, what are the data collection procedures for diagnosis codes from a supplemental source? A: In the HHS Notice of Bene?t and Payment Parameters for 2014, Final Rule, HHS indicated that standards related to use of chart review for data collection would be provided in future guidance. This FAQ is the initial guidance that HHS is providing on the subject of chart review as a source of supplemental diagnosis codes for acceptable claims and encounter data as de?ned under 45 CFR 153.710. Additional, detailed operational guidance related to collection of supplemental diagnosis codes will be provided in future guidance and in advance of the final data submission deadline of April 30, 2015. Guidance on Supplemental Diagnosis Codes for HHS-Operated Risk Adjustment: 1. HHS will accept supplemental diagnosis codes from the following sources: a. Fee-For-Service Claims Environment: i. Chart (medical record) review by the issuer subsequent to medical billing when an issuer has submitted risk adjustment data related to an allowed claim for hospital inpatient, hospital outpatient and professional medical services. In this case, the issuer has paid a claim that is the result of services provided to an enrollee and is supported by medical record documentation. In 353 Updated 1-31-17 2017--00453 Updated 1-31-17 2. such cases, the chart review must evaluate all diagnoses on the original claim, and the issuer must delete any diagnoses not supported by the chart. We note that any chart review would be governed by applicable privacy and security laws and standards. Any diagnoses added through such a process would be linked to an individual?s de-identi?ed record on the issuer?s edge server; HHS will not access individual records except in cases of audit. Diagnosis codes that are received via electronic data interchange (EDI) and exceed the number of diagnosis codes that are accepted by the issuer?s claims system. HHS understands that in some instances the number of an enrollee?s diagnosis codes exceeds the number of diagnosis codes that the issuer?s translator and claims system can accept. Issuers are allowed to pick up diagnoses that were on the submitted claim transaction but truncated in the translator/EDI front-end. b. Encounters in a Capitated Environment: Chart (medical record) review by the issuer subsequent to medical billing when an issuer has submitted risk adjustment data related to an allowed claim for hospital inpatient, hospital outpatient and professional medical services. In this case, the issuer has paid a claim that is the result of services provided to an enrollee and is supported by medical record documentation. In such cases, the chart review must evaluate all diagnoses on the original claim, and the issuer must delete any diagnoses not supported by the chart. We note that any chart review would be governed by applicable privacy and security laws and standards. Any diagnoses added through such a process would be linked to an individual?s de-identi?ed record on the issuer?s edge server; HHS will not access individual records except in cases of audit. Routine medical record (chart) review. Supplemental diagnosis codes must be related to services that are de?ned as an encounter for hospital inpatient, hospital outpatient and professional medical services. . Diagnosis codes from allowed encounters. . Diagnosis codes that are received via electronic data interchange (EDI) and exceed the number of diagnosis codes that are accepted by the issuer?s encounter system. HHS understands that in some instances the number of an enrollee?s diagnosis codes exceeds the number of diagnosis codes that the issuer?s translator and claims system can accept. Issuers are allowed to pick up diagnoses that were on the submitted claim transaction but truncated in the translator/EDI front-end process. Issuer shall submit supplemental diagnosis codes to the distributed data environment (Edge Server) during the appropriate data collection period in a format designated by HHS (45 CFR 153.700). NOTE: Because HHS is allowing supplemental diagnosis codes, an additional ?le format will be established to support this submission. HHS intends to provide information in future guidance for this additional format. The ?le format for collection of supplemental diagnosis codes shall require the identi?cation of the source of the diagnosis codes. Speci?cally, a quali?er for source type will be a required data element. 354 2017-?00454 3. Deletions of incorrect diagnoses shall also be submitted. If an allowable source of supplemental diagnosis codes (see item 1 above) identi?es incorrect diagnosis codes, then an issuer shall submit a deletion in the additional ?le format (described in item (2). 4. Denied claims are not a source of supplemental diagnoses. (HHS-Operated Data Collection Policy FA Qs 6/26/13) Q: Does HHS plan to utilize health assessments as a source of risk adjustment diagnosis codes? A: For the ?rst year of operations, HHS will allow health assessment diagnoses to be submitted for the HHS-operated risk adjustment program provided that the diagnoses submitted based on these assessments comply with clinical coding guidelines. We would like to discuss this issue with the issuer community and determine the best approach to use in future years. We note that any diagnoses added through such a process would be linked to an individual?s de-identi?ed record on the issuer?s edge server; HHS will not access individual records except in cases of audit. (HHS-Operated Data Collection Policy FAQs 6/26/13) Q: What diagnosis codes can be submitted in the EDGE Server Supplemental Diagnosis File Submission (ESSFS) A: Any valid diagnosis code can be submitted through September 30, 2015. Valid ICD10 diagnosis codes will be required starting October 1, 2015. (REGTAP FAQ Database - FAQ #6520; #6520a 10/31/14; updated 09/21/15) Q: Is there a limit to the number of diagnosis codes in each supplemental file detail record that can be submitted to the External Data Gathering Environment (EDGE) server and is there a limit on the number of supplemental diagnosis codes per Medical Claim A: You can submit 99 diagnosis codes on a supplemental record; however, there is no limit to the number of supplemental records that can be submitted for an individual 1 1/25/14,? updated 6/7/16 355 Updated 1-31-17 2017--00455 Data Submission Pharmacy Files Q18. When can the Dispensing Status field be blank for the Pharmacy A18. Issuers who do not capture the dispensing status may submit a blank. A blank implies a single complete fill was performed. As outlined in the Edge Server Business Rules, a indicator is used for a partial fill and a indicator is used for the completion of a partial fill. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #3 07/23/13; REGTAP FAQ Database - FAQ #226 07/23/13) Q7. Will pharmacy data need to be submitted to the Edge Server? A7. Pharmacy claims data must be submitted to the Edge Server. Please refer to the latest version of the Interface Control Document (ICD) from the June 26, 2013 webinar. It can be found in the REGTAP Library at (Distributed data collection for Reinsurance and Risk Adjustment FAQ #4 08/16/13) Q8. Should rebates be included in the paid amount indicated on the pharmacy claim submission file? A8. At this time, the reinsurance (RI) program is not considering pharmacy rebates in the calculation for RI payments. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #4 08/16/13) Q: Will the Centers for Medicare Medicaid Services (CMS) be changing the data type for the Fill Number from integer to string? A: No. The data type for Fill Number will not be changed from integer to string. Issuers may submit a value of or 051' on the inbound pharmacy ?le; neither value will be rejected. The value that will be stored in the data table will be (REGTAP FAQ Database - FAQ #7256 11/14/14) Q: The EDGE Server Business Rules (ESBR) v2.0 document states 'only pharmacy claims for enrollees in the individual and small group market, both inside and outside the Marketplace will be accepted.? Since pharmacy claims are only used for the Reinsurance (RI) program, which only applies to individual plans, are issuers required to submit pharmacy claims for small group health plans to the EDGE server? A: Regardless of market type (individual or small group) issuers must submit all data types (enrollment, pharmacy, medical and supplemental diagnosis) to the EDGE server. (REGTAP FAQ Database - FAQ #7259 11/14/14) 356 Updated 1-31-17 2017--00456 Q: Some issuers may have three (3) separate vendors that provide pharmacy, vision and dental care data to submit for EDGE server reporting. When loading or quarterly data to the EDGE server, should the EDGE report reflect one (1) file for each line of business or one (1) file that encompasses all lines of business? A: Pharmacy data submissions should be uploaded to the EDGE server on the EDGE Server Pharmacy Claim Submission (ESPCS) ?le. All dental and vision claims covered under major medical should be included on the ESMCS ?le. However, stand-alone dental plans and stand-alone vision plans are excluded from Risk Adjustment (RA) and Reinsurance (RI) and should not be submitted to the EDGE server for consideration. Please note that each EDGE server submission ?le should only contain information for one issuer. Information on the requirements for each of type of ?le submission can be found in the EDGE Server Business Rules (ESBR) and the Interface Control Document (ICD) posted in the REGTAP Library. (REGTAP FAQ Database - FAQ #7260 11/14/14) Q: For EDGE Server Pharmacy Claim Submission (ESPCS) files, can the Fill Date exceed the Paid Date? A: Yes. There is no logical check between the Fill Date and the Paid Date on an ESPCS ?le. (REGTAP FAQ Database - FAQ #7261 11/14/14) Q: Is a reference check performed on the National Drug Code (NDC) field for EDGE Server Pharmacy Claim Submission (ESPCS) file claims on the EDGE server, and if so, which source will be used for reference? A: There is no reference check being performed on the NDC. (REGTAP FAQ Database - FAQ #7262 11/14/14) Q: Can the Centers for Medicare Medicaid Services provide information on how the Prescription Service Number is used on EDGE Server Pharmacy Claim Submission (ESPCS) ?les? A: The Prescription Service Number is one mof the eight (8) seven?(l) key elements used to identify a claim that should be voided or replaced. (REGTAP FAQ Database - FAQ #7263; 7263a 11/14/14; updated 12/30/15) Q: Is it acceptable for an issuer to use a Fill Number of zero (0) for pharmacy claims? A: No. The minimum value for the Fill Number is one (1). Issuers who use zero (0) as the initial Fill Number must change the original Fill Number to one (1) or the claims will be rejected. (REGTAP FAQ Database - FAQ #7264 11/14/14) Q: Some issuers have pharmacy claims processed by a third party. The issuer sends an original claim, and the third party sends back either a reversal or an adjustment, but not a new claim. Should the issuer aggregate both the claim and adjustment to get the net cost and make a new claim out of the individual actions? A: Issuers may submit the original claim and then submit a replacement claim when the adjustment is received from the third party vendor. Issuers may, alternatively, submit one (1) claim with the aggregation of both the initial claim and any adjustment performed 357 Updated 1-31-17 2017--00457 by the third party. (REGTAP FAQ Database - FAQ #7265 11/14/14) Q: Can the Centers for Medicare Medicaid Services (CMS) please confirm if a voided pharmacy claim amount should be included in the 'Total Plan Paid Amount' fields on the EDGE Server Pharmacy Claim Submission (ESPCS) ?le? A: Pharmacy claims use seven (7) key data elements to identify a unique claim for purposes of identifying duplicates and processing void and replacement requests. When voiding a claim, only the seven (7) key elements need to be present. Therefore, no Total Plan Paid Amount is necessary when voiding a pharmacy claim. When replacing a claim, all data elements must be present. (REGTAP FAQ Database - FAQ #7266 11/14/14) Q: Can issuers integrate vaccines with pharmacy claims in the 'Total Amount Allowed?? A: Yes, issuers can include the pharmacy administration cost for vaccines in the "Total Amount Allowed." (REGTAP FAQ Database - FAQ #4623 11/26/14) Data Submission Medical Files 02. Are issuers required to submit dental and/or vision data? A2. Dental and vision claims that are included in major medical coverage will be accepted on the medical claim ?le. Stand-alone dental and vision plans are excluded from risk adjustment and reinsurance and therefore must not be submitted. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #5 09/23/13; REG TAP FAQ Database - FAQ #395 09/23/13) Q3. Is there special logic to handle mother and newborn baby claims? A3. CMS will provide additional guidance regarding the submission of mother and newborn baby claims. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #5 09/23/13; REG TAP FAQ Database - FAQ #396 09/23/13) Q4. Can you provide more information on what bill types will and will not be accepted on the edge server? A4. Institutional claims must be submitted with a bill type. The ?rst digit of the bill type indicates the type of facility. There are no exclusions related to the ?rst digit of the bill type. The second digit of the bill type indicates the bill classification. There are no exclusions related to the second digit of the bill type. The third digit of the bill type indicates the frequency. There are exclusions related to the frequency digit. The edge server will not accept bill types with a frequency code Interim bills and late charge claims, whether inpatient or outpatient, should be aggregated into one final claim for submission and be submitted using a frequency code of 1. For illustrative purposes, we will further clarity with a few examples. Acceptable Bill Types: - Bill Type 211 (skilled nursing, inpatient, admit through discharge) - Bill Type 137 (home health, outpatient, replacement claim) - Bill Type 381 (hospital, swing bed, admit through discharge) 358 Updated 1-31-17 2017--00458 Unacceptable Bill Types: - Bill Type 112 (hospital, inpatient, interim-first claim) - Bill Type 113 (hospital, inpatient, interim-continuing claim) - Bill Type 134 (hospital, outpatient, interim-?nal) - Bill Type 215 (skilled nursing, inpatient, late charge) Inpatient interim and late charges normally billed with bill types ending in 2, 3, 4 or 5 would need to be aggregated with any additional bills to produce a ?nal bill with all services and charges included and a bill type with a frequency code of 1. Additional business rules will be provided in the future related to how bill types will be used for the risk adjustment and reinsurance programs. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #5 09/23/13) Q: There is no documentation stating how to report unacceptable bill types ending in xx6 and xx9. Should issuers aggregate these bill types into a final claim with a frequency of xx1 or xx7? A: The bill type ending in xx9 is excluded from edge server submissions because it is reserved for national use only. The bill type ending in xx6 is used for claim adjustment purposes. If an issuer receives an adjusted claim, they can either include this bill type into a ?nal claim with a frequency of xx1 or submit it as an adjustment to the original claim with a frequency of xx7. Please refer to the (User Group 2 - Edge Sever Medical and Pharmacy Claims Files Review and Clari?cations (11/06/13) (REGTAP FAQ Database - FAQ #544 12/09/13) Q: Can issuers submit a zero (0) Amount Allowed on the EDGE Server Medical Claim Submission (ESMCS) at the claim header? A: No. The Amount Allowed at the claim header must be greater than zero (0) as stated in the Interface Control Document (ICD). The Amount Allowed at the line level may be equal to or greater than zero (0), however. For issuers submitting encounters or capitated services a default value greater than one (1) may be used. (REGTAP FAQ Database - FAQ #7268 11/14/14) Q: Issuers perform line level adjudication for Professional Claims. As such, voids can be performed on the line and claim level. However the EDGE Server Business Rules (ESBR) indicate that Voids and Replacements are performed at the Claim Header Level. Are issuers to report each claim line at the claim header level? A: EDGE Server Medical Claim Submission (ESMCS) ?les must include both the claim header and the claim lines associated with the claim header. Since every claim submitted requires both a header level and claim line detail level, any void or replacement of a claim, even if only a single claim line is adjusted, must also include both the header and line level components. For example if issuers update a single claim line of claim, issuers would have to submit a replacement claim that contains the updated information for the modi?ed claim line or submit a void claim to void the original claim and then submit a new claim that contains updated claim line information in addition to all of the other claim lines from the original claim. (REGTAP FAQ Database - FAQ #7274 11/14/14) 359 Updated 1-31-17 2017--00459 Q: Are issuers required to populate the Paid Date when submitting encounter claims? A: For issuers who are submitting capitated encounters, a derived indicator of is required and the Paid Date is optional. For issuers who are submitting fee for service claims, a derived indicator of is required and the Paid Date is required. (REGTAP FAQ Database - FAQ #7275 11/14/14) Q: Rule 4 of Table 52 in the EDGE Server Business Rules (ESBR) Version 3.0 states that 'At the claim line, at least one (1) line must include the same Amount Allowed value reported at the claim header; all other Amount Allowed values at the claim line level may be reported with a zero Does this rule apply when issuers use a default value for the Total Amount Allowed at the claim header or when using a derived value for the Total Amount Allowed? A: The sum of the lines must equal the total amount at the header for both capitated encounters and fee for service claims. (REGTAP FAQ Database - FAQ #7277 11/14/14) Q: Regarding interim bill submission, how should an issuer submit data to the EDGE server if the initial date of service (DOS) on the claim is December 2013, the next claim has a DOS of January 2014, and the final claim has a DOS of February 2014? A: Only plans that meet the Market Reform rules should be submitted to the EDGE server. The service that was covered in 2013 presumably was not under a Market Reform Plan, and therefore that service is not eligible to be submitted. If a plan migrates from a plan that is ineligible to a plan that is eligible to submit data to the EDGE server, the issuer would only submit charges incurred under the plan that was eligible in 2014. (REGTAP FAQ Database - FAQ #7278 11/14/14) Q: If issuers do not have the Billing Provider ID, can issuers use the Rendering Provider A: If the Billing Rendering Provider ID is not available, issuers can submit the Rendering Billing Provider ID as the Billing Rendering Provider ID. (REGTAP FAQ Database - FAQ #7279 11/14/14; updated as #7279a on 03/24/15) Q: How should issuers submit dental services on the EDGE Server Medical Claim Submission (ESMCS) file? A: Issuers should submit dental services on the ESMCS file using a Service Code Quali?er value of ?01? as the indicator. Dental codes would be populated in the Service Code field. If the issuer is unable to populate a diagnosis code, we V700 may be populated as a default code for dental services. (REGTAP FAQ Database - FAQ #7280 11/14/14; updated as #7280a on 01/22/15) Q: What is the definition of the Paid Amount field? Are issuers permitted to include surcharges as part of claims submissions? A: Under 45 CFR 153.230 (0), Reinsurance (RI) payments are calculated based upon the claims costs for an individual enrollee's covered benefits under a RI-eligible plan. The issuer's claims costs for an individual enrollee's covered bene?ts under a RI-eligible plan should include the full claims costs paid by the issuer, including any non-medical 360 Updated 1-31-17 2017--00460 costs assessed by the provider that are included as part of the provider's standard billing practices, including provider administrative fees, taxes, and claims-based surcharges assessed by states. However, issuers may not include in the Plan Paid Amount incentive or performance payments to providers, interest due to late payments or any other payments made to providers outside of the standard provider payment rates or based on the timing of payments or volume of payments or services. Issuers should not deduct payment hold backs such as risk withholds from the Paid Amount. For example, if an issuer applies a $5 hold back on a $100 claim to address the possibility of overpayment's to the provider under the overall issuer-provider relationship, the issuer should enter $100 in the Plan Paid Amount for this claim. (REGTAP FAQ Database - FAQ #7281 11/14/14) Q: May issuers use a default value for outpatient institutional claims? A: Yes. Issuers may use as a default to populate the discharge status for outpatient institutional claims. (REGTAP FAQ Database - FAQ #7282 11/14/14) Q: If an inpatient claim starts in 2014 but ends in 2015, meaning the discharge date is in 2015, to which year does that claim belong? When should the claim be submitted? A: For both Reinsurance (RI) and Risk Adjustment (RA), claims will be allocated to a benefit year based on the statement covers through date reported on the claim header. Therefore, a claim that starts in 2014 but ends in 2015 will be allocated to the 2015 bene?t year. The Centers for Medicare Medicaid Services (CMS) does not require issuers to submit 2014 and 2015 claims on different submission files. Issuers would submit the claim after final adjudication of the claim has occurred. (REGTAP FAQ Database - FAQ #7283 11/14/14) Q: there may be a clinical-only encounter, such as a nurse visit that would not make it through our billing system, is there a default Current Procedural Terminology (CPT) or procedure code that can be used to that record if it doesn't have one (1) of the valid CPT procedure codes presentvalid Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System code on any services that are provided. The CPTs and will be validated against the current American Medical Association (AMA) coding, so an appropriate code for the service must be used. (REGTAP FAQ Database - FAQ #7386 11/18/14) Q: Does vision include pediatric vision? Updated 1-31-17 A: Vision services, pediatric or adult, that are included in major medical coverage under an Affordable Care Act (ACA) compliant plan are eligible for consideration in Risk Adjustment (RA) and Reinsurance (RI). (REGTAP FAQ Database - FAQ #7389 11/18/14) 361 2017-?00461 Q: Please con?rm if International Classification of Diseases (ICD) 9 procedure codes will be accepted if submitted on the inbound medical claim file; how should issuers submit office visits, such as routine exams and obstetrics and gynecology visits? A: The EDGE server will not accept ICD-9 procedure codes. The acceptable service type codes used to report medical services are Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (REGTAP FAQ Database - FAQ #7395 11/18/14) Q: Can the Centers for Medicare Medicaid Services (CMS) provide additional information on the submission of non-standalone dental claims? A: Standalone dental is excluded from the Risk Adjustment (RA) and Reinsurance (RI) programs but issuers who provide dental services as part of a small group or individual market plan should submit dental services to the EDGE server for consideration. Issuers should use Service Code Quali?er (1501' to indicate a dental service is being submitted. Issuers should also include the appropriate dental service code in the Service Code Quali?er ?eld. (REGTAP FAQ Database - FAQ #7396 11/18/14) Q: What value should capitated issuers use to populate the Amount Allowed field? A: Capitated providers who do not capture an Amount Allowed value, must populate the Amount Allowed fields on the inbound pharmacy and medical claim ?les with a value greater than $1.00. Capitated issuers do not need to derive the Amount Allowed and may use a default value of $1.00 for all claims submitted. Capitated providers must derive all paid amounts for submitted pharmacy and medical claims. (REGTAP FAQ Database - FAQ #7397 11/18/14) Q: In the EDGE Server Business Rules (ESBR) there is a rule on inpatient overlapping stay logic. What determines an inpatient claim - is Bill Type code used to segregate inpatient and outpatient claims? A: The Bill Type is used to distinguish inpatient from outpatient claims. The list of Bill Types and how they are classified (inpatient or outpatient) may be found on REGTAP. (REGTAP FAQ Database - FAQ #7402 11/18/14) Q: When submitting encounter claims, should files contain data covering several quarters, or is submission required for each quarter? A: Claim files may include both fee for service claims and encounter data. Claim ?les are incremental and must be submitted at least quarterly. Issuers have the option of submitting ?les more frequently. (REGTAP FAQ Database - FAQ #3757 11/26/14) Q: Is it acceptable for an issuer to submit an original claim with a paid amount referencing all Claim A: Yes. Issuers may choose to submit a ?nal version of the claim if the claim is processed multiple times in a given period, even if those claims have different IDs. (REGTAP FAQ Database - FAQ #4467 11/26/14) 362 Updated 1-31-17 2017--00462 Q: Are there restrictions associated with the use of file identifiers? A: The only restriction is that the File ID must be a string of 12 and cannot be a duplicated for a speci?c ?le type and zone. If the ?le was previously submitted and rejected, then the ?le ID may be reused. (REG TAP FAQ Database - FAQ #4606 11/26/14) Q: The latest External Data Gathering Environment (EDGE) guidance for transplant claims is that donor services should be consolidated under the recipient claims. The guidance goes on to state that all inpatient, outpatient and professional donor claims should be consolidated into one (1) single claim line on the recipient inpatient institutional claim. What is the purpose of combining the professional claims into the inpatient claim? A: Professional claims are combined with inpatient claims, when transplant donor services are covered under the transplant recipient coverage: 0 Submit one (1) institutional inpatient claim for the transplant recipient and include all the incurred costs for the transplant donor on the recipient inpatient claim. 0 Submit all incurred inpatient, outpatient and professional paid claim costs for the donor as a single claim line on the recipient inpatient institutional claim. 0 An allowed amount at the line level is not required but may be included. 0 The allowed amount at the claim header should be adjusted to include the allowed amounts related to the donor. 0 If no allowed amount is available for the donor services, issuers should add the paid amount for the donor services, reported at the line level, to the allowed amount reported at the claim header. 0 Statement Covers From and Through dates on the transplant recipient inpatient institutional claim header do not need to be changed to accommodate line level transplant donor services that are outside the inpatient stay. . Date of Service From and To at the line level do not need to re?ect the actual Dates of Service. These may be submitted as a single Date of Service or multiple Dates of Service. 0 The Date(s) of Service reported must fall within the statement coverage period for the claim to be accepted. 0 Only the diagnoses associated with the transplant recipient should be submitted. Do not include diagnoses for the transplant donor. 0 All other recipient services (outpatient institutional and professional) would be submitted as unique claims and do not need to be combined with the recipient's inpatient claim. Only donor claims are combined and submitted on the transplant recipient inpatient claim. If the issuer is responsible for reimbursing donor claims under a Risk Adjustment Reinsurance (RI) eligible plan, then the donor claims would be submitted separately. (REGTAP FAQ Database - FAQ #18401a 12/06/16) 363 Updated 1-31-17 2017--00463 Data Submission RA Related Q: What do issuers do with partial premiums? If somebody is only enrolled for part of a month, issuers do not actually have a good way of getting partial premiums. Is an estimate acceptable or should the issuer put the full premium and let the Centers for Medicare Medicaid Services (CMS) prorate it? A: For a partial month, issuers would have one (1) enrollment period that re?ects the partial month. For example: The member is enrolled from the 15th through the 30th, that would be on one (1) line and then issuers would have another line where the full month began. When calculating the premium for the partial month, the issuer can choose to either put in a zero (0) (in some cases some issuers do not charge a premium for a partial month) or estimate the partial premium amount. (REGTAP FAQ Database - FAQ #7269 11/14/14) Q: Issuers have about three (3) percent of policies billed off cycle, so instead of billing for the calendar month, issuers bill from the 15th to the 14th. Do issuers have to convert those to calendar months in order to report them to the Department of Health and Human Services A: The EDGE Server Business Rules (ESBR) state that when a subscriber has either a partial month or $0 Premium Amount, issuers must create a distinct enrollment period, an enrollment period for a full month premium rate and an enrollment period for a partial month or $0 Premium Amount. In the scenario where an issuer bills premiums from the 15th to the 14th of the month, the issuer will need to create three (3) enrollment periods the first beinq from the date of issuance to the end of that first partial month, the second beinq all full months starting on the 1st through the 30th (or 31st, if applicable), and the third being for the last partial month of the issuance where the enrollment period would be from the 1st of the month to the last date of issuance. (REG TAP FAQ Database - FAQ #7270; 72 70a 11/14/14; updated 12/30/15) Q: Does the Centers for Medicare Medicaid Services (CMS) know the out-of-pocket maximums to apply when calculating Reinsurance A: On every inbound file, issuers will provide the 16 digit Plan ID. The last two (2) digits of the Plan ID indicate the Cost Sharing Reduction (CSR) variation for every policy. (REGTAP FAQ Database - FAQ #7272 11/14/14) Q: Revenue Code 272 - Supplies, is listed as an exception to the duplicate logic at the claim line level. Should Revenue Codes 270-279 - Supplies, also be listed as exceptions to the duplicate logic at the claim line level? A: The Centers for Medicare Medicaid Services (CMS) has expanded the list of supply Revenue Codes identi?ed as exceptions to include the full range from 0270 - 0279. This 364 Updated 1-31-17 2017--00464 information will be updated in version 4.0 of the EDGE Server Business Rules (ESBR). (REGTAP FAQ Database - FAQ #7276 11/14/14) Q: What Discharge Status Code should issuers use for interim claims at a location other than a hospital? A: Issuers do not need to modify the Discharge Status Code when submitting modified interim bills for a facility other than a hospital. If an enrollee is still in a facility, the interim bill would be submitted with an xx1 bill type and the discharge status would re?ect the current status of the patient. This will not result in a reject. Upon such time as the enrollee is no longer in residence at a facility, the discharge status would be updated. For inpatient stays at a hospital, the Centers for Medicare Medicaid Services (CMS) requires issuers to aggregate all interim bills into a final bill with the discharge status that applies at the end of the stay. (REGTAP FAQ Database - FAQ #7387 11/18/14) Q: If there is no discharge status for a facility outpatient claim, what should issuers submit since a discharge status is required for institutional claims? A: Issuers may use discharge status - discharged to home. (REGTAP FAQ Database - FAQ #7388 11/18/14) Data Submission Other Q19: Please confirm if 'void' is used to eliminate a previously submitted and accepted claim from consideration and a 'replacement' is used when the issuer still wants the claim considered for reinsurance and risk adjustment, but only the replacement version of the claim (not the original claim version). A19: Correct. A void will inactivate a stored claim if the key ?elds match and a is populated in the Void/Replace Indicator ?eld and a replacement that has an in the field where the key ?elds match will inactivate the original stored claim and make the replacement claim the active claim. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #3 07/23/13; REG TAP FAQ Database - FAQ #227 07/23/13) Q20: What eligibility dates and claim dates of service should an issuer submit beginning on January 1, 2014? A20: Data submitted to the Edge Server will only include small group and individual market plans that are eligible under the new market rules as of January 1, 2014. Therefore, only enrollment and claims information for these plans effective January 1, 2014 or later would be submitted. Edge Server enrollment submission files are full replacements; therefore, each enrollment submission should include all enrollment for the applicable enrollment periods. Pharmacy and medical claims submissions are not full replacement ?les; therefore, an individual claims ?le submission is not required to contain all claims data for the relevant dates of service. It is up to each issuer to determine the method by which they will produce and submit their claims data. Issuers should consider the impact of adjusted and voided claims when developing their processes. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #3 07/23/13; REGTAP FAQ Database - FAQ #228 07/23/13) 365 Updated 1-31-17 2017--00465 QQ. Should all medical and pharmacy data for Reinsurance eligible plans be placed on the Edge Server, or only data for enrollees whose claim costs exceed the attachment point be placed on the Edge Server? A9. Claim and enrollment data submitted to the Edge Server is used for both the HHS operated risk adjustment and reinsurance program and should include all allowable services for all plans in the small group and individual markets. The CMS software will identify the claims that are eligible for risk adjustment and reinsurance by applying the provisions outlined in the Final Payment Notice. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #4 08/16/13; REG TAP FAQ Database - FAQ #264 08/16/13) Q5. How do I submit files to my edge server? A5. There are two methods for submitting a ?le for processing on an edge server - user interface (UI) and secure ?le transfer protocol (SFTP). Issuers have the option of using either method (Ul or however, any ?le that exceeds 10MB must be uploaded via SFTP. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #5 09/23/13; REGTAP FAQ Database - FAQ #380 09/23/13) Q6. Are separate data elements required for risk adjustment and for reinsurance? A6. In order to reduce issuer burden, a single ?le including data elements for both the risk adjustment and reinsurance programs was developed. Upon initiation of either the risk adjustment or reinsurance software, only the relevant data elements for the specific program will be used for payment related actions. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #5 09/23/13; REGTAP FAQ Database - FAQ #381 09/23/13) Q7. Will data submissions be cumulative (year-to-date) or incremental for all file types? A7. Enrollment submissions are full replacement ?les; therefore, all correct data must be included on each submission. If there are errors they should be corrected with the next full enrollment ?le submission. The pharmacy and medical claims submission files are not full replacements. If there is an error or correction for a pharmacy or medical claim submission, then the Void or Replace Indicator should be used to replace or delete incorrect information. The active claims are stored in pharmacy and medical tables for reference. The table contains the accumulated data. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #5 09/23/13; REG TAP FAQ Database - FAQ #382 09/23/13) Q8. Do edge server files use a file naming convention? Updated 1-31-17 A8. File naming conventions are determined by the submitter. The only restrictions are the data type and length as specified in the Interface Control Document (ICD). (Distributed data collection for Reinsurance and Risk Adjustment FAQ #5 09/23/13; REG TAP FAQ Database - FAQ #383 09/23/13) 366 2017--00466 Q: In submitting adjusted claims, do issuers use the same Claim ID as the Original Claim ID claim 126 replaces claim 126)? A: There are key elements that identify a claim as unique during the void/replace process. For Medical claims they are the Issuer ID and the Original Claim ID. For Pharmacy claims they are the Issuer ID, Fill Date, Dispensing Provider ID Quali?er, Fill Number, Dispensing Provider ID, Dispensing Status and Prescription Service Number. The key elements on a void/replace claim may reference any previously submitted claim. For example, if a medical claim 123 was submitted and later replaced with claim 456. The next void/replace could use either 123 or 456 as the key element. To adjust a claim the void/replace indicator must be present along with the original claim ID or replacement claim ID for a medical claim, or the 7 key data elements for a pharmacy claim. (REGTAP FAQ Database - FAQ #547 12/09/13) Q: Is there a document with the file naming conventions for Federally-facilitated Small Business Health Options Program (FF-SHOP) 8345, 9993, and A: Yes, a naming convention document for transmitting 834$, 9993, and TA1s is available at (REGTAP FAQ Database - FAQ #2552 07/03/14) Q: What is an orphan(ed) claim? A: An orphaned claim is a claim that was submitted and accepted but cannot be linked to an active enrollment period for an enrollee. Orphaned claims are not identi?ed during medical or pharmacy claim ?le processing. Claims are compared to the stored active enrollment table prier?te?generating when Risk Adjustment (RA) and Reinsurance (RI) commands are executed. reperts. Orphan claims appear on the Enrollees (Without) Claims Detail (ECD) Report that is produced when the RA and RI command is executed. The Unique Enrollee ID and Plan ID are?is used to match active claims to an active enrollment period. If the enrollee does not have an active enrollment period that covers the claim's Statement Covers From date and the Plan ID of the enrollee and claim do not match, then the claim will be orphaned. (REGTAP FAQ Database - FAQ #7245; 72458 11/14/14; updated 12/30/15) Q: If a claim is orphaned, may an issuer submit the enrollee and enrollment period so the claim(s) may be considered for Risk Adjustment (RA) and/or Reinsurance Updated 1-31-17 A: Issuers will have an opportunity to review the and?RI? Enrollee (Without) Claims Detail (ECD) report which includes Claim IDs that have no associated enrollment record for the Enrollee ID on the claim. An enrollment period may not be associated either because it was not submitted, the coverage period does not cover the claim date or service, or the Plan ID on the claim and enrollment period do not match. Issuers may make corrections by submittinq new enrollee and/or enrollment periods so that orphaned claims may be considered in RA and RI. For more information, please see the Interface Control Document Addendum, located under the Distributed Data Collection (DDC) proqram area at in the Registration for Technical Assistance Portal (REGTAP) Library. (REGTAP FAQ Database - FAQ #7247; 72473 11/14/14; updated 12/30/15) 367 2017-?00467 Q: Are issuers permitted to submit all claims for January through December 15th, or do issuers have the option of submitting January, February, and March data A. Issuers have the option to submit all claims In one (1 ?le, or to separate the claims across multiple files. is n_ot a restriction on the number of Ies an issuer may submit, nor is there a restriction on the frequency with which data may be submitted The Centers for Medicare Medicaid Services (CMS) has set up data reportinq milestones for 2015. Accordinq to the schedule, issuers must submit to production 90% of the enrollment records and 25% of the pharmacy and medical records for the first and second quarters of 2015 by November 16, 2015. For additional information, please see the Reinsurance and Risk Adjustment Data Reportinq Milestones for the 2015 Benefit Year document, located in the REGTAP Library at (REGTAP FAQ Database - FAQ #7251; 72513 11/14/14; updated 12/11/15) Q: Can large issuers split large EDGE server submissions into several smaller submissions and will the Date Timestamp on the file name be used to distinguish one (1) submission from another? A: Medical and pharmacy ?les should be incremental ?les. Enrollment ?les are full files and subsequent ?les must also be full replacement ?les. Issuers are required to submit data to the EDGE server at least once per quarter. However, issuers may submit the data more frequently. The Date Timestamp on the file name is used to determine the order the files should be processed. (REGTAP FAQ Database - FAQ #7271 11/14/14) Q: The Interface Control Document (ICD) and the EDGE Server Business Rules (ESBR) covers Bill Types XX1 through XX9, but the documents do not cover institutional claims that could end with an XXA, XXB, XXG. What should issuers do with those Bill Types: Send them as XX1s, or not send them at all? A: The Centers for Medicare Medicaid Services (CMS) has provided issuers with the list of acceptable Bill Type codes. CMS will reject any Bill Type codes that do not meet the Bill Type requirements provided. (REGTAP FAQ Database - FAQ #7273 11/14/14) Q: Can issuers resubmit a single claim or do issuers need to resubmit the whole claim file; how does the error correction process work? A: Issuers should not resubmit the whole file because the previously accepted records would be rejected as duplicates. Issuers should resubmit only rejected claims on subsequent claim ?le submissions. If the entire claim ?le was rejected, issuers may resubmit the ?le in its entirety. (REGTAP FAQ Database - FAQ #7392 11/18/14) Q: If an issuer has vendors located throughout different time zones, and its system does not capture the time zone where the claim was adjudicated/processed, can issuers assume a standard time zone for all its submissions to convert the claim date-timestamp and other timestamps for enrollment, pharmacy, supplemental claim and medical claim extracts to Greenwich Mean Time (GMT) zone? Updated 1-31-17 A: There is no time zone requirement. Issuers may choose the appropriate time zone based on their business needs. It is important to note that the Centers for Medicare 368 2017--00468 Medicaid Services (CMS) host is located in the United States Eastern Time (ET) zone. Issuers who use GMT may experience rejection of ?les if the ?le generation time on the submitted ?le is later than ET at the time of ?le submission. (REGTAP FAQ Database - FAQ #7424 11/18/14) Q: The Interface Control Document (ICD) version 02.0.00 states all times should be submitted as Greenwich Mean Time (GMT). This is a change from the previous ICD. Will EDGE server submission data be rejected if the time is not A: The current version of the ICD has been updated. The GMT time zone is no longer required. Issuers may choose the appropriate time zone based on their business needs. It is important to note that the Centers for Medicare Medicaid Services (CMS) host is located in the United States Eastern Time (ET) zone. Issuers who use GMT may experience rejection of files if the file generation time on the submitted file is later than ET at the time of ?le submission. (REGTAP FAQ Database - FAQ #7425 11/18/14) Q: In the EDGE Server submission file naming convention, is the Submitting Entity ID the Issuer ID or another A: The Submitting Entity ID is the ?ve (5) digit Health Insurance Oversight System (HIOS) assigned Issuer ID. (REGTAP FAQ Database - FAQ #2807; 2807a 11/26/14; updated 12/11/15) Note: REGTAP issued an ?update? to this FAQ on 12/11/15, but the only changes from the original FAQ were capitalization of ?Submitting Entity? and ?lssuer ID. Q: Does the Centers for Medicare Medicaid Services (CMS) base the Total Claims Count on the Original Claim ID or the Original Claim ID and the Void/Replace Indicator? A: Replaced and voided claims will count towards the Total Claims count. In other words, the Total Claims count should include all claims in the file including void and replacement claims. (REGTAP FAQ Database - FAQ #2920 11/26/14) Q: How will the Centers for Medicare Medicaid Services (CMS) identify a denied claim line? A: Denied claims are identi?ed when the allowed amount at the header equals Any claims with an allowed amount of $0 at the header will be rejected. The same logic cannot be applied at the line level as claim lines may have a $0 allowed amount if they are part of a more inclusive service. Issuers may include a service that was denied because it was covered as part of another service that was paid. Issuers must not submit claim lines that were denied because the claims they were not covered Ear-net authorized as these services are not considered incurred by the issuer, and therefore, not eligible for consideration under risk adjustment or reinsurance. (REGTAP FAQ Database - FAQ #2932; 29323 11/26/14; updated 12/11/15) Q: Should issuers submit patient-initiated telephone and email encounter data to the EDGE server? A: The only claims eligible for submission for Risk Adjustment (RA) and Reinsurance (RI) consideration, are those that are billed and processed using Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System codes. 369 Updated 1-31-17 2017--00469 Claims which do not have valid CPT or code, are not eligible for RA RI consideration. (REGTAP FAQ Database - FAQ #3369 11/26/14) Q: Can The Centers for Medicare Medicaid Services (CMS) provide issuers guidance on how to handle virtual encounters and scheduled phone call claims? A: The only claims eligible for submission for Risk Adjustment (RA) and Reinsurance (RI) consideration, are those that are billed and processed using valid Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System codes. Claims which do not have a valid CPT or code are not eligible for RA RI consideration. (REGTAP FAQ Database - FAQ #3371 11/26/14) Q: Do issuers submit claims when they are the secondary payer? A: Issuers may submit claims if they are the secondary payer on a claim. The EDGE server software is designed to allow the same services to be submitted by multiple issuers. (REGTAP FAQ Database - FAQ #3551 11/26/14) Q: Can issuers report their local time when submitting files to the EDGE server? A: There is no time zone requirement. Issuers may choose the appropriate time zone based on their business needs. It is important to note that the CMS host is located in the US Eastern Time zone. Issuers who use GMT may experience rejection of ?les if the ?le generation time on the submitted file is later than Eastern Time at the time of file submission. (REGTAP FAQ Database - FAQ #3709 11/26/14) Q: Can issuers resubmit one (1) individual claim or do issuers need to resubmit the whole file; how does the error correction process work? A: In accordance with the void/replace rules found in EDGE Server Business Rules Issuers should not replace the whole ?le because some ?les are incremental, and if issuers resubmitted the whole ?le, the previously accepted records would then be rejected as duplicates. Issuers should either resubmit the one (1) previously rejected file by itself or submit the rejected ?le in the next incremental batch of files. (REGTAP FAQ Database - FAQ #4799; 4799a 11/26/14; updated 12/30/15) e; . . retired 06/01/0 Q: If an issuer acquires policies in the Individual or Small Group Market that include risk adjustment covered plans or reinsurance-eligible plans partway through a benefit year, how should the issuer submit enrollment and claims data to the EDGE server? 16) A: As outlined in the HHS Notice of Bene?t and Payment Parameters for 2017 Final 370 Updated 1-31-17 2017--00470 Rule (81 FR 12204, 12238), an entity acquiring or entering into another arrangement with an issuer to serve the current enrollees under a plan with substantially the same coverage terms, may accrue the previous months of claims experience for purpose of risk adjustment and reinsurance to fully reflect the enrollees' risk and claims costs. Multiple options are available in submitting the insolvent or acquired issuer's enrollment and claims data to the EDGE server(s): 1. Both the acquiring entity and acquired issuer could separately submit EDGE server enrollment and claims data, with each submitting the claims data related to the period of time in which it provided coverage to the respective enrollees. This data would be considered separate in the reinsurance payment calculations and risk adjustment transfer calculations. 2. The acquiring entity and acquired issuer may arrange for a single EDGE server data submission. CMS finalized a ?substantially the same? standard because in many of these situations, an acquiring entity's platform may require some adjustments to the plan arrangement and coverage terms. As part of meeting this standard, an acquiring entity would be required to carry over accumulators for deductibles and annual limitations on cost sharing. If the ?substantially the same" standard is met, and the acquired issuer and the acquiring entity agree that the acquiring entity will accrue the previous months of claims experience, the acquiring entity must take responsibility for submitting to the respective EDGE server(s) complete and accurate claims and baseline information for that benefit year (including data from the insolvent issuer) in accordance with HHS's operational guidance to maintain eligibility to receive payments under this program for the given bene?t year. Operationally, the acquiring entity may elect to have the insolvent issuer submit the data on behalf of both entities CMS will work with issuers and acquiring entities in these situations to facilitate the submission of accurate and complete data to EDGE servers that is necessary to calculate risk adjustment financial transfers and reinsurance payments, though the ultimate responsibility for the submission will rest with those parties. Please contact EDGE server data@cms.hhs.qov for CMS assistance. (REGTAP FAQ Database - FAQ #15580 04/20/16) Data Submission Other Q: When can we begin submitting 2016 benefit year files to the Edge server? A: Thank you for your inquiry. Issuers may begin submitting 2016 files to the Test zone now. However, they cannot start submitting to the Production Zone until after the blackout period is lifted. (REGTAP FAQ Database - FAQ #15707 04/27/16) Q: Do you know when the email with the attestation template for the final 2015 Edge submission (due 5/2/16) will be sent from CMS to the issuers? Updated 1-31-17 A: CMS will not be emailing issuers an attestation template. Issuers will attest and file discrepancies as outlined in the 4/21 presentation entitled: Risk Adjustment (RA) and Reinsurance (RI) Attestation and Discrepancy Reporting Process for the 2015 Benefit Year, located in the REGTAP library. (REG TAP FAQ Database - FAQ #15708 05/02/16) 371 2017-?00471 Edqe Server/Risk Adjustment Operations - Policy Q11. Where can I find more information about the masked enrollee ID for distributed data collection? A11. As established in 45 CFR ?153.720, the issuer must establish a unique masked enrollee identi?cation number for each enrollee, in accordance with HHS-de?ned requirements. The Interface Control Document (ICD) further clari?es that this number cannot be a medical record number or cardholder ID number. The ICD is available in the REGTAP Library available at (Distributed data collection for Reinsurance and Risk Adjustment FAQ #5 09/23/13; REG TAP FAQ Database - FAQ #386 09/23/13) Q12. Is the edge server only applicable to plans inside the Marketplace? A12. No. Risk adjustment covered plans and reinsurance eligible plans operate inside and outside of the Marketplace (formerly Exchange) (Reference: ACA Sections 1341 and 1343). Please refer to 45 CFR ?153.700 for distributed data environment (edge server) requirements. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #5 09/23/13; REG TAP FAQ Database - FAQ #387 09/23/13) Q13. Why are pharmacy claims for small group members required if the reinsurance program is only applicable to individuals? A13. In order to reduce issuer burden, a single ?le including data elements for both the risk adjustment and reinsurance programs was developed. Upon initiation of either the risk adjustment or reinsurance software, only the relevant data elements for the specific program will be used. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #5 09/23/13; REG TAP FAQ Database - FAQ #397 09/23/13) Q27. Why are the minimum requirements for an Edge Server so much for a small issuer (1TB for data and 20063 for operating system)? A27. The recommended minimum requirement for the Edge Server provides for suf?cient data storage for three (3) years of production data. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #2 07/15/13; REG TAP FAQ Database - FAQ #258 07/15/13) Q44: Will the supplemental claim diagnosis information for the risk adjustment program be submitted separately from the medical claim and not as a 'Void/Replacement' of a previously submitted claim? A44: Yes. The supplemental data will be submitted using its own format, which is in development. The format will be provided when it becomes available. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #3 07/23/13; REG TAP FAQ Database - FAQ #436 07/23/13) 372 Updated 1-31-17 2017-?00472 Q45: Will the risk adjustment software be available for issuers to calculate their own risk scores? A45: Risk scores will be calculated using CMS developed software that will be run on the Edge Server. Details regarding the risk adjustment specific code that will reside on an Edge Server will be provided in the future. Until the risk adjustment code is ready for release, you can utilize the HHS-Developed Risk Adjustment Model Algorithm Software available at: Guidance/index.htm #Premium Stabilization Programs (posted on May 7, 2013). (Distributed data collection for Reinsurance and Risk Adjustment FAQ #3 07/23/13; REG TAP FAQ Database - FAQ #274 07/23/13) Q46: Are the processing rules on the Edge Server ICD-10 complaint? A46: In developing the Edge Server software, CMS has considered ICD-1O coding. As we approach the implementation date of issuers will be provided with any changes that may be necessary when submitting claims containing information. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #3 07/23/13; REG TAP FAQ Database - FAQ #244 07/23/13) Q47: How are management tools McAfee) maintained on the Edge Server whenever updates are pushed to the Edge Server from the CMS Management Console and how is change management coordinated with issuers? A47: Antivirus and related security software is the responsibility of the Edge Server owner. HHS will use the CMS Management Console to provide software updates to the CMS-supplied software on the Edge Server. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #3 07/23/13; REG TAP FAQ Database - FAQ #212 07/23/13) Q48: How will issuers know if a claim is orphaned? Orphaned claims are de?ned as having no enrollment period record associated with a submitted claim? A48: Outbound reports of claims without enrollee records and enrollees without claims will be provided at intervals to be determined in the near future. These outbound reports will be provided prior to identifying claims eligible for risk adjustment and reinsurance. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #3 07/23/13; REG TAP FAQ Database - FAQ #245 07/23/13) Q49: Should issuers place all medical and pharmacy data for Risk Adjustment eligible plans on the Edge Server, or only data applicable to an A49: Issuers should submit all claims to the Edge Server. Issuers should not filter claims since claims are used for both risk adjustment and reinsurance, and filtering will likely remove relevant claims for one or both programs. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #3 07/23/13; REGTAP FAQ Database - FAQ #213 07/23/13) Q50: Are there rules about what bill types should or should not be submitted to an Edge Server? A50: As indicated in the Edge Server Business Rules, Section 7.10, Bill Types xx2, xx3, xx4, xx5, xx6, xx9 will not be accepted. Claims submitted with bill type xx2, xx3, xx4, xx6 373 Updated 1-31-17 2017--00473 or xx9 will result in rejected records. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #3 07/23/13) Q51: Are there implications for the overlapping stay logic if an individual has primary and secondary coverage in two different plans? A51: We will be adding Plan ID to the overlapping stay logic to prevent claims from rejecting when an individual is dual enrolled. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #3 07/23/13; REG TAP FAQ Database - FAQ #279 07/23/13) Q14. When will sessions about risk adjustment and reinsurance be conducted? A14. CMS will notify issuers of upcoming sessions on the risk adjustment and reinsurance programs through the REGTAP system. CMS anticipates providing information on reinsurance and risk adjustment calculations in 2014. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #4 08/16/13; REGTAP FAQ Database - FAQ #267 08/16/13) Q: Will Risk Adjustment and Reinsurance transfers need to be allocated to each plan based on premium or do the resulting transfers have to be directly assigned to the QHP from which the transfer resulted? A: The pooled amount of allowable costs in the risk corridors numerator should be reduced by the overall amount of net risk adjustment payments and reinsurance payments that the issuer has received for all of its non-grandfathered, ACA compliant plans in a particular market within a state. (REGTAP FAQ Database - #1718 05/28/14) Q: Can issuers change from an On-Premise server to an Amazon server over time? A: For assistance with system miqration, please contact the Financial Management Coordinating Center (FMCC) Service Representative and they will be able to assist you. Send an email to and copy CMS FEPS@cms.hhs.gov. Please make sure to add the Service Representative's nameinthesubiectline. -- . Q: What types of organizations are required to set-up an EDGE server? Updated 1-31-17 A: All issuers in the individual markets offering non-grandfathered, Affordable Care Act (ACA) compliant major medical coverage both on and off of the Marketplaces in a State where the Department of Health and Human Services (HHS) is operating Reinsurance (RI) are required to establish an EDGE server in order to receive RI payments. issuers in the individual and small group markets offering non-grandfathered, ACA- compliant coverage both on and off of the Marketplace in a State where HHS is operating Risk Adjustment (RA) are required to participate in the RA program. Issuers that only offer transitional plans, grandfathered plans or plans that do not conform with 374 2017-?00474 the ACA market reform and coverage rules ACA rating requirements, essential health bene?ts requirements) are not eligible to receive RI payments and participate in the RA program). (REGTAP FAQ Database - FAQ #7223 11/14/14) Note: REGTAP issued an ?update? to this FAQ on 12/11/15, but upon comparison to the original FA Q, no changes were identi?ed. Q: Do issuers using an On-Premise EDGE server need to set up an Amazon Web Services (AWS) account? A: Issuers using an On-Premise EDGE server will not need to set up an AWS account. However, yeu?eethe server must will?have?te be able to connect to the Centers for Medicare Medicaid Services' (CMS) AWS environment to pull files the EDGE application, update scripts). Please refer to the EDGE Server On-Premise and Amazon pre-registration and Registration Presentation Slides posted in library for more information on con?guring your On-Premise server. (REGTAP FAQ Database - FAQ #7224; 7224a 11/14/14; updated 12/11/15) Q: Is there a minimum amount of data that issuers must send to the Centers for Medicare Medicaid Services (CMS) via the EDGE server? A: No, there is no minimum amount of data that issuers must send to CMS. CMS requires issuers to submit data quarterly and recommends that issuers submit data more frequently, as needed. As a reminder, enrollment ?les must be complete ?les of all enrollees and enrollment periods. (REGTAP FAQ Database - FAQ #7249 11/14/14) Q: Will the Centers for Medicare Medicaid Services (CMS) allow files that issuers send to the EDGE server after January 1, 2015 to include data for the 2014 Benefit Year as well as the 2015 Benefit Year, or should files submitted through April 30, 2015 only include data for the 2014 Bene?t Year? A: Enrollment, medical and pharmacy claim ?les and supplemental ?les can contain both 2014 and 2015 data even if the data is submitted after January 1, 2015. It is important to note that issuers must submit full EDGE Server Enrollment Submission (ESES) ?les for all benefit years until notified by CMS. Medical, pharmacy and supplemental ?les should be incremental and may include information for multiple benefit years. (REGTAP FAQ Database - FAQ #7250 11/14/14) Q: Since self-insured plans do not share in distributions from the Reinsurance (RI) Fund, and enrollment numbers will already be reported through Pay.gov, what data should self- insured plans submit through the EDGE server? A: Self-insured plans do not need to setup or submit data to the EDGE server. Only non- grandfathered, small group and individual market plans, both on and off the marketplace, should submit data to the Edge server. (REGTAP FAQ Database - FAQ #7255 11/14/14) Q: If a member moves from one (1) issuer to another issuer due to a plan change or relocation across States, does the Unique Enrollee ID remain the same or should the new issuer generate a new Unique Enrollee ID and can an enrollee hold two (2) Unique Enrollee IDs across two issuers? A: Risk Adjustment (RA) and Reinsurance (RI) diagnoses and payments are only 375 Updated 1-31-17 2017--00475 aggregated at the ?ve-digit Health Insurance Oversight System (HIOS) issuer ID level. Issuers must use the same Unique Enrollee ID if the enrollee switches plans within the same issuer and within the same state. Each issuer would assign its own Unique Enrollee ID. The IDs do not need to be maintained if an enrollee moves to a plan with a different HIOS issuer ID within the same organization. (REGTAP FAQ Database - FAQ #7258 11/14/14) Q: Are issuers required to submit claims from grandfathered and transitional plans to the EDGE server? A: EDGE server data collection is speci?c for Reinsurance (RI) and Risk Adjustment (RA) programs. Individual and small group plans are subject to RI and RA reporting; grandfathered plans are not included, nor are transitional plans. Issuers must not report grandfathered or transitional plans when submitting enrollment or claims to the EDGE server. (REGTAP FAQ Database - FAQ #7391 11/18/14) Q: Can issuers submit 2014 and 2015 EDGE server data at the same time? A: Yes. Since enrollment ?les are full replacement ?les, 2014 and 2015 enrollment data must be submitted together until such time as issuers are noti?ed by the Centers for Medicare Medicaid Services (CMS) to stop submitting 2014 enrollment data. Since medical, pharmacy and supplemental files are incremental files issuers may combine the data, for multiple years, into a single submission or submit them separately. (REGTAP FAQ Database - FAQ #7394 11/18/14) Q: Section 7.2, Table 41 of the EDGE Server Business Rules (ESBR), version 2.0, states claims from 'both inside and outside the marketplace' are accepted. Can the Centers for Medicare Medicaid Services (CMS) elaborate on what this means? A: In general, issuers with non-grandfathered plans in the individual or small group market, both inside and outside the Marketplace will need to be included in EDGE server data submissions. However, only plans that are subject to the 2014 market reform rules are required to submit data for the Risk Adjustment (RA) and Reinsurance (RI) programs. Grandfathered or transitions plans are excluded from the risk adjustment and reinsurance programs. Please refer to the 2014 Payment Notice for more information on the plans that are required to participate in the RA and RI programs. (REGTAP FAQ Database - FAQ #7400 11/18/14) Q: How does the EDGE application verify that stored data meets the following Risk Adjustment (RA) and Reinsurance (RI) payment requirements: all enrollees provided are tied to at least one (1) claim or encounter; all claim and encounters records are tied to a valid enrollee; and all claims and encounters record were incurred during a valid enrollment period for an enrollee? A: Comparisons of claims and enrollees are done prior to the running of RA and RI calculations. Issuers will be provided with outbound files of claims without enrollees (orphan claims) and enrollees without claims and issuers will have an opportunity to submit additional data to resolve any missing information. Claims are selected, for the appropriate benefit year, using multiple selection criteria which is part of the risk adjustment and reinsurance software. The Centers for Medicare Medicaid Services (CMS) will provide information on how claims are selected and risk scoring and RI 376 Updated 1-31-17 2017--00476 calculations are performed later in 2014. (REGTAP FAQ Database - FAQ #7407 11/18/14) Q: If an issuer adds plans that are effective after January 1, 2015, when should that issuer 1) complete EDGE server provisioning, 2) submit test files and 3) submit production files? A: Issuers who have eligible 2014 plans must register and provision an EDGE server by November 21, 2014. If an issuer does not have any eligible plans until 2015, they may register and provision an EDGE server in the early part of 2015 but would not be expected to submit enrollment or claims data to the production zone until the first quarter of 2015. The Centers for Medicare Medicaid Services (CMS) will provide more information on the timing of registration and provisioning for issuers with plans that ?rst become eligible in 2015 later this year. (REGTAP FAQ Database - FAQ #7416 11/18/14) Q: If an issuer fails to submit enrollment and claims files to the EDGE server production zone by December 5, 2014, what are the consequences? A: In order to ensure that all issuers the integrity of the data submission process it is critical that all issuers follow the implementation schedule that was shared during our recent webinar. The Centers for Medicare Medicaid Services (CMS) will be conducting follow up actions with issuers that do not comply with the schedule. (REGTAP FAQ Database - FAQ #7426 11/18/14) Q: Can The Centers for Medicare Medicaid Services (CMS) provide issuers a deadline for quarterly EDGE server data submissions and define effective periods for submitted data? A: As soon as issuers complete the registration and provisioning process, they will be able to submit ?les to their EDGE servers. All data for the 2014 coverage year will have to be submitted by April 30, 2015 for the 2014 coverage year. Issuers must submit their ?rst production ?les to the EDGE server by December 5, 2014. The initial production submission should include the most up-to-date claims and enrollment data that the issuer has available at the time of the submission. Issuers should begin the process of submitting ?les to the test zone as soon as they complete the provisioning process in order to identify and resolve data discrepancies prior to their first production submission. Following the initial production submission, issuers with incomplete submissions or identi?ed data de?ciencies must, submit a ?le at least until they have submitted complete error free set of data for the 2014 coverage year. (REGTAP FAQ Database - FAQ #2736 11/26/14) Q: What is the source of the codes in the Enrollment Period Activity field of the EDGE Server Enrollment Submission and are they Department of Health and Human Services (HHS)ICenters for Medicare Medicaid Services (CMS) provided or expected to be in an issuer's system already? Updated 1-31-17 A: Codes 021028, 021041 and 021 EC are based on the concatenation of the 834 05021' maintenance type code and 834 maintenance reason codes and Code is based on the 834 maintenance type code for a change. We use these codes for the specific purpose of identifying enrollment period changes that are important to the Risk Adjustment and Reinsurance programs. For additional information, 377 2017-?00477 please refer to operational guidance related to the Enrollment Period Activity Indicator (EPAI) codes that was published in the REGTAP library in October ESES- 5CR 100314.pdf). (REGTAP FAQ Database - FAQ #7911 11/25/14) Q: When submitting data for Risk Adjustment (RA) to the External Data Gathering Environment (EDGE) server, are plan members outside of the Marketplace included in data collection? A: Yes, issuers must submit enrollment and claims data for members enrolled in their small group and individual plans on-Marketplace and off-Marketplace. For more information, please see the 2014 Payment Notice (REGTAP FAQ Database - FAQ #7962 12/02/14) Q: Are issuers supposed to send both primary and secondary diagnosis codes and does the order matter? A: Issuers should just apply the diagnosis codes from the original claim. Order is not relevant for risk adjustment calculations, but should be similar to what is represented on the original claim or encounter. For additional information, please refer to the External Data Gathering Environment (EDGE) Server Business Rules (ESBR) document in the REGTAP library 50R 081114.pdf). (REGTAP FAQ Database - FAQ #7925 11/25/14) Q: What is the Center for Medicaid Medicare Services (CMS) definition of rating area in regards to the Risk Adjustment (RA) program? A: A rating area is based on a geographic area in a state. Each state determines the geographic rating areas that all issuers in the state must uniformly use as part of rate setting. For additional information on rating area, please go to: on the CCIIO website. (REGTAP FAQ Database - FAQ #7967 12/02/14) Q: How do payment transfers in the Risk Adjustment (RA) program transfer funds between metal levels? Updated 1-31-17 A: Risk adjustment payment transfers are calculated for all plans in a risk pool in a state market. There are three risk pools in all HHS-operated states except Vermont: 1) individual market and all metal plans; 2) individual market and all catastrophic plans, and 3) small group market and all metal plans. Please note that for Vermont there are two 378 2017-?00478 risk pools because Vermont has merged their individual and small group markets: 1) individual and small group markets and all metal plans and 2) individual market and all catastrophic plans. We will provide additional information on risk adjustment payment transfers in a future risk adjustment webinar. For more information, see the Market Rules regulations (REGTAP FAQ Database - FAQ #7969 12/02/14) Q: Does the Center for Medicare and Medicaid Services (CMS) intend to publish the Geographic Cost Factor (GCF) values? A: CMS does not intend to publish a consolidated list of GCF values at this time. The issuer's GCF values will be included on the issuer's plan transfer report. (REGTAP FAQ Database - FAQ #7978 12/02/14) Q: Are issuers able to delete a diagnosis code from the original claim or encounter submitted to the External Data Gathering Environment (EDGE) server with the supplemental file or the supplemental diagnosis code that was added? A: Yes, if a diagnosis code on a medical claim was removed due to a medical chart review, a supplemental delete record can be used to remove the diagnosis code from the medical claim. This will also work to remove a diagnosis code th - 2 the-REGIAP?Library? (REGTAP FAQ Database- FAQ #8135; 81353 12/10/14- updated 06.07/16) diagnoseSQ?Will' Issuers receive a report documenting deletlon of supplemental diagnosiSI ?les? Updated 1-31-17 A: There is not currently any report that lists which diagnosis codes were added or deleted due to supplemental records. In order to confirm if the supplemental records were applied as intended the issuer must validate the diagnosis codes for the enrollee that appear in the Risk Adjustment Risk Score Detail (RARSD) Report 2017-?00479 leeated?imthe?REGIAP?EibraryT (REGTAP FAQ Database - FAQ #8136; 81368 12/10/14; updated 06.07/16) Q: If an issuer voids and replaces an External Data Gathering Environment (EDGE) server medical claim that links to a supplemental diagnosis record, and the new medical claim will not reference the original claim, will the supplemental diagnosis code be associated with the new claim? A: Since the supplemental ?le must reference an active medical claim ID, the EDGE server software will link any accepted supplemental diagnosis ?les to that medical claim ID and any subsequent claim IDs in the referenced claim family. For example: If you void the original claim ID after the supplemental file is accepted, then the supplemental diagnosis codes will not be considered for risk adjustment. If you replace the original claim ID with another claim ID after the supplemental ?le is accepted, then both claim IDs are in the same claim family and the supplemental diagnosis codes will still be considered for Risk Adjustment. For more information, please see the EDGE Server Business Rules document located in the REGTAP Library 5CR O81114.pdf). (REGTAP FAQ Database - FAQ #8137 12/10/14) Q: Should Enrollment Period Activity Indicator (EPAI) codes and be used? A: Code is used when a change occurs to the policy at the subscriber's level. Examples of changes for when code should be used include a change in the premium amount, a change in the subscriber's rating area (that does not result in a new policy issuance), and the addition of a new policy member. Code is used to indicate the initial issuance of a policy during the ?rst year of enrollment in an Affordable Care Act (ACA) compliant, Risk Adjustment covered and/or Reinsurance eligible health plan. Code is used to indicate policy renewal for continuous enrollment in an ACA compliant, Risk Adjustment covered and/or Reinsurance eligible health plan from one year to the next year. Code is used to indicate when a new member is added to the subscriber's policy in an ACA compliant, Risk Adjustment covered and/or Reinsurance eligible health plan. For additional information, please refer to operational guidance related to the EPAI codes that was published in the REGTAP Library in October 2014. (REGTAP FAQ Database - FAQ #8138 12/10/14) Q: Should issuers include the principal diagnosis/external causes of injury codes, or e- codes? A: Yes, e-codes should be submitted to the External Data Gathering Environment (EDGE) server along with other ?nal diagnosis codes in the medical claim ?le even if an e-code is not in the same claim location as principal and other diagnosis codes. (REGTAP FAQ Database - FAQ #8139 12/10/14) 380 Updated 1-31-17 2017--00480 Q: Can the Centers for Medicare Medicaid Services (CMS) elaborate on which plans are not included in the Risk Adjustment (RA) calculations? A: Any grandfathered or non-Affordable Care Act (ACA) compliant plans, dental plans or student health plans are not included in RA calculations. In addition, any plans that do not provide RA data for their enrolled members, or submit inadequate RA data will not be included in RA calculations, and will therefore be assessed a default charge. (REGTAP FAQ Database - FAQ #8144 12/11/14) - retired 06/01/016) Q: When calculating member months, how many decimal places will the Centers for Medicare Medicaid Services (CMS) use when rounding calculated values? A: All Risk Adjustment (RA) calculations on the External Data Gathering Environment (EDGE) server are rounded to 15 decimal places. (REGTAP FAQ Database - FAQ #8150 12/11/14) Q: Can the Centers for Medicare Medicaid Services (CMS) confirm that the dates of services associated with diagnosis codes on claims will be checked against the enrollee's enrollment period? A: Yes, dates of service on claims will be assessed against enrollment periods for the enrollee ID that are submitted on the enrollment ?le, and plan enrollment periods to determine acceptability for risk adjustment calculations. (REGTAP FAQ Database - FAQ #8152 12/11/14) Q: How does an enrollee's metal level factor into Risk Adjustment (RA) calculations? A: The risk adjustment model provides different plan liability cost factors for calculation of enrollee risk scores based on type of metal plan in which the person is enrolled. (REGTAP FAQ Database - FAQ #8153 12/11/14) Q: What is the significance of assigning an age band category? A: In order to perform the necessary RA calculations, all enrollees must be divided into three (3) age categories. The division into these categories is important in determining the algorithm that CMS will need to use to calculate RA risk scores. Each age band (adult, infant, and child) has a different method for calculating risk scores. Enrollees are 381 Updated 1-31-17 2017--00481 divided into these age bands enrollment period. Fer?mere additional information please refer to the 'Risk Adiustment New Issuer Risk Score Calculation (03/17/16)? document, located under the RA proqram area at in the REGTAP Librarv. (REGTAP FAQ Database - FAQ #8154 and 8154a 12/11/14; updated 04/14/16) 42/14/14; retired 06/01/16) Q: How will the Department of Health and Human Services (HHS)/Centers for Medicare Medicaid Services (CMS) assign the correct risk adjustment allowable rating factor for subscribers and policy members when the enrollment start and end dates are not based on a calendar year (JAN to A: The risk adjustment software code will compute each policy member's age at enrollment start date for initial policy issuance (code policy renewal (code or date of addition to the policy (code The Center for Consumer Information and Insurance Oversight (CCIIO) will end date all enrollment periods at for each payment year or use the end date provided by the issuer if the enrollment end date occurs before the end of the calendar year. For additional information, please refer to operational guidance related to the enrollment period activity indicator codes published in the REGTAP library in October 2014. (REGTAP FAQ Database - FAQ #8156 12/11/14) Updated 1-31-17 retired 06/01/16) 382 2017-?00482 Q: What is 'supplemental data' submission? A: Supplemental data refers speci?cally to supplemental diagnosis codes that were missed or omitted during initial External Data Gathering Environment (EDGE) server data submission and that are not part of the base adjudicated claim or accepted encounter on which the EDGE data is established. You must follow the EDGE Server ICD and business rules for submission of supplemental diagnosis data located in the REGTAP library. (REGTAP FAQ Database - FAQ #8158 12/11/14) Q: Regarding supplemental diagnosis codes, if an issuer rejects a claim and the provider re-submits the claim with additional diagnosis codes, and the issuer adjudicates that claim and the diagnosis code is on the adjusted claim, is it necessary for the issuer to also include this information on the Supplemental Diagnosis File? A: Based on this scenario, it is not necessary for the issuer to submit a supplemental diagnosis record if the diagnoses are part of the issuer's ?nal paid claim or accepted encounter. Reminder: Only ?nal, paid claims or encounters must be submitted to the External Data Gathering Environment (EDGE) server. (REGTAP FAQ Database - FAQ #8159 12/11/14) Q: What is the difference between a market and a risk pool? A: Market refers to the groups that are eligible to enroll in Affordable Care Act (ACA) compliant health insurance plans. There are two (2) ACA markets in each state?s individual and small group. A risk pool is a grouping of plan types within each market. Platinum, gold, silver and bronze metal level plans are one group of plans in each market. Catastrophic plans are a separate group that only exists in the individual market. In addition, States have the option to merge their individual and small group markets and are referred to as a merged market. Therefore, in most states there are three (3) risk pools: 1) individual market and platinum, gold, silver, and bronze plans; 2) individual market and catastrophic plans; and 3) small group market and platinum, gold, silver, and bronze plans. In merged market states there are two (2) risk pools: 1) individual market and small group market and all platinum, gold, silver, and bronze plans, and 2) individual market and catastrophic plans. For more information on Risk Adjustment (RA) program risk pools, please review the 11/5/2014 Risk Adjustment Webinar available at: Traininq1slides 110514 v2 5CR 1112 14.9df) in the REGTAP Library. (REGTAP FAQ Database - FAQ #8479 01/14/15) retired 06/01/16) Q: Where can issuers access the correct list of Risk Adjustment (RA) bill types? A: Issuers should refer to the list of acceptable bill types on slide 33 of the 'Risk Adjustment New Issuer RiskISchegajgujatiqn (03/17/16)? document, located under the 383 Updated 1-31-17 2017--00483 RA proqram area at in the REGTAP Library. in?the?Risk ??9!ng 3' retired 06/01/16) Q: Can the Centers for Medicare Medicaid Services (CMS) clarify the definition of spouse in the context of billable member months and Allowable Rating Factor (ARF A: The External Data Gathering Environment (EDGE) server enrollment file does not speci?cally identify the spouse on the subscriber's plan. The EDGE server RA software will derive the spouse based on the oldest non-subscriber greater than or equal to 18 years old. Any person designated as a spouse by the software is a billable member. In order to calculate ARF, the EDGE server uses all billable member months. (REGTAP FAQ Database - FAQ #9067 02/19/15) Q: Can issuers apply diagnosis codes on claims belonging to a baby to the mother's claims to ensure inclusion in Risk Adjustment (RA) calculations? A: The RA program subjects certain diagnosis codes to age or sex limiting. If the issuer submits these codes assigned to the mother, the External Data Gathering Environment (EDGE) server will not accept the diagnosis code if the code is restricted by age or sex. (REGTAP FAQ Database - FAQ #9069 02/19/15) Q: How should issuers address mother-baby bundled claims if the baby is never enrolled in a plan within the same issuer as the mother and will not have a Unique Enrollee CMS requires issuers to unbundle mother-baby claims and submit individual enrollment records and claims under separate Unique Enrollee IDs for the mother and the baby. Issuers should adopt and adhere to a consistent policy for unbundlinq claims. If the issuer is mandated to cover a newborn, a separate enrollment record and Unique Enrollee ID must be created for the baby?. Even if the baby is not enrolled, issuers must submit an enrollment record for time the issuer is required to cover the baby and the 384 Updated 1-31-17 2017--00484 issuer must submit any claims incurred durinq that time for the baby under the baby's Unique Enrollee ID. As a reminder for Risk Adjustment (RA) purposes: RA has separate adult, child and infant models and requires assiqnment to the correct model for an enrollee based on aqe. If claims are not unbundled, then the RA software code will only produce a risk score for the masked Unique Enrollee ID that is successfully matched to an enrollee record. As a reminder for Reinsurance (RI) purposes: All claims are aqqreqated based on the Unique Enrollee ID submitted on the claim. If claims are not unbundled, then claim costs will not be aqqreqated to each unique enrollee. Please see the EDGE Server Business Rules for further information on creatinq enrollment records for mandated coveraqe, quidance on Enrollment Period Activity Indicators (EPAI) and examples of creatinq separate enrollment records for mother and baby, and for quidance on unbundlinq mother and baby claims. *5.10 Mandated Enrollment Coveraqe?Table 29: Mandated Enrollment Coveraqe (EDGE Sever Business Rules) (REGTAP FAQ Database - FAQ #9070; 9070a 02/19/15; updated 12/31/15) Q: Can you provide a list of External Data Gathering Environment (EDGE), Risk Adjustment (RA) and Reinsurance (RI) reports? A: For a list of EDGE server, RA and RI Reports, please see the February 9, 2014 job aid at RA RI ReportsJobAid 020915 50R 0209 15.9df in the REGTAP Library. (REGTAP FAQ Database - FAQ #9255 03/11/15) Q: What is the purpose of the Data Quality Analysis Reports A: The DQAR reports help identify potential technical data problems, such as: derived values in the outbound reports are incorrectly calculated or are inconsistent with the established CMS risk adjustment methodologies; accepted claims and enrollment data that were incorrectly excluded from the calculations; or calculated values that are understated because of claims and enrollment records that were incorrectly rejected during the file processing edit checks. (REGTAP FAQ Database - FAQ #9256 03/11/15) Q: How should issuers submit External Data Gathering Environment (EDGE) Server Enrollment Submissions (ESES) so terminated enrollee claims are not considered orphaned claims? Updated 1-31-17 A: Under Marketplace rules, issuers are required to maintain a person as an enrolled member for 90 days if the member has ?nancial assistance, and after 90 days of non- payment the person is terminated back to the 31st day. That member is enrolled for those 30 days and the issuer must pay all claims in that 30-day period. The issuer owes no money for claims outside that 30-day period of coverage. If there is a state grace period for a non-?nancial assistance member, the answer lies in whether or not the state requires coverage for the 30 days without retroactive termination. If the answer is yes (the person is covered without retroactive termination), 385 2017--00485 then the person is considered to be enrolled even though the issuer did not receive a premium payment. If the answer is that the person is retroactively terminated, then the person is not enrolled and the claims should ultimately be rejected. Only report periods for which the person is considered enrolled, which is 30 days in Marketplace and up to state law period for outside the Marketplace. In all cases, when a person is considered to be enrolled despite non-payment of premium, the premium to be reported is the premium owed. (REGTAP FAQ Database - FAQ #9257 03/12/15) Q: How do the Centers for Medicare Medicaid Services (CMS) plan to handle the transition from to with regard to the interim bill claims? As an example if a member has an interim bill for 9/1/2015 through 9/30/2015 and then a final 10/1/2015 through 10/31/2015 when we do the aggregation what service code qualifier would we use? The issue is that one claim would use and the other would use A: For hospital inpatient bill type 11x with a discharge after 10/1/2015, the ?nal bill should include all discharge diagnoses along with the service code qualifier. For all other institutional bill types (non-hospital and hospital outpatient) that are accepted by the External Data Gathering Environment (EDGE) sewer, issuers can split the claims so all codes remain on one claim with Dates of Service (DOS) through 9/30/2015 and all codes placed on the other claim with DOS beginning 10/1/2015 and later. Please use the appropriate EDGE server diagnosis code quali?er for and (REGTAP FAQ Database - FAQ #9565 04/07/15) Q: How will the Risk Adjustment (RA) program calculate partial member months A: The RA software will calculate partial member months by dividing the number of days in the enrollment period by 30. (REGTAP FAQ Database - FAQ #9978 04/17/15) Q: How are partial member months calculated for baseline reporting? Updated 1-31-17 A: On the External Data Gathering Environment (EDGE) server, 30 days of enrollment equals one (1) member month. When calculating member months for baseline reporting, issuers should use the same standard as the EDGE server. When calculating member months for partial month enrollments, issuers must use the following conversion rate of days to member months: 386 2017--00486 One (1) day 0.033333 member months [rounded to the nearest hundredth or two (2) decimal places] Example: If a member is added on the 16th of a month with 15 days of enrollment coverage in that month, then the total member months reported for that enrollee would be: - (15 days of enrollment) (0.033333 member months) 0.499995 member months - The issuer would report 0.50 member months when rounded to the nearest hundredth. Member month estimates are for the applicable portion of the corresponding bene?t year. (REGTAP FAQ Database - FAQ #17860 10/19/16) Q: What is an insurance company attesting to when completing and signing the EDGE Data Attestation sent on May 22, 2015? A: The insurance company's Chief Executive Of?cer (CEO) or another individual who is authorized to legally and ?nancially bind the organization must attest that to the best of their information, knowledge, and belief, subject to any discrepancy reports identified in the attestation that the organization has ?led, the ?nal dedicated distributed data environment report reflects the enrollment, claims and encounter data submitted to the EDGE server through the May 15, 2015 grace period for the 2014 Bene?t Year and this data is accurate and consistent with the organization's own internal claims and enrollment data. This attestation is for all Health Insurance Oversight System (HIOS) Issuer IDs listed in the attestation letter. (REGTAP FAQ Database - FAQ #10797 05/28/15) Q: What is the final dedicated distributed data environment report referred to in the EDGE Data Attestation sent on May 22, 2015? A: The final dedicated distributed data environment report is the ?nal summary EDGE report generated after the May 15, 2015 grace period deadline. (REGTAP FAQ Database - FAQ #10798 05/28/15) Q: What should an insurance company do if the data submitted to the EDGE server does not reflect all of their issuers' 2014 enrollment, claims and encounter data? Updated 1-31-17 A: The Centers for Medicare Medicaid Services (CMS) has used the issuer's self- reported baseline data and EDGE server processing report to determine the completeness of the issuer's data. With the EDGE data attestation, issuers are certifying that the self-reported baseline data most recently provided to CMS and the EDGE file processing reports provide an accurate depiction of the overall completeness of issuers' data submissions to the best of their knowledge and belief. Issuers should ?le a discrepancy report if there are issues regarding the completeness of data that are not reflected in the self-reported baseline data or file processing EDGE reports. (REGTAP FAQ Database - FAQ #10799 05/28/15) 387 2017-?00487 Q: Are insurance companies required to separately attest to their self-reported baseline data? A: No, however, issuers must notify the Centers for Medicare Medicaid Services (CMS) as soon as possible if the reported baseline data is incorrect in a material way as to alter your data completion status. Issuers should notify CMS by emailing (REGTAP FAQ Database - FAQ #10800 05/28/15) re Q: Does the Risk Adjustment (RA) program consider revenue codes when processing institutional claims? A: No, the RA program only considers procedure codes when processing institutional claims. (REGTAP FAQ Database - FAQ #11622 08/19/15) Q: Does the one-year period of claims payment leniency for codes apply for the HHS-operated Risk Adjustment Program? A: No, the guidance applies only to Medicare fee-for-service claims from physician or other practitioner claims billed under the Medicare Fee-for-Service Part physician fee schedule. The HHS-operated Risk Adjustment Program remains unchanged and follows current clinical coding guidelines that require an accurate diagnosis accompanied by a valid code. (REGTAP FAQ Database - FAQ #13033 09/15/15) A: No, the coding guidelines are unchanged. (REGTAP FAQ Database - FAQ #13034 09/15/15) Q: Pursuant to 45 CFR 153.420(b) and 45 CFR 153.730, a risk adjustment covered plan or a reinsurance-eligible plan in a State in which the U.S. Department of Health and Human Services (HHS) is operating the Risk Adjustment (RA) or Reinsurance (RI) program, must submit data to be considered for RA payments and charges and RI payments for a benefit year by April 30th of the year following the applicable benefit year. However, April 30, 2016 is a Saturday. May an issuer of an RA covered plan or an Rl-eligible plan submit its data the next business day? A: Yes. For the 2015 Bene?t Year, a RA covered plan or a RI-eligible plan in a State in which HHS is operating the RA or RI program, must submit data to be considered for RA payments and charges and RI payments for the 2015 Benefit Year by Monday, May 2, 388 Updated 1-31-17 2017--00488 2016 by 5:00 pm. ET, which is the ?rst business day following the April 30, 2016 regulatory deadline. (REGTAP FAQ Database - FAQ #14472 12/21/15) Q: How should an issuer count an employer's employees in determining whether an employer is a small employer or large employer for purposes of the MLR, risk corridors, and risk adjustment programs? Note: This FAQ was issued under two different FAQ numbers: 15449 and 15450 Updated 1-31-17 A: For the Medical Loss Ratio (MLR) program established under Section 2718 of the Public Health Service Act (PHS Act), the issuer should use an employee counting method to determine group size consistent with the de?nitions in Section 2791(e) of the PHS Act. Therefore, issuers should determine small and large group market classifications for the MLR program by counting the total number of all employees (including full-time, part-time, and seasonal) employed by the employer on business days of the calendar year preceding the coverage effective date, and average it over the number of business days in that year. See 45 CFR 158.103 and related technical guidance.* Risk Corridors: For the risk corridors program, the issuer should use the employee counting method used to determine group size under State law. See 45 CFR However, under section 1304(b)(4)(D) of the Affordable Care Act and 45 CFR when a small employer participating in a SHOP ceases to be a small employer solely by reason of an increase in the number of its employees, it will continue to be treated as a small employer for purposes of SHOP participation, and the issuer should treat such an employer as a small employer for purposes of risk corridors. Risk Adjustment: For the risk adjustment program, the issuer should use the employee counting method used to determine group size under State law, unless that counting method does not account for employees that are not full-time. If the State counting method does not take non-full-time employees into account, then the issuer should use the counting method under section 4980H(c)(2) of the Internal Revenue Code. See 79 FR 13754-13755. However, under section 1304(b)(4)(D) of the Affordable Care Act and 45 CFR when a small employer participating in a SHOP ceases to be a small employer solely by reason of an increase in the number of its employees, it will continue to be treated as a small employer for purposes of SHOP participation, and the issuer should treat such an employer as a small employer for purposes of risk adjustment. Technical Guidance (CCIIO 2011-004): MLR FAQ #18 (July 18, 2011); CCIIO Technical Guidance (CCIIO 2012-002): MLR FAQ ##27-28 (Apr. 20, 2012); CCIIO Technical Guidance (CCIIO 2012-003): MLR FAQ #39 (May 24, 2012); available from Loss Ratio. See also Frequently Asked Questions on the Impact of PACE Act on State Small Group Expansion (Dec. 17, 2015), available at (REG TAP FAQ Database - FAQ #15449; also issued as #15450 04/12/16) 389 2017--00489 Edqe Server/Risk Adjustment Operations - Reports Q34. It was mentioned several times in the March 20 presentation that detailed and summary reports will be available to issuers quarterly. Will these reports include only the issuer's data or will they also include market information? A34. The summary and detailed reports from the Edge Server are provided to issuers after each Edge Server submission. These ?les will contain information about the submitted ?le only. Reporting related to the Risk Adjustment and Reinsurance Programs speci?cally is currently under development. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #1 05/09/13) Q33: Is the accept-reject report file format XML or regular text file? A33: The format for the outbound report files is XML. The Interface Control Document (ICD) provides the layout for the XML. The XSDs for the layout are available in the REGTAP Library at so issuers can develop their Extract, Transform, and Load (ETL). (Distributed data collection for Reinsurance and Risk Adjustment FAQ #3 07/23/13; REG TAP FAQ Database - FAQ #236 07/23/13) Q37: Do issuers have to manually retrieve ?les or can FTP be used to retrieve the reports? A37: Outbound reports will be available both through the User Interface (UI) as well as the Secure File Transfer Protocol (SFTP) process. Reports can be retrieved from either one of those locations. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #3 07/23/13; REGTAP FAQ Database - FAQ #239 07/23/13) Q38: If the reports indicate that some elements are not accepted, do we need to resubmit the entire file again or just corrected data? A38: Resubmission of data depends on the inbound ?le. For enrollment ?les, the files always have to be full replacement files. If something is rejected in the enrollment ?le, the next submission of the enrollment file should have the corrections within that full ?le replacement. Medical and pharmacy claims files are not full replacement ?les. Therefore, if ?ve claims reject, then only those ?ve claims need to be resubmitted. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #3 07/23/13; REG TAP FAQ Database - FAQ #240 07/23/13) Q39: Will the risk adjustment and reinsurance software run on the same Edge Server used for data submission? Updated 1-31-17 A39: Yes. The risk adjustment and reinsurance software will run against the data tables on which the ?le processing results were stored. Outbound ?les related to risk adjustment and reinsurance will also be produced for issuers or their designated TPAs. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #3 07/23/13; REG TAP FAQ Database - FAQ #241 07/23/13) 390 2017--00490 Q40: Where can I ?nd information about the specifications of outbound reports available on the Edge Server? A40: Detail and summary report specifications are provided in the Interface Control Document (ICD) published in the REGTAP library. Outbound ?les will be available when the Edge Server software is released. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #3 07/23/13) Q41: Will outbound files be provided in a format other than Will there be software available to translate the XML into a readable format? A41: All outbound files will be produced in XML for retrieval by the issuer. It is the responsibility of the issuer to develop a process to translate the XML. The outbound XML can be retrieved via the User Interface (UI) and the File Transfer Protocol (FTP). (Distributed data collection for Reinsurance and Risk Adjustment FAQ #3 07/23/13; REG TAP FAQ Database - FAQ #242 07/23/13) Q42: When will reference table updates occur and how will this information be communicated? A42: Reference table updates may occur outside of a software release. Updates to software or reference tables will be communicated through the release management process. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #3 07/23/13; REGTAP FAQ Database - FAQ #280 07/23/13) Q43: When will information about outbound reports be available? A43: Detail and summary report specifications are provided in the latest version of the Interface Control Document (ICD). CMS hosted a webinar providing an overview of the outbound files on June 26, 2013. Outbound files will be available when Edge Server software is released. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #3 07/23/13; REG TAP FAQ Database - FAQ #268 07/23/13) Q10. What type of email notifications will we receive when the Edge Server outbound files/reports are ready? A10. There are different types of email notifications. The ?rst informs you whether the file met the three conditions to continue processing in XML format, test/production zone, and ?le type indicator - medical/pharmacy/enrollment type). That email will indicate if it accepted or failed and is not an actual outbound report. If accepted, it will provide a job ID. The Edge Server will then process the file, generate reports, and produce email notifications that reports are available. A Detail Accept or Reject report is produced for each file type that passes all the header verifications. This is sent only to the submitter and authorized receiver(s). CMS does not receive Detail Error reports. The Interface Control Document (ICD) Section 6.2, provides information about the speci?cations for outbound ?les. The ICD is available in the REGTAP Library at (Distributed data collection for Reinsurance and Risk Adjustment FAQ #4 08/16/13; REGTAP FAQ Database - FAQ #265 08/16/13) 391 Updated 1-31-17 2017--00491 Q11. Will a timeline be provided for the release of additional outbound data ?les/reports? A11. As additional reports become available, information will be provided through a Release Management process. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #4 08/16/13; REGTAP FAQ Database - FAQ #266 08/16/13) Q12. Who receives notification that outbound Edge Server ?les/reports are available? A12. An email noti?cation is sent to the submitter when an outbound report is produced. This is sent only to the submitter and authorized receiver(s). The Interface Control Document (ICD) Section 6.2, provides information about the speci?cations for outbound ?les. The ICD is available in the REGTAP Library at (Distributed data collection for Reinsurance and Risk Adjustment FAQ #4 08/16/13) Q14. What risk adjustment reports will issuers receive? A14: HHS plans to provide risk adjustment data reports for each issuer in 2014. More details about plans to report risk adjustment speci?c information at state and market levels prior to June 30, 2015, will be available in the future. (Distributed data collection for Reinsurance and Risk Adjustment FAQ #5 09/23/13; REG TAP FAQ Database - FAQ #388 09/23/13) Q: What are the file names for the different edge server outbound Detailed Error Reports and where will these ?les be stored? A: Outbound reports generated from the edge server include Edge Server Enrollment Detail Error Report, Edge Server Medical Claim Detail Error Report, Edge Server Pharmacy Claim Detail Error Report and Accept Reject Report for Enrollee, Medical and Pharmacy. Outbound reports will be available on issuers' edge servers both through the User Interface (Ul) as well as the Secure File Transfer Protocol (SFTP) process. Reports can be retrieved from either one of those locations. The Interface Control Document (ICD) Section 6.2, provides information about the speci?cations for outbound ?les. The ICD is available in the REGTAP Library at (REGTAP FAQ Database - FAQ #519 12/03/13) Q: How will the Centers for Medicare Medicaid Services (CMS) report orphaned supplemental diagnosis records to issuers, and when will CMS provide report speci?cations? Updated 1-31-17 A: There are currently no reports for supplemental record. Issuers will need to confirm that the correct diaqnosis codes are included in the Risk Adjustment Risk Score Detail (RARSD) report for each enrollee to verify if supplemental records were applied as intended. (REGTAP FAQ Database - FAQ #6526; 6526a; 10927a 10/31/14: updated 11/25/14 06/11/15 and 06/07/16) 392 2017-?00492 Q: How will the Centers for Medicare Medicaid Services (CMS) report orphaned supplemental diagnosis records to issuers, and when will CMS provide report speci?cations? (REGTAP FAQ Database - FAQ #6526a 11/25/14) Q: How are reports pushed from the On-Premise EDGE server to the Amazon server? A: There is an Application Program Interface (API) built into the EDGE application that invokes an Amazon Web Services (AWS) storage API to transfer the issuer's report or ?le to the Centers for Medicare Medicaid Services (CMS) 83 bucket. (REGTAP FAQ Database - FAQ #7241 11/14/14) Q: How will orphaned claims be handled in the EDGE server? Will it come back on a report or will they be rejected? Updated 1-31-17 A: Orphaned claims are not identified during medical or pharmacy claim file processinq. Therefore, claims cannot be reiected because they are orphaned. Accepted claims, stored as active records, are compared to the stored active enrollment records when Risk Adiustment (RA) and Reinsurance (RI) commands are executed. The Enrollee (Without) Claims Detail (ECD) Report will list the orphaned claims submitted to the External Data Gatherinq Environment (EDGE) server. The ECD Report (orphaned claims) includes Enrollee IDs that do not have any associated claims, as well as any Claim IDs that have no associated enrollment record for the Enrollee ID on the claim. The RA and RI proqrams will not utilize any orphaned claim data for RA and RI calculations. In order for a claim to be accepted for RA and RI calculations, it must be matched to an active enrollee. For more information, please see the Interface Control Document Addendum, located under the Distributed Data Collection (DDC) proqram area at in the Reqistration for Technical Assistance Portal (REGTAP) Library. meat?Glam (REGTAP FA 393 2017--00493 12/30/15) Q: When issuers submit data through the EDGE server and an error record is produced, is there a speci?c time frame in which issuers must correct the error? A: Issuers should establish a process for reviewing and resolving the outbound ?le and the reported reject errors on a regular basis. All corrections must be submitted no later than April 30th of the year following a bene?t year April 30, 2015 for 2014 bene?t year). After April 30th issuers will not have an opportunity to make corrections to rejected data. (REGTAP FAQ Database - FAQ #7248 11/14/14) Q: If an issuer receives an error report and identifies a necessary change for an entire file (medical, pharmacy or supplemental diagnosis), is there a mechanism within the EDGE server that will allow issuers to resubmit a full replacement rather than void and replace line by line, similar to the enrollment file submission process? A: If issuers receive an error report and need to void or replace claims for an entire file, full ?le replacement is not an option for medical, pharmacy or supplemental diagnosis resubmission. The claims must be resubmitted with the or indicator for each claim. The Centers for Medicare Medicaid Services (CMS) will allow issuers to purge their data in the test zone of the server in order for their test zone data tables to mirror the production data tables. A script will be provided to issuers to run through command line interface that will purge their test zone data. Issuers do not need CMS approval to purge test data. With regards to the production zone, in general, all issuers are expected to resolve issues with their stored claims data by submitting void and replacement claims. Issuers must resolve enrollment data issues by submitting full, updated replacement enrollment ?les. On a case-by-case basis, CMS may approve requests from issuers to purge all of their production zone data. Issuers will have to demonstrate that they have widespread systemic errors in their stored claims data that require complete purging of all their tables. Issuers must submit data purging requests to the Help Desk and get approval from CMS prior to purging production data. In order to maintain the integrity and traceability of the data collection process, issuers will not be allowed to delete or make modifications to individual stored records in the data tables. CMS will check for changes to the tables as part of the Reinsurance (RI) and Risk Adjustment (RA) audit process. (REGTAP FAQ Database - FAQ #7380 11/18/14) Q: Issuers understand there is a 30-day period to respond to interim reports and a 15 day period to respond to final reports produced by the Centers for Medicare Medicaid Services (CMS) for EDGE server data. What will be included in the interim report and the final report, and how will issuers respond to the reports? Updated 1-31-17 A: Issuers will receive information about Risk Adjustment (RA) and Reinsurance (RI) reports later this fall including the review process and how to communicate with CMS about those reports. Issuers will receive risk scores and RI payment estimates at the enrollee level. CMS will receive reports with plan level risk score and reinsurance payment estimates. CMS plans to continue hosting webinars and user groups through the end of 2014 to cover important information related to the RA and RI programs, including RA and RI reports and the issuer discrepancy reporting process. (REGTAP FAQ Database - FAQ #7381 11/18/14) 394 2017-?00494 Q: Regarding the outbound Extensible Markup Language (XML) reports that the Centers for Medicare Medicaid Services (CMS) sends to issuers, if there are no errors indicating the rejected record on the Summary Accept-Reject Report, can issuers assume that there are no errors regarding rejected records on the Detail Error Report? A: Yes, if there are no errors indicating the rejected record on the Summary Accept- Reject Report, there should not be errors regarding rejected records on the Detail Error Report. (REG TAP FAQ Database - FAQ #7382 11/18/14) Q: Is there an occasion where the EDGE server would provide an Accept or Reject status for every record received in the submitted inbound file? A: Yes, if the EDGE Server Medical Claim Submission (ESMCS) claim header passes, and there are several claim lines, some of which are accepted and some of which are rejected, the issuer would get an Accept-Reject message. At the header level it would say rejected because more than one (1) claim line failed; therefore the header has to be rejected as well, but in that case there would be detail on each claim line. Likewise, for the Enrollment file, if the parent passes, detail on the child will always be provided. (REGTAP FAQ Database - FAQ #7383 11/18/14) Q: When the EDGE server returns an EDGE Server File Accept-Reject Report (ESFAR) with an processing status for informational message, will the EDGE Server File Accept- Reject Report (ESFAR) include the error elements explaining what the warning is? A: Yes. The informational status code will include a detailed description of the reason for the code. If there is a discrepancy in the Paid Amount for what was reported at the issuer level versus what the sum is throughout the entire file, then the issuer will get the informing the issuer that to the file will continue processing, but the issuer reported dollar amount at the header does not add up to the sum of the plan or claim level reported paid amounts. (REGTAP FAQ Database - FAQ #7384 11/18/14) Q: Does each error type code for the EDGE server have a unique error message; and can the details be different or customized? A: Yes, error type codes for the EDGE server have a unique error message. The error messages may not be customized by issuers. (REGTAP FAQ Database - FAQ #7385 11/18/14) Q: When will the Centers for Medicare Medicaid Services (CMS) run the ?rst Reinsurance (RI) and Risk Adjustment (RA) payment estimate reports? A: The ?rst payment RI and RA payment estimate reports will be run in mid-December 2014. (REGTAP FAQ Database - FAQ #7409 11/18/14) Q: How will issuers identify the completion of file processing if the Amazon Web Services (AWS) is automated? A: At the completion of file processing, issuers will receive outbound reports corresponding to the file submission. Issuers may enable the email noti?cation feature in AWS to notify them when a ?le has completed processing. Instructions for enabling email noti?cations is included in the Job Aid titled, Server Job Aid: AWS File 395 Updated 1-31-17 2017--00495 Processing Email Notification - Step (REGTAP FAQ Database - FAQ #4599 1 1/26/14) retired 06/01/16) Q: Which reports provide a list of claim details with the diagnosis codes submitted to External Data Gathering Environment (EDGE) server? A: The RA Claims Selection Detail (RACSD) report includes the claims and diagnosis codes accepted for each individual, while the RA Risk Score Detail Report (RARSD) identi?es the codes included in the calculation of each individual's risk score. For more information, please see the Interface Control Document Addendum ICD RARIAddendum 5CR O13015.pdf located in the REGTAP Library. (REGTAP FAQ Database - FAQ #8889 02/09/15) Q: Which report provides a listing of orphaned claims for the Risk Adjustment (RA) program that fall outside of the member's enrollment period? A: The Enrollment Claims Detail (ECD) report will list the orphaned claims submitted to the EDGE server. For more information, please see the Interface Control Document Addendum ICD RARIAddendum 5CR 013015.pdf located in the REGTAP Library. (REGTAP FAQ Database - FAQ #8890 02/09/15) Q: What is the difference between discrepancy reports and Data Quality Analysis Reports A: ports (DQARs) are separate from the EDGE Server Outbound Reports. These reports are not generated on an issuer's EDGE server. These reports are separate analyses conducted by CMS to provide issuers with technical summary metrics related to their RI payment calculation and RA score calculation estimates. The DQARs also identify potential technical data problems. CMS may require follow-up with issuers and con?rmation of ?ndings based on data summaries in the DQAR. For more information, see the discrepancy reporting and DQAR webinar from 1/28 at RI DR DQARslides 012815 5CR 020415. in the REGTAP Library. (REGTAP FAQ Database - FAQ #8893 02/09/15) Q: My DQAR has errors, should I submit a discrepancy report? A: No, the discrepancy reporting process is only for the EDGE server outbound reports. Possible errors in DQARs can be addressed through instructions that CMS will provide when distributing these reports to issuers. For more information, see the discrepancy reporting and DQAR webinar from 1/28 at RI DR DQARslides 012815 5CR 020415. p_df in the REGTAP Library. (REGTAP FAQ Database - FAQ #8894 02/09/15) 396 Updated 1-31-17 2017--00496 Q: What should I do if I have previously truncated my records and now my DQAR is showing too many records? A: The Centers for Medicare Medicaid Services (CMS) is aware of the issue in DQARs with issuers who have previously truncated their records. Please disregard this for now and respond to the information requests to the best of your ability. For more information, see the discrepancy reporting and DQAR webinar from 1/28 at DR DQARslides 012815 5CR 020415. p_df in the REGTAP Library. (REGTAP FAQ Database - FAQ #8895 02/09/15) Q: I have added more data and would like to see a Data Quality Analysis Report (DQAR) report. Can you send me a new one? A: At this time, the Centers for Medicare Medicaid Services (CMS) does not intend to send out DQARs based off issuers' individual requests. The DQARs are generated If you make changes to the data in your EDGE server, please check subsequent DQARs for corrections. For more information, see the discrepancy reporting and DQAR webinar from 1/28 at RI DR DQARindes 012815 5CR 020415. p_df in the REGTAP Library. (REGTAP FAQ Database - FAQ #8896 02/09/15) Q: Why should I submit an informal discrepancy if it isn't required? A: Submitting an informal discrepancy will help both issuers and CMS prepare for the formal discrepancy reporting process, and can address issues well in advance of final payment calculations. For more information, see the discrepancy reporting and DQAR webinar from 1/28 at RI DR DQARindes 012815 5CR 020415. in the REGTAP Library. (REGTAP FAQ Database - FAQ #8897 02/09/15) Q: Why does the Risk Adjustment (RA) Risk Score Detail (RARSD) report and RA Risk Score Summary (RARSS) report restrict the Plan ID to 14 digits when the Reinsurance (RI) Detail Enrollment (RIDE) report allows for a 16 digit Plan ID and what is the reason for the difference? A: The RARSD and RARSS reports limit the Plan ID value to 14 digits because the last two (2) digits of a 16-digit Plan ID identify the plan's Cost-sharing Reduction (CSR) factor. RA risk score calculations include the CSR factor as an input. In addition, the calculation of RA payment transfers requires PLRS at the 14-digit plan ID and rating area level. (REGTAP FAQ Database - FAQ #9068 02/19/15) Q: Will issuers receive risk score values with information relative to other plans within a rating area? A: Issuers will receive elements of the risk score as compared to issuers nationally on their Data Quality and Analysis Reports. They will not receive risk adjustment payment and charge estimates, as they relate to other issuers, until payment transfers are calculated in June. (REGTAP FAQ Database - FAQ #9254 03/10/15) 397 Updated 1-31-17 2017-?00497 Q: What does the ?enrollee utilizer? field on the Risk Adjustment Risk Score Summary (RARSS) report describe? A: According to the External Data Gathering Environment (EDGE) Interface Control Document (ICD), an enrollee utilizer is an enrollee with at least one claim. For additional information, please refer to the ICD Addendum located under the Distributed Data Collection (DDC) program at in the REGTAP Library. (REGTAP FAQ Database - FAQ #11626 08/19/15) Q: Why is the amount on the Risk Adjustment (RA) Dunning Letter different from the amount on the RA payment transfer report? A: RA Dunning Letters provide issuers with their total outstanding balance for RA charge amounts by risk pool/ market. The RA payment transfer report provides the issuer with a detailed report of the RA transfer calculation results. The RA payment transfer report does not re?ect netting against other program charges Advanced Payment of Premium Tax Credits (APTC), Federally-facilitated Marketplace User Fees (FFM UF), 398 Updated 1-31-17 2017--00498 etc.], holdback, and sequestration amounts in the total. (REGTAP FAQ Database - FAQ #14699 01/26/16) Q: How do I access my Risk Adjustment (RA) reports? A: The RA payment transfer and RA proration reports will only be accessible on the External Data Gathering Environment (EDGE) server management console to users with Issuer Approver roles in the Health Insurance Oversight System (HIOS). The Issuer Approver will log into the EDGE management console. From the home page, a link will display titled ?View Payments Charges Reports?. The RA payment transfer report is labeled Transfer? and the RA proration report is labeled Proration?. In a separate process, issuers will receive their RA default charge report, RA default charge allocation report, RA default charge allocation proration report, and the RA user fee report (for issuers that owe default charges only) as a password protected file by electronic mail from the mailbox. (REGTAP FAQ Database - FAQ #14700 01/26/16) Q: Where is the Risk Adjustment (RA) risk pool/market on an issuer's invoice? A: An issuer can use the following information to determine which RA risk pool/market matches their invoice number. The ?rst letter in the invoice corresponds to the following programs and market designators. Program and Market Designator: RA (Risk Adjustment Transfers) - I (Individual) - (Small Group) - (Catastrophic) - (Merged) RAD (Risk Adjustment Default Charge) - (Individual) - 0 (Small Group) - (Catastrophic) - (Merged) (REGTAP FAQ Database - FAQ #14702 01/26/16) Risk Adjustment Operations Risk Scores Q: How will bundled Mother/Baby claims be calculated in terms of Risk Adjustment Updated 1-31-17 A: Each claim or encounter submitted to the EDGE has only one enrollee ID. If mother/baby claims are bundled, only the claims information for the enrollee ID on the claim may be eligible for risk score calculation if an associated plan enrollment record exists. Mother/baby claims should be unbundled to separate claim for the mother and for the baby, so the appropriate diagnosis codes can be assigned to each unique enrollee ID. For more information, please see the Risk Adjustment model algorithm software posted on June 2, 2014 and located under Premium Stabilization on the CCIIO 399 2017--00499 website (REGTAP FAQ Database - FAQ #7963 12/02/14) Q: How will an enrollee's age be calculated for risk score application? A: The risk adjustment software that will run on the EDGE server will use the enrollee's date of birth to calculate the risk adjustment model age based on the last date of enrollment in a plan, within the issuer, for the payment year. For example, if an enrollee is enrolled until August 31st, then the enrollee' age will be calculated as of August 31st, and that age is what will apply for calculation of the enrollee' 3 risk scores for all enrollment periods within the Issuer. additional information please refer to the 'Risk Adjustment New Issuer Risk Score Calculation document, located under the RA proqram area at in the REGTAP Library (REGTAP FAQ Database - FAQ #7964, 7964a 12/02/14; updated 04/14/16) Q: In the Plan Liability Average Risk Score (PLRS) formula, does the term 'plan' refer to a single plan or an issuer? A: In the formula for PLRS, the term ?plan' refers to a risk adjustment covered plan within an issuer. For more information, please see the 2014 Payment Notice (REGTAP FAQ Database - FAQ #7976 12/02/14) Q: What are the age bands that the Centers for Medicare Medicaid Services (CMS) have defined for risk score calculation? A: CMS has defined the risk adjustment model age bands as follows: infant model - age 0 and less than age 2; child model - age 2 through age 20; adult model - age 21 an over. For more information, please see the 2014 Payment Notice (REGTAP FAQ Database - FAQ #7977 12/02/14) Q: Can the Centers for Medicare Medicaid Services (CMS) clarify how the calculation of rating factors over two (2) different enrollment periods would occur? A: CMS will provide more details and examples of how the risk adjustment software that will run on the EDGE server calculates the allowable rating factor in a future risk adjustment webinar. (REGTAP FAQ Database - FAQ #7980 12/02/14) Q: What will be in the Risk Adjustment (RA) risk score report provided by the Centers for Medicare Medicaid Services (CMS) to the issuer? A: There are two outbound risk adjustment risk score reports. The Risk Adjustment Risk Score Summary (RARSS) report is available to both CMS and issuers. The Risk Adjustment Risk Score Detail (RARSD) report is available only to issuers and is not available to CMS. The RARSS report notifies CMS and issuers about issuer and plan level summary values from the risk score. The RARSD report contains detailed enrollee claim information used to calculate the individual risk score on the EDGE server. For 400 Updated 1-31-17 2017--00500 . A additional information, please refer to the 'Risk Adjustment New Issuer Risk Score Calculation (03/17/16)' document, located under the RA proqram area at in the REGTAP Library. (REGTAP FAQ Database - FAQ #7981 and 79816 12/02/14; udated 04/14/16) Q: Do risk score calculations exclude pharmacy claims? A: Pharmacy claims data will not be included in the calculation of risk scores. However, we note that issuers should not filter their own claims prior to submitting claims data to the External Data Gathering Environment (EDGE) Server. The risk adjustment ?ltering process will take place after all claims have been submitted to the EDGE Server. The calculations only include data from medical claims files, enrollment files and supplemental diagnosis ?les. Pharmacy claims are used for reinsurance. For more information on submitting claims, visit the EDGE Server Business Rules in the REGTAP Library 5CR 081114.pdf). (REGTAP FAQ Database - FAQ #8141 12/10/14) Q: Will Risk Adjustment (RA) risk score calculations include a newborn infant if they are the fourth child and not part of the three (3) oldest children identified in the Affordable Care Act (ACA) family rating? A: The newborn will have an individual risk score. That risk score will be used in determining the Plan Liability Average Risk Score (PLRS). However, when calculating PLRS, risk scores are weighted by billable member months. The infant's member months will not be counted towards the total billable member months of that plan. (REGTAP FAQ Database - FAQ #8148 12/11/14) Q: If an enrollee is enrolled in two (2) different plans (in the same market) in a benefit year and receives a diagnosis for a condition under one plan, how would the Risk Adjustment algorithm calculate the enrollee's individual risk score? A: For each enrollee ID, the Centers for Medicare Medicaid Services (CMS) will use all risk adjustment eligible claims submitted from across all plans within the issuer to calculate a risk score for each of the enrollee's enrollment periods. This means that if the member changes plans within the same issuer, claims data from each plan will be utilized to calculate the member's plan-speci?c risk scores. Note: the risk score value could change based on CSR status or plan actuarial value. If the member changes issuers, even within the same insurance company, then the claims data used to calculate the risk scores will relate to each speci?c issuer only. CMS will not link enrollee data across different issuers. (REGTAP FAQ Database - FAQ #8151 12/11/14) Q: How are risk scores aggregated to the issuer level? A: Risk scores are only aggregated to the plan level in a rating area and results in the Plan Liability Risk Score (PLRS). Please refer to the 2014 ?nal payment notice on the GPO website. (REGTAP FAQ Database - FAQ #8487 01/14/15) 401 Updated 1-31-17 2017--00501 Q: Will the required resubmission of enrollment files affect the Risk Adjustment (RA) risk score estimates produced by the current RA risk score estimate run? A: Yes, resubmitting enrollment ?les will affect RA risk score estimates due to the External Data Gathering Environment (EDGE) server code ?x regarding dependent enrollee records. The RA software code on the EDGE server uses dependent enrollee records to calculate a plan's member months and billable member months. Member months and billable member months are part of the calculation for plan liability risk score (PLRS). (REGTAP FAQ Database - FAQ #8675 01/21/15) Q: What stage of the Risk Adjustment (RA) claims selection process excludes orphaned claims from inclusion in RA calculations? A: Accepted claims without a corresponding enrollee ID (orphan claim) are included in the RA claims selection process since the process occurs immediately after ?le ingest. The next step is risk score calculation and it is during this process that ?orphan? claims are excluded from risk score calculation. (REGTAP FAQ Database - FAQ #9253 03/10/15) Q: During Risk Adjustment (RA) claims selection, must a claim include both an acceptable Current Procedural Terminology (CPT) code and an acceptable bill type, or will the External Data Gathering Environment (EDGE) server accept a claim that has either an acceptable CPT code or an acceptable bill type? A: The EDGE server will automatically consider institutional inpatient claims with bill types 111 and 117. For institutional outpatient bill types 131, 137, 711, 717, 761, 767, 771, and 777 and all professional claims to be included in RA claims selection, at least one (1) CPT code that is acceptable for RA must be on the claim. For more information, see the November 19, 2014 RA webinar slides 34-35, available at SlidesTrZ 111914 5CR 112114.pdf in the REGTAP Library. (REGTAP FAQ Database - FAQ #9258 03/11/15) Q: If an issuer does not have a metal level assigned for any plans, will risk scores for plan enrollees be zero A: Correct, the risk score calculation requires a plan metal level for the enrollee. The risk adjustment (RA) methodology consists of concurrent RA models, one for each combination of metal level (platinum, gold, silver, bronze and catastrophic) and age group (adult, child and infant). This information is displayed on slide 10 of the November 5, 2014 RA training slides located in the REGTAP library Traininq1slides 110514 v2 5CR 111214.p For more information on RA models, see the Do-lt-Yourself (DIY) Software Instructions at 402 Updated 1-31-17 2017--00502 on the Centers for Medicare Medicaid Services (CMS) website. (REGTAP FAQ Database - FAQ #9976 04/17/15) Q: Why is the value for plan liability risk score (PLRS) different between the Risk Adjustment Risk Score Detail (RARSD) report and the Risk Adjustment Transfer Elements Extract (RATEE) report? A: The External Data Gathering Environment (EDGE) server calculates member months differently for the Allowable Rating Factor (ARF) and the PLRS. The differing method of calculating member months causes slight differences between values in the RARSD and RATEE reports. The RARSD uses enrollee-level data at the 14-digit Plan ID which does not have a Cost-sharing Reduction (CSR) variant. The RATEE uses plan-level data and a 16-digit Plan ID, which includes the CSR variant. Please note that reports with plan- Ievel data are used for EDGE and should be used for your comparison. Issuers should contact the Help Desk at CMS FEPS@cms.hhs.qov or 1-855-267?1515 with speci?c questions regarding the reports. (REGTAP FAQ Database - FAQ #10802 06/01/15) Q: Why is the value for plan liability risk score (PLRS) different between the Risk Adjustment Risk Score Detail (RARSD) report and the Risk Adjustment Transfer Elements Extract (RATEE) report? A: The External Data Gathering Environment (EDGE) server calculates member months differently for the Allowable Rating Factor (ARF) and the PLRS. The differing method of calculating member months causes slight differences between values in the RARSD and RATEE reports. The RARSD uses enrollee-level data at the 14-digit Plan ID which does not have a Cost-sharing Reduction (CSR) variant. The RATEE uses plan-level data and a 16digit Plan ID, which includes the CSR variant. Please note that reports with plan-- level data are used for EDGE and should be used for your comparison. Issuers should contact the Help Desk at CMS FEPS@cms.hhs.qov or 18552671515 with specific questions regarding the reports. (REGTAP FAQ Database - FAQ #10857 06/04/15) Q: If a member who changes plans and metal levels within the same issuer has a diagnosis in one (1) plan that does not occur in the next plan, will the Centers for Medicare Medicaid Services (CMS) include the diagnoses from the prior plan in risk score calculation? A: All RA-eligible claims for the enrollee for the year are included in the risk score calculation for each enrollment period. CMS will apply all diagnosis codes from both plans for the entire enrollment period in the risk score calculation, as long as the enrollee maintains the same unique enrollee ID for each plan. (REGTAP FAQ Database - FAQ #14991 02/2916) Risk Adjustment Operations Payments Q: What is a Risk Adjustment (RA) default charge? Updated 1-31-17 A: The RA default charge is a charge assessed to issuers that have not provided adequate information, fail to set up an External Data Gathering Environment (EDGE) server, or omit pertinent data from the RA program. Additional information regarding default charges may be found in the 2015 Payment Notice located at 403 2017--00503 on the GPO website. (REGTAP FAQ Database - FAQ #8482 01/14/15) I .A-A retired 06/01/016) Q: At what level do Risk Adjustment (RA) payment transfers net to zero (0) or achieve budget neutrality? A: RA payments and charges within a market and risk pool should net to zero (0) dollars. (REGTAP FAQ Database - FAQ #9259 03/11/15) Q: How will Risk Adjustment (RA) payments and charges be transferred? A: The Centers for Medicare Medicaid Services (CMS) will collect funds from issuers due to remit charges and disburse funds to issuers receiving a payment. Risk Adjustment is a budget neutral program that transfers funds from plans with lower risk enrollees to plans with higher risk enrollees in a state market risk pool. (REGTAP FAQ Database - FAQ #9260 03/11/15) Q: Some issuers have been notified by CMS that their risk adjustment transfer amounts were adjusted after the release of the June 30, 2015, notification of payments and charges report. Do these issuers have to resubmit their new risk adjustment transfer amounts for risk corridors and medical loss ratio (MLR) ?lings for the 2014 benefit year? Updated 1-31-17 A: After posting the June 30 report, CMS notified some issuers of updates to their risk adjustment transfers and risk adjustment default charge allocations. Because these notifications did not occur in time for these issuers to submit by the July 31, 2015, risk corridors and MLR filing deadline, CMS stated that issuers must resubmit their 2014 risk corridors and MLR reports. Following the release of the updated risk adjustment payment noti?cations, some issuers have asked CMS if they must resubmit their data in cases where their updated risk adjustment payments had a nominal impact on their risk corridors and MLR calculations. If the inclusion of an issuer?s adjusted risk adjustment amount results in a $25 or less difference in their risk corridors or MLR amount in a given state and market, we will not require the issuer to resubmit the risk corridors and MLR reports for the 2014 bene?t year for that state and market. If an issuer is under this threshold and does not resubmit for 2014, this adjusted amount must be included and reflected in its 2015 risk corridors and MLR filings. All issuers that were notified of updates to their risk adjustment payment transfers or risk adjustment default charge allocations after the release of CMS's June 30 report must 404 2017--00504 recalculate their risk corridor payment or charge and MLR rebate amounts. Issuers with a calculated difference of more than $25 (greater or less than the original amount) must resubmit their 2014 MLR and risk corridors templates to CMS. Please contact MLRQuestions@cms.hhs.qov for resubmission instructions. If affected issuers have additional questions about this minimum resubmission threshold, please contact ACARiskCorridors@cms.hhs.qov or MLRQuestions@cms.hhs.qov and include your lD(s). (Risk Corridors and Medical Loss Ratio (MLR) Resubmissions for the 2014 Bene?t Year (08/14/15) Q: If CMS is unable to collect full risk adjustment charges from a particular issuer, how would charges and payments for other issuers in the same market and state be affected? A1: Although CMS will use all appropriate debt collection processes available to the federal government to enforce the collection of risk adjustment charges, in rare circumstances it is possible that an issuer may be unable to make full payment for its risk adjustment charges on time. To the extent CMS is not able to fully collect 2014 bene?t year risk adjustment charges in a risk pool in a market in a state, 2014 benefit year risk adjustment payments for that risk pool will be adjusted on a pro rata basis to re?ect the under collection. Risk adjustment charges for other issuers in the risk pool would not be affected. If CMS is unable to collect full risk adjustment charges in a state and market, the issuer can re?ect this reduction in payment on the following year?s risk corridors and medical loss ratio (MLR) ?ling. (Risk Adjustment Charges FAQ (08/14/15)) Q: When reviewing the Risk Adjustment (RA) transfer report from Health Insurance Oversight System if the dollar amount is positive does this indicate a transfer amount to the issuer, and if the dollar amount is negative (-) does this indicate a payment the issuer owes to the Centers for Medicare Medicaid Services Updated 1-31-17 A: If the dollar amount on the report is a negative (-) amount, this indicates a charge owed from the issuer to CMS. If the dollar amount on the report is a positive amount, this indicates a payment is due to the issuer from CMS. (REGTAP FAQ Database - FAQ #11624 08/19/15) 405 2017--00505 Q: Are my Risk Adjustment (RA) payments and charges netted across risk pool/markets? A: No, the RA payment transfer amount is calculated for each plan within a risk pool/market and plan rating area. The RA payments and charges within a risk pool/market should net to zero (0) dollars. The funds within a risk pool/market are transferred between plans only in the same risk pool/market. CMS invoices issuers with RA charges first by sending that issuer a Dunning Letter as noti?cation of monies owed in the risk pool/market. Issuers receive one (1) Dunning Letter for each program and risk pool/market for which there is an outstanding balance. RA proration payments begin after issuers have paid charges and funds are collected for each risk pool/market. The charges collected will be distributed based on the amount collected within the payment cycle in the same risk pool/market. (REGTAP FAQ Database - FAQ #14701 01/26/16) Q: How do the Centers for Medicare Medicaid Services (CMS) determine my Risk Adjustment (RA) default charge (RADC) allocation proration amount? Updated 1-31-17 A: RA default charges will be distributed based on the amount collected within the payment cycle in the same risk pool/market. The cycle of proration will only distribute funds that have been collected in your same risk pool/market. Issuers may only receive a portion of their allocation payments amount because the RADC was not collected in full prior to the cycle. An issuer will receive an allocation payment when CMS receives funds from an issuer who was assessed a default charge in the same risk pool/market. If an issuer did not receive the total amount expected for their RADC allocation payment, then the issuer should receive additional funds in a future payment cycle when monies are collected. Payments are made around the 20th of each month. The RADC allocation proration payment reports are sent by the end of each month to issuers who received payments. The RADC allocation proration payment report is emailed as a password protected file by electronic mail from the mailbox. Please note that this report does not re?ect holdback and sequestration amounts in the total. 406 2017--00506 (REGTAP FAQ Database - FAQ #14703 01/26/16) Q: How do the Centers for Medicare Medicaid Services (CMS) determine my Risk Adjustment (RA) transfer proration amount? A: The cycle of RA proration payments will only distribute funds that have been collected in your same risk pool/market. Issuers will only receive payments if CMS has collected an RA transfer charge in your risk pool/market. Issuers will only receive a portion of their payment amount because the RA transfer charges were not collected in full prior to the cycle and sequestration and holdback are applied. If an issuer receives an RA proration payment for the month, then the issuer should expect to receive an additional payment in a future payment cycle. Payments are made around the 20th of each month. Financial Transaction Reports and RA Proration reports are sent by the end of each month for issuers who received transfer payments. The RA proration report is made available on an issuer External Data Gathering Environment (EDGE) server management console. The report is labeled - RA Proration?. Please note that this report does not reflect holdback and sequestration amounts in the total. (REGTAP FAQ Database - FAQ #14704 01/26/16) Q: In light of some 2014 risk adjustment appeals being resolved and closed, will CMS release payment amounts held back for appeals and sequestration in States that no longer have a pending risk adjustment appeal? Updated 1-31-17 A: Yes. As CMS indicated in FAQ 13869, published 11/3/15, CMS will release the 10 percent holdback from the 2014 bene?t year risk adjustment payments in the payment cycle following final resolution of all 2014 bene?t year risk adjustment appeals in that State. For additional information on the administrative appeal process and timelines, refer to 45 CFR 156.1220. The release of holdback amounts will not be sequestered. See the July 15, 2015, and July 29, 2015, ,,Payments, Invoicing and Collections Process for the Risk Adjustment and Reinsurance Programs%o webinar presentation (available at: under the Payments- Remitting Amounts Due program area) for more information. Based on the administrative appeal process as of January 14, 2016, CMS will release payment amounts held back for risk adjustment appeals and ?scal year 2015 sequestration in the following States in the February 2016 payment cycle: 1. California 2. Colorado 3. Connecticut 4. Georgia 5. Indiana 6. Maine 7. Missouri 8. New Hampshire 9. Virginia 10. Wyoming 407 2017--00507 Note: CMS already released the payment amounts held back for risk adjustment appeals and sequestration in 28 States and the District of Columbia. Please see FAQ #13869 for the full listing of these States. (REGTAP FAQ Database - FAQ #14753 02/01/16) Q: As 2014 risk adjustment appeals are resolved, will the CMS release payment amounts held back for appeals and sequestration in States that no longer have a pending risk adjustment appeal? A: Yes. As CMS indicated in FAQ 13869 (published 11/3/15) and FAQ 14753 (published 2/1/16), CMS will release the 10 percent holdback from the 2014 bene?t year risk adjustment payments in the payment cycle following ?nal resolution of all 2014 benefit year risk adjustment appeals in that State. The administrative appeal process and timeline are contained in 45 CFR 156.1220. The release of holdback amounts will not be sequestered. See the July 15, 2015, and July 29, 2015, ?Payments, Invoicing and Collections Process for the Risk Adjustment and Reinsurance Programs" webinar presentation (available at: under the Payments- Remitting Amounts Due program area) for more information. Based on the current status of risk adjustment administrative appeals as of March 14, 2016, CMS will release payment amounts held back for 2014 benefit year risk adjustment appeals and ?scal year 2015 sequestration in the following States in the April 2016 payment cycle: 1. Nevada 2. Oregon 3. Kentucky Note: CMS already released the payment amounts held back for 2014 benefit year risk adjustment appeals and sequestration in 38 States and the District of Columbia. Please see FAQs 13869 and 14753 for the full listing of these States. (REGTAP FAQ Database - FAQ #15276 03/23/16) Q: What is the difference between the and Risk Adjustment payment type codes? A: The payment type code RA is used for Risk Adjustment transfer payment transactions and the payment type code RAD is used for Risk Adjustment default charge transactions. (REGTAP FAQ Database - FAQ #15404 04/08/16) Q: As 2014 risk adjustment appeals are resolved, will CMS release payment amounts held back for appeals and sequestration in States that no longer have a pending risk adjustment appeal? Updated 1-31-17 A: Yes. As CMS indicated in FAQ 13869 (published 11/3/15), FAQ 14753 (published 2/1/16), and FAQ 15276 (published 3/23/16) CMS will release the 10 percent holdback from the 2014 bene?t year risk adjustment payments in the payment cycle following ?nal resolution of all 2014 bene?t year risk adjustment appeals in that State. The administrative appeal process and timeline are contained in 45 CFR 156.1220. 408 2017--00508 The release of holdback amounts will not be sequestered. See the July 15, 2015, and July 29, 2015, ?Payments, Invoicing and Collections Process for the Risk Adjustment and Reinsurance Programs? webinar presentation (available at: under the Payments Remitting Amounts Due program area) for more information. Based on the current status of risk adjustment administrative appeals as of May 18, 2016, CMS will release payment amounts held back for 2014 benefit year risk adjustment appeals and ?scal year 2015 sequestration in the following States in the June 2016 payment cycle: 1. Alabama 2. Illinois 3. Iowa 4. Ohio 5. Texas Note: CMS already released the payment amounts held back for 2014 bene?t year risk adjustment appeals and sequestration in 41 States and the District of Columbia. Please see FAQs 13869, 14753 and 15276 for the full listing of these States. (REGTAP FAQ Database - FAQ #16057 05/23/16) Q: For the 2014 benefit year, some issuers who received risk adjustment payments may not have received full risk adjustment payments because some part (or all) of the 2014 benefit year payments were made during the 2016 fiscal year, which were sequestered at a rate of 7.0 percent. When will issuers receive the 2016 sequestered funds? A: As stated in the HHS Notice of Benefit and Payment Parameters for 2017 (March 8, 2016) (81 FR 12204, 12216), the funds that are sequestered in fiscal year 2016 from the Risk Adjustment program will become available for payment to issuers in ?scal year 2017 without further Congressional action. However, if a risk adjustment appeal for the 2014 benefit year is pending in a State, sequestered funds will be released once all risk adjustment appeals are resolved in their State. (REGTAP FAQ Database - FAQ #16312 06/08/16) Q: Why is the amount on my Dunning Letter (initial invoice) different from my original risk adjustment charge on the June 30th report? Updated 1-31-17 A: For the 2015 benefit year, CMS began invoicing issuers their risk adjustment charges as set forth in the June 30, 2016 report in the August 2016 payment cycle. Pursuant to 45 CFR each month, CMS processes accounts payable (AP) and accounts receivable (AR) transactions together for the financial management programs (APTC, CSRand RC). If an issuer has both APs and ARs, they will be netted together at the Payee Group level. If any amount is still owed by the Payee Group to CMS, this amount will be communicated via an Initial Invoice for the amount owed after netting. To see the details of the transactions included within a payment cycle, prior to netting, please review your Preliminary Payment Report (PPR). To see the details of the transactions included within the payment cycle post netting, please review your HIX 820. (REGTAP FAQ Database - FAQ #17445 09/14/16) 409 2017--00509 Risk Adjustment Operations - Other Q: What format should issuers use for the Rating Region? A: The correct format will be 3 characters and single digits will begin with zeroes; for example, 001 for a State rating area. (REGTAP FAQ Database - FAQ #6519 10/31/14) Q: Are denied medical claims accepted for the commercial risk adjustment program, and what documentation provides guidance on denied medical claims? A: In accordance with the HHS Notice of Bene?ts and Parameters for 2014 (78 FR 15499, March 11, 2013) denied claims are not acceptable. (REGTAP FAQ Database - FAQ #6521 10/31/14) Q: Are the business rules for the Medicare risk adjustment program the same as the HHS risk adjustment program that is in place for commercial health insurance? A: The Medicare risk adjustment model provided the diagnostic framework for the ACA HHS risk adjustment model. However, the Medicare risk adjustment program and the ACA risk adjustment program are different. Business rules for the HHS risk adjustment program are in place to meet distributed data collection requirements for the HHS risk adjustment payment transfer methodology, neither of which (distributed data and payment transfers) are concepts for the Medicare risk program. CMS has customized the HHS risk adjustment methodology and business rules to best mitigate adverse selection in the commercial health insurance individual and small group markets. (REGTAP FAQ Database - FAQ #6524 10/31/14) Q: Which states are not participating in the federal process and have defined their own submission rules? A: At this time, Massachusetts is the only State to have developed and implemented a state-run risk adjustment program. CMS qualified this methodology as Federally certified for use in Massachusetts. A summary of the Massachusetts risk adjustment methodology, as prepared by the Commonwealth, is provided in the HHS Notice of Bene?ts and Parameters for 2014 (78 FR 15439, March 11, 2013). (REGTAP FAQ Database - FAQ #6527 10/31/14) 410 Updated 1-31-17 2017--00510 Q: How do issuers submit bill types 2, 3, 4, 5 9? A: The External Data Gathering Environment (EDGE) server accepts bill types with a frequency code of 1, 7 or 8. Issuers may convert bill types with a frequency code accordance with the EDGE business rules. For additional information on bill types, please refer to the EDGE Server Business Rules document in the REGTAP library 5CR 081114.pdf). (REGTAP FAQ Database - FAQ #7908 11/25/14) Q: Regarding the Risk Adjustment (RA) calculation for people who are in the hospital at the end of the year and are not discharged until after the new year, do those diagnoses go towards the following year? A: Yes, the diagnoses would be applied to the following year for calculation of enrollee risk scores and Plan Liability Risk Score (PLRS). (REGTAP FAQ Database - FAQ #7909 1 1/25/14) Q: How do issuers identify the discharge status code on outpatient or institutional claims when they do not have a discharge date? Updated 1-31-17 A: You should use the ?eld ?Statement Covers Through" (XML element name statementCoverToDate) to indicate the end of outpatient service. For inpatient claims this would be the discharge code. Please refer to the Interface Control Document (ICD) Version 02.01.00 ES ICD v02 01 00 50R 091714.pdf) available on the REGTAP library for more information. (REGTAP FAQ Database - FAQ #7910 11/25/14) 411 2017-?0051 1 Q: Where can I find a consolidated list of enrollment scenarios that maps all enrollment scenarios to the Enrollment Period Activity Indicators A: Please refer to operational guidance related to the enrollment period activity indicator codes in the REGTAP library ESES- 5CR 100314.pdf). (REGTAP FAQ Database - FAQ #7912 11/25/14) Q: What Enrollment Period Activity Indicator (EPAI) should be used for a disenrollment from a policy? A: There is no EPAI for disenrollment. When an enrollee is disenrolled or dropped from a policy, the most current enrollment period must be updated with the new enrollment period end date and the previous EPAI is used. For additional information, please refer to operational guidance related to the EPAI codes that was published in the REGTAP library in October 2014. (REGTAP FAQ Database - FAQ #7913 11/25/14) Q: What Enrollment Period Activity Indicator (EPAI) should be used for a change in gender or a change to the date of birth A: Since the EDGE Server Enrollment Submission (ESES) ?le is a complete replacement ?le, DOB and gender changes are executed at the ESES Enrollee Category Data ?le level and do not require a change at the enrollment period level. For additional information, please refer to operational guidance related to the EPAI codes published in the REGTAP library in October 2014. (REGTAP FAQ Database - FAQ #7914 11/25/14) Q: If multiple changes to the Enrollment Period Activity Indicator (EPAI) or other enrollment elements are made over the course of an enrollment period, should issuers submit every version of the enrollment file for each enrollee? A: The EDGE Server Enrollment Submission (ESES) ?le is a complete replacement file every time it is submitted to an External Data Gathering Environment (EDGE) server. Changes that are important for Risk Adjustment and Reinsurance must be accounted for by distinct enrollment periods for the subscriber and all non-subscribers on the policy. For additional information, please refer to operational guidance related to the Enrollment Period Activity Indicator (EPAI) codes that was published in the REGTAP library in October 2014. (REGTAP FAQ Database - FAQ #7915 11/25/14) Q: If an issuer's External Data Gathering Environment (EDGE) server system does not have an Enrollment Period Activity Indicator (EPAI) that matches the Centers for Medicare Medicaid Services (CMS) requirements, how should the issuer handle this? A: The issuer is responsible for translating their enrollment and claims data into the EDGE Server formats described in the EDGE server Interface Control Document (ICD) and business rules documents. Although issuers may not maintain their enrollment and claims data in EDGE server formats, issuers have the necessary data to submit the required data to the EDGE server. For additional information, please refer to operational guidance related to the EPAI codes that was published in the REGTAP library in October 2014. (REGTAP FAQ Database - FAQ #7916 11/25/14) 412 Updated 1-31-17 2017--00512 Q: Why do issuers have to submit such detailed information in the Enrollment Period Activity Indicator A: The commercial Risk Adjustment program requires speci?c enrollment details in order to calculate payment transfers and risk scores, specifically identifying billable members and their months that will need to be associated with a subscriber's policy for certain transfer parameter calculations. Issuers will retain the details on their External Data Gathering Environment (EDGE) servers while the Centers for Medicare Medicaid Services (CMS) will receive summary information based on the software that will be run to the servers for risk adjustment. For additional information, please refer to operational guidance related to the EPAI codes that was published in the REGTAP library in October 2014. (REGTAP FAQ Database - FAQ #7917 11/25/14) Q: Can the Centers for Medicare Medicaid Services (CMS) provide clarification on whether the renewal Enrollment Period Activity Indicator (EPAI) should be based on the calendar year being reported, or based on the member's group renewal month? A: The renewal EPAI should be based on the member's group renewal month. For additional information, please refer to operational guidance related to the EPAI codes that was published in the REGTAP library in October 2014. (REGTAP FAQ Database - FAQ #7918 11/25/14) Q: Regarding the Enrollment Period Activity Indicator (EPAI) code of '001' for Modification of a Policy: Can issuers use '001' for a dependent member any time there is a premium change? A: The '001' EPAI code is only to be used for the subscriber. With the premium amount changing, it would only affect the subscriber's enrollment period because the premium is reported on the subscriber's record, not the dependent. For additional information, please refer to operational guidance related to the EPAI codes that was published in the REGTAP library in October 2014. (REGTAP FAQ Database - FAQ #7919 11/25/14) Q: What will be included in the Risk Adjustment (RA) calculation estimate? A: The RA calculation estimate is comprised of the issuer's plan average and individual enrollee Plan Liability Risk Scores (PLRS). (REGTAP FAQ Database - FAQ #7920 11/25/14) Q: Are issuers required to add the adult child (AC) and spouse (SP) suffixes to enrollee A: Due to issuer feedback, we are no longer requiring the suf?x be added. (REGTAP FAQ Database - FAQ #7921 11/25/14) Q: Regarding the premium amount, how should issuers report premiums for partial months? Are issuers required to calculate partial premiums on each individual enrollment or can the premium amount be zero? A: In section 5.7 of the EDGE Server Business Rules document (version 4.0, April 2015), the Centers for Medicare and Medicaid Services (CMS) indicated that $0 or prorated premiums can be month enrollment periods. Full 413 Updated 1-31-17 2017--00513 premiums and $0 premiums are still acceptable; however, prorated premiums should not be submitted and have a impact on the risk adiustment calculation of plan averaqe premium, which is an input to the risk adjustment transfer formula. The EDGE Server Business Rules document also provides the de?nition of premium amount (see below). In accordance with this de?nition, a full premium amount should always be reported unless there is truly a $0 premium enrollment period grace period). Issuers should review the reported plan averaqe premium that appears on the RATEE report. This calculated amount is provided at the 14-diqit plan ID plus ratinq area level. It is recommended that issuers use the reported plan averaqe premium to compare to their own calculated plan averaqe premium. The business rules definition for premium amount: The Premium Amount is the total rated premium charqed for a subscriber's policy, including the advanced premium tax credit (APTC) amount. The Premium Amount may include more than the amount charged directly to a subscriber. The Premium Amount does not necessarily represent the amount charged to the subscriber. The Premium Amount is only reported on the enrollee record when the enrollee is identified as the subscriber with a Subscriber Indicator of Q: If a policy member has been effective for one (1) month, is the reported premium amount still required to be greater than zero for the subscriber? A: Yes. If reporting for one (1) or more months, the subscriber premium should be the premium. (REGTAP FAQ Database - FAQ #7924 11/25/14) Q: If a person is enrolled in a plan that is not compliant with the Affordable Care Act (ACA) and later renews into an Affordable Care Act (ACA) compliant plan with the same issuer, should the issuer mark that change as a renewal or as an initial enrollment? A: Issuers should treat the process of members renewing from noncompliant plans into Affordable Care Act (ACA) compliant plans as initial enrollment. (REGTAP FAQ Database - FAQ #7926 11/25/14) Q: Does a subscriber need to have a new enrollment period for an addition or a removal of a dependent if the premium does not change? A: Yes, there is an operational rule that a non-subscriber policy member's enrollment period must align with the subscriber's enrollment period group. Please refer to operational guidance related to the Enrollment Period Activity Indicator (EPAI) codes published in the REGTAP library in October 2014. (REGTAP FAQ Database - FAQ #7927 11/25/14) 414 Updated 1-31-17 2017--00514 Q: With regard to Enrollment Period Activity Indicator (EPAI) values, if a dependent joins a plan during the renewal period, should the issuer assign a plan renewal value, or a new dependent value, and is there a hierarchy associated with the A: If a subscriber adds a dependent to their policy during the renewal period, the dependent would need to have the same EPAI as the subscriber. If this occurs during the renewal period, the value populated should be '021041.? For additional information, please refer to operational guidance related to the Enrollment Period Activity Indicator (EPAI) codes that was published in the REGTAP library in October 2014. (REGTAP FAQ Database - FAQ #7928 11/25/14) Q: Do issuers need to resubmit supplemental diagnosis files if the issuer replaces an original medical claim and receives a new claim A: No, after the February 2015 release went live, if a medical claim is replaced and the claim ID is changed then any accepted supplemental records that refer to the old medical claim ID do not need to be resubmitted in order for the supplemental to still be included for RA. . (REGTAP Q: Can issuers clone their External Data Gathering Environment (EDGE) servers for internal testing? Updated 1-31-17 A: The Centers for Medicare Medicaid Services (CMS) does not allow issuers to clone their servers, as indicated in CMS guidance under Frequently Asked Question (FAQ) 232. Issuers who set up two (2) EDGE servers with the same issuer Health Insurance Oversight System (HIOS) ID will be at high risk for incorrect Risk Adjustment (RA) and Reinsurance (RI) calculations. Issuers who believe they have a need to set up two (2) EDGE servers for a single HIOS ID must contact CMS at edqe server data@cms.hhs.qov. (REGTAP FAQ Database - FAQ #15579 04/20/16) 415 2017--00515 Q: Can I delete or alter data in my EDGE server tables? A: CMS does not allow issuers to delete or alter data in EDGE server tables as indicated in the October 2, 2014 Data Management? webinar. In order to maintain the integrity and traceability of the data collection process, issuers will not be allowed to delete or make modi?cations to individually stored records in the data tables. If during the audit, it is identified that data was deleted or altered, issuers may be subject to civil money penalties under 45 CFR 153.740. (REGTAP FAQ Database - FAQ #15581 04/20/16) Q: Hello. Today I attended the EDGE Server Webinar Series Announcement for (5/10/16) can you tell me where I can get the handouts for the presentation please? A: Thank you for your question. The weekly announcements that we provide on our Tuesday Edge Server call are published Every Friday in a document called: EDGE Server Updates 2015 Data Submission. This document can be found in the REGTAP library under Distributed Data Collection for Edge Server and then Supporting Documents. Since this is a cumulative document it will have historical announcements from prior sessions. (REGTAP FAQ Database - FAQ #16314 06/10/16) Risk Adjustment Data Validation (RADV) Q: Is there a crosswalk that compares the Risk Adjustment and Data Validation (RADV) methodology that the Department of Health and Human Services (HHS) runs on behalf of State based Marketplaces (SBMs) to the Medicare RADV methodology? A: CMS does not have a common crosswalk that compares these two programs. Both programs adopt similar methods regarding the sampling concepts and methods that require implementation of national acceptable standards for review of enrollee health conditions to validate payment accuracy. However, HHS-operated RADV program differs in that our methods for assessing payment accuracy are driven primarily by principles that underlie our risk adjustment payment transfer methodology, which is not a payment concept for the MA program. (REGTAP FAQ Database - FAQ #1405 04/14/14) Q: Is the schedule for HHS-operated Risk Adjustment Data Validation (HRADV) audits being modified? A: Yes, the Centers for Medicare Medicaid Services (CMS) are revising the schedule for HRADV to ensure timely implementation of External Data Gathering Environment (EDGE) data operations for Risk Adjustment (RA) payment transfer process. CMS will publish a revised HRADV timeline in the coming months. (REGTAP FAQ Database - FAQ #8489 01/14/15) Updated 1-31-17 416 2017--00516 Q: Will the risk score estimate detail and summary report include payment transfer data? A: Risk score reports will only include Risk Adjustment (RA) transfer data as it relates to a speci?c plan and rating area in a risk pool/market via the RA Transfer Elements Extract (RATEE) report. RA transfer payment information will be provided in a separate report that the Centers for Medicare Medicaid Services (CMS) will share in the future. (REGTAP FAQ Database - FAQ #8677 01/21/15) Q: Which telehealth services are valid for HHS Risk Adjustment data submission and subsequent data validation under the HHS-operated Risk Adjustment Data Validation (HHS-RADV) program? A: Any service provided through telehealth that is reimbursable under the State law of the State of licensure of the issuer that otherwise meets risk adjustment data submission standards may be submitted for Risk Adjustment. Initial Validation Audit (IVA) entities should also apply these veri?cation steps when encountering telehealth services during the IVA for HHS-RADV. 2. Con?rm that the applicable State insurance law regarding telehealth services requires or permits issuer reimbursement for telehealth services. The applicable State insurance law would be determined by the State of licensure of the issuer. 3. Con?rm that the provider is a valid telehealth provider under State insurance law in the State of licensure of the issuer. Telehealth rules typically specify those providers that are allowed, such as physicians, certain categories of nurses, and certain mental health professionals. A telehealth provider should also meet any applicable licensing requirements in the State in which he or she practices and the State in which the patient is located. 4. Verify the diagnosis and procedure code(s) for which the telehealth service was rendered and follow all applicable coding guidelines. (REGTAP FAQ Database - FAQ #14288 12/16/15) 5 Q: Is the deadline for submitting auditors for HHS-operated Risk Adjustment Data Validation (HRADV) audits being modified? Updated 1-31-17 A: The Centers for Medicare Medicaid Services (CMS) are revising the schedule for the HHS-operated Risk Adjustment Data Validation (HRADV) program to ensure timely implementation of External Data Gathering Environment (EDGE) data operations for the Risk Adjustment (RA) payment transfer process. CMS will publish a revised HRADV timeline in the coming months. Although CMS is shifting the HRADV timeline, we anticipate providing the same duration of time for all stages of the HRADV process. Do not send any auditor information to CMS at this time. CMS will notify issuers when and where to send auditor information. Any information submitted before CMS provides updated guidance will not be regarded and will need to be resubmitted upon the official request from CMS. Information regarding the HHS-operated RADV process, including general audit standards and quali?cation requirements for Initial Validation Auditors (lVAs) is available in the 2015 Final Payment Notice located at 11/pdf/2014-05052pdf. Additionally, CMS will host training sessions related to HRADV in the near future. Please log on to REGTAP at for registration 417 2017-?00517 and additional information on future training sessions. (REGTAP FAQ Database - FAQ #9567 04/07/15) Q: Can the Centers for Medicare Medicaid Services (CMS) provide additional guidance on how to calculate plan average premium? A: Issuers can locate the formula to calculate an individual plan's average premium on slide 43 of the 2/11/15 RA webinar slides at PTslides 021115 5CR 021315.pdf in the REGTAP Library. To calculate member months, issuers should divide the total number of days in an enrollment period by 30. (REGTAP FAQ Database - FAQ #9975 04/17/15) Q: When will the risk adjustment data validation program (RADV) begin? A: In the HHS Notice of Bene?t and Payment Parameters for 2014 (78 FR 15410), CMS stated that In conducting the HHS RADV program, it would adjust Risk Adjustment (RA) payments and charges based on the results of the HHS- RADV program in 2018 for 2016 bene?t year data. CMS explained that issuers and auditors would have two (2)_preliminary years in which to implement and test the HHS-RADV program, and adjust their audit procedures in response to that experience. Risk?adjustment ?payments and charges will continue to be adjusted in 2018 for 2016 bene?t year data, in keeping with the original schedule. However, CMS will not conduct RADV on 2014 data, originally onele of two (2) preliminary testing years. CMS will still conduct HHS-RADV in 2016 for 2015 bene?t year data - thus, issuers and auditors will have one (1L preliminary testing year instead of two QLin which to implement and test the HHS-RADV program, and adjust their audit procedures in response. Winter 2017 Preliminary RADV data released; REGTAP FAQ Database- FAQ #11290 07/16/15; updated 03/07/16) Q: When will the HHS-Operated Risk Adjustment Data Validation program (HHS-RADV) begin? Updated 1-31-17 A: In the HHS Notice of Bene?t and Payment Parameters for 2014 (78 FR 15410), CMS stated that in conducting the HHS-RADV program, it would adjust Risk Adjustment (RA) payments and charges based on the results of the HHS-RADV program in 2018 for 2016 bene?t year data. CMS explained that issuers and auditors would have two (2) preliminary years in which to implement and test the HHS-RADV program, and adjust their audit procedures in response to that experience. RA payments and charges will continue to be adjusted in 2018 for 2016 benefit year data, in keeping with the original schedule. 418 2017--00518 However, CMS will not conduct HHS-RADV on 2014 data, originally one (1) of two (2) preliminary testing years. CMS will still conduct HHS-RADV in 2016 for 2015 bene?t year data - thus, issuers and auditors will have one (1) preliminary testing year instead of two (2) in which to implement and test the HHS-RADV program, and adjust their audit procedures in response. A revised timeline for HHS-RADV for 2015 bene?t year* data is included below: Fall 2015 - HHS-RADV trainings to begin . December 31, 2015 - 2015 benefit year ends Winter 2015 through Spring 2016 - Issuers select Initial Validation Audit (IVA) entity . Spring 2016 - Issuers submit IVA entity to CMS for approval April 30, 2016- 2015 data submission deadline Summer through Fall 2016 - CMS generates sample of enrollees and their medical claims for each issuer and the IVA is conducted Fall 2016 through Winter 2017 - Second Validation Audit (SVA) is conducted . Winter 2017 - Pilot results and lessons learned will be released, including 2015 error rates *The 2015 benefit year is a pilot year. There will be no payment adjustments or appeals activities for the 2015 pilot year. (REGTAP FAQ Database - FAQ #11290 12/15/15; also issued as a separate FAQ in the REGTAP library on 12/15/15 under the title: Operated Risk Adjustment Data Validation Program (HHS RAD V) Begin?? timelineFAQ 5CR 121515. Q: Where can issuers locate the Risk Adjustment User Fee (RAUF) report and identify the total user fee amount due on the RAUF report? A: The External Data Gathering Environment (EDGE) server generates the RAUF report when the Centers for Medicare Medicaid Services (CMS) sends a remote command to an issuer's EDGE server. The EDGE server sends the RAUF report to both the issuer and CMS. Issuers can ?nd the RAUF report in the EDGE Server Outbound File Directory with the other EDGE Server Outbound reports. Issuers can locate the total RAUF on the RAUF report. The RAUF report contains a row under both the Issuer Level and Plan Category called the Total RA User Fee. This data element displays the issuer's RA User Fee amount (total enrollee member months multiplied by $0.08 per enrollee). For additional information, refer to the Interface Control Document (ICD) - Addendum (located under the Distributed Data Collection program area) and the Risk Adjustment Reports Handout Job Aid (located under the RA program area) at in the REGTAP Library. (REGTAP FAQ Database - FAQ #11369 07/30/15) Q: Why would an issuer receive a Risk Adjustment Default Charge (RADC) Allocation Report in addition to a Risk Adjustment (RA) transfer report? A: If an issuer receives a Risk Adjustment Default Charge Allocation Report and an RA transfer report, it means that a non-complaint issuer receiving a risk adjustment default 419 Updated 1-31-17 2017--00519 charge is in that complaint issuer's state and market. The compliant issuer will receive an allocated payment, which is the distribution of the risk adjustment default charge to compliant issuers in the same state risk pool as the issuer that is assessed the default charge. (REGTAP FAQ Database - FAQ #11625 08/19/15) Q: An issuer is attempting to download the Risk Adjustment (RA) transfer report via the External Data Gathering Environment (EDGE) server Management Console. Where exactly is the EDGE server Management console located? A: The reports will only be accessible on the registration site to users with Issuer Approver role in Health Insurance Oversight System (HIOS). From HIOS, select the Server Management? option from the menu on the left side of the page. Once in the EDGE Server Management Tab in HIOS, click the ?Access the EDGE Server Management Application" link. For additional details on accessing the EDGE Server Homepage, refer to the Accessing the EDGE Server Registration Site Video, located at under the Distributed Data Collection (DDC) program area in the REGTAP Library. For additional details on downloading the reports once on the EDGE Server Homepage, refer to slides 24-30 of the RA Payment Transfers, Default Charges and Reporting (6/17/15) slides located at under the RA program area in the REGTAP Library. (REGTAP FAQ Database - FAQ #11627 08/19/15) Q: Do all issuers of Risk Adjustment (RA) covered plans need to hire an Initial Validation Auditor (IVA) Entity for purposes of 2015 HHS Risk Adjustment Data Validation (HHS- A: Given that 2015 HHSRADV is a ?pilot year? and audit results will not adjust issuers' payments, CMS will not enforce the 2015 HHSRADV requirements for: 1) Issuers that have no RA-covered plans in the individual and small group markets in the 2016 bene?t year and 2) issuers with fewer?than??OO 12 000 or fewer billable member months in the individual and small group markets combined statewide as of the February-21 2046 April 1, 2016 data submission deadline for 2015 bene?t year Risk Adjustment. (REGTAP FAQ Database - FAQ #14740; 14740a 01/29/16; updated 04/20/16) CMS has determined that issuers with 12,000 or fewer billable member months have a disproportionately hiqher administrative burden to participate in the pilot year of HHS- RADV and thus, CMS will not enforce participation for issuers with 12,000 or fewer billable member months in 2015 HHS-RADV. We note that issuers who previously met the criteria as of the February 2, 2016 data submission and received letters from CMS that we would not enforce participation, continue to not be required to participate in 2015 HHS-RADV. Q: Do all issuers of Risk Adjustment (RA) covered plans need to hire an Initial Validation 420 Updated 1-31-17 2017--00520 Auditor (IVA) Entity for purposes of 2015 HHS Risk Adjustment Data Validation (HHS- A: Given that 2015 HHS-RADV is a ,,pilot year%o and audit results will not adjust issuers' payments, CMS will not enforce the 2015 HHS-RADV requirements for: (1) issuers that have no RA-covered plans in the individual and small group markets in the 2016 bene?t year and (2) issuers with 500 or fewer billable member months in the individual and small group markets combined statewide as of the February 2, 2016 data submission deadline for 2015 benefit year Risk Adjustment. (REGTAP FAQ Database - FAQ #14740 02/08/16) Q: What is the operating timeline for HHS-Operated Risk Adjustment Data Validation (HHS-RADV) for the 2015 benefit year? A: The operating timeline for HHS-RADV for the 2015 benefit year includes:* 1. January 2016 - May 2016: Issuers select Initial Validation Audit (IVA) Entities. 2. March 15, 2016: HHS-RADV Senior Of?cial (SO) Designation Letter emailed to External Data Gathering Environment (EDGE) server Chief Executive Of?cer (CEO) designate. 3. April 25, 2016: SO Designation Letter due back to CMS. 4. Late April 2016: CMS provides 803 with Audit Tool access. 5. Late April 2016 - Early May: 803 complete IVA Entity designation form in Audit Tool and download IVA Entity attestation form for CEO signature. 6. May 9, 2016: Issuer SOs submit CEO-signed IVA Entity Attestation Form to CMS for review. 7. Late May 2016: CMS pushes HHS-RADV sampling command to EDGE servers; Issuers execute command. 8. Early June 2016: CMS provides IVA Entities with Audit Tool access. 9. June 2016: CMS validates IVA samples. 10. July 1, 2016: CMS releases HHS-RADV sample reports to issuers via the EDGE server. 11. July 2016 - December 2016: IVA is conducted. 12. Early December 2016: IVA results and supporting documentation submitted. 13. December 2016 - March 2017: Second Validation Audit (SVA) is conducted. 14. Spring 2017: Bene?t year 2015 HHS-RADV Pilot lessons learned and results, including error rates will be released. *These dates are subject to change. (REGTAP FAQ Database - FAQ #15071 03/08/16) Risk Adjustment Payment Update for the 2014 Benefit Year Q: For the 2014 benefit year, has CMS collected all Risk Adjustment charges in all States and markets? A: CMS is still in the process of collecting 2014 Risk Adjustment charges for some States and markets. Below we set forth the status of completed Risk Adjustment charge collections by State and market as of February 11, 2016 (not including default charges, which are covered in the next question). 421 Updated 1-31-17 2017--00521 State Completed Collecting Risk Adjustment Charges for all market segments: - Catastrophic - Individual - Small Group Yes for catastrophic and Individual No for small group CO Yes for catastrophic and Individual No for small group Yes for catastrophic and Individual No for small group HI Yes for Individual No for catastrophic and small group Yes 422 Updated 1-31-17 2017--oo522 State Completed Collecting Risk Adjustment Charges for all market segments: - Catastrophic - Individual - Small Group RI Yes for individual and small group No for catastrophic Yes for catastrophic No for individual and small group Yes (Risk Adjustment Payment Update for the 2014 Bene?t Year {03/08/16)} Q: Has CMS collected all Risk Adjustment Default Charges? A: CMS is still in the process of collecting funds for 2014 Risk Adjustment default charges for some States and risk pools in which an issuer or issuers were assessed a Risk Adjustment default charge. Below we set forth the status of completed Risk Adjustment default charge collections by State and market as of February 11, 2016. State RiSk P??l Completed Collecting Risk Adjustment Default Charges AZ Small group Yes CA Individual Yes CA Small group No ID Small group No IN Small group Yes MD Small group Yes Ml Small group No MT Small group Yes NV Small group Yes NY Individual No NY Small group No TX Small group No UT Small group No (Risk Adjustment Payment Update for the 2014 Bene?t Year (03/08/16)) Updated 1-31-17 423 2017--00523 Q: When will I receive the rest of my risk adjustment payments for the 2014 benefit year? If payments are completed, why doesn't my RA Proration Report for 2014 benefit year show $0 under the ?remaining payment balance?? A: As stated in the HHS Notice of Benefit and Payment Parameters for 2014, the risk adjustment program is designed to be a budget-neutral revenue redistribution among issuers. As such, risk adjustment payments can only be made from collected risk adjustment charges. CMS is still in the process of collecting 2014 risk adjustment charges for some risk pools and markets. CMS will not pay the full remaining balance if CMS is unable to fully collect 2014 bene?t year risk adjustment charges in a risk pool or market. In addition, the total payments and charges in a State and market may not perfectly align in light of rounding, and so issuers in those States or markets may have a residual balance in pennies that will not be paid. CMS intends to notify issuers when we have fully collected all the charges from the 2014 benefit year for each risk pool and market, or when CMS has exhausted all means to collect outstanding debts. (REGTAP FAQ Database - FAQ #15072 03/08/16) Risk Adjustment Methodology I. General Topics Q: How will CMS modify the risk adjustment models in the 2018 Payment Notice? Updated 1-31-17 A: CMS intends to propose a number of improvements to the HHS risk adjustment methodology in the 2018 Payment Notice. While we continue to consider additional proposals, there are two we expect to include. First, we intend to propose a modi?cation to the HHS risk adjustment methodology to account for partial year enrollment. The modi?cation would add 11 indicator variables to re?ect additional predicted risk for enrollees with different enrollment duration (that is, one indicator variable signifying 1- month enrollment duration, a different indicator variable signifying 2-month enrollment duration, etc., with enrollees with 12 months of enrollment being treated as the baseline). The risk factors associated with enrollment duration would decrease monotonically (with the 1-month duration group having the highest coef?cient). This modification will be proposed for both the 2018 and 2017 bene?t years. Second, we intend to propose to incorporate a small number of prescription drug classes as predictors in the HHS risk adjustment methodology for the 2018 bene?t year to impute missing diagnoses and to indicate severity of illness. We believe that including prescription drugs as a proxy for missing diagnoses could reduce the extent to which an issuer?s risk score depends upon its level of experience with medical coding, and result in more accurate risk scores for enrollees with prescription drug claims, but who have not had a provider encounter with a documented diagnosis. Using prescription drug data as an indicator of the severity of a particular diagnosis can also offer a more complete picture of enrollee health status. A more complete measurement of enrollee health status should improve the accuracy of risk adjustment across all health plans. We intend to limit the number of prescription drug classes included as predictors to only those drug classes where we are con?dent that the risk of unintended effects on provider prescribing behavior is low; we intend to monitor prescription drug utilization for unintended effects, and may remove drug classes based on such evidence. 424 2017-?00524 We may also propose other changes to the risk adjustment methodology discussed in the March 31, 2016 Risk Adjustment Meeting Discussion Paper4 and during the Risk Adjustment Conference. We will seek comment on all proposed changes during the rulemaking process. (03/31/16 HHS-Operated Risk Adjustment Methodology Meeting Q: In 2017, the HHS risk adjustment methodology will take into account preventive services. Please comment on how exactly it will be done, and what the Centers for Medicare and Medicaid Services (CMS) expects to accomplish by doing it? A: CMS incorporated preventive services into the simulation of plan liability in the recalibration of the risk adjustment models for 2017. This incorporation of preventive services is intended to more accurately compensate risk adjustment covered plans with enrollees who use preventive services. Section 2713 of the PHS Act, as added by the Affordable Care Act, requires that individual and small group non-grandfathered plans (among others) provide coverage for a range of preventive services and may not impose cost sharing on patients receiving those services. By incorporating zero cost sharing preventive services in the calculation of plan liability when calibrating the models? coefficients, we will increase the accuracy of the model overall, accounting for any differential use of preventive services at the plan level. (03/31/16 HHS-Operated Risk Adjustment Methodology Meeting Q: Going forward, will a statewide interim risk score be provided to issuers so they can predict the financial impact of their own specific interim risk scores? A: For the 2015 bene?t year, we released the interim report year in March 2016.5 We will assess the impact and usefulness of releasing the interim report for future years. Once we are able to compare the results of this year?s release, we will make that determination. (03/31/16 HHS-Operated Risk Adjustment Methodology Meeting Q: Would you be willing to release the plan-level data used in the slides during the Risk Adjustment Conference? A: In the June 30, 2015 Summary Report on Transitional Reinsurance Payments and Permanent Risk Adjustment Transfers for the 2014 Bene?t Year,6 CMS has made the issuer-level data available, but not the plan-level results. We do not currently have plans to release plan-level results. (03/31/16 HHS-Operated Risk Adjustment Methodology Meeting Q: It is possible that consumer behavior on the Marketplaces differs significantly from the privately insured data used to calibrate the HHS risk adjustment models. ls CMS considering use of Marketplace data to develop or recalibrate the risk models in lieu of 4 Avaliable at: 5 Avaliable at: BY2015 5CR 032816.pdf 6 Latest version available at: 425 Updated 1-31-17 2017--00525 MarketScan? A: Yes. One of the proposals presented in the White Paper and during the Risk Adjustment Conference discusses using enrollee?level data from the External Data Gathering Environment (EDGE) server to calibrate the risk adjustment models based on actual individual and small group market data, rather than MarketScan data, to improve the precision of the HHS risk adjustment model. However, we would note that at this point in time, we have no evidence that using MarketScan data is any less accurate than using actual individual and small group market data. (03/31/16 HHS-Operated Risk Adjustment Methodology Meeting Q: Would CMS consider using the EDGE data to calibrate the risk adjustment model as early as the 2018 benefit year? A: In order to use the EDGE data to recalibrate the risk adjustment model, CMS would first need to establish the policy to use the enrollee-level data. Once CMS has established the policy, we would need to implement and execute the code on EDGE to collect enrollee-level data. After this point, CMS would be able to analyze the EDGE data and use it to recalibrate the risk adjustment model for a subsequent year. The earliest we are able to establish policy to collect enrollee-level data from EDGE is in rulemaking for the 2018 benefit year to run reports in the spring of 2017 on EDGE 2016 benefit year data. We would be able to use EDGE 2016 bene?t year data to recalibrate the model for the 2019 bene?t year. If the data collection policy was ?nalized for the 2018 benefit year, we would be able to use EDGE 2016 bene?t year data to recalibrate the model for the 2019 bene?t year at the earliest. (03/31/16 HHS-Operated Risk Adjustment Methodology Meeting Q: For the enrollee-level data collection proposal to recalibrate the risk adjustment model on the EDGE data, would CMS publish the de-identified national data set, or a subset thereof, that is being proposed to calibrate the 2019 HHS risk adjustment models? A: We are still considering the the policy and analytical implications of using de- identi?ed enrollee-level data that is currently maintained on issuers' EDGE servers to recalibrate the risk adjustment models in future years. If we decide to move forward with the proposal, we will propose this policy in notice and comment rulemaking and solicit comment on whether and in what circumstances to release that data. (03/31/16 HHS- Operated Risk Adjustment Methodology Meeting Q: For the enrollee-level data use proposal, if an enrollee stays with an issuer for multiple years, will CMS be able to link data for the enrollee across multiple plan years to facilitate longitudinal studies? Updated 1-31-17 A: Because we have not used enrollee-level data to date in the risk adjustment program, CMS has not provided any guidance on how issuers should create enrollee IDs across multiple years. We do state at 45 CFR that an issuer must maintain the same de-identi?ed enrollee ID for an enrollee across enrollments or plans within the issuer, within the state, during a bene?t year. That is, if an enrollee switches plans within the same issuer in a bene?t year, the issuer should use the same enrollee ID throughout the year so that the enrollee can be matched with their associated enrollment periods and claims for the full year. (03/31/16 HHS-Operated Risk Adjustment Methodology 426 2017--00526 Meeting Q: Would CMS be willing to do a risk adjustment calculation (and hypothetical transfer) under the current risk score methodology and proposed recalibration in parallel to help issuers understand how the new model will behave? A: Currently, we do not have the technical capacity to conduct those parallel operations, but we are exploring avenues for doing so. We are also exploring whether we have the operational capacity to conduct these calculations in parallel, given the timing of EDGE operations, and whether performing these parallel calculations could introduce or reduce uncertainty in the market. (03/31/16 HHS-Operated Risk Adjustment Methodology Meeting Q: The last slide of the presentation on using enrollee-level data from the EDGE server showed data going to CMS before ls data before or after going to A: Data from the EDGE server is before it is transmitted to CMS. When CMS receives the data it is in the format, at which point the data is available for recalibration and analysis. This was a typographical error on the slide. (03/31/16 HHS- Operated Risk Adjustment Methodology Meeting Q: The HHS-Operated Risk Adjustment Methodology Meeting presentation showed the analysis of risk transfers between small plans versus large plans. An issuer requested to see how risk is being transferred between fast-growing and new plans versus slower growing or more established plans. Has CMS done that analysis, and if so can CMS release it to issuers? A: The current set up of the EDGE server makes it dif?cult for CMS to conduct longitudinal, cross-year, and other detailed analyses. We will continue to assess ways to understand differences in outcomes for new and fast-growing plans and the more established plans in the market. (03/31/16 HHS-Operated Risk Adjustment Methodology Meeting Q: A national actuarial firm is estimating that some of the rate increases for 2017 are due to the uncertainty of risk adjustment. ls CMS concerned about this? A: Our analysis of the 2014 risk adjustment transfers indicates the model is working to stabilize the market by transferring payments to issuers with sicker enrollees, but we are always considering ways to improve the model. We believe there will be more certainty over time and we have worked to reduce uncertainty by incorporating feedback received from issuers releasing interim risk scores prior to ?nal risk scores). As the Marketplace matures, we believe that issuers? experience will mitigate any uncertainty over the effects of risk adjustment. (03/31/16 HHS-Operated Risk Adjustment Methodology Meeting ll. Model Overview 427 Updated 1-31-17 2017--00527 Q: What is process for evaluating the hierarchical condition categories (HCCs) included in the risk adjustment models? ls CMS considering adding HCCs or splitting Hepatitis off from the Chronic Hepatitis A: Splitting the Chronic Hepatitis HCC is something we have previously received comments on in the Payment Notice. We are currently considering the implications of this. We do not believe at this stage we need to re-evaluate all of our HCC classifications, however, CMS will revisit HCCs as clinically necessary in future years and as better data becomes available. (03/31/16 HHS-Operated Risk Adjustment Methodology Meeting Q: Why has only one state elected to operate its own risk adjustment program? A: The Affordable Care Act and implementing regulations allowed states to opt out of operating their own risk adjustment program. Many states chose not to operate a separate risk adjustment model, as such CMS operated the risk adjustment program on behalf of those states. Massachusetts was not recerti?ed to operate its alternate risk adjustment methodology for the 2017 bene?t year. CMS will transition to operate risk adjustment in Massachusetts in 2017. (03/31/16 HHS-Operated Risk Adjustment Methodology Meeting Q: The Risk Adjustment Conference presentation on results from the 2014 benefit year risk adjustment program seemed to indicate large subsidization of gold and platinum plans by bronze policy-holders. Have you considered separate risk adjustment calculations for each metal level? A: We believe that the risk adjustment program is working as intended by correctly transferring payments from issuers with high proportions of bronze metal level enrollment, which attracted many healthy enrollees, to issuers with high proportions of platinum metal level enrollment, which are more subject to adverse selection. (03/31/16 HHS-Operated Risk Adjustment Methodology Meeting Ill. Prescription Drug Data Q: Please provide a specific example of ?gaming? risk associated with adding prescription drug claims to the risk adjustment methodology. What drug would be so low cost while also impacting risk score enough that an issuer would be motivated to increase utilization? A: In the White Paper we provided an example of diabetes treatments that could be prescribed in lieu of diet and exercise management treatments. (03/31/16 HHS- Operated Risk Adjustment Methodology Meeting Q: Has the assumption that Prescription Drug Categories (RXCs) impute an HCC been empirically tested and have the medical records for such members been reviewed to 428 Updated 1-31-17 2017--00528 substantiate or negate the imputed For example, the White Paper gives counts where an RXC imputes an HCC. The relationship between a prescription drug and a particular medical condition may not be strong enough to warrant an imputation type model. A: We have not attempted to validate RXC imputations with medical records. We have assessed cases where an individual is in two consecutive years in the MarketScan data. For instances where the individual has the prescription drug without the associated diagnosis that we are attempting to impute, we looked at the following year and a number of those individuals do have the diagnosis in the following year. The percentage of individuals with diagnosis coded in the following year varies by drug category. (03/31/16 HHS-Operated Risk Adjustment Methodology Meeting Q: Could CMS go into more depth about auditing challenges that will arise if prescription drugs are added to the model? There is a concern that if prescription drugs are added to the model, plans will compete on their ability to induce providers to prescribe drugs in the RXCs chosen for the model, regardless of clinical need. Could CMS build an auditing process that would promote confidence in the RXCs to reflect health status and not the relative ability of plans to induce extra prescriptions? A: Avoiding unintended incentives is a challenge when incorporating prescription drugs into our model or any utilization-based method of risk adjustment. We are investigating ways of mitigating this risk by incorporating high-cost drugs with speci?c, limited uses. We do not believe an audit plan would consist of CMS conducting medical review or utilization review activity to determine the appropriateness of a course of treatment. (03/31/16 HHS-Operated Risk Adjustment Methodology Meeting Q: New and fast-growing plans are particularly likely to have missing or incomplete diagnoses. The use of prescription drug data in the risk adjustment model could help impute these missing diagnoses in 2018 and later. Has CMS considered using a ?credibility approach? in the near term to determine the extent to which risk adjustment should apply? Plans with a high proportion of truly new members could be subject to reduced levels of risk adjustment transfers from 2015 through 2017 until the prescription drug hybrid model could be implemented. A: At this time, we do not have data to evaluate whether these types of plans are particularly likely to have missing or incomplete diagnoses. We will continue to assess ways to evaluate how the risk adjustment program is affecting different types of issuers. (03/31/16 HHS-Operated Risk Adjustment Methodology Meeting Q: What were the ?select few? drugs and diagnoses that had high predictive power? A: Use of Hepatitis drug data signi?cantly increased predictive power. A number of other high-cost drugs did so as well. Please refer to the White Paper for more information. (03/31/16 HHS-Operated Risk Adjustment Methodology Meeting Q: One of the principles of the diagnosis based HCC risk adjustment model is to encourage more complete and accurate documentation and coding of conditions. Could 429 Updated 1-31-1 7 2017--00529 the proposal to incorporate prescription drug data to impute conditions violate that principle and relieve plans of the responsibility to completely and accurately code conditions? A: The hybrid model would use both conditions and prescription drugs, and the incentive to code fully varies by the type of hybrid model. None of the hybrid models would induce a penalty for recording additional diagnoses. We do not currently believe a hybrid model would encourage issuers to reduce accurate documentation and coding of conditions. (03/31/16 HHS-Operated Risk Adjustment Methodology Meeting Q: To minimize gaming with the pharmacy indicator, is CMS considering a long minimum drug usage such as the 181 days of daily dosage used by Germany and the Netherlands? A: CMS has assessed instances for which length of use indicates the different conditions and different treatment patterns. We believe the length of use can be used to distinguish disease severity and prophylactic use, but we are conscious of the tradeoff that would occur in imputing missing diagnoses for enrollees with partial year enrollment if we were to implement a long minimum days supply requirement. (03/31/16 HHS- Operated Risk Adjustment Methodology Meeting IV. Partial Year Enrollment Q: Is it possible that new or fast-growing plans could be helped by incorporating the plan's proportion of partial year enrollment into risk adjustment, which CMS has begun to study? A: We believe that adjusting for partial year enrollment could make the risk adjustment methodology more accurate for all plans. We therefore intend to propose a modi?cation to do so, and will seek comment on this modification to the methodology as part of the 2018 Payment Notice. (03/31/16 HHS-Operated Risk Adjustment Methodology Meeting Q: For partial year modeling, would MarketScan data be relevant? It is mainly employer- sponsored insurance data from employees/dependents with stable, 12-month enrollment. New hires and terms might be quite different from the Affordable Care Act individual and small group markets? partial year enrollees. Should CMS wait for actual individual and small group market data? A: The MarketScan data may not entirely reflect the nuances of partial year enrollment in the individual and small group markets. However, we do believe that these data are useful in analyzing the effects of partial year enrollees in the risk adjustment model calibration, and in developing methods to adjust for partial year enrollees. (03/31/16 HHS-Operated Risk Adjustment Methodology Meeting V. Transfer Formula 430 Updated 1-31-17 2017--00530 Q: If you were to use the plan?s own premium rather than the statewide average premium, how would you maintain the program's budget neutrality? A: We have considered a few options to achieve budget neutrality in risk adjustment transfers if we used a plan?s own premium instead of statewide average premium, but are continuing to assess the best approach to calculating transfers. (03/31/16 HHS- Operated Risk Adjustment Methodology Meeting Q: Has CMS considered the impact of the updates to the risk adjustment methodology on preservation of competition within the individual and small group markets? A: CMS carefully considers the impact of any changes to the risk adjustment methodology on individual and small group market dynamics. Our goal is to continually improve the accuracy of the risk adjustment models. We believe that a robust risk adjustment program is critical to providing all issuers large and small, new and established with the incentive to serve all consumers in the broad risk pool. (03/31/16 HHS-Operated Risk Adjustment Methodology Meeting Q: Is there any consideration being given to implementing a cap on risk adjustment transfers as a percent of premium perhaps related to Medical Loss Ratio A: CMS has considered such a limit on risk adjustment transfers. However, we are concerned that any cap on charges would also result in a cap on payments that CMS is able to make to issuers with adverse selection into their plans, undermining the goal of the program. (03/31/16 HHS-Operated Risk Adjustment Methodology Meeting Vl. High Risk Pooling Q: How would the high risk enrollee pool concept discussed in the White Paper interact with commercial reinsurance purchased by the issuer? A: The high risk enrollee pool concept would be modeled into the risk adjustment program and transfers would be calculated in accordance with newly recalibrated models incorporating this concept. CMS would not dictate issuers? decisions on the use of commercial reinsurance. (03/31/16 HHS-Operated Risk Adjustment Methodology Meeting Q: Issuers may renegotiate or incentivize large claims from providers in exchange for reductions elsewhere. The potential for gaming the high risk enrollee pool likely outweighs any predictive gain. Additionally, while issuers can avoid sick members, it is difficult to see how they can avoid members with catastrophic claims. Does this problem currently exist and how will large claims be validated? A: A high risk pool may help issuers with catastrophic costs that are unavoidable, and are otherwise detrimental to issuers since the individual and small group markets do not have annual limits or lifetime limits. These costs can be exceptionally high compared to what issuers have experienced in the past. We also continue to believe that high risk pooling would be a useful tool for discouraging issuers from avoiding members with conditions that may be particularly likely to trigger catastrophic claims. (03/31/16 HHS- Operated Risk Adjustment Methodology Meeting 431 Updated 1-31-17 2017--00531 Q: There are significant variations in provider fee levels around the country and even within a city. The variation could inappropriately impact the high risk pooling concept and pooling transfers. Does CMS plan to address the impact provider fee variations may cause on pooling transfers? A: CMS understands this concern and we are evaluating concerns that a national high risk enrollee pooling mechanism could result in low cost geographic areas or states funding high cost geographic areas or states. (03/31/16 HHS-Operated Risk Adjustment Methodology Meeting Reinsurance Q: For?the-2045?Bene?t??ear, What is the date in the 4th quarter of 2015 for which contributions for the General Fund of the U.S. Treasury for the 2014 benefit year are due? {alayiacieritsfi2 A: Applicable to Mane?2046 Reinsurance Contribution 2014 Benefit Year: For the 2014 Benefit Year, the second remittance is due by November 15, 2015. The U.S. Department of Health and Human Services (HHS) will offer Contributinq Entities the option to pay: (1) the entire 2014 Benefit Year contribution amount in one (1) payment no later than January 15, 2015, reflectinq $63.00 per covered life; or (2) in two (2) separate payments for the 2014 Benefit Year, with the first remittance due by January 15, 2015, re?ectinq $52.50 per covered life, and the second remittance due by November 15, 2015, re?ectinq $10.50 per covered life. Reqardless of the selected option, the payments should be scheduled by November 15, 2015. 432 Updated 1-31-17 2017--00532 matehr (REGTAP FAQ Database - FAQ #2524a 02/02/14; updated 09/21/15 and 09/13/16) Note: REGTAP indicates that this FAQ has been updated, but the underlying FAQ was not reported/found for the original date of issue. Q: How will a contributing entity complete the reinsurance contributions process for the 2015 Benefit Year? A: HHS has maintained will?implement a streamlined process for the collection of reinsurance contributions for the 2015 Benefit Year throuqh Pay.qov. A contributing entity, or a third-party administrator (TPA) or an Administrative Services-Only (ASO) contractor on behalf of the contributing entity, can complete all required steps for the reinsurance contributions process on Pay.gov: registration, submission of the annual enrollment count, and remittance of contributions. A?fem The ?2015 ACA Transitional Reinsurance Program Annual Enrollment Contributions Form? will be available via on October 1, 2015 where a contributing entity or a TPA or ASO contractor on its behalf will provide basic company and contact information, and the annual enrollment count for the applicable bene?t year no later than November 16 2015 45th. The form will auto-calculates the contribution amounts. To complete the submission, entities will also submit payment information and schedule a payment datets) for remittance of the contributions. Pay.gov provides a ?one-stop" approach to complete the reinsurance contributions process. Traininq on this process for the 2015 Bene?t Year and traininq slides will be available throuqh the Reqistration for Technical Assistance Portal (REGTAP) in the end of September. A web-based traininq will be available on the Center for Consumer Information and Insurance Oversiqht (CCIIO) website cms. and- Initiatives/Premium- Stabilization- Transitional- Reinsurance- ProqlramlReinsurance- Contributions f_or trainings- (CMS FAQs. Reinsurance Contribution Process 05/22/14 and REGTAP FAQ #1674a 05/23/14; updated 09/21/15) Q: Will the Health Insurance Oversight System (HIOS) be used in the Reinsurance Contribution submission process for the 2014I 2015, or 2016 Bene?t Years? A: Applicable to All Reinsurance Contribution Benefit Years No. A Contributing Entity or Reporting Entity does not need to register with HIOS to complete the reinsurance contribution submission process. A Contributing Entity (or Reporting Entity on a Contributing Entity's behalf) can complete all required steps for the Reinsurance Contribution submission process on Pay.gov. (REGTAP FAQ Database - FAQ #2548a 07/03/14; updated 09/21/15 and 09/13/16) Note: REGTAP indicates that this FAQ has been updated, but the underlying FAQ was not reported/found for the original date of issue. Q: Are the counting methods for calculating the Annual Enrollment Count for reinsurance contribution purposes the same as the counting methods used for the Patient-Centered Outcome Research Trust Fund fee (PCORI Fee)? 433 Updated 1-31-17 2017--00533 A: Applicable to All Reinsurance Contribution Benefit Years No. The counting methods for the Reinsurance program are similar to, but vary in certain instances from, the counting methods permissible for the largely due to the differences in the timing of the payments from the two (2) programs. For the Reinsurance program, a Contributing Entity must use one mof the permitted counting methods in 45 CFR 153.405(d) through 45 CFR These counting methods generally calculate covered lives based on enrollment in the ?rst nine (9) months of a calendar year. You may also refer to the Supporting Document, titled: 'The Transitional Reinsurance Program Operational Guidance: Examples of Counting Methods for Contributing Entities . - available In the Registration for Technical Assistance Portal (REGTAP) Library under ?Reinsurance- Contributions,? and the applicable bene?t year or Module 2: Counting Methods Overview for the applicable benefit year. (REGTAP FAQ Database - FAQ #2644a 07/03/14; updated 09/18/15 and 09/21/16) Note: REGTAP indicates that this FAQ has been updated, but the underlying FAQ was not reported/found for the original date of issue. Q: May a contributing entity remit the entire 2045 Benefit Year reinsurance contribution amount Wary?1572045, in a single payment rather than making two (2) separate payments? Updated 1-31-17 A: Applicable to All Reinsurance Contribution Benefit Years Y_.es The U. S. Department of Health and Human Services will offers Contributing Entities the option to pay: (1 the full?2045 e_ntire Bene?t Year contribution in one (1) payment re?ecting t_he full contribution amount per covered life for the applicable benefit year; $44?OO?per?eever?ed life- or (2) in?a?twe-paFt?payment, separate payments for the bene?t year, with the ?rst remittance re?ecting the per covered life amount for the applicable bene?t year for Program Payments and Program Administration Funds and the second remittance reflective the amount per covered life for the General Fund of the U. S. Treasury. Combined Collection (full contribution amount One (1) payment) 2014 Bene?t Year $63.00 due January 15, 2015 2015 Bene?t Year $44.00 due January 15, 2016 2016 Bene?t Year $27.00 due January 17, 2017 Two (2) Separate Payments 2014 Bene?t Year 434 2017--00534 First Collection: $52.50 due January 15, 2015 Second Collection: $10.50 due November 16, 2016 2015 Bene?t Year First Collection: $33.00 due January 15, 2016 Second Collection: $11.00 due November 15, 2016 2016 Bene?t Year First Collection: $21.60 due January 17, 2017 Second Collection: $5.40 due November 15, 2017 match? (REGTAP FAQ Database - FAQ #2659a 07/07/14; updated 09/21/15 and 09/13/16) Note: REGTAP indicates that this FAQ has been updated, but the underlying FAQ was not reported/found for the original date of issue. Q: Is the reinsurance contribution based on the calendar year even if a Contributing Entity operates on a plan year that is not on a calendar-year basis? Updated 1-31-17 A: Yes. The Annual Enrollment Count for the Transitional Reinsurance Program is based on a calendar year. A Contributing Entity must use one (1) of the permitted counting methods in 45 CFR 153.405(d) through 45 CFR These counting methods generally calculate covered lives based on enrollment in the ?rst nine (9) months of a calendar year. Entities may also refer to 'The Transitional Reinsurance Program Operational Guidance: Examples of Counting Methods for Contributing Entities - UPDATED FOR THE 2015 BENEFIT and 'Module 2: 2015 Reinsurance Contributions Counting Methods Overview' available in the REGTAP Library at under the Reinsurance-Contributions Filter or the Center for Consumer Information and Insurance Oversight (CCIIO) website (REG TAP FAQ Database - FAQ #2692a 07/07/14; updated 09/18/15) Note: REG TAP indicates that this FAQ has been updated, but the underlying FAQ was not reported/found for the original date of issue. 435 2017--00535 Q: How should the Annual Enrollment Count be calculated when a non-calendar year group health plan that offers only one (1) coverage opion changes from self-funded to fully insured mid-calendar year? Updated 1-31-17 A: Applicable to All Reinsurance Contribution Benefit Years If coverage changes from a fully insured plan to a self-insured plan or self-insured to fully insured during the ?rst nine (9) months of 20_14 2?9?157 the issuer of the fully insured plan is responsible for paying the per covered life contribution amount for reinsurance contribution enrollees for the portion of the calendar year they are enrolled in the fully insured plan. The self-insured plan is responsible for paying the per covered life contribution amount for reinsurance contribution enrollees for the portion of the year they are enrolled in the self-insured plan. Therefore, both plans are responsible for paying a portion of the fee for the year in which the change is made on behalf of the covered lives in those plans using one (1) of the permitted counting methods in 45 CFR 153.405(d) and 45 CFR 153.405(e) as applicable. These counting methods generally calculate covered lives based on enrollment in the ?rst nine (9) months of a calendar year. If a plan or coverage is established or terminated during the ?rst nine (9) months of 2015, then the Contributing Entity must select a set of counting dates for the nine (9)-month period in which had enrollees on each of the dates, if possible. For examples of how to calculate reinsurance contributions in these situations, please refer to 'The Transitional Reinsurance Program Operational Guidance: Examples of Counting Methods for Contributing Entities" for the applicable benefit year. (REGTAP FAQ Database- FAQ #2753a 07/10/14; updated 09/18/15 and 09/13/16) Note. REGTAP indicates that this FAQ has been updated, but the underlying FAQ was not reported/found for the original date of issue. Q: How will a contributing entity account for covered lives when an employer that offers only one group health plan coverage option changes from a fully insured plan to a self- insured plan in May 2014? A: When an employer offers only one group health plan coverage option, the issuer of the fully insured plan would be responsible for paying the per covered life contribution amount for enrollees for the portion of the calendar year they are enrolled in the fully insured plan (in your example, from January 1, 2014 through April 30, 2014). The self- insured plan would be responsible for paying the per covered life contribution amount for enrollees for the portion of the year they are enrolled in the self-insured plan (in your example from May 1, 2014 through September 30, 2014). Therefore, both plans would be responsible for paying a portion of the fee using one of the permitted counting methods in 45 CFR 153.405(d) and 45 CFR as applicable, based on the portion of the year these covered lives were enrolled in the self-insured and fully-insured plans. These counting methods generally calculate covered lives based on enrollment in the ?rst nine months of a calendar year, and most of the counting methods account automatically for partial years. (REGTAP FAQ Database - FAQ #3337 08/07/14) 436 2017--00536 Q: Is the Automated Clearing House (ACH) process via Pay.gov the only vehicle being accepted for reinsurance contributions payment for the 2014 benefit year? A: Yes. HHS is implementing a streamlined approach to complete the contributions process through Pay.gov. Presently, an Automated Clearing House (ACH) process via Pay.gov is the only vehicle being accepted for reinsurance contributions payment for the 2014 benefit year. We believe that the use of Pay.gov as the sole collector of contributing entity data and contributions should ease the burden on contributing entities and reporting entities. (REGTAP FAQ Database - FAQ #3338 08/07/14) Q: Can a third party, such as a Third Party Administrator (TPA), Administrative Services Only (ASO) contractor, broker, aqent or attorney submit reinsurance contributions on behalf of a contributing entity and are they required under federal regulations to do so? A: Applicable to All Reinsurance Contribution Benefit Years Yes, a third party may submit reinsurance contributions on behalf of a Contributinq Entity. hewevethhe However, responsibility to make reinsurance contributions lies remains with the contributing entity and the decision to delegate the function of submitting the reinsurance contribution resides with with the contributing entity. HHS does not regulate who may submit the reinsurance contributions on behalf of the contributinq entity. Additionally, HHS regulations do not require a TPA or ASO contractor to perform this function if requested; a TPA's or ASO contractor's obligation to do so would be a function of the arranqement between the TPA or ASO contractor and the Contributinq Entity and any applicable state law. A Contributinq Entity is responsible for the reinsurance contribution, althouqh the entity may elect to use a TPA or ASO contractor for submission of the entity's enrollment count and transfer of the reinsurance contribution. (REGTAP FAQ Database - FAQ #3339; #3339a 08/07/14; updated 09/21/15 and 09/13/16) Q: Will the 2015 and 2016 timing of the reinsurance contribution submission process be similar to 2014? A: Yes. We anticipate that the contribution submission schedule for the 2015 and 2016 bene?t years will be similar to the schedule for the 2014 bene?t year. (REGTAP FAQ Database - FAQ #3340 08/07/14) Q: What are the penalties if the reinsurance contribution payment is not made on time? Updated 1-31-17 A: Pursuant to 45 CFR any amount owed to the Federal government by an issuer and its af?liates for reinsurance is a determination of a debt and will be subject to Federal debt collection rules. Additionally, reinsurance contributions are considered Federal funds that would be subject to the False Claims Act. Similarly, pursuant to 45 CFR any amount owed to the Federal government by a self-insured qroup health plan (includinq a qroup health plan that is partially self-insured and partially insured, where the health insurance coveraqe does not constitute maior medical coveraqe) and its affiliates for reinsurance is a determination of a debt. (REGTAP FAQ Database - FAQ #3341, #3341 a 08/07/14; updated 09/21/15) 437 2017--00537 Q: How does the criteria for self insured plans change in 2016? A: Pursuant to the definition of contributing entity in 45 CFR 153.20, a contributing entity means: 0 For all three benefit years, a health insurance issuer; For the 2014 bene?t year, a self-insured group health plan (including a group health plan that is partially self-insured and partially insured, where the health insurance coverage does not constitute major medical coverage), whether or not it uses a third party administrator; and For the 2015 and 2016 bene?t years, a contributing entity means a health insurance issuer or a self-insured group health plan (including a group health plan that is partially self-insured and partially insured, where the health insurance coverage does not constitute major medical coverage) that uses a third party administrator in connection with claims processing or adjudication (including the management of internal appeals) or plan enrollment for services other than for pharmacy benefits or excepted bene?ts within the meaning of section 2791(0) of the PHS Act. Notwithstanding the foregoing, a self-insured group health plan that uses an unrelated third party to obtain provider network and related claim repricing services, or uses an unrelated third party for up to 5 percent of claims processing or adjudication or plan enrollment, will not be deemed to use a third party administrator, based on either the number of transactions processed by the third party, or the value of the claims processing and adjudication and plan enrollment services provided by the third party. (REGTAP FAQ Database - FAQ #3342 08/07/14) Q: Is a Third Party Administrator (TPA) or Administrative services Only (ASO) contractor required under federal regulations to submit the Annual Enrollment Count and reinsurance contributions on behalf of a contributing entity if the contributing entity requests the TPA or ASP contractor to do so? - . HHS regulations do not require a TPA or ASO contractor to perform this function if requested; a TPA's or ASO contractor's obligation to do so would be a function of the arrangement between the TPA or ASO contractor and the contributing entity and any applicable state law. A contributinq entity is responsible for the reinsurance contributions, although it may elect to use 3 TPA or ASO contractor for submission of its enrollment count and transfer of the reinsurance contributions. (REGTAP FAQ Database - FAQ #3343; #33438 08/07/14; updated 09/21/15) Q: Who is responsible for the payments when a plan changes from fully-insured to self- funded in the middle of the year? Updated 1-31-17 A: When an employer offers only one group health plan coverage option, the issuer of the fully insured plan would be responsible for paying the per covered life contribution amount for enrollees for the portion of the calendar year they are enrolled in the fully insured plan. The self-insured plan would be responsible for paying the per covered life contribution amount for enrollees for the portion of the year they are enrolled in the self- insured plan. Therefore, both plans would be responsible for paying a portion of the fee 438 2017--00538 using one of the permitted counting methods in 45 CFR 153.405(d) and 45 CFR as applicable, based on the portion of the year these covered lives were enrolled in the self-insured and fully-insured plans. These counting methods generally calculate covered lives based on enrollment in the first nine months of a calendar year, and most of the counting methods account automatically for partial years. (REGTAP FAQ Database - FAQ #3345 08/07/14) Q: Are there any exemptions from the obligation to make reinsurance contributions for religious organizations? A: Where are no exemptions from the obligation to make reinsurance contributions speci?cally available to religious organizations. However, there are several types of coverage that are exempt as well as several circumstances under which a contribution is not reguired, ethepexemptiens?ma-y?appl-y, see 45 CFR 153. 400 f_or more. (REGTAP FAQ Database- FAQ #3539; #35393 08/07/14; updated 09/21/15) Q: Can a third party administrator (TPA) or insurance company that administers its own plan for its employees qualify for the self-insured, self-administered exemption for the 2015 and 2016 benefit years for those enrollees? A: Applicable to All Reinsurance Contribution Benefit Years A third party administrator or health insurance issuer that provides self-insured, self- administered coverage for purposes of the definition of ?contributing entity" in 45 CFR 153.20 would be exempt from making reinsurance contributions for the 2015 and 2016 bene?t years. (REGTAP FAQ Database - FAQ #3540 08/07/14; updated 09/13/16) Q: If a plan provides minimum value but not a ?broad range of services and treatments provided in various settings,? is that plan exempt from the requirement to make reinsurance contributions? A: No. Under 45 CFR 156.28, ?major medical coverage" is de?ned, for purposes of the Reinsurance program to include a plan that provides minimum value as defined under 45 CFR 156.145. Reinsurance contributions are general required for is-deemed?te?be major medical coverage that is considered to be part of a commercial book of business, but are not required to be paid more than once with respect to the same covered life. 49: FAQ Database- FAQ #3541; #3541 8 08/07/14,? updated 09/21/15) Q: Are retro-active enrollment adjustments, due to enrollment terminations, permitted for reporting reinsurance covered lives in the first nine (9) months of the year? lf?a?eevered Updated 1-31-17 appheable? The permitted counting methods In 45 CFR 153. 405(d) and 45 CFR 153. 405(e calculate covered lives based on enrollment only In the ?rst 9 months of a calendar year. We understand that fluctuations may occur in the fourth quarter of a bene?t year; however, those fluctuations are ignored for purposes of counting covered 439 2017--00539 lives for purposes of reinsurance contributions. (REGTAP FAQ Database - FAQ #3542; 3542a 08/07/14; updated 09/18/15) Q: Pursuant to 45 CFR no later than November 15 of benefit year 2014, 2015, or 2016, as applicable, or, if such date is not a business day, the next business day, a contributing entity must submit an Annual Enrollment Count of the number of covered lives of reinsurance contribution enrollees for the applicable benefit year to U.S. Department of Health and Human Services (HHS). However, November 15, 2015 is a Sunday and the Pay.gov Help Desk is not open on non-business days; therefore, can we have till the next applicable business day to submit our Annual Enrollment Count? A: For the 2015 Bene?t Year a Contributing Entity may submit its Annual Enrollment Count of the number of covered lives of reinsurance contribution enrollees to HHS no later than Monday, November 16, 2015. However, we strongly encourage contributing entities to ?le before November 15, 2015, so as to avoid any technical dif?culties. (REGTAP FAQ Database - FAQ #5415a 10/07/14; updated 09/21/15) Note: REG TAP indicates that this FAQ has been updated, but the underlying FAQ was not reported/found for the original date of issue. Q: Can the reinsurance contribution be paid out of a self-insured plan's trust account? A: Applicable to All Reinsurance Contributions Benefit Years tho-oontubutmg?entity? HHS regulations do not specify or prohibit any particular source for the funds. We CMS refers Issuers you to the U. S. Department of Labor for any applicable restrictions under ERISA. Please contact the U.S. Department of Labor at 202-693-8335 for any questions. The responsibility to make reinsurance contributions remains with the contributing entity and the decision to deleqate the function of submitting the reinsurance contribution resides with the contributing entity (REGTAP FAQ Database - FAQ #5417; #5417a 10/07/14; updated 09/21/15 and 09/21/16) Q: How will the number of covered lives be audited? Updated 1-31-17 A: Applicable to All Reinsurance Contributions Benefit Years Pursuant to 45 CFR 153. 405(i), HHS or its designee may audit a contributing entity to assess its compliance with the requirements of 41?5 CFR Part 153 subpart E. naticipates I - - - that any audit of a contributing entity_ will should focus on records relating to enrollment In the applicable self-insured or insured plan, to con?rm that the number of covered lives was correctly calculated and that the correct amount of reinsurance contributions was paid. Additionally, these audits may be used to identify entities that were required to but did not make reinsurance contributions. We?intend?on We CMS also notes that pursuant to 45 CFR a contributing entity must maintain documents and records, whether paper, electronic, or in other media, suf?cient 440 2017--00540 to substantiate the enrollment count submitted pursuant to this section for a period of at least 10 years, and must make those documents and records available upon request from HHS, the OIG, the Comptroller General, or their designees, to any such entity, for purposes of veri?cation, investigation, audit, or other review of reinsurance contribution amounts. (REGTAP FAQ Database - FAQ #5429, #5429a 10/07/14; updated 09/21/15 and 09/21/16) Q: Please clarify whether the plan sponsor of a self-insured plan (the contributing entity) which changes Third Party Administrators (TPAs) during the 1st 3 quarters of the year can have each TPA submit the 12045 ACA Transitional Reinsurance Program Annual Enrollment and Contributions Submission Form? (the Form) attesting to the annual member count during the portion of the 1st 3 quarters the TPA administered the plan, or should issuers only submit iust one (1) Form mustebesubmitted if the plan was self- insured for the entire period? A: Applicable to All Reinsurance Contributions Benefit Years The ultimate responsibility to make reinsurance contributions lies with the contributing entity, and the decision to delegate the function of submitting the reinsurance contribution is with the contributing o_n y only one (1) reporting entity should ?le the 12045 ACA Transitional Reinsurance Program Annual Enrollment and Contributions Submission Form and Supporting Documentation (.CSV f' le), if applicable per contributing entity; therefore, both TPAs would not be able to report for the same contributing entity only covering a portion of the benefit year because the submission must reflect the entire bene?t year. FAQ Database- FAQ #5431, #5431a 10/07/14, updated 09/21/15 and 09/13/16) Q: For the actual method, can Contributing Entities we?use any day within a month to count Updated 1-31-17 and tie these membership numbers to the manual payment process through A: Applicable to All Reinsurance Contributions Benefit Years No, the Actual Count Method requires a contributing entity to add the total number of lives (enrollees) covered for each day of the ?rst nine months of the benefit year and divide that total by the number of days in those nine months [see 45 However, Contributinq Entities you?may want to use a different counting method, such as the snapshot count method, set forth in 45 CFR if an entity yea?want chooses to use only one day per month, if those membership counts include all of the covered lives enrolled in the contributing entity's plan(s) and coverage. We note that submission for the manual payment process is only for QHPs, and the requirement to make reinsurance contributions is not limited to enrollment in a QHP. We CMS _encourages you to review 'The Transitional Reinsurance Program Operational Guidance: Counting Method Examples for Contributing Entities for the applicable benefit 441 2017-?00541 updated 09/18/15 and Q: For reinsurance membership counts, can Contributing Entities we use the membership counts at the 15th for each of the 9 months that correspond with the CMS Enrollment and Payment template for payment of APTC and A: Applicable for All Reinsurance Contribution Benefit Years Yes, if the date falls within the same week of the month of the quarter, the these membership counts include all of the covered lives enrolled in the contributing entity's plan(s) and coverage and the Contributinq Entity uses the Snapshot Count Method described in 45 CFR We note that submission for the manual payment process is only for QHPs, and the requirement to make reinsurance contributions is not limited to enrollment in a QHP. 45% Under the snapshot count method, to determine the number of covered lives of reinsurance contribution enrollees under a health Insurance plan for a bene?t year, a health insurance issuer must add the total number of lives covered on any date (or more dates, if an equal number of dates are used for each quarter) during the same corresponding month in each of the ?rst three quarters of the bene?t year, and dividing that total by the number of dates on which a count was made. For this purpose, the same months must be used for each quarter (for example January, April and July) and the date used for the second and third quarter must fall within the same week of the quarter as the corresponding date used for the ?rst quarter. ?eu Contribution Entities may also reference 'The Transitional Reinsurance Program Operational Guidance: Counting Method Examples for Contributing Entities' f_or the applicable benefit year. (REGTAP FAQ Database- FAQ #5437 #5437 a 10/07/14; updated 09/21/15 and 9/21/16) Q: Can an issuer that has multiple major medical plans with different covered lives in each plan use a separate counting method for each plan? Updated 1-31-17 A: As noted in the US. Department of Health and Human Services (HHS) Notice of 442 2017-?00542 Bene?t and Payment Parameters for 2014, the counting methods for the Transitional Reinsurance Program are designed to align with the methods permitted for purposes of the fee to fund the Patient-Centered Outcomes Research Trust Fund (PCORTF Rule) to promote administrative efficiencies. The PCORTF Rule requires consistency in the use of counting methods for calculating covered lives for the duration of the year. Similarly, for purposes of the Transitional Reinsurance Program, Contributing Entities that are health insurance issuers, who have multiple major medical plans covering different lives in multiple States are encouraged to use the same counting method when calculating the covered lives of reinsurance contribution enrollees for all plans (including both the individual and group markets) offered in one (1) State. The Centers for Medicare Medicaid Services (CMS) will clarify the consistency requirements for purposes of calculating covered lives for the Transitional Reinsurance Program in future rulemaking. (REGTAP FAQ Database - FAQ #6037 10/21/14) Q: For employers with multiple health plans, fully insured and self-insured, is the employer responsible for remitting reinsurance contribution payments for the self- insured plans only? Updated 1-31-17 A: The definition of a ?Contributing Entity" under 45 CFR 153.20 generally includes health insurance issuers and self-insured group health plans (including group health plans that are partially self-insured and partially insured, where the health insurance coverage does not constitute major medical coverage). Each Contributing Entity is responsible for remitting reinsurance contributions for the covered lives enrolled in a major medical coverage plan, unless an exception in 45 CFR 153.400(a) applies. If there are multiple group health plans (including self-insured and fully-insured plans) offered by a plan sponsor that provides major medical coverage for different covered lives, the general procedures for counting covered lives under 45 CFR 153.405(d) and would apply. Therefore, a health insurance issuer is responsible for contributions for the covered lives enrolled in an insured plan that provides major medical coverage, and a self-insured group health plan is responsible for contributions for the covered lives enrolled in a self-insured plan (including a plan that is partially insured and partially self- insured) that provides major medical coverage, unless an exception in 45 CFR 153.400(a) applies. To determine the number of covered lives, the health insurance 443 2017--00543 issuer would use one (1) of the counting methods for insured coverage at 45 CFR 153.405(d) and the self-insured group health plan would use one (1) of the counting methods for self-insured plans at 45 CFR (REGTAP FAQ Database - FAQ #6242; #6242a 10/27/14; updated 09/21/15) Q: When selecting dates for the Snapshot Factor Method or Snapshot Count Method, are the last days of the quarter acceptable? Specifically: March 31, June 30 and September 30. These days are consistent, but may not fall in the same week of the quarter. A: Applicable to All Reinsurance Contribution Benefit Years Yes. When considering a full year?s coverage, methods require a Contributing Entity to add the total number of covered lives of reinsurance contribution enrollees on any date (or more dates, if an equal number of dates are used for each quarter) during the same corresponding month in each of the first three (3) quarters of the calendar year (that is, March, June and September), and dividing that total by the number of dates on which a count was made. The date used for the second and third quarters must fall within the same week of the quarter as the corresponding date used for the ?rst quarter. We note that the Contributing Entity may use th_e last day of each month regardless of the actual week only if coverage was provided for the full year (January September). Under the Snapshot Factor Method, the number of lives covered on a date is calculated by adding (1) the number of participants with self-only coverage on the date and (2) the product of the number of participants with coverage other than self-only coverage on the date and a factor of 2.35. (REGTAI5 FAQ be abase - FAQ #6436; #6436a 0/29/14; updated 09/21/15 and 9/21/16) Q: To qualify for the exemption set forth in 45 CFR what parts of Medicare must an enrollee have as primary under the Medicare Secondary Payer rules under section 1862(b) of the Act and the regulations issued thereunder? 444 Updated 1-31-17 2017--00544 A: Applicable to All Reinsurance Contribution Benefit Years As stated in the HHS Notice of Benefit and Payment Parameters for 2014 (78 FR 15456), when an individual has both Medicare coverage and employer-provided group health coverage, the Medicare Secondary Payer (MSP) rules under section 1862(b) of the Act would apply, and the group health coverage would be considered major medical coverage only if the group health coverage is the primary payer of medical expenses (and Medicare is the individual?s secondary payer) under the MSP rules. For purposes of this exemption from the requirement to make reinsurance contributions, if an employee with employer-provided coverage receives primary coverage under Medicare, Part A or Part B, then that employee does not need to be counted when the employer is calculating its Annual Enrollment Count for the purposes of reinsurance contributions. (REGTAP FAQ Database - FAQ #6437 10/29/14; updated 09/21/16) Q: How should a Contributing Entity determine the number of covered lives of reinsurance contribution enrollees under a health insurance plan or coverage using the Snapshot Count Method, set forth In 45 CFR 153. 405(d)(2), or the Snapshot Factor Method, set forth in 45 CFR 153. 405(e)(2) if, for one (1) of the three (3) quarters during the benefit year, the plan or coverage did not have covered lives enrolled in the plan or coverage for the entire quarter? Updated 1-31-17 A: Applicable to All Reinsurance Contribution Benefit Years A: Pursuant to 45 CFR 153.400(a) (1 reinsurance contributions are generally required for major medical coverage, but contributions are not required to be paid more than once with respect to the same covered life. The reinsurance contribution required from a Contributing Entity is calculated by multiplying the number of covered lives determined under a permitted counting method set forth in 45 CFR 153.405(d) through 45 CFR 153.405(g) during the applicable calendar year for all applicable plans and coverage of the Contributing Entity by the applicable contribution rate for the respective bene?t year. We understand that a health insurance plan or coverage may be established or terminated, or change funding mechanisms from fully insured to self-insured or self- insured to fully insured) in the middle of a quarter. In these circumstances, the new plan or coverage would not have covered lives enrolled in the plan or coverage for the entire quarter. -- -- We note that if this occurs, a Contributing Entity could, due to its selection of dates, be required to pay an amount signi?cantly greater or lesser than the amount that would be due based on its average count of covered lives under the plan or coverage over the course of the ordinarily applicable nine-month counting penod. To avoid this result and to effectuate the principle that contributions are required to be paid once with respect to the same covered life, we clarify that if the plan or coverage in question had enrollees on any day during a quarter and if the Contributing Entity elects to and is permitted to use either the Snapshot Count Method or Snapshot Factor Method set forth in 45 CFR and respectively, it must choose a set of counting dates for the nine-month counting period such that the plan or coverage has enrollees on each of the dates, if possible. However, the enrollment count for a date during a quarter in which the plan or coverage was not in existence 2017--00545 Updated 1-31-17 during the entire quarter can be reduced by a factor re?ecting the amount of time during the quarter for which the plan or coverage did not have enrollment. This approach is intended to accurately capture the amount of time during the quarter for which major medical coverage was provided to reinsurance contribution enrollees, while not requiring contributions to be paid more than once with respect to ?the same covered life. For example, a Contributing Entity that has a plan that terminates on August 31st (that is, 62 days into the third quarter) would not be permitted to use September 1st as the date for the third quarter under the Snapshot Count or Snapshot Factor Methods because this would not properly re?ect the number of covered lives of reinsurance contribution enrollees under the plan in the third quarter of the benefit year. However, it would be entitled to reduce its count of covered lives for the third quarter by 30/92, the proportion of the quarter during which the plan had no enrollment. This reduction factor is only applicable for the Snapshot Count and Snapshot Factor Methods set forth in 45 CFR and respectively, as all of the other permitted counting methods automatically account for partial year enrollment. Using the example from this paragraph, Table 1 (attached) illustrates how the reduction factor would work when using the Snapshot Count Method set forth in 45 CFR is the Annual Enrollment Count.) As another example, a Contributing Entity that has a plan that was established on September 1st (that is, 62 days into the third quarter) would not be permitted to use a date in July 1st or August 1st as the date for the third quarter under the Snapshot Count or Snapshot Factor Methods because this would not properly re?ect the number of covered lives of reinsurance contribution enrollees under the plan in the third quarter of the benefit year. However, it would be entitled to reduce its count of covered lives for that quarter by 62/92, the proportion of the quarter during which the plan had no enrollment. This reduction factor is only applicable for the Snapshot Count and Snapshot Factor Methods set forth in 45 CFR and respectively, as all of the other permitted counting methods automatically account for partial year enrollment. Using the example from this paragraph, Table 2 (attached) illustrates how the reduction factor would work when using the Snapshot Count Method set forth in 45 CFR Files: RIC FAQ Attachment1 5CR 1029146438. RIC FAQ Attachment2 SCR 1029146438. 446 2017--00546 (REG TAP FAQ Database - FAQ #6438; 64388 10/29/14; updated 09/21/15 and 09/13/16) Q: For a third party filing on behalf of a Contributing Entity, does the third party and the Contributing Entity need to register for Pay.gov? A. No, only the entity actually filinq and submitting the form will reqister on Pay. qov. lf?a The U. S. Department of Health and Human Services (HHS) does not regulate who may submit the reinsurance contributions on behalf of the Contributing Entity. The responsibility to make reinsurance contributions remains lies-with the Contributing Entity and the decision to delegate the function of submitting the reinsurance contribution is further resides with the Contributing Entity. (REGTAP FAQ Database - FAQ #6439; #64393 10/29/14; updated 09/21/15) Q: Will you CMS explain the ?Type of Contributing Entity? section of the Supporting Documentation (.CSV file)? Updated 1-31-17 A: The ?Type of Contributing Entity? section of the Supporting Documentation is determined based on whether the entity is a health insurance issuer (Hll) or self-insured group health plan (SI). If the entity is a self-insured group health plan, it must determine whether the health plan includes multiple group health plans Aggregated Reporting or Separate Reporting) and how they are reported. er?is-a?single Therefore, Multiple Group Health Plans Sinqle Plan Treatment means that the plan sponsor chooses to treat the multiple group health plans as a single group health plan for purposes of calculating the reinsurance contribution Annual Enrollment Count. Multiple Group Health Plans Multiple Plan Treatment means that the plan sponsor treats the multiple plans as separate qroup health plans, where the plan sponsor determines the number of covered lives under each separate qroup health plan as if the separate group health plan provided major medical coverage is its own plan for which reinsurance contributions are required). If the plan sponsor maintains multiple group health plans, the selected counting method used for reporting enrollment counts, pursuant to 45 CFR 153.405(9) must be considered. Pursuant to 45 CFR a Contributing Entity may be multiple group health plans including an insured plan maintained by the same plan sponsor that collectively provides major medical coverage for the same covered lives simultaneously, or multiple self-insured group health plans maintained by the same plan sponsor that collectively provides major medical coverage for the same covered lives simultaneously. Pursuant to 45 CFR if there are multiple group health plans maintained by the same plan sponsor, the plan sponsor generally must treat the multiple plans as a single group health plan for purposes of calculating the reinsurance contribution Annual Enrollment Count. However, the plan sponsor may also treat the multiple group health plans as separate group health plans if the plan sponsor determines the number of 447 2017-?00547 covered lives under each separate group health plan as if each separate group health plan provided major medical coverage is its own plan for which reinsurance contributions are required). If a plan sponsor that maintains multiple group health plans that collectively provide maior medical coverage for the same covered lives simultaneously and does not include an insured plan chooses aggregate reporting under 45 CFR the plan sponsor can only claim the self-insured, self-administered exemption if all of its self- insured coverage options meet the criteria for being self-administered as outlined in the de?nition of Contributing Entity under 45 CFR 153.20. If a plan sponsor that maintains multiple group health plans that collectively provide major medical coverage for the same covered lives simultaneously includes an insured plan chooses aggregate reporting under 45 CFR the plan sponsor cannot claim the self-insured, self-administered exemption in light of the insured plan. However, if a plan sponsor chooses to report each coverage option separately under 45 CFR that is the plan sponsor chooses to treat the multiple plans as separate group health plans and determines the number of covered lives of reinsurance contribution enrollees under each separate group health plan as if the separate group health plan provided maior medical coverage (that is, as its own plan for which reinsurance contributions are reguired)l then the plan sponsor could claim the self-insured, self-administered exemption for any self- insured coverage option that is deemed self-administered pursuant to the definition of Contributing Entity under 45 CFR 153.20. For further information on calculating the enrollment count, we encourage you to review ?The Transitional Reinsurance Program Operational Guidance: Examples of Counting Methods for Contributing Entities UPDATED FOR THE 2015 BENEFIT and Module 2. 2015 reinsurance Contributions Counting Methods Overview available in the REGTAP library under Reinsurance- Contributions or the CCIIO website element-that http: cms. gov/CCIIO/Programs- and- Initiatives/Premium- Stabilization- Programs/The-Transitional- Reinsurance- Program/Reinsurance- or visit Select Library, and Filter by: Reinsurance-Contributions. (REGTAP FAQ Database - FAQ #6440; #6440a 10/29/14; updated 09/21/15) Q: If a third party is submitting reinsurance contribution payments on behalf of all of its health plans, does the payment for all Contributing Entities have to be made at one (1) time or can the payments be at different times per Contributing Entity? 448 Updated 1-31-17 2017--00548 Updated 1-31-17 A: Applicable to All Reinsurance Contribution Benefit Years The reinsurance contributions submission process on Pay.gov has ?exibility to choose e_ither allow a combineds single payment or two- -part payment schedule-process that allows scheduling of payments at different times for each filing. Therefore if. a The Reporting Entity who has Contributing Entities that wish to pay using different collection schedules, you Mll?have?te??le more than one (_)_Form would be reguired, grouping together the Contributing Entities that plan to make a combined, single payment and the Contributing Entities that plan to make a two-part payment. Also, if each Contributing Entity is paid from different banking accounts, separate ?lings will be required from each of the other en??es. Regardless of the payment option selected, a Contributing Entity must submit its Annual Enrollment Count and schedule their reinsurance contribution payment date(s) for the 2015 Bene?t Year no later than Monday, November 16, 2015 by completing the '2015 ACA Transitional Reinsurance Program Annual Enrollment and Contribution Submission Form' through Pay.gov. Combined Collection (full contribution amount- One 1) payment) 2014 Bene?t Year $63.00 due January 15, 2015 2015 Bene?t Year $44.00 due January 15,2016 2016 Bene?t Year $27.00 due January 17, 2017 Two (2) Separate Payments 2014 Bene?t Year First Collection: $52.50 due January 15, 2015 Second Collection: $10.50 due November 16, 2016 2015 Bene?t Year First Collection: $33.00 due January 15, 2016 Second Collection: $11.00 due November 15, 2016 2016 Bene?t Year First Collection: $21.60 due January 17, 2017 Second Collection: $5.40 due November 15, 2017 If a two (2)-part payment option is chosen, the Contributing Entity is?alse?required?te should ?le the ?Form a?Eenm for the Second Collection on the same day as the Form filing for the First collection. submission-deadline. To do this, duplicate the Form filing for the First Collection and submit it to re?ect the Second Collection. You should schedule the Second Collection remittance grior to November 15, 2017. 449 2017-?00549 The Second Collection amount will not be withdrawn until the scheduled date or the next business day if the scheduled payment date is a weekend or a Federal Reserve holiday. The Gross Annual Enrollment Count in the Form (and Supporting Documentation (.CSV if applicable) for both the First and Second Collection must match. As mentioned before, each Form submission is related to one bank account. To schedule different payments on different dates or from different bank accounts, a Reporting Entity would simply submit additional Forms for each contributinq entity. (REGTAP FAQ Database- FAQ #6441; #6441a 10/29/14; updated 09/21/15 and 09/13/16) Q: Is there another way to remit reinsurance contributions other than the Automated Clearing House (ACH) debit? Updated 1-31-17 A: Applicable to All Reinsurance Contribution Benefit Years No. An ACH debit transaction through Pay.gov is the only vehicle being accepted for reinsurance contributions payment for the?2044 Benefit Years. The Contributing Entity must input banking information (routing and account number) when scheduling the payment date on Pay.gov's payment page. Pay.gov is a secure website operated by the US. Department of Treasury. Automatic debits to a business account may be blocked by the bank through a security feature called an ACH Debit Block, ACH Positive Pay, or ACH Fraud Prevention Filters. To remove the ACH Debit Block, an organization must provide a list of allowed ACH company IDs to enable automatic debits from authorized companies. When working with the US. Government, these company ID codes are referred to as the Agency Location Code Contributing Entities must contact their bank to add the to their list of allowed ACH company IDs for debit transactions. The Transitional Reinsurance Program's for the 2014 and 2015 benefit years is 7505008015 and company name is The Transitional Reinsurance Proqram?s for the 2016 Bene?t Year is 7505008016 and company name is additional features for their customers to manage ACH transactions originating from their list of allowed ACH company le including. setting a ?xed or maximum dollar amount for the debit, reviewing and approving ACH transactions, authorizing a single payment, authorizing recurring payments including dollar amount thresholds, and establishing an expiration date for any authorized payments. 450 2017--00550 For additional questions, please contact Pay.gov at 1-800-624-1373 (toll free, select Option or 216-579-2112 (select Option (REGTAP FAQ Database - FAQ #6442; #6442a 10/29/14; updated 09/21/15 and 09/13/16) Q: What does ?Invoice? represent in the ?Type of Payment? section of the Form? Are A: Applicable to All Reinsurance Contribution Benefit Years For reinsurance contributions purposes, an Invoice results when a data er?payment error has occurred resultinq in additional payment or fees been-detemnned. Receiving an Invoice is not an alternative to the ACH debit process, as all Invoices must also be paid through Pay.gov using the ACH debit process. Automatic debits to a business account may be blocked by the bank through a security feature called an ACH Debit Block, ACH Positive Pay, or ACH Fraud Prevention Filters. To remove the ACH Debit Block, an organization must provide a list of allowed ACH company IDs to enable automatic debits from authorized companies. When working with the US. Government, these company ID codes are referred to as the Agency Location Code Contributing Entities must contact their bank to add the to their list of allowed ACH company IDs for debit transactions. The Transitional Reinsurance Program's for the 2014 and 2015 Benefit Years is 7505008015 and company name is The Transitional Reinsurance Proqram?s for the 2016 benefit year is 7505008016 and company name is For additional questions, please contact Pay.gov at 1-800-624-1373 (toll free, select Option or 216-579-2112 (select Option (REGTAP FAQ Database - FAQ #6443; #6443a 10/29/14; updated 09/21/15 and 09/13/16) Q. If a self-insured group health plan files the 2043 2044 prior year?s Form 5500 by October 15, of the current benefit year will the entity be 20452044?are-they? Is?theself- msured?greupheatth?plan able to use those enrollment counts for t_he from?the?2044 Form 5500 Counting Method for Wreinsurance purposes, as described in 45 CFR 153. 405(e)(3)? A: Applicable to All Reinsurance Contribution Benefit Years Yes. Pursuant to 45 CFR which outlines the Form 5500 Counting Method, a plan may use the number of lives covered for the most current plan year calculated based upon the ?Annual Return/Report of Employee Benefit Plan? filed with the Department of Labor (Form 5500) for the last applicable time period. Therefore, if a plan uses the Form 5500 Counting Method for determining the Annual Enrollment Count, and the most current plan year calculated based upon the Form 5500 ?led with the Department of Labor for the last applicable time period represents a period of time during the 2040 2044 prior Calendar Year, the plan may use this period in determining the plan's Annual Enrollment Count for the 2044 2045 current Benefit Year for the purpose of reinsurance contributions. For the applicable Benefit Years, a plan may use its Form 5500 filed with the Department of Labor as follows: 451 Updated 1-31-17 2017--00551 - 2013 Form 5500 for the 2014 Annual Enrollment Count - 2014 Form 5500 for the 2015 Annual Enrollment Count - 2015 Form 5500 for the 2016 Annual Enrollment Count ?eu?Entities may also reference ?The Transitional Reinsurance Program Operational Guidance: ?Examples of Counting Methods for Contributing Entities? for the applicable - -- - that explains the counting methods available by type of Contributing Entity, summarizes the counting methods and provides examples for the application of each counting method. To access the document, go to: the Transitional Reinsurance Program webpage at or visit Select Library, and Filter by: Reinsurance-Contributions and the applicable bene?t year. (REGTAP FAQ Database - FAQ #6444; #64448 10/29/14; updated 09/21/15 and 09/13/16) Q: Can you CMS explain the difference between the three Types of Payment options (First Collection, Second Collection and Combined Collection)? Updated 1-31-17 A: Applicable to All Reinsurance Contribution Benefit Years The US. Department of Health and Human (HHS) offers Contributing Entities the option to pay: (1) the entire bene?t year contribution in one (1) combined payment Combined Collection); or (2) in two (2) separate payments First Collection and Second Collection. Please see the below for details by benefit year). Regardless of the payment option selected, A Contributing Entity must submit their Annual Enrollment Count and schedule its reinsurance contribution payment date(s) no later?than?NevembeF?WTZOM by completing the Transitional Reinsurance Program Annual Enrollment and Contribution Submission Form" through Pay.gov. If a two (2)-part payment is chosen, the Contributing Entity is to ?le the Form for the Second Collection on the same day as the Form ?ling for the First Collection. To do this, duplicate the Form filing for the First Collection and submit it to re?ect the Second Collection. The Second Collection amount will not be withdrawn until the scheduled date or the next business day if the scheduled payment date is a weekend or a Federal Reserve holiday. The Annual Enrollment Count in the Form (and Supporting Documentation (.CSV file), if applicable) for both the First and Second Collection must match. Combined Collection (full contribution amount- One (1) payment) 2014 Bene?t Year $63.00 due January 15, 2015 2015 Bene?t Year $44.00 due January 15, 2016 2016 Bene?t Year 452 2017-?00552 $27.00 due January 17, 2017 Two (2) Separate Payments 2014 Bene?t Year First Collection: $52.50 due January 15, 2015 Second Collection: $10.50 due November 16, 2016 2015 Bene?t Year First Collection: $33.00 due January 15, 2016 Second Collection: $11.00 due November 15, 2016 2016 Bene?t Year First Collection: $21.60 due January 17, 2017 Second Collection: $5.40 due November 15, 2017 (REG TAP FAQ Database- FAQ #6445 10/29/14, updated 09/13/16) Q: Where are the regulations associated with the collection of the transitional reinsurance contribution? A: Applicable to All Reinsurance Contribution Benefit Years Section 1341 of the Affordable Care Act established the Transitional Reinsurance Program to help stabilize premiums in the individual market. 45 CFR Part 153 Subparts A, C, and contain seqrare?theregulationS associated with the Transitional Reinsurance Program. We encourages yea entities to review program related documents and FAQs on REGTAP. To access these documents, visit Select Library or FAQ, and Filter by: Reinsurance-Contributions and the applicable benefit year. Entities also can locae quidance related to the Transitional Reinsurance Proqram on the Center for Consumer Information and Insurance Oversiqht (CCIIO) website (REGTAP FAQ Database - FAQ #6446; #6446a 10/29/14; updated 09/21/15 and 09/13/16) Q: How much detail is required in the Supporting Documentation file - should issuers list every individual enrollee? Updated 1-31-17 A: Member level information is not required in the Supporting Documentation. The required Supporting Documentation must include information on each Contributing Entity and the Annual Enrollment Count that is represented in the Gross Annual Enrollment Count entered in the Pay.gov Form. A Job Aid for the Supporting Documentation, with the ability to cut and paste data and instructions for using the Job Aid, as well as a list of 453 2017--00553 the data fields required for the Supporting Documentation are currently available on REGTAP. To locate these documents, visit Select ?Library? or and Filter by: Reinsurance-Contributions. Additionally, the webinar presentation titled ?Submission of Supporting Documentation through Pay.gov? gives a detailed walk-through of the process. To locate these documents, visit Select Library or FAQ, and Filter by: Reinsurance-Contributions. Additionally, the webinar presentation titled ?Submission of Supporting Documentation through Pay.gov? gives a detailed walk- through of the process. (REGTAP FAQ Database - FAQ #6447 10/29/14) Q: Does an employer need to make reinsurance contributions if the employer-provided group health coverage applies to individuals with individual market health insurance coverage for which reinsurance contributions are required, or such coverage is supplemental or secondary to group health coverage for which reinsurance contributions must be made for the same covered lives? A: Applicable to All Reinsurance Contributions Benefit Years Reinsurance contributions are generally required for major medical coverage that IS part of a commercial book of business, but are not required to be paid more than once with respect to the same covered life However pursuant to 45 CFR reinsurance contributions are not required, in the case of employer-provided group health coverage if: such coverage applies to individuals with individual market health insurance coverage for which reinsurance contributions are required or such coverage is supplemental or secondary to group health coverage for which reinsurance contributions must be made for the same covered lives. We?nete?that?as?we?stated In the HHS Notice of Benefit and Payment Parameters for 2015 (79 FR 13782), we CMS stated that if it is not clear from the terms of the health plans which group health plan is supplemental, the group health plan that offers the greater portion of inpatient hospitalization bene?ts is deemed the primary health plan. If it is-net remains unclear from the terms of the health plans which group health plan is primary and which is secondary, weweulddefer deference is given to the arrangements on primary and secondary liability set forth by the respective plan sponsors, in accordance with applicable State coordination of benefit laws and regulations. ln?sueh?a srtuahen?weweuldheld Therefore a plan sponsor is held harmless from non- compliance actions for failure to pay reinsurance contributions to the extent the sponsor relied in good faith upon a written representation by the other sponsor that the other sponsor's coverage has primary liability for claims for particular covered lives (and is responsible for making reinsurance contributions with respect to those covered lives). (REGTAP FAQ Database - FAQ #6448; #6448a 10/29/14; updated 09/21/15 and 09/21/16) Q: When should a Contributing Entity deduct exempted lives from its Annual Enrollment Count for reinsurance contribution purposes? A: Applicable to All Years 454 Updated 1-31-17 2017--00554 As stated in the HHS Notice of Benefit and Payment Parameters for 2014 (78 FR 15456), Contributing Entities may use any reasonable method of estimating the number or percentage of its enrollees who are exempted from the requirement to make reinsurance contributions, as set forth in 45 CFR For example, a Contributing Entity may calculate the percentage of enrollees for which the employer group health coverage is secondary under the Medicare Secondary Payer (MSP) rules on the dates it uses when applying the Snapshot Count Method or Actual Count Method, or on other periodic dates, and reduce the enrollment count calculated using one (1) of the applicable methods in 45 CFR 153.405(d) through (9) by that percentage. A Contributing Entity may also calculate the total enrollment of individuals for which the employer group health coverage is secondary under the MSP rules on the last day of the third quarter and reduce the enrollment count that was calculated using one (1) of the methods in 45 CFR 153.405. Alternatively, if a plan has enrollees who should not be included in the enrollee count pursuant to an exemption in 45 CFR a reasonable method of estimating the number of exempted lives could include subtracting the exempted lives as follows: . Actual Count Method (45 CFR - subtract any exempted covered lives from the total for each day, prior to adding the total number of lives covered for each day of the ?rst nine (9) months of the benefit year and then divide that total by the number of days in the ?rst nine (9) months. . Snapshot Count Method (45 CFR - subtract any exempted covered lives from the total for each date(s) on which a count is taken in a quarter, prior to adding the total number of lives covered on any date (or more dates, if an equal number of dates are used for each quarter) during the same corresponding month in each of the first three (3) quarters of the bene?t year, and then divide that total by the number of dates on which a count was made. . Snapshot Factor Method (45 CFR - add the total number of lives covered on any date (or more dates, if an equal number of dates are used for each quarter) during the same corresponding month in each of the ?rst three quarters of the bene?t year (provided that the date used for the second and third quarters must fall within the same week of the quarter as the corresponding date used for the ?rst quarter), and dividing that total by the number of dates on which a count was made, except that the number of lives covered on a date is calculated by adding the number of participants with self-only coverage on the date to the product of the number of participants with coverage other than self-only coverage on the date and a factor of 2.35. For this purpose, the same months must be used for each quarter (for example, January, April, and July). Following this determination, subtract from the total number of lives covered the number of exempted covered lives. 0 State Form or Member Months Method (45 CFR - determine the average number of policies for the first nine (9) months of the calendar year and multiply that that number of policies by the ratio of covered lives per policy in effect, calculated using the prior National Association of Insurance Commissioners (NAIC) Supplemental Health Care Exhibit (or a form ?led with the issuer's State of domicile for the most recent time period). Following this determination, subtract from the total number of lives covered the number of exempted covered lives. 0 Form 5500 Method (45 CFR - determine the number of lives covered for the most current plan year calculated based upon the "Annual Return/Report of Employee Benefit Plan? filed with the Department of Labor (Form 5500) for the last 455 Updated 1-31-17 2017--00555 applicable time period. For purposes of this method, the number of lives covered for the plan year for a plan offering only self-only coverage equals the sum of the total participants covered at the beginning and end of the plan year, as reported on the Form 5500, divided by two (2), and the number of lives covered for the plan year for a plan offering self-only coverage AND coverage other than self-only coverage equals the sum of the total participants covered at the beginning and the end of the plan year, as reported on the Form 5500. Following this determination, subtract from the total number of lives covered the number of exempted covered lives. (REGTAP FAQ Database - FAQ #6449; #6449a 10/29/14; updated 09/21/15 and 09/21/16 Note: while included as an updated FAQ, no updates were found when comparing the new to the original language) Q: What do you do if you have trouble creating and attaching the Supporting Documentation? What do I do if I have trouble with the Supporting Documentation Job Aid? Updated 1-31-17 A: Applicable to All Reinsurance Contribution Benefit Years The US. Department of Health and Human Services (HHS) created a Job Aid Template and Manual that includes macros that perform validations and allows for the creation of the Comma Separated Value (CSV) ?le at a push of a button within the spreadsheet. Go tg and click the link entitled ?Supperting?Deeumentatien 2015 Job Aid Template? under ?Additional Resources." Once you have it opened, save the file to a location that will be easy to find. If you are-encountering encounter a problem downloading the Supporting Documentation Job Aid from the webpage for the Transitional Reinsurance Program, please go to the REGTAP Library, and ?lter by Reinsurance-Contributions to download the ?le there. Enabling Macros: If you open the Job Aid workbook and the first page you see is a Start Message screen, it means that macros are not enabled. Microsoft Excel requires that you con?rm the source of the Excel file by explicitly enabling macros to prevent users from inadvertently downloading harmful Excel ?les from unknown sources. 456 2017--00556 To establish a Trusted Location that will allow you to continue to work with the Job Aid by enabling macros for all ?les in the de?ned location, follow the steps below. For Excel 2007 1. Set/confirm the global macro security setting for your computer: a) Select the 'Of?ce' button and select 'Excel Options.? b) Select 'Trust Center,? 'Trust Center Settings,? then 'Macro Settings.? 0) Select 'Disable all macros with noti?cations.? 2. Enable macros for the Job Aid: a) Select the 'Options' button and select 'Enable this content.? For Excel 2010 1. Set/confirm the global macro security setting for your computer: a) Select 'File' and select 'Options.? b) Select 'Trust Center,? 'Trust Center Settings', then 'Macro Settings.? 0) Select 'Disable all macros with noti?cations.? 2. Enable macros for the Job Aid by setting up a Trusted Location on your computer where the Job Aid will run: a) From the ?Trust Settings' screen, select 'Trusted Locations.? b) Select 'Add New Location.? 0) Browse to the path where you plan to store and run the Job Aid, and select If you see the ?Security Warning" in the yellow banner at the top of your screen, select the button ?Enable Content.? This should take you to the Data Entry Worksheet screen. We encourage you to review the following document: Supporting Documentation File Layout Requirements. Please visit the REGTAP Library and ?lter by ?Reinsurance- Contributions? or the Center for Consumer Information and Insurance Oversiqht (CCIIO) website (REGTAP FAQ Database - FAQ #7208; #7208a 11/13/14; updated 09/21/15) Q: Do you need Are Contributing or Reporting Entities required to include company-level information in the Supporting Documentation (.CSV file)? Updated 1-31-17 A: Applicable to All Reinsurance Contribution Benefit Years For the purposes of reinsurance contributions, the Reporting Entity must submit the required Supporting Documentation as a Comma Separated Value (CSV) file in conjunction with the ACA Transitional Reinsurance Program Annual Enrollment and Contributions Submission Form (Form). A CSV ?le is also known as a ??at ?le? or ?comma delimited The required Supporting Documentation requires company-level information that identifies each Contributing Entity and its Annual Enrollment Count among other data. Member level information should NOT be submitted. The Supporting Documentation contains one (1) row for each Contributing Entity. Therefore, a single Contributing Entity submitting their Annual Enrollment Count will have one (1) row of data within the Supporting Documentation. 457 2017--00557 CMS released the Supporting Documentation Job Aid and the Supporting Documentation Job Aid Manual to assist Reporting Entities in creating the Supporting Documentation. The Job Aid acts as a template for creating the Supporting Documentation. CMS also released the 'Supporting Documentation: File Layout Requirements? that explains the general requirements for the Supporting Documentation. To access these documents, visit the REGTAP Library, and filter by Reinsurance- Contributions. We encourage you to carefully review these documents and to use the Supporting Documentation Job Aid to create your CSV file to ensure it meets all the ?le format and data content requirements needed for successful submission and upload to Pay.gov. (REGTAP FAQ Database - FAQ #7209 11/13/14; updated 09/13/16) Q: How (494 can entities view the Comma Separated Value (CSV) file to check if data it is correct? A: Applicable to All Reinsurance Contribution Benefit Years The CSV file created by the 2045 Supporting Documentation Supporting?Documentation Job Aid will appear in the form of a Microsoft Excel spreadsheet in Windows Explorer when opened with Microsoft Excel. If an entity opens a you?open your CSV file in Microsoft Excel, it appear correctly because Excel automatically truncates zeros in anything that appears to be a number; theretereswe CMS recommends viewing the ?le in Microsoft Notepad to review its accuracy. If yeua an entity would like to view the CSV ?le outside of an Excel workbook a spreadsheet, the entity should perform the following steps: Using Windows Explorer, or a similar program, navigate to the folder where you saved the .csv file you created using the Supporting Documentation Job Aid. 2. Right-click the CSV file and place the cursor over the ?Open with' option. 3. Select the Notepad option on ?Open with' menu. Notepad will open the ?le and you will see the data with commas separating each value. If yeua an entity would simply like to confirm that the ?le is in the correct CSV file layout, the entity should perform the following steps: .Right?click the CSV file created using the Supporting Documentation Job Aid. Select the ?Properties' option. The Properties window opens. Under the General tab, locate ?Type of field. The ?Type of should display Microsoft Excel Comma Separated Values File (CSV). swwe Once the Supporting Documentation is uploaded to Pay.gov, you the entity can view the ?le prior to moving forward with scheduling payment by clicking on the ?le name. The uploaded CSV will appear in a new internet window or tab depending on your browser version. (REGTAP FAQ Database - FAQ #7210; #72103 11/13/14; updated 09/21/15 and 09/21/16) Q: What should the naming convention be for the Supporting Documentation (.CSV file)? A: Applicable to All Reinsurance Contribution Benefit Years 458 Updated 1-31-17 2017--00558 We CMS encourages entities to use the following naming convention, Insert SubmissionDate, however this is not required. F_or example, using Company' for the 2016 bene?t year, fer?example; the ?ling naming convention would be XYZCompany_BY2016_11_07_201?. The naming convention cannot contain special characters or the Supporting Documentation (.CSV ?le) will be rejected. Other naming conventions are permitted as long as they do not contain special characters. A list of special characters is available in the Supporting Documentation File Layout document for the applicable benefit year Reqeirements, which can be found in the REGTAP Library when you ?lter by Reinsurance-Contributions and the applicable benefit year. (REGTAP FAQ Database - FAQ #7211; #7211a 11/13/14; updated 09/21/15 while this FAQ is included in the ?updated issued by REG TAP on 09/21/15, no changes to this FAQ were discovered when comparing the new language to the original updated again on 09/21/16.) Q: When should I entities input the Pay.gov Tracking ID number? A: Applicable to All Reinsurance Contribution Benefit Years A Pay.gov Tracking ID is auto-generated when a user enters data into the 2015 ACA Transitional Reinsurance Program Annual Enrollment and Contributions Submission Form (Form). The Pay. gov Tracking ID ?eld must NOT be provided on the Form for the initial submission(s) (First, Second or Combined Collections). The Pay. gov Tracking ID number IS required mm only if it Is necessary for a Reporting Entity to refile or resubmit to resolve a Wdiscrepancy or error. reqardleseet?type?ef?eayment. The Pay.gov Tracking ID does not appear to the user until they reach the Payment Con?rmation page. Please refer to-Page?ZS?ef?the Transitional Reinsurance Program Annual Enrollment and Contributions Submission Form Manual" (Manual) for the applicable bene?t year for a screenshot of how the Pay.gov Tracking ID will display on the screen. In addition, the Manual provides the situations when the Pay. gov Tracking ID must be populated. To access the document visit the REGTAP Library, and ?lter by Reinsurance- Contributions for the applicable bene?t year. The-manuaI?is?leeated (REGTAP FAQ Database- FAQ #7212; #7212a 11/13/14; updated 09/21/15 and 09/13/16) Q: What?is Can you explain the difference between the three (3) types of payment options (First collection, Second Collection and Combined Collection)? 459 Updated 1-31-17 2017--00559 The US. Department of Health and Human Services (HHS) offers Contributing Entities the feltewing?seheduting options to pay: (1 remit the full 2015 entire?2044 Bene?t Year contribution in (1) one payment Combined Collection) no later than January 15, 2016 2045 reflecting $44.00 $5390 per covered life (Gembined?Gelieetien); or (2) in_a two-part payment twe?separate?payments with the first amount remittanee due by January 15, 2016 _20-15 re?ecting $33. 00 $52.50 per covered lifeI (i.e .First Collection), and the second payment remittance due no later than November 15,2016 2045 reflecting $11. 00 $40-50 per covered life .Second Collection). Regardless of the payment option selected, a Contributing Entity must submit its Annual Enrollment Count and schedule their reinsurance contribution payment date(s) no later than Monday, November 16, 2015 by completing the '2015 ACA Transitional Reinsurance Program Annual Enrollment and Contribution Submission Form' through Pay.gov. If a two-part payment option is chosen, the Contributing Entity is required to ?le the ?201 5 ACA Transitional Reinsurance Program Annual enrollment and Contributions Submission Form" (Form) for the Second Collection on the same day as the Form filing for the first collection. deadiine? To do this, immediately duplicate the Form ?ling for the First Collection and submit it to re?ect the Second Collection. You must ?schedule the Second Collection remittance prior to November 15,2 16 2045. The Second Collection amount will not be withdrawn until the scheduled date or the next business day if the scheduled payment date is a weekend or a Federal Reserve holiday. The Gross Annual Enrollment Count in the Form (and Supporting Documentation, if available) for both the First and Second Collection must match. FAQ Database- FAQ #7213; #7213a 11/13/14; updated 09/21/15) Q: What is the difference between the Reporting Entity and Contributing Entity? Updated 1-31-17 A: Applicable to All Reinsurance Contribution Benefit Years A Reporting Entity is the organization completing the steps for the reinsurance contribution submission process on Pay.gov. The Reporting Entity can be the Contributing Entity, or a third party on behalf of a Contributing Entity. A Contributing Entity means generain-ineludes a health insurance issuer and for the 2014 benefit year, er?a self-insured group health plan (including a group health plan that is partially self-insured and partially insured, where the health insurance coverage does not constitute major medical coverage), whether or not it uses a Third Party Administrator and for the 2015 and 2016 benefit years, a self-insured group health plan (including a group health plan that is partially insured and partially self- insured, where the health insurance coverage does not constitute maior medical coverage) that uses a TPA in connection with claims processing or adiudication (including the management of internal appeals) or plan enrollment for services other than for pharmacy benefits or excepted bene?ts within the meaning of section 2791 of the PHS Act. Nothwithstanding the foregoing, a self-insured group health plan that uses 460 2017--00560 an unrelated third party to obtain provider network and related claim repricinq services, or uses an unrelated third party for up to five (5) percent of claims processing or adjudication or plan enrollment, will not be deemed to use a TPA, based on either the number of transactions processed by the third party, or the value of the claims processing and adjudication and plan enrollment services provided by the third party. .A self- insured group health plan that Is a Contributing Entity Is responsible for the _submission reinsurance contributions payment, although it may elect to use a third party administrator or administrative services- -only contractor for transfer of for?oompieting the reinsurance contributions. See 45 CFR 153.20 for more details on the definition of ?Contributing Entity.? (REGTAP FAQ Database - FAQ #7214; #7214a 11/13/14; updated 09/21/15 and 09/21/16) Q: What should I entities do if one of the contacts on my th_e Form changes after submission? A: Applicable to All Reinsurance Contribution Benefit Years If changes to contacts (Billing Contact, Submitter Contacts, or Authorizing Of?cial) or billing information occur after Form submission, the Reporting Entity is required to notify CMS through email at Changes to the contact(s) do not require refiling steps, but CMS must be informed so that the appropriate individuals are contacted, if necessary. When submitting an information chanqe request and to ensure proper routinq, place in the subject line: ?Notice of Information Change in-this-situation? The Reporting or Contributing Entity will need to include the following in the email. Benefit year, Pay. gov tracking ID, Taxpayer identi?cation Number, and Gross Annual Enrollment Count. When-submitting?this pmporiy. (REGTAP FAQ Database- FAQ #7215; #7215a 11/13/14, updated 09/21/1 and 09/21/16) Q: Maet?do?l?need?to?do?if?l If an entitiy discovers that the dataiintonnation?submitted?on th_e Form l?submitted is incorrect wrong after payment?was-made? the payment date has passed and the contribution was paid, what course of action does CMS recommend the entity take to resolve the issue? Updated 1-31-17 A: Applicable to All Reinsurance Contribution Benefit Years If a Reporting or Contributing Entity discovers that data entered abatabntor on the Form is incorrect after remitting payment, it?the entity will need to contact CMS at reinsurancecontributions@cms. hhs.. qov 'to provide a disclosure of this disoloseLtne In thIs situation, the Reporting or Contributing Entity will need to include the following in the email: Pay.gov tracking ID, Taxpayer Identification Number, and Gross Annual Enrollment Count. When submitting this information, use the subject line of ?Discrepancy Disclosure' to ensure it is routed properly. 461 2017--00561 Also please see the April 14, 2015, quidance for the 2015 and 2016 Benefit Years statinq that 'refund requests must be submitted 90 days from the date of Form submission (available at: (REGTAP FAQ Database - FAQ #7216? 7216a 11/13/14; updated 09/21/15 and 09/13/16) Q: Why did some group health plans receive an email requesting information regarding their reinsurance contribution submission even if the employer, issuer, Third-Party Administrator (TPA) or Administrative-Services Only (ASO) contractor already submitted a reinsurance contribution for their respective covered lives? Updated 1-31-17 A: Applicable to All Reinsurance Contribution Benefit Years A: The Centers for Medicare Medicaid Services (CMS) is contacting group health plans for whom CMS has been unable to locate a Transitional Reinsurance Program Annual Enrollment and Contributions Submission Form? (Form) for the 2044 applicable Benefit Year, and requesting that plans provide information to con?rm the status of their Form ?ling for the 2-0?14 applicable Bene?t Year, so that CMS can 462 2017-?00562 reconcile records. CMS realizes that some group health plans may have already ?led a Form directly, or had 3 TPA or ASO contractor file on their behalf. In addition, if the group health plan is insured, CMS recognizes that the health insurance issuer may have submitted the Form and remitted the 2044 reinsurance contribution for the plan?s covered lives for the applicable Bene?t Year reinsuranee?eentributien feHhe?planis severed?Wee: CMS requests that these group health plans complete the information on the webpage by answering a series of questions.* If the group health plan believes a health insurance issuer, TPA or ASO contractor has successfully ?led on its behalf or that they are exempt from ?ling, the plan should select ?No? for the question ?Have you completed a form ?ling?? By making this selection, they will be directed to a series of screens that will allow for veri?cation of this information. If an issuer, TPA or ASO contractor ?led on the group health plan's behalf, the plan will need to provide the Pay.gov tracking lD(s) for the Form ?ling. If the group health plan is exempt from submitting reinsurance contributions under 45 CFR 153.400, the employer will need to select a reason for the exemption. Before beginning, the Contributing Entity can access the series of questions by clicking on the webpage link and then clicking on the link on the upper right-hand of the webpage. Please send any further inquiries to would like to clarify that this is not phishing, although this is ?.com" rather than (REGTAP FAQ Database - FAQ #10524 05/12/15; updated 09/21/16) Reinsurance 2015 P/an Year Q: What is the definition of a Contributing Entity under the Reinsurance program for the 2015 and 2016 Benefit Years? Updated 1-31-17 A: A Contributing Entity is de?ned under 45 CFR 153.20 to mean, for purposes of the Reinsurance program: a health insurance issuer or for the 2015 and 2016 Benefit Years, a self-insured group health plan (including a group health plan that is partially self-insured and partially insured, where the health insurance coverage does not constitute major medical coverage) that uses a Third-Party Administrator (TPA) in connection with claims processing or adjudication (including the management of internal appeals) or plan enrollment for services other than for pharmacy benefits or excepted bene?ts within the meaning of section 2791(0) of the Public Health Service (PHS) Act. However, a self-insured group health plan that uses an unrelated third party to obtain provider network and related claim re-pricing services, or uses an unrelated third party for up to ?ve (5) percent of claims processing or adjudication or plan enrollment, will not be deemed to use a TPA, based on either the number of transactions processed by the third party, or the value of the claims processing and adjudication and plan enrollment services provided by the third party. Therefore, they would not be considered a Contributing Entity for purposes of the Reinsurance program. We consider a TPA to be, with respect a self-insured group health plan, an entity that is not under common ownership or control with the self-insured group health plan or its plan sponsor that provides the speci?ed core administrative services claims processing or adjudication, including the management of internal appeals, or plan enrollment). See the US. Department of Health and Human Services (HHS) Notice of 463 2017--00563 Bene?t and Payment Parameters for 2015 Final Rule (79 FR 13773). In the HHS Notice of Bene?t and Payment Parameters for 2016 Final Rule (80 FR 10772), we clari?ed that principles similar to the controlled group rules of section 414(b) and of the Internal Revenue Code should be used to determine whether the TPA is under common ownership or control with the self-insured group health plan or its sponsor for purposes of the de?nition of ?Contributing Entity" at 45 CFR 153.20. (REGTAP FAQ Database - FAQ #13101 09/18/15) Q: How can a self-insured group health plan or plan sponsor determine whether it uses an unrelated third party for up to ?ve (5) percent of claims processing or adjudication or plan enrollment for purposes of the de?nition of ?Contributing Entity? under 45 CFR ?153.20? A: Applicable to All Reinsurance Contribution Benefit Years As stated in the Health and Human Services (HHS) Notice of Benefit and Payment Parameters for 2015 Final Rule (79 FR 13775), for a self-insured group health plan or plan sponor to determine whether it uses an unrelated third party for up to five (5) percent of claims processing or adjudication or plan enrollment for purposes of the definition of ?Contributing Entity? under 45 CFR 153.20, the ?ve (5) percent of claims processinq or adjudication or plan enrollment this is measured by the amount of enrollment or claims processing transactions for non-pharmacy and non-excepted bene?ts which are outsourced, or by the value of the outsourced enrollment or claims processing transactions for non-pharmacy and non-excepted bene?ts (measured by the cost of the outsourced services compared to the sum of those costs plus the fully loaded costs - that is, including an appropriate share of indirect costs, such as ?xed and overhead expenses - reasonably allocated, borne by the self-insured plan for such services). (REGTAP FAQ Database - FAQ #13102 09/18/15; updated 09/13/16) Q: How much did the Centers for Medicare Medicaid Services (CMS) collect during the 2014 reinsurance contribution submission process? A: Please see the guidance CMS issued on April 14, 2015, titled ?Transitional Reinsurance Program's Contribution Collections for the 2014 Bene?t Year" available at: (REGTAP FAQ Database - FAQ #13103 09/18/15) Q: Is a Contributing Entity required to make reinsurance contributions in the 2015 and 2016 Benefit Years for lives covered by its self-insured group health plans and health insurance coverage if such plan or coverage is expatriate health coverage? Updated 1-31-17 A: Applicable to All Reinsurance Contribution Benefit Years No. A Contributing Entity is not required to make reinsurance contributions for lives covered by its self-insured group health plans and health insurance coverage if such plan or coverage is expatriate health coverage. 45 CFR provides an exemption from the reinsurance contribution for expatriate health coverage, as de?ned by the Secretary, or for the 2015 and 2016 Bene?t Years only, is a self-insured group 464 2017--00564 health plan with respect to which enrollment is limited to participants who reside outside of their home country for at least six (6) months of the plan year, and any covered dependents. In Affordable Care Act (ACA) Implementation FAQ guidance, an expatriate health plan was defined as an insured group health plan with respect to which enrollment is limited to primary insureds for whom there is a good faith expectation that such individuals will reside outside of their home country for at least six (6) months of a 12-month period and any covered dependents, and its associated group health insurance coverage. The 12-month period can fall within a single plan year or across two (2) consecutive plan years. CMS intends to undertake future rulemaking in conjunction with the Departments of the US. Treasury and Labor governing the application of the ACA to expatriate plans to harmonize existing regulations with the Expatriate Health Coverage Clari?cation Act of 2014 (EHCCA). The EHCCA generally applies to expatriate health plans issued or renewed on or after July 1, 2015. Interim guidance was issued by the Departments in June 2015 on the EHCCA and the application of certain provisions of the ACA to expatriate health insurance issuers, expatriate health plans and employers in their capacity as plan sponsors of expatriate health plans. (REGTAP FAQ Database - FAQ #13104 09/18/15; updated 09/13/16) Q: What is the timing associated to request a refund if a Contributing Entity determines it misreported its Annual Enrollment Count for either the 2015 or 2016 Benefit Years? Updated 1-31-17 A: The Centers for Medicare Medicaid Services (CMS) is aware that some Contributing Entities may misreport their Annual Enrollment Counts due to misapplying an allowable counting method under 45 CFR 153.405(d) through (9) or including individuals in their Annual Enrollment Counts who are exempt from consideration for purposes of reinsurance contributions under 45 CFR potentially resulting in an overpayment. On April 14, 2015, CMS issued guidance for the 2015 and 2016 Bene?t Years stating that ?refund requests must be submitted 90 days from the date of Form submission?. available at: This deadline does not apply when a Contributing Entity requests a refund because it has paid reinsurance contributions more than once for the same covered life. Therefore, to enable CMS to provide issuers with their respective reinsurance payment amounts, for the 2015 and 2016 Bene?t Years, refund requests resulting from Annual Enrollment Count misreporting must be submitted 90 days from the date of Form submission. These requests and other inquiries regarding the reinsurance contribution submission process should be sent to Please note that a Contributing Entity that correctly applied one (1) of the counting methods set forth in 45 CFR 153.405(d) through (9) cannot request to change its Annual Enrollment Count and associated payment after the reporting deadline for the applicable bene?t year. Counting methods do not need to be consistent across bene?t years and a Contributing Entity could elect to use a different counting method as applicable under 45 CFR 153.405(d) through (9) for the 2015 and 2016 Benefit Years. (REGTAP FAQ Database - FAQ #13106 09/18/15; updated 09/21/16) 465 2017--00565 Q: A fully insured plan offering medical coverage has a December 31st plan year, and a self-insured group health plan providing only prescription drug coverage has a January 31 st plan year. All full-time employees are enrolled in the medical and prescription plans at the same time. Retirees, however, can elect to enroll in either or both plans. Does the prescription drug plan need to make reinsurance contributions? A: Applicable to All Reinsurance Contribution Benefit Years No. Pursuant to 45 CFR a Contributing Entity is not required to make contributions on behalf of a self-insured group health plan or health insurance coverage that consists solely of benefits for prescription drugs. (REGTAP FAQ Database - FAQ #13107 09/18/15; updated 09/13/16) Q: May a contributing entity remit the entire 2015 Benefit Year reinsurance contribution amount by January 15, 2016, rather than making two (2) separate payments? A: Applicable to Reinsurance Contributions 2015 Benefit Year: The U.S. Department of Health and Human Services (HHS) offers Contributing Entities the option to pay: (1) the full 2015 Benefit Year contribution in one (1) payment Combined Collection) no later than January 15, 2016, re?ecting $44.00 per covered life; or (2) in a two-part payment, with the ?rst amount due by January 15, 2016, re?ecting $33.00 per covered life First Collection), and the second payment due November 15, 2016, reflecting $11.00 per covered life Second Collection). Regardless of the payment option selected, a Contributing Entity must submit its Annual Enrollment Count and schedule its reinsurance contribution payment date(s) no later than Monday, November 16, 2015 by completing the '2015 ACA Transitional Reinsurance Program Annual Enrollment and Contribution Submission Form? through Pay.gov. If a two-part payment is chosen, the Contributing Entity should file the ?2015 ACA Transitional Reinsurance Program Annual Enrollment and Contributions Submission Form' (Form) for the Second Collection on the same day as the Form filing for the First Collection. To do this, duplicate the Form ?ling for the First Collection and submit it to reflect the Second Collection. You must schedule the Second Collection remittance prior to November 15, 2016. The Second Collection amount will not be withdrawn until the scheduled date or the next business day if the scheduled payment date is a weekend or a Federal Reserve holiday. The Annual Enrollment Count in the Form (and Supporting Documentation, if applicable) for both the First and Second Collection must match. (REGTAP FAQ Database - FAQ #13611 10/09/15) Q: Pursuant to 45 CFR no later than November 15 of benefit year 2014, 2015, or 2016, as applicable, or, if such date is not a business day, the next business day, a contributing entity must submit an Annual Enrollment Count of the number of covered lives of reinsurance contribution enrollees for the applicable benefit year to U.S. 466 Updated 1-31-17 2017--00566 Department of Health and Human Services (HHS). However, November 15, 2015 is a Sunday and the Pay.gov Help Desk is not open on non-business days; therefore, can we have until the next applicable business day to submit our Annual Enrollment Count? A: Applicable to Reinsurance Contributions 2015 Benefit Year: For the 2015 Bene?t Year a Contributing Entity may submit its Annual Enrollment Count of the number of covered lives of reinsurance contribution enrollees to HHS no later than Monday, November 16, 2015. However, we strongly encourage contributing entities to ?le before November 15, 2015, so as to avoid any technical difficulties. (REGTAP FAQ Database - FAQ #13612 10/09/15) Q: What should the naming convention be for the 2015 Benefit Year Supporting Documentation? A: Applicable to Reinsurance Contributions 2015 Bene?t Year: We encourage entities to use the following naming convention, Date. The naming convention cannot contain special characters or the Supporting Documentation will be rejected. A list of special characters is available in the Supporting Documentation 2015 File Layout Requirements, which can be found in the Registration for Technical Assistance Portal (REGTAP) Library when you ?lter by 'Reinsurance-Contributions'. (REGTAP FAQ Database - FAQ #13613 10/09/15) Q: How will a Contributing Entity complete the reinsurance contributions process for the 2015 Benefit Year? Updated 1-31-17 A: Applicable to Al Reinsurance Contributions 2045 Bene?t Years: The US. Department of Health and Human Services (HHS) has maintained a streamlined process for the collection of reinsurance contributions for the M, 2015 and 2016 Bene?t Year through Pay.gov. A Contributing Entity, or a Third-Party Administrator (TPA) or an Administrative Services-Only (ASO) contractor, on behalf of the Contributing Entity, can complete all required steps for the reinsurance contributions process on Pay.gov: registration, submission of the Annual Enrollment Count, and remittance scheduling of contributions. The 2045 ACA Transitional Reinsurance Program Annual Enrollment Contributions Form' will be available via en?Oeteber?4,?2?0?15 where a Contributing Entity, or 3 TPA or ASO contractor on its behalf, will provide basic company and contact information, and the Annual Enrollment Count for the applicable benefit year ne?later than?NevembeHSTZ-Q-HS. The form auto-calculates the contribution amounts. To complete the submission, entities will also submit payment information and schedule a payment date(s) for remittance of the contributions. Pay.gov provides a 'one-stop? approach to complete the reinsurance contributions process. 467 2017--00567 iaFtheFedi?eatiem (REGTAP FAQ Database - FAQ #13622 10/09/15; updated 09/21/16) O: For the 2015 Benefit Year, what are the deadlines for submitting payment for transitional reinsurance contribution payments? A: Applicable to Reinsurance Contributions 2015 Bene?t Year: The US. Department of Health and Human Services (HHS) offers Contributing Entities the option to pay: (1) the full 2015 Benefit Year contribution in one (1) payment Combined Collection) no later than January 15, 2016, re?ecting $44.00 per covered life; or (2) in a two-part payment, with the ?rst amount due by January 15, 2016, re?ecting $33.00 per covered life First Collection), and the second payment due November 15, 2016, reflecting $11.00 per covered life Second Collection). Regardless of the payment option selected, a Contributing Entity must submit its Annual Enrollment Count and schedule its reinsurance contribution payment date(s) no later than Monday, November 16, 2015 by completing the '2015 ACA Transitional Reinsurance Program Annual Enrollment and Contribution Submission Form' through Pay.gov. If a two (2)-part payment is chosen, the Contributing Entity must ?le the '2015 ACA Transitional Reinsurance Program Annual enrollment and Contributions Submission Form' (Form) for the Second Collection on the same day as the Form ?ling for the First Collection. To do this, duplicate the Form ?ling for the First Collection and submit it to reflect the Second Collection. You must schedule the Second Collection remittance prior to November 15, 2016. The Second Collection amount will not be withdrawn until the scheduled date or the next business day if the scheduled payment date is a weekend or a Federal Reserve holiday. The Annual Enrollment Count in the Form (and Supporting Documentation, if applicable) for both the First and Second Collection must match. (REGTAP FAQ Database - FAQ #13623 10/09/15) Q: How should the Annual Enrollment Count be calculated when a health plan or coverage is established or terminated, or changes funding mechanisms during the first nine (9) months of a bene?t year? Updated 1-31-17 A: Applicable to Reinsurance Contributions 2015 Bene?t Year: If coverage changes from a fully insured plan to a self-insured plan or self-insured to fully insured during the ?rst nine (9) months of 2015, the issuer of the fully insured plan is responsible for paying the per covered life contribution amount for reinsurance contribution enrollees for the portion of the calendar year they are enrolled in the fully insured plan. The self-insured plan is responsible for paying the per covered life contribution amount for reinsurance contribution enrollees for the portion of the year they are enrolled in the self-insured plan. Therefore, both plans are responsible for paying a portion of the fee for the year in which the change is made on behalf of the covered lives in those plans using one (1) of the permitted counting methods in 45 CFR 153.405(d) and 45 CFR 153.405(e) as applicable. These counting methods generally calculate covered lives based on enrollment in the ?rst nine (9) months of a calendar year. If a plan or coverage is established 0 468 2017--00568 terminated during the ?rst nine (9) months of 2015, then the Contributing Entity must select a set of counting dates for the nine (9)-month period in which had enrollees on each of the dates, if possible. For examples of how to calculate reinsurance contributions in these situations, please refer to 'The Transitional Reinsurance Program Operational Guidance: Examples of Counting Methods for Contributing Entities - UPDATED FOR THE 2015 BENEFIT and 'Module 2: 2015 Reinsurance Contributions Counting Methods Overview' available in the Registration for Technical Assistance Portal (REGTAP) Library under Reinsurance-Contributions or the Center for Consumer Information and Insurance Oversight (CCIIO) website (REGTAP FAQ Database - FAQ #13624 10/09/15) Q: Are retroactive enrollment adjustments, due to enrollment terminations, permitted for reporting reinsurance covered lives in the first nine (9) months of the year? A: Applicable to All Reinsurance Contributions Benefit Years: No. The permitted counting methods in 45 CFR 153.405(d) and 45 CFR 153.405(e) calculate covered lives based on enrollment only in the ?rst nine (9) months of a calendar year. We understand that fluctuations may occur in the fourth quarter of a bene?t year; however, those fluctuations are ignored for purposes of counting covered lives for purposes of reinsurance contributions. (REGTAP FAQ Database - FAQ #13625 10/09/15) Q: Please clarify whether the plan sponsor of a self-insured plan (the Contributing Entity) which changes Third Party Administrators (TPAs) during the 1st three (3) quarters of the year can have each TPA submit the '2015 ACA Transitional Reinsurance Program Annual Enrollment and Contributions Submission Form' attesting to the annual member count during the portion of the 1st three (3) quarters the TPA administered the plan, orjust one (1) Form must be submitted if the plan was self-insured for the entire period. A: Applicable to Reinsurance Contributions 2015 Bene?t Year: Only one (1) Reporting Entity is to file the '2015 ACA Transitional Reinsurance Program Annual Enrollment Contributions Form' per Contributing Entity; therefore, both TPAs would not be able to report for the same Contributing Entity only covering a portion of the bene?t year because the single submission must re?ect the entire benefit year. The ultimate responsibility to make reinsurance contributions remains with the Contributing Entity, and the decision to delegate the function of submitting the reinsurance contribution resides with the Contributing Entity. (REGTAP FAQ Database - FAQ #13626 10/09/15) Q: How should a Contributing Entity determine the number of covered lives of reinsurance contribution enrollees under a health insurance plan or coverage using the Snapshot Count Method, set forth in 45 CFR or the Snapshot Factor Method, set forth in 45 CFR for a partial year; i.e. one (1) of the three (3) Updated 1-31-17 469 2017--00569 quarters during the benefit year, the plan or coverage did not have covered lives enrolled for the entire quarter? A: Applicable to Reinsurance Contributions 2015 and 2016 Benefit Years: Health insurance plans or coverages may be established or terminated, or change funding mechanisms from fully insured to self-insured or self-insured to fully insured) in the middle of a quarter. In these circumstances, it is possible that the new plan or coverage would not have covered lives enrolled in the plan or coverage for the entire quarter. As clari?ed in the US. Department of Health and Human Services (HHS) Notice for Bene?t and Payment Parameters for 2016 Final Rule (80 FR 10774), if the plan or coverage in question had enrollees on any day during a quarter and if the Contributing Entity elects to (and is permitted to) use either the Snapshot Count or Snapshot Factor Method, it must choose a set of counting dates for the 9-month counting period such that the plan or coverage has enrollees on each of the dates. However, the enrollment count for a date during a quarter in which the plan or coverage was in existence for only part of the quarter could be reduced by a factor reflecting the amount of time during the quarter for which the plan or coverage was not in existence. This approach is intended to accurately capture the amount of time during the quarter for which major medical coverage that is part of a commercial book of business and subject to reinsurance contributions was provided to enrollees, while not requiring contributions to be paid more than once for the same covered life. CMS encourages further review of the 'The Transitional Reinsurance Program Operational Guidance: Examples of Counting Methods for Contributing Entities - UPDATED FOR THE 2015 BENEFIT and 'Module 2: 2015 Reinsurance Contributions Counting Methods Overview' available in the Registration for Technical Assistance Portal REGTAP Library under Reinsurance-Contributions or the Center for Consumer Information and Insurance Oversight (CCIIO) website (REGTAP FAQ Database - FAQ #13627 10/09/15) Q: If a self-insured group health plan files the 2014 Form 5500 by October 15, 2015, is the self-insured group health plan able to use those enrollment counts from the 2014 Form 5500 Counting Method for purposes of calculating its enrollment count for the 2015 Benefit Year, as described in 45 CFR Updated 1-31-17 A: Applicable to Reinsurance Contributions 2015 Benefit Year: Yes. Pursuant to 45 CFR which outlines the Form 5500 Counting Method, a plan may use the number of lives covered for the most current plan year calculated based upon the 'Annual Return/Report of Employee Bene?t Plan' ?led with the Department of Labor (Form 5500) for the last applicable time period. Therefore, if a plan uses the Form 5500 Counting Method for determining the Annual Enrollment Count, and the most current plan year calculated based upon the Form 5500 ?led with the Department of Labor for the last applicable time period represents a period of time during the 2014 Calendar Year, the plan may use this period in determining the plan's Annual Enrollment Count for the 2015 Benefit Year for the purpose of reinsurance contributions. 470 2017--00570 Refer to 'The Transitional Reinsurance Program Operational Guidance: Examples of Counting Methods for Contributing Entities - UPDATED FOR THE 2015 BENEFIT and 'Module 2: 2015 Reinsurance Contributions Counting Methods Overview' available in the Registration for Technical Assistance Portal (REGTAP) Library under Reinsuranee-Contributions or the Center for Consumer Information and Insurance Oversight (CCIIO) website (REGTAP FAQ Database - FAQ #13628 10/09/15) Q: What should an entity do you?do if the entity experiences you?have trouble creating and attaching the Supporting Documentation (.CSV file)? What should an entity do if th_e entity experiences have trouble with the Supporting Documentation Job Aid? A: Applicable to Reinsurance Contributions 2045 Bene?t Years: The US. Department of Health and Human Services (HHS) created a Job Aid Template and Manual that includes macros that perform validations and allows for the creation of the Comma Separated Value (CSV) ?le at a push of a button within the spreadsheet. Go to: Programs/The- Transitional- Reinsurance- Proqram/Reinsurance- and click the link for the applicable entitled?2045 Job Aid Template' under the applicable benefit year Once you have opened it, save the ?le to a location that will be easy to ?nd. If you an entity encounters a problem downloading the Supporting Documentation Job Aid from the webpage for the Transitional Reinsurance Program, please go to the Registration for Technical Assistance Portal (REGTAP) Library, and ?lter by Reinsuranee-Contributions and applicable bene?t year to download the file there. 471 Updated 1-31-17 2017--00571 The Centers for Medicare Medicaid Services (CMS) encourages entities to review the File Layout document,? available for each bene?t year. Please visit the Reqistration for Technical Assistance Portal (REGTAP) Library and ?lter by ?Reinsurance-Contributions? and the applicable Benefit Year or the Center for Consumer Information and Insurance Oversiqht (CCIIO) website Q: Can you explain the difference between the three (3) types of payment options (First Collection, Second Collection and Combined Collection)? Updated 1-31-17 A: Applicable to Reinsurance Contributions 2015 Bene?t Year: The US. Department of Health and Human Services (HHS) offers Contributing Entities the option to pay: (1) the full 2015 Benefit Year contribution in one (1) payment Combined Collection) no later than January 15, 2016, re?ecting $44.00 per covered life; or (2) in a two-part payment, with the ?rst amount due by January 15, 2016, re?ecting $33.00 per covered life First Collection), and the second payment due November 15, 2016, reflecting $11.00 per covered life Second Collection). Regardless of the payment option selected, a Contributing Entity must submit its Annual Enrollment Count and schedule their reinsurance contribution payment date(s) no later than Monday, November 16, 2015 by completing the '2015 ACA Transitional Reinsurance Program Annual Enrollment and Contribution Submission Form' through Pay.gov. If a two-part payment is chosen, the Contributing Entity is to ?le the '2015 ACA Transitional Reinsurance Program Annual Enrollment and Contributions Submission Form' (Form) for the Second Collection on the same day as the Form filing for the First Collection. To do this, duplicate the Form ?ling for the First Collection and submit it to reflect the Second Collection. You must schedule the Second Collection remittance prior to November 15, 2016. The Second Collection amount will not be withdrawn until the 472 2017-?00572 scheduled date or the next business day if the scheduled payment date is a weekend or a Federal Reserve holiday. The Annual Enrollment Count in the Form (and Supporting Documentation, if applicable) for both the First and Second Collection must match. (REGTAP FAQ Database - FAQ #13630 10/09/15) Q: What?de?I?need?te?de?if If and entity discovers that the data/information submitted on the Form is incorrect after payment was made submitted, how should the entity report the error? Updated 1-31-17 A: Applicable to Reinsurance Contributions 2015 and 2016 Bene?t Years: If a Reporting or Contributing Entity discovers a data error on the Form after remitting payment, it will need to contact the Centers for Medicare Medicaid Services (CMS) at to disclose the error. When submitting an error noti?cation and to ensure proper routing, use the subject line of 'Discrepancy Disclosure'. The Reporting or Contributing Entity will need to include the following in the email: Benefit Year, Pay.gov tracking ID, Taxpayer Identi?cation Number and Gross Annual Enrollment Count. Corrections: Before Filing Deadline and Remittance of Payment If an error is identified prior to the ?ling deadline and prior to the scheduled payment date, the Reporting Entity can cancel the payment(s) in Pay.gov and 'Re?le' the Form with the corrected data while referencing the previous Pay.gov Tracking ID in the Form, as required. After Filing Deadline and Before Remittance of Payment If an error is identified before the scheduled payment date, but within 90 days of the initial ?ling of the Form, the Reporting Entity can cancel the payment(s) in Pay.gov and 'Re?le' the Form with the corrected data while referencing the previous Pay.gov Tracking ID in the Form, as required. After Filing Deadline and Payment If an error is identified after the scheduled payment date and after the filing deadline, a refund is generally permitted if identified within 90 days of the initial filing of the Form. The Reporting Entity will 'Refile' the Form with the corrected data while referencing the previous Pay.gov Tracking ID in the Form, as required. A refund noti?cation must be submitted to CMS identifying the Pay.Gov ID, TIN, Gross Annual Enrollment to be refunded and the corrected re?ling. Please note that these deadlines do not apply when a Contributing Entity requests a refund because it has paid reinsurance contributions more than once for the same covered life. In addition, a Contributing Entity that correctly applied one (1) of the counting methods set forth in 45 CFR 153.405(d) through (9) cannot request to change its Annual Enrollment Count and associated payment after the reporting deadline for the applicable bene?t year. Please see our guidance issued on April 14, 2015, 'Transitional Reinsurance Program - Timing of Contributions Refund Requests Due to Annual Enrollment Count Misreporting,? available at: (REGTAP FAQ Database - FAQ #13631 10/09/15; updated 09/21/16) 473 2017--00573 Q: Are counting methods for calculating the Annual Enrollment Count for Reinsurance Contribution purposes the same as the counting methods used for the Patient-Centered Outcome Research Trust Fund fee (PCORI Fee)? A: Applicable to Reinsurance Contributions 2015 Bene?t Year: No. The counting methods for the Reinsurance program are similar to, but vary in certain instances from, the counting methods permissible for the Patient-Centered Outcome Research Trust Fund fee, largely due to the differences in the timing of the payments from the two (2) programs. For the Reinsurance program, a Contributing Entity must use one of the permitted counting methods in 45 CFR 153.405(d) through 45 CFR These counting methods generally calculate covered lives based on enrollment in the ?rst nine (9) months of a calendar year. You may also refer to the Supporting Document, titled: 'The Transitional Reinsurance Program Operational Guidance: Examples of Counting Methods for Contributing Entities - UPDATED FOR THE 2015 BENEFIT and 'Module 2: 2015 Reinsurance Contributions: Counting Methods Overview' available in the Registration for Technical Assistance Portal (REGTAP) Library under Reinsurance-Contributions. (REGTAP FAQ Database - FAQ #13632 10/09/15) Q: Is the reinsurance contribution based on the calendar year even if the Contributing Entity operates on a plan year that is not on a calendar-year basis? A: Applicable to Reinsurance Contributions 2945 Bene?t Years: Yes. The Annual Enrollment Count for the Transitional Reinsurance Program is based on a calendar year. A Contributing Entity must use one (1) of the permitted counting methods in 45 CFR 153.405(d) through 45 CFR These counting methods generally calculate covered lives based on enrollment in the ?rst nine (9) months of a calendar year. Entities may also refer to 'The Transitional Reinsurance Program Operational Guidance: Examples of Counting Methods for Contributing Entities for the applicable benefit year (REGTAP FAQ Database- FAQ #13633 10/09/15; updated 09/13/16) Q: How do I view a Comma Separated Value (CSV) file to check if it is correct? Updated 1-31-17 A: Applicable to Reinsurance Contributions 2015 Bene?t Year: The CSV file created by the 2015 Job Aid will appear in the form of a Microsoft Excel spreadsheet in Windows Explorer when opened with Microsoft Excel. If you open your CSV ?le in Microsoft Excel, it may not appear correctly because Excel automatically truncates zeros in anything that appears to be a number; therefore we recommend 474 2017-?00574 viewing the ?le in Microsoft Notepad to review its accuracy. If you would like to view the CSV ?le outside of a spreadsheet, perform the following steps: 1. Using Windows Explorer, or a similar program, navigate to the folder where you saved the .csv file you created using the Supporting Documentation Job Aid. 2. Right-click the CSV file and place the cursor over the 'Open with' option. 3. Select the Notepad option on 'Open with' menu. Notepad will open the ?le and you will see the data with commas separating each value. If you would simply like to confirm that the ?le is in the correct CSV ?le layout, perform the following steps: Right-click the CSV file created using the Supporting Documentation Job Aid. Select the 'Properties' option. The Properties window opens. Under the General tab, locate 'Type of field. The 'Type of should display Microsoft Excel Comma Separated Values File (CSV). Once the Supporting Documentation is uploaded to Pay.gov, you can view the ?le prior to moving forward with scheduling payment by clicking on the file name. The uploaded CSV will appear in a new internet window or tab depending on your browser version. (REGTAP FAQ Database - FAQ #13634 10/09/15) Q: When should I input a Pay.gov Tracking ID number? A: Applicable to Reinsurance Contributions 2015 Bene?t Year: A Pay.gov Tracking ID is auto-generated when a user enters data into the '2015 ACA Transitional Reinsurance Program Annual Enrollment and Contributions Submission Form' (Form). The Pay.gov Tracking ID ?eld must NOT be provided on the Form for the 'New' type of filing on any type of payment; i.e. First, Second or Combined Collections. The Pay.gov Tracking ID number is required under the type of filing: 'Re?ling' and 'Resubmission' to resolve a payment or discrepancy error, regardless of type of payment. The Pay.gov Tracking ID does not appear to the user until they reach the Payment Con?rmation page. The manual is located on the Center for Consumer Information and Insurance Oversight (CCIIO) website under 'Additional Resources'. (REGTAP FAQ Database - FAQ #13635 10/09/15) Q: After the reinsurance contribution submission filing deadline Wiser?1672045 for the applicable benefit year, can a Contributing (or Reporting) Entity seek a refund or ask to cancel a prior filing and refile because another allowable counting method would result in a more advantageous Annual Enrollment Count for the Contributing Entity in?the Updated 1-31-17 475 2017--00575 2045 for that Benefit Year? A: Applicable to AA Reinsurance Contributions 2045 Bene?t Years: No, a Contributing (or Reporting) Entity can select any of the applicable counting methods set forth in 45 CFR 153.405(d) through (9) prior to completing the reinsurance contribution submission process. However, after the contribution submission filing deadline of November 16, 2015, a Contributing (or Reporting) Entity that correctly applied one (1) of the permitted counting methods cannot seek a refund or request to cancel their ?ling and re?le because another allowable counting method would result in a more advantageous Annual Enrollment Count for the Contributing Entity for the 2015 Bene?t Year. For additional information, we also encourage all Contributing and Reporting Entities to review the Centers for Medicare Medicaid Services (CMS)-issued guidance on April 14, 2015, Transitional Reinsurance Program - Timing of Contributions Refund Requests Due to Annual Enrollment Count Misreporting', available at: As we state in this guidance document, a Contributing or Reporting Entity may seek a refund up to 90 days from their original ?ling if they misapplied a permissible counting method (for example, the entity included 12 months of data when calculating their Annual Enrollment Count under the actual count method) or the entity included covered lives in the Annual Enrollment Count that are exempt under 45 CFR 153.400. However, a Contributing (or Reporting) Entity is not able to change the counting method as part of this process if it used a permitted counting method. For any refund requests, CMS will need the original information used to calculate the annual enrollment count and the counting method. CMS will validate this information to confirm that no entity is attempting to seek a refund because another allowable counting method would result in a more advantageous Annual Enrollment Count for the Contributing Entity for the 2045 Bene?t Year. Lastly, you may also reference the Counting Methods Overview webinar presentation for each benefit year and The Transitional Reinsurance Program Operational Guidance: Examples of Counting Methods for Contributing Entities for each applicable benefit year, which document that explains the counting methods available by type of Contributing Entity. To access these documents, go to: the Transitional Reinsurance Program webpage at: or visit (REGTAP FAQ Database - FAQ #13662 10/13/15; updated 09/13/16) Q: After the reinsurance contribution submission ?ling deadline of November 15, 2016, can a Contributing (or Reporting) Entity seek a refund or ask to cancel a prior ?ling and refile because another allowable counting method would result in a more advantageous Annual Enrollment Count for the Contributing Entity in the 2016 Benefit Year? Updated 1-31-17 476 2017--00576 A: Applicable to Reinsurance Contributions 2016 Benefit Year: No, a Contributing (or Reporting) Entity can select any of the applicable counting methods set forth in 45 CFR 153.405(d) through (9) prior to completing the reinsurance contribution submission process. However, after the contribution submission ?ling deadline of November 15, 2016, a Contributing (or Reporting) Entity that correctly applied one (1) of the permitted counting methods cannot seek a refund or request to cancel their ?ling and re?le because another allowable counting method would result in a more advantageous Annual Enrollment Count for the Contributing Entity for the 2016 Bene?t Year. For additional information, we also encourage all Contributing and Reporting Entities to review the Centers for Medicare Medicaid Services (CMS)?issued guidance on April 14, 2015, Transitional Reinsurance Program Timing of Contributions Refund Requests Due to Annual Enrollment Count Misreporting,? available at: As we state in this guidance document, a Contributing or Reporting Entity may seek a refund up to 90 days from their original ?ling if they misapplied a permissible counting method (for example, the entity included 12 months of data when calculating their Annual Enrollment Count under the actual count method), or the entity included covered lives in the Annual Enrollment Count that are exempt under 45 CFR 153.400. However, a Contributing (or Reporting) Entity is not able to change the counting method as part of this process if it used a permitted counting method. For any refund requests, CMS will need the original information used to calculate the Annual Enrollment Count and the counting method. CMS will validate this information to confirm that no entity is attempting to seek a refund because another allowable counting method would result in a more advantageous Annual Enrollment Count for the Contributing Entity for the 2016 Bene?t Year. (REGTAP FAQ Database - FAQ #13663 10/13/15) Q: How do I submit the 2014 ACA Transitional Reinsurance Program Annual Enrollment Contributions Submission Form (Form)? A: Applicable to All Reinsurance Contributions Benefit Years: If you need to submit a 2014 ACA Transitional Reinsurance Program Annual Enrollment Contributions Submission Form, you have two options: (1) if you previously submitted a 2014 Form, you can still access that Form through the ,,My Account%o page of Pay.gov and duplicate that previously submitted Form or (2) use this link to locate the 2014 Form. (REGTAP FAQ Database - FAQ #137826 10/26/15) Q: What is the difference between a Reporting Entity and a Contributing Entity? Updated 1-31-17 A: Applicable to Reinsurance Contributions 2015 and 2016 Benefit Years: A Reporting Entity is the organization completing the steps for the Reinsurance Contributions submission process on Pay.gov on their own behalf or for another Contributing Entity. The Reporting Entity can be the Contributing Entity or a third party on behalf of a Contributing Entity. 477 2017-?00577 A Contributing Entity is a health insurance issuer; or self-insured group health plans that use a Third Party Administrator (TPA) in connection with claims processing or adjudication (including the management of internal appeals) or plan enrollment for services other than for pharmacy bene?ts or excepted bene?ts within the meaning of section 2791(0) of the Public Health Service (PHS) Act. (REGTAP FAQ Database - FAQ #137827 10/26/15) Q: How should an entity de?l?proceed when experiencing issues continuing within the 2045 ACA Transitional Reinsurance Program Annual Enrollment and Contributions Submission Form? A: Applicable to Reinsurance Contributions 2045 Bene?t Years: Features such as auto-fill and disabled noti?cations are preventing users from proceeding past page 1 of the 2045ACA Transitional Reinsurance Program Annual Enrollment and Contributions Submission Form (2045 Form). If you are experiencing this issue, please complete the following steps: 1. Save the current form 2. Log out of Pay.Gov 3. Exit your current web browser 4. Open Internet Explorer web browser 5. Log into Pay.Gov to access your saved form under My Forms If you still experience issues with the 2045 Form, please contact (REGTAP FAQ Database - FAQ #13839 10/30/15; updated 09/21/16) Q: What is the coinsurance rate for the 2015 Bene?t Year reinsurance payments and when should issuers expect to receive them? Updated 1-31-17 A: As noted in the ?Transitional Reinsurance Program: Pro Rata Adjustment to the National Coinsurance Rate for the 2015 Bene?t Year" Guidance* published on June 17, 2016, reinsurance payments for the 2015 Bene?t Year will be made at an estimated 55.1 percent coinsurance rate.* This coinsurance rate is re?ected in the ?Summary Report on Transitional Reinsurance Payments and Permanent Risk Adjustment Transfers for the 2015 Bene?t Year.?* As indicated in the Adjusted Reinsurance Payment Report emailed to reinsurance- eligible issuers on June 30, 2016, the Centers for Medicare Medicaid Services (CMS) will remit the 2015 Bene?t Year reinsurance payments in the August 2016 payment cycle at an 89.1 percent cycle proration factor. The cycle proration factor is calculated by applying the 55.1 percent coinsurance rate and 2016 Fiscal Year's 6.8 percent holdback rate to issuers' estimated reinsurance payments after CMS has accounted for payment adjustments (including overlapping claims) reported by July 15, 2016. For each reinsurance payment remitted, CMS will email the External Data Gathering Environment (EDGE) Chief Executive Officer (CEO) Designate and alternate contacts an updated Adjusted Reinsurance Payment Report, which will re?ect the actual reinsurance payment after applying year-to-date adjustments for the 2015 Bene?t Year. 478 2017--00578 For details on payments of sequestered funds, please see FAQ 17162. For details on how reinsurance payment cycle amounts are calculated, please review the Reinsurance Payment series webinar presentation from June 30, 2016, located at Slides 063016 v1 5CR 070116.pdf. This guidance is available at The coinsurance rate for the 2015 Benefit Year is subject to change - and may increase or decrease - in light of overlapping claims, differences between projected and actual reinsurance contribution collections, discrepancies and appeals. An issuer's initial, estimated reinsurance payment for the 2015 bene?t year may also change. The Summary Report for the 2015 benefit year is available at REGTAP FAQ Database - FAQ #17171 08/09/16) Q: If an entity qualifies for the self-insured, self-administered exemption for the 2016 Benefit Year reinsurance contribution submission process, set forth in 45 CFR 153.20, should the entity report this information to the Centers for Medicare Medicaid Services A: For the 2016 Bene?t Year, CMS requests that any plan claiming the self-insured, self- administered exemption send an email to with their company Legal Business Name (LBN), Tax Identi?cation Number (TIN), 2014 ?ling Pay.gov Tracking ID, and whether they identi?ed themselves as SISA in their 2014 filing. Providing this information will assist CMS in not sending these entities emails related to non-compliance because they ?led for 2014 but did not file in 2016. Please note that even if an entity completed this process in 2015, you must complete it again for the 2016 Bene?t Year. In order to ensure proper routing of the information, please include Exemption' in the subject line. Entities do not need to complete the 2016 ACA Transitional Reinsurance Program Annual Enrollment Contributions Form. In order to ensure proper routing of the information, please include Exemption' in the subject line of your email to (REGTAP FAQ Database - FAQ #17773 10/07/16) Q: What are the notable changes for the 2016 Benefit Year reinsurance contribution submission process? A: The following are the notable changes for the 2016 Bene?t Year reinsurance contribution submission process: 1. A Unique Billing Contact and Contact for Submission information is required on the 2016 ACA Transitional Reinsurance Program Annual Enrollment and Contributions Submission Form (2016 Form) 2. The questions on the 2016 Form have been reworded as follows: 479 Updated 1-31-17 2017--00579 - Are you reporting for three (3) or fewer Contributing Entities using this Form? - If yes, are you both the Reporting Entity and Contributing Entity for this Form submission? 3. 2016 Uniform Contribution Rate is $27.00 per covered life 4. Key Deadlines for 2016. 5. Automated Clearing House (ACH) Debt Block Number for the 2016 Benefit Year; - The reinsurance contribution number is 7505008016. - The Company Name is (REGTAP FAQ Database - FAQ #17800 10/11/16) Reinsurance Payments Q: When will CMS release the 2014 reinsurance payment amounts held back for fiscal year 2015 sequestration? A: CMS will release the reinsurance payment amounts for the 2014 bene?t year that were held back for ?scal year 2015 sequestration in the November 2015 payment cycle. The reinsurance program was sequestered at a rate of 7.3 percent for payments made in ?scal year 2015. (REGTAP FAQ Database - FAQ #13868 11/03/15) Q: Will amounts owed to the Federal government by an issuer for reinsurance contributions for a given benefit year be included in the netting process outlined under 45 CFR Updated 1-31-17 A: Applicable to 2015 and 2016 Rensurance Contribution Benefit Years: Yes, any amounts owed for reinsurance contributions for a given bene?t year that are not paid by the January 15, 2016 or November 15, 2016 payment deadlines for the 2015 bene?t year and by the January ?45, 2017 or November 15, 2017 payment deadlines for the 2016 bene?t year, will be included in the netting process outlined under 45 CFR such that the US. Department of Health and Human Services (HHS) will collect past due reinsurance contributions by netting these amounts against premium stabilization program payments and/or advance payments of the premium tax credit (including the cost-sharing reduction portion of the advance payment) that it owes to an issuer and its af?liates operating under the same tax identi?cation number. We Please note that sequestered funds for reinsurance payments are generally made available after the beginning of the subsequent ?scal year (October 1). Therefore, if an issuer of a reinsurance-eligible plan that is to receive a sequestered funds payment has failed to remit the reinsurance contribution amount due for a given bene?t year prior to the Centers for Medicare Medicaid Services (CMS) release of the sequestered funds, CMS would net any contribution amounts due from any sequestered payment amount for that issuer or its affiliates operating under the same tax identi?cation number. If any outstanding contribution is still owed after netting, that amount will be considered a debt owed to the Federal government pursuant to 45 CFR and CMS will issue a Dunning Letter for that amount. (REGTAP FAQ Database - FAQ #14240 12/09/15; updated 09/21/16) 480 2017--00580 Q: Will any amounts owed for reinsurance contributions for a given benefit year that are not paid by the January 15, 2016 or November 15, 2016 payment deadlines for the 2015 benefit year and by the January 45 2017 or November 15, 2017 payment deadlines for the 2016 bene?t year, be included in the netting process outlined under 45 CFR A: Applicable to All Reinsurance Contributions Benefit Years: Please see FAQ 14240. (REGTAP FAQ Database - FAQ #14242 12/11/15; updated 09/21/16) Q: How will CMS process 2015 reinsurance payments? A: CMS will process the 2015 reinsurance payments using the HIX 820 system. Issuers can submit questions regarding the payment method CMS uses to remit RI payments to the Payment Processing mailbox at Payment Processinq@cms.hhs.qov. (REGTAP FAQ Database - FAQ #14246 12/11/15) Q: For netting purposes, will amounts owed to the Federal government by an issuer for reinsurance contributions for a given benefit year be included in the netting process outlined under 45 CFR A: Please see FAQ FAQ Database - FAQ #14241 12/11/15) Q: With the update to the External Data Gathering Environment (EDGE) server that occurred on January 22, 2016, will cross-year claims with an admit date in 2014 and end date in 2015 now be eligible for reinsurance payments consistent with the 2015 payment parameters? A: Yes, provided cross-year claims meet all the other standard requirements for reinsurance payments not an orphan claim) and are associated with an active 2014 enrollment period they would be considered for reinsurance payments. Cross-year claims are not subject to the Cost Sharing Reduction (CSR) Maximum Out-of-Pocket (MOOP) adjustment, but the national reinsurance parameters (attachment point: $45,000, reinsurance cap: $250,000) for the 2015 Benefit Year apply. (REGTAP FAQ Database - FAQ #14754 02/01/16) Q: If the Marketplace directs an issuer of a reinsurance-eligible plan to enroll an individual retroactively for a benefit year after the end of that benefit year, pursuant to 45 CFR or such that the issuer of the reinsurance-eligible plan is unable to submit claims that were incurred in the prior benefit year by the applicable External Data Gathering Environment (EDGE) server data submission deadline, can the issuer submit claims for that individual for reinsurance purposes after the data submission deadline for the applicable benefit year? A: Issuers must submit all relevant claims and enrollment information for the applicable benefit year to the EDGE server by the EDGE server data submission deadline applicable for that benefit year. However, to the extent practicable and reinsurance funds are available, if, pursuant to 45 CFR or the Marketplace directs an issuer to retroactively enroll an individual after January 1 of the benefit year following the applicable bene?t year (that is, January 1, 2015 for the 2014 bene?t year) into coverage 481 Updated 1-31-17 2017--00581 for a prior benefit year, and the issuer is consequently unable to submit paid claims and enrollment information for that individual by the EDGE server data submission deadline applicable for the benefit year in which services were rendered, the Centers for Medicare Medicaid Services (CMS) will permit that issuer to submit claims and enrollment information for the individual enrolled in a reinsurance-eligible plan and will consider those claims when calculating reinsurance payments. CMS will issue future guidance on the process and timing for submitting the claims and enrollment information in such limited circumstances. (REGTAP FAQ Database - FAQ #15054 03/07/16) Q: If the Marketplace requires an issuer of a reinsurance-eligible plan to enroll an individual retroactively for a benefit year after the end of that benefit year, pursuant to 45 CFR or such that the issuer of the reinsurance-eligible plan is unable to submit claims that were incurred in the prior benefit year by the applicable External Data Gathering Environment (EDGE) server data submission deadline, can the issuer submit claims for that individual for reinsurance purposes after the data submission deadline for the applicable benefit year? A: Issuers must submit all relevant claims and enrollment information for the applicable benefit year to the EDGE server by the EDGE server data submission deadline applicable for that benefit year. However, to the extent practicable and reinsurance funds are available, if, pursuant to 45 CFR or the Marketplace directs an issuer to retroactively enroll an individual after January 1 of the benefit year following the applicable bene?t year (that is, January 1, 2015 for the 2014 bene?t year) into coverage for a prior benefit year, and the issuer is consequently unable to submit paid claims and enrollment information for that individual by the EDGE server data submission deadline applicable for the bene?t year in which services were rendered, the Centers for Medicare Medicaid Services (CMS) will permit that issuer to submit claims and enrollment information for the individual enrolled in a reinsurance-eligible plan and will consider those claims when calculating reinsurance payments. CMS will issue future guidance on the process and timing for submitting the claims and enrollment information in such limited circumstances. (REGTAP FAQ Database - FAQ #15070 03/07/16) Q: When will the Centers for Medicare Medicaid Services (CMS) notify issuers who are considered data outliers? A: In January and February of 2016, CMS performed two rounds of data outlier analysis and noti?ed issuers whether they were deemed outliers by sending letters to their External Data Gathering Environment (EDGE) CEO-designates and alternates. Issuers should continue to update their 2015 Bene?t Year EDGE data. CMS will continue to assess data and notify issuers that are outliers as indicated in the ?Evaluation of EDGE Data Submissions for 2015 Bene?t Year? posted March 18, 2016 on the CMS website Q-Guidance 03182016.pdf. (REGTAP FAQ Database - FAQ #15313 03/28/16) Q: When does the Centers for Medicare Medicaid Services (CMS) anticipate releasing the interim reinsurance (RI) payment to issuers? A: CMS released interim reinsurance payments on March 23, 2016. Issuers identified as 482 Updated 1-31-17 2017--00582 outliers on February 12, 2016 were required to submitjustifications by February 26, 2016. If CMS determined these justifications to be suf?cient, reinsurance-eligible issuers will receive interim reinsurance payments in late April 2016. (REGTAP FAQ Database - FAQ #15314 03/28/16) Q: Will the Centers for Medicare Medicaid Services (CMS) distribute the interim Reinsurance (RI) payment in March 2016 without sequestration? A: Holdback for sequestration and appeals is not applied to interim reinsurance payments, but will be applied to the final reinsurance payments. (REGTAP FAQ Database - FAQ #15315 03/28/16) Q: Are the reinsurance (RI) payment parameters applied to an issuer's claims costs at the issuer or plan level? A: Reinsurance payment estimates are calculated at the enrollee level. An issuer's plan paid amounts for reinsurance-eligible claims are aggregated to the enrollee-level for all individual plan enrollments for a single issuer in the applicable benefit year. Then, the applicable CSR MOOP adjustment is applied. After this, the applicable bene?t year's national parameters are applied to each enrollee?s remaining aggregated issuer plan paid amount. Estimated RI payment for each enrollee is summed to arrive at the total estimated RI payment for the issuer. For more information, please see the RI Calculation Guide located in REGTAP Library under the Reinsurance program area. (REGTAP FAQ Database - FAQ #2529 07/02/14; updated 06/21/16; note: original FAQ not found in compilation, so changes are not shown) Q: Can the Centers for Medicare Medicaid Services (CMS) provide information on the adjustment of the Maximum Out-of-Pocket A: CMS provides issuers with advance Cost Sharing Reduction (CSR) payments for Marketplace plan enrollees who are participating in CSR-eligible plans. In calculating the reinsurance payment for CSR plans, CMS applies a MOOP adjustment to account for the advance CSR payment. The MOOP adjustment is the MOOP difference between the CSR plan and the corresponding standard plan. This adjustment does consider various scenarios such as family policy and change in family structure during the reinsurance payment calculation. For more information, issuers should refer to the Reinsurance Calculation Guide, posted in the REGTAP Library under the Reinsurance program area. (REGTAP FAQ Database FAQ #8939 02/11/15; updated 06/21/16; note: original FAQ not found in compilation, so changes are not shown) Q: With regard to the Cost-Sharing Reduction (CSR) Maximum Out-of-Pocket (MOOP) adjustment for a family plan and the Detailed Reinsurance Report, if an issuer takes the individual MOOP, and adjusts that number by the standard cost-sharing silver level, would this be the accurate amount for adjusting the CSR A: A family's CSR MOOP adjustment is calculated by subtracting the MOOP of the CSR plan variant from the MOOP of the corresponding standard plan, prorated by the number of days in the family policy. The result is then allocated across all enrollees of that plan by each enrollee's proportion of the family's total paid claims during the policy period. For more information, issuers should refer to the Reinsurance Calculation Guide posted in the REGTAP Library under the Reinsurance program area. (REGTAP FAQ Database 483 Updated 1-31-17 2017--00583 - FAQ #9479 04/01/15; updated 06/21/16; note: original FAQ not found in compilation, so changes are not shown) Q: Can the Centers for Medicare Medicaid Services (CMS) provide issuers with information on the Reinsurance (RI) Eligible Cost-Sharing Reduction (CSR) Maximum - Out-of-Pocket (MOOP) Adjustment, and describe how this differs from the CSR MOOP Adjustment? A: The CSR MOOP adjustment is the amount deducted from the paid claims amount of a CSR plan enrollee in order to appropriately calculate reinsurance. The MOOP Adjustment for RI Eligible Enrollees' data element in the Reinsurance Summary Report (RISR), on the other hand, is the sum of all such adjustments, for all RI-eligible enrollees. The RISR also contains the MOOP Adjustment for RI Enrollees with Payments' data element, which is the sum of the adjustments only for those enrollees actually receiving RI payments-(REGTAP FAQ Database - FAQ #9573 04/07/15; updated 06/21/16; note: original FAQ not found in compilation, so changes are not shown) Q: When calculating the Cost-Sharing Reduction (CSR) Adjustments, should issuers divide the member month for the initial plan by the member's total number of covered months and multiply that number by the CSR Adjustment for the plan? A: No. The reinsurance calculation prorates the CSR MOOP adjustment of an enrollee by number of days in an enrollment period; member or billable months are used only in risk adjustment calculations. Any changes in enrollment for example, changing enrollment from an individual plan to a family plan, or adding a new member to an existing family plan necessitates a new CSR MOOP adjustment. The CSR MOOP adjustments for each enrollment period of an enrollee are summed to arrive at the total CSR MOOP adjustment for that enrollee for the applicable benefit year. For more information, issuers should refer to the Reinsurance Calculation Guide, posted in the REGTAP Library under the Reinsurance program area. (REGTAP FAQ Database - FAQ #9575 04/07/15; updated 06/21/16; note: original FAQ not found in compilation, so changes are not shown) Q: In regards to the Centers for Medicare Medicaid Services (CMS) Maximum 0ut-of-- Pocket (MOOP) expense calculations, what fields and processes does CMS go through to determine whether a plan is an individual plan or family plan? A: A family plan is identified when an enrollee's Subscriber Indicator ?eld is NULL, the Subscriber Identi?er field is populated, and the enrollment periods overlap with the enrollment periods of the subscriber. An individual plan is identi?ed when an enrollee's Subscriber Indicator field is populated with and there are no other enrollees with the same Subscriber Identifier. (REGTAP FAQ Database - FAQ #10572 05/15/15; updated 06/21/16; note: original FAQ not found in compilation, so changes are not shown) Q: In regards to family policies, if none of the enrollees have claims in the current benefit year, how does the Centers for Medicare Medicaid Services (CMS) apportion the Maximum Out-of-Pocket (MOOP) expense and is the MOOP evenly split between enrollees on the plan? Updated 1-31-17 484 2017--00584 A: If none of the enrollees in a family policy have claims in the bene?t year, then the total family MOOP adjustment amount for the policy is split equally between all members (subscriber and all dependents) in the policy. However, enrollees with no claims will always have a $0 RI payment, regardless of any CSR MOOP adjustment. (REGTAP FAQ Database - FAQ #10573 05/15/15; updated 06/21/16; note: original FAQ not found in compilation, so changes are not shown) Q: Are student health plans eligible to receive reinsurance payments? A: In accordance with the policy established in the HHS Notice of Bene?t and Payment Parameters for 2014, student health plans are not eligible to receive reinsurance payments because student health plans are not subject to the single risk pool requirement of section 1312(c) of the Affordable Care Act and 45 CFR 156.80. Because student health plans are not eligible for reinsurance payments, issuers of student health plans will not need to set up an External Data Gathering Environment (EDGE) Server. However, we note that a student health plan would be considered part of a Contributing Entity's ?commercial book of business" and, to the extent that the plan provides major medical coverage, as defined in 45 CFR 153.20, a Contributing Entity must make reinsurance contributions on behalf of their enrollees, absent another exception in 45 CFR 153.400. To the extent a student health plan must make reinsurance contributions, the plan will follow the same operational process as any other Contributing Entity. (REG TAP FAQ Database - FAQ #3293 07/31/14; updated 06/21/16; note: original FAQ not found in compilation, so changes are not shown) Q: Do reinsurance-eligible Individual Market plans include both Individual and Small Group plans? A: No. In 45 CFR 153.20, a reinsurance-eligible plan means, for the purpose of the Reinsurance (RI) program, any health insurance coverage offered in the Individual Market, except for grandfathered plans and health insurance coverage not required to submit reinsurance contributions under 45 CFR We note that pursuant to 45 CFR 153.234, a reinsurance-eligible plan's covered claims costs for an enrollee incurred prior to the application of the following provisions do not count towards either the national reinsurance payment parameters or the State supplemental reinsurance payment parameters: 45 CFR 147.102, 147.104 (subject to 147.145), 147.106 (subject to 147.145), 156.80, and subpart of part FAQ Database - FAQ #4983 09/19/14; updated 06/21/16; note: original FAQ not found in compilation, so changes are not shown) Q: Can the Centers for Medicare Medicaid Services (CMS) explain the payment process between CMS and the State of Connecticut? A: Connecticut will be issuing speci?c guidance concerning this topic because it is a State-run Reinsurance Program. CMS will run reports that will be available to all issuers, including those in Connecticut. The State of Connecticut will remit reinsurance payments to its issuers-(REGTAP FAQ Database - FAQ #7950 12/01/14; updated 06/21/16; note: original FAQ not found in compilation, so changes are not shown) Q: With the State of Connecticut administering payments of the Reinsurance program, should issuers still upload payments to the External Data Gathering Environment (EDGE) server? Updated 1-31-17 485 2017--00585 A: Yes, issuers should still upload their enrollment and claims data that meets EDGE server data submission requirements to the EDGE server. (REGTAP FAQ Database - FAQ #7951 12/01/14; updated 06/21/16; note: original FAQ not found in compilation, so changes are not shown) Q: Can issuers submit claims as paid and then do the Maximum Out-Of?Pocket (MOOP) adjustment, which will account for the Cost-Sharing Reduction (CSR) amount? A: No, issuers should not carve out any advance CSR payments remitted by CMS for the applicable bene?t year. The reinsurance payments calculation methodology applies the CSR MOOP adjustment to account for these advance CSR payments. For more information, please see the Reinsurance (RI) Calculation Guide located in REGTAP Library under the Reinsurance program area. (REGTAP FAQ Database - FAQ #7826 11/24/14; updated 06/21/16; note: original FAQ not found in compilation, so changes are not shown) Q: Are Catastrophic plans eligible for Reinsurance? A: The only plans considered reinsurance-eligible plans are defined in 45 CFR 153.20 as any health insurance coverage offered in the Individual Market, except for grandfathered plans and health insurance coverage not required to submit reinsurance contributions under FAQ Database - FAQ #8037 12/04/14; updated 06/21/16; note: original FAQ not found in compilation, so changes are not shown) Q: How will the Centers for Medicare Medicaid Services (CMS) distribute Reinsurance (RI), Risk Adjustment (RA) and Risk Corridors (RC) payments to issuers? A: Payments for RI, RA and RC follow the same process as Advanced Premium Tax Credit (APTC) Payments and advance Cost Sharing Reductions (CSR) payment distribution. Issuers must create a vendor pro?le through the Vendor Management module, located in the Health Insurance Oversight System (HIOS), to receive payments. Additional guidance on the creation of Vendor Management profiles is located in the REGTAP Library. (REG TAP FAQ Database - FAQ #10976 06/15/15; updated 06/21/16; note: original FAQ not found in compilation, so changes are not shown) Reinsurance Reports Q: When an issuer runs the command to execute Reinsurance reports, when should issuers receive the reports? Updated 1-31-17 A: Once reinsurance reports are executed, the issuer's External Data Gathering Environment (EDGE) server will generate both the Reinsurance Detail Report (RIDE), and the Reinsurance Summary Report (RISR) and place them in the issuer's Outbox. If after running the command to execute these reports, an issuer has not received this information, the issuer should review the error logs to ensure the calculation runs were successfully executed. If additional on a technical assistance is required, please contact CMS at EDGE server data@cms.hhs.qov. (REGTAP FAQ Database - FAQ #8550 01/20/15; updated 06/21/16; note: original FAQ not found in compilation, so changes are not shown) 486 2017--00586 Q: Is there a difference between the Risk Adjustment (RA) and Reinsurance (RI) reports that are generated by the issuer, in comparison to those that are generated by the Centers for Medicare Medicaid Services A: Provided that the enrollment/claims data and EDGE server version are the same, the only difference between EDGE outbound reports generated by the issuer and those generated from CMS report commands is that locally generated outbound reports have in the filename; othenivise, the calculations and XML data elements are the same. Note, however, that CMS does not receive issuer-generated reports, with the exception of Enrollee (Without) Claims Summary and (E08) Reports run in the production environment. All other CMS reports are summary-level. (REGTAP FAQ Database - FAQ #9198 03/04/15; updated 06/21/16; note: original FAQ not found in compilation, so changes are not shown) Q: Can the Centers for Medicare Medicaid Services (CMS) confirm that all Reinsurance (RI) eligible claims submitted by issuers to the External Data Gathering Environment (EDGE) server will appear in the Reinsurance Detail Report (RIDE) and the Reinsurance Summary Report A: No, only active, non-orphaned, Rl-eligible (Individual Market) claims accepted by the EDGE server will appear in the RIDE and RISR. (REGTAP FAQ Database - FAQ #9904 04/15/15; updated 06/21/16; note: original FAQ not found in compilation, so changes are not shown) Q: For the Reinsurance Summary Report (RISR), can the Centers for Medicare Medicaid Services (CMS) clarify if the expected Reinsurance (RI) payment amount is located in the estimated RI payment field or in the coinsurance-adjusted RI payment field? Answer: The RISR does not provide the CMS determined national coinsurance rate for the applicable bene?t year. The final RI payment will be determined only after the national coinsurance rate is applied to the total estimated RI payment in the RISR. The national coinsurance rate is calculated by dividing total RI contributions to be available for the applicable benefit year by total estimated RI payment for all RI-eligible issuers from the RISRs, not to exceed 100%.Issuers can expect to see the ?nal RI payment amount to be published on June 30th or the next business day in the Risk Adjustment and Reinsurance Notification of Payments and Charges. (REGTAP FAQ Database - FAQ #10790 05/27/15; updated 06/21/16; note: original FAQ not found in compilation, so changes are not shown) Q: Does the Centers for Medicare Medicaid Services (CMS) want issuers to review interim reports and check data from Reinsurance and Risk Adjustment Detail Report? A: Yes, issuers should review Reinsurance and Risk Adjustment detail reports regularly to ensure stored claims and enrollment data are accurately re?ected. If the issuer does ?nd a problem, the issuer should notify CMS as soon as possible by sending an email to edge server data@cms.hhs.qov. (REGTAP FAQ Database - FAQ #7932 12/01/14; updated 06/21/16; note: original FAQ not found in compilation, so changes are not shown) 487 Updated 1-31-17 2017--00587 Q: What are the issuer requirements and deadlines for reinsurance in a State where the State is running its own Risk Adjustment (RA) program but HHS is operating the Reinsurance (RI) program? A: Issuers in a State which elected to operate the RA program but deferred operation of the RI program to HHS are required to comply with the requirements applicable to HHS-- operated reinsurance programs. Therefore, an issuer in a State where HHS is operating reinsurance must comply with the data requirements and deadlines set forth in 45 CFR Subpart H, speci?cally 45 CFR 153700153730. Additionally, as set forth in 45 CFR 153.230, a health insurance issuer of a reinsurance-- eligible plan becomes eligible for reinsurance payments from contributions under the national contribution rate when its incurred claims costs for an individual enrollee's covered benefits in a bene?t year exceed the national attachment point. As set forth in the HHS Notice of Benefit and Payment Parameters for 2015 for the 2014 bene?t year, the national reinsurance payment parameters are as follows: $45,000 attachment point, $250,000 reinsurance cap, and 80% coinsurance rate. (REGTAP FAQ Database - FAQ #2523 07/02/14; updated 06/21/16; note: original FAQ not found in compilation, so changes are not shown) Risk Corridors Q44: Will offering the identical benefit plan under two separate HIOS Product IDs on and off the Exchange preclude participation in the risk corridor program? A44: Section 1342 of the Affordable Care Act directs HHS to establish a temporary risk corridors program during the years 2014 through 2016 and requires that all Issuers of qualified health plans in the individual and small group markets to participate. We are currently working on the risk corridors program. The approach of establishing separate product IDs for QHPs on and off the Exchange would not preclude the QHPs off the Exchange from participating in the risk corridors program. As we continue our work, we will consult with stakeholders to ensure that we provide suf?cient flexibility. (QHP Webinar Series FAQ #10 05/09/13) Q: Where can issuers find information regarding risk corridors? A: Section 1342 of the Patient Protection and Affordable Care Act 2010 (ACA) establishes the legislation of the temporary Risk Corridors Program for plans in the individual and small group markets. HHS has also issued regulations and guidance for the risk corridors program that can be accessed at: Programs/index.html. As more information becomes available, will conduct training sessions and publish related documents at (REGTAP FAQ Database - FAQ #824 02/20/14) Q: Where can issuers sign up for email alerts related to the Risk Corridors Program? A: The Department of Health Human Services (HHS) has issued regulations and guidance for the risk corridors program that can be accessed at: 488 Updated 1-31-17 2017--00588 Stabilization Programs. The deadline to submit risk corridors data for the 2014 benefit year is July 31, 2015. HHS will provide issuers with updates closer to the data submission deadline, and may conduct technical training sessions. As more information becomes available HHS will publish related documents at (REGTAP FAQ Database - FAQ #6212 10/28/14) Risk Corridors Calculations Q: Are Catastrophic Plans included with Individual Plans and therefore, included in Risk Corridors calculations? A: For the purposes of calculating 'allowable costs' in the numerator of the risk corridors calculation, issuers should include the experience of all of their non-grandfathered, ACA- compliant plans in a market (individual or small group) within a State. The risk corridors ratio will be calculated based on this data, which will include the experience of catastrophic plans that meet this de?nition. Risk corridors payments and charges only apply to quali?ed health plans (QHPs), as de?ned at 45 CFR 153.500. To the extent that a catastrophic plan meets the de?nition of a QHP for the purposes of the risk corridors program (45 CFR 153.500), the plan will be eligible for risk corridors payments or subject to risk corridors charges. If a catastrophic plan is not a QHP, it will not receive or make risk corridors payments or charges. (REG TAP FAQ Database - FAQ #823 02/20/14) Q: Which types of plans should be considered when allocating expenses for the risk corridor calculation? Should all non-grandfathered plan expenses (claim and admin) be allocated proportionally based on premium and then the risk corridor calculation done on QHPs only? A: For each market within a state, the claims and admin expenses of all of a QHP issuer's non-grandfathered, ACA-compliant plans should be allocated pro-rata based on the QHP's premiums. In this way, the risk corridors payment or charge amount will reflect the QHP's share of the QHP issuer's market-wide allowable costs and premiums. (REGTAP FAQ Database - #1715 05/28/14) Q: If there are administrative expenses or taxes and fees that relate specifically to a QHP, do those expenses have to be allocated proportionally across all non-grandfathered plans? Or can we take those direct expenses straight to the QHP risk corridor calculation without allocating to other plans? A: The treatment of administrative expenses and taxes and fees (including Exchange user fees) should conform to the market-wide calculation for allowable costs and premiums. In this way, allowable claims costs and allowable administrative costs will be pooled for all of an issuer's non-grandfathered, ACA compliant plans, and will be allocated proportionally to an issuer's QHPs, based on the QHP's premium. (REGTAP FAQ Database - #1716 05/28/14) Q: Is there any reason to make the risk corridor calculations by each Or would consolidating by issuer for each single-risk pool result in the same ending value (assuming all expenses are proportionally allocated by premium)? 489 Updated 1-31-17 2017--00589 A: Yes, the calculation is the same if the issuer pools all of its allowable costs for its non- grandfathered, ACA compliant plans in the numerator of the risk corridors calculation, and pools the target amount in the denominator of the risk corridors calculation. The resulting ratio will indicate an overall risk corridors charge or payment amount, that will then be allocated pro-rata to a QHP based on the QHP's premium, in order to determine the actual risk corridor payment or charge amount that the issuer will receive or be obligated to pay. (REGTAP FAQ Database - #1717 05/28/14) Q: For Risk Corridors reporting and calculation, how should issuers classify reinsurance contributions made for Individual Insured Products (Ceded Premium payments) and does it increase 'Allowable Costs,? 'Taxes/Fees' or 'Premium Earned'? A: Issuers should treat Transitional Reinsurance Program contributions as a regulatory fee in order to calculate the Risk Corridors target amount (reinsurance contributions are an adjustment to premium reported for the risk corridors calculation), not as an adjustment to risk corridors ?Allowable Costs.? (REGTAP FAQ Database - FAQ #6235 10/28/14) Q: The guidelines for Risk Adjustment and Reinsurance program are specific regarding the calculation of costs from capitated providers indicating the submission of priced encountered claims) and guidelines for the Medical Loss Ratio (MLR) program are specific about the use of capitation payments including the actual amount of capitation payment to these providers). How will capitated providers be handled in Risk Corridors' calculations and should issuers submit the priced encountered claims or the actual capitation paid to capitated providers? A: In determining the amount of allowable costs to report for the risk corridors calculations, issuers should treat capitated provider payments in the same manner that these payments are treated for purposes of the MLR calculation. (REG TAP FAQ Database - FAQ #6241 10/28/14) Q: If a small group market purchases a Quali?ed Health Plan (QHP) and subsequently becomes a large group market, should enrollment data for the large group market be excluded from Risk Corridor calculations? A: If a small group issuer becomes a large group market issuer in the middle of the year (2014), only the experience for the months that the issuer was a small group issuer should be reported for Risk Corridors calculation purposes. Please note, the Risk Corridors program uses the employee counting method established in state law to determine employer size. (REGTAP FAQ Database - FAQ #8763 02/02/15) Q: Guidance from the Centers for Medicare Medicaid Services (CMS) for the Risk Corridors calculation suggests the calculation is an 'either or' calculation and not a combined payment. Are Qualified Health Plans (QHPs) supposed to calculate the payment amount between 103 percent and 108 percent and add to that amount the 490 Updated 1-31-1 7 2017--00590 calculated amount over 108 percent? A: According to 45 CFR 153.500 which details the Risk Corridors establishment and payment methodology, the Department of Health and Human Services (HHS) will make payment to QHP issuers under two (2) scenarios: (1) When a QHP's allowable costs for a bene?t year exceed 103 percent, but are not more than 108 percent of the target amount, HHS will pay the QHP issuer an amount equal to 50 percent of the allowable costs in excess of 103 percent of the target amount; (2) When a QHP's allowable costs for a bene?t year are more than 108 percent of the target amount, HHS will pay the QHP issuer an amount equal to the sum of 2.5 percent of the target amount plus 80 percent of allowable costs in excess of 108 percent of the target amount. In a single year, a QHP issuer can either be required to pay a Risk Corridors charge amount to HHS, or would be eligible to receive payment from it is not possible for the issuer to be in both categories. The calculation of the Risk Corridors is a single calculation. When issuers submit Risk Corridors data, HHS will automatically calculate the Risk Corridors ratio and the Risk Corridors payment or charge amount for the issuer. (REGTAP FAQ Database - FAQ #8764 02/02/15) Q: If an organization has multiple entities within one (1) State, should issuers report the aggregated Risk Corridor calculation of all entities, or report the Risk Corridor calculation separately for each entity? A: The Risk Corridors calculation is performed separately for each legal entity that is licensed to sell insurance in a market (individual or small group) in a state. Although the calculation is performed at the issuer level, the report of Risk Corridors data may be submitted by a parent company for all of its QHP issuers. (REGTAP FAQ Database - FAQ #8768 02/02/15) Q: Can you tell me how the 2014 Transitional Reinsurance adjustment will be calculated? For example, say 10% of our Individual member months are in a transitional product. How would we calculate the adjustment? A: CMS will calculate the transitional adjustment percentage for each state based on transitional enrollment data submitted by issuers. The adjustment percentages will be published prior to the Corridors data collection that begins on July 1, 2015. Issuers will then enter the adjustment percentage for the appropriate business state in the MLR form and it will be factored into the risk corridors calculation. A description of the calculation can also be found in the HHS Notice of Bene?t and Payment Parameters for 2015. (REGTAP FAQ Database - FAQ #9818 04/21/15) Q: Does the Centers for Medicare Medicaid Services (CMS) recommend that the value for premium earned entered in the Risk Corridors (RC) Plan-Level Data Form reflect the premium charged to members and the Advanced Payments of the Premium Tax Credit or should the premium in the RC Plan-Level Data Form be identical to the Updated 1-31-17 491 2017-?00591 premium entered in the Medical Loss Ratio (MLR) Report? A: Earned premium includes both the premium charged to members and the premium tax credit portion of advance payments (APTC) for both MLR and RC reporting purposes. Issuers should report the earned revenue that was received as of December 31, 2014. (REGTAP FAQ Database - FAQ #11033 06/18/15) Q: Will the Centers for Medicare Medicaid Services (CMS) include the transitional Reinsurance (RI) contributions in the total earned premium of the Medical Loss Ratio (MLR) Report and the Risk Corridors (RC) Form? A: Yes. The transitional RI contribution is treated as a ?tax or regulatory fee? in the RC calculation. Because RI contributions are treated as such, issuers should not separately adjust their premiums to account for RI contributions. Issuers can find instructions for accounting for RI contributions in the Annual MLR Reporting Instructions. (REGTAP FAQ Database - FAQ #11035 06/18/15) Q: When calculating allowable costs for the Risk Corridors (RC) program, are issuers permitted to factor in incurred claims not processed through the External Data Gathering Environmental (EDGE) server? A: Yes. For the purposes of determining allowable costs, an issuer should submit all claims incurred for the duration of the year for non-grandfathered, Affordable Care Act (ACA)?compliant plans. Issuers should also factor in incurred claims for non- grandfathered, ACA-compliant plans that were not processed through the EDGE server. (REGTAP FAQ Database - FAQ #11036 06/18/15) Q: When the June 30, 2015 Risk Adjustment (RA) and Reinsurance (RI) reports are distributed, are issuers required to recalculate the Federal taxes based on the June 30, 2015 report for the RA and RI payment amount on the Medical Loss Ratio (MLR) Report, or should issuers continue to use the Federal tax amount reported in their annual statement for the purposes of risk corridors reporting? A: The Federal taxes reported on the MLR Form should be the amount of federal taxes incurred in 2014 Calendar Year as reported on the issuer's ?nancial statement. (REGTAP FAQ Database - FAQ #11038 06/18/15) Q: Should issuers include estimated taxes on Risk Corridors (RC) payments when reporting taxes for the RC calculation? A: Issuers should exclude RC payments or charges when considering tax amounts used to calculate risk corridors and the tax amounts entered in the RC columns of the Medical Loss Ratio (MLR) Annual Form. (REGTAP FAQ Database - FAQ #11039 06/18/15) Q: If an issuer expects a payment from the Centers for Medicare Medicaid Services (CMS) for an individual plan, and is also charged for a small business plan, will CMS combine the payment amount and the charged amount into one (1) receipt to balance the payment/charge amount? 492 Updated 1-31-1 7 2017--00592 A: Yes. CMS collects charges and makes payments at the company tax identification number level. CMS will prorate the payment to an issuer ?rst then offset it with the charge so that the issuer receives one (1) payment/charge amount for both markets. (REGTAP FAQ Database - FAQ #11045 06/18/15) Q: Should issuers report on-Exchange or off-Exchange Qualified Health Plans (QHP) in the Medical Loss Ratio (MLR) report for the Risk Corridors (RC) programs? A: Issuers should report all non-grandfathered ACA-compliant business (including exchange QHPs, off-exchange QHPs, and plans that are substantially the same as exchange QHPs) in the Risk Corridors columns on the MLR Reporting Form. The only areas where CMS requests QHP premium data separately for Exchange QHPs, off- Exchange QHPs, and substantially the same QHPs in the individual and small group markets are Tables 2, 3, and 4 of the Risk Corridors Plan-Level Data Form. (REGTAP FAQ Database - FAQ #11095 06/29/15) Q: In Part 3 of the Medical Loss Ratio (MLR) Form, taxes and regulatory fees are excluded from Line 3.6a; however, taxes and regulatory fees are included in Line 3.6b, can the Centers for Medicare Medicaid Services (CMS) clarify why taxes and regulatory fees are excluded in Line 3.6a? A: CMS has corrected Line 3.6a in Part 3 of the MLR 2014 Annual Form to include taxes in the de?nition of allowable administrative costs. CMS has also updated the MLR Calculator and Form Tool available on the home page of the MLR module and on the CCIIO website. As of June 18, 2015 issuers can download corrected MLR Annual Form templates from the HIOS MLR module. (REGTAP FAQ Database - FAQ #11096 06/29/15) Q: Does the Centers for Medicare Medicaid Services (CMS) recommend that issuers enter the Advance Payments of Cost Sharing Reductions amount received from CMS into Tab P2, Premiums and Claims, in the Medical Loss Ratio (MLR) Reporting Form, or can issuers enter an actuarial estimate of actual Cost-Sharing Reduction payments made in Tab P2 of the MLR Reporting Form? A: CMS addressed Cost-Sharing Reduction Amounts in Risk Corridors and Medical Loss Ratio reporting in guidance published on June 19, 2015. The guidance is available at the link below: 6192015.pdf (REGTAP FAQ Database - FAQ #11097 06/29/15) Q: According to the United States Department of Health and Human Services (HHS) instructions for completing the Risk Corridors (RC) Form; HHS states that, 'For 2014 only, in States where the issuer participated in the State and Federal Exchanges (sometimes referred to as 'Marketplaces') in the individual and/or small group market(s), 493 Updated 1-31-17 2017--00593 the issuer may multiply the sum of the amounts reported in the CY Column Lines 1.2 1.3 by 1.0004 before including it in the calculation for Line 1.8, Total Column, in the relevant State and market.? Are issuers permitted to multiply Lines 1.2 1.3 by 1.0004 before including the total calculation in columns 4A and 8A in the RC Plan-Level Data Form if the issuer participated in the Exchange for a particular State? A: No, issuers should not multiply Lines 1.2 1.3 by 1.0004 before when calculating the amounts for the risk corridors program in columns 4A and 8A of the 2014 MLR Reporting Form. The 1.0004 adjustment is speci?c to the MLR program only, and does not apply to risk corridors calculations. (REGTAP FAQ Database - FAQ #11336 07/22/15) Risk Corridors Payments Q: When will the Risk Corridor payments webinars begin? A: At this time, no risk corridors webinars are scheduled. We encourage you to review the regulations and guidance for the risk corridors program that can be accessed at: Stabilization Programs. The risk corridors data submission deadline for the 2014 benefit year is July 31, 2015. HHS will inform issuers of additional information through RegTap, and may announce training sessions or webinars closer to the data submission deadline. (REGTAP FAQ Database - FAQ #6237 10/28/14) Q: When will the Centers for Medicare Medicaid Services (CMS) issue risk corridor payments to insurance companies? A: Issuers must submit risk corridors payments for the 2014 bene?t year by July 31, 2015. CMS will make risk corridors payments to eligible issuers as soon as possible after this data submission deadline, likely in the early Fall 2015. (REGTAP FAQ Database - FAQ #6240 10/28/14) Q: In the HHS Notice of Bene?t and Payment Parameters for 2015 final rule (79 FR 13744) and the Exchange and Insurance Market Standards for 2015 and Beyond NPRM (79 FR 15808), HHS indicated that it intends to implement the risk corridors program in a budget neutral manner. What risk corridors payments will HHS make if risk corridors collections for a year are insufficient to fund risk corridors payments for the year, as calculated under the risk corridors formula? A: We anticipate that risk corridors collections will be sufficient to pay for all risk corridors payments. However, if risk corridors collections are insufficient to make risk corridors payments for a year, all risk corridors payments for that year will be reduced pro rate to the extent of any shortfall. Risk corridors collections received for the next year will first be used to pay off the payment reductions issuers experienced in the previous year in a proportional manner, up to the point where issuers are reimbursed in full for the previous year, and will then be used to fund current year payments. If, after obligations for the previous year have been met, the total amount of collections available in the current year is insufficient to make payments in that year, the current year payments will be reduced pro rata to the extent of any shortfall. If any risk corridors funds remain after prior and current year payment obligations have been met, they will be held to offset potential insufficiencies in risk corridors collections in the next year. 494 Updated 1-31-17 2017--00594 Example 1: For 2014, HHS collects $800 million in risk corridors charges, and QHP issuers seek $600 million risk corridors payments under the risk corridors formula. HHS would make the $600 million in risk corridors payments for 2014 and would retain the remaining $200 million for use in 2015 and potentially 2016 in case of a shortfall. Example 2: For 2015, HHS collects $700 million in risk corridors charges, but QHP issuers seek $1 billion in risk corridors payments under the risk corridors formula. With the $200 million in excess charges collected for 2014, HHS would have a total of $900 million available to make risk corridors payments in 2015. Each QHP issuer would receive a risk corridors payment equal to 90 percent of the calculated amount of the risk corridors payment, leaving an aggregate risk corridors shortfall of $100 million for benefit year 2015. This $100 million shortfall would be paid for from risk corridors charges collected for 2016 before any risk corridors payments are made for the 2016 benefit year. (REGTAP FAQ Database - FAQ #1407 04/14/14) Q: What happens if risk corridors collections do not match risk corridors payments in the final year of risk corridors? A: We anticipate that risk corridors collections will be sufficient to pay for all risk corridors payments over the life of the three-year program. However, we will establish in future guidance or rulemaking how we will calculate risk corridors payments if risk corridors collections (plus any excess collections held over from previous years) do not match risk corridors payments as calculated under the risk corridors formula for the final year of the program. (REGTAP FAQ Database - FAQ #1408 04/14/14) Q: If HHS reduces risk corridors payments for a particular year because risk corridors collections are insufficient to make those payments, how should an issuer's medical loss ratio (MLR) calculation account for that reduction? A: Under 45 CFR an issuer should reflect in its MLR report the risk corridors payment to be made by HHS as reflected in the notification provided under Because issuers will submit their risk corridors and MLR data simultaneously, issuers will not know the extent of any reduction in risk corridors payments when submitting their MLR calculations. As detailed in 45 CFR that reduction should be reflected in the next following MLR report. Although it is possible that not accounting for the reduction could affect an issuer's rebate obligations, that effect will be mitigated in the initial year because the MLR ratio is calculated based on three years of data, and will be eliminated by the second year because the reduction will be re?ected. We intend to provide more guidance on this reporting in the future. (REGTAP FAQ Database - FAQ #1409 04/14/14) Q: In the 2015 Payment Notice, HHS stated that it might adjust risk corridors parameters up or down in order to ensure budget neutrality. Will there be further adjustments to risk corridors in addition to those indicated in this A: HHS believes that the approach outlined in this FAQ is the most equitable and efficient approach to implement risk corridors in a budget neutral manner. However, we may also make adjustments to the program for benefit year 2016 as appropriate. (REGTAP FAQ Database - FAQ #1410 04/14/14) 495 Updated 1-31-17 2017--00595 Q1: In the HHS Notice of Bene?t and Payment Parameters for 2015 final rule (79 FR 13744) and the Exchange and Insurance Market Standards for 2015 and Beyond NPRM (79 FR 15808), HHS indicated that it intends to implement the risk corridors program in a budget neutral manner. What risk corridors payments will HHS make if risk corridors collections for a year are insufficient to fund risk corridors payments for the year, as calculated under the risk corridors formula? A1: We anticipate that risk corridors collections will be suf?cient to pay for all risk corridors payments. However, if risk corridors collections are insufficient to make risk corridors payments for a year, all risk corridors payments for that year will be reduced pro rata to the extent of any shortfall. Risk corridors collections received for the next year will first be used to pay off the payment reductions issuers experienced in the previous year in a proportional manner, up to the point where issuers are reimbursed in full for the previous year, and will then be used to fund current year payments. If, after obligations for the previous year have been met, the total amount of collections available in the current year is insufficient to make payments in that year, the current year payments will be reduced pro rata to the extent of any shortfall. If any risk corridors funds remain after prior and current year payment obligations have been met, they will be held to offset potential insufficiencies in risk corridors collections in the next year. Example 1: For 2014, HHS collects $800 million in risk corridors charges, and QHP issuers seek $600 million risk corridors payments under the risk corridors formula. HHS would make the $600 million in risk corridors payments for 2014 and would retain the remaining $200 million for use in 2015 and potentially 2016 in case of a shortfall. Example 2: For 2015, HHS collects $700 million in risk corridors charges, but QHP issuers seek $1 billion in risk corridors payments under the risk corridors formula. With the $200 million in excess charges collected for 2014, HHS would have a total of $900 million available to make risk corridors payments in 2015. Each QHP issuer would receive a risk corridors payment equal to 90 percent of the calculated amount of the risk corridors payment, leaving an aggregate risk corridors shortfall of $100 million for benefit year 2015. This $100 million shortfall would be paid for from risk corridors charges collected for 2016 before any risk corridors payments are made for the 2016 benefit year. (Risk Corridors and Budget Neutrality 04/14/14) 02: What happens if risk corridors collections do not match risk corridors payments in the final year of risk corridors? A2: We anticipate that risk corridors collections will be suf?cient to pay for all risk corridors payments over the life of the three-year program. However, we will establish in future guidance or rulemaking how we will calculate risk corridors payments if risk corridors collections (plus any excess collections held over from previous years) do not match risk corridors payments as calculated under the risk corridors formula for the final year of the program. (Risk Corridors and Budget Neutrality 04/14/14) Q3: If HHS reduces risk corridors payments for a particular year because risk corridors collections are insuf?cient to make those payments, how should an issuer?s medical loss ratio (MLR) calculation account for that reduction? 496 Updated 1-31-17 2017--00596 A3: Under 45 CFR an issuer should re?ect in its MLR report the risk corridors payment to be made by HHS as reflected in the notification provided under Because issuers will submit their risk corridors and MLR data simultaneously, issuers will not know the extent of any reduction in risk corridors payments when submitting their MLR calculations. As detailed in 45 CFR that reduction should be reflected in the next following MLR report. Although it is possible that not accounting for the reduction could affect an issuer?s rebate obligations, that effect will be mitigated in the initial year because the MLR ratio is calculated based on three years of data, and will be eliminated by the second year because the reduction will be reflected. We intend to provide more guidance on this reporting in the future. (Risk Corridors and Budget Neutrality 04/14/14) Q4: In the 2015 Payment Notice, HHS stated that it might adjust risk corridors parameters up or down in order to ensure budget neutrality. Will there be further adjustments to risk corridors in addition to those indicated in this A4: HHS believes that the approach outlined in this FAQ is the most equitable and efficient approach to implement risk corridors in a budget neutral manner. However, we may also make adjustments to the program for benefit year 2016 as appropriate. (Risk Corridors and Budget Neutrality 04/14/14) Q: Can the Centers for Medicare Medicaid Services (CMS) confirm that Risk Corridors payments for the 2014 and 2015 Benefit Years (BY) will be made in full; additionally, can CMS provide information on how insufficient Risk Corridors payments will be handled? A: anticipates that Risk Corridors collections will be sufficient to pay for all Risk Corridors payments. If Risk Corridors collections are insuf?cient to make Risk Corridors payments for a year, all Risk Corridors payments for that year will be reduced pro rate to the extent of any shortfall. Risk Corridors collections received for the next year will first be used to pay off the payment reductions issuers experienced in the previous year in a proportional manner, up to the point where issuers are reimbursed in full for the previous year, and will then be used to fund current year payments. If, after obligations for the previous year have been met, the total amount of collections available in the current year is insufficient to make payments in that year, the current year payments will be reduced pro rata to the extent of any shortfall. If any Risk Corridors funds remain after prior and current year payment obligations have been met, they will be held to offset any potential in suf?ciency in Risk Corridors collections in the next year. (REGTAP FAQ Database - FAQ #8759 02/02/15) Q: Are issuers required to submit Risk Corridors (RC) charges through Pay.gov or will the Centers for Medicare Medicaid Services (CMS) collect RC charges in the same way that it collects Federal Exchange user fees? Updated 1-31-17 A: First, CMS will collect RC charges by automatically netting the charges against any premium stabilization payments and premium tax credit and Cost-Sharing Reduction (CSR) portions of the advanced payments that CMS makes to the issuer. If CMS cannot collect the full amount of the RC charge through this automatic netting process, CMS will invoice the issuer directly and collect the payment through Pay.gov. (REGTAP FAQ Database - FAQ #11046 06/18/15) 497 2017--00597 Q: When will Risk Corridors payments be made and will they be included on the HIX 820 in January? A: Currently CMS is targeting December to begin making Risk Corridors Payments. Any Risk Corridors payments made in January will be re?ected on the HIX 820 at the program-level with the Payment Type Code of Any payments made prior to January 2016 will be re?ected on the Manual Process Payment Report. (REGTAP FAQ Database - FAQ #13738 10/20/15) Risk Corridors Transitional Adjustment Reporting Q: What criteria should issuers use to report the total enrollment count and the transitional enrollment count for the Risk Corridors program? A: As stated in the 2015 Payment Notice, HHS will calculate the amount of the adjustment that applies to each state based on the state's member-month enrollment count for transitional plans and non-transitional plans in the individual and small group markets. A notice was published in the Federal Register on September 5, 2014, providing the public with a 60-day period to submit written comments on the information collection requirement and data elements associated with the Transitional Adjustment Reporting form. (REGTAP FAQ Database - FAQ #6217 10/28/14) Q: Where can issuers locate the Transitional Adjustment Reporting Form? A: The Transitional Adjustment Reporting Form is found on The Centers for Medicare Medicaid Services (CMS) website. The link below provides direct access to both the reporting form, and form instructions. Issuers may contact the Risk Corridors adjustment mailbox at: RCadiustment@cms.hhs.qov with additional questions. (REGTAP FAQ Database - FAQ #8755 02/02/15) Q: When will the Transitional Adjustment Reporting Form be made available for issuers, and will the Centers for Medicare Medicaid Services (CMS) also provide issuers with instructions for populating the Transitional Adjustment Reporting Form? Updated 1-31-17 A: Issuers may access the Transitional Adjustment Reporting Form, as well as form instructions at the following link: All forms should be emailed to CMS at RCadiustment@cms.hhs.qov from Monday, February 9, 2015 through Friday, February 13, 2015. CMS intends to conduct a training session for completing the form, and will announce the training date and time through REGTAP. CMS expects to publish the proposed Annual Risk Corridors Reporting Form for public comment in the Federal Register on January 30, 2015. The deadline for submitting the Annual Risk Corridors Reporting Form is July 31, 2015. Further instructions on training for the Annual Risk Corridors Reporting Form will be provided in the coming months. 498 2017--00598 (REG TAP FAQ Database - FAQ #8756 02/02/15) Q: Can the Centers for Medicare Medicaid Services (CMS) provide issuers with a writable copy of the Transitional Adjustment Reporting Form? A: CMS expects to post a MS Excel version of the Transitional Adjustment Reporting Form on the CMS website during the week of January 26-January 30, 2015. The Transitional Adjustment Reporting Form may be accessed at the link provided below. All forms should be emailed to RCadiustment@cms.hhs.qov between Monday, February 9, 2015 and Friday, February 13, 2015. Inquiries regarding the transitional data collection can also be directed to: RCadjustment@cms.hhs.qov (REGTAP FAQ Database - FAQ #8757 02/02/15) Q: Can the Centers for Medicare Medicaid Services (CMS) provide information for issuers regarding where to submit the data collection for the Risk Corridors Transitional Policy Form? A: Issuers should submit the completed Risk Corridors Transitional Policy Form to RCadiustment@cms.hhs.qov between February 9, 2015 - February 13, 2015. (REGTAP FAQ Database - FAQ #8758 02/02/15) Q: Can the Centers for Medicare Medicaid Services (CMS) confirm that the enrollment range of a small group should be between one (1) and 100 for Risk Corridors enrollment? A: The Risk Corridors program uses the employee counting method determined by state law. The Risk Adjustment program permits issuers to use either a Federal or state employee counting method, provided that the method accounts for part-time employees. The Medical Loss Ratio (MLR) program uses a Federal counting method. Because this could result in a discrepancy in the de?nition of market between the MLR and Risk Corridors programs, CMS intends to modify the MLR Annual Reporting Form to accommodate this difference. CMS expects to publish the proposed version of the Risk Corridors plan-level data collection form and the Annual MLR Reporting Form (modified to include collection of Risk Corridors data) in the Federal Register on January 30, 2015. The forms will be open for public comment for 60 days following publication. (REGTAP FAQ Database - FAQ #8760 02/02/15) Q: Can the Centers for Medicare Medicaid Services (CMS) provide information on how the transitional adjustment percentage, which applies to each state, will be applied to Risk Corridor calculations; in addition, how will the transitional adjustment percentage impact issuers without transitional policies? 499 Updated 1-31-17 2017--00599 A: The Risk Corridors program only applies to Quali?ed Health Plan (QHP) issuers. The transitional adjustment for Benefit Year 2014 will be applied to a QHP issuer's Risk Corridors calculation in states that have adopted the HHS transitional policy. The adjustment will increase an issuer's Risk Corridors ratio, thereby increasing the amount of Risk Corridors payment an issuer will receive, or decreasing the issuer's Risk Corridors charge amount owed. If a QHP issuer is in a transitional state, but does not have transitional policies, the issuer may still receive the benefit of the transitional adjustment (which is intended to mitigate the effect of the transitional policy on the entire state's risk pool). All individual and small group market issuers in transitional states are required to submit the Transitional Adjustment Reporting Form to CMS February 09 - February 13, 2015, even if the issuer has no enrollment in transitional policies. The Transitional Adjustment Reporting Form must be submitted by email to: RCadjustment@cms.hhs.qov. The Transitional Data Collection Form and instructions can be found on the CMS website at: CMS expects to conduct a training session for the transitional collection during the first week of February. CMS will announce the training date and time through REGTAP. (REGTAP FAQ Database - FAQ #8766 02/02/15) Q: Who is required to submit the Transitional Adjustment Reporting Form? A: Companies with entities that offer health insurance coverage in the individual or small group market in a transitional state must submit the Transitional Adjustment Reporting Form to RCadiustment@cms.hhs.qov. The data submission window is February 9, 2015- February 13, 2015. (REGTAP FAQ Database - FAQ #8944 02/11/15) Q: 0n the form and instructions the Centers for Medicare Medicaid Services (CMS) asks for the parent company to complete one (1) form for all subsidiaries in all states; however, the attestation is specific to each legal entity, which seems to imply that the parent company could not sign this attestation. Should the parent company complete the form or should each legal entity complete a separate form? A: Only a single attestation is required. The parent or holding company can attest to the submission on behalf of all of its legal entities. (REGTAP FAQ Database - FAQ #8945 02/1 1/15) Q: Can the Centers for Medicare Medicaid Services (CMS) provide an Excel version of the Transitional Adjustment Reporting Form? A: Yes. The Excel version of the form is located on the CCIIO website at: 5.xlsx(REG TAP FAQ Database - FAQ #8946 02/11/15) Q: For a company that does not offer plans on the Exchange, is it necessary to submit 500 Updated 1-31-17 2017--00600 data for the transitional adjustment? A: The transitional adjustment data collection applies to companies that offer individual or small group health insurance coverage in transitional states. This includes companies that do not offer plans through the Marketplaces. (REGTAP FAQ Database - FAQ #8947 02/11/15) Q: If a company does not offer plans that participate in the Risk Corridors program, should that company submit for the transitional adjustment? A: The transitional adjustment data collection applies to companies that offer individual or small group health insurance coverage in transitional states. This includes companies that do not offer plans through the Marketplaces. (REGTAP FAQ Database - FAQ #8948 02/11/15) Q: A company offers three (3) individual plans that all have grandfathered status. Should that company submit data for the transitional adjustment? A: No. The transitional adjustment data collection does not apply to companies that only offered grandfathered plans through 2014. (REGTAP FAQ Database - FAQ #8949 02/11/15) Q: For a company that only has business in a state that did not adopt the transitional policy; however, is listed on the Transitional Adjustment Reporting Form, is the company required to submit data for the transitional adjustment? A: No. Although the form lists all states and the District of Columbia, the requirement to submit information only applies to business in transitional states. Companies with no business in transitional states are not required to submit the Transitional Adjustment Reporting Form. For 2014, the transitional states are: Alabama, Alaska, Arizona, Arkansas, California (small group only), Colorado, Florida, Georgia, Hawaii, Idaho, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Michigan, Mississippi, Missouri, Montana, Nebraska, New Hampshire, New Jersey, New Mexico, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, South Carolina, South Dakota, Tennessee, Texas, Utah, West Virginia, Wisconsin, and Wyoming. (REGTAP FAQ Database - FAQ #8950 02/11/15) Q: If a company has an early renewal plan that renewed in November 2013, should the company submit data for this plan and if so, for which months? A: Any plan that renews in 2014, and that is not compliant with the Affordable Care Act (ACA) becomes a transitional plan at the time that it renews in 2014. Transitional member-months should be counted only for the months in which the plan was transitional during 2014. For example, if the plan that was previously an early renewal plan in 2013 renews on November 1, 2014 and is not compliant with the a result of state policy to not enforce compliance with ACA rules), that plan becomes transitional for November and December of 2014. It would count two (2) months of enrollment as transitional enrollment. (REGTAP FAQ Database - FAQ #8951 02/11/15) Q: If a company offers a policy that regularly renews on July 1, does this qualify as a transitional policy in 2014? 501 Updated 1-31-17 2017--00601 A: Possibly. Any plan that renews in 2014 and after renewal is not compliant with certain provisions of the Affordable Care Act (ACA) pursuant to the Transitional Policy becomes a transitional plan at the time that it renews in 2014. Transitional member-months should be counted only for the months in which the plan was transitional. On the other hand, if, following renewal on July 1, 2014, the plan was compliant with the ACA, it should report member months for the last six (6) months of the year in Columns 2 and 4 (All other Non-grandfathered, ACA-compliant Policies) of the Transitional Adjustment Reporting Form. (REGTAP FAQ Database - FAQ #8952 02/11/15) Q: A company offers Medicare Advantage and Medicaid plans in transitional states. Should the company submit transitional adjustment reports for these plans? A: No. Medicare Advantage and Medicaid plans are excluded from transitional adjustment reporting, as stated in the instructions for the 2014 Transitional Adjustment Reporting Forms. (REGTAP FAQ Database - FAQ #8953 02/11/15) Q: Do association health plans need to submit the Transitional Adjustment Reporting Form? A: Transitional plans that are association plans are not exempt from transitional adjustment reporting solely due to their status as association health plans. For individual business sold through an association, data should be reported for the state where the certificate of coverage was issued (if the state has adopted the Transitional Policy). For employer small group coverage issued through a group trust, data should be reported for the state in which the employer has its principal place of business (if the state has adopted the Transitional Policy). For small group coverage issued through a Multiple Employer Welfare Association (MEWA), the user should submit data for the state in which the MEWA has its principal place of business (if the MEWA is the policyholder and the state has adopted the Transitional Policy). For small group coverage that is transitional and that is issued through a association, the user should submit transitional member-month data for each employer in each state, based upon the aggregation rules for employer-based insurance. (REGTAP FAQ Database - FAQ #8954 02/1 1/15) Q: Do union plans need to submit the Transitional Adjustment Reporting Form? A: Union plans are not required to submit the Transitional Adjustment Reporting Form, unless the policy qualifies as small group coverage in the state where the certi?cate of coverage was issued. (REGTAP FAQ Database - FAQ #8955 02/11/15) Q: How is the Centers for Medicare Medicaid Services (CMS) calculating the transitional adjustment? A: CMS will calculate the transitional adjustment based on the percentage of individual and small group market enrollment that is transitional enrollment in each transitional state. This adjustment will be applied to the administrative cost ceiling and profit floor of the risk corridors calculation when risk corridors payment amounts are calculated for Quali?ed Health Plan (QHP) issuers in transitional states. Details on the methodology that CMS will use to calculate the transitional adjustment to the risk corridors formula can be found in the HHS Notice of Benefit and Payment Parameters for 2015. (REGTAP 502 Updated 1-31-17 2017--00602 FAQ Database - FAQ #8956 02/11/15) Q: For plans that have multiple Issuer IDs and several Employer Identification Numbers (Ele) between companies that are in their States, should the companies submit separate forms for each Issuer ID, or can the companies populate one (1) form? A: A parent company is permitted to submit one (1 form that includes information for all of its subsidiaries. In that case, the parent company must ensure that all Health Insurance Oversight System (HIOS) Issuer IDs that are under the parent company and its subsidiaries are included on one (1) form. (REGTAP FAQ Database - FAQ #8957 02/11/15) Q: Should a plan's enrollment qualify as transitional enrollment if the state did not adopt the transitional policy until later in the year, and the plan qualifies in all other respects as transitional? A: Plan enrollment should be counted as transitional if the policy quali?es as a transitional policy under state requirements that apply to transitional policies. (REGTAP FAQ Database - FAQ #8958 02/11/15) Q: For states that are not transitional, should companies leave those states blank, or should companies populate or zero A: For States that are not transitional, leave those rows blank. (REGTAP FAQ Database - FAQ #8959 02/11/15) Q: The state of California did not implement the Transitional Policy for the individual market, should companies leave the first two (2) columns of the Transitional Adjustment Reporting Form blank, and only input data for small group plans? A: For California, it is only necessary to input data for small group plans (Columns 3 and 4). Columns 1 and 2 may be left blank. (REGTAP FAQ Database - FAQ #8960 02/11/15) Q: When does the Centers for Medicare Medicaid Services (CMS) expect to publish the transitional adjustment? A: CMS expects to publish the transitional adjustment percentage that applies to each state in the spring of 2015. (REGTAP FAQ Database - FAQ #8961 02/11/15) Q: How will the transitional adjustment be factored into the risk corridors calculation? A: A detailed description of the process that the Centers for Medicare Medicaid Services (CMS) will use to make the calculation is described in the 2015 Payment Notice. (REG TAP FAQ Database - FAQ #8962 02/11/15) Q: If after submitting a Transitional Adjustment Reporting Form, a company discovers an error in the data, should the company submit another form? A: Yes. If a company notices an error during the submission window, the company 503 Updated 1-31-17 2017--00603 should resubmit its template. Each new template received for a company will overwrite earlier submissions. If a company notices an error after the February 13, 2015 submission deadline has passed, the company should contact RCadjustment@cms.hhs.qov. (REGTAP FAQ Database - FAQ #8963 02/11/15) Q: Can the Centers for Medicare Medicaid Services (CMS) provide issuers with information regarding whether or not a zero (0) or should be populated on the Transitional Adjustment Reporting Form? A: For States that are not transitional (including such the individual market in California) leave those rows blank. If a company operates in a transitional state, but does not operate in a particular market individual or small group), place in the cell that corresponds to the market in which the company doesn't operate. You can also refer to the Frequently Asked Questions in REGTAP for additional information. (REGTAP FAQ Database - FAQ #9031 02/20/15) Q: Does the Transitional Adjustment Report pertain to an Ohio company covering more than 50 employees with partially self-insured and reinsured health care, administered by United Health A: The requirement to submit the Transitional Adjustment Reporting Form only applies to companies in the individual and small group insurance markets that directly issue major medical health insurance in transitional states. Although Ohio was a transitional state in 2014, partially insured and reinsured employers do not directly issue health insurance coverage and are not subject to this data submission requirement. (REGTAP FAQ Database - FAQ #9032 02/20/15) Q: Where can issuers locate information regarding the transitional adjustment for each State? A: Issuers may locate information regarding transitional adjustment for each State in the Health Insurance Oversight System (HIOS) module. Additional information is also located on the Center for Consumer Information and Insurance Oversight (CCIIO) website under Premium Stabilization. Guidance/Downloads/RC TransitionalAdiGuidance 5CR FAQ Database - FAQ #11032 06/18/15) Q: Will issuers need Risk Adjustment (RA) information from the External Data Gathering Environment (EDGE) server June 30, 2015 report to complete the Medical Loss Ratio (MLR) Report and the Risk Corridors (RC) Plan-Level Data Form? A: Yes. Issuers must have the RA and the Reinsurance (RI) amounts that are located on the June 30, 2015 report in order to complete the MLR Report and the RC Form. (REGTAP FAQ Database - FAQ #11037 06/18/15) Q: When reporting information for the Risk Corridors (RC) program, are issuers required to report the full, expected payment received for Reinsurance 504 Updated 1-31-17 2017--00604 A: Yes. The RC reports should re?ect the total RI and Risk Adjustment (RA) net payment amounts that the Centers for Medicare Medicaid Services (CMS) provided in the June 30, 2015 report, including any amounts that are subject to holdback or sequestration. (REGTAP FAQ Database - FAQ #11041 06/18/15) Risk Corridors Other Reporting/Data Submission Q: Can the Centers for Medicare Medicaid Services (CMS) provide issuers a release date for the Risk Corridors Reporting Form? A: CMS expects to publish the proposed version of the Risk Corridors plan-level data collection form and the Annual MLR Reporting Form (modified to include collection of Risk Corridors data) in the Federal Register on January 30, 2015. The forms will be open for public comment for 60 days after publication. (REGTAP FAQ Database - FAQ #8761 02/02/15) Q: Should premiums earned during the development of the Risk Corridors target amount include payments made under the Risk Adjustment, Risk Corridor, and Reinsurance programs, as referenced in 158.130 (5) of the Federal Register? A: Section 1342 of the Affordable Care Act requires that Risk Adjustment and Reinsurance payments received by a Qualified Health Plan (QHP) issuer must be deducted from the calculation of that issuer's allowable costs in the numerator of the Risk Corridors calculation. Reinsurance Contribution amounts are considered administrative costs that are deducted from premiums, which is part of the target amount in the denominator of the Risk Corridors calculation. (REGTAP FAQ Database - FAQ #8765 02/02/15) Q: Can the Centers for Medicare Medicaid Services (CMS) confirm the submission deadline for Risk Corridors data and the Risk Corridors Annual Reporting Form? A: CMS expects to publish the proposed annual reporting form for calculating Risk Corridors payments and charges on January 30, 2015 in the Federal Register. The proposed form will be open for public comment for 60-days after publication. The Risk Corridors data submission deadline for the 2014 Bene?t Year is July 31, 2015. HHS will inform issuers of additional information through REGTAP, and may announce training sessions or webinars closer to the data submission deadline. CMS is also collecting enrollment data for transitional plans from issuers in the individual and small group markets in transitional state. Transitional data must be submitted between February 9, 2015 - February 13, 2015 to: RCadiustment@cms.hhs.qov. The Transitional Data Collection Form and instructions can be found on the CMS website at: CMS expects to conduct a training session for the transitional collection during the first week of February. CMS will announce the training date and time through REGTAP. (REGTAP FAQ Database - FAQ #8770 02/02/15) Q: The final Transitional Adjustment Reporting Form removed the Company Code? and Group Code? fields from the form header and in its place added a 505 Updated 1-31-17 2017--00605 Company field. The instructions for the form do not define what the Health Insurance Oversight System (HIOS) HIOS Company ID is. Should plans use the NAIC Company Code, as this is the only ID plans would have at the company level? A: Users are not required to input information for the HIOS Company the user must input only the parent company Federal Employer Identi?cation Number (FEIN) in the form header. CMS removed the Company field from the final Of?ce of Management and Budget (OMB) approved Excel form. (Please see below for information regarding posting of the Excel form). The NAIC Group Code is also not required. (REGTAP FAQ Database - FAQ #8965 02/11/15) Q: When should plans submit risk corridors data for 2014? A: Risk corridors data for the 2014 Bene?t Year will be submitted with 2014 Medical Loss Ratio (MLR) data in July 2015. The deadline for submitting risk corridors data for the 2014 Benefit Year is July 31, 2015. Risk corridors data submissions will be accepted through Health Insurance Oversight System (HIOS) from July 1, 2015-July 31, 2015. (REGTAP FAQ Database - FAQ #8964 02/11/15) Q: Are the Chief Executive Officer (CEO) or Chief Financial Officer (CFO) required to complete the attestation? A: The CFO or any designee of the CFO may complete the attestation. (REGTAP FAQ Database - FAQ #8966 02/11/15) Q: Are plans required to digitally sign the attestation? A: CMS will accept digitally signed attestations, typed signatures in the Excel workbook, or manually signed and scanned attestations in PDF format. (REGTAP FAQ Database - FAQ #8967 02/11/15) Q: Where can issuers find the Transitional Adjustment Reporting Form, and form instructions? A: The Transitional Adjustment Reporting Form is found on the Centers for Medicare Medicaid Services (CMS) website. The deadline to submit the Transitional Adjustment Reporting Form is February 13, 2015. An Excel version of the Transitional Reporting Form that is available at: Filing instructions that are available at: Issuers may contact the Risk Corridors adjustment mailbox at: RCadjustment@cms.hhs.qov with additional questions. (REGTAP FAQ Database - FAQ #8894 02/16/15) Q: Can the Centers for Medicare Medicaid Services (CMS) provide issuers with 506 Updated 1-31-17 2017--00606 information regarding whether or not a zero (0) or should be populated on the Transitional Adjustment Reporting Form? A: For States that are not transitional (including such the individual market in California) leave those rows blank. If a company operates in a transitional state, but does not operate in a particular market individual or small group), place in the cell that corresponds to the market in which the company doesn't operate. You can also refer to the Frequently Asked Questions in REGTAP for additional information. (REGTAP FAQ Database - FAQ #9031 02/20/15) Q: Does the Transitional Adjustment Report pertain to an Ohio company covering more than 50 employees with partially self-insured and re-insured health care, administered by United Health A: The requirement to submit the Transitional Adjustment Reporting Form only applies to companies in the individual and small group insurance markets that directly issue major medical health insurance in transitional states. Although Ohio was a transitional state in 2014, partially insured and re-insured employers do not directly issue health insurance coverage and are not subject to this data submission requirement. (REGTAP FAQ Database - FAQ #9032 02/20/15) Q: Is there a calendar or timeline available of what is due when from health plans and what and when health plans will receive information for Risk Corridors (RC), Cost- sharing Reduction (CSR), Risk Adjustment (RA), and Reinsurance Updated 1-31-17 A: There are no consolidated schedules available or individual schedules available for RC or RI. However, the Centers for Medicare Medicaid Services (CMS) established the following timeline for CSR reconciliation. According to the document ?Timing of Reconciliation of Cost-sharing Reductions for the 2014 Bene?t Year? located in the REGTAP Library at CSR Recon timinq quidance 5CR 021315.pd I, April 16, 2016 is the updated deadline for CSR reconciliation for the 2014 bene?t year. April 16, 2016 is also the deadline for Issuers that selected the simpli?ed methodology to switch to the more accurate standard methodology to calculate CSR reconciliation. For risk adjustment, an operating schedule can found on slide 29 of the November 5, 2014 RA slide deck on REGTAP at Traininq1slides 110514 v2 5CR 111214.pd f. Please note this schedule is subject to change. For risk corridors, issuers are required to submit data for the 2014 bene?t year during the combined Corridors open submission window from July 1-July 31, 2015. CMS will provide more information about this submission window during training sessions in May. While issuers will know their risk corridors payments and charges upon submitting their data, no payments will be made until all charges have been collected due to budget neutrality requirements for the program. We recommend continuing to check the library in REGTAP at for updates as materials are posted ongoing as they become available. (REGTAP FAQ Database - FAQ #9721 04/21/15) 507 2017--00607 Q: Will the Centers for Medicare Medicaid Services (CMS) add reports to the Medical Loss Ratio (MLR) that is due in July to allow calculations to be made by both qualified and non-qualified plans or will CMS use the MLR to calculate risk corridors? A: Risk corridors data for the 2014 Bene?t Year will be submitted with 2014 Medical Loss Ratio (MLR) data in July 2015 and will be accepted through Health Insurance Oversight System (HIOS) from July 1, 2015-July 31, 2015. Issuers will submit risk corridors data in the MLR form as well as in a separate form for plan-level data. However, only issuers with at least one Qualified Health Plan (QHP) in the 2014 Bene?t Year are required to complete the risk corridors plan level form and the risk corridors information that is included on the MLR Reporting form. (REGTAP FAQ Database - FAQ #9766 04/21/15) Q: Can the Centers for Medicare Medicaid Services (CMS) provide issuers a timeline for the submission of Risk Corridors (RC) plan data? A: A complete timeline of this process can be found in the June 1, 2015 ?Completing the Risk Corridors Plan-Level Data Form 2014? slide deck in the Registration for Technical Assistance Portal (REGTAP) Library. Issuers can begin downloading the Medical Loss Ratio (MLR) Report and Risk Corridors (RC) Plan- Level Data Form templates on June 1, 2015 from the MLR module in the Health Insurance Oversight System (HIOS). Issuers have from June 1, 2015 until July 31, 2015 to complete and submit the MLR Report and the RC Plan-Level Data Form to CMS. RC charge amounts will be collected from issuers from October 2015 through November 2015. CMS will begin to make RC payments to issuers in December 2015. (REGTAP FAQ Database - FAQ #11020 06/18/15) Q: Where can issuers locate the pre-populated Medical Loss Ratio (MLR) Report template in the Health Insurance Oversight System (HIOS) module? A: Issuers must first con?rm the Company/Issuer Associations tab; once the tab is confirmed, issuers can locate the template to complete the MLR Report in the HIOS module. If issuers confirm the Company/Issuer Associations tab and still cannot locate the MLR Report template, issuers can contact ACARiskCorridors@cms.hhs.qov in order to resolve the issue. (REGTAP FAQ Database - FAQ #11021 06/18/15) Q: If the Company/Issuer Associations tab in the Medical Loss Ratio (MLR) module does not indicate any issuer associations; what plan of action should issuers take? A: Issuers should email the Centers for Medicare Medicaid Services (CMS) with a screenshot of the issue at ACARiskCorridors@cms.hhs.qov for further guidance. (REGTAP FAQ Database - FAQ #11022 06/18/15) Q: On the Company/Issuer Association tab of the Medical Loss Ratio (MLR) Module, ?No? is prepopulated in the Not-For-Profit field. If an issuer's not-for-profit status was reinstated, how can the issuer correct this information? 508 Updated 1-31-17 2017--00608 A: Issuers can locate guidance regarding a change of company or issuer association in the Health Insurance Oversight System (HIOS) module's MLR Report Annual Training slides. Issuers can also locate the Annual Training presentation slides on the Center for Consumer Information and Insurance Oversight (CCIIO) website under the ?Trainings' tab. Issuers may email the Centers for Medicare Medicaid Services (CMS) at ACARiskCorridors@cms.hhs.qov if the issue cannot be resolved. (REGTAP FAQ Database - FAQ #11023 06/18/15) Q: If an issuer had an Affordable Care Act (ACA)-compliant plan available for sale for an entire benefit year, but the plan was sold after the January 1, 2014 start date, can the issuer report the plan in the Risk Corridors (RC) Plan-Level Data Form? A: Yes. The issuer should report experience of a non-grandfathered ACA-compliant plan regardless of when in 2014 the individual or employer purchased the plan. (REGTAP FAQ Database - FAQ #11024 06/18/15) Q: The Centers for Medicare Medicaid Services (CMS) stated that issuers can only report Affordable Care Act (ACA)-compliant plans for the full 2014 Bene?t Year in the Risk Corridors (RC) Plan-Level Data Form. If an issuer has a plan that renews February 1, 2014, can the issuer report the plan in the RC Plan-Level Data Form? A: Yes. If a plan renews during 2014 and becomes compliant with Affordable Care Act (ACA) requirements, issuers should include that plan's experience in all RC data (including allowable costs, administrative costs, and earned premium) for the months in the 2014 Calendar Year that the plan was compliant with ACA requirements. Once a plan renews in 2014, CMS considers the ACA-compliant offering to be a separate, new plan. (REGTAP FAQ Database - FAQ #11025 06/18/15) Q: If an issuer has both off-Exchange and on-Exchange plans, and both plan types have the same 14-digit Health Insurance Oversight System (HIOS) ID, but have a different plan variant (the last two (2) digits of the 16-digit HIOS Plan is there a section in the Risk Corridors (RC) Form that differentiates the two (2) plans? A: A plan that is the same offering both through the Exchange and outside of the Exchange, if the 16?digit HIOS Plan ID ends in issuers should report the plan in the ?Exchange section of the RC Form; if the 16-digit HIOS Plan ID plan ends in issuers should report the plan in the off-Exchange section of the RC Plan-Level Data Form. (REGTAP FAQ Database - FAQ #11026 06/18/15) Q: What experience should issuers report in the risk corridors columns of the Medical Loss Ratio (MLR) Form? Should the risk corridors columns of the MLR Form only contain information that applies to the issuers Quali?ed Health Plans A: The risk corridors columns of the MLR form should only be completed by issuers that offered at least (1) certi?ed QHP through an Exchange in 2014. These issuers should report experience of all of their non-grandfathered, ACA-compliant plans, including QHPs and in the risk corridors columns of the MLR Form. Experience pertaining to grandfathered and non-ACA compliant business should not be reported in the risk corridors columns. (REGTAP FAQ Database - FAQ #11028 06/18/15) 509 Updated 1-31-17 2017--00609 Q: If an issuer has an Exchange Qualified Health Plan (QHP) with zero (0) premium, is the issuer permitted to report the off-Exchange version of the QHP in the Risk Corridors (RC) Plan Data Form? A: Yes, although the Centers for Medicare Medicaid Services (CMS) expects that this situation will be rare. In order to be an off-Exchange QHP, the plan must be identical to a QHP that is certi?ed and actually offered through the Marketplace. If this condition is satisfied, but the issuer has not collected any premium for the Exchange QHP, the user may input for premium in the ?Exchange section of the RC plan level form, and the applicable premium in the ?off-Exchange section. (REGTAP FAQ Database - FAQ #11030 06/18/15) Q: Can the Centers for Medicare Medicaid Services (CMS) provide information on the billable premium section of the Risk Corridors (RC) Plan-Level Data Form and explain how the billable premium corresponds with the Medical Loss Ratio (MLR) Report? A: CMS updated the instructional manual for completing the MLR Report and the RC Plan-Level Data Form, changing the billable premium to read ?earned premium? on the RC Plan- Level Data Form and the MLR Report. The total earned premium for non- grandfathered, ACA-compliant plans that the user inputs in Section 1 of the RC Plan- Level Data Form (for the individual and small group market, respectively) should equal the amount reported in Part 3, Line 2.1 of the MLR reporting form in column 4A (individual market) and column 8A (small group market). Columns 4A and 8A of the MLR reporting form only re?ect the experience of an issuer's non-grandfathered, ACA- compliant plans. (REGTAP FAQ Database - FAQ #11034 06/18/15) Q: Can the Centers for Medicare Medicaid Services (CMS) provide information on the format for the Risk Adjustment Reinsurance (RI) June 30, 2015 report A: CMS will provide issuers with information regarding the format of the June 30, 2015 report during Registration for Technical Assistance Portal (REGTAP) trainings on June 17 and June 25, 2015. The June 17,2015 report will focus on RA and the June 25, 2015 training will focus on RI. More information on these trainings will be available on REGTAP. (REGTAP FAQ Database - FAQ #11040 06/18/15) Q: Will the Centers for Medicare Medicaid Services (CMS) provide issuers with additional training for the completion of the Risk Corridors (RC) Plan-Level Data Form? A: CMS will not provide additional webinar training sessions for the completion of the RC Plan-Level Data Form; however, CMS conducts technical assistance calls each Thursday from 2:00 p.m.to 3:00 pm. ET for the full duration of the July 1, 2015 - July 31, 2015 RC data submission window. (REGTAP FAQ Database - FAQ #11047 06/18/15) Q: In Part 3 of the Medical Loss Ratio (MLR) 2014 Annual Form, taxes and regulatory fees are not included in the de?nition of allowable administrative costs in Line 3.6a; however, taxes and regulatory fees are included in the regulatory definition of allowable administrative costs. How should issuers report information for allowable administrative Updated 1-31-17 510 2017--00610 costs? Q: A: The Centers for Medicare Medicaid Services (CMS) has corrected Line 3.6a in Part 3 of the MLR 2014 Annual Form to include taxes in the de?nition of allowable administrative costs. CMS has also updated the MLR Calculator and Form Tool available on the home page of the MLR module and on the Centers for Consumer Information and Insurance Oversight (CCIIO) website. As of June 18, 2015 issuers can download corrected MLR Annual Form templates from the Health Insurance Oversight System (HIOS) MLR module. (REGTAP FAQ Database - FAQ #11049 06/18/15) What is the deadline for submission of Medical Loss Ratio (MLR) reports and risk corridors data for the 2015 Bene?t Year? Pursuant to 45 CFR the MLR report for each reporting year must be submitted to HHS by July 31 of the year following the end of an MLR reporting year. Similarly, 45 CFR 153.530(d) states that a Qualified Health Plan (QHP) issuer must submit risk corridors data by July 31 of the year following the benefit year. However, July 31, 2016 falls on a Sunday. Therefore, for the 2015 Reporting and Bene?t Year, an issuer may submit its MLR and risk corridors data for the 2015 Benefit Year by 11:59 pm. ET on Monday, August 1, 2016, which is the ?rst business day following the July 31, 2016 regulatory deadline(s). The Centers for Medicare Medicaid Services (CMS) intends to propose this clarification in future rulemaking, such that the data submission deadline would be July 31 of the year following the end of the applicable reporting and benefit year, or, if such date is not a business day, the next business day. However, CMS encourages issuers to submit MLR and risk corridors data as early as possible to avoid technical difficulties. (REG TAP FAQ Database - FAQ #15329 03/29/16; updated 07/26/16) Q: For the 2015 Benefit Year Medical Loss Ratio (MLR) and Risk Corridors (RC) Reporting, what reinsurance (RI) amount should be reported? Updated 1-31-17 A: Issuers must report the reinsurance payment amount for their Health Insurance Oversight System (HIOS) ID, as listed in the June 30, 2016 Summary Report on Transitional Reinsurance Payments and Permanent Risk Adjustment Transfers for the 2015 Bene?t Year, located here: Summary-Report-SCR-O63016.pdf. The reinsurance payment amount listed in the June 30, 2016 report should match the adjusted RI payment report that was sent directly to the Chief Executive Of?cer (CEO) Designates and Alternate contacts. If the amounts do not match, please email as soon as possible. 511 2017-?0061 1 The Centers for Medicare Medicaid Services (CMS) would like to note that the reinsurance payment amount on the June 30, 2016 report and adjusted RI payment report will not match the RI issuer report available on the EDGE Management Console (EMC) because that report has not been adjusted for any overlapping claims discrepancies. (REGTAP FAQ Database - FAQ #16816 07/19/16) Risk Corridors Other Q: Can the Centers for Medicare Medicaid Services (CMS) clarify whether Sole Proprietors with a Small Group Qualified Health Plan (QHP) should be moved to the Individual market, or remain in the Small Group market; and if Sole Proprietors should remain in the Small Group market, will CMS update the Medical Loss Ratio (MLR) Instructions to reflect this decision? A: The Risk Corridors program uses the employee counting method established under state law to determine employer size. The MLR Annual Reporting Form will be modified to allow for information that is collected differently for the two (2) programs. CMS expects to publish draft instructions for the MLR Annual Reporting Form (which will contain instructions on how Risk Corridors and MLR information should be reported in different markets) in the Federal Register on January 30, 2015. The forms will be available for public comment. (REGTAP FAQ Database - FAQ #8762 02/02/15) Q: Given the uncertainty of Risk Corridor receivables, if external auditors and/or state regulators pressure health insurers to reserve financial statement allowances, how would the Centers for Medicare Medicaid Services (CMS) recommend these allowances be reflected in the insurer's financial statement? A: State rules will dictate how an issuer reports Risk Corridors (as well as Risk Adjustment and Reinsurance) receivables for the purposes of ?nancial reporting. The National Association of Insurance Commissioners (NAIC) has set forth policy on the reporting of these premium stabilization payments. Because this is a state issue, CMS has not issued guidance on this matter. (REGTAP FAQ Database - FAQ #8767 02/02/15) Q: Can the Centers for Medicare Medicaid Services (CMS) provide issuers with information on and examples of Risk Corridor eligible Qualified Health Plans A: Eligible QHPs that are subject to the Risk Corridors program are health plans offered outside the Exchange by an issuer of the same plan as a QHP, as de?ned by 155.20 of the Federal Registrar. In order to be the same plan as a QHP, the health plan offered outside the Exchange has identical bene?ts, premium, cost-sharing structure, provider network, and service area as the QHP. Consequently, an off-Exchange plan with a different service area from the QHP offered by the issuer on the Exchange, will not be considered the 'same plan' as an Exchange QHP, and will not be eligible for the Risk Corridors program. As de?ned in 45 CFR 153.500, a plan offered outside of the Exchange is substantially the same as an Exchange QHP, if it is the same as an Exchange QHP (according to the de?nition above), except for any variations in bene?ts and cost-sharing structure that are directly tied to Federal or State requirements or prohibitions on the coverage of bene?ts (for example, coverage of the Pediatric Dental Essential Health Bene?t) that apply 512 Updated 1-31-17 2017--00612 differently to plans depending on whether they are offered through the Exchange. Plans that are offered outside of the Exchange that meet the de?nition of a plan that is 'substantially the same' as an Exchange QHP are also eligible for the Risk Corridors program. (REGTAP FAQ Database - FAQ #8769 02/02/15) Q: Can the Centers for Medicare Medicaid Services (CMS) describe how issuers should complete the Risk Corridors (RC) Form if the issuer's off-Exchange Qualified Health Plans (QHP) ID does not match the Exchange Health Insurance Oversight System (HIOS) A: The off-Exchange QHP ID is pre-populated into the RC Form. Because CMS considers an Exchange QHP and its off-Exchange equivalent to be the same plan same premium, benefits, provider network, cost-sharing structure, and service area) the form will automatically pre-populate with the same 14-digit standard component HIOS ID for these offerings. If an issuer offered an off-Exchange QHP in 2014 under a HIOS ID does not match the prepopulated HIOS ID, the issuer should contact CMS at ACARiskCorridors@cms.hhs.gov. When ?lling out the form, the user should input premium information for that off-Exchange QHP in the same row as the equivalent Exchange QHP. (REGTAP FAQ Database - FAQ #11027 06/18/15) Q: In which section of the Risk Corridors (RC) Plan-Level Data Form should issuers submit identical off-Exchange and on-Exchange plan data? A: For off-Exchange plans that are identical to on-Exchange plans, issuers should submit data in the ?off-Exchange sections of the RC Plan-Level Data Form. (REGTAP FAQ Database - FAQ #11029 06/18/15) Q: If issuers conduct a validation check on the final Risk Corridors (RC) Plan-Level Data Form after the form is uploaded into the Health Insurance Oversight System (HIOS) module, is time allotted for issuers to resubmit files with errors? A: Yes. The validation check ensures that the file uploaded into the HIOS module does not contain errors. If the file fails the validation check, issuers will receive an email from the Centers for Medicare Medicaid Services (CMS) describing errors within the files. Once errors are corrected, the issuer may re-upload the ?le into HIOS. (REGTAP FAQ Database - FAQ #11042 06/18/15) Q: Can the Centers for Medicare Medicaid Services (CMS) clarify the attestation processes for Medical Loss Ratio (MLR) and Risk Corridors (RC) data? A: For Quali?ed Health Plans (QHP) issuers, there are two (2) parts to attestation. First, on the RC Plan-Level Data Form, the Chief Executive Officer (CEO) and Chief Financial Officer (CFO) should type or insert an electronic signature of their names on the designated lines on the ?Attestation? tab. Second, after both MLR and RC submissions are uploaded into the HIOS module, the issuer's CEO and CFO will each navigate to the Attestation page and attest to both the MLR Report and the RC Plan-Level Data Form. The attester should check the attestation boxes and select ?Attest? in order to attest to both documents. (REGTAP FAQ Database - FAQ #11043 06/18/15) Q: Can the Centers for Medicare Medicaid Services (CMS) provide issuers with information on what will be released as part of the August 14, 2015 guidance on initial 513 Updated 1-31-17 2017--00613 Risk Corridors (RC) estimates? Will the August 14, 2015 guidance contain a final estimate for the RC program? A: On August 14, 2015, CMS will release guidance with a preliminary estimate of aggregate RC charges and RC payments calculated nationally. These preliminary estimates will not be issuer-speci?c. The preliminary estimates will not be the ?nal amounts, and will not re?ect information for late submissions during the second submission window, data corrections, or amounts that CMS is required to hold back for RC program appeals. The guidance will provide issuers with a preliminary estimate of the percentage, if any, by which RC payments may be prorated in order to maintain the budget neutrality of the RC program. Prorated payments will only be made if aggregate collections are not suf?cient to cover the aggregate payment amounts calculated. (REGTAP FAQ Database - FAQ #11044 06/18/15) Q: Can the Centers of Medicare Medicaid Services (CMS) inform issuers of when the slide deck for the Completing the Risk Corridors (RC) Plan-Level Data Form 2014 webinar will become available on the Registration for Technical Assistance Portal A: The slide deck for the Completing the RC Plan-Level Data Form 2014 webinar is currently available in the REGTAP Library under the RC program area. (REGTAP FAQ Database - FAQ #11048 06/18/15) Q: Can the Centers for Medicare Medicaid Services (CMS) clarify if Stand-Alone Pediatric Dental Plans offered through the Exchange qualify for the Risk Corridors (RC) program? A: Risk Corridors (RC) does not apply to stand-alone dental plans, even those offered on an Exchange. (REGTAP FAQ Database - FAQ #11093 06/29/15) Q: When must an issuer request reconsideration of a risk corridors payment or charge for the 2014 Benefit Year? A: Pursuant to 45 CFR an issuer may file a request for reconsideration to contest a processing error by the Department of Health and Human Services (HHS), HHS's incorrect application of the relevant methodology, or HHS's mathematical error only with respect to the amount of a risk corridors payment or charge for a benefit year. For the 2014 Bene?t Year, an issuer must file a request for reconsideration to contest a processing error by HHS, HHS's incorrect application of the relevant methodology, or HHS's mathematical error only with respect to the amount of a risk corridors payment or charge within 60 calendar days of the November 19, 2015 ?Risk Corridors Payment and Charge Amounts for Bene?t Year 2014? Report setting forth the ?nal calculated risk corridors payment or charge amounts for the 2014 Bene?t Year.* As such, an issuer must ?le a request for reconsideration of a risk corridors payment or charge for the 2014 Bene?t Year no later than Tuesday, January 19, 2016. CMS notes that a request for reconsideration in order for the issuer to correct an error on its risk corridors submission will not be granted because it would fail to state a proper basis for reconsideration under 45 CFR Issuers can submit a request for reconsideration to contest a processing error by HHS, HHS's incorrect application of the relevant methodology, or HHS's mathematical error, by following the link provided Please see 45 CFR 514 Updated 1-31-17 2017--00614 156.1220 for more information on the administrative appeals process. *Available at: (REGTAP FAQ Database - FAQ #14470 12/21/15) ESSENTIAL HEALTH BENEFITS (EHBS) General Q10: Can plan limits for EHB be higher than the benchmark? For example, if the benchmark plan limits hospital stays to 30 days, can the plan on the Exchange have 120 days? A10: To meet the requirement of providing EHB, set forth at a plan must provide bene?ts that are substantially equal to the EHB benchmark plan. However, plans may provide benefits that are more generous than those included in the EHB-benchmark plan. The state enforcing the requirement to provide EHB (or CMS, if applicable) will determine whether the more generous benefits are substantially equal to the bene?ts provided by the EHB-benchmark plan. or whether they would be considered in excess of EHB, and thus to that extent, not be considered EHB (see Q13 below). (Plan Management Webinar 01/24/13) Q12: Wellness services are included in one of the 10 categories of EHB. Would a membership be considered an EHB so that APTCs or the cost-sharing reductions (CSR) can apply towards the benefit, or so that member expenses for such a benefit could count toward the out-of-pocket maximum? The EHB-benchmark plan in New York includes a benefit. A12: If the bene?t is part of New York State's EHB-benchmark plan, then it is part of the New York State EHB package. Pursuant to the bene?t substitution policy at issuers could substitute another wellness benefit that is actuarially equivalent to the benefit. (Plan Management Webinar 01/24/13) Q13: If a state?s EHB-benchmark plan limits visits to 30 days, and an insurer elects to allow 60 days, are the additional visits eligible for the APTC and Would cost sharing obligations for the additional visits accumulate toward the out-of-pocket maximum? A13: CMS relies on state enforcement of the substantially equal standard at Your state regulators will determine if bene?ts with higher limits than those in the EHB-benchmark plan will be viewed as substantially equal to the benefits provided by the EHB-benchmark plan or whether these services would be considered in excess of EHB. If the benefits are considered in excess of EHB, benefits and limitation applicable to EHB, such as APTC and CSR and out-of?pocket maximums would not apply. (Plan Management Webinar 01/24/13) 515 Updated 1-31-17 2017--00615 Q16: Where a plan offers an EHB service in excess of the state benchmark (such as 30 visits as opposed to 15), how will visits 16 through 30 be treated with respect to both metal-tier actuarial value and the cost-sharing maximum? A16: Any EHB/Benchmark services offered, even in excess of minimums of the benchmark, are considered EHB services and apply to the index rate and must be spread evenly across the risk pool. See and the preamble discussion at 78 FR 12843 regarding ?156.115. (Plan Management Webinar QHP FAQ #1 04/08/13) 022: Should issuers provide information about optional riders that do not impact Essential Health Benefits A22: The FFE and State Partnership Exchange templates do not collect and will not display optional riders. In situations where an issuer would traditionally offer a rider and is interested in offering that optional benefit on the FFM an issuer should submit two plans, one with and one without the rider. Depending upon the benefit that would have been traditionally offered in a rider, it may not be displayed on the FFM website to consumers, but it may be displayed by issuers and provided to consumers in plan documents. (Plan Management Web/nar QHP FAQ #3 04/11/13) 024: Can issuers have a small group plan at the silver level that exceeds the $2000/4000 deductible in some plan variations even if the issuer can reach the silver level with a $2000/4000 deductible (as long as the AV meets the silver level)? A24: Per 45 CFR ?a health plan's annual deductible limit may exceed the annual deductible limit if the plan may not reasonably reach the actuarial value of a given level of coverage as de?ned in 156.140 of this subpart without exceeding the annual deductible limit.? However, for example, if you input a plan with a $2,000 deductible with a 75% coinsurance and $5,000 out-of-pocket maximum, subjecting all of the benefits to the deductible and the coinsurance, the AV will be within the silver range. (QHP Webinar Series FAQ #7 04/24/13) 027: The Missouri individual market ?PlansBenefits.xlsm? template does not include ?Applied Behavior Analysis Based Therapies,? which is an EHB-benchmark plan benefit that the HIOS application collection system requires in order to validate a submission. What should issuers in Missouri do to ensure that they can submit their PlansBenefit.xlsm template in A27: To ensure that Missouri issuers can submit their applications in HIOS, prior to clicking ?Create Cost Sharing Variances? on the Plans Benefits ribbon, issuers should add the bene?t ?Applied Behavior Analysis Based Therapies" to the Bene?ts Package 1 tab of the template. This should be done by clicking ?Add Bene?t? on the Plans Benefits ribbon, and completing all associated fields with the same information that populates for the Missouri SHOP (Small Group). As a reference, those data elements should be as follows: ?Bene?ts Applied Behavior Analysis Based Therapies,? ?Is this Bene?t Covered Covered," ?Subject to Deductible (Tier 1) Yes," "Subject to Deductible (Tier 2) Yes,? ?Excluded from In Network MOOP No,? ?Excluded from Out of Network MOOP No.? If an issuer has already clicked ?Create Cost Sharing Variances," they should delete the Cost Sharing Variances 1 tab and then 516 Updated 1-31-17 2017--00616 ?Create Cost Sharing Variances" on the Plans Bene?ts ribbon. (QHP Webinar Series FAQ #7 04/24/13) 023: Can issuers offer products off the Exchange that include EHB but do not meet the metal level? A23: No. The Affordable Care Act requires issuers offering non-grandfathered health insurance coverage in the individual and small group markets both inside and outside the Exchange ensure that plans meet a level of coverage specified in Section 1302(a)(3) of the Affordable Care Act and defined in 45 CFR Each level of coverage corresponds to an AV calculated based on the cost-sharing features of the plan. (QHP Webinar Series FAQ #9 05/03/13 and REG TAP database FAQ #2141 06/11/14) 027: Will a metal plan qualify if prescription coverage is not included? A27: Per 45 CFR 156.100, prescription bene?ts are one of the 10 bene?t categories of EHB and therefore must be covered. (QHP Webinar Series FAQ #9 05/03/13) Q1: For plans that must provide coverage of the essential health benefit package under section 1302(a) of the Affordable Care Act, if an issuer imposes a waiting period before an enrollee can access a covered benefit, is that a violation of 45 CFR 156.125? Updated 1-31-17 A: 45 CFR 156.125 states that an issuer does not provide EHB if its benefit design, or the implementation of its bene?t design, discriminates based on an individual?s age, expected length of life, present or predicted disability, degree of medical dependency, quality of life, or other health condition. We are concerned that waiting periods for speci?c bene?ts discourage enrollment of or discriminate against individuals with significant health needs or present or predicted disability. For example, a plan that includes a waiting period for any type of transplant would discriminate against those whose conditions make it likely that they would need a transplant: those with kidney disease, heart conditions, or similarly critical and life-threatening ailments. In addition, imposing a waiting period on an EHB could mean the issuer is not offering coverage that provides EHB as required by 45 CFR 156.115, which would be a violation of Section 2707(a) of the Public Health Service Act (PHS Act) and its 2 implementing regulations. Therefore, with respect to plans that must provide coverage of the essential health benefit package, issuers may not impose bene?t-speci?c waiting periods, except in covering pediatric orthodontia, in which case any waiting periods must be reasonable pursuant to ?156.125 and providing EHB. Any issuer that currently has a waiting period in its plan policy for an EHB needs to amend the policies to remove the waiting period within a reasonable timeframe of the release of this document. This clarification refers to a waiting period that is applied uniformly to a speci?c bene?t within the plan design and not reasonable medical management. (CMS FA OS on Health Insurance Market Reforms and Marketplace Standards 05/16/14) 517 2017-?00617 Q: For plans that must provide coverage of the essential health bene?t package under section 1302(a) of the Affordable Care Act, if an issuer imposes a waiting period before an enrollee can access a covered benefit, is that a violation of the EHB requirements? Yes. We are revising our previously released guidance (May 16, 2014 Frequently Asked Questions on Health Insurance Market Reforms and Marketplace Standards, in which we explained the policy in regard to waiting periods for essential health bene?ts (EHBs). In that FAQ we stated that waiting periods for specific benefits may discourage enrollment of or discriminate against individuals with significant health needs or present or predicted disability. In addition, imposing a waiting period on an EHB could mean the issuer is not offering coverage that provides EHB as required by 45 CFR 156.115. After further consideration of whether pediatric orthodontia should be excepted from this prohibition on waiting periods, we are revising our policy to no longer allow waiting periods for pediatric orthodontia, as we have determined that the same concerns we previously noted also apply to these bene?ts. This FAQ supersedes the previously noted FAQ, and it is immediately applicable prospectively to all plans subject to the requirement to provide EHB. For issuers that have submitted plans subject to EHB to their State regulatory authorities for approval and/or to the Marketplace in their State for certification, we recognize that it may be difficult to make any necessary changes to such plans in time for the start of the 2017 benefit year. Therefore, we expect issuers to make such changes at the earliest possible opportunity to do so in accordance with applicable federal and state law, but no later than plan years beginning on or after January 1, 2018, and will not take enforcement action until such time. We encourage States to take a similar enforcement approach. (FAQs on Insurance Market Reforms and Marketplace Standards 05-26-16) Benchmark Plans 12. What level of benefit is required in a specific benchmark to satisfy the ten essential health benefit categories? What process will be undertaken by HHS to select backfilling bene?t options if a state defaults to the largest small group product? Updated 1-31-17 A: In section 156.100 of the proposed rule on Essential Health Bene?ts/Actuarial Value/Accreditation, we propose criteria for the selection process for a state that chooses to select a benchmark plan. The essential health bene?ts benchmark plan would serve as a reference plan, re?ecting both the scope of services and limits offered by a typical employer plan in that state. This approach and benchmark selection, which would apply for at least the 2014 and 2015 benefit years, would allow states to build on coverage that is already widely available, minimize market disruption, and provide consumers with familiar products. Since some base-benchmark plan options may not cover all ten of the statutorily required essential health benefits categories, we propose standards for supplementing a base-benchmark plan that does not provide coverage of one or more of the categories. We also propose that if a base-benchmark plan option does not cover any items and services within an essential health bene?ts category, the base-benchmark plan must be supplemented by adding that particular category in its entirety from another base- benchmark plan option. The resulting plan, which would reflect a base-benchmark that covers all ten essential health benefits categories, must meet standards for non- 518 2017--00618 discrimination and balance. After meeting these standards, it would be considered the essential health bene?ts-benchmark plan. The proposed rule also outlines the process by which HHS would supplement a default base-benchmark plan, if necessary. We clarify that to the extent that the default base benchmark plan option does not cover any items and services within an essential health benefits category, the category must be added by supplementing the base-benchmark plan with that particular category in its entirety from another base-benchmark plan op?on. Specifically, we propose that HHS would supplement the category of bene?ts in the default base benchmark plan with the ?rst of the following options that offer bene?ts in that particular essential health bene?ts category: (1) The largest plan by enrollment in the second largest product in the state's small group market; (2) The largest plan by enrollment in the third largest product in the state's small group market; (3) The largest national Federal Employees Health Bene?t Program plan by enrollment across states that is offered to federal employees; (4) The largest dental plan under the Federal Employees Dental and Vision Insurance Program, for pediatric oral care bene?ts; (5) The largest vision plan under the Federal Employees Dental and Vision Insurance Program, for pediatric vision care benefits; and (6) Habilitative services as described in section 156.110(f) or (FAQs on Exchanges, Market Reforms, and Medicaid (12/10/12)) Q7: Regarding EHBs in the EHB-benchmark plan?s scope of services, our plan is focusing on the limits and exclusions that were shared on the CMS website, not the member responsibility (copays, coinsurance and deductible). Is that correct? A7: That is correct. In terms of whether the plan covers EHB, CMS is only looking at those benefits and limits. The cost sharing features are considered in the Actuarial Value (AV) calculation and the maximum out-of-pocket calculations. (Plan Management Webinar 01/24/13) Q19: Can a State adopt different benchmark plans for the individual market and for the small group markets? For example, could a state adopt an FEHBP plan as the benchmark plan for the individual market and select one of the largest small group plans as the benchmark plan small group market? Updated 1-31-17 A19: No. As described in the EHB Final Rule published in the Federal Register on February 25, 2013 (78 FR 12834), a State would select only one of the benchmark options as the applicable EHB benchmark plan across its individual and small group markets both inside and outside of the Exchange. HHS believes that selecting one benchmark for these markets in a State would result in a more consistent and consumer- oriented set of options that would also serve to minimize administrative complexity. HHS seeks to provide ?exibility to issuers by permitting actuarially equivalent substitution of benefits within the ten categories of bene?ts required by the Affordable Care Act. As set forth in 45 CFR 156.100, the benchmark plan options included: (1) the largest plan by enrollment in any of the three largest products by enrollment in the State's small group market; (2) any of the largest three State employee health benefit plans options by 519 2017--00619 enrollment; (3) any of the largest three national Federal Employees Health Bene?ts Program (FEHBP) plan options by enrollment; or (4) the HMO plan with the largest insured commercial non-Medicaid enrollment in the State. The final rule also clarified that for States that did not make a benchmark selection, HHS selected the largest plan by enrollment in the largest product by enrollment in the State?s small group market as the default base-benchmark plan. The selected benchmark plans have been finalized for bene?t year 2014. Appendix A of the final regulation includes the ?nal list of EHB- benchmark plans for coverage in years 2014 and 2015. (Plan Management Webinar QHP FAQ #2 04/09/13) 023: What can be used as a source document for understanding the required bene?ts of the benchmark? Updated 1-31-17 A23: The regulatory standard for plans wishing to offer EHB is that plans must offer bene?ts and limits that are substantially equal to the bene?ts and limits in the benchmark, as outlined in 45 CFR 156.115. The bene?ts available through the CCIIO website are a summary of the EHBs for each respective state. The CCIIO website also includes an explanation of what is listed and how to review, and a document called ?Guide to Reviewing Essential Health Benefits Benchmark Plans.? In order to provide states, issuers, and others more information on the benchmark, the National Association of Insurance Commissioners (NAIC) has recently made more detailed bene?t documents available. As published in the EHB ?nal rule, EHB compliance is the responsibility of states regardless of Exchange type. We would encourage issuers to work with their enforcing state to further understand what enforcement or review for EHB will entail. (Plan Management Webinar QHP FAQ #3 04/11/13) CMS revised and re-re/eased this FAQ on the REG TAP database on 6/11/14: Q: What can be used as a source document for understanding the required benefits of the state benchmark plan? A: Among other things, plans must offer bene?ts and limits that are substantially equal to the bene?ts and limits in the benchmark, as established in 45 CFR 156.115. Summaries of the EHBs for each state as well as a guide to reviewing benchmark plans are available on the CCIIO website at To ensure that accurate state-speci?c EHB benchmark bene?ts are provided in Plans Bene?t Temp/ate submissions, issuers should refer to the Revised Benchmark Bene?ts Instructions available at com/plan management data temp/ates 2015.htm. These Instructions identify revised benchmark bene?ts for each state and instructions for updating the Plan and Bene?ts temp/ate accordingly. In order to provide states, issuers, and others more information on the benchmark, the National Association of Insurance Commissioners (NAIC) has more detailed benefit documents available at health reform section.htm. We would encourage issuers to work with their enforcing state to further understand what enforcement or review for EHB will entail. (REG TAP FAQ Database - FAQ #2139 06/11/14) 520 2017--00620 023: If the benchmark lists a benefit, does it need to be listed on the template as well? If an issuer don?t list each and every benefit covered by the benchmark, will the issuer be deemed non-compliant? A23: Please see the plan documents (Evidence of Coverage, Plan Benefits Summary, etc.) for more information regarding the particular items or services covered by the benchmark plan. As stated in the EHB ?nal rule, published at 78 FR 12834, the benchmark plan defines the benefits. See, generally, 45 CFR 156.110 and 156.115. Moreover, an EHB plan is expected to be substantially equal to the benchmark pursuant to 45 CFR so you may not list every benefit but you would have to substitute or offer other benefits to be deemed substantially equal. (QHP Webinar Series FAQ #7 04/24/13) 026: If the benchmark plan includes waiting periods, can these be included in QHP offerings? A26: If the benchmark plan has waiting periods (not to exceed 90 days) then the EHB plan can also have waiting periods, but keep in mind the EHB plan limits must be substantially equal to the benchmark plan limits. (QHP Webinar Series FAQ #7 04/24/13) Q32: If a State's benchmark plan includes coverage for bariatric surgery, does the QHP have to cover bariatric surgery? A32: Any state-required benefits enacted prior to 12/31/11 are considered EHB (45 CFR 155.170). QHP benefits and limits must be substantially equal to benchmark bene?ts and limits. See the final rule on EHB for additional explanation, available at (QHP Webinar Series FAQ #9 05/03/13) Q3: How much of the plan design of the benchmark transfers over to other carriers - just things listed as EHBs in the CCIIO template, things that could be categorized as EHBs by individual carriers, or all benefits (including those listed as "other" in the CCIIO template)? A3: Any bene?ts and services that the benchmark plan covers are considered EHB and other carriers must be sustainably equal to the benchmark. See 45 CFR (QHP Webinar Series FAQ #10 05/09/13) Q4: Since carriers cannot substitute benefits across categories, categorization of bene?ts in the benchmark plan is important. What authority does the state have (or not have) to adjust categorization of benefits? A4: Enforcing states have the authority to categorize the bene?ts. In the preamble to the final rule on EHB, at 78 FR 12843 we noted that states maintain ?exibility in defining bene?ts within the 10 statutory categories. (QHP Webinar Series FAQ #10 05/09/13) 521 Updated 1-31-17 2017--00621 Q1. Under the approach described in the [12/16/11 Bulletin would the Secretary permit the State to adopt different benchmark plans for its individual and small group markets? A1: No. A State would select only one of the benchmark options as the applicable EHB benchmark plan across its individual and small group markets both inside and outside of the Exchange. HHS believes that selecting one benchmark for these markets in a State would result in a more consistent and consumer-oriented set of options that would also serve to minimize administrative complexity. HHS seeks to provide flexibility to issuers by permitting actuarially equivalent substitution of bene?ts within the ten categories of benefits required by the Affordable Care Act. (FAQs on Essential Health Bene?ts Bulletin 02. When a State chooses an EHB benchmark plan, would the benefits be frozen in time, or as the benchmark plan updates benefits each year, would the benchmark plan reflect these updates? A: As indicated in the Bulletin, we intend to propose a process for updating EHB in future rulemaking. Under the intended approach, the specific set of benchmark bene?ts selected in 2012 would apply for plan years 2014 and 2015. For 2014 and 2015, the EHB benchmark plan selection would take place in the third quarter of 2012. A consistent set of benefits across these two years would limit market disruption during this transition period. As indicated in the Bulletin, HHS intends to revisit this approach for plan years starting in 2016. (FAQs on Essential Health Bene?ts Bulletin 05. How must a State supplement a benchmark plan if it is missing coverage in one or more of the ten statutory categories? Updated 1-31-17 A5: We intend to propose that if a benchmark plan is missing coverage in one or more of the ten statutory categories, the State must supplement the benchmark by reference to another benchmark plan that includes coverage of services in the missing category, as described in the Bulletin. For example, if a benchmark plan covers newborn care but not maternity services, the State must supplement the benchmark to ensure coverage for maternity services. The default benchmark plan would be supplemented by looking ?rst to the second largest small group market benchmark plan, then to the third, and then, if neither of those alternative small group market benchmark plans offers benefits in a missing category, to the FEHBP benchmark plan with the highest enrollment. Our research found that three categories of bene?ts - pediatric oral services, pediatric vision services, and habilitative services - are not included in many health insurance plans. Thus, the Bulletin describes special rules to ensure meaningful bene?ts in those categories: 0 As a transitional approach for habilitative services, the Bulletin discusses two alternative options that we are considering proposing: A plan would be required to offer the same services for habilitative needs as it offers for rehabilitative needs and offer them at parity. 0 A plan would decide which habilitative services to cover and report the coverage to HHS. HHS would evaluate and further define habilitative services in the future. Under either approach, a plan would be required to offer at least some habilitative bene?t. 522 2017-?00622 For pediatric oral care, we are considering proposing that the State would supplement the benchmark plan with benefits from either: 0 The Federal Employees Dental and Vision Insurance Program (FEDVIP) dental plan with the largest national enrollment; or The State?s separate Children?s Health Insurance Program (CHIP). For pediatric vision care, we are considering proposing that the State would supplement the benchmark plan with the benefits covered in the FEDVIP vision plan with the highest enrollment. (FAQs on Essential Health Bene?ts Bulletin 06. One of the currently intended benchmark plans is the largest plan by enrollment in any of the three largest products in the small group market. What is the difference between a plan and a product? A6: For the purpose of administering the health plan ?nder on HealthCare.gov, HHS has de?ned ?health insurance product" (product) as a package of benefits an issuer offers that is reported to State regulators in an insurance ?ling. Generally, this filing describes a set of benefits and often a provider network, but does not describe the manner in which bene?ts may be tailored, such as through the addition of riders. For purposes of identifying the benchmark plan, we identify the plan as the benefits covered by the product excluding all riders. HHS intends to propose that if benefits in a statutory category are offered only through the purchase of riders in a benchmark plan, that required EHB category would need to be supplemented by reference to another benchmark as described in question 5. (FAQs on Essential Health Bene?ts Bulletin Q7. What is the minimum set of benefits a plan must offer in a statutory category to be considered to offer coverage within the category consistent with the benchmark plan? A7: Under the approach described in the Bulletin, a plan could substitute coverage of services within each of the ten statutory categories, so long as substitutions were actuarially equivalent, based on standards set forth in CHIP regulations at 42 CFR 457.431, and provided that substitutions would not violate other statutory provisions. For example, a plan could offer coverage consistent with a benchmark plan offering up to 20 covered physical therapy visits and 10 covered occupational therapy visits by replacing them with up to 10 covered physical therapy visits and up to 20 covered occupational therapy visits, assuming actuarial equivalence and the other criteria are met. The benchmark plan would provide States and issuers with a frame of reference for the EHB categories. (FAQs on Essential Health Bene?ts Bulletin Q8. Can scope and duration limitations be included in the Updated 1-31-17 A8: Yes. Under the intended approach, a plan must be substantially equal to the benchmark plan, in both the scope of benefits offered and any limitations on those benefits such as visit limits. However, any scope and duration limitations in a plan would be subject to review pursuant to statutory prohibitions on discrimination in benefit design. In addition, the Public Health Service Act (PHS Act) section 2711, as added by the Affordable Care Act, prohibits imposing annual and lifetime dollar limits on EHB. Note that for annual dollar limits, the prohibition generally applies in full starting in 2014, with certain restricted annual limits permitted until that time. The prohibition on annual dollar limits does not apply to grandfathered individual market policies. (FAQs on Essential Health Benefits Bulletin 523 2017--00623 09. State-mandated benefits sometimes have dollar limits. How does the intended EHB policy interact with the annual and lifetime dollar limit provisions of the Affordable Care Act? A: PHS Act section 2711, as added by the Affordable Care Act, does not permit annual or lifetime dollar limits on EHB. Therefore, if a benefit, including a State-mandated benefit, included within a State-selected EHB benchmark plan was to have a dollar limit, that bene?t would be incorporated into the EHB definition without the dollar limit. However, based on the Bulletin describing our intended approach, plans would be permitted to make actuarially equivalent substitutions within statutory categories. Therefore, plans would be permitted to impose non-dollar limits, consistent with other guidance, that are at least actuarially equivalent to the annual dollar limits. (FAQs on Essential Health Bene?ts Bulletin Q10. How would the intended EHB policy affect self-insured group health plans, grandfathered group health plans, and the large group market health plans? How would employers sponsoring such plans determine which benefits are EHB when they offer coverage to employees residing in more than one State? Updated 1-31-17 A10: Under the Affordable Care Act, self-insured group health plans, large group market health plans, and grandfathered health plans are not required to offer EHB. However, the prohibition in PHS Act section 2711 on imposing annual and lifetime dollar limits on EHB does apply to self-insured group health plans, large group market health plans, and grandfathered group market health plans. These plans are permitted to impose non- dollar limits, consistent with other guidance, on EHB as long as they comply with other applicable statutory provisions. In addition, these plans can continue to impose annual and lifetime dollar limits on benefits that do not fall within the de?nition of EHB. To determine which benefits are EHB for purposes of complying with PHS Act section 2711, the Departments of Labor, Treasury, and HHS will consider a self-insured group health plan, a large group market health plan, or a grandfathered group health plan to have used a permissible definition of EHB under section 1302(b) of the Affordable Care Act if the de?nition is one that is authorized by the Secretary of HHS (including any available benchmark option, supplemented as needed to ensure coverage of all ten statutory categories). Furthermore, the Departments intend to use their enforcement discretion and work with those plans that make a good faith effort to apply an authorized de?nition of EHB to ensure there are no annual or lifetime dollar limits on EHB. (FAQs on Essential Health Benefits Bulletin REG TAP issued a follow-up FAQ on this topic on 03/31/14, as follows: Q: 10 in guidance from February 2012 states that will consider a self- insured group health plan, a large group market health plan, or a grandfathered group health plan to have used a permissible definition of EHB under section 1302(b) of the Affordable Care Act if the definition is one that is authorized by the Secretary of The only definition that appear to be authorized by HHS are the state benchmark plans. Does this mean that a large group or self-funded employer must select the state whose benchmark plan will define EHB services for purposes of the large group/ASO plan? Are there other methods these plans can use that would be considered authorized by If such a plan does not 524 2017-?00624 impose any annual or lifetime dollar limits on any services, would they still have to designate a state benchmark plan? A: In order to determine which bene?ts are essential health bene?ts for the purpose of removing annual and lifetime dollar limits, 3 self-insured group health plan, large group market health plan, or grandfathered group health plan may choose any benchmark plan from any state that was approved by the Secretary. (REGTAP FAQ Database - FAQ #1364 03/31/14) Q11. In the case of a non-grandfathered insured small group market plan that offers coverage to employees residing in more than one State, which State-selected EHB benchmark plan would apply? A11: Generally, the current practice in the group health insurance market is for the health insurance policy to be issued where the employer's primary place of business is located. As such, the employer's health insurance policy must conform to the bene?ts required in the employer?s State, given that the employer is the policyholder. Nothing in the Bulletin or our proposed approach seeks to change this current practice. Therefore, the applicable EHB benchmark for the State in which the insurance policy is issued would determine the EHB for all participants, regardless of the employee?s State of residence. Health insurance coverage not required to offer EHB, including grandfathered health plans and large group market coverage, would comply with the applicable annual and lifetime limits rule, as described in the answer to the previous question. (FAQs on Essential Health Bene?ts Bulletin Q12. How do the requirements regarding coverage of certain preventive health services under section 2713 of the PHS Act interact with the intended EHB policy? A12: The preventive services described in section 2713 of the PHS Act, as added by section 1001 of the Affordable Care Act, will be a part of EHB. (FAQs on Essential Health Benefits Bulletin Q14. Could a State legislature require that issuers offer a unique set of the way Medicaid and CHIP benchmarks have options for Secretary-approved benefits, or benchmark equivalent benefits, if the State benefits are actuarially equivalent to one of the choices that HHS defines to be A14: No. Under the approach we intend to propose, States would be required to adhere to the guidelines for selecting a benchmark plan outlined in the Bulletin. Otherwise, EHB in that State would be defined by the default benchmark plan. (FAQs on Essential Health Benefits Bulletin (02/1 Q15. Would States need to identify the benchmark options themselves? Updated 1-31-17 A15: HHS plans to report the top three FEHBP benchmark plans to States based on information from the Office of Personal Management. HHS also plans to provide States with a list of the top three small group market products in each State based on data from HealthCare.gov from the ?rst quarter of the 2012 calendar year. We intend to continue working with States to reconcile discrepancies in small group market product enrollment data. If a State chooses to consider State employee plans and/or the largest commercial HMO benchmark plans, the State would be required to identify benchmark options for 525 2017--00625 those benchmark plans, as is done today in Medicaid and CHIP. (FAQs on Essential Health Benefits Bulletin Q16. When would States be required to select a benchmark plan? A16: As noted in the Bulletin, we intend to propose that States must select an EHB benchmark plan in the third quarter two years prior to the coverage year, based on enrollment from the ?rst quarter of that year. Thus, HHS anticipates that selection of the benchmark plan for 2014 and 2015 would need to take place in the third quarter of 2012 in order to provide each State's EHB package, which includes the benchmark plan, any State-supplemented bene?ts to ensure coverage in all statutory categories, and any adjustments to include coverage for applicable State mandates enacted before December 31, 2011. This schedule would ensure plans have time to determine bene?t offerings before QHP applications are due. Separate guidance on the selection of Medicaid benchmark plans is forthcoming. (FAQs on Essential Health Bene?ts Bulletin Q17. How would a State of?cially designate and communicate its choice of benchmark plan and the corresponding benefits to A17: HHS is currently evaluating options for collecting a State?s benchmark plan selection and benefit information. A State?s EHB package would include the bene?ts offered in the benchmark plan, any supplemental benefits required to ensure coverage within all ten statutory categories of benefits, and any adjustments to include coverage for applicable State mandates enacted before December 31, 2011. HHS anticipates that submissions will be collected from States in a standardized format that includes the name of the benchmark plan along with benefit information and, if necessary, the benefits used to ensure coverage within a missing statutory category. (FAQs on Essential Health Bene?ts Bulletin Q18. How can my State ?nd benefit information with respect to the default benchmark plan? A18: As indicated in the Bulletin, we intend to propose that the default benchmark plan in each State would be the largest small group market product in the State?s small group market. HHS anticipates that it will identify and provide benefit information with respect to State-speci?c default benchmark plans in the Fall of 2012. (FAQs on Essential Health Bene?ts Bulletin (02/1 Q19. By empowering the State to select an EHB benchmark plan, does HHS intend that the State executive branch State Insurance Department) or the legislative branch must make the selection? Updated 1-31-17 A19: Each State would be permitted to select a benchmark plan from the options provided by HHS by whatever process and through whatever State entity is appropriate under State law. In general, we expect that the State executive branch would have the authority to select the benchmark plan. It is also possible that, in some States, legislation would be necessary for benchmark plan selection. It is important to note that, regardless of the entity making these State selections, it is the State Medicaid Agency that will be held responsible for the implementation of EHB through the Medicaid benchmark coverage option. (FAQs on Essential Health Bene?ts Bulletin 526 2017--00626 020. How would EHB be defined for Medicaid benchmark or benchmark-equivalent plans? A20: Since 2006, State Medicaid programs have had the option to provide certain groups of Medicaid enrollees with an alternative benefit package known as ?benchmark? or ?benchmark-equivalent" coverage, based on one of three commercial insurance products, or a fourth, ?Secretary-approved" coverage option. Beginning January 1, 2014, all Medicaid benchmark and benchmark equivalent plans must include at least the ten statutory categories of EHBs. Under the Affordable Care Act, the medical assistance provided to the expansion population of adults who become eligible for Medicaid as of January 1, 2014, will be a benefit package consistent with section 1937ii benchmark authority. For Medicaid benchmark and benchmark equivalent plans, three of the benchmark plans described in section 1937 (the State?s largest non-Medicaid HMO, the State's employee health plan, and the FEHBP 8088 plan) may be designated by the Secretary as EHB benchmark plans, as described in the EHB Bulletin. A State Medicaid Agency could select any of these section 1937 benchmark plans as its EHB benchmark reference plan for Medicaid. There would be no default EHB benchmark reference plan for purposes of Medicaid; each State Medicaid Agency would be required to identify an EHB benchmark reference plan for purposes of Medicaid as part of its 2014-related Medicaid State Plan changes. If the EHB benchmark plan selected for Medicaid were to lack coverage within one or more of the ten statutorily-required categories of benefits, the EHB benchmark plan (and therefore the section 1937 benchmark plan) would need to be supplemented to ensure that it provides coverage in each of the ten statutory bene?t categories. This would be in addition to any other requirements for Section 1937 plan, including Mental Health Parity and Addition Equity Act compliance. (FA OS on Essential Health Bene?ts Bulletin {02/17/12)} 021. Could a State select a different EHB benchmark reference plan for its Medicaid section 1937 benchmark and benchmark equivalent plans than the EHB reference plan it selects for the individual and small group market? A22: Yes. Under our intended proposal, a State would not be required to select the same EHB benchmark reference plan for Medicaid section 1937 plans that it selects for the individual and small group market, and it could have more than one EHB benchmark reference plan for Medicaid, for example, if the State were to develop more than one bene?t plan under section 1937. (FAQs on Essential Health Bene?ts Bulletin 022. Could a State select its regular Medicaid bene?t plan as its Section 1937 benchmark cove ra Updated 1-31-17 ge package? A22: Yes. A State could propose its traditional Medicaid bene?t package as a section 1937 benchmark plan under the Secretary-approved option available under section 1937 of the Social Security Act. The State would have to ensure, either through that benefit plan or as a supplement to that plan, that the ten statutory categories of EHB are covered. (FAQs on Essential Health Benefits Bulletin 527 2017-?00627 Q: Where can issuers find a summary of benefits provided by the benchmark plan? A: The information on the CCIIO website is a snapshot -- a summary of the benefits provided by the benchmark plan. Issuers can go to the NAIC website health reform section.htm) to locate the actual policy for that benchmark plan to see more detail about coverage, limitations, and exclusions. We would encourage issuers to work with their enforcing state to further understand what enforcement or review for EHB will entail. (REGTAP FAQ Database - FAQ #1327 4/1/14) Substantially Similar/Meaningful Difference 024: When will issuers get more clarification about what "substantially similar" means with respect to bene?ts? A24: An enforcing State (or HHS in non-enforcing states) will determine whether or not an EHB plan is substantially equal to the benchmark plan. As noted in the preamble to the ?nal rule on EHB at 78 FR 12844, we seek to allow for ?exibility of plan design. At this time, HHS does not expect to release additional guidance on this standard. (QHP Webinar Series FAQ #9 05/03/13) 025: For FFEs, who is making the assessment that the bene?ts are substantially equal? A25: Enforcement of the requirement to cover EHB is governed by section 2723 of the PHS Act, which looks first to States for enforcement, then to the Secretary where a State has failed to substantially enforce the standard. If the State is enforcing the Affordable Care Act requirement, the State will make the assessment. If, however, the State does not enforce Affordable Care Act requirements, then HHS will make the assessment. Whichever entity makes the assessment will do so for the entire market (both inside and outside). The standards for the review are outlined in the Guidance on the State Partnership Exchange, posted to the CCIIO website on January 3, 2013 and available at quidance-O1-03-2013.pdf (QHP Webinar Series FAQ #9 05/03/13) 026: Is there a definition of ?meaningful difference?? A26: The Letter to Issuers provides further information and guidance on the meaningful difference standard. Please see pages 15 and 16 of the Letter to Issuers for more information. The Letter to Issuers on Federally-facilitated and State Partnership Exchanges, published on April 5, 2013, is available at letter to issuers 04052013.pdf (QHP Webinar Series FAQ #9 05/03/13) State Mandates 040: How do issuers work with State-mandated offers of coverage? A40: The Federally-facilitated Exchange (FFE), including State Partnership Exchanges, will not collect or display State-mandated offers of coverage. It is the issuer?s 528 Updated 1-31-17 2017--00628 responsibility to ensure these State-mandated offers of coverage are provided to consumers. (QHP Webinar Series FAQ #4 04/16/13) 09: Are coverage mandates that impose pharmaceutical benefits into medical plans, for example, state mandates that require coverage of oral chemotherapy, considered to be subject to state compensation? A9: Any state-imposed requirement on a medical bene?t for which an issuer is required to cover a particular bene?t is considered a mandate. If that mandate was enacted after 12/31/2011, then the state would be required to defray the cost. However, per the prescription drug EHB policy described in 45 CFR 156.122, every drug list must cover the greater of: i) one drug in each USP category and class or, ii) the same number of prescription drugs in each category and class as the EHB-benchmark plan. This policy is a minimum requirement and plans are permitted to go beyond the number of drugs offered by the benchmark without exceeding EHB. Therefore, state-mandates related to the coverage of speci?c drugs do not exceed EHB. (QHP Webinar Series FAQ #5 04/18/13) Q11: Excel generates a warning that the maximum out-of-pocket (MOOP) exceeds the IRS out of pocket max for 2013 ($6,250 and $12,500 family). We?ve have been directed that the government amount is $6400. A11: Since the IRS limits for 2014 have not been established, the 2013 limits were used to alert you that you may have exceeded the maximum. Please check the QHP Application Instructions, Chapter 10, for more detailed instructions. (QHP Webinar Series FAQ #5 04/18/13) Q16: What further details can you provide on how states will reimburse issuers for bene?t offer mandates requirements to make a benefit optional through a rider) that are required to be offered in addition to the A16: We do not consider ?offer only? or ?make available? mandates to be required benefits that would be subject to state payment. Although the applicable state law requires issuers to offer the coverage/rider, the law does not mandate that the issuer actually provide the bene?t to all enrollees in that market. (QHP Webinar Series FAQ #10 05/09/13) Q17: Will states be required to defray the costs that qualified health plans (QHPs) sold outside the Marketplaces incur in meeting state benefits mandates (as they are required to do to have those mandates be required of QHPs sold through the Marketplace)? Updated 1-31-17 A17: Per section 131 1 of the Affordable Care Act, as implemented by 45 CFR 155.170, if the state requires a qualified health plan (QHP) to cover additional bene?ts beyond EHB, the state must defray the cost. The definition of QHP is established by section 1301(a) of the Affordable Care Act and implemented in 45 CFR 155.20. This de?nition requires that the QHP have in effect a certification issued or recognized by each Marketplace through which such plan is offered. The requirement to defray the cost of additional benefits applies to all QHPs, including QHPs offered outside of the Marketplace. (QHP Webinar Series FAQ #10 05/09/13 and REG TAP FAQ Database - FAQ #2147 06/11/14) 529 2017--00629 Q39: If a state enacts a new requirement that issuers that provide coverage of intravenous (IV) chemotherapy must cover oral chemotherapy at parity, does the state have to defray the cost? A40: A39: No. We do not consider such payment parity bills to create a requirement to cover a new bene?t. In addition, in the preamble to the ?nal rule on EHB at 78 FR 12845, we stated that plans are permitted to go beyond the number of drugs offered by the benchmark without exceeding EHB. (QHP Webinar Series FAQ #10 05/09/13) Q40: If a state enacts a new requirement for applied behavioral analysis (ABA) therapy, is that a benefit in excess of EHB, or can ABA be considered EHB because it is a service speci?c to an EHB category (falls within habilitative or mental health including behavioral health treatment)? A40: De?ning habilitative services would not result in a mandate, but requiring specific treatments/bene?ts, including ABA, creates a new mandate. Below is an example of a de?nition of habilitative services and a mandate for services, for illustrative purposes. Example of de?nition - Habilitative bene?ts for purposes of the state's EHB benchmark plan are de?ned as follows: "Habilitative services are services that help a person retain, learn, or improve skills and functioning for daily living that are offered in parity with, and in addition to, any rehabilitative services offered in the state?s EHB benchmark plan. Parity in this context means of like type and substantially equivalent in scope, amount, and duration." Example of mandate A bill requires private insurance companies to provide coverage under group health insurance policies for care; care; habilitative or rehabilitative care (including ABA therapy); therapeutic; and pharmacy care to children who have been diagnosed with autism spectrum disorder (ASD). (QHP Webinar Series FAQ #10 05/09/13) Q41: Our state has a mandated adoption indemnity benefit that states if an insured has coverage for maternity benefits on the date of an adoptive placement, the insured's policy shall provide an adoption indemnity benefit payable to the insured, if a child is placed for adoption with the insured within 90 days of the child's birth. This allows for a $4000 payment. We can provide that payment to the insured or apply it towards plan benefits-for example the deductible. There is no requirement to provide any specific benefits. This mandate is not included in our benchmark plan as it is a state employee plan and not subject to this state mandate. Our question is whether this benefit is considered If so, does the benefit dollar limit have to be removed? A41: As stated in the preamble to the ?nal rule on EHB at 78 FR 12838, we interpret ?state-required benefits? to include the care, treatment and services that an issuer must provide to its enrollees. Other state laws that do not relate to specific bene?ts, including those relating to providers and bene?t delivery method, are not considered state- required bene?ts. In this case, there is no requirement to cover a speci?c benefit. The issuer is required to pay a certain amount to the insured and the insured can use that money in any way. The requirement does not pertain to health services and would not fit into any of the 10 EHB categories. Therefore, it is not EHB and the prohibition on dollar limits and the requirement to defray the cost would not apply. (QHP Webinar Series FAQ #10 05/09/13) 530 Updated 1-31-17 2017--00630 Q10: If a state enacts a new requirement that issuers who provide coverage of IV chemotherapy must cover oral chemotherapy at parity, does the state have to defray the cost? A10: No. We do not consider such payment parity bills to create a requirement to cover a new bene?t. In addition, in the preamble to the EHB Final Rule (45 CFR 156.122) we stated that plans are permitted to go beyond the number of drugs offered by the benchmark without exceeding EHB.) (QHP Webinar Series FAQ #12 06/28/13 and REGTAP FAQ #2144 06/11/14) Q11: If a state enacts a new requirement for Applied Behavioral Therapy, is that a benefit above EHB or can Applied Behavioral Therapy be considered EHB because it is a service specific to an EHB category (falls w/in habilitative 0R mental health including behavioral health treatment). A11: De?ning habilitative services would not result in a mandate, but requiring specific treatments/bene?ts, including ABA, creates a new mandate. Example of Definition Habilitative bene?ts for purposes of the state's EHB Benchmark plan are de?ned as follows: "Habilitative services are services that help a person retain, learn, or improve skills and functioning for daily living that are offered in parity with, and in addition to, any rehabilitative services offered in the state's EHB benchmark plan. Parity in this context means of like type and substantially equivalent in scope, amount, and duration." Example of mandate Bill requires private insurance companies to provide coverage under group health insurance policies for care, care, habilitative or rehabilitative care (including applied behavior analysis (ABA) therapy), therapeutic and pharmacy care to children who have been diagnosed with autism spectrum disorder (ASD). (QHP Webinar Series FAQ #12 06/28/13 and REGTAP database FAQ #2143 06/11/14) Q3. Would States be required to defray the cost of any State-mandated benefit? Updated 1-31-17 A3: The Affordable Care Act requires States to defray the costs of State-mandated bene?ts in quali?ed health plans (QHPs) that are in excess of the EHB. If a State were to choose a benchmark plan that does not include all State-mandated benefits, the Affordable Care Act would require the State to defray the cost of those mandated bene?ts in excess of EHB as de?ned by the selected benchmark. States have several benchmark options from which to choose, including the largest small group market plan in the State, which is the default benchmark plan for each State. Generally, insured plans sold in the small group market must comply with State mandates to cover bene?ts. Thus, if a small group market benchmark plan was selected, these mandated bene?ts would be part of the State-selected EHB. However, if there are State mandates that do not apply to the small group market, such as mandates that apply only to the individual market or to HMOs, the State would need to defray the costs of those mandates if the mandated bene?ts were not covered by the selected benchmark. 531 2017-?00631 As indicated in the Bulletin, the treatment of State bene?t mandates is intended as a two-year transitional policy that HHS intends to revisit for plan years starting in 2016. (FAQs on Essential Health Bene?ts Bulletin Q4. Could a State add State-mandated benefits to the State-selected EHB benchmark plan today without having to defray the costs of those mandated benefits? A4: No. We intend to clarify that under the proposed approach any State-mandated benefits enacted after December 31, 2011 could not be part of EHB for 2014 or 2015, unless already included within the benchmark plan regardless of the mandate. Note that any State-mandated bene?ts enacted by December 31, 2011 would be part of EHB if applicable to the State-selected EHB benchmark plan. As mentioned above, HHS intends to revisit this approach for plan years starting in 2016. (FAQs on Essential Health Benefits Bulletin Cost-Sharing Q34: How do cost sharing limits work with the embedded pediatric dental EHB in a medical plan? A34: When the pediatric dental EHB is offered as part of a medical plan, it is treated as any other benefit in terms of cost sharing limits. The pediatric dental EHB is included in the AV Calculator calculation for medical plans. (Plan Management Webinar 01/24/13) Q8: For facility out-of-network fees, coinsurance pays 20% out-of-state and 50% in state. When completing the cost-sharing variation, do we choose the most likely scenario, which would be 20% coinsurance out-of-state in this case? Or do we report the higher deductible since it is the worst case, but less likely scenario? A8: We recommend that the issuer fill out the copay and/or coinsurance that would be most typical for most enrollees highest utilized). In the "Explanations" field, the issuer should add appropriate and brief detail to communicate other cost sharing in other scenarios outside of the most common one already entered into the worksheet. (QHP Webinar Series FAQ #5 04/18/13) Q12: For a small group market QHP issuer using more than one service provider to administer benefits subject to the maximum out-of-pocket (MOOP), the final 2014 Letter to Issuers states that the MOOP limitations will be met if the QHP complies with MOOP for major medical coverage and MOOP on coverage not consisting solely of major medical does not exceed the dollar amounts set forth in the Letter ($6,400 for self-only and $12,800 for family). However, the QHP submission template does not appear to accept this separate $6400 MOOP amount for prescription drug, pediatric dental, or pediatric vision, and results in a validation error. A12: The Plans and Benefits template allows for separate medical and drug out of pocket maximum. Regarding the AV Calculator, it is true that an error will be returned if the sum of the separate medical and drug out of pocket maximum exceeds $6,500. In that case, we recommend that the issuer submit this plan as a "unique plan design" which will allow the template to pass out of pocket maximum validations and bypass the AV Calculator error message. As unique plan designs incompatible with the AV 532 Updated 1-31-17 2017--00632 Calculator, issuers will be required to submit an actuarial certi?cation. (QHP Webinar Series FAQ #5 04/18/13) 025: How do maximum out-of-pocket limitations apply to large group plans providing coverage for both in and out-of-network services? A25: Out-of?pocket amounts for covered services received from providers outside of the plan?s network are not required to count towards the out-of?pocket limitations. As stated in 45 CFR the case of a plan using a network of providers, cost-sharing paid by, or on behalf of, an enrollee for bene?ts provided outside of such network shall not count towards the annual limitation on cost-sharing (as defined in paragraph of this section)." This would apply regardless of whether the plan expresses its out-of- pocket maximum separately for in- and out-of-network services, or as a uni?ed amount for any services received. Only out-of?pocket amounts for covered services received from in-network providers would count towards the amount which is subject to the statutory/regulatory limitation. However, the plan would need to be able to track in- network cost sharing amounts in order to ensure that it is complying with the limitation. (QHP Webinar Series FAQ #7 04/24/13) Updated 1-31-17 Clarification of this FA Q, released 08/02/13 (old FAQ not included in revised version) Q1: HHS stated that cost sharing towards services that are essential health benefits (EHB) must accumulate towards the maximum out-of-pocket limit (MOOP). If an issuer covers benefits that are not EHB, can those benefits also accumulate towards For instance, in order to design high deductible health plans that are health savings account (HSA) certified, issuers would be able to accumulate all services (EHB and non-EHB) to the MOOP. In such a case, issuers would also include these non-EHB in the calculation of actuarial value (AV), which would be done outside of the AV Calculator. Is this permissible? A1: For purposes of calculating AV, non-EHB benefits may not accumulate towards MOOP amounts. Per section 1302(a) of the Affordable Care Act, the term ?essential health benefits package" must consist of those bene?ts de?ned under section 1302(b), limits on cost-sharing for such coverage in accordance 533 2017--00633 with section 1302(c), and a package that meets applicable metal levels. Section 1302(0) contains cost sharing requirements, including MOOP limitations. Furthermore, 1302(d) on AV clarifies that the level of coverage of a plan shall be determined on the basis that the EHB bene?ts be provided to a standard population. However, operationally, a plan may (but is not required to) count cost sharing for non?EHB towards the MOOP. (QHP Webinar Series FAQ #10 05/09/13, updated 08/02/13) Q13: In the preamble to the proposed rule on EHB at 77 FR 70654, HHS presents an example of a three-tiered network design and explains that the first two tiers would be considered in-network, and accumulate to the MOOP, while only the third tier would be out-of-network and not have to accumulate to the MOOP. We request, instead, that HHS permit issuers to consider the first tier as the primary in-network tier and accumulate only those costs to the COP maximum as long as the first tier provides adequate access to providers, in compliance with network adequacy requirements. This would permit issuers to design a second tier that provides enhanced access to out-of-network providers relative to a third tier, with protections for members against significant costs from balance billing, without having to accumulate those costs to the MOOP. Requiring that these costs accumulate to the MOOP would make it unfeasible for issuers to offer members this benefit. A13: All benefits that are in-network have to count towards EHB, regardless of network adequacy requirements and no matter how broad or narrow the benefits are. (QHP Webinar Series FAQ #10 05/09/13) Q14: We request clarification that issuers may have flexibility in applying the annual limitation on deductibles in the small group market or to use other types of cost sharing. For instance, issuers should be permitted to apply a deductible to only a subset of EHB, or to use fixed dollar co-pays for some services physician office visits or prescription drugs) rather than making them subject to the deductible. Issuers could also choose not to have a deductible at all. A14: We interpret the limits in section 1302(c)(2) of the Affordable Care Act to apply to all EHB where there is a deductible being used as a form of cost sharing. However, the QHP has the option of excluding a particular category of bene?ts from the deductible, which, in effect, would be having a $0 deductible for that category of bene?t. (QHP Webinar Series FAQ #10 05/09/13) 025: If a carrier has separate in- versus out-of-network out-of-pocket maximum amounts but covers services such as emergency room and ambulance from any provider, including out-of-network providers, can the services from out-of-network ambulance companies or emergency rooms accrue to the in-network out-of-pocket maximum? A25: The general rule, as noted at 45 CFR is that cost sharing for bene?ts provided out-of-network by a network plan do not count toward the annual limits on deductibles or maximum out-of?pocket limits. However, where the plan does not offer coverage of a particular service in network, the plan is not considered a network plan for purposes of this rule with respect to that service. Because plans are not permitted to limit coverage of emergency services set forth in 45 CFR 147.138(b) to network providers, plans are similarly not considered network plans for purposes of such services, and cost- 534 Updated 1-31-17 2017--00634 sharing for such services received by non-network providers would apply to the out of pocket maximum. (QHP Webinar Series FAQ #10 05/09/13) 026: If an indemnity plan does not have a provider network, does that plan need to comply with annual limits on deductibles or maximum out-of-pocket limits? A26: Yes. A plan without a network must comply with the annual limits on deductibles or maximum out-of?pocket limits and cannot consider certain expenses to be non-network. The exception for non-network amounts only applies if a plan has a network (45 CFR (QHP Webinar Series FAQ #10 05/09/13) This FAQ was revised and released as REG TAP on 03/31/14, as follows: Q: If an indemnity plan does not have a provider network, does that plan need to comply with annual limits on deductibles or maximum out-of-pocket limits? A: Yes. A plan without a network must comply with the annual limits on deductibles or maximum out-of?pocket limits and cannot consider covered expenses to be non-network. The provision for excluding cost sharing for non- network amounts from maximum out-of?pocket limitations only applies if a plan has a network (45 CFR (REGTAP FAQ Database - FAQ #1336 03/31/14) Q1: Do issuers need to update their maximum out-of-pocket and deductible values for certain plans now that the IRS has published the 2014 out-of-pocket limits for high deductible health plans A1: The annual limitation on cost sharing (commonly referred to as a maximum out-of- pocket limit) for 2014 is $6,350 for self-only coverage and $12,700 for other than self- only coverage. This affects the allowable maximum out-of?pocket value for Essential Health Benefits for all plans submitted in a QHP application. It also affects the allowable deductible value for catastrophic plans. These limits are lower than the CMS estimates published on April 5, 2013 in the ?Letter to Issuers on Federally-facilitated and State Partnership Exchange.? Issuers that have submitted quali?ed health plan (QHP) applications to State Regulators or CMS with maximum out-of?pocket values above $6,350 for self-only coverage or $12,700 for other than self-only coverage will need to revise their applications. If an issuer used the CMS 2014 estimated limit of $6,400 and $12,800, the maximum out of pocket values will only need to change by $50 or $100, respectively, which will have a very minor impact on actuarial value. It is unlikely that plans in this situation will need to make changes to other cost sharing data elements in order to meet an actuarial value for a given level of coverage under 45 CFR ?156.140. (QHP Webinar Series FAQ #11 05/22/13) 02: When should an issuer participating in a Federally-facilitated Marketplace (FFM) revise their application? Updated 1-31-17 A2: Issuers have already submitted their QHP applications to CMS through the Health Insurance Oversight System (HIOS) and some plans may be out of compliance with the limits for maximum out-of?pocket or deductible values. Issuers in States enforcing the Affordable Care Act market reforms, including the annual limitation on cost sharing, should contact their State Regulator regarding the process and timing for correcting and 535 2017--00635 resubmitting their applications. In States in which CMS is directly enforcing the Affordable Care Act market reforms, CMS will be contacting those issuers and requesting revisions to their applications. (QHP Webinar Series FAQ #11 05/22/13) Q3: When should an issuer participating in a State Partnership or State Based Marketplace revise their application? A3: The issuer should contact their State Regulator regarding the process and timing for correcting and resubmitting their applications if an issuer has already submitted a QHP application to a State Partnership or State Based Marketplace that does not comply with the limits for maximum out-of-pocket or deductible values. (QHP Webinar Series FAQ #11 05/22/13) This FAQ was revised and released as REG TAP on 03/31/14, as follows: Q: When should an issuer participating in a States Performing Plan Management Functions or State-based Marketplace revise their application? A: As in the 2013 QHP application process for the 2014 coverage year, issuers seeking certi?cation of QHPs in 2014 for the 2015 coverage year in States Performing Plan Management Functions and State-based Marketplaces should contact their state regulators for detailed instructions and information about the QHP application process. (REGTAP FAQ Database - FAQ #1333 03/31/14) Q50: For plan 03 above 300% FPL), are issuers required to only apply the $0 cost share to Tribal providers to the on exchange states? A50: 45 CFR as described in the final Payment Notice requires QHP issuers to offer a limited cost sharing plan variation with no cost sharing on any item or service that is an EHB furnished directly by the Indian Health Service, an Indian Tribe, Tribal Organization, or Urban Indian Organization, or through referral under contract health services regardless of the state in which the coverage is provided, or the state in which the provider is located. Please see 084 of QHP FAQ #9 for additional information. (QHP Webinar Series FAQ #12 06/28/13) 051: Can individual plans gain relief using the MOOP ?safe harbor? referred to in the February 20 FAQ similar to group plans? Updated 1-31-17 A51: No. The one-year transitional exemption from the ACA's MOOP limitations does not apply to individual market plans. It only applies to small and large group market plans 536 2017--00636 and self-insured plans that use multiple bene?t administrators. (QHP Webinar Series FAQ #12 06/28/13) 02: Does the one-year transitional exemption to the statutory out-of?pocket maximum, described in the Annual Letter to Issuers in Chapter 1, Section apply where a small group market Issuer has a dental benefit that is separately administered from its major medical benefits? A2: Yes. A small group market Issuer that uses multiple benefit administrators to administer its major medical benefits separate from its dental bene?ts will be considered to meet the maximum out of pocket limits as long as: 1) The plan complies with the annual out-of-pocket maximum with respect to its major medical coverage; and 2) To the extent that the plan includes an out-of?pocket maximum on its separately administered dental coverage, such out-of?pocket maximum does not exceed the dollar amounts set forth in section 1302(c)(1). (QHP Webinar Series FAQ #10 05/09/13, updated 08/02/13) Q: Are QHPs required to cover pediatric vision benefits at no cost sharing? 45 CFR 147.126 prohibits annual or lifetime dollar limits on EHB but does not prohibit coinsurance and deductible as these apply to other EHB as well. Can you verify? A: The Affordable Care Act prohibits annual and lifetime dollar limits on EHB, so even if the benchmark plan includes such limits, EHB plans cannot impose such limits. Cost sharing is permitted unless the benefit is considered a preventive service. (REGTAP FAQ Database - FAQ #1328 03/31/14) Q: Is there a complete list of the validations that the Master Review and Cost-sharing Reduction (CSR) Tools perform? A: Yes, within the Master Review Tool, Issuers can click on the Cost-sharing tab for a complete list of details on the cost-sharing related bene?t evaluations. Issuers can also review each column of the CSR Tool for a list of each evaluation. The review tools are available on the CMS ZONE website (REGTAP FAQ Database - FAQ #2635 07/03/14) Q: When calculating the Maximum Out-Of Pocket (MOOP) for an individual with both a QHP and a stand-alone dental plan (SADP), does the issuer combine the total MOOPs for each plan ($6000 for the QHP and $350 for the A: No, the regular MOOP would apply only to the QHP and the SADP would have a separate MOOP of $350. (REGTAP FAQ Database - FAQ #2638 07/03/14) 537 Updated 1-31-17 2017--00637 Q: The final 2016 Notice of Bene?t and Payment Parameters (2016 Payment Notice) (80 FR 10750) clarified that the self-only annual limitation on cost sharing applies to each individual regardless of whether the individual is enrolled in a self-only or other than self- only plan. As a result, how can issuers offer a family high deductible health plan (HDHP) with a $10,000 family deductible? A: In the 2016 Payment Notice, CMS established that starting in the 2016 plan year, the self-only annual limitation on cost sharing applies to each individual, regardless of whether the individual is enrolled in other than self-only coverage, including in a family HDHP. Under the requirements for an HDHP, except for preventive care, a plan may not provide bene?ts for any year until the deductible for that year has been met. As discussed in IRS Notice 2004-2 lRB/ar09.html in the case of family coverage, a plan is an HDHP only if, under the terms of the plan and without regard to which family member or members incur expenses, no amounts are payable from the HDHP until the family has incurred annual covered medical expenses in excess of the minimum annual deductible for family coverage. For example, an HDHP plan that has a $10,000 family deductible may provide payment for covered medical expenses for a member of the family if that member has incurred covered medical expenses during the year of at least $2,600 (the minimum deductible for a 2015 family HDHP). Under the policy ?nalized in the 2016 Payment Notice, this plan must also apply the annual limitation on cost sharing for self-only coverage ($6,600 in 2015) to each individual in the plan, even if this amount is below the $10,000 family deductible limit. As stated in the 2016 Payment Notice, while cost sharing incurred towards the deductible must count towards the annual limitation on cost sharing for essential health benefits (EHB), the deductible limit is not treated in the same manner as the annual limitation on cost sharing under 45 CFR ?156.130. Therefore, family that count the family?s cost sharing to the deductible limit can continue to be offered under this policy, as long as the self-only annual limitation on cost sharing is applied to each individual in the FAQ, 03/10/15 5CR 031015.pdf) Q1: In the final 2016 Notice of Bene?t and Payment Parameters (2016 Payment Notice) (80 FR 10750), HHS clarified that the self-only annual limitation on cost sharing applies to each individual, regardless of whether the individual is enrolled in a self-only or other than self-only plan. How should issuers enter information in the Plans and Benefits template to accurately represent cost sharing under this standard? Updated 1-31-17 A1: To accurately record this information, the family ?elds for the ?In Network,? ?In Network (Tier and ?Out of Network? annual limitation on cost sharing now have additional options. When an issuer selects these ?elds, a pop-up window will appear, allowing an issuer to enter a per-group amount and a per-person amount. The per-group amount is the total annual limitation when accruing cost sharing for all enrollees on a policy the covered members in a family). The per-person amount is the annual limitation that applies separately to each person on a policy a dependent covered by the policy). If a plan is available as other than self-only coverage, an issuer must enter a per-person amount in addition to the per-group amount. The per-person amount for other than self- 538 2017--00638 only coverage must be less than or equal to the annual limitation for self-only coverage ($6,850 in 2016) and for the speci?c cost-sharing reduction plan variations. Please refer to section 4.15 of the ?Chapter 10: Instructions for the Plans and Bene?ts Application Section" for guidance on how to enter annual limitations on cost sharing (located here: (Embedded Self-Only Annual Limitation on Cost Sharing FAQs 05/08/15 and REGTAP FAQ Database - FAQ #10451 05/08/15) 02: How can an issuer be in compliance with the requirement that the self-only annual limitation on cost sharing applies to each individual, regardless of whether the individual is enrolled in a self-only or in an other than self-only plan, and offer a family high deductible health plan (HDHP) with a $10,000 family deductible? A2: For 2016, the maximum annual limitation on cost sharing for self-only coverage is $6,850. Consequently, for 2016, an issuer can offer a family HDHP with a $10,000 family deductible, as long as it applies a maximum annual limitation on cost-sharing of $6,850 to each individual in the plan, even if the family $10,000 deductible has not yet been satisfied. This standard does not con?ict with IRS rules on Under the requirements for an HDHP, except for preventive care, an HDHP plan may not provide bene?ts for any year until the minimum statutory annual deductible for that year has been met. The minimum annual deductible for a family HDHP is $2,600 for 2016. Because the $6,850 self-only maximum annual limitation on cost sharing will exceed the 2016 minimum annual deductible amount for family HDHP coverage, it will not cause the plan to fail to satisfy the requirements for a family HDHP. ((Embedded Self-Only Annual Limitation on Cost Sharing FAQs 05/08/15 and REG TAP FAQ Database - FAQ #10452 05/08/15) Q4: Regarding zero cost-sharing plans, if a plan is a Preferred Provider Organization (PPO) that covers out-of-network and has a default coinsurance for all benefits, is the cost-sharing variance zero cost-sharing? A4: For Essential Health Benefits (EHBs) in and out-of?network, the zero cost-sharing plan variation for the coinsurance must be covered by the issuer, therefore zero percent For non-EHBs out-of-network that are covered, the zero cost-sharing plan variation must follow successive cost-sharing with a limited plan variation. If the standard plan is a silver plan, then the zero cost-sharing plans must follow successive cost- sharing with a 94% Actuarial Value (AV) plan variation. Please refer to 5.5 of the ?Chapter 10: Plans and Bene?ts Template Instructions? located here: (QHP Certi?cation Process FAQs #4 {09/29/15)} Q1: If there are different deductibles and coinsurances for a plan, should issuers create new benefit packages? Updated 1-31-17 A1: Issuers do not have to create a new benefits package if there are different deductibles and coinsurances for a plan as each plan in a bene?ts package may have different cost-sharing values. A new benefits package is required if the plan does not cover the same benefits or does not have an identical bene?ts package structure as the 539 2017--00639 other plans included in the bene?ts package. Please refer to section 4.3 of the Chapter 10: Plan and Bene?ts Template Instructions for guidance on plan identi?ers (located here: (QHP Certi?cation Process FAQs #5 (09/29/15) 02: Are modifications to cost-sharing structures considered plan modifications or new plans? A2: If modi?cations to a plan qualify as a uniform modi?cation of coverage, then the plan may be considered to be the same plan. 45 CFR 147.106 provides that within the product, each plan must have the same cost-sharing structure as before the modi?cation, except for any variation in cost sharing solely related to changes in cost and utilization of medical care, or to maintain the same metal tier level described in sections 1302(d) and of the Affordable Care Act. (QHP Certi?cation Process FAQs #5 {09/29/15) 02: Regarding the cost-sharing for high deductible health plans guidance, must issuers satisfy the minimum family deductible set by the Internal Revenue Service (IRS), prior to paying for benefits? A2: Yes, issuers must ensure that the minimum family deductible set by the Internal Revenue Service (IRS) is satis?ed prior to paying for bene?ts. For calendar year 2016, a ?high deductible health plan? is de?ned under 223(c)(2)(A) as a health plan with an annual deductible that is not less than $1,300 for self-only coverage or $2,600 for family coverage. There are some family that have deductibles for both the family as a whole and for individual family members. Under these plans, if you meet the individual deductible for one family member, you do not have to meet the higher annual deductible amount for the family. However, if either the deductible for the family as a whole or the deductible for an individual family member is less than the minimum annual deductible for family coverage, the plan does not qualify as an HDHP. The minimum annual deductible for a family HDHP is $2,600 for 2016. (Issuer Outreach FAQ #1 (10/27/15)) Mental Health Parity 13. Under the intended EHB approach, would the parity requirements in MHPAEA be required in A: Yes. Consistent with Congressional intent, we intend to propose that the parity requirements apply in the context of EHB. (FAQs on Essential Health Benefits Bulletin (02/17/12)) 022: For testing Mental Health parity, does the Mental Health and Substance Abuse category also include services in the office? A22: Yes, parity does include office visits for services included under the de?nition of mental health or substance use disorder bene?ts. (QHP Webinar Series FAQ #9 05/03/13) 540 Updated 1-31-17 2017--00640 Q31: Does the Mental Health parity requirement apply to both SHOP and individual markets? A31: Yes, all EHB plans must include mental health and substance use disorder services and those must comply with parity. Per 45 CFR since EHB plans are sold in the small group and individual markets, that means parity is required in both markets. (QHP Webinar Series FAQ #9 05/03/13; REG TAP FAQ Database - FAQ #151 05/03/13) Dental 06: What is cosmetic orthodontia? A6: The term ?cosmetic orthodontia,? used in the EHB proposed rule, was replaced with ?non-medically necessary orthodontia." (Plan Management Webinar 01/24/13) Q17: Is the purchase of pediatric dental required? A17: Under the ACA, QHPs generally must cover all 10 categories of EHB. But, if there is a stand-alone dental plan offered in the Exchange, QHPs in that Exchange can omit the pediatric dental EHB. Additionally, all stand-alone dental plans on the Exchange must cover at least the pediatric dental EHB. By combining those two (2) provisions, all 10 categories of EHB will always be available to consumers in the Exchanges. CMS notes that, while all 10 EHBs always have to be offered through an Exchange, if someone buys a QHP without the pediatric dental EHB, there are no HHS requirements on the bene?ts purchased by individuals, therefore there is no requirement to buy a stand-alone dental plan. (Plan Management Webinar 01/24/13) 06: If there is a stand-alone dental plan offered on the exchange, does a QHP still need to offer pediatric dental benefits as part of its Essential Health Benefits A6: No. Please see 45 CFR In prior rulemaking, we sought information from issuers regarding whether they planned to offer stand-alone dental plans, and we collected this information through a PRA package, OMB Control Number 0938-1174. Further information on this voluntary dental reporting is available at on website. (Plan Management Webinar QHP FAQ #1 04/08/13) Q7: Do plans offered outside of the Exchange have to have pediatric dental embedded in the medical benefit? Does this also apply in the small group market outside of the Exchange? A7: Plans offered outside of the Exchange must offer the full set of essential health benefits. However, in cases in which an individual has purchased stand-alone pediatric dental coverage offered by an Exchange-certified stand-alone dental plan off the Exchange, that individual would already be covered by the same pediatric dental bene?t that is a part of EHB. When an issuer is reasonably assured that an individual has obtained such coverage through an Exchange certified stand-alone dental plan offered outside an Exchange, the issuer would not be found non-compliant with EHB requirements if the issuer offers that individual a policy that, when combined with the Exchange-certi?ed stand-alone dental plan, ensures full coverage of EHB. See the 541 Updated 1-31-17 2017-?00641 comment/response discussion for ?156.150 of the EHB ?nal rule at 78 FR 12852, available at (Plan Management Webinar QHP FAQ #1 04/08/13) Q9: Does the out-of-pocket maximum include both medical and dental benefits if pediatric dental benefits are embedded in the medical plan? Having a separate out-of- pocket maximum for medical and dental has been suggested. A9: Please refer to ?156.150 of the EHB final rule for further information on stand-alone dental plans. If pediatric dental benefits are embedded in the QHP, then the one out-of- pocket maximum for the QHP applies. (Plan Management Webinar QHP FAQ #1 04/08/13) Note: This FAQ was updated and released as REG TAP FAQ 1337 on 03/31/14, as follows: Q: Does the out-of-pocket maximum include both medical and dental benefits if pediatric dental benefits are embedded in the medical plan? Having a separate out-of-pocket maximum for medical and dental has been suggested. A: Please refer to ?156. 150 of the EHB ?nal rule for further information on stand- alone dental plans. If pediatric dental bene?ts are embedded in the QHP, then the combined out-of-pocket costs for major medical and dental bene?ts are limited to $6350 for individuals and $12, 700 for other than individuals for the 2014 plan year. (REG TAP FAQ Database - FAQ #1337 03/31/14) Q10: When the Advanced Payment of Premium Tax Credit (APTC) is calculated, will it balance for the missing cost of pediatric dental if the second lowest silver plan is a medical only plan? A10: If the second lowest cost silver plan for a particular taxpayer is a QHP that does not include the pediatric dental EHB, and the taxpayer chooses to enroll in the second lowest cost silver plan, the APTC will not cover the cost of the pediatric dental EHB, even if the taxpayer also enrolls in a stand-alone dental plan. However, if the taxpayer enrolled in a QHP and stand-alone dental plan that, together, were lower in cost than the second lowest cost silver plan, the APTC could cover some or all of the cost of the pediatric dental EHB covered by the stand-alone dental plan, provided that the total APTC does not exceed the limit established by the second lowest cost silver plan. Please see the IRS ?nal rule at 77 FR 30377 for a description of this. The rule is available at .pdf (Plan Management Webinar QHP FAQ #1 04/08/13). Q14: Does pediatric dental follow exactly the same age curve/factors, etc. as medical? Should there be a separate rating algorithm for dental? Or would pediatric dental be submitted as a different plan and the exchange would add the pediatric dental and medical rates together? Updated 1-31-17 A14: As outlined in Chapter 4 in the 2014 Letter to Issuers: ?In addition, 45 CPR. 156.210 requires QHP and stand-alone dental plan issuers to submit rate and benefit information to the Exchange as a standard for certification by the Exchange. Due to their excepted benefit status, stand-alone dental plans are not required to meet the rating 542 2017-?00642 rules of PHS Act section 2701 that underlie the QHP Rating Tables and business rules template. However, stand-alone dental plans will still need to complete these tables, and based on that information, CMS will display basic, comparable rate information for stand-alone dental plans on the web portal. CMS will also calculate the advance payment of the premium tax credit for stand-alone dental plans using the pediatric dental Essential Health Bene?t (EHB) premium allocation." Issuers of stand- alone dental plans can elect to charge an additional premium beyond what is reported. Please see Chapter 4 of the issuer letter for additional information. (Plan Management Webinar QHP FAQ #2 04/09/13) Q12: What is the definition of medically necessary orthodontia? A12: Issuers will be responsible for developing standards to de?ne medically necessary orthodontia. (Plan Management Webinar QHP FAQ #2 04/09/13) Q12: Is dental subject to the same minimum thresholds as medical in regards to Essential Community Providers A12: Yes, dental plan issuers are subject to the Essential Community Provider thresholds. See 45 CFR ?156.235 for more information on Essential Community Providers. More information on the thresholds can be found in the Letter to Issuers in Federally-facilitated and State Partnership Exchanges on the Center for Customer Information and Insurance Oversight (CCIIO) website at: letter to issuers 04052013.pdf. The list of ECPs that provide dental services is available here: kiqg (Plan Management Webinar QHP FAQ #3 04/11/13) This FAQ was revised and re-re/eased with a new link to dental ECP providers on 6/11/14: A: Yes, dental plan issuers are subject to the Essential Community Provider thresholds. See 45 CFR ?156. 235 for more information on Essential Community Providers. The list of ECPs that provide dental services is available here: (REG TAP FAQ Database - FAQ #2156 06/11/14) Q13: Will there be a dental ECP list? Updated 1-31-17 A13: Yes, ECP providers that cover dental services will be identi?able. The list of ECPs that provide dental services is available at: (Plan Management Webinar QHP FAQ #3 04/11/13) This FAQ was re-released with a new link to dental ECP providers on 6/11/14: A: Yes, ECP providers that cover dental services can be identi?ed on the list of ECPs. The list of ECPs that provide dental services is available at: (REGTAP FAQ Database - FAQ #2157 06/11/14) 543 2017--00643 Q14: If someone enrolls in the pediatric oral Essential Health Bene?t (EHB) offered through a stand-alone dental plan (SADP) during the normal open enrollment process and then drops the coverage mid-year, will he or she be allowed to re-enroll during the next open enrollment period with the same company, or can plans include and enforce a lock-out period (for example 2 years) to discourage this anti-selection behavior? A14: Yes, when provided under a separate policy or contract, limited scope dental benefits are excepted bene?ts, as de?ned by PHS Act section 2791, and thus not subject to the requirements of the PHS Act, including section 2702 guaranteed availability standards [Please refer to the Letter to Issuers in Federally-facilitated and State Partnership Exchanges for more information: Guidance/Downloads/2014 letter to issuers 04052013.pdf (Plan Management Webinar QHP FAQ #3 04/11/13) Q5: Outside of the Exchange, does the medical plan need to provide dental benefits if an individual provides reasonable assurance to an issuer that he/she has already purchased an exchange-certified stand-alone dental plan that covers the pediatric A5: No. Outside of the Exchange, the issuer must have reasonable assurance that the individual has purchased exchange-certi?ed stand-alone dental coverage that covers the pediatric EHB requirement, as noted in the preamble to the ?nal rule on EHB at 78 FR 12853. This assurance could be obtained by requiring proof of coverage from the individual or establishing a method of confirming coverage directly with the stand-alone dental plan. The method of obtaining assurance is at the discretion of the issuer. (QHP Webinar Series FAQ #9 05/03/13) Q7: For off-Exchange business, if an individual does not purchase an Exchange-certified stand-alone dental plan, does the issuer have to embed the pediatric dental benefit into the medical plan? A7: Outside the Exchange, the issuer should embed dental services including pediatric dental coverage if the issuer is not reasonably assured that the individual is enrolled in an Exchange-certi?ed stand-alone dental plan. (QHP Webinar Series FAQ #9 05/03/13 and REGTAP FAQ Database - FAQ #2150 06/11/14) Q10: Will dental plans complete the Unified Rate Review Template? A10: As stated in the Letter to Issuers, stand-alone dental plans will not need to complete the unified rate review template. The Letter to Issuers on Federally facilitated and State Partnership Exchanges, published on April 5, 2013, is available at letter to issuers 04052013.pdf. (QHP Webinar Series FAQ #9 05/03/13) Q7: How is preventive care defined in reference to the pediatric oral Essential Health Benefit (EHB) for the purpose of applying the requirement of no cost-sharing? A7: Pediatric oral bene?ts as an EHB category are de?ned by reference to each state?s EHB-benchmark plan. A plan required to cover EHB is expected to offer bene?ts substantially equal to those pediatric oral benefits offered by the EHB-benchmark plan, as set forth in 45 CFR Preventive care must also be covered, with zero 544 Updated 1-31-17 2017-?00644 cost-sharing, but the speci?c preventive care services that are required to be covered are not tied to the state?s EHB-benchmark, but instead to the certain preventive services as required by 45 CFR 147.130. For more information on preventive services that must be covered without cost sharing under the requirements of the Affordable Care Act, please see list.html. (QHP Webinar Series FAQ #10 05/09/13) Q11: If the health plans are using the default 0-20 age band with a single age factor for children between 0-20, may the dental issuer apply separate age bands, such as 0-1, 2- 10, 11-19 (children?s dental only goes to age)? A11: For the purposes of completing the application for certification of stand-alone dental plans in the FFE, stand-alone dental plans must comply with the rating rules in order to fill out the rates table and the associated business rules table, which does not permit for age banding under age 20. Note that stand-alone dental plans, as excepted benefits, have additional ?exibility to adjust premiums based on other rating factors. Please see the excerpt below and pages 31-32 of the Letter to Issuers released on April 5, 2013 at letter to issuers 04052013.pdf, for additional information. Excerpt: "To the extent that stand-alone dental plans qualify as excepted benefits, they are not required to meet the rating rules of PHS Act section 2701(a) that underlie the QHP Rating Tables and business rules template. However, stand-alone dental plans will still need to complete these tables, and based on that information, CMS will display basic, comparable rate information for stand-alone dental plans on the web portal. When a consumer is directed to the stand-alone dental plan issuer to make the initial premium payment to effectuate enrollment, the stand-alone dental plan issuers would have the ability to make any premium adjustments beyond those accounted for in the Rating Tables and based on additional rating factors available to issuers of stand-alone dental plans." (QHP Webinar Series FAQ #10 05/09/13) Q14: The dental benefits in the Plan Benefits template seem very general compared to the benchmark plan. How do I indicate that I cover other benefits or have more specific limits and do I need to enter these at a diagnostic code level? A14: The pediatric dental EHB is determined by the benchmark plan selected by the state, not by the categories of bene?ts in the Plan Bene?ts template. For the purposes of meeting EHB requirements, pursuant to 45 CFR the plan must offer benefits and limits that are substantially equal to the state's EHB benchmark plan. Although the categories of bene?ts may be broader than what is included in the benchmark plan, issuers should ?ll out the template in a manner that best represents the EHB covered by the plan. This does not need to be at a diagnostic code level. An issuer may add additional or more granular bene?ts and limits using the "Other" tab in the plan and bene?ts template. (QHP Dental FAQ updated 05/31/13) Q16: In the plan and benefits template, how should the [pediatric dental] maximums and deductibles be entered if they are different from adults and children as there is only one data ?eld? Updated 1-31-17 A16: Issuers should enter maximums and deductibles in the plan and benefits template that are speci?c to the pediatric dental EHB. There are no regulatory requirements related to the non-EHB adult dental benefits, and therefore, the information necessary for certification that the stand-alone dental plan meets the pediatric dental EHB 545 2017--00645 standards is the information specific to the pediatric dental benefit. For purposes of plan compare, consumers can access additional information about adult benefits through the link to the plan brochure. (QHP Dental FAQ updated 05/31/13) Q: Are carriers required to obtain reasonable assurance that individuals have dental coverage if they choose a medical plan that does not have embedded dental coverage? A: As stated in the Essential Health Bene?t (EHB) ?nal rule (78 FR 12834), with respect to coverage of pediatric dental EHB in the outside market (not in an Exchange or Marketplace) individuals must be offered the full ten EHB categories, including the pediatric dental bene?t. However, in cases in which an individual has purchased stand-alone pediatric dental coverage offered by an Exchange-certi?ed stand-alone dental plan off the Exchange, that individual would already be covered by the same pediatric dental bene?t that is a part of EHB. When an issuer is reasonably assured that an individual has obtained such coverage through an Exchange-certified stand-alone dental plan offered outside an Exchange, the issuer would not be found non-compliant with EHB requirements if the issuer offers that individual a policy that, when combined with the Exchange-certi?ed stand-alone dental plan, ensures full coverage of EHB. We note that the stand-alone dental plan would have to be an Exchange-certi?ed stand-alone dental plan to ensure that it covered the pediatric dental EHB, as required for Exchange certification under section 1311(d)(2)(B)(ii) of the Affordable Care Act. This alternate method of compliance is at the option of the medical plan issuer, and would only apply with respect to individuals for whom the medical plan issuer is reasonably assured have obtained pediatric dental coverage through an Exchange-certified standalone dental plan. The reasonable assurance requirement does not apply to QHP issuers offering coverage on the Marketplace. (REGTAP FAQ Database - FAQ #3496 08/06/14) Embedded Dental 056: Is an issuer required to have a health plan with the pediatric dental EHB embedded for consumers who have not purchased a stand-alone dental plan? Updated 1-31-17 A56: The answer depends on whether the health plan is offered inside or outside of the Exchange. Inside of the Exchange: As stated in the Issuers of Stand-alone Dental Plans: Intent to Offer in FFE States document available at: ?The Affordable Care Act also permits a health plan that does not provide the pediatric dental EHB to be certified as a qualified health plan (QHP) eligible for Exchange participation so long as such Exchange offers at least one stand- alone dental plan. In order to allow QHP issuers to exercise the statutory option to omit the pediatric dental essential health bene?t (EHB), CCIIO established a voluntary reporting process for dental issuers to communicate their intent to offer pediatric dental EHB through stand-alone dental plans in Exchanges. Given that there are at least three issuers planning to offer such plans in both markets statewide, we believe that HHS can reasonably expect there to be suf?cient stand-alone dental coverage to permit QHPs in the FFE in these states to omit the pediatric dental EHB if they choose to do so." The EHB ?nal rule, published 2/25/13 at 78 FR 12834, further clari?es: ?Nothing in this rule 546 2017--00646 requires the purchase of the full set of EHB if the purchase is made through an Exchange. Thus, in an Exchange, someone (with a child or without) can purchase a QHP that does not cover the pediatric dental EHB without purchasing a stand-alone dental plan.? Outside of the Exchange: As stated in the EHB ?nal rule available at ?The Affordable Care Act does not provide for the exclusion of a pediatric dental EHB outside of the Exchange as it does in section 1302(b)(4)(F) of the Affordable Care Act for QHPs. Therefore, individuals enrolling in health insurance coverage not offered on an Exchange must be offered the full ten EHB categories, including the pediatric dental bene?t. However, in cases in which an individual has purchased stand-alone pediatric dental coverage offered by an Exchange-certi?ed stand-alone dental plan off the Exchange, that individual would already be covered by the same pediatric dental bene?t that is a part of EHB. When an issuer is reasonably assured that an individual has obtained such coverage through an Exchange- certi?ed stand-alone dental plan offered outside an Exchange, the issuer would not be found non-compliant with EHB requirements if the issuer offers that individual a policy that, when combined with the Exchange-certi?ed stand-alone dental plan, ensures full coverage of EHB. We note that the stand-alone dental plan would have to be an Exchange-certi?ed stand-alone dental plan to ensure that it covered the pediatric dental EHB. This alternate method of compliance is at the option of the medical plan issuer, and would only apply with respect to individuals for whom the medical plan issuer is reasonably assured have obtained pediatric dental coverage through an Exchange-certified stand- alone dental plan." (QHP Webinar Series FAQ #4 04/16/13) Q17: Will issuers be required to file a separate network name for products that have embedded dental? A17: Issuers are not required to file a separate network for products that have embedded dental. The Network ID for a network with dental providers can be used for both QHPs with embedded dental and QHPs without embedded dental. However, if the issuer would like to offer a QHP with a network including dental providers, and a second QHP with a network that excludes those providers, then the issuer will need to set up two different network IDs. (QHP Webinar Series FAQ #6 04/23/13) Q8: If the pediatric benefits have to be embedded, do they have to track to a single combined deductible and out-of-pocket max? Updated 1-31-17 A8: According to the EHB Final Rule, when the pediatric dental benefit is embedded in a health insurance plan subject to standards set forth in 45 CFR 156.130 and 156.140, HHS does not distinguish it from other benefits with respect to AV and cost-sharing requirements. The dental benefit can have a separate deductible and/or maximum out- of-pocket as long as the total combined with medical does not exceed what is allowed by the statute. (QHP Webinar Series FAQ #9 05/03/13) 547 2017-?00647 Q11: If an issuer offers a plan with pediatric dental carved out and an identical plan that includes pediatric dental coverage, should these plans have the same actuarial value for metal-level determination? Should issuers adjust the AV results for pediatric benefits? A11: Although they are not separate calculator inputs, the AV Calculator does include both pediatric dental and vision claims as part of the standard population. However, a plan's inclusion of the pediatric dental benefit generally will not result in a material difference in AV because both cost and utilization are low in the standard population. Therefore, in most cases there will be no need to adjust the AV results. (QHP Webinar Series FAQ #9 05/03/13) Q12: For an integrated pediatric dental and medical plan, is it permitted to establish two separate buckets for the out-of?pocket limit for medical and dental coverage as long as the total out-of-pocket limit does not exceed the QHP limit? A12: Yes, that would be permitted. (QHP Webinar Series FAQ #9 05/03/13) Q10: For Exchange plans with an embedded dental benefit, is the dental carrier allowed to use different geographic area factors and/or network factors than the health plan geographic area and network factors? A10: No, this is not permissible. (QHP Webinar Series FAQ #10 05/09/13) Q27: What is the difference between an embedded pediatric dental benefit and a bundled pediatric dental benefit? A27: The pediatric dental benefit is considered embedded in a medical plan when it is offered like any other benefit under same premium and included in the same AV calculation for that medical plan. Although the medical plan issuer may contract with a dental issuer to offer the pediatric dental benefit the dental benefits provided under the contract would only be considered embedded if the medical plan issuer fully assumes all risks and liabilities of covering the dental bene?t. A medical plan with an embedded dental bene?t provided under contract would be considered a single plan for purposes of calculating the out-of?pocket maximum and actuarial value. Under a bundled arrangement, a medical plan issuer would pair with a stand-alone dental plan to offer the pediatric dental bene?t. The issuer of each of these plans would assume the risks and liabilities associated with providing coverage under its own plan. In this situation, the medical plan and the stand-alone dental plan would each be considered a separate plan, with the stand-alone dental plan considered an excepted bene?t under title XXVII of the Public Health Service Act. Accordingly, each plan would be held to applicable standards, including those related to the COP maximum and actuarial value. (QHP Webinar Series FAQ #10 05/09/13) Q15: Within the Exchange, is it considered two plans if we offer a plan with and without embedded dental? A15: Yes, for purposes of QHP certification these would be considered two plans. (QHP Webinar Series FAQ #12 06/28/13) 548 Updated 1-31-17 2017--00648 Q16: How will plans with an embedded pediatric dental EHB apply for certification in the A16: If pediatric dental benefits are embedded in the QHP, then the pediatric dental EHB would be treated like any other bene?t for the purposes of premiums, AV, and out-of- pocket maximums for purposes of the FFE certification application. The pediatric dental EHB is considered embedded if the medical plan is also collecting the premium for the dental bene?ts, includes the dental benefits as part of its contract, and is legally liable for the claims experience of the dental coverage. This can be achieved through a subcontractual agreement; the key feature is the party that is legally responsible for the claims. (QHP Webinar Series FAQ #12 06/28/13) Q: Is there any guidance or information about pediatric dental in stand-alone plans outside of the Marketplace? A: The Stand-alone Dental Plan guidance is posted on REGTAP in the QHP Instructions, Chapters 13 and 15. (REGTAP FAQ Database - FAQ #1335 03/31/14) Q7: Must issuers that offer on-Marketplace plans without pediatric dental offer an identical off-Marketplace plan? A7: In the preamble to the proposed rule, HHS Notice of Benefit and Payment Parameters for 2016, published in the Federal Register on November 26, 2014 (79 FR 70674), CMS explained the following with respect to the guaranteed availability requirement: "We note that an exception to the requirement that QHP must be guaranteed available and renewable outside the Exchange arises from the statutory permission for QHPs offered through the Exchange or SHOP to omit coverage of the pediatric dental EHB where a stand-alone dental plan offering the pediatric dental EHB is offered through the Exchange or SHOP. This is not similarly permitted when the plan is offered outside the Exchange or SHOP. This results in certain QHPs only being legally available in the market when offered through the Exchange or SHOP. If the QHP omits coverage of the pediatric dental EHB, the issuer would not be required to offer, renew, or continue enrollment in the QHP outside the Exchange, but could do so, at the enrollee?s option, if the issuer is ?reasonably assured? that the enrollee has obtained such coverage through an Exchange-certi?ed stand-alone dental plan.? See 79 FR 70710, footnote 31, available at (Issuer Outreach FAQ #1 (10/27/15)) Stand-alone Dental Q15: The Exchange final rule, published last year, implements the prohibition on annual and lifetime limits on pediatric dental EHB. How does that work in a stand-alone dental plan? Updated 1-31-17 A15: The pediatric dental EHB may not have annual and lifetime limits applied to it even when offered through a stand-alone dental plan. (See If stand- alone dental plans offer other benefits in addition to the pediatric dental EHB, such as adult bene?ts, the issuer may impose annual and lifetime limits on those bene?ts. (Plan Management Webinar 01/24/13) 549 2017--00649 Q16: The statute says that if there is a stand-alone dental plan in the Exchange, then QHPs in that Exchange are allowed to omit the pediatric dental EHB from their coverage. How will this work? A16: In the Paper Reduction Act (PRA) package released last year (OMB control number 0938-1174), CMS requested that stand-alone dental plans voluntarily report if they intended to offer stand-alone dental plans in Exchanges by state and market. CMS has the results of the voluntary reports and has made them available for states in which FFEs will operate at 28-13.pdf. (Plan Management Webinar 01/24/13) Q27: Do APTC and CSR apply to stand-alone dental plans? A27: APTCs may apply to cover the portion of a stand-alone dental plan premium attributable to coverage of the pediatric dental EHB. Section 155.340 of the ?nal Notice of Benefit and Payment Parameters for 2014, published on March 11, 2013 at 78 FR 15410, requires that the APTC be allocated to the stand-alone dental plan only after being allocated to the medical QHP plan. CSRs do not apply to stand-alone dental plans. (Plan Management Webinar 01/24/13) Q33: Do various market reforms that fall under the Public Health Service (PHS) Act also apply to stand-alone dental plans? A33: Stand-alone dental plans are considered excepted health bene?ts and, as such, title XVII of the PHS Act does not apply. More information on this can be found in the draft Issuer Letter on page 29. (Plan Management Webinar 01/24/13) Q35: What is the application process for stand-alone dental plans? Is the application to be offered through the Exchanges the same as for medical A35: For the FFE, the application process will be similar for stand-alone dental plans. It will involve many of the same things in the QHP application, with slight modifications to accommodate the unique features of stand-alone dental plans. (Plan Management Webinar 01/24/13) Q36: If a stand-alone dental plan is offered outside of the Exchanges, are carriers allowed to exclude coverage of the pediatric dental EHB in their plans offered outside the Exchanges? A36: In the preamble to the ?nal EHB rule, at 78 FR 12853, we explain that if an issuer is reasonably assured that an individual has purchased an Exchange-certified stand-alone dental plan, an issuer that is otherwise required to cover EHB could offer that individual a plan that excludes the pediatric dental EHB. (Plan Management Webinar 01/24/13) 550 Updated 1-31-17 2017--00650 Q37: When the APTC is calculated, will it take into account the premiums for a stand- alone dental plan to cover the pediatric dental EHB if the second lowest cost silver plan omits coverage of this category of EHB, or will the APTC be calculated using only the EHB covered by the second lowest cost silver plan? A37: No. The APTC is based on the second lowest cost silver plan on the Exchange regardless of whether that plan offers dental coverage or not. (Plan Management Webinar 01/24/13) 05: Will there be benefit and rate templates specific for stand-alone pediatric dental plans? A5: For the FFE, we are planning to use a modi?ed bene?ts template for stand-alone dental plans. (Plan Management Webinar QHP FAQ #1 04/08/13) 08: Can stand-alone dental plans submit actuarial certification to demonstrate that they meet the high or low Actuarial Value A8: Yes, according to of the final EHB rule, found at 78 FR 12869, in order to demonstrate that stand-alone dental plan AV standards are met, an actuarial certification is required. (Plan Management Webinar QHP FAQ #1 04/08/13) Q13: Do the rating reforms apply to stand-alone dental plans? A13: Stand-alone dental plans are not subject to Parts A and of the Public Health Service Act. Please reference Chapter 4 of the Letter to Issuers referenced above for a more detailed explanation. (Plan Management Webinar QHP FAQ #2 04/09/13) The answer to this FAQ was revised and re-re/eased on the REG TAP database on 6/11/14: A: Stand-alone dental plans are not subject to Parts A and of the Public Health Service Act, and therefore are not subject to market reform rating rules. (REGTAP FAQ Database - FAQ #2152 06/11/14) 021: When creating a stand-alone dental plan, no functionality appears to change in the EHB section. The EHBs do not apply and most of the benefit information is geared toward the medical products. A21: The Plans and Benefits template will be updated to simplify the data submission for stand-alone dental by approximately May 15, 2015. A testing version will be made available prior to that. There will be a later submission window to accommodate stand- alone dental applications. (QHP Webinar Series FAQ #5 04/18/13) 022: Do dental plans need to offer child-only plans? How should the field regarding child-only be answered in the plan and bene?ts template? A22: As stated in the Exchange final rule released March 27, 2012, stand-alone dental plans need to comply with the requirement to offer child-only coverage. The ?nal rule explains that 45 CFR would apply the standard of 45 CFR to offer a child-only plan to stand-alone dental plans certi?ed to be offered through the 551 Updated 1-31-17 2017--00651 Exchange. Please see number 14 and 15 on page 10-8 in the instructions for ?lling out the child only field in the plan and benefits template, found here: management data instructions ch10.pdf. If an Issuer assures that child enrollees would be treated equally under a QHP as they would be under a child-only plan, such that there would be no substantive difference between having a child-only plan and issuing child-only policies under the QHP same premium rating), then the issuer does not need to ?le a separate child-only plan. Separate child-only plans are not required for the Federally-facilitated Exchange (FFE) as long as the QHP indicates it will accept child-only enrollees. Also, note that the plan and bene?ts template for stand-alone dental plans will not be ?nalized until May, as described in the final Letter to Issuers available at letter to issuers 04052013.pdf. (QHP Webinar Series FAQ #5 04/18/13) 06: Can the Exchange-certified stand-alone dental plan and medical plan have separate deductibles and out-of-pocket maximums (provided the Exchange-certified stand-alone dental plan amounts are determined to be "reasonable")? A6: According to the Letter to Issuers, under 45 CFR 156.150, rather than meeting the speci?c dollar limits that apply to comprehensive medical QHPs, stand-alone dental plans offered inside an Exchange will be required to demonstrate to the Exchange (FFE or othenivise) that they have a reasonable annual limitation on cost-sharing in place. The ?nal rule also clarified that the Exchange is responsible for determining the level for ?reasonable.? For 2014 in the FFE, the annual out-of?pocket maximum for a stand-alone dental plan is $700 for one child and $1,400 for two or more children. The Letter to Issuers on Federally-facilitated and State Partnership Exchanges, published on April 5, 2013, is available at letter to issuers 04052013.pdf (QHP Webinar Series FAQ #9 05/03/13) 09: Is there an AV Calculator for stand-alone dental? A9: As described in 45 CFR a stand-alone dental plan may not use the AV Calculator, and instead must demonstrate that the stand-alone dental plan offers the pediatric dental EHB at either a low level of coverage with an AV of 70 percent or a high level of coverage with an AV of 85 percent, and within a de minimis variation of percentage points. In order to meet this standard, the AV level of coverage for stand- alone dental plans must be certi?ed by a member of the American Academy of Actuaries using generally accepted actuarial principles. (QHP Webinar Series FAQ #9 05/03/13) Q13: What certification, if any, is required for a stand-alone dental plan? Updated 1-31-17 A13: Please refer to Chapter 4 of the Letter to Issuers for details on the certification requirements. The Letter to Issuers on Federally-facilitated and State Partnership Exchanges, published on April 5, 2013, is available at letter to issuers 04052013.pdf. (QHP Webinar Series FAQ #9 05/03/13) 552 2017--00652 Q14: Where can issuers ?nd information about stand-alone dental plans submitting intent to participate in A14: Information about the intent to participate in the FFE by stand-alone dental plan issuers can be found here: reporting-Iist-1-28-13.pdf (QHP Webinar Series FAQ #9 05/03/13) Q15: When will the stand-alone dental plan templates be finalized? A15: As stated in the Letter to Issuers: "Stand-alone dental plans will generally use the same QHP Application, but will complete and submit the application on an adjusted timeline. Some portions of the QHP certi?cation application require modifications to accommodate the limited scope of stand-alone dental plans. For the 2013 QHP certification cycle, HHS anticipates that the draft plan bene?ts template will be ready for stand?alone dental plans by May The Letter to Issuers on Federally-facilitated and State Partnership Exchanges, published on April 5, 2013, is available at letter to issuers 04052013.pdf (QHP Webinar Series FAQ #9 05/03/13) Q16: What is the submission window for stand-alone dental plans? A16: As stated in the Letter to Issuers: ?Issuers of stand-alone dental plans can begin to work on completing the other QHP templates in advance of May; however, ?nal submission of stand?alone dental plan applications will need to occur between May 15 and May 31." The Letter to Issuers on Federally-facilitated and State Partnership Exchanges, published on April 5, 2013, is available at letter to issuers 04052013.pdf (QHP Webinar Series FAQ #9 05/03/13) Q17: Can the required pediatric dental EHB be a stand-alone dental plan? A17: The pediatric dental EHB can be offered through a stand-alone dental plan in the Exchange. (QHP Webinar Series FAQ #9 05/03/13) Q34: How can a State identify the issuers that have reported that they intend to offer stand-alone dental plans in the Exchange? A34: At we explained how dental issuers voluntarily reported their intent to offer stand-alone dental coverage and we provided a list of states and how many issuers in each state intend to offer stand-alone coverage. (QHP Webinar Series FAQ #9 05/03/13) Q5: Are pre-existing condition exclusions permitted on stand-alone pediatric dental plans? A5: Yes. Stand-alone dental plans are not subject to Public Health Service Act 2704 - Prohibition of Preexisting Condition Exclusions or Other Discrimination Based on Health Status. Therefore, for the purposes of Exchange certi?cation, CMS will not be publishing guidance on look-back periods; rather, applicable Federal and State laws apply. (QHP Webinar Series FAQ #10 05/09/13) 553 Updated 1-31-17 2017--00653 06: Are issuers allowed to include a 24-month waiting period for orthodontia services (currently part of the FEDVIP benchmark) for both stand-alone pediatric dental and an embedded medical product that includes the pediatric dental A6: Yes, this is permissible. (QHP Webinar Series FAQ #10 05/09/13) Q4: Do health plans outside of the Exchange need to cover the pediatric dental How would that work with stand-alone dental plans outside of the Exchange? A4: The EHB final rule (78 FR 12834) stated the following with respect to coverage of pediatric dental EHB in the outside market: ?The Affordable Care Act does not provide for the exclusion of a pediatric dental EHB outside of the Exchange as it does in section 1302(b)(4)(F) of the Affordable Care Act for QHPs. Therefore, individuals enrolling in health insurance coverage not offered on an Exchange must be offered the full ten EHB categories, including the pediatric dental benefit. However, in cases in which an individual has purchased stand-alone pediatric dental coverage offered by an Exchange- certified stand-alone dental plan off the Exchange, that individual would already be covered by the same pediatric dental bene?t that is a part of EHB. When an issuer is reasonably assured that an individual has obtained such coverage through an Exchange- certified stand-alone dental plan offered outside an Exchange, the issuer would not be found noncompliant with EHB requirements if the issuer offers that individual a policy that, when combined with the Exchange-certified stand-alone dental plan, ensures full coverage of EHB. HHS notes that the stand-alone dental plan would have to be an Exchange-certi?ed stand-alone dental plan to ensure that it covered the pediatric dental EHB, as required for Exchange certification under section 1311(d)(2)(B)(ii) of the Affordable Care Act. However, the Exchange-certi?ed stand- alone dental plan would not need to be purchased through an Exchange. This alternate method of compliance is at the option of the medical plan issuer, and would only apply with respect to individuals for whom the medical plan issuer is reasonably assured have obtained pediatric dental coverage through an Exchange-certi?ed stand- alone dental plan." (QHP Dental FAQ #1 05/13/13) [Note ?the 05/31/13 update to the Dental FAQ #1 re-Iabels this FAQ as Q5 and the following FAQ as Q4. CMS also re-re/eased this FQ as REGTAP FAQ Database - FAQ #2148 06/11/14] Q1: Can an issuer be certified to offer stand-alone dental plans only off of the Exchange? Updated 1-31-17 A1: If an issuer would like to offer a stand-alone dental plan only off of the Exchange in a state with a Federally-facilitated Exchange but receive Exchange certi?cation that it meets standards related to the pediatric dental essential health benefits, then the issuer must select the ?off Exchange? option in the dental-speci?c plan and benefits template. To be considered the issuer of the stand-alone dental plan must complete the certi?cation process up the point of signing the agreement. This process would provide a stand-alone dental plan with the ?Exchange-certified? status outlined in the EHB ?nal rule where a health insurance issuer could offer a health plan without the pediatric dental EHB to an individual if the issuer is reasonably assured that the individual has obtained pediatric dental EHB coverage through an Exchange-certified stand-alone dental plan. (QHP Dental FAQ #1 05/13/13) 554 2017--00654 02: What benefits are required to be included in stand-alone dental plans? A2: In order to be certi?ed, all stand-alone dental plans must cover the pediatric dental essential health bene?ts, as required in the Affordable Care Act. As outlined in section 156.150 of the EHB final rule, a stand?alone dental plan must offer the pediatric dental EHB but may offer additional bene?ts, which could include non-pediatric coverage. We note that only the pediatric dental bene?t, and not any non-pediatric coverage, would be subject to EHB standards, including complying with the requirement to offer benefits that are substantially equal to the benchmark and meeting AV and out-of?pocket limit requirements for stand-alone dental plans. Stand-alone dental plans that are submitted without coverage of the pediatric dental EHB will not be certified. State-speci?c benchmarks for the pediatric dental benefit are listed in the EHB ?nal rule. We note that a stand-alone dental plan could enroll adults only in a family plan. All of the templates for the certi?cation application are the same for stand-alone dental plans as for QHPs, except for the modi?ed plan and benefits template. These templates, including the dental plan and benefits template, are available on and SERFF. (QHP Dental FAQ #1 05/13/13) [Note ?the 05/31/13 update to the Dental FAQ #1 re- labels this FAQ as Q3 and the following FAQ as Q3: What parts of the Federally-facilitated Exchange certification application do stand- alone dental plan issuers complete? A3: Issuers of stand-alone dental plans must complete all sections of the QHP application for stand-alone dental plans in the FFE, except for the pharmacy template, the accreditation template, and the uni?ed rate review template. Issuers should use the dental plan and benefits template 1.32 or later in order to activate the modi?cations that are speci?c to stand-alone dental plans. More information on what parts of the application apply to stand-alone dental plans can be found in three documents: 1) a chart titled ?Application requirements related to stand-alone dental plans? posted on Regtap on April 18, 2013; 2) the presentation ?Stand-alone Dental Plans Applying for Certification in the posted on 05l02l13; and, 3) Chapter 4 of the Letter to Issuers letter to issuers 04052013.pdf). (QHP Dental FAQ #1 05/13/13) 05: How do rating tables and rating business rules apply to stand-alone dental plans? Updated 1-31-17 A5: For the purposes of completing the application for certi?cation of stand-alone dental plans in the FFE, stand-alone dental plans must complete the rates table and associated business rules table according to the rating rules. Stand-alone dental plans, as excepted benefits, have additional ?exibility to adjust premiums based on other rating factors. The modi?ed dental plan and benefits template will have a data field in which dental issuers will indicate whether they are committing to the rates in the template, and thereby voluntarily complying with the rating rules, or whether the issuer reserves the right to make further premium adjustments. The plan display will indicate to consumers whether the premium displayed for stand-alone dental plans is a guaranteed rate or an estimated rate. Please see pages 31-32 of the letter to issuers for additional information letter to issuers 04052013.pdf). (QHP Dental FAQ #1 05/13/13) 555 2017--00655 06: What if a stand-alone dental plan does not contract with any of the essential community providers listed on the dental ECP list, or contracts with the dentists at those facilities directly but not with the facility itself? A6: Only facilities should be listed on the ECP template, not individual providers. If an issuer of a stand-alone dental plan does not believe the ECP standard can be met due to the limited number of dental-specific ECP providers, then the issuer should submit a narrative justification using the ECP Supplemental Response Form to describe why the standard cannot be met and how the existing network would provide access for low- income and medically underserved populations. If an issuer of a stand-alone dental plan contracts with ECP-like providers, but not the facilities listed on the list, then this should also be described in the ECP Supplemental Response Form. For the submission of the ECP template, please follow the instructions for entering ?dummy data" on page 9 of the Chapter 7 Instructions for the Essential Community Providers Application section if you do not have any dental ECPs to submit. The Chapter 15 SADP Application Instructions also contains additional information. (QHP Dental FAQ #1 updated 05/31/13) 06: If an issuer has not submitted a medical QHP application yet, can the issuer submit medical and stand-alone dental plan applications during the dental plan window? A6: Applications for medical QHP were due to the FFM on May 3, 2013. The stand-alone dental submission window is available only for the submission of stand-alone dental plans. Issuers of QHPs who have already submitted QHP applications can use the stand-alone dental submission window to add information related to dental to their existing QHP applications where appropriate, but the addition of QHPs is not allowed. The document titled ?Application requirements related to stand-alone dental plans? that was posted to Regtap on April 18, 2013 outlines how stand-alone dental plan information should be added to QHP applications that have already been submitted. (QHP Dental FAQ #1 05/13l13) [Note ?the 05/31/13 update to the Dental FAQ #1 re-labels this FAQ as Q7: Because the windows overlap, what should issuers do if they are submitting changes for the Limited Correction Window but also want to add information to the existing QHP applications for stand-alone dental plans? A7: Issuers that have received noti?cation from CMS that they should make certain data corrections during the Limited Correction Window should make the changes and resubmit the complete QHP applications between May 20 22nd. After the QHP submissions are processed, the issuer should then proceed with the process of re- opening the applications to start adding information related to stand-alone dental plans. The application must then be resubmitted with all information for stand-alone dental plans by June 5th. (QHP Dental FAQ #1 05/13/13) [Note ?the 05/31/13 update to the Dental FAQ #1 re-labels this FAQ as 09: What are the constraints on stand-alone dental plans when filling out the rating tables? Updated 1-31-17 A9: The rating tables should be ?lled out according to federal requirements and any applicable state law. As described in the FAQ released on May 10, 2013, because dental is an excepted benefit, issuers then have the option to indicate whether the release is ?guaranteed" or ?estimated" in the plan and bene?ts template. Please see 556 2017--00656 page 31 of the Letter to Issuers for more detail on the estimated/guaranteed rate distinction. (QHP Dental FAQ #1 updated 05/31/13) Q10: Is the dental application window the same for issuers seeking certi?cation for off- Exchange stand-alone dental plan products only? A10: All applications for certification of stand-alone dental plans in states with a Federally-facilitated Marketplace must be submitted between May 20 and June 5, 2013. (QHP Dental FAQ #1 updated 05/31/13) Q11: Does a stand-alone dental plan have to use the Chapter 13m SADP Actuarial Value form? A11: Issuers of stand-alone dental plans must provide documentation that the actuarial values submitted in the plan and bene?ts template were based on analyses conducted by a member of the American Academy of Actuaries and were performed in accordance with generally accepted actuarial principles and methodologies. The Chapter 13m contains the minimum information needed for certi?cation and serves as a template for the actuarial value documentation, but issuers could provide alternate documentation that provides the same information. (QHP Dental FAQ updated 05/31/13) Q12: To what extent should issuers of stand-alone dental plans enter information for adult dental benefits? A12: For purposes of filling out the rating tables and plan and bene?t template for off- Exchange plans, we recommend entering the rates and benefits as you intend to offer the plan, which could be as a child-only plan or as a family plan that includes adult coverage. The FFM will certify submitted plans based on whether they meet the minimum standards for certi?cation for stand-alone dental plans, particularly the pediatric dental EHB. Because adult bene?ts are not considered EHB, there are no specific federal bene?t and rate requirements. The amount of plan-level information included for such bene?ts is at the discretion of the issuer. (QHP Dental FAQ updated 05/31/13) Q13: With respect to the Rates Template for QHP Application submission, how should stand-alone dental plans complete the tables for the pediatric under 19 rates? There appears to only be an option of 0-20 in the drop-down column for "Age". A13: Stand-alone dental plans should enter their 0-18 rate in the 0-20 column of the rating tables. If the issuer chooses to indicate a guaranteed rate, the 0-18 rate will be the rate charged for 19 and 20-year olds as well. Note that the rates for 19 and 20 year olds can be averaged into the overall rate for that age band. In addition, there is no requirement to offer EHB coverage to individuals over 18 or the pediatric age set by your state, so while the rate will be encompassed in the age band the benefits can be different. Dental issuers may also identify the rates as ?estimated? and charge a different premium before the consumer effectuates enrollment. Please see page 31 of the Letter to Issuers for more detail on the estimated/guaranteed rate distinction. (QHP Dental FAQ updated 05/31/13) 557 Updated 1-31-17 2017--00657 Q15: What information needs to be provided for the EHB Apportionment field in the plan and benefits template for stand-alone dental plans? A15: Issuers of stand-alone dental plans in the individual market should enter into the EHB Apportionment field the dollar amount that re?ects the portion of the premium allocable to the pediatric dental essential health bene?t. The dollar amount should re?ect the statewide average amount for that plan. This number will be used to determine the amount of the advance payment of the premium tax credit under 45 CFR The issuer of the stand-alone dental plan also needs to submit the Chapter 13n Description of EHB Allocation form as a supporting document. (QHP Dental FAQ updated 05/31/13) Q17: As URAC and NCQA accreditation does not apply to stand-alone dental plans, can a stand-alone dental issuer offering no QHPs answer "No" to accreditation questions and not be subject to certification denial? A17: The QHP certi?cation requirement to have URAC or NCQA accreditation does not apply to stand-alone dental plans, so an Issuer offering only dental plans should answer ?No? to the accreditation questions. This will not be considered a de?ciency in the application. Outside of the Exchange, any applicable state laws regarding accreditation would apply. (QHP Webinar Series FAQ #12 06/28/13) Q18: If an issuer offers a stand-alone dental plan, can it set up the business rule or eligibility rules to ensure that only consumers that have selected the issuer?s medical policy can purchase the dental plan? A18: In the FFE, an issuer will not be able to tie enrollment between a QHP and a stand- alone dental plan. (QHP Webinar Series FAQ #12 06/28/13) Q: If a parent enrolls several children in one Stand-alone Dental product but not themselves, is each child sent as a separate subscriber or is this sent as one enrollment group, and who is designated as the subscriber? A: If the dental plan allows one sibling to be the dependent of another, all the children can be in one enrollment group, with the youngest child identi?ed as the subscriber. If the dental plan does not allow a sibling to be a dependent, each child will be enrolled as a subscriber in their own individual enrollment groups. (REGTAP FAQ Database - FAQ #407 11/22/13) Q: Can an issuer be certified to offer stand-alone dental plans only off of the Marketplace? A: If an issuer would like to offer a stand-alone dental plan only off of the Marketplace in a state with a Federally-facilitated Exchange but receive Exchange certi?cation that it meets standards related to the pediatric dental essential health benefits, then the issuer must select the ?off Exchange? option in the dental-speci?c plan and benefits template. To be considered ?Exchange-certified," the issuer of the stand-alone dental plan must complete the certi?cation process up the point of signing the agreement. This process would provide a stand-alone dental plan with the ?Exchange-certified? status outlined in the EHB ?nal rule where a health insurance issuer could offer a health plan without the pediatric dental EHB to an individual if the issuer is reasonably assured that the 558 Updated 1-31-17 2017--00658 individual has obtained pediatric dental EHB coverage through an Exchange-certified stand-alone dental plan. (REGTAP FAQ Database - FAQ #2151 06/11/14) Q: When will CMS release guidance for Stand-alone Dental Plans (SADPs) Recerti?cation and Guaranteed Availability? A: CMS released guidance related to SADP recertification in the Exchange and Insurance Market Standard for 2015 and Beyond Final Rule SADPs, as excepted benefits. are not subject to guaranteed availability standards. However as stated in the Final Rule, CMS is borrowing the uniform modi?cation of coverage test for the purposes of recerti?cation of SADPs. (REGTAP FAQ Database - FAQ #2639 07/03/14) Q: How is the Essential Health Benefit (EHB) apportionment for a child-only stand-alone dental plan (SADP) determined? A: For SADPs, the EHB apportionment is re?ective of the issuer's average EHB apportionment state-wide, but cannot be more than the lowest premium for that plan in any area. It should represent the dollar amount of the portion of the expected premium allocated for the pediatric dental EHB. (REGTAP FAQ Database - FAQ #2964 07/23/14) Q: What is a bundled medical and dental plan? A: Under a bundled arrangement, a medical plan that does not include pediatric dental services pairs with a stand-alone dental plan (SADP) to offer pediatric dental bene?ts. The bundle appears as just one plan to the consumer, so the consumer does not have to purchase two different plans and the consumer pays one premium. The issuer of each of these plans assumes the risks and liabilities associated with providing coverage under its own plan. In contrast, if a plan has embedded dental services, then the issuer assumes the risks and liabilities of both medical and dental coverage. In a bundled arrangement the medical plan and the SADP would each be considered a separate plan, with the SADP considered an excepted bene?t under Title of the Public Health Service Act. Accordingly, each plan would be held to applicable standards, including those related to the out-of-pocket maximum and actuarial value. Currently, the FFM does not certify bundled medical and dental plans. Some SBMs do allow these arrangements, so issuers in a state with an SBM should check with their state regulators. (REG TAP FAQ Database - FAQ #2949 07/22/14) 05: How are Stand-alone Dental Plans (SADPs) to use the Actuarial Value (AV) Calculator for coinsurance default percentages? Updated 1-31-17 A5: As established under 45 CFR SADPs may not use the AV Calculator. SADP issuers determine the level of coverage using an actuarial certification from a member of the American Academy of Actuaries using generally accepted actuarial principles. (QHP Certi?cation Process FAQs #1 (09/29/15) 559 2017--00659 Q18: Do 2015 Stand-alone Dental Plans (SADPs) sold outside the Federally-facilitated Marketplace seeking recertification for 2016 need to resubmit all application materials? A18: Issuers seeking recerti?cation, including SADPs sold outside of the Marketplace, should submit all information required under the 2016 QHP Application. (QHP Certi?cation Process FAQs #1 {09/29/15) Q19: Can the Centers for Medicare Medicaid Services (CMS) provide guidance whether off-Marketplace Stand-alone Dental Plans (SADPs) can use the same Plan and Product IDs that were used in 2015, and recertify the same IDs, or create new plans? A19: Issuers should use the same HIOS Plan ID if the same plan was offered in the previous plan year and remains available for the upcoming 2016 plan year. In the 2015 Letter to Issuers in the Federally-facilitated Marketplaces (2015 Letter to Issuers), we indicated that we will apply the guaranteed renewability standards to determine whether a plan offered in 2014 is the same plan for purposes of recertifying the plan for sale in 2015 through the Federally-facilitated Exchange, and that this standard would also apply to the determination of whether SADPs are being renewed for purposes of recerti?cation. This is merely using the uniform modi?cation standard for the purpose of identifying SADPs that can be recerti?ed and renewed, rather than certi?ed as different plans from those that were Exchange-certi?ed in 2014. (QHP Certi?cation Process FAQs #1 {09/29/15) 020: How can off-Marketplace Stand-alone Dental issuers offer products on the Marketplace? A20: Stand-alone Dental Plans (SADPs) must complete a Quali?ed Health Plan (QHP) Application and have that application approved to participate on-Marketplace. (QHP Certi?cation Process FAQs #1 {09/29/15) Q21: How should Stand-alone Dental Plan (SADP) issuers report the Essential Health Benefit (EHB) allocation amounts? A21: Issuers must refer to Chapter 15 instructions for guidance on allocation amounts, online at: Certi?cation Process FAQs #1 {09/29/15) 022: Does the Centers for Medicare Medicaid Services (CMS) require embedded Pediatric Dental benefits for off-Marketplace plans? A22: The Affordable Care Act does not provide for the exclusion of the pediatric dental essential health bene?t (EHB) outside of the Marketplace, as it does in section 1302(b)(4)(F) of the Affordable Care Act for qualified health plans (QHPs). Therefore, individuals enrolling in off-Marketplace coverage must be offered the full ten EHB categories, including the pediatric dental benefit. However, in cases in which an individual has purchased stand-alone pediatric dental coverage offered by an Exchange- certified stand-alone dental plan, that individual would not have to purchase a plan with 560 Updated 1-31-17 2017--00660 the pediatric dental bene?t embedded. This alternate method of compliance is at the option of the medical plan issuer, and would only apply with respect to individuals for whom the medical plan issuer is reasonably assured have obtained pediatric dental coverage through an Exchange-certified stand- alone dental plan. If the issuer does not have this reasonable assurance, it must embed the bene?t. (QHP Certi?cation Process FAQs #1 (09/29/15) Q4: How can Stand-alone Dental Plans (SADPs) determine which Indian health care providers on the non-exhaustive HHS Essential Community Provider (ECP) List offer dental services? A4: Issuers can identify Indian health care providers that offer dental services by searching the Indian worksheet within the ECP List for the word ?dental? and searching the Dental worksheet within the ECP List for the words ?Indian" or ?Tribe." (QHP Certi?cation Process FAQs #3 {09/29/15)} Q5: How do Stand-alone Dental Plans (SADPs) track and report Essential Community Provider (ECP) contract offers, regardless of whether the offer is accepted, pending, or dec?ned? A5: Issuers can use the ECP tool to track executed ECP contracts. Issuers should internally track the full universe of their ECP contract offers those that were accepted, declined, or are pending), and be prepared to report such contract offers to CCIIO upon request to address consumer access concerns that may arise. (QHP Certification Process FAQs #3 {09/29/15)} Q8: Must off-Marketplace Stand-alone Dental Plans (SADPs) complete the new Marketplace Name and Marketplace Customer Service fields in the Health Insurance Oversight System A8: No, off-Exchange SADPs do not complete those fields. (Issuer Outreach FAQ #1 (10/27/15)) Q2: Can plans that include the pediatric dental Essential Health Benefit (EHB) and plans that omit the pediatric dental EHB be included under the same product? A2: No. The definitions of product and plan are established in 45 C.F.R. 144.103. Under these de?nitions, a product is a discrete package of health insurance coverage benefits covered services), and a plan is the pairing of the benefits covered under the product with a particular cost-sharing structure, provider network, and service area. The product comprises all plans offered with those characteristics. Therefore, to be part of the same product, all plans within that product must have exactly the same set of covered benefits, and any differences in covered benefits, such as differences in coverage of the pediatric dental EHB, by de?nition, constitute separate products. (Issuer Outreach FAQ #2 (10/27/15)) Q: Are Exchange-certified Stand-alone Dental Plans offered Off-Exchange permitted to accept enrollments outside the Exchange enrollment periods? Yes. Nothing in CMS regulations prohibits Exchange-certified stand-alone dental plans (SADPs) offered off-Exchange from accepting enrollments outside the Exchange 561 Updated 1-31-17 2017--00661 enrollment periods. Under 45 CFR an Exchange may only permit a qualified individual to enroll in a qualified health plan (QHP) or an enrollee to change QHPs during an enrollment period specified in the Exchange regulations. Therefore, enrollments through an Exchange are limited to these enrollment periods. However, the Exchange would not be involved in off-Exchange enrollments. Therefore, we are confirming that neither this regulation, nor any other CMS regulation, would prohibit Exchange-certi?ed SADPs that wish to enroll consumers outside the Exchange outside the enrollment periods speci?ed in the Exchange regulations from doing so, provided they comply with applicable State laws. (CMS FAQs on Health insurance Marketplace Standards 10/14/16) Dental and Vision 08: If pediatric dental and vision EHBs are embedded in the medical plan, but are administered by a third party, does the third party also have to be Utilization Review Accreditation Committee (URAC) or National Committee of Quality Assurance (NCQA) accredited? A8: No, those third party pieces would not require URAC or NCQA certification. (Plan Management Webinar 01/24/13) 09: Since the plan design is based on the EHB-benchmark plan, can adult vision and dental be embedded in those plan designs? A9: An issuer is always able to offer benefits in excess of EHB. However, routine adult vision and dental may not considered EHB, as set forth in Therefore, among other limitations, these services may not be included in the calculation of any advance payments of the premium tax credit (APTC). (Plan Management Webinar 01/24/13) Q11: Do pediatric dental and vision have to be provided for the whole policy year? Or will an individual no longer receive those services on their 19th birthday? A11: Plans must cover pediatric EHB categories, at least for individuals up to 19 years of age, as noted in the preamble of the final EHB rule at pages 12842 and 12843, but states can always impose requirements to provide pediatric services to individuals up to a higher age. CMS intends to provide further information regarding coverage of pediatric bene?ts when the individual?s 19th birthday falls during the policy year. (Plan Management Webinar 01/24/13) Q13: The PA Benefit File includes adult vision as a required covered benefit; however, per the EHB final rule adult vision is not EHB, per 45 CFR 156.110. How should we handle this? A13: If a QHP does not cover adult vision, please select ?not covered" and note the EHB variance reason as ?other law/reg." (QHP Webinar Series FAQ #5 04/18/13) 562 Updated 1-31-17 2017--00662 09: Under the FEDVIP benchmark, there is a lifetime limit on orthodontia services (per child) in the amount of $3,500. During a recent call it was (we believe) concluded that this limit could be included in a stand-alone pediatric dental plan because it?s an excepted benefit plan. However, in reviewing the attestations we are required to sign, and the draft CMS letter to issuers posted on March 1, it looks like this limit may be prohibited. For example, the attestations require us to attest as follows: . Applicant attests that all stand-alone dental plans that it offers will comply with all benefit design standards and federal regulations and laws for stand-alone dental plans, as applicable, including that: a. The out-of-pocket maximum for its stand-alone dental plan is reasonable for the coverage of pediatric dental b. It offers the pediatric dental c. It does not include annual and lifetime dollar limits on the pediatric dental EHB. . Applicant attests that any stand-alone dental plans it offers are limited scope dental plans. . Applicant attests that any stand-alone dental plans it offers will adhere to the standards set forth by HHS for the administration of advance payments of the premium tax credit. 0 Applicant attests that it either offers no stand-alone dental plans or attests to all of the above. Can you offer any further guidance on this? Is it permissible to include in the $3,500 lifetime max (per child) in our stand-alone pediatric dental plan? A9: Annual and lifetime limits cannot be applied to the pediatric dental EHB, as established in 45 CFR 155.1065. Thus, to the extent that orthodontia is considered part of the pediatric dental EHB it is medically necessary), the bene?t cannot have any annual and lifetime limits. (QHP Webinar Series FAQ #10 05/09/13; appears as FAQ #11 in the 08/02/13 update to this FAQ) 029: The FEDVIP brochure lists a lot of specifics in terms of specific dollar amounts that are allowed. If a pediatric vision plan has an allowance, can it be a dollar allowance amount and would that be considered some sort of limit? A29: The Affordable Care Act prohibits annual and lifetime dollar limits on EHB, so even if the FEDVIP brochure includes such limits, EHB plans cannot impose such limits. See 45 CFR 147.126. (QHP Webinar Series FAQ #9 05/03/13 and REGTAP database FAQ #2145 06/11/14) Q30: Could a child who receives coverage for lenses and frames under pediatric vision benefit receive an additional benefit under our Lenses and Frames rider for the amount that isn?t covered? A30: Yes, issuers can offer riders to cover additional benefits beyond EHB. (QHP Webinar Series FAQ #9 05/03/13) CMS issues a revised FAQ that changes the answer to this question on 06/11/14: 563 Updated 1-31-17 2017--00663 A: No. Due to the single risk pool, issuers cannot offer benefits via rider. If the issuer wishes to make a benefit optional it must offer one plan with the benefit embedded and another plan without the benefit. (REGTAP FAQ Database - FAQ #2142 06/11/14) Q1: We would like confirmation that the reasonable assurance provision in the EHB preamble applies to both individual and small group coverage. A1: Yes, issuers of both individual and small group plans off the Exchange must be reasonably assured that enrollees have obtained pediatric dental coverage through an Exchange-certi?ed stand-alone dental plan. (QHP Webinar Series FAQ #10 05/09/13 and REGTAP FAQ Database - FAQ #2146 06/11/14) Q9. Can you offer any further guidance on this? Is it permissible to include in the $3,500 lifetime max (per child) in our stand-alone pediatric dental plan? A9: Annual and lifetime limits cannot be applied to the pediatric dental EHB, as established in 45 CFR 155.1065. Thus, to the extent that orthodontia is considered part of the pediatric dental EHB it is medically necessary), the bene?t cannot have any annual and lifetime limits. (QHP Webinar Series FAQ #10 05/09/13) Prescription Drugs QZ: Regarding the substitution in drug classes, in the FFE, drugs may need to be reported by plans prior to the finalization of the CMS rule. Will CMS allow plans to make formulary substitutions after submission? State deadlines are coming up and there is not yet a final rule. The FFE application has a section for the formulary submission for each plan in that submission, what happens if there is a substitution between the time that the initial plan is submitted and the actual product is offered? A2: The ?nal rule regarding EHB was published in the Federal Register on February 25, 2013, at 78 FR 12834. In we note that a plan must cover at least the number of drugs per United States Pharmacopeial Convention (USP) category and class as the EHB-benchmark or one drug in each in each class and category, whichever is greater. The plan can switch drugs as long if the plan always meets this standard. (Plan Management Webinar 01/24/13) Q3: If a plan covers a drug through a medical benefit, does it have to be covered as part of the pharmacy benefit as well? A3: No, as long as the plan has met the minimum standard set forth in (Plan Management Webinar 01/24/13) Q4: Regarding copay and cost sharing for the pharmacy benefit, plans need to cover at least the greater of one drug in every USP category and class or the same number of prescription drugs in each category and class as the EHB-benchmark plan. If the drugs are in the third tier of a 3 tier plan (and those drugs require a copay or cost sharing), will the plan still fulfill the requirement? A4: The third tier drugs in this type of plan will still meet the definition of being covered. However, the copay or cost sharing will be considered part of the enrollee?s overall out- of-pocket, which cannot exceed the limit that will be set in 2014. We also direct issuers 564 Updated 1-31-17 2017--00664 to ?156.125, which prohibits employing a discriminatory benefit design. (Plan Management Webinar 01/24/13) 05: Medical drugs do not use National Drug Codes they use J-codes. How will CMS capture medical (non-pharmacy) drugs? A5: Drug information will be collected with the RX Concept Unique Identi?er which is a higher level of coding. CMS will follow up later regarding the J-code. (Plan Management Webinar 01/24/13) Q14: If the EHB-benchmark plan in our state does not cover drugs in a specific category, do issuers still have to cover at least 1 drug in that category? A14: The policy in the EHB final rule at ?156.122(a) is that a plan must cover the greater of either the number of drugs in each USP category and class as the benchmark plan, or at least one drug in each category and class. (Plan Management Webinar 01/24/13) 023: What clarification can HHS provide for issuers that may make mid-year formulary changes to remove drugs that are found to be unsafe or ineffective or that become available over-the-counter? Specifically, we ask that issuers not be required to add a replacement drugs to the formulary mid-year to match the number of drugs covered by the EHB benchmark plan, as long as at least one drug in the class remains covered. A24: States will be responsible for monitoring drug lists for compliance with EHB policy as part of their review and enforcement responsibilities. Issuers will submit their drug lists to HIOS once (during the April submission period). As drug lists change, issuers are still responsible for meeting the EHB standard (the greater of one drug or the number of drugs in the state EHB benchmark plan in each USP category and class). State-based Exchanges could set their own rules in terms of requiring plans to notify the Exchange of any drug list changes or limit the frequency. Regardless, mid-year formulary changes should be infrequent. In addition to assuring formulary compliance with EHB, Exchanges should be aware of the potential for formulary discrimination. (QHP Webinar Series FAQ #10 05/09/13) This FAQ has been revised and released as REG TAP as follows: Q: What clarification can HHS provide for issuers that may make mid-year formulary changes to remove drugs that are found to be unsafe or ineffective or that become available over-the-counter? Speci?cally, we ask that issuers not be required to add a replacement drugs to the formulary mid-year to match the number of drugs covered by the EHB benchmark plan, as long as at least one drug in the class remains covered. A: States will be responsible for monitoring drug lists for compliance with EHB policy as part of their review and enforcement responsibilities. Issuers will submit their drug lists to HIOS once (during the annual QHP application process). As drug lists change, issuers are still responsible for meeting the EHB standard (the greater of one drug or the number of drugs in the state EHB benchmark plan in each USP category and class). Steps have been taken to add new/y approved FDA drug to the existing Crosswalk (based on USP version 5 Category/ Class Model Guidelines) and delete associated with discontinued drugs 565 Updated 1-31-17 2017--00665 in order to improve issuer compliance. (REG TAP FAQ Database - FAQ #1369 03/31/14) Q: When will CMS release the Essential Health Benefit (EHB) Prescription Drug Crosswalk? A: The EHB RX Crosswalk is currently available on SERVIS for states and on ZONE for Issuers The EHB RX Crosswalk can be used as a resource to identify those drugs covered on plan formularies that are credited towards meeting the states benchmark count. (REGTAP FAQ Database - FAQ #2631 07/03/14) Q: Can CMS clarify that issuers may make mid-year formulary changes such as removing unsafe or unavailable drugs and/or adding newly approved drugs? Updated 1-31-17 A: As we state in the 2016 HHS Notice of Bene?t and Payment Parameters (80 FR 10750), CMS is concerned about issuers making mid-year formulary changes, and especially changes that negatively affect enrollees. We are monitoring this issue to consider whether further standards are needed. We also note that, under guaranteed renewability requirements and the de?nitions of ?product" and ?plan," issuers generally may not make plan design changes, including changes to drug formularies, other than at the time of plan renewal. However, we recognize that certain mid-year changes to drug formularies related to the availability of drugs in the market may be necessary and appropriate. For the purpose of 45 CFR for a formulary drug list to be considered complete, the formulary drug list must list all drugs that are essential health bene?ts (EHB) and all drug names that the plan covers at that time. Issuers must publish formulary drug lists in a manner that is easily accessible to plan enrollees, prospective enrollees, the State, the Marketplace, HHS, 0PM, and the general public. A formulary drug list is easily accessible when it can be viewed on the plan's public web site through a clearly identi?able link or tab without requiring an individual to create or access an account or enter a policy number; and, if an issuer offers more than one plan, when an individual can easily discern which formulary drug list applies to which plan. QHPs issuers in the FFM must also make available their formulary information on their Web site in an HHS-speci?ed format and also submit this information to HHS, in a format and at times determined by HHS. For additional information on the 2016 Payment Notice, please refer to the following link: Additional information on formulary drug list publication, URLs, and format can be found in the Final 2016 Letter to Issuers under the Prescription Drugs section of Chapter Two: As formularies change, issuers must continue to adhere to EHB market-wide and QHP requirements, as outlined in 45 CFR 156.122, 156.125, and 156.225. (REGTAP FAQ Database - FAQ #10801 06/01/15) 566 2017--00666 Ancillary Products Q1: Can stand-alone vision plans and other ancillary insurance products such as disability or life insurance products be offered in or through an Exchange? A1: No. An Exchange only may offer qualified health plans (QHPs), including stand- alone dental plans, to quali?ed individuals and qualified employers, due to sections 1311 and 1312 of the Affordable Care Act. However, ancillary insurance products, which are not QHPs, may be offered by separate state programs that share resources and infrastructure with a State-based Exchange. (CMS FAQs Use of Exchange for Ancillary Products 03/29/13) 02: Can an Exchange provide any information about vision plans and other ancillary insurance products to the public? A2: Yes. An Exchange may provide basic information about vision or other ancillary insurance products on the Exchange website, such as explaining the type of coverage these products provide. This basic information must include that enrollment in vision and ancillary insurance products does not constitute enrollment in a QHP or enrollment through the Exchange but rather enrollment in a separate legally and publicly-distinct program. In addition, the basic information must include that advance payment of premium tax credits and cost-sharing reductions are not available for vision or other ancillary insurance products. For example, an Exchange could include information on its Exchange website or through its call center about stand-alone vision plans and other ancillary insurance products, the bene?ts these products provide, and how to purchase these products. Purchasing information could include the ability for consumers to click on a product link that would take them to a page containing product and pricing information, where they could add the product to a shopping basket and purchase the product along with any QHP products. The product page would need to include the basic information described above. These ancillary products pages may reside on the Exchange information technology infrastructure as long as the web pages and call center information meets the requirements in Q3. (CMS FA 03 Use of Exchange for Ancillary Products 03/29/13) Q3: How may State-based Exchange resources be used by other, separate state programs to offer these non-QHP ancillary plans? Updated 1-31-17 A3: The Exchange information technology infrastructure can be reused by other, separate non-Exchange state programs to facilitate coverage in ancillary products, provided that all of the following conditions are met. . The Exchange neither provides services nor makes non-QHPs available in a manner that is prohibited or inconsistent with the Affordable Care Act. . The agency or program facilitating the coverage must be legally and publicly distinct from the Exchange. The non-Exchange program facilitating the coverage must be responsible for non-Exchange activities. . Federal funds must not be used to support non-Exchange activities. Further, Exchange user fees and assessments may not be used to support non-Exchange 567 2017--00667 activities. Exchange funds should not be co-mingled with the funds used to support the separate state programs facilitating enrollment in non-QHPs. . To the extent that an Exchange resource is used for non-Exchange purposes, the cost of using the resource must be paid by the other, non-Exchange state program. An appropriate portion of the costs of rent, maintenance, etc., must be charged to the other, non-Exchange state program. For example, programming and information technology infrastructure, such as servers or coding for website applications, that supports the Exchange website could be used to support the website of another state program that facilitates enrollment in non-QHP insurance coverage. Under this arrangement, the websites themselves would need to be clearly identified as distinct, the ?state Exchange website? and the ?other non- Exchange state program website.? As a further example, while the call center supporting the Exchange might also support other non-Exchange state programs, the phone numbers for each program would need to be different and the scripts for the call center operators would need to be tailored to each program. Development of the differing scripts, maintenance of separate phone numbers, and associated staff time would need to be charged to the other, distinct Non- Exchange state program. (CMS FA 03 Use of Exchange for Ancillary Products 03/29/13) Q: Do Federally-facilitated Small Business Health Options Program (FF-SHOP) Marketplaces support stand-alone vision plans? A: No, FF-SHOPs do not support stand-alone vision plans. (REGTAP FAQ Database - FAQ #2509 07/01/14) ACTUARIAL VALUE Actuarial Value General Q18: Is the silver metal tier plus or minus or plus or minus A18: The silver metal tier has a de minimis range of plus or minus 2 percentage points per but silver plan variations (meeting the cost-share reduction standards) have a de minimis range of plus or minus 1 percentage points per 156.400. (Plan Management Webinar 01/24/13) 020: Will CMS be providing additional guidance on how to evaluate wellness-based designs? A20: CMS does not plan to provide additional guidance on how to evaluate wellness- based designs. (Plan Management Webinar 01/24/13) 021: What impact do pediatric dental and vision have on the A21: If the pediatric dental bene?t is embedded in the medical plan, issuers should use the AV Calculator as usual. There are no inputs into the AV calculator that are specific to the pediatric dental rather, it is treated as part of a whole group of unclassi?ed 568 Updated 1-31-17 2017--00668 bene?ts that are incorporated into the calculator. The pediatric dental EHB is generally a low cost benefit incorporated into those unclassi?ed benefits and generally does not have a material impact on AV. The pediatric dental EHB is based on your state?s benchmark plan. (Plan Management Webinar 01/24/13) 024: When a plan enters a $500 employer contribution in the Health Savings Account (HSA) or Health Reimbursement Arrangement (HRA) fields, it dramatically changes the AV from a silver to a gold tier in a standard plan with a $2,000 deductible and $6,000 out- of-pocket maximum. If a plan increases the deductible for the employee to $2,500, it will not move the plan back to the silver plan. Why does this occur? A24: The HSA value is not required if the HSA value is not embedded in the plan and the employer makes that contribution to it. A $500 contribution of this type goes towards the first $500 of medical spending in the year, covering those with any spending at all, while a deductible change from $2500 to $2000 only impacts the subset of individuals with medical spending in a year in excess of $2000. (Plan Management Webinar 01/24/13) 055: Do issuers have to enter health savings account (HSA) contributions when calculating the AV of a plan? What happens if issuers do not know what the contribution is going to be? A55: The amount of the employer contribution to the HSA has to be known to the issuer at the time of purchase. If issuers are not able to con?rm the health savings account when using the AV Calculator, it cannot be included in the plan. When the issuer does not know the actual value of the HSA contribution, as long as the AV is within the de minimis range, it is acceptable. The AV Calculator is available on the CCIIO website at (QHP Webinar Series FAQ #4 04/16/13) 029: In a plan that has multiple tiers, if the out-of?network tier is a non-contracted tier; is it correct that bene?ts in that non-contracted tier do not apply to the AV value? A29: If there is an in-network tier and an out-of-network tier, the out-of?network benefits would not be entered in the AV Calculator. (Plan Management Webinar 01/24/13) 021: There is a provision that allows the annual deductible to exceed $2,000 if needed in order to get to the appropriate AV. Does this mean stand-alone dental EHB can have a separate deductible amount (dental standard example $50) that would not be subject to coordination of bene?ts with the medical EHB plan in order to achieve the required AV levels? A21: A stand-alone dental plan may have a separate deductible amount and will not need to coordinate with the medical plan. Because AV levels are different for stand- alone dental plans, high of 85% and low of 70%, as established in 45 CFR 156.150, CCIIO does not currently expect that stand-alone dental plans will exceed allowable deductible amounts in the small group market in order to reach AV targets. (Plan Management Webinar QHP FAQ #3 04/11/13) 569 Updated 1-31-17 2017--00669 02: There have been several instances where the AV calculated by the bene?ts template does not match for the same benefit from the AV Calculator. In some cases, the difference is quite a bit; in all cases they failed the metal test in the template but not in the calculator. A2: Chapter 11 of the instructions is posted on the REGTAP portal and on SERFF and provides detailed information on how this process works and how the ?elds are mapped from the Plans and Benefits Template to run the AV Calculator. Issuers are encouraged to assess the AV of a given plan design by ?rst using the stand-alone AV Calculator. After completion of the Plans and Bene?ts Template, the AV obtained from the Template should match the value obtained via the stand-alone AV Calculator. If the AVs are not matching, the issuer should first ensure that it correctly filled out the Template per the instructions in Chapter 11. If the issuer is still having dif?culty matching AVs, you can contact the Help Desk at: CMS FEPS@cms.hhs.qov or via phone at Please submit a screen shot of the AV Calculator and a copy of the Plans and Bene?ts template with your completed data for that given plan, which will help us identify the problem. If at the end of this process the issuer is still unable to obtain an AV from the Plans and Bene?ts Template that matches what it obtains via the stand-alone AV Calculator, then there is an option mentioned in the Chapter 11 instructions that would allow a plan to submit their plan as a unique plan design, complete the Issuer Actuarial Value data ?eld, and upload a screen shot of the AV Calculator with the obtained value as the supporting documentation. Please see these instructions for more details. Also please note that in this situation, designating your plan as a unique plan design will not require submission of an actuarial certi?cation pursuant to 45 CFR 156.135(b) and will cause the plan to be considered unique for review purposes. We also revised the Plan and Bene?ts Add-In File on April 11 to address discrepancies related to the AV calculation that some issuers were encountering. This updated file is now available for download at the online repository at to those users who are part of the Issuer Community. The same templates have also been made available by the NAIC on their website at management data templateshtm. If you encountered a discrepancy before April 11, please try again. (QHP Webinar Series FAQ #5 04/18/13) Q3: What guidance is there on selecting metal tiers for cost share reduction plans in the AV calculator and the Plans and Benefits Template? Updated 1-31-17 A3: Per the AV Calculator Methodology that was published with the essential health bene?ts ?nal rule, we provided guidance on which metal tier should be chosen to align with the expected utilization for each plan variation. (QHP Webinar Series FAQ #5 04/18/13) Household Silver Plan Variation AV Desired Metal Tier Income 100-150% of FPL Plan Variation 94% Platinum 150-200% of FPL Plan Variation 87% Gold of FPL Plan Variation 73% Silver 570 2017--00670 Q1: Is any other supporting documentation screenshots or other display of how we entered inputs into the AV Calculator) expected to be submitted when we provide the AV of a given plan design, or are we providing only the actual AV figures, along with justification for any modifications? A1: Additional documentation is not required. For the FFM, the only requirement for general plan designs is inputting the plan designs into the Plans and Benefits Template and using the AV calculator within the template to determine the AV of the plan. Additional information is needed only if 1) for some reason there is a discrepancy (outside the de minimus range) between the AV determined by the template and the AV determined directly by the calculator; or 2) you are submitting a unique plan design utilizing non-AV Calculator data for which you will need to provide supplemental information. For more information on exceptions to using the AV Calculator, see 45 CFR (QHP Webinar Series FAQ #5 04/18/13) Q8: In preamble to the EHB final rule published February 25, 2013 page 12850 made note of a safe harbor that allows for the use of single-only plans? actuarial value (AV) for the family plan equivalents if family accumulators fell within a multiplier. When will CMS offer additional guidance on the safe harbor? A8: We do not intend to provide a multiplier at this time. Instead, in the 2014 Letter to Issuers on Federally-facilitated and State Partnership Exchanges, published on the CCIIO website on April 5, we provide guidance on options that issuers may use to calculating a plan's AV using the AV Calculator, where the deductibles and/or out of pocket maximum costs accumulate at the family level, depending on how the deductibles and/or out of pocket maximum costs accumulate. Please see the Letter to Issuers for further clarification at letter to issuers 04052013.pdf. (QHP Webinar Series FAQ #10 05/09/13) Q12: Can states require issuers to exclude non-preferred drugs as being non-EHB and, as a result, exclude this tier of drugs from a plan?s actuarial value calculation? A12: No. States may not require plans to exclude non-preferred drugs from EHB and, thereby, exclude these drugs from calculating a plan?s actuarial value. EHB policy does not prohibit tiering unless such tiers are designed in a discriminatory manner. As stated in the preamble of the Final Essential Health Bene?ts Rule (78 FR 12848), while plans must offer at least the greater of one drug in each USP category and class or the number of drugs (in each USP category and class) as in the EHB benchmark plan, plans are permitted to go beyond the number of drugs offered by the benchmark without exceeding EHB. In other words, all drugs offered by the plan are considered essential health bene?ts. Therefore plans must take all drugs into account when calculating actuarial value. Plans that cover non-preferred drugs should mark that category as ?covered? on the plans and benefits template and use the EHB Variance reason ?additional (QHP Webinar Series FAQ #12 06/28/13) Q13: Will a catastrophic plan have a lower AV than a bronze plan below 58% A13: No, a catastrophic plan does not have an AV. Information on how to input these plans into the Plans and Bene?ts Template is available the Chapter 10 instructions 571 Updated 1-31-17 2017--00671 under "Catastrophic Plan Instructions." (QHP Webinar Series FAQ #12 06/28/13 and REGTAP FAQ database FAQ #2120 06/11/14) Q14: If a Bronze or Silver or possibly Gold plan has a deductible in excess of $2,000 in excess of the limits set forth in Section 1302(c)(2)) of the Affordable Care Act, what does that do to its status as a A14: Section 1302(c)(2) of the Affordable Care Act only applies to the small group market. As a result, the AV Calculator can exceed a $2,000 deductible to allow the calculator to account for situations where the user is running plan designs that are not small group plans. (QHP Webinar Series FAQ #12 06/28/13) Actuarial Value Calculator Q19: The AV Calculator allows for the calculation for four tiers for formulary. What if a plan has additional formulary tiers? A19: If a plan has more than four benefit tiers with substantial utilization that cause a material effect on the AV, the plan may have a unique plan design that is not compatible with the use of the AV calculator. CMS suggests that issuers seeking to use the AV calculator exercise actuarial judgment when entering numbers into the four tiers provided for in the AV calculator. For example, a plan may have seven tiers, but four of those tiers may be fairly similar in terms of cost sharing. In such cases, it may be actuarially justifiable to combine the four similar tiers into a single fourth tier. More information on unique plan design and use of the AV Calculator is in Appendix of the draft Letter to Issuers on Federally-facilitated and State Partnership Exchanges (Issuer Letter), released on March 1, 2013, and available on the CCIIO website. (Plan Management Webinar 01/24/13) 022: Do issuers have to submit a completed AV Calculator as part of QHP certification? A22: The Plans and Benefits Template that is used to certify QHPs is integrated with the AV Calculator. Therefore, if the issuer is using the Plans and Bene?ts Template, the issuer will need to download the AV Calculator because the Plans and Bene?ts Template will require the user to open the AV Calculator into the Plans and Bene?t Template. Then, the Plans and Benefits Template will automatically map the fields to the AV Calculator to produce the plan?s AV. Additional information on this process is available in Chapter 11 the Plans and Bene?ts Instructions at: management data instructions ch11.pdf . Issuers should defer to their state regulator regarding the submission of a completed AV Calculator. (QHP Webinar Series FAQ #7 04/24/13) 022: Will the Minimum Value (MV) Calculator be released at the same time as the updated AV Calculator? A22: The MV Calculator and AV Calculator can be found on the CCIIO website at (Plan Management Webinar 01/24/13) 572 Updated 1-31-17 2017--00672 023: In the demonstration of the AV Calculator, coinsurance boxes were unchecked in the drug section. However the 75% remained in the coinsurance box at the top. If the coinsurance box at the top is changed to 100%, will the AV value change? A23: The AV should not change in this case. By unchecking the coinsurance box in the drug section, the algorithm will not consider the coinsurance at the top. If there is a technical error found in the AV Calculator, please send a screen shot and a brief description to: Reqistrar@REGTAP.info. (Plan Management Webinar 01/24/13) 026: How do the AV calculator and cost sharing limits standards apply to a stand-alone dental plan? A26: Stand-alone dental plans would not use the AV calculator but, instead, have to demonstrate that they meta 70% AV or 85% AV, certi?ed by a member of the American Academy of Actuaries. See ?156.150 and the discussion in the preamble of the ?nal EHB rule at 78 FR 12852. With regard to cost sharing limits, stand-alone dental plans must demonstrate that they have a reasonable annual limitation on cost-sharing as determined by the Exchange. For the 2014 coverage year in the FFE, any annual limit on cost sharing that is $700 or below for one child or $1,400 or below for two or more children will be considered reasonable for the pediatric dental EHB. (Plan Management Webinar 01/24/13) 028: In the AV Calculator, it appears that copays do not count for the out-of-pocket maximum if the coinsurance box is not checked for a particular benefit, but it is our understanding that copays do count to the out-of-pocket max. Is that correct? A28: Copays do count toward the out-of?pocket max. Technical errors in the draft version of the AV Calculator have been be addressed and corrected in the final version. (Plan Management Webinar 01/24/13) Q30: How can we incorporate copays for outpatient surgery in the AV Calculator? A30: The AV Calculator does not include the ability to input copays for outpatient surgery because the data that supports the AV Calculator does not allow for copays for outpatient surgery. Instead, HHS recommends that plans estimate the copay?s percentage of total cost for the benefit and input the remaining percentage into the calculator as coinsurance. (Plan Management Webinar 01/24/13) Q31: Will the AV Calculator be unlocked with all the formulas shown? A31: CMS has unlocked the formulas in the AV Calculator. (Plan Management Webinar 01/24/13) Q32: There is a checkbox in row 37 of the AV Calculator for coinsurance. If it is checked with other items unchecked and the file is saved, all the boxes for coinsurance are automatically checked when the file is opened again. A32: This is a very technical question. Please send a screen shot and a brief description of questions associated with this webinar to Reqistrar@REGTAP.info. (Plan Management Webinar 01/24/13) 573 Updated 1-31-17 2017--00673 020: As is mentioned in the Actuarial Value (AV) Calculator user guide, 100% general coinsurance rates should only be used for copay based plans, but in cases where the issuer is inputting a coinsurance based plan that has 100% coinsurance, what should the issuer input for the coinsurance rate? A20: When inputting 100% coinsurance rate, the AV Calculator will attempt to calculate an effective coinsurance rate to apply, expecting a copay plan. However, if the plan is a 100% coinsurance plan and is not a copay-based plan, the plan should use 99.99% coinsurance rate as the effective coinsurance rate. (Plan Management Webinar QHP FAQ #3 04/11/13) 053: How does the AV Calculator account for the dental and vision benefits and their cost sharing inputs? A53: The dental and vision bene?ts are accounted for in AV Calculator. These speci?c services do not generally amount to a material difference in the actuarial value calculation. Please refer to the AV Calculator methodology for further information on the calculator?s underlying logic, development, and usage. (QHP Webinar Series FAQ #4 04/16/13) Q54: How does the AV Calculator account for Health Savings Accounts A54: The AV Calculator allows for an employer?s contribution to an HSA to be taken into account for the AV determination. This is consistent with our regulation at 45 CFR The EHB final rule is available at (QHP Webinar Series FAQ #4 04/16/13) Q33: The AV Calculator only has a ?eld for ?Mental/Behavioral Health and Substance Abuse Disorder Outpatient Services? and doesn?t split out the office visit services from the outpatient services. As a result, we don?t know if we need to fill out that field with parity to outpatient or parity to of?ce visits. Our plan was to put in similar cost sharing for that benefit as medical outpatient and to explain in our Explanation of Coverage that behavioral health office visits would receive PCP cost sharing. A33: We developed the AV Calculator for the purpose of calculating AV with a limited number of service inputs, and it was not speci?cally designed to demonstrate parity. Therefore, for the purposes of calculating AV, we recommend that you use your best actuarial determination to align these benefits to the AV Calculator, as described in the AV calculator methodology incorporated by reference into the Standards Related to Essential Health Bene?ts, Actuarial Value, and Accreditation Final Rule. We further recommend taking the higher cost-sharing rate where possible. Per your example, we agree that you should provide any additional information in your EOC. We also note that, under the mental health parity requirements applicable to coverage of the essential health bene?t category of mental health and substance use disorder services, including behavioral health treatment, outpatient services and office visit services are considered to be within the same classi?cation (see 45 CFR. (QHP Webinar Series FAQ #9 05/03/13) 574 Updated 1-31-17 2017--00674 Q15: We request clari?cation that while EHB must apply to the AV calculation and annual limitation on cost sharing, issuers may exclude additional state-required benefits that are outside the scope of the EHB from the AV calculation. Likewise, issuers would not be required to apply these additional state-required benefits to the annual limitation on cost sha?ng. A15: The AV Calculator was based on claims data from a standard population that included state mandated bene?ts. If the state required benefit is determined to be EHB, it should be applied to the annual cost sharing limits. (QHP Webinar Series FAQ #10 05/09/13) 02: When is a plan incompatible with the AV Calculator such that it would be required to use an alternative method for calculating A: As stated in the 2014 Letter to Issuers on Federally-facilitated and State Partnership Exchanges (2014 Letter to Issuers), the AV Calculator was designed to accommodate the vast majority of plan designs, but it is impossible for a single calculator to accommodate every type of plan design. For this reason, pursuant to 45 CFR issuers with plan designs that are not compatible with the AV Calculator will need to use an alternate method to calculate AV. Section 156.135(b) provides two alternative methods of calculating AV for plans that cannot meaningfully ?t within the parameters of the AV Calculator. Plans that use an alternative method must adhere to the regulatory requirements under 45 CFR These alternative methods are only for cases where the unique features of the plan design are not compatible with the AV Calculator. A plan design is incompatible when the use of the AV Calculator yields a materially different AV result from using the other approved methodologies. Building on the examples given in the 2014 Letter to Issuers, an example of a plan design that would not be compatible with the 2015 AV Calculator would be a plan that uses wellness incentives to set cost-sharing rates for the plan design, such as varying deductible and copayment amounts. This plan would not be compatible with the AV Calculator because the AV Calculator cannot account for varying deductible or copayment amounts. Generally, a plan design that includes different cost sharing for services not included in the AV Calculator would be considered compatible with the AV Calculator. For example, advanced imaging is a single cost-sharing input in the AV Calculator; a plan design would not be considered incompatible because it assigns different copayment amounts to different types of imaging MRI versus CT). Similarly, because the AV Calculator does not consider quantitative or qualitative limits, the application of limits to a particular bene?t would generally not necessitate one of the alternative methods for AV calculation. (CMS FAQs on Health Insurance Market Reforms and Marketplace Standards 05/16/14) Q3. What guidance can you provide issuers in inputting their plans designs into the AV Calculator? Updated 1-31-17 A: Issuers must always use an actuarially justi?able process when inputting their plan designs into the AV Calculator. Similar to the above examples, plans with more than four drug tiers do not necessarily require the issuer to use an alternative method, nor would the conversion of a copayment into a coinsurance rate for the AV Calculator input for Outpatient Surgery Physician/Surgical Services or Facility Fee. In the case of more than 575 2017--00675 four drug tiers with a plan with two generic drug tiers where one tier has a significantly higher utilization rate, the plan could use the cost sharing from the higher utilization rate tier. Or, if the plan has two generic drug tiers with similar utilization rates, the plan could use the tier that has a higher cost-sharing rate. Thus, in these cases, issuers would need to use an actuarially justifiable process for inputting these cost-sharing features, and in cases where using the AV Calculator yields a materially different AV result from using the other approved methodologies, the issuer should use an alternative method under 45 CFR To assist issuers in using the AV Calculator, the Centers for Medicare and Medicaid Services (CMS) provided additional clari?cation on the operation and functions of the AV Calculator in the 2015 AV Calculator User Guide. For example, in the AV Calculator User Guide, we explain the effect of the AV for drug deductibles where in certain circumstances increasing the drug deductible can increase AV because of the increased rate at which the annual limit on cost sharing is reached and the interaction with copayments and the medical bene?ts. Although efforts have been made to evaluate plans with similar deductibles on equal footing with regards to the point at which the annual limitation on cost sharing is reached, the interaction of the drug deductible with medical benefits can result in counterintuitive AV movements that may be accurate based on the impact of the higher deductible on the calculated level of the annual limit on cost sharing of the plan design. However, in these cases, issuers may also ?nd that by using an actuarially justi?able process they may need to use an alternative method under 45 CFR 156.135(b) when accounting for their plan?s drug deductible limit. Issuers should adhere to industry standards of practice when calculating AV and in pursuing an alternative method under 45 CFR (CMS FAQs on Health Insurance Market Reforms and Marketplace Standards 05/16/14) Q1: How are issuers to proceed when the Actuarial Value (AV) value from the Plans and Benefits Template does not correlate with the output of the AV Calculator? A1: Issuers are to refer to the Chapter 11 instructions Section 5.1 for guidance on matching the Stand-alone AV calculations to the Plans and Benefits Template at: (Issuer Outreach FAQ #1 (10/27/15)) TEMPLATES Templates General 024: Please provide the XML standards for the templates - are they different for each template? A24: Yes, they are different for each template. The template itself will generate the .xml ?le. (Plan Management Webinar QHP FAQ #1 04/08/13) 576 Updated 1-31-17 2017--00676 Q25: Are the Individual (FFE) and SHOP (FF-SHOP) templates similar or exactly the same? A25: There is a single template for FFE and submissions. You will be required to submit your Individual Plans and Benefits separately from your SHOP plans and bene?ts, but both use the same template. The template validation will apply the market (FFE or FF-SHOP) dependent business rules. (Plan Management Webinar QHP FAQ #1 04/08/13; REGTAP FAQ Database - FAQ #171 04/08/13) Q47: Are the individual templates similar to or exactly the same as the SHOP templates? A47: Regardless of the market in which you offer plans, the templates are exactly the same. (Plan Management Webinar QHP FAQ #2 04/09/13) Q48: For the ?elds that are the same between the RBIS and QHP, are the formats and acceptable field values exactly the same? A48: Where possible, the validations are the same. (Plan Management Webinar QHP FAQ #2 04/09/13) Q49: Do all templates need to be uploaded at same time? A49: QHP data collection templates do not need to be uploaded at the same time. However, all QHP data collection templates must be uploaded in order to submit the complete QHP application to HHS for review. (Plan Management Webinar QHP FAQ #2 04/09/13) Q1: Can issuers copy and paste data into the templates? A1: All the templates allow for the copying and pasting of data. See ?Copying and Pasting in Plan Management Templates" at (QHP Webinar Series FAQ #4 04/16/13) Q2: Why is the ?le not automatically defaulting to be saved in .xml format? A2: Depending on your Microsoft Office settings, when you click ?Finalize? and are prompted to enter a document name, Excel will automatically populate the ?eld with the current ?le format, which is ?.xls? or ?.xlsm." Simply delete this and enter your desired ?le name. You do not have to add ?.xml" at the end, just the file name. (QHP Webinar Series FAQ #4 04/16/13) Q4: Why do issuers see errors displayed when clicking ?validate?? A4: The message box with the validation errors allows issuers to see what needs to be corrected. The template can be validated multiple times, and clicking the ?Finalize" button will perform those validations again. If there are any errors that were not corrected, the error messages will display again. (QHP Webinar Series FAQ #4 04/16/13) 577 Updated 1-31-17 2017--00677 Q5: Do the templates have to be submitted in a special order? A5: The templates can be submitted in any order, as long as they are submitted by the deadline. There is no dependency that one be entered before another. However, in the Plans and Bene?ts Template, it is easier to have the IDs for the Network, Formulary, and Service Area prior to completing the template. (QHP Webinar Series FAQ #4 04/16/13) 06: Do issuers need to complete every segment of a module before the validator can check the submission? A6: As sections are completed, the validator can check each section. When the Admin Data Template is completed, the submitter clicks ?submit? and the validator can validate the template. Call the Helpdesk if there are any issues. (QHP Webinar Series FAQ #4 04/16/13) Q7: Why is there an error message on the Product ID field? A7: The Product ID is a 10 digit, alphanumeric, unique identifier. The Product ID consists of an Issuer ID, the State, and the 3-digit unique Product ID. In the Rating Business Rules Template, the Product ID is only given if the Issuer business rule does not apply to a given product. In the first row of the Ratings Business Rules Template, issuers should not enter a Product ID or a Plan ID as the ?rst row is the default issuer-level rule. For each row after, issuers should not enter a Product ID and Plan ID on the same row; only one ID -- the Product ID or the Plan ID -- should be entered. The template does not validate the Product ID itself, it validates the format of the ID. If there is an error message on the Product ID field, it is related to the format of the Product ID. (QHP Webinar Series FAQ #4 04/16/13) Q8: Why do issuers get an error message for a required field that does not have an asterisk? A8: The asterisk?labeled ?elds are always required. If there is ever an exception, there is no asterisk. There are data elements that may be required, depending on the situation and business rules, so there will be an error message that the ?eld was required even though the ?eld did not have an asterisk in the template. (QHP Webinar Series FAQ #4 04/16/13) 09: Why do issuers sometimes receive error messages, debugging messages, and have difficulty saving the template? Updated 1-31-17 A9: All of the templates allow you to ?Save As? and create multiple different copies. If you encounter problems, please contact the helpdesk with details on your problem. With the Plans and Bene?ts Template, these issues usually relate to the Add-in File. For best results: Delete all previous versions of the Add-In File from your computer. Save the latest version of the Add-in File in same the folder as the template. Select the command ?Save? button when downloading from a web browser. Do not open the Add-in File from the web browser. 578 2017--00678 When saving the Add-in file, in the ?Save" dialog box, make sure that the name and ?le extension is ?PlansBenefitsAddln.xlam.? The Add-in will not work correctly if the name or file extension is different. When uploading the data into the system, it is an .xml file that is difficult to read. Once the file is uploaded and validated, the data is displayed once again in the original Excel format in the template. When you open the regenerated template, you may see a message that the ?le needs to be recovered. This is an issue with the Java library. Click "ok? and then click through all the messages and the file will open normally with all data intact. (QHP Webinar Series FAQ #4 04/16/13) Q10: Have the issues with the User Interface in HIOS been corrected? A10: The issues with uploading supporting documents in the User Interface are ?xed. The ?Next" button is now displayed. Users that have both submitter and validator roles will need to navigate between sections of the Issuer module from the summary page to avoid the white screen issue. (QHP Webinar Series FAQ #4 04/16/13) Q11: When a person entering data completes the data entry, the user would then click the ?validate? button, the errors would pop up that need to be ?xed, the user would click the ?validate? button again, and then lastly the user would finalize. The templates are all being completed separately. When that is all finished, is it at that point that issuers can have internal reviews of the templates, just before things are finally submitted? A11: Particularly if issuers are submitting through SERFF, make sure that the templates match each other. The Formulary ID, Service Area ID, and Network ID for each plan should match in the Plans and Benefits Template, Service Area Network, and Prescription Drug Templates. Each plan in the Plans and Bene?t Template should have rates. This is the cross-validation that is done at the very end of the process. Make sure that that all matches before the ?nal submission. (QHP Webinar Series FAQ #4 04/16/13) Q12: Regarding the sequence of review, does it happen at the end, after all templates are submitted, or can it happen after each module is completed? In other words, could management review module by module? Is there a preferred work flow? A12: Issuers can review the templates in Excel before submitting them. The system performs the validations after the template submission, but management can review the templates at any point. (QHP Webinar Series FAQ #4 04/16/13) Q13: Once the templates are submitted, is it too late to go back and correct things that may be found during a management review? A13: Issuers can resubmit the templates any time in HIOS for the FFE (before April 30). Resubmissions are not restricted in any way; submitting a template does not make it ?nal, nor does it stop an issuer from making changes. To revise a module or section that has been validated, the Validator will have to answer ?No? to the validation question to allow the Submitter to revise the submission. In the Issuer module, if you need to revise your submission after the validator clicks on the ?Submit Application? button on the Review page, you will need to call the help desk to allow this change. Issuers applying into SERFF should consult with the state about their rules. (QHP Webinar Series FAQ #4 04/16/13) 579 Updated 1-31-17 2017--00679 Q14: Is the cross validation an automated process, or a manual process that issuers can perform? A14: The cross validation can be manually performed from the Issuer module, the Rates and Benefits module, or the Service Area module. The submitter can click the validate button at any time to perform the cross-validations - even if all the templates are not submitted. When the completed templates pass all the cross-validations, Issuers can make the submission to CMS. (QHP Webinar Series FAQ #4 04/16/13) Q10: Will plans be allowed to update their marketing name prior to plan preview in August? Many companies have not fully identi?ed their marketing name and would like to include a placeholder name in the interim. We are having trouble doing this in the template?when we update the ?Plan Marketing Name? on the benefits tab and complete an update for the cost-share variance tab, the plan marketing name of the CSR tab does notchange. A10: Issuers will be able to correct this on the Administrative Template during resubmission or Plan Preview periods. In version 1.3 of the add-in ?le, the Update Cost Share Variances macro will now automatically update any changes to the Plan Marketing Name on the Bene?ts tab to the Cost Share Variances tab. (QHP Webinar Series FAQ #5 04/18/13) 060: Will there be a Con?dentiality template to identify fields on the templates that are proprietary or con?dential? A60: Currently, the data supplied in the templates will be used only for QHP certification purposes and for population of the FFM website, for example, for population of the premium calculator. To the extent that data is being entered for rate review purposes, the process related to proprietary information that is currently in place under that program would apply to that information. We may receive Freedom of Information Act requests or other data release requests for this information, and we will work on a process for handling these requests while protecting issuer con?dentiality. (QHP Webinar Series FAQ #5 04/18/13) 061: When user clicks on the Validator tab, the screen goes white and nothing happens. When refreshing or going back an error is encountered. The application will eventually let the user go back. These errors prevent the user from completing the test script. A61: This occurs for users that have both the Submitter and Validator roles. You may navigate successfully through the sections of the module from the Summary Page rather than using the links at the side of the page. (QHP Webinar Series FAQ #5 04/18/13) 064: The ?le is not automatically defaulting to be saved in .xml format as speci?ed in test scenarios. It defaults to .xls instead. A64: Excel 2007 automatically defaults to the current file name and format. You will need to manually select the .xml format when you save the finalized submission ?le generated by the ?nalize template macro. (QHP Webinar Series FAQ #5 04/18/13) 580 Updated 1-31-17 2017--00680 060: Can the templates be validated and finalized from a SharePoint site? A60: Depending on your organization's settings, it may not be possible to use the Plans and Benefits template from a network drive or SharePoint site. The Import IDs and Check AV Calculation macros require you to browse for additional ?les. In general, you will get best results if you work with the templates on a local drive. You may store the saved versions anywhere. (QHP Webinar Series FAQ #7 04/24/13) 05: How are the new data traceability matrices (DTMs) used in completing the templates? A5: These ?les, available on CMS describe the data elements in the templates and the high-level business rules and validation requirements for each element. (QHP Webinar Series FAQ #12 06/28/13) 062: What network ID should an issuer use for a network consisting of other networks? A62: Each QHP submitted must be associated with a single Network ID as identified in the Network ID Template. If an issuer has, for example, three networks associated with a given QHP, the issuer will need to create a fourth Network ID consisting of those three networks, and use that single ID for completing the Bene?ts Template. (QHP Webinar Series FAQ #9 10/31/13) Q: If an issuer discovered an error in one of the templates and submitted a revised template after the submission window closed, will CMS look at the corrected template? A: No, CMS will not review your revised submission until after the correction window closes on August 10. The initial FFM QHP application submission window closes on June 27 and any submissions after that date will not be included in the initial CMS reviews. Note that you could receive a data integrity notice or correction notice that may no longer apply to your application. After the correction window closes on August 10, CMS will review any applications that have changed since the initial submission window and will only send out notices regarding errors that remain at that time. (REGTAP FAQ Database - FAQ #2637 07/03/14) Q: What system should issuers use to submit the Qualified Health Plan (QHP) templates? A: As noted in the 2015 Letter to Issuers, issuers offering QHPs in Federally-facilitated Marketplaces (FFMs) for the 2015 plan year should complete QHP applications electronically through HIOS. ln states performing plan management functions, issuers will work directly with the state to submit all QHP issuer application data in accordance with state guidance, typically through SERFF. When an issuer is required to submit a Uniform Rate Review Template (URRT) for any reason, the issuer must submit the URRT to both CMS and their state regulator. When the issuer is submitting the URRT to CMS, they must submit it in the URR module of HIOS. When the issuer is submitting their URRT to their state regulator, they should check with the state to see what the system the state requires for submission. The 2015 Letter to Issuers is available at: issuer-letter-3-14-2014.pdf 581 Updated 1-31-17 2017--00681 A list of states that use HIOS and/or SERFF is available at: v1 5CR 032014.pdf. (REGTAP FAQ Database - FAQ #2950 07/22/14) Q: What is the required or recommended sequence for completing/entering data into the ten Qualified Health Plan (QHP) application templates? Does the sequence matter when the issuer enters the data into each of the ten QHP templates? A: There is no required sequence for the order of submission of templates. However, CMS recommends completing the Network ID Template, Service Area Template, and Prescription Drug Template first before completing the Plans and Benefits and Essential Community Provider (ECP) Templates, because the Network ID, Service Area ID, and Formulary ID in those templates are used in the Plans and Bene?ts Template. The issuer should take note of the sequence of Network, Service Area, and Formulary IDs for use in linking across templates. For more information about completing templates, please see (REGTAP FAQ Database - FAQ #2954 07/22/14) Q59: May issuers submit incomplete templates if final guidance and tools are not available prior to the submission deadline? A59: Issuers should submit templates using the most recent guidance and tools that are available. Current tools and instructions can be found at Issuers should not submit templates with blank ?elds per the data element requirement for submissions. (QHP Certification Process FAQs #1 (09/29/15)) Accreditation Template Q29: For the Product IDs on the National Committee for Quality Assurance (NCQA) Revision Template, must issuers include Product IDs that issuers will offer in 2016? A29: Yes, issuers must include the 2016 Product IDs. However, issuers are only required to include a single Product ID per Market type. (QHP Certi?cation Process FAQs #1 (09/29/15) Q30: Must issuers that offer two separate products types include the product types on separate rows within the National Committee for Quality Assurance (NCQA) Template? A30: Yes, issuers that offer two separate products types must include the product types on separate rows within the NCQA Template. (QHP Certification Process FAQS #1 {09/29/15) Q31: Must issuers wait until the receipt of a new National Committee for Quality Assurance (NCQA) certification expiration date prior to uploading templates? A31: No, issuers should complete the Quali?ed Health Plan (QHP) application process 582 Updated 1-31-17 2017--00682 using current NCQA expiration dates. (QHP Certi?cation Process FAQs #1 (09/29/15) Administrative Template Q15: What is the format needed for the Tax ID number? A15: The Tax ID ?eld will accept nine (9) characters (no hyphen) or 10 characters (including the hyphen). If users enter 10 numbers, it will not pass validation. (QHP Webinar Series FAQ #4 04/02/13) Q46: What is the purpose of the contracts section within the administrative template? For example, will that be externally facing; will it be for HIOS only? A46: The contact provided by the issuer should re?ect which person at the issuer can answer questions about the specific topic. The contacts related to finances should be able to answer questions for both inside and outside the Exchange market. The contacts provided will not be made public. (Plan Management Webinar QHP FAQ #2 04/09/13) Q16: Why are there issues with leading zeros in the Tax IDs, Health Insurance Oversight System (HIOS) Product IDs (HPIDs) and National Provider Identifiers (NPIs) on the template? A16: This issue with the Tax ID is corrected in the current version of the template. HPle and do not begin with zero. (QHP Webinar Series FAQ #4 04/16/13) Q17: Why does the Administrative (Admin) Template not accept a phone extension beginning with a zero? A17: There is a work-around procedure for this issue. Users should copy and paste the phone extension from another source into the cell (it will be accepted and will pass validation); users should not type a phone extension beginning with a zero directly into the template, because Excel will reformat the entry. (QHP Webinar Series FAQ #4 04/16/13) Q18: What kind of information is required for the Admin Template in the ?Proposed Exchange Market Coverage? field and the ?Current Sales Market? field? A18: The ?Proposed Exchange Market? ?eld indicates the market where the plan will be offered: ?Individual,? or ?Both.? The appropriate primary contact is required based on this value. The ?Current Sales Market" field indicates where products are currently being offered. The same options, ?Individual," or ?Both" are in the drop- down. If there are no products currently offered in either the Individual or SHOP market, Issuers must select ?Both.? (QHP Webinar Series FAQ #4 04/16/13) Q19: Which address should be entered in the Primary Contact ?eld in the Administrative Template? A19: The Issuer address should be the company address associated with the HIOS ID and entered in HIOS. The company address in HIOS is the relevant address for that issuer in that state. It needs to be entered in the ?Primary Contact? field of the 583 Updated 1-31-17 2017--00683 Administrative Template. The SHOP address should be the primary place of business in that state, not the employee address. (QHP Webinar Series FAQ #4 04/16/13; REGTAP FAQ Database - FAQ #163 04/16/13) 020: Is the ?Primary Contact? information required to be the Chief Executive Officer (CEO) or the Chief Financial Officer A20: ?The Primary Contact? information does not need to be the CEO or the CFO. (QHP Webinar Series FAQ #4 04/16/13) 021: What does ?Third Party Administrators? (TPA) mean in the Administrative Template? A21: TPA is used for any vendor that provides services in the functional area listed. The information will provide a list of partners for potential interaction, such as secure routing of data. (QHP Webinar Series FAQ #4 04/16/13) Q4: The Customer Service TTY field asks for a 10-digit number, but TTY values are usually three digits. We inputted 711 as our TTY number since the FCC established the 711 telecommunications relay service (TRS) in order to make the process easier and more reliable for the hearing impaired. However the field requires a 10digit number. Do you not accept the 711 number? If not, do we need to create a new 10-digit TTY number? A4: Please use your Customer Service phone number if there is no 10-digit TTY number (QHP Webinar Series FAQ #5 04/18/13) Q5: We have found when entering information into the administrative template that any ID which begins with a drops the and shorts the number by 1. For example, tax ID number 06-1475928 displays as 61-475928. Because a dash is placed after the first two numbers and the place holder disappears, the template makes it look as though we?ve entered an incorrect number. A5: All tax IDs now accept leading zeros in the templates. Valid HPle and do not begin with leading zeroes. For any ?eld where this remains an issue, you may copy paste the value from another document into the template. (QHP Webinar Series FAQ #5 04/18/13) 02: On the administrative template, is the term Third Party Administrators (TPA) indicative of vendors or any companies outside of our organization performing a service speci?c to the three functional areas referenced? A2: We use the term to apply to any vendors that provide services in the functional areas listed. This information will provide a list of partners for potential interactions such as secure routing of data. Later this year, we will ask TPAs to register in HIOS so that issuers can link to their TPAs for different markets when applicable. (QHP Webinar Series FAQ #6 04/23/13) 584 Updated 1-31-1 7 2017--00684 Q3: We encountered an invalid issuer legal name system error when uploading the file in the administrative template. How do we upload the file? A3: The Issuer legal name must match exactly the name associated with your Issuer ID in HIOS. (QHP Webinar Series FAQ #6 04/23/13) 063: What should issuers enter for the field ?User Access Contact? on the administrative template? A63: The optional User Access contact should be supplied if the issuer would like to have a single point of contact for addressing issues related to HIOS system access. (QHP Webinar Series FAQ #9 10/31/13) 067: Can an administrative template contain more than one Issuer A67: Issuers must submit a single application for each Issuer ID. (QHP Webinar Series FAQ #9 10/31/13) Q32: Is the Administrative Template a requirement for issuers that file with System for Electronic Rate and Form Filing A32: In SERFF, issuers must include an Administrative Template. Issuers must include the same template for all binders if there are Individual and Small Group plans. In addition, issuers must complete two customer service ?elds in the Health Insurance Oversight System (HIOS). The Administrative Instructions found at Marketplaces/th.html provide additional information on completing the HIOS ?elds. (QHP Certi?cation Process FAQs #1 {09/29/15) Business Rules Template Q52: 0n the Business Rules Template, is there a maximum age for a dependent? Is this field related to the dependent price capping or is it related to the dependent eligibility? A52: The maximum age for a dependent ?eld is related to dependent eligibility. This is the maximum age a child can reach to be to be covered under the QHP as a dependent. States may increase the maximum age for a child-dependent through state law. For instance, a state could determine that any child under the age of 30 must be offered coverage on a policy. (It does not affect calculating the family premium or the market rules under 45 CFR which states that the premiums for no more than the three oldest covered children must be taken into account in determining the total family premium.) (QHP Webinar Series FAQ #4 04/16/13) Q30: With regard to the business rules for age on effective date in SHOP, does this refer to the date of employer group policy issuance/renewal or date of the individual employee?s policy issuance renewal? A30: Age is determined based on effective date of coverage, not age at time of contract ?nalization with the employer. (QHP Webinar Series FAQ #5 04/18/13; REGTAP FAQ Database - FAQ #161 04/18/13) 585 Updated 1-31-17 2017--00685 the REG TAP database on 08/26/14 Q64: Is there a policy limit to the number of children on a SHOP plan? How should the Business rules template field ?number of children allowed under a contract-only be completed? A64: There is no limit on number of children covered in a SHOP. The selection speci?cally states 1, 2, or 3-or-more. Limiting it to a maximum of 3 (or more) children is strictly for purposes of pricing the family rate. It does not mean there is a limit on the number of children that could be on a given policy. (QHP Webinar Series FAQ #9 10/31/13; REGTAP FAQ Database - FAQ #154 05/03/13) 065: How should an issuer indicate any exceptions to this limiting age? For example, if an issuer operates in a State that requires coverage of dependents older than age 26 if they are disabled. A65: If certain other types of dependent are allowed, this can be noted in the final column on the business rules template, which asks what dependent relationships are allowed. (QHP Webinar Series FAQ #9 10/31/13) thaHs4aken?eareef-elsewhere (QHP Webinar Series FAQ #9 04/30/13? Note? CMS has issued three versions of FAQ this question appeared In the version issued on 04/30/13, but not in the version issued on 05/03/13 or the one issued 10/31/13.) 586 Updated 1-31-17 2017--00686 Q: When the Business Rules Template refers to same-sex partners being treated as secondary subscribers, does ?same-sex partner? mean same-sex spouses wedded in states that legally recognize same-sex weddings? A: No, the term ?same-sex partners? does not require that the individuals are same-sex spouses who are wedded in a state which legally recognizes same-sex weddings. The term is inclusive of same-sex partners regardless of marital status. (REGTAP FAQ Database - FAQ #2966 07/23/14; re-re/eased as REGTAP FAQ #3363 on 07/31/14) Q: Can the Business Rules Template support two separate dependent ages for a Small Business Health Options Program (SHOP) Qualified Health Plan (QHP), specifically in Column F, which asks the Q: ?Is there a maximum age for a dependent?? A: In the Business Rules template an issuer can de?ne the maximum age for a dependent at the issuer-level, product-level or plan-level. The template allows for the entry of multiple products or plans which differ in values for maximum age of a dependent, as long as the products and plans are differentiated below the issuer-level row of the template. Multiple entries can be made regardless of whether the product or plan is a QHP or SADP, or is offered in the individual market or SHOP market. (REGTAP FAQ Database - FAQ #2967 07/23/14; re-re/eased as REG TAP FAQ #3364 on 07/31/14) Q: Are issuers required to submit separate Business Rules Templates and the Rates Table Templates for Individual and Small Group plans? A: No. In the Rates Table template, issuers can submit rate information for individual market plans and SHOP market plans within the same template. If the issuer is offering plans with individual age rating and plans with family tier rating, the issuer should place these sets of plans on separate tabs of the template. In the Business Rules template, issuers can submit information for individual and SHOP market plans within the same template, as long as these plans are differentiated within the template at either the product or plan level. (REGTAP FAQ Database - FAQ #2968 07/23/14; re-re/eased as REGTAP FAQ #3365 on 07/31/14) Q: If an issuer lists ?Brother or Sister? as an allowed relationship on the Business Rules Template, can the issuer apply an age limit to the relationship (only brothers and sisters under a specified age allowed)? A: The issuer cannot apply an age limit for a brother/sister relationship in the Business Rules Template. For child-only plans with an allowed relationship of ?Brother or Sister,? the covered siblings must be under the age of 21. (REGTAP FAQ Database - FAQ #3518 08/07/14) Q39: Why is there a requirement for QHPs to enter age ?25? and not ?26? under field of the Business Rules Template? A39: In the Business Rules Template, the age entered in the field for maximum age of a dependent is inclusive through that age (25), rather than up to that age. Market rules require Qualified Health Plan (QHP) issuers that make available dependent coverage of children to make such coverage available for children until attainment of age 26 through the age of 25). (QHP Certification Process FAQs #1 {09/29/15)} 587 Updated 1-31-17 2017--00687 Q40: Must issuers in State-based Marketplaces (SBMs) submit Service Area, Formulary, Business Rules, Administrative and Network Adequacy templates through the Health Insurance Oversight System (HIOS) for on and off-Marketplace products? A40: Issuers in State-based Marketplaces (SBMs) should confer with their State Departments of Insurance (DOI) regarding certification data submission requirements. (QHP Certi?cation Process FAQs #1 {09/29/15) Q41: Are issuers to list both the copayment and the coinsurance for the greater of or the lesser of the copayment and the coinsurance on the Plans and Benefits Template? A41: The 2016 Business Rules Template does not allow issuers to capture the greater of or the lesser of the copayment and coinsurance data. Issuers may capture the cost- share design on the Plans and Bene?ts Template in the explanation ?eld or on the Plan Brochure and Formulary Uniform Resource Locator (URL). (QHP Certification Process FAQs #1 {09/29/15)} Plans and Benefits Template Q34: Why is there a warning message about exceeding the 2013 IRS Maximum Out-of- Pocket? A34: Since the IRS has not yet established limits for 2014, the alert level is set at the 2013 out-of-pocket maximum to alert users that the maximum may be exceeded. There is more detailed information on how to address this in the QHP Application Instructions. The template will be able to validate successfully and be submitted. (QHP Webinar Series FAQ #4 04/02/13) Q41: If benefits that are mandates in a State, are they required in the QHP Plans and Benefit Template submission? A41: mandates in a State are treated like an optional rider. Those bene?ts that are ?must-offer" mandates are not required to be included in the template. In situations where an issuer would traditionally offer a rider and is interested in offering that optional benefit on the Federally-facilitated Exchange (FFE), an issuer should submit two plans, one with and one without the rider. Depending on the benefit that would have been traditionally offered in a rider, it may not be displayed on the FFE website to consumers, but it may be displayed by issuers and provided to consumers in plan documents. (QHP Webinar Series FAQ #4 04/02/13) 024: Is the section ?Disease management programs? displayed on the SBC and/or plan compare? A24: As noted in Chapter 10: Instructions for the Plans Benefits Application Section, issuers can indicate if Disease Management Programs will be available on the QHP through this optional data ?eld. Issuers will have the option to select from a dropdown menu that includes the following programs: asthma, heart disease, depression, diabetes, high blood pressure high cholesterol, low back pain, pain management and pregnancy. This information will be displayed on Plan Compare. (Plan Management Webinar QHP FAQ #2 04/09/13) 588 Updated 1-31-17 2017--00688 025: Please provide guidance on those data elements outlined in the Appendices that are not included in a template benefit cost sharing - start day if charge is day; Summary of Benefits and Coverage (SBC) - what is the total cost to the customer for costs and exclusions?). A25: Please refer to the SBC Scenario and AV Calculator Additional Bene?t Design data elements in the Plans Bene?ts template and Chapter 10: Instructions for the Plans Bene?ts Application Section, which describes how to complete the data elements in the template. (Plan Management Webinar QHP FAQ #2 04/09/13) 026: When will the bene?ts template be made available with the state specific EHBs populated? A26: The Plan Bene?ts Template populated with state speci?c EHBs is currently available to States and Issuers through the NAIC website management data templateshtm). (Plan Management Webinar QHP FAQ #2 04/09/13) 027: How do issuers obtain Network A27: To obtain a network ID, issuers may refer to Chapter 8: Instructions for the Network Identi?cation Application Section at These instructions will walk the issuer through obtaining a Network ID. The Create Network IDs button generates the Network IDs. The button will ask how many networks you have and generate them for you. (Plan Management Webinar QHP FAQ #2 04/09/13) 028: What does the header, mean, and how does it relate to the contents in the drop downs? A28: QHP is a required ?eld in the Plan Bene?ts Template. Issuers must indicate whether the plan is offered on the Exchange, off the Exchange, or both. The contents of the drop down are: On Exchange?if the plan will be offered on the Exchange; Off Exchange?if the plan will be offered off the Exchange; Both?if the plan will be offered both on and off the Exchange. FFM is not currently collecting off Exchange plans. is applicable as it provides flexibility for the template being used for other purposes outside of QHP submission. (Plan Management Webinar QHP FAQ #2 04/09/13) 029: What if an issuer is still working on finalizing its prescription drug formulary at the time of application, such that adding EHB drugs is problematic? Updated 1-31-17 A29: As noted in Chapter 12: Instructions for the Prescription Drug Application Section, the Formulary URL is a required ?eld, and issuers are required to enter the included in any drug list and also the associated cost-sharing tier level in the Prescription Drug Template. For the FFE, issuers should include the that they intend to offer. In order to meet EHB standards, plans must offer at least the greater of one drug in every USP category and class or the number of drugs in each USP category and class offered by the EHB-benchmark. Plans are permitted to go beyond the drug count in the benchmark and can add more drugs to their formularies. If the drug does not have a USP category/class then it will not be counted, but the plan is not precluded from 589 2017--00689 offering that drug. Since the State is responsible for monitoring compliance with EHB policy, the State should be notified of any change in formulary, but State-based Exchanges could set their own rules in terms of requiring plans to notify the Exchange of any drug list changes. (Plan Management Webinar QHP FAQ #2 04/09/13) Q30: What is the definition of a network A30: The network URL is the web address on the issuer website that consumers can use to view the providers in the issuer?s network. (Plan Management Webinar QHP FAQ #2 04/09/13) Q31: If there is more than one service area ID, how is this entered in the template? A31: Each QHP submitted must be associated with a single Service Area ID as identified in the Service Area Template. If a QHP is offered in three service areas, the issuer will need to create a fourth service are consisting of those all three areas combined, and use that single ID for completing the Benefits Template. (Plan Management Webinar QHP FAQ #2 04/09/13) Q32: Will upcoming drafts of templates indicate which fields are required for the QHP application? A32: The Data Traceability Matrix (DTM) is currently available through the NAIC website management data templateshtm). The DTM outlines how data should be entered for each field in the QHP data collection templates, and the template fields note which entries are required vs. not required. (Plan Management Webinar QHP FAQ #2 04/09/13) Q37: Why is there a column for HSA eligibility but not HRA eligibility? Updated 1-31-17 A37: On February 25, 2013, the Department published its ?nal rule on EHB at 78 FR 12834, which includes provisions on cost sharing and the calculation of actuarial value for health plans. Section 156.135(c) of this regulation implements section 1302(d)(2)(B) of the Affordable Care Act regarding employer contributions to HSAs when determining the level of coverage for a plan of the employer. Under this regulation, a plan?s employer contribution to an HSA or an integrated HRA may be counted towards the total anticipated medical spending and adjusted to reflect the expected spending for health care costs in the calculation of actuarial value that determines the level of coverage of the plan. As detailed in the regulation, because it is the issuer that uses the Actuarial Value Calculator to determine a plan?s actuarial value, the employer contribution, or the amount newly made available by the employer under an integrated HRA that may only be used for cost sharing, may be considered part of the actuarial value calculation when the contribution is available and known to the issuer at the time the plan is purchased. Further information about how an HSA or integrated HRAs are used in the calculation of actuarial value is available the Actuarial Value Methodology available at: (Plan Management Webinar QHP FAQ #2 04/09/13) 590 2017--00690 Q34: What does the ?eld variation type? mean? A34: CSR Variation Type is a required ?eld in the Plan Benefits Template. The data in the plan variation type ?eld auto populates based on information the issuer previously entered in the template. (Plan Management Webinar QHP FAQ #2 04/09/13) Q35: Will the data templates from the initial application in April 2013 be used on an ongoing basis, such as when filling new products with the state? A35: As noted in the Issuer Letter mentioned previously, the QHP Application will collect both issuer-level and plan-level benefit and rate data and information, largely through standardized data templates for the Federally-facilitated and State Partnership Exchanges. States will continue to perform regulatory activities such as reviews of health plan rates, benefits, and provider networks with respect to all plans offered in the State, both inside and outside the Exchange. Issuers should defer to any State-speci?c guidelines for review and resubmission of state-reviewed standards. (Plan Management Webinar QHP FAQ #2 04l09/13) This FAQ was revised and released as REG TAP on 03/31/14, as follows: Q: Will the data templates from the initial application in April 2013 be used on an ongoing basis, such as when filling new products with the state? A: As in 2013, the QHP Application for the 2015 coverage year will collect both issuer-level and plan-level bene?t and rate data and information, largely through standardized data templates for the Federally-facilitated Marketplaces and Marketplaces in States Performing Plan Management Functions. For the 2014 bene?t year, CMS is proposing revisions to the QHP application templates via the PRA process form number OMS-10433). QHP application templates will be ?nalized after the PRA process is complete. States will continue to perform regulatory activities such as reviews of health plan rates, bene?ts, and provider networks with respect to all plans offered in the State, both inside and outside the Marketplace. Issuers should defer to any State-speci?c guidelines for review and submission of new or existing products for review under state law. (REG TAP FAQ Database - FAQ #1363 03/31/14) Q36: Can an issuer submit one QHP application, since the templates allow several bene?t packages within one template? If no, what rules dictate how many QHP applications need to be submitted? Updated 1-31-17 A36: Yes, the issuer can submit one QHP Application to represent multiple products and plans. (Plan Management Webinar QHP FAQ #2 O4l09/13) This FAQ was revised and released as REGTAP on 03/31/14, as follows: Q: Can an issuer submit one QHP application, since the templates allow several benefit packages within one template? If no, what rules dictate how many QHP applications need to be submitted? 591 2017-?00691 A: Yes, the issuer can submit one QHP Application to represent multiple products and plans in a given state. If the issuer wishes to offer plans in multiple states, the issuer must submit a single QHP Application for each state. (REGTAP FAQ Database - FAQ #1359 03/31/14) Q38: What should be included in the content of the drop down option, ?Plans Benefits - Plan Level Exclusions?? A38: Users may enter Plan Level Exclusions in this optional field. This ?eld is a free text field. (Plan Management Webinar QHP FAQ #2 04/09/13) Q39: What is the ?Add Benefit? button intended to do? A39: The ?Add Bene?t? button in the Plan Benefits template is used to add a bene?t that is not on the template. Click the Add Benefit button on the menu bar under the Plans and Benefits ribbon to add a bene?t or refer to Chapter 10: Instructions for the Plans Bene?ts Application Section for additional information. (Plan Management Webinar QHP FAQ #2 04/09/13) Q40: What is the purpose of multiple tabs in the benefits template? A40: The Plan Bene?t template enables users to create multiple benefit packages within a single QHP submission. This feature reduces data entry burden on the issuer as it eliminates the need to enter duplicate data throughout the application. An issuer may associate multiple plans with a bene?t package, which is comprised of the same bene?ts and limits. (Plan Management Webinar QHP FAQ #2 04/09/13) Q41: Since all cost sharing (Drug and EHB) has to apply to the out-of-pocket maximum, why are there separate out-of-pocket maximum columns? A41: Some issuers have bene?t package designs with separate out-of?pocket maximums for medical and drug benefits. You are correct that the annual limitation on cost sharing (for the out-of?pocket maximum) applies to the total for in-network bene?ts. A given plan design with separate out of pocket limits for in network medical and drug costs would comply with the annual limitation on cost sharing if the sum of the limits is less than or equal to the maximum amount allowed under regulation. (Plan Management Webinar QHP FAQ #2 04/09/13) Q42: How do issuers answer column P, ?Indian Plan variation - Est advanced payment,? for products without an Indian variation? Updated 1-31-17 A42: If applicable, issuers should enter a dollar amount in this optional field. Estimated amount of cost-sharing reductions for eligible enrollees to be provided in the form of an advance payment to the issuer should be entered here. This amount is estimated by the issuer and applies to Indian plan variations described in section of the final HHS Notice of Bene?t and Payment Parameters for 2014 (78 FR 15410). (Plan Management Webinar QHP FAQ #2 04/09/13) 592 2017--00692 Q43: Please advise how issuers should populate the cost share variance ?elds for ?non- emergency care when outside the country,? as the copay and coinsurance could vary. A43: HHS recognizes that the copay/coinsurance amounts could vary for this category of services. The issuer should populate these ?elds with the amounts that would most typically apply. In the explanations field, the issuer should note that cost sharing could vary based on the type of service rendered and place it is received. (Plan Management Webinar QHP FAQ #2 04/09/13) Q44: In reviewing the most recent SERFF templates, we did not notice a way to indicate if a medical benefit plan required a PCP/Gatekeeper. Is this a field that is projected to be added? A44: In the Plan Bene?ts template, the field marked ?Is a Referral Required for Specialist?? may be used to indicate if a referral is required to see a specialist. (Plan Management Webinar QHP FAQ #2 04/09/13) Q45: Can HHS make public the EHB Crosswalk that is mentioned in the recently published Methodology document? A45: HHS has made available a tool called ?the USP Category Class Count Service? (the Counting Service) to enable issuers and States to submit formularies using unique identi?ers called RxNorm Count Unique Identi?ers and receive a report of the category, class, and count of unique drugs applicable to the submitted information to use to crosscheck the counts against the relevant State?s EHB standards to ensure the plan meets the benchmarks for their State. This tool was released March 2013 through HIOS. (Plan Management Webinar QHP FAQ #2 04/09/13) Q32: What is the purpose of the ?eld ?Unique Plan Design? in the bene?ts template? Updated 1-31-17 A32: As noted in Chapter 10: Instructions for the Plans Benefits Application Section, issuers must indicate if the health insurance plan has a unique design, for purposes of the AV Calculator. This is a ?Yes? or ?No? field, and issuers will be asked to indicate whether the plan design is unique, meaning it cannot use the standard AV Calculator. If the plan design is unique for purposes of calculating AV, upload the Unique Plan Design Supporting Documentation and Justi?cation (See Chapter 13: Unique Plan Design Supporting Documentation and Justi?cation for a suggested format). The actuarial certification is a signed and dated certi?cation indicating that a member of the American Academy of Actuaries performed the calculation, which complies with all applicable Federal and State laws and actuarial standards of practice. An example of plan designs that could be considered ?unique? for purposes of determining AV would be a plan with coinsurance rates that increase with out-of?pocket spending, such as a plan design with 10 percent coinsurance for the first $1,000 in consumer spending after the deductible, 20 percent coinsurance for the next $1,000 in consumer spending, and 40 percent coinsurance up to a $6,400 out-of?pocket maximum. This plan design would be considered ?unique? because the current AV Calculator can only accommodate a single coinsurance rate for each benefit. (Plan Management Webinar QHP FAQ #3 04/11/13) 593 2017--00693 Q33: How should the benefits template be completed if infertility is not covered? A33: As noted in Chapter 10: Instructions for the Plans Benefits Application Section, if a benefit is not covered, select ?Not Covered? in the ?Is this Bene?t Covered? ?eld of the Plan Benefits template. If this ?eld is changed to 'Not Covered' for an EHB then you must substitute another bene?t or combination of benefits in its place and provide the EHB-Substituted Benefit (Actuarial Equivalent) Supporting Documentation and Justification (Instructions Chapter 138) to support the actuarial equivalence of the substitution. (Plan Management Webinar QHP FAQ #3 04/11/13) Q34: What should be entered in fields starting with ?Primary Care Visit to Treat an Injury or Illness,? when a plan has a copay or coinsurance, but not both?? A34: Please refer to the ?Covered Benefits? section of Chapter 10: Instructions for the Plans Bene?ts Application Section for information to complete the copayment and coinsurance ?elds of the Plans Benefits Template. For example, under "Copay?In Network (Tier if an in-network copayment is charged, enter the dollar amount. If no copayment is charged, enter No Charge. Choose from the following: a. No Charge b. No Charge after deductible c. Copay d. Copay after deductible e. Copay before deductible. Under "Coinsurance?In Network (Tier if an in-network coinsurance is charged, enter the percentage. If no coinsurance is charged, enter ?No Charge," unless your plan has a tier 1 in-network copayment that the enrollee pays only until the deductible is met. In this case, enter Choose from the following: a. No Charge b. No Charge after deductible c. Coinsurance after deductible d. (Plan Management Webinar QHP FAQ #3 04/11/13) Q35: What are the "Plan Data Elements" identified in appendix B1 needed for? Updated 1-31-17 A35: Plan-level data elements are used to identify high-level data about each plan, including its ID and which network, service area, and formulary the plan will be using. Plan-level information applies to each standard plan you want to create for this bene?ts package. A standard plan is a QHP offered at the bronze, silver, gold, platinum, or catastrophic level of coverage, and a bene?ts package is a group of plans that cover the same set of bene?ts; each plan in a bene?ts package can have different cost sharing, which is defined in the Cost Share Variances tab. (Plan Management Webinar QHP FAQ #3 04/11/13) 594 2017--00694 Q36: In the Benefits template what do utilization, cost share, and projected utilization rates mean? A36: When the user is using Multiple In-Network Tiers, the Plans and Benefits Template requires that the user input the service utilization rates in each of those tiers that are equal to 100%. This information is used in the calculation of AV. If the user does not have multiple in-network tiers and selects "no" under column (Multiple ln-Network Tiers), the Plans and Benefits Template grays out the second tier of utilization and the user should input the "100%" under the ?rst tier. (Plan Management Webinar QHP FAQ #3 04/11/13) Q38: What does the field variation type? mean? A38: The Variation Type" refers to Cost Sharing Reduction information that must be submitted at the plan and bene?t cost sharing levels. This ?eld auto populates with the following based on cost sharing data entered into the template: Standard Silver Off Exchange Plan, Standard Silver On Exchange Plan, Zero Cost Sharing Plan Variation, Limited Cost Sharing Plan Variation, 73% AV Level Silver Plan, 87% AV Level Silver Plan and 94% AV Level Silver Plan. (Plan Management Webinar QHP FAQ #3 04/11/13) Q39: What fields will be pre-populated with the Benchmark Plan data? A39: As noted in Chapter 10: Instructions for the Plans Benefits Application Section, the following ?elds may auto-populate in the Plan Bene?ts Template: EHB, State Mandate, Is this Bene?t Covered?, Quantitative Limit on Service, Limit Quantity, Limit Unit, Minimum Stay and Explanation. (Plan Management Webinar QHP FAQ #3 04/1 1/13) Q40: For State-based Exchanges, will issuers receive pre-populated templates? A40: HHS has made the add-in ?le with benchmark information available to all States. In a State-based Exchange, please defer to the State for guidance on the speci?c data collection instrument that will be used. (Plan Management Webinar QHP FAQ #3 04/1 1/13) Q41: Are coverage level and metal level the same? A41: As noted Chapter 10: Instructions for the Plans Benefits Application Section, the terms coverage level and metal level are used interchangeably throughout the templates and QHP Application. (Plan Management Webinar QHP FAQ #3 04/11/13) Q42: How do issuers incorporate riders? Updated 1-31-17 A42: The FFE and State Partnership Exchange templates will not collect or display optional riders. In situations where an issuer would traditionally offer a rider and is interested in offering that optional benefit on the FFM, an issuer should submit two plans, one with and one without the rider. Depending upon the benefit that would have been traditionally offered in a rider, it may not be displayed on the FFM website to consumers, but it may be displayed by issuers and provided to consumers in plan documents. (Plan Management Webinar QHP FAQ #3 04/11/13) 595 2017--00695 Q43: How do issuers enter coinsurance values in the Plans Bene?ts template and the AV Calculator? A43: While the coinsurance values in the Plans Bene?ts template represent the percentage of costs that the enrollee pays for a given service, the coinsurance values in the AV Calculator represent the percentage of costs the issuer pays. Thus, the coinsurance values entered into the AV Calculator must be set equal to where is the coinsurance value entered in the Plans Bene?ts template. For example, if enrollees pay 10 percent of Specialist Visit costs, the coinsurance in the Plans Bene?ts template would be equal to 10 percent. The coinsurance in the AV Calculator would be equal to 90 percent to represent the 90 percent of costs incurred by the issuer. (Plan Management Webinar QHP FAQ #3 04/11/13 and REG TAP database FAQ #2121 06/1 1/14) Q44: There have been a variety of technical problems with the bene?ts template. How can issuers move forward with using this template? A44: Issuers may have technical issues when the Plans and Bene?ts Template Add-in file is not installed. To ?x this: 1.De ete all versions of the add-in file.2.Down oad the current version of the add-in ?le. Make sure you select ?Save? from the dialog box, not ?Open.? 3.0pen the Plans and Bene?ts Template. You should see a ?Plans and Bene?ts on the features bar. 4.Enab e Macros.5.See the user guide and instructions for troubleshooting help.6.Call the helpdesk if the previous suggestions do not solve the technical problem. (Plan Management Webinar QHP FAQ #3 04/11/13) Q3: How do the Service Area ID, Network ID, and Formulary ID relate to the Plans and Benefits Template? A3: The Plans and Bene?ts Template includes macros that allow users to import their IDs from other templates into the Plans and Bene?ts Template. Macros create the IDs required for all medical plans, with the exception of the Stand-alone dental plans, which do not require a Formulary ID. For each plan, there can only be a single instance of the ID. The Service Area ID must include the entire service area for the plan. The Network ID must include the link that consumers will use to get information about the all the covered providers under the plan. The Formulary ID must include the link that consumers will use to get information about the formulary. (QHP Webinar Series FAQ #4 04/16/13 and REGTAP FAQ Database - FAQ #2137 06/11/14) 027: In the Plans and Benefits Template, how will American Indian variations for plans for above 300% of the Federal Poverty Level (FPL), the limited cost share plans, be distinguished in the certification materials? Updated 1-31-17 A27: Plans are certi?ed at the Standard Component ID level. All cost sharing variants, including the Zero Cost Sharing and Limited Cost Sharing variants, must meet the QHP certification standards to be certified. On the Cost Sharing Variance worksheet of the Plans and Bene?ts template, the variants are distinguished by adding a code to the Standard Component Plan ID as follows: . 00 non-exchange variant . 01 exchange variant (not CSR) 02 Zero Cost Sharing Plan Variation 596 2017--00696 03 Limited Cost Sharing Plan Variation 0 04 73% AV Level Silver Plan CSR 05 87% AV Level Silver Plan CSR 06 94% AV Level Silver Plan CSR. (QHP Webinar Series FAQ #4 04/16/13 and (REG TAP FAQ Database - FAQ #2161 06/11/14) 028: Why does the Plans and Benefits Template have Column to indicate plan variation for a limited cost sharing variation or a zero cost sharing variation? A28: Column on the Bene?ts Package is the Estimated Advanced Payment per Enrollee for the Limited Cost Sharing Plan, not the Zero Cost Sharing Plan. It is an optional ?eld. The Estimated Advanced Payment amounts for the other Cost Sharing Variants are reported on the Unified Rate Review template. (QHP Webinar Series FAQ #4 04/16/13) 029: What happens if there are blanks in the pre-populated area of the template? A29: Although the ?elds may be required fields, blanks mean ?Not covered.? No fields are required for bene?ts that are not covered. (QHP Webinar Series FAQ #4 04/16/13) Q30: What is the difference between ?Not Applicable? and ?Not Covered?? A30: If a bene?t is not covered, it should be marked ?Not covered" (or left blank) in the benefits package. It will not display on the cost sharing sheet; the template will not indicate copayments or coinsurances for that benefit. ?Not Applicable? is only an option for the Maximum Out of Pocket and Deductible ?elds on the Cost Share Variance sheet. (QHP Webinar Series FAQ #4 04/16/13) Q31: Copayment and coinsurance are entered for specific benefits throughout the Benefits Template, although it is usually just one and not the other. How do Issuers indicate ?No Charge,? and how will that be displayed to the consumer? A31: The consumer will see only the cost-sharing attribute that applies. For example, if there is a 20% coinsurance and $0 copay, only the 20% coinsurance will be displayed. (QHP Webinar Series FAQ #4 04/16/13) Q32: How do issuers indicate a benefit is not covered out-of-network and is covered in- network only? A32: Issuers can indicate a bene?t is not covered out-of-network by entering a 100 coinsurance for the out-of?network cost sharing information for that bene?t. (QHP Webinar Series FAQ #4 04/16/13) Q33: If a plan does not include an out-of-network benefit (except for emergency care), how do issuers complete the ?Combined In/Out Network? ?eld of the Plans and Benefits Template? A33: The issuer should complete the combined medical and drug in-network for that given benefit. If there is no coverage out-of?network, enter 100% coinsurance. The 597 Updated 1-31-17 2017--00697 Deductibles and Maximum Out of Pocket ?elds have a ?Not Applicable? option that can be selected for the Combined ln/Out Network fields. The benefits do not have a Combined In/Out of Network ?eld. (QHP Webinar Series FAQ #4 04/16/13) Q35: How can the template accommodate more complex plan designs, such as custom deductibles or combinations of copayslcoinsurances that are speci?c to the number of visits? A35: Please refer to the detailed QHP Application Instructions, Chapters 10 and 11, for instructions on how to enter the coinsurance information/copay amount and how they map to Actuarial Value (AV) Calculator. Issuers can create up to five deductible groups for each benefit package. This option appears when you click on the ?Create Cost Share Variance" macro button. Additional information can be provided to consumers using the ?Exclusions" or ?Explanations? text fields in the benefit package section of the template. Note that the ?elds in the AV Calculator Additional Bene?t Design section of the template such as ?Begin Primary Care Deductible and Coinsurance" and ?Set Number of Copays? are for the Actuarial Value calculation and most likely will not display to consumers. Further, users can see more details about the plan bene?ts through the Uniform Resource Locator (URL) to the plan brochure. (QHP Webinar Series FAQ #4 04/16/13) Q36: Do the bene?ts ?generic drugs?, ?preferred brand drugs?, ?non-preferred brand drugs? and ?specialty drugs? on the Benefit Template conflict with information entered to create a Formulary ID on the Pharmacy Template? A36: The information that consumers will view is from the Benefits Template. There are detailed instructions on how to map the information from the Prescription Drug Template to the Benefits Template in Chapter 10 of the QHP Application Instructions. (QHP Webinar Series FAQ #4 04/16/13) Q37: The Plans and Benefits module only allows for one cost sharing amount per benefit; depending on the plan design, this could vary depending on the site of service; for example, chemotherapy (physician?s office has a physician office copay; outpatient or inpatient facility has a deductible and coinsurance). How do issuers enter the site of service designation and appropriate cost share? A37: If there are provider types like Primary Care and Specialist, use them to differentiate the cost sharing. For others, if there is nothing available for a given benefit, where different cost sharing can apply depending on the site of service, the recommendation is to complete the copay or coinsurance that is typical for most enrollees, and using the explanation field for the appropriate and brief detail for the cost sharing and other scenarios, outside of the most common one entered in the standard data field. (QHP Webinar Series FAQ #4 04/16/13) Q38: There are some benefits listed that are not clear in the EHB section, such as domestic violence treatment. Is the treatment for physical injury or for counseling services? Is it for emergency room, a doctor?s office, or a specialist?s office? A38: The information on the CCIIO website is a snapshot -- a summary of the bene?ts provided by the benchmark plan. Issuers can go to the NAIC website health reform sectionhtm) to locate the actual policy for that benchmark plan to see more detail about coverage, limitations, and exclusions. We 598 Updated 1-31-17 2017--00698 would encourage issuers to work with their enforcing state to further understand what enforcement or review for EHB will entail. (QHP Webinar Series FAQ #4 04/16/13) Q14: The Plan and Benefits template does not appear to allow the application of 3 cost shares (Deductible Coinsurance Copay) on select services within a plan design. A14: Select services on the Plan and Benefits template will not allow both a coinsurance and copay. For example, the generic drug data ?eld cannot accept both because the AV Calculator requires one or the other. Per the user guide to the AV Calculator, the prescription drug bene?ts do not allow for both a copay and coinsurance for the same drug tier. When you input the plan design into either the Template or the AV Calculator, we recommend that you use your best actuarial determination to align your benefits to the four drug tiers. We recommend that you take the highest cost-sharing rate where possible. If you feel that this approach results in a material difference for AV, there is the option for issuers to submit plans as unique plan design. In addition, the AV Calculator does not include the ability to input copays for outpatient surgery because the data that supports the AV Calculator does not allow for copays for outpatient surgery. Instead, HHS recommends that plans estimate the copay?s percentage of total cost for the bene?t and input the remaining percentage into the calculator as coinsurance. (QHP Webinar Series FAQ #5 04/18/13) Q15: The Plans and Benefits template does not appear to allow the application of a copay for a select number of visits before a Deductible Coinsurance applies. A15: When completing the cost sharing for the specific benefits, we recommend that the issuer ?ll out the copay and/or coinsurance that would be most typical for most enrollees within the confines of the data entry permitted by the template. highest utilized). In the "Explanations" field, the issuer should add appropriate and brief detail to communicate cost sharing in other scenarios outside of the most common one already entered into the worksheet. (QHP Webinar Series FAQ #5 04/18/13) Q16: How do we input cost share methods other than simple copay or coinsurance? Greater oflLesser of; Copayment/Coinsurance; $1000 a day for days 1-3, then covered at a copay/ coinsurance) A16: When completing the cost sharing for the specific benefits, we recommend the issuer should fill out the copay and/or coinsurance that would be most typical for most enrollees within the con?nes of the data entry permitted by the template. highest utilized). In the "Explanations" field, the issuer should add appropriate and brief detail to communicate other cost sharing in other scenarios outside of the most common one already entered into the worksheet. (QHP Webinar Series FAQ #5 04/18/13) Q18: We are trying to enter an HSA-compatible plan at one metal level, but not at any of the other metal levels. When we select ?Yes? or? No? for the ?Subject to Deductible? question, the response applies to all plans on the template. Is it possible to enter an HSA at one metal level and then PPOs at the other levels, on the same template? Is it possible to only enter one metal level on the template, and not all required metal levels (Silver and Gold)? A18: All of the data elements in the bene?t package section of the template apply to all plans. You can create additional bene?t packages within the template with the Create 599 Updated 1-31-17 2017--00699 New Bene?ts Package macro. You may copy past the cells from your initial bene?t package, and then make the changes that apply to your new package. There is no requirement that all plans associated with a product have the same benefit package. (QHP Webinar Series FAQ #5 04/18/13) Note: This FAQ was revised and released as REG TAP on 03/31/14, as follows: Q: How does an Issuer enter an HSA-compatible plan at one metal level, but not at any of the other metal levels? A: All of the data elements in the benefit package section of the template apply to all plans. To create an HSA-compatible plan at one metal level, but not at any of the other metal levels, you can create additional bene?t packages within the template with the Create New Benefits Package macro. You may copy paste the cells from your initial benefit package, and then make the changes that apply to your new package. (REGTAP FAQ Database - FAQ #1331 03/31/14) Q19: There is a problem with the Component Numbers column in the Plan Benefit Add-in. The new product numbers that are viewable include some repetition and do not correspond to the product numbers that appear on the HIOS template successfully uploaded. A19: Standard Component Plan IDs must be entered in the Plans and Bene?ts template by the issuer. There is no macro or functionality in the Plans and Bene?ts Add-in file to support this. If you are seeing this issue in the Excel version of your .xml upload that you got from SERFF or the Benefits and Service Area module in HIOS, please contact the Help Desk. They will need a copy of your Excel template, your .xml upload, and the Excel ?le that you downloaded after successful validation. (QHP Webinar Series FAQ #5 04/18/13) 023: For all of the specific benefits throughout the Benefits template, you must enter both a copayment and coinsurance, although you usually have one and not the other. The template allows you to enter ?no charge? or a dollar amount or percentage. The CMS instructions indicate to enter ?no charge? when there is no copayment or coinsurance, but we are concerned about how that translates to the consumer. A23: In our system, ?no charge? and are the same (QHP Webinar Series FAQ #5 04/18/13) 024: There is con?icting guidance and instructions for ?ling as to whether and how to put a copay on the three primary care visits for the catastrophic plans. A24: The issuer is permitted to impose cost sharing in connection with the three primary care visits as along as permitted by other applicable law the preventive services provisions of PHS Act section 2713). (QHP Webinar Series FAQ #5 04/18/13) 600 Updated 1-31-17 2017--00700 025: On the Bene?t template, should the coinsurance re?ect what the member will pay or what the issuer will pay? A25: On the Plans and Bene?ts template, the coinsurance amount should be the amount that the member will pay. The Check AV Calculator Validation macro will convert that to the amount that the issuer will pay for the AV Calculator. (QHP Webinar Series FAQ #5 04/18/13) 026: For the Specialists Requiring Referrals and Plan Exclusions fields within the Plan Benefit Template, are these fields truly optional and is there a character limitation? A26: Specialist Requiring A Referral is required when the Is a Referral Required for Specialist? field is ?yes." Plan Level Exclusions is required when there are plan level exclusions. There are no automated checks for this. The template will accept values up to the Excel limit. However, the following ?elds have size limits in the system: . Plan Marketing Name: 255 characters 0 Plan Level Exclusions: 2000 characters 0 Out of Country Coverage Description: 2000 characters 0 Out of Service Area Coverage Description: 2000 characters - Exclusions: 2000 characters Explanation: 2000 characters (QHP Webinar Series FAQ #5 04/18/13) 05: If we are participating in the risk corridor program for both on and off Exchange products, do we report our off Exchange products on the benefit template? The Plans and Benefits template does not appear to allow the application of a copay for a select number of visits before a Deductible Coinsurance applies. A5: The bene?ts template for the QHP application process are to be used for the Exchange-offered products and plans. For Exchange products that are offered off the Exchange, we will collect data needed for the risk corridor program at a later date. It should not be submitted as part of the QHP application process. (QHP Webinar Series FAQ #6 04/23/13) 06: Are there character limits on the open data fields in the templates? Is there a way to submit additional information in a supporting document? Updated 1-31-17 A6: Here are the ?elds from the Plan and Benefits template that have size limits: 1) Plan Marketing Name - 255 characters 2) Plan Level Exclusions 2000 characters 3) Out of Country Coverage Description 2000 characters 4) Out of Service Area Coverage Description 2000 characters 5) Exclusions 2000 characters 6) Explanation 2000 characters Yes, the bene?ts module has a ?supporting documents? upload feature that supports the submission of additional information for a QHP application. Some of these supporting documents may include justi?cations explaining in more detail how a given QHP bene?t design meets application requirements actuarial certi?cation for actuarial value). 601 2017-?00701 Please see our Chapter 10 and 13 instructions for more information on supporting documents and justi?cations. We also want to highlight that plans may submit a URL for their plan brochures as well as their Summary of Benefits Coverage via the Plans and Bene?ts template. These links will be provided to consumers so that they can obtain more detailed information on a given QHP if they would like it during the shopping process. (QHP Webinar Series FAQ #6 04/23/13) Note: This FAQ was revised and released as REG TAP FAQ #1329 on 03/31/14 Q: Are there character limits on the open data fields in the templates? A: Yes, there are character limits on the open data ?elds in the templates and they vary by template and field. For speci?c information about the character limits for each open data field and each template, please review the Data Traceability Matrix, located at org/plan management data templateshtm. Also, please note that the templates used for the 2014 plan year data collection may change prior to the 2015 plan year data collection. (REG TAP FAQ Database - FAQ #1329 03/31/14) Q8: Do we need to supply the product name in the templates to display on healthcare.gov? A8: For the Federally Facilitated Marketplace, the product name will not display to consumers, only the Plan Marketing Name. (QHP Webinar Series FAQ #6 04/23/13) 061: If an issuer has an ER copay of $150, which covers the facility charge part, but at the same time the member will be billed the physician part subject to deductible and coinsurance, how should the template be filled out? A61: The template cannot accommodate the described situation where the facility charge is not subject to deductible/coinsurance but the physician/professional charges are. The issuer should fill out this benefit identical to how it would complete the stand- alone AV Calculator. We recommend that the issuer use whichever charge typically is predominant for consumers. For example, if the facility charge typically makes up the majority of the total allowed costs, then input the facility portion of the bene?t into the data ?elds and enter the physician portion into the free text explanations field. (QHP Webinar Series FAQ #7 04/24/13) 062: Do the silver cost reduction variations need to be submitted with separate standard component A62: No. The template on the Cost Share Variances tab will automatically add suf?xes to the standard ID for the appropriate cost sharing reduction variations. (QHP Webinar Series FAQ #7 04/24/13) 602 Updated 1-31-17 2017--00702 063: In the Cost Share Variances tab, are issuers expected to run the SBC calculator and input numbers into the columns A63: As noted in Chapter 10 of the instructions, this template section contains ?elds for basic information about two SBC scenarios. While these data ?elds are optional, issuers are advised that the FFE may be using certain data elements from the SBC in Plan Compare. If this issuer does not provide this information, then Plan Compare will show ?not available." (QHP Webinar Series FAQ #7 04/24/13) 064: Is there documentation on the macros in the plan management data templates plans benefits workbook or add-in? Where can issuers find the source code? A64: There are several documents available on to give you more detailed technical information about the templates, including: - Data Traceability Matrix (DTM) - Data Dictionary - Populating FFE Spreadsheets By Developers (QHP Webinar Series FAQ #7 04/24/13) 065: How should plans represent a sanction for out-of-network claims? A65: In the case of a monetary penalty that cannot be de?ned using the copay and coinsurance fields, the issuer may use the Explanations ?elds (at the bene?ts level) or the Plan-Level Exclusions ?eld to describe the extra cost sharing associated with out of network sanctions. (QHP Webinar Series FAQ #7 04/24/13) 066: What should issuers enter in the out-of-pocket maximum fields if there are no separate drug and EHB benefits? A66: If the plan does not have separate medical and drug deductibles or maximum out- of-pockets (MOOPs), you should use the ?Medical Drug Deductibles Integrated?" or ?Medical Drug Maximum Out of Pocket Integrated?" ?elds on the Cost Share Variances tab of the Plans Bene?ts template to indicate that the deductibles or MOOPs are integrated and not separate. Answering ?Yes? to these ?elds will grey out the separate deductible or MOOP ?elds, so that you only need to enter deductibles or MOOPs in the ?Maximum Out of Pocket for Medical and Drug EHB Benefits (Total)? or ?Combined Medical and Drug EHB Deductible" fields, respectively. If you have integrated deductibles or MOOPs, only one individual deductible or MOOP and one family deductible or MOOP will be displayed to consumers on the Plan Compare website. (QHP Webinar Series FAQ #7 04/24/13) Q67: For an HMO copay driven plan that does not have out-of-network benefits or coinsurance applied, what should be entered in the template? A67: For a benefit category where there is a copay, but no coinsurance applies, enter ?No Charge? in the coinsurance ?eld. For a bene?t category that does not have out-of- network bene?ts, enter $0 in the out of network copay field and 100 percent in the out-of- network coinsurance ?eld. (QHP Webinar Series FAQ #7 04/24/13) 603 Updated 1-31-17 2017--00703 Q68: How should we complete Column ?Limited Cost Sharing Plan Variation - Est Advanced Payment? A68: Please refer to Chapter 10: Instructions for the Plans Bene?ts Application Section regarding how to complete the Plan Bene?ts Template. The ?Limited Cost Sharing Plan Variation?Estimated Advance Payment? is an optional field. Leaving column Q, "Limited Cost Sharing Plan Variation - Est Advanced Payment" blank indicates that the issuer does not request advance payments for the value of cost-sharing reductions provided under the limited cost sharing plan variation for the QHP associated with the bene?t template. As indicated in the HHS Notice of Bene?t and Payment Parameters for 2014 (available at: QHP issuers may, but are not required to, estimate the value of cost-sharing reductions that they will provide through their limited cost sharing plan variation if they wish to receive advance payments from HHS. Issuers that choose not to submit such estimates by leaving column blank must still provide the cost-sharing reductions to enrollees in the limited cost sharing plan variation, and will be reimbursed by HHS at the close of the benefit year. More information on issuer options with respect to such estimates is included on page 15495 at the link above. (QHP Webinar Series FAQ #7 04/24/13) Q69: Are issuers required to list medical necessity as a requirement for all benefits? A69: It is not required for the issuers submit medical necessity with each covered bene?t. (QHP Webinar Series FAQ #7 04/24/13) Q69: If an issuer intends to offer some identical plans on and off the Exchange in the individual market in order to take advantage of protections available through the 3Rs, the issuer must have a unique Component ID. In the Plans Benefits Template, should the issuer select ?on-Exchange,? ?off-Exchange,? or ?both? for the component identifier? A69: By selecting ?both," the issuer is indicating that the plan will be offered both on and off the Exchange. (QHP Webinar Series FAQ #7 04/24/13) Q70: How should an issuer indicate that it covers a benefit in limited circumstances? A70: If an issuer covers a bene?t in limited circumstances, it should indicate that the benefit is covered and use the Exclusions and/or Explanations field to describe the circumstances in which the benefit is covered. Please do not enter any information into the Exclusions and Explanations field if a bene?t is not covered. (QHP Webinar Series FAQ #7 04/24/13) Q71: What should issuers fill in if none of the EHB Variance options are appropriate for the scenario? A71: As noted in Chapter 10: Instructions for the Plans Benefits Application Section, a comprehensive list of EHB variance reasons is identi?ed. If you believe that none of the reasons are appropriate, please select "Other Law/Regulation" and provide an explanation. (QHP Webinar Series FAQ #7 04/24/13) 604 Updated 1-31-17 2017--00704 Q72: If an issuer enters a 100% coinsurance plan with a deductible and OOP of $3,000 and then change the OOP to $4,000, why does the AV change, even though there is no coinsurance applying to the additional A72: When the user changes the MOOP, the AV should change because the plan is changing its cost-sharing parameters, which is what the AV is measuring. Also, please note that the AV Calculator User Guide clari?es that the plan should not specify a 100% General Coinsurance Rate unless specifying a copay based plan. Therefore, when inputting 100% General Coinsurance, the calculator is anticipating cost-sharing on the copay side. (QHP Webinar Series FAQ #7 04/24/13) Q73: Could HHS clarify the purpose of the POS label on the tier 2 portion of the AV Calculator, given that the Calculator is not meant to be used for plans that include out-of- network? A73: Per the AV Calculator Methodology document the AV Calculator produces estimates of actuarial value based only on in-network services and allows the user to specify only in-network cost-sharing parameters. This is consistent with 45 CFR The ?nal version of the AV Calculator can accommodate plans utilizing a multi-tiered in-network plan design with up to two tiers of in-network services. Users may input separate cost-sharing parameters?such as deductibles, coinsurance rates, MOOPs, and schedules for service-specific copayments and coinsurance?and specify the share of utilization that occurs within each tier. The resulting actuarial value is a blend of the AV for the two tiers. (QHP Webinar Series FAQ #7 04/24/13) Q74: How should the impact of excluded or limited-coverage EHBs a closed formulary pharmacy design meeting benchmark minimums) be addressed in the calculation of actuarial value? A74: For the purpose of calculating actuarial value, the user only needs to specify the plan's cost-sharing for the four tiers of prescription drugs: generics, preferred brand drugs, non-preferred brand drugs, and specialty drugs. (QHP Webinar Series FAQ #7 04/24/13) Q75: If an issuer has a higher co-pay on a benefit not specified on the AV Calculator, is the plan compatible with the AV Calculator? A75: In the 2014 Letter to Issuers released on April 5, we provide two examples of plans that are not compatible with the AV Calculator. See the discussion in Appendix C, starting on page 56. We also state that a plan design that includes different cost sharing for services not included in the AV Calculator would be considered compatible with the AV Calculator. (QHP Webinar Series FAQ #7 04/24/13) Q76: If a company has eight plans available in six service areas, how should they be listed in one template to avoid errors? A76: In the Plans and Benefits template, a plan ID is associated with one Service Area ID, Network ID, and Formulary ID. Each Service Area ID, Network ID, or Formulary ID may be associated with multiple plans in the Plans and Benefits template. In the Service Area template, a county may be included in multiple Service Areas. The applicant needs 605 Updated 1-31-17 2017--00705 to create a Service Area ID for each unique combination of counties (or partial counties) that is covered by a single plan. If more than one plan covers the same Service area, then both plans can use the same Service Area ID. (QHP Webinar Series FAQ #7 04/24/13) Q77: Should issuers include the 94%, 87% and 73% Silver Tier plans and benefits to the templates? How do issuers identify that these are the various levels of a Silver Plan? Is that the Unique Plan Design Column? A77: *As noted in Chapter 10: Instructions for the Plans Benefits Application Section, complete the Plan Identi?ers section for each standard plan you want to create for a bene?ts package. A standard plan is a QHP offered at the bronze, silver, gold, platinum, or catastrophic level of coverage, and a benefits package is a group of plans that cover the same set of bene?ts; each plan in a benefits package can have different cost sharing, which is de?ned in the Cost Share Variances tab. After the bene?t-related information is completed, click the ?Create Cost Share Variances" button on the menu bar under the Plans and Bene?ts ribbon. The Cost Share Variances tab is designed to collect more detailed cost sharing bene?t design information for all plans and cost? sharing reduction plan variations submitted by the issuer. A new worksheet, ?Cost Share Variances,? will be created for each Bene?ts Package worksheet. The template will automatically create rows for the appropriate cost-sharing reduction plan variations. For example, if the standard plan is a silver plan, the template will create five different plan variations. These plan variations are not related to the ?unique plan design? column. The ?unique plan design? refers to whether or not the plan design can be evaluated using the actuarial value calculator. Edited on 04/26/13 (QHP Webinar Series FAQ #7 04/24/13) Q78: How do you add a row for more product A78: If you run out of empty rows for new plans, click the ?Add Plan" button on the menu bar under the Plans and Bene?ts ribbon and a new row will appear for an additional plan. Each bene?ts package can have up to 50 plans. If you have more than 50 plans associated with the same bene?t package, you will have to create a new bene?t package with the identical plan structure. (QHP Webinar Series FAQ #7 04/24/13) Q79: If an issuer wants to file a Platinum Plan to sell off-Exchange, but doesn?t want it on the Exchange, should an issuer still add the plan to the template? A79: Do not submit information to the FFE for plans that you do not want made available on the Exchange. (QHP Webinar Series FAQ #7 04/24/13) Q80: Do issuers need to list all of their specialists in the ?Specialists Requiring a Referral tab? text box? A80: On the Plan Bene?ts Template, users must enter all of the specialist types in the ?Specialists Requiring a Referral? tab. (QHP Webinar Series FAQ #7 04/24/13) Q81: Does the ?Plan Level Exclusions? tab refer to the entire list of exclusions for each plan? A81: On the Plan Bene?ts Template, in terms of the "Plan Level Exclusions" users may list all exclusions of the insurance plan at the plan level; this applies to all bene?ts. 606 Updated 1-31-17 2017--00706 Users may also refer to Chapter 10: Instructions for the Plans Benefits Application Section for additional information. (QHP Webinar Series FAQ #7 04/24/13) 028: Are issuers required to provide the services outlined in 45 CFR 156.115 even if they are on the Plans Benefits Template marked as A28: Issuers are not required to provide the four services listed at 45 CFR 156.115(d) routine non-pediatric dental; routine, non-pediatric exam services; long- term/custodial nursing home care; and non-medically necessary orthodontia -- (even if the benchmark covers those services) because those particular services are not EHB. (QHP Webinar Series FAQ #9 05/03/13) For updated information on the state-specific EHB benchmark benefits, issuers should refer to the Revised Benchmark Benefits Instructions available at manaqement data templates 2015.htm. These Instructions identify revised benchmark benefits for each state and instructions for updating the Plan and Benefits template accordingly. (REGTAP FAQ Database - FAQ #2140 06/11/14) CMS added the language in red above when it re-issued this FAQ in the REG TAP database on 06/11/14. 02: If a state discovers a clerical error or discovers an omission in the EHB template, how does the state change it? If the state wants to change a "decision" previously made about EHBs, how does the state change it? A2: Unfortunately, the bene?ts, limits, and explanations representing a summary of the benchmarks that is posted on website cannot be changed at this time. The add- in ?le that populates the Plans Benefits template is derived from this information. Please use the Variance Reason" to identify benefits as ?Additional EHB Benefit? that you feel are part of the benchmark. (QHP Webinar Series FAQ #10 05/09/13) Q82: How should QHP issuers indicate health savings account (HSA) eligibility if the standard plan is HSA eligible, but one of the cost-sharing reduction plan variations is not HSA eligible? A82: If a QHP issuer chooses to offer an HDHP standard plan, with associated plan variations that are not eligible for pairing with an HSA, the QHP issuer should still select ?yes" in the Eligible" ?eld on the Plans Bene?ts template. (QHP Webinar Series FAQ #9 10/31/13; Note: this FAQ was repeated as #38 of the QHP Webinar Series FAQ #10 05/09/13) Q16: In the plan and benefits template, how should the maximums and deductibles be entered if they are different from adults and children as there is only one data field? Updated 1-31-17 A16: Issuers should enter maximums and deductibles in the plan and bene?ts template that are speci?c to the pediatric dental EHB. There are no regulatory requirements related to the non-EHB adult dental benefits, and therefore, the information necessary for certification that the stand-alone dental plan meets the pediatric dental EHB standards is the information specific to the pediatric dental benefit. For purposes of plan 607 2017-?00707 compare, consumers can access additional information about adult benefits through the link to the plan brochure. (QHP Dental FAQ updated 05/31/13) 02: Does each benefits template submitted require both a gold and silver plan? If an issuer is offering product off exchange only, are they required to offer a silver and gold plan? A2: Under a QHP issuer must offer through the Exchange at least one QHP in the silver coverage level and at least one QHP in the gold coverage level as described in section 1302(d)(1) of the Affordable Care Act. However, there is no federal requirement to offer gold or silver plans off the Exchanges. For additional information on how to access the Plans and Bene?ts Template that can account this, please refer to the May 22 announcement entitled ?Guidance for QHP Issuers Submitting Non-Exchange Plans and/or Dental Rates" that is posted in REGTAP portal. (QHP Webinar Series FAQ #12 06/28/13) Q7: For the network URL, are there requirements for the number of clicks it will take to view the network providers? A7: There is no requirement; however, we do advise issuers to ensure that network information is easily accessible to consumers. (QHP Webinar Series FAQ #12 06/28/13) Q57: Where do issuers supply what an estimated payment would be for the three CSR variations of each Silver plan? A57: As discussed on page 15487 of the ?nal Payment Notice for the 2014 bene?t year, the advance payment estimates for the silver plan variations and the zero cost sharing plan variations will be developed using a methodology that utilizes data that QHP issuers submit for other purposes speci?cally, the expected allowed claims cost (from the Uni?ed Rate Review Template) and the actuarial value (from the Plans and Bene?ts Template). As a result, issuers would not be required to submit any additional data or supporting documentation to receive advance payments in bene?t year 2014 for the value of the cost-sharing reductions that would be provided under the silver plan variations or the zero cost sharing plan variation. However, if a QHP issuer wants to receive advance payments for the value of cost-sharing reductions provided under the limited cost sharing plan variation, the QHP issuer must submit an estimate of this advance payment amount through the Plans and Benefits Template, along with a justi?cation for the estimate (see Chapter 13i of the QHP application instructions). (QHP Webinar Series FAQ #12 06/28/13) Q58: How do issuers enter the combined In/Out of Network MOOP and Deductible? What about the Combined ln/Out of Network Medical/Drug EHB deductible? Updated 1-31-17 A58: If the plan has separate MOOPs or deductibles, it would enter these separately on the benefits template. If the plan only has a combined (no in network) MOOP (or deductible), either all of the plans in a benefits package need to set their in network MOOP (or deductible) to a dollar value, or they all need to set their in network MOOP (or deductible) equal to Not Applicable and set their combined in/out network MOOP (or deductible) to a dollar value. (QHP Webinar Series FAQ #12 06/28/13) 608 2017--00708 059: In order to qualify for the 2014 safe harbor for small group plans, must the MOOP for medical and pharmacy total less than $6350, or must each independently be less than $6350? A59: A QHP can be structured with combined or separate OOP amounts for medical and pharmacy. The GOP limitations apply to non-grandfathered individual and small group market plans, requiring that the combined OOP or the total sum of the separate medical and pharmacy OOPs do not exceed the statutory limitation of $6350 for 2014. Some small group market plans which have separate medical and pharmacy MOOPs may qualify for a one-year exemption from the statutory MOOP limits if the major medical and pharmacy (or other EHB benefit) are separately administered. In such cases, and solely for group market plans 2014, each of these MOOPs is separately subject to the statutory limits, such that they medical MOOP must not exceed the $6350 limit and the separate pharmacy MOOP cannot exceed the $6350 limit. Please see the Letter to Issuers on Federally-facilitated and State Partnership Exchanges released on April 5, 2013. (QHP Webinar Series FAQ #12 06/28/13) 060: Can we submit multiple plans in a single benefits tier (for example, 3 silver plans), using the templates? A60: Yes, you can submit and offer multiple benefit plans at the same level of coverage silver, bronze). All plans de?ned within a Benefits Package will share the same set of bene?ts and limits but may differ in cost sharing. To offer a different set of bene?ts and limits, you will need to create a new Bene?ts Package. Please refer to Chapters 10 in our instructions guide for more details which is available on the CMS online repository at or on (QHP Webinar Series FAQ #12 06/28/13) CMS re-released this FAQ on 06/11/14. The new FAQ, #2135, does not include the reference to the instruction guide. Q61: Should the coinsurance reflect what the member will pay or what the insurer will pay? A61: On the Plan and Benefits template, the coinsurance amounts should re?ect what the member will pay. (QHP Webinar Series FAQ #12 06/28/13) 062: My template validated successfully, but when I uploaded it, I got a validation error requesting a valid EHB variance reason. How can this be fixed? Updated 1-31-17 A62: For state mandates that are market-speci?c, the template populates the bene?ts based on the market and validates the mandates as EHB. However, the upload validation only considers these bene?ts to be EHB when they are mandated in both markets. Therefore, if your state has market-speci?c mandates, you will be asked to submit an EHB variance reason when you submit one of the market-specific state mandated benefits. In this case, the EHB variance reason should be ?Additional EHB Bene?t.? (QHP Webinar Series FAQ #12 06/28/13) 609 2017--00709 063: In the "Plan Type" column of the Plan Bene?ts Template, what does mean? A63: EPO refers to an Exclusive Provider Organization. (QHP Webinar Series FAQ #12 06/28/13) 064: If an issuer has a major medical plan where the member pays 100% out-of-pocket until the deductible is met, but then 0% is paid by the member once meeting the deductible, how does an issuer enter this in the Cost Sharing ?elds? A64: If a copayment is charged for a bene?t, enter the dollar amount in the copay ?eld. If no copayment is charged, choose from No Charge, No Charge after deductible, Copay, Copay after deductible, or Copay before deductible in the Plan Benefit Template. If coinsurance is charged for a bene?t, enter the percentage in the coinsurance ?eld. If no coinsurance is charged, enter No Charge, unless your plan has a tier 1 copayment that the enrollee pays only until the deductible is met. In this case, enter Choose from No Charge, No Charge after deductible, X?/o Coinsurance after deductible, or Plan Benefit Template. Issuers may refer to Chapter 10: Instructions for the Plans Benefits Application Section for additional information. (QHP Webinar Series FAQ #12 06/28/13) 065: If the plan does not pay for a benefit but the members are entitled to a discount on the services since they are a member, would this be considered a covered bene?t? A65: Benefits may only be included in the Plan and Benefits template if the issuer covers all or part of the service. Discounts on services or products that come with the coverage would not be considered covered bene?ts. (QHP Webinar Series FAQ #12 06/28/13 and REGTAP FAQ database FAQ #2138 06/11/14) Q8: How should plan variations for QHPs that are high-deductible health plans designed to be paired with a health savings account (HSA) be structured? A8: If an issuer seeks to offer a QHP designed to be eligible for pairing with an HSA in 2014, the issuer must comply with the cost-sharing reduction standards described in 45 CFR 156 subpart E. CMS recognizes that certain plan variations of a QHP may require a low or zero deductible, or that certain services be exempt from the deductible. This may result in the plan variation not meeting IRS standards for an HDHP and therefore not being eligible to be offered in conjunction with an HSA. We recommend that issuers and Marketplaces educate consumers about this issue, both during open enrollment and when an individual has a change in eligibility for cost-sharing reductions. An individual who would not be eligible for the tax advantages of an HSA because the plan variation to which he or she would be assigned does not qualify as an HDHP may purchase the plan without cost-sharing reductions. (CMS FAQs - Health Insurance Marketplaces 07/29/13) 069: If an issuer does not cover routine foot care except in the case of a diabetes diagnosis, how should the issuer list Routine Foot Care on the QHP template? A69: Issuers should place any additional limitations in the Explanation field for Routine Foot Care. Any bene?t level exclusions should be placed in the Exclusions ?eld for Routine Foot Care. Please refer to Chapter 10: Instructions for the Plans Bene?ts 610 Updated 1-31-17 2017--00710 Application Section for more information. The Instructions can be found on the or at (QHP Webinar Series FAQ #9 10/31/13) Q70: How should issuers use the fields ?1st tier and 2nd tier utilization?? A70: If the plan applies different levels of in-network cost sharing depending on the tier of the provider or facility, indicate that the plan has multiple in-network tiers in the Plans Benefits template. For plans with multiple in-network tiers, you are required to enter the proportion of claims cost that is anticipated to be utilized in each tier. These utilization amounts are entered into the "1st Tier Utilization" and "2nd Tier Utilization" fields in the Plans Benefits template. If the plan does not have multiple in-network tiers, "1st Tier Utilization" will be pre-populated to 100% and "2nd Tier Utilization" will be grayed out. (QHP Webinar Series FAQ #9 10/31/13) Q71: How should issuers fill in the field ?Plan Effective Date?? A71: As noted in Chapter 10: Instructions for the Plans Benefits Application Section, the Plan Effective Date is a required ?eld. It must be January 1 for individual market and SHOP. The instructions can be found on the ZONE or at (QHP Webinar Series FAQ #9 10/31/13) Q72: How does an issuer complete the Copay and Coinsurance columns in the cost share variance worksheet under the following scenarios: the cost sharing for a particular bene?t varies based on place of service the cost sharing for a particular benefit varies based on provider type specialist copay versus PCP copay)? A72: The Cost Share Variance worksheet does not allow copays or coinsurances to vary for a particular bene?t based on place of service or provider type. The Actuarial Value Calculator can only accommodate a single coinsurance rate or copay for each benefit. If you have multiple coinsurance rates or copays for a single benefit, then you should consider this plan to be a unique plan design (and indicate this on the Benefit Package worksheet) and ?ll out the necessary supporting document, and an actuarial certi?cation for unique plan design, as set forth in 45 CFR 156.135. (QHP Webinar Series FAQ #9 10/31/13) Q73: Should each benefits package be created on a separate tab? Updated 1-31-17 A73: Each benefit package needs to have its own tab. If you want to create additional benefits packages, click the ?Create New Benefits Package? button on the menu bar under the Plans and Bene?ts ribbon. The HIOS Issuer ID, Issuer State, Market Coverage, Dental Only Plan, and TIN ?elds will be auto- populated. If the benefit package for all of your products and plans is identical, only one benefit package tab is needed. (QHP Webinar Series FAQ #9 10/31/13) 611 2017-?0071 1 Q74: Rather than importing the Service Area IDs, Formulary IDs and Network IDs, is it possible to manually enter them in? A74: Yes, issuers may manually enter the IDs. However, the IDs must match the IDs that are generated in the Service Area, Prescription Drug, and Network ID templates. (QHP Webinar Series FAQ #9 10/31/13) Q75: Is there a problem with the bene?ts template that requires leaving cells for outpatient surgery and prescription drugs blank? A75: You should be able to run plans with outpatient surgery and prescription drug cost sharing inputs. However, please note that the Chapter 11 Plans and Bene?ts Template Instructions on Actuarial Value provide some specific guidance on inputting these items: 1) The AV Calculator does not support copay values for the Outpatient Facility Fee or Outpatient Surgery Physician/Surgical Services bene?t categories. If either of these bene?t categories has a copay in the Plans Bene?ts template, the AV Calculator will return an error. For purposes of the AV Calculator, issuers may convert a plan?s Outpatient Facility Fee or Outpatient Surgery Physician/Surgical Services copay into an estimated coinsurance and enter this coinsurance into the Plans Benefits template. 2) The AV Calculator does not allow a drug bene?t to have both a copay and a coinsurance not equal to the relevant default coinsurance. If a copay and a coinsurance are entered for a drug bene?t in the Plans Benefits template, the AV Calculator will return an error. This document is available at: 11 Ver1 3 O42213.pdf. (QHP Webinar Series FAQ #9 10/31/13) Q76: Are medical copay amounts considered when using the AV calculator macro? A76: Yes, the medical copay amounts are considered in the AV Calculation of the Plans and Benefits Template. Specifically, it you refer to the Plans and Bene?t Template Chapter 11 Instructions on Actuarial Value, there is a section that explains how the Plans and Bene?ts Template maps to the data inputs to the stand-alone AV Calculator inputs. This document is available at: 11 Ver1 3 O42213.pdf (QHP Webinar Series FAQ #9 10/31/13) An updated RE TAP FAQ provides the same answer but provides a different link." (REGTAP FAQ Database - FAQ #2119 06/11/14) Q77: Do all limits need to be identi?ed, or can issuers list one limit and then state ?other limits apply?? Updated 1-31-17 A77: Per 45 CFR 156.115, plans must have bene?ts that are substantially equal to the benchmark. EHB plans may include quantitative limits that are substantially equal to quantitative limits in the benchmark. Both the medical plan template and the dental template provide an area for plans to describe both limits that are present in the benchmark or other limits. While we encourage detailed provision of any bene?t limits, there is no requirement that every limit in the plan is input in the plan?s application. Issuers may include additional details in the explanations ?eld and plan brochure to inform consumers about the plan?s limits. (QHP Webinar Series FAQ #9 10/31/13) 612 2017-?00712 Q78: Does every exclusion need to be noted in the template? If an issuer does not list a benefit as excluded, is it assumed to be covered? A78: As noted in Chapter 10: Instructions for the Plans Benefits Application Section Exclusions is an optional field in the Plan Bene?ts template. Issuers may enter any bene?t level exclusions in this field if particular services or diagnoses are subject to exclusions (covered under some circumstances but not others) or if no services or diagnoses are excluded, leave this field blank. Information regarding exclusions will help inform consumers, and additional information may be included in the plan brochure. The instructions are available on the ZONE or at (QHP Webinar Series FAQ #9 10/31/13) Q79: In regards to relating to differing PCP visits on a CSR variant plan in the Plans Benefits template: The ?Begin Primary Care Cost-Sharing after a Set Number of Visits?? input is only set once in the Plans Bene?ts template and therefore cannot differ among silver plan CSRs and limited cost sharing plan variations. How should an issuer complete the Plans and Benefits template for this issue? Should this be a unique plan design with an included screenshot or is there something else that an issuer should be entering in? Updated 1-31-17 A79: As described in 45 CFR 156.420, silver plan variations must have equal or more generous cost sharing with respect to each essential health bene?t than the standard silver plan or any other silver plan variation with a lower actuarial value (AV). This includes cost sharing parameters described in the Plans and Bene?ts Template as ?Begin Primary Care Cost-Sharing After a Set Number of Visits," ?Begin Primary Care Deductible/Coinsurance After a Set Number of Copays? and ?Set a Maximum Number of Days for Charging an IP Copay?? However, since the QHP issuer cannot change the these inputs in the Plans and Benefits Template for the silver plan variations without modifying the standard silver plan design, a QHP issuer wanting to provide more generous cost sharing through these parameters would need to designate that particular standard silver plan and its plan variations as a unique plan design using the ?Unique Plan Design?? field of the Plans and Bene?ts Template. The QHP issuer should then calculate the actuarial value of the plan variation using the stand-alone AVC, and input the more generous cost sharing parameters. The QHP issuer must then complete the ?Issuer Actuarial Value? data ?eld with the value from the stand-alone AVC for the appropriate plan variations. The QHP issuer should also upload a screen shot of the stand-alone AVC for the plan variations with the more generous cost sharing parameters, as a supporting document for each plan variation for which this situation occurs. They should indicate the HIOS Plan ID (Standard Component) in the Description ?eld when uploading the screen shot as a supporting document in HIOS as well as indicating the HIOS Plan ID (Standard Component) in the ?le name of the screen shot. Note that the QHP issuer will need to follow this same process for the standard silver plan on which these plan variations are based. Please note that in this situation designating the plan as a unique plan design will not require submission of an actuarial certification and you will not be considered unique for review purposes. QHP issuers should also note that the ?Begin Primary Care Cost- Sharing After a Set Number of Visits,? ?Begin Primary Care Deductible/Coinsurance After a Set Number of Copays" and ?Set a Maximum Number of Days for Charging an IP Copay?? fields should reflect the values for the standard plan not the plan variations. 613 2017-?00713 We note that these data elements will not be displayed on the Plan Compare website. Lastly, QHP issuers should note that pursuant to 45 CFR 156.420(d) they may NOT change the values of these parameters for the zero cost sharing plan variation or the limited cost sharing plan variation of any of their QHPs. (QHP Webinar Series FAQ #9 10/31/13) 080: Will the MOOP be changed from $6400 to $6350 for 2014? A80: At the time of writing this response, the IRS has not issued this number yet. Per the Letter to Issuers released on April the FFE, if IRS-published limits are below HHS will ?ag QHP applications with out-of?pocket maximums above the allowed amount. Affected issuers will be permitted to revise their out-of?pocket maximums during the resubmission window built into the QHP certi?cation process. HHS will allow issuers to adjust other associated data elements for affected plans if necessary. For example, issuers will be permitted to modify other cost-sharing parameters in order to maintain an actuarial value (AV) consistent with the standards of 45 CFR 156.140." The Letter to Issuers on Federally-facilitated and State Partnership Exchanges, published on April 5, 2013, is available at: letter to issuers 04052013.pdf HHS encourages States, particularly those participating in a State Partnership Exchange, to use this approach to allow updates during the revision window. States may instruct issuers to follow an alternate process to correct de?ciencies of this type of issue. (QHP Webinar Series FAQ #9 10/31/13) Q81: For a limited cost sharing plan variation of a QHP that does not cover services when furnished by an out-of-network provider, does the cost sharing need to be eliminated for EHB out-of-network services furnished directly by the Indian Health Service, an Indian Tribe, Tribal Organization, or Urban Indian Organization, or through referral under contract health services? Updated 1-31-17 A81: As discussed in 27 of QHP FAQ #3 (published on REGTAP on April 11, 2013) in relation to the zero cost sharing plan variation, enrollee spending for non-covered services is not considered cost sharing. As a result, if a QHP does not cover certain services (or all services) furnished by a provider outside of the network, the spending for these non-covered services would not need to be eliminated for the zero cost sharing plan variation or the limited cost sharing plan variation, even if the service was furnished directly by the Indian Health Service, an Indian Tribe, Tribal Organization, or Urban Indian Organization, or through referral under contract health services. QHP issuers, including HMOs, should note however, that reimbursement is required in compliance with section 206 of the Indian Health Care Improvement Act. In general, QHP issuers should be aware that they can indicate that a service is not covered by marking the service as not covered on the Bene?ts Package Worksheet, or, if a service or no services are covered when furnished by an out-of?network provider, the QHP issuer can set the out-of-network coinsurance for the service(s) to 100%, set the out-of?network copay(s) to ?no charge," and indicate that enrollee spending for those service(s) does not count towards any deductible or towards any maximum out-of?pocket limit. 614 2017-?00714 In addition, as discussed in Chapter 10 of the Plans and Bene?ts Application, QHP issuers should be aware that the cost-sharing reductions under the limited cost sharing plan variation do not need to be recorded in the Plans and Bene?ts Template. (QHP Webinar Series FAQ #9 10/31/13) Q: Where would I locate a Bene?ts Template? A: The Plans Bene?ts template and add-in file should be downloaded from the Health Insurance Oversight System (HIOS.) The 2015 templates are not yet available. More information regarding the Plans and Bene?ts Template can be located in the REGTAP Library in the Qualified Health Plans (QHP) Instructions: Instructions: Chapter 10 Plan Bene?t Template Instructions.' The link to this document is provided below: 10 Ver1 4 042213.pdf. (REGTAP FAQ Database - FAQ #1332 03/31/14) Q: How can Issuers resolve Actuarial Value (AV) calculation errors in the Plans and Benefits template Add-in file? A: CMS is aware of the AV calculation errors in the Plans and Bene?ts template Add-in file. Issuers can reference Chapter 11 of the 2015 Qualified Health Plan (QHP) Template Instructions for a list of known AV errors in the Plans and Bene?ts template. Issuers can access the 2015 QHP Template Instructions from the Center for Consumer Information and Insurance Oversight (CCIIO) Issuer Resources page at the following link: Marketplaces/th.html. When Issuers report errors, CMS encourages Issuers to submit screenshots to CMS FEPS@cms.hhs.qov with an explanation of the issue. (REGTAP FAQ Database - FAQ #2630 07/03/14) Q: The Plans and Benefits Template will not validate an ?adult-only catastrophic plan? unless the issuer links it to an equivalent ?child-only plan.? If the issuer does not intend to offer a ?child-only catastrophic plan,? how should the issuer resolve this conflict in the Template? Updated 1-31-17 A: Catastrophic plans do not need to have a corresponding child-only plans because only platinum, gold, silver, and bronze are de?ned in 1302(d)(1). However, if ?Allows Adult Only" is selected Plans and Benefit Template in the ?Child-Only Offering" field, a corresponding Child-Only Plan ID must be entered in order for the template to validate. Therefore, issuers who wish to offer adult only catastrophic plans for the 2015 Plan Year should select ?Allows Adult Only" and identify a corresponding plan in the ?Child Only Plan field that allows child-only enrollment. This can be any existing plan with a value of either ?Allows Adult and Child-Only? or ?Allows Child Only? in the ?Child-Only Offering? field. If an issuer selects this option, they should also note in the ?Plan Level Exclusions" ?eld that the adult only catastrophic plan ?excludes child-only enrollment Please note that the plan "Allows Child-Only" or "Allows Adult and Child-Only" that you use to pass this validation must be on the same benefit package as the "Allows Adult- Only" plan." (REGTAP FAQ Database - FAQ #2974 07/23/14) 615 2017-?00715 Q: How should issuers enter bene?t level cost sharing that varies on the basis of place of service or provider type? A: Please see page 10-36 of the instructions for the Plans Bene?ts Template which states the following: ?If cost sharing varies on the basis of place of service or provider type, ensure that no bene?t already specifically applies to the place of service or provider type. If there is not one available, ?ll out the copay and/or coinsurance most typical for most enrollees (such as the highest utilized); in the Benefit Explanations ?eld, add appropriate and brief detail to communicate the cost sharing in the scenarios other than the most common one already entered into the worksheet. An issuer's plan brochure (which the consumer can access via the submitted URL) should also clearly communicate any cost-sharing information that may vary on the basis of place of service or provider type." (REGTAP FAQ Database - FAQ #2975 07/23/14) Q: What plan ?Effective Date? should issuers enter for 2014 and 2015 plans submitted on the Plans and Benefits Template for the 2015 Plan Year? A: Instructions in Chapter 10 for the Plans and Bene?ts Template direct issuers to use the January 1, 2015 Effective Date for the upcoming 2015 Plan Year, for existing plans offered on the Marketplace in 2014, and for the Federally-facilitated Marketplace (FFM) and Federally-facilitated Small Business Health Options Program (FF-SHOP) plans. Issuers can ?nd the instructions on the Center for Consumer Information and Insurance Oversight (CCIIO) website at as well as the Centers for Medicare Medicaid Services (CMS) website at (REGTAP FAQ Database - FAQ #2976 07/23/14) Q: Are the Summary of Benefits and Coverage (SBC) scenarios optional in the Plans and Benefits Template for the 2015 plan year? A: Yes. The SBC scenarios are optional in 2015, but as noted in the Chapter 10 Plans Bene?ts Instructions available on Zone the FFM may use certain data elements from the SBC in Plan Compare. If the issuer does not provide this information, Plan Compare shows ?not available.? Also, the SBC URL is not optional and must be provided by September 4, 2015. (REGTAP FAQ Database - FAQ #2977 07/23/14) Q: Can an issuer submit the Plans and Benefits Template even though the Actuarial Value (AV) calculation is off by a couple tenths of a percent? Updated 1-31-17 A: If the issuer cannot replicate the stand-alone AV Calculator results due to the design of the Plans and Bene?ts Template, but the AVs obtained from the stand-alone AVC and through the Plans and Benefits template are both within the relevant de minimis range for the plan's metal level or cost sharing reduction (CSR) variation, the plan would not need to be designated as an unique plan design. Instead, the issuer should verify that all of the information within the template is correct before running the AV Calculator and submit the template using the integrated AV Calculator. For additional information, please refer to Section 5.1 of the Chapter 11 instructions on Actuarial Value that is available at: Marketplaces/th.html. (REGTAP FAQ Database - FAQ #3521 08/07/14) 616 2017-?00716 Q: How should an issuer complete the Plans and Benefits Template for an Individual and Family Health Savings Account (HSA) plan if the Data Integrity Tool (DIT) generates an error message stating, ?If the medical essential health benefits (EHB) deductible out-of- network for Individual is numeric, the corresponding drug EHB deductible should be applicable when medical and drug are not integrated?? A: The issuer may ignore the error and submit the Qualified Health Plan (QHP) Application, as this error is a known bug in the DIT. (REGTAP FAQ Database - FAQ #3522 08/07/14) Q: Is the EHB Percent of Total Premium required in the Plans Benefits template for SHOP market plans? The template indicates that it is only required for Individual plans. A: Although the field is not required in the template, we recommend that issuers complete the EHB Percent of Total Premium ?eld for SHOP market plans, as stated in the Plans Benefits QHP Application Instructions. Please ensure that the value matches the value in the Unified Rate Review template. In the next Data Integrity Tool (DIT) release, we will reclassify this as a warning message for SHOP QHPs. (REGTAP FAQ Database - FAQ #9903 04/14/15) Q33: On the Plans and Benefits Template on the Cost Variance tab, there is an in- network, out of network, and a combined in and out of network deductible. Is the combined in and out of network deductible not applicable if the two fields are genuinely separate fields and the Maximum out-of-pocket A33: Yes, if the in-network and out of network deductibles are not combined, issuers should enter ?Not Applicable? for the combined in and out of network deductible ?eld. This entry indicates that the in network and out of network values are separate fields. Please refer to section 4.15 of ?Chapter 10: Instructions for the Plans and Benefits Application Section? for guidance on entering MOOP and deductible information (located here: (QHP Certification Process FAQs #1 (09/29/15) Q34: On the Plan and Benefits Template, how are issuers to enter a plan with a deductible equal to the out-of-pocket maximum, with the plan paying 100% once the deductible is met? A34: The Centers for Medicare Medicaid Services (CMS) recommends that issuers enter that the plan has a deductible equal to the maximum out-of-pocket amount. (QHP Certification Process FA 03 #1 {09/29/15) Q35: Does the guidance for Summary of Benefits and Coverage (SBC) Uniform Resource Locators (URLs) apply to Small Business Health Options Program (SHOP) plans? A35: Issuers should link directly to plan-specific SBCs for plans they intend to offer in a Federally-facilitated Marketplace (FFM) for the individual market and those in a Federally-facilitated Small Business Health Options Program (FF-SHOP) for the small group market. (QHP Certi?cation Process FAQs #1 (09/29/15) 617 Updated 1-31-17 2017-?00717 Q36: Is it permissible for issuers to have some indicator of Actuarial Value (AV) level within the Plan Brochure A36: Issuers should link URLs directly to all plans and plan variations. The link for each plan may include information for that plans AV level. Please refer to section 4.24 of the ?Chapter 10: Instructions for the Plans and Bene?ts Application Section? for guidance on linking URLs to plans (located here: (QHP Certi?cation Process FAQs #1 {09/29/15) Q37: May issuers provide customers with one Summary and Benefits and Coverage (SBC) Uniform Resource Locator (URL) to all available SBCs rather than linking directly to one specific A37: Issuers should link directly to plan-specific SBCs. The Centers for Medicare Medicaid Services (CMS) also expects that issuers will provide links directly to SBCs for cost sharing reduction (CSR) plan variations as de?ned in the 2016 HHS Notice of Bene?t and Payment Parameters. Issuers should also ensure that prospective enrollees can view the relevant information without logging on to a website, clicking through several web pages, or creating user accounts, memberships, or registrations. (QHP Certi?cation Process FAQs #1 {09/29/15) Q38: Is the Plan Brochure Uniform Resource Locator (URL) a required field on the Cost- Share Variance tab of the template or may issuers not input a URL in that ?eld? A38: The Plan Brochure Uniform Resource Locator (URL) is an optional ?eld on the Cost-Share Variance tab of the template. This field may be used by issuers to clearly communicate any cost sharing and other information not displayed by Plan Compare that consumers need to understand when shopping for insurance coverage. (QHP Certification Process FAQs #1 {09/29/15) Q6: If an issuer provides out of country or out of service area coverage as ?emergency only,? should the issuer select ?yes? under the ?Out of Country Coverage? or ?Out of Service Area Coverage? sections? A6: The Geographic Coverage section of the Plans Bene?ts Template captures product-level data for CMS review or for display on Healthcaregov. Therefore, as a general rule, an issuer should only select ?yes? for the data elements in that section? Out of Country Coverage, Out of Service Area Coverage, and National Network?if it offers the entire package of bene?ts for those geographic unit levels. As previously noted on a CMS Issuer Webinar, issuers should not enter ?yes" in the National Network field if the plan only offers emergency services nationally. (QHP Certification Process FAQs #2 {09/29/15)} Q7: Should the Plans and Benefits Template include on-Marketplace and off-Marketplace plans? A7: Unless a State speci?cally requests that an issuer of Quali?ed Health Plans (QHPs) submit off-exchange plans, issuers should only submit templates for QHPs they wish to offer on the Marketplaces. To indicate whether a QHP will be made available on the 618 Updated 1-31-17 2017-?00718 Marketplace, off the Marketplace, or both, issuers should follow the Chapter 10 Instructions for populating the Quali?ed Health Plan ?eld at The Plans Bene?t Template Instructions state that "Issuers that offer a plan through the Exchange should select the ?Both? option unless an exception to guaranteed availability applies." As noted in the proposed HHS Notice of Bene?t and Payment Parameters for 2016 ?an exception to the requirement that QHP must be guaranteed available and renewable outside the Exchange arises from the statutory permission for QHPs offered through the Exchange or SHOP to omit coverage of the pediatric dental EHB where a stand-alone dental plan offering the pediatric dental EHB is offered through the Exchange or SHOP. This is not similarly permitted when the plan is offered outside the Exchange or SHOP. This results in certain QHPs only being legally available in the market when offered through the Exchange or SHOP. If the QHP omits coverage of the pediatric dental EHB, the issuer would not be required to offer, renew, or continue enrollment in the QHP outside the Exchange, but could do so, at the enrollee's option, if the issuer is ?reasonably assured" that the enrollee has obtained such coverage through an Exchange-certi?ed stand-alone dental plan.? In contrast, issuers of Stand-Alone Dental Plans (SADPs) should submit templates for SADPs they wish to sell on the Marketplaces as well as any SADPs they want to offer off the Marketplaces. The FFM will review off-exchange stand-alone dental plans for QHP certification if submitted by the issuer. Please note that issuers are not required to submit templates for off-Exchange SADPs unless they are seeking certi?cation for those plans. There is no requirement or need to submit templates for off-Exchange SADP products for which the issuer is not seeking certi?cation. Issuers of SADPs should submit their templates through HIOS or SERFF, depending upon how issuers are required to submit templates for medical plans for that state. (QHP Certi?cation Process FAQs #2 (09/29/15)) Q8: What is the character limitation for plan marketing names? A8: The Uni?ed Rate Review Template has a limit of 100 characters. There is no limit within the Plans and Bene?ts Template, however the validation service on upload will return an error when plan marketing name is more than 255 characters. The Federally- facilitated Marketplace (FFM) Small Business Health Options Program (SHOP) displays a limit of 200 characters. (QHP Certi?cation Process FAQs #2 (09/29/15)) Q7: Must Small Business Health Options Program (SHOP) plans appear in separate Plans and Benefits Templates or may issuers add a separate tab when applicable? Updated 1-31-17 A7: As noted on page 10-6 of the Chapter 10 Plans Benefits Instructions available on the CCIIO website issuers must submit separate templates, rather than using a single ?le, for SHOP and the Individual market. Issuers will need to submit a separate template for plans they intend to offer in a Federally-facilitated Marketplace (FFM) for the individual market and those in a Federally-facilitated Small Business Health Options Program (FF-SHOP) for the small group market. (QHP Certi?cation Process FAQs #3 (09/29/15)) 619 2017-?00719 Q8: In regards to the Plans and Benefits Template, are issuers to enter ?Maximum Coinsurance for Specialty Drugs? for drugs that do not have a maximum copay? Should issuers enter a dollar amount or a percentage? A8: "Maximum Coinsurance for Specialty Drugs? is an optional field that indicates whether the per script coinsurance amount for specialty drugs is capped at a set amount. Issuers should enter the maximum coinsurance dollar amount for specialty prescription drugs. If no maximum coinsurance exists, leave the field blank. (QHP Certi?cation Process FA Os #5 {09/29/15) Q9: Regarding the ?not applicable? option in the Plans and Benefits Template, what should issuers enter for benefits with no charge? A9: Issuers should enter ?no charge" in both the copay and the coinsurance ?elds if there is no charge. Issuers should not enter ?not applicable? in the copay and coinsurance fields because they will appear as ?not applicable" on Healthcaregov. (QHP Certi?cation Process FA 08 #5 {09/29/15) Q10: In the Plans and Benefits Template, on the columns that contain the maximum out- of-pocket medical and drug for Essential Health Benefits (EHBs), where should issuers enter any additional out-of-pocket costs for non-EHBs so that the information displays properly for consumer? A10: There is no submission in the Plans and Bene?ts Template for additional out-of- pocket costs for non-EHBs. The template collects the maximum out-of?pocket costs for EHBs. The Centers for Medicare Medicaid Services (CMS) recommends that issuers provide precise information in the Plan Brochure for consumers. In addition, any benefits displaying on Plan Compare should include precise information. If the bene?t is a non- EHB and a separate maximum out-of-pocket applies, issuers may enter this information in the explanations ?eld. (QHP Certi?cation Process FAQs #5 {09/29/15) Q11: Is the Centers for Medicare Medicare Services (CMS) aware that on the Plans and Benefits Template, cells are locked when issuers attempt to enter plan data after row 53 on the Cost-share Variance worksheet? The error message reads ?Protected and read only,? which does not allow issuers to choose from the drop-down menu or enter text into the spreadsheet. A11: Yes, the Cost-Share Variance worksheet does not allow issuers to choose from the drop-down menu below row 53. Issuers should create a separate benefits package for the plans they cannot add. This bene?ts package must cover the same bene?ts and have the same bene?ts package structure. (QHP Certi?cation Process FAQs #5 {09/29/15) Q12: In the Plans and Benefits Template, on the Cost Share Variance worksheet, can issuers combine two plans into one worksheet or must issuers submit two individual worksheets for both plans? A12: Each benefits package may have up to 50 plans. If you have more than 50 plans associated with the same bene?ts package, you need to create a new benefits package with the identical bene?ts package structure. Each plan in a benefits package may have different cost-sharing values, which are entered in the corresponding Cost Share 620 Updated 1-31-17 2017-?00720 Variances worksheet. (QHP Certi?cation Process FA Os #5 (09/29/15) Q4: Regarding the Plans and Benefit Template, must issuers use ?No Charge? solely for in-network preventive services? A4: Issuers offering ?no charge? for any bene?t, in or out-of-network should enter ?no charge" for the copay and insurance. ?No charge? indicates that no cost-sharing is charged and that the bene?t is not subject to the deductible. If an issuer wants to indicate that only a copay or a coinsurance is charged for a benefit, enter ?Not Applicable" for the other. For example, if you wish to charge a $20 copay for a bene?t, you would enter for the copay and ?Not Applicable? for the coinsurance. Please note ?No Charge? was used for this scenario in previous templates in past years, but ?Not Applicable" is the correct option in the 2016 template. (QHP Certi?cation Process FAQs #6 (09/29/15) Q5: May issuers have multiple metal tiers within one (1) Plan Brochure for the purposes of having a single Uniform Resource Locator (URL) in the Plan Brochure? A5: Issuers should link URLs directly to all plans and for each plan variation. The primary reason is that this will provide consumers with the best and most accurate shopping experience when searching for available plans through Federally-facilitated Marketplaces (FFMs). Linking directly to the SBCs and plan brochures will guarantee that consumers will see the document that directly applies to the health plan that they are considering for purchase. Issuers should ensure that prospective enrollees can view the relevant information without logging on to a website, clicking through several web pages, or creating user accounts, memberships, or registrations. (QHP Certi?cation Process FAQs #6 {09/29/15) 02: How should issuers denote dollar copay per day after deductible in the ?Delivery and All Inpatient Service for Maternity Care? benefit category? A2: The ?elds Inpatient Hospital Services Hospital Stay), Skill Nursing Facilities, Mental/ Behavioral Health Inpatient Services, and Substance Abuse Disorder Inpatient Services are the only fields on the plans and bene?ts template that accommodate a cost sharing option of copay per day after deductible. The template does not accommodate per day and per stay options for the benefit ?Delivery and All Inpatient Service for Maternity Care?, so issuers would note the copay design in the Benefit Explanation field and in the plan brochure. (QHP Certi?cation Process FAQs #9 (09/29/15)) 05: Is the Essential Health Benefit (EHB) percent of total premium field required for Small Business Health Options Program (SHOP) plans submitted in the Plans Benefits Template? Updated 1-31-17 A5: As stated in the Chapter 10 Plans Bene?ts Template Instructions available on the CCIIO website the EHB percent of total premium field is required for Individual market plans sold on the Federally-facilitated Marketplaces. While the EHB percent of total premium field is not required for SHOP plans submitted in the Plans Bene?ts Template, CMS recommends issuers complete the ?eld for Federally-facilitated SHOP (FF-SHOP) market plans. Issuers must ensure the values match the Uni?ed Rate Review (URR). (Issuer Outreach FAQ #2 (10/27/15)) 621 2017-?00721 06: Since the Plans 8. Bene?ts Template macro has been corrected, must issuers submit additional Essential Health Benefits (EHBs) for 2016 Plan Year? A6: This year the Centers for Medicare Medicaid Services (CMS) updated the Plans Bene?ts template add-in ?le to better re?ect state-specific EHB benchmark plan data. If an issuer (or an issuer?s state) believes that the auto-populated benchmark data is incorrect, the issuer can use the EHB Variance Reasons to complete the Plans Bene?ts template. Pages 10-22 through 10-24 of the Chapter 10 QHP application instructions Marketplaces/th.html) explain all of the EHB Variance Reasons. If a benefit is covered by the EHB benchmark but is not auto-populated as EHB, the issuer should add the bene?t, indicate that it is covered, and use the ?Additional EHB Benefit? variance reason. (Issuer Outreach FAQ #2 (10/27/15)) Prescription Drug Template Q19: What is the format for the USP Category and Class Count input file? A19: The USP Category and Class Count service input ?le must contain a header line that reads (not case sensitive), must not contain any blank lines, must contain RxCUl?s that contain only numbers, and are no longer than 8 digits in length (any leading 0?s will be truncated). For more information about this ?le, please see section 4.2 of the User Guide. (Plan Management Webinar QHP FAQ #3 04/11/13) Q37: How should the Drug Tier IDs be defined? A37: The Drug Tier ID is a required field in the Prescription Drug template (see Chapter 12: Instructions for the Prescription Drug Application Section). This template populates the number of tiers according to your selection in Number of Tiers. Issuers may refer to the ?Suggested Coordination of Drug Data Between Templates? in Chapter 10: Instructions for the Plans Bene?ts Application Section for additional information related to tier and deductible data for drug and medical benefits. (Plan Management Webinar QHP FAQ #3 04/11/13) Q43: What about the fields for the data elements not collected (days supplied, quantity limit, cost sharing amounts other than for a one month or three month supply, etc.)? Updated 1-31-17 A43: The purpose of the template is to collect enough information to determine that the formulary meets the Essential Health Benefit (EHB) and non-discrimination criteria, as well as to evaluate prescription drug coverage for certi?cation. The consumers will only see information about the prescription drug coverage that is submitted in the Bene?ts Template. Consumers will be directed to the issuer?s website (via the URL provided in the Formulary Template) for more detailed information about the prescription drug coverage. Also note that the deductibles and out-of pocket limits for prescription drug coverage are to be submitted on the Plans and Bene?ts Template. (QHP Webinar Series FAQ #4 04/16/13) 622 2017-?00722 Q44: How do issuers indicate the cost sharing and/or deductible subgroups for each tier? A44: Each formulary will always take up seven rows. The rows to enter information for each tier will display when users enter the Formulary ID and number of tiers for each formulary in the steps below: 0 Step 1: Select the Issuer ID in the State. 0 Step 2: Create the Formulary IDs (more Formulary IDs can always be added later by clicking the ?Create Formulary macro button). 0 Step 3: Select the ?rst Formulary ID in Cell A-13. This will create rows for the cost sharing in tiers 1-7. 0 Step 4: Select the number of tiers in the formulary. This will lock the tiers not used so that the correct number of tiers to enter the cost sharing information for each tier appears. Users can click on the next blank row in the template and repeat these steps for each formulary. (QHP Webinar Series FAQ #4 04/16/13) Q45: On the template, how do issuers populate a separate brand and drug deductible that does not apply to tier 1 drugs? A45: Issuers can create deductible subgroups on the Plans and Benefits template as outlined in Q44 and can refer to Chapter 10 of the QHP Application Instructions. (QHP Webinar Series FAQ #4 04/16/13) Q46: In the earlier versions of the template, the copay and coinsurance fields would not accept zero. Has this been corrected? A46: These ?elds will now accept a zero value for the one month retail cost sharing; it is corrected on the final version of the template. (QHP Webinar Series FAQ #4 04/16/13) Q47: How does the Formulary Template work? A47: The Formulary ID is a combination of the drug list on the second tab and the cost sharing structure. Issuers can use the same drug list for multiple cost sharing structures; each combination of drug list/cost sharing structure should have a unique Formulary ID. Only a single Formulary ID can be associated with a plan. (QHP Webinar Series FAQ #4 04/16/13) Q48: Where do issuers get access to the drugs listed in each category and class that are making up the state benchmark count? A48: As stated in the EHB final rule, published 2/25/13 at 78 FR 12834, the regulatory standard for EHB compliance does not require that issuers cover the same drugs as the EHB benchmark, only the greater of one or the number of drugs in each United States Pharmacopeia (USP) category and class. As such, CMS published the drug count service. Issuers may use publicly available sources to research the benchmark (available at: health reform section.htm). If issuers are having problems meeting the count because the USP Category Class Count Service (Count Service) is not recognizing drugs being submitted, please contact the Helpdesk. (QHP Webinar Series FAQ #4 04/16/13) 623 Updated 1-31-17 2017--00723 Q49: How do issuers include drugs that do not have an RxNorm Concept Unique Identifier associated to them? A49: Issuers can offer drugs that are not counted in the drug count service and may include this information in the formulary list available on their website. Additionally, issuers may submit supporting documentation. (QHP Webinar Series FAQ #4 04/16/13) Q39: We have several concerns on the prescription drug template: (1) The enterprise-assigned formulary name for states where the issuer?s health plan is the benchmark has a set name, The template assigns a formulary name automatically. (2) Specialty is not available from retail or mail, only specialty provider. There is no place in the template to provide this information, and the assumption made is that in- network retail equals a specialty preferred provider. (3) There is no area to state the number of days? supply at retail and through mail order. (4) There is no area to state if there is a deductible prior to the coinsurance or copayment; (5) It is not possible to validate until all of the information has been entered. A39: The purpose of the template is to collect enough information to determine whether or not the prescription drug coverage meets the requirements for QHP certification, such as EHB and non-discrimination standards. The consumers will only see the information about prescription drug coverage that is submitted in the bene?ts template. They will be directed to the issuer?s website (the URL in the formulary template) for the detailed information about the prescription drug coverage. Drug deductibles are entered in the Plans and Bene?ts template. The template does not validate successfully until all required data is entered. (QHP Webinar Series FAQ #5 04/18/13) Q40: The following errors/issues have not yet been addressed in the prescription drug template: (1) No entry available for pharmacy deductible value and corresponding pharmacy deductible tier administration; (2) No entry available for pharmacy per script maximum (PSM) value and corresponding PSM tier administration; (3) No entry available for pharmacy OOP maximum value and corresponding OOP maximum tier administration. A40: 1) Prescription Drug deductibles are entered in the Plans and Bene?ts template. (2) You may enter a Maximum Coinsurance for Specialty Drugs in the Plans and Bene?ts template for AV calculation purposes. (3) Prescription drug out of pocket maximums are entered in the Plans and Benefits Template. (QHP Webinar Series FAQ #5 04/18/13) Q41: How will the prescription drug template link/connect to the Plans and Benefits template since the pharmacy benefit is embedded in the medical plan? A41: On the Plan Bene?ts Template under Plan Identi?ers, each plan can designate its Formulary ID from the Prescription Drug Template (QHP Webinar Series FAQ #5 04/18/13) 624 Updated 1-31-1 7 2017-?00724 Q42: There is no field to enter a maximum per prescription for coinsurance. A42: You may enter a Maximum Coinsurance for Specialty Drugs in the Plans and Bene?ts template for AV calculation purposes. (QHP Webinar Series FAQ #5 04/18/13) Q43: The template does not include a Drug Tier Type for "Preferred Specialty." How should these drugs be defined? A43: A maximum of two drug types (one generic type and one brand type) should be selected for each tier. If a tier contains both preferred and non-preferred generics, you may use the Only Select Generics option (the same applies for preferred and non- preferred brands). Please note that consumers will only see the information about prescription drug coverage that is submitted in the benefits template. They will be directed to the issuer?s website (the URL in the formulary template) for the detailed information about the prescription drug coverage. (QHP Webinar Series FAQ #5 04/18/13) Q44: How do we indicate tier 2 coverage for specialty pharmacy? A44: Consumers can see more details about the issuer?s prescription drug coverage via the formulary URL. The information can also be provided at the bene?t level in the explanation ?eld. (QHP Webinar Series FAQ #5 04/18/13) Q45: We do not understand how we connect the Prescription Drug Template to the Plans Benefits Template. The Prescription Drug Template connects to plans by the formulary ID so the cost shares feed into the Plans Benefits Template, but they are not as detailed as the Prescription Drug Template. Updated 1-31-17 A45: Each plan in the Plans Benefits template must list the formulary ID with which it is associated. The formulary IDs are created in the Prescription Drug template. The Plans Benefits template does not extract any information from the Prescription Drug template, although you can import the formulary ID from the Prescription Drug template into the Plans Benefits template. While there will be a validation after submission in the FFM to ensure that plans are associated with valid formulary IDs, you must ?ll out each template separately. To accommodate the Actuarial Value Calculator, the Plans Benefits template contains four drug benefit categories that represent a typical four tier drug design available in the market today: Generic Drugs, Preferred Brand Drugs, Non Preferred Brand Drugs, and Specialty Drugs. CMS understands that plans may have drug bene?ts that do not ?t neatly into the Plans Bene?ts template. To that end, we recommend ways issuers might translate their cost sharing data from the Prescription Drug template into the Plans Benefits template, as noted in the section titled "Suggested Coordination of Drug Data Between Templates" in Chapter 10: Instructions for the Plans Benefits Application Section. For more information on the Prescription Drug template, please see Chapter 12: Instructions for the Prescription Drug Application Section. The consumers will only see the information about prescription drug coverage that is submitted in the Plans Bene?ts template. They will be directed to the issuer?s website (the URL in the formulary template) for the detailed information about the prescription drug coverage. (QHP Webinar Series FAQ #5 04/18/13) 625 2017-?00725 Q46: In states with an EHB benchmark plan that requires coverage of over the counter (OTC) tobacco cessation products, how does a QHP verify their inclusion in the QHP submission? OTC products do not have RxNorm Concept Unique Identifiers (RxCUls), which are used to add prescription drugs to a formulary. A46: RxCUls do exist for a number of OTC products. However, if you cannot ?nd RxCUls for the specific OTC drugs covered by your plan, you do not need to include them on the Prescription Drug template. To describe in more detail which OTC tobacco products your plan covers, you can use the Explanations ?elds associated with the drug bene?t categories in the Plans Bene?ts template. On the Plan Compare website, consumers will see the Explanations from the Plans Bene?ts template, along with the formulary URL and the plan brochure URL, if provided. (QHP Webinar Series FAQ #5 04/18/13, REGTAP FAQ Database - FAQ #1367 03/31/14) Q47: What is the underlying reference file for the HIOS Rx tool so that plans can ensure they are meeting EHB requirements? A47: CMS has provided methodology for the drug count service on the CCIIO web site at While the EHB Rx Crosswalk is based on version 5 of the United States Pharmacopeia (USP) Medicare Model Guidelines, it is not identical to the USP alignment ?le found at uspmqinteqrated?le.xls. The EHB Rx Crosswalk uses from the December 3, 2012 RxNorm release, which you can download at full 12032012.zip. To download the file, you need a Uni?ed Medical Language System (UMLS) Metathesaurus License and a UMLS Terminology Services Account. You can obtain a license and account at no charge by following the instructions at request. Please crosscheck the RxCUls you are submitting with the December 3, 2012 RxNorm release to ensure they are up-to-date. CMS requests that you include your entire drug list, notjust the recognized RxCUls, when submitting a QHP application. (QHP Webinar Series FAQ #5 04/18/13) Q48: How do you submit $0 drugs on the pharmacy template? For example, a generic oral contraceptive that is covered at $0 would be submitted with all other generics (tier 1) how do you designates these differences out of pocket vs. true cost share)? A48: If you have no cost sharing for the tier, select Copayment as the cost-sharing type, and set the copayment equal to (QHP Webinar Series FAQ #5 04/18/13) Q49: In order to satisfy the drug counts for some categories, intravenous drugs will need to be included. However, these drugs are covered under medical benefits, not pharmacy benefits, and are not obtainable at a retail pharmacy. How should we proceed? A49: As noted in the ?le rule on EHB at 45 CFR 156.122, 3 health plan does not provide EHB unless it covers at least the greater of: 1) One drug in every USP category and class; or 2) The same number of prescription drugs in each category and class as the EHB-benchmark plan. If the plan uses the USP Category Class Count Service and uploads a list of all covered under the plan?s prescription drug bene?t and meets (or exceeds) the benchmark drug counts, the plan will be in compliance with this 626 Updated 1-31-17 2017--00726 requirement. If the plan cannot meet the count without including medical drugs in the drug list, we recommend the following steps to submit the QHP application: . For each of the issuer's drug lists, enter all RxCUls covered under the plan?s prescription drug bene?t in the Prescription Drug Template, 0 Use the Formulary-lnadequate Category/Class Count Supporting Documentation and Justification, identified in Chapter 13C of the instructions, to identify how the drug list meets the requirement and submit the RxCUls associated with the medical drugs for each drug list. Please note that the EHB requirement is a minimum standard, and an issuer should include the entire drug list, notjust the recognized RxCUls, when submitting a QHP application. (QHP Webinar Series FAQ #5 04/18/13) Q11: Chapter 12 of the Instructions says that ?if you have no cost sharing for the tier, select COPAYMENT as the cost-sharing type, and set the copayment equal to We have a two tier benefit where that is setup as follows: Generics are covered at 100% and brands require a 20% coinsurance. In this case, can we submit COINSURANCE rather than selecting COPAYMENT as directed in the guidance? The new template does validate either way. A11: Issuers can submit a 0% coinsurance instead of a $0 copayment. (QHP Webinar Series FAQ #6 04/23/13) Q12: What is the preferred way to represent prescription drug cost sharing in an HDHP plan, understanding that once a member satisfies an integrated (med/Rx) deductible, the plan covers 100%? Does the entry in the ?Tier Cost Sharing? columns for these HDHP plans assume that the deductible is met so member co-insurance should be input at A12: Yes, it is assumed that coinsurance applies after the deductible is met. (QHP Webinar Series FAQ #6 04/23/13) Q13: What is the preferred way to represent an HDHP formulary on the QHP prescription drug template understanding that drugs are not in tiers? A13: This should be represented as a formulary with one tier. All drugs in the formulary should be in tier 1. (QHP Webinar Series FAQ #6 04/23/13) Q14: Under the Drug EHB deductible section there are two fields labeled "Default Coinsurance." Is the default coinsurance field looking for the overall plan coinsurance or a drug coinsurance? If drug coinsurance, our plans have varying Rx coinsurance based on the type of drug generic drugs may have one coinsurance whereas brand or specialty drugs may have different coinsurance). A14: As noted in Chapter 10 of the instructions ibrary.php), the Default Coinsurance under the Drug EHB Deductible section is only applicable if deductibles are not integrated, and the numerical value for the in-network drug coinsurance should be entered. Speci?cally, to input a separate drug EHB deductible and coinsurance rate, the user needs to input ?No? under the column ?Medical Drug Deductibles Integrated?? As for entering separate coinsurance rates for individual drug tiers, the user can input the different coinsurance rates in the columns of the particular tier level in the Cost Share Variance Template. All of these data elements are used in the calculation of AV and for information on how their 627 Updated 1-31-17 2017-?00727 inputs are mapped to the AV calculator, please refer to the Chapter 11 instructions ibrary.php). (QHP Webinar Series FAQ #6 04/23/13) Q15: How do you submit $0 drugs on the pharmacy template? For example, a generic oral contraceptive that is covered at $0 would be submitted with all other generics (tier 1) - how do you designate these differences out of pocket vs. true cost share)? A15: Issuers can describe any cost sharing features that do not directly fit into the Prescription Drug Template in the Explanations field of the Plans Benefits Template. Issuers should complete cost sharing ?elds for the most typical/most utilized circumstance. Preventive services under the ACA must be covered without the consumer having to pay a copayment or co-insurance or meet the deductible. (QHP Webinar Series FAQ #6 04/23/13) Q16: Some of our plans have 4-tier drug copays. At the end of the template in the cost share variances sheet there are columns for "Off Label Prescription Drugs" and "Prescription Drugs Other." Our practice is that we do not consider whether a drug is "off label" or not - it always gets the copay of the tier it happens to land in. Since there are four different copays depending on the tier and we can only enter one, what do we enter here? A16: Regarding ?lling in cost sharing, these two fields are not associated with the AV Calculator (only Generic Drugs, Preferred Brand Drugs, Non-Preferred Brand Drugs, and Specialty Drugs are associated). For cost sharingthe drug tiers and use the Explanations to indicate that the cost sharing depends on the tier. Note: this information will not be displayed on Plan Compare, so consumers will not see the cost sharing that you enter. (QHP Webinar Series FAQ #6 04/23/13) Q15: If there is more than one RXCUI for a particular drug, which RXCUI should be included for the drug list to be compatible with the USP Category Class Count Service in A15: The USP Category Class Count Service is provided to assist issuers in complying with the essential health benefits (EHB) prescription drug benefit policy. Per 45 CFR 156.122, this policy requires that every EHB plan covers at least the greater of: one prescription drug in every United States Pharmacopeia (USP) category and class; or (ii) the same number of prescription drugs in each category and class as the EHB- benchmark plan. However, meeting these EHB-required prescription drug coverage levels is a minimum requirement and issuers are permitted to exceed this requirement. Please refer to the EHB final rule 25/pdf/2013-04084pdf) for further information on the EHB benchmark standard and prescription drug policy. A drug list should include all drugs (RXCUIs) the issuer intends to cover under its prescription drug plan, which means issuers should not leave out the unrecognized RxCUls from the drug list. Please note that only the ones that are recognized by the EHB Rx Crosswalk will be considered for EHB compliance. The EHB Rx Crosswalk contains only 5,306 RxCUls and 916 chemically distinct drugs. There are many more valid RxCUls in the RxNorm database. Therefore, almost any drug list submitted to the USP Category Class Drug Count Service will contain some unrecognizable RxCUls. As long as you meet the EHB drug count standard for your State, you can ignore the unrecognized RxCUls and include them in your drug list. (QHP Webinar Series FAQ #7 04/24/13) 628 Updated 1-31-17 2017--00728 Q16: What types of RxCUls are included in the EHB Rx Crosswalk? A16: Use the December 3, 2012, full release of RxNorm to find a list of valid RxCUls, which should have one of the following term types (TTYs): semantic branded drug (SBD), semantic clinical drug (SCD), branded pack (BPCK), or generic pack (GPCK). (QHP Webinar Series FAQ #7 04/24/13) Q17: What does the error ?unrecognized mean and why are they ?unrecognized?? A17: Unrecognized RXCUIs are RxCUls with valid formats (8 digits or less) that are not included in the EHB Rx Crosswalk. As noted above, the Count Service only recognizes 5,306 RxCUls and 916 chemically distinct drugs. There are many more valid RxCUls in the RxNorm database. Therefore, almost any drug list submitted to the Count Service will contain some unrecognizable RxCUls. Plans must meet the prescription drug EHB standards, described in 45 CFR 156.122, but plans may also continue to cover unrecognized drugs that are not counted towards EHB compliance. (QHP Webinar Series FAQ #7 04/24/13) Q18: Are there any over-the-counter (OTC) drugs included in the EHB drug counts? A18: A manual review was performed on RxCUls that were identi?ed as OTC drugs in the RxNorm database. RxCUls that were con?rmed as OTC drugs were removed from the EHB Rx Crosswalk, so those OTC drugs were not included as part of the benchmark drug counts and will not be counted in the USP Category Class Count Service. However, plans may continue to cover OTC drugs. (QHP Webinar Series FAQ #7 04/24/13) Q19: Does the USP Category Class Count Service report categories and classes with no drugs? A19: The ?Category Class Count Report? returned by the USP Category Class Count Service only includes category and class combinations in which the uploaded drug list has at least one drug. If the uploaded drug list does not include any drugs in a particular category and class combination, the category and class will not be included in the ?Category Class Count Report.? (QHP Webinar Series FAQ #7 04/24/13) 020: How can an issuer determine if its drug list meets the benchmark count? A20: (1) Use the December 3, 2012, full release of RxNorm to find a list of valid RxCUls. Download the RxNorm release at full 12032012.zip. To download the ?le, you need a Unified Medical Language System (UMLS) Metathesaurus License and a UMLS Terminology Services Account. You can obtain a license and account at no charge by following the instructions at request. (2) Upload the drug list?s RxCUls into the USP Category Class Count Service.3.Down oad the ?Category Class Count Report? returned by the Count Service.4.Download your state's ?Summary of EHB benefits, limits, and prescription drug coverage? ?le at This document includes each state?s benchmark plan drug count by category and class. Compare 629 Updated 1-31-17 2017--00729 these benchmark drug counts to your drug list?s counts in the ?Category Class Count Report." The drug list must include at least the greater of: 1) One drug in every United States Pharmacopeia (USP) category and class; or 2) The same number of prescription drugs in each category and class as the EHB-benchmark plan, per 45 CFR 156.122. (QHP Webinar Series FAQ #7 04/24/13) 021: Should Loperamide be included in the EHB Rx Crosswalk? A21: Based on issuer input, CMS has noted an error in the USP Category Count Service. The brand name for Loperamide 2mg was mistakenly included in the EHB Rx Crosswalk. Loperamide, as the distinct chemical ingredient, should not have been included on the EHB Rx Crosswalk in brand form because it has an Over the Counter (OTC) equivalent. If issuers have problems with meeting the Gastrointestinal Agents Category, Other class due to this error, please follow the steps that are listed below: For each of the issuer?s drug lists, enter all RxCUls covered under the plan?s prescription drug bene?t in the Prescription Drug Template, Use the Formulary- Inadequate Category/Class Count Supporting Documentation and Justi?cation, identified in Chapter 13C of the QHP Application instructions manual, to identify reasons for an inadequate drug count in a specific category or class. (QHP Webinar Series FAQ #7 04/24/13) Q38: Can HHS provide a crosswalk table that maps the to the class and counts? A38: We do not intend to release the crosswalk table. We note, however, that the RxCUls are drawn from the December 3, 2012, RxNorm release, which you can download at full 12032012.zip. To download the ?le, you need a Uni?ed Medical Language System (UMLS) Metathesaurus License and a UMLS Terminology Services Account. You can obtain a license and account at no charge by following the instructions at request. The EHB Rx Crosswalk contains only 5,306 RxCUls and 916 chemically distinct drugs. There are many more valid RxCUls in the RxNorm database. Therefore, almost any drug list submitted to the USP Category Class Service will contain some unrecognizable RxCUls. As long as you meet the EHB drug count standard for your State, you can ignore the list of unrecognized RxCUls. (QHP Webinar Series FAQ #9 05/03/13) Q39: What is considered ?Off Label Prescription Drugs?? A39: Off-label prescription drugs are FDA-approved prescription drugs that are prescribed for indications other than those stated in the labeling approved by the FDA. (QHP Webinar Series FAQ #9 05/03/13) Q40: What tier should issuers assign for items that are mandated to be provided at a $0 cost share, when Tiers 1 7 are already utilized to list therapies which include a member cost share? Updated 1-31-17 A40: The number of tiers in the prescription drug formulary template is limited to seven. For drugs with $0 cost sharing, you may add those to the lowest cost-sharing tier and indicate in the Plans and Bene?ts template that certain drugs in that tier have no cost sharing. (QHP Webinar Series FAQ #9 05/03/13) 630 2017--00730 Q41: Since drugs covered under medical are not captured in the pharmacy drug list, how will these medical drugs be included to determine compliance with Will they need to be reported separately? A41: Issuers will need to submit a list of the medical drugs covered as they would any other supporting documentation to justify any exception to any ?eld in the Plans and Bene?ts template, upload a MS Word or PDF document into HIOS. Please note that HHS still advises issuers to make use of the drug count tool in HIOS to verify that the RxCUls in their list of "medical drugs" satisfy the category and class counts for the issuer?s State's benchmark plan (as well as having at least 1 drug in each category and class). (QHP Webinar Series FAQ #9 05/03/13) Q42: Will issuers be able to update their drug list throughout the year and is this allowed for plans offered on the Exchange? Are issuers required to submit notice of adjustments made after the submission of the QHP application? Updated 1-31-17 A42: In States with a Federally-Facilitated Exchange, issuers submit their drug list once during the annual QHP certi?cation period. HHS understands that drug lists are dynamic and updated often. Issuers are permitted to change their drug lists throughout the year as long as they remain compliant with the EHB policy (45 CFR 156.122) requiring that every drug list includes at the least the greater of (1) one drug in every USP category and class or (2) the same number of prescription drugs in each category and class as the EHB state benchmark plan. Issuers are not required to submit updated drug lists to HHS throughout the year; however, policies in States with a State-based or Partnership Exchange may differ. (QHP Webinar Series FAQ #9 05/03/13) This FAQ was revised and released as REG TAP on 03/31/14, as follows: Q: Will issuers be able to update their drug list throughout the year and is this allowed for plans offered on the Marketplace? Are issuers required to submit notice of adjustments made after the submission of the QHP application? A: In States with a Federally-facilitated Marketplace, issuers submit their drug list once during the annual QHP certi?cation period. HHS understands that drug lists can change during the year. While issuers are not required to submit updated drug lists to HHS throughout the year, issuers should work with their state department of insurance to understand the state '3 rules for updating drug lists throughout the year. Issuers must remain compliant with the EHB policy (45 CFR 156. 122) requiring that every drug list includes at the least the greater of 1) one drug in every USP category and class or (2) the same number of prescription drugs in each category and class as the EHB state benchmark plan. The State or CMS, as the administrator of the FFM, have the right to check drug lists mid-year to assure that they continue to meet these requirements. In order to access the formulary, CMS also request that Issuers maintain an active, up-to-date formulary URL that allows for reviewing plan drug coverage, utilization management restrictions, and cost share. The URL link should be accessible without restrictions, such as log in or registration requests. Issuers in State-based Marketplaces should work with the appropriate review entity regarding the frequency of updates to the drug lists. (REG TAP FAQ Database - FAQ #1368 03/31/14) 631 2017-?00731 Q43: If a benchmark plan does not cover any drugs in a speci?c Rx category, do issuers have to cover at least one drug in that category? A43: The policy at 45 CFR 156.122 states that a formulary must include the greater of one drug in each USP category and class or the same number in each category and class as the State benchmark. Therefore if the State's benchmark drug list does not cover a drug in a particular USP category and class, then the issuer is responsible for covering one drug in that USP category and class. (QHP Webinar Series FAQ #9 05/03/13) Q44: If a plan has drugs offered through the medical benefit that it wants to count -- for reasons of compliance with EHB policy -- the minimum number of drugs per category/class, how should that be submitted to A44: If the plan uses the USP Category Class Count Service and uploads a list of all RxCUls covered under the plan?s prescription drug bene?t and meets (or goes above) the benchmark drug counts, the plan will be in compliance with this requirement. However, if the plan cannot meet the count unless it includes medical drugs in the drug list, HHS recommends the following steps to submit the QHP application - For each of the issuer's drug lists, enter all RxCUls covered under the plan?s prescription drug bene?t in the Prescription Drug Template, . Use the Formulary-lnadequate Category/Class Count Supporting Documentation and Justification, identified in Chapter 13C of the instructions, to identify how the drug list meets the requirement and submit the RxCUls associated with the medical drugs for each drug list. (QHP Webinar Series FAQ #9 05/03/13) Q66: Can issuers use the column ?Drug Tier Type? in the prescription drug template to indicate specialty drugs? A66: Please use the ?Only select brands? option in the Drug Tier Type field to indicate that the tier is a specialty drug tier. (QHP Webinar Series FAQ #9 10/31/13) Q: Will the Marketplace EHB benchmark counts and categories be updated for the 2015 plan year? A: The State benchmark counts will remain in effect throughout the 2015 plan year. Steps have been taken to add newly approved FDA drug RxCUls to the existing Crosswalk (based on USP version 5 Category Class Model Guidelines) and delete RxCUls associated with discontinued drugs in order to improve issuer compliance. (REGTAP FAQ Database - FAQ #1366 03/31/14) Q: Can issuers input drugs covered under the medical benefit on separate formulary tiers in the Prescription Drug template or should ?medical drugs? be included in the Jus??ca?on? A: Issuers should include only drugs covered under the pharmacy benefit on the Drug List worksheet in the Prescription Drug template. If an Issuer offers drugs under the medical benefit and needs those drugs in order to satisfy the state benchmark drug count, the Issuer must include the drugs covered under the medical benefit in the 632 Updated 1-31-17 2017--00732 Formulary-Inadequate Category/Class Count Supporting Documentation and Justification form, and submit the RxCUls associated with the medical drugs for each drug list. Justification forms are located at (REGTAP FAQ Database - FAQ #2632 07/03/14) Q: Where should issuers submit the RxNorm Concept Unique Identifier Justi?cation Form? A: Issuers may submit the Formulary?lnadequate Category/Class Count Supporting Documentation and Justification and any otherjusti?cation forms as part of the QHP Application. Detailed instructions on submitting justifications can be found at: 16 Justi?cation-Ver1 04162014.pdf. Issuers should respond to any de?ciencies identi?ed by a state or federal regulator even if the identi?ed issue is different than the results an issuer obtained by using the QHP application review tools. Issuers will be provided with an opportunity to upload justification forms during the resubmission process. For FFM states using HIOS, justi?cation forms and supporting documents may be uploaded to HIOS as part of the bene?ts module submission. (REGTAP FAQ Database - FAQ #2978 07/23/14) Q: How can issuers validate drug categories when using the Clinical Appropriateness Tool? A: The Clinical Appropriateness review is based on drugs available for each speci?c condition that can be found on the RxNorm Extract. The RxNorm Extract is a reference ?le that lists the subset of RxCUls in the RxNorm that are fully speci?ed (ingredient, strength, dose form, and brand name, where applicable). This RxNorm Extract is based on the November 4, 2013 release of RxNorm, and it can be used by issuers to convert drugs on their formularies into RxCUls. Drugs not on the November 4, 2013 Extract or approved when the tool was developed will not validate when using the Clinical Appropriateness tool. Please use the Discrimination?Formulary Clinical Appropriateness Supporting Documentation and Justi?cation form to describe any justi?cations for the Clinical Appropriateness review. Each justification should be associated with a speci?c drug list, medical condition, and class or drug. (REGTAP FAQ Database - FAQ #2979 07/23/14) Q: Where can an issuer find the (USP) Category Class Count Module for 2015 Updated 1-31-17 A: The Category Class Drug Count Tool (Drug Count Tool) posted on the CMS website will replace the USP Category Class Drug Count Service that is located in HIOS. The USP Category Class Drug Count Service will be removed from HIOS. To access the Drug Count Tool, sign into and paste the following link into the browser to access the tools: (REGTAP FAQ Database - FAQ #2980 07/23/14) 633 2017--00733 Q: How can an issuer successfully complete the Prescription Drug Template if the issuer receives an error message that states an RxNorm Concept Unique Identifier is not recognized, despite the issuer having verified that each in the template is listed on the USP Medicare Model Guidelines? A: CMS has made available the Category Class Drug Count Tool and the EHB Rx Crosswalk as optional resources to be used in support of determining and meeting compliance with 45 CFR 156.122. While an issuer should include the entire drug list in the Prescription Drug Template, not just the recognized RxCUls, only RxCUls in the EHB Rx Crosswalk will be counted towards meeting a particular category and class. Additionally, RxCUls should have one of the following term types semantic branded drug (SBD), semantic clinical drug (SCD), branded pack (BPCK), or generic pack (GPCK). The issuer may download the EHB Rx Crosswalk located on CMS to identify the missing CMS can be accessed from the following link: (REGTAP FAQ Database - FAQ #3523 08/07/14) Q: What should issuers do when the Category Class Count tab of the Drug Count Tool shows that all Essential Health Benefit (EHB) benchmarks are met and the ?All Groupings Numbers? tab of the tool shows that there are drugs missing? A: In the Category Class Count tab of the Prescription Drug List Output folder, if the drug list returns a ?Met? in the Count Standard column, then the issuer is in compliance with the EHB benchmark count for that category and class. The ?All Grouping Numbers" tab is there for issuers who have not met the EHB benchmark count in a particular category and class. The tab highlights drugs that issuers may add in order to meet the de?cient categories and classes. (REGTAP FAQ Database - FAQ #3524 08/07/14) 050: How should a benefit appear on the Prescription Drug Template that has a percentage with minimum copay and maximum copay? A50: The Prescription Drug Template does not allow for minimum or maximum copays and coinsurances. Issuers should complete all fields in the Prescription Drug Template for the most typical or most utilized method. Issuers can describe any nuances to their plan design and cost sharing features that do not directly ?t into the Prescription Drug Template in the Explanations field of the Plans Benefits Template or in plan brochure and formulary URL, and include the information on the Summary of Benefits and Coverage (SBC) which are linked to Healthcaregov. (QHP Certi?cation Process FAQs #1 (09/29/15)) 051: On the Prescription Drug Template, will the co-pay display differently to the consumer depending on which option issuers choose, ??no charge? co-pay or $0.00 copay? Updated 1-31-17 A51: The Prescription Drug Template will validate regardless if the copay is $0.00 or ?No charge.? Cost sharing data from the Prescription Drug Template will not be visible to consumers on HealthCare.gov. The cost sharing data will be pulled from the Plans and Bene?ts Template. HealthCare.gov only displays the formulary URL and the Yes/No option of the three-month mail order bene?ts offered from the Prescription Drug Template. (QHP Certi?cation Process FAQs #1 {09/29/15)} 634 2017-?00734 052: Should issuers create formulary IDs within the Prescription Drug Template for variant plans, although the IDs are not incorporated into the Plans and Benefits Template? A52: Only one formulary ID may be associated with a Plan ID. The cost sharing differences for the variants should be reported in the Plans and Benefits template and the Plan Brochure. (QHP Certification Process FAQs #1 (09/29/15)) 053: For the Prescription Drug Template, must issuers provide a balanced billing explanation for out-of- network retail pharmacy benefits? A53: No, the Prescription Drug Template does not have an explanations field. Please describe any cost-sharing features that do not directly fit into the Prescription Drug Template in the Explanation ?eld of the Plans Benefits Template or in a plan brochure and Formulary URL. (QHP Certi?cation Process FAQs #1 (09/29/15)) Q54: Must an issuer use the Prescription Drug Template for both Individual and Small Group plans? A54: Yes, for plans with a prescription drug benefit, issuers must include both Small Group and individual plans in the same Prescription Drug Template when submitting to HIOS. In states that collect templates in SERFF, issuers may submit separate sets of templates for Individual and SHOP plans. (QHP Certification Process FAQs #1 {09/29/15)} 055: May issuers continue to enter the copay amounts and then refer to the Plans and Benefits Template to identify whether or not the copays are subject to deductibles? A55: No, issuers should use the updated copayment and coinsurance options, which include subject to deductible options, in the 2016 Prescription Drug Template. If copays and coinsurances are subject to deductible, please use the options in the copayment and coinsurance ?elds that contain deductible considerations. Please describe the cost sharing details that are not captured in the Prescription Dug Template in the Explanations ?eld of the Plans and Bene?ts Template and in the Plan Brochure and Formulary URL. (QHP Certification Process FAQs #1 {09/29/15)} 056: How are issuers to proceed with Formulary IDs that are entered into the Prescription Drug Templates that are not used for Qualified Health Plans A56: It is recommended that issuers delete any Formulary IDs not associated with a Drug List. The Prescription Drug Template will validate with Formulary IDs that are not used for QHPs. Issuers should also delete any unused drug lists from the Prescription Drug Template. (QHP Certification Process FAQs #1 {09/29/15)} 057: What are some possible causes for Formulary Tier errors on the Drug List tab? A57: If the Tier Level column in the Drug List worksheet contains text rather than numbers the issuer will receive an error when the template tries to validate. One ?x is to copy the Tier Level column into a blank workbook, convert the text to numbers, and then paste (not paste values) those numbers back into the template. 635 Updated 1-31-17 2017--00735 If there is a Formulary ID in the Formulary Tiers worksheet linked to a Drug List as de?ned in the Drug List worksheet, and the Formulary ID and Drug List have a different number of tiers, then the issuer will receive an error when the template tries to validate. (QHP Certi?cation Process FAQs #1 {09/29/15)} QQ: In the Prescription Drug Template, how should issuers depict specialty drugs if the tier contains both preferred and non-preferred specialty drugs? A9: If issuer?s formularies have the same cost sharing for both preferred and non- preferred specialty drugs, then they can be listed in one tier and that tier can be designated as ?Specialty.? If issuers have different cost sharing for their preferred and non-preferred specialty drugs, then they can create two tiers and differentiate between the two using cost sharing. One way to represent this design is to designate the ?rst as ?Preferred Brand, Specialty? and the second as ?Non-Preferred Brand, Specialty." Additional information can be found in the QHP Application Instructions Chapter 12: Instructions for the Prescription Drug Application Section: (QHP Certification Process FAQs #3 {09/29/15)} Q10: May issuers submit a Prescription Drug Template with Tier 1 as a generic, Tier 2 a preferred brand, and Tier 3 as non-preferred brand, because specialty drugs fall into all three tiers? A10: Yes. Issuers may select up to two drug tier types, one generic type and one brand type for each tier. For example, the three drug tiers may be represented as: Tier 1: Preferred Generic, Specialty, Tier 2: Preferred Brand, Specialty and Tier 3: Non- Preferred Brand, Specialty. Multiple tiers may have the same drug tier types, but tiers should have different cost sharing. (QHP Certi?cation Process FAQs #3 (09/29/15)) Q10: When must issuers have a live formulary Uniform Resource Locator A10: The formulary URL must be submitted during the Quali?ed Health Plan (QHP) Application process to validate the pharmacy template. The formulary URL must be functional at the time of QHP Agreement Signing. (QHP Certi?cation Process FAQs #1 {09/29/15) Q11: Is the Rx Norm a resource for the RxNorm Concept Unique Identifiers (RxCUls)? Updated 1-31-17 A11: Yes, issuers may download the Rx Norm for a list of from either the National Library of Medicine website at: or on website in the drug count tool at: (QHP Certi?cation Process FAQs #1 {09/29/15) 636 2017--00736 Unified Rate Review Template (URRT) Q17: When will the rate review template be published? A17: The Uni?ed Rate Review template was published in the Federal Register on February 27, 2013 at 78 FR 13406. The publication of this template contains all the data elements that issuers are required to submit. (Plan Management Webinar QHP FAQ #1 04/08/13) 026: When is the rate review template due and will this be concurrently with the rest of the templates at the end of April? A26: If an issuer has at least 1 QHP Application, April 30 is the deadline. If the issuer is not submitting any QHPs, then they must follow State rules or submit before January 1, 2014. (Plan Management Webinar QHP FAQ #1 04/08/13) 050: How does the copy/paste function work from one version of the Rating Template to the next? A50: Users should select and copy all the rows in the previous template, starting below the header and continuing all the way to the end. In the new template, users should paste starting in the first row below the header. Do not click ?Paste Values As,? just click ?Paste,? conserving the original formatting. (QHP Webinar Series FAQ #4 04/16/13) 051: How do the age bands work in the Rating Template? A51: The age bands are automated; users do not need to enter ages since they will automatically display. Once any age is selected, the template will populate ?0 through 20? and the other age bands required. Users just need to enter the rates. (QHP Webinar Series FAQ #4 04/16/13) Q50: For issuers with ?ling only new products as QHPs, is it correct that they do not need a Unified Rate Review (URR) Template as part of their QHP submission, given that the URR Template is only for rate increases? A50. No. Any time that the URR Template is filled out, all plans in the risk pool -- even those not being submitted for QHP certification -- have to be included. Since the Index Rate can be set only once per year for the whole risk pool, that also means that all plans in the risk pool have to have their rates approved at the same time, both on and off the Exchange, as required by a combination of Exchange (77 FR 18310) and Rate Review rules (78 FR 13406). This is true even if all of the plans are new. (QHP Webinar Series FAQ #5 04/18/13) 637 Updated 1-31-17 2017--00737 Q51: There appear to be errors in the validation macro in the rate template. When the macro is trying to check for proper relationship between rates for different age brackets and tobacco vs. non-tobacco rates, it produces erroneous results. If the Tobacco field is listed with "No Preference" and changes to "Tobacco User/ Non-Tobacco User" after the Age is selected, the Individual Tobacco Rate column will not show. A51: The macros in the Rate Table Template are written such that the tobacco use column is hidden (not deleted) when ?no preference" is input for tobacco use. If issuers find this confusing, they can generate additional sheets and use separate sheets for plans which use tobacco rating and those that do not. If a plan has some age bands which use tobacco rating and some which do not, the issuer should not mark the age bands as no preference, but should instead enter the same rate in both the tobacco use and non-tobacco use columns for those age bands which do not differentiate. This will avoid the display issue. (QHP Webinar Series FAQ #5 04/18/13) Q52: The calculation of 3:1 ratio on non-tobacco rates is not correct. The validation macro marks some of the cells as in violation of 3:1, which is not the case. Per the Market Reform Final Rules at 45 CFR ?such rate may not vary by more than 3:1 for adults." In an example provided by CMS Plan Management Support, sample data was used to demonstrate that the age 21 individual rate must be multiplied by 3 to derive the maximum age 65 individual rate. However, in order to check for an allowed ratio of 3:1, you need to take the age 65 rate and divide by the age 21 rate and see if that ratio equals to 3:1. The problem with the validation method cited by CMS and included in the template macros is that it uses the wrong operation when checking for 3:1 compliance. The small differences resulting from using this incorrect operation for validation will result in a huge problem for issuer billing systems. A52: Due to a system limitation in the Rating Tables Template, the system currently cannot process a premium for a 65-year-old smoker that is rated more than 3 times the premium of a 21-year-old smoker. We ask that all issuers submitting rates via the Rating Tables Template for non-grandfathered plans in the individual and small group markets implement the tobacco rating factor so that older adult smokers are not rated in total more than 3 times of the total rate for a younger adult smoker. One way to accomplish this is if an issuer imposes a 1.2 to 1 tobacco rating factor on a 21-year -old smoker, the issuer should use the same 1.2 tobacco rating factor for the 65-year-old smoker. If an issuer implements the tobacco rating factor with the result that an older smoker is rated up more than 3 times of that of a younger smoker, the submission of the issuer will be rejected by the system. We intend to implement a system change that will allow for processing of tobacco rating factors that vary based on age, and we expect this to be completed after calendar year 2014. (QHP Webinar Series FAQ #5 04/18/13) 053: The template allows entry of a Rating Area ID and allows up to 150 Rating Areas to be selected. It is unclear how these rating areas will be mapped to the appropriate area within each state (or service area) to identify the appropriate rating. How will the Exchange know the proper premium based on a member?s address? How will rating areas be consistent across multiple QHP issuer submissions within each state? A53: Each individual state is setting its own rating areas and providing the speci?c areas within a state that associate to each rating area. The Rate Table Template collects the rates for each rating area in the state. Issuers should use those state-provided rating areas to complete the Rating Area ID piece of the template. The rating areas for each 638 Updated 1-31-1 7 2017--00738 state are published on the CCIIO website (QHP Webinar Series FAQ #5 04/18/13) 054: When tabbing out of the Age field, the debugging macro pop-up was generated. A54: For states that do not have community rating, the template automatically creates rows for all age bands when a single age band is selected. The age bands once created may not be edited. If you continue to have this issue, please contact the Help Desk. (QHP Webinar Series FAQ #5 04/18/13) 056: After entering Age in the appropriate ?eld, upon keying cursor up, Age decrements and is placed in incorrect row on spreadsheet. A56: Rates must be submitted for all age bands. The age bands will populate in order regardless of the age that you select. (QHP Webinar Series FAQ #5 04/18/13) 057: The Tobacco Rate column does not appear until Age Bracket is selected, instead of upon selection of value in the Tobacco drop-down. A57: This is by design. The template requires both the tobacco option and the family/age band option to be selected before displaying the appropriate columns for the rates. (QHP Webinar Series FAQ #5 04/18/13) 028: When will the rate review template be published? A28: The Uni?ed Rate Review (URR) template was published in the Federal Register on February 27, 2013 at 78 FR 13406. The HIOS enabled version is available within the Unified Rate Review Module of the Plan Management and Market Wide Functions section of HIOS, along with downloadable URR Template Instructions and the Actuarial Memorandum Instructions. (QHP Webinar Series FAQ #7 04/24/13) 029: Do non-Exchange plans have to be submitted for rate review at the same time as A29: Yes, any time that the URR template is completed, all plans in the risk pool, even those not being submitted for QHP have to be included. Since the Index Rate can be set only once per year for the whole risk pool, that also means that all plans in the risk pool have to have their rates approved at the same time, both on and off the Exchange. (QHP Webinar Series FAQ #7 04/24/13) Q30: Does the URR template have to be submitted in HIOS for a partnership State? A30: Yes, any time that the URR template is submitted to a State, it must also be submitted to CMS via HIOS. Alternatively, any time the URR template is submitted to CMS in HIOS, it must be submitted to the State. This includes modifications or changes required by either government entity. (QHP Webinar Series FAQ #7 04/24/13) 639 Updated 1-31-17 2017--00739 Q31: Will a ?user guide? be provided for the URR Template? A31: Yes, one is currently available in the URR Module of HIOS. (QHP Webinar Series FAQ #7 04/24/13) Q33: If a State with a State Partnership Exchange has a different submission deadline, when is the URR template required to be submitted to A33: The submission to CMS in HIOS should be at the same time as the submission to the state. (QHP Webinar Series FAQ #7 04/24/13) Q34: Does the Part Actuarial Memorandum have to be submitted every time the Part I, Unified Rate Review Template is submitted? A34: Yes, the Part Actuarial Memorandum is now required with every initial Part URR template submission. The Part II Consumer Justification Narrative is only required when at least 1 product in the risk pool is experiencing a rate increase of 10% or more. (QHP Webinar Series FAQ #7 04/24/13) Q35: What the difference between the Unified Rate Review system and the Rate Review Justi?cation system? A35: The Uni?ed Rate Review (URR) Module, within the Plan Management Market- Wide Functions section of HIOS is the module used to submit all rate filings required after 4/1/2013. The Rate Review Justification (RRJ) Module is the legacy system which was used to submit rate filing justi?cations prior to 4/1/2013. The RRJ Module continues to be used to provide rate reasonableness determinations and justi?cations until all submission made prior to 4/1/2013 have received determinations. (QHP Webinar Series FAQ #7 04/24/13) Q39: Will there be instructions released for the URR template and Actuarial Memorandum? A39: Yes, they are published in the URR Module within HIOS. (QHP Webinar Series FAQ #7 04/24/13) Q40: Are there different rate review templates for new rates versus rate increases? A40: No, the same template is used for all new and existing plan rates. The instructions provide an explanation of how to handle discontinuing plans rate experience, continuing plans experience and projections, and new plan projections. (QHP Webinar Series FAQ #7 04/24/13) Q41: If an issuer wants to include grandfathered experience in its projections, how is this done? A41: The URR template instructions provide further guidance on this, but grandfathered experience, if included, should be included in the Credibility Manual Adjustment within worksheet 1. (QHP Webinar Series FAQ #7 04/24/13) 640 Updated 1-31-17 2017--00740 Q42: If we plan to modify all grandfathered health plans such that it will lose grandfathered status, should we include the experience of those grandfathered health plans in the experience period? A42: Yes, if you are modifying the entire grandfathered health plan such that it will no longer be considered a grandfathered health plan, the experience should be included in the experience period data on the URR template. (QHP Webinar Series FAQ #7 04/24/13) Q43: If an issuer changes rates by less than 10% in 2013, does it have to submit them in the new URR template after April 1, 2013? A43: Yes, all rate changes submitted after April 1st, 2013 must be submitted on the URR template, and when submitted, the entire risk pool must be included. (QHP Webinar Series FAQ #7 04/24/13) Q45: If a State has an Effective Rate Review program and an issuer has no QHPs, does the issuer still have to submit the URR template to A45: If an issuer has a rate increase on any plan after April 1, 2013, it is required to submit the increase and the entire risk pool to both their state and CMS pursuant to 45 CFR 154.200. (QHP Webinar Series FAQ #7 04/24/13) 022: How are ?optional? riders reflected in the CCIIO rate review template to differentiate what is an offer versus a rider that is embedded as required? A22: For Rate Review only, since EHBs cannot be optional, any ?optional? rider must only cover bene?ts in addition to EHB, and we would expect any premium and claims for such bene?ts to appear in the ?other? categories on worksheet 2. Additionally, all benefits offered must be benefits for which the issuer is liable for paying the claims; setting the premium; and reporting on the annual statement, MLR, and other required reporting formats as part of the issuer?s claims and premium liabilities. Issuers are not allowed to report claims or premiums for ?bundled? benefits, which are actually offered by another issuer but are sold in combination with or similar to a rider on their medical plan. (QHP Webinar Series FAQ #10 05/09/13) 025: How do issuers indicate the rate trends for Small Group in the templates? A25: In order to indicate rate trends for Small Group, issuers can create four sheets on the template, with the appropriate (and non-overlapping) effective and end dates on the appropriate tab. (QHP Webinar Series FAQ #12 06/28/13) 026: What does ?No Preference? mean in the tobacco use drop-down list? A26: No preference means that there is only one rate, regardless of smoking status. If an issuer selects the other option another column will appear, allowing the issuer to enter both smoking and non-smoking rates. (QHP Webinar Series FAQ #12 06/28/13) 641 Updated 1-31-17 2017-?00741 027: Will there be a field for a dependent child rate separate from ages 0-20? A27: No, that is not available. (QHP Webinar Series FAQ #12 06/28/13) Q29: Why are rates being requested by tier when the rates have to be built up by member? A29: Rates, for the majority of States (except only New York at this point) are to be entered by age and tobacco status. These rates will then be used to build rates for individuals and families in the Exchange as their family demographics are determined. (QHP Webinar Series FAQ #12 06/28/13) Q31: The age column uses the term ?subscriber? in the definition but the rate will be built by adding each individual member?s rate together, correct? A31: That is correct. In individually rated States, the rate will be determined by adding up the age-determined rates of all the individual members. (QHP Webinar Series FAQ #12 06/28/13) Q32: Does the rating template allow a tobacco rate for 18-20 year olds as well as 0 to 17 year olds? A32: No. Individuals 20 years and under should be subject to the same rating rules. (QHP Webinar Series FAQ #12 06/28/13) Q36: In column of the Business Rules template, why is it significant that the individuals on the policy live together? A36: This field is provided because some issuers may allow certain dependent relationships when the dependent lives in the same household as the subscriber, but not if the dependent lives elsewhere. (QHP Webinar Series FAQ #12 06/28/13) Q37: Will there be only one area rating applied per application? A37: Correct. This is necessary for both the federal rating engine and risk adjustment systems and processes. (QHP Webinar Series FAQ #12 06/28/13) Q38: Are child-only policies being sold strictly on a one per child basis? Will issuers be allowed to sell child-only with the three-child limit? A38: The market rules do not specify that child only policies should be issued with a certain number of children covered. The Exchange tools are built to support the inclusion of any number of children, with a maximum of three children being quoted on a policy. There is no way to identify a specific number of children who may be included. If an issuer desires to limit child-only policies to a single child, it may do so by indicating that it does not cover any of the allowed relationships to the reference person on the policy (rating rules template, right most column). If a plan is reported as not allowing siblings or other relationships, a child-only request would assign the reference to the youngest person under that request, and if no allowed relationship is identi?ed, the other individuals on the request would be communicated back to enrollment as needing separate policies, which would be rated independently of the first policy. The exception 642 Updated 1-31-17 2017-?00742 to this is if one of the additional children is a spouse or domestic partner of the reference person, in which case that person would be allowed on the original policy as consistent with laws and the business rules evaluations. (QHP Webinar Series FAQ #12 06/28/13) Q39: In order to enter plans on a combined basis, does each plan need to have the same exact rate increase? A39: Plan rate increases can be entered as combined for the product or individually. (QHP Webinar Series FAQ #12 06/28/13) Q40: Is the uniform rate review template required only for rate increases on existing products, not new rates? A40: All plans are required to be included when the template is submitted, including new plans. (QHP Webinar Series FAQ #12 06/28/13) Q66: Do issuers need to submit two sets of HIOS rate sheet templates (one with on exchange plan codes and one with off exchange) even though the benefits and rates are the same? A66: HHS cannot comment on how SBEs are prepared to combine data. In general, rate tables are stored and calculated based on QHP IDs (standard component IDs generated in HIOS). QHPs are submitted exclusively to the FFM, and the integration of on and off- exchange plans is not an issue. HHS would anticipate that rate tables need to be submitted based on Standard Component IDs. HHS might expect an SBE to ask for two templates (one for QHPs, one for off exchange), but that is simply an expectation. (QHP Webinar Series FAQ #12 06/28/13) 067: The regulations allow for a 1.5:1 rate factor for tobacco use. However, the Rate Template does not allow for this and errors out because the spread in some instances is more than 3:1 by age. For example, take a 21 year old smoker and a 64 year old smoker, you might have a 1.10 smoking factor for the 21 year old and a 1.30 factor for the 64 year old smoker. When you apply the age factors, the 64 year old smoker would have a rate that is more than 3 times higher than the 21 year old smoker. Will there be an opportunity to updates the rates issuers submitted during the application window? A67: The preamble to the Health Insurance Market Rules Rate Review final rule (Market Rule), published on February 27, 2013, states that younger enrollees could be charged a lower tobacco use factor than older enrollees provided the tobacco use factor does not exceed 1.5:1 for any age group. For example, a 21-year-old smoker could be rated at 1.2 to 1 and a 65-year-old smoker can be rated in the same plan at 1.5 to 1. Because of a system limitation in the Rating Tables Template, however, the system currently cannot process a premium for a 65-year-old smoker that is rated more than 3 times the premium of a 21-year-old smoker. Accordingly, HHS asks that, until further notice, all issuers that are required to use the Rating Tables Template and that will be offering non-grandfathered plans in the individual and small group markets implement the tobacco rating factor for their non- grandfathered policies so that older adult smokers are not rated in total more than 3 times of the total rate for a younger adult smoker. One way to accomplish this is if an issuer imposes a 1.2 to 1 tobacco rating factor on a 21-year -old smoker, the issuer 643 Updated 1-31-17 2017--00743 should use the same 1.2 tobacco rating factor for the 65-year-old smoker. If an issuer implements the tobacco rating factor with the result that an older smoker is rated up more than 3 times of that of a younger smoker, the submission of the issuer will be rejected by the system. HHS intends to implement a system change that will allow for processing of tobacco rating factors that vary based on age, and HHS expects this to be completed after calendar year 2014. HHS also reminds issuers that the Market Rule provides that a tobacco rating factor may be applied only with respect to individuals who may legally use tobacco under federal and state law. Different states may have different age limits regarding the sale of cigarettes. If a state, for example, prohibits the sale of cigarettes to individuals under the age of 19, then individuals under the age of 19 in that state cannot be rated for tobacco use. Therefore, health insurance issuers seeking to impose tobacco rating should be aware of the age limit in every state where they will offer health insurance coverage subject to tobacco premium rating. (QHP Webinar Series FAQ #12 06/28/13) 068: If an issuer is entering a market for the first time and has no experience, how should they input information on Worksheet 1 of the Unified Rate Review Template under the Section 1: Experience Period and how will the results be published? A68: Issuers have to input a number greater than which was an unintended error in the template. HHS does not know how information will be published at this time, but as required by rule, issuers will be notified before we publish and given the opportunity to make comments and/or seek a con?dentiality exemption for information determined to be published. (QHP Webinar Series FAQ #12 06/28/13) Q69: How do issuers enter Product IDs on past experience for terminated plans in the A69: Most products in the individual market have been required to be submitted to the HIOS Plan Finder for over 2 years and over 1 year for the small group market, so HHS anticipates that most issuers will have at least 1 Product ID to input for terminating products. If not, the issuer will be required to seek a Product ID from HIOS and that request will be handled as quickly as possible. (QHP Webinar Series FAQ #12 06/28/13) Q: What issues would generate an error message stating, ?Effective and expiration dates must not overlap? in an issuer's Rate Template? A: Issuers should verify that for each plan with submitted trended quarterly rates, there is no overlap in rate effective date and rate expiration dates among the submitted quarters. Only Small Business Health Options (SHOP) plans may submit trended quarterly rates in the Rates Table template. (REGTAP FAQ Database - FAQ #3525 08/07/14) Q: What should an issuer do if there are rounding error issues for the Rates Table Template or validating the Rates Table template through the System for Electronic Rate and Form Filling Updated 1-31-17 A: If issuers are receiving errors in the Rates Table Template and/or in SERFF, issuers should contact the Exchange Operations Support Center (XOSC) Help Desk at CMS FEPS@cms.hhs.qov. (REGTAP FAQ Database - FAQ #3526 08/07/14) 644 2017-?00744 Q: If an issuer operating in a State-Based Marketplace (SBM) adds a plan to the Small Group Market mid-year, must the issuer submit an updated Unified Rate Review Template A: If an issuer wants to offer a new plan mid-year and the state allows a mid-year plan addition, the issuer must submit a quarterly URRT re?ecting that the addition of the new plan(s) to the issuer's risk pool. Note that CMS does not allow issuers to add new plans mid-year in the Federally-facilitated Marketplace (FFM). (REGTAP FAQ Database - FAQ #3527 08/07/14) Q: How can an issuer confirm that CMS has processed the issuer's Unified Rate Review Template A: When regulatory review of an issuer's URRT is complete, it will be placed in a ?nal submission status. If the submission does not have a rate increase that is 10% or more, it will be placed in ?rate ?ling accepted" status when the review is complete. If the submission has a rate increase that is 10% or more, it will be placed in ?review complete? status when the review is complete. (REGTAP FAQ Database - FAQ #3528 08/07/14) Q: Does the Unified Rate Review Template (URRT) apply to Small Business Health Options Program (SHOP) Stand-alone Dental Plans A: No, the URRT does not apply to SHOP SADPs. (REGTAP FAQ Database - FAQ #3529 08/07/14) Q: Do effective and termination dates on the Unified Rate Review Template (URRT) illustrate when rates are effective for purchasing or payment purposes? Will the URRT produce an error if an issuer includes a termination date greater than 12 months from the effective date? A: The Effective Date of Rate Change(s) on 1 - Market Experience of the URRT is the latest rate effective date of the submission. The Effective Date of Proposed Rates on 2 - Plan Product Info is the earliest rate effective date for each plan listed in the submission. This date represents the earliest date the rate becomes effective for each plan. Issuers do not enter a termination date on the URRT. (REGTAP FAQ Database - FAQ #3530 08/07/14) Q: Should issuers cross-validate validated records with the Unified Rate Review Template A: Issuers do not need to cross-validate validated records with the URRT. (REGTAP FAQ Database - FAQ #3531 08/07/14) Q58: Have the Centers for Medicare 8. Medicaid Services (CMS) released the final Unified Rate Review Template A58: Yes, the final URRT and instructions are on the Center for Consumer Information and Insurance Oversight (CCIIO) website at: of Insurance Rates. (QHP Certi?cation Process FAQs #1 (09/29/15)) 645 Updated 1-31-17 2017--00745 QQ: When will the Centers for Medicare Medicaid Services (CMS) release the percent increase for Qualified Health Plans (QHPs) and non-QHPs? A9: On June 1, 2015, CMS will release proposed increases of 10% or greater for QHPs and non-QHPs. Between October 19, 2015 and November 1, 2015, CMS will release final rate increases for QHPs and non-QHPs, regardless of the size of the ?nal rate increase. The rate increases, along with a link to the issuer?s redacted Actuarial Memorandum, will be posted at (QHP Certification Process FAQs #2 (09/29/15)) Q10: Should the Historical Rate Increase read as "Plan A Plan in the Plan column? A10: Yes, the entry should read ?Plan A Plan This has been corrected in the latest version of the slides, which can be found on the CMS website at of Insurance Rates (QHP Certification Process FAQs #2 {09/29/15)} Q11: Must Stand-alone Dental Plan (SADP) Issuers submit Unified Rate Review (URR) Templates? A11: No, SADP issuers do not submit URR Templates. (QHP Certification Process FAQs #2 (09/29/15)) Q5: May issuers submit the Unified Rate Review Template (URRT) before finalizing rates and may issuers update the rates after submission? A5: Yes, the URRT is an annual filing requirement and Small Group URRTs are a quarterly ?ling requirement. (QHP Certification Process FAQs #7 {09/29/15)} Q6: When should State-partnership Marketplace (SPM) issuers submit the Unified Rate Review Template (URRT) in the Health Insurance Oversight System A6: SPM issuers must upload the URRT and the Redacted Actuarial Memorandum into HIOS, when SPM issuers submit State ?llings. For the 2016 plan year, the submission window was from 4/15/2015 to 5/15/2015. Prior to open enrollment, CMS will allow issuers to make corrections to the URRT. (QHP Certification Process FAQs #7 {09/29/15)} Q1: Are issuers that receive State Form Filing objections for benefits, which may directly affect rates, permitted to upload Rate Template revisions? A1: An issuer is permitted to submit a Rates Table template with updated rates that are approved by their State no later than the data lockdown date of August 25, 2015. After this date, CMS will permit SHOP quarterly rate changes approved by their State during speci?c data change windows that CMS opens during the 2016 plan year. (QHP Certi?cation Process FAQs #8 {09/29/15)} 646 Updated 1-31-17 2017--00746 Q10: When will the Centers for Medicare Medicaid Services (CMS) release a new version of the Unified Rate Review Template (URRT) addressing issues that were fixed? Is the v2.0.3 version of the Unified Rate Review Template (URRT) the latest version? A10: The most recent version of the URRT is v2.0.4, which CMS released on April 15, 2015. Issuers may locate the latest version in the Health Insurance Oversight System (HIOS) or on the CCIIO website at Rate Review Templatexlsm. Issuers that already submitted the URRT using v2.0.3 do not need to resubmit using v2.0.4. (Issuer Outreach FAQ #1 (10/27/15)) Network Adequacy/ECP Templates Q: Should issuers include ECPs (Essential Community Providers) in the Network Adequacy Template? A: Yes, issuers should include all in-network providers in the network adequacy template that are located in the state or in contiguous states where the plan offers bene?ts. (REGTAP FAQ Database - FAQ #2171 06/11/14) Q: On the Network Adequacy template, should Issuers enter out-of-state providers that are not located in surrounding states? A: No, the Network Adequacy template should only include providers in the state in which the plan is being offered or in contiguous states. (REGTAP FAQ Database - FAQ #2622 07/03/14) Q: Where can I find the Network Adequacy template instructions? A: A complete set of instructions for the QHP Application, including the Network Adequacy Instructions, is located on the CMS website at for States and Issuers as well as on the CCIIO website at (REGTAP FAQ Database - FAQ #2623 07/03/14) Q: On the Network Adequacy template, how should Issuers enter facilities, such as Durable Medical Equipment (DME) facilities, which are not technically located in a contiguous state, but may provide a service to the Qualified Health Plan A: For this year, the Issuer should only enter information for facilities located in the state where the plan is offered or in contiguous states. If there is a concern about adequate access to any provider type CMS will notify the Issuer via the Correction Notice and the Issuer will have the opportunity to submit justification. (REGTAP FAQ Database - FAQ #2624 07/03/14) Q: 0n the Network Adequacy template, how should Issuers enter providers that practice in multiple locations? A: Issuers can enter providers that practice in multiple locations by adding ?001" or ?002? at the end of the provider's last name for each location as indicated in the network adequacy instructions. A complete set of instructions for the QHP Application, including 647 Updated 1-31-17 2017-?00747 the Network Adequacy Instructions, is located on the CMS website at for States and Issuers as well as on the CCIIO website at (REGTAP FAQ Database - FAQ #2625 07/03/14) Q: How do Issuers list Pediatric Sub-specialists on the Network Adequacy template? For example, should issuers indicate ?Other? for Pediatric Endocrinologists? A: Issuers should list Pediatric Sub-specialists in the ?Other? field on the Network Adequacy template. (REGTAP FAQ Database - FAQ #2626 07/03/14) Q: Do Issuers in states performing Plan Management functions issuers in State Partnership Marketplaces use the same Network Adequacy template as issuers in Federally-facilitated Marketplace (FFM) states? A: Yes, Issuers in SPMs should use the same Network Adequacy template as issuers in FFM states. (REGTAP FAQ Database - FAQ #2627 07/03/14) Q: Does CMS anticipate future updates to the 2015 Plan and Benefits template Add-in file? A: No, CMS does not anticipate any future updates to the 2015 Plan and Bene?ts template Add-in file. (REGTAP FAQ Database - FAQ #2628 07/03/14) Q: Can an Issuer enter different ln-Network and Out-of-Network medical deductibles while using a single drug deductible in the combined ln-Network/Out-of-Network field in the Plans and Benefits template? A: An Issuer can enter different ln-Network and Out-of-Network medical deductibles while using a single drug deductible in the combined field in the Plans and Bene?ts template. (REGTAP FAQ Database - FAQ #2629 07/03/14) Q: Should issuers include third party vendors and retail pharmacy locations on the Network Adequacy Template? A: Issuers should include all third party vendors and retail pharmacy locations that are in-network in the Network Adequacy Template. (REGTAP FAQ Database - FAQ #2969 07/23/14) Q: Should issuers classify physicians and providers as ?other? if the appropriate specialty type is not listed on the Network Adequacy Template? A: Yes, issuers should use ?other? unless the provider matches one of the specialty types listed in the NA template. (REGTAP FAQ Database - FAQ #2970 07/23/14) Q: Where do issuers upload the Network Adequacy Template in the Health Insurance Oversight System A: Issuers must upload the Network Adequacy Template under ?other? uploads in the Rates, Benefit and Service Area Module in HIOS. The process is detailed in the Network Adequacy Instructions found on the Center for Consumer Information and 648 Updated 1-31-17 2017--00748 Insurance Oversight (CCIIO) website at as well as the Centers for Medicare Medicaid Services (CMS) website at (REGTAP FAQ Database - FAQ #2971 07/23/14) Q: Can an issuer list a facility multiple times in the Network Adequacy Template to enter multiple Specialty Types? A: Issuers should not list a facility with the same address multiple times in the Network Adequacy Template. Multiple Specialty/Facility Types can be assigned to a provider in 1 of 2 ways. The first way is to use the selection box feature that is built into the Network Adequacy Template. The selection box allows users to select as many Specialty/Facility Types as are applicable to the selected provider. The second way is to manually create a comma separated list of each Specialty/Facility Type. The process for doing this is described on the ?Provider Types? tab of the Network Adequacy Template. Users should be careful when using this method that they match the Specialty/Facility Types listed in the ?Provider Types" tab exactly or they will receive a template validation error. For instance, if a user would like to assign the Facility Types of Cardiac Surgery Program and Cardiac Catheterization Services to a facility they should enter ?041 Cardiac Surgery Program, 042 Cardiac Catheterization Program.? (REGTAP FAQ Database - FAQ #2972 07/23/14) Q: Has CMS released any documentation regarding the evaluation criteria for the Network Adequacy Template? A: CMS will evaluate the Network Adequacy Template in accordance with the guidance outlined in the 2015 Letter to Issuers (online at issuer-Ietter-3-14-2014.pdf) and the Federal Register Code of Federal Regulations (CFR) 45 CFR 156.230 Network Adequacy Standards (online at 220.9df). (REGTAP FAQ Database - FAQ #2973 07/23/14) Q: How should a Stand-alone Dental Plan (SADP) issuer, which contracts directly with providers, complete the Essential Community Provider (ECP) Template? Does the issuer list the providers on the ECP Template or does the issuer leave the ECP Template blank and provide supplemental information with a list of all the providers? Updated 1-31-17 A: Issuers should list their ECPs within the ECP template, rather than within the supplemental response form. The only time an issuer must complete the supplemental response form is if the issuer is unable to satisfy one or more of the three requirements for the ECP standard contracting with at least 30 percent of available ECPs in the plan's service area, offering a contract to all available Indian health providers in the plan's service area, and offering a contract to at least one ECP per category per county in the service area). If an issuer contracts directly with multiple providers located at the same street address of a facility, the issuer should list the facility as the ECP along with the facility-level National Provider Identifier (NPI). If an issuer contracts with only a subset of providers located at the same street address, then the issuer should list only one of these providers on their ECP template, as only one provider per street address counts toward the issuer's satisfaction of the 30 percent ECP standard. (REGTAP FAQ Database - FAQ #3519 08/07/14) 649 2017-?00749 Q: If an Essential Community Provider (ECP) has multiple locations, must issuers enter each location separately in the ECP Template? Must issuers select ?Yes? on the ECP Template to indicate that each location is located on the non-exhaustive ECP List? A: Issuers should enter each ECP location separately in the ECP Template. If the provider name is the same for each location, the issuer must differentiate each provider name with a suf?x of ?-001 and so on. If the ECP locations have different street addresses, the issuer can count each location towards the 30 percent ECP threshold. The issuer may select ?Yes? for each street address that matches the CMS non-exhaustive ECP list. If the street address for a given location does not match the speci?c address provided on the non-exhaustive ECP list, the issuer may count the ECP as a write-in if the provider is located in a low-income zip code based on the low-income zip code list published by CMS, but should mark ?No" to indicate that the specific address is not listed on the non-exhaustive CMS ECP list. (REGTAP FAQ Database - FAQ #3520 08/07/14) Q: When submitting the network URL in the Network ID template, should issuers link each QHP to a unique Provider Directory, or may issuers allow consumers to navigate to a landing page and select QHPs from a drop down list? A: CMS encourages issuers to link each QHP to a unique Provider Directory. However, as long as the issuer provides a clear, intuitive, and transparent method for consumers to obtain direct access to the Provider Directories for each QHP, the issuer may use a drop down list, as long as each plan name matches exactly to the plan name that displays on the Federally-facilitated Marketplace (FFM) website. (REGTAP FAQ Database - FAQ #3532 08/07/14) Q42: May issuers select more than one Essential Community Provider (ECP) category on the ECP Template for a single provider if that provider has indicated that it provides both categories of services, even if only one type of service is reflected for that provider on the HHS ECP list? A42: Yes, if the provider indicates to the issuer that it provides two different types of services that are options within the ECP template dropdown menu, issuers may select both ECP categories even if the HHS ECP list re?ects that the provider provides only one type of service. (QHP Certification Process FAQs #1 (09/29/15)) Q43: Can issuers satisfy the Essential Community Provider (ECP) category requirements by offering a contract in good faith to at least one ECP per ECP category per county in the plan?s service area? A43: Yes, to satisfy the ECP category requirement, issuers must offer a contract in good faith to at least one ECP per ECP category per county in the plan?s service area. However, for purposes of issuer satisfaction of the ECP 30 percent threshold requirement, only fully executed contracts count toward satisfying the 30 percent threshold. (QHP Certi?cation Process FA Q3 #1 (09/29/15)) Q44: How can issuers identify the type(s) of services provided by Essential Community Providers (ECPs) listed in the ?other? category on the ECP list? A44: As outlined in Table 11 of the 2016 Payment Notice, the ?Other ECP Providers" 650 Updated 1-31-17 2017--00750 category includes STD Clinics, TB Clinics, Hemophilia Treatment Centers, Black Lung Clinics, Community Mental Health Centers, Rural Health Clinics, and other entities that serve predominantly low-income, medically underserved individuals. As CMS strengthens the ECP list, we anticipate collecting additional information from providers that results in fewer ECPs falling in this ?Other ECP Providers" category in future years. (QHP Certification Process FAQs #1 {09/29/15)} Q45: How must issuers with embedded dental products enter the dental provider type on the Essential Community Provider (ECP) Template? A45: Issuers, including both Stand-alone Dental Plans (SADPs) and plans with embedded dental products, must select ?Other ECP Provider? from the ECP category column on the ECP Template to re?ect providers that provide dental services. (QHP Certification Process FAQs #1 {09/29/15)} Q46: On the Essential Community Provider (ECP) Template, are multiple suite numbers for a single billing address considered different billing addresses? A46: No, if two providers share the same street address with different suite numbers, the two providers count only once toward satisfaction of the ECP 30 percent threshold requirement. (QHP Certification Process FAQs #1 {09/29/15)} Q47: May issuers use underscores instead of dashes to indicate a provider with multiple practice locations on the Essential Community Provider (ECP) Template? A47: If the ECP has multiple locations using the same provider name, issuers must add a three-digit number to the provider name to distinguish each location Provider Name-001). Issuers must use dashes and not underscores. Using a dash will ensure that the ECP tool correctly identifies each ECP as unique. (QHP Certification Process FAQs #1 (09/29/15)) Q48: For the purposes of the Network Adequacy Template, how does the Centers for Medicare Medicaid Services (CMS) define physician and non-physician? A48: CMS defines a physician as an individual who holds a license(s) to practice medicine such as Medical Doctor (MD), Doctor of Osteopathic Medicine (D.O.) or Doctor of Dental Surgery (D.D.S.). (QHP Certi?cation Process FAQs #1 {09/29/15)} Q49: Does the Network Adequacy Template require issuers to complete Tier Levels? A49: At this time, the Network Adequacy Template does not require issuers to complete Tier Levels. (QHP Certification Process FAQs #1 {09/29/15)} 08: May issuers that offer medical plans with supplemental dental benefits count both medical and dental providers toward satisfaction of the 30 percent threshold on the Essential Community Provider (ECP) Template? A8: While issuers may include both medical and dental providers on the ECP Template itself, the ECP Tool does not calculate both medical and dental providers towards the 30 percent ECP threshold requirement within the same ECP tool (Le, a distinct ECP Tool must be used for medical versus dental providers). Issuers that offer medical plans with 651 Updated 1-31-17 2017--00751 supplemental dental bene?ts may submit justifications requesting that CMS consider dental providers as counting towards the 30 percent ECP threshold requirement. (QHP Certification Process FAQs #3 {09/29/15)} 02: May issuers continually amend the Network Adequacy Template through August 25, 2015 or must issuers ensure all providers and/or facilities are final at the time of the initial submission? A2: Issuers should submit up-to-date and accurate templates and can update the template during the certi?cation process through data lock-down on August 25. Issuers must also adhere to the regulatory requirements under 45 CFR ?156.230 that states issuers need to provide reasonable access to all covered services that would apply to all times during the year. Even when issuers encounter a problem with a network, such as the loss of a provider, the issuer is still required to have a network that provides reasonable access. This requirement applies at all times despite network changes. (QHP Certification Process FA 03 #7 {09/29/15)} Q3: When should issuers purge 2015 provider directories? A3: Plans should continue to display 2015 provider directories for consumers in the Individual Market through the end of the Calendar Year, December 31, 2015. For SHOP plans, the provider directory information should remain current for entire duration of the plan. (QHP Certification Process FA 03 #7 {09/29/15)} 09: Where should issuers capture facility names on the Network Adequacy Template? A9: Issuers should provide both first and last names for providers in the 3rd and 5th columns of the ?Individual tab, respectively, in order for the data to validate. If an issuer can only provide the practice group, like a speech therapy group or an outpatient dialysis group instead of a particular provider?s name, the issuer must ensure that there is text in both the ?rst and last name columns. (Issuer Outreach FAQ #1 (10/27/15)) Q7: Once an issuer removes the ?001? identifier from the first provider name on its Essential Community Provider (ECP) Template that matches a provider name and address on the HHS ECP List, may the issuer append ?002? to the second site location of the same ECP if that site location does not appear on the HHS ECP List, so that the issuer does not have to renumber the multiple sites of an ECP on its ECP Template? A7: Yes, an issuer may append a ?002? identi?er to the provider name of an ECP whose site location does not match against the HHS ECP List. Such as ECP will count as ECP write-in toward the issuer?s satisfaction of the 30 percent ECP threshold, so long as the ECP meets the ECP write-in criteria outlined in the Final 2016 Letter to Issuers in the Federally-facilitated Marketplaces (FFMs) released February 20, 2015. (Issuer Outreach FAQ #2 {10/27/15)} 652 Updated 1-31-17 2017--00752 Q8: If a provider?s name and address listed on an issuer?s Essential Community Provider (ECP) Template match the data that appear on the non-exhaustive U.S. Department of Health and Human Services? ECP list but the provider?s National Provider Identifier (NPI) does not match the NPI that appears on the HHS ECP List, should the issuer enter ?no? in the column indicating whether the provider is on the HHS ECP List? A8: For the 2016 bene?t year, CCIIO is not using the NPI ?eld to match an issuer's ECPs listed on its ECP Template with those on the HHS ECP List; therefore, an issuer may select ?yes? in the column indicating if the ECP is on the HHS ECP List if the ECP shares the same address and provider name. (Issuer Outreach FAQ #2 (10/27/15)) NETWORK ADEQUACY General Q17: In the instance an issuer cannot attest to ?network adequacy? and has to submit ?network access plan,? when would the issuer have to attest to their ?network adequacy?? A17: All applicants are required to attest to meeting network adequacy requirements. Additionally, issuers categorized as "Tier 3" (as explained in the instructions) are required to submit a network access plan. Please refer to the Application Instructions, available on the REGTAP portal, for more information on completing the Network Adequacy instruction of the application. (Plan Management Webinar QHP FAQ #2 04/09/13) Q18: Will there be any specific components related to pharmacy network or will that information be considered as part of the entire network filing? A18: Network adequacy is a QHP certification requirement per 45 CFR 156.230, and this includes pharmacy access. Issuers are not required to submit their (non-ECP) networks to the FFE for QHP certi?cation. Please see the Application Instructions for more information on the network adequacy section. (Plan Management Webinar QHP FAQ #2 04/09/13) Q24: Should issuers submit the medical and dental together as a network? A24: The entire network must be contained under one Network ID. The medical and dental must be combined, but not necessarily on one website. It is also acceptable if the link to the medical network has another separate link to the dental network. (QHP Webinar Series FAQ #4 04/16/13) Q25: Will there be any specific components of network adequacy related to the pharmacy network? A25: CMS expects pharmacy will be part of the network and that the attestation to provide sufficient access to providers includes pharmacy access. (QHP Webinar Series FAQ #4 04/16/13) 653 Updated 1-31-17 2017--00753 Q14: If an issuer has different networks for dental, vision, and medical, should all three be submitted? A14: Each QHP must be associated with a single Network ID. If an issuer has dental, vision, and medical networks for a QHP offering all three types of benefits, the network URL provided in the Network ID template should provide the consumer access to view all three networks. If an issuer is Tier 3 and is submitting a network access plan, that plan should describe standards applicable to all three parts of the network. See the Chapter 6 of the Instructions for more information on Network Adequacy reviews. An issuer offering dental benefits should also include its dental providers in the ECP network provided through the ECP template. A list of dental ECPs is available here: kiqu. (QHP Webinar Series FAQ #7 04/24/13) This FAQ was revised and released as REGTAP on 03/31/14, as follows: Q: If an issuer has different networks for dental, Vision, and medical, should all three be submitted? A: Each QHP must be associated with a single Network ID. If an issuer has dental, vision, and medical networks for a QHP offering all three types of bene?ts, the network URL provided in the Network ID template should provide the consumer access to view all three networks. An issuer offering dental bene?ts should also include its dental providers in the ECP network provided through the ECP template. A list of dental ECPs is available here: Pr/nwve-k4gu. (REG TAP FAQ Database - FAQ #1360 03/31/14) Q35: If an issuer is accredited, can it skip the Network Adequacy section? A35: Issuers must respond to all sections of the QHP Application, including Network Adequacy. The Network Adequacy section does not use a template, but has attestations that all issuers must complete in the QHP Application System. As noted in the Letter to Issuers, in States without sufficient network adequacy review HHS will accept an issuer?s accreditation (commercial or Medicaid) from an HHS- recognized accrediting entity. Unaccredited issuers will be required to submit an access plan as part of the QHP Application. The access plan must demonstrate that an issuer has standards and procedures in place to maintain an adequate network consistent with 45 Accredited issuers are still required to submit their Essential Community Provider (ECP) networks via the ECP template. (QHP Webinar Series FAQ #9 05/03/13) Q36: Are the network adequacy standards for FFEs the same as for Medicare Advantage? Updated 1-31-17 A36: The network adequacy standards in the application apply to the FFE. They are different from the standards used in the Medicare Advantage program. Exchange network adequacy standards can be found at 45 CFR 156.230. More information is also in Chapter 1 of the Issuer Letter. (QHP Webinar Series FAQ #9 05l03l13) 654 2017-?00754 The answer to this question was revised in a 6/11/14 REG TAP FAQ: A: The required network adequacy standards are listed at 45 CFR 156.230. These requirements are different from the standards used in the Medicare Advantage program. (REGTAP FAQ Database - FAQ #2158 06/11/14) Q37: What is the definition of a network? A37: A network is the system of health care providers offered by a speci?c plan. (QHP Webinar Series FAQ #9 05/03/13) Q: Is CMS requiring issuers to submit the Network Access Plan in 2015? How should issuers respond to the Network Access Plan Attestations in the Network Adequacy instructions listed on A: No, CMS is not requiring issuers to submit the Network Access Plan in 2015. The Application Instructions on HIOS user interface contain outdated information regarding Network Access Plans. Issuers should respond to the Attestations (even though speci?c questions may not apply) and follow the most recent 2015 Network Adequacy Instructions found on the CCIIO website at as well as the CMS ZONE website at (REGTAP FAQ Database - FAQ #2957 07/23/14) Q: Should the Network ID Template include leased networks in addition to the issuer's network? A: The purpose of the Network ID Template is to allow the issuer to map each network to its associated QHPs. Therefore, the issuer should identify all networks that are associated with QHPs. To the extent that a network's providers are available to enrollees in that QHP and are treated by the issuer as providing in-network bene?ts, even if the network is leased in-network cost sharing applies), that network information should be included in the template. The Federally-facilitated Marketplace (FFM) will use the URL in this template to link from the QHP information on the healthcaregov website to the associated provider directory. (REGTAP FAQ Database - FAQ #3495 08/06/14) Q14: Must an issuer apply Provider Directory tiering methodology across the issuer?s network? Updated 1-31-17 A14: Yes. Provider directory requirements are established in 45 CFR Specifically, we require Qualified Health Plan (QHP) issuers to publish an up-to-date, accurate, and complete provider directory, including information on which providers are accepting new patients, the provider's location, contact information, specialty, medical group, and any institutional affiliations, in a manner that is easily accessible to plan enrollees, prospective enrollees, the State, the Exchange, HHS, and the Of?ce of Personnel Management (0PM). As part of this requirement, the QHP issuer must update the directory information at least once a month, and that a provider directory will be considered easily accessible when the general public is able to view all of the current providers for a plan on the plan's public Web site through a clearly identi?able link or tab without having to create or access an account or enter a policy number. The general public should be able to easily discern which providers participate in which plan(s) and 655 2017--00755 provider network(s) if the health plan issuer maintains multiple provider networks, and the p an(s) and provider network(s) associated with each provider, including the tier in which the provider is included, should be clearly identi?ed on the Web site and in the provider directory. The network adequacy template that is submitted during the certification process does not collect information about tiers and for that template issuers should include all providers they consider ?in-network?. (QHP Certi?cation Process FAQs #1 (09/29/15) Q15: Where can issuers locate a precise explanation of the machine-readable standard for provider directories? A15: CMS released a PRA package on March 30, 2015, for a 60-day comment period, which can be found at The Centers for Medicare Medicaid Services (CMS) intends to seek feedback from issuers, States and other stakeholders prior to finalizing the requirements. (QHP Certi?cation Process FAQs #1 {09/29/15) Q16: Must issuers provide consumers with an electronic copy or hardcopy provider directory? Must issuers print new provider directories or only update the website? A16: Issuers must provide consumers with a copy of the provider directory on the website. Issuers must also provide a hard copy upon request. The provider directory must be current and updated at least once a month. This requirement applies to both print and electronic directories. (QHP Certification Process FAQs #1 (09/29/15) Q17: May issuers provide customers with a Uniform Resource Locator (URL) to a provider list search tool and another link within the search tool for the Provider Directory? A17: The Centers for Medicare Medicare Services (CMS) prefers issuers to provide customers with direct links to Provider Directories and in general to provide access with as few links as possible. (QHP Certi?cation Process FAQs #1 {09/29/15) Q. Should qualified health plan (QHP) issuers, including stand-alone dental plan (SADP) issuers, include in their provider directories providers on the Of?ce of the Inspector General?s (OlG?s) List of Excluded Individuals and Entities A. List of Excluded Individuals/Entities (LEIE) provides information to the health care industry, patients, and the public regarding individuals and entities currently excluded from participation in Medicare, Medicaid, and all other Federal health care programs. Individuals and entities who have been reinstated are removed from the LEIE. The OIG imposes exclusions under the authority of Sections 1128 and 1156 of the Social Security Act. A list of all OIG exclusions and their statutory authorities can be found on the Exclusion Authorities page. No payment will be made by any Federal health care program for any items or services furnished, ordered, or prescribed by an excluded individual or entity. This payment prohibition applies to the excluded person, 656 Updated 1-31-17 2017--00756 anyone who employs or contracts with the excluded person, any hospital or other provider for which the excluded person provides services, and anyone else. The exclusion applies regardless of who submits the claims, and it applies to all administrative and management services furnished by the excluded person. The Department of Health and Human Services (HHS) does not consider QHPs to be federal health care programs. However, HHS encourages QHP issuers not to contract with providers on the OIG LEIE. Pursuant to 45 CFR a QHP issuer, including issuers of SADPs, must publish an up-to-date, accurate, and complete provider directory, including information on which providers are accepting new patients, the provider?s location, contact information, specialty, medical group, and any institutional affiliations, in a manner that is easily accessible to plan enrollees, prospective enrollees, the State, the State-based Marketplace (SBM) or Federally facilitated Marketplace (FFM), the Department of Health and Human Services (HHS), and the Of?ce of Personnel Management (0PM). CMS considers a provider directory to be up-to-date if the issuer updates it at least If an issuer ceases to contract with a provider after placement on the OIG LEIE, the issuer should remove the provider from their provider directory on a timely basis. CMS also requires QHP issuers in the FFMs, including issuers of SADPs, to make this provider directory information publicly available on their websites in a machine-readable ?le and format speci?ed by HHS, to allow the creation of user-friendly aggregated information sources. (QHP Provider Directory Requirements and OIG List of Excluded Individuals and Entities (05-20-16)) Essential Community Providers (ECPs) Q18: Can you please clarify what is an "Essential Community Provider"? Please provide a full de?nition and parameters for states that may not have all ECPs due to population size, geographic barriers, or provider types that do not exist speci?c to the state. A18: As defined in section 1311(c)(1)(C) of the Affordable Care Act and in 45 CFR. ECPs are providers that serve predominantly low-income, medically underserved individuals, including providers described in section of the PHS Act, and providers described in section of the Act. Please note that ECP inclusion will be evaluated based upon the extent to which ECPs are available in the service area of the issuer. (Plan Management Webinar QHP FAQ #1 04/08/13) Q19: Is the evaluation of ECPs at a county or service area level? Updated 1-31-17 A19: The percentage thresholds will be calculated based upon the issuer?s service area. See 45 CFR ?156.235 and the Letter to Issuers on Federally?facilitated and State Partnership Exchanges. To qualify for the safe harbor articulated in the issuer letter starting on page 7, the issuer will be expected to have contracts with at least 20 percent of the available ECPs in the proposed service area (published on the CCIIO website on April 5, 2013, at: Letter to Issuers 04052013.pdf) . To meet the safe harbor, please note that the issuer would also need to offer contracts to all Indian providers in the service area, and offer contracts to at least one ECP in each ECP category in each county of the service area, as noted in the letter. (Plan Management Webinar QHP FAQ #1 04/08/13) This question was repeated in a REG TAP FAQ released on 03/31/14: 657 2017-?00757 Q: Is the evaluation of ECPs at a county or service area level? A: The percentage thresholds will be calculated based upon the issuer's service area. See 45 CFR ?156. 235 and the 2015 Letter to Issuers in the Federal/y- facilitated Marketplaces. (REG TAP FAQ Database - FAQ #1340 03/31/14) 020: If a service area is statewide, does the safe harbor standard mean that the issuer can contract with 20 percent of the ECPs in the state overall and meet the requirements? A20: If the issuer?s service area is statewide, then the issuer would need to contract with at least 20 percent of the ECPs in the State to quality for the safe harbor. The issuer would also need to meet the standard set forth in the issuer letter and noted above, in question 20, regarding Indian providers and offering contracts to at least one ECP in each ECP category. (Plan Management Webinar QHP FAQ #1 04/08/13) 021: How will the requirement to offer contracts to at least one ECP per category apply if there are no ECPs in the category in the service area? A21: As a condition of the safe harbor, issuers will need to offer contracts to at least one ECP in each ECP category in each county in the service area, where an ECP in that category is available. Please be sure to check the non-exhaustive listing of ECPs to determine the availability of ECPs in the service area. This list was published 3/26/13. Information on the list and a link to the list can be found at (Plan Management Webinar QHP FAQ #1 04/08/13) Q22: If there are not any available Indian Health Service (IHS) providers in the state per the IHS website, do the ECP requirements still apply? A22: Indian providers also include tribal and urban Indian organizations. Please check the non-exhaustive list of ECPs referenced previously to verify whether any Indian providers are available in the proposed service area. (Plan Management Webinar QHP FAQ #1 04/08/13 and REGTAP FAQ Database - FAQ #2153 06/11/14) 023: If the network adequacy standard for ECP cannot be met, issuers can submit a satisfactory narrative justification. What elements would make the response satisfactory as opposed to unsatisfactory? A23: HHS expects that an issuer that does not achieve the safe harbor standard submit a narrative justification using the ECP Supplemental Response Form. The QHP Application identifies the speci?c elements that must be addressed in the narrative justi?cation in the ECP Supplemental Response Form. This would include providing information on why the issuer was not able to achieve the safe harbor standard, how the issuer plans to increase ECP participation, and how the existing network would provide access for low-income and medically underserved populations. Issuers will need to respond to each speci?c element requested in the ECP Supplemental Response Form, as applicable. (Plan Management Webinar QHP FAQ #1 04/08/13) 658 Updated 1-31-17 2017--00758 Q15: Regarding the ECP template, if an ECP has multiple addresses should we list the ECP twice, once with each address? A15: When entering an ECP with multiple locations but the same Provider Name, append the Provider name with a unique 3-digit number for each location, eg. Provider 001. (Plan Management Webinar QHP FAQ #2 04/09/13) Q16: ls every QHP required to have If the service area is not rural, and the network has suf?cient coverage, is it required to also have A16: Each QHP is required to have a suf?cient number and geographic distribution of ECPs, where available, in accordance with 45 CFR 156.235. The QHP issuer must ensure reasonable and timely access to a broad range of such ECPs for low-income, medically underserved individuals. Nothing in the regulation would preclude a QHP issuer from credentialing an ECP, similar to any other provider. HHS notes that many 34OB providers currently meet provider accreditation standards. The Issuer Letter includes more information on ECPs, in Chapter 1. (Plan Management Webinar QHP FAQ #2 04/09/13) 028: The Essential Community Provider (ECP) Template includes a column for Provider Name. Is an issuer required to enter each ECP by name or can the issuer enter the ECP entity name when applicable, knowing that an ECP entity may include multiple providers? A28: Please enter the name of the ECP entity for each location of the ECP entity, even if the ECP entity has multiple providers at a specific location. (Plan Management Webinar QHP FAQ #3 04/11/13) 029: If we subcontract our work, how do we represent that on the ECP template? A29: If the issuer subcontracts with another entity for services and the entity in turn contracts with an ECP, the ECP should be included in the issuer's ECP template if listed in the provider directory for the issuer's QHP. (Plan Management Webinar QHP FAQ #3 04/11/13) Q30: If an Indian health provider does not contract with an issuer, can the issuer treat it as a non-participating provider? A30: Even if an issuer does not have a contract with an Indian health provider, and the Indian health provider provides services to an Indian who is a member of the issuer?s QHP, the Indian health provider would have a right of recovery authorized under section 206 of the Indian Health Care Improvement Act (25 U.S.C. ?1621e). Section 206(a) and of the Indian Health Care Improvement Act provide that the Indian Health Service, an Indian tribe, tribal organization, and urban Indian organization have a right to recover reasonable charges billed, or, if higher, the highest amount an insurance carrier would pay to other providers. However, HHS notes that if an issuer and Indian health provider sign a QHP agreement that uses the model QHP Addendum for Indian health providers and the issuer and Indian health provider mutually agree to rates or amounts speci?ed in the QHP agreement as payment in full, the QHP issuer is deemed to be compliant with 659 Updated 1-31-17 2017--00759 Section 206 of Indian Health Care Improvement Act. (Plan Management Webinar QHP FAQ #3 04/11/13) Q31: How should an issuer handle out-of-state Indian providers; should they be treated as in network or out-of-network? A31: To the extent that an out-of-state Indian health provider is not a part of an issuer?s network, the issuer could consider the Indian health provider as an out-of?network provider. However, the Indian health provider?s right of recovery afforded under section 206 of the Indian Health Care Improvement Act referenced in the response to the question ?If an Indian health provider does not contract with an issuer, can the issuer treat it as a non-participating provider?? (above) would apply. HHS notes that issuers may want to consider contracting with Indian health providers in neighboring states, as tribal lands often cross state borders. (Plan Management Webinar QHP FAQ #3 04/1 1/13) 022: On the Essential Community Provider (ECP) template, how do users enter a provider name that is associated with several different addresses? If the provider name is the same on several rows, the template will not validate. A22: Please refer to the QHP Application Instructions that state that if the ECP has several locations, the issuer should add a number to the provider name to distinguish each location; for example, ?Provider Name 001 If the provider has a national provider identi?er (NPI) number, only enter it with the ?rst location of the provider and leave blank for all other locations. (QHP Webinar Series FAQ #4 04/16/13) 023: Should the dental providers and pharmacies be included on the Essential Community Provider (ECP) spreadsheet? How are all the providers combined under single Network A23: Each QHP must be associated with a single Network ID. If the network has multiple parts, for example medical and dental, the medical and dental providers are combined under a single network ID. There is no need to submit pharmacies in the ECP network unless applying under the alternate standard. Alternate standard providers use the ?Provider Type" column and have the option to check ?Pharmacy" if the facility includes a pharmacy (which is purely for informational purposes and not for evaluation). Issuers applying under the regular standard do not fill out ?Provider Type"; but only ?ll out the Category" column. For those under the regular standard, there is no need to submit pharmacies as part of the ECP network. (QHP Webinar Series FAQ #4 04/16/13) 026: If the provider name is the same on multiple lines of the ECP template because there are multiple locations and issuers distinguish them with an additional number, how do issuers correct the error message because of the duplication of the NPI number? Updated 1-31-17 A26: On the ?rst instance for that provider, list the NPI number. On the subsequent locations, omit the NPI number so it does not trigger an error message in the duplicates check. The NPI is an optional ?eld; omit it for multiple locations. (QHP Webinar Series FAQ #4 04/16/13) 660 2017--00760 Q34: It is unclear in the QHP Application instructions how to list an Essential Community Provider more than once for multiple locations. What convention should issuers use in the ECP Template? A34: Three digits should be added at the end of the Provider Name Provider Name- 003). (QHP Webinar Series FAQ #5 04/18/13) Q35: In the ECP template, should issuers include in the ECP providers that are currently not contracted but with which the issuer intends to contract prior to September 2013? A35: The issuer should only enter ECPs with which it currently has contracts in the ECP template for purposes of meeting the safe harbor standard. In the justification, the issuer should list any additional ECPs with which it is in the process of contracting. (QHP Webinar Series FAQ #5 04/18/13) Q36: If the issuer is reaching out to ECPs in its region to see if they would be interested in participating in the issuer?s network, where and how does the issuer document this action of good intent in its QHP Application? A36: The applicant can document these efforts in the narrative justification. (QHP Webinar Series FAQ #5 04/18/13) Q37: If the ECP address is incorrect on the official HHS ECP list, can the issuer enter the correct address in the ECP template or does the template need to match the HHS List? A37: The applicant should enter the correct address information into the ECP Template. (QHP Webinar Series FAQ #5 04/18/13) Q38: There are ECPs in the CMS non-exhaustive list that are closed that prevent the issuer from offering a contract to at least one ECP in each county where plans will be offered. How should the applicant indicate this information to A38: In order to meet the safe harbor standard, the applicant would need to indicate by submitting the ECP Template that at least 20% of available ECPs in the plan's service area participate in the issuer's provider network. In addition, the issuer must offer contracts prior to the coverage year to: 1) All available Indian providers in the service area, and 2) At least one ECP in each category in each county in the service area, where an ECP in that category is available. If there is no single ECP in a given category in a given county and service area, the issuer should note this in its justification. The ECP list is not exhaustive, and does not include every provider that may qualify as an ECP. Issuers that are clearly unable to meet the regulatory standard, including the 20% safe harbor standard, because of limitations of the list (such as a provider that is no longer in business) may provide a justi?cation using the ECP Supplemental Response Form, which can be found at Please note the issuer also has the ability to write in additional ECPs in the ECP Template. More information on the ECP standards can be found in Chapter 1 of the 2014 Issuer Letter, available at letter to issuers 04052013.pdf. (QHP Webinar Series FAQ #5 04/18/13) 661 Updated 1-31-17 2017--00761 Q49: Where can the Supplemental Response form" be found? A49: You may download the form at under QHP Application Materials, speci?cally at supplemental response Form 03 08 13.pdf. (QHP Webinar Series FAQ #7 04/24/13) 050: For ECPs that are facilities, can issuers list both the facility and the provider in the ECP template? A50: Please list the location of each facility. (QHP Webinar Series FAQ #7 04/24/13) Q51: If an Indian Health Provider refuses to contract with an issuer, can the issuer treat them as a non-participating provider? A51: Even if an issuer does not have a contract with an Indian health provider, and the Indian health provider provides services to an Indian who is a member of the issuer?s QHP, the Indian health provider would have a right of recovery authorized under section 206 of the Indian Health Care Improvement Act (25 U.S.C. ?1621e). Section 206(a) and of the Indian Health Care Improvement Act provide that the Indian Health Service, an Indian tribe, tribal organization, and urban Indian organization have a right to recover reasonable charges billed, or, if higher, the highest amount an insurance carrier would pay to other providers. The issuer could not balance bill. However, we note that if an issuer and Indian health provider sign a QHP agreement that uses the model QHP Addendum for Indian health providers and the issuer and Indian health provider mutually agree to rates or amounts specified in the QHP agreement as payment in full, the QHP issuer is deemed to be compliant with Section 206 of Indian Health Care Improvement Act. (QHP Webinar Series FAQ #7 04/24/13 and REG TAP FAQ Database - FAQ #2155 06/11/14) Q52: How should an issuer treat out-of-state Indian Health Providers? A52: Even if the Indian provider is out-of-state, the Indian health provider?s right of recovery afforded under section 206 of the Indian Health Care Improvement Act references in the response to the previous question would apply. We note that issuers may want to consider contracting with Indian health providers in neighboring states, as tribal lands often cross state borders. (QHP Webinar Series FAQ #7 04/24/13) 053: If an Indian Health Provider is contracted, does an issuer treat that provider as an Indian Health Provider or does that mean they are treated as a network provider can the issuer balance bill)? Are referrals from Indian Health Providers to a non-Indian Health Provider for individuals who make over 300% FPL included in the 100% cost share or treated as normal contract rates? A53: *If a QHP issuer contracts with an Indian Health provider, the QHP issuer may pay the Indian Health provider at the negotiated rate when using the QHP Addendum for Indian providers, even if it is a lower rate than the reasonable billed charged. If the QHP issuer does not contract with an Indian Health provider, the QHP issuer must reimburse the provider as required by section 206 of the Indian Health Care Improvement Act. This policy applies regardless of whether or not the enrollee has a household income greater than 300% of the Federal Poverty Level (FPL) and is eligible for the limited cost sharing plan variation. *Edited on 4/26/13 (QHP Webinar Series FAQ #7 04/24/13) 662 Updated 1-31-17 2017--00762 054: On the ECP template, please clarify what ?Ancillary? and ?Other? refer to. A54: Only issuers that qualify for the alternate ECP standard outlined in Chapter 1 of the Issuer Letter should list locations of ancillary providers in HPSA or low-income zip codes. Ancillary providers that are those not providing primary care, specialty care, inpatient or outpatient hospital services, or pharmacy. For issuers that do not qualify for the alternate ECP standard, please see the description of the "Other ECP Category" contained in the Issuer Letter. (QHP Webinar Series FAQ #7 04/24/13) 055: In the HRSA 3403 database, ECPs may have multiple NPI numbers based on their organizational structure. Will HHS be matching on all an entity has or a specific NPI that an entity has? A55: As noted in Chapter 7 of the QHP application instructions, NPI is an optional ?eld in the ECP template for this year. We are not matching on NPI this year, but are gathering data on available NPIs. If multiple NPIs exist for a given ECP, please use the NPI that mostly closely matches the speci?c location or department for the provider listed in the ECP database, if possible. (QHP Webinar Series FAQ #7 04/24/13) Note: This FAQ was revised and released as REG TAP FAQ 1339 on 03/31/14, as follows: Q: In the HRSA 3408 database, ECPs may have multiple NPI numbers based on their organizational structure. Will HHS be matching on all NPIs an entity has or a specific NPI that an entity has? A: NPI is an optional ?eld in the ECP template. If multiple NPIs exist for a given ECP, please use the NPI that mostly closely matches the specific location or department for the provider listed in the ECP database, if possible. (REG TAP FAQ Database - FAQ #1339 03/31/14) 056: When would an issuer enter NA in the ECP template? A56: Please see Chapter 7 of the QHP application instructions. If the alternate ECP standard applies to the issuer, please complete the Provider Type column and mark in the ECP Category column. If the alternate ECP standard does not apply to the issuer, please complete the ECP Category column and mark in the Provider Type column. (QHP Webinar Series FAQ #7 04/24/13) 057: Both the ECP and Network templates generate Network IDs. Do those both refer to the same network? Do the network names need to be consistent? A57: When entering Network IDs, you must assign networks the same numbers as those assigned in the Network ID and Benefit templates. Please see Chapter 7 of the QHP application instructions. (QHP Webinar Series FAQ #7 04/24/13) 058: What if an ECP provider type does not exist in our State in some regions? A58: As specified in 45 CFR a QHP issuer must have a sufficient number of ECPs, where available, to ensure reasonable and timely access to a broad range of 663 Updated 1-31-17 2017--00763 such providers for low-income, medically underserved individuals in the QHP's service area. If there are no ECPs that belong to a particular ECP category in the service area of the issuer, the issuer should indicate this in the justification. However, if there are ECPs in a particular ECP category in some regions of service area, the issuer would still be expected to offer contracts to those ECPs as part of the safe harbor standard. (QHP Webinar Series FAQ #7 04/24/13) Q59: If an issuer contracts with some of the providers that work at an ECP listed on the non-exhaustive ECP database, but not with the ECP itself, can the issuer include the ECP on its ECP template? A59: No. If the issuer contracts with providers that work for an ECP listed on the non- exhaustive ECP database, but not with the ECP entity itself, the issuer cannot include the ECP on the issuer?s ECP template. However, if the issuer does not meet either the 10% or 20% thresholds, the issuer may list or describe its contracts with individual providers that work for the ECP as part of its justi?cation. (QHP Webinar Series FAQ #7 04/24/13) Q18: In contracting with an Essential Community Provider (ECP), can an issuer contract with a doctor in the practice or does the issuer need to contract with the listed practice? A18: The issuer would need to contract with the ECP as listed in the HHS non- exhaustive list of ECPs. The list is available at (QHP Webinar Series FAQ #9 05/03/13) Q19: Where can issuers find the Model Indian Addendum referenced in the ECP Template instructions? A19: The Model Indian Addendum can be found on the CCIIO website at QHP Addendum 04 04 13.pdf. (QHP Webinar Series FAQ #9 05/03/13) 020: Is the Model Indian Addendum document required to be submitted with the QHP Application? A20: This addendum does not need to be submitted to HHS with the QHP application. (QHP Webinar Series FAQ #9 05/03/13) 021: If a company is made up of multiple Physician Hospital Organizations, does it qualify for the alternate standard for A21: As referenced in the [2015] Letter to Issuers, in order to be considered as meeting the alternate standard, the issuer must meet the requirements laid out in 45 CFR and 45 CFR states that a QHP issuer that provides a majority of covered professional services through physicians employed by the issuer or through a single contracted medical group may instead comply with the alternate standard described in paragraph of this section. 664 Updated 1-31-17 2017--00764 45 CFR 156.235(b) states that Alternate standard. A QHP issuer described in paragraph of this section must have a suf?cient number and geographic distribution of employed providers and hospital facilities, or providers of its contracted medical group and hospital facilities to ensure reasonable and timely access for low-income, medically underserved individuals in the service area, in accordance with the Exchange?s [marketplace's] network adequacy standards. (QHP Webinar Series FAQ #9 05/03/13, REGTP FAQ #2122 06l11l12 note that the REG TAP update of this FAQ references the 2015 letter to issuers and use the term ?marketplace in lieu of ?exchange. 024: Could an issuer enter into a contract with an Essential Community Provider (ECP), requiring members to have a referral to receive in-network benefits from the In this circumstance, the ECP would not appear in the provider directory. A24: Issuers may enter into contracts with ECPs and require members to get a referral to the ECP for non-primary care in-network bene?ts, to the extent that such referrals are part of the issuer?s utilization management plan and program. Issuers may have such arrangements count towards the ECP inclusion standard. We are concerned, however, that the issuer might not list the ECP in the provider directory, and we discourage issuers from taking such steps that would prevent consumers from knowing whether they could access the contracted ECP. Issuers must ensure that such arrangements do not interfere with the requirement that provider networks have a sufficient number and geographic distribution of essential community providers that serve low-income and medically underserved individuals, as set forth at 45 CFR 156.235. (QHP Webinar Series FAQ #10 05/09/13) The answer to this FAQ was revised and re-re/eased in a REGTAP FAQ on 6/11/14: A: Issuers may enter into contracts with ECPs and require members to get a referral to the ECP for non-primary care in-network bene?ts, but only to the extent that such referrals are part of the issuer's utilization management plan and program and apply more broadly to all providers are concerned, however, that the issuer might not list the ECP in the provider directory, and we discourage issuers from taking such steps that would prevent consumers from knowing whether they could access the contracted ECP. Issuers must ensure that such arrangements do not interfere with the requirement that provider networks have a suf?cient number and geographic distribution of essential community providers that serve low-income and medically underserved individuals, as set forth at 45 CFR 156.235. (REGTAP FAQ Database - FAQ #2154 06/11/14) Q1. What should providers that serve predominantly low-income, medically underserved individuals be aware of as issuers build their quali?ed health plan (QHP) networks? Updated 1-31-17 A1. Issuers (health insurance companies) are currently building their provider networks to meet new requirements set by the Affordable Care Act (ACA) and may be seeking participation. A provider?s uninsured patients may be eligible to participate in and purchase insurance via the Health Insurance Marketplace in your state. Issuers that offer plans on the Health Insurance Marketplaces (sometimes called Exchanges) now have a requirement under the Affordable Care Act to include in their network a sufficient number and geographic distribution of providers that serve predominately low-income, medically underserved individuals (referred to as Essential Community Providers (ECPs). (CMS FAQs Essential Community Providers 05/13/13 and 06/12/14) 665 2017--00765 02. What does this mean for providers that serve predominantly low-income, medically underserved individuals? A2. At this time, CMS is simply alerting providers that serve predominantly low-income and medically underserved individuals of an important potential new opportunity to participate in a QHP issuer?s network. Issuer requirements of providers serving in their networks will vary. (CMS FA 03 Essential Community Providers 05/13/13 and 06/12/14) Q3. Is there a list of A3. A non-exhaustive database of ECPs is available at mswg. See 03262013.pdf for a cover sheet explaining the database. (CMS FAQs Essential Community Providers 05/13/13) re-re/ease of these ECP FA 08 on 6/12/14 provided some additional links and information: Q4. Will issuers be able to write in ECPs that are not on the list? A4. Yes, CMS realizes that the list is not exhaustive and that issuers may identify and write in other providers who meet the regulatory standard. (CMS FAQs Essential Community Providers 05/13/13 and 06/12/14) 05. Is an issuer seeking QHP certification required to do business with my organization? A5. No, but there is a new requirement for QHP issuers to include a suf?cient number and geographic distribution of ECPs in their provider networks participating in the Health Insurance Marketplaces. For Federally-facilitated and State Partnership Marketplaces, this is described in ?Letter to Issuers on Federally-facilitated and State Partnership Exchanges?, available at: letter to issuers 04052013.pdf. The Letter to Issuers provides additional background on the ECP requirement. It also notes the expectation that issuers failing to meet a ?Safe Harbor? or ?Minimum Expectation? standard will offer a narrative justification explaining how the provider network(s) will provide an adequate level of service for low-income and medically underserved enrollees consistent with the regulatory standard. CMS also reserves the right to monitor issuers on a post-certification basis to ensure suf?cient ECP participation. (CMS FA Qs Essential Community Providers 05/13/13) Q6. How does CMS determine what are considered ?available? Updated 1-31-17 A6. For Federally-facilitated and State Partnership Marketplaces, CMS will use the non- exhaustive database of ECPs found at as the basis for determining the number of available ECPs in the Qualified Health Plan?s service area. This would form the denominator of the percentage of available ECPs included in the issuer?s provider networks(s), as referenced in the Letter to Issuers. (CMS FAQs Essential Community Providers 05/13/13) The 6/12/14 re-release of this FAQ included a different hyperlink: 666 2017--00766 insurancemarketplaceslth.html (CMS FA 08 Essential Community Providers 05/13/13) Q7. Who should I contact with questions? A7. If you have questions, please direct them to: (CMS FAQs Essential Community Providers 05/13/13) 08. Where can we ?nd information on the ACA and the ECP program? A8. Please use the following link to obtain additional information on the Affordable Care Act and on the ECP inclusion standard as contained in the ?Letter to Issuers on Federally-facilitated and State Partnership Exchanges": letter to issuers 04052013.pdf. If you are located in a state that will operate a State-based Marketplace, please contact the entity that is operating the Marketplace for more information on how the ECP provisions of the Affordable Care Act will be applied in the state. We also suggest identifying and contacting your state?s association of insurance issuers. (CMS FAQs Essential Community Providers 05/13/13) The re-re/ease of this FAQ on 06/12/14 revised the answer as follows: A8. Please use the following link to obtain additional information on the Affordable Care Act and on the ECP inclusion standard as contained in the ?2015 Letter to Issuers in the Federal/y facilitated Marketplaces?: If you are located in a state that will operate a State-based Marketplace, please contact the entity that is operating the Marketplace for more information on how the ECP provisions of the Affordable Care Act will be applied in the state. We also suggest identifying and contacting your state ?3 association of insurance issuers. (CMS FAQs on Essential Community Providers 06/12/2014) 09. Where can we ?nd information on the insurance coverage offered on the Marketplaces? A9. Please use the following link to obtain more information: Please note that the actual QHPs that will be offered on the Marketplaces will not be available for enrollment until November 15, 2014. (CMS FAQs Essential Community Providers 05/13/13 and 06/12/14) Q10. What is the timeline for this process, and is it too late to contract with issuers? Updated 1-31-17 A10. Issuers will be submitting initial information to apply for certi?cation as QHPs through the month of June and will have an opportunity to revise this information throughout the summer if necessary. However, we note that building and maintaining a provider network is an ongoing process. The Marketplaces will be available for enrollment starting on November 15, 2014, with initial coverage effective as early as January 1, 2015. (CMS FAQs on Essential Community Providers 06/12/2014) 667 2017-?00767 Q11. Who should potential ECPs contact in their state to get more information about potential A11. The QHPs that will be offered on the Marketplaces will not be certi?ed until later this year. In the meantime, potential ECPs should contact the insurance carriers? association in their state, which may be aware of health insurance products being submitted for QHP certification. Finally, we also recommend that potential ECPs identify health insurance issuers with the greatest market share in the individual and small group markets, and reach out to those issuers directly. (CMS FAQs Essential Community Providers 05/13/13 and 06/12/14) Q12. How was the Minimum Expectation threshold chosen? A12. Recognizing that it typically takes issuers 12-18 months to fully contract their networks, we are evaluating issuers using the Safe Harbor standard and Minimum Expectation level (as described in the Letter to Issuers) for Federally-facilitated and State Partnership Marketplaces in the 2014 coverage year. CMS will continue to assess QHP provider networks, including ECPs, and may revise its approach to reviewing for compliance with network adequacy and ECPs in later years. (CMS FAQs Essential Community Providers 05/13/13) Q42: Should the non-exhaustive database listing for a particular service area be used to calculate a plan's ECP compliance with the Safe Harbor standard and/or Minimum Expectation? A42: The evaluation of an issuer's compliance with the safe harbor or minimum expectation standards as articulated in the Letter to Issuers on Federally-facilitated and State Partnership Exchanges in Chapter 1, Section 1 will consider the extent to which each network includes a suf?cient number of ECPs that meet the regulatory standard for each service area the QHP will cover. HHS will use the non-exhaustive database of ECPs as the basis for determining the number of available ECPs in the service area. This would form the denominator of the percentage of available ECPs included in the issuer?s provider networks(s). All providers included in a QHP issuer?s application that meet the federal regulatory standard will count toward the numerator of the evaluation percentage. The Letter is available at Guidance/Downloads/2014 letter to issuers 04052013.pdf (QHP Webinar Series FAQ #12 06/28/13) Q4: How does a provider request to be added to the ECP list? Updated 1-31-17 A4: The non-Exhaustive HHS list of ECPs is derived from the HHS programs that qualify for participation in the 34GB discount drug program authorized under section 3408 of the PHS Act or described under section of the Social Security Act. However, CMS allows issuers to write in any providers that meet the regulatory de?nition of an essential community providers, including providers that are currently eligible to participate in programs offered under section 3408 of the Public Health Service (PHS) Act or section 1927(c)(1)(D)(i)(lV) of the Social Security Act, but that are not included on the HHS developed list, or not-for-pro?t or state-owned providers that would be entities described in section 3408, but do not receive federal funding under the relevant section 668 2017--00768 of law referred to in section 3408. Such providers include not-for-pro?t or governmental family planning service sites that do not receive a grant under Title of the PHS Act. Providers who believe that they should be included on the non-exhaustive HHS list of ECPs, based on qualifying for participation in the 3408 discount drug program authorized under section 3408 of the PHS Act or described under section 1927(c)(1)(D)(i)(lV) of the Social Security Act, may contact CMS via email at describing their specific qualification. Such providers should also contact the federal entity that provided their funding grant, and request to update their information, so that the information can be corrected in the system of record on which CMS relies for maintaining the nonexhaustive HHS list of ECPs. The HHS non-exhaustive ECP listing is refreshed annually, and may be updated periodically after the annual refresh. (CMS FAQs on Essential Community Providers 06/12/2014) Q12. How was the increase in the ECP threshold for the general ECP inclusion standard determined for benefit year 2015? A12. An application for QHP certification that adheres to the general ECP inclusion standard does not need to provide further documentation. For bene?t year 2015, we will utilize a general ECP enforcement guideline whereby if an application demonstrates that at least 30 percent of available ECPs in each plan?s service area participate in the provider network, we will consider the issuer to have satisfied the regulatory standard. In addition, and as required for the prior year, we expect that the issuer offer contracts in good faith to all available Indian health providers in the service area, and at least one ECP in each ECP category in each county in the service area, where an ECP in that category is available. To be offered in good faith, a contract should offer terms that a willing, similarly-situated, non-ECP provider would accept or has accepted. We would expect issuers to be able to provide veri?cation of such offers if CMS chooses to verify the offers. As only one issuer submitted a justi?cation for the 2014 benefit year as a means to satisfy the 20 percent ECP threshold, we anticipate that issuers will readily be able to contract with at least 30 percent of ECPs in a plan?s service area and that issuers will largely be able to satisfy this without having to submit a written justification. (CMS FAQs on Essential Community Providers 06/12/2014) Q: Do the 2015 QHP Attestations include the Indian Health Essential Community Provider (ECP) contract offerings? A: As part of the ECP section of the application, issuers must attest that contracts were offered to all available Indian Health ECPs. If the issuer cannot attest to this, then the issuer must provide an explanation in the justi?cation detailing the issuer's contracting efforts. (REGTAP FAQ Database - FAQ #2955 07/22/14) Q: Is an issuer required to submit a justification if the issuer meets the 30 percent Essential Community Provider (ECP) threshold? Updated 1-31-17 A: An issuer must submit a justi?cation, using the Supplemental Response Form if it fails to meet any one of the three ECP requirements: the 30 percent threshold; good faith contract offers to all available Indian Health Providers in each plan's service area; and good faith contract offers to at least one ECP in each ECP category in each county in 669 2017--00769 the issuer's service area. Issuers meeting all three of these requirements do not need to submit a justi?cation. (REGTAP FAQ Database - FAQ #2956 07/23/14) Q: Does CMS only calculate the 30 percent Essential Community Provider (ECP) requirement for Stand-alone Dental Plans (SADPs) from the Dental ECP List tab, or must issuers combine the dental list with the Indian Health Provider list? A: When calculating the 30 percent ECP requirement for SADPs, CMS uses the universe of dental providers located in the Dental List tab as well as any dental ECPs the issuer adds as a ?write in" in the ECP template. (REGTAP FAQ Database - FAQ #2958 07/23/14) Q: Are Stand-alone Dental Plan (SADPs) required to submit the Essential Community Provider (ECP) type on the ECP Template? A: SADPs should populate the Type" ?eld only if they qualify as an alternate issuer as defined under CFR SADPs that are standard issuers must populate the Category? field and may select ?Other under the Category? dropdown menu if that is the most applicable option for the issuer. (REGTAP FAQ Database - FAQ #2959 07/23/14) Q: Should stand-alone dental plan (SADP) issuers continue utilizing the Essential Community Provider (ECP) Supplementary Response Form in 2015 if they are unable to satisfy the 30 percent ECP threshold? A: Yes, CMS will continue to allow SADP issuers to utilize the ECP Supplementary Response Form in 2015 if an issuer is unable to satisfy the 30 percent ECP threshold through a combination of contracting with ECPs on the non-exhaustive HHS ECP list and ECP write-ins that the issuer has included on its ECP template. (REGTAP FAQ Database - FAQ #2960 07/23/14) Q: If a stand-alone dental plan (SADP) issuer is located in a State that does not have dental Essential Community Providers (ECP), can the issuer indicate on the ECP Template? A: If an SADP issuer is located in a State without dental ECPs, the issuer should follow the guidance outlined in Chapter 9, Part of the 2015 QHP Application Instructions. If the issuer qualifies for the alternate standard, the issuer must select ?Ancillary Services? in the ?Provider Type? column, and must select in the Category" column. If the issuer is a standard issuer, the issuer must select ?Other in the Category? column, and must select in the ?Provider Type? column. Both alternate and standard issuers must leave the National Provider Identi?er (NPI) ?eld blank, enter ?Blank? in the Provider Name ?eld, and enter ?00000 for the Street Address. Issuers can reference the 2015 QHP Application Instructions for further guidance: Marketplaces/th.htm (REGTAP FAQ Database - FAQ #2961 07/23/14) 670 Updated 1-31-17 2017--00770 Q: Do the 2015 QHP Attestations include the Indian Health Essential Community Provider (ECP) contract offerings? See FAQ ID: 2955. A: ble Indian Health ECPs [Note: This incomplete sentence is a clear error in this If the issuer cannot attest to this, then the issuer must provide an explanation in the justi?cation detailing the issuer's contracting efforts. (REGTAP FAQ Database - FAQ #3358 07/31/14) Q: Does CMS only calculate the 30 percent Essential Community Provider (ECP) requirement for Stand-alone Dental Plans (SADPs) from the Dental ECP List tab, or must issuers combine the dental list with the Indian Health Provider list? See FAQ ID: 2958. A: When calculating the 30 percent ECP requirement for SADPs, CMS uses the universe of dental providers located in the Dental List tab as well as any dental ECPs the issuer adds as a ?write in? in the ECP template. (REGTAP FAQ Database - FAQ #3359 07/31/14) Q: Are Stand-alone Dental Plan (SADPs) required to submit the Essential Community Provider (ECP) type on the ECP Template? See FAQ ID: 2959. A: SADPs should populate the Type? ?eld only if they qualify as an alternate issuer as defined under CFR SADPs that are standard issuers must populate the Category? field and may select ?Other under the Category? dropdown menu if that is the most applicable option for the issuer. (REGTAP FAQ Database - FAQ #3360 07/31/14) Q: Should stand-alone dental plan (SADP) issuers continue utilizing the Essential Community Provider (ECP) Supplementary Response Form in 2015 if they are unable to satisfy the 30 percent ECP threshold? See FAQ ID: 2960. A: Yes, CMS will continue to allow SADP issuers to utilize the ECP Supplementary Response Form in 2015 if an issuer is unable to satisfy the 30 percent ECP threshold through a combination of contracting with ECPs on the non-exhaustive HHS ECP list and ECP write-ins that the issuer has included on its ECP template. (REGTAP FAQ Database - FAQ #3361 07/31/14) Q: If a stand-alone dental plan (SADP) issuer is located in a State that does not have dental Essential Community Providers (ECP), can the issuer indicate on the ECP Template? See FAQ ID: 2961. A: If an SADP issuer is located in a State without dental ECPs, the issuer should follow the guidance outlined in Chapter 9, Part of the 2015 QHP Application Instructions. If the issuer qualifies for the alternate standard, the issuer must select ?Ancillary Services? in the ?Provider Type? column, and must select in the Category? column. If the issuer is a standard issuer, the issuer must select ?Other in the Category" column, and must select in the ?Provider Type" column. Both alternate and standard issuers must leave the National Provider Identi?er (NPI) ?eld blank, enter Blank? in the Provider Name field, and enter 00000 for the Street Address. Issuers can reference the 2015 QHP Application Instructions for further guidance: FAQ ID E2 (REGTAP FAQ Database - FAQ #3362 07/31/14) 671 Updated 1-31-17 2017-?00771 Q12: Must issuers use the Centers for Medicare Medicaid Services (CMS) version of the Essential Community Provider (ECP) Supplemental Response Form? If issuers must use the CMS version and there is no header, should issuers create a header to include the State, Health Insurance Oversight System (HIOS) ID and Network A12: Issuers must use the CMS version of the ECP Supplemental Response Form available at marketplaces/th.html . CMS recommends issuers include the State, HIOS ID, and Network ID in the text portion of the response at the top of the form. This information does not appear as an entry ?eld on the form, because the information appears on the Quali?ed Health Plan (QHP) Application. When uploading the form in the Issuer Module, the module will link the QHP Application to the Issuer ID. (QHP Certi?cation Process FAQs #1 (09/29/15) Q13: Must an issuer?s provider contract with an essential community provider be exclusive to the Marketplace? A13: While an issuer?s contract with an essential community provider need not be exclusive to the Marketplace, the contract should include Marketplace requirements pertinent to the provider?s contractual arrangement with the issuer. (QHP Certi?cation Process FAQs #1 {09/29/15) Essential Community Provider Petition for 2017 Bene?t Year Q1. Under what authority is HHS collecting this provider data? A1. In accordance with section 131 1 of the Affordable Care Act (ACA), Quali?ed Health Plans (QHPs), including Stand-alone Dental Plan (SADP) issuers, are required to include within their network essential community providers (ECPs), where available, that serve predominantly low-income, medically-underserved individuals. To satisfy this ECP requirement, QHP and SADP issuers must submit an ECP template as part of their QHP application, in which they must list the ECPs with whom they have contracted to provide health care services to low-income, medically underserved individuals in their service areas. HHS has compiled a list of available ECPs, based on data it and other Federal partners maintain, which has been used as an initial source of ECP information. HHS updates this ECP list annually to assist issuers with identifying providers that qualify for inclusion in an issuer?s plan network toward satisfaction of the ECP standard under 45 CFR 156.235. (ECP Petition for 2017 Bene?t Year FAQs 12/12/15) Q2. What is the purpose of the Essential Community Provider (ECP) Petition? Updated 1-31-17 A2. The purpose of the ECP petition is to achieve the following: To ensure that the ECP list more accurately re?ects the universe of quali?ed available ECPs In a given service area. - To correct erroneous provider data on the HHS ECP list and collect missing provider data National Provider Identifier, facility FTEs, points of contact, etc.). - To ensure that providers are aware of their status on the HHS ECP list. 0 To help inform future proposals for counting issuers? ECP write-ins toward issuer satisfaction of the ECP standard. (ECP Petition for 2017 Bene?t Year FAQs 12/12/15) 672 2017-?00772 Q3. How does a provider access the Essential Community Provider (ECP) Petition? A3. Providers may access the ECP petition at the following link: petition. (ECP Petition for 2017 Bene?t Year FAQs 12/12/15) Q4. When should a provider submit its Essential Community Provider (ECP) Petition? A4. Submit your petition by no later than 11:59 pm. ET on January 8, 2016, in order for HHS to consider your provider data for the 2017 ECP List. Petitions submitted after January 8, 2016, but by no later than August 22, 2016, will be allowed as a write-in for a respective issuer that has listed the provider on its ECP template for the 2017 QHP certification cycle. (ECP Petition for 2017 Bene?t Year FAQs 12/12/15) Q5. Can providers submit modifications to a previously submitted Essential Community Provider (ECP) Petition? A5. Providers can re-submit the ECP petition multiple times until the deadline of January 8, 2016, for modifications to appear on the 2017 HHS ECP list. The version of the petition that the provider submits last will be the petition used to populate the 2017 HHS ECP list. Petitions submitted after January 8, 2016, will be considered for the 2018 HHS ECP list. (ECP Petition for 2017 Bene?t Year FAQs 12/12/15) Q6. When is the next time that providers can update their provider data on the Essential Community Provider (ECP) list? What should providers do if they have an address or staffing change mid-year? A6. The ECP petition window will remain open year-round, allowing providers to update their data on an ongoing basis. However, for purposes of adding or correcting data for the final 2017 HHS ECP list, providers must submit their petition by no later than January 8, 2016. Petitions submitted after January 8, 2016, will be considered for the 2018 HHS ECP list. (ECP Petition for 2017 Bene?t Year FAQs 12/12/15) Q7. How does a provider determine whether it needs to submit an Essential Community Provider (ECP) Petition? A7. All providers who qualify as an ECP and wish to be added to the ECP list, as well as providers who appear on the existing ECP list and need to correct their data or provide required data that are missing from the ECP list should submit an ECP petition. (ECP Petition for 2017 Bene?t Year FA Qs 12/12/15) Q8. If a provider is already included on the official Draft 2017 HHS Essential Community Provider (ECP) List and its provider data are accurately displayed on the ECP list, does the provider need to complete and submit the ECP Petition? A8. Yes, a provider that appears on the of?cial Draft 2017 HHS ECP List with accurately displayed data will need to complete several additional required data ?elds within the ECP petition, such as the provider?s National Provider Identi?er, facility FTEs, and points of contact. (ECP Petition for 2017 Bene?t Year FAQs 12/12/15) 673 Updated 1-31-17 2017--00773 09. When will the final 2017 HHS ECP list be published and how will it be made available? A9. The ?nal 2017 HHS ECP list will be published during the winter of the 2016 calendar year and made available at the following link: (ECP Petition for 2017 Bene?t Year FAQs 12/12/15) Q10. Who is authorized to submit the Essential Community Provider (ECP) Petition? A10. Authorized petitioners include the following: Providers petitioning to make a change to their own HHS ECP listing. - Providers petitioning to remain, be added to, or be removed from the HHS ECP list. - Individuals explicitly authorized by the provider to submit the petition on behalf of the provider facility. - Practitioners who practice within a multi-practitioner facility and are authorized by the facility to submit the petition on behalf of the facility (using the facility-level NPI). - Solo practitioners petitioning under their individual practitioner NPI. CMS is not accepting petitions from unauthorized third-party entities, including issuers, advocacy groups, State Departments of Health, State-based provider associations, and providers other than the provider about which the petition is applicable. However, if any of the above entities own or are the authorized legal representatives of an ECP, then they may submit a petition on behalf of a provider. For example, a local health department that operates its own family planning clinics may appropriately petition for those clinics. In contrast, a State department of health should not attempt to correct ECP listings based on its own database of similar providers. (ECP Petition for 2017 Bene?t Year FAQs 12/12/15) Q11. How can a provider determine whether it needs to update its provider data on the HHS Essential Community Provider (ECP) list or complete any missing data fields? A11. Since there are several new data fields National Provider Identi?er, number of FTEs representing MDs, DOs, PAs, NPs authorized by the state to independently treat and prescribe within the listed facility, etc.) that will be included in the 2017 ECP list, every provider that currently appears on the HHS ECP list will need to provide such missing data through the ECP petition process. A provider can determine whether it needs to update or correct existing provider data on the ECP list by reviewing the draft ECP list available within the petition. (ECP Petition for 2017 Benefit Year FAQS 12/12/15) Q12. How does a provider know whether it qualifies to be included on the HHS Essential Community Provider (ECP) list? Updated 1-31-17 A12. A provider can determine whether it qualifies to be included on the ECP list by completing the ECP petition and reading the instructions that accompany each question within the petition. Detailed instructions are available within the I icon that appears next to each question within the petition. (ECP Petition for 2017 Bene?t Year FAQs 12/12/15) 674 2017-?00774 Q13. How does a provider know if it is eligible for or participating in a 3403 Program? A13. Please refer to for a complete list of organizations that are eligible for the 3408 program. (ECP Petition for 2017 Bene?t Year FAQs 12/12/15) Q14. Should practitioners list their individual National Provider Identifier (NPI) or their facility?s A14. If an individual practitioner practices within the same provider group or organization at the same street location with other affiliated practitioners, the facility NPI should be listed rather than the individual practitioner?s NPI. Af?liated practitioners who practice within a multi-practitioner facility should submit a petition only if authorized by the facility to submit on behalf of the facility using the facility-level NPI and indicating the number of FTE practitioners practicing within the facility. In contrast, solo practitioners may submit the petition under their individual practitioner NPI. (ECP Petition for 2017 Bene?t Year FAQs 12/12/15) Q15. Should a practitioner who works at multiple facilities submit a separate Essential Community Provider (ECP) Petition for each facility? A15. No, practitioners who practice at multiple facilities should not submit a petition independent of the facilities in which they practice; rather, only individuals authorized by the facility should submit the petition using the facility-level NPI and indicating the number of FTE practitioners practicing within the respective facility. In contrast, solo practitioners may submit the petition under their individual practitioner NPI. (ECP Petition for 2017 Bene?t Year FAQs 12/12/15) Q16. Should a facility with multiple locations submit an Essential Community Provider (ECP) Petition for each of its facility locations? A16. Yes, a facility with multiple locations should submit a separate petition for each site location, entering the NPI associated with each of its facility-specific site locations and indicating the number of FTE practitioners practicing only within the facility-speci?c site location. For a provider that shares the same NPI among its multiple site locations, the provider should still submit a separate petition for each unique site location. (ECP Petition for 2017 Bene?t Year FA 03 12/12/15) Q17. What should a provider do if they no longer want to be on the HHS ECP list? A17. If a provider no longer wants to be on the HHS ECP list, then they should select ?Remove? when asked ?Are you petitioning to be added to the list, change your data on the list, or remove your facility from the list?? to ensure that the data are removed from the ECP list. (ECP Petition for 2017 Bene?t Year FAQs 12/12/15) Q18. How can providers confirm that their facility is located in a low-income ZIP code or Health Professional Shortage Area Updated 1-31-17 A18. Providers can determine if their facility is located in a low-income ZIP code or Health Professional Shortage Area (HPSA) by referencing the HHS ?Low-Income and HPSA ZIP Code Listing,? available at 675 2017-?00775 (ECP Petition for 2017 Bene?t Year FAQs 12/12/15) Q19. How does HHS plan to verify my ECP category that I list in my Essential Community Provider (ECP) Petition? A19. CMS coordinates closely with its Federal partners, including the Health Resources and Services Administration (HRSA), the Indian Health Service (IHS), and the Of?ce of the Assistant Secretary for Health/Of?ce of Population Affairs to update the ECP list annually and review requested corrections and additions received directly from providers. If CMS is unable to verify a provider's speci?c ECP category with our Federal partners but can verify that the provider otherwise quali?es as an ECP, CMS may default the provider?s ECP category listing to the ?Other ECP Providers" category until such verification can be made. (ECP Petition for 2017 Bene?t Year FAQs 12/12/15) 020. Must all providers be located in a low-income ZIP code or Health Professional Shortage Area (HPSA), accept patients regardless of ability to pay, and offer a sliding fee schedule to successfully submit the Essential Community Provider (ECP) Petition? A20. A provider that has been included in one of the veri?ed datasets from our Federal partners HRSA, IHS, as reflected on the Draft 2017 ECP List, or is a not-for-profit or governmental family planning service site that does not receive Federal funding under Title of the PHS Act or other 34OB-qualifying funding, is not required to be located in a low-income ZIP code or HPSA, accept patients regardless of ability to pay, or offer a sliding fee schedule, because these entities have been recognized as ECPs under section 1311(c)(1)(C) of the ACA and regulations at 45 CFR 156.235. All other providers must be located in a low-income ZIP code or HPSA, accept patients regardless of ability to pay, and offer a sliding fee schedule to successfully submit the ECP petition. (ECP Petition for 2017 Bene?t Year FAQs 12/12/15) Q21. What is meant by a sliding fee schedule and is it equivalent to a percentage discount program? A21. A percentage discount program is not equivalent to a sliding fee schedule. In a sliding fee schedule, a consumer could have zero cost, but in a percentage discount program, a consumer would still have costs that could be potentially burdensome. For example, a very low-income consumer could have zero out-of?pocket cost when a sliding fee schedule is applied to a medical procedure that costs $1,000. Whereas, in a percentage discount program, even if the provider applies a ninety percent discount, the consumer would have to pay $100, which could be burdensome for a very low-income consumer. (ECP Petition for 2017 Bene?t Year FAQs 12/12/15) 022. Can a provider list a PD. Box for its site address within the Essential Community Provider (ECP) Petition? Updated 1-31-17 A22. No, a PO. Box is not acceptable for a provider?s site address, because the site address must reflect the location at which patients receive health care services from the provider. If a PO. Box is currently included as the site address on the Draft 2017 ECP List, the provider should replace the PO. Box with a street address using the ECP petition. (ECP Petition for 2017 Bene?t Year FAQs 12/12/15) 676 2017-?00776 Q23. When indicating the number of contracts executed with Qualified Health Plan (QHP) issuers, should providers indicate only those contract offers made in good faith? And what constitutes a good faith contract offer? A23. Yes, providers should indicate only those contract offers by QHP issuers made in good faith. As stated in the established policy in the Final 2016 Letter to Issuers in the Federally-facilitated Marketplaces, a good faith contract should offer terms that a willing, similarly situated, non-ECP provider would accept or has accepted. Collecting this information will assist CMS in better determining issuer compliance with the ECP requirements pertaining to the offering of contracts in good faith to quali?ed ECPs. (ECP Petition for 2017 Bene?t Year FA Qs 12/12/15) Q24. Whom can providers contact regarding technical issues with the Essential Community Provider (ECP) petition? A24. If you need technical assistance, click the ?Need Help?? button within the ECP petition or email your question(s) to the following mailbox: (ECP Petition for 2017 Bene?t Year FA 03 12/12/15) HIOS AND SERFF Q1: Data are submitted through the Health Insurance Oversight System (HIOS) in the Federally-facilitated Exchange (FFE). Does the FFE make the determination whether or not substituted benefits are actuarially equivalent and that the plan continues to be substantially equal to the EHB-benchmark plan? Will the determination be made in partnership with the state? How will it work in a fully Federally-facilitated model? A1: The requirement to cover Essential Health Bene?ts (EHB) applies to health insurance coverage in the individual and small group markets, both inside and outside of the Exchanges. Moreover, section 2723 of the Public Health Service Act makes the state the primary enforcement authority for the EHB requirement. If the state is not substantially enforcing EHB, the Centers for Medicare Medicaid Services (CMS) will step in and perform those reviews. States may choose to use CMS templates for conducting reviews of issuers? compliance with the EHB requirement. (Plan Management Webinar 01/24/13) Q58: How do issuers remove HIOS-EIDM accounts for terminated employees? A58: Please call the Help Desk and have the terminated or departed employee removed from the organization. (QHP Webinar Series FAQ #5 04/18/13) 085: How do issuers use HIOS if they are in a Partnership state? A85: There are several instances when a user submitting a QHP Application to a SERFF State will need to utilize HIOS. First, anyone using the templates will need to access HIOS to obtain product and plan IDs. If your organization has been selling in the Individual or Small Group Markets, than you should have been entering HIOS for the PIanFinder collection associated with HealthCare.gov, and the process is exactly the 677 Updated 1-31-17 2017-?00777 same. Issuers need to submit basic information on their form filings as ?products? which generates product IDs. All QHP submissions must link up to a reported product in HIOS. Once you have submitted that basic information, you can request a block of Standard Component IDs (formerly called plan IDs). Instructional materials are available at the REGTAP site If you have staff who have been reporting for HealthCare.gov, those individuals should be able to walk you through the process. In addition to the above, in Partnership States, HIOS will receive data from SERFF for use in ?nalizing the QHP Certi?cation process. Issuers who submitted QHP Applications in SERFF will need to interact with HIOS as part of the Plan Preview period (currently estimated August 22-26) as well as to ?nalize the certi?cation of QHPs at the end of the process and sign agreements with HHS (currently estimated September 5-9). Also, existing filing and submission requirements for other HHS programs still apply, such as the requirements related to providing rate increase submissions under CFR 45 154.215. If you plan to offer products outside of the Federally Facilitated Exchange, please follow the rate review ?ling requirements under CFR 45 154.220 and contact your State to determine state specific ?ling requirements. As noted in the Health Insurance Market Rules; Rate Review ?nal rule when making a rate filing submission, all on- and off-Exchange products must file the Part I Unified Rate Review template and Part Actuarial Memorandum into HIOS. If an issuer is not applying to offer any QHPs in the same risk pool, the Part I Uni?ed Rate Review template and Part Actuarial Memorandum are due on the timeline set by the state, but before January 1, 2014. (QHP Webinar Series FAQ #9 4/20/13) Q82: How are identifiers from HIOS used (component IDs, plan IDs, etc.) and for which templates? A82: HIOS Product IDs reference a form ?ling level, and allow us to link bene?t packages back to State regulatory oversight. Standard Component IDs identify the speci?c package of bene?ts and cost sharing for which a rate can be assigned, and a speci?c premium can be quoted based on rating rules. Standard Component IDs contain the Issuer and Product IDs with which they are associated. When submitting Bene?t Templates, Unified Rate Review Templates, and Rate Table templates, you will need to use Standard Component IDs, which allow us to link different information together at the level a consumer will see it. The Business Rules Template (for policy construction and rating rules) can accept either the higher-level product IDs, or the lower level Standard Component IDs, depending on the level a company uses to define its rules. HIOS Issuer IDs (which identifies a company operating in a State) are required for all templates, and indicate the high level organization of who is submitting these prospective QHPs for certification. (QHP Webinar Series FAQ #7 04/24/13) Q83: If a State is requiring SERFF to submit the QHP application, do issuers still need to work on HIOS in any way? If yes, how? What specifically has to be done on Updated 1-31-17 A83: There are several instances when a user submitting a QHP Application to a SERFF State will need to utilize HIOS. First, anyone using the templates will need to access HIOS to obtain product and plan IDs. If your organization has been selling in the individual or small group markets, then you should have been entering HIOS for the 678 2017-?00778 PIanFinder collection associated with HealthCare.gov, and the process is exactly the same. Issuers need to submit basic information on their form filings as ?products" which generates product IDs. All QHP submissions must link up to a reported product in HIOS. Once you have submitted that basic information, you can request a block of Standard Component IDs (formerly called plan IDs). There have been trainings, and instructional materials are available both at traininq02252013.pdf as well as the RegTap site. If you have staff who have been reporting for HealthCare.gov, those individuals should be able to walk you through the process. In addition to the above, in Partnership States, HIOS will receive data from SERFF for use in finalizing the QHP Certification process. Issuers who submitted QHP Applications in SERFF will need to interact with HIOS as part of the Plan Preview period (currently estimated August 22-26) as well as to finalize the certi?cation of QHPs at the end of the process to sign agreements with CMS (currently estimated September 5-9). Also, existing filing and submission requirements for other CMS programs still apply, such as the requirements related to providing rate increase submissions under 45 CFR 154.215. If an issuer plans to offer products outside of the Federally Facilitated Marketplace, please follow the rate review filing requirements under 45 CFR 154.220 and contact the State to determine state speci?c ?ling requirements. As noted in the Health Insurance Market Rules; Rate Review ?nal rule when making a rate ?ling submission, all on- and off-Exchange products must ?le the Part I Unified Rate Review template and Part Actuarial Memorandum into HIOS. If an issuer is not applying to offer any QHPs in the same risk pool, the Part I Uni?ed Rate Review template and Part Actuarial Memorandum are due on the timeline set by the state, but before January 1, 2014. (QHP Webinar Series FAQ #7 04/24/13) Q84: How do issuers sign up for A84: The website is An issuer will need a CALT User ID and Password to access the site. Once on the site go to the ?Issuer Community" and simply click on the ?Request Membership" to be made a member which will allow Issuers to access information and documents. (QHP Webinar Series FAQ #7 04/24/13) Q85: Do issuers need to register one user per carrier or multiply users per carrier to use the new ZONE forum? A85: Each individual Issuer (user) should have its own User ID and Password. (QHP Webinar Series FAQ #7 04/24/13) Q86: When will the fixed QHP templates be released to A86: Templates were released to SERFF and posted to CMS ZONE starting on March 18, 2013. Updated templates are posted to CMS ZONE and released to SERFF as they become available. (QHP Webinar Series FAQ #7 04/24/13) 087: What trainings are appropriate for Updated 1-31-17 A87: The current training offered on CMS is listed under ?Events? and includes 101? (a webinar on basic features and how-to on CMS Previous training (April 1st and April 3rd) included ?Catch-up Direct Enrollment Technical 679 2017-?00779 Specification Review? and ?Weekly Direct Enrollment Technical Review? sessions. (QHP Webinar Series FAQ #7 04/24/13) Q83: How do issuers use HIOS if they are in a non-Partnership A84: To offer QHPs in non-Partnership FFEs for the 2014 plan year, health insurance issuers will complete QHP Applications electronically through HIOS. Before submitting an application, issuers must gain access to HIOS and de?ne user roles (such as data submitter, data validator, and attester), and obtain HIOS user IDs. HHS expects that between April 1 and April 30, 2013, the issuers will access the QHP Application in HIOS to submit all information necessary for certi?cation of health plans as QHPs. The QHP Application will collect both issuer-level and plan-level benefit and rate data and information, largely through standardized data templates. Applicants will also be required to attest to their adherence to the regulations set forth in 45 CFR parts 155 and 156 and other programmatic requirements necessary for the operational success of an Exchange, and provide requested supporting documentation. These attestations will also apply to vendors and contractors of the issuer or company. (QHP Webinar Series FAQ #9 10/31/13) Q: For issuers that participate in SHOPs in several states, can CMS confirm that issuers should submit a separate file per state? A: The SHOP 2014 Excel Format contains a HIOS/Issuer ID that would segregate the members between the two HIOS IDs. Thus, they can be sent as separate files or they may be combined into one MS Excel spreadsheet prior to sending to the EFT SPOE Mailboxing Folder. (REGTAP FAQ Database - #1586 05/13/14) Q: Please clarify if issuers can submit both Issuer IDs in one template since they're both in the same state. A: The SHOP 2014 Excel Format contains a HIOS/Issuer ID that would segregate the members between the two HIOS IDs. Thus, they can be sent as separate files or they may be combined into one MS Excel spreadsheet prior to sending to the EFT SPOE Mailboxing Folder. (REGTAP FAQ Database - #1589 05/13/14) Q: Is there a naming convention for the excel file Issuers will be sending or will this be covered in future guidance? Updated 1-31-17 A: The ?les sent by partners to CMS follow the ?le naming convention given in this section. APP ID is optional. Format: Example: FEP00220.EGRP.D140507. T201599166. T. IN (REGTAP FAQ Database - #1590 05/13/14) 680 2017--00780 Q: When calculating the percentage of Essential Community Providers (ECPs) in an issuer's service area, what should an issuer use for the denominator? A: As referenced in the 2015 Letter to Issuers, CMS uses the non-exhaustive Department of Health and Human Services (HHS) list of ECPs as the basis for determining the number of available ECPs in a QHP issuer's service area. This forms the denominator of the percentage of available ECPs included in the issuer's provider network(s). In addition, any qualified ECPs that an issuer writes in count toward the denominator for issuer satisfaction of the 30 percent ECP inclusion standard. Note that ECP write-ins count only toward the denominator of the individual issuer that wrote in the ECP. Letter to Issuers: As described in the 2015 Letter to Issuers, any ECPs that an issuer writes in should be located in a 5-digit zip code in which at least 30 percent of the population falls below 200% of the federal poverty level. This list of low-income zip codes is provided at the following CCIIO link: marketplaces/th.html. The non-exhaustive HHS list of ECPs is available at this same link. (REGTAP FAQ Database - FAQ #3490 08/06/14) Q: Will CMS accept requests to add new providers who meet the Essential Community Provider (ECP) criteria to the non-exhaustive HHS list of A: The non-exhaustive Department of Health and Human Services (HHS) list of ECPs reflects providers that qualify for participation in the 3408 discount drug program authorized under section 3408 of the Public Health Service (PHS) Act or described under section of the Social Security Act. At this time, providers that do not participate in one of these grant programs would not be added to the non- exhaustive HHS list of ECPs. However, CMS allows issuers to write in any providers that meet the regulatory definition of an ECP, including providers that are currently eligible to participate in programs offered under section 3408 of the PHS Act or section 1927(c)(1)(D)(i)(lV) of the Social Security Act, but that are not included on the HHS- developed list, or not-for-pro?t or state-owned providers that would be entities described in section 3408, but do not receive federal funding under the relevant section of law referred to in section 3408. Such providers include not-for-pro?t or governmental family planning service sites that do not receive a grant under Title of the PHS Act. As described in the 2015 Letter to Issuers, any such ECPs that an issuer writes in should be located in a 5-digit zip code in which at least 30 percent of the population falls below 200% of the federal poverty level. This list of low-income zip codes is provided at the following CCIIO link - (REGTAP FAQ Database - FAQ #3491 08/06/14) Q: The CMS non-exhaustive list contains many closed sites. Can these locations be removed from the denominator of available ECPs in the service area? A: The data in the non-exhaustive Department of Health and Human Services (HHS) list of ECPs are maintained by the individual HHS agencies that operate grant programs that qualify under section 3408 of the Public Health Service (PHS) Act. If an issuer ?nds 681 Updated 1-31-17 2017--00781 that there are providers on the non-exhaustive HHS list of ECPs that no longer offer ECP-type services, or that some of the locations are no longer valid, and the issuer believes that it will be unable to satisfy the ECP requirement due to the loss of these ECPs, an issuer may submit an ECP supplemental response with its QHP application, explaining why the issuer is unable to comply with the ECP requirement. Any identified ECPs listed on the non-exhaustive HHS list determined to be closed will not count toward the denominator for issuer satisfaction of the 30 percent ECP inclusion standard. (REGTAP FAQ Database - FAQ #3492 08/06/14) Q: How do issuers include dental providers in the Essential Community Provider (ECP) Template? A: If the issuer is offering a Quality Health Plan (QHP) with an embedded or integrated dental bene?t, the issuer should enter medical and dental providers together in the same ECP template. The 30 percent ECP inclusion threshold will apply at the network level, meaning that the 30 percent calculation will apply to the issuer's medical and dental providers together. If the issuer is offering both a QHP with or without an integrated dental benefit) and a SADP, the issuer must create a separate network ID to distinguish its QHP providers from its SADP dental providers. CMS's determination of a dual issuer's satisfaction of the 30 percent ECP inclusion standard will be calculated separately for its QHP and its SADP. If the issuer is offering Stand Alone Dental Plans (SADPs), the issuer should only include dental providers in the Template for its dental networks. The issuer can either select from the non-exhaustive HHS list of ECPs that provide dental care, or write in other providers that meet the regulatory definition of an ECP, including providers that are currently eligible to participate in programs offered under section 3408 of the PHS Act or section of the Social Security Act, but that are not included on the HHS-developed list, or not-for-pro?t or state-owned providers that would be entities described in section 3408, but do not receive federal funding under the relevant section of law referred to in section 3408. The percentage thresholds will apply only to the dental providers in this case non-dental providers will not be counted in the numerator or denominator when assessing whether the issuer meets ECP standards). As with other networks, if an issuer does not meet the percentage thresholds for a dental-only network, the issuer can submit a narrative response. The response should indicate that the network is dental-only for an SADP, and describe how the issuer's provider sites are accessible to, and have services that meet the needs of predominantly low-income, medically-underserved individuals or othen/vise meets the regulatory de?nition of an ECP. (REGTAP FAQ Database - FAQ #3494 08/06/14) 027: Where can issuers locate instructions and guidance for creating Health Insurance Oversight System (HIOS) Plan and Product Updated 1-31-17 A27: Issuers may locate the HIOS Portal User Guide on the Center for Consumer Information and Insurance Oversight (CCIIO) website at plan finder data entry.html (QHP Certification Process FAQs #1 {09/29/15) 682 2017-?00782 028: Where can issuers locate the billing address filed in the Health Insurance Oversight System A28: Issuers will use HIOS to provide insurance company and product information, such as issuer names, addresses, contact information, and product level data. (QHP Certi?cation Process FAQs #1 {09/29/15) 06: Which documents should issuers upload in the Benefit and Service Area Module in the Health Information Oversight System (HIOS) to associate with the drop-downs for ?Actuarial Certification? and ?Essential Health Benefit (EHB) Variance Justification?? A6: Issuers access all of the justi?cations on the CCIIO Quali?ed Health Plan (QHP) portal at Marketplaces/th.html. On that page there is a link to both the Unique AV Plan Design Justification and the EHB Substituted Bene?t Justi?cation, which issuers can upload in HIOS. (QHP Certi?cation Process FAQs #3 {09/29/15)} Q7: Where can issuers locate instructions on how to update administrative information in the Health Insurance Oversight System A7: Issuers can locate instructions for using the HIOS Plan Finder portal at: (QHP Certification Process FAQs #5 {09/29/15) Q3: What is the Health Insurance Oversight System (HIOS) role needed to receive the Correction Notices, Certification, Data Integrity, and Plan Crosswalk Notices? A3: QHP notices will be sent to individuals with HIOS roles of Attester, Validator or Submitter in the QHP module. (Issuer Outreach FAQ #2 (10/27/15)) Q4: How can issuers prevent timing out of the Health Insurance Oversight System (HIOS) when uploading the Issuer Module? A4: The Centers for Medicare Medicaid Services (CMS) has certain security settings that require HIOS modules to have a certain time-out settings. Issuers can prevent timing out by returning to the original HIOS tab and clicking on various cells on that tab every 10 minutes or so. (Issuer Outreach FAQ #2 (10/27/15)) HIOS IDs Q1: Can a unique Component Plan ID be used for both on and off exchange plans where the Product offers both, or should the Component Plan ID be different? A1: A Component ID can be used both on and off the Exchanges provided that the bene?ts and cost sharing are the same. (QHP Webinar Series FAQ #8 04/23/13) 02: Is a QHP a "Product" or is it a "Plan"? A2: A QHP is a "plan". (QHP Webinar Series FAQ #8 04/23/13) 683 Updated 1-31-17 2017--00783 Q3: What is the difference between a QHP and a "Component" of a What are the definitions - Product, Plan, and Component? A3: A Component ID is just the enumeration of a plan (QHP), which is a speci?c pairing of bene?ts to a given cost sharing option, which would allow a rate to be determined. A product is a set of benefits and cost-sharing options, like an issuer would submit to a state for approval. (QHP Webinar Series FAQ #8 04/23/13) Q4: What is the definition of a Product A4: A Product ID enumerates a speci?c set of bene?ts and cost-sharing options. (QHP Webinar Series FAQ #8 04/23/13) Q5: If an issuer offers HMO products in different parts of the state under different marketing names but with the same legal entity, can it still use one Product A5: As long as the HMO product has the same benefits and cost-sharing options, it can be one Product ID. (QHP Webinar Series FAQ #8 04/23/13) 06: If an issuer wants to offer one standard Silver plan, and 3 Silver CSR plans, will the three plans each has its own Plan ID, and share the common Product A6: Enumeration of CSR plans is not done at on the issuer side. The issuer would use one Component (plan) ID for the Silver plan, and the identical (but cost-share reduced) plans would be differentiated by Variant IDs on the CMS side. (QHP Webinar Series FAQ #8 04/23/13) Q7: What entity is performing the review and confirmation of the requested role for a particular issuer A7: CCIIO will do these reviews. (QHP Webinar Series FAQ #8 04/23/13) Q8: Will each QHP cost-sharing variation need a component Will a Silver plan in the Individual Exchange need 4 Plan IDs because there are 4 sets of specific cost sharing to the member? A8: Each QHP cost-sharing variation Indian within of poverty level) does NOT need its own component ID. The Component ID enumerates plans. Any sort of CSR is done on the CMS side. But yes, Issuers would need different Component IDs if its cost- sharing options are different within a single product, so its $1500/30/30% plan would have a different ID than its 1000/25/25%. (QHP Webinar Series FAQ #8 04/23/13) 09: If an issuer requests component IDs in preparation for the QHP submission and then does not need the number requested, what is the process to delete those unused? A9: If component IDs are not used, they do not need to be deleted. The issuer can just leave them in the system, where they will not impact anything, but will be available when needed in the future. (QHP Webinar Series FAQ #8 04/23/13) 684 Updated 1-31-17 2017--00784 Q10: Will Issuers use the existing HIOS product lD's for new Exchange products? A10: If the Exchange plans would ?t under an existing product, an existing product may be used for QHP submissions. This would include the bene?ts being the same. Exchange plans will use Standard Component IDs, and the variant IDs will be assigned on the CCllO-side. (QHP Webinar Series FAQ #8 04/23/13) Q11: If an issuer edits a product, will that generate a new product A11: If an issuer edits a product, it will retain the same product ID. (QHP Webinar Series FAQ #8 04/23/13) Q12: Do issuers need new HIOS Plan IDs for the exchange or can an issuer use some of its current empty A12: If an issuer has empty IDs, those should be available for use on the Exchange. If an issuer needs others, the issuer should request them via the Request Component IDs tab. (QHP Webinar Series FAQ #8 04/23/13) Q13: Do SCIDS need to be obtained in by March 28th in order to be considered for QHP entry and submission for the A13: No. They must be requested in time to make the QHP submission. (QHP Webinar Series FAQ #8 04/23/13) Q14: In which template is the Plan ID generated? A14: Plan IDs are not generated in the templates. Plan (Component) IDs are generated via the Request Component IDs tab in the HIOS Plan Finder module. Once an issuer has created Product IDs, the issuer can request Component IDs for each product. (QHP Webinar Series FAQ #8 04/23/13) Q15: If an insurer already offers plans in a state, but wants to offer new plans/products through the Exchange [Marketplace], will a new ID need to be obtained? A15: The issuer would not need to get a new Issuer ID, but may likely need to get new Product IDs if the Exchange [Marketplace] products do not have identical benefits and cost-sharing options as the existing products. (QHP Webinar Series FAQ #8 04/23/13; the REG TAP Database version of this FAQ uses the term Marketplace in lieu of ?Exchange? FAQ #2166 06/11/14) Q16: Will there be a reconciliation process in order to ensure that the Plan ID and HIOS ID match in all systems? A16: These validations are done both in the creation of these IDs and after templates are submitted. (QHP Webinar Series FAQ #8 04/23/13 and REG TAP FAQ Database FAQ #2170 06/11/14) 685 Updated 1-31-17 2017--00785 Q17: Are all Plan IDs converting to the new 13-digit format with the hyphen, will they stay in the format that they are, or can we expect to be using both formats? A17: They will stay in the current, 14-digit format. (QHP Webinar Series FAQ #8 04/23/13 and REG TAP FAQ Database FAQ #2163 06/11/14) Q18: If an issuer?s EIN remains the same, but the name of the organization changes, what steps are needed to update this information? A18: This can be done through the HIOS help desk. (QHP Webinar Series FAQ #8 04/23/13) Q19: Can a product contain more than 50 plan/component IDs via multiple requests? A19: This is correct. The limit is 50 Component IDs per request, but issuers can request as many as needed for their submission. (QHP Webinar Series FAQ #8 04/23/13) 020: How do we obtain the Associate Health Plan A20: This is done through the HPOES module in the HIOS system. (QHP Webinar Series FAQ #8 04/23/13) 021: What is the processing time between submitting complete plan lD/component ID bene?ts and cost sharing via the Excel template in HIOS and viewing that information within the QHP application environment? A21: Times will vary, but generally uploads complete in a few minutes. (QHP Webinar Series FAQ #8 04/23/13) 022: If an issuer requests Product IDs today in HIOS for 2014 products on the Exchange templates, can the issuer use those Product IDs now but change the product names prior to the launch of the exchange? A22: It is okay to change the product name after original submission in HIOS, but that will be time sensitive to the Exchange go-live. (QHP Webinar Series FAQ #8 04/23/13) 023: Will vendor organizations receive an issuer A23: Vendors receive company IDs, but do not issue insurance, and therefore do not receive issuer IDs. If the vendor is contracting with an insurance issuer, it is assumed thee vendor will be working with the issuer using the issuer?s issuer ID. (QHP Webinar Series FAQ #8 04/23/13) 024: Will the Plan IDs for the Standard and Variation plans be transmitted on the 834? A24: Yes, though variant ID may be entered in a separate field. Please refer to the 834 documentation. (QHP Webinar Series FAQ #8 04/23/13) 686 Updated 1-31-17 2017--00786 025: Will HIOS still be used to generate Product ID's for State Partnership exchanges and 0HP submissions via A25: Yes. (QHP Webinar Series FAQ #8 04/23/13) A revised version of the FAQ is available on the REG TAP database: 0: Will HIOS still be used to generate Product ID's for State performing Plan Management functions and QHP submissions via A: Yes. (REGTAP FAQ Database - FAQ #2169 06/11/14) 026: If someone has already registered your issuers, will that show up when attempting to register? A26: Yes. When the Federal EIN is entered, the system will show all issuers associated to that EIN, so there will be no duplications. (QHP Webinar Series FAQ #8 04/23/13) 027: Is there an accelerated route for obtaining HIOS Product ID's for new exchange metallic products? A27: There is no accelerated process for obtaining HIOS product IDs for Exchange process, though those can be entered presently. (QHP Webinar Series FAQ #8 04/23/13) 028: What if products are under contemporary review by the state's department of insurance? A28: If the product is under review, please note under the "Approved" field that the product is not approved by the state. It will be possible to move forward with the process, but it will be noted and can be changed when the review is complete. (QHP Webinar Series FAQ #8 04/23/13) 029: What is an issuer A29: An Issuer ID is a 5-digit ID that is unique to the provider/state pairing. (QHP Webinar Series FAQ #8 04/23/13) 052: Do issuers have to close all Product IDs and request new IDs for the QHP application submission? A52: No. Products should only be closed if they are being removed from the market. If QHPs are being created based on existing ?lings and HIOS products, they can use those product IDs and related standard component IDs. If new filings are being done to support the creation of QHPs, those ?lings should have an equivalent new product ?led in HIOS, and standard component IDs generated to submit the QHPs. (QHP Webinar Series FAQ #12 06/28/13) 687 Updated 1-31-17 2017--00787 053: At what point is the HIOS Plan ID generated? A53: After an issuer has reported the product ?lings as Products in HIOS, Standard Component IDs (plan IDs) can be generated. This should precede filling out the QHP templates for submission to the FFM or an SBE. (QHP Webinar Series FAQ #12 06/28/13) Q: Are plans offered on exchange and off exchange supposed to have the same HIOS Plan For example, would the on exchange plan ID be 123450H010002 and the off exchange plan would be 123450H010002 as well? A: Yes, plans with the same benefits and cost shares offered on exchange and off exchange are supposed to have the same HIOS ID. On the Plan Bene?ts Template, when the issuer chooses "Both" for "Exchange Plan?" then the template will allow the issuer to input a SCID and it will pre-populate two variants (123450H010002-00 and 123450H010002-01), one for off exchange and the other for exchange. They are both the "same plan" and have the same ID. The variant code is what distinguishes whether a plan is sold on or off the exchange. (REGTAP FAQ Database - #1559 05/08/14) Q: Under what circumstances should a plan continue to use the same HIOS Plan ID from one plan year to the next? A: The Centers for Medicare and Medicaid Services (CMS) expects that a plan (as de?ned in 45 CFR 144.103) that was offered the previous plan year and that remains available under the same product (as defined in 144.103 and consistent with 147.106) will use the same HIOS Plan ID if the plan is offered at the same metal tier level (bronze, silver, gold, platinum or catastrophic) and continues to cover at least some of the same service area. For the 2015 plan or policy year only, an issuer may deviate from this guidance if the issuer receives prior approval from the applicable State or Federal authority to use a different HIOS Plan ID. In the case of Multi-State Plan options, an issuer may deviate from this guidance if the issuer receives prior approval from the Office of Personnel Management. SADP issuers should follow the process outlined above for QHPs for using the same HIOS Plan ID, if the plan is offered at the same actuarial value level (high or low) and continues to cover at least some of the same service area. Please also see REGTAP FAQ 2039 if an issuer chooses to divide a 2014 plan to accommodate the Geographic Rating Area (GRA) factor variation. (REGTAP FAQ Database - FAQ #2392 06/19/14) Q: Does a two-tier network need a separate Network ID in Updated 1-31-17 A: Each Qualified Health Plan (QHP) submitted in HIOS must be associated with a single Network ID as identified in the Network ID Template. The Network ID is associated with the Network Uniform Resource Locator (URL) that will allow issuers to view the Network on the issuer's website. The issuer should distinguish between tiers when listing cost sharing information in the Plans and Benefits Template, and on the website provider directory listing, which is referenced in the submitted Network URL. 688 2017--00788 If an issuer is offering two different plans, one with a single-tier network and another with a two-tier network, then the issuer should list two separate Network IDs in HIOS and associate each network with the appropriate plan(s). For more information please see QHP Application Instructions at: (REGTAP FAQ Database - FAQ #2952 07/22/14) 024: May Multi-State Plans (MSPs) appear under the same Product ID as a Qualified Health Plan A24: Yes, as long as the products share the same benefits. Issuers participating in the Multi-State Plan (MSP) Program are required to complete a separate template for their MSP options and follow a different submission process. The Centers for Medicare and Medicaid Services (CMS) recommends that issuers contact the Of?ce of Personnel Management (0PM) for guidance. (QHP Certi?cation Process FAQs #1 (09/29/15) Q: Can the Centers for Medicare Medicaid Services (CMS) clarify how Issuers can resolve a scenario where subscribers have multiple Health Insurance Oversight System (HIOS) A: Policy based payment disputes should be submitted for each policy identi?ed as discrepant. If an issuer believes that a subscriber is being reported as enrolled with a speci?c HIOS number erroneously, then a dispute should be submitted to the Enrollment Reconciliation and Resolution contractor at errsupportcenter@coqnosantecom citing the FFM data from either the PPR or HIX 820 and the supporting issuer data as submitted on the RCNI. (REGTAP FAQ Database - FAQ #16507 09/09/16) HIOS Roles Q30: If a user sets up a person in role as backup, can they change that role to primary at a later date? A30: An individual can change their role from Backup to Primary by accessing the Role Management tab in HIOS and making that request. You cannot do it for another person, but they can do it themselves. (QHP Webinar Series FAQ #8 04/23/13) Q31: Will issuers be allowed to have different user enter information into the HIOS system for the QHP certi?cation process or will this just be the existing HIOS users? A31: Each user can determine their user roles and use those roles to either submit or validate (or attest) data. Users can be specifically associated to the QHP module. (QHP Webinar Series FAQ #8 04/23/13) Q32: How does HIOS know a new user has the authority to set up an account and assign users? A32: HIOS works to ascertain that a potential user is associated with the organization that they seek roles for. Additionally, once a user assigns a role to themselves, it will be 689 Updated 1-31-17 2017--00789 associated with the organization and can be checked. (QHP Webinar Series FAQ #8 04/23/13) Q33: Are there restrictions or limitations to who gets access to the system? A33: In order to enter the system, users must go through the EIDM system in the CMS Enterprise portal, and their requested HIOS roles must be approved on the CCIIO side. (QHP Webinar Series FAQ #8 04/23/13) Q34: Can primary and secondary work in the web entry at the same time? A34: It is possible, but not recommended, because the system is not set up to dynamically update, creating the possibility of overwriting data and losing work. (QHP Webinar Series FAQ #8 04/23/13) Q35: Do the HIOS submitter and HIOS validator have to be two unique users? A35: No, they do not. (QHP Webinar Series FAQ #8 04/23/13) Q36: For the EIDM setup, does an adverse credit score disqualify an employee from signup? A36: No. Credit score had no impact. At this time, the credit veri?cation has been suspended. (QHP Webinar Series FAQ #8 04/23/13) Q37: For EIDM, How often is the identify check re-validated? A37: The check is only done once. (QHP Webinar Series FAQ #8 04/23/13) Q38: How does a company change the person who is already set up as the issuer - is there a way to delete and change? A38: Please contact the HIOS help desk in order to delete users. (QHP Webinar Series FAQ #8 04/23/13) Q39: Which user roles can add/edit product information? A39: Submitters for any module can add/edit product information, while validators can do some editing, depending on the module. (QHP Webinar Series FAQ #8 04/23/13) Q40: Is there a deadline for Finder registration for a 1/1/14 coverage effective date? A40: The deadline is essentially the latest date that will still allow an issuer to complete its QHP submission. (QHP Webinar Series FAQ #8 04/23/13) Q41: When an access holder leaves a company, is there a way to remove future access to the HIOS Rx tools on behalf of that company? A41: The user or the company can contact the HIOS help desk and have those roles removed. (QHP Webinar Series FAQ #8 04/23/13) 690 Updated 1-31-17 2017--00790 Q42: On HIOS, the role job-aid mentioned a contractor role. How do issuers assign that role? A42: There are CMS contractor roles not revealed to issuers. Contractors working on behalf of issuers will be assigned issuer roles. (QHP Webinar Series FAQ #8 04/23/13) Q43: How many HIOS users (validators and submitters) can be used per Health Plan or Issuer? A43: There is no restriction on this number. (QHP Webinar Series FAQ #8 04/23/13) Q44: Is there a limit to how many USP user roles an organization may have? A44: There is not a limit to the number of USP users per issuer. (QHP Webinar Series FAQ #8 04/23/13) Q45: If an issuer has identified QHP Submitter and Validator Users that are associated with multiple Issuers, can the issuer set up QHP User Access for multiple Issuers instead of doing one Issuer at a time? A45: This must be done one issuer at a time. (QHP Webinar Series FAQ #8 04/23/13; REGTAP FAQ Database FAQ #2167 06/11/14) Plan Finder/RBIS Q46: Do Issuers only have to submit RBIS information and not plan finder if the issuer does not expect to participate on the exchange A46: Any product that is offered in any state must be entered into the HIOS Plan Finder module, whether on the Exchange or off. If a plan is not offered on the exchange, it must be submitted to RBIS. (QHP Webinar Series FAQ #8 04/23/13) The REG TAP Database has an updated version of this FAQ: Q: Do Issuers only have to submit RBIS information and not plan ?nder if the issuer does not expect to participate on the Marketplace? A: Any product that is offered in any state must be entered into the HIOS Plan Finder module. If a plan is not offered on the Marketplace, it must be submitted to RBIS. (REGTAP FAQ Database - FAQ #2165 06/11/14) Q47: Is the HIOS product entry only for intended exchange products, or for all products issuers currently offer or want to offer in the future? A47: Any product that is offered in any state must be entered into the HIOS Plan Finder module, whether on the Exchange or off. If a plan is not offered on the exchange, it must be submitted to RBIS. (QHP Webinar Series FAQ #8 O4l23/13) A revised version of the FAQ is available on the REGTAP database: 691 Updated 1-31-17 2017--00791 Q: Is the HIOS product entry only for intended Marketplace products, or for all products issuers currently offer or want to offer in the future? A: Any product that is offered in any state must be entered into the HIOS Plan Finder module. If a plan is not offered on the Marketplace, it must be submitted to RBIS. (REGTAP FAQ Database - FAQ #2168 06/11/14) Q48: Does the HIOS information need to be submitted prior to a certain date? A48: HIOS information must be submitted before issuers can begin the QHP application, but there is not a limit outside of the QHP deadline. (QHP Webinar Series FAQ #8 04/23/13) Q49: If an issuer currently files its off exchange rates through SERFF can the issuer continue to do so, or does the issuer have to do it through A49: Issuers are required to submit all off-Exchange plans to RBIS, in addition to any SERFF requirement. (QHP Webinar Series FAQ #8 04/23/13) 050: Will the templates be replacing the current RBIS templates? A50: That is not the plan for the near future. There will be an announcement well before any change to the RBIS template is made. (QHP Webinar Series FAQ #8 04/23/13) Q51: Will QHP submissions ultimately be posted to Healthcare.gov's plan finder tool? A51: The current design is to keep the plans separate for the time being. Comments and suggestions are welcome. (QHP Webinar Series FAQ #8 04/23/13) Registration Q: I am an insurer and want to get plan or product information displayed for consumers on the Plan Finder. What is the process? A: Issuers can access CMS applications, including those for the Plan Finder, through the CMS Enterprise Portal at . Users of CMS applications must complete the Enterprise Portal registration process, which includes identity verification (ID proofing). ID proo?ng veri?es that the individual referenced in the account is the same person creating the account. Once users have completed the registration process and have an account, they will go to the CMS Enterprise Portal and access CMS systems. You will use the Health Insurance Oversight System (HIOS) to provide insurance company and product information, such as the issuer names, addresses, contact information, and product level data. You will enter cost-sharing and bene?t information in a separate tool?the Rate and Bene?ts Information System (RBIS), which is accessed using the HIOS system and has the same user ID and password as HIOS. Information you enter into RBIS will appear on the Plan Finder for consumers to review and compare with other plans and products. (CMS FAQs Plan Finder Data Entry - 01/28/15) 692 Updated 1-31-17 2017--00792 Q: I understand that I also need an Issuer What is an Issuer A: CMS has defined a structure of identi?ers to be associated with issuer data submissions required under the ACA. Issuers represent the organization within an insurance company that is responsible for insurance offerings within a given state. Insurance companies may use different staff or the same staff, but any health insurance company will have one issuer per state in which they are licensed to do business. Registering an entity as an Issuer within HIOS will generate the unique Issuer ID. Once in HIOS, you will request one or more ?user roles,? such as primary data submitter for small group market. The HIOS User Manual provides technical guidance on user management. (CMS FAQs Plan Finder Data Entry - 01/28/15) Q: When may I enter information into HIOS or A: You may log into HIOS and RBIS at any time except for when they are closed every 10 weeks for a three-week maintenance and enhancement period. These dates are communicated to issuers via weekly calls and memos. (CMS FAQs Plan Finder Data Entry - 01/28/15) Q: What mechanisms are supported for data submissions? A: There are three available mechanisms for the issuers to submit their data: Microsoft Excel templates, XSD template for XML submissions and web-entry forms. The HIOS application works within any of the following compatible Internet browsers: 1) Internet Explorer (version 7 or higher) 2) Mozilla FireFox (version 5 or higher) 3) Chrome (version 9.0 or higher) (CMS FAQs Plan Finder Data Entry - 01/28/15) Q: Can multiple issuers be in a single ZIP or pipe-delimited file (up to 30 A: Yes. (CMS FAQS Plan Finder Data Entry - 01/28/15) Q: Can the same person upload and validate the data? A: Yes. (CMS FAQs Plan Finder Data Entry - 01/28/15) Product and Plan Level Information Q: What is the difference between a product and a plan as defined in the Plan Finder? Updated 1-31-17 A: A health insurance product is de?ned as a package of bene?ts an issuer offers that is reported to State regulators in an insurance filing or the sets of bene?ts which are associated with various versions of cost sharing, such as deductibles, co-payments etc. In most states, issuers submit forms identifying the sets of bene?ts being approved for sale. A block of business which is sold under that form ?ling is referred to as an insurance ?product.? The identi?er for an insurance product sold in a State is the Product ID and it 693 2017--00793 is generated upon submission to HIOS. Plans are a speci?c combination of bene?ts, cost sharing and premium that are offered to consumers. You enter cost-sharing and benefit information in RBIS, which is accessed using the HIOS system. Information you enter into RBIS will appear on the Plan Finder for consumers to review and compare with other plans and products. Each plan entered in RBIS must match to a product record in HIOS. The product ID. and the issuer combine with information at the plan level to create a unique identi?er called the Standard Component which maps the combination of speci?c benefits and cost sharing arrangements sold for a speci?c price. (Prior to Feb. 2013, this unique standard component ID was called a ?Plan Finder (CMS FAQs Plan Finder Data Entry - 01/28/15) HIOS Data Submissions Q: What products should I enter into A: All products, whether they are opened or closed for enrollment, should be entered into HIOS. A product not yet approved by your State DOI may be entered into HIOS but must be marked ?closed? until it is approved. The data requirement is for ?major medical? products and plans. Examples of basic health services include physician services, inpatient and outpatient hospital services, medically necessary emergency health services, medical treatment and referral services, diagnostic laboratory and diagnostic and therapeutic radiological services, home health services, and preventive health services. The data requirement does not cover supplemental health insurance products. (CMS FAQs Plan Finder Data Entry - 01/28/15) Q: How is product enrollment defined? A: Enrollment is defined as ?number of people covered to obtain total membership.? For example, if a product is sold to 1 person, but it covers that person and their spouse, enrollment equals 2, not 1. (CMS FAQS Plan Finder Data Entry - 01/28/15) Q: What is the definition of ?effective date? and ?expiration date?? A: Effective start date refers to the ?rst day on which an issuer offers a product to the public. Consequently, the effective end date is the last day on which an issuer offers a product to the public. (CMS FAQs Plan Finder Data Entry - 01/28/15) Q: Our state operates with a small group definition which differs from that proposed by the Affordable Care Act. How do we report the data? A: You should report data to the Plan Finder based on the state law and definitions applicable at that time. (CMS FAQs Plan Finder Data Entry - 01/28/15) 694 Updated 1-31-17 2017--00794 Q: When I enter the tools, it asks for my SERFF number? What is a SERFF number and do I have to have one to use the system? A: The NAIC maintains a reporting service called SERFF which is used by most states and required by 27 states to track submissions from insurance carriers to state DOI commissioners. If your state does not require participation in SERFF, you are not required to obtain a SERFF number. If you have a product that is associated with a SERFF number, you are required to enter it in HIOS. Although the data collection tool shows the SERFF ?eld as ?optional? since many states do not use this system, all existing numbers must be reported. (CMS FAQs Plan Finder Data Entry - 01/28/15) Q: My company offers the in-network piece of a POS product, but the out-of-network is filed under a separate NAIC code. Should both companies enter these products? A: We want to show consumers their range of meaningful choices. 80 this should be represented as one choice and different products. For products which are exclusively parts of PCS-combined services, identify the product type as POS, but enter either ?in- network? or ?out-of-network? in the ?Type Other" field. (CMS FA 08 Plan Finder Data Entry - 01/28/15) Q: If a product is open for enrollment but enrollment is very small, may we mark it as ?closed? in A: No. As the documentation notes, this field is intended to differentiate between products closed for enrollment and products that are open for new enrollment. (CMS FAQs Plan Finder Data Entry - 01/28/15) Q: We have a product line which we are authorized to sell but has never been offered and does not have any enrollment. Do we need to report on this product? A: You have the discretion to report or not report such products to HIOS. (CMS FAQs Plan Finder Data Entry - 01/28/15) Q: How do we report enrollment numbers in A: For products reported in HIOS, you are required to report enrollment where it is offered (sometimes called the ?situs" level), such as the location of a business offering its employees small group coverage. If you do not collect at the situs level, you may report enrollment by membership residence. For products reported in HIOS, enrollment numbers represent the total number of covered lives in that product. Enrollment numbers for HIOS should be reported as of the last date of the previous quarter. (CMS FAQs Plan Finder Data Entry - 01/28/15) Q: Are we required to report formulary and provider network URLs into A: If a provider network and/or formulary list is used to set the base price for your product, then you must report these networks in HIOS in the form of URLs so that consumers may access this information. (CMS FAQs - Plan Finder Data Entry - 01/28/15) 695 Updated 1-31-17 2017--00795 Q: Why do I have to report closed blocks that are not accepting new members? A: You are required to provide information on major medical products in HIOS for which you are licensed to sell in the individual and small group market. CCIIO is including this data to make sure we have a complete picture and are adequately representing the market. For example, because many people are enrolled in closed blocks, it helps account for higher enrollment numbers if you have a significantly smaller number of plans. In addition, a closed block might be reopened in some states. Closed products will not be displayed online at this point, but we are exploring displaying them in the future if consumers would benefit from comparing open and closed products without introducing a new element of confusion. You are not required to report Finder products that are closed to enrollment into RBIS. (CMS FAQs Plan Finder Data Entry - 01/28/15) Q: Do the brochure, formulary and provider network URLs that are entered into HIOS have to be compliant with federal standards for accessibility (508 compliant)? A: Materials posted on the Plan Finder that can be directly accessed by the public must meet federal accessibility standards. We encourage you to make your data accessible to all users, however, the section 508 law does not apply to private ?rms which do not receive federal funding and does not extend to links on the Plan Finder to items hosted by your own website. (CMS FAQs Plan Finder Data Entry - 01/28/15) RBIS Data Submissions Q: What products or plans should I enter into A: You should only enter plans or products in RBIS that are for sale to the general public and approved by your State DOI. In order to conform to the 2014 Market Rules, all issuers in all States must submit to RBIS if they offer Individual or Small Group plans. In order to provide issuers with uniform data collection tools, currently, the RBIS data collection utilizes the 2015 QHP Plans and Bene?ts, Business Rules, Rating and Service Area Templates. (CMS FAQs Plan Finder Data Entry - 01/28/15) Q: We do not actively market individual plans, but we are required to have a 30-day open enrollment period each year to let anyone into our individual plan. How do we list this type of plan? Do we mark it as ?closed? most of the year and then ?open? during open enrollment period? A: Please mark it as open" when it is open for new enrollment and ?closed" when it is not open for enrollment. (CMS FAQs Plan Finder Data Ently - 01/28/15) 696 Updated 1-31-17 2017--00796 Q: Why do I enter plan level information into RBIS for the individual and family market and product level information for the small group market? A: Consumers seeking information about their insurance options for themselves and their families (the individual insurance marketplace) benefit from reviewing the range of benefits and cost-sharing information at the plan level. However, in the small group market, small employers are more likely to offer one insurance product and allow their employees to choose among various cost-sharing options within that product. As a result, for the small group market, insurers enter product level data that shows the set of available deductibles, co-pay amounts, and coinsurance ranges which apply to each product. (CMS FAQs Plan Finder Data Entry - 01/28/15) Q: I understand that if I submit my plans into RBIS, I may be deemed compliant with the electronic pre-notification requirements of the Summary of Benefits and Coverage (SBC) provisions. How do issuers enter their information for the A: The individual/family market RBIS benefits template has ?elds, including coverage examples information for both maternity and diabetes. The data ?elds are used to populate a PDF version of the SBC with plan information for consumers to download. You do not have to upload the Uniform Benefit Glossary to be deemed compliant with SBC requirements on HealthCare.gov. The PDF includes a link to the Uniform Bene?t Glossary. (CMS FAQs Plan Finder Data Entry - 01/28/15) Q: In the small group market, are services that have specific limitations or exclusions as part of the broader service category still considered ?covered?? Will there be a disclaimer indicating that limitations and exclusions may apply? A: Under the circumstance, issuers should choose ?covered with limitations,? if these limits are outside the generally identi?ed limitations. (CMS FAQs Plan Finder Data Entry - 01/28/15) Q: For the small group market, are we expected to submit all States on one benefit template or separate templates for each issuer A: You may do either one. (CMS FAQs Plan Finder Data Entry - 01/28/15) Q: For ancillary services like dental and vision/eye exams, should we answer in terms of what is a part of our certi?cate and if those services are a rider to the actual medical plan? A: You should answer on the basis of the certificate of coverage. If the riders were free to enrollees and applied to all enrollees, then they should be included as covered. However, if they are separate and premium amounts are involved, then the appropriate response would be ?covered at extra cost." (CMS FA 03 Plan Finder Data Entry - 01/28/15) 697 Updated 1-31-17 2017--00797 Q: How do we enter small group products that bundle medical and pharmacy coverage? Are we expected to remove the pharmacy portion of the premium? A: If the products are bundled and there is no separate pharmacy premium, then the pharmacy portion of the premium should not be removed from Total Written Premium. (CMS FAQs Plan Finder Data Entry - 01/28/15) Plans with Limited or Private Enrollment Q: Do I need to enter self-funded Multiple Employer Welfare Arrangements A: If your MEWAs are regulated by your state insurance department and they offer individual and small group products, we require that a row be entered for the product in HIOS. Identify the type by the drop down box as HMO, PPO, etc. as it applies. Please mark the product as ?Association? in the appropriate ?eld, and identify whether it is open or closed for new enrollment. (CMS FAQs Plan Finder Data Entry - 01/28/15) Q: I have a product which is only offered to members of a specific association (like the Lion?s Club or AARP) in my state. How do I enter these? A: Enter a row for the product, identify the type by the drop down box as HMO, PPO, etc. as it applies. In the ?Association? field, choose option ?Yes." Also mark whether the product is open or closed for new enrollment. Currently, we are not displaying Association products online. (CMS FAQs Plan Finder Data Entry - 01/28/15) Q: I have products that are only available to limited populations, such as professional associations, cooperatives, etc. Do those need to be reported? A: Yes. All major medical products approved for sale in the individual and small group markets are to be reported in HIOS. If a product has plans offered to both the general public and associations, please treat it as you would any other general issuance product. If all the plans under this product are sold only to associations, cooperatives, etc, then you can indicate this by choosing option ?Yes? in the ?Association" field in HIOS. (CMS FAQs Plan Finder Data Entry - 01/28/15) Q: How should issuers enter a product that contains a mix of association and non- association plans? A: Issuers should split this product into two separate products: one that contains all of the association plans and one that contains all of the non-association plans. Issuers must mark ?Yes? in the association field for the product that contains all of its association plans, and ?No? in the association ?eld for the product that contains all of its non- association plans. Only the non-association products marked as open will be displayed on HealthCare.gov. (CMS FAQs Plan Finder Data Entry - 01/28/15) Q: How should issuers enter association products that contain several plan types PPO, A: Issuers with an association product that contains several plan types should mark the predominant type in the ?product type" ?eld. (CMS FAQs Plan Finder Data Entry - 01/28/15) 698 Updated 1-31-17 2017--00798 Q: How should an issuer treat an association product in HIOS that is sold to individuals, small groups, and large groups? A: Under the current Plan Finder reporting requirements issuers must label an association product with a mix of small group and individual business as a small group product. Issuers should not report on large group products (the Plan Finder template only allows issuers to label a product as individual or small group). An association product with a mix of individual, small group and large group business should be entered into Plan Finder as a small group product. As appropriate, the issuer should exclude the large group segment of the product in its Plan Finder reporting. Similarly, the rate review reporting requirements only applies to the individual and small group segments of the product. (CMS FAQs Plan Finder Data Entry - 01/28/15) Q: Do issuers have to complete all of the ?elds in the Plan Finder template for association products? A: Yes, issuers must complete all ?elds. Please note that CCIIO is not collecting or displaying number of applications, denials, or up-rates for the Small Group market at this time or planning to use or display it in the known future. Therefore, for Small Group submissions, issuers should enter zero for those three columns. However, issuers must report enrollment for each small group product. (CMS FAQs Plan Finder Data Entry - 01/28/15) Q: Do we need to report on Medicare supplements, Medigap policies, accident insurance, single condition coverage, short term or other limited benefit insurance? A: No. Plan Finder data collections are aimed at gathering comprehensive major medical health insurance only. (CMS FAQs Plan Finder Data Entry - 01/28/15) Pricing and Benefits Information Q: How are ?base rates? construed for this data collection for the individual market? A: Base rates for HIOS are being represented as estimates which may change during the underwriting process when health status and pre-existing conditions are factored in. The base rate is the lowest rate before medical underwriting for a person within demographic categories. The base rate should include the cost of coverage for items that are covered or covered with limitations. If an item is not covered or covered for an additional premium, that information should not be included in the base rate for a plan. (CMS FAQS Plan Finder Data Entry - 01/28/15) Q: What is the Average Cost Per Enrollee for the small group market? A: For the small group market, issuers use HIOS to report the number of reported covered lives. Our data tools then calculate the per-person cost for the product, which is displayed on HealthCare.gov. (CMS FAQs Plan Finder Data Entry - 01/28/15) 699 Updated 1-31-17 2017--00799 Q: Will total written premium be displayed on HealthCare.gov for the small group market? A: Total written premium will not be displayed on HealthCare.gov. Total written premium is being collected to calculate the average cost per enrollee, which will be displayed within the HealthCare.gov Plan Finder, corresponding to each small group product represented. The average cost per enrollee is based on one-third of the quarterly premium divided by the enrollment number. Issuers should report the enrollment as of the last day of the reported quarter into HIOS as well as the total written premium during the reporting quarter into RBIS. (CMS FAQs Plan Finder Data Entry - 01/28/15) Q: How do I decide whether to consider a category ?covered? or ?covered with limitations?? A: Reporting for HealthCare.gov should be conducted in accordance with reporting standards for the Summary of Bene?ts and Coverage requirements which emerge from section 2715 of the ACA. In general, issuers should report in a manner which represents the predominant business practices associated with that product. General definitions have been provided in Section 17 of the Users? Handbook available on the CCIIO website. Any item that is listed as covered or covered with limitations should be included in the written premium for a speci?c product. If an item is not covered or covered for an additional premium, that information should not be included in the total written premium. (CMS FAQs Plan Finder Data Entry - 01/28/15) Q: Should the premium data only include medical in A: No. If a separate product is sometimes bundled, but exists as a separate product, the premium amounts associated with that other product should not be reported. (CMS FAQs Plan Finder Data Entry - 01/28/15) Q: How do we report a product whose deductible or out-of-pocket limit is a combination of in-network and out-of-network? A: Issuers that offer products with a combined in-network and out-of?network deductible should put the combined value in the in-network deductible ?eld as well as the out-of- network deductible ?eld. Issuers should also put the appropriate duplicate value into the two ?elds for the in-network and out-of?network out-of?pocket limit. (CMS FAQs Plan Finder Data Entry - 01/28/15) Q: How does an issuer indicate that they do not cover out-of-network deductible, co-pay, and/or co-insurance? A: If an issuer does not cover any of the out-of-network ?elds (deductible, co-pay, and co-insurance) they should mark ?None? in that field. If an enrollee is not required to pay a deductible, co-pay, or co-insurance, the issuer should enter into the corresponding ?elds. (CMS FAQs Plan Finder Data Entry - 01/28/15) Q: How should an issuer enter percent co-pay for a PCP visit in Updated 1-31-17 A: If a product has a ?xed co-pay for a PCP visit, an issuer should input that value in the PCP Co-pay ?eld. If there is a percentage that an enrollee must pay for a PCP visit, than 700 2017--00800 an issuer should enter that percentage into the co-insurance ?eld. (CMS FAQs Plan Finder Data Entry - 01/28/15) Q: How should an issuer report indemnity values for out-of-network fields? A: Issuers should enter the same value for in-network and out-of-network fields for indemnity products. For example, the co-pay value should be entered the same in both the in-network and out-of?network ?elds. (CMS FAQs - Plan Finder Data Entry - 01/28/15) Q: If we need to list all deductibles, out-of-pockets, and office visit copays in one cell, are we required to specify the limit for the small group products we submit in For example, a $1000 deductible is available only with $5000 out-of-pocket maximum. 90/80 coinsurance is available only with a $6000 deductible. If yes, what is the format? A: Issuers are not required to identify the speci?c combinations. List all values for each field and submit a range. (CMS FAQs Plan Finder Data Entry - 01/28/15) Q: Do issuers need to enter all deductibles options for a product into A: It is our expectation that issuers report every deductible option for a product. If an issuer has more than 50 different deductible options for a particular product, the issuer should enter the minimum and maximum deductible along with 48 deductible options in increments between the maximum and minimum deductibles. This is the only case in which issuers would not enter all of their deductible options for a product. Please note that here is a character string length limit of 256 for this field. (CMS FAQs Plan Finder Data Entry - 01/28/15) Q: If product categories in HIOS are grouped in a broad sense including PPO plans currently being marketed on the street for new business along with older PPO policies which groups can renew upon but aren't available to new business), do issuers only input into RBIS the benefit specifics on the actively marketed plans? A: Issuers should input all bene?t information for actively marketed small group products into RBIS. Issuers should be cautious, however, to enter the full written premium, representing every covered life reported in the enrollment for a product (including any open and closed plans within a product). (CMS FAQs Plan Finder Data Entry - 01/28/15) Q: What level should issuers report deductibles and out-of-pocket maximums in A: Deductibles and out of pocket maximums should be reported on the individual level, not the family level. (CMS FAQs Plan Finder Data Entry - 01/28/15) Entering Information on Riders Q: How should riders be entered into RBIS for the small group market? A: Riders should not be reported in the HIOS product level information. When additional riders are available, the coverage options should be marked as ?available at an 701 Updated 1-31-17 2017--00801 additional cost.? The collected rider premiums should not be reported. (CMS FAQs Plan Finder Data Entry - 01/28/15) Data Discrepancies and Corrections Q: Can you provide additional information on how data discrepancies are veri?ed or corrected? A: Issuers should review their data in HIOS. If an issuer has identified a data discrepancy between their submitted file and the data displayed in the system, they should contact the HIOS Help Desk. The Help Desk will create a ticket and investigate the root cause of the discrepancy. If the issue is caused by the data submission, the Help Desk will request that the issuer correct their ?le and resubmit. If the issue is caused by the system, we will be responsible for correcting the issue. (CMS FAQs Plan Finder Data Entry - 01/28/15) Q: Can errors in HIOS be corrected without having to resubmit the entire data file? A: It depends on the nature of the issue. If the error has occurred because of a problem in the issuer's data ?le, then the entire data ?le must be resubmitted. If the error has occurred because of a defect in our system, we will correct the issue without requiring a revised file submission. Users should contact the Exchange Operations Support Center XOSC) Help Desk at 1-855-CMS-1515 (855-267-1515) or CMS FEPS@cms.hhs.qov if they have questions about a particular error. (CMS FAQs Plan Finder Data Entry - 01/28/15) Q: How does CCIIO ensure that the Plan Finder is consistent with the information provided on states' websites? A: The Plan Finder links directly to state Medicaid, CHIP and high risk pool web pages. HealthCare.gov also links to nsureKidsNow.gov for CHIP information. In addition, CMS CMSO works with states to review the information that CMS CMSO is pulling from federal records about Medicaid and CHIP. We work with NASCHIP to collect and verify information in cooperation with affected states on the high risk pools. Information on major medical products and plans sold in the individual and small group markets is verified by Issuers who provide the information, and this information is also made available to states if they decide to verify what Issuers report to us. We welcome feedback from states on these fronts. (CMS FAQs Plan Finder Data Entry - 01/28/15) Attestation Requirements Q: When I enter plans in the RBIS, it says they need attestation by the CEO or CFO. What does this refer to? Updated 1-31-17 A: Your company?s CEO or CFO (but not both) must attest to the accuracy and to the completeness of your data. The CEO and CFO are the only individuals allowed to attest to a company?s data. If the is unable to attest for a given reason, a delegate for the an 702 2017--00802 individual who is designated as a stand-in for other business purposes), may attest to the data. Consequently, there should be no alternate designated to attest to a company?s data on a permanent basis. The attestation language now reads: By selecting agree in my capacity as CEO or CFO that I have examined the small group product submission to the best of my information and knowledge, and I believe it accurately represents the bene?t and cost sharing information of the reported products based on current temp/ate parameters. The attestation applies to an issuer?s submission including information submitted for the 1103 requirement associated with HealthCare.gov. They are not attesting as to any additional information regarding rate review filings. (CMS FAQs Plan Finder Data Entry - 01/28/15) Q: When does the CEO or CFO have to attest to my data? A: Whenever you make updates during a data submission window. (CMS FAQs Plan Finder Data Entry - 01/28/15) Additional Questions Q: Who may I contact if I have a question not answered in the A: To obtain answers about technical questions related to the HIOS System, contact the XOSC Help Desk at 1- 855-CMS-1515 (855-267-1515) or CMS FEPS@cms.hhs.qov. For policy questions regarding the HealthCare.gov Plan Finder, please email CCIlOPIanFinder@cms.hhs.qov. (CMS FAQs Plan Finder Data Entry - 01/28/15) HPID 054: Are QHPs required to get a Health Plan Identifier A54: HPIDs are not required for certi?cation of QHPs. (QHP Webinar Series FAQ #12 06/28/13) 055: Will the "Associated field within the Administrative Data Elements section be a required field? A55: It is not currently a required ?eld. Issuers may need to provide this identifier at a later date. (QHP Webinar Series FAQ #12 06/28/13) 056: How can issuers receive information about our A56: Now that the HPOES Module is open in HIOS, an issuer can enter the module to request an HPID. An issuer will receive an HPID when the process is completed. (QHP Webinar Series FAQ #12 06/28/13) 703 Updated 1-31-17 2017--00803 Q: Will the Health Plan Identifier (HPID) number be used in the Reinsurance Contribution submission process for?the?20458ene?t??(ea? A: Applicable to All Reinsurance Contributions Benefit Years: No. The HPID is not needed for the submission of Annual Enrollment Counts and/or contributions for the reinsurance program. A Contributing Entity or Reporting Entity can complete all required steps for the reinsurance contributions process on Pay. gov. HPID is used In a separate Center for Medicare Medicaid Services (CMS) program and (REGTAP FAQ Database- FAQ #2657a 07/07/14, updated 09/21/15 and 09/21/16) Note: REGTAP indicates that the original FAQ was issued on 07/07/14, but the underlying FAQ was not reported/found for the original date of issue. SERFF Q27: How does the plan information get into HIOS for HHS to review once the issuer submits through the SERFF system? Will the SPE QHPs submitted by the issuer to SERFF be automatically transferred to HIOS, or will we need to submit them to HIOS as well? A27: In States in which an SPE is operating, transfer of the issuer?s QHP application data from SERFF to HIOS will take place after the State has reviewed the applications. The State will select recommended plans and then initiate the transfer of recommended data to HIOS. (Plan Management Webinar QHP FAQ #1 04/08/13) Q45: After issuers in State partnership States complete their application in SERFF, what further steps are required? A45: States will communicate with issuers about the status of their applications once completed in SERFF. (Plan Management Webinar QHP FAQ #3 04/11/13) 027: Is Limited Cost Sharing Plan Variation - Estimated Advanced Payment truly an optional ?eld? A27: Leaving column Q, "Limited Cost Sharing Plan Variation Estimated Advanced Payment" blank indicates that the issuer does not request advance payments for the value of cost-sharing reductions provided under the limited cost sharing plan variation for the QHP associated with the bene?t template. As indicated in the HHS Notice of Bene?t and Payment Parameters (available at: QHP issuers may, but are not required to, estimate the value of cost-sharing reductions that they will provide through their limited cost sharing plan variation if they wish to receive advance payments from HHS. Issuers that choose not to submit such estimates by leaving column blank must still provide the cost-sharing reductions to enrollees in the limited cost sharing plan variation, and will be reimbursed 704 Updated 1-31-17 2017--00804 by HHS at the close of the bene?t year. More information on issuer options with respect to such estimates is included on page 15495 at the link above. (QHP Webinar Series FAQ #5 04/18/13) 028: Under the Copay and Coinsurance sections, we actually need options for both ?not applicable? and ?not covered." Being able to specify a benefit as not covered is consistent with what we do for SBC, and is more communicative to a consumer. A28: If a bene?t is not covered, the value for Is This Benefit Covered? On the benefits package worksheet should be Not Covered. Only covered benefits copy to the Cost Share Variance worksheet. If a bene?t is covered in-network only, enter 100% for Out Of Network Coinsurance. (QHP Webinar Series FAQ #5 04/18/13) 059: We just submitted our state filing and the rates template was too large to upload into SERFF. SERFF has a maximum file size of 3 MB. The XML version is difficult for the state to read, so unless they know how to translate it, they will be confused. A59: After the .xml ?le is uploaded, the system validates the ?le, then returns an Excel version of the data. This is available to submitters and reviewers. Additionally, SERFF has increased its maximum ?le size. (QHP Webinar Series FAQ #5 04/18/13) Q: For an issuer in an FFM, whose state is using SERFF to review form filings, should issuers complete HIOS or SERFF uploads first? A: As long as FFM deadlines are met, the order does not matter. However, if the state is the primary reviewer, CMS would generally expect the issuer to submit to the state first. (REGTAP FAQ Database - FAQ #2123 06/11/14) QHP PROCESS General 14. Can a state-based Exchange certify a Medicaid bridge plan as a qualified health plan? A: Yes. HHS has received questions about whether a state could allow an issuer that contracts with a state Medicaid agency as a Medicaid managed care organization to offer quali?ed health plans in the Exchange on a limited-enrollment basis to certain populations. This type of limited offering would permit the qualified health plan to serve as a ?bridge" plan between Medicaid/CHIP coverage and private insurance. This would allow individuals transitioning from Medicaid or CHIP coverage to the Exchange to stay with the same issuer and provider network, and for family members to be covered by a single issuer with the same provider network. This approach is intended to promote continuity of coverage between Medicaid or CHIP and the Exchange. In general, an Exchange may allow an issuer with a state Medicaid managed care organization contract to offer a qualified health plan as a Medicaid bridge plan under the following terms: 0 The state must ensure that the health insurance issuer complies with applicable laws, and in particular with section 2702 of the Public Health Service Act. Consistent with section 2702(c) of the Public Health Service Act, a health plan whose provider 705 Updated 1-31-17 2017--00805 network reaches capacity may deny new enrollment generally while continuing to permit limited enrollment of certain individuals in order to fulfill obligations to existing group contract holders and enrollees. Therefore, if the issuer demonstrates that the provider network serving the Medicaid managed care organization and bridge plan has sufficient capacity only to provide adequate services to bridge plan eligible individuals and existing Medicaid and/or CHIP eligible enrollees, the bridge plan could generally be closed to other new enrollment. However, in order to permit additional enrollment to be limited to bridge plan eligible individuals, the state must ensure there is a legally binding contractual obligation in place requiring the Medicaid managed care organization issuer to provide such coverage to these individuals. We note that any such contract would need to have provisions to prevent cost-shifting from the non-Medicaid/CHIP population to the Medicaid/CHIP population. We also note that the guaranteed availability provision of section 2702 of the Public Health Service Act is an important protection that provides consumer access to the individual and small group markets. Accordingly, we plan to construe narrowly the network capacity exception to the general guaranteed issue requirement. . The Exchange must ensure that a bridge plan offered by a Medicaid managed care organization meets the qualified health plan certification requirements, and that having the Medicaid managed care organization offer the bridge plan is in the interest of consumers. . As part of considering whether to certify a bridge plan as a qualified health plan, the Exchange must ensure that bridge plan eligible individuals are not disadvantaged in terms of the buying power of their advance payments of premium tax credits. 0 The Exchange must accurately identify bridge plan eligible consumers, and convey to the consumer his or her quali?ed health plan coverage options. - The Exchange must provide information on bridge plan eligible individuals to the federal government, as it will for any other individuals who are eligible for qualified health plans on the Exchange, to support the administration of advance payments of premium tax credits. This will be done using the same mechanism that will be in place for the larger Exchange population Successful implementation of a Medicaid bridge plan will involve a high degree of coordination between the state Medicaid agency, department of insurance and the Exchange. States operating State-Based Exchanges will be best positioned to achieve the level of coordination needed to implement and support the offering of a Medicaid bridge plan on an Exchange. Additional guidance will be issued soon. (FAQs on Exchanges, Market Reforms, and Medicaid (12/10/12)) Q3: What are the QHP certification submission window dates? Is this different for the Federally-facilitated Exchanges (FFEs) and State Partnership Exchanges Updated 1-31-17 A3: We expect that the QHP Application window in the FFE will be April 1-30, 2013. All parts of the applications are due at that time. In the SPE, the State will de?ne the timeline for application submission. For more information on this, please reference chapter two of the draft issuer letter. (Plan Management Webinar QHP FAQ #1 04/08/13) 706 2017--00806 Q4: What data elements will be part of the certi?cation process? In an earlier call, HHS indicated that there are elements that will not be part of the certification and can be adjusted. For example, the network URL could be changed within the templates and not have an impact, because it was not an element that was under final approval. A4: All QHP Application final data elements and definitions can be viewed in the QHP Certification PRA package, OMB Control Number 0938-1187, available at nbr=201303-0938-004. The specific part of the certi?cation process that this question speaks to is Plan Preview, scheduled for late August. Issuers will only be allowed to submit corrections to inaccurate data once they a) contact the FFE with the data inaccuracy concern and b) receive confirmation that they are allowed to resubmit the data. Only data that does not cause a "re-review" of the application, such as the network URL, will be eligible for correction. (Plan Management Webinar QHP FAQ #1 04/08/13) Q1: If an issuer?s product is not approved as a QHP for January 2014, is there an opportunity to seek approval for January 1 of subsequent years? A1: Yes, we anticipate that issuers will have the opportunity to apply for QHP certification in future years. (Plan Management Webinar QHP FAQ #2 04/09/13) This FAQ was revised and reissued as REGTAP FA on 03/31/14, as follows: Q: If an Issuer's product is not approved as a QHP for January 2015, is there an opportunity to seek approval for January 1 of subsequent years? A: Yes, Issuers not quali?ed for the 2015 plan year will have the opportunity to apply for QHP certi?cation the following year for the 2016 plan year. (REG TAP FAQ Database - FAQ #1356 03/31/14) Q3: Will there be a way to withdraw plans from the QHP certification process after the window closes but before open enrollment? A3: Issuers will be provided a chance to withdraw QHPs that HHS has determined as qualified for certification. The withdrawal request will be made to HHS during a speci?c timeframe and must be assessed in order to guarantee the issuer offers all required QHPs given the change/withdrawal. (Plan Management Webinar QHP FAQ #2 04/09/13 and REGTAP FAQ Database - FAQ #2124 06/11/14) Q4: How will the Exchange display plans? Should issuers include the plan type in each plan name? A4: The exchange will identify the plan as Issuer Marketing Name, Plan Marketing Name, and Plan type so including plan type in marketing name would be duplicative. (Plan Management Webinar QHP FAQ #2 04/09/13) 707 Updated 1-31-17 2017--00807 Q5: Can issuers submit plans without State Department of Insurance approval? If yes, will there be a process to make changes after the window closes? A5: QHP issuers can submit plans that are not yet approved by the State regulatory entity. During application submission, an issuer attests that it will have a license by the end of the certi?cation period, be in good standing, and be authorized to offer each speci?c type of insurance coverage offered in each State in which the issuer offers a QHP. The issuer must submit evidence of licensure by the end of the resubmission window. At the time of certi?cation, the QHP issuer must agree that it is in compliance with all State laws and statutes related to its QHP plans in the State in which QHP plans are being offered, including that the forms for the QHPs it will offer have been approved or deemed by the State (as applicable in that State), and agree to notify HHS if in the future it is not compliance. (Plan Management Webinar QHP FAQ #2 04/09/13) Q1: Will there be an opportunity to update the URL for provider networks after the initial application period? A1: As included in the Letter to Issuers (Table 2.1 Key Dates), issuers will have the opportunity to review data during the plan preview period and submit data corrections (this is tentatively scheduled from August 22 ?August 26). URL updates/corrections can be made at that time. The Letter to Issuers can be found at letter to issuers 04052013.pdf (Plan Management Webinar QHP FAQ #3 04/11/13) 02: At what level does the organizational chart need to be submitted? A2: This data needs to be submitted at the issuer applicant level. (Plan Management Webinar QHP FAQ #3 04/11/13) Q3: What should issuers fill in for a Network ID, Service Area ID, and Formulary A3: Network IDs, Service area IDs, and Formulary IDs are internal system generated IDs. In each template you have the ability to generate these IDs. You must assign networks the same numbers as those assigned in the Network ID and Bene?t templates. (Plan Management Webinar QHP FAQ #3 04/11/13) Q4: Do the sections of the application have to be completed in order? A4: No, the sections may be completed in any order. (Plan Management Webinar QHP FAQ #3 04/11/13) Q57: When will the draft QHP Agreement be available for issuers to review? A57: The draft QHP Agreement is expected to be released mid-summer. (QHP Webinar Series FAQ #4 04/16/13) Q42: Do issuers have to file separate child-only policies for all of the QHP applications? A42: Provided that child enrollees would be treated equally under the QHP as they would be under a child-only plan -- such that there would be no substantive difference between having a child-only plan and issuing child-only policies under the QHP 708 Updated 1-31-17 2017--00808 same enrollment opportunities, same premium rating, etc.) the issuer would not need to file a separate child-only plan. Separate child-only plans are not required for the Federally-facilitated Exchange (FFE) as long as the QHP indicates it will accept child- only enrollees. In the FF-SHOP, children may only be added to an employee policy if the employee also enrolls. There may be instances when employees under the age of 21 enroll in an employee-only plan. In this instance, this would be considered child-only coverage. (QHP Webinar Series FAQ #4 04/16/13; REGTAP FAQ Database - FAQ #164 04/16/13) A revised version of this FAQ added to the REG TAP database on 06/11/14 as FAQ #2172 -- dropped the bolded language above. CMS removed this FAQ from the REG TAP database on 08/26/14 058: Can an issuer request that a plan be certi?ed and not placed on the Exchange? A58: All "certi?ed" plans will be placed on the Exchange. An issuer can withdraw the plan before ?nal certi?cation by contacting the Helpdesk before signing the agreement. (QHP Webinar Series FAQ #4 04/16/13) Q59: When will there be dedicated content support for questions as issuers go through the QHP application process? A59: The of?cial Account Manager role is not yet available. The Helpdesk is the best mechanism to direct a question to the right expert. There will be more FAQ calls and open calls. The QHP Application Support and series is scheduled on Thursdays during the month of April. The HIOS calls will also respond to QHP questions on Wednesdays. As questions are coming into the Helpdesk, or submitted via REGTAP and the associations, FAQ will be compiled. (QHP Webinar Series FAQ #4 04/16/13) 060: How will issuers be able to confirm that their data will display correctly? A60: Testing will be similar to the Plan Finder post-submission testing and validation; essentially, issuers will have the opportunity to run rate quotes to check that business rules are functioning properly. As noted in the Letter to Issuers on Federally facilitated and State Partnership Exchanges in Chapter 2 letter to issuers 04052013.pdf), there will be a resubmission window in June to address de?ciencies. There will be a Plan Preview period in late August to run and check the rates. Issuers that identify a problem can contact the Helpdesk. If the issue identi?ed does not trigger re-review of the QHP application, issuers will be allowed to resubmit. Issuers in the FFE will conduct that resubmission through issuers in the State Partnership Exchange (SPE) will conduct that resubmission through the System for Electronic Rate and Form Filing (SERFF) and SERFF will transmit that change into HIOS. (QHP Webinar Series FAQ #4 04/16/13) Q18: The released on April 8, ?Plan Management Webinar Frequently Asked Questions, Frequently Asked Questions (FAQ) 1? include information (Q4) about flexibility for changing URLs during plan preview. How will issuers submit corrections to inaccurate data? What con?rmation is required that a change will be allowed? Updated 1-31-17 A18: Changes to network URLs or plan marketing name are not criteria for certi?cation and may therefore be changed. During the resubmission window, the issuer is free to 709 2017--00809 resubmit the Network ID template with changes to the network URLs, or the plan and benefits template with changes to the marketing name. During plan preview, issuers will need to have data changes approved by calling the help desk and indicating the change. The issuer will receive con?rmation that the change will be allowed from the help desk. Changes that do not trigger re-review, including network URL and plan marketing name changes, will always be allowed, but still must be veri?ed with the help desk. (QHP Webinar Series FAQ #6 04/23/13) Q19: We are looking at submitting multiple networks for QHP certi?cation. If we later decide we would like to only use one of the networks, can we pull the other network and the products associated with that network? What is the latest date we can decide to not use a network? A19: There is no requirement to use all networks that an issuer submits. Issuers will have the opportunity to withdraw QHPs before agreement signing in late September. If an issuer withdraws all QHPs associated with a given network, there is no need to remove the unused network from the QHP Application. (QHP Webinar Series FAQ #6 04/23/13) This FAQ was revised and released as REG TAP on 03/31/14, as follows: Q: We are looking at submitting multiple networks for QHP certification. If we later decide we would like to only use one of the networks, can we pull the other network and the products associated with that network? What is the latest date we can decide to not use a network? A: There is no requirement to use all networks that an issuer submits. Issuers will have the opportunity to withdraw QHPs before agreement signing. (REG TAP FAQ Database - FAQ #1361 03/31/14) 020: For the 4/30 FFE submission in HIOS, we know the opportunity to respond to deficiencies will occur the week of 6/17. What exactly can plans change during this time? We know we can respond to deficient items, upload accreditation data, and submit additional justifications. What else can be changed? A20: In addition to responding to de?ciencies, updating accreditation data, and submitting justi?cations, issuers may also change data that are not related to the certification standards plan marketing names, network URLs, contact information). Issuers may also resubmit in response to state feedback at any time allowed by the state (including outside of the of?cial FFE resubmission window), provided that those changes are made only to fields directly impacted by the State review. (QHP Webinar Series FAQ #6 04/23/13) 021: Our URLs will not validate if they have a dash. How should we submit this data? A21: The next versions of the templates will allow hyphens in the URL name. Issuers may submit templates now with placeholder URLs and will be able to change URLs through the Resubmission or Plan Preview processes. (QHP Webinar Series FAQ #6 04/23/13) 710 Updated 1-31-17 2017--00810 Q1: Can an issuer remove a plan from the Exchange, but still offer it off-Exchange? A1: As long as a plan originally submitted as "Both", the issuer can withdraw it from on the Exchange and still offer it off the Exchange, subject to meeting any applicable state approval requirements. However, HHS encourages issuers to only submit applications for plans that it currently intends to offer on the Exchange. (QHP Webinar Series FAQ #9 05/03/13) This FAQ was revised and released as REG TAP on 03/31/14, as follows: Q: Can an issuer remove a plan from the Marketplace before completing the Certification process, but still offer it off-Exchange? A: Yes, an issuer can withdraw a plan from the Marketplace that was originally identi?ed as an on-exchange plan at any point until the Certi?cation process is completed. The issuer can still offer the plan off the Marketplace, subject to meeting any applicable state approval requirements. However, HHS encourages issuers to only submit applications for plans that it intends to offer on the Exchange. (REGTAP FAQ Database - FAQ #1358 03/31/14) Q3: Where can issuers view the QHP Agreement? A3: HHS plans to release a copy of the agreement by mid-summer. (QHP Webinar Series FAQ #9 05/03/13) Q4: Do products and/or networks need to be approved by the applicable state regulatory agency prior to April submission? A4: QHP issuers can submit plans that are not yet approved by the State regulatory entity. During application submission, an issuer attests that it will have a license by the end of the certi?cation period, be in good standing, and be authorized to offer each speci?c type of insurance coverage offered in each State in which the issuer offers a QHP. The issuer must submit evidence of licensure by the end of the resubmission window. At the time of certi?cation, QHP issuers must agree that it is in compliance with all State laws and statutes related to its QHP plans in the State in which QHP plans are being offered, including that the forms for the QHPs it will offer have been approved or deemed by the State (as applicable in that State), and agree to notify HHS if in the future it is not compliance. (QHP Webinar Series FAQ #9 05/03/13) Q1: ls ?Justification 139: Cost Sharing for plans exceeding annual limitation on small group deductibles? required during the application, or during deficiency phase? Updated 1-31-17 A1: To the extent that the submitted plan deductibles exceed the statutory deductible limitations, the applicant should have submitted justification 139 along with its application. However, this form can be submitted during the resubmission window in response to communicated de?ciencies. Through submission of this form, the applicant attests that the identi?ed health plans that are listed on the form exceed the annual limitation on small group deductibles and are doing so because they could not ?reasonably reach a given level of coverage metal level) without doing so.? The applicant should also include discussion of why they could not reach the coverage levels. HHS would also recommend the issuer reach out to their state regulators as to 711 2017-?0081 1 their requirements in this area, as some states will be conducting the review of this information. (QHP Webinar Series FAQ #12 06/28/13) Q3: Is there a limit on the number of plans an issuer can offer in the Exchange? A3: Not specifically, but issuers must ensure that their plan designs are meaningfully different. (QHP Webinar Series FAQ #12 06/28/13) Q8: What will be the time window and process for the plans to update the links to their plan brochures and SBC's prior to October 1, 2013 Exchange go-Iive? A8: Issuers may update the links to their Plan Brochures and 8803 during either the resubmission process or the Plan Preview process. (QHP Webinar Series FAQ #12 06/28/13) Q47: Are issuer?s member-facing websites required to be 508 compliant if they participate on the Exchange? A47: No. 45 CFR 156.250 establishes standards for issuer applications and notices, but not websites. (QHP Webinar Series FAQ #12 06/28/13 and REG TAP FAQ Database - FAQ #1338 03/31/14) Q49: What elements will the Exchange combine to form plan display names? A49: The plan name will be displayed as [Issuer Marketing Name Plan Marketing Name Plan type]. The combination of these plan attributes make up the plan name in that order. The ?nal name that will be displayed on the marketplace will be displayed in this format. (QHP Webinar Series FAQ #12 06/28/13) Q: How does an Issuer make changes to their Financial Information Template or inquire about the status of its submission? A: For assistance with updating your Financial Information Template or to inquire about the status of your submission, please contact the CMS Help Desk at: CMS FEPS@cms.hhs.qov (REGTAP FAQ Database - FAQ #453 11/12/13) Q: Do you anticipate an issuing of a 'Model Agreement' (much like the Model HIPAA Business Associate Agreement recently required by the HIPAA Omnibus Regulations) to a Non-Exchange Entity to use when contracting Third Parties? A: No, not at this time. (REGTAP FAQ Database - FAQ #1341 03/31/14) Q: Should Issuers submit QHP plans that they do not intend to offer on-exchange? A: When submitting health plans for sale on the Federally-facilitated Marketplace (FFM) during the QHP application window, issuers should only submit on-exchange health plans. In contrast, for SADP offerings, issuers should submit both on-exchange and off- exchange for certification by CCIIO. In non-FFM states, issuers should review any state- speci?c requirements for the submission of off-exchange QHPs. However, issuers are reminded that they are required to include all non-grandfathered plans subject to Single 712 Updated 1-31-17 2017-?00812 Risk Pool requirements in the Unified Rate Review Template, regardless of whether the plans are offered on the Marketplace or not. . (REGTAP FAQ Database - FAQ #1330 03/31/14) Q: Can issuers withdraw plans which have already been submitted for the 2015 certification year, and how? A: After submitting the QHP application for the 2015 certi?cation year, issuers will generally be able to withdraw plans up until agreement signing (note that if the issuer is withdrawing the entire product, this may have to occur at an earlier date to meet the requirements for product discontinuation). To withdraw a plan(s), issuers must complete the withdrawal noti?cation form posted on Completed withdrawal notification forms should be submitted to CMS FEPS@cms.hhs.qov, using the subject line Plan Withdrawal Notice.? In addition to submitting formal notification, issuers who wish to withdraw a plan(s) prior to the deadline for ?nal submission of QHP Application data on 9/4/14, should delete the particular plan(s) by removing it from the template(s) and resubmit the template(s) in HIOS or SERFF. We note that issuers are subject to the standards under 45 CFR 156.290 when electing not to seek recertification with the Marketplace. We expect to provide further details about the 2015 re-enrollment and renewal process in the near future. (REGTAP FAQ Database - FAQ #2746 07/09/14) Q: Can issuers submit a new product or plan for Qualified Health Plan (QHP) certification in the Federally-facilitated Marketplace (FFM) after the close of the initial submission window on June 27? A: No, issuers were required to submit complete QHP applications for all products and plans to be offered in the FFM by June 27, 2014. (REGTAP FAQ Database - FAQ #2962 07/23/14) Q: What is the latest date an issuer can withdraw a Qualified Health Plan (QHP) for the 2015 Plan Year? A: As noted in the 2015 Letter to Issuers, the issuer can withdraw plans any time prior to signing the Agreement. An issuer can withdraw an entire product earlier than Agreement signing for various reasons related to Rate Review and the Index Rate. The 2015 Letter to Issuers is located at the following link: issuer-Ietter-3-14-2014.pdf. (REGTAP FAQ Database - FAQ #2963 07/23/14) Q: Will the Account Manager remain the same for both individuals and Small Business Health Options Program (SHOP) groups? A: The Account Manager will remain the same for both individual and SHOP groups. (REGTAP FAQ Database - FAQ #8203 12/15/14) Q: How quickly will issuers' updated machine-readable data appear on HealthCare.gov in the Decision Support Features? A: CMS will crawl the data at least daily. Users will see updated data within 1-2 days of 713 Updated 1-31-17 2017--00813 when the issuers update their JavaScript Object Notation (JSON) files, depending on the time of day. (REGTAP FAQ Database - FAQ #13905 11/05/15) Q: What if a consumer sees provider or drug information in the tools that they think is wrong? A: Consumers will be able to provide feedback about the information in the tools if they think it's incorrect. The feedback is gathered anonymously in an electronic form available through a link in the tools. (REGTAP FAQ Database - FAQ #13906 11/05/15) Q: How will issuers receive feedback if a consumer thinks the data is wrong? A: Initially issuers will receive aggregated weekly excel reports of all consumer feedback from the electronic form from their account managers. Eventually aggregated data will be reported through CMS's Health Insurance Casework Tracking (HICS) tracking system. (REGTAP FAQ Database - FAQ #13907 11/05/15) Q: What should issuers plan to do with consumer feedback data? A: During the first month, issuers should review the reports for trends and make efforts to ?x veri?ed data inaccuracies. CMS will provide guidance regarding a longer term process for addressing data inaccuracies. (REGTAP FAQ Database - FAQ #13908 1 1/05/15) Q: Will consumers who believe the data in the search features was wrong when they selected their plan be eligible for a special enrollment period A: No. At this time consumers are not eligible for SEPs based upon provider or drug information CMS displays in the Decision Support Features. We inform consumers through disclaimer language in multiple locations on the website that the only way to ensure that a particular provider or drug is covered is to contact the issuer or plan provider directly. (REGTAP FAQ Database - FAQ #13909 11/05/15) Q: How can issuers ask technical questions about their machine-readable files and data? A: Issuers should continue to use the UserVoice community at directory.uservoice.com to review the knowledge base, post questions and get answers to technical questions about the index ?les and JSON files, and see other (REGTAP FAQ Database - FAQ #13910 11/05/15) Q: Can you clarify a Qualified Health Plan issuer's obligations? A: Quali?ed health plan (QHP) issuers must meet certain statutory and regulatory standards. Issuers may not waive or alter their obligation to meet these standards by including language in their contracts with enrollees that is inconsistent with issuers' obligations with respect to their QHPs. Any contractual language between an issuer and enrollee purporting to change or relieve an issuer of QHP obligations, including pending external litigation or other regulatory action, is inconsistent with QHP requirements and is a violation of the QHP agreement. (REGTAP FAQ Database - FAQ #17069 08/03/16) 714 Updated 1-31-17 2017--00814 Q: Can you clarify a Qualified Health Plan Issuer?s obligations? A: Quali?ed health plan (QHP) issuers must meet certain statutory and regulatory standards. Issuers may not waive or alter their obligation to meet these standards by including language in their contracts with enrollees that is inconsistent with issuers? obligations with respect to their QHPs. Any contractual language between an issuer and enrollee purporting to change or relieve an issuer of QHP obligations, including pending external litigation or other regulatory action, is inconsistent with QHP requirements and is a violation of the QHP agreement. (Transparency, QHP Obligations, and QRS Marketing Guidelines FAQS 08/04/16) QHP Application Q7: If an uploaded document is incorrect, can issuers upload a new document to replace it? A7: Yes. (Plan Management Webinar QHP FAQ #3 04/11/13) Q8: What format do uploaded supporting documents need to be in? A8: Supporting documents can be uploaded as PDF or Word formats. (Plan Management Webinar QHP FAQ #3 04/11/13) QQ: How do issuers correct errors found upon final submission (cross template validation) if it is not possible to change the information once the data validation has been performed? A9: For states using the FFE, the validator can reverse the validation decision to allow revision of the submitted data during the initial submission period. For states using the System for Electronic Rate and Form Filing (SERFF), issuers will need to manually validate that each plan has a valid network, service area, and prescription drug that there are rates submitted for each plan; and that they have submitted the rating rules template. (Plan Management Webinar QHP FAQ #3 04/11/13) Q10: What documents can be deleted or overwritten after they are uploaded in the QHP application? A10: For templates, a newly uploaded template will overwrite the previous template in the Issuer, Rating and Benefits, and Service Area Modules. Supporting documents may be deleted in the Issuer Module. Supporting documents may not be deleted in the other modules. In the Bene?ts and Service Area module, issuers may use the comment ?eld to indicate that an updated version has been submitted. (Plan Management Webinar QHP FAQ #3 04/11/13) Q11: Will HHS provide validation reports when issuers submit the templates? Will issuers be able to correct errors during the application window? A11: Every template has a validate button. After you upload the template, the system will complete a validation. There is an update status button to check the status. There is an error report delivered on screen. (Plan Management Webinar QHP FAQ #3 04/11/13) 715 Updated 1-31-17 2017--00815 062: If we are not filing to be a part of the Exchange/offer QHPs, do we need to do anything? A62: An issuer is not required to notify CMS that it will not seek QHP certi?cation. However, existing filing and submission requirements for other CMS programs still apply, such as the requirements related to providing rate increase submissions under 45 CFR 154.215. If you plan to offer products outside of the Federally Facilitated Marketplace, please follow the rate review ?ling requirements under 45 CFR 154.220 and contact your State to determine state specific ?ling requirements. As noted in the ?nal Market Rules at: when making a rate filing submission, all on- and off-Exchange products must ?le the Part Unified Rate Review template and Part Actuarial Memorandum into HIOS. If an issuer is not applying to offer any QHPs in the same risk pool, the Part Unified Rate Review template and Part Actuarial Memorandum are due on the timeline set by the state, but before January 1, 2014. (QHP Webinar Series FAQ #5 04/18/13) 063: I am trying to clarify data submission requirements for April 30 as applicable to FFE states. In the QHP Certification PRA notice, Appendix has data elements related to the EDGE server listed as required for the QHP application process. None of the QHP application templates available via HIOS have a place to enter the Edge server related data. Please con?rm that we are not required to submit the Edge Serve data elements described in Appendix of the QHP Certification PRA notice with the April 30th 0HP application submission. A63: Appendix represents data required for reinsurance, risk adjustment, and payment operations. Those data elements will be collected outside of the QHP application process as they are not required for QHP certi?cation. The collection of the Appendix data will occur later this year. The PRA package can be found at: nbr=201303-0938-004. (QHP Webinar Series FAQ #5 04/18/13) 050: How can issuers determine if and how a template has changed from what is currently available on the SERFF website compared to what is available on the Plan Management tool? A50: All templates contain a version number. Use that number to determine whether the SERFF template is the same as the one on the one from the Plan Management Tool. (QHP Webinar Series FAQ #9 05/03/13) 051: When will the final user guide for QHP submission through HIOS will be available and where users will be able to obtain the user guide? A51: The most current HIOS portal user guide is available at under the section titled "Content Requirements for Healthcare.gov." The complete instructions for submitting the QHP Application can be found at (QHP Webinar Series FAQ #9 05/03/13) 052: Can issuers submit more than one attachment? A52: In the Issuer Module, each supporting document is a single upload. If you upload a document again, it will replace the previous upload. In the Benefits and Service area 716 Updated 1-31-17 2017--00816 module, you can upload multiple ?other? supporting documents. The Rating module does not require supporting documents. (QHP Webinar Series FAQ #9 05/03/13) 053: Can a partially completed template be stored in the system? A53: You cannot download or upload partially completed templates. We recommend that you download the template and save to your local drive, then enter data. Once you complete the template, save it on your local drive then upload the XML generated by the completed template. (QHP Webinar Series FAQ #9 05/03/13) 054: When are the zip codes provided in the Service Area Template validated? A54: The zip codes are validated after the template is uploaded and processed. (QHP Webinar Series FAQ #9 05/03/13) Q55: Are there special character limitations in text fields? A55: This depends on the ?eld and if the ?eld is in a template or on the User Interface. The HIOS User Guide provides the valid characters for the fields in the templates. If it is a field on the User Interface, there are no special character limitations in text ?elds. (QHP Webinar Series FAQ #9 05/03/13) 056: If an issuer has multiple Issuer IDs, will the issuer need to complete multiple plan and bene?ts templates? A56: Yes, the issuer would require multiple Plan and Benefit Templates. However, the issuer would be able to use the same add-in ?le for all of the templates as long as the add-in file was stored to the same hard-drive as all the bene?ts templates. Note: It is recommended that the issuer not have more than one Plan and Benefit template open at once. (QHP Webinar Series FAQ #9 05/03/13) 057: Do separate Plan and Benefits templates need to be completed for the SHOP and Individual markets if the issuer is submitting for both markets? Updated 1-31-17 A57: Yes, each application would require a SHOP and Individual template. However, the issuer would be able to use the same add-in ?le for all of the templates as long as the add-in file was stored to the same hard-drive as all the bene?ts templates. Again, we recommend that the issuer not have more than one Plan and Bene?t template open at once. (QHP Webinar Series FAQ #9 05/03/13) The answer to this FAQ was revised and re-re/eased on the REG TAP database on 06/1 1/14: A: Yes, each application would require a SHOP and Individual template. However, the issuer would be able to use the same add-in file for all of the templates as long as the add-in file was stored to the same hard-drive as all the bene?ts templates. To ensure that you re?ect accurate state-speci?c EHB benchmark bene?ts, we recommend that issuers refer to the Revised Benchmark Bene?ts Instructions available at 717 2017-?00817 manaqement data templates 2015.htm. These Instructions identify revised benchmark bene?ts for each state and instructions for updating the Plan and Benefits template accordingly. Lastly, we recommend that the issuer not have more than one Plan and Benefit template open at once. (REGTAP FAQ Database - FAQ #2136 06/11/14) 021: Is there any specific federal requirement for a company that may sell off Exchange health insurance (major med) products that it must file templates for any of the QHP certification process templates? If so, can you cite the section to help me with an explanation to the company? A21: Speci?c requirements for selling off the Exchange are of the purview of the state. (QHP Webinar Series FAQ #10 05/09/13) Q: Do issuers need to submit a separate application for each product offered in each state? For example, if an issuer is offering three different products one group and two individual products), must an issuer file three different applications for each state? A: Issuers may submit one Quali?ed Health Plan (QHP) application to represent multiple products and plans in each state. Individual and Small Business Health Options Program (SHOP) information may be combined in all templates except for the Plans and Bene?ts Template. Issuers submit one Plans and Benefits Template for individual market plans and one Plans and Bene?ts Template for SHOP market plans. For more information, please see QHP Application Instructions at: Marketplaces/th.html. (REGTAP FAQ Database - FAQ #2951 07/22/14) Q: Where can issuers locate the editable QHP Application Justification Forms? A: Issuers can locate the editable Justi?cation forms on the Centers for Consumer Information and Insurance Oversight (CCIIO) website at Marketplaces/th.html as well as the Centers for Medicare Medicaid Services (CMS) ZONE website at (REG TAP FAQ Database - FAQ #2984 07/23/14) Q: If an issuer only submits a qualified health plan (QHP) application for the Individual Market, does CMS require the issuer to submit Federally-facilitated SHOP (FF-SHOP) Participation Provision Supporting Documentation and Justification for the Federally- facilitated Individual Marketplace? A: Each QHP issuer filing a QHP to be sold through the FFM Individual Marketplace must complete this form for each applicable FFM state. (REGTAP FAQ Database - FAQ #3514 08/07/14) Q: Does the June 27, 2014 CMS deadline for QHP application also apply to State Partnership Marketplace (SPM) States and State-based Marketplace (SBM) States? A: The June 27, 2014 deadline only applies to issuers that are submitting the entire qualified health plan (QHP) application in the Health Insurance Oversight System (HIOS) to participate in the Federally-facilitated Marketplace (FFM). As mentioned in the 2015 718 Updated 1-31-17 2017--00818 Letter to Issuers, in an FFM state where the state is performing plan management functions, commonly referred to as a State Partnership Marketplace (SPM), issuers will work directly with the state to submit all QHP issuer application data in accordance with state guidance. These states will use SERFF to collect QHP Applications from issuers, review QHP applications and submit QHP certi?cation recommendations to CMS. Issuers in State-based Marketplaces should work directly with the state to submit QHP applications. State-based Marketplaces will conduct their own review of QHP applications and make certi?cation decisions based on this review. (REGTAP FAQ Database - FAQ #3517 08/07/14) Q: Who will CMS contact regarding Quali?ed Health Plan (QHP) correction noti?cations? How will CMS communicate the identified corrections to issuers? A: CMS will email correction notices to those individuals identi?ed as a Submitter, Validator, or Attester in HIOS. (REGTAP FAQ Database - FAQ #3535 08/07/14) Q: Will CMS send confirmation notices to issuers verifying a successful Quali?ed Health Plan (QHP) Application submission? A: CMS does not send con?rmation notices for QHP Application submissions. CMS started reviewing QHP Applications on June 27, 2014 and sent out ?rst correction notices on July 29, 2014. On July 29, 2014, CMS also sent the issuer a notice if the QHP Application did not need revisions. (REGTAP FAQ Database - FAQ #3536 08/07/14) Marketing 09: Will HHS review QHP marketing materials? Updated 1-31-17 A9: We do not plan to review marketing materials, as noted in Chapter 3 of the Letter to Issuers on Federally-facilitated and State Partnership Exchanges, released on the CCIIO website on April 5 at letter to issuers 04052013.pdf . In the Letter, we stated, ?Because states generally already regulate health plan marketing materials and other documents under state law, CMS does not intend to review QHP marketing materials for compliance with state standards as described at 45 C.F.R. 156.225. However, to assist consumers in identifying plans that have been certified by an Exchange, we recommend that all marketing materials distributed to enrollees and to potential enrollees, contain the following disclaimer: ?[lnsert plan?s legal or marketing name] is a Qualified Health Plan issuer in the [Health Insurance Marketplace].? A logo for the Health Insurance Marketplace will also be made available for use on marketing materials. Marketing materials should include communications to consumers and enrollees, such as advertising materials, consumer notices, and brochures. We note that consumer-facing materials will refer to the Exchange as the ?Health Insurance Marketplace.? We also noted that, in addition to complying with state marketing standards that apply to all issuers, QHP issuers must ensure that all marketing products and materials meet the meaningful access standards. Finally, issuers will need to attest as part of the QHP application process that they will market QHPs in accordance with all applicable state laws and regulations and will not employ discriminatory marketing practices in accordance with 45 CFR 156.225. (QHP Webinar Series FAQ #6 04/23/13) 719 2017--00819 Q10: Regarding the requirement that all marketing products and materials meet ?meaningful access? standards, will HHS provide guidance on these standards? A10: In the final Letter to Issuers, we provided more information on meaningful access standards in the FFE in Chapter 5, Section 6. As noted in the Letter, we intend to provide further information on this in the future. (QHP Webinar Series FAQ #6 04/23/13) Q: When can issuers begin marketing 2015 qualified health plans A: Issuers may begin marketing 2015 QHPs after the QHP Agreement has been signed. (REGTAP FAQ Database - FAQ #3516 08/07/14) State Review and Approval Q1: Can a state evaluate whether health plans and issuers meet certification standards and conduct other specified plan management activities as a part of its established regulatory role and in connection with market reform standards without submitting a Blueprint? A1: Yes. An interested State should submit to HHS a letter as soon as possible from its Governor or Commissioner of Insurance attesting that the State will perform all the plan management activities listed in Section 4.0 of the Blueprint in time for the 2013 QHP selection process. This letter also should include speci?c attestations that the State will: (1) have the legal authority and operational capacity to conduct the plan management activities required to support certi?cation of QHPs, as described in 45 CFR (2) collect and analyze information on plan rates, covered bene?ts, and cost-sharing requirements pursuant to 45 CFR 155.1020; (3) help ensure ongoing plan compliance and resolve consumer complaints described in 45 CFR (4) provide issuer technical assistance as needed; (5) help manage decerti?cation of issuers and associated appeals in compliance with 45 CFR 155.1080; and (6) participate in a one- day review of its operational plans and capacity to perform these functions. After receiving this letter and completing a review, HHS will initiate a process under which it may rely on the state?s recommendations that health plans meet QHP certification requirements. This process would likely involve a written understanding between the state and HHS, in addition to any Agreement under which 1311(a) grant funds are provided. Assuming a state continues to act in accordance with its attestations, HHS would continue to rely on its recommendations with regards to Exchange speci?c requirements for QHPs, for example, anti-discrimination and network adequacy. HHS will maintain its responsibility for ensuring that QHPs meet all QHP certification standards. Finally, a state is eligible to apply for an Exchange Establishment Grant, consistent with the guidance set forth in the Funding Opportunity Announcement, to fund these activities. If a state does apply, it is agreeing to participate in the review, reporting, and technical assistance programs associated with oversight of these Establishment Grants and to ensure appropriate use of grant funds and effective performance of the required plan management activities. (State Evaluation of Plan Management Activities of Health Plans and Issuers 002/20/13) 720 Updated 1-31-17 2017--00820 Q15: How do you envision the coordination process occurring between the FFE QHP filing and the State rate and policy form filing? What happens if the FFE approves the QHP application, but the State does not approve, or requires minor changes to the policy form? A15: No product can be sold on any Exchange unless it is first approved for sale by the State Department of Insurance (DOI). For more information on our approach and state/FFE roles, please see the General Guidance on the FFE, published May 16, 2012, at In the FFE, the issuer will submit the QHP application to the FFE in the Health Insurance Oversight System (HIOS) and will also submit form ?ling as required by the State. Before an issuer signs a QHP Agreement for a certi?ed QHP, the issuer will have to confirm that the QHP has been approved for sale by the State. If a plan is approved as a QHP but does not attain approval by the DOI, it will not be available on the Exchange. (Plan Management Webinar QHP FAQ #1 04/08/13) Q43: Does the QHP Application impact state rate and form ?ling requirements? Will states use the QHP application in lieu of their form and rate filings? A43: States will continue to establish standards for rate and form filings, including what information and data issuers should provide, how issuers should submit such data, and when issuers should submit such data. Issuers should contact the appropriate state regulator(s) for assistance in complying with state requirements. Issuers should not assume that completion of the QHP Application will satisfy state rate and form ?ling requirements. (QHP Webinar Series FAQ #12 06/28/13) The answer to this FAQ was revised and released on the REG TAP database on 6/11/14: A: No, it does not impact state rate and form filing requirements. State regulators continue to review rate and form filings for state requirements pursuant to any applicable state law, including the information and data issuers should provide, how issuers should submit such data, and when issuers should submit such data. Issuers should contact the appropriate state regulator(s) for assistance in complying with state requirements. Issuers should not assume that completion of the QHP Application will satisfy state rate and form filing requirements. (REG TAP FAQ Database - FAQ #2149 06/11/14) Q44: How do issuers know which components the state will review vs. which components will be reviewed by the Updated 1-31-17 A44: Where a FFM is operating, CMS will conduct QHP certi?cation. However, as CMS indicated in the ?Guidance on State Partnership Exchanges? (available at: CMS recognizes that determination of whether issuers and health plans meet QHP certi?cation standards outlined in 45 CFR 156.200 involves activities that are already or will be performed by state regulators under state law, including state laws that address 2014 market reforms. For example, we know that many states will conduct reviews for the following: coverage of EHB, including formulary reviews for EHB purposes; compliance with actuarial value (AV) and market rating reforms; and rate increases, consistent with state authority and federal law. Accordingly, CMS will not duplicate state reviews where a state is enforcing these and other 721 2017-?00821 Affordable Care Act standards. CMS will evaluate QHPs against all other certification standards. The list of certification standards is included in the State Partnership guidance linked above. (QHP Webinar Series FAQ #12 06/28/13) This FAQ was revised and released as REG TAP on 03/31/14, as follows: Q: How do issuers know which components the state will review vs. which components will be reviewed by the A: Issuers seeking certi?cation of QHPs in a Federally-facilitated Marketplace should consult the 2015 Letter to Issuers for information about how QHP Applications will be evaluated. As was done last year, states will continue to perform all regulatory reviews and functions under state law, while the FFM will focus on Marketplace-specific standards. (REG TAP FAQ Database - FAQ #1334 03/31/14) Q45: If our product form filings are ?deemed? approved by the appropriate state regulatory authority because our state failed to timely review them in accordance with state law, will the Exchange consider the product approved by the state? A45: Yes. If a product can be considered ?approved for sale? in a state pursuant to the terms of a deemer clause under state law, the FFM will accept the issuer?s attestation that the product has been approved for sale by the State Department of Insurance. (QHP Webinar Series FAQ #12 06/28/13) Q46: Should issuers complete HIOS or SERFF uploads ?rst? A46: The order does not matter, but if the state is the primary reviewer, HHS would generally expect the issuer to submit to the state first. (QHP Webinar Series FAQ #12 06/28/13) Accreditation and Quality Q1: How should the National Committee of Quality Assurance (NCQA) I Utilization Review Accreditation Committee (URAC) accreditation templates be filled out if we are in the first year of the accreditation process? A1: We will be collecting accreditation information only from issuers that are currently accredited by NCQA and/or URAC on their commercial, Medicaid and/or Exchange market, if applicable. See 45 CFR 155.1045, which can be found at 78 FR 12865. Issuers that are in the process of receiving accreditation but are not yet accredited should mark "No" (that they are not accredited) in the accreditation section of the QHP application and should not ?ll out the templates. (Plan Management Webinar QHP FAQ #1 04/08/13) 722 Updated 1-31-17 2017-?00822 02: Once QHP Issuer Applications have been submitted, what is the process health plans should follow to report that Exchange products have received NCQAIURAC accreditation and when will this information be posted to the website? For example, if a health plan is scheduled to undergo an review in June and/or July and receives accreditation by September, how soon will that update be posted to the website? A2: At this time, HHS is only accepting accreditation information from currently accredited issuers. Issuers that are not accredited at the time of submitting their QHP application should mark that they are not accredited, on the Accreditation section of the application. If you receive an accreditation status after the application closes, you should notify HHS and during the resubmission window you may submit your new accreditation information. For more information on this process, see pages 10-12 of the final Letter to Issuers on Federally-facilitated and State Partnership Exchanges (Issuer letter), published on the CCIIO website on April 5, 2013, at Letter to Issuers 04052013.pdf. (Plan Management Webinar QHP FAQ #1 04/08/13) 06: Is there any federal requirement for an issuer to document that it has "scheduled or planned to schedule accreditation" during certification for its initial year of QHP certification, as provided in ?155.1045(b) (1) of the Accreditation Timeline? A6: No, there is no separate documentation required for an issuer. As part of completing the QHP application the issuer is indicating that they have scheduled or planned to schedule accreditation. (Plan Management Webinar QHP FAQ #2 04/09/13) 05: For an issuer offering products during Federally-facilitated Exchange (FFE)/Partnership Exchange open enrollment in 2013 and not holding existing National Committee of Quality Assurance (NCQA) or Utilization Review Accreditation Committee (URAC) accreditation, on or before what date must it be awarded accreditation by URAC or NCQA to allow its Quality Health Plans (QHPs) to continue participation on the Exchange? A5: Issuers without existing accreditation that offer a product as part of an FFE or Partnership Exchange in 2014 (open enrollment in 2013) must be accredited on QHP policies and procedures 90 days prior to 2014 open enrollment in order to be certi?ed for the 2015 coverage year. (Plan Management Webinar QHP FAQ #3 04/11/13) CMS revised and re-re/eased this FAQ on the REG TAP database on 6/11/14: Q: For an issuer offering products in 2014 in either a Federally-facilitated Marketplace (FFM) or a State performing plan management functions and not holding existing accreditation, on or before what date must it be awarded accreditation to allow its Quality Health Plans (QHPs) to continue participation on the Marketplace in the 2015 coverage year? A: Issuers without existing accreditation that offer a product in a FFM or State Performing Plan Management functions in 2014 must be accredited on QHP policies and procedures 90 days prior to open enrollment in order to be certi?ed for the 2015 coverage year. (REGTAP FAQ Database - FAQ #2126 06/11/14) 723 Updated 1-31-17 2017--00823 QG: Must accreditation be completed before the QHP issuer's second year of certification, but not before the third year of certification? A6: The issuer must be accredited on the QHP policies and procedures before the issuer?s second year of certi?cation, and must continue to be accredited on the policies and procedures in the third year of certi?cation. The issuer must obtain full accreditation (in accordance with 45 CFR 156.275) by the fourth year of certi?cation. (Plan Management Webinar QHP FAQ #3 04/11/13 and REG TAP FAQ database FAQ #2128 06/1 1/14) Q1: I am in the process of accreditation, and I have CAHPS data. Can I submit the CAHPS data? A1: As stated in the ?Letter to Issuers on Federally-facilitated and State Partnership Exchanges,? available on the CCIIO website at: letter to issuers 04052013.pdf, for the 2014 coverage year, an Exchange website will only display selected CAHPS survey results from an issuer?s accredited product lines when these existing data are available for the same QHP product types and adult/child populations. If applicable CAHPS data are not available through existing accreditation, the Exchange website will display a neutral statement such as ?No data available.? Please see Chapter 1, Section 2 of the Issuer Letter for more details. (QHP Webinar Series FAQ #6 04/23/13) Q7: If an issuer is submitting a QHP application for a State-based Exchange through SERFF, and the State is not requiring the NCQA and URAC templates, does it need to submit the NCQA and URAC templates to SERFF in order to pass validation of the SERFF application? A7: Issuers in State-based Exchanges should comply with the requirements for accreditation data collection that have been speci?ed by the State-based Exchange. Issuers who are submitting QHP applications through SERFF for a State-Partnership exchange do not need to submit the Accreditation templates. Issuers that are submitting QHP applications through SERFF may also contact the NAIC for information about SERFF-specific requirements. (QHP Webinar Series FAQ #7 04/24/13) Q: When does CMS require accredited status for an insurer working toward first-year participation in the 2015 Federally-facilitated Marketplace Would CMS consider it sufficient for an insurer to have a survey scheduled, but not completed at the time of Qualified Health Plan (QHP) submission, or even not completed at the time of open enrollment, with an accreditation decision obtained before the end of 2014? A: 45 CFR 1) 04084.9df) details the accreditation requirement for QHP issuers in their initial year of participation in the FFM. The initial year is considered to be the ?rst year of the QHP issuer's participation. The requirement is as follows: during certi?cation for an issuer's initial year of QHP certification (for example, in 2013 for the 2014 coverage year), a QHP issuer without existing commercial, Medicaid, or Exchange health plan accreditation granted by a recognized accrediting entity for the same State in which the issuer is applying to offer coverage must have scheduled, or plan to schedule, a review of QHP policies and procedures of the applying QHP issuer with a recognized accrediting entity. 724 Updated 1-31-17 2017--00824 Additionally, as CMS noted in the 2014 and 2015 Letter to Issuers, for certi?cation in future years, the timeline noted above will be applied by looking at the issuer's accreditation status 90 days prior to open enrollment. QHP issuers who are new to an FFM or State Partnership Marketplace (SPM) in 2015 are not required to be accredited. However, they must schedule, or plan to schedule, an accreditation review in their ?rst year on the marketplace. Stand-alone dental plan (SADP) issuers will not be reviewed for accreditation status. (REGTAP FAQ Database - FAQ #2945 07/22/14) Q: When do QHP issuers have to complete accreditation? A: The issuer must be accredited on the QHP policies and procedures before the issuer's second year of certification, and must continue to be accredited on the policies and procedures in the third year of certi?cation. The issuer must obtain full accreditation, in accordance with 45 CFR 155.1045, by the fourth year of certification. (REGTAP FAQ Database - FAQ #2946 07/22/14) Q: If an issuer is submitting a Quali?ed Health Plan (QHP) application for a State-based Marketplace (SBM) through SERFF, and the state does not require the NCQA and URAC templates, does the issuer need to submit the NCQA and URAC templates to SERFF in order to pass validation of the SERFF application? A: Issuers do not need to submit the Accreditation Templates if they are submitting a QHP Application for a State-based Marketplace through SERFF and the state does not require the templates. Instead, issuers in SBMs should comply with the requirements for accreditation data collection that have been speci?ed by the state. The issuer will be able to pass validation without the inclusion of NCQA or URAC templates. Issuers that are submitting QHP applications through SERFF may also contact the National Association of Insurance Commissioners (NAIC) for information about SERFF-specific requirements (call 816-783-8990 or e-mail (REGTAP FAQ Database - FAQ #2947 07/22/14) Q: Once Qualified Health Plan (QHP) issuer applications have been submitted, what process should issuers follow to report that Marketplace products have received accreditation? A: At this time, CMS only accepts accreditation information from currently accredited issuers. Issuers that are not accredited at the time of submitting their QHP application should mark "No" on the accreditation section of the application, indicating that they are not accredited. The QHP issuer may submit changes to the application, including new accreditation information, prior to September 4, 2014. (REGTAP FAQ Database - FAQ #2948 07/22/14) Q: What types or forms of accreditation do Qualified Health Plan (QHP) issuers in a Federally-facilitated Marketplace (FFM) need to list in the Accreditation Template? Updated 1-31-17 A: In completing the Accreditation Template, QHP issuers should provide accreditation information for each of the applicable markets: Commercial, Medicaid or Marketplace. 725 2017--00825 For instance, if accredited in both the Commercial and Marketplace markets, QHP issuers should include their accreditation information for both markets. For certification in 2014 for the 2015 benefit year, CMS has recognized the Accreditation Association for Ambulatory Health Care National Committee for Quality Assurance (NCQA) and URAC. Issuers are required to provide information on accredited market type, accredited product type, accreditation status, and accreditation expiration date in the Accreditation Template. To verify accreditation information, issuers must upload their current and relevant accreditation certi?cates issued by the accrediting entities recognized for QHP certification. Additional information regarding completing the Accreditation Template is available on the SERFF website: manaqement data instructions ch5.pdf. An issuer will be considered accredited if the issuer obtains one of the following: ?accredited? status; NCQA -- ?excellent," ?commendable, accredited," and/or ?interim? status; or URAC ?full,? ?provisional,? and/or ?conditional? status. ?1 An issuer will not be considered accredited if the accreditation review is scheduled or in process. (Please see the 2015 Letter to Issuers: issuer-letter-3-14-2014.pdf) (REGTAP FAQ Database - FAQ #2953 07/22/14) Q: Where can an issuer find instructions for completing the Accreditation Attestation? A: All issuers applying in the Federally-facilitated Marketplace (FFM) must complete a signed Accreditation Attestation as a part of the Accreditation Access section of the QHP application. The instructions for completing and accessing the Accreditation Attestation are located in the 2015 QHP Application Instructions. Issuers can reference the 2015 QHP Application Instructions on the Center for Consumer Information and Insurance Oversight (CCIIO) web page at the following link for further guidance: (REGTAP FAQ Database - FAQ #3511 08/07/14) Q: Should issuers update the Accreditation status after the June 27, 2014 submission dead?ne? Updated 1-31-17 A: If 2015 is the second year the issuer is participating in the Federally-facilitated Marketplace (FFM) and the issuer did not upload the Accreditation status with the initial qualified health plan (QHP) application submission, the issuer will receive a correction notice indicating the issuer is not accredited. The issuer will not encounter any problems certifying the QHP as related to accreditation requirements as long as the issuer receives accreditation from a CMS-recognized accrediting entity by 90 days prior to the open enrollment period, or August 17, 2014. Issuers have until September 4, 2014 to update the Accreditation status in the QHP application. (REGTAP FAQ Database - FAQ #3512 08/07/14) 726 2017--00826 Q: Can the Quality Improvement Strategy (QIS) Implementation Plan and Progress Report form be submitted independently of the larger Qualified Health Plan (QHP) Application? A: Issuers should submit their QIS Implementation Plan and Progress Report forms as part of QHP certi?cation when they submit their QHP applications. Submission instructions related to the QHP application and QIS Implementation Plan and Progress Report form may vary by Marketplace. For example, issuers operating in the Federally- facilitated Marketplaces will submit via the Health Insurance Oversight System (HIOS). For the 2017 plan year, the QIS Implementation Plan and Progress Report form will be submitted through the accreditation module. Issuers operating in State Partnership Marketplaces will submit via the System for Electronic Rate and Form Filing (SERFF). Issuers operating in State-based Marketplaces (SBMs) or SBM-Federal Platform states should contact their Marketplaces for specific instructions on QHP Application submission, including QIS submission. (REGTAP FAQ Database - FAQ #14786 02/10/16) Q: Does 45 CFR ?156.1110 apply to all hospitals? A: CMS encourages all hospitals and health care providers to engage in patient safety improvement activities with the goal of reducing harm and achieving better patient health outcomes. Consistent with section 131 of the Affordable Care Act, the implementing regulation at 45 CFR ?156.1110, however, only apply to hospitals, as that term is de?ned in section 1861 of the Social Security Act (SSA), with greater than 50 beds. Quali?ed health plan (QHP) issuers may continue to contract with other types of hospitals that do not fall under this de?nition; however, the patient safety standards outlined in 45 CFR ?156.1110 would not apply. For example, the QHP issuer patient safety standards under 45 CFR ?156.1110 do not apply to or otherwise prevent QHP issuers from contracting with hospitals that fall under the definition at section 1861(f) of the SSA. Nor do these requirements apply to or otherwise prevent QHP issuers from contracting with hospitals with 50 beds or less. As such, QHP issuers would not be required to collect and maintain documentation collect and maintain current agreements to partner with a Patient Safety Organization, Hospital Engagement Network or Quality Improvement Organization) for hospitals, as that term is de?ned in section 1861 of the SSA, or for hospitals with 50 beds or less but would be able to continue to contract with such hospitals. (REGTAP FAQ Database - FAQ #18036 11/03/16) Q: What is the timeframe for collecting and maintaining documentation from contracted hospitals? Updated 1-31-17 A: The requirements related to collection of documentation from contracted hospitals to demonstrate compliance with the Quali?ed health plan (QHP) issuer patient safety standards are captured at 45 CFR 45 CFR maintains the existing documentation standard for plan years beginning before January 1, 2017. As such, a QHP issuer would have to demonstrate compliance with the patient safety standards at 45 CFR collect CCNs) for plan years beginning before January 1, 2017; 727 2017-?00827 and . 45 CFR provides that for plan years beginning on or after January 1, 2017, a QHP issuer would have to demonstrate compliance with the patient safety standards at 45 CFR For example, a QHP issuer could demonstrate compliance with the collection of current agreements to partner with a Patient Safety Organization Hospital Engagement Network or Quality Improvement Organization Consistent with the attestation included as part of the QHP certification process for participation in the Federally-facilitated Marketplaces (FFMs), CMS expects issuers to have collected the appropriate documentation CCNs) for plan years before January 1, 2017 prior to the start of the applicable plan year to demonstrate compliance with the applicable patient safety standards, currently codi?ed at 45 CFR Similarly, for plan years beginning on January 1, 2017, CMS expects that appropriate documentation current agreement with a PSO) will be collected by January 1, 2017 in order to comply with the new standards in 45 CFR Pursuant to 45 CFR QHP issuers participating in FFMs must maintain records related to compliance with FFM requirements, such as the documentation required under 45 CFR for 10 years and must make these records available upon request. (REGTAP FAQ Database - FAQ #18037 11/03/16) Q: What type of documentation should a Qualified Health Plan (QHP) issuer collect from a contracted hospital with greater than 50 beds as evidence of its internal patient safety initiative, if it chooses to pursue this option under the reasonable exceptions provision at 45 CFR Updated 1-31-17 A: Beginning with the 2017 plan year, pursuant to the reasonable exceptions provision at 45 CFR a QHP issuer may verify its contracted hospitals with greater than 50 beds implement an evidence-based initiative to improve health care quality through the collection, management and analysis of patient safety events that reduces all cause preventable harm, prevents hospital readmission, or improves care coordination. In such circumstances, CMS provides ?exibility to QHP issuers and their contracted hospitals to identify the relevant documents that can be used to satisfy the documentation requirement captured in 45 CFR to accommodate the variety of types of patient safety initiatives in which hospitals may engage. Hospitals that have internal patient safety initiatives can, for example, demonstrate compliance with a hospital attestation, to document that the hospital implements an evidence-based initiative to improve health care quality through the collection, management, and analysis of patient safety events, that reduces all cause preventable harm, prevents hospital readmissions, or improves care coordination. (REGTAP FAQ Database - FAQ #18038 1 1/03/16) 728 2017--00828 Q: Does a contracted hospital's participation in Quality Innovation Network-Quality Improvement Organization (QIN-QIO) patient safety activities count for purposes of fulfilling the Qualified Health Plan (QHP) patient safety requirement under 45 CFR A: The QHP issuer patient safety standards for plan years beginning on or after January 1, 2017 captured at 45 CFR are intended to be broad. If a contracted hospital with greater than 50 beds participates with a QIN-QIO and can demonstrate that a patient safety initiative implemented through quality improvement is one that improves health care quality, then it may meet the QHP patient safety standards. The QHP issuer will need to collect from the hospital documentation to demonstrate implementation of an evidence-based initiative to improve health care quality through the collection, management, and analysis of patient safety events that reduces all cause preventable harm, prevents hospital readmission, or improves care coordination. There is no validation requirement; it is the responsibility of the QHP issuer and its contracted hospitals to ensure ongoing compliance. For additional information, please reference the transcript, slides, and recording from webinar on May 3, 2016 related to the QHP patient safety standards. Please use the following link to navigate to the webinar: Once you have accessed the page, scroll down to the Federal Update and Discussion: Section. (REGTAP FAQ Database - FAQ #18039 11/03/16) Q: If a hospital, speci?cally an Long term Acute Care or Rehabilitation facility, has multiple locations which report under one CCN and has a combined total of greater than 50 beds a CCN belongs to a hospital which includes 5 different locations; each location has 12 beds, for a total of 60 beds) subject to the patient safety standards at 45 CFR 156.1110? A: The regulation outlined in 45 CFR ?156.1110 apply to Quali?ed Health Plan (QHP) issuers that contract with hospitals with greater than 50 beds. Similar to the approach for the Medicare Hospital Condition of Participation standards and the issuance of CMS Certi?cation Numbers (CCNs), if a QHP issuer contracts with a hospital entity with multiple locations which report under one CCN and has a combined total of greater than 50 beds, the QHP patient safety standards at 45 CFR would apply. (REGTAP FAQ Database - FAQ #18040 11/03/16) Quality Ratinq System (QRS) and QHP Enrollee Survey Q: What are the guidelines for using QRS quality ratings and QHP Enrollee Survey results from the 2015 beta test in marketing materials? Updated 1-31-17 A: This FAQ serves as guidance to QHP issuers regarding inclusion of 2015 QRS quality ratings and QHP Enrollee Survey results in marketing materials. Since 2015 is a beta test year for the QRS and QHP Enrollee Survey, CMS determined that QHP issuers should not reference these initial results in any marketing materials (whether paper, electronic, or other media). This guidance is in accordance with 45 CFR 156.1120 and 45 CFR 156.1125, which indicates that a QHP issuer may reference the QRS quality ratings and QHP Enrollee Survey results for its QHPs in marketing materials, in a 729 2017--00829 manner speci?ed by HHS. Beginning in 2016, QHP issuers may include their 2016-speci?c results in marketing materials in accordance with CMS guidance. CMS will issue marketing guidelines as part of the Quality Rating System and Quali?ed Health Plan Enrollee Experience Survey: Technical Guidance for 2016 (published in September 2015). (REGTAP FAQ Database - FAQ #13659 10/13/15) Q: In 2016, should enrollees in off-Marketplace plans be excluded from Quality Rating System (QRS) and Qualified Health Plan Enrollee Experience Survey (QHP Enrollee Survey) data submissions? A: Yes, enrollees in plans offered outside the Marketplace (off-Marketplace) should be excluded from the 2016 QRS and QHP Enrollee Survey data submission. Off Marketplace plans include those that mirror Quali?ed Health Plans (QHPs) offered on the Marketplace due to guaranteed availability requirements (Section 147.104a of the Affordable Care Act), and are designated with a HIOS variant ID -00, and other traditional commercial plans, that typically do not have HIOS IDs. Enrollees in QHPs that are offered on the Marketplace, regardless of how they enrolled in these QHPs, should be included in the 2016 QRS and QHP Enrollee Survey data submissions. CMS is putting emphasis on the plan in which an enrollee enrolled, rather than the method of enrollment, as it is possible for an individual to enroll in a QHP offered on the Marketplace through a means other than a Marketplace. For example, an eligible enrollee who does not have access to a Marketplace website could enroll in a Marketplace QHP directly with a QHP issuer; such an enrollee is to be included in 2016 QRS and QHP Enrollee Survey data submissions. These QHPs will be designated by HIOS ID variants -01 through -06. (REG TAP FAQ Database - FAQ #14045 11/20/15) Q: Should an issuer use its Quality Rating System (QRS) survey results as its Quality Improvement Strategy (QIS) baseline data in Element 24 of the QIS Implementation Plan and Progress Report form? A: Issuers are not required to use QRS survey results for their QIS baseline data. Issuers may choose to use QRS survey results or may choose to use other data sources that identify QHP enrollee population needs and support their QIS rationale for their QIS baseline data in Element 24 of the QIS Implementation Plan and Progress Report form. (REGTAP FAQ Database - FAQ #14787 02/10/16) Q: What is the due date for Quality Improvement Strategy (QIS) Implementation Plan and Progress Report form submission? Updated 1-31-17 A: The QIS Implementation Plan and Progress Report form must be submitted during the QHP Application Submission and Review Period (QHP Application Period). proposed timeline can be found in the 2017 Draft Letter to Issuers. (REGTAP FAQ Database - FAQ #14788 02/10/16) 730 2017--00830 Q: Should an issuer password protect or scan its Quality Improvement Strategy (QIS) Implementation Plan and Progress Report form prior to submission? A: No. Issuers should not password protect or scan their QIS Implementation Plan and Progress Report forms prior to submission via the Health Insurance Oversight System (HIOS) or the System for Electronic Rate and Form Filing (SERFF). Issuers should submit their QIS forms as ?llabIe-PDF ?les, as opposed to ?les that have been scanned. Password protecting and/or scanning QIS submissions prevents the Centers for Medicare Medicaid Services (CMS) from processing QIS submissions for evaluation. Issuers who submit scanned and/or password protected QIS Implementation Plan and Progress Report forms will be asked to reformat and/or remove password protection and resubmit. (REGTAP FAQ Database - FAQ #16817 07/19/16) Q: Can Qualified Health Plan (QHP) issuers reference the 2016 Quality Rating System (QRS) star ratings and QHP Enrollee Experience Survey results in their marketing materials? A: QHP issuers may reference their respective 2016 QRS star ratings and QHP Enrollee Experience Survey results in their marketing materials if the issuer participates in a consumer display pilot State (Michigan, Ohio, Oregon, Virginia, Wisconsin), or if the issuer is in an SBM that chooses to display 2016 QRS star ratings for the 2017 open enrollment period. These QHP issuers may reference the 2016 quality rating information (Le, 2016 QRS star ratings and QHP Enrollee Experience Survey results) in accordance with the guidelines outlined in the 2016 QRS and QHP Enrollee Experience Survey Technical Guidance. CMS will also provide additional supplemental disclaimer language that the issuers must include to inform consumers that CMS is conducting additional consumer testing regarding the public display of this quality rating information. QHP issuers that are not participating in a pilot State or are participating in an SBM that chooses not to display 2016 QRS star ratings for the 2017 open enrollment period should not reference the 2016 quality rating information in their marketing materials. For more information on pilot for the 2016 QRS star ratings, reference the Quality Rating Information Bulletin at The 2016 QRS and QHP Enrollee Experience Survey Technical Guidance can be accessed at (REGTAP FAQ Database - FAQ #17068 08/03/16) Q: Can Qualified Health Plan (QHP) issuers reference the 2016 Quality Rating System (QRS) star ratings and QHP Enrollee Experience Survey results in their marketing materials? Updated 1-31-17 A: QHP issuers may reference their respective 2016 QRS star ratings and QHP Enrollee Experience Survey results in their marketing materials if the issuer participates in a consumer display pilot State (Michigan, Ohio, Oregon, Virginia, Wisconsin), or if the issuer is in an SBM that chooses to display 2016 QRS star ratings 731 2017-?00831 for the 2017 open enrollment period. These QHP issuers may reference the 2016 quality rating information (Le, 2016 QRS star ratings and QHP Enrollee Experience Survey results) in accordance with the guidelines outlined in the 2016 QRS and QHP Enrollee Experience Survey Technical Guidance. CMS will also provide additional supplemental disclaimer language that the issuers must include to inform consumers that CMS is conducting additional consumer testing regarding the public display of this quality rating information. QHP issuers that are not participating in a pilot State or are participating in an SBM that chooses not to display 2016 QRS star ratings for the 2017 open enrollment period should not reference the 2016 quality rating information in their marketing materials. For more information on pilot for the 2016 QRS star ratings, reference the Quality Rating Information Bulletin at 6.pdf The 2016 QRS and QHP Enrollee Experience Survey Technical Guidance can be accessed at (Transparency, QHP Obligations, and QRS Marketing Guidelines FAQS 08/04/16) Q: For the Quality Rating System (QRS) Immunizations for Adolescents (IMA) measure, will Qualified Health Plan (QHP) issuers be required to submit data for Combinations 1 and 2 for the 2017 QRS ratings year (the 2017 No. For the 2017 QRS, QHP issuers are only required to submit validated data for Combination 2 of the Immunizations for Adolescents (IMA) measure, including the related antigens. This updated IMA measure will not be used in QRS scoring for 2017, given the changes with this measure speci?cation. Details on the QRS measure data submission requirements are provided in the QRS and QHP Enrollee Survey: Technical Guidance for 2017, available at: QRS and QHP Enrollee Surve Technical Guidancepdf . (REGTAP FAQ Database - FAQ #18003 10/31/16) Q1: What disclaimers are QHP issuers required to display in their marketing materials alongside 2016 quality rating information? Updated 1-31-17 A1: QHP issuers may reference their respective 2016 QRS star ratings and QHP Enrollee Experience Survey results in their marketing materials if the issuer participates in a consumer display pilot State, or if the issuer is in a State-based Marketplace (SBM) that chooses to display 2016 QRS star ratings for the 2017 open enrollment period. These QHP issuers must prominently display the following disclaimer language to inform consumers that CMS is conducting additional consumer testing regarding the public display of this quality rating information: 732 2017--00832 1. Plan quality ratings and enrollee survey results are calculated by CMS using data provided by health plans in 2016. The ratings will be displayed for health plans for the 2017 plan year. CMS is testing the use of star ratings this year and will use this test to improve the program. Learn more about these ratings. [Link to appropriate explanatory page on respective Marketplace?s site.] For more information on consumer display pilot for the 2016 QRS star ratings, reference the Quality Rating Information Bulletin at 110/ Resources/ Regulationsand-Guidance/ Downloads/QRS-Bulletin-4- 29-2016.pdf. For more information on 2016 quality rating information marketing guidelines, reference the 2016 QRS and QHP Enrollee Experience Survey Technical Guidance at . (REG TAP Quality Rating System (QRS) FAQ 12/06/16) Attestations 02: How should issuers respond to Small Business Health Options Program (SHOP) attestations if they only intend to participate in the individual market? A2: The ?nal Program Attestations are written so that if an issuer does not offer QHPs in the SHOP, a response of "yes" will indicate that the issuer does not sell in that market. (Plan Management Webinar QHP FAQ #2 04/09/13) Q11: There is an attestation that asks whether there is any pending legal action against the issuer. Is that limited to any pending legal action by the government? A11: This attestation relates to pending legal action against the issuer in connection with the performance or award of a contract or grant with the Federal or State government. (Plan Management Webinar QHP FAQ #2 04/09/13) 06: What is the CMS guideline for significant change to the organizational chart? Who in HHS do we need to inform of the significant change? If there is not a specific person, what group within HHS do we need to inform? A6: What is considered a significant change varies for each organization depending on its organizational structure, the size of the organization, and the chain of command for reporting operational issues. Changes that could be reasonably foreseen to affect the day-to-day operations of the QHP issuer in an FFE or to compromise the ability of the QHP issuer to maintain compliance with Federal standards should be reported to the FFE. Issuers operating QHPs in the FFE will be assigned a CMS Account Manager as their primary point of contact, and are encouraged to discuss signi?cant organizational changes with that person. (QHP Webinar Series FAQ #5 04/18/13) Q7: How should we respond to the Stand Alone Dental Attestation if we are not offering Stand-Alone Dental plans? What happens to the 3 sub-questions in this case? A7: In the Stand Alone Dental Attestation section, selecting ?Yes? indicates that either: 733 Updated 1-31-17 2017--00833 - You are attesting to all the statements in the section, OR - You do not offer Stand Alone Dental plans. (QHP Webinar Series FAQ #5 04/18/13) Q4: In the attestations section, what does it mean that we will ?accept? the total premium breakdown from the Exchange? A4: The FFE will use the rate tables submitted by QHP issuers during QHP certi?cation to determine the total premium amount (and associated premium breakdown) for the enrollment group. This breakdown is captured in the 2750 loop of the 834 transaction. If QHP issuers do not believe that the Exchange arrived at the correct total premium amount (and associated premium breakdown) for the enrollment group, there will be a process established to resolve any discrepancies. (QHP Webinar Series FAQ #6 04/23/13) Q1: Does a certi?cation year equal exactly 12 months? A1: In the Federally-facilitated Exchange, a certi?cation year is 12 months. At 45 CFR 155.1075, we state that ?an Exchange must establish a process for recerti?cation of For the FFE, we have established that QHP certification is for 12 months, as generally discussed in various guidance documents, including the Letter to Issuers on Federally-facilitated and State Partnership Exchanges, published on April 5, 2013, at letter to issuers 04052013.pdf . We note that this does not apply to CO-OP and Multi-State Plans. (QHP Webinar Series FAQ #7 04/24/13) QZ: What if an issuer is unable to correct a deficiency within the resubmission window? For example, what if the problem is with the certification of good standing? A2: If the de?ciency identified requires follow-up with the State or other parties that cannot be completed in the time allowed for resubmission, the issuer should submit an explanation describing the activities being conducted to address the de?ciency. (QHP Webinar Series FAQ #7 04/24/13) Q3: What supplementary documentation is needed for the "Good Standing" section? A3: If the issuer is in compliance with State solvency requirements and is not under any corrective action related to financial review, then no supporting documentation is required. Please see Chapter 4 of the Instructions for a description of supporting documentation and justi?cations required if an issuer is out of compliance or under corrective action. (QHP Webinar Series FAQ #7 04/24/13) Q4: Is a final provider directory required at the time of application or may updated provider directories be submitted after the QHP application is submitted? A4: Issuers are required to provide a URL link to their provider directory at the time of submission. However, the sites themselves do not need to be live until open enrollment. Also, Issuers will have the opportunity to correct any errors to URLs that are provided at the time of submission during the plan preview period. (QHP Webinar Series FAQ #7 04/24/13) 734 Updated 1-31-17 2017--00834 Q5: When can issuers update their provider directories? A5: If an issuer has an error in the network URL, the issuer can submit a correction during the resubmission window or during plan preview in late August. No changes will be accepted after Plan Preview. (QHP Webinar Series FAQ #7 04/24/13) 06: Where do issuers submit plan materials such as evidence of coverage? A6: Supplemental documentation such as evidence of coverage can be submitted using the upload ?supplemental document" feature in the Benefits Service Area module of the QHP Application. Users may refer to Plan and Benefits user guide for additional information on submitting supplemental documents. (QHP Webinar Series FAQ #7 04/24/13) Q2: What are the specific actions that an issuer attester must perform? A2: The attester will be required to agree to the final plan offerings list, which will contain the QHPs the FFE is recommendation for certi?cation, as well as sign the QHP Agreement. The submitter and validator will provide the response to the Program Attestations during the initial QHP submission. The Attester?s input is not required during the initial submission window. (QHP Webinar Series FAQ #9 05/03/13) Q4: Where are the specific attestations asking about network adequacy? A4: The attestations relating to network adequacy are listed in QHP Instructions: Chapter 06 Network Adequacy Instructions which can be found on the Website. (QHP Webinar Series FAQ #12 06/28/13) Q: In the attestations section, what does it mean that we will ?accept? the total premium breakdown from the Marketplace? A: The FFM will use the rate tables submitted by QHP issuers during QHP certification to determine the total premium amount (and associated premium breakdown) for the enrollment group. This breakdown is captured in the 2750 loop of the 834 transaction. If QHP issuers do not believe that the Marketplace arrived at the correct total premium amount (and associated premium breakdown) for the enrollment group, there will be a process established to resolve any discrepancies. (REGTAP FAQ Database - FAQ #2163 06/11/14) Q1: Where can I ?nd the Statement of Detailed Attestation Responses for issuers in Federally-facilitated Marketplaces (FFMs), State-partnership Marketplaces (SPMs) and State-based Marketplaces A1: CMS has posted the FFM and SPM statements on the Center for Consumer Information and Insurance Oversight (CCIIO) Quali?ed Health Plan (QHP) website: marketplaces/th.htm Issuers in SBMs should reach out to their state regulators for a copy of the SBM statement. (QHP Certification Process FAQs #2 {09/29/15)} 735 Updated 1-31-17 2017--00835 Q2: Can the Centers for Medicare Medicaid Services (CMS) provide specifics for the modifications to Attestations added to the latest version of the Statement of Detailed Attestations? A2: CMS has released a crosswalk of the changes to program attestations at Crosswalk 2015v32016 5 CR 040715.9df (QHP Certi?cation Process FAQs #2 (09/29/15)) Q3: Are Attestations optional for the 2016 Plan Year? A3: Issuers applying for QHP certification for the 2016 plan year in FFM states must complete the program attestations section of the application, either in the HIOS module or through submission of the appropriate Statement of Detailed Attestation Responses. Issuers applying for QHP certification in SPM states must complete and submit the SPM Statement of Detailed Attestations located on the CCIIO QHP website: marketplaces/th.html (QHP Certi?cation Process FAQs #2 {09/29/15)} Q4: Per the Attestations and Good Standing Qualified Health Plan (QHP) Application?s guidelines, the test link column mentions ?no template uploads Attestations? in the Health Insurance Oversight System (HIOS) Issuer Module. How are issuers to proceed with Attestation submissions in A4: Good Standing and Program Attestations are required sections of the QHP application, though neither requires the submission of a template to complete. Rather, these sections are completed within HIOS. Depending on an applicant?s response to the Program Attestations within HIOS, an applicant may need to complete and submit a Statement of Detailed Attestations document as part of their QHP Application. Detailed guidance is provided in both the QHP Application Instructions (found here: marketplaces/th.html) and in the HIOS Issuer Module User Guide. (QHP Certi?cation Process FAQs #2 (09/29/15)) Q1: Will the 2016 Attestation form require an electronic signature? A1: An ?ink? signature or a certi?ed electronic signature are acceptable. (QHP Certi?cation Process FAQs #4 {09/29/15)} QZ: When are program attestations due? A2: Like all other components of the QHP application, program attestations were to be completed and submitted to CMS by the end of the Initial FFM QHP Application Submission Window on May 15, 2015. After that date, if any corrections are required of an issuer's program attestations, they must be made and submitted by the Final Deadline for Submission of QHP Data on August 25, 2015. (QHP Certi?cation Process FAQs #4 (09/29/15)) 736 Updated 1-31-17 2017--00836 Plan Preview (Individual and SHOP) Q1: What is the Plan Preview period? A1: Plan Preview will be conducted in August during which issuers in SPMs and FFMs will be able to log into HIOS and review a selection of their submitted issuer and plan data. The data that will be displayed during plan preview will represent all of the issuer?s submitted plans, not necessarily those that will be certi?ed as QHPs. Issuers will be able to communicate any data errors to CMS and will then have an opportunity to correct certain data within a speci?ed timeframe. (Plan Management Webinar QHP FAQ #13 7/29/13) QZ: When is Plan Preview? A2: Plan Preview will begin on August 8, 2013. Issuers should plan to submit all requests to make changes to QHP data by August 16th and to make any necessary data submissions with adjusted QHP data templates by August 23rd. (Plan Management Webinar QHP FAQ #13 7/29/13 Updated 06/30/14: A: Plan preview begins on June 30. FFM issuers will be able to access Plan Preview to view their data starting June 30. Issuers in states performing plan management functions will be able to view their data after their state transfers it from SERFF. Exact dates for SERFF transfers will be dependent on state-specific deadlines. (REGTAP FAQ Database - FAQ #2448 06/30/14) Q3: When can issuers view or change their accreditation information? A3: QHP issuers will be able to review their accreditation status and CAHPS data between August 19th and August 23rd. Issuers will be asked to submit requests for updates/corrections to accreditation data as rapidly as possible after August 19th. Issuers that have received a new accreditation from NCQA or URAC may update their applications during Plan Preview from August 8th to August 23rd (Plan Management Webinar QHP FAQ #13 7/29/13) Q4: If an issuer submitted its QHP data through SERFF, will it be able to review its data during Plan Preview? Updated 1-31-17 A4: Yes. Plan Preview is for all issuers in Federally-facilitated Marketplaces (FFM) and State Partnership Marketplaces (SPM). Issuers that submitted QHP Applications in SERFF will be able to view their plan data in Plan Preview in the HIOS system. If an FFM issuer was asked by its state to submit a separate QHP application submission in SERFF, these data will not be transferred to HIOS. The data that will be displayed for Plan Preview for these states will be the data that were submitted into HIOS. (Plan Management Webinar QHP FAQ #13 7/29/13) Updated 06/30/14: A: Yes. Plan Preview is available to all issuers who have applied to have plans available on the FFM. Issuers that submitted QHP Applications in SERFF will be able to view their 737 2017--00837 plan data in Plan Preview in the HIOS system after their state transfers data through SERFF. If an FFM issuer was asked by its state to submit a separate QHP Application submission in SERFF, these data will not be transferred to HIOS. The data that will be displayed for Plan Preview for FFM states will be the data that were submitted into HIOS. (REG TAP FAQ Database - FAQ #2449 06/30/14) Q5: How can an issuer access the Plan Preview module in A5: Issuers in FFM and SPM states must have Validator user roles in HIOS. Issuers that do not already have HIOS User IDs should follow the instructions in the HIOS User Guide (located at the link below) to request a HIOS User ID. The issuer will need to request a Validator role for at least one of the following three QHP modules in HIOS: the QHP Issuer Module; the QHP Bene?ts Service Area Module; or the QHP Rating Module. The link to the HIOS User Guide is: user manual 032013.pdf (Plan Management Webinar QHP FAQ #13 7/29/13) Updated 6/30/14: A: Issuers must have a Validator or Submitter user role in HIOS. Issuers that do not already have HIOS User IDs should follow the instructions in the HIOS User Guide (located at the link below) to request a HIOS User ID. The issuer will need to request a Validator or Submitter role for at least one of the following three QHP modules in HIOS: the QHP Issuer Module; the QHP Bene?ts Service Area Module; or the QHP Rating Module. The link to the HIOS User Guide is: user manual 032013.pdf (REGTAP FAQ Database - FAQ #2451 06/30/14) 06: What will be the process for Plan Preview of OPM Multi-State Plans A6: OPM MSPs will be on a later timeline than QHPs. CMS is working with OPM to define the process and timeline for Plan Preview for MSPs. (Plan Management Webinar QHP FAQ #13 7/29/13) Updated 6/30/14: A: MSP Plan Preview in the FFM plan preview module in HIOS will occur later than FFM Plan Preview. Please contact OPM for further details. (REG TAP FAQ Database - FAQ #2452 06/30/14) Q7: What data can issuers check and validate during Plan Preview? A7: Issuers will be able to view the following three pages during the Plan Preview period: the Plan Preview Summary page, the Rating Scenarios page, and the Plan Details page. The Plan Preview Summary and Rating Scenarios pages will provide the issuer with the opportunity to view their list of submitted plans and to select a plan, a rating scenario, and a zip code in order to populate a Plan Details page. The Plan Details page displays plan information in a manner similar to the Consumer Portal. This information includes the calculated premium for the plan according to the selected rating scenario, other cost information such as the deductible and out-of?pocket maximum for the plan, and selected cost-sharing information for certain bene?ts. (Plan Management Webinar QHP FAQ #13 7/29/13) 738 Updated 1-31-17 2017--00838 Q: In our Plan Display, our Insurance Regulator reported our deductible shows with the verbiage 'group total'. Since this is showing on Individual Plans, what does that verbiage mean? A: The deductible value displayed is tailored to the enrollment group size. A single person enrollment group is shown the single deductible, while a multi-person enrollment group is shown the family deductible. The same "group total" label is shown for both single and family enrollment groups. (REGTAP FAQ Database - FAQ #1352 03/31/14) Q: Why do benefits display both the copay and coinsurance in Plan Preview? A: If the issuer submitted both a copay and coinsurance for a particular bene?t, both cost-sharing elements will display. On the initial plan results view, only in-network Tier 1 cost sharing is displayed, while the detailed plan view displays out-of-network cost- sharing as well. (REGTAP FAQ Database - FAQ #1353 03/31/14) Q: For the Federally-facilitated Small Business Health Options Program (FF-SHOP) Marketplace, will the list of benefits display in the details/summary screen for a plan? A: Yes, a list of benefits from the Plan Management templates will display on the Plan Details page. (REGTAP FAQ Database - FAQ #3777 08/14/14) Q3: Which internet browsers support Plan Preview? A3: Issuers may use Internet Explorer Versions 9 and 10, Firefox Version 28, and Chrome Version 33 for Plan Preview. (QHP Certification Process FAQs #5 (09/29/15) Q4: Will the 2016 Plan Preview format remain the same as last year? A4: There are expanded capabilities, additional scenarios, and improvements to the 2016 Plan Preview. The Centers for Medicare and Medicaid Services (CMS) provided training during the May 21, 2015 Quali?ed Health Plan (QHP) webinar session. Slides are available at: Slides 052115 5CR 052715.pdf (QHP Certi?cation Process FAQs #5 {09/29/15) 05: How long will Plan Preview be accessible to issuers? A5: Plan Preview will be available until at least data lockdown on August 25, 2015. (QHP Certification Process FAQs #5 {09/29/15) 02: In Plan Preview, if the last smoking date was greater than six months ago will the enrollee receive a non-smoker rate? A2: The tobacco look-back period is a maximum of six months for Quali?ed Health Plans (QHPs), so the enrollee will receive a non-smoker rate. (QHP Certi?cation Process FAQs #6 (09/29/15) 739 Updated 1-31-17 2017--00839 Q3: Will Plan Preview display plans for a sixty-five year of age or older consumer? A3: Yes, Plan Preview will display plans for a sixty-?ve year of age or older consumer. (QHP Certi?cation Process FAQs #6 {09/29/15) Q4: Do the data elements for ?Maximum Coinsurance for a Specialty Drug? and ?Maximum Number of Days for Charging an Inpatient Copay?, appear on Plan Preview? A4: No, those data elements do not appear on Plan Preview because they are not displayed to consumers on Healthcare.gov. Issuers can explain the maximum coinsurance in the Bene?t Explanation field, which does appear in Plan Preview. (QHP Certification Process FAQs #7 {09/29/15)} Q1: What modifications were made to the dental benefits icon in Plan Preview and Plan Compare for Stand-alone dental plans in the individual market Federally-facilitated Marketplaces? A1: As part of a planned technical correction to Plan Preview and Plan Compare for individual market Stand-alone dental plans (SADPs), the dental benefits icon will now only display for those SADPs with three categories of adult benefits. Prior to the correction, SADPs with two adult bene?ts were erroneously displayed as providing a ?Dental: Child Adult? icon on the plan selection page. The Centers for Medicare Medicaid Services (CMS) made this technical change in order to be consistent with our stated policy, as noted in the 2014, 2015 and 2016 Plan Preview User Guide.1 The User Guide explains that in order to have the ?Dental: Child Adult? icon display, CMS requires SADPs to cover three categories of pediatric bene?ts Dental Check-up, Basic, and Major), as well as all three categories of adult bene?ts Routine, Basic, and Major). CMS believes that a consumer should have the general expectation that an SADP that offers adult bene?ts would cover services typically offered by a dental plan, including preventive care and minor and major dental services. This is similar to how CMS interprets pediatric bene?ts for the purpose of displaying the ?Dental: Child? icon. However, CMS understands that some issuers may not have noted this policy even though it is articulated in the Plan Preview User Guide. As such, CMS is giving issuers that did not meet the standard for displaying the "Dental: Child Adult? icon the opportunity to meet the criteria by submitting a Data Change Request and correcting their data within the Data Correction Window to re?ect the addition of Major Dental to their adult bene?ts in order to have the applicable icon display, to the extent such a change is permitted in accordance with applicable State requirements. Affected issuers have been sent an email inviting the issuer to participate in the Data Correction Window. (REG TAP FA Q: Dental Plan Preview and Plan Compare display (10/09/15)) Process for Requesting Changes to QHP Data Displayed on Plan Preview 08: What is the process for making a change to QHP data in the QHP Application submission? A8: Issuers that wish to make changes to their QHP data templates based on the display in Plan Preview should submit a request to the XOSC Helpdesk. The XOSC Help Desk 740 Updated 1-31-17 2017--00840 may be contacted via email at CMS FEPS@cms.hhs.qov or via phone at 1515. CMS encourages issuers to consolidate the changes they would like to make in as few communications to the Help Desk as possible. All corrections except rate corrections can be grouped in a single communication. Rate corrections can be grouped together in a second communication. However, to the extent that an issuer identi?es problems with the premium calculations displayed in Plan Preview, CMS encourages the issuer to first work through any additional rating scenarios and plans that they have not yet tested and then contact CMS via the Help Desk as soon as possible. When contacting the Help Desk, issuers should include the following information: Subject Line: ?Request to Change QHP Data for Issuer (HIOS A. HIOS Application ID B. HIOS Issuer ID C. Issuer Name D. Issuer State E. Impacted Plan ID (and variant if applicable) F. Screenshot highlighting where the problem exists (if sending an email) G. Notation of the inputs selected in the rating scenarios if identifying a premium calculation error H. Description of the change(s) requested and as much description as possible of the error or problem identi?ed I. Justification if changing the Plan Bene?ts, Business rules, or Rating Table Template(s) (Plan Management Webinar QHP FAQ #13 7/29/13) Updated 6/30/14: A: Issuers may make changes to their QHP Application submission by resubmitting their templates to the appropriate application system. Issuers that submitted in HIOS should resubmit in HIOS. Issuers that submitted in SERFF should resubmit in SERFF, and then contact their state about retransferring their data from SERFF to HIOS. For issuers in FFM states, please note that while issuers may resubmit their templates to view updated data on Plan Preview, CMS will review data that was in the system on the QHP deadline dates. New data received after these deadlines will not be reviewed until the next data submission window. All data changes must be approved by the issuer's state or for QHP or Dual issuers in Direct Enforcement states, CMS Form Filing must approve the changes. (REGTAP FAQ Database - FAQ #2455 06/30/14) 09: What QHP data can Issuers request to change during Plan Preview? Updated 1-31-17 A9: Issuers will only be allowed to change data that do not trigger a re-review of the issuer?s QHP Application. Issuers may not change any data during Plan Preview without the explicit and speci?c approval of CMS. To assist issuers in preparing for Plan Preview and for submitting requests for data changes, below is a draft list of data changes that CMS will likely approve. However, even if a data element appears on this list, all issuers must submit a formal request and obtain CMS approval before altering the QHP Application. To the extent that issuers wish to change additional data, these requests should also be routed through the same process. However, CMS is unlikely to approve significant data changes beyond the list below. Requests for changes that CMS expects to approve include changes to: . Issuer Marketing Name 741 2017-?00841 Plan Marketing Name Network URL Formulary URL Plan Brochure URL SBC URL Enrollment Payment URL Certain ?elds on Plans Benefits Template: Is a referral required for a specialist? 0 Specialist requiring a referral Bene?t-Level Exclusions (deletions permitted; revisions must be substantively equal to original) 0 Bene?t-Level Explanations (deletions permitted; revisions must be substantively equal to original) 0 Wellness Program Offered 0 Disease Management Program Offered . Issuer business rules 0 Issuer rating tables (only changes not impacting the URRT will be allowed) Accreditation status and other ?elds in the Accreditation Template (Plan Management Webinar QHP FAQ #13 7/29/13) Q10: How will an issuer know whether a request for change has been approved? A10: CMS will review each request to change QHP data, and consult with the state if applicable. After a determination is made, issuers will receive a response to their help desk tickets. Some issues will be resolved more quickly than others depending on complexity. (Plan Management Webinar QHP FAQ #13 7/29/13) Q11: How do issuers make approved changes? A11: Issuers that originally submitted their applications in HIOS should log into HIOS and make the necessary corrections to the application templates. Issuers that originally submitted their applications in SERFF will submit their changes into SERFF. CMS will work with each state to approve requests for changes, and states may be reaching out to issuers related to these requests. (Plan Management Webinar QHP FAQ #13 7/29/13) Q12: How will an issuer confirm that changes have been processed and uploaded? Updated 1-31-17 A12: For changes submitted into HIOS, most changes will be processed by the system within approximately 24 hours and appear on Plan Preview the next day; however, in some instances this may take more time. Changes submitted into SERFF will likely take longer to appear in HIOS. Issuers should check HIOS to verify their new data before the end of Plan Preview on August 23rd. Issuers may not be able to con?rm updates/corrections to accreditation data due to the need to verify this data with NCQA and/or URAC. (Plan Management Webinar QHP FAQ #13 7/29/13) Updated 6/30/14: A: For changes submitted into HIOS, most will be processed and appear in Plan Preview within 24 hours of issuer cross-validation; however, in some instances it may take more time. Changes submitted into SERFF will take longer to appear in Plan Preview, and will depend on the state re-transferring data. Once the data has been successfully transferred by the state to HIOS, plans will appear in Plan Preview. 742 2017-?00842 For issuers in FFM states, please note that while issuers may resubmit their templates to view updated data on Plan Preview, CMS will review data that was in the system on the QHP deadline dates. New data received after these deadlines will not be reviewed until the next data submission window. All data changes must be approved by the issuer's state or for QHP or dual issuers in Direct Enforcement states, CMS Form Filing must approve the changes. (REGTAP FAQ Database - FAQ #2456 06/30/14) Q13: How will states be involved in the Plan Preview process? A13: CMS will involve the state in approving or disapproving requests for data changes submitted by issuers to the extent desired by the state. SPM states will also need to communicate with issuers about making changes in SERFF associated with approved requests for changes. Finally, states will need to send only revised plans in SERFF to HIOS so the revised data can be viewed in Plan Preview. (Plan Management Webinar QHP FAQ #13 7/29/13) Updated 6/30/14: A: States performing plan management functions will communicate with issuers about making changes in SERFF. States send revised data from SERFF to HIOS, after which the revised data will display in Plan Preview. States will also have the opportunity to view issuer data in Plan Preview, and may contact issuers about the displayed information. (REGTAP FAQ Database - FAQ #2457 06/30/14) Q14: What is the process for updating an Issuer Marketing Name? Updated 1-31-17 A14: The issuer will need to utilize the existing HIOS web edit feature to make changes to its Issuer Marketing Name. Issuers wishing to make this change will need to take the following steps: 1. Login to HIOS 2. Navigate to the Plan Finder (PF) module listed under HIOS Functions 3 Select the ?View Issuer Submitted Data? tab a. Select the ?Issuer General Information? link 4. Using the dropdown, select the Issuer requiring the Marketing Name update 5. Under the ?Issuer General Information for Issuer: select ?Edit Issuer General Information? 6. The Issuer Marketing Name is the second data element from the top in the right hand column 7. After making the desired change scroll to the bottom of the page a. Select the ?Submit? button 8. The change is then committed to the database and seen on the screen The Issuer Marketing Name does not need to be changed in the Administrative Template unless the issuer wishes to change other data elements in this template. If the issuer wishes to change other data in the Administrative Template, the issuer will first need to make the change to the Issuer Marketing Name in the HIOS web edit feature and then download a new version of the Administrative Template with the revised Issuer Marketing Name pre-populated in the template. Then the template can be resubmitted into the QHP Issuer Module. (Plan Management Webinar QHP FAQ #13 7/29/13) 743 2017--00843 Q15: Can issuers change rates during Plan Preview? A15: Issuers may make corrections to the rating template or to the business rules template, but any such corrections must not impact an issuer?s rates as submitted on the Unified Rate Review Template and approved by the applicable regulator the state department of insurance). Any corrections to rating tables or business rules must be approved or requested by the applicable review authority. (Plan Management Webinar QHP FAQ #13 7/29/13) Updated 6/30/14: A: Issuers may make corrections to the Rates Table template or to the Business Rules template. Rates must match what was approved and submitted on the Unified Rate Review template. Any corrections to Rates Table templates or Business Rules template must be approved or requested by the applicable review authority. (REGTAP FAQ Database - FAQ #2458 06/30/14) Q16: Do QHP issuers need to provide a URL for the Summary of Benefits and Coverage (SBC) during plan preview? A16: Yes, if a QHP issuer has not already provided a URL for the 880, an issuer must include the URL during plan preview. As noted in Chapter 10: Instructions for the Plans Benefits Application Section, while this was identi?ed as an optional field, issuers are required to submit it prior to open enrollment. SADP issuers are not required to provide a URL for the SBC. (Plan Management Webinar QHP FAQ #13 7/29/13) Q: What is Plan Preview? A: Plan Preview is an opportunity for issuers to review a selection of their submitted issuer and plan data in HIOS. Plan Preview will display data similarly to how consumers view plan data on Plan Compare in HealthCare.gov. Issuers will be able to address any data issues by re-submitting their templates with corrected data. If issuers believe the display is due to a system issue, they should submit a ticket to the XOSC Helpdesk at CMS FEPS@cms.hhs.qov. (REGTAP FAQ Database - FAQ #2447 06/30/14) Q: Will SBM issuers be able to view their data in Plan Preview? A: No. The federal Plan Preview functionality is for issuers who have applied to have plans available on the FFM. Issuers in SBMs should consult their State Marketplace for any information about any equivalent plan preview functionality in their state. (REGTAP FAQ Database - FAQ #2450 06/30/14) Q: Will Issuers be able to see 2014 Plan Data? Updated 1-31-17 A: No, Plan Preview will display only 2015 Plan Data. (REGTAP FAQ Database - FAQ #2453 06/30/14) 744 2017-?00844 Q: Will SADP Issuers be able to view dental plans in the unique dental display in Plan Preview? A: Yes, Plan Preview supports both QHP and SADP plan display. (REGTAP FAQ Database - FAQ #2454 06/30/14) Q: Will issuers be able to see all plans in Plan Preview? A: HIOS submitters will be able to view all plans submitted in their application. Issuers in states performing plan management functions that submitted in SERFF will only be able to view plans that their state has transferred to HIOS. Issuers that are not seeing a plan display that they believe should be displaying should contact the XOSC Helpdesk at CMS FEPS@cms.hhs.qov or their state, as applicable. (REGTAP FAQ Database - FAQ #2459 06/30/14) Q: After a HIOS submitter completes the QHP submission, how does the issuer make changes to the data as a result of the Plan Preview review? A: QHP data will display in Plan Preview after an issuer's QHP submission is in ?Cross- Validation Complete? status. If the issuer wishes to make changes, it would remove the QHP submission from Cross-Validation, upload any new templates, and then complete cross-validation again to have the new data display in Plan Preview. For issuers in FFM states, please note that while issuers may resubmit their templates to view updated data on Plan Preview, CMS will review data that was in the system on the QHP deadline dates. New data received after these deadlines will not be reviewed until the next data submission window. All data changes must be approved by the issuer's state or for QHP or dual issuers in Direct Enforcement states, CMS Form Filing must approve the changes. (REGTAP FAQ Database - FAQ #2460 06/30/14) Q: After an issuer in a state performing plan management functions completes the QHP submission, how can that issuer make changes to the data as a result of their Plan Preview review? A: The issuer should reach out to the state for permission to make changes to the SERFF binder. If approved, the issuer should make the changes in SERFF, and then request that their state re-transfer their binder to HIOS. After the data is transferred, the issuer will be able to see the updated data in Plan Preview. (REGTAP FAQ Database - FAQ #2461 06/30/14) Q: How often can an issuer make modi?cations to the displayed plan data? A: Issuers will be able to make ongoing modi?cations to their templates until September 4, 2014. HIOS submitters must complete the cross-validation process in HIOS in order for new data to display in Plan Preview. SERFF submitters are dependent upon and thus potentially limited by their states transferring their data into HIOS. For issuers in FFM states, please note that while issuers may resubmit their templates to view updated data on Plan Preview, CMS will review data that was in the system on the QHP deadline dates. New data received after these deadlines will not be reviewed until the next data submission window. All data changes must be approved by the issuer's 745 Updated 1-31-17 2017--00845 state or for QHP or dual issuers in Direct Enforcement states, CMS Form Filing must approve the changes. (REGTAP FAQ Database - FAQ #2462 06/30/14) Q: Will issuers need to refile all templates in HIOS in order to change content displayed in Plan Preview? A: No. Issuers only need to resubmit the changed template. However, issuers must complete the cross validation process in HIOS in order for new data to display in Plan Preview. SERFF submitters will see their changes in Plan Preview after their state transfers their data into HIOS. For issuers in FFM states, please note that while issuers may resubmit their templates to view updated data on Plan Preview, CMS will review data that was in the system on the QHP deadline dates. New data received after these deadlines will not be reviewed until the next data submission window. All data changes must be approved by the issuer's state or for QHP or dual issuers in Direct Enforcement states, CMS Form Filing must approve the changes. (REGTAP FAQ Database - FAQ #2463 06/30/14) Q: If an issuer has a question about Plan Preview, how should the issuer contact A: Issuers should contact the XOSC Helpdesk at CMS FEPS@cms.hhs.qov. Please fully describe both the data submitted by the issuer, the question about the display, and provide screenshots as applicable. Please ensure that each ticket includes the below information: Email subject line: Plan Preview Question" 2) HIOS Issuer ID (the one you were viewing) Issuer name Issuer state Impacted Plan A screenshot of the issue Date of the error The data element in question (please refer to the Plan Preview User Guide) A detailed description of the problem, including: What is appearing in Plan Preview, and what the user was expecting to see 0 What demographic information was entered in Plan Preview for both the primary and secondary subscriber 10) Preferred contact information (desk, mobile, email) in case the Help Desk needs to follow-up on your ticket (REGTAP FAQ Database - FAQ #2464 06/30/14) Q: If a state performing plan management functions requires an issuer to submit to SERFF, should the issuer also submit data in HIOS in order to access Plan Preview earlier? Updated 1-31-17 A: No. Issuers that submit in SERFF for a state performing plan management functions should not also submit their data in HIOS. Doing so will cause technical issues when the state transfers data from SERFF. Issuers in FFMs whose states have also requested that they submit plan data in SERFF should submit in both HIOS and SERFF as needed. (REGTAP FAQ Database - FAQ #2465 06/30/14) 746 2017--00846 Q: What rates will be available to test in Plan Preview in 2014 (for the 2015 plan year)? A: Plan Preview will support a modified rating engine. Issuers will choose an effective date, a CSR plan variation, and certain demographic information about a subscriber and one spousal dependent. Issuers will be able to test rates for all ages. (REGTAP FAQ Database - FAQ #2466 06/30/14) Q: What demographic information will issuers specify about the primary subscriber in Plan Preview? A: Issuers can specify the primary subscriber's date of birth, sex, number of months since last tobacco use, zip code, and county. (REGTAP FAQ Database - FAQ #2467 06/30/14) Q: What demographic information will issuers specify about the spouse subscriber in Plan Preview? A: The spouse subscriber is an optional subscriber for plan preview. If chosen, issuers can specify date of birth, sex, number of months since last tobacco use, relationship to the primary subscriber, and whether the spouse lives in the same residence as the primary subscriber. (REGTAP FAQ Database - FAQ #2468 06/30/14) Q: How will issuers select a plan to view in Plan Preview? A: In Plan Preview in 2014, issuers will enter the module then complete the following actions: 1) Select an issuer 2) Choose an effective date and plan cost sharing variation; and complete the demographic information for the primary subscriber, and the optional spouse 3) Click ?Update table of Plans? 4) Only plans available to the specified subscribers will display 5) Select a plan to view (REGTAP FAQ Database - FAQ #2499 06/30/14) Q: Will issuers be able to view multiple plans/compare plans in Plan Preview? A: No. Issuers will only be able one plan at a time in the Plan Details page in Plan Preview. (REGTAP FAQ Database - FAQ #2470 06/30/14) Q: Will issuers be able to see other issuers' plans and rates in Plan Preview? A: Issuers will only be able to see their own information in Plan Preview. HIOS Users who have roles for multiple issuers will select which issuer to view data for in Plan Preview. (REGTAP FAQ Database - FAQ #2471 06/30/14) Q: Will issuers be able to test all of their allowed relationships in Plan Preview? A: No, the current Plan Preview functionality will not allow issuers to test all of their allowed relationships. The only relationship selection available in Plan Preview is ?Spouse.? (REGTAP FAQ Database - FAQ #2472 06/30/14) 747 Updated 1-31-17 2017--00847 Q: Will issuers be able to test Individual Market Family Rates? A: Issuers will be able to test rates for up to two individuals in a family. Issuers will not be able to test, for example, a two parent family with two children. Although it is referred to as a spousal subscriber in Plan Compare, there are no limits on the age input for the primary or spousal subscriber. Therefore, issuers can test rates for two adults or for one adult and one child. (REGTAP FAQ Database - FAQ #2473 06/30/14) Q: In Plan Preview, the HIOS Plan ID is displayed on the final screen. Will this display in Plan Compare? A: No. This ?eld is exclusive to Plan Preview and will not display in Plan Compare. The Cost Sharing Variant, also displayed on the same line in Plan Preview, will also not display in Plan Compare. (REGTAP FAQ Database - FAQ #2474 06/30/14) Q: In Plan Preview, the Cost Sharing Variation is displayed on the final screen. Will this display in Plan Compare? A: No. This ?eld is exclusive to Plan Preview and will not display in Plan Compare. The HIOS Plan ID, also displayed on the same line in Plan Preview, will also not display in Plan Compare. (REGTAP FAQ Database - FAQ #2475 06/30/14) Q: Will issuers be able to see their SHOP plans during Plan Preview? A: Issuers will be able to see their SHOP plan data in FFM Plan Preview beginning on July 18. The data will display identically to individual market QHPs. Plan Preview will not reflect the unique SHOP bene?t display and rating engine. (REGTAP FAQ Database - FAQ #24 76 06/30/14) Q: Where can Issuers find the Plan Preview User Guide? A: The Plan Preview user guide is available in the Plan Preview Module in HIOS via a link in the top right corner. The user guide will also be posted on CMS (REGTAP FAQ Database - FAQ #2477 06/30/14) Q: If an issuer accesses the Plan Preview system, enters demographic information, but does not see a plan display in the available table of plans, what are the issuer's next steps? A: Please review both the Service Area template and Plan Bene?ts template to check the following: 1) The plan is available in the speci?ed service area (zip code and county) 2) The plan is available to adult subscribers/child subscribers (as appropriate) 3) The plan is available in the speci?ed cost sharing variation If, after reviewing the above information, the issuer determines that the plan should be displaying but is not displaying, it should follow the instructions to submit a QHP Plan Preview Question to the XOSC Helpdesk at CMS FEPS@cms.hhs.qov. (REGTAP FAQ Database - FAQ #2478 06/30/14) 748 Updated 1-31-17 2017--00848 Q: If an issuer accesses the Plan Preview system, enters demographic information, and the issuer believes that the displayed rate is incorrect, what are the issuer's next steps? A: Please review the rating table and business rules templates: 1) Check the enrollment date entered for the subscriber versus the rating date on the rating template 2) Check the age of the subscriber (and secondary subscriber) versus the rating template 3) Check the business rules template for whether spouse is an allowed relationship, if the optional secondary subscriber was entered 4) Check whether either subscriber was listed as a tobacco user If, after reviewing the above information, the issuer determines that the rate is still displaying incorrectly, please follow the instructions to submit a QHP Plan Preview Question to the XOSC Helpdesk at CMS FEPS@cms.hhs.qov. (REGTAP FAQ Database - FAQ #2479 06/30/14) Q: If an issuer accesses the Plan Preview system, enters demographic information, and the issuer believes that the displayed benefit is incorrect, what are the issuer's next steps? A: Please review the Plan and Bene?ts template: 1) Check the bene?t ?eld against the Plan and Benefits template instructions marketplaces/th.html) to confirm that the ?eld was ?lled out correctly 2) Confirm that the bene?t display logic matches the displayed language, using the Plan Preview User Guide or Plan and Benefits template instructions. If, after reviewing the above information, the issuer determines that their benefit is still displaying incorrectly, please follow the instructions to submit a QHP Plan Preview Question to the XOSC Helpdesk at CMS FEPS@cms.hhs.qov. (REGTAP FAQ Database - FAQ #2480 06/30/14) Q: If the issuer's information is not displaying correctly on the first page of Plan Preview (?Issuer Summary Page?) how can the issuer correct it? Updated 1-31-17 A: The ?Issuer Summary Page" displays the HIOS Issuer ID, HIOS Issuer Legal Name and State. If the HIOS Issuer ID or State are displaying incorrectly, please follow the instructions to submit a QHP Plan Preview Technical Question to the XOSC Helpdesk at CMS FEPS@cms.hhs.qov. If the HIOS Issuer Legal Name seems to be incorrect, ?rst check HIOS Plan Finder to confirm the name listed for the issuer in the Issuer Legal Name field. If the name listed in the field is incorrect, please send an email to the XOSC Helpdesk at CMS FEPS@cms.hhs.qov titled Plan Finder Legal Name change." Please note that the names listed in HIOS are veri?ed with the IRS. If the HIOS Issuer Legal Name in Plan Preview does not match the Issuer Legal Name field in HIOS Plan Finder, please follow the instructions to submit a QHP Plan Preview 749 2017--00849 Question to the XOSC Helpdesk at CMS FEPS@cms.hhs.qov (REGTAP FAQ Database - FAQ #2481 06/30/14) Q: If the issuer's administrative information is not displaying correctly on the second page of Plan Preview (?Rating Scenarios Page?) how can the issuer correct it? A: The ?Rating Scenarios Page? displays the HIOS Plan ID, Plan Marketing Name, Plan Market Type, Plan Type, Plan Metal Level and Plan Product Type. If the HIOS Plan ID is displaying incorrectly, please follow the instructions to submit a QHP Plan Preview Question to the XOSC Helpdesk at CMS FEPS@cms.hhs.gov. If the Plan Marketing name is incorrect, please check the name against the name entered in the Plan and Bene?ts template and update if needed. If the Plan Market Type, Plan Type, or Plan Metal Level is incorrect, please check the displayed value against the value in the Plan and Bene?ts template and update if needed. If, after reviewing the above information, the issuer determines that their data is still displaying incorrectly, please follow the instructions to submit a QHP Plan Preview Question to the XOSC Helpdesk at CMS FEPS@cms.hhs.qov. (REGTAP FAQ Database - FAQ #2482 06/30/14) Q: Can an issuer that submitted its QHP data through SERFF review its data during Plan Preview? A: Yes. Plan Preview is for all issuers who apply to have plans available on the FFM, whether they submit through SERFF or HIOS. Plan data for SERFF submitters will be available after their state transfers it to HIOS. Note that a HIOS submitter that is also required by its state to submit a QHP Application in SERFF will only see the information they submitted into HIOS. (REGTAP FAQ Database - FAQ #10627 05/20/15) Q: How does an issuer user access the Plan Preview module in Updated 1-31-17 A: Issuers must have a HIOS ID with a Validator or Submitter user role for one of the QHP Modules (Issuer, Rating, and Bene?ts and Service Areas modules). If an issuer does not have a HIOS ID it should follow the instructions in the HIOS User Guide (located at the link below) to request one. Once the issuer has a HIOS ID, the issuer can request a Validator or Submitter role for at least one of the three QHP modules. Once an issuer has a validator or submitter role for one of the QHP modules they will be automatically given access to the Plan Preview module. The link to the HIOS User Guide is: (REGTAP FAQ Database - FAQ #10628 05/20/15) 750 2017--00850 What is the process for OPM Multi-State Plans (MSPs) Plan Preview? A: Plan preview for MSPs in the HIOS Plan Preview module will be available around June 1. OPM will contact MSP applicants with more details. (REGTAP FAQ Database - FAQ #10629 05/20/15) Will Issuers see 2014 Plan Data? A: No, Plan Preview displays only 2015 or 2016 Plan Data. (REGTAP FAQ Database - FAQ #10630 05/20/15) Will Issuers see 2015 Plan Data and 2016 Plan Data? A: Yes. 2015 Plan Data is displayed in 2015 Plan Preview, and 2016 Plan Data is displayed in 2016 Plan Preview. Please note that the 2015 functionality and 2016 functionality are different. (REGTAP FAQ Database - FAQ #10631 05/20/15) Will SADP Issuers be able to view dental plans in Plan Preview? A: Yes, Plan Preview supports both QHP and SADP plan display. (REGTAP FAQ Database - FAQ #10632 05/20/15) How does an issuer change its QHP data during Plan Preview? A: Issuers may make changes to their QHP Application submission by resubmitting their templates in the appropriate application system, either HIOS or SERFF. Issuers that submit in SERFF should contact their state to transfer updated templates from SERFF to HIOS. (REG TAP FAQ Database - FAQ #10633 05/20/15) How does an issuer confirm that changes have been processed and uploaded? A: Most HIOS submitted changes (FFM issuers) will be processed and appear in Plan Preview within 24 hours of issuer cross-validation. Changes submitted to SERFF (issuers in states performing plan management functions, or MSPs) will see the update within 24 hours of the data being successfully transferred from SERFF to HIOS. (REGTAP FAQ Database - FAQ #10634 05/20/15) How do states participate in the Plan Preview process? A: States performing plan management functions will work with issuers to transfer their SERFF submitted updates. States send revised data from SERFF to HIOS, after which the revised data will display in Plan Preview. States can also view issuer data in Plan Preview, and may contact issuers about the displayed information. (REGTAP FAQ Database - FAQ #10635 05/20/15) How does a HIOS submitter change its template after it's been cross-validated? A: HIOS submitted QHP data will display in Plan Preview after an issuer's QHP submission has a status of ?Cross-Validation Complete" status. If the issuer wishes to make changes, it must remove the QHP submission from Cross-Validation, upload 751 Updated 1-31-17 2017-?00851 revised templates, and then complete cross-validation again for the new data display in Plan Preview. (REGTAP FAQ Database - FAQ #10636 05/20/15) Q: How does an issuer in a state performing plan management change its template after plans are displayed in Plan Preview? A: The issuer must follow its state's guidelines to make changes to the SERFF binder. If approved, the issuer should make the changes in SERFF, and then request that their state re-transfer their binder to HIOS. After the State transfers the data the issuer will be able to see the updated data in Plan Preview. (REGTAP FAQ Database - FAQ #10637 05/20/15) Q: How do issuers contact CMS with Plan Preview questions? A: Issuers should contact the XOSC Helpdesk at CMS FEPS@cms.hhs.qov to submit a helpdesk ticket. Please fully describe both the data submitted by the issuer, the question about the display, and provide screenshots as applicable. Please ensure that each ticket includes the below information: - Email subject line: Plan Preview Question? - Include the following information: HIOS Issuer ID (the one you were viewing) Issuer name Issuer state Impacted Plan A screenshot of the issue Date of the error The data element in question (please refer to the Plan Preview User Guide) A detailed description of the problem, including: - Zip code, county, smoking status and birthdates used in scenario - What appeared in Plan Preview - What the user was expecting to see 9. Preferred contact information (desk, mobile, email) in case the Help Desk needs to follow-up on your ticket. (REG TAP FAQ Database - FAQ #10638 05/20/15) Q: What rates and scenarios will be available to test in Plan Preview in 2015 (for the 2016 plan year)? A: Plan Preview supports a modified rating engine. Issuers will choose an effective date, whether they want to see the plan with a CSR plan variation or not, and certain demographic information about up to 5 subscribers. Users will be able to test rates for all ages. (REGTAP FAQ Database - FAQ #10639 05/20/15) Q: What demographic information will users specify about the primary subscriber in Plan Preview? Updated 1-31-17 A: Users will specify the primary subscriber?s date of birth, sex, number of months since last tobacco use, zip code, and county. (REGTAP FAQ Database - FAQ #10640 05/20/15) 752 2017--00852 Q: What demographic information will users specify about subscriber Spousel Life Partner in Plan Preview? A: The Spouse or Life Partner is an optional subscriber in Plan Preview. If chosen, users can specify date of birth, sex, number of months since last tobacco use, relationship to the primary subscriber, and whether the Spouse/Life Partner lives in the same residence as the primary subscriber. (REGTAP FAQ Database - FAQ #10641 05/20/15) Q: What demographic information will users specify about additional dependents in Plan Preview? A: Users will provide date of birth, sex, and number of months since last tobacco use. (REGTAP FAQ Database - FAQ #10642 05/20/15) Q: How will users select a plan to view in Plan Preview? A: Users will enter the Plan Preview module in HIOS, then complete the following actions: 1. Select an issuer ID from the list 2. Choose an effective date and plan cost sharing variation 3 Complete the demographic information for the primary subscriber, and the optional additional subscribers 4. Click ?Update Plan Results" 5. By default, plans available to the specified subscribers will display 6 Select a plan to view Users can view some plans that are not available for the specified subscribers by selecting ?unavailable plans.? (REGTAP FAQ Database - FAQ #10643 05/20/15) Q: Will Users be able to view multiple plans/compare plans in Plan Preview? A: No. Users will only be able to view one plan at a time in Plan Preview. (REGTAP FAQ Database - FAQ #10644 05/20/15) Q: Will users be able to see other issuers' issuer and plan data, including rates, in Plan Preview? A: No, issuer users will only be able to see their own issuer information in Plan Preview. HIOS users who have roles for multiple issuers IDs will select one issuer ID to view at a time. State users will be able to see issuer and plan data for all issuers in their state. (REGTAP FAQ Database - FAQ #10645 05/20/15) Q: Will users be able to test all of their allowed relationships in Plan Preview? A: No, 2016 Plan Preview functionality will not support all allowed relationships. Spouse, life partner, and child relationships are supported. (REGTAP FAQ Database - FAQ #10646 05/20/15) 753 Updated 1-31-17 2017--00853 Q: Will users be able to test Individual Market Family Rates? A: Users will be able to test rates for up to ?ve individuals in a family. Users will be able to test, for example, a two-parent family with three children, or a single parent with four children. (REGTAP FAQ Database - FAQ #10647 05/20/15) Q: Will users be able to test child-only rates? A: Users will be able to test rates for one child in a child-only plan. Sibling relationships are not recognized in Plan Preview, so child-only plans with multiple children cannot be tested. (REGTAP FAQ Database - FAQ #10648 05/20/15) Q: The Cost Sharing Variation is displayed on the final screen of Plan Preview. Will this display in Plan Compare? A: No. The HIOS Plan ID and Cost Sharing Variant which display for convenience in Plan Preview do not display in Plan Compare. (REGTAP FAQ Database - FAQ #10649 05/20/15) Q: Will users be able to see their SHOP plans during Plan Preview? A: SHOP plan data displays in Plan Preview identically to individual market QHPs. Plan Preview does not re?ect the SHOP Plan Compare benefit display and rating engine. (REGTAP FAQ Database - FAQ #10650 05/20/15) Q: Where can users find the Plan Preview User Guide? A: The Plan Preview user guide is available in the Plan Preview Module in HIOS via a link in the top right corner. Click the ?Instructions and Reference Materials? link to download the User Guide. (REGTAP FAQ Database - FAQ #10651 05/20/15) Q: If a user accesses Plan Preview and does not see a plan display in the available table of plans, what are the issuer's next steps? A: First change the table of plans to show 'unavailable' plans. Each unavailable plan should have a reason code associated with it. Review the reason code. Details about each reason code can be found in the Plan Preview User Guide. Depending on the reason code, the user should review the Service Area template and Plan Benefits template to check the following: 1. The plan is available in the speci?ed service area (zip code and county) 2. The plan is available to the scenario of subscribers and dependents 3. The plan is available in the speci?ed cost sharing variation If after reviewing the above information the user determines that the plan should be displaying but is not, the user should follow the instructions to submit a QHP Plan Preview Question to the XOSC Helpdesk at CMS FEPS@cms.hhs.qov. (REGTAP FAQ Database - FAQ #10652 05/20/15) 754 Updated 1-31-17 2017--00854 Q: If a user accesses Plan Preview and sees incorrect rates, what are the user's next steps? A: Please review the Rates Table template and the Business Rules template: 1. If it's a SHOP plan, check the enrollment date entered for the subscriber versus the date on the Rates Table template. 2. Con?rm that the birthdate entered results in the age expected. 3. If the enrollment group has a spouse or life partner, con?rm that spouse or life partner is an allowed relationship on the Business Rules template. 4. Con?rm tobacco status of each subscriber and dependent. If after reviewing the above information the user determines that the rate is still displaying incorrectly, please follow the instructions to submit a QHP Plan Preview Question to the XOSC Helpdesk at CMS FEPS@cms.hhs.gov. (REGTAP FAQ Database - FAQ #10653 05/20/15) Q: If a user sees a benefit and/or cost sharing that is incorrect in Plan Preview what are the issuer's next steps? A: Please review the Plan and Benefits template: 1. Check the bene?t ?eld against the Plan and Bene?ts template instructions to con?rm that the field was completed correctly Con?rm that the benefit display logic matches the displayed language, using the Plan Preview User Guide or Plan and Benefits template instructions. If after the issuer reviews the above information the issuer determines that their bene?t displays incorrectly, please follow the instructions to submit a QHP Plan Preview Question to the XOSC Helpdesk at CMS FEPS@cms.hhs.qov. (REGTAP FAQ Database - FAQ #10654 05/20/15) Q: If the issuer's information does not display correctly on the first page of Plan Preview (?Issuer Summary Page?) how can the issuer correct it? Updated 1-31-17 A: The ?Issuer Summary Page? displays the HIOS Issuer ID, HIOS Issuer Legal Name and State. If the HIOS Issuer ID or State displays incorrectly, please submit a QHP Plan Preview Technical Question to the XOSC Helpdesk at CMS FEPS@cms.hhs.qov. If the HIOS Issuer Legal Name is incorrect, first check HIOS Plan Finder to con?rm the name listed for the issuer in the Issuer Legal Name ?eld. If the name listed in the ?eld in HIOS Plan Finder is incorrect, please send an email to the XOSC Helpdesk at CMS FEPS@cms.hhs.qov titled Plan Finder Legal Name change." Please note that the names listed in HIOS are veri?ed with the IRS. If the HIOS Issuer Legal Name in Plan Preview does not match the Issuer Legal Name ?eld in HIOS Plan Finder but the name in HIOS Plan Finder is correct, please follow the instructions to submit a QHP Plan Preview Question to the XOSC Helpdesk at CMS FEPS@cms.hhs.qov. (REGTAP FAQ Database - FAQ #10655 05/20/15) 755 2017--00855 Q: If the issuer's administrative information does not display correctly on the second page of Plan Preview (?Rating Scenarios Page?) how can the issuer correct it? A: The ?Rating Scenarios Page? displays the HIOS Plan ID, Plan Marketing Name, Plan Market Type, Plan Type, Plan Metal Level and Plan Product Type. If the HIOS Plan ID is incorrect, please follow the instructions to submit a QHP Plan Preview Question to the XOSC Helpdesk at CMS FEPS@cms.hhs.qov. If the Plan Marketing name is incorrect, please check the name against the name entered in the Plan and Bene?ts template and update the Plans and Benefits template, if needed. If the Plan Market Type, Plan Type, or Plan Metal Level is incorrect, please check the displayed value against the value in the Plan and Bene?ts template and update if needed. If after the issuer reviews the above information the issuer determines that their data is still displaying incorrectly, please follow the instructions to submit a QHP Plan Preview Question to the XOSC Helpdesk at CMS FEPS@cms.hhs.qov. (REGTAP FAQ Database - FAQ #10656 05/20/15) Dental Plan Preview and Plan Compare Q1: What modifications were made to the dental benefits icon in Plan Preview and Plan Compare for Stand-alone dental plans in the individual market Federally-facilitated Marketplaces? Updated 1-31-17 A1: As part of a planned technical correction to Plan Preview and Plan Compare for individual market Stand-alone dental plans (SADPs), the dental benefits icon will now only display for those SADPs with three categories of adult benefits. Prior to the correction, SADPs with two adult bene?ts were erroneously displayed as providing a ?Dental: Child Adult" icon on the plan selection page. The Centers for Medicare Medicaid Services (CMS) made this technical change in order to be consistent with our stated policy, as noted in the 2014, 2015 and 2016 Plan Preview User Guide.1 The User Guide explains that in order to have the ?Dental: Child Adult? icon display, CMS requires SADPs to cover three categories of pediatric bene?ts Dental Check-up, Basic, and Major), as well as all three categories of adult bene?ts Routine, Basic, and Major). CMS believes that a consumer should have the general expectation that an SADP that offers adult bene?ts would cover services typically offered by a dental plan, including preventive care and minor and major dental services. This is similar to how CMS interprets pediatric bene?ts for the purpose of displaying the ?Dental: Child" icon. However, CMS understands that some issuers may not have noted this policy even though it is articulated in the Plan Preview User Guide. As such, CMS is giving issuers that did not meet the standard for displaying the ?Dental: Child Adult" icon the opportunity to meet the criteria by submitting a Data Change Request and correcting their data within the Data Correction Window to re?ect the addition of Major Dental to their adult bene?ts in order to have the applicable icon display, to the extent such a change is permitted in accordance with applicable State requirements. Affected issuers have been sent an email inviting the issuer to participate in the Data Correction Window. (Dental Plan Preview and Plan Compare Display FAQs 10/09/15) 756 2017--00856 SHOP Plan Preview and Plan Compare Q: How does a user access SHOP Plan Preview? A: Users can access SHOP Plan Preview through the same module as Individual Plan Preview. After users log into HIOS, they will select the ?Plan Preview? module, and select the desired issuer. The ?Rating Scenario? page will display and there will be a market selection option. Users will select ?Small Group (REGTAP FAQ Database - FAQ #3053 07/28/14) Q: What are the differences between SHOP Plan Preview and Individual Market Plan Preview? A: Once the user selects the market type of ?Small Group on the Rating Scenario page, the page will update to show the SHOP specific ?elds. On the screen, the following changes are made: (1) CSR option removed (2) Option to select the Employer Code and Employer County appears (3) Primary removed (4) Indicator of whether the dependent lives in the same residence removed SHOP Plan Preview will not display plan data in the same way that data will be displayed in FF-SHOP Plan Compare. For further information about FF-SHOP Plan Compare data display, please review the Plan Preview User Guide, appendix A. (REGTAP FAQ Database - FAQ #3054 07/28/14) Q: Is there a SHOP specific Plan Details page? A: No. SHOP plans will display in the same format as individual plans on the Plan Details page. The page does include an explanation at the top that states SHOP plans will display to consumers in a different format than the one shown here." (REGTAP FAQ Database - FAQ #3055 07/28/14) Q: What testing or data verification can SHOP issuers complete using SHOP Plan Preview? A: SHOP Issuers can verify that their information is correctly loaded in HIOS, and identify any template or submission errors. (REGTAP FAQ Database - FAQ #3056 07/28/14) Q: Will issuers be able to view SHOP data from an employer perspective in SHOP Plan Preview? A: No. Issuers will only be able to view data from an employee perspective. (REGTAP FAQ Database - FAQ #3057 07/28/14) Q: Where can Issuers find information about the FF-SHOP Plan Compare system? A: Information about the FF-SHOP Plan Compare system will be covered during the regularly scheduled SHOP issuer calls. (REGTAP FAQ Database - FAQ #3058 07/28/14) 757 Updated 1-31-17 2017--00857 Q: Is there a list of the differences between FF-SHOP Plan Compare and Individual Market Plan Compare? A: In the Plan Preview User Guide, there is a crosswalk between data elements for SHOP and the Individual Market in Appendix A. CMS encourages issuers to thoroughly review the user guide for details about SHOP speci?c data display. (REGTAP FAQ Database - FAQ #3059 07/28/14) Q: If an issuer discovers a submission error in its SHOP plans during Plan Preview and corrects the error prior to data lockdown, will the correction be reflected in FF-SHOP Plan Compare in time for open enrollment? A: Yes, corrections made to SHOP data prior to data lockdown on September 4, 2014 will be re?ected in FF-SHOP Plan Compare when open enrollment begins. (REGTAP FAQ Database - FAQ #3060 07/28/14) Certification and Issuer Agreement Signing Process Q1: When will Issuers receive notification of whether their plans are approved for certification? A1: All quali?ed health plan (QHP) and Stand-alone Dental Plan (SADP) Issuers will receive an Application Notice on September 9th. The notice will also include a ?Plan Con?rmation? section, which lists the results of the reviews completed by CMS. The Plan Con?rmation will include, as applicable, 3 list of plans that will be certified as In addition, the Plan Confirmation will include information on any that CMS has determined to be ineligible for certi?cation as well as recently withdrawn The notice will also contain the QHP Agreement. (Plan Management Webinar QHP FAQ #14 09/04/13) Q2: If an Issuer believes that there is an error within the Application Notice, what is the process for getting this corrected? A2: The Issuer should immediately contact the Exchange Operations Support Center (XOSC) Help Desk via email at CMS FEPS@cms.hhs.qov or via phone at 855-CMS- 1515. (Plan Management Webinar QHP FAQ #14 09/04/13) Q3: What are the final steps an Issuer must take to complete the certification process? A3: An Issuer must return a signed Agreement and completed table in the Plan Con?rmation to CMS no later than September 11, 2013 (see Question 12 below for more details). (Plan Management Webinar QHP FAQ #14 09/04/13) Q4: Are corrections allowed for plans not approved to be certified? A4: No corrections will be allowed. If an Issuer believes that the de?ciency was issued in error, please contact the Exchange Operations Support Center (XOSC) Help Desk via email at CMS FEPS@cms.hhs.qov or via phone at 855-CMS-1515. (Plan Management Webinar QHP FAQ #14 09/04/13) 758 Updated 1-31-17 2017--00858 Q5: Can I make changes to a that is approved but has unresolved data issues? A5: CMS understands that limited accuracy issues with QHP data may still exist for plans approved to be certi?ed. CMS is considering how to implement a narrow and final process for identifying and correcting these remaining issues. (Plan Management Webinar QHP FAQ #14 09/04/13) 06: Will Issuers of SADPs also sign the Agreement? A6: Yes, Issuers of on-Exchange SADPs will also sign the Agreement. (Plan Management Webinar QHP FAQ #14 09/04/13 and REG TAP database FAQ #2132 06/1 1/14) Q7: Should SADP Issuers sign the Agreement or complete the Plan Confirmation if they are only offering SADPs off-Exchange? A7: No. Unless they are also offering on-Exchange plans, Issuers that submitted off- Exchange SADPs for review do not need to sign the Agreement or complete the plan con?rmation. (Plan Management Webinar QHP FAQ #14 09/04/13 and REGTAP database FAQ #2129 06/11/14) Q8: Who should sign the Agreement? A8: The Agreement must be signed by a senior of?cer of the company who has contractual authority to bind the QHP or SADP Issuer legal entity that has been approved for certification. (Plan Management Webinar QHP FAQ #14 09/04/13) This FAQ was revised and re-re/eased via the REG TAP database on 06/11/14; the revised answer clari?es that the senior of?cer who signs must have the authority to contractually bind the issuer legal entity: A: The Agreement must be signed by a senior of?cer of the company who has legal authority to contractually bind the QHP or SADP Issuer legal entity that has been approved for certi?cation. (REG TAP FAQ Database - FAQ #2131 06/11/14) Q9: Can the senior official sign one agreement for multiple Issuer A9: No. Each QHP or SADP Issuer must populate, execute, and return one Agreement per HIOS ID. The HIOS ID must be the same HIOS ID used by the Issuer during the application process. Dual QHP and SADP Issuers will sign only one Agreement per HIOS ID. However, the senior officer who signs an Agreement for one HIOS ID may also sign the Agreement for another HIOS if this person is the appropriate persons to bind the company associated with the other HIOS (Plan Management Webinar QHP FAQ #14 09/04/13 and REGTAP database FAQ #2125 06/11/14) Q10: What is the process for an Issuer to sign the Agreement? A10: The Issuer should print the Agreement and populate the documents as indicated, including ?lling in the Issuer name and ID in the space indicated. The appropriate of?cial 759 Updated 1-31-17 2017--00859 must sign the Agreement by hand (electronic signature is not permitted). The signed Agreement must be converted into a PDF ?le. (Plan Management Webinar QHP FAQ #14 09/04/13) Q11: What Issuer name should be filled in on the Agreement? A11: Issuers must use their HIOS Issuer Legal Name on the agreement. If an Issuer uses any other name, the Agreement will not be validated. (Plan Management Webinar QHP FAQ #14 09/04/13 and REGTAP FAQ #2130 06/11/14) Q12: How should Issuers confirm the list of plans to which the agreement applies? A12: The Application Notice will include a section entitled ?Plan Con?rmation" that lists the plans that will be approved for certification by CMS. The Issuer should copy and paste the tables from the Plan Con?rmation into the response email when returning the agreement to CMS. To confirm its plan offerings, the Issuer should complete ?Table 1. Summary of Review of Plans? indicating ?Offer? for every plan it intends to offer and ?Withdraw? for any plan it wishes to withdraw. (Plan Management Webinar QHP FAQ #14 09/04/13) Q13: How will Issuers know if a plan is not recommended for certification? A13: The Application Notice will provide a list of any plans that will not be approved by CMS for certi?cation as (Plan Management Webinar QHP FAQ #14 09/04/13) CMS revised the answer to this FAQ when it released it as REGTAP FAQ on 6/11/14: A: CMS will provide a list of any plans that will not be approved by CMS for certification as at the end of the certi?cation process. (REG TAP FAQ Database - FAQ #2127 06/11/14) Q14: How should the Issuer submit the signed Agreement and Plan Confirmation to Updated 1-31-17 A14: The Issuer will submit the requirement documents by email to CMS Issuer Communications mailbox (CMS Issuer Communications@cms.hhs.qov) no later than September 11, 2013. The Issuer should submit the email as follows: . Use the subject line ?Signed Agreement and Plan Con?rmation for HIOS ID (insert ID) (insert name of Issuer)" 0 Name the PDF of the completed and executed Agreement ID (insert ID) signed Agreement" . In the body of the email, copy and paste the Plan Con?rmation table from the Application Notice In this table, ?ll in ?Offer? for every plan the Issuer intends to offer on the Marketplace, and ?Withdraw? for any plan the Issuer wishes to withdraw in the ?Offer on the Exchange?? column 760 2017--00860 Include contact information for the appropriate personnel in case CMS has any questions related to confirming the completed agreement or the plan confirmations (Plan Management Webinar QHP FAQ #14 09/04/13) Example of e-mail: 0 iv Wyau?t?mmcamommaufm (ahaammuwa u. ?mom Moron In Lunch-?7 Meg/imam) . omr ?ilduu Mam: Sr-ll' 1553 155 3:55 :2 ?11m vu Q15: When is the signed agreement due? A15: Signed agreements are due by September 11 via email to the CMS Issuer Communications mailbox. (Plan Management Webinar QHP FAQ #14 09/04/13) Q16: Will Issuers receive a confirmation that CMS received the email? A16: Yes, Issuers will receive a con?rmation within 24 hours that CMS received the e- mail. This will not be a con?rmation that the Agreement was completed properly by the Issuer, or of any other legal agreement. (Plan Management Webinar QHP FAQ #14 09/04/13) Q17: When will Issuers receive ?nal con?rmation of certi?cation? A17: If there are any problems with the submitted Agreement, CMS will contact the Issuer. CMS will countersign the Agreement. The Issuer will receive ?nal con?rmation of Certification via e-mail in mid to late September. (Plan Management Webinar QHP FAQ #14 09/04/13) Q18: What if Issuers have questions about the signing process? Updated 1-31-17 A18: For questions regarding the Agreement please contact the Exchange Operations Suppon Center (XOSC) Help Desk via email at CMS FEPS@cms.hhs.qov or via phone at 855- CMS-1515. (Plan Management Webinar QHP FAQ #14 09/04/13) 761 2017-?00861 Q: I am new to a health plan in Massachusetts and am trying to determine if our plan needs to sign the Issuer agreement? A: For State-Based Marketplaces, Issuers should contact their State regulator to ?nd out the timeline and process for Issuer agreement signing. (REGTAP FAQ Database - FAQ #1357 03/31/14) Q: Should Stand-Alone Dental Issuers (SADP) Issuers sign the Agreement or complete the Plan Confirmation if they are only offering SADPs off-Exchange? A: No. Unless they are also offering on-Exchange plans, Issuers that submitted off- Exchange SADPs for review do not need to sign the Agreement or complete the plan con?rmation. (REGTAP FAQ Database - FAQ #2129 06/11/14) Q: Does an issuer have to be an approved Federal contractor in order to sign an agreement to market and sell on the Federally-Facilitated Marketplace(FFM A: No, the issuer does not need to be an approved Federal contractor. (REGTAP FAQ Database - FAQ #2133 06/11/14) QHP Certification Process - Other Data Integrity Tool and Review Too/s Q: Are you aware of errors with Version 1.1 of the Data Integrity Tool A: Yes, please see below for a list of known errors and responses. . When the Plans Bene?ts template is imported to the DIT, the HIOS Plan ID (Standard Component Variant) is deleted 0 We are aware of this problem with the import function of the DIT for the Plans Bene?ts templates that causes an error when a bene?ts package only contains one row of data on the Cost Share Variances tab. As a result, the HIOS Plan ID (Standard Component Variant) ?eld is not importing correctly for some benefits packages. 0 We will fix this in a future DIT release, but in the meantime please manually enter the HIOS Plan ID (Standard Component Variant) into the tab of the DIT for any plans where this field is missing after importing the template data. This should allow the validations to run properly. 0 The DIT incorrectly applies federal and state age curves to tobacco rates 0 Please disregard any error message related to adherence to an individual tobacco rate curve. Such a tobacco age curve does not exist (though the 1:15 tobacco rule still applies). This error will be ?xed in a future update of the tool. . The DIT generates an error message when we enter a special plan design separate medical/drug deductibles in/out of network) 0 Please disregard any error message related to the plan design. The DIT incorrectly ?ags such a plan design as an error because it does not account for a deductible structure as described. . The DIT generates an error message when the Rate template has multiple sheets and the only difference is effective date or expiration date 762 Updated 1-31-17 2017--00862 Updated 1-31-17 0 Please disregard the error message. The DIT incorrectly flagged this as an error. It is permissible to have the same set of plan IDs, rating areas, and age bands for an issuer on multiple worksheets as long as the effective or expiration dates are distinct. The DIT does not import Product or Plan Rules data from the Business Rules template if the ?rst data element in that row is empty 0 Since there is no data entered into column for row 11, the DIT erroneously assumes there is no additional data in the row and is therefore not importing the row. Please enter a value for that ?eld (even if it is the same as the issuer-level rule). The DIT incorrectly ?ags the following as an error: "Medical Drug EHB Deductible - In Network - Default Coinsurance should NOT be blank or non-numeric for Dental Only Plans." 0 Since default coinsurance does not apply to dental plans, please disregard this error message. When checking for Child-Only Plan ID, the DIT references the wrong ?eld Employer Contribution) 0 Please disregard the errors related to the Child Only Plan IDs. We will fix this in the next DIT release. The DIT incorrectly checks for Network IDs, Service Area IDs, and Formulary IDs that exist in the Network, Service Area, and Prescription Drug template but not in the Plans Benefits Template 0 Response: The DIT runs cross-validation checks to make sure that data elements are consistent across multiple templates, including Network ID, Formulary ID and Service Area ID. However, it appears that the tool is incorrectly ?agging as an error any ?unused that are found in certain templates Network template, Prescription Drug template and Service Area template) but are not found in the Plans Benefits template. The DIT cross-validation check should verify that the template contains only Network IDs, Formulary IDs or Service Area IDs that are documented in their respective templates. It is acceptable for the template to contain only a subset of the IDs that are listed in the ?shared? templates. For example, an individual market template and a small group market template can draw different IDs from the same "shared" Network, Prescription Drug or Service Area template. Please disregard these specific error and warning messages. The cross- validation check will be corrected in a future DIT release. In the Essential Community Provider (ECP) template, multiple Network IDs listed in the same field (separated by comas) do not match other templates when DIT cross- validation is performed 0 The DIT looks for exact matches in the values entered in the Network ID ?eld in the Network and ECP templates. If multiple Network IDs are listed in your ECP template, the identical value is not found in the Network template and that is why the DIT generates an error. Please disregard these errors related to the Network IDs, but ensure that you carefully review all other errors to make sure you have determined the cause. The DIT will be updated in a future release so that the cross validation accounts for the presence of multiple Network IDS for a provider 763 2017--00863 in the ECP template, as long as each Network ID is also represented in the Network template. (REGTAP FAQ Database - FAQ #2050 06/06/14) Q: When should an Issuer use the Data Integrity Tool A: Issuers' proper use of the DIT may help the Issuers demonstrate an attempt to comply in good faith with program/operational requirements, absent any evidence to the contrary. (REGTAP FAQ Database - FAQ #2633 07/03/14) Q: How do the 2015 Review Tools relate to the Qualified Health Plan (QHP) template validations? A: The Qualified Health Plan (QHP) Application Review Tools are a set of Excel-based evaluation services for specific issuer and plan standards for the QHP Application process. These tools are different from the template validations themselves. In addition, the Data Integrity Tool (DIT) performs template and cross-template checks conducted by the Health Insurance Oversight System (HIOS) and System for Electronic Rate and Form Filing (SERFF). The DIT is not an exact replica of these checks, and the tool includes checks that are not in HIOS or SERFF but are necessary for correct template submission. The review tools and the DIT are available on the CMS ZONE website (REGTAP FAQ Database - FAQ #2634 07/03/14) Q: What should an issuer do after receiving a data integrity notice about an error in a template when the error has already been ?xed? A: The initial FFM QHP application submission window closes on June 27. Any submissions after that date will not be included in the initial CMS reviews. If you have altered your templates since uploading them during the application submission window, you could receive data integrity errors on your submission that no longer apply. Use the Data Integrity Tool (DIT) to ensure that your revised templates do not contain data integrity errors. If your templates do not have any validations errors, you will not receive a data integrity notice after the correction window, currently scheduled for July 29?August 10. (REGTAP FAQ Database - FAQ #2636 07/03/14) Q6: Are off-Marketplace only submissions able to use the Data Integrity Tool A6: DIT checks do not apply to plans that are offered only off the exchange. Any off- Marketplace plans imported into the DIT will be ignored. (QHP Certification Process FAQs #1 (09/29/15) Q7: Are issuers that solely offer Stand-alone Dental Plans (SADPs) off-Marketplace required to use the Data Integrity Tool A7: Issuers offering only off-exchange SADPs should not use the DIT, as the tool validations are not designed to check for off-Marketplace plans. (QHP Certi?cation Process FAQs #1 {09/29/15) Q8: Is the Meaningful Difference Tool applicable to Stand-alone Dental Plans Updated 1-31-17 A8: No, the Meaningful Difference Tool is not applicable to SADPs. (QHP Certification Process FAQs #1 {09/29/15) 764 2017--00864 09: Is the new Summary of Bene?ts and Coverage (SBC) Examples Calculator available to calculate additional scenarios for 2016 SBC calculations? A9: The SBC template that the Departments of Health and Human Services, Labor, and the Treasury issued in connection with the Dec. 30, 2014 proposed rule is proposed and not authorized for use. Issuers should use the SBC template that is currently authorized for use. This template contains two coverage examples, having a baby and managing type 2 diabetes, and is available in Word format on the CCIIO web page at of Bene?ts and Coverage and Uniform Glossary. In addition, because a third coverage example is not a part of the currently authorized template, issuers and group health plans are permitted to continue to use the calculator tool that has been created to complete the two existing coverage examples. (QHP Certi?cation Process FAQs #1 {09/29/15) Q1: Why would an issuer receive a zip code validation error within the Essential Community Provider (ECP) Tool? A1: A zip code validation error can occur if the issuer enters a zip code that does not contain five digits or if the issuer writes in a provider located in a zip code that does not match any of the zip codes on the HHS Low-Income and HPSA Zip Code Listing for the 2016 benefit year, available at ECPs that an issuer writes in must be located in a low-income or HPSA zip code in order to count toward the issuer?s satisfaction of the ECP standard, described in the Final 2016 Letter to Issuers in the Federally-facilitated Marketplaces (FFMs) released February 20, 2015. In contrast, issuers may enter ECPs that already appear on the published HHS ECP List without regard to the provider?s zip code location matching against the HHS Low-Income and HPSA Zip Code Listing for the 2016 benefit year, because the eligibility of those ECPs has been con?rmed by our HHS Federal partners Health Resources and Services Administration, the Indian Health Service, and the Office of the Assistant Secretary for Health/Of?ce of Population Affairs). (QHP Certi?cation Process FAQs #3 (09/29/15)) 02: How does the Essential Community Provider (ECP) Tool differentiate between dental and medical providers? Updated 1-31-17 A2: CCIIO has published two distinct ECP Tools, one for dental providers and one for medical providers, available at Therefore, it is important that issuers utilize the applicable ECP tool for determining satisfaction of the ECP standard applicable to the issuer?s plan type medical QHP versus SADP). The medical ECP Tool includes a worksheet tab containing the US. Department of Health and Human Services? (HHS) medical ECP List, which the medical ECP Tool uses to match the issuer?s listed ECPs against the HHS Medical ECP List. Similarly, the dental ECP Tool includes a worksheet tab containing the HHS Dental ECP List, which the dental ECP Tool uses to match the issuer?s listed ECPs against the HHS Dental ECP List. Any ECPs that an issuer writes in that do not match against the applicable HHS ECP List will appear as write-ins. Stand- alone Dental Plans (SADPs) should not enter medical providers on the dental ECP tool and medical QHPs should not enter dental providers on the medical ECP tool. (QHP Certification Process FAQs #3 {09/29/15)} 765 2017--00865 Q3: If an issuer has contracted with three out of eleven available Essential Community Providers (ECPs) in the plan?s service area, resulting in the issuer?s networked ECP participation rate of 27.3%, will the Center round up to 30 percent to determine that the issuer has met the 30 percent ECP threshold requirement? A3: No, CCIIO will not round up the issuer?s ECP participation to 30 percent. Rather, the ECP tool will round down to 27 percent for the issuer?s ECP participation rate, below the required 30 percent ECP threshold requirement. (QHP Certification Process FAQs #3 (09/29/15)) Q3: How can an issuer find out who has received the Data Integrity Tool (DIT) notices? A3: The bottom of the DIT notice lists the specific individuals in the organization who received the notice. CMS sends e-mail notices to individuals having the following user roles in HIOS: QHP Attester; QHP Submitter; and QHP Validator. To ensure that issuers have the appropriate representatives from their organizations to receive these notices, they should update this information in HIOS. Additionally, please ensure that QHP Applications@cms.hhs.m is on the approved senders list for your incoming emails. (QHP Certi?cation Process FAQs #10 (09/29/15)) Q3: How are issuers to proceed with a Data Integrity Tool (DIT) error that states a family combined medical or family group Maximum Out-of-Pocket (MOOP) is not equal to two times or three times the individual A3: The DIT validation comparing family per group MOOP to individual MOOP is classified as a warning. DIT warnings ?ag possible data errors which may or may not need addressing prior to template submission. For example, issuers should verify instances in which the family MOOP is equal or less than the individual MOOP, or if the family MOOP is larger than the individual MOOP due to typographical error. If issuers verify that the data are correct and conform with issuer?s form filing, no action is needed. (Issuer Outreach FAQ #1 {10/27/15)} Q4: Will the Data Integrity Tool (DIT) continue to work if issuers exclude templates because they are incomplete? A4: Not all templates need to be imported into the DIT for the tool to work. For example, issuers may run the DIT for any imported templates while excluding the Rates Table template and Uni?ed Rate Review Template. The Centers for Medicare Medicaid Services (CMS) recommends running the tool with at least the imported Plans and Bene?ts Template. (Issuer Outreach FAQ #1 (10/27/15)) 05: How do the application review tools differ from the Data Integrity Tool(DlT)? Updated 1-31-17 A5: Unlike the other application review tools, the DIT does not generally check for compliance with Qualified Health Plan (QHP) or Standalone Dental Plan (SADP) certification standards. The DIT checks for data errors that would result in exclusion or improper display of plan information onHealthcare.gov. The DIT also checks for data compliance with some of the market-wide requirements. (Issuer Outreach FAQ #1 (10/27/15)) 766 2017--00866 06: How should issuers proceed if they are unable to reproduce the same deficiency identified by Centers for Medicare Medicaid Services For example, deficiencies received from the Category Class Drug Count Tool or Clinical Appropriateness Tool? A6: Issuers are encouraged to use these tools proactively before submitting their Quali?ed Health Plan (QHP) Applications and can also reference them when a state or federal regulator requests corrections after a review that relied on these tools. However, please note that issuers must respond to any deficiencies identified by a State or federal regulator even if an identified issue is different than the results obtained by using these tools. The All Grouping Numbers tab in the Category Class Drug Count tool provides a list of all chemically distinct drugs that appears in the Essential Health Bene?t (EHB) RX Crosswalk. It identifies if a grouping number is missing from the tested drug list. This may help issuers identify where RXCUIs can be added to meet the EHB Benchmark counts for the categories and classes that were insuf?cient. The Detailed Drug Count tab of the Clinical Appropriateness tool displays the results from the tested drug list of chemically distinct drugs in the four conditions. Issuers may use information from this tab to help them explore the drug lists that do not meet the requirements. (Issuer Outreach FAQ #1 (10/27/15)) Q1: Should issuers ignore Data Integrity Tool (DIT) errors stating that Market rules prohibit placing a residency requirement on the child-dependent relationship for children under age 26? A1: The error message in the DIT refers to a Market-wide requirement for Qualified Health Plans (QHPs) that prohibits QHPs from requiring that a child dependent live in the same household as the primary subscriber. This market rule applies to the child dependent relationships of child, adopted child, foster child, and stepson or stepdaughter. Issuers must correct this error in the Business Rules template to comply with this market-wide requirement. (Issuer Outreach FAQ #2 {10/27/15)} Data Correction and Data Change Request Q1: Will changes to the Qualified Health Plan (QHP) Application after May 15, 2015 appear on the first Data Correction Notice? May issuers disregard errors on the first Data Correction Notice for post May 15, 2015 changes? A1: Issuers should ensure that they have completely addressed any errors identified in the ?rst correction notice. Reviews are done on data at a point of time, in this case May 15, but because issuers can continue to resubmit data after that point, it's possible that by the time the issuer receives their correction notice, they?ve already made the necessary changes. CMS recommends issuers thoroughly review ?ndings identified in their correction notice to ensure they?ve fully addressed the issues. (QHP Certi?cation Process FAQs #6 (09/29/15) Q1: Will the Centers for Medicare Medicaid Services (CMS) provide issuers with any support around reviewing and responding to the findings in their Data Correction notice? A1: CMS will conduct outreach for remaining de?ciencies or correction errors and discuss common corrections on future webinars. The issuer can also refer to the Decoding Your Correction Notice fact sheet in the Issuer 767 Updated 1-31-17 2017--00867 Toolkit for help understanding corrections identi?ed. CMS also recommends issuers use the Master Review Tool to make sure that any edits made have addressed the issue appropriately. (QHP Certi?cation Process FA 08 #7 {09/29/15)} Q1: Where can issuers locate the "Decoding a Correction Notice" fact sheet? A1: On the CCIIO website at: Toolkit Combined 061115.pdf, there is a link to the QHP Application toolkit for issuers. The ?Decoding a Correction Notice" is the 9th section of the document, which is a revision to the QHP Application toolkit for issuers. (QHP Certi?cation Process FAQs #10 {09/29/15)} 02: Why would an issuer not receive Correction Notices? Other A2: If an issuer does not receive a correction notice, they should first check to ensure that their state Marketplace model is due to receive a correction notice in a particular round. For example, issuers in State Partnership Marketplaces did not receive correction notices detailing ?ndings of certi?cation reviews for the first review round, but did receive DIT and plan crosswalk results. If the issuer con?rms that they should expect a correction notice, they should then confirm the notice was not received by staff with HIOS user roles of QHP Attester, QHP Validator, or QHP Submitter. CMS recommends issuer staff with those roles check their spam folder. In rare instances, the issuer?s IT security might not allow certain incoming emails. If this occurs, the issuer should receive a copy of their notice from their CMS account manager, and submit a Helpdesk ticket for further assistance. (QHP Certi?cation Process FA 03 #10 {09/29/15)} Q: Will FFM issuers be able to change their application/template data after the initial application period, which ends June 27th, 2014? A: Yes, but all data changes must be approved by the issuer's state or for QHP or Dual Issuers in Direct Enforcement states; CMS Form Filing must review your request. Issuers will be able to upload revised QHP data templates and make other necessary changes to QHP Applications in response to CMS's feedback until September 4th, 2014. Issuers will also be able to make changes based on state feedback and make other minor corrections to their applications, with state approval, on the same timeline. Issuers may not add new plans after June 27th, 2014. Issuers must petition CMS for permission to make any changes to their service area. (REGTAP FAQ Database - FAQ #2041 06/05/14) Q: How do issuers petition CMS for permission to make changes to their service area after the initial application period (ending June 27th, 2014)? Updated 1-31-17 A: Issuers may request changes between June 27th, 2014 and September 4th, 2014. Please indicate in your ticket or your call to the help desk that this request is related to changes to QHP data. If submitting your request via email, please utilize the subject line ?Request for Changes to QHP Data.? Requests MUST contain the following information: 768 2017--00868 HIOS Issuer ID Issuer Name Issuer State Impacted Plan A detailed description of the QHP data changes requested: Speci?c information about data ?elds that require revisions Details about the revisions needed including original and revised values; Justi?cation for why the change is required, including but not exclusive to: Why the service area change is necessary Why the change is non-discriminatory Why it is in the best interest of potential enrollees and the Exchange program Evidence of state approval with speci?c content about the requested data changes if operating in an FFM state, OR request for CMS Form Filing review if a QHP or Dual issuer in a Direct Enforcement state . Such as an email that lists the speci?c changes included in the request, indicating that these speci?c changes are approved by the state. Non-specific approvals will not be accepted nor will assurances that changes are approved by the state without submitted evidence. . Contact name, telephone number, and email address for any relevant follow-up communication . Attached PDF worksheet signed by an of?cer of the company Once approval is obtained from CMS, the issuer will need to ensure that all QHP templates impacted by these approved changes are submitted and cross-validated in HIOS. (REG TAP FAQ Database - FAQ #2042 06/05/14) Q: Can Issuers add new plans after the initial application period (ending June 27th, 2014)? A: Issuers must submit a data change request (petition) to the XOSC Help Desk at CMS FEPS@cms.hhs.qov. (REGTAP FAQ Database - FAQ #2043 06/05/14) Q: Are issuers in states performing plan management required to submit petitions/data change requests? A: No, issuers do not need to submit petitions to CMS. The petition/data change request process applies only to issuers in FFMs. Issuers in states performing plan management should contact their states about any needed data changes such as service area changes. (REG TAP FAQ Database - FAQ #2045 06/05/14) Q: Are issuers in SBMs required to submit petitions/data change requests? A: No. The petition/data change request process applies only to issuers in FFMs. (REGTAP FAQ Database - FAQ #2046 06/05/14) 769 Updated 1-31-17 2017--00869 Q: If an issuer submits a petition/data change request on September 3rd, but does not receive a response from CMS before September 4th, will the issuer be able to submit their changes? A: No. All changes to service area must be explicitly approved by CMS before an issuer submits their changes. Requests should be submitted in advance of the September 4th deadline in order to allow CMS adequate time to review requests. (REGTAP FAQ Database - FAQ #2047 06/05/14) Q: Is there additional guidance on submitting service area change request justifications? A: Please see the QHP Application Instructions, Chapter 9, Service Area (found at The instructions provide guidelines for partial county justi?cations. CMS expects to follow similar justi?cation requirements for service area change requests. (REGTAP FAQ Database - FAQ #2048 06/05/14) Q: What kinds of service area change requests does CMS expect to approve? A: Per the 2015 Letter to Issuers (available at some examples of service area change requests that CMS may approve are: . To address limitations in provider contracting: issuers will need to provide substantial documentation of their contracting efforts in the geographic areas dropped, including lists of providers with whom the issuer attempted to contract and the contracts offered. . Expansions at the request of the state and/or CMS to address an unmet consumer need. . To address a data error in the issuer's initial Service Area Template submission: issuers will need to provide significant evidence documenting the error, including evidence in other parts of the QHP Application indicating an intent to cover a different area and/or a mismatch with the service area in the issuer's form filing. (REG TAP FAQ Database - FAQ #2049 06/05/14) Q25: Are plan design modifications allowable during the third quarter or only rate changes? A25: Issuers cannot make plan design modi?cations during the middle of a plan year. Small Business Health Options (SHOP) issuers can make quarterly rate changes for any prospective quarter, during quarterly data change windows. (QHP Certi?cation Process FAQs #1 (09/29/15) 026: Does Chapter 16 regarding the supporting documentation naming convention requirement apply to State Partnership Marketplaces in which the State requires a different naming convention for supporting documentation? A26: Issuers are not required to adhere to the naming convention. However, the Centers for Medicare Medicaid Services (CMS) highly recommends that issuer use the naming conventions in Chapter 16 to ensure CMS properly receives justi?cation forms. Chapter 770 Updated 1-31-17 2017--00870 16 instructions can be found at 021315.pdf (QHP Certi?cation Process FAQS #1 {09/29/15) 060: Where can issuers locate Payment Notice Frequently Asked Questions (FAQs) and product definitions? A60: Frequently Asked Questions (FAQs) regarding the HHS Notice of Bene?t and Payment Parameters for 2016 are located at The ?Payment Notice? itself is available at .pdf (QHP Certi?cation Process FAQs #1 (09/29/15)) Q1: Does the child dependent residency requirement for Qualified Health Plans (QHPs), which specifies that QHPs cannot require dependents to live in the same household as the primary subscriber for certain relationships, apply to QHP medical-only products and/or off-Marketplace Stand-alone Dental Plans A1: The Patient Protection and Affordable Care Act; Exchange and Insurance Market Standards for 2015 and Beyond Final Rule Market Rules, 79 FR 30239) requires, at 45 CFR 147. 120, QHP issuers that make dependent coverage of children available to make such coverage available for children until attainment of age 26, regardless of support, residency, or dependency factors. As excepted bene?ts, issuers of stand-alone dental plans are not subject to the Market Rules but would be subject to any existing State laws on child residency. (QHP Certi?cation Process FAQs #9 {09/29/15)} QHP Certification Process Data Correction and Data Change Request Q: Will FFM issuers be able to change application/template data after the initial application period, which ends May 15, 2015? A: Yes. After the close of the initial QHP Application submission window, issuers will be able to upload revised data templates on an as-needed basis until the final data submission deadline of August 25, 2015. Issuers will be able to upload revised QHP data templates and make other necessary changes to QHP Applications in response to State or CMS feedback until the ?nal data submission deadline of August 25. An issuer must also submit a petition to make service area changes during this period and evidence of State approval for service area changes. All data changes must be authorized by the State; however, issuers should con?rm the level of approval necessary from each state. For QHPs in direct enforcement States, the CMS Form Filing team, instead of the State, must authorize data changes. Issuers can contact the CMS Form Filing team at Issuers may not add new plans after May 15, 2015, or change an off-Marketplace plan to both on- and off-Marketplace. (REG TAP FAQ Database - FAQ #10371 05/01/15) Q: How do issuers petition CMS for permission to make changes to service area after the initial application period (ending May 15, 2015)? A: Issuers may request changes between May 15, 2015 and August 11, 2015. 771 Updated 1-31-17 2017--00871 All requests for changes to QHP data must be submitted to the XOSC Help Desk at CMS FEPS@cms.hhs.qov. Requests MUST contain the following information. If this information is not provided, the request will be automatically disapproved. . A detailed description of the QHP data changes requested: (REGTAP FAQ Database - FAQ #10372 05/01/15) Q: Can Issuers add new plans after the initial submission deadline (ending May 15, 2015)? A: No. After the initial submission deadline of May 15, 2015, issuers cannot add new plans to a QHP Application or change an off-Marketplace plan to both on- and off- Marketplace. (REGTAP FAQ Database - FAQ #10373 05/01/15) Q: If an issuer is making a correction to its application in response to a correction notice, is the issuer required to submit a petition/data change request? A: No. Issuers are not required to submit a petition/data change request to CMS if it is revising the application in response to a correction notice issued by CMS, unless the issuer is making a change to its service area. If the issuer is making a service area change then it must follow the petition process. (REGTAP FAQ Database - FAQ #10374 05/01/15) Q: Are issuers in states performing plan management required to submit petitions for service area changes? A: Yes. Issuers in states performing plan management functions must petition for service area changes. Additionally, issuers in states performing plan management functions cannot add new plans to a QHP Application or change an off-Marketplace plan to both on- and off-Marketplace after May 15, 2015. (REGTAP FAQ Database - FAQ #10375 05/01/15) Q: If an issuer submits a service area change request on August 10, but does not receive a response from CMS before August 25, will the issuer be able to submit the changes? A: No. All changes to service area must be explicitly approved by CMS before an issuer submits the changes. (REGTAP FAQ Database - FAQ #10376 05/01/15) 05: Where can issuers locate the chapter on justifications? Are there any requirements for how issuers must complete and upload justi?cations? A5: There is a Justifications Overview document located at (QHP Certi?cation Process FAQs #4 (09/29/15)) 06: Where can issuers upload supporting documentation such as benefit booklets for summary plan descriptions, enrollment forms, and group contracts? A6: Issuers can upload additional documents the Essential Health Bene?t (EHB) 772 Updated 1-31-17 2017--00872 allocation supporting document and the Actuarial Value supporting document) in the Bene?ts Service Area Module. The module allows you to select a number of document types, such as Actuarial Certi?cation, Form, and EHB Variance Justification. If you cannot find a label that ?ts your document, you can select the ?Other? option. Suggested naming conventions for supporting documents can be found in the Justi?cation Overview document available at (QHP Certi?cation Process FAQs #4 (09/29/15)) Q7: Must issuers upload forms or benefit booklets in Health Insurance Oversight System (HIOS) as part of the QHP certification application? A7: Qualified Health Plan (QHP) and Stand-alone Dental Plan (SADP) certi?cation do not require issuers to upload forms or contracts if the issuer is not in a direct enforcement state; however, if a State requires issuers to provide the documents, then issuers must upload the documents in the system identi?ed by the state regulator. Plan documents, including forms and booklets, are required to be submitted to CCIIO through the HIOS Document Collection Form Filing Module for health insurance products (not Stand-Alone Dental plans, which are excepted bene?ts) in direct enforcement states of Alabama, Missouri, Oklahoma, Texas, and Wyoming. You can contact formfilinq@cms.hhs.qov with questions you may have regarding these required submissions. (QHP Certi?cation Process FAQs #4 (09/29/15)) 08: What do I need to do in HIOS to ensure that my QHP application is finalized and CMS receives my data? A8: After validating the Issuer, Bene?ts Service Area, and Rating Modules, proceed to the Final Submission tab available in each of the modules. Each successfully validated module will display with a status of ?Validation Completed? on the Final Submission tab. If all three modules have a ?Validation Completed? status, click on the ?Cross Validate? button and, after resolving any cross validation errors, click the Submit button. Issuers will then receive a message at the top of the screen stating, ?Issuer ID has been Submitted.? While users with either a Submitter and Validator role can cross validate the Final Submission data, only a Validator has the rights to submit an application. (QHP Certi?cation Process FAQs #4 (09/29/15)) 09: In regards to uploading non-excel files, should issuers follow the naming convention for excel file names and ensure there are no spaces or capital letters? A9: The Health Insurance Oversight System (HIOS) does not accept file names with spaces; however, issuers may upload ?le names with capital letters. (QHP Certi?cation Process FAQs #4 (09/29/15)) 06: May issuers submit discrimination justifications with the initial Qualified Health Plan (QHP) Application prior to receiving a Correction Notice? A6: Yes, the Centers for Medicare Medicaid Services (CMS) will accept justi?cations with an initial QHP application. (QHP Certi?cation Process FAQs #5 {09/29/15) 773 Updated 1-31-17 2017--00873 Q16: May issuers upload templates revisions between May 15, 2015 and August 25, 2015? A16: The conditions under which an issuer may submit revisions to their QHP application data during this period are outlined in the 2016 Letter to Issuers, Table 1.2 which can be found here: (QHP Certi?cation Process FAQs #5 {09/29/15) Q3: When should issuer/plan Uniform Resource Locators (URL) required as part of the Quali?ed Health Plan (QHP) application be active/live? A3: URLs should be active by the time issuers send signed QHP agreements to CMS. There is no prohibition on having URLs go live before then, although URLs should clearly identify the plan year to which they apply (Le. 2015 or 2016) to ensure that consumers may correctly identify the benefit and formulary year. (QHP Certi?cation Process FAQs #9 (09/29/15)) 023: Does the Centers for Medicare Medicaid Services (CMS) allow issuers to have counties in more than one Service Area? A23: Yes, CMS permits issuers to include the same county in more than one Service Area ID. The Service Area of a QHP or SADP is the geographic area in which an enrollee could access services and be covered under that particular plan. Issuers identify their Service Areas by state or by one or more counties within a state. Counties may be included in more than one Service Area. QHPs and SADPs may not use the same service areas. Dual product issuers offering QHPs and dental plans must create two different Service Area IDs for use with the two plan types regardless of whether the Service Area is intended to serve both QHPs and dental plans. However, within the coverage type (QHP or SADP) multiple plans and products may be included in the same service area. A different Service Area ID is not required for each product within a county. Note that a plan may only be associated with a single service area. (QHP Certi?cation Process FAQs #1 {09/29/15) General Q: If a broker is not appointed by an issuer, may that broker continue to service the issuer's accounts? Updated 1-31-17 A: All issuers and producers must comply with State appointment laws, and act within the authority of applicable State licenses. Issuers should contact the State Department of Insurance (DOI) for inquiries regarding the scope of practice for unappointed producers. (REGTAP FAQ Database - FAQ #2586 07/03/14) 774 2017-?00874 Q: In an enrollment transaction that relies on direct enrollment functionality, which FFE User ID should a Web-based entity (WBE) submit during the secure redirect and fetch eligibility service that occurs between the WBE's website and the Federally-facilitated Marketplace (FFM) website?* A: During the secure redirect and fetch eligibility service, WBEs should transmit the FFE User ID of the specific agent or broker who is conducting the enrollment transaction, as an assertion of the identity of the user on behalf of whom the web service call is made. The WBE should not transmit a single FFE User ID for all transactions, as this may result in system errors, including record locks. FFE User ID is the User ID of the user submitting the enrollment to the FFM, and is required when the user type is an agent or broker. See ?Federally Facilitated Marketplace (FFM) Direct Enrollment API for Web Brokers/Issuers Technical Specifications Version pg. 33, last modified Nov. 20, 2013. (REGTAP FAQ Database - FAQ #9200 03/04/15; re-issued as REG TAP FAQ Regarding FFE User ID Submission 07/18/16) Q: Can web-brokers take advantage of the marketing opportunities offered by A: All stakeholders in the Marketplace are able to use the marketing opportunities. To order Marketplace materials, review the instructions at: (REGTAP FAQ Database - FAQ #15669 04/25/16) Q: Is there a list of active web-brokers who use the Direct Enrollment Pathway? A: There is a list of registered web-brokers available on the Agents and Brokers Resources webpage available at or by going to HealthCare.gov and selecting the 'Resources for Agents and Brokers' link at the bottom of the landing page. (REGTAP FAQ Database - FAQ #15670 04/25/16) Q: If a state has concerns about a certain agent or broker, should it share these concerns with A: Yes. States should notify CMS of any specific agents and brokers whose conduct raises concerns, especially with regard to potential or confirmed instances of noncompliance with FFM requirements. States should also notify CMS of state enforcement actions against speci?c agents and brokers. CMS intends to coordinate resolution actions addressing suspected or con?rmed noncompliance by FFM agents or brokers with all affected states, and any resolution actions taken under its statutory or regulatory authority will not supplant the states' authority to pursue their own enforcement actions. States should contact their respective CMS Center for Consumer Information Insurance Oversight State Officer to relay any concerns about specific agents and brokers. (REGTAP FAQ Database - FAQ #15771 05/02/16) Q: If CMS has concerns about a specific agent or broker, will the agency share these concerns with the state(s) in which the agent or broker is licensed? A: Yes. CMS is conducting ongoing oversight of FFM-registered agents and brokers to 775 Updated 1-31-17 2017--00875 ensure compliance with FFM requirements. CMS noti?es state regulatory agencies regarding speci?c agents or brokers about whom it has concern(s) so that the investigation and resolution can be coordinated appropriately with the licensing state(s). CMS typically relays these concerns through the respective CMS Center for Consumer Information Insurance Oversight State Officer. CMS's monitoring efforts focus primarily on concerns that relate to agent and broker compliance with the FFM-speci?c requirements. The agency relies on states to continue to monitor agent and broker compliance with state laws and requirements. To the extent that CMS detects a potential compliance issue related to state requirements, it will inform the state and expect the state to assume the primary role for resolving the issue. (REGTAP FAQ Database - FAQ #15772 05/02/16) Q: Do the Federally-facilitated Marketplaces (FFMs) independently verify agents' and brokers' state licenses? A: No. The FFMs do not independently verify the state licenses of FFM-registered agents and brokers. Pursuant to 45 CFR 156.340, a quali?ed health plan (QHP) issuer maintains responsibility for the compliance of its delegated and entities, including affiliated agents and brokers. Accordingly, CMS expects QHP issuers to verify that the agents and brokers selling their products have valid state licenses and comply with applicable agent and broker FFM registration requirements. The QHP issuer is responsible for con?rming the validity of the agent's or broker's state license and the inclusion of the agent's or broker's National Producer Number (NPN) on the CMS registration completion list before allowing an agent or broker to access the QHP issuer's connection to the FFMs (if the QHP issuer supports the Direct Enrollment Pathway) and before issuing compensation. Issuers may accept a copy of an agent's or broker's registration completion certificate as evidence that the agent's or broker's NPN will appear on the next publicly available registration completion list. (REGTAP FAQ Database - FAQ #15773 05/02/16) Q: Are agents and brokers permitted to use the Federally-facilitated Marketplace (FFM) online functionality that is designed for consumer-only use, such as the plan shopping and enrollment functions? Updated 1-31-17 A: No. Agent or broker use of the consumer plan shopping and enrollment functions on the FFMs is prohibited because agents and brokers may not assist consumers using consumers' online FFM accounts. These functions are designed for consumer use only, and only consumers may access those functions using their consumer accounts. CMS has previously provided guidance that documents how agents and brokers who are registered with the FFMs may assist consumers with the FFM enrollment process via two options: (1) the Direct Enrollment Pathway, through which the agent/broker can use an issuer's or web-brokers website to assist a consumer; or (2) the Marketplace Pathway, using a side-by-side model, through which the agent or broker can help a consumer using the Marketplace website. (See ?Role of Agents, Brokers, and Web- brokers in Health Insurance Marketplaces,? last revised January 12, 2016, available at 6 16.pdf .) This guidance was clear that agents and brokers are required to use their own FFM user IDs and accounts when assisting consumers to enroll in quali?ed health plans using the Direct Enrollment Pathway. The guidance also explained that agents and brokers assisting consumers using the Marketplace Pathway should not have independent access to consumer's FFM 776 2017--00876 online user IDs, passwords, and accounts. Agents and brokers therefore are not permitted to use direct URL access and/or any other pathways or methods of enrollment that would allow them access to consumer online accounts and consumer-speci?c functions. This is applicable during Open Enrollment and special enrollment periods. (REGTAP FAQ Database - FAQ #15778 05/02/16) Q: Are agents and brokers permitted to use FFM online functionality that is designed for consumer use only such as the plan shopping and enrollment functions? A: No. Agent/broker use of the consumer plan shopping and enrollment functions on the FFM is prohibited because agents and brokers may not assist consumers using consumers? online FFM accounts. These functions are designed for consumer use only, and only consumers may access those functions using their consumer accounts. CMS has previously provided guidance that documents how agents and brokers who are registered with the FFM may assist consumers with the FFM enrollment process via two options: (1) the Direct Enrollment pathway, through which the agent/broker can use an issuer?s or website to assist a consumer; or (2) the Marketplace pathway, using a side by side model, through which the agent/broker can help a consumer using the Marketplace website. (See ?Role of Agents, Brokers, and Web-brokers in Health Insurance Marketplaces,? last revised Nov. 7, 2014, available at Marketplaces/Downloads/Mav 1 2013 CCIIO AB - Guidance 110414 508.pdf .) This guidance was clear that agents and brokers are required to use their own FFM user IDs and accounts when assisting consumers to enroll in qualified health plans using the Direct Enrollment pathway. The guidance also explained that agents and brokers assisting consumers using the Marketplace pathway side by side model should not have independent access to consumer?s FFM online user IDs, passwords and accounts. Agents and brokers therefore are not permitted to use direct URL access and/or any other pathways or methods of enrollment that would allow them access to consumer online accounts and consumer-speci?c functions. This is applicable during open enrollment and special enrollment periods. (FAQ Regarding Agents and Brokers (Including Web-brokers) and Federally-facilitated Marketplace (FFM) Online Consumer Functionality 07/18/16) Q: May agents and brokers, including web brokers, use automation retention and loading of consumer information functionality on a third party site and then submit the completed application to the Updated 1-31-17 A: No. The only approved Direct Enrollment pathway that can be used to facilitate enrollments through the FFM is the established Direct Enrollment pathway that includes the consumer-facing redirect with Security Assertion Markup Language (SAML) assertion.1 It is impermissible for consumers to complete an application on a third party website and have their data automatically input into HealthCare.gov as part of the direct enrollment process. Specifically, CMS regulations at 45 CFR 155.405 require the use of the single streamlined application to collect information and determine eligibility for: enrollment in a Quali?ed Health Plan (QHP) offered through the advance payments of the premium tax credit; cost-sharing reductions; and Medicaid, Children?s Health Insurance Plan (CHIP) or the Basic Health Program (collectively, state health subsidy programs). Third party websites to collect consumer information to apply for coverage or other state 777 2017-?00877 health subsidy programs through the FFMs may not collect the appropriate level or amount of information necessary to make eligibility determinations. As a result, such web sites do not satisfy the FFM single streamlined application requirement and are not approved by CMS. CMS is committed to working with all agents and brokers to ensure that all Marketplace enrollment channels ensure consistent eligibility results, privacy and security safeguards on consumer data, and smooth application processing. If you have any questions on this guidance or require technical assistance, please contact us at webbroker@cms.hhs.qov . (FAQ regarding Agents and Brokers (Including Web-brokers) and Federally-facilitated Marketplace (FFM) On/ine Enrollment Functionality 07/18/16) Q: Are agents and brokers allowed to log in to HealthCare.gov on behalf of a consumer to complete his or her application and choose the consumer's health care coverage? A: No; if the consumer is using HealthCare.gov and the agent or broker is helping the consumer, CMS requires that the consumer log in with his or her own credentials user name and password).The consumer's credentials are con?dential and should not be shared with the agent or broker. However, if an agent or broker is assisting the consumer using the Direct Enrollment Pathway, which is sometimes known as the issuer-based or web-broker pathway, then the agent and broker can log in to the issuer's or web-broker's website and complete an application on behalf of the consumer. (REGTAP FAQ Database - FAQ #17977 10/28/16) Q: When helping a consumer enroll in a qualified health plan (QHP) through the Marketplace, will I be able to see the information the consumer is submitting on the application live, or will I be looking at a blank application so I can walk the consumer through it? A: There are two pathways in which agents and brokers can help consumers enroll in the Marketplace. For the Marketplace 'side-by-side' pathway, agents and brokers are generally sitting side-by-side assisting consumers with their applications. For the Direct Enrollment pathway, agents and brokers generally log into an issuer's website or a web- broker's website and enter the information on behalf of the consumer. Agents/brokers not registered for plan year 2017 are not authorized to assist consumers with enrollments through the Marketplace, cannot access the direct enrollment pathway, and for both enrollment channels, issuers are unable to compensate agents/brokers if they are not on the Registration Completion List for plan year 2017 at the time of enrollment assistance. (REGTAP FAQ Database - FAQ #18301 12/02/16) Q: Agents and brokers are not able to fill out a Marketplace application for consumers, but it sounds like they can follow along in the application with them. How do agents and brokers do this if they cannot sign into the consumer's account? Updated 1-31-17 A: In the Marketplace side-by-side approach, the consumer logs into his or her account with their private Marketplace credentials. The agent or broker may then assist the consumer with completion of the application. The agent or broker should not ask a consumer to share his or her private Marketplace credentials. (REGTAP FAQ Database - FAQ #18302 12/02/16) 778 2017--00878 Q: Do consumers need to sign the individual consent required under 45 CFR prior to an agent or broker helping them enroll in a qualified health plan (QHP) through the Marketplace? If so, what is the necessary form? A: Agents and brokers do need to obtain consent from consumers prior to assisting with enrollment through the Marketplace. While CMS does not provide the form, or specify that it has to be signed, agents and brokers can use a broker of record form from an affiliated Marketplace issuer. (REGTAP FAQ Database - FAQ #18303 12/02/16) Q: Are subsidy amounts or the formula to generate subsidy amounts different from the last plan year? A: The formula is the same, but some variables (such as the federal poverty level (FPL) amount) are updated each year. (REGTAP FAQ Database - FAQ #18304 12/02/16) Q: How does an agent or broker know if a consumer has a data matching issue? A: When a consumer submits an application through the Marketplace and there is a data matching issue, he or she will see an indication on the screen that shows eligibility results and also in the eligibility determination notice that is a downloadable PDF. It will tell the consumer what type of information he or she needs to provide to the Marketplace depending on the type of data matching issue. If time has passed and the consumer wants to check the status of the data matching issueAccount section of the application to see if the issue still exists. Consumers may also contact the Marketplace Call Center for a status update. (REGTAP FAQ Database - FAQ #18305 12/02/16) Agent/Broker Compensation Q: How are agents and brokers compensated or credited for enrolling consumers in coverage through the Federally-facilitated Marketplaces Updated 1-31-17 A: Agents and brokers are compensated or credited directly by qualified health plan (QHP) issuers per the terms of their QHP issuer contracts for assisting consumers to enroll in QHPs through the FFMs. Compensation or credit for enrollments includes commissions, fees, or other incentives as established in the relevant contract between a QHP issuer and an agent or broker. An agent or broker must be affiliated or have a contractual relationship with the respective issuer offering a QHP or a qualified stand- alone dental plan in accordance with applicable state law in order to be paid for a Marketplace transaction. The FFMs will not establish a commission schedule or pay commissions directly to agents or brokers. CMS expects that the amount and terms of any commission would be established by the terms of the contract between a QHP issuer and an agent or broker. However, QHP issuers are required to provide the same compensation or credit to agents and brokers for enrollment in QHPs through the Marketplaces as for enrollment in similar health plans offered outside the Marketplaces. (REGTAP FAQ Database - FAQ #15774 05/02/16) 779 2017--00879 Q: Can agents and brokers receive commissions for enrolling individuals in Medicaid managed care plans? A: The Federally-facilitated Marketplaces do not have authority over state Medicaid program rules or over the relationships between Medicaid managed care organizations and their af?liated agents and brokers. For information on state-specific Medicaid rules, agents and brokers should contact their state Department of Insurance or state Medicaid agency. (REG TAP FAQ Database - FAQ #15775 05/02/16) Q: If an agent or broker assisted an individual in enrolling in a qualified health plan (QHP) through a Federally-facilitated Marketplace (FFM), but the agent's or broker's National Producer Number (NPN) is not associated with the enrollment transaction on the 834 enrollment transaction file provided by the FFM to the QHP issuer, can the agent's or broker's information be added at a later date, so that the agent or broker can receive compensation from the QHP issuer? A: In general, the agent's or broker's NPN, name, and FFM user ID should be recorded as part of the consumer's application. This information identifies the agent or broker on the enrollment transaction so the FFMs can appropriately track enrollment and the QHP issuer can compensate the agent or broker based upon the enrollment (as may be appropriate). However, if a QHP issuer identi?es a particular enrollment that should have had an agent or broker associated with it, the QHP issuer should add the agent or broker to the enrollment record internally, even if the agent or broker was not re?ected on the initial enrollment transaction, in case there is any follow-up required as a result of the enrollment. If an agent or broker has a legitimate reason to believe he or she should be credited for an FFM enrollment, but has not been credited for it, the agent or broker should contact the respective QHP issuer directly to discuss the speci?c situation. Please note that agents and brokers must meet registration requirements prior to assisting with an FFM application in order to be credited for the enrollment transaction. (REGTAP FAQ Database - FAQ #15776 05/02/16) Q: May agents and brokers be compensated for a Federally-facilitated Marketplace (FFM) enrollment if they are not af?liated with a quali?ed health plan (QHP) issuer? Can the FFMs credit an agent or broker for an enrollment transaction or direct the QHP issuer to do so? A: No. The FFMs have not established a commission schedule and do not pay commissions directly to agents or brokers. The FFMs transmit agent and broker identifying information the National Producer Number), which is recorded as part of the consumer's application, to QHP issuers in order to facilitate any payment or compensation from a QHP issuer. The amount and terms of any compensation or credit are governed by the QHP issuer's contract with the agent or broker. Unless otherwise required under state law, a QHP issuer is not obligated to compensate an agent or broker with whom the QHP issuer is not af?liated, even if the agent or broker assists a consumer in enrolling in the issuer's QHP through the Marketplaces. However, FFM policy recommends that QHP issuers keep a record of enrolling agents or brokers in their systems, even if an agent or broker is not af?liated with the QHP issuer, in case there is any follow-up required as a result of the enrollment. To become affiliated with a QHP issuer, agents and brokers must contact the QHP issuer directly, or they can 780 Updated 1-31-17 2017--00880 contact their state Department of Insurance for more information. (REGTAP FAQ Database - FAQ #15777 05/02/16) Q: Can agents or brokers, including web-brokers, charge a reasonable application fee to a consumer that it is assisting in selecting and enrolling in a Qualified Health Plan (QHP) through the Federally-facilitated Marketplace A: In guidance, we stated that we expect that consumers are not charged a separate transaction or service fee for shopping or enrolling in a QHP offered through the FFM using a web-broker's services or website. See the Role of Agents, Brokers and Web- brokers in the Health Insurance Marketplaces (November 7, 2014). It has come to our attention that some web-brokers may have invested significant resources to develop special software to assist consumers with selection and enrollment in QHPs offered through the FFM, and some independent agents and brokers may leverage those web sites to facilitate QHP selection and enrollment. We believe that in these circumstances, where there is a bona fide service of value that goes beyond the traditional assistance provided by an agent or broker registered with the FFM, it may be appropriate to allow for the collection of an additional fee. However, any practice of collecting such fees from consumers for providing assistance with QHP selection and enrollment through the FFM would be subject to applicable state law. If permitted under state law, agents, brokers, and web-brokers that elect to pass on these types of costs to consumers for selecting and submitting QHP applications offered through the FFM through a non-FFM website should provide a disclaimer to consumers that: 1) clearly discloses the amount and reason for the fee, and 2) informs the consumer that he/she can apply through the FFM website (Healthcare.gov) at no cost. As a reminder, use of web-broker websites to assist with selection and enrollment in coverage through the FFM must comply with the requirements of 45 C.F.R. including but not limited to providing consumers with the ability to withdraw from the process and use the FFM website instead at any time. (FAQ regarding Agents and Brokers (including Web-brokers) and Application Fees 07/18/16) Q: What should I tell consumers on how I will protect their personally identifiable information (Pll) while helping them complete enrollment through the Federally-facilitated Marketplaces Updated 1-31-17 A: Prior to collecting Pll, you must provide consumers a Privacy Notice that is on the electronic or paper form you use to collect information that is written in plain language and provided in a manner that is accessible and timely to people living with disabilities and with limited English language pro?ciency. At minimum, the statement must contain the following information: 1) Legal authority to collect PH 2) Purpose of the information collection 3) To whom might be disclosed and for what purposes 4) Authorized uses and disclosures of any collected information 5) Whether the request to collect PM is voluntary or mandatory under the law 6) Effects of non-disclosure if a consumer chooses not to provide the requested information 781 2017-?00881 You can refer to the ?Protection Requirements and Appropriate User of Consumers' Pll" FINAL 5-19-16 v2.pdf) webinar slides for more guidance on how to protect consumer's Pll. (REGTAP FAQ Database - FAQ #17097 08/04/16) Q: Can I call the Marketplace Call Center on behalf of my consumer? A: Consumers can authorize the Marketplace Call Center to allow an agent or broker to work on their behalf. To do so, a consumer will need to call the Marketplace Call Center and give the call center representative your National Producer Number (NPN). Please note that this is not the same as ensuring your NPN is on the consumer's application. Consumers need to reauthorize the agent or broker with the Marketplace Call Center every 365 days. We recommend working with your consumers to get your reauthorization processed prior to the start of Open Enrollment. (REGTAP FAQ Database - FAQ #17098 08/04/16) Q: Since I'm an agent, if I have a question on how to help a client and my client has authorized me to access their information, can I call the Agent and Broker Call Center help desk? A: The Agent and Broker Call Center cannot help you with a consumer's specific issues. When you have exhausted the self-service options and you still need help assisting a consumer, you may contact the Marketplace Call Center at: 1-800-318-2596. This center is available 24 hours a day, seven days a week. (REGTAP FAQ Database - FAQ #17099 08/04/16) Q: How do I receive my commissions for assisting consumers with selecting and enrolling in coverage for plan year 2017 through the Marketplace? A: Agents and brokers in the Marketplace are credited via the 834 enrollment transactions in accordance with their agreements with quali?ed health plan (QHP) issuers and any state-speci?c requirements. The Marketplace does not directly appoint agents or brokers and do not set compensation/credit levels. To the extent permitted by a state, agents and brokers may receive compensation/credit from QHP issuers in the form of commissions as a result of assisting qualified individuals in selecting QHPs through the Marketplaces. A QHP issuer must pay the same compensation/credit for QHPs offered through the Marketplace as it does for similar health plans offered in the state but outside of the Marketplace. Agents and brokers should ensure they enter a correct National Producer Number (NPN) in their Marketplace Learning Management System (MLMS) pro?les to ensure issuers are able to credit them appropriately. (REGTAP FAQ Database - FAQ #17980 10/28/16) Q: Will National Producer Numbers (NPN) be dropped if consumers update their Marketplace application information? A: No. NPNs are only removed if the consumer removes or othenlvise makes changes to the NPN from his or her application. Consumers can also contact the Marketplace Call 782 Updated 1-31-17 2017--00882 Center to ask for assistance with making changes to their application (including but not limited to changes to the NPN). (REGTAP FAQ Database - FAQ #18290 12/02/16) Q: If consumers want help updating and making changes to an existing application, will they have the option to add an National Producer Number (NPN) to the existing application? A: Yes. If consumers are updating their application information, they are able to add or change the agent or broker information at that time. They can also contact the Marketplace Call Center to ask for assistance with making changes to their application. (REGTAP FAQ Database - FAQ #18291 12/02/16) Q: If a consumer changes plans without telling the agent or broker of record on their application, does the National Producer Number (NPN) stay with the customer? A: Yes. The NPN stays with the application unless the consumer removes or otherwise makes changes to the NPN. Marketplace Call Center representatives won't remove agent/broker NPNs unless requested by the consumer. If you think there might be an issue with your NPN being removed, please submit the Application ID with a description of the problem so we can research the matter. Send speci?c information (without consumer Pll) to (REGTAP FAQ Database - FAQ #18292 12/02/16) Q: Can a consumer call the Marketplace Call Center mid-year in order to change the agent or broker of record on his or her application? A: Yes. Consumers can call the Marketplace Call Center to change the agent or broker of record on their applications. However, CMS recommends that consumers do this only when they are making other updates to their applications. Consumers can also do this online themselves while making other updates to their applications. (REGTAP FAQ Database - FAQ #18293 12/02/16) Q: If a consumer contacts the Marketplace Call Center directly regarding a change to his or her application (such as contact information or income), will the Marketplace retain the agent of record and National Producer Number (NPN) on the application? Updated 1-31-17 A: Yes. The NPN stays with the application unless the consumer requests that it be removed. Marketplace Call Center representatives only remove NPNs from a consumer application if directed to do so by the consumer. If you think there might be an issue with your NPN being removed, please submit the Application ID with a description of the problem so we can research this further. Send speci?c information (without consumer personally identi?able information) to (REGTAP FAQ Database - FAQ #18294 12/02/16) 783 2017--00883 Q: Will the Marketplace enroll consumers who have a discontinuing plan into qualified health plans (QHP) offered by insurers who do not work with agents or brokers and who do not pay commissions? A: When a consumer is enrolled in coverage through the Marketplace and does not actively select a plan for the next plan year in time to ensure coverage is effective January 1, the Marketplace identi?es alternative plans for the consumer according to the auto re-enrollment crosswalk hierarchy. In doing so, the Marketplace does not take into consideration whether an issuer pays a commission when auto-renewing consumers. (REGTAP FAQ Database - FAQ #18295 12/02/16) Q: How do agents or brokers who assist consumers to enroll in Marketplace coverage receive compensation? A: Agents and brokers who participate in the Marketplace may be compensated directly by qualified health plan (QHP) issuers in accordance with their agreements with QHP issuers and any applicable state-specific requirements. Compensation or credit for enrollments includes commissions, fees, or other incentives as established in the relevant contract between a QHP issuer and an agent or broker. The Marketplace does not establish a commission schedule or pay commissions directly to agents or brokers. However, under Marketplace regulations, an issuer must pay the same agent or broker compensation for selling a QHP inside or outside the Marketplace. (REG TAP FAQ Database - FAQ #18296 12/02/16) Q: Do agents and brokers have to be appointed with a specific carrier in order to get paid? A: Generally, agents and brokers must be affiliated or have a contractual relationship with the respective issuer offering a qualified health plan (QHP) or a qualified stand- alone dental plan in accordance with applicable state law in order to be paid for a Marketplace enrollment. To become appointed with a particular QHP issuer, we recommend that agents and brokers contact the QHP issuer directly, and contact their state regulators, such as the Department of Insurance (DOI), with any questions on this topic. (REGTAP FAQ Database - FAQ #18297 12/02/16) Q: Do issuers have to pay agents/brokers for Marketplace enrollments? A: The Marketplace does not establish compensation requirements for participating issuers, though many issuers do compensate affiliated agents/brokers. However, issuers should only compensate af?liated agents and brokers that are compliant with applicable Federal requirements, including those for registration with the Marketplace. (REGTAP FAQ Database - FAQ #18298 12/02/16) Q: Some issuers have stopped compensating agents and brokers for Marketplace enrollments. Is this allowed? A: A compensation arrangement in which an issuer pays no commission for sale of aqualified health plan (QHP) through the Marketplace but does pay a commission for sale of a similar plan outside of the Marketplace, would violate Marketplace regulations 784 Updated 1-31-17 2017--00884 at 45 CFR If agents or brokers have concerns about such practices, they should contact the Agent/Broker Email Help Desk at AssisterHelpDesk@cms.hhs.qov. (REGTAP FAQ Database - FAQ #18299 12/02/16) Q: When an agent or broker enrolls a consumer through the Marketplace pathway, where does the consumer enter the broker's National Producer Number (NPN) on the application? A: There are two locations to enter agent and broker NPNs on Marketplace application: one is at the beginning of the application and the other is after plan selection. To be properly compensated for a sale or renewal, agents and brokers should check to see that their name and NPN are in both locations on the application. Generally, look for a question about someone helping with applying or enrolling in order to add your information to the application and to plan selection prior to con?rming enrollment. (REGTAP FAQ Database - FAQ #18300 12/02/16) Q: Is the payment of agent/broker commissions a marketing practice under 45 CFR 147.104(e) and Updated 1-31-17 Yes. Federal rules prohibit marketing practices that have the effect of discouraging the enrollment of individuals with signi?cant health needs in health insurance coverage, both inside and outside of the Marketplaces. Issuers commonly use agents and brokers as an important part of their marketing and sales distribution channels, and the way an issuer structures its compensation to agents and brokers influences the enrollment and retention of consumers. Therefore, a commission arrangement or other agent/broker compensation that is structured to discourage agents and brokers from marketing to and enrolling consumers with signi?cant health needs constitutes a discriminatory marketing practice prohibited under 45 CFR 147.104(e) and For example, if an issuer pays agents or brokers less through all forms of compensation for higher metal level plans (such as platinum and gold level plans), which are associated with higher utilization, than the issuer pays for lower mental level plans (such as bronze and silver level plans), this act constitutes a failure on the part of the issuer to comply with the applicable Federal guaranteed availability provisions and QHP marketing standards. Guidance Implementation We recognize that agent/broker compensation is included among the costs used to establish the plan-adjusted index rate for an issuer?s plans within the single risk pool and that some issuers may have to modify their rates based on the above guidance. Accordingly, CMS will not take enforcement action against an issuer for failing to comply with this guidance until the issuer?s next opportunity to update rates consistent with applicable Federal and State law and regulations. For example, this guidance will not be enforced with respect to agent/broker compensation arrangements in connection with policy years beginning before January 1, 2018 in an individual or merged market, and plan years beginning before April 1, 2017 in a small group market in a State that permits quarterly rate updates. States, as the primary regulators of the guaranteed availability requirements, may exercise similar enforcement discretion and will not be considered by CMS to be failing to substantially enforce for this reason. For non-grandfathered coverage offered with a plan or policy year beginning on or after such dates, issuer agent/broker compensation arrangements and accompanying 785 2017--00885 marketing and distribution practices must comply with this guidance, regardless of whether such coverage is offered through or outside of the Marketplaces. (REGTAP FA OS on Agent/Broker Compensation and Discriminatory Marketing Practices 12/16/16) A gent/Broker Registration Q1: How do agents/brokers register for the A1: To the extent permitted by the licensing state, agents and brokers may assist in enrolling individuals in quali?ed health plans (QHP) in the FFM Individual Marketplaces, provided they complete the following steps: 0 Part I: Register on the Medicare Learning Network (MLN) complete assigned training and exams, and execute the Federally-facilitated Marketplace Agreements. This can be accessed at: Please note: 0 You will need to enter basic identifying information, including your National Producer Number (NPN), as prompted. It is vital that you enter your NPN correctly and that you remember your MLN user ID. When you enter your NPN, use numeric digits only and do not include leading zeroes or hyphens. (Your NPN must be 10 digits or less.) 0 Keep the training curriculum certi?cates you receive. You will need to provide copies of your curriculum certificates to the issuers and web-brokers with which you are af?liated. You will receive a certi?cate for each curriculum you complete successfully. 0 After you complete training, please allow 48 business hours to elapse before you attempt to access the identity proo?ng process?this will better ensure that your training records have been fully transmitted to the CMS Enterprise Portal. 0 Part II: Create an FFM User ID and complete identity proo?ng through the CMS Enterprise Portal: Please note: 0 As part of this process, you will be prompted to enter your NPN and MLN User ID. It is vital that you enter both of these items accurately, or the system will not be able to match your training records. When you enter your NPN, use numeric digits only. (Your NPN must be 10 digits or less.) 0 Instructions from earlier CMS webinars may be useful as agents/brokers complete the registration process. Those instructions, and other information, may be found on our webpage: See especially: (Agent and Broker FAQ #1 09/19/13; REGTAP FAQ Database - FAQ #323 09/19/13) Note: A similar FAQ was released through REGTAP on 03/31/14, as follows: 786 Updated 1-31-17 2017--00886 Q: Do licensed agents and brokers, including captive agents, who sell directly to consumers need to complete training? A: Part I: Register on the Medicare Learning Network complete assigned training and exams, and execute the Federally-facilitated Marketplace Agreements. This can be accessed at Please note: 0 Agent and brokers will need to enter basic identifying information, including their National Producer Number (NPN), as prompted. It is vital that they enter their NPN correctly, using numeric digits only and no leading zeros, and remember their MLN user ID. . Agents and brokers must keep the training curriculum certi?cates they receive. They will need to provide copies of their curriculum certi?cates to the issuers and web- brokers with which they are af?liated. After completing the curriculum, agents and brokers should allow 48 business hours to elapse before you attempting Part II. This will better ensure that their training records have been fully transmitted to the CMS Enterprise Portal. Part II: Create an FFM User Account (ID and password) and complete identity proo?ng through the CMS Enterprise Portal: Please note: As part of this process, agents and brokers will be prompted to enter their NPN and MLN User ID. It is absolutely vital that they enter both of these items accurately, or the system will not be able to match their training records. . When entering the NPN, use only numeric digits and no leading zeros. (The NPN must be 10 digits or less.) Agents and brokers who want to operate exclusively within the Federally-facilitated Small Business Health Insurance Options Program (FF-SHOP) Marketplaces are strongly encouraged to complete Marketplace-speci?c training courses and pass the accompanying exams, and they are required to electronically sign the Federally- facilitated SHOP Marketplace Agreement. They are not required to complete Part II of the registration process. To learn more about the role of agents and brokers in the FFM, please visit Marketplaces/assistance.html and There are a number of links and documents on those pages which contain information about the FFM registration. (REGTAP FAQ Database - FAQ #1365 03/31/14) 02: Is there a deadline to complete the agent/broker registration with the Updated 1-31-17 A2: There is no calendar deadline to complete registration requirements for the FFM. However, the Marketplace-specific requirements must be met before assisting quali?ed individuals, employers and employees with eligibility and enrollment determinations for the 2014 plan year. Open enrollment for the 2014 plan year begins on October 1, 2013. In states where an FFM is operating, all agents and brokers must register with the FFM before assisting qualified individuals to select Individual Marketplace coverage for the 787 2017--00887 2014 plan year. (Agent and Broker FAQ #1 09/19/13; REGTAP FAQ Database - FAQ #324 09/19/13) Q3: Ifl have more than one NPN, which NPN should I use when I register? How are corporate NPNs registered for the Updated 1-31-17 A3: If an entity has a corporate National Producer Number (NPN), that NPN should be registered with the Federally-facilitated Marketplaces (FFM), based on the steps described below. In addition, each individual agent should register with the FFM using their individual NPN. Prior to assisting consumers, each agent or broker needs to have completed the FFM training and registration process. For most agents and brokers, the registration process for the Federally-facilitated Marketplaces will consist of two parts. Part includes training, exams, and the electronic signing of Federally-facilitated Marketplace Agreements. Part I occurs on the Medicare Learning Network (MLN) and can be accessed at: Part II includes identity proo?ng and the creation of an FFM User ID. Part II occurs on the CMS Enterprise Portal, which can be accessed at (Please be advised: Agents and brokers who want to operate exclusively within the Federally- facilitated Small Business Health Insurance Options Program (FF-SHOP) Marketplaces are strongly encouraged to complete Marketplace-speci?c training courses and pass the accompanying exams, and they are required to electronically sign the Federally- facilitated SHOP Marketplace Agreement. They are not required to complete Part II of the registration process.) Below is information about entering your NPN during the FFM registration process. For Part of the FFM reqistration process: 0 It is vital that you enter your NPN correctly in your MLN pro?le. Do not add any leading zeroes. If you have multiple NPNs?for example, if you are an agent/broker who is licensed as an individual and you also own a business entity that has a separate NPN?you must create a separate MLN account for each NPN and you must complete the required training for each MLN account/NPN. For business entities that wish to register and participate in the FFM, the business entity must select an authorized official to complete the required training on MLN using the NPN of the corporate entity. For example, the business entity may select the president or the CEO to complete the MLN training, using the business entity?s NPN. (Remember, however?in addition to the business entity registering, each individual agent should register with the FFM using their individual NPN. Prior to assisting consumers, each agent or broker needs to have completed the FFM training and registration process.) 0 Remember, all compensation arrangements must be made directly with the issuers or web-brokers with whom you are af?liated. 788 2017--00888 For Part II of the FFM registration process: . It is vital that you enter your NPN and your MLN user ID correctly in Part II. Do not add any leading zeroes to your NPN. If you have multiple NPNs: During Part II of the registration process, you should enter the NPN that you anticipate will be included on the majority of the QHP enrollment applications you assist with. In other words, enter the NPN under which you expect to conduct the majority of your FFM business. You will need to enter the MLN user ID that is associated with that NPN. You will only complete Part II identity veri?cation for one of your you will not complete identity verification for each of your NPNs. In the case of business entities, the authorized official who completed the MLN training with the NPN of the corporate entity is the individual who must complete Part II of the registration process. When completing Part II, the authorized of?cial should again enter the NPN of the corporate entity, and the MLN user ID that is associated with that account. (Agent and Broker FAQ #1 09/19/13; REG TAP FAQ Database - FAQ #325 09/19/13) Q4: How do I know what my NPN is? Where can I find my A4: National Producer Numbers (NPN) are managed and controlled by the National Insurance Producer Registry (NIPR). Your NPN is an up to 10-digit number, without leading zeros. An NPN is a unique sequential number used to identify individual producers. If you are unable to recall your NPN, you may obtain it by visiting It is vital that you enter your NPN correctly when you are registering for the FFM. Do not enter leading zeroes, and do not enter hyphens. (Agent and Broker FAQ #1 09/19/13; REGTAP FAQ Database - FAQ #326 09/19/13) 05: Where can I get more information about being an agent/broker in the A5: To learn more about being an agent or broker in the FFM, please visit: 0 Marketplaces/assistance.html and There are a number of links and documents on those pages, which will help you to learn more about the roles of agents and brokers in the FFM. Instructions from earlier CMS webinars may be useful as agents/brokers complete the FFM registration process. See especially (Agent and Broker FAQ #1 09/19/13; REG TAP FAQ Database - FAQ #327 09/19/13) 789 Updated 1-31-17 2017--00889 Q: Can an Agent or Broker focus only off the Marketplace for Small Groups or Individual businesses? A: Yes, nothing requires an agent or broker to participate on the FFM or FF-SHOP. (REGTAP FAQ Database - FAQ #1342 03/31/14) Q: Do agents that work with one specific QHP issuer have to inform a consumer about the whole range of QHPs offered by other issuers on the Marketplace as well? A: In the FFM, currently there is no requirement for the agent who works with one issuer to inform the consumer about all QHPs offered on the Marketplace. (REGTAP FAQ Database - FAQ #1343 03/31/14) Q: Do QHP employees that are licensed agents have to complete the ACA Marketplace and SHOP training? A: Yes. (REGTAP FAQ Database - FAQ #1344 03/31/14) Q: How will the FFM verify that an agent is properly licensed before issuing an FFM user ID to the agent? A: The FFM is not verifying agent/broker licensure, and expects that issuers will continue to verify state licensure when they onboard agents, as is current practice today. (REGTAP FAQ Database - FAQ #1345 03/31/14) Q: In order for issuers to register Agents and Brokers within the system, Agent/Broker information, such as name, address, contact information, Tax ID, and NPN must be available. Based on 834 Companion Guide there is only one field within 1000 loop that will have NPN number. How will this information be transmitted to Issuers? A: The agent's or broker' name and NPN will be transmitted on the 834 file to the issuer. (REGTAP FAQ Database - FAQ #1346 03/31/14) Q: Is the issuer's role in confirming the Agent or Broker's registration required or optional? A: We expect issuers to check for evidence of agent/broker registration with the FFM. (REGTAP FAQ Database - FAQ #1347 03/31/14) Q: Will Agents and Brokers know the commission they will receive if they are not currently enrolled with a QHP they select for a client on the Marketplace? For example, QHPs that are new to an Agent/Broker because of area expansion. A: Agents and brokers should establish compensation arrangements with each QHP issuer, including QHP issuers that may have expanded into a new service area. (REGTAP FAQ Database - FAQ #1349 03/31/14) 790 Updated 1-31-1 7 2017--00890 Q: Will issuers get a ?rm name for web brokers or do they need to track all the information for all web brokers' agents? A: Issuers should work directly with web-brokers to determine how their agents will be reported and compensated. (REGTAP FAQ Database - FAQ #1350 03/31/14) Q: Will the Federally-facilitated Marketplace (FFM) validate if an Agent/Broker is licensed in the State that the Agent/Broker is selling and effectuating policies? A: The FFM will not validate National Producer Numbers (NPNs) provided by Agent/Brokers. It is the Issuer's responsibility to make sure that Agent/Brokers appointed with them hold a current and valid state health insurance license. (REGTAP FAQ Database - #1720 05/27/14) Q: Are issuers permitted to credit agents and brokers participating in the FFM who have not registered with the FFM for the current plan year for their QHP enrollment? Do issuers need to verify agent/broker FFM registration prior to crediting agents/brokers for passive and/or active re-enrollments? A: 45 CFR 155.220 requires agents and brokers to be registered with the FFM prior to assisting or enrolling consumers in QHPs offered through the FFM. Af?liated agents and brokers who have agreements with issuers to be compensated or otherwise credited for assistance with enrollment of consumers through the FFM are considered entities of the issuer, as that term is defined under 45 CFR 156.20. Pursuant to 45 CFR. 156.340, a QHP issuer participating in the FFM maintain responsibility for ensuring that its entities, including af?liated agents and brokers, comply with applicable laws and regulations. CMS expects issuers to verify the registration status of affiliated agents and brokers before crediting and/or compensating them for enrollments through the FFM, and conduct reasonable oversight of their compliance with applicable Marketplace standards, laws and regulations. QHP issuers may verify agents and brokers' FFM registration according to the registration completion list of the CMS agent and broker resource page or by requesting a copy of the FFM User ID and training completion certi?cation (if applicable) from each af?liated agent or broker. CMS believes that these steps, at a minimum, would be required for an issuer to demonstrate good faith efforts at complying with 45 CFR 156.340 as it relates to oversight of affiliated agents and brokers. Agents or brokers who are assisting consumers with enrollment in QHPs offered through the FFM must have a current registration at the time they are providing assistance. Because passive re-enrollments assume that agents or brokers are not providing assistance to consumers to facilitate their re-enrollments, agents or brokers would not need to have a current registration to be listed on the 2015 re-enrollment transaction. In contrast, for active re-enrollments that involve agent or broker assistance, agents or brokers must have a current registration with the FFM at the time they are assisting consumers. (REGTAP FAQ Database - FAQ #8134 12/10/14) Q: Can I still take plan year 2016 registration training on the CMS-approved vendor sites when Marketplace Learning Management System (MLMS) is closed? A: No. Agents and brokers must access CMS-approved vendors' learning management systems via the MLMS. Vendor training will also close on July 15. 791 Updated 1-31-17 2017--00891 Check the Agents and Brokers Resources webpage for updates and look for emails from CMS for information about when the MLMS and CMS- approved vendors' learning management systems ?go live' for plan year 2017 registration and training. (REGTAP FAQ Database - FAQ #16704 07/15/16) Q: What is the last date I can complete plan year 2016 Federally-facilitated Marketplace (FFM) registration? A: While sign up for a new plan year 2016 FFM training curriculum ended on July 1, you have until July 14 to complete a curriculum you already have in progress, and to complete any other registration steps, including identity proofing and signing the applicable Agreements. The Marketplace Learning Management System will close on July 15 at 11:59 AM Eastern Time. (REGTAP FAQ Database - FAQ #16705 07/16/16) Q: If I have already started the plan year 2016 registration steps before the Marketplace Learning Management System (MLMS) closes on July 15, can I complete registration? A: No, you cannot complete Federally-facilitated Marketplace registration and training for plan year 2016 after July 15 at 11:59 AM Eastern Time. The MLMS will be closed so CMS can prepare to launch plan year 2017 registration and training. Please note that this also includes access to your Registration Completion Certificate (3). If you have not done so already, CMS recommends accessing your Registration Completion Certi?cate(s) and printing or saving a copy for your records before the MLMS closes. (REGTAP FAQ Database - FAQ #16706 07/17/16) Q: How can I check to be sure I completed all the steps for plan year 2016 FFM registration? A: You can con?rm you have completed plan year 2016 registration by con?rming your National Producer Number (NPN) is listed in the CMS Agent and Broker FFM Registration Completion List, which is available via the Agents and Brokers Resources webpage at: The Registration Completion List will continue to be available to you, even after the Marketplace Learning Management System (MLMS, and your access to your plan year 2016 Registration Completion closes on July 15 at 11:59 AM Eastern Time. (REGTAP FAQ Database - FAQ #16707 07/18/16) Q: How can I prove to an issuer that I have completed plan year 2016 registration so I can be compensated for enrolling consumers in the issuer's health plans? A: While you should retain copies of your Registration Completion Certificate(s), CMS has directed issuers and web-brokers to use the CMS Agent and Broker FFM Registration Completion List to confirm you have completed all Federally-facilitated Marketplace (FFM) registration requirements, including required training. Issuers can con?rm you completed all registration steps and confirm your National Producer Number (NPN) by accessing the FFM Agent and Broker Registration Completion List. (The FFM Agent and Broker Registration Completion list is available to 792 Updated 1-31-17 2017--00892 you via the Agents and Brokers Resources webpage at: (REGTAP FAQ Database - FAQ #16708 07/19/16) Q: I forgot to print a copy of my plan year 2016 Registration Completion Certificate. How do I do that? A: You can print a copy of your plan year 2016 Federally-facilitated Marketplace (FFM) Registration Completion Certificate(s) until July 14. The Marketplace Learning Management System (MLMS) closes on July 15 at 11:59 AM Eastern Time so CMS can prepare to launch registration and training for plan year 2017. Plan year 2016 certificates will not be available after that time. To print your plan year 2016 certificate(s), sign in to the CMS Enterprise Portal with your User ID and Password. On the "My Status" page, the ?Complete Agent Broker Training" entry will show ?Complete? in the ?Status? column if you have completed training. Select the ?Print link and follow the prompts. Note that issuers and web-brokers can use the CMS Agent and Broker FFM Registration Completion List to con?rm you have completed all plan year FFM registration requirements, including required training, even if you don't have a copy of your Registration Completion Certificate. (REGTAP FAQ Database - FAQ #16709 07/20/16) Q: Can I use my plan year 2016 registration to help consumers reenroll in existing coverage for plan year 2017 or choose new coverage during November and December 2016? Answer: No. The Agreement(s) you signed as part of plan year 2016 registration expire on October 31, 2016, just before the plan year 2017 Open Enrollment period starts. You must complete plan year 2017 registration before you can assist consumers in reenrolling or signing up for new coverage for plan year 2017 during the Open Enrollment period that starts on November 1, 2016. You must also complete plan year 2017 registration to assist consumers who qualify to enroll in plan year 2016 coverage in November or December 2016 via a special enrollment period. (REGTAP FAQ Database - FAQ #16712 07/23/16) Q: How will I know when plan year 2017 Federally-facilitated Marketplace (FFM) registration and training goes live? Updated 1-31-17 A: Agents and brokers who want to be prepared to assist consumers with selecting and enrolling in coverage through the FFMs for plan year 2017 will be able to access and complete plan year 2017 FFM training on the Marketplace Learning Management System (MLMS) and on CMS-approved vendors' websites in the summer of 2016. CMS will communicate when the MLMS 'goes live' through: . The Agents and Brokers Resources webpage . Emails and the 'News for Agents and Brokers' newsletter (email your request to be added to the distribution to the FFM Producer and Assister Help Desk at: . Tweets (search these hashtags: and and follow CMS on Twitter) 793 2017--00893 Also, CMS will present a series of webinars on plan year 2017 registration and training during July and August 2016. You can ?nd information about when these webinars are scheduled and instructions on how to register for them in the 'Agent and Broker Webinar' section of the Agents and Brokers Resources webpage To register for the webinar, please log in to (REGTAP FAQ Database - FAQ #16713 07/24/16) Q: How do I find information online about plan year 2017 Federally-facilitated Marketplace (FFM) registration? Answer: CMS will provide information on plan year 2017 registration via a variety of communications channels: . First, CMS provides a variety of online resources available 24/7 in the 'Registration for the Federally-facilitated Individual Marketplace (FFM) and the Small Business Health Options Program (SHOP) Marketplace' section of the Agents and Brokers Resources webpage . Second, CMS will present a series of webinars on plan year 2017 registration and training during July and August 2016. You can find information about when these webinars are scheduled and instructions on how to register for them in the 'Agent and Broker Webinar' section of the Agents and Brokers Resources webpage To register for the webinar, please log in to . . Third, if you are not already registered to receive email noti?cations and the 'News for Agents and Brokers' newsletter, email your request to be added to the distribution to the FFM Producer and Assister Help Desk at AssisterHelpDesk@cms.hhs.qov . You will receive timely noti?cations when new resources are posted to the Agents and Brokers Resources webpage and invitations to register for webinars. . Fourth, you can follow CMS on Twitter and ?nd Tweets about agents and brokers in the FFMs by searching these hashtags: and (REGTAP FAQ Database - FAQ #16714 07/25/16) Q: If I cannot ?nd the answer to my questions about plan year 2017 registration online, what do I do? A: First, please see the online resources available 24/7 in the 'Registration for the Federally-facilitated Individual Marketplace (FFM) and the Small Business Health Options Program (SHOP) Marketplace' section of the Agents and Brokers Resources webpage If you still have questions about how to complete registration so you can support consumers and employers in the FFMs, email the FFM Producer and Assister Help Desk at or call the Agent and Broker Call Center at 1855CMS1515 (855 2671515) and select option Monday through Saturday from 8:00 AM to 10:00 PM Eastern Time (ET). (REGTAP FAQ Database - FAQ #16715 07/26/16) Q: completed plan year 2016 Federally-facilitated Marketplace (FFM) registration and am returning for this year, do I need to recomplete all the registration requirements? Answer: Agents and brokers who participated in the FFMs during plan year 2016 only need to complete the assigned training courses and pass the exams through the 794 Updated 1-31-17 2017--00894 Marketplace Learning Management System (MLMS) via the CMS Enterprise Portal or through a CMS-approved vendor via the CMS Enterprise Portal, and read and accept the applicable Marketplace Agreement(s) on the MLMS. You do not need to need to create a new CMS Enterprise Portal account, recomplete identity proo?ng, or assign the Agent/Broker role. If you are unsure if you already have a FFM User ID and password, see the resource ?Avoiding the Creation of a Duplicate CMS Enterprise Portal Account? on the Agents and Brokers Resources webpage at: (REGTAP FAQ Database - FAQ #16717 07/28/16) Q: What happens if I am not able to complete identity proofing online? How do I provide the Marketplaces with the necessary documentation to prove my identity? A: If your information cannot be veri?ed remotely electronically) using the Enterprise Identity Management (EIDM) System, the Centers for Medicare Medicaid Services (CMS) Enterprise Portal will provide you with a phone number and code to confirm your identity directly with Experian, the identity proofing vendor of CMS. (REGTAP FAQ Database - FAQ #17081 08/04/16) Q: I participated in the Federally-facilitated Marketplaces (FFMs) for Plan Year 2016 and am returning for plan year 2017. Do I need to complete identity proofing again? A: No. Agents and brokers who previously completed identity proo?ng, even if they did not complete all registration requirements, do not need to complete identity proofing again. (REGTAP FAQ Database - FAQ #17082 08/04/16) Q: Will the National Producer Numbers (NPNs) that I entered into my Marketplace Learning Management System (MLMS) profile for Plan Year 2016, including the NPN for a web-broker with whom I'm associated, be automatically uploaded into my profile for Plan Year 2017, or will I have to reenter that information? A: Yes. The NPN or NPNs that you entered into your MLMS pro?le for plan year 2016 will automatically be entered in your Plan Year 2017 pro?le. However, we encourage you to con?rm that all your other pro?le information is current and correct. (REGTAP FAQ Database - FAQ #17083 08/04/16) Q: Where in my Marketplace Learning Management System (MLMS) profile do I enter the National Producer Numbers (NPNs) for a web-based entity for which I am an authorized representative? A: The MLMS pro?le will capture up to three (3) sets of information. The first pro?le, which is required, is the agent's or broker's business contact information and personal NPN. Next, the agent or broker has the option to select one (1) or two (2) additional sets of pro?le fields to indicate that he or she is the authorized representative for either a web-broker and/or a corporate entity other than a web-broker. For more information on this process, including step-by-step instructions and screenshots, see the ?How to Add an Agent, Broker, or Web-broker Corporate Entity's NPN to the FFM Registration Completion List" video, which you can access from the ?General Resources" section of the Agents and Brokers Resources webpage (REGTAP FAQ Database - FAQ #17084 08/04/16) 795 Updated 1-31-17 2017--00895 Q: When will the Agent and Broker Federally-facilitated Marketplace (FFM) Registration Completion List be available at Data.HealthCare.gov? A: The Agent and Broker FFM Registration Completion and Termination Lists are now available directly at Data.HealthCare.gov ab reqistration lists). You can also continue to access the Registration Completion List via the Agents and Brokers Resources webpage Registration records for all plan years will be displayed in one list. Every plan year the registration record will include an end date to facilitate identi?cation of terminations and any gaps in registration between plan years. The Centers for Medicaid Medicare Services (CMS) anticipate refreshing the Registration Completion List as frequently as daily. (REGTAP FAQ Database - FAQ #17085 08/04/16) Q: I registered to sell coverage through the Marketplace in Plan Years 2014 and 2015, but did not participate in Plan Year 2016. Am I eligible to take the Refresher Training? A: No, you are not eligible to take the Refresher Training unless you successfully completed registration in Plan Year 2016. However, if you complete the full training for Plan Year 2017, you will be eligible for Refresher Training in the next Plan Year. (REGTAP FAQ Database - FAQ #17086 08/04/16) Q: complete Federally-facilitated Marketplace (FFM) registration and am registered in my state of residence, where I do most of my business, can I also sell Marketplace plans to consumers who live in other states, even though I do not have state licenses in those states? A: Quali?ed Health Plan (QHP) issuers are responsible for the compliance of their delegated and entities, including affiliated agents and brokers. Accordingly, the Centers for Medicare Medicaid Services (CMS) expect QHP issuers to verify that agents and brokers selling their products have valid state licenses and comply with applicable agent and broker FFM registration requirements. (REGTAP FAQ Database - FAQ #17096 08/04/16) Q: I created a Centers for Medicare Medicaid Services (CMS) Enterprise Portal account last year, but I have forgotten my Federally-facilitated Marketplaces (FFM) User Identifier (ID) and password. What should I do? A: Refer to the ?Quick Reference Guide: Avoiding the Creation of a Duplicate CMS Enterprise Portal Account,? which you can link to via the Agents and Brokers Resources webpage for detailed instructions on self-help options for retrieving your FFM User ID and password. (REG TAP FAQ Database - FAQ #17100 08/04/16) Q: When does registration and training go live for Plan Year 2017? A: As of August 1, Plan Year 2017 Federally-facilitated Marketplace (FFM) agent and broker registration and training is available on the Centers for Medicare Medicaid Services (CMS) Enterprise Portal 796 Updated 1-31-17 2017--00896 For a better user experience, CMS suggests the best days and times to access registration and training are Monday through Friday, between 5:00 PM and 11:00 AM Eastern Time, and on the weekends. (REG TAP FAQ Database - FAQ #17101 08/04/16) Q: Where can I find answers to my Plan Year 2017 registration and training-related ques?ons? A: If you have questions related to Plan Year 2017 registration and training, the ?Plan Year 2017 Federally-facilitated Marketplace (FFM) Agent and Broker Registration and Training Kickoff? short video for a registration kick-off welcome message and information on what is new for Plan Year 2017 registration, presented by Kevin Counihan, the Centers for Medicare Medicaid Services (CMS) Center for Consumer Information and Insurance Oversight (CCIIO) Chief Executive Of?cer. You can ?nd this video on the Agents and Brokers Resources Webpage as well as the Registration for Technical Assistance Portal (REGTAP) website CY17Kickoff 50R O72616/story.html. CMS has posted hyperlinks on the Agents and Brokers Resources webpage to a number of additional resources to explain the process and requirements as well as answer frequently asked questions. (REG TAP FAQ Database - FAQ #17102 08/04/16) Q: I don't believe the Marketplace has captured my National Provider Number (NPN) on a speci?c enrollment. What should I do? A: When helping a consumer complete a new application or update an existing application using the ?Side-by-Side? Marketplace) Pathway, the agent or broker should ensure the customer enters his or her name and NPN to get credit for that enrollment. The Direct Enrollment Pathway will automatically capture the agent's or broker's information in the submit enrollment response. An agent or broker or a consumer should not return to the Marketplace (via the Side-by-Side or Direct Enrollment Pathway) to edit an application only for the purpose of adding/changing the NPN on record; instead, the consumer should be reporting some type of life change when adding/changing the NPN on record. If an Marketplace-registered agent or broker has a reason to believe his or her NPN should have been included on a Marketplace enrollment transaction and was not, the agent or broker may contact the respective QHP issuer directly to discuss the situation. CMS expects that a QHP issuer would issue compensation to an af?liated agent or broker who is registered to participate in the Marketplace if it is determined from the issuer's, agent's, or broker's records that the agent or broker did in fact assist the consumer, but the NPN was erroneously left off of the enrollment. Such records may include a consent form from the consumer, an issuer's broker of record form, or similar documentation to demonstrate that the consumer was the agent's or broker's consumer for the enrollment in question. (REGTAP FAQ Database - FAQ #17978 10/28/16) Q: How do agents and brokers con?rm they have completed the Marketplace registration requirement? A: Agents and brokers can check their Marketplace registration status on the Agent and Broker Registration Completion List (RCL). Agents and brokers can access the RCL via the Agents and Brokers Resources webpage or directly at: 797 Updated 1-31-17 2017--00897 ab reqistration lists. (REGTAP FAQ Database - FAQ #18306 12/02/16) Q: If I completed Marketplace agent and broker registration for plan year 2016, do I need to register again to assist consumers for plan year 2017? A: Yes, it is an annual registration process. Therefore, agents and brokers who participated in the Marketplace during plan year 2016 need to complete the assigned training courses and pass the exams through the Marketplace Learning Management System (MLMS) via the CMS Enterprise Portal or through a CMS-approved vendor via the CMS Enterprise Portal, and read and accept the applicable Marketplace Agreement(s) on the MLMS. They do not need to need to create a new CMS Enterprise Portal account, recomplete identity proo?ng, or request the Agent/Broker role. Agents and brokers who participated in the Individual Marketplace for plan year 2016 are eligible to take a streamlined Refresher Training either through the MLMS or a CMS- approved vendor, regardless of how they completed the plan year 2016 training. (REGTAP FAQ Database - FAQ #18307 12/02/16) Q: How can I be added to the Find Local Help page on HealthCare.gov? A: Your profile page in the Marketplace Learning Management System (MLMS) provides an option to display or not display your information on Find Local Help?for both the Individual Marketplace and the Small Business Heath Options Program (SHOP) Marketplace accessed via HealthCare.gov. Please ensure that you have selected the option(s) you prefer. Upon completing Marketplace agent and broker registration, it may take up to one week for your information to appear on Find Local Help. (REGTAP FAQ Database - FAQ #18308 12/02/16) Q: How long does it take for the Marketplace Direct Agent/Broker Call Line to recognize my National Producer Number (NPN) after I register with the Marketplace for plan year 2017? A: It can take up to 5 business days for your NPN to be recognized by the new Marketplace Direct Agent/Broker Call Line. (REGTAP FAQ Database - FAQ #18309 12/02/16) Agent/Broker Training Q6: What is the URL to complete the agent/broker training (?Part A6: Agent/broker training for the FFMs is located on the Medicare Learning Network. The URL is: (Agent and Broker FAQ #1 09/19/13; REGTAP FAQ Database - FAQ #328 09/19/13) Q7: How do I reset my password/username on the MLN site? A7: Click the "Forgot your login and "Forgot your password?" links on the login page of Medicare Learning Network (MLN). (Agent and Broker FAQ #1 09/19/13; REG TAP FAQ Database - FAQ #329 09/19/13) 798 Updated 1-31-17 2017--00898 Q8: Can I take the agent/broker courses on my iPad? Can I take the agent/broker courses on my phone? Can I take the agent/broker courses on my handheld device? A8: The agent/broker training courses for the Federally-facilitated Marketplaces (FFM) are not currently compatible with iPads or handheld devices. (Agent and Broker FAQ #1 09/19/13; REGTAP FAQ Database - FAQ #330 09/19/13) 09: I am an agent/broker, and I am trying to set up my account on MLN, to take training. What should I enter in the organization fields? A9: As you set up your MLN account, you will see that there are two fields displayed that relate to organization information. It is very important that you select your appropriate User Type/User Role before you enter any organization information. As an agent or broker, you should select one of the three agent/broker User Roles, based on the insurance market(s) you wish to serve. After you select the appropriate agent/broker User Type/User Role, you will see that the first ?eld, labeled ?Organization Type? is automatically grayed-out, because it is not a ?eld that agents/brokers need to complete. You will not be able to enter text in the ?Organization Type? ?eld. The second field, labeled ?Organization,? is a required ?eld for agents/brokers. Next to the ?Organization? ?eld, please click on the blue text that says ?Select?. A new screen will pop up. When that next screen appears, click the gray ?Search? button, and the Organization named ?Marketplace" will appear as the only option. Please click the circle to select Marketplace, select ?Save and you will then be returned to the previous screen, where you can ?nish creating your MLN account. (Agent and Broker FAQ #1 09/19/13; REGTAP FAQ Database - FAQ #331 09/19/13) Q10: I took an examcurriculum certificate. How do I get a curriculum certificate? A10: To successfully complete the training requirements, you must register for a curriculum on the MLN website, rather than for individual courses. If you register only for individual courses, you will not earn the curriculum completion status that is required. (Agent and Broker FAQ #1 09/19/13; REGTAP FAQ Database - FAQ #332 09/19/13) Q11: I am having technical problems viewing the training content, or getting the MLN site to display Properly. A11: Below are some pointers that have enabled many other users to complete the training. If you are having problems accessing the training, we recommend you address each of these pointers. Pop-up blockers?This setting must be turned off. . Cookie settings?Be sure to allow cookies. Some users' company network settings or individual computer settings are not set to allow cookies, and this has caused problems for them 0 FIashPlayer?Be sure this is installed on your computer. The Marketplace training requires FlashPIayer; it can be downloaded at . Browser?Courses and exams do not run well on Internet Explorer 10, Google Chrome, or Firefox. The Marketplace training is optimized on Internet Explorer 8 or 9. 799 Updated 1-31-17 2017--00899 0 Physical Computer?The Marketplace training cannot be accessed on a tablet or other hand-held/mobile device, so you must use a desktop or laptop computer. 0 Bandwidth or servers issues?Check with your network provider for more assistance. Some users have encountered bandwidth and server issues related to the settings on their computer or on their company?s network. (Agent and Broker FAQ #1 09/19/13; REGTAP FAQ Database - FAQ #333 09/19/13) Q12: How do I print my training certificates on A12: Please note that the only certi?cate(s) that should be printed are those listed as type "Curriculum." Disregard certificates listed as type You only need to provide the curriculum certi?cates to the issuers. The curriculum certificates typically generate in HTML format. To save a copy to your computer we recommend that you either: 1. Click the ?print? link at the top of the certi?cate screen and select ?Microsoft XPS Document Writer? in your print options, or 2. Click the ?print? link at the top of the certi?cate screen and select ?Adobe (if you have Adobe Acrobat installed on your machine), or 3. Use the print screen function and paste the image into a Microsoft Word document. The print screen button is located your keyboard? usually near the number keypad on the right of the keyboard. After you have your certi?cate open, press the print screen button. Nothing obvious will occur. Go to your Word document, right click, and click ?paste? in order to paste the image of your certi?cate into the Word document. If none of these three options work on your computer, the issue relates to your computer?s individual settings, browser settings, and/or your network?s settings. We suggest that you try to print your certi?cate from a different computer. Alternately, you may choose to ask your network administrator or a colleague for help with your computer/network settings, or you may contact the help line of the company from whom you purchased your computer. Please understand that CMS is unable to provide each individual agent or broker with a copy of their training curriculum (Agent and Broker FAQ #1 09/19/13; REG TAP FAQ Database - FAQ #334 09/19/13) Q13: Can I get a PDF version of the agent/broker training? Can I download the agent/broker training? A13: At this time, CMS does not have a copy of the agent/broker training available in downloadable format. However, a summary of the training is available on the CMS website: (Agent and Broker FAQ #1 09/19/13; REGTAP FAQ Database - FAQ #3354 09/19/13) Q14: Can you provide me with my MLN number? Where do I find my MLN number? Updated 1-31-17 A14: There is no Medicare Learning Network (MLN) number. You will create an MLN User ID when you complete the training in Part I. You will have to use your MLN User ID, and the National Producer Number (NPN) that you used to register on the MLN site, to create a Federally-facilitated Marketplace (FFM) user account and complete identity 800 2017--00900 veri?cation on the CMS Enterprise Portal. (Agent and Broker FAQ #1 09/19/13; REG TAP FAQ Database - FAQ #336 09/19/13) Q15: When will the MLN site assign me my FFM registration number? A15: There are no registration numbers,? and you will not be assigned an FFM registration number. You will create your FFM User ID when you create your account on the CMS Enterprise Portal during Part II of the agent/broker registration process. (Agent and Broker FAQ #1 09/19/13; REGTAP FAQ Database - FAQ #337 09/19/13) Q16: I cannot access Part II of the FFM registration process on the MLN site. A16: Part II of the agent/broker registration process is available on the CMS Enterprise Portal: (Agent and Broker FAQ #1 09/19/13; REG TAP FAQ Database - FAQ #338 09/19/13) Q: When will 2015 training for Agent/Brokers be available? A: The 2015 Marketplace training for Agent/Brokers will kick-off in July 2014. (REGTAP FAQ Database - #1719 05/27/14) Q: What requirements must agents and brokers fulfill if they have previously completed registration for the Federally-facilitated Marketplaces A: To continue participation in the Federally-facilitated Individual Marketplace (Individual Marketplace), agents and brokers must complete an annual registration renewal process that includes completion of a required training curricula and exams, and execution of the Individual Marketplace General Agreement (General Agreement) and the Individual Marketplace Privacy and Security Agreement. To continue participation in the Small Business Health Option Program (SHOP) Marketplace, agents and brokers must execute the SHOP Marketplace Agreement annually, and are strongly encouraged to complete the relevant training curricula and exam. As a reminder, agents and brokers who will be participating in the Individual Marketplace for the first time for plan year 2016 must complete seven steps: 1) create a CMS Enterprise Portal account, 2) request the FFM Agent/Broker role on the CMS Enterprise Portal, 3) conduct identity proofing on the CMS Enterprise Portal, 4) complete the required training curricula and exams on the Marketplace Learning Management System (MLMS) or through a CMS-approved vendor, 5) complete profile information on the MLMS, which is available via the CMS Enterprise Portal, 6) execute the General Agreement and the Individual Marketplace Privacy and Security Agreement on the MLMS, and 7) confirm completion of all required steps on the Agent Broker Registration Status page on the CMS Enterprise Portal. Agents and brokers who will be participating in the SHOP Marketplace for the ?rst time in plan year 2016 must complete seven steps and have the option of an additional step: 1) create a CMS Enterprise Portal account, 2)request the FFM Agent/Broker role on the CMS Enterprise Portal, 3) conduct identity proo?ng on the CMS Enterprise Portal, 4)comp ete the training curriculum on the MLMS or through a CMS-approved vendor 801 Updated 1-31-17 2017--00901 (this step is optional, but strongly encouraged), 5) complete profile information on the MLMS which is available via the CMS Enterprise Portal, 6) execute the SHOP Marketplace Agreement on the MLMS, 7) con?rm completion of all required steps on the Agent Broker Registration Status page on the CMS Enterprise Portal, and 8) establish a profile on the SHOP Marketplace Agent/Broker Portal. Agents and brokers who completed FFM registration in a previous plan year should not create a new CMS Enterprise Portal account or conduct identity proo?ng again. Agents and brokers who completed FFM registration for plan year 2014, but not for plan year 2015, will need to log in to their existing CMS Enterprise Portal account and request the FFM Agent/Broker role. (REGTAP FAQ Database - FAQ #15769 05/02/16) Q: Ifl completed plan year 2016 Federally-facilitated Marketplace registration and am returning for this year, do I need to complete the full training again? A: No. New for plan year 2017, agents and brokers who completed plan year 2016 FFM registration requirements for the Individual Marketplace will have a streamlined registration and are eligible to take a shorter Refresher Training through their choice of several training options Marketplace Learning Management System (MLMS) or CMS-approved vendors) to meet the training registration requirement. Returning agents and brokers will be auto-enrolled into MLMS Refresher Training. The Refresher Training is estimated to take two hours to complete versus the four hours for the full training. If you did not complete the plan year 2016 FFM agent and broker registration requirements for the Individual Marketplace, you are not eligible to take Refresher Training. Note: this applies to agents and brokers who completed FFM registration for plan years 2014 or 2015. (REGTAP FAQ Database - FAQ #16716 07/27/16) Q: How will I know if I have completed all the training modules needed to meet the training requirement for the Individual Marketplaces? A: After you enroll in one (1) of the three (3) Federally-facilitated Marketplace (FFM) registration curricula, you will be prompted to progress through the modules that comprise the curriculum. If you decide to take training through the Marketplace Learning Management System (MLMS) the ?Current Training" section of the MLMS home page will list all the modules you have left to complete. Centers for Medicare Medicaid Services (CMS)?approved vendors' learning management systems may show your progress differently. (REGTAP FAQ Database - FAQ #17087 08/04/16) Q: I participated in the Federally-facilitated Marketplaces (FFM) for Plan Year 2016 and am returning for Plan Year 2017. Am I required to take the Refresher Training? Updated 1-31-17 A: No. Returning agents and brokers have the option to take the shortened Refresher Training or the complete training. If you are interested in taking the complete training, you will need to enroll in the full curriculum, it will not automatically populate in your account. (REGTAP FAQ Database - FAQ #17088 08/04/16) 802 2017--00902 Q: I am unable to spend several hours on training at one time. Can I come and go, and not have to start at the beginning of a module again after I have closed out of it? A: Yes. You can use the bookmarking feature to return to the same screen you last viewed. If you decide to take training through the Marketplace Learning Management System (MLMS) you activate the bookmarking feature by selecting the ?Exit? button, not by closing the browser window, in the upper right corner of the screen. Then, when you log back in to the Centers for Medicare Medicaid Services (CMS) Enterprise Portal and navigate to the ?Current Training? page where all the modules you have left to complete are listed, you can select the module you left mid-stream and be returned to the page you last viewed before you exited the module. CMS-approved vendors' learning management systems may use a different bookmarking system. (REGTAP FAQ Database - FAQ #17089 08/04/16) Q: Is the Refresher Training for agents and brokers who are returning to the Individual Marketplace quicker to complete than the full training for agents and brokers who are new to the Individual Marketplace? A: Yes. The Centers for Medicare Medicaid Services (CMS) estimates returning agents and brokers will spend two (2) hours completing the scenario-based Refresher Training modules and exam, in comparison to the estimated four (4) hours to complete the full training and exams. (REGTAP FAQ Database - FAQ #17090 08/04/16) Q: Is it too late for an agent or broker to complete the Plan Year 2016 training if he or she enrolled in the course before the Marketplace Learning Management System (MLMS) closed? A: Yes. The MLMS closed for Plan Year 2016 registration and training on July 15, 2016. Agents and brokers who did not complete Plan Year 2016 registration by that date cannot assist consumers to enroll in or manage their coverage through the end of Plan Year 2016. However, they can complete Plan Year 2017 registration when it opens on August 1, 2016, so they are prepared to assist consumers when Plan Year 2017 Open Enrollment starts on November 1, 2016. (REGTAP FAQ Database - FAQ #17091 08/04/16) Q: If I completed the free training through Marketplace Learning Management System (MLMS) in Plan Year 2016, can I complete refresher training through one (1) of the participating vendors this year to receive continuing education units A: Yes. All Plan Year 2017 Centers for Medicare Medicaid Services (CMS)?approved vendors will be offering refresher training. Completion of a training curriculum, including the associated exams, through one (1) of the CMS-approved vendors will fulfill the Federally-facilitated Marketplace (FFM) training requirement for agents and brokers registering to participate in the Individual Marketplaces for Plan Year 2017. (REGTAP FAQ Database - FAQ #17092 08/04/16) 803 Updated 1-31-17 2017--00903 Q: To clarify, training is free through the Marketplace Learning Management System (MLMS) but that vendors can charge a fee. What do I get for that added cost if the training covers the same content? A: Centers for Medicare Medicaid Services (CMS)-approved vendors are required to offer continuing education unit (CEU) credits in a minimum of five (5) states where the Marketplace is operating. The number of CEUs and the states where they are available vary by vendor. CMS-approved vendors are required to cover, at a minimum, the same topic areas as are covered in the CMS training. (REGTAP FAQ Database - FAQ #17093 08/04/16) Q: Do vendors offer a discount if I sign up for both Individual Marketplace and Small Business Health Options Program (SHOP) Marketplace training? A: You will have to contact the Centers for Medicare Medicaid Services approved vendors directly for information about their fees. You can ?nd the CMS- approved vendors' contact information on the Agents and Brokers Resources webpage (REGTAP FAQ Database - FAQ #17094 08/04/16) Q: Are continuing education units (CEUs) available if I complete registration training through the Marketplace Learning Management System A: No. CEUs are not available if you complete the free training available via the they are only available if you complete training through a Centers for Medicare Medicaid Services (CMS)?approved vendor. The states in which vendors offer CEUs varies by vendor, so please check the vendors' websites for more information. (REGTAP FAQ Database - FAQ #17095 08/04/16) Q: How can I confirm have completed all the plan year 2017 registration and training requirements for the Marketplace? A: The Federally-facilitated Marketplace (FFM) Agent and Broker Registration Completion List (RCL) is the authoritative list of National Producer Numbers (NPNs) issuers use to con?rm agents and brokers have completed Marketplace registration and are eligible for compensation for enrolling consumers in Marketplace plans. CMS is now updating the RCL as frequently as daily, and has made it easier for issuers and for agents and brokers to access the RCL Directly at Data.Hea thCare.gov ab registration lists). Remember that agents and brokers must complete all plan year 2017 registration and training requirements prior to assisting consumers. (REGTAP FAQ Database - FAQ #17979 10/28/16) Agent/Broker Identity Proofinq (Part II of FFM Registration, on CMS Enterprise Portal) Q17: What is the URL to complete the agent/broker identity proofing and set up an FFM account (?Part A17: To set up an FFM account and complete identity proofing, visit the CMS Enterprise Portal: (Agent and Broker FAQ #1 09/19/13; REG TAP FAQ Database - FAQ #339 09/19/13) 804 Updated 1-31-17 2017--00904 Q18: How do I reset my password/username on the CMS Enterprise Portal? A18: To recover your User ID or password information, click on the ?Forgot my User lD/Password? link on the Centers for Medicare Medicaid Services (CMS) Enterprise Portal log-in web page at Clicking this link will provide you with instructions for how to recover your User ID or initiate a password reset. (Agent and Broker FAQ #1 09/19/13; REG TAP FAQ Database - FAQ #340 09/19/13) Q19: I have been unable to request access under the FFM Agent Broker role on the CMS Enterprise Portal. When I go to the page to add a role under the FFM, Agent Broker? role is not a choice. A19: Agents and brokers who are using the CMS Enterprise Portal to create a Federally- facilitated Marketplace (FFM) user account and complete identity proo?ng should select Application" next to ?Application Description" on the ?My Access?Request New Application Access? page. You will then be prompted to make a selection next to ?Role.? You should select Agent Broker." There is no additional role that needs to be added once you have made this selection and completed identity proo?ng. Identity proofing includes accurately entering your Medicare Learning Network (MLN) user ID and NPN, and going through identity proo?ng by entering identifying information and answering ?Out-of-Wallet" questions. If you have previously established an account through the CMS Enterprise Portal, please follow these steps: 1. To add the Agent Broker? role, make sure you select ?Request Access Now? on the right side of the window after logging in to the CMS Enterprise Portal. 2. A new page will appear. Select ?Request New Application Access? on the left side, under ?My Access.? 3. You should then select Application? from the drop-down list next to? Application Description.? 4. You will then be prompted to make a selection next to ?Role". You should select Agent Broker.? Please note: Agent Broker? is the only role that needs to be added, and you will not see this role reappear after you have accessed it. (Agent and Broker FAQ #1 09/19/13; REGTAP FAQ Database - FAQ #341 09/19/13) 020: I completed the training in Part I, but when I try to do identity proofing in Part II, I am getting an error message that my information cannot be verified. I am not sure how to ?ll out the screen that is asking for my MLN user ID and my NPN. Updated 1-31-17 A20: After you complete training, please allow 48 business hours to elapse before you attempt to access the identity proo?ng process?this will help to ensure that your training records have been fully transmitted to the CMS Enterprise Portal. . You created your MLN user ID when you completed the training during Part on the Medicare Learning Network If you cannot recall your MLN user ID, return to the MLN website and click the" Forgot your login link on the login page. 805 2017--00905 When you enter your NPN during Part II on the CMS Enterprise Portal, it should not be more than 10 numeric digits. It may be less than 10 digits. 0 During Part II on the CMS Enterprise Portal, enter your NPN the same way that you enter edit in your MLN pro?le for Part I. However, do not use any hyphens or any letters in your NPN when you enter it during Part II on the CMS Enterprise Portal. Do not add leading zeroes. . If you cannot recall how you entered your NPN in your MLN pro?le, you may return to the MLN website, log in, and locate your name at the top right corner of the page. Click your name, and a drop-down list will appear. Select "My Account". The NPN that you completed training with should appear in your pro?le. (Agent and Broker FAQ #1 09/19/13; REGTAP FAQ Database - FAQ #342 09/19/13) 021: How do I know when have completed my registration on the CMS Enterprise Portal? A21: When you successfully complete the identity proofing in Part II, you will see the following screen message, which is titled Request Acknowledgement. The screen message states: ?Your request has been successfully completed. You will need to logout and then log back on to access the FFM Application. Select to continue." When you see this screen message, you have successfully completed the identity proo?ng process. To the degree permitted by state law, you will be able to provide assistance in the Federally-facilitated Marketplace when open enrollment begins this fall. (Agent and Broker FAQ #1 09/19/13; REG TAP FAQ Database - FAQ #343 09/19/13) 022: When will I receive my FFM registration number? When will I be assigned my FFM number? A22: There are no registration numbers? and you will not be assigned an FFM registration number. You created your FFM User ID when you created your account on the CMS Enterprise Portal during Part II of the agent/broker registration process. If you have forgotten your FFM User ID or password information, click on the ?Forgot my User lD/Password? link on the CMS Enterprise Portal log-in web page at (Agent and Broker FAQ #1 09/19/13; REGTAP FAQ Database - FAQ #345 09/19/13) FEDERALLY FACILITATED (FFEIFFM) Q18: Will issuer logos display on the FFE website? A18: No, logos will not be displayed on the FFE website. (QHP Webinar Series FAQ #10 05/09/13) Q19: Do you know if/where during the FFE shopping experience shoppers will be presented with a phone number or URL to use if they have pre-enrollment questions regarding product offerings or how to enroll? Updated 1-31-17 A19: A consumer can access an issuer?s contact information via the link to the issuer's plan brochure. We also intend to display the issuer?s contact information once a consumer has confirmed her/his plan selection. (QHP Webinar Series FAQ #10 05/09/13) 806 2017--00906 020: Last I knew, the number of plans that an issuer could submit and presumably be approved and available on the FFE was not limited subject to the plans being materially differentiated in some way - can you verify (or correct) our understanding that for instance a gold plan and gold HSA qualified plan would be ?different enough? for both to display as applicable in the shopping experience. A20: As detailed in the Letter to Issuers, we provide guidance on how the FFE will review for meaningful difference for 2014: 0 ?First, an issuer?s plans from a given state will be organized into subgroups based on plan type, metal level and overlapping counties/service areas. 0 Second, CMS will review each subgroup to determine whether the potential QHPs in that subgroup differ from each other on least any one of the following criteria: 0 Different network; 0 Different formulary; 0 $50 or more difference in both individual and family in-network deductibles;o$100 or more difference in both individual and family in-network maximum-out-of-pocket; and 0 Difference in covered EHB. If CMS flags a potential QHP for follow-up based on this review, we anticipate that the issuer will be given the opportunity to amend or withdraw its submission for one or more of the identi?ed health plans. Alternatively, the issuer may submit supporting documentation to CMS explaining how the potential QHP is substantially different from others offered by the issuer for QHP certi?cation and, thus, is in the interest of consumers to certify as a QHP. For example, an issuer may make the case that one QHP is an Accountable Care Organization. This additional information will factor into the determination of whether it is in the interest of the qualified individuals and qualified employers to certify the plan as a QHP (see 45 CFR 155.1000). CMS anticipates its approach related to meaningful difference may be updated in future years.? (QHP Webinar Series FAQ #10 05/09/13) Q48: Will the FFE support mobile devices? Updated 1-31-17 A48: As stated in chapter 6 of the ?nal Letter to Issuers on Federally-facilitated and State Partnership Exchanges, released on April 5, 2013 and available on the CCIIO website at Guidance/Downloads/2014 letter to issuers 04052013.pdf the FFE ?website will be provided in a mobile-friendly format using responsive design techniques." (QHP Webinar Series FAQ #12 06/28/13) A similar FAQ was released on REG TAP on 03/31/14: Q: Is HealthCare.gov available in a mobile-friendly format so that people can readily access it from a cell phone or tablet? Is there a HealthCare.gov app? A: Currently we do not have a HealthCare.gov app. However, the website, HealthCare.gov, is available in a mobile-friendly format. (REGTAP FAQ Database - FAQ #1362 03/31/14) 807 2017--00907 FFM User Fees 02. Since the FFM will not be collecting premium from the SHOP groups, please clarify how the additional payments for user fees will be transmitted in 2014. With this, specify how data will be transmitted in the 2100 Loop to designate this as a payment for a policy with SHOP. A2. FFM user fee amounts will be included in the RMR02 element of a 2300 loop at the enrollment group level with the policy information being sent in the 2100 Loop. When the BPR02 element for SHOP only Issuers would otherwise be negative, a 2300 loop will be added to show the amount to be invoiced and bring the BPR02 element to zero. CMS will provide additional information on payment of FFM user fees at a later time. (ASC X12 Exchange Related Payments (820) Implementation Guide 05/14/13) Q3. Please confirm whether there will be combined or separate 820s for the Individual and FF-SHOP markets for 3Rs Program payments and the user fee? If CMS would provide one 820 file for BOTH Individual and FF-SHOP payments, there may be fairly significant implications for some Issuers. Individual premiums must be routed to one financial institution, while FF-SHOP must be routed to another. If one 820 will roll up all payments for the Individual marketplace and SHOP, please confirm that such program level payments will be listed separately for SHOP and individual. A3. A combined HIX 820 will be sent by CMS. CMS will use the HIX 820 to report remittance information only; actual payments will be made separately using existing federal processes. In 2014, the FF-SHOP will not make premium payments. Issuers are responsible for sharing data with their business affiliates as appropriate to support their operations. (ASC X12 Exchange Related Payments (820) Implementation Guide 05/14/13) 028. Will CMS reconsider deducting FFM user fees from Federally-administered Marketplace-related program payments to Issuers? A28. CMS will address this topic in the future. (ASC X12 Exchange Related Payments (820) Implementation Guide 05/14/13) Q: In the 820 file received from CMS, for Advance Premium Tax Credit (APTC) and Cost Sharing Reduction (CSR) payments, it is stated that a user fee (UF) will be deducted. How much is the UF per Enrollment group? A: FFM User Fees will be 3.5% of total premium and will be represented in the HIX 820 at the enrollment group (policy) level with an Exchange Payment Type code of UF for Individual Market and SHOPUF for Shop Market. (REGTAP FAQ Database FAQ #505 11/22/13) Q: Is the User Fee 3.5% Per Member Per Month (PMPM) or $5.25 A: The User Fee is 3.5% PMPM as established in 78 FR 15496 and 45 CFR 156.50. (REGTAP FAQ Database FAQ #576 102/13/13) 808 Updated 1-31-1 7 2017--00908 Q: Will any user fee amount assessed be subtracted from the payment made for the January payment month? If yes, what is the process if the user fee assessed exceeds the amount of A: CMS requires total premium, total number of effectuated enrollment groups, and total number of effectuated members to be reported for all on Exchange QHPs. User Fee amounts will be calculated and netted against APTC and advance CSR payments at the payee group level. Payee groups are comprised of single or multiple issuers and reflect organizational decisions about how to aggregate payments across issuers. If User Fee amounts, at the payee group level, exceed payments, issuers will be notified but no invoices will be generated for January under the interim payment process. (REG TAP FAQ Database FAQ #588 12/17/13) Q: If an issuer does not have any APTC or CSR, but will owe user fees and since CMS is still determining the collection process, can the issuer opt out of template submission until the final collection process is determined? A: No, the issuer should still submit the template regardless of whether an issuer reports no APTC or CSR. (REGTAP FAQ Database - FAQ #666 01/16/14) Q: If an issuer owes a user fee, what is the expected future month that the issuer can expect to receive an invoice from A: CMS is still determining the user fee collection process and will provide that information at a later date. Please note this only applies to those payee groups that did not receive suf?cient APTC or CSR amounts in which to net against payments to collect the user fees. (REGTAP FAQ Database - FAQ #677 01/16/14) Q: What is the rationale for continuing to net SHOP user fees from instead of reducing the SHOP premium payments? A: HHS will not net FF-SHOP user fees during the premium aggregation process for operational reasons. Instead, HHS will net user fees from advance premium tax credits (APTC) or advance cost sharing reduction (CSR) payments due to related issuers of Quali?ed Health Plans with the same Tax Identi?cation Number. Where an issuer does not participate in the individual market and thus does not receive APTC or advance CSR payments, HHS will invoice the issuer for FF-SHOP user fees. (REGTAP FAQ Database - FAQ #838 02/21/14) Q: Since user fees will be netted against payments, will there at least be a statement or method to reconcile the SHOP user fees? Updated 1-31-17 A: HHS will provide issuers with a payment report showing payments and charges and amounts netted, including user fees. As discussed in the preamble to Section 156.1210 of the Program Integrity rule, an issuer will have 15 calendar days from the date of the payments report to either confirm the amounts in the report for the timeframe speci?ed, or describe to HHS any inaccuracy it identifies in the report. HHS will work with issuers to resolve any discrepancies and make adjustments, if any, in the next possible payment report. (REGTAP FAQ Database - FAQ #839 02/21/14) 809 2017--00909 FFM User Fees Adjustments for Contraceptive Payments Q: The final rules stated that Third Party Administrators (TPAs) must submit the ?Notice of Intent Disclosure Form? to the Centers for Medicare Medicaid Services (CMS) by the later of January 1, 2014 or the 60th day following the date on which the TPA receives a copy of a self-certi?cation from an eligible organization or notification from the Department of Labor. That deadline has passed. Are TPAs still required to submit this form to If so, what deadline applies? A: Yes, TPAs and Pharmacy Benefits Managers (PBMs) must still submit the Notice of Intent Disclosure Form indicating that they intend to seek a user fee adjustment. TPAs and PBMs must submit the form to the mailbox by November 13, 2015. TPAs and PBMs should email the form (in either a document or [Portable Document Format] PDF as an attachment with the email subject line Notification of Intent?. (REGTAP FAQ Database - FAQ #14013 11/13/15) Q: The final rules stated that Federally-facilitated Marketplace (FFM) issuers must submit the required forms and information to receive the user fee adjustment for the 2014 benefit year to the Centers for Medicare Medicaid Services (CMS) by July 15, 2015. That deadline has passed. Are FFM issuers still required to submit this form to If so, what deadline applies? A: The July 15, 2015 deadline for submitting these forms will not apply for FFM issuers. For the initial collection of 2014 benefit year data, participating FFM issuers seeking the user fee adjustment should submit the spreadsheet with the required data elements to by December 11, 2015. FFM issuers should email the spreadsheet as an attachment with the email subject line Issuer Submission.? (REGTAP FAQ Database - FAQ #14014 11/13/15) Q: How should Federally-facilitated Marketplace (FFM) issuers and Third Party Administrators (TPAs) or Pharmacy Benefit Managers (PBMs) submit the required information to the Centers for Medicare Medicaid Services Is this data collected through the Health Insurance Oversight System (HIOS), or the External Data Gathering Environment (EDGE) server? What format should be used? A: CMS will not be collecting this information through HIOS or through the EDGE server. CMS has published two Microsoft Excel spreadsheets one for FFM issuers and one for TPAs or PBMs, respectively that will be used to collect the information necessary to process the user fee adjustment. FFM issuers and should complete the information requested for their respective spreadsheets, and email the spreadsheet to by December 11, 2015. FFM issuers should email the form with the subject line Issuer Submission%o. TPAs and PBMs should email the spreadsheet as an attachment with the email subject line Submission". (REGTAP FAQ Database - FAQ #14015 11/13/15) Q: Will the Centers for Medicare Medicaid Services (CMS) provide training on how to fill out the forms? Is there a resource for additional questions? A: Yes, CMS will conduct a webinar to train issuers, Third Party Administrators (TPAs), and Pharmacy Bene?t Managers (PBMs) on successfully completing and submitting the forms. Training will be conducted in the Fall of 2015, and details will be announced 810 Updated 1-31-17 2017--00910 through REGTAP. Policy questions can be emailed to (REGTAP FAQ Database - FAQ #14016 11/13/15) Q: Can a Pharmacy Benefit Manager (PBM) enter into an identical arrangement with an issuer in order to receive reimbursement for contraceptive services that it has provided to participants and beneficiaries of a group health plan of an eligible organization? A: Yes, like Third Party Administrators (TPAs), PBMs that perform these functions for participants and beneficiaries of a group health plan of an eligible organization can enter into an arrangement with an issuer to receive reimbursement for contraceptive services that it has provided. If a PBM intends to enter into this arrangement with an Federally- facilitated Marketplace (FFM) issuer for reimbursement of contraceptive claims provided, it will be subject to all of the requirements that apply to TPAs, including the requirement to submit the ?Noti?cation of Intent? to the Department of Health Human Services (HHS). (REGTAP FAQ Database - FAQ #14017 11/13/15) Q: If the Third Party Administrator (TPA) or Pharmacy Benefit Manager (PBM) and the Federally-facilitated Marketplace (FFM) issuer are part of the same entity parent company or holding group), do the TPA and FFM issuer each have to submit separate forms to the Centers for Medicare Medicaid Services (CMS) in order to receive the user fee adjustment? A: If the TPA or PBM are part of the same entity or parent company as the FFM issuer, the TPA or PBM does not need to submit the TPA submission form. If part of the same entity, only the FFM issuer should submit the spreadsheet to with the email subject line Issuer Submission.? The FFM issuer should indicate on the spreadsheet that it is part of the same entity as the TPA or PBM. (REGTAP FAQ Database - FAQ #14018 11/13/15) Q: Can a Federally-facilitated Marketplace (FFM) issuer simply include the paid claims amount on the participating issuer form without the Third Party Administrator (TPA) needing to also complete and submit the separate form applicable to A: If the TPA and FFM issuer are separate entities, the TPA must still submit a form indicating the total value of eligible contraceptive claims that were paid. The FFM issuer must also submit the total dollar value of eligible contraceptive claims incurred and the total amount that was paid to the TPA. Receiving the information from both entities will help the Centers for Medicare Medicaid Services (CMS) ensure that the amounts are being reported consistently and that the FFM issuer is reporting eligible claims for which it has actually reimbursed the TPA. (REGTAP FAQ Database - FAQ #14019 11/13/15) Q: Can the Federally-facilitated Marketplace (FFM) issuer or Third Party Administrator (TPA) include claims costs incurred in 2015 as part of its claims submission for the 2014 benefit year? A: For the 2014 benefit year, FFM issuers and TPAs or Pharmacy Benefit Managers (PBMs) should report the total dollar amount for contraceptive claims, as de?ned at incurred by plan participants and bene?ciaries as of December 31, 2014. FFM issuers and TPAs or PBMs should count the dollar value of claims incurred by this date in the total amount reported, even if the claims were not paid by December 811 Updated 1-31-17 2017--00911 31, 2014. (REGTAP FAQ Database - FAQ #14020 11/13/15) Q: Is the user fee adjustment amount limited to the dollar amount of contraceptive claims? Is there a way that the Federally-facilitated Marketplace (FFM) issuer can be reimbursed for the administrative costs associated with entering into an agreement with a Third Party Administrator A: Yes, the user fee adjustment amount that is credited toward an FFM issuer's user fee obligation is equal to the dollar amount of contraceptive claims paid to the TPA or Pharmacy Bene?t Manager (PBM), plus an additional 15% for administrative costs incurred. For example, if the FFM issuer paid $100,000 in contraceptive claims to a TPA for claims incurred through December 31, 2014, the issuer's total user fee adjustment amount would be $115,000. (REGTAP FAQ Database - FAQ #14021 11/13/15 Q: Can a Third Party Administrator (TPA) or Pharmacy Benefit Manager (PBM) be reimbursed for the administrative costs associated with entering into an agreement with a Federally-facilitated Marketplace (FFM) issuer? A: CMS has not established a mechanism through which TPAs or PBMs can be directly reimbursed for the administrative costs associated with administering contraceptive claims for eligible organizations. However, the agreement between the FFM issuer and the TPA or PBM may provide that the FFM issuer share a portion of its administrative margin with the TPA or PBM in order to help offset the TPA or PBM's administrative costs. (REGTAP FAQ Database - FAQ #14022 11/13/15) Q: How will issuers receive payment for the contraceptive claims costs and associated claims costs that they have incurred? Does an Federally-facilitated Marketplace (FFM) issuer need to do something to ensure that Centers for Medicare Medicaid Services (CMS) can properly transfer the monies to the issuer's account? A: After an FFM issuer has submitted the required data to CMS through the mailbox, the FFM issuer does not need to take any further action to ensure that the user fee adjustment is applied. CMS will not make direct payments to FFM issuers for the user fee adjustment amount. Instead, CMS will automatically deduct the user fee adjustment amount from the user fee amount that the issuer owes for a given month. CMS collects FFM user fees by automatically deducting the user fee amount from issuers advance payment of premium tax credits (APTCs) and cost-sharing reductions (CSRs). (REGTAP FAQ Database - FAQ #14023 11/13/15) Q: When will the Federally-facilitated Marketplace (FFM) issuer receive the user fee adjustment? Will the Centers for Medicare Medicaid Services (CMS) pay the total amount of an FFM issuer's user fee adjustment all at once? A: CMS anticipates applying the FFM user fee adjustment on a basis beginning at the end of the 2015 calendar year. CMS will automatically deduct the user fee adjustment amount from the issuer's user fee obligation. (REGTAP FAQ Database - FAQ #14024 11/13/15) 812 Updated 1-31-17 2017--00912 Q: How will the Centers for Medicare Medicaid Services (CMS) credit the user fee adjustment to the Federally-facilitated Marketplace (FFM) issuer if the user fee adjustment amount is greater than the FFM issuer's user fee obligation for any one (1) month? A: CMS will credit the user fee adjustment amount against an FFM issuer's user fee obligation until the user fee obligation for that month has been completely offset. Any remaining user fee adjustment amount will be credited towards the user fee obligation for the next month. CMS will continue this process until the user fee adjustment amount is fully exhausted. (REGTAP FAQ Database - FAQ #14025 11/13/15) Q: What happens if the user fee adjustment amount is greater than the Federally- facilitated Marketplace (FFM) issuer's total user fee obligation for the year? A: The Centers for Medicare Medicaid Services (CMS) will credit the user fee adjustment amount against the FFM issuer's user fee obligation on a basis. If the FFM issuer's user fee obligation has been fully offset at the end of the year and a user fee adjustment amount still remains to be credited to the issuer, CMS will rollover the amount of the adjustment to the next year and will credit the remaining amount against the next year's user fees. (REGTAP FAQ Database - FAQ #14026 11/13/15) Q: If a Third Party Administrator (TPA) or Pharmacy Benefit Manager (PBM) is part of the same entity or parent company as the Federally-facilitated Marketplace (FFM) issuer, who is required to submit user fee adjustment forms? A: If the TPA and FFM issuer are part of the same parent company then only the FFM issuer is required to submit the FFM Issuer Data Submission Form. The TPA Notice of Intent and TPA Submission Form are not required when the TPA and FFM issuer are part of the same parent company. (REGTAP FAQ Database - FAQ #14091 12/08/15) Q: On the Third Party Administrator (TPA) Submission for Claims Cost Reimbursement of Certain Preventative Services Form, must TPAs include the Tax Identification Number (TIN) of the eligible organization that the TPA is requesting reimbursement on behalf of? A: Yes. TPAs should submit the TIN for the eligible organization for which the TPA is requesting reimbursement. (REGTAP FAQ Database - FAQ #14093 12/08/15) Q: If an employer is contracting with a Third Party Administrator (TPA) and that TPA is contracting with a Federally-facilitated Marketplace (FFM) issuer of a separate entity, must the issuers and TPAs submit separate Forms? A: Yes. The TPA is required to submit the Notice of Intent Disclosure Form and the TPA Submission Requirement Form. The issuer is required to submit the FFM Issuer User Fee Adjustment Form. (REGTAP FAQ Database - FAQ #14094 12/08/15) Q: Can the Centers for Medicare Medicaid Services (CMS) clarify the requirements for an issuer and a Third-Party Administrator (TPA), respectively, to claim a contraceptive Federally-facilitated Marketplace (FFM) user fee adjustment? A: The TPA is the entity making payments for contraceptive services on behalf of the 813 Updated 1-31?17 2017--00913 self-insured group health plan. The Federally-facilitated Marketplace (FFM) issuer must have an agreement with a TPA stating that it will reimburse the TPA for the contraceptive costs in order to receive the user fee adjustment. The Department of Health and Human Services will then reimburse the fully-insured FFM issuer by adjusting the issuer's FFM user fee. (REG TAP FAQ Database - FAQ #14096 12/08/15) Q: Where should issuers input identifying information for each self-insured group on the Issuer Submission to Receive the Federally-facilitated Marketplace (FFM) User Fee Adjustment Form? A: The Third Party Administrator (TPA) is the entity making payments for contraceptive services on behalf of the self-insured group health plan. Therefore, the issuer need only list the TPA or Pharmacy Benefit Manager (PBM) who made payments on behalf of the self-insured group plan on the User Fee Adjustment Form. (REGTAP FAQ Database - FAQ #14221 12/08/15) Q: Will the Centers for Medicare Medicaid Services (CMS) make Federally-facilitated Marketplace (FFM) user fee adjustments or annually? A: CMS will begin making FFM user fee adjustments in early 2016 and continue the adjustments with each payment cycle. (REGTAP FAQ Database - FAQ #14225 12/08/15) Q: For the 2017 Benefit Year and beyond, CMS has made available the option for State- based Marketplaces using the Federal Platform (SBM-FP) to request that CMS collect the SBM-FP user fee from the State instead of directly collecting the user fee from the issuers. If an issuer in such State has qualified to receive an adjustment to the user fee for contraceptive payments set forth at 45 C.F.R. how will it receive credit for the user fee adjustment? A: Several States have requested the option to have CMS collect the SBM-FP user fee from the State instead of directly collecting the user fee from the issuers. For these States, as part of the SBM-FP user fee collection process, CMS will apply the contraceptive adjustment to the SBM-FP portion of the user fee amount that it invoices the State. The adjustment will only apply to the portion of the user fee owed to CMS for operation of the Federal platform, and will not affect any additional amounts that the State chooses to collect to fund its Marketplace operations. The adjustments will be equal to the sum of the user fee amount that would apply to all issuers in the State, limited to the amount that each issuer owes CMS for the SBM-FP user fee each month. The contraceptive user fee adjustments will be re?ected in the payment processing report with a program code labeled UFR. (Contraceptive Adjustment in SBM- FP Alternative User Fee Payment States 01/19/17) SBE User Fees Q1: Can States collect assessment fees in their first year of Exchange operations for use in the second year of operations? A1: Each State-based Marketplace is expected to be self-sustaining in 2015 and assessment fees, or user fees, are one way that states can meet the sustainability requirements of the Affordable Care Act. States may decide to collect assessment fees 814 Updated 1-31-17 2017--00914 in year one for operations in year two, however, in doing so, states must develop and maintain appropriate internal processes and controls, such as generally accepted accounting procedures, to distinguish and appropriately utilize section 1311 grant funds from other operational funds. States must also meet the requirements of section 1311(d)(7) which require public disclosure of Marketplace costs. (CMS FAQs Assessment Fees 07/10/13) SMALL GROUP MARKET AND FF-SHOP General 025: If HSAs, HRAs or Flexible Spending Accounts (FSA) require some type of employer action (payroll deduction, sponsorship of the HRA, etc.), how does that occur from a practical application on Small Business Health Options Plans What happens if an individual selects one of those plans and the employer does not want to do it? A25: CMS intends to address this point at a later time. (Plan Management Webinar 01/24/13) Updated 1-31-17 2017--00915 Webmar?Senes?EAQ?t?Q?OMSOI?is ote CMS has issued three versions of FAQ #9 this question appeared in the version issued on 04/30/13, but not in the versions issued on 05/03/13 or 10/31/13.) Q4: SHOP (ESI) Business Question: Will the FF-SHOP share dependent addresses? If dependent addresses are not provided, should an issuer default to the subscriber's address when calculating premiums? A4: We intend to propose in future rulemaking that the geographic area premium rating factor must be based on the employer's primary business location in each state. This would apply both inside and outside of the SHOP. (QHP SHOP FAQ 05/21/13) Q39: How is the exchange going to validate that all eligible employees have been offered coverage and are participating in A39: The is considering conducting audits to validate information on employer and employee applications. (QHP Webinar Series SHOP FAQ #1 06/20/13; REGTAP FAQ Database - FAQ #137 06/20/13) Q40: Can you clarify what an "issuer group" is with regards to having to apply for certification in the A40: Issuer group means all entities treated under subsection or of section 52 of the Internal Revenue Code of 1986 as a member of the same controlled group of corporations as (or under common control with) a health insurance issuer, or issuers affiliated by the common use of a nationally licensed service mark. (QHP Webinar Series SHOP FAQ #1 06/20/13; REGTAP FAQ Database - FAQ #138 06/20/13) Q41: How can issuers get a copy of the SHOP presentation materials or other CCIIO presentations? A41: Presentations from the CCIIO webinars are available in the resource section of the REGTAP website (QHP Webinar Series SHOP FAQ #1 06/20/13; REGTAP FAQ Database - FAQ #139 06/20/13) 816 Updated 1-31-17 2017--00916 06: How may QHPs differ for employers offering QHPs in multiple A6: Network requirements, service areas, etc. of a QHP will be determined by the SHOP certifying the QHP. If an employer allows out-of-state employees to enroll in a QHP through a SHOP serving the employee?s primary worksite (and not the SHOP serving the employer?s headquarters), then the employee will receive coverage through a QHP that may have a different premium, bene?t benchmark, rating criteria, etc., than a QHP certified through the SHOP serving the employer?s headquarters. (SHOP FAQ #2 07/05/13; REGTAP FAQ Database - FAQ #75 07/05/13) Q13: Will the FF-SHOP support, require, or disallow coverage of retirees? A13: Yes. The FF-SHOP allows for coverage of retirees. This information will be reported on 834 enrollment transactions under the category of retirees. Retirees will not receive a different contribution amount through the FF-SHOP from other enrollees. All retirees, active employees, and dependents will be rated using the same under the standard age curve. (SHOP FAQ #2 07/05/13; REGTAP FAQ Database - FAQ #82 07/05/13) REG TAP database on 08/26/14 Q39: Can you describe the process for the employer to pick a product to offer employees? Can the employer run ?what if? premium cost scenarios? A39: As part of the application process, an employer will be able to enter basic demographic information on employees and dependents likely to participate in an employer group?s plan and be able to run ?what it" premium scenarios. (SHOP FAQ #2 07/05/13; REG TAP FAQ Database - FAQ #101 07/05/13) Q40: If an employer group in the FF-SHOP allows coverage of domestic partners but an Issuer?s business rules do not cover domestic partners, will the plans be excluded from the available options? A40: The QHP application process provides information on which dependents are required to be covered in a state. Depending on how an Issuer responded to allowable dependent coverage questions on its QHP application, the domestic partner relationship identi?er would be populated in the list of available dependent relationship identifiers on the employee online application. Issuers would be expected to cover required dependents accordingly. (SHOP FAQ #2 07/05/13; REG TAP FAQ Database - FAQ #102 07/05/13) 817 Updated 1-31-17 2017--00917 Q42: Can CMS describe how an Issuer?s Summary of Benefits and Coverage (SBCs) will be made available to a group?s benefits administrator and to a group?s members during open enrollment for the A42: Existing Issuer requirements regarding making Summary of Bene?ts and Coverage (SBCs) available to a group?s benefits administrator and a group?s members have not changed. (SHOP FAQ #2 07/05/13; REGTAP FAQ Database - FAQ #104 07/05/13) 06: With respect to the SHOP program, is there a possibility that a benefit year will not match a contract year? Will Issuers be permitted to have benefit years that differ from the contract years for small groups? Yes, if state law allows it, it is possible that a bene?t year will not match a contract year in the FF-SHOPs for 2014 and 2015. This information would need to be communicated to consumers clearly in plan benefit materials provided by Issuers to employers and employees. For 2016, CMS is considering requiring all small group market plans to use a benefit year contract year unless state law requires otherwise. (Enrollment FAQ #3 07/24/13; REGTAP FAQ Database - FAQ #156 and #156a 07/24/13; updated 08/27/14) 06: Are there federal guidelines on whether QHP issuers can impose late payment fees on groups participating in the A6: Currently, there are no federal standards or guidelines that address late payment fees. (SHOP FAQ #3 07/30/13) 021: What is the exception process to handle out-of-state participation? A21: There is no exception allowance for out-of?state participation. Only employers with a business location in a given state may participate in the FF-SHOP serving that state. (SHOP FAQ #3 07/30/13,? REG TAP FAQ Database - FAQ #68 07/30/13) 022: What is the exception process for out-of-state employer participation? A22: Only employers with a business location within a given state may participate in the FF-SHOP serving that state. Multi-state employers may establish one account and enroll in a QHP with multi-state provider networks. Alternatively, multi-state employers may establish a separate SHOP account in each state where they have a business location. (SHOP FAQ #4 08/28/13; REGTAP FAQ Database - FAQ #26 08/28/13) 818 Updated 1-31-17 2017--00918 he REOTAP database on 09/02/14. Q5: What will a Small Business Health Options Program (SHOP) employer see on the issuer website if they are not paying premiums online? A5: A SHOP employer will see summary text describing what the employer can expect next, which includes receipt of an invoice or bill from the issuer. (Enrollment FAQ #7 - Premium Payment Redirect 09/17/13; REG TAP FAQ Database - FAQ #192 09/09/13) Q: For the 2014 plan year, will employers be able to attest that they employ 50 or fewer full-time equivalent employees (FTEs) through information provided directly to the FF- A: Yes, for the 2014 plan year, employers may attest to having 50 or fewer FTEs. Issuers will not be required to determine FTE counts for SHOP eligibility purposes. Employers can ?nd guidance about how to calculate the number of their FTEs at HealthCare.gov If an issuer's usual small group enrollment process would exclude eligible employers from coverage, the issuer should contact the SHOP Employer Call Center (1-800-706-7893 or TTY: 1-800-706-7915) for a ?nal determination of eligibility, and then enroll the group in coverage if it is determined eligible. (REGTAP FAQ Database - FAQ #602 and #6023 12/24/13; updated 08/27/14) Q: Are Small Business Health Options Program (SHOP) participants required to complete the Financial Information Template, Authorization Agreement and Bank Verification Letter? A: For the sole purpose of receiving 2014 payments, FFM and SBM issuers, issuers of Stand Alone Dental Plans (Pediatric), and SHOP issuers that also provide quali?ed health plans in the individual marketplace should submit the requested documentation as you may be eligible to receive APTC and CSR payments on behalf of enrollees. Instructions for submitting the requested payee and banking information and copies of the Financial Information Template and the Financial Information Authorization Agreement can be found in the REGTAP library at under ?Payments-?Payee Groups.? (REG TAP FAQ Database - FAQ #482 11/20/13) Q: May issuers quote only plans certified through the FF-SHOP or may issuers also provide a quote for small group plans not certified by the A: Employers seeking to enroll in a FF-SHOP QHP or QDP should be given the information necessary to enroll in FF-SHOP QHPs and QDPs. Additional plan information may also be quoted alongside QHP and QDP plans. (REGTAP FAQ Database - FAQ #655 01/16/14) Q: How will FF-SHOPs interact with State-based A: FF-SHOPs will not integrate with other FF-SHOPs or State-based SHOPS. (REGTAP FAQ Database - FAQ #992 03/10/14) 819 Updated 1-31-17 2017--00919 Q: Can employers who enroll outside a FF-SHOP claim the small business healthcare tax credit worth up to 50% of employer contributions? A: No. Only those employers who have an eligibility determination from the FF-SHOP and who have enrolled in a QHP certi?ed by the FF-SHOP may receive the Small Business Healthcare Tax Credit. (REGTAP FAQ Database - FAQ #1425 04/14/14) Q: The 4-1 -14 presentation in the REGTAP library states that issuers are encouraged to provide feedback to CMS on a few open items. How may Issuers provide feedback? A: Issuers may submit input on Tuesdays during the weekly SHOP REGTAP calls (either via the chat feature or during the open Q/comment period). (REGTAP FAQ Database - FAQ #1432 04/14/14) Q: Will employers have a choice in 2015 on whether to set up benefits on a calendar or a contract year? If so, how will CMS provide that information to Issuers? If not, will groups enrolling through the FF-SHOP be set up on a calendar year or contract year? A: Employers will not have a choice in 2015 whether to set up bene?ts on a calendar or a contract year. Issuers may establish plan years based on what's allowed under applicable state law. (REGTAP FAQ Database - FAQ #1441 04/14/14) Q: Are issuer in-house sales staff required to execute the Small Business Health Options Program (SHOP) Privacy and Security Agreement or can the issuer rely on Health Insurance Portability and Accountability Act (HIPAA) compliance of the organization? A: All Agent/Brokers who wish to participate in the FF-SHOP Marketplace must complete all required registration requirements. In 2014 and 2015, Agent/Brokers must complete the FF-SHOP Marketplace Privacy and Security Agreement housed on the Medicare Learning Network (MLN). Beginning in 2015, Agent/Brokers must also be identity proofed on the CMS Enterprise Portal in order to gain access to the online FF-SHOP Marketplace portal. (REGTAP FAQ Database - #1721 05/27/14) Q: Where is the current version of the Small Business Health Options Program (SHOP) privacy and security agreement available? A: You may review the current version of the SHOP Privacy and Security Agreement located on the Medicare Learning Network (MLN): (REGTAP FAQ Database - #1722 05/27/14) Q: Where can issuers email Small Business Health Options Program (SHOP) questions? A: Issuers may email technical questions about the Marketplace to CMS FEPS@cms.hhs.qov. (REGTAP FAQ Database - #1991 05/30/14) Q: Are Federally-facilitated Small Business Health Options Program (FF-SHOP) group plan years on a calendar year or a contract year? Also, define contract year. A: Issuers may establish plan years based on what is allowed under applicable state law, either a calendar year or a contract year. A contract year begins when a group 820 Updated 1-31-17 2017--00920 establishes coverage and ends 12 months after the original effective date. (REGTAP FAQ Database - FAQ #1997 05/30/14) O: For Federally-facilitated Small Business Health Options Program (FF-SHOP) plans, will the deductible and maximum out-of-pocket amount reset each January or when a plan renews? A: For plan year 2015, issuers may establish Small Business Health Options Program (SHOP) plan benefit years according to applicable state law, either a calendar year or a 12-month contract year. So the answer to this question depends on whether the plan benefit period is filed and approved based on a calendar year or a contract year. Either way, the rates for all SHOP plans must be locked in for 12 months based on when a group initially enrolls. (REGTAP FAQ Database - FAQ #2436 06/26/14) Q: Can employers in the Federally-facilitate Small Business Health Options Program (FF- SHOP) select preferred issuers, based on service area, or are the plans available to employers always based on the employer's business location? A: Plans available to employers in FF-SHOPs are always based on the primary business address of an employer. Thus, employers may not select preferred issuers based on service area. (REGTAP FAQ Database - FAQ #2589 07/03/14) Q: If a State only allows high Actuarial Value (AV) dental plans, will only those plans display in Plan Compare for Federally-facilitated Small Business Health Options Program A: Yes, if a State only allows high AV dental plans, only high AV dental plans will display (because only high AV dental plans will be approved by the State/OMS as part of the FF- SHOP Quali?ed Health Plan (QHP) certi?cation process. (REGTAP FAQ Database - FAQ #2592 07/03/14) Q: What kind of guidance or training will the Small Business Health Options Program (SHOP) enrollment website provide for employers? A: The initial roll-out of the online SHOP website (on November 15, 2014) will include extensive information for employers and Agent/Brokers. States wanting to assist with this education campaign should inform the corresponding state of?cer at the Center for Consumer Information and Insurance Oversight (CCIIO). (REGTAP FAQ Database - FAQ #2593 07/03/14) Q: Issuers requested that the Federally-facilitated Small Business Health Options Program (FF-SHOP) send all notices, including termination notices, to maintain consistency in noti?cation procedures. Have the Centers for Medicare Medicaid Services (CMS) reached a decision regarding this request? A: The FF-SHOP is not able to accommodate this request at this time, so issuers remain responsible for sending termination notices. In the future, CMS hopes to support regulatory changes that will allow the FF-SHOP to send termination notices as part of a future release. (REGTAP FAQ Database - FAQ #3018 07/25/14) 821 Updated 1-31-17 2017--00921 Q: When will the Federally-facilitated Small Business Health Options Program (FF-SHOP) Marketplace open for business? A: The FF-SHOP Marketplace has been open for business since October 2013. The online FF-SHOP Marketplace will open on November 15, 2014. (REGTAP FAQ Database - FAQ #3394 08/01/14) Q: When will the Centers for Medicare Medicaid Services (CMS) post the July 1 Business Application Acknowledgment (BAA) Transactions webinar presentation? A: The Federally-facilitated Small Business Health Options Program (FF-SHOP) will not support BAA transactions as of November 15, 2014. CMS will post the BAA transactions webinar presentation at a later date. (REGTAP FAQ Database - FAQ #3410 08/01/14) Q: Do Small Business Health Options Program (SHOP) plans need to comply with Individual Market plan requirements, which include a requirement for issuers to offer one silver plan and one gold plan? A: Yes, in order for an Issuer to participate in SHOP, QHP certi?cation requires that issuer to offer a minimum of one sliver plan and one gold plan. (REGTAP FAQ Database - FAQ #3515 08/07/14) Q: If an employer is based in more than one state, will the employer enroll separately in each state? A: Employers with multiple business locations may enroll in 1 Small Business Health Options Program (SHOP) (using a multi-state or national plan network) or enroll separately in each state SHOP. (REGTAP FAQ Database - FAQ #3766 08/14/14) Q: Will employees be able to change or update data elements that are brought over from the employer roster? A: Employees will be able to update a limited number of ?elds entered by his or her employer, including dependent name, mailing address, and phone number(s). Other elements, such as employee DOB, SSN, etc. must be made on the official employee roster. (REGTAP FAQ Database - FAQ #3778 08/14/14) Q: When reviewing an employer's offer of coverage, is there an opportunity for the employee to save employee information prior to selecting a plan? A: Yes, an employee can save employee information at various points throughout the application and election process. (REGTAP FAQ Database - FAQ #3779 08/14/14) Q: Does an employee have the ability to change plans prior to the employer finalizing the group enrollment? A: Yes, employees can change plans multiple times before employers submit the ?nal enrollment application. Once enrollment information is sent to issuers, employees may not change plans before renewal unless they qualify for a special enrollment period. (REGTAP FAQ Database - FAQ #3781 08/14/14) 822 Updated 1-31-17 2017--00922 Q: Does an employer receive a notification after an employee has selected a plan? Will the employer have to check periodically if and how many employees have selected plans? A: Whenever an employee selects or changes a plan, the Federally-facilitated Small Business Health options Program (FF-SHOP) will notify the employer. (REGTAP FAQ Database - FAQ #3783 08/14/14) Q: Can employers participating in the Federally-facilitated Small Business Health Options Program (FF-SHOP) offer the same plan to employees who work out of state as the plan offered to in-state employees? A: Yes, an employer may offer the same plan to employees who work out of state as the plan offered to in-state employees. An employer with employees working in more than one state has two options: 1) Cover all employees from the data in which the employer has its main business, or 2) Cover the employees through the SHOP in each state using the primary business address in that state. (REGTAP FAQ Database - FAQ #5515 10/09/14) Q: Can issuers resubmit effectuation files to transmit missing information or update issuer-assigned identifiers? A: Yes, the Federally-facilitated Small Business Health Options Program (FF-SHOP) will accept updated effectuation ?les with the corrected information and will override previously submitted data. (REG TAP FAQ Database - FAQ #10777 05/27/15) 05: Where can issuers locate the Small Business Health Options Program (SHOP) Justi?cation Provision Template? A5: Issuers may locate the Federally-facilitated SHOP (FF-SHOP) Participation Provision Supporting Documentation and Justi?cation for the Federally-facilitated Individual Marketplace on info and on ZONE. In addition, issuers may contact an Account Manager or submit a Help Desk ticket for further guidance. (QHP Certi?cation Process FAQs #2 {09/29/15)} Q: Are there any tax credits for employers available through the SHOP Marketplace? A: Yes, the Small Business Healthcare Tax Credit is available exclusively through the SHOP Marketplace. The tax credit can be worth up to 50% of an employer's contribution toward premium costs and up to 35% for tax-exempt employers. To qualify for the tax credit, small employers must have fewer than 25 full-time equivalent, or FTE, employees and the average employee salary must be about $50,000 per year or less. The employer must also offer coverage to all full-time employees and contribute at least 50% to their employee premium costs. There is a Small Business Healthcare Tax Credit Estimator available at HealthCare.gov to help small employers, or the agents and brokers assisting them, determine if they may be eligible for the tax credit and, if they are eligible, estimate how much the credit might be worth. (REGTAP FAQ Database - FAQ #15720 05/02/16) 823 Updated 1-31-17 2017--00923 Q: Are employers able to deduct the health insurance premiums they pay from their taxes? A: Generally, employer health insurance premium contributions are tax deductible. For more information, visit RS.gov. (REGTAP FAQ Database - FAQ #16166 05/27/16) Q: Should SHOP issuers with plans effective beginning in Plan Year 2016 and ending during Plan Year 2017 continue to update their 2016 machine readable data up to the plan expiration during Plan Year 2017? A: Yes. Issuers with SHOP plans in states utilizing the Federally-facilitated Marketplaces (FFMs) should update their machine readable data for a particular plan year until all SHOP plans for that plan year are expired. For example, an issuer with SHOP that were effective December 2016 should continue to update their 2016 machine-readable data until November 30, 2017. (CMS FAQs Machine Readable Data FAQs 01/19/19) Q: Should issuers keep their machine readable URLs active for a particular plan year once all applicable issuers QHP plans for that plan year are expired? A: CMS rules and policies do not require issuers utilizing the FFM to keep provider and drug machine-readable URLs active once all applicable plans have expired. However, issuers do need to preserve their provider and drug information in accordance with 45 CFR 156.705, applicable state and accreditation record retention requirements, as well as their own internal record retention policies. (CMS FAQs Machine Readable Data FAQs 01/19/19) Electronic Data lnterchanqe (EDI) Q: Do issuers who established 834 connectivity with the Federally-facilitated Small Business Health Options Program (FF-SHOP) last year need to resubmit Electronic Data Interchange (EDI) Registration forms for 2015? A: If Issuers have already established Electronic File Transfer (EFT) connectivity with the Centers for Medicare Medicaid Services (CMS) for the Trading Partner that will receive FF-SHOP transactions, additional connectivity testing is not required. Issuers must, however, update the EDI Registration Form to include routing for 2015 FF-SHOP QHPs. (REGTAP FAQ Database - FAQ #3416 08/01/14) Q: Where is the most current version of the Electronic Data Interchange (EDI) registration form located? A: The EDI Registration Form is available to the CMS ZONE issuers community at Remember to log-in to before clicking on this link. (REGTAP FAQ Database - FAQ #3419 08/01/14) Q: When is the deadline for issuers to submit the 2015 Electronic Data Interchange (EDI) Registration Form for the Federally-facilitated Small Business Health Options Program A: The Centers for Medicare Medicaid Services (CMS) does not impose any deadlines for the submission of registration forms. However, CMS recommends that the issuers 824 Updated 1-31-17 2017--00924 complete EDI registration at least two weeks before the testing period starts to give suf?cient time for the approval process. Thus, CMS suggest issuers submit these forms for the 2015 plan year no later than August 29, 2014. (REGTAP FAQ Database - FAQ #3771 08/14/14) Q: If an FF-SHOP issuer has an approved 2014 Electronic Data Interchange (EDI) Registration form on file for the Individual Marketplace that notates what must issuers update on the onboarding form? A: EDI Registration forms filed in 2014 may not contain an issuer's Quali?ed Health Plan's (QHP's) certi?ed for 2015. Also, EDI Registration forms may not have the Payee group information setup. These changes are required for the Centers for Medicare Medicaid Services (CMS) to deliver Group XML, 834, and 820 files properly to issuers. (REGTAP FAQ Database - FAQ #4435 09/05/14) Q: What is the expected duration for the Centers for Medicare Medicaid Services (CMS) approving Electronic Data Interchange (EDI) forms? A: EDI Registration forms go through multiple approval levels before getting ?Approved.? On average, the approval process takes about 5-8 business days to get the forms approved. (REGTAP FAQ Database - FAQ #4706 09/11/14) Q: How do issuers update the issuer's Electronic Data Interchange (EDI) registration forms with Quali?ed Health Plan (QHPs) and Qualified Dental Plans (QDPs) for 2015? A: Issuers should contact the EDI Support Desk at for guidance on successfully submitting onboarding forms. (REGTAP FAQ Database - FAQ #4906 09/17/14) Q: What is the deadline for Federally-facilitated Small Business Health Option Program (FF-SHOP) issuers to complete an Electronic Data Interchange (EDI) Registration form for 2015? A: FF-SHOP issuers are encouraged to make applicable updates to issuer EDI registration forms (when applicable) as soon as possible in order to participate in testing in September and October. (REGTAP FAQ Database - FAQ #4908 09/17/14) Q: For Federally-facilitated Small Business Health Options Program (FF-SHOP) issuers who completed an Electronic Data Interchange (EDI) Registration form for 2014 plans, what steps must the issuer take in order to update plans for 2015? A: Issuers must submit a 'change' listing the new Quali?ed Health Plans (QHPs) for 2015 on the EDI Registration form available at edi-reqistration-form(REGTAP FAQ Database - FAQ #4926 09/17/14) 825 Updated 1-31-17 2017--00925 Q: When adding or making changes to the issuer's 2015 Qualified Health Plans (QHPs) on the Electronic Data Interchange (EDI) Registration form, must issuers use Version 3.2 or the current version available on A: Issuers may use the current version of the EDI Registration form available on FAQ Database - FAQ #5324 10/02/14) Q: Must issuers who have already connected with the Federally-facilitated Marketplaces (FFMs) for the upcoming plan year resubmit the Electronic Data Interchange (EDI) Registration form when the Centers for Medicare and Medicaid Services (CMS) releases the new version 3.2 form? A: It is not mandatory for issuers to resubmit the EDI Registration Form for every update CMS releases. However, issuers should verify that all Qualified Health Plan (QHP) and Quali?ed Dental Plan (QDP) information for 2015 is updated and the Payee Group ID is listed on the existing form. (REG TAP FAQ Database - FAQ #5345 10/03/14) Q: If an issuer needs to make corrections to an Electronic Data Interchange (EDI) Registration form, who can the issuer contact? A: Issuers should submit an updated EDI Registration form when making corrections. The Centers for Medicare Medicaid Services (CMS) will contact issuers if the agency has any questions. Issuers may also email with questions regarding submitting updated EDI Registration forms. (REGTAP FAQ Database - FAQ #5496 10/09/14) Q: After the Centers for Medicare Medicaid Services (CMS) sends issuers approvals for the Electronic Data Interchange (EDI) registration forms, when will CMS contact issuers to set up their Electronic File Transfer (EFT) folder and connectivity? A: CMS will immediately notify issuers when CMS receives the EDI Registration form. The forms then go through multiple approval levels. One approval level is EFT setup and connectivity testing. The EFT team will reach out to the issuer to complete this process. Once complete, the form is approved to move to the next level of approval. (REGTAP FAQ Database - FAQ #5509 10/09/14) Q: How will the Centers for Medicare and Medicaid Services (CMS) push enrollment and payment files to the issuer's servers from the Federally-facilitated Small Business Health Options Program A: CMS will place the files in the issuer's Secure Point-of?Entry (SPOE) folder. The Electronic File Transfer (EFT) team will work with issuers on this process during the Electronic Data Interchange (EDI) Registration process. (REGTAP FAQ Database - FAQ #5325 10/02/14) 826 Updated 1-31-17 2017--00926 HIOS IDS Q: If a member has signed up with one Qualified Health Plan (QHP) issuer and one Stand- alone Dental Plan (SADP) issuer, which issuer's Health Insurance Oversight System (HIOS) ID will the Federally-facilitated Small Business Health Options Program (FF-SHOP) include in the Exchange Assigned A: The FF-SHOP will use the HIOS ID for the QHP medical plan. (REGTAP FAQ Database - FAQ #4686 09/11/14) Q: If an issuer has established financial information for the Individual Marketplace, must the issuer set up the same information for the Small Business Health Options Program (SHOP) Marketplace even if business in both Marketplaces are under the same Health Insurance Oversight System (HIOS) A: Generally, no further action is required at this time. Issuers should send issuer IDs to vendor management@cms.hhs.gov in order to confirm. (REGTAP FAQ Database - FAQ #4703 09/11/14) Q: If a Federally-facilitated Small Business Health Options Program (FF-SHOP) issuer has two Health Insurance Oversight System (HIOS) IDs, should the designated tester receive a confirmation email for each state? A: FF-SHOP issuers will receive one testing account per issuer, per state. Issuers will only receive dummy data sets for the number of states in which the issuer offers coverage. (REGTAP FAQ Database - FAQ #4932 09/17/14) Q: Will the Federally-facilitated Small Business Health Options Program (FF-SHOP) prefix the plan's Health Insurance Oversight System (HIOS) ID to the Exchange Assigned Policy A: No, HIOS IDs are not pre?xed to the Exchange Assigned Policy IDs in the FF-SHOP. (REGTAP FAQ Database - FAQ #5328 10/02/14) Q: Where can issuers locate a breakdown of the Health Insurance Oversight System (HIOS) Qualified Health Plan (QHP) Identification A: The Standard Component ID generated by the Centers for Medicare and Medicaid Services (CMS) is a 14-characters alphanumeric sequence: Five-digit Issuer ID Two-character State ID Three-digit Product Number Four-digit Standard Component Number An example is as follows: 12345VA0020021 The Variant Component ID is 2 characters (Numeric) with the following values and description: 00 - Non-exchange variant 01 - Exchange variant. For more information, see (REGTAP FAQ Database - FAQ #12220 08/27/15) 827 Updated 1-31-17 2017--00927 Testing Q: When will the Centers for Medicare Medicaid Services (CMS) send the 2015 Federally-facilitated Small Business Health Options Program (FF-SHOP) testing material packets, and how will an issuer know which representative will receive the testing packet when the testing packet is ready? A: FF-SHOP issuers need to register for 2015 testing at issuer reqistration@cms.hhs.qov. When registering, issuers will identify which person from within the issuer's company will be testing. This person will receive the 2015 testing packet by e-mail when it is ready--approximately 1-5 days prior to testing. (REGTAP FAQ Database - FAQ #4413 09/05/14) Q: Will FF-SHOP issuers receive a test account to simulate the employer or employee expe?ence? A: For initial Increment 1 testing, issuers will receive instructions on how to create an employer testing account prior to the start of testing. The Centers for Medicare Medicaid Services (CMS) will deliver employee functionality as part of Increment 2 testing. (REGTAP FAQ Database - FAQ #4414 09/05/14) Q: What is the deadline for issuers to submit test scenarios to the Federally-facilitated Small Business Health Options Program A: Issuers may continue testing as long as the testing window is open and the test environments are available. (REG TAP FAQ Database - FAQ #4415 09/05/14) Q: Will the Federally-facilitated Small Business Health Program (FF-SHOP) send Group XML transactions as part of Increment 1 FF-SHOP) testing? A: No, Increment 1 testing does not include Group XML, 834, or 820 transactions. Issuers will test these transactions as part of Increment 2 testing scheduled to begin in October. (REGTAP FAQ Database - FAQ #4416 09/05/14) Q: If an issuer did not participate in the Federally-facilitated Small Business Health Options Program (FF-SHOP) last year, will the issuer use its 2015 Health Insurance Oversight System (HIOS) Plan IDs for 2015 testing? A: For Increment 1 testing, the will provide dummy data for issuers who did not participate in the FF-SHOP last year. (REGTAP FAQ Database - FAQ #4417 09/05/14) Q: Can FF-SHOP issuers test additional scenarios not supplied by the Centers for Medicare Medicaid Services A: Yes, FF-SHOP issuers can test additional scenarios not supplied by CMS, though the ability for CMS to respond to defects stemming from these additional scenarios will be limited. (REGTAP FAQ Database - FAQ #4418 09/05/14) 828 Updated 1-31-17 2017--00928 Q: If an issuer participated in testing last year, does the issuer need to submit a new Electronic Data Interchange (EDI) Registration form? A: The A: depends on a couple of parameters. 1. Is there any trading partner relationship change for the organization, clearinghouse change or introduction of a trading partner for the new plan year? If the A: to either of these scenarios is ?Yes?, then the issuer needs to submit a change form. 2. Has the issuer filed its 2015 plans? If no, then the issuer needs to submit a change form to fill in the 2015 plan information. 3. Is the issuer payee group information already ?led? Or is that information changing? If the issuer has not ?led this information, then a change form is required. If the information is already ?led but the information is changing, then CMS also needs a change form. (REGTAP FAQ Database - FAQ #4431 09/05/14) Q: Can more than one person from within a company participate in Federally-facilitated Small Business Health Options Program (FF-SHOP) issuer testing? A: No, the Federally-facilitated Small Business Health Options Program (FF-SHOP) will allow one testing account, per issuer, per state. If an insurance company is licensed and operating in the FF-SHOP in more than one state, the issuer may receive a testing account for each state represented in the FF-SHOP. (REGTAP FAQ Database - FAQ #4448 09/05/14) Q: Are issuers required to complete identity proofing as a part of the Federally-facilitated Small Business Health Options Program (FF-SHOP) testing? A: Yes, as part of account creation, The Centers for Medicare Medicaid Services will give issuers a set of 'dummy data' to conduct ID proofing. issuers will not have to use actual Social Security Numbers (SSN) or other personally identi?able information (Pll) when creating testing accounts. (REGTAP FAQ Database - FAQ #4909 09/17/14) Q: Can issuers begin creating accounts for testing on the Federally-facilitated Small Business Health Options Program (SHOP) test website? A: The FF-SHOP issuer testing environment is still undergoing enhancements. The Centers for Medicare and Medicaid Services (CMS) will send a message to all registered testers when CMS has con?rmation the environment is up for account creation. (REGTAP FAQ Database - FAQ #4927 09/17/14) Q: Where can issuers download the test files needed for Federally-facilitated Small Business Health Options Program (FF-SHOP) testing beginning in September 2014? A: All registered testers will receive the test packets through email. issuers must register at issuer reqistration@cms.hhs.qov. Registration packets can take up to ?ve (5) business days to process so issuers should register early. (REGTAP FAQ Database - FAQ #4930 09/17/14) 829 Updated 1-31-17 2017--00929 Q: When conducting Federally-facilitated Small Business Health Options Program (FF- SHOP) testing, can issuers test plan and enrollment data for any state in which the issuer offers certified Qualified Health Plans A: Yes. FF-SHOP issuers can test plan and enrollment data for any state in which the issuer offers certi?ed QHPs. (REGTAP FAQ Database - FAQ #5342 10/03/14) Q: If an issuer participated in the Individual Marketplace for the 2014 plan year and is new to the Small Business Health Options Program (SHOP) for the 2015 plan year, must the issuer participate in the Marketplace 2.0 Testing or will the SHOP End-to-End testing suffice? A: Issuers are not required to participate in testing for either Marketplace though participation is highly encouraged. (REGTAP FAQ Database - FAQ #5495 10/09/14) Q: Can Federally-facilitated Small Business Health Options Program (FF-SHOP) issuers meet the requirement to send notices to employees by having employers communicate the applicable notices to employees on their behalf? A: FF-SHOP issuers may arrange to have another person or entity, for example, a group administrator or a plan sponsor (employer), distribute the required notices on the issuer's behalf; however, if this arrangement is established, the FF-SHOP issuer (rather than the employer) is still the party ultimately responsible for providing the notices to employees, and the issuer cannot force the employer to distribute the notices on the issuer's behalf. In addition, if the employer does not provide the notices, then the issuer has not met the FF-SHOP notice requirement at (REGTAP FAQ Database - FAQ #6672 11/03/14) Q: In the case of a small employer that purchases a Qualified Health Plan (QHP) through a Small Business Health Options Program (SHOP) for a plan year that is not the calendar year, will the QHP be certi?ed through the duration of the employer's 12-month plan year? A: Under 45 CFR the SHOP must permit a quali?ed employer to purchase coverage for its small group at any point during the year. The employer's plan year must consist of the 12-month period beginning with the qualified employer's effective date of coverage. This means that for groups enrolled in a QHP through the SHOP, the employer's plan year might not coincide with the calendar year. However, in the case of a QHP that is certified on the basis of a calendar year, the certification expires at the end of the applicable calendar year and will not apply to the portion of the employer's plan year that extends into the following calendar year. We recognize that having a health plan lose or change its certi?cation mid-plan year may create undue burden on issuers, employers, and employees alike. It could also affect a small employer's eligibility for the tax credit under section 45R of the Internal Revenue Code. To address these concerns, we intend to propose in future rulemaking that, if a SHOP certi?es QHPs on a calendar year basis, the certi?cation will remain in effect through the duration of the quali?ed employer's 12-consecutive-month plan year that began in the calendar year with respect to which the plan was certified. 830 Updated 1-31-17 2017--00930 Pending rulemaking on this topic, the Federally-facilitated SHOP will treat a QHP certified with respect to a calendar year and purchased by a small employer as having in effect such certi?cation through the duration of the qualified employer's 12-consecutive- month plan year. State-based SHOPS are encouraged to adopt similar treatment. The Department of the Treasury and the Internal Revenue Service have advised CMS that they would consider coverage that is subject to this guidance to be coverage in a QHP offered through a SHOP through the duration of the quali?ed employer's plan year for purposes of determining the employer's eligibility for the section 45R credit. (REGTAP FAQ Database - FAQ #6987 11/06/14) Q: Will the Federally-facilitated Small Business Health Options Program (FF-SHOP) support 820 transactions in 2016 testing? A: No, the FF-SHOP will not support 820 transactions for all issuer 2016 testing. (REGTAP FAQ Database - FAQ #10781 05/27/15) Q: Will the Federally-facilitated Small Business Health Options Program (FF-SHOP) require issuers to support end-to-end testing by submitting effectuations for 2016 test transactions? A: Issuers are required to send effectuation transactions to participate in FF-SHOPs though testing of these transactions is not in scope for all issuer 2016 testing. (REGTAP FAQ Database - FAQ #10782 05/27/15) Q: Will the Centers for Medicare Medicaid Services (CMS) allow more than one (1) issuer-tester, per Health Insurance Oversight System (HIOS) ID, per state for Federally- facilitated Small Business Health Options Program (FF-SHOP) testing? A: CMS will provide FF-SHOP issuers one (1) issuer test account per HIOS ID per state. Issuers may, however, create additional test accounts to enable concurrent testing during the testing time period. (REGTAP FAQ Database - FAQ #10784 05/27/15) Q: If Federally-facilitated Small Business Health Options Program (FF-SHOP) issuers have multiple Health Insurance Oversight System Identifications (HIOS IDs) which issuers would like to submit for 2015 testing, can all HIOS IDs be submitted in one email? A: Issuers may send multiple HIOS IDs together in one email. Please be sure to align the HIOS ID with its corresponding State. (REGTAP FAQ Database - FAQ #12165 08/27/15) Q: For 2016 Federally-facilitated Small Business Health Options Program (FF-SHOP) issuer testing, can issuers who previously tested use the same account used in 2015? A: The Centers for Medicare and Medicaid Services (CMS) has not tested old accounts in the new environment. Thus, accounts used by FF-SHOP issuers last year may or may not work. For 2016, all registered testers will be provided a new testing account (one account per issuer, per State). (REGTAP FAQ Database - FAQ #12167 08/27/15) 831 Updated 1-31-17 2017--00931 Q: During All Issuer Testing, what plan year information will be available to issuers? Will the issuer plans be tested by county? A: 2016 Plan Year data will be available to issuers during AII Issuer Testing. In the Federally-facilitated Small Business Health Options Program (FF-SHOP) Marketplace, rates are calculated by county. During testing, an issuer will be able to enter whatever Zone Improvement Plan (ZIP) code and State the issuer wants to for testing purposes. (REGTAP FAQ Database - FAQ #13133 09/22/15) Issuer Support Q: When experiencing issues submitting Enrollment/Reconciliation files for the Federally-facilitated Small Business Health Options Program (FF-SHOP), where should issuers submit questions or problems? A: For SHOP Enrollment/Reconciliation ?les that have not reached the Enrollment/Reconciliation Team from the issuer due to an improper ?le naming convention, routing issues, or if the issuer is experiencing connectivity problems, please contact the Electronic File Transfer (EFT) Team Support Team as they have access to the Managed File Transfer (MFT) folders and the routing of the files. EFT Tier 2 Support is available by emailing EFTTier28upport@qssinc.com. (REGTAP FAQ Database - FAQ #13661 10/13/15) Child-only Plans removed this FAQ from the REG TAP database on 08/26/14 Q: If an employer has an employee age 18 who enrolls in coverage, would this be considered a child-only policy? A: Small Business Health Options Program (SHOP) plans must be designated as "Allows Adult Only" or "Allows Adult and Child Only". An 18-year-old employee will be accommodated on a FF-SHOP plan. (REGTAP FAQ Database - FAQ #2430 06/26/14) Q: Does the Federally-facilitated Small Business Health Options Program (FF-SHOP) allow child-only plans? A: No, child-only plans are not allowed in FF-SHOPs for 2015. Issuers should plan to submit plans that cover both adults and children. Operationally, a dependent may not enroll in FF-SHOPs without an employee also enrolling. Additionally, if an employee enrolls a dependent in a SHOP Quali?ed Health Plan (QHP), and also elects to enroll in stand-alone dental coverage, both the employee and dependent will be enrolled in the same health and dental plans. (REGTAP FAQ Database - FAQ #2438 06/26/14) 832 Updated 1-31-17 2017--00932 Q: Will the Federally-facilitated Small Business Health Options Program (FF-SHOP) support child-only plans and if so, will the FF-SHOP send a child-only indicator? A: The FF-SHOP will not support child-only plans in 2015. (REGTAP FAQ Database - FAQ #2887 07/16/14) Q: How can issuers identify child-only plans in the Federally-facilitated Small Business Health Options Program A: The will not display child-only plans for the 2015 Plan Year. (REGTAP FAQ Database - FAQ #3413 08/01/14) Dependent Coverage Q: For dependent-only policies, who is the subscriber? A: Dependents are unable to enroll in Federally-facilitated Small Business Health Options Program (FF-SHOP) coverage without an employee also enrolling. (REGTAP FAQ Database - FAQ #2418 06/26/14) Q: Are issuers required to effectuate initial enrollment transactions even if the transaction only adds a spouse or dependent to the policy? A: Dependents may never enroll in a Federally-facilitated Small Business Health Options Program (FF-SHOP) Qualified Health Plan (QHP) or Stand-alone Dental Plan (SADP) without the employee also enrolling. Per QHP agreements, issuers must effectuate all enrollment transactions submitted to issuers from the FF-SHOP and maintain that coverage (assuming premium payments are up to date). (REGTAP FAQ Database - FAQ #2863 07/16/14) Q: When sending a new enrollment transaction to add a dependent to the existing enrollment group, will the Federally-facilitated Small Business Health Options Program (FF-SHOP) send the transaction that contains only the new dependent or will the FF- SHOP also send the subscriber record? A: The new dependent addition is sent as an Initial Enrollment, and any ?nancial changes are sent as a financial change transaction to the subscriber. (REGTAP FAQ Database - FAQ #2869 07/16/14) Q: Will the Federally-facilitated Small Business Health Options Program (FF-SHOP) evaluate requests to cover over-age dependents under special circumstances? A: The FF-SHOP is not evaluating requests to cover over-age dependents, however, the FF-SHOP is supporting "Ward" as a dependent category. (REGTAP FAQ Database - FAQ #2890 07/16/14) Q: Will the Centers for Medicare Medicaid Services (CMSdesignate dependents on 834 Enrollment transactions for the 2015 Plan Year? A: No, these indicators are used for the 2014 FF-SHOP Enrollment/Reconciliation reporting process. CMS is supporting nine (9) dependent relationships for the 2015 Plan 833 Updated 1-31-17 2017--00933 Year. Rules regarding how issuers treat dependents the age when a child ages off a parent's plan) will be consumed from information submitted by issuers on the business rules template. The document containing a listing of relationships supported on the FF- SHOP system in 2015 can be found at Slides 050814 5CR 052714.pdf (REGTAP FAQ Database - FAQ #3415 08/01/14) Q: Clarifying FAQ 2415: Will the Federally-facilitated Small Business Health Options Program (FF-SHOP) verify dependent age off for employer groups renewing coverage in 2016? A: Yes, the FF-SHOP plans to conduct age out veri?cations for employer groups renewing coverage in 2016. (REGTAP FAQ Database - FAQ #4419 09/05/14) Q: If a dependent ages off in the Federally-facilitated Small Business Health Options Program (FF-SHOP) at the age of 26, what is the termination effective date? A: The termination effective date for dependents aging off of a parents' plans is the end of the month the dependent ages off the plan. (REG TAP FAQ Database - FAQ #4204 09/02/14) Q: If an employee in a Federally-facilitated Small Business Health Options Program (FF- SHOP) employer group passes away, how will the FF-SHOP handle coverage for the employee's dependents? A: Because dependents are only allowed to enroll in coverage if an employee is also enrolled, when an employee dies, this event will trigger a termination transaction for the entire family. These family members would be eligible for a Special Enrollment Period (SEP) in the Individual Marketplace. (REGTAP FAQ Database - FAQ #4426 09/05/14) Q: What is the process for determining disability status for dependents in the Federally- facilitated Small Business Health Options Program A: The FF-SHOP does not require dependent status documentation upon enrollment. (REGTAP FAQ Database - FAQ #5317 10/02/14) Q: When a dependent is terminated from coverage in the Federally-facilitated Small Business Health Options Program (FF-SHOP), to whom must the issuer send the termination letter? A: At this time, The Centers for Medicare Medicaid Services (CMS) requires issuers in the FF-SHOP to send cancellation and termination notices to employers and employees. Issuers may, but are not required to, send notices to dependents. (REGTAP FAQ Database - FAQ #5339 10/02/14) 834 Updated 1-31-17 2017--00934 Q: Middle name is noted as required for the 2015 FF-SHOP enrollment reconciliation process. What should be populated if there is no middle name? A: Middle name will be changed to an optional data element to accommodate this scenario. The Interface Control Document (ICD) will be updated to re?ect this change. (REGTAP FAQ Database - FAQ #11050 06/19/15) Eligibility Q14: How many eligible employees may a SHOP group have? A14: 100 full-time equivalent employees, although States may keep the upper limit of their small group market at 50 for 2014 and 2015; we anticipate that virtually all States will keep their upper limit at 50 for the ?rst two years. See 45 CFR 155.20 for a de?nition of ?small employer," and 45 CFR 155.710(b) for its applicability to the SHOP. (Plan Management Webinar QHP FAQ #1 04/08/13; REG TAP FAQ Database - FAQ #170 04/08/13) Q18: In States with an FFE, will the State definition be followed in States that define small group as 2-50 employees? A18: Section 2791 of the PHSA de?nes the small group market for employers with 1 100 employees. Flexibility is provided to State-based Exchanges in 2014 and 2015 regarding the upper limit of the small group market (the state may reduce the upper limit to 50) and the method of determining employer size for the state's small group market - not regarding whether or not a group health plan exists. As described in the preamble to the Exchange Final Rule (77 FR 18398) A State-based SHOP may use both the numerical upper limit and the state method of determining employer size. The FF-SHOP will use the state's numerical upper limit (50 or 100) but must use the FTE method of determining employer size. States, State-based SHOPS, and FF-SHOPs must use Act provisions that prevent a business without at least one common law employee from forming a group bene?t plan (sole proprietors, certain S-corp shareholders, and family members of either are not common law employees). (Plan Management Webinar QHP FAQ #3 04/11/13; REG TAP FAQ Database - FAQ #168 04/11/13) Q48: Are individual market issuers (currently not a small group issuer) allowed to participate in SHOP to sell individual policies to small group employees? A48: Only small group market products can be sold on SHOP. (QHP Webinar Series FAQ #9 05/03/13; REGTAP FAQ Database - FAQ #152 05/03/13) Q49: If a group is larger than the small group threshold and subsequently the size falls below the small group threshold, will the group be allowed to keep its existing products, or will it be required to purchase new products? A49: An employer has the right to renew or continue in force coverage originally purchased in the large or small group market, even though the employer may no longer meet the de?nition of a large or small employer. If the employer voluntarily drops the coverage, however, that employer would only be able to purchase coverage in the relevant market (and the coverage would have to comply with the relevant market 835 Updated 1-31-17 2017--00935 requirements). Please reference Insurance Standards Bulletin Series, Group Size Issues under Title XXVII of the Public Health Service Act, Transmittal 99-03, available at 99 03 508.pdf.pdf. (QHP Webinar Series FAQ #9 05/03/13; REG TAP FAQ Database - FAQ #153 05/03/13) Q4: Can an employer participate in multiple A4: Multi-state employers may participate in multiple SHOPs [see 45 CFR however, an employer will be limited to establishing one account per state. (SHOP FAQ #2 07/05/13; REGTAP FAQ Database - FAQ #73 07/05/13) Q43: How should issuers account for working Medicare eligibles and their dependents under the FF-SHOP employer groups? If dependents are eligible for coverage, how will the FF-SHOP report this membership to the health plans? Will they enroll the next oldest dependent as the subscriber, or will they report the Medicare member as a non-covered subscriber and enroll the dependents under the non-covered subscriber account? A43: The FF-SHOP enrollment system only allows dependents to be covered if an employee is enrolled in the group plan. adiustmentS?in-the?future: (SHOP FAQ #4 08/28/13; REGTAP FAQ Database - FAQ #46 08/28/13; updated 08/27/14; the strikethrough reflects a revised REG TAP FAQ #46a) Q: For plan years beginning in 2014, who is making FF-SHOP eligibility determinations for employers and employees? A: Issuers are not responsible for making FF-SHOP eligibility determinations for either employers or employees. In 2014, just as in all other years, CMS, as operator of the FF- SHOP, is making FF-SHOP employer eligibility determinations. Until online functionality is available in the these determinations will be based on paper employer applications mailed to the FF-SHOP. Until online functionality is available, the FF-SHOP will also verify whether an employee is eligible to enroll in an FF-SHOP plan, by comparing the employee roster submitted with the employer application with QHP and QDP enrollment data sent by issuers to the FF-SHOP. (REGTAP FAQ Database - FAQ #650 01/16/14) Q: The ACA defines a small employer as having 1-100 employees, but gives states flexibility to set the upper threshold of this amount at 50 for plan years prior to 2016. Some states currently define a small employer group as 2-50 employees and do not allow issuers to provide coverage to a group with only 1 common law employee. Must issuers enroll groups of 1 common law employee into SHOP coverage regardless of these state requirements? A: SHOP issuers are expected to follow the ACA de?nition and to enroll groups with only 1 common law employee, regardless of con?icting state requirements. (REGTAP FAQ Database - FAQ #825 02/21/14) 836 Updated 1-31-17 2017--00936 Q: How does an issuer know whether an employer or employee qualifies for Does the FF-SHOP require employers to disclose FF-SHOP eligibility to the issuer? A: Because of guaranteed availability, issuers offering QHPs and/or QDPs must accept any employer group that applies for coverage in the applicable market, through the Marketplace or outside it. Accordingly, issuers can enroll an employer group in an FF- SHOP QHP regardless of whether they know that the employer is eligible to participate in the FF-SHOP. Issuers may need to know whether a speci?c employee is eligible to enroll in an employer's offered FF-SHOP plan, however. Until FF-SHOP online functionality becomes available, issuers should enroll employer groups seeking FF- SHOP coverage by utilizing existing enrollment processes and enrollment systems, but to the extent those processes and systems might exclude a possibly eligible employer group from FF-SHOP coverage, the matter should be referred to CMS for a ?nal determination. Additionally, if CMS determines through the reconciliation process that a speci?c employee should not have been enrolled in a specific employer plan, CMS will notify the issuer and employee about the ineligibility determination and provide the employee with appeals information. CMS notes that issuers may choose to wait for a formal determination of eligibility from the FF-SHOP before enrolling employers who are seeking FF-SHOP coverage. In such cases, issuers may request that the employer share its eligibility determination with them before proceeding to enroll any employees, or may seek con?rmation of an employer's eligibility from the FF-SHOP by calling the FF-SHOP Call Center. (REGTAP FAQ Database - FAQ #654 01/16/14) Q: What should an issuer do if an employer group is enrolled in a SHOP QHP and, if applicable, QDP but the employer is deemed ineligible by the FF-SHOP after the enrollment is already effectuated? A: Because issuers offering QHPs and/or QDPs must accept any employer group that applies for coverage in the applicable market, through the Marketplace or outside it, employees enrolled in a SHOP QHP or QDP generally can maintain coverage from an issuer even if the employer is deemed ineligible by the FF-SHOP. Employers, however, will not be able to claim the Small Business Health Care Tax Credit if they are determined ineligible for the FF-SHOP. (REGTAP FAQ Database - FAQ #658 01/16/14) Q: Are issuers allowed to deny coverage for a group if the employer has only 1 common law employee? A: No, issuers are not allowed to deny coverage for a group if the employer has only 1 common law employee. Employers with 1-50 FTE employees are eligible for SHOP coverage. (REGTAP FAQ Database - #743 02/10/14) Q: Is a sole proprietor that has zero (0) common-law employees technically not an employer group of one A: That is correct. This individual would be directed to enroll in coverage through the Individual Marketplace. (REGTAP FAQ Database - FAQ #910 03/05/14) 837 Updated 1-31-17 2017--00937 Q: If a sole proprietor with no common law employees is directed to the Individual Marketplace, does that rationale also suggest that outside the Marketplaces a sole proprietor is not eligible for group coverage? A: Yes, this Market rule applies both inside and outside the SHOP. (REGTAP FAQ Database - FAQ #911 03/05/14) Q: If an employee is Medicare-eligible, can they enroll their dependents in FF-SHOP coverage? A: Employees must enroll in FF-SHOP coverage in order to enroll their dependents. Individuals who are not eligible for SHOP coverage may purchase an individual policy on a guaranteed issue basis. (REGTAP FAQ Database - FAQ #915 03/05/14) Q: How are husband and wife owners treated when determining SHOP eligibility? A: When calculating FTEs for SHOP eligibility, business owners and spouses of business owners are not included in the calculation. Once a business is deemed eligible, however, business owners and spouses of business owners may participate in the SHOP plan. (REGTAP FAQ Database - FAQ #988 03/10/14 Q: We had been told that Issuers were not permitted to knowingly enroll Medicare enrollees in exchange plans but that we could not terminate them if we discovered that they were enrolled at a later timeframe. Can we knowingly enroll Medicare enrollees in A: Medicare enrollees are eligible for SHOP coverage and may enroll in FF-SHOP plans. Thus, Issuers may knowingly enroll Medicare enrollees in SHOP QHPs. (REGTAP FAQ Database - FAQ #993 03/10/14) Q: Will FF-SHOPs provide groups with all of the eligibility rules dates individuals will be eligible when a SEP applies) or are Issuers expected to provide this information? A: FF-SHOPs will have information about SEPs, coverage effective dates, and other consumer information online at HealthCare.gov though this does not remove any issuer responsibility to communicate this information to enrollees. (REGTAP FAQ Database - FAQ #1429 04/14/14) Q: Who administers waiting period policies for groups with FF-SHOP coverage? A: Waiting periods will be administered by the FF-SHOP based on the new hire policy established by employers at the time of initial enrollment. (REGTAP FAQ Database - FAQ #1428 04/14/14) Q: What is Medicare ?creditable prescription drug coverage,? and what obligations do QHPs have to inform CMS and consumers whether the QHP prescription drug coverage is ?creditable prescription drug coverage?? A: Some individuals who are enrolled in QHPs may also be eligible to obtain prescription drug coverage under Medicare Part D, pursuant to 42 CFR 423.30. These individuals will have to pay a late enrollment penalty if they delay enrollment in a Medicare Part 838 Updated 1-31-17 2017--00938 prescription drug plan unless they can show that they delayed enrollment because they had ?creditable prescription drug coverage? under other insurance. 42 CFR Group health plans and individual health insurance coverage are among the types of plans that may offer creditable prescription drug coverage. The prescription drug coverage is creditable if the actuarial value of the coverage equals or exceeds the actuarial value of the Medicare Part defined standard prescription drug coverage. 42 CFR Thus, the drug coverage benefit offered under QHPs sold inside and outside the Marketplace, including SHOP plans, may qualify as creditable coverage. Medicare regulations impose notice requirements on entities that offer prescription drug coverage. These entities must inform enrollees and potential enrollees whether the prescription drug coverage constitutes creditable coverage. They also must disclose to CMS whether the prescription drug coverage they provide is creditable. 42 CFR 423.56 and Consumers who establish to CMS that they were not adequately informed that their prescription drug coverage was not creditable may not be subject to the late enrollment penalty when they eventually enroll in a Medicare prescription drug plan. 42 CFR 423.56 (9). QHP issuers therefore must (1) determine whether the prescription drug coverage offered through each QHP constitutes creditable prescription drug coverage, and (2) notify enrollees, potential enrollees, and CMS of the determination pursuant to the Medicare prescription drug regulations and guidance. In making the creditable prescription drug coverage determination and in complying the notice requirements, QHPs are advised to follow the procedures described on the CMS Creditable Coverage page, and in the Creditable Coverage Disclosure To CMS Instructions and Screen 292012.pdf. (REGTAP FAQ Database - FAQ #4355 09/02/14) Q: For 2016, what is the wording in the updated Federally-facilitated Small Business Health Options Program (FF-SHOP) employer eligibility attestations? A: The updated language used by the Centers for Medicare and Medicaid Services (CMS) is: 'To be eligible, your small business must have a primary business address in the state where you are buying coverage, and have at least one employee who is not the owner or business partner or the spouse of the owner or business partner enrolling in coverage. You must have 100 or fewer full-time equivalent (FTE) employees, and offer SHOP coverage to all full-time FAQ Database - FAQ #12166 08/27/15) Q: If a group has 70 employees as of 11/1/2015, will the Centers for Medicare and Medicaid Services (CMS) stop that employer's enrollment? Updated 1-31-17 A: When completing the initial enrollment application, groups must attest that they have one (1) to 50 employees or one (1) to 100 employees, depending on their State's Small Group Market de?nition. If an issuer believes a group greater than 50 has inappropriately enrolled in the Small Business Health Options Program (SHOP) Marketplace, they 839 2017--00939 should submit a ticket to CMS FEPS@cms.hhs.qov for CMS to investigate. (REGTAP FAQ Database - FAQ #13747 10/20/15) Q: Are small cities and government special districts (with fewer than 50 employees) eligible for SHOP Marketplace coverage? A: Small employers with one to 50 full-time equivalent (FTE) employees in most states are able to enroll in health and/or dental coverage through the SHOP Marketplace. (REGTAP FAQ Database - FAQ #16154 05/27/16) Q: If an employer with 10 employees offers coverage to all employees, but nine of them are covered by their spouses' health plans, can the one employee be enrolled in the SHOP Marketplace at renewal on June 1? A: In order for a group to enroll in SHOP Marketplace coverage, at least one employee who is not a business owner or a spouse needs to enroll and accept the offer of coverage. As long as that one employee is not a business owner or a spouse, that group should be able to enroll in coverage through the SHOP Marketplace. Under the SHOP Marketplace rules for minimum participation, in order for an employer to enroll in SHOP Marketplace coverage, 70% of employees offered coverage (in most states) must accept, unless the employees who waive their offer of coverage are enrolled in another form of minimum essential coverage. Those employees with coverage through a spouse or another form of minimum essential coverage are not held against an employer's minimum participation rate. For more information on how to calculate an employer's minimum participation rate in the SHOP Marketplace, please visit the Minimum Participation Rate Calculator at HealthCare.gov. (REGTAP FAQ Database - FAQ #16161 05/27/16) Small Business Employee Tax Credit Q: What is the timeline for an employer to mail the FF-SHOP application? A: To be eligible to claim the Small Business Health Care Tax Credit for 2014, employers must receive an eligibility determination prior to the end of 2014. We suggest employers ensure that their FF-SHOP application is mailed within 1 week of enrolling employees later than December 1, 2014. CMS will share information contained on the employer application and enrollment information provided by issuers with the IRS to assist the IRS in administering the Small Business Health Care Tax Credit. (REGTAP FAQ Database - FAQ #653 01/16/14) Q: What enrollment steps must an employer take in the FF-SHOP to be eligible to claim the Small Business Health Care Tax Credit for 2014? Updated 1-31-17 A: In states with an FF-SHOP, employers that meet the criteria for the Small Business Health Care Tax Credit (including having no more than 25 full-time equivalent employees and average wages of less than $50,000 per year) and that want to file to receive the Small Business Health Care Tax Credit in 2014 must: 1) have a determination from the FF-SHOP Marketplace that they are eligible to participate in the FF-SHOP, and 2) have employees enroll in a QHP certified by the FF-SHOP. (REGTAP FAQ Database - FAQ #656 01/16/14) 840 2017--00940 1. Can State-based Small Business Health Options Programs (SHOPS) allow direct enrollment for 2015? And 2016? Can employers who use direct enrollment to purchase a SHOP QHP in such circumstances access the Small Business Health Care Tax Credit, if they are otherwise eligible? Yes as a transition to full online functionality when certain criteria are met. Building on the direct enrollment process state-based SHOPS used in 2014, the Centers for Medicare Medicaid Services (CMS) will consider requests from state-based SHOPS that are not yet able to provide for online enrollment to utilize a direct enrollment approach through SHOP Quali?ed Health Plan (QHP) issuers as a transitional measure. This direct enrollment approach should meet the following three criteria: 1) the employer applies for, and receives, a favorable eligibility determination from the SHOP either before or after enrollment is completed; 2) enrollment is in a SHOP and 3) the SHOP QHP issuer conducts enrollment consistent with all SHOP rules and policies. State-based SHOPS interested in taking this option must submit a plan, with specific implementation milestones and dates, to achieve the automated functionality needed to comply with CMS functional requirements for SHOP, including providing the capability to file an application for SHOP eligibility and complete enrollment via an Internet Web site. CMS expects that all State-based SHOPS will have online functionality in place for plan years beginning on or after January 1, 2017. Outside of a CMS-approved transition period, State-based SHOPS are not permitted to allow direct enrollment. State-based SHOPS interested in taking this option should work with CMS and the Department of the Treasury to ensure that small employers who directly enroll with a QHP issuer in a state- based SHOP will be able to access the Small Business Health Care Tax Credit, if eligible. State- based SHOPS taking this option should also make clear to both employers and issuers that employers can, but are not required to, complete the enrollment process directly with a SHOP QHP issuer before receiving the formal eligibility determination, and that an employer who does so might not be able to access the Small Business Healthcare Tax Credit if the employer is later determined ineligible to participate in the SHOP. State-based SHOPS that are not yet able to provide for online SHOP enrollment should contact CMS and the Department of the Treasury to determine how to establish direct enrollment as a transition policy to ensure eligible small businesses may claim the Small Business Health Care Tax Credit. State-based SHOPS should not implement such a policy absent the approval of CMS and the Department of the Treasury. (CMS FAQs - Flexibilities for State-based SHOP Direct Enrollment 06/01/15) Q: Regarding the Small Business Health Care Tax Credit should issuers take inflation into consideration when calculating the average wages of employees within a business who may claim the credit? A: The Small Business Health Care Tax Credit requirement around average wages for 2014 has been adjusted to $50,800. This amount can be displayed on an issuer's website. For additional information, issuers may reference: (REGTAP FAQ Database - FAQ #12169 08/27/15) Q: How can small employers apply for the Small Business Healthcare Tax Credit? A: The Small Business Health Care Tax Credit is available to small employers with fewer than 25 Full-time Equivalent employees, and it is available exclusively through the 841 Updated 1-31-17 2017--00941 SHOP Marketplace. Eligible small employers can claim the tax credit using Internal Revenue Service Form 8941, and is titled, 'Credit for Small Employer Health Insurance Premium.? Employers can use that to calculate the credit. For more information on the Small Business Health Care Tax Credit and how to claim it, visit RS.gov. And if you are not sure whether your clients are eligible to claim the Small Business Health Care Tax Credit, HealthCare.gov does offer a tool, the Tax Credit Estimator, that can help you determine if your small business clients are eligible to claim the tax credit, and if so, estimate how much the credit could be worth to their small business. (REGTAP FAQ Database - FAQ #15722 05/02/16) Q: Does the employer need to have an average of no more than $50,000 in employee wages to be eligible to offer employees a SHOP Marketplace plan? A: The $50,000 average wage cap only applies to those employers who are interested in applying for the Small Business Health Care Tax Credit. If an employer has 25 or fewer full-time equivalent (FTE) employees and those employees have an average wage of $50,000, the employer can apply for the Small Business Health Care Tax Credit after enrolling in SHOP Marketplace coverage. For purposes of enrolling in the SHOP Marketplace, there is no average wage cap or threshold. Small employers with one to 50 FTE employees that meet the other eligibility requirements are able to enroll in the SHOP Marketplace, regardless of the average employee wage. (REGTAP FAQ Database - FAQ #16165 05/27/16) Q: Is the Small Business Health Care Tax Credit only available through SHOP Marketplace plans, or is it also available for similar plans outside of the SHOP Marketplace? A: The Small Business Health Care Tax Credit is only available to those small employers whose businesses are enrolled in health insurance through the SHOP Marketplace. (REGTAP FAQ Database - FAQ #16152 05/27/16) Q: When determining the average employee income of under $50,000, do you take all wages and average them employee salaries above and below $50,000)? A: When determining the average wages of employees for the purposes of determining eligibility for the Small Business Health Care Tax Credit, all employee wages are added together and then divided by the number of employees. The Small Business Health Care Tax Credit Estimator at HealthCare.gov may help you determine if a small employer might be eligible for the Small Business Health Care Tax Credit and, if so, how much it could be worth. (REGTAP FAQ Database - FAQ #16157 05/27/16) O: For tax credit calculation, do average wages include the employer's pay? Updated 1-31-17 A: For the purposes of applying for the Small Business Health Care Tax Credit, the employer's average wage is not factored in, just the average wages of employees. The employer's wages are removed from that calculation. For more information on the Small Business Health Care Tax Credit calculation, please visit the Small Business Health Care Tax Credit Estimator on HealthCare.gov. (REGTAP FAQ Database - FAQ #16160 842 2017-?00942 05/27/16) Q: Do employers receive the Small Business Health Care Tax Credit annually or is there a two-year limit and then no tax bene?t to the employer? A: The Small Business Health Care Tax Credit is available to employers for a limit of two consecutive tax years. It is a tax credit, so employers ?le for the credit with their tax returns. They will receive the credit as a refund as they would any other refund. (REGTAP FAQ Database - FAQ #16162 05/27/16) Q: Is the Small Business Health Care Tax Credit just for medical coverage or is it also available for dental coverage? A: The Small Business Health Care Tax Credit is currently only available for employers offering health coverage. If employers are only offering dental coverage, they will not be eligible for the tax credit. (REGTAP FAQ Database - FAQ #16163 05/27/16) Employer/Employee Choice and Premium Aggregation Q: Is CMS going to provide any payment aggregation tools? A: CMS will not provide premium payment aggregation tools for issuers in the individual market Exchange. However, CMS will provide premium aggregation services for the 843 Updated 1-31-17 2017--00943 SHOP market for plan years starting January 1, 2015. (REGTAP FAQ Database - FAQ #288 10/3/13) Q: Can issuers participating in the FF-SHOPs offer employee choice, that is, can they provide employers the option of offering their employees more than one QHP or GDP for plan years beginning in 2014? A: The FF-SHOP regulations effective for plan years beginning in 2014 do not permit issuers of QHPs and QDPs to provide employers the option of offering their employees more than one QHP and, if applicable, one QDP. (REGTAP FAQ Database - FAQ #663 01/16/14) Q: When an employer chooses employee choice, do all members on the contract (employee and dependents) have to select the same plan? A: Yes, when employee choice becomes available in an employee and his/her dependents will be required to select the same plan as the employee. (REGTAP FAQ Database - FAQ #987 03/10/14) Q: When will premium aggregation services for FF-SHOPs become available? A: For new groups and renewals, premium aggregation services will be effective when a group's 2015 plan year begins. For example, a group that completes the enrollment process by January 5th will have premium aggregation services available on their coverage effective date of February 1st. A group that completes the enrollment process by January 20th will have premium aggregation services available on their coverage effective date of March 1st. Employers wanting to renew their SHOP coverage for the 2015 plan year may do so by enrolling using the FF-SHOP online portal as early as November 15, 2014. Premium aggregation services would be available as of the 2015 plan year effective date. (REGTAP FAQ Database - FAQ #1418 04/14/14) Q: When an employer picks the employee choice option tie?2045, will all QHPs within a metal level from an Issuer be sent on the group file--even when an employee does not select a A: The FF-SHOP will not send a QHP or SADP on a group XML file unless it is selected by at least one employee. (REG TAP FAQ Database - FAQ #1442 04/14/14; updated 01/19/17) Q: Will Group XML files contain all the Issuers in the case of employee choice? A: No, Issuers will only receive their on the Group XML ?le. (REGTAP FAQ Database - #1565 05/08/14) Q: In the case of employee choice, will Group XML transactions contain all the issuer's plan information (multiple issuers and plans selected)? A: No. Issuers will only receive their plan information. (REGTAP FAQ Database - #1974 05/30/14) 844 Updated 1-31-17 2017--00944 Q: Are issuers in states not offering employee choice in 2015 handling billing and payments directly with employer groups, or through the Federally-facilitated Small Business Health Options Program A: No, as outlined in Centers for Medicare Medicaid Services (CMS) final regulations, premium aggregation services will be available regardless of whether a State has employee choice available in 2015. Issuers will not handle billing/payments in FF-SHOP Marketplaces as of the 2015 plan year. (REGTAP FAQ Database - FAQ #2565 07/03/14) Q: For 2015, will the Centers for Medicare and Medicaid Services (CMS) require an employer to have a $0.00 balance before interacting with the Federally-facilitated Small Business Health Options Program (FF-SHOP) Premium Aggregation Service? A: When an employer enrolls online with the FF-SHOP, CMS will assume the group has a $0.00 account balance with the FF-SHOP, even for groups who enrolled directly with an issuer in 2014. The FF-SHOP will only be responsible for collecting 2015 plan year premiums. Issuers are responsible for collecting any money owed for the 2014 plan year. (REGTAP FAQ Database - FAQ #2574 07/03/14) Q: In the Federally-facilitated Small Business Health Options Program (FF-SHOP), if an employer selects only one carrier, can the employer select all metal tiers or must the employer select one plan from one metal tier? A: Employers in states with employee choice may choose to offer employees either 1) all medical plans across a single metal level and all dental plans across a single coverage level, or 2) a single medical plan and a single dental plan. Employers without employee choice in 2015 may offer employees a single medical plan and a single dental plan. (REGTAP FAQ Database - FAQ #2597 07/03/14) Q: Will the Federally-facilitated Small Business Health Options Program (FF-SHOP) control the no-choice option in States that do not allow employee choice? A: Yes, the FF-SHOP will control the no-choice option as part of the employer/consumer experience. Employers in non-employee choice states will only be able to choose 1 Quali?ed Health Plan (QHP) and 1 Stand-alone Dental Plan (SADP) to offer employees. (REGTAP FAQ Database - FAQ #2885 07/16/14) Q: In the case of employee choice in Federally-facilitated Small Business Health Options Program (FF-SHOP), can an employee select a medical product from one carrier and a dental product from another carrier? A: Yes, when employee choice is available, an employee may select a medical product from one carrier and a dental product from a different carrier. (REGTAP FAQ Database - FAQ #3400 08/01/14) 845 Updated 1-31-17 2017--00945 Q: In an employer-choice state, will the Federally-facilitated Small Business Health Options Program (FF-SHOP) send the Health Insurance Oversight System (HIOS) Plan ID on the group level file? A: In an employee choice state, the group level ?le will contain an issuer's plan information if at least one employee has chosen to enroll in that plan and in an employer-choice state, the single plan chosen by an employer. (REGTAP FAQ Database - FAQ #3425 08/01/14) Q: If an employer selects 'employee choice' for group enrollment, are issuers required to communicate 'employee choice' directly to employees or are issuers required to only communicate through the employer group? A: All enrollments for the 2015 plan year will go through the online Federally-facilitated Small Business Health Options Program (FF-SHOP) Marketplace. Thus, the FF-SHOP will communicate availability of employer or employee choice. (REGTAP FAQ Database - FAQ #4132 08/26/14) Q: Under the employee choice model in the Federally-facilitated Small Business Health Options Program (FF-SHOP), if an employee does not select a specific carrier at the time of initial enrollment, what is the group effective and renewal date for a new hire that enrolls mid-way through the plan year? A: The group effective and renewal date aligns with the original coverage effective dates for the group. (REGTAP FAQ Database - FAQ #4206 09/02/14) O: For the 2015 plan year, when employee choice is available in a state, if different members of the same group select multiple plans, will FF-SHOP issuers receive a separate Group XML for each plan selected? A: CMS will send one employer group ?le per employer per Issuer per Trading Partner. Hence, the group file depends on how the Trading Partner to QHP relationship is established in the EDI registration form. (REGTAP FAQ Database - FAQ #4449 09/05/14) Q: What are the three (3) dates on the Group Extensible Markup Language (XML) file for employee choice groups who have employees enroll in an FF-SHOP issuer's plan after initial enrollment? A: The three dates on the Group XML for employee choice groups who have employees enroll in an FF-SHOP issuer's plan after the initial enrollment are as follows: 1. Original Effective Date Coverage: Effective Date (CCYY-MM-DD) for that Plan. This date is the same as the Initial enrollment for the group. 2. Renewal Effective Date: Renewal Effective Date (CCYY-MM-DD). This date is the same as the Coverage Effective date; just the year will be incremented by 1. Therefore, if the Coverage effective date is 2014-01-01, renewal effective date will be 2015-01-01. This date is the same as the Initial enrollment for the group. 3. Plan Maintenance Effective Date: Same Date as Original Effective Date in the case of an Added Transaction. For all others, it will be the effective date of the transaction for that issuer. (REGTAP FAQ Database - FAQ #4903 09/17/14) 846 Updated 1-31-17 2017--00946 Q: In the Federally-facilitated Small Business Health Options Program (FF-SHOP), when employee choice is available and a family picks a new plan when a baby is born, is it possible the newborn could have a different coverage effective date than the family since the newborn's coverage is effective on the birth date? A: No, the FF-SHOP will add the newborn to the existing plan as of the date of the birth and the FF-SHOP will terminate the newborn at the end of the month along with all of the other family members. The coverage effective date for the new plan for the entire family will be the 1st of the month following the birth of the baby. (REGTAP FAQ Database - FAQ #4919 09/17/14) Q: For enrollments submitted by employers on weekends or after business hours, will the maintenance effective date for the Group Extensible Markup Language (XML) be the date the employer submitted the enrollments online or will the effective date be dated as of Monday when the Federally-Facilitated Small Business Health Options Program (FF- SHOP) actually generated the file? A: The Centers for Medicare Medicaid Services (CMS) de?nes the maintenance effective date on the Group XML as the date the FF-SHOP creates the file. Thus, if an employer submits enrollments after hours or on weekends, the FF-SHOP will not generate the Group XML transaction until the next business day. For example, if an employer submits enrollments on a Saturday, the will generate the Group XML with a Monday maintenance effective date. (REGTAP FAQ Database - FAQ #10865 06/05/15) Q:Can States using the FF-SHOP platform oopt out of employee choice? During?a A: All States are required by statute to offer ?horizontal choice" (all plans at a single coverage level). However, States may opt out of offering ?vertical choice" (all plans from Q: When employee choice is available and employees do not sign up for a Federally- facilitated Small Business Health Options Program (FF-SHOP) issuer's plan upon effectuation of the group's coverage, but the issuer receives an enrollment transaction during the middle of the plan year, when should issuers expect to receive a payment to effectuate coverage? A: Binder payments are only required when groups establish new coverage, and upon renewal. For mid-plan year effectuations with an issuer in an employee choice environment, issuers should expect to receive a payment within the month of when the enrollee enrolled in coverage. For example, if a group?s coverage was effectuated on January 1 and the issuer has no enrollments in their issuer's plan but has an employee who signs up for the issuer's plan for coverage effective on August 1, 2015, the issuer 847 Updated 1-31-17 2017--00947 should expect to receive a payment by September 1, 2015. (REGTAP FAQ Database - FAQ #13535 10/07/15) Q: What states are offering employee choice in the SHOP Marketplace this year? A: Beginning for plan year 2016, all states will be offering employee choice through the SHOP Marketplace. That means that employers in all states will be able to offer their employees a choice of health and/or dental plans. Regardless of the fact that employee choice is available, a small employer may choose to offer just a single health or dental plan. (REGTAP FAQ Database - FAQ #15712 05/02/16) Q: If an employer offers its employees a choice of plans in the SHOP Marketplace, will the employer receive a bill from all of the health insurance companies the employees enroll with? A: No. With the SHOP Marketplace, more choice comes with less paperwork. No matter how many different insurance companies or plans employees select, the employer gets and pays just one bill. That bill always comes from the SHOP Marketplace and never from the insurance companies. Employers pay the SHOP Marketplace a single payment and SHOP Marketplace takes care of dispersing all the employer's payments to the insurance companies associated with the account and enrollment. (REGTAP FAQ Database - FAQ #15725 05/02/16) Agents Brokers Q34: How will the SHOP know if a Broker is appointed? A34: The FF-SHOP will pass broker identifying information to issuers on the group enrollment file. Issuers are expected to con?rm appointments before paying commissions. (QHP Webinar Series SHOP FAQ #1 06/20/13) Q35: Will the TIN Identi?cation number be used as the Broker ID or will it be the Contact A35: At minimum, the FF-SHOP will capture a broker?s name and National Producer Number and transmit this identifying information to issuers on the group enrollment ?le. (QHP Webinar Series SHOP FAQ #1 06/20/13) Q36: Assuming a broker does not have a Tax ID Number (TIN), would you be sending a Social Security Number (SSN) in an application? A36: Consistent with the model SHOP employer application (OMB Control No. 0938- 1193), the FF-SHOP will pass a TIN number if one is entered by the broker, and will pass a SSN if that is what the broker enters into this ?eld instead. (QHP Webinar Series SHOP FAQ #1 06/20/13) 848 Updated 1-31-17 2017--00948 Q37: Please clarify what broker (and Agency) information will be included in files sent to the issuer. In order to efficiently process commissions, it is very important to have, at least, broker SSN, broker name, and Agency (Payee) TIN. A37: Issuers will be sent a broker?s name, National Producer Number, SSN or TIN, and contact Information when these are provided on an employer?s FF-SHOP application. (QHP Webinar Series SHOP FAQ #1 06/20/13) Q31: The FF-SHOP indicated that commissions for groups sold through the FF-SHOP must be similar to commissions sold outside the FF-SHOP. Does this apply to an Agent who is not appointed by an Issuer? A31: Unless state law requires otherwise, an Issuer would not be expected to pay a commission to a Broker who is not appointed with the Issuer. (SHOP FAQ #2 07/05/13) Q32: What measures will be in place to ensure that a Broker is certified and authorized to service an employer in the A32: Consistent with 45 CFR 155.260, an Agent or Broker operating in the FF-SHOP is required to sign a privacy and security agreement with the Marketplace. While Agents and Brokers operating in the FF-SHOP will be encouraged to complete Marketplace training, the final Exchange regulations do not require such training as a condition of participation in the FF-SHOP. (SHOP FAQ #2 07/05/13) Q33: What happens if a Broker attempts to create a quote for an employer after another Broker already started the workflow for that employer? A33: The FF-SHOP is not taking responsibility for competition between Brokers for employer business. It is the employer?s decision to work with a particular Broker and to enter the appropriate name and National Producer Number of the Agent or Broker associated with the employer application when applying online. (SHOP FAQ #2 07/05/13) Q34: Can the employer add, change, or remove an associated Broker within the FF- If the answer is yes, what security will be in place to ensure that the Broker is authorized to work with the employer? A34: CMS intends to allow an employer enrolled in FF-SHOP coverage to add, change, or remove the Broker of record from within his or her secure My Account. Only a validated employer can make a Broker of record change. (SHOP FAQ #2 07/05/13) Q35: Can one Broker work with some employees in a group while a different Broker works with other employees within the same group? A35: No. The employer determines the Broker relationship. All employees will have the same Broker associated with a SHOP employer. (SHOP FAQ #2 07/05/13) 849 Updated 1-31-17 2017--00949 Q36: What happens when a Broker ceases to provide service to the employer group due to retirement, loss of license, etc.? A36: It is the responsibility of the employer to manage the Broker/employer relationship. If a Broker retires or loses his or her license, the employer will need to ?nd an alternate Broker. (SHOP FAQ #2 07/05/13) Q2: What role will Agents and Brokers play in the A2: Agents and Brokers will play a key role in the FF-SHOP?helping employers and employees understand the SHOP Marketplace and assisting them complete online applications for coverage. Please refer to this resource document for additional information on the role of Agents, Brokers, and Web- Brokers' In Health Insurance Marketplaces: http: cms. qov/cciio/proqrams- and- initiatives/health- -insurance- b- -resources. (SHOP FAQ #2 07/05/13; REGTAP FAQ Database - FAQ #71 07/05/13; REG TAP FAQ Database - 07/05/13,? updated 08/27/14); the REG TAP revision of this FAQ released on 8/27/14 included a new web link) Q34: Will there be a call center supporting employers and agents/brokers working with A34: Yes. There will be a call center available to support employers with enrollment related matters in 2014 and beginning in 2015 for payment related matters. Agents and brokers working with employers will also be able to access the SHOP call center. (QHP Webinar Series FAQ #10 05/09/13 updated 08/02/13) removed this FAQ from the REG TAP database on 08/26/14. Q: Will CMS, as operator of the FF-SHOPs, contact employers who already submitted FF- SHOP paper applications and instruct them to reach out to issuers and/or an agent/broker? A: Yes, CMS, as operator of the FF-SHOPs, will send formal eligibility determinations to employers who submitted a FF-SHOP application. We will advise those who are eligible to participate to contact an issuer or agent/broker to complete the enrollment process. Those who are determined ineligible will be provided with information about the appeals process. (REGTAP FAQ Database - FAQ #660 01/16/14) 850 Updated 1-31-17 2017--00950 Q: For SHOP plan years beginning in 2014, does CMS expect agents and brokers selling SHOP plans to be registered with and sign the FF-SHOP Marketplace agreement or is it sufficient for the agent/broker to be appointed with the Issuer? A: Yes, CMS expects agents and brokers selling SHOP plans to register with and sign the FF-SHOP Marketplace agreement. Agents and brokers assisting with SHOP enrollments must agree to the privacy and security standards of SHOP. (REGTAP FAQ Database - FAQ #996 03/10/14) Q: For plan years beginning in 2014, does CMS expect agents and brokers selling FF- SHOP plans to register with and sign the FF-SHOP agreement or is it sufficient to be appointed with the issuer? A: Agents and brokers selling FF-SHOP plans must sign the FF-SHOP Marketplace privacy and security agreement. (REGTAP FAQ Database - FAQ #1438 04/14/14) Q: Are Issuers required to validate that brokers have signed the FFM privacy and security agreement in order to sell in FF-SHOP, for plan year 2014? A: Issuers are expected to validate that brokers in have a valid state license and have completed the FFM privacy and security agreement. (REGTAP FAQ Database - #1573 05/08/14) Q: What evidence would the issuer need to obtain from a broker in order to comply with the requirement to validate broker certification? A: Brokers are able to log into the FFM Marketplace training system and print out a certificate documenting they have completed required training and privacy and security agreements. (REGTAP FAQ Database - #1591 05/13/14) Q: Can an employer change the selected Agent/Broker after the point of sale or enrollment? A: Beginning in 2015, employers in the Federally-facilitated Small Business Health Options Program (FF-SHOP) Marketplace will be able to change the broker authorized to act on their behalf no more than two times within the same plan year. Employers may make these changes through the FF-SHOP online portal or by calling the FF-SHOP Call Center. (REGTAP FAQ Database - #1724 05/27/14) Q: When an employer changes to a new Agent/Broker, will the Centers of Medicare Medicaid Services (CMS) send the effective date that the new Agent/Broker is tied to the group? A: Centers for Medicare Medicaid Services (CMS) will not send the effective date on the maintenance Group XML transaction. Issuers should make the change effective immediately or as of the next commission payment cycle. (REGTAP FAQ Database - #1725 05/27/14) 851 Updated 1-31-17 2017--00951 Q: Can agents submit agent of record changes to the carrier or must these changes be made through the Federally-facilitated Small Business Health Options Program (FF- SHOP) online system? A: Agents are not authorized to make changes to FF-SHOP agent/broker relationships with employer groups. Employers may authorize these changes through the FF-SHOP Marketplace (either online or through the Call Center). (REGTAP FAQ Database - #1727 05/27/14) Q: When an employer group is searching for an Agent/Broker, will company appointment information be available to the consumer? A: In the Federally-facilitated Small Business Health Options Program (FF-SHOP) Agent/Broker Portal, a producer will establish a profile which may include the following elements: name (?rst, last), agency name, email address, business location, National Producer Number (NPN), and languages supported. Appointment information will not be displayed because we have no way to validate issuer appointments at this time. (REGTAP FAQ Database - #1728 05/27/14) Q: Will the National Producer Number (NPN) be sent for the writing Agent/Broker along with the Tax Identification Number (TIN) for the payee? A: The Centers for Medicare Medicaid Services (CMS) are sending one Agent/Broker NPN and one Agent/Broker TIN per employer group. (REGTAP FAQ Database - #1729 05/27/14) Q: Will an Agent be able to register with the Small Business Health Options Program (SHOP) using a corporate agency National Producer Number (NPN) in states that issue licensed agencies NPNs at the agency (instead of the individual) level? A: Yes, an Agent will be able to register using the corporate agency NPN rather than their individual NPN. (REGTAP FAQ Database - #1730 05/27/14) Q: When someone registers for the Centers for Medicare Medicaid Services (CMS) Enterprise Portal, will the person be asked if they are an agent and be required to provide a National Producer Number (NPN) number at that time, or is the NPN added when the person completes the agent profile in the agent portal section? A: An individual may only be identi?ed as a SHOP agent or broker in the CMS Enterprise Portal once they have completed the Small Business Health Options Program (SHOP) Privacy and Security Agreement located on the Medicare Learning Network (MLN). In order to complete the agreement, the agent must register with to create an MLN User ID the user must provide their NPN. (REGTAP FAQ Database - #1731 05/27/14) Q: Will the Centers for Medicare Medicaid Services (CMS) be conducting any webinars targeting the Agent/Broker community to inform them of changes for 2015? A: CMS will be conducting robust technical assistance and education effort with Agent/Brokers to inform and train them on the tools available through the FF-SHOP Marketplace in 2015. (REGTAP FAQ Database - #1732 05/27/14) 852 Updated 1-31-17 2017--00952 Q: If an Agent is not certi?ed with the Federally-facilitated Small Business Health Options Program (FF-SHOP), will he or she be able to access the Centers for Medicare Medicaid Services (CMS) Enterprise Portal? A: The CMS Enterprise Portal is available to Marketplace Agent/Brokers as well as other Marketplace users who have gone through remote identity proo?ng. Only Agent/Brokers who have signed the FF-SHOP Privacy and Security Agreement will have access to the FF-SHOP online Agent/Broker Portal. (REGTAP FAQ Database - #1733 05/27/14) Q: Will the broker Tax Identification Number (TIN) in the group file always be unique, or can multiple brokers have the same A: It is possible for multiple brokers to have the same TIN. (REGTAP FAQ Database - #1984 05/30/14) Q: Will the Sender ID in the group file be the same as the Source Exchange ID in 834 enrollment transactions? A: The Sender ID in the employer group ?le will be the same 3 character "TenantlD" as in 834 GS level Sender ID. (REGTAP FAQ Database - #1985 05/30/14) Q: If an employer changes its agent authorization, will the Small Business Health Options Program (SHOP) notify the agent that they are no longer associated with the group? A: An employer's authorization update will be reflected through the agent's list of active cases and authorizations within an agent's Agent/Broker Portal MyAccount. No speci?c notice will be sent to Agent/Brokers when they are no longer associated with an employer group. (REGTAP FAQ Database - #1993 05/30/14) Q: Since broker training for participation in the Federally-facilitated Small Business Health Options Program (FF-SHOP) and the Individual Marketplace is required annually, will the Centers for Medicare and Medicaid Services accept training for the same year the certificates of completion are issued? If a producer completes training in July 2014, will it apply to both 2014 and 2015? A: The FF-SHOP Marketplace training is encouraged for Agents and Brokers who wish to participate in FF-SHOP Marketplaces, but is not required. Agents and Brokers who wish to participate in FF-SHOP Marketplaces must complete all registration requirements for the 2015 plan year, which includes the completion of the FF-SHOP privacy and security agreement located on the Medicare Learning Network (MLN) and identity proo?ng on the CMS Enterprise Portal. All training and registration requirements for Agents and Brokers must be completed on an annual basis. In July, CMS will kick-off the Agent/Broker registration and training cycle for the 20 15 plan year and release the new training curriculum for the Individual and FF-SHOP Marketplaces. Though the FF- SHOP Marketplace training is encouraged, Individual Marketplace training is required for all Agents and Brokers who wish to participate in the Federally-facilitated Marketplace for individuals. Training will apply to the remainder of 2014 and 201 5 for producers completing the 2015 registration and training requirements as of July 2014. (REGTAP FAQ Database - FAQ #2572 07/03/14) 853 Updated 1-31-17 2017--00953 Q: In the Individual Marketplace, issuers are ensuring that Agent/Brokers selling Marketplace plans have completed required Centers for Medicare Medicaid Services (CMS) training by collecting copies of certificates. Do issuers also need to con?rm training for Agent/Brokers in the Federally-facilitated Small Business Health Options Program (FF-SHOP) Marketplace? A: The Federally-facilitated Marketplace (FFM) will not validate National Producer Numbers (NPNs) provided by Agent/Brokers. It is the issuer's responsibility to ensure that the Agent/Brokers appointed with each issuer hold a valid state health insurance license. The Marketplace will only allow Agent/Brokers to access the online portal if the Agent/Broker is registered with the FFM and has completed the FF-SHOP Privacy and Security Agreement. Issuers are encouraged (though not required) to collect this information from appointed Agent/Brokers. Agent/Brokers can print copies to send to affiliated Qualified Health Plan (QHP) issuers by logging into the Medicare Learning Network? (MLN) and selecting the ?Transcript? from the top menu. (REGTAP FAQ Database - FAQ #2607 07/03/14) Q: Does a broker need to be authorized by an employer before providing assistance for that employer in the A: Yes, an employer must ?rst authorize an agent/broker before the agent/broker will have access to their application and account information. (REGTAP FAQ Database - FAQ #3767 08/14/14) Q: Will Agents and Brokers have access to view and print the payment history and invoices of client accounts? A: Yes, Agents and Brokers will be able to view associated accounts and print copies of client's invoices from the Federally-facilitated Small Business Health Options Program (FF-SHOP). (REGTAP FAQ Database - FAQ #4159 08/26/14) Q: What is the Federally-facilitated Small Business Health Options Program (FF-SHOP) Agent/Broker portal? Are there any requirements around broker commissions? A: The FF-SHOP Agent/Broker portal allows authorized Agents and Brokers to act on behalf of employers utilizing the Marketplace as of 2015. Issuers are responsible for paying commissions to Brokers selling products in the FF-SHOP and issuers are required to pay Brokers an amount equal to what the issuer pays in the small group market outside FF-SHOP Marketplaces. (REGTAP FAQ Database - FAQ #4427 09/05/14) Will CACs assist employers with the SHOP options? If not, who will do this? CACs may but are not required to assist employers with SHOP. Agents, brokers, Navigators, and non-Navigator in-person assistance personnel are available to assist employers with the SHOP process. CACs will, however, assist employees with SHOP options. (CMS Technical Assistance Resources SHOP FAQs 01/17/14) 854 Updated 1-31-17 2017--00954 Q: How should issuers proceed if a group switches brokers but the broker selected by the group is either not appointed with the issuer or is not qualified? A: If a broker is not qualified, issuers should reach out to the applicable State regulatory authority and the Centers for Medicare and Medicaid Services (CMS) with the relevant information. In addition, if a broker is not appointed with a carrier, issuers are encouraged to reach out to the broker in order to complete the necessary appointment paperwork. (REGTAP FAQ Database - FAQ #12181 08/27/15 Q1: What do agents and brokers need to do to assist clients in the SHOP Marketplace? A1: Agents and brokers who wish to assist small employers with the SHOP Marketplace application and enrollment process must complete the following: 1) Complete SHOP Marketplace Registration: Agents and brokers interested in assisting small employers in the Small Business Health Options Program (SHOP) Marketplace must complete registration requirements. The SHOP Marketplace registration requirements include creation of a Marketplace account, completion of the SHOP Marketplace Privacy and Security Agreement through the Marketplace Learning Management System (MLMS), and identity proo?ng. Agents and brokers are highly encouraged, but not required, to complete SHOP Marketplace training also available through the MLMS or, one of the three CMS- approved vendors. The 2016 SHOP Marketplace Privacy and Security Agreement as well as the optional trainings can be accessed here: Note: Returning agents and brokers who have already created a Marketplace account and completed identity proofing do not need to repeat those steps. Create a searchable pro?le on the SHOP Marketplace Agent/Broker Portal: For operational reasons, once the SHOP Marketplace registration is complete, agents and brokers will have to establish a pro?le on the SHOP Marketplace Agent/Broker Portal in order to begin assisting clients. To establish their pro?le, agents and brokers will login to the SHOP Agent/Broker Portal using their username and password created during registration: The information provided in the pro?le will be searchable by small employers seeking assistance in the SHOP Marketplace. Agents and brokers should make sure their appropriate contact information is listed. (FAQs Regarding Agents and Brokers Operating in the SHOP Marketplace (09/18/15) 02: What is the SHOP Marketplace Agent/Broker Portal? Updated 1-31-17 A2: The SHOP Marketplace Agent/Broker Portal is an online system that allows agents and brokers registered with the SHOP Marketplace to service their clients. Once an agent or broker has established a pro?le in the SHOP Marketplace Agent/Broker Portal, their name and the contact information provided while creating the pro?le will be searchable by small employers seeking assistance with the SHOP Marketplace. Through the SHOP Marketplace Agent/Broker Portal, agents and brokers can help their small group clients apply and enroll in SHOP Marketplace health or dental coverage. SHOP Marketplace agents and brokers also have the ability to manage their clients? accounts, change a client's status, create proposals, become associated with a group?s account to receive compensation for sales, submit client enrollments, and monitor their 855 2017--00955 client?s enrollment and payment status, once authorized. Agent and broker National Producer Numbers and other identifying information for compensation purposes will automatically be sent to issuers when SHOP Marketplace agents and brokers submit an enrollment through the SHOP Marketplace Agent/Broker Portal. (FAQs Regarding Agents and Brokers Operating in the SHOP Marketplace {09/18/15) Q3: How can agents and brokers who have completed SHOP Marketplace registration begin assisting clients in the SHOP Marketplace? A3: For operational reasons, an employer will have to send an agent or broker an authorization request to their preferred agent or broker through the SHOP Marketplace before an agent or broker who has completed the SHOP Marketplace registration process can begin to work on that employer?s behalf. Employers should log in to their HealthCare.gov account and click the ?Get Assistance? tab to search for an agent or broker registered with the SHOP Marketplace in their area. Employers can search for an agent or broker by name, National Producer Number (NPN), or location. Once an employer has found an agent or broker, he or she can send the agent or broker an authorization request. To accept a pending authorization request, agents and brokers will log into the SHOP Marketplace Agent/Broker Portal, select the ?Manage Clients? tab, and accept the pending authorization. Once the authorization has been accepted, the agent or broker may perform all application and enrollment functions on behalf of their employer clients, except for making premium payments. Agents and brokers registered with the SHOP Marketplace can be added to an employer?s account at any point during the application and enrollment process, and compensation information will be shared with issuers when the authorization has occurred. (FA 03 Regarding Agents and Brokers Operating in the SHOP Marketplace (09/18/15) Q4: Where do agents and brokers registered with the SHOP Marketplace add their National Producer Number (NPN) on the SHOP Marketplace application? Updated 1-31-17 A4: Once an agent or broker registered with the SHOP Marketplace accepts an authorization request from an employer in the SHOP Marketplace, the agent or broker becomes the agent or broker of record on the enrollment. The agent or broker does not need to manually input his/her NPN on the SHOP Marketplace application; this happens automatically when the registered agent or broker accepts an employer?s authorization request in the SHOP Marketplace and the employer?s enrollment is completed through the SHOP Marketplace Agent/Broker Portal. When the employer client?s SHOP Marketplace enrollment is submitted, the SHOP Marketplace sends the registered agent or broker?s NPN and other identifying information for compensation purposes along with the enrollment information to the applicable health or dental issuers. Health and dental issuers are responsible for paying and distributing agent and broker commissions on all SHOP Marketplace enrollments consistent with applicable state laws; the SHOP Marketplace does not pay or set agent or broker commissions. (FAQs Regarding Agents and Brokers Operating in the SHOP Marketplace {09/18/15) 856 2017--00956 05: Does it cost employers more to work with an agent or broker in the SHOP Marketplace? A5: No. The premium a small employer will pay for health insurance purchased through the SHOP Marketplace will be the same regardless of whether they work with an agent or broker registered with the SHOP Marketplace. Issuers are required to compensate their af?liated agents and brokers the same regardless of whether the enrollment was completed through the SHOP Marketplace. (FAQs Regarding Agents and Brokers Operating in the SHOP Marketplace {09/18/15) 05: Do agents and brokers need to be re-authorized on a client?s account upon renewal? A5: No. Once an agent or broker who maintains an active registration with the SHOP Marketplace has been authorized to work on behalf of an employer in the SHOP Marketplace, the agent or broker remains associated with the enrollment unless the employer or the agent or broker actively changes the authorization status. (FAQs Regarding Agents and Brokers Operating in the SHOP Marketplace (09/18/15) 06: Can an employer change the agent or broker associated with their account in the SHOP Marketplace? A6: Yes. An employer may change the agent or broker that he or she is working with in the SHOP Marketplace up to two times per year. Employers may add or remove a SHOP Marketplace registered agent or broker to their SHOP Marketplace account by logging into their HealthCare.gov account. Agents and brokers registered with the SHOP Marketplace may also change a client?s account status through the SHOP Marketplace Agent/Broker Portal. (FAQs Regarding Agents and Brokers Operating in the SHOP Marketplace {09/18/15) Q7: Where can agents and brokers registered with the SHOP Marketplace go with questions about their SHOP Marketplace Agent/Broker Portal account or SHOP Marketplace application questions? A7: The SHOP Call Center, at 1-800-706-7893 (TTY: 711), is open Monday - Friday from 9:00 am. - 7:00 pm. ET and is available to assist agents and brokers, employers, and employees. (FAQs Regarding Agents and Brokers Operating in the SHOP Marketplace {09/18/15) Q: Will my clients need to reauthorize me as their agent or broker upon renewal in the SHOP Marketplace? Updated 1-31-17 A: No. Once the agent and broker and employer/client relationship has been established, that authorization will remain valid as long as the agent's or broker's registration for the next plan year remains valid. If the employer wants to end the relationship with the agent or broker, the employer can remove the authorization in their account. Otherwise the agent or broker will remain on the application upon renewal. (REGTAP FAQ Database - FAQ #15711 05/02/16) 857 2017--00957 Q: Where do I enter my National Producer Number (NPN) on the SHOP Marketplace application? A: For an agent and broker to begin assisting a small business client through the SHOP Marketplace, the employer will need to authorize the registered agent or broker to work on their behalf. An employer can authorize an agent or broker to assist them in the SHOP Marketplace by creating or logging into their account on HealthCare.gov and selecting the 'Get Assistance' tab within their SHOP Marketplace application. Employers may search for an agent or broker by name, National Producer Number (NPN) or zip code. Once an agent or broker has been found, the employer can send the agent or broker an authorization request for the agent or broker to accept though their SHOP Marketplace Agent/Broker Portal account. Once that authorization is established, the agent's or broker's NPN is then tied to the small business' record, so there's no need to input the NPN anywhere on the application. The authorized agent's or broker's information will be sent along to the issuers with the SHOP Marketplace enrollment. For more information on the SHOP Marketplace Agent/Broker Portal and a step-by-step description of this process, go to HealthCare.gov, select the ?Small Businesses' tab, and then select the green 'For Agents and Brokers? button. (REGTAP FAQ Database - FAQ #15714 05/02/16) Q: What call center do I contact if I have questions about the SHOP Marketplace Agent/Broker Portal? A: The SHOP Call Center is available to assist agents and brokers, small business employers, and employees who have an offer of SHOP Marketplace coverage. The SHOP Call Center is able to assist you with any problems you may be experiencing with the SHOP Marketplace Agent/Broker Portal. SHOP Call Center can be reached at 1- 800-706-7893 Monday- Friday 9:00am. - 7:00p.pm Eastern. (REGTAP FAQ Database - FAQ #15715 05/02/16) Q: I have a client renewing his SHOP Marketplace coverage for this year. When can the renewal process begin and will I need to be reauthorized on my client's account upon renewal? A: SHOP Marketplace renewals can begin as soon as the rates for the quarter the renewal is to take place in are released, generally about 60 days before the renewal date. Your clients will receive a renewal notice around that time letting them know that they are up for renewal. You do not need to be reauthorized by your client upon their SHOP Marketplace renewal, so long as your registration is current for the plan year. Once the authorization has been established, it does not need to be reestablished. (REGTAP FAQ Database - FAQ #15716 05/02/16) Q: What is the phone number for an employer to call to ensure an agent or broker's National Producer Number (NPN) is on file for a SHOP Marketplace enrollment? Updated 1-31-17 A: Once an employer has submitted the authorization for an agent or broker to work on his or her behalf in the SHOP Marketplace and the agent or broker has accepted the authorization request through the SHOP Marketplace Agent/Broker Portal, the agent's or broker's NPN will be associated with that employer's SHOP Marketplace application and enrollment. If agents and brokers have any questions or are experiencing problems 858 2017--00958 logging into their SHOP Marketplace Agent or Broker Portal accounts, please visit: or contact the SHOP Call Center at 1-800-706-7893. (REGTAP FAQ Database - FAQ #15718 05/02/16) Q: I have a client who offers both health and dental coverage to her employees and their dependents through the SHOP Marketplace. Do employees and their dependents have to enroll in the same plan or can they enroll in one and other dependents enroll in another? A: When dependent coverage is offered, employees and their dependents must enroll in the same health and dental plans through the SHOP Marketplace. If an employee enrolls in health and dental coverage, his or her dependents can enroll in both the health and dental plan chosen by the employee, just the health plan, orjust the dental plan. The employee must enroll in a plan before the dependents can enroll, but the dependents do not need to enroll in the same combination of plans chosen by the employee. This option will be helpful for those employees and dependents who may receive health coverage through another employer, but just need dental coverage or vice versa. (REGTAP FAQ Database - FAQ #15719 05/02/16) Q: Why should small employers enroll into SHOP Marketplace, instead of letting their employees enroll themselves in the Individual Marketplace? A: There are several reasons why employers should consider enrolling their small business in SHOP Marketplace coverage. The Small Business Health Care Tax Credit is available to eligible small employers exclusively through the SHOP Marketplace. Small employers are also able to offer their employees a single health or dental plan, or a choice of health and dental plans, all while controlling how much they'd like to contribute to their employees and, if applicable, dependents premium costs. If an employer decides to offer his/her employees and if applicable, dependents a choice of health or dental plans, the employer will receive and pay just one bill, the SHOP Marketplace takes care of disbursing payments. SHOP Marketplace registered agents and brokers are available to assist small employers with their SHOP Marketplace application and enrollment. Employers without a HealthCare.gov account can search for a SHOP Marketplace registered agent of broker through the Find Local Help tool on HealthCare.gov. Employers with a HealthCare.gov account can login to their SHOP Marketplace application and select the 'Get Assistance' tab to find and authorize and agent or broker to work on their behalf. The SHOP Call Center is also available to assist employers, agents, brokers, and employees with an offer of SHOP Marketplace coverage. The SHOP Call Center is available Monday- Friday from 9:00a.m.- 7:00p.pm Eastern at 1-800-706-7893, TTY users can use 711. (REGTAP FAQ Database - FAQ #15726 05/02/16) Q: What do agents and brokers need to do to assist clients in the SHOP Marketplace? A: Agents and brokers who wish to assist small employers with the SHOP Marketplace application and enrollment process must complete the following: 1) Updated 1-31-17 Complete SHOP Marketplace Registration: Agents and brokers interested in assisting small employers in the SHOP Marketplace must complete registration requirements. The SHOP Marketplace registration requirements include creation of a Marketplace account, completion of the SHOP Marketplace Privacy and Security Agreement through the Marketplace Learning Management System (MLMS), and identity proofing. Agents and 859 2017--00959 brokers are highly encouraged, but not required, to complete SHOP Marketplace training also available through the MLMS or, one of the CMS- approved vendors. The 2016 SHOP Marketplace Privacy and Security Agreement as well as the optional trainings can be accessed here: Note: Returning agents and brokers who have already created a Marketplace account and completed identity proo?ng do not need to repeat those steps. Create a searchable profile on the SHOP Marketplace Agent/Broker Portal. For operational reasons, once the SHOP Marketplace registration is complete, agents and brokers will have to establish a pro?le on the SHOP Marketplace Agent/Broker Portal in order to begin assisting clients. To establish their profile, agents and brokers will login to the SHOP Agent/Broker Portal at the following URL using their user name and password created during registration: The information provided in the pro?le will be searchable by small employers seeking assistance in the SHOP Marketplace. Agents and brokers should make sure their appropriate contact information is listed. (REGTAP FAQ Database - FAQ #15727 05/02/16) Q: What is the SHOP Marketplace Agent/Broker Portal? A: The SHOP Marketplace Agent/Broker Portal is an online system that allows agents and brokers registered with the SHOP Marketplace to service their clients. Once an agent or broker has established a pro?le in the SHOP Marketplace Agent/Broker Portal, his or her name and the contact information provided while creating the pro?le will be searchable by small employers seeking assistance with the SHOP Marketplace. Through the SHOP Marketplace Agent/Broker Portal, agents and brokers can help their small group clients apply and enroll in SHOP Marketplace health or dental coverage. SHOP Marketplace agents and brokers also have the ability to manage their clients' accounts, change a client's status, create proposals, become associated with a group's account to receive compensation for sales, submit client enrollments, and monitor their client's enrollment and payment status, once authorized. Agent and broker National Producer Numbers (NPN's) and other identifying information for compensation purposes will automatically be sent to issuers when SHOP Marketplace agents and brokers submit an enrollment through the SHOP Marketplace Agent/Broker Portal. (REGTAP FAQ Database - FAQ #15728 05/02/16) Q: How can agents and brokers who have completed SHOP Marketplace registration begin assisting clients in the SHOP Marketplace? Updated 1-31-17 A: For operational reasons, an employer will have to send an agent or broker an authorization request to his or her preferred agent or broker through the SHOP Marketplace before an agent or broker who has completed the SHOP Marketplace registration process can begin to work on that employer's behalf. Employers should log in to their HealthCare.gov accounts and click the ?Get Assistance? tab to search for an agent or broker registered with the SHOP Marketplace in their area. Employers can search for an agent or broker by name, National Producer Number (NPN), or location. Once an employer has found an agent or broker, he or she can send the agent or broker an authorization request. To accept a pending authorization request, agents and brokers will log into the SHOP Marketplace Agent/Broker Portal, select the ?Manage Clients? tab, and accept the pending authorization. Once the authorization has been accepted, the agent or broker may perform all application and enrollment functions on behalf of his or 860 2017--00960 her employer clients, except for making premium payments. Agents and brokers registered with the SHOP Marketplace can be added to an employer's account at any point during the application and enrollment process, and compensation information will be shared with issuers when the authorization has occurred. (REGTAP FAQ Database - FAQ #15729 05/02/16) Q: Where do agents and brokers registered with the SHOP Marketplace add their National Producer Number (NPN) on the SHOP Marketplace application? A: Once an agent or broker registered with the SHOP Marketplace accepts an authorization request from an employer in the SHOP Marketplace, the agent or broker becomes the agent or broker of record on the enrollment. The agent or broker does not need to manually input his/her NPN on the SHOP Marketplace application; this happens automatically when the registered agent or broker accepts an employer's authorization request in the SHOP Marketplace and the employer's enrollment is completed through the SHOP Marketplace Agent/Broker Portal. When the employer client's SHOP Marketplace enrollment is submitted, the SHOP Marketplace sends the registered agent or broker's NPN and other identifying information for compensation purposes along with the enrollment information to the applicable health or dental issuers. Health and dental issuers are responsible for paying and distributing agent and broker commissions on all SHOP Marketplace enrollments consistent with applicable state laws; the SHOP Marketplace does not pay or set agent or broker commissions. (REG TAP FAQ Database - FAQ #15730 05/02/16) Q: Does it cost employers more to work with an agent or broker in the SHOP Marketplace? A: No. The premium a small employer will pay for health insurance purchased through the SHOP Marketplace will be the same regardless of whether they work with an agent or broker registered with the SHOP Marketplace. Issuers are required to compensate their af?liated agents and brokers the same regardless of whether the enrollment was completed through the SHOP Marketplace. (REGTAP FAQ Database - FAQ #15731 05/02/16) Q: Do agents and brokers need to be re-authorized on a client's account upon renewal? A: No. Once an agent or broker who maintains an active registration with the SHOP Marketplace has been authorized to work on behalf of an employer in the SHOP Marketplace, the agent or broker remains associated with the enrollment unless the employer or the agent or broker actively changes the authorization status. (REGTAP FAQ Database - FAQ #15732 05/02/16) Q: Can an employer change the agent or broker associated with their account in the SHOP Marketplace? Updated 1-31-17 A: Yes. An employer may change the agent or broker that he or she is working with in the SHOP Marketplace up to two times per year. Employers may add or remove a SHOP Marketplace-registered agent or broker from their SHOP Marketplace account by logging into their HealthCare.gov account. Agents and brokers registered with the SHOP Marketplace may also change a client's account status through the SHOP Marketplace Agent/Broker Portal. (REG TAP FAQ Database - FAQ #15733 05/02/16) 861 2017-?00961 Q: Where can agents and brokers registered with the SHOP Marketplace go with questions about their SHOP Marketplace Agent/Broker Portal account or SHOP Marketplace application questions? A: The SHOP Call Center, at 1-800-706-7893 (TTY: 711), is open Monday - Friday from 9:00 am. -7:00 pm. ET and is available to assist agents and brokers, employers, and employees. (REG TAP FAQ Database - FAQ #15734 05/02/16) Q: What requirements must agents and brokers fulfill if they have previously completed registration for the Federally-facilitated Marketplaces Updated 1-31-17 A: To continue participation in the Federally-facilitated Individual Marketplace (Individual Marketplace), agents and brokers must complete an annual registration renewal process that includes completion of a required training curricula and exams, and execution of the Individual Marketplace General Agreement (General Agreement) and the Individual Marketplace Privacy and Security Agreement. To continue participation in the Small Business Health Option Program (SHOP) Marketplace, agents and brokers must execute the SHOP Marketplace Agreement annually, and are strongly encouraged to complete the relevant training curricula and exam. As a reminder, agents and brokers who will be participating in the Individual Marketplace for the first time for plan year 2016 must complete seven steps: 1) create a CMS Enterprise Portal account, 2) request the FFM Agent/Broker role on the CMS Enterprise Portal, 3) conduct identity proo?ng on the CMS Enterprise Portal, 4) complete the required training curricula and exams on the Marketplace Learning Management System (MLMS) or through a CMS-approved vendor, 5) complete profile information on the MLMS, which is available via the CMS Enterprise Portal, 6) execute the General Agreement and the Individual Marketplace Privacy and Security Agreement on the MLMS, and 7) confirm completion of all required steps on the Agent Broker Registration Status page on the CMS Enterprise Portal. Agents and brokers who will be participating in the SHOP Marketplace for the ?rst time in plan year 2016 must complete seven steps and have the option of an additional step: 1) create a CMS Enterprise Portal account, 2)request the FFM Agent/Broker role on the CMS Enterprise Portal, 3) conduct identity proo?ng on the CMS Enterprise Portal, 4)complete the training curriculum on the MLMS or through a CMS-approved vendor (this step is optional, but strongly encouraged), 5) complete profile information on the MLMS which is available via the CMS Enterprise Portal, 6) execute the SHOP Marketplace Agreement on the MLMS, 7) con?rm completion of all required steps on the Agent Broker Registration Status page on the CMS Enterprise Portal, and 8) establish a profile on the SHOP Marketplace Agent/Broker Portal. Agents and brokers who completed FFM registration in a previous plan year should not create a new CMS Enterprise Portal account or conduct identity proo?ng again. Agents and brokers who completed FFM registration for plan year 2014, but not for plan year 2015, will need to log in to their existing CMS Enterprise Portal account and request the FFM Agent/Broker role. (REGTAP FAQ Database - FAQ #15769 05/02/16) 862 2017--00962 Q: If a state has concerns about a certain agent or broker, should it share these concerns with A: Yes. States should notify CMS of any specific agents and brokers whose conduct raises concerns, especially with regard to potential or confirmed instances of noncompliance with FFM requirements. States should also notify CMS of state enforcement actions against speci?c agents and brokers. CMS intends to coordinate resolution actions addressing suspected or con?rmed noncompliance by FFM agents or brokers with all affected states, and any resolution actions taken under its statutory or regulatory authority will not supplant the states' authority to pursue their own enforcement actions. States should contact their respective CMS Center for Consumer Information Insurance Oversight State Officer to relay any concerns about specific agents and brokers. (REGTAP FAQ Database - FAQ #15771 05/02/16) Q: If CMS has concerns about a specific agent or broker, will the agency share these concerns with the state(s) in which the agent or broker is licensed? A: Yes. CMS is conducting ongoing oversight of FFM-registered agents and brokers to ensure compliance with FFM requirements. CMS notifies state regulatory agencies regarding speci?c agents or brokers about whom it has concern(s) so that the investigation and resolution can be coordinated appropriately with the licensing state(s). CMS typically relays these concerns through the respective CMS Center for Consumer Information Insurance Oversight State Officer. CMS's monitoring efforts focus primarily on concerns that relate to agent and broker compliance with the FFM-speci?c requirements. The agency relies on states to continue to monitor agent and broker compliance with state laws and requirements. To the extent that CMS detects a potential compliance issue related to state requirements, it will inform the state and expect the state to assume the primary role for resolving the issue. (REGTAP FAQ Database - FAQ #15772 05/02/16) Q: Do the Federally-facilitated Marketplaces (FFMs) independently verify agents' and brokers' state licenses? Updated 1-31-17 A: No. The FFMs do not independently verify the state licenses of FFM-registered agents and brokers. Pursuant to 45 CFR 156.340, a quali?ed health plan (QHP) issuer maintains responsibility for the compliance of its delegated and entities, including affiliated agents and brokers. Accordingly, CMS expects QHP issuers to verify that the agents and brokers selling their products have valid state licenses and comply with applicable agent and broker FFM registration requirements. The QHP issuer is responsible for con?rming the validity of the agent's or broker's state license and the inclusion of the agent's or broker's National Producer Number (NPN) on the CMS registration completion list before allowing an agent or broker to access the QHP issuer's connection to the FFMs (if the QHP issuer supports the Direct Enrollment Pathway) and before issuing compensation. Issuers may accept a copy of an agent's or broker's registration completion certificate as evidence that the agent's or broker's NPN will appear on the next publicly available registration completion list. (REGTAP FAQ Database - FAQ #15773 05/02/16) 863 2017--00963 Q: How are agents and brokers compensated or credited for enrolling consumers in coverage through the Federally-facilitated Marketplaces A: Agents and brokers are compensated or credited directly by qualified health plan (QHP) issuers per the terms of their QHP issuer contracts for assisting consumers to enroll in QHPs through the FFMs. Compensation or credit for enrollments includes commissions, fees, or other incentives as established in the relevant contract between a QHP issuer and an agent or broker. An agent or broker must be affiliated or have a contractual relationship with the respective issuer offering a QHP or a quali?ed stand- alone dental plan in accordance with applicable state law in order to be paid for a Marketplace transaction. The FFMs will not establish a commission schedule or pay commissions directly to agents or brokers. CMS expects that the amount and terms of any commission would be established by the terms of the contract between a QHP issuer and an agent or broker. However, QHP issuers are required to provide the same compensation or credit to agents and brokers for enrollment in QHPs through the Marketplaces as for enrollment in similar health plans offered outside the Marketplaces. (REGTAP FAQ Database - FAQ #15774 05/02/16) Q: Can agents and brokers receive commissions for enrolling individuals in Medicaid managed care plans? A: The Federally-facilitated Marketplaces do not have authority over state Medicaid program rules or over the relationships between Medicaid managed care organizations and their af?liated agents and brokers. For information on state-specific Medicaid rules, agents and brokers should contact their state Department of Insurance or state Medicaid agency. (REG TAP FAQ Database - FAQ #15775 05/02/16) Q: If an agent or broker assisted an individual in enrolling in a qualified health plan (QHP) through a Federally-facilitated Marketplace (FFM), but the agent's or broker's National Producer Number (NPN) is not associated with the enrollment transaction on the 834 enrollment transaction file provided by the FFM to the QHP issuer, can the agent's or broker's information be added at a later date, so that the agent or broker can receive compensation from the QHP issuer? Updated 1-31-17 A: In general, the agent's or broker's NPN, name, and FFM user ID should be recorded as part of the consumer's application. This information identifies the agent or broker on the enrollment transaction so the FFMs can appropriately track enrollment and the QHP issuer can compensate the agent or broker based upon the enrollment (as may be appropriate). However, if a QHP issuer identi?es a particular enrollment that should have had an agent or broker associated with it, the QHP issuer should add the agent or broker to the enrollment record internally, even if the agent or broker was not re?ected on the initial enrollment transaction, in case there is any follow-up required as a result of the enrollment. If an agent or broker has a legitimate reason to believe he or she should be credited for an FFM enrollment, but has not been credited for it, the agent or broker should contact the respective QHP issuer directly to discuss the speci?c situation. Please note that agents and brokers must meet registration requirements prior to assisting with an FFM application in order to be credited for the enrollment transaction. (REGTAP FAQ Database - FAQ #15776 05/02/16) 864 2017--00964 Q: May agents and brokers be compensated for a Federally-facilitated Marketplace (FFM) enrollment if they are not affiliated with a qualified health plan (QHP) issuer? Can the FFMs credit an agent or broker for an enrollment transaction or direct the QHP issuer to do so? A: No. The FFMs have not established a commission schedule and do not pay commissions directly to agents or brokers. The FFMs transmit agent and broker identifying information the National Producer Number), which is recorded as part of the consumer's application, to QHP issuers in order to facilitate any payment or compensation from a QHP issuer. The amount and terms of any compensation or credit are governed by the QHP issuer's contract with the agent or broker. Unless otherwise required under state law, a QHP issuer is not obligated to compensate an agent or broker with whom the QHP issuer is not af?liated, even if the agent or broker assists a consumer in enrolling in the issuer's QHP through the Marketplaces. However, FFM policy recommends that QHP issuers keep a record of enrolling agents or brokers in their systems, even if an agent or broker is not af?liated with the QHP issuer, in case there is any follow-up required as a result of the enrollment. To become af?liated with a QHP issuer, agents and brokers must contact the QHP issuer directly, or they can contact their state Department of Insurance for more information. (REGTAP FAQ Database - FAQ #15777 05/02/16) Q: Are agents and brokers permitted to use the Federally-facilitated Marketplace (FFM) online functionality that is designed for consumer-only use, such as the plan shopping and enrollment functions? Updated 1-31-17 A: No. Agent or broker use of the consumer plan shopping and enrollment functions on the FFMs is prohibited because agents and brokers may not assist consumers using consumers' online FFM accounts. These functions are designed for consumer use only, and only consumers may access those functions using their consumer accounts. CMS has previously provided guidance that documents how agents and brokers who are registered with the FFMs may assist consumers with the FFM enrollment process via two options: (1) the Direct Enrollment Pathway, through which the agent/broker can use an issuer's or web-brokers website to assist a consumer; or (2) the Marketplace Pathway, using a side-by-side model, through which the agent or broker can help a consumer using the Marketplace website. (See ?Role of Agents, Brokers, and Web- brokers in Health Insurance Marketplaces,? last revised January 12, 2016, available at This guidance was clear that agents and brokers are required to use their own FFM user IDs and accounts when assisting consumers to enroll in quali?ed health plans using the Direct Enrollment Pathway. The guidance also explained that agents and brokers assisting consumers using the Marketplace Pathway should not have independent access to consumer's FFM online user IDs, passwords, and accounts. Agents and brokers therefore are not permitted to use direct URL access and/or any other pathways or methods of enrollment that would allow them access to consumer online accounts and consumer-speci?c functions. This is applicable during Open Enrollment and special enrollment periods. (REGTAP FAQ Database - FAQ #15778 05/02/16) 865 2017--00965 Q: When can businesses sign up for SHOP Marketplace coverage without having to meet the minimum participation rate requirement? A: From November 15 through December 15 of each year, small employers that are interested in enrolling in SHOP Marketplace coverage can do so without needing to meet the minimum participation rate requirement for their state. (REGTAP FAQ Database - FAQ #15710 05/02/16) Q: Will my clients need to reauthorize me as their agent or broker upon renewal in the SHOP Marketplace? A: No. Once the agent and broker and employer/client relationship has been established, that authorization will remain valid as long as the agent's or broker's registration for the next plan year remains valid. If the employer wants to end the relationship with the agent or broker, the employer can remove the authorization in their account. Otherwise the agent or broker will remain on the application upon renewal. (REGTAP FAQ Database - FAQ #15711 05/02/16) Q: What states are offering employee choice in the SHOP Marketplace this year? A: Beginning for plan year 2016, all states will be offering employee choice through the SHOP Marketplace. That means that employers in all states will be able to offer their employees a choice of health and/or dental plans. Regardless of the fact that employee choice is available, a small employer may choose to offerjust a single health or dental plan. (REGTAP FAQ Database - FAQ #15712 05/02/16) Q: Will a group be accepted into the SHOP Marketplace when the SHOP Marketplace minimum participation rate requirement is waived if the only members enrolling in the plan are the owner and the spouse? A: For any group to enroll in the SHOP Marketplace, either inside or outside of the minimum participation rate window, at least one employee who is not a business owner or a spouse must enroll in order for the group to participate in SHOP Marketplace coverage. (REGTAP FAQ Database - FAQ #15713 05/02/16) Q: Where do I enter my National Producer Number (NPN) on the SHOP Marketplace application? Updated 1-31-17 A: For an agent and broker to begin assisting a small business client through the SHOP Marketplace, the employer will need to authorize the registered agent or broker to work on their behalf. An employer can authorize an agent or broker to assist them in the SHOP Marketplace by creating or logging into their account on HealthCare.gov and selecting the 'Get Assistance? tab within their SHOP Marketplace application. Employers may search for an agent or broker by name, National Producer Number (NPN) or zip code. Once an agent or broker has been found, the employer can send the agent or broker an authorization request for the agent or broker to accept though their SHOP Marketplace Agent/Broker Portal account. Once that authorization is established, the agent's or broker's NPN is then tied to the small business' record, so there's no need to input the NPN anywhere on the application. The authorized agent's or broker's information will be sent along to the issuers with the SHOP Marketplace enrollment. 866 2017--00966 For more information on the SHOP Marketplace Agent/Broker Portal and a step-by-step description of this process, go to HealthCare.gov, select the 'Small Businesses' tab, and then select the green 'For Agents and Brokers' button. (REGTAP FAQ Database - FAQ #15714 05/02/16) Q: What call center do I contact if I have questions about the SHOP Marketplace Agent/Broker Portal? A: The SHOP Call Center is available to assist agents and brokers, small business employers, and employees who have an offer of SHOP Marketplace coverage. The SHOP Call Center is able to assist you with any problems you may be experiencing with the SHOP Marketplace Agent/Broker Portal. SHOP Call Center can be reached at 1- 800-706-7893 Monday- Friday 9:00am. - 7:00p.pm Eastern. (REGTAP FAQ Database - FAQ #15715 05/02/16) Q: I have a client renewing his SHOP Marketplace coverage for this year. When can the renewal process begin and will I need to be reauthorized on my client's account upon renewal? A: SHOP Marketplace renewals can begin as soon as the rates for the quarter the renewal is to take place in are released, generally about 60 days before the renewal date. Your clients will receive a renewal notice around that time letting them know that they are up for renewal. You do not need to be reauthorized by your client upon their SHOP Marketplace renewal, so long as your registration is current for the plan year. Once the authorization has been established, it does not need to be reestablished. (REGTAP FAQ Database - FAQ #15716 05/02/16) Q: Small businesses were able to enroll in the SHOP Marketplace without meeting the Minimum Participation Rate requirements during the requirement waiver period, but can the health issuers terminate the small business for non-participation upon renewal? A: In the SHOP Marketplace, the Minimum Participation Rate is calculated upon initial enrollment and upon renewal. If a small business drops below the Minimum Participation Rate throughout the year, it is still eligible to participate in the SHOP Marketplace. (REGTAP FAQ Database - FAQ #15717 05/02/16) Q: What is the phone number for an employer to call to ensure an agent or broker's National Producer Number (NPN) is on ?le for a SHOP Marketplace enrollment? A: Once an employer has submitted the authorization for an agent or broker to work on his or her behalf in the SHOP Marketplace and the agent or broker has accepted the authorization request through the SHOP Marketplace Agent/Broker Portal, the agent's or broker's NPN will be associated with that employer's SHOP Marketplace application and enrollment. If agents and brokers have any questions or are experiencing problems logging into their SHOP Marketplace Agent or Broker Portal accounts, please visit: or contact the SHOP Call Center at 1-800-706-7893. (REGTAP FAQ Database - FAQ #15718 05/02/16) 867 Updated 1-31-17 2017--00967 Q: I have a client who offers both health and dental coverage to her employees and their dependents through the SHOP Marketplace. Do employees and their dependents have to enroll in the same plan or can they enroll in one and other dependents enroll in another? A: When dependent coverage is offered, employees and their dependents must enroll in the same health and dental plans through the SHOP Marketplace. If an employee enrolls in health and dental coverage, his or her dependents can enroll in both the health and dental plan chosen by the employee, just the health plan, orjust the dental plan. The employee must enroll in a plan before the dependents can enroll, but the dependents do not need to enroll in the same combination of plans chosen by the employee. This option will be helpful for those employees and dependents who may receive health coverage through another employer, but just need dental coverage or vice versa. (REGTAP FAQ Database - FAQ #15719 05/02/16) Q: Are there any tax credits for employers available through the SHOP Marketplace? A: Yes, the Small Business Healthcare Tax Credit is available exclusively through the SHOP Marketplace. The tax credit can be worth up to 50% of an employer?s contribution toward premium costs and up to 35% for tax-exempt employers. To qualify for the tax credit, small employers must have fewer than 25 full-time equivalent, or FTE, employees and the average employee salary must be about $50,000 per year or less. The employer must also offer coverage to all full-time employees and contribute at least 50% to their employee premium costs. There is a Small Business Healthcare Tax Credit Estimator available at HealthCare.gov to help small employers, or the agents and brokers assisting them, determine if they may be eligible for the tax credit and, if they are eligible, estimate how much the credit might be worth. (REGTAP FAQ Database - FAQ #15720 05/02/16) Q: Can you provide an example of how the new Minimum Participation Rate (MPR) calculation works in the SHOP Marketplace? A: In most states, 70% of employees offered coverage must accept the offer of coverage in order for an employer to enroll in SHOP Marketplace coverage. For plans beginning in 2016, an employer's MPR in the SHOP Marketplace will be calculated by taking the number of employees enrolled in health coverage, either on or off the SHOP Marketplace, divided by the number of employees who were offered SHOP Marketplace coverage. For example, an employer offering SHOP Marketplace coverage to 10 full- time employees, two of which are enrolled in coverage through a spouse and one is covered by Medicare for a total of three employees declining SHOP Marketplace coverage. In this example, only four employees must accept SHOP Marketplace coverage to meet the 70% MPR. HealthCare.gov offers an MPR Calculator to help small employers and the agents or brokers assisting them to predicted whether the employers will meet the participation rate for their state. (REGTAP FAQ Database - FAQ #15721 05/02/16) Q: My client's SHOP Marketplace coverage was terminated due to non-payment. Is there a way for the group to be reinstated? Updated 1-31-17 A: If a group's coverage is terminated due to non-payment in the SHOP Marketplace, that group can be reinstated up to 30 days past the termination date. The group can be reinstated by paying its total premium owed. If the group's outstanding balance is not paid within the 30 -day reinstatement period, the group will need to complete a new 868 2017--00968 SHOP Marketplace application and reenroll in SHOP Marketplace coverage. (REGTAP FAQ Database - FAQ #15723 05/02/16) Q: Can employers offer dental coverage without having to offer health coverage through the SHOP Marketplace? A: New for plan year 2016, small employers may offer their employees dental coverage without also having to offer health coverage through the SHOP Marketplace. Unless the employer decides to offer both health and dental coverage through the SHOP Marketplace, its employees can choose to enroll in health-only coverage, dental-only coverage, or both health and dental coverage. For the dependents of the employees electing SHOP Marketplace coverage, they may also choose which coverage they would like to enroll in. Dependents may choose to enroll in health-only, dental-only, or both, but they must always enroll in the same plan or plans chosen by the employee. (REGTAP FAQ Database - FAQ #15724 05/02/16) Q: If an employer offers its employees a choice of plans in the SHOP Marketplace, will the employer receive a bill from all of the health insurance companies the employees enroll with? A: No. With the SHOP Marketplace, more choice comes with less paperwork. No matter how many different insurance companies or plans employees select, the employer gets and pays just one bill. That bill always comes from the SHOP Marketplace and never from the insurance companies. Employers pay the SHOP Marketplace a single payment and SHOP Marketplace takes care of dispersing all the employer's payments to the insurance companies associated with the account and enrollment. (REGTAP FAQ Database - FAQ #15725 05/02/16) Q: Why should small employers enroll into SHOP Marketplace, instead of letting their employees enroll themselves in the Individual Marketplace? Updated 1-31-17 A: There are several reasons why employers should consider enrolling their small business in SHOP Marketplace coverage. The Small Business Health Care Tax Credit is available to eligible small employers exclusively through the SHOP Marketplace. Small employers are also able to offer their employees a single health or dental plan, or a choice of health and dental plans, all while controlling how much they'd like to contribute to their employees and, if applicable, dependents premium costs. If an employer decides to offer his/her employees and if applicable, dependents a choice of health or dental plans, the employer will receive and pay just one bill, the SHOP Marketplace takes care of disbursing payments. SHOP Marketplace registered agents and brokers are available to assist small employers with their SHOP Marketplace application and enrollment. Employers without a HealthCare.gov account can search for a SHOP Marketplace registered agent of broker through the Find Local Help tool on HealthCare.gov. Employers with a HealthCare.gov account can login to their SHOP Marketplace application and select the 'Get Assistance' tab to find and authorize and agent or broker to work on their behalf. The SHOP Call Center is also available to assist employers, agents, brokers, and employees with an offer of SHOP Marketplace coverage. The SHOP Call Center is available Monday- Friday from 9:00a.m.- 7:00p.pm Eastern at 1-800-706-7893, TTY users can use 711. (REGTAP FAQ Database - FAQ #15726 05/02/16) 869 2017--00969 Q: What do agents and brokers need to do to assist clients in the SHOP Marketplace? A: Agents and brokers who wish to assist small employers with the SHOP Marketplace application and enrollment process must complete the following: 1) Complete SHOP Marketplace Registration: Agents and brokers interested in assisting small employers in the SHOP Marketplace must complete registration requirements. The SHOP Marketplace registration requirements include creation of a Marketplace account, completion of the SHOP Marketplace Privacy and Security Agreement through the Marketplace Learning Management System (MLMS), and identity proofing. Agents and brokers are highly encouraged, but not required, to complete SHOP Marketplace training also available through the MLMS or, one of the CMS- approved vendors. The 2016 SHOP Marketplace Privacy and Security Agreement as well as the optional trainings can be accessed here: Note: Returning agents and brokers who have already created a Marketplace account and completed identity proo?ng do not need to repeat those steps. 2) Create a searchable profile on the SHOP Marketplace Agent/Broker Portal. For operational reasons, once the SHOP Marketplace registration is complete, agents and brokers will have to establish a pro?le on the SHOP Marketplace Agent/Broker Portal in order to begin assisting clients. To establish their pro?le, agents and brokers will login to the SHOP Agent/Broker Portal at the following URL using their user name and password created during registration: The information provided in the profile will be searchable by small employers seeking assistance in the SHOP Marketplace. Agents and brokers should make sure their appropriate contact information is listed. (REG TAP FAQ Database - FAQ #15727 05/02/16) Q: What is the SHOP Marketplace Agent/Broker Portal? Updated 1-31-17 A: The SHOP Marketplace Agent/Broker Portal is an online system that allows agents and brokers registered with the SHOP Marketplace to service their clients. Once an agent or broker has established a pro?le in the SHOP Marketplace Agent/Broker Portal, his or her name and the contact information provided while creating the pro?le will be searchable by small employers seeking assistance with the SHOP Marketplace. Through the SHOP Marketplace Agent/Broker Portal, agents and brokers can help their small group clients apply and enroll in SHOP Marketplace health or dental coverage. SHOP Marketplace agents and brokers also have the ability to manage their clients' accounts, change a client's status, create proposals, become associated with a group's account to receive compensation for sales, submit client enrollments, and monitor their client's enrollment and payment status, once authorized. Agent and broker National Producer Numbers (NPN's) and other identifying information for compensation purposes will automatically be sent to issuers when SHOP Marketplace agents and brokers submit an enrollment through the SHOP Marketplace Agent/Broker Portal. (REGTAP FAQ Database - FAQ #15728 05/02/16) 870 2017--00970 Q: How can agents and brokers who have completed SHOP Marketplace registration begin assisting clients in the SHOP Marketplace? A: For operational reasons, an employer will have to send an agent or broker an authorization request to his or her preferred agent or broker through the SHOP Marketplace before an agent or broker who has completed the SHOP Marketplace registration process can begin to work on that employer's behalf. Employers should log in to their HealthCare.gov accounts and click the ?Get Assistance? tab to search for an agent or broker registered with the SHOP Marketplace in their area. Employers can search for an agent or broker by name, National Producer Number (NPN), or location. Once an employer has found an agent or broker, he or she can send the agent or broker an authorization request. To accept a pending authorization request, agents and brokers will log into the SHOP Marketplace Agent/Broker Portal, select the ?Manage Clients" tab, and accept the pending authorization. Once the authorization has been accepted, the agent or broker may perform all application and enrollment functions on behalf of his or her employer clients, except for making premium payments. Agents and brokers registered with the SHOP Marketplace can be added to an employer's account at any point during the application and enrollment process, and compensation information will be shared with issuers when the authorization has occurred. (REGTAP FAQ Database - FAQ #15729 05/02/16) Q: Where do agents and brokers registered with the SHOP Marketplace add their National Producer Number (NPN) on the SHOP Marketplace application? A: Once an agent or broker registered with the SHOP Marketplace accepts an authorization request from an employer in the SHOP Marketplace, the agent or broker becomes the agent or broker of record on the enrollment. The agent or broker does not need to manually input his/her NPN on the SHOP Marketplace application; this happens automatically when the registered agent or broker accepts an employer's authorization request in the SHOP Marketplace and the employer's enrollment is completed through the SHOP Marketplace Agent/Broker Portal. When the employer client's SHOP Marketplace enrollment is submitted, the SHOP Marketplace sends the registered agent or broker's NPN and other identifying information for compensation purposes along with the enrollment information to the applicable health or dental issuers. Health and dental issuers are responsible for paying and distributing agent and broker commissions on all SHOP Marketplace enrollments consistent with applicable state laws; the SHOP Marketplace does not pay or set agent or broker commissions. (REG TAP FAQ Database - FAQ #15730 05/02/16) Q: Does it cost employers more to work with an agent or broker in the SHOP Marketplace? Updated 1-31-17 A: No. The premium a small employer will pay for health insurance purchased through the SHOP Marketplace will be the same regardless of whether they work with an agent or broker registered with the SHOP Marketplace. Issuers are required to compensate their af?liated agents and brokers the same regardless of whether the enrollment was completed through the SHOP Marketplace. (REGTAP FAQ Database - FAQ #15731 05/02/16) 871 2017-?00971 Q: Do agents and brokers need to be re-authorized on a client's account upon renewal? A: No. Once an agent or broker who maintains an active registration with the SHOP Marketplace has been authorized to work on behalf of an employer in the SHOP Marketplace, the agent or broker remains associated with the enrollment unless the employer or the agent or broker actively changes the authorization status. (REGTAP FAQ Database - FAQ #15732 05/02/16) Q: Can an employer change the agent or broker associated with their account in the SHOP Marketplace? A: Yes. An employer may change the agent or broker that he or she is working with in the SHOP Marketplace up to two times per year. Employers may add or remove a SHOP Marketplace-registered agent or broker from their SHOP Marketplace account by logging into their HealthCare.gov account. Agents and brokers registered with the SHOP Marketplace may also change a client's account status through the SHOP Marketplace Agent/Broker Portal. (REGTAP FAQ Database - FAQ #15733 05/02/16) Q: Where can agents and brokers registered with the SHOP Marketplace go with questions about their SHOP Marketplace Agent/Broker Portal account or SHOP Marketplace application questions? A: The SHOP Call Center, at 1-800-706-7893 (TTY: 711), is open Monday - Friday from 9:00 am. -7:00 pm. ET and is available to assist agents and brokers, employers, and employees. (REG TAP FAQ Database - FAQ #15734 05/02/16) Q: If an employee missed his or her employers' Open Enrollment period or was never informed of the Open Enrollment period, is he or she eligible for advance payments of the premium tax credit (APTC) for the months before eligibility? A: If an individual has an offer of employer sponsored coverage that is affordable and meets the minimum value standard, that individual is not eligible for APTC. This is true even if the individual missed the open enrollment period to enroll in his or her employer's coverage. (REGTAP FAQ Database - FAQ #16090 05/24/16) Q: When I enter in my browser window, it does not bring up a website. A: This is the email address for our Agent and Broker Help Desk, not a website. Please input this email address into to 'To' ?eld in an email, not your web browser. (REGTAP FAQ Database - FAQ #16153 05/27/16) Q: What happens if an employer has employees in different states, and the agent supporting the employer is not licensed in all those states? Does the agent have to go to the National Insurance Producer Registry (NIPR) and pay the fee to register in additional states to receive compensation from the issuer for enrolling employees who live in and will use coverage in states where the agent is not currently licensed? A: Agents and brokers are responsible for maintaining the appropriate appointments with health and dental insurance companies. Being registered with the SHOP Marketplace does not automatically appoint agents and brokers with any insurance company. 872 Updated 1-31-17 2017--00972 Any questions regarding appointments and compensation should be directed to the insurance company, not the SHOP Marketplace. (REGTAP FAQ Database - FAQ #16164 05/27/16) Q: How do I access available plans and pricing to help a small employer renew SHOP Marketplace coverage? A: Once the quarterly rates for the quarter during which the employer intends to renew coverage are released, employers and the agents and brokers who may be assisting them can visit the 'See Plans and Prices' tool at HealthCare.gov to get a sense of what plans and prices will be available for that employer upon renewal. Employers may also begin the formal renewal process approximately 60 days before the end of the current plan year. (REGTAP FAQ Database - FAQ #16167 05/27/16) Q: If we did not sign the SHOP Marketplace Agreement during the Open Enrollment period, can we sign it now so that we begin prospecting? A: Agents and brokers can sign the ?Agreement Between Agents and Brokers and CMS for the Federally-facilitated Small Business Health Options Program? at any time. For more information on how to register to sell in the SHOP Marketplace, please visit: (REGTAP FAQ Database - FAQ #16168 05/27/16) Q: Can I complete registration for the Small Business Health Options Program (SHOP) Marketplace any time, even when the Marketplace Learning Management System (MLMS) is closed, since qualified small employers and their employees can start or renew coverage any month of the year not just during the Open Enrollment period? A: No. Even though there is no required training to SHOP Marketplace registration, you must read and sign the SHOP Marketplace Privacy and Security Agreement, which you access via the CMS Enterprise Portal and Marketplace Learning Management System (MLMS). If you have completed registration for the SHOP Marketplace for plan year 2016, you can continue to assist small employers and their employees enroll in coverage until your plan year 2016 SHOP Marketplace Privacy and Security Agreement expires on October 31, 2016. (REGTAP FAQ Database - FAQ #16710 07/21/16) Q: Can I help small employers and their employees start or renew coverage when the Marketplace Learning Management System (MLMS) is closed? Updated 1-31-17 Answer: Yes. If you completed registered for the Small Business Health Options Program (SHOP) Marketplace for plan year 2016, you can continue to assist small employers and their employees enroll in coverage until your plan year 2016 SHOP Marketplace Privacy and Security Agreement expires on October 31, 2016. You must complete plan year 2017 registration to assist small employers and their employees starting on November 1, 2016. (REGTAP FAQ Database - FAQ #16711 07/22/16) 873 2017--00973 Rating Q16: If an employer with less than 20 employees signs up through the SHOP, would an employee who is also on Medicare pay the same rate on the A16: The SHOP follows the same Medicare Secondary Payer rules as the outside market. All else equal, a small group rate does not differ based on Medicare eligibility. Please see 45 CFR 147.102. (Plan Management Webinar QHP FAQ #3 04/11/13; REGTAP FAQ Database - FAQ #166 04/11/13) 02: Is the primary employer address rating requirement applicable to SHOP in a state based exchange as well as the A2: Yes, the primary employer?s address rating requirement will apply inside and outside of SHOPS and will apply to the FF- SHOP as well as state-based SHOPS. (QHP SHOP FAQ 05/21/13) Q3: SHOP Business Question: When calculating (building) rates for small employer coverage (ESI) policies do we build rates based on the employer address or the subscriber address? A3: We intend to propose in future rulemaking that the geographic area premium rating factor must be based on the employer?s primary business location in each state. This would apply both inside and outside of the SHOP. (QHP SHOP FAQ 05/21/13) 874 Updated 1-31-17 2017--00974 05: Off-exchange Small Employer Business Question: When calculating (building) rates for small employer coverage (ESI) policies, do we build rates based on the employer address or the subscriber address? A5: We intend to propose in future rulemaking that the geographic area premium rating factor must be based on the employer's primary business location in each state. This would apply both inside and outside of the SHOP. (QHP SHOP FAQ 05/21/13) 06: Off-exchange Small Employer Business Question: If required to utilize the subscriber address when building premiums in the small group market - are we able to default to the subscriber's address for everyone on the policy 0R are issuers required to base rates off of the dependent addresses as well? A6: We intend to propose in future rulemaking that the geographic area premium rating factor must be based on the employer's primary business location in each state. This would apply both inside and outside of the SHOP. (QHP SHOP FAQ 05/21/13) Q7: How do we rate an employee who works out of state from home for an organization that is located in our state? A7: We intend to propose in future rulemaking that the geographic area premium rating factor must be based on the employer's primary business location in each state. This would apply both inside and outside of the SHOP. We intend to propose that, where a multi-state employer has established an account in more than one state, the primary business location of the business in each applicable state must be used for geographic rating area purposes. However, if there is only one account, we intend to propose to use the employer's business location in the state where the account is established for geographic rating--regardless of other work locations. (QHP SHOP FAQ 05/21/13) Q32: Will the geographic area premium rating factor in the small group market be based on the geographic area of the employee or that of the employer? Will this approach apply only for plans offered through the FF-SHOPs, or will it apply market-wide? A32: We intend to propose in future rulemaking that the geographic area premium rating factor must be based on the employer?s primary business location in each state. This would apply both inside and outside of the SHOP. In the context of the FF-SHOPs, we intend to propose that an employer, except multi-state employers, generally may have only one SHOP account per state. Multi-state employers will still be able to establish either one SHOP account for all employees or establish multiple SHOP accounts in each state with a business location. We intend to propose that, where a multi-state employer has established an account in more than one state, the primary business location of the business in each applicable state must be used for geographic rating area purposes. (QHP Webinar Series FAQ #10 05/09/13, updated 08/02/13; REGTAP FAQ Database - FAQ #146 08/02/13) Q35: Will quarterly rate increases be allowed in the A35: Issuers participating in SHOP will be able to submit trend increases to their rates at the time of their original QHP application and, after that, whenever submitting new rates. We intend to propose an amendment to 45 CFR clarifying that, consistent with the general rules for the small group market, issuers in all SHOPs will be permitted 875 Updated 1-31-17 2017--00975 to increase rates no more frequently than quarterly. We also intend to propose that issuers with plans offered through the FF-SHOPs will be able to submit non-trend rate updates on a quarterly basis beginning in July 2014. (As we have previously explained in guidance, it will not be possible for the to process non-trend rate changes until the third quarter of 2014.) Issuers will be noti?ed when the begin processing non-trend quarterly rate updates. Regardless of when an employer enrolls in a plan through a SHOP, the rates applied to that employer's plan must be guaranteed for the 12 months of the plan year. (QHP Webinar Series FAQ #10 05/09/13 updated 08/02/13 REGTAP FAQ Database - FAQ #148 08/02/13) Q3: Will the geographic area premium rating factor in the small group market be based on the geographic area of the employee or that of the employer? Will this approach apply only for plans offered through the FF-SHOPs or will it apply market-wide? A3: As proposed in the Patient Protection and Affordable Care Act; Program Integrity: Exchange, SHOP, Premium Stabilization Programs, and Market Standards published on June 19, 2013 (Federal Register Vol. 78, No. 118), the geographic area premium rating factor must be based on the group policy holder?s principal business address in each state. This approach would apply both inside and outside of the FF-SHOP. This draft regulation was finalized as proposed. (SHOP FAQ #2 07/05/13; REGTAP FAQ Database - #72 and #728 07/05/13; updated 08/27/14) Q44: When will subscriber rates be calculated? Will they be based on the age of an enrollee using the group?s original effective date or will they be based on the age of a subscriber when they actually enroll? For example: Updated 1-31-17 One subscriber has a Date of Birth of July 18, 1967, and enrolls when the group initially enrolls on May 1st, 2013. For billing submitted to this subscriber on September 1, 2013, the subscriber would remain 45-years-old until May 1, 2014. 876 2017--00976 Another subscriber has a Date of Birth of July 18, 1967 in the same SHOP group with an original effective date of coverage of August 1, 2013. For billing submitted to this subscriber on September 1, 2013, is the subscriber's age 45 or 46 until May 1, 2014? A44: Subscriber rates in the FF-SHOPs are calculated at the time of initial enrollment and upon renewal based on the coverage effective dates. Thus in the example above, the subscriber with an effective date of August 1, 2013 will be billed using the per- member rate for a 46-year-old. (SHOP FAQ #4 08/28/13; REG TAP FAQ Database - FAQ #47 08/28/13) Q1: How will premiums be calculated in the Federally-facilitated SHOPs A1: Per the ?nal Market rules published on February 27, 2013 (78 FR 13406) and codi?ed at 45 C.F.R. the total premium charged to the group is determined by summing the premiums of each of the participants and bene?ciaries covered under the plan. Under the individual rating method, the premium for each individual covered participant and bene?ciary under a speci?c plan may be adjusted using allowable rating factors, which include age and tobacco usage. A composite rating method (discussed below in question may also be used. All the premiums would be adjusted using the applicable geographic rating area. As ?nalized at 147.102 for small group plans (inside and outside SHOPS), the geographic rating area will be determined using the principal business address of the group policyholder. The market rules require that health insurance issuers in the small group market offer a tobacco user the opportunity to avoid paying the full amount of the tobacco rating factor if he or she participates in a wellness program meeting the standards of section 2705 of the PHS Act and its implementing regulations. (SHOP FAQ #6 10/2/13; REGTAP FAQ Database - FAQ #345 10/2/13) 02: If a qualified employer has multiple worksites in a state, which address will be used to adjust premiums for the qualified employer?s qualified employees and their dependents using the geographic rating area premium rating factor? A2: An employer enrolling in coverage through the FF-SHOPs will be able to establish one account per State. As finalized at 147.102 for plans in the FF-SHOP, rating area is determined by the employer's principal business address in the State. Thus, the principal address entered by the employer on the employer application will be used for rating purposes for the entire group. (SHOP FAQ #6 10/2/13; REGTAP FAQ Database - FAQ #346 10/2/13) Q3: When an employer group moves its headquarters (a change in primary business location) and that move is to a different rating area, will the FF-SHOPs apply the new geographic rating factor to the coverage when the move occurs? Updated 1-31-17 A3: Pursuant to 45 C.F.R. and issuers may not vary rates for a quali?ed employer during the employer?s plan year. The FF-SHOPs, therefore, may apply a new geographic rating factor only upon renewal. If an employer group moves its principal business address to a different geographic rating area in the same state, the FF-SHOPs will re-run the eligibility determination process to verify that the employer is still located in the same state. If the employer moves to a different state and continues to opt to offer coverage to all full-time employees through the SHOP in 877 2017-?00977 which it has its principal business address, the group will lose its eligibility for enrollment in the SHOP in its former state, and would have to re-apply to participate in the SHOP in its new state. (SHOP FAQ #6 10/2/13; REGTAP FAQ Database - FAQ #347 10/2/13) Q: In the past, rates for individuals 65 and over had varied based on the size of the group. Specifically, when Medicare was the primary payer, the rate for an enrollee was generally lower. Will this policy be reviewed for 2015? A: The new market rules do not allow rates to vary based on whether an enrollee has Medicare or not. There are currently no plans to change this policy. (REGTAP FAQ Database - FAQ #990 03/10/14) Q: Can the Centers for Medicare Medicaid Services (CMS) explain how rates will be displayed to employers and employees in the Federally-facilitated Small Business Health Options Program (FF-SHOP) Marketplace? Will contribution options display as dollar amounts or percentage contribution amounts? Will employers be able to set one contribution amount per metal level? Can CMS set different contribution amounts per plan within a metal level? A: Premium amounts displayed to employers while establishing their offer of coverage will be based on an average of per-member rates for all employees on an employer's employee roster (assuming all employees enroll in coverage). Employers will be able to establish a different percentage contribution amount for employees and dependents. In addition, employers will be able to establish a different percentage contribution amount for medical and dental plans. Whatever percentage employers establish for these categories will apply to all plans within a metal/coverage level. (REGTAP FAQ Database - #1726 05/27/14) Q: Is the rating area on the 834 based on the Employer's Rating Area or based on where the Subscriber lives? A: Employer rates (both inside and outside the Small Business Health Options Program are always based on the primary business address of the employer and not on the home address of employees and dependents. (REG TAP FAQ Database - FAQ #2424 06/26/14) Q: Can an employee attest mid-year that the employee has completed a smoking cessation program and receive nonsmoker rates at that time? A: No, tobacco status and rate calculations are determined only one time per year, upon initial enrollment and upon a group's annual renewal. (REGTAP FAQ Database - FAQ #2598 07/03/14) Q: If the employee selects a plan from an issuer that does not impose a tobacco surcharge, will the Federally-facilitated Small Business Health Options Program (FF- SHOP) ask the employee about tobacco usage, and will the 834 transactions (sent to issuers) include the employee's response? A: The FF-SHOP will always inquire about enrollee tobacco usage. The FF-SHOP will send employee responses to issuers even if an issuer does not impose a tobacco surcharge. (REGTAP FAQ Database - FAQ #2600 07/03/14) 878 Updated 1-31-17 2017--00978 Q: If an employer changes the business address during the plan year, are the employer group's rates impacted or are rates locked in for the plan year? A: Pursuant to 45 C.F.R. and issuers may not vary rates for a quali?ed employer during the employer's plan year. Therefore, the Federally- facilitated Small Business Health Options Program (FF-SHOP) may apply a new geographic rating factor only upon renewal. If an employer group moves the employer's principal business address to a different geographic rating area in the same state, the FF-SHOP will re-run the eligibility determination process to verify the employer is still located in the same state. If the employer moves to a different state, and continues to opt to offer coverage to all full-time employees through the SHOP in which the employer has principal business address, the group will lose its eligibility for enrollment in the SHOP in its former state, and would have to re-apply to participate in the SHOP in the new state. (REGTAP FAQ Database - FAQ #4199 09/02/14) Q: How will Federally-facilitated Small Business Health Options Program (FF-SHOP) issuers receive domestic partners on 834 enrollment transactions? If the domestic partner comes in as a dependent, how will the FF-SHOP rate domestic partners under age 21 for billing purposes? Will the FF-SHOP include the domestic partner in the 3-child maximum for purposes of rating? A: The FF-SHOP will send 53 'Life Partner' code for domestic partners. The 3-child maximum for purposes of rating only applies to the following relationships: 1. Son/Daughter 2. Stepson/Stepdaughter 3. Adopted Son/Daughter 4. Foster Child (REGTAP FAQ Database - FAQ #5348 10/03/14) Q: Can FF-SHOP issuers who did not submit a quarterly trend increase with their annual filing submission submit a quarterly rate change request? A: FF-SHOP issuers may submit quarterly rate changes according to schedule. If a FF-SHOP issuer originally submitted rates with annual rate effective dates in the Rates Table template and now wishes to institute quarterly rate changes for these plans during the plan year, the revised template must include quarterly rates, where any current and previous quarter exactly matches the original annual rates submitted. Only rate changes for applicable prospective quarters are permitted. Note that templates without previously approved annual rates for prior quarters will fail validation. (REGTAP FAQ Database - FAQ #10858 06/05/15) Tobacco Ratinq/Tobacco Cessation Proqrams Q1: If an employee or an employee?s dependent obtaining coverage through the FF- SHOPS uses tobacco (as defined in 45 CFR how can the employee or dependent avoid the tobacco premium rating surcharge? Updated 1-31-17 A1: The will not impose the tobacco premium rating surcharge at the time of initial enrollment (or re-enrollment) if the employee or dependent, as applicable, agrees at the time of enrollment (or renewal or re-enrollment) to participate in a wellness program meeting the standards of section 2705 of the Public Health Service Act, such as 879 2017--00979 a tobacco cessation program. (SHOP FAQ #5 09/13/13; REGTAP FAQ Database - FAQ #3 09/13/13) 02: If an employee or enrollee?s dependent already enrolled in coverage through the FF- SHOPs decides to participate in a wellness program in the middle of a plan year after initially declining the offer of such enrollment, will his or her premium be reduced immediately or retroactively to the time of open enrollment? A2: In the FF-SHOPs, an employee?s or employee?s dependent?s premium will be established for a period of one year upon enrollment, renewal, or re-enrollment of that employee or dependent. At that time, the enrollee or dependent can agree to participate in a wellness program meeting the standards of section 2705 of the Public Health Service Act, such as a tobacco cessation program in order to avoid the tobacco premium surcharge. If the employee or dependent does not agree at that time to participate in such a wellness program, the employee or dependent will have an opportunity to avoid the tobacco premium surcharge upon renewal or reenrollment for subsequent coverage. (SHOP FAQ #5 09/13/13; REGTAP FAQ Database - FAQ #4 09/13/13) Q: Will the 834 reflect that a tobacco user participating in a tobacco cessation program is a tobacco user? Will the premium in this instance be a non-tobacco rate? A: The rate on the 834 will be the premium an issuer should expect to receive from the FF-SHOP based on the allowable rating factors for that enrollee. Thus, an employee who is a regular tobacco user and participates in a smoking cessation program will have the non-tobacco rate on the 834. We are also planning to have a ?ag for tobacco use and an enrollee's expected participation in a wellness program. (REGTAP FAQ Database - FAQ #912 03/05/14) Q: If a state does not allow tobacco use to be a rating factor, will issuers be able to use them in A: No. If a state does not allow for tobacco rating, then the issuer must follow state law and cannot establish rates based on tobacco use. (REGTAP FAQ Database - FAQ #989 03/10/14) Q: How will employees know if an employer is offering a tobacco cessation program? A: It is not an employer's responsibility to offer a tobacco cessation program. New market rules require that issuers wanting to impose a tobacco surcharge in both the Small Group and Small Business Health Options Program (SHOP) markets are required to offer a tobacco cessation program that will remove the surcharge if an enrollee agrees to participate in the program. (REGTAP FAQ Database - FAQ #2606 07/03/14) Q: Can the 834 transaction include a specific tobacco use status to indicate that the enrollee is participating in a tobacco cessation program? A: Yes, this information is outlined in the Companion Guide 1.7), and will be communicated in the 2750 loop. The updated Companion Guide is available on the ZONE website at: and REGTAP at: Draft Companion Guide Version1 7 05 2914 CR 060214.pdf (REGTAP FAQ Database - FAQ #2608 07/03/14) 880 Updated 1-31-17 2017--00980 Q: Are issuers expected to report to the Federally-facilitated Small Business Health Options Program (FF-SHOP) if an enrollee is participating in an issuer's tobacco cessation program? A: FF-SHOP enrollees attest to participating in an issuer's tobacco cessation program upon initial enrollment. Therefore, issuers are not required to report this information back to the FF-SHOP. (REGTAP FAQ Database - FAQ #3455 08/01/14) Q: What values will the Federally-facilitated Small Business Health Options Program (FF- SHOP) send to issuers to indicate an enrollee has agreed to participate in a tobacco cessation program? A: The FF-SHOP will send a Value on the 834 enrollment transaction in a tag called 'SHOPOnIyCessation' when a member states the member will enroll in a tobacco cessation program on the initial application. (REGTAP FAQ Database - FAQ #3776 08/14/14) Q: If an employee attests to participating in a tobacco cessation program, what steps can Federally-facilitated Small Business Health Options Program (FF-SHOP) issuers take to ensure that the employee is actually participating in the tobacco cessation program? A: An issuer may take any reasonable approach to con?rm that an employee has satisfied the standard for obtaining a reward under a wellness program, such as a tobacco cessation program. If the employee is found to have not satis?ed the wellness program standard, or the employee is found to have reported false or incorrect information about their tobacco use, the issuer may attempt to recoup from the employee the tobacco premium surcharge that should have been paid since the beginning of the plan year. The issuer may not, however, non-renew or discontinue or rescind the group health insurance coverage for this reason. (REG TAP FAQ Database - FAQ #5499 10/09/14) Q: Can an issuer use the default tobacco status of if the issuer does not charge a tobacco surcharge? A: The Federally-facilitated Small Business Health Options Program (FF-SHOP) uses the tobacco status as an optional data element on the inbound issuer ?le, so issuers should leave the tobacco status ?eld blank if they the issuer does not charge a tobacco surcharge. (REGTAP FAQ Database - FAQ #10861 06/05/15) Composite Rating Updated 1-31-17 2017--00981 CMS removed thi FAQ from the REG TAP database on 09/02/14. Updated 1-31-17 2017--00982 removed this FAQ from the REG TAP database on 09/02/14. Q: For 2015, are composite premiums for small group coverage allowed outside SHOP Marketplaces? A: Depending on state law, composite premiums are allowed outside SHOP Marketplaces pursuant to rules established as part of the 2015 Final Payment Notice. (REGTAP FAQ Database - FAQ #1440 04/14/14) Q: Until the FF-SHOPs can support premiums based on average enrollee premium amounts (?composite premiums?), can a FF-SHOP issuer utilize composite premiums when selling a QHP or SADP outside the FF-SHOP and NOT utilize composite premiums when selling the same QHP or SADP through a A: Due to operational and resource limitations, the FF-SHOPs will not be able to support composite premiums for plan years beginning in 2016. Until composite premiums can be supported by the FF-SHOPs, issuers may utilize composite premiums that are based on a CMS approved methodology (either CMS market-wide methodology or state alternative methodology) for determining average enrollee premium amounts when selling QHPs or SADPs outside a FF-SHOP, without utilizing composite premiums when selling QHPs or SADPs through a FF-SHOP. In future guidance, CMS intends to address the policies that will apply with respect to composite premiums after the FF- SHOPs are able to support composite premiums. (REGTAP FAQ Database - FAQ #9597 04/08/15) Q: If a group adds a plan in the last quarter of the year, is the premium based on rates at the time at which the plan is added, or on rates effective as of 1/1? A: The premium is based on the coverage effective date chosen by the employer. Thus, the coverage effective date could be 11/1, 12/1, or 1/1. (REG TAP FAQ Database - FAQ #12172 08/27/15) 883 Updated 1-31-17 2017--00983 Q: Are rates based on the age of each subscriber at the time of the group's renewal, or does each subscriber's rate go up as the subscriber ages throughout the year? A: Rates in the Federally-facilitated Small Business Health Options Program (FF-SHOP) are based on the age of the enrollee as of the enrollee's initial coverage effective date and are updated one time per year upon a group's renewal date. (REGTAP FAQ Database - FAQ #12173 08/27/15) Minimum Participation Rates/Minimum Contribution Q19: Does the FF-SHOP participation provision at 45 C.F.R. 156.200(g) apply to stand- alone dental issuers wanting to participate in the individual market A19: No. For the following reasons, we do not interpret the FF-SHOP participation provision as applying to stand-alone dental plans seeking certi?cation to participate in the FF-SHOPS. First, the FF-SHOP participation provision provides that issuers are subject to it based on small group market share, which is determined based on earned premium data submitted annually to HHS by medical plan issuers pursuant to 45 C.F.R. 158.110. Stand-alone dental issuers are not subject to the reporting requirement at 158.110, and therefore HHS would generally not have the data it would require to determine whether they are subject to the participation provision. Second, the FF-SHOP participation provision requires issuers subject to it to offer both a silver QHP and a gold QHP in the FF-SHOP. The terms ?silver" and ?gold? refer to comprehensive medical plans subject to the metal tier actuarial value requirements. Generally speaking, issuers of stand-alone dental plans, which are subject to different actuarial value level requirements and are permitted to issue stand-alone dental plans at only one level, would not be able to meet this requirement. We note that 45 C.F.R. requires stand-alone dental plans being offered through an Exchange to meet all quali?ed health plan (QHP) certification standards, except for any certi?cation requirement that cannot be met by a stand-alone dental plan. We believe that the exception at applies to the participation provision. (QHP Webinar Series FAQ #12 06/28/13; REG TAP FAQ Database - FAQ #141 06/28/13) 05: How will out-of-state employees be counted when assessing participation requirements? Updated 1-31-17 A5: Employers with worksites in more than one state may establish either one FF-SHOP account serving all work locations or establish multiple SHOP accounts in each state where employees have a primary worksite. When one account is established, employees in all states will be considered when calculating an employer?s FF-SHOP participation rate. When multiple accounts are established, employees on each employee roster in each state will be considered separately when calculating an employer?s FF-SHOP participation rate. (SHOP FAQ #2 07/05/13; REGTAP FAQ Database - FAQ #74 and #74a 07/05/13) 884 2017--00984 CMS removed this FAQ from the database on 08/26/14. 08: Will an employer be able to participate in the FF-SHOP if it does not meet the 70 percent minimum participation requirement? A8: For coverage effective January 1, the guaranteed availability requirements in the Public Health Service Act (PHSA) 2702 will apply, as required in 45 CFR During this special enrollment period (November 15 - December 15), an employer is not subject to a minimum participation requirement and any employer otherwise qualifying for FF-SHOP coverage will be able to enroll in the regardless of its level of employee participation. Outside of this period, the minimum participation requirement will be enforced for new groups applying for FF-SHOP coverage. This guaranteed availability requirement will be in effect as of November 15 - December 15, 2013. Outside of the annual special enrollment period, the FF-SHOP will hold an employer's application until the employer meets the 70 percent minimum participation requirement (or the threshold required in that employer?s state). The FF-SHOP will not send any information to Issuers until the group has met the minimum participation requirement. (SHOP FAQ #2 07/05/13; REGTAP FAQ Database - FAQ #77 07/05/13) 09: Will groups not meeting the minimum participation rate be able to reapply within the same calendar year? A9: Yes. An employer can reapply within the same calendar year. The FF-SHOP will re- open the enrollment period for those wishing to reapply. (SHOP FAQ #2 07/05/13; REG TAP FAQ Database - FAQ #78 07/05/13) Q10: Will groups falling below the minimum participation rate during a plan year be allowed to continue their participation in the FF-SHOP throughout the plan year? A10: Yes. The FF-SHOP will only check minimum participation rates one time per year, at initial enrollment and at renewal for the next plan year. (SHOP FAQ #2 07/05/13; REG TAP FAQ Database - FAQ #79 07/05/13) Q11: If an employer in the FF-SHOP signs up during the November 15 December 15 annual enrollment period, will the employer need to meet the minimum participation requirement upon renewal? A11: Yes. The FF-SHOP will require all employers renewing the same QHP to meet the applicable minimum participation rate upon renewal. (SHOP FAQ #2 07/05/13) 885 Updated 1-31-17 2017--00985 Q14: Will retirees be counted when determining the minimum participation rate? A14: If a retiree is on an employer?s roster, he or she will be included in the denominator of the minimum participation percentage equation. (SHOP FAQ #2 07/05/13; REGTAP FAQ Database - FAQ #83 07/05/13) Q15: Will the FF-SHOP collect data regarding employees currently in their waiting period? Will these employees count toward the SHOP minimum participation requirement? A15: For initial FF-SHOP applications, any employee on the roster submitted by an employer will be eligible for coverage on the effective date of coverage for the group. Waiting periods will only be considered for new employees added to the roster after coverage has been effectuated for the group. (SHOP FAQ #2 07/05/13; REGTAP FAQ Database - FAQ #84 07/05/13) Q41: For the FF- SHOP, will Issuers have the ability to impose contribution rates, even though CMS is not setting a specific contribution amount? A41. No. Issuers will not have the ability to impose minimum contribution rates for (SHOP FAQ #2 07/05/13; REGTAP FAQ Database - FAQ #103 and #1033 07/05/13; updated 08/27/14) 02: Will minimum participation rates take into account employees who have coverage elsewhere? A2: Yes, minimum participation rate calculations will take into account employees that have coverage elsewhere. Generally, employees with other group coverage from a spouse, and those with public coverage, such as Medicare or Medicaid) will be excluded from minimum participation rate calculations. Employees with individual coverage, including Individual Marketplace coverage, will be included in minimum participation rate calculations. See 45 C.F.R. of the HHS Notice of Bene?t and Payment Parameters for 2014 for additional information on how minimum participation rates will be calculated in the (SHOP FAQ #3 07/30/13; REGTAP FAQ Database - FAQ #50 07/30/13) Q3: Does the FF-SHOP minimum participation requirement apply to stand-alone dental coverage? Updated 1-31-17 A3: No, the minimum participation rate provision in 45 C.F.R. applies only to comprehensive medical QHPs offered through the CMS does not intend for the FF-SHOP minimum participation requirements to apply to stand-alone dental coverage. Many of the adverse risk segmentation concerns that exist for medical plans do not apply to stand-alone dental plans. Unlike medical QHPs in the FF-SHOP, dental plan issuers may continue to adjust premiums to re?ect risk when pricing plans in 886 2017--00986 the FF-SHOP by redirecting employers to dental plan issuer sites for quoting and enrollment purposes. (SHOP FAQ #3 07/30/13; REGTAP FAQ Database - FAQ #51 07/30/13) Q4: Previously, it was mentioned that state minimum participation rates would be adhered to if a state's rate was higher than the FF-SHOP's default 70% rate. Is that still accurate or will all states participating in the FF-SHOP be required to adhere to the 70% participation rate? A4: Pursuant to 45 C.F.R. states participating in the FF-SHOP must follow the 70% minimum participation rate rule. However, if a State can provide evidence to CMS that either State law or wide-spread issuer practice dictates a rate higher or lower than the FF-SHOP's default rate, that State rate may be used in place of the 70% participation rate requirement. Based on information received to date from States, will use different minimum participation rates in the following States for 2014 and 2015: State State FF-SHOP Minimum Participation Rate Arkansas 75% Iowa 75% Louisiana 75% New Hampshire 75% New Jersey 75% South Dakota 75% Tennessee 50% Texas 75% (SHOP FAQ #3 07/30/13; REGTAP FAQ Database - FAQ #52 and #523 07/30/13; updated 08/27/14) 05: Will there be any contribution requirements for small groups that participate in the A5: No, minimum contribution rates will not apply in the FF-SHOP. In addition, issuers will not have the ability to impose minimum contribution rates for groups participating in the FF-SHOP. (SHOP FAQ #3 07/30/13; REGTAP FAQ Database - FAQ #53 07/30/13) 029: How will the minimum participation rate be effected if changes are made that impact the eligibility of the group? For example, what will happen if an employee cancels before group coverage is effectuated, resulting in a reduced participation rate? A29: Employers that no longer meet FF-SHOP eligibility criteria as described in 45 CFR 155.710 of the HHS Final Exchange Establishment Rule may no longer participate in the FF-SHOP. Minimum participation rates are calculated once a year at 887 Updated 1-31-17 2017--00987 the time of initial group submission and subsequently at the time of renewal. (SHOP FAQ #4 08/28/13; REG TAP FAQ Database - FAQ #33 08/28/13) Database?FAM34?08/2843) CMS removed this FAQ from the database on 08/26/14. Q: Will employers need to meet the minimum participation requirement upon renewal for renewals occurring from November 15-December 15? A: No. For operational and consumer consideration reasons, employers will not have to meet the FF-SHOP's minimum participation rate for renewals occurring during Nov. 15- Dec. 15. Because under guaranteed availability requirements at an employer must be allowed to purchase coverage from Nov. 15-Dec. 15, even if the employer cannot meet minimum participation requirements, we believe it would impose undue burden on issuers, employers, their employees, and the FF-SHOP to non-renew coverage under the exception to guaranteed renewability for failure to meet minimum participation rates and then re-enroll employers under guaranteed availability during this period. Therefore, the FF-SHOP will not impose (and QHP issuers offering coverage through the FF-SHOP may not enforce) minimum participation requirements for renewals occurring between Nov. 15-Dec. 15. (REGTAP FAQ Database - FAQ #574 12/11/13) Q: Are state-based SHOPs delaying open enrollment until January 2014 or later able to deny enrollment during 2014 to small employers that fail to meet minimum participation requirements? A: No. The exception to guaranteed availability allowing issuers to restrict enrollment for small employers that fail to meet minimum participation requirements requires that enrollment be available to such employers from Nov. 15-Dec. 15 of the preceding year. If that exception is not met, such as in the case of SHOPS that did not provide for open enrollment during that period for plans available in 2014, guaranteed availability requires that small employers, even those that fail to meet minimum participation requirements, be permitted to enroll at any point during 2014. (REGTAP FAQ Database - FAQ #575 12/11/13) Q: Do issuers enrolling employees in QHPs have to enforce the FF-SHOP minimum participation requirement for plan years beginning in 2014? Updated 1-31-17 A: SHOP regulations require issuers in the FF-SHOPs to use the minimum participation rate methodology and default 70% rate that is set forth in CMS regulations at 45 CFR (or any alternative de?ned minimum participation rate for a State as permitted by CMS regulations and posted on Reg-tap and HealthCare.gov). However, if an issuer conducting direct enrollment in the FF-SHOP in 2014 demonstrates to CMS that it would be operationally impracticable for it to apply the FF- SHOP minimum participation rate required by CMS regulations, CMS would not take any 888 2017--00988 adverse action against such an issuer for failing to impose the applicable minimum participation rate during the period that the issuer is implementing capability to comply with CMS regulations. If it would be operationally impracticable for an issuer to apply the FF-SHOP minimum participation rate, issuers would have the following options for plan years beginning in 2014: a) Do not impose a minimum participation rate; b) Use a minimum participation rate and methodology that is allowable in the relevant state small group market. If this option is used, the issuer may not deny enrollment to an employer group before contacting the SHOP Employer Call Center (1-800-706- 7893 or TTY: 1-800-706-7915) for a final determination of eligibility. Issuers may not deny enrollment to any employer group that is eligible to enroll in SHOP coverage and that meets the FF-SHOP minimum participation rate. The FF-SHOP will make a ?nal determination in such cases based on the minimum participation methodology and rates set forth in CMS regulations, and as further interpreted through guidance posted on Reg-tap and Healthcaregov. (REGTAP FAQ Database - FAQ #601 12/24/13) Q: When calculating participation percentages, are plans allowed to exclude eligible individuals that have other coverage through a spouse)? A: The FF-SHOP currently excludes from minimum rate calculations employees who are covered by another employer sponsored group health plan, a public insurance program, such as Medicare or Medicaid, or a health plan for enlisted military personnel. We ask issuers to contact the FF-SHOP Employer Call Center before they exclude a group from SHOP coverage, including when a group is unable to meet minimum participation rate requirements. (REGTAP FAQ Database - #739 02/10/14) Q: Does the 11/15-12/15 minimum participation rate waiver apply to off-Marketplace plans? Does it apply to standalone dental plans in A: Issuers both inside and outside the SHOP are not allowed to impose a minimum participation rate from 11/15 through 12/15. These rules do not apply to standalone dental plans in FF-SHOPs because they provide excepted benefits. (REGTAP FAQ Database - FAQ #908 03/05/14) Q: Outside of the window, how will minimum participation rates be tracked? Will the issuer or FFM be responsible for calculating participation rates? A: Minimum participation rates in FF-SHOPs are only calculated at the time of initial enrollment (and upon renewal outside of The FFM is responsible for calculating participation rates for plan years beginning on and after January 1, 2015. (REGTAP FAQ Database - FAQ #909 03/05/14) Q: Are there any minimum contribution requirements for employers participating in FF A: No, there are no minimum contribution requirements in FF-SHOPs. However, eligible employers must contribute at least 50% in order to claim the expanded small business healthcare tax credit. (REGTAP FAQ Database - FAQ #914 03/05/14) 889 Updated 1-31-17 2017--00989 Q: How will the FF-SHOP's minimum participation rate work in 2015? Will employers have to meet the default 70% minimum participation rate overall, and there are no minimum participation rates for each Issuer and/or Does this mean issuers could get only one employee for an employer group? A: CMS regulations require the FF-SHOP to calculate minimum participation rates at the level of the at the level of an Issuer or QHP. Thus, an Issuer may only receive one employee from an employer group. (REGTAP FAQ Database - #1566 05/08/14) Q: When can businesses sign up for SHOP Marketplace coverage without having to meet the minimum participation rate requirement? A: From November 15 through December 15 of each year, small employers that are interested in enrolling in SHOP Marketplace coverage can do so without needing to meet the minimum participation rate requirement for their state. (REGTAP FAQ Database - FAQ #15710 05/02/16) Q: Small businesses were able to enroll in the SHOP Marketplace without meeting the Minimum Participation Rate requirements during the requirement waiver period, but can the health issuers terminate the small business for non-participation upon renewal? A: In the SHOP Marketplace, the Minimum Participation Rate is calculated upon initial enrollment and upon renewal. If a small business drops below the Minimum Participation Rate throughout the year, it is still eligible to participate in the SHOP Marketplace. (REGTAP FAQ Database - FAQ #15717 05/02/16) Q: Can you provide an example of how the new Minimum Participation Rate (MPR) calculation works in the SHOP Marketplace? A: In most states, 70% of employees offered coverage must accept the offer of coverage in order for an employer to enroll in SHOP Marketplace coverage. For plans beginning in 2016, an employer's MPR in the SHOP Marketplace will be calculated by taking the number of employees enrolled in health coverage, either on or off the SHOP Marketplace, divided by the number of employees who were offered SHOP Marketplace coverage. For example, an employer offering SHOP Marketplace coverage to 10 full- time employees, two of which are enrolled in coverage through a spouse and one is covered by Medicare for a total of three employees declining SHOP Marketplace coverage. In this example, only four employees must accept SHOP Marketplace coverage to meet the 70% MPR. HealthCare.gov offers an MPR Calculator to help small employers and the agents or brokers assisting them to predicted whether the employers will meet the participation rate for their state. (REGTAP FAQ Database - FAQ #15721 05/02/16) Q: Can an employer go through the SHOP Marketplace and choose a plan for employees without paying any portion of employees' premiums since there is no requirement to do so? A: The SHOP Marketplace gives employers control when it comes to their health and dental costs for their business. There is no employer premium contribution requirement to participate in the SHOP Marketplace, although some states have contribution 890 Updated 1-31-17 2017--00990 requirements in place for small group coverage. To ?nd out more, work with your agent or broker or contact your state Department of Insurance. (REGTAP FAQ Database - FAQ #16155 05/27/16) Q: When can businesses sign up for Small Business Health Options Program (SHOP) Marketplace coverage without having to meet the Minimum Participation Rate (MPR) requirement? A: Small businesses that are interested in enrolling in SHOP Marketplace coverage can enroll between November 15 and December 15 of each year without being required to meet the MPR requirement. In most states, the general rule is that 70% of employees must accept the offer of SHOP Marketplace coverage or be enrolled in other quali?ed health coverage for a group to participate in a SHOP Marketplace. The MPR Calculator is available to help employers predict if they will meet the MPR required to enroll in the SHOP Marketplace mgr/l. (REGTAP FAQ Database - FAQ #17975 10/28/16) Q: Will an employer be accepted into the Small Business Health Options Program (SHOP) Marketplace during the Minimum Participation Rate (MPR) waiver period (November 15 to December 15) if the only members enrolling in the plan are the owner and the spouse? A: No; to qualify, small employers must still meet the requirement to have at least one employee enrolling in coverage who is not an owner, co-owner or spouse of an owner or co-owner. (REGTAP FAQ Database - FAQ #17976 10/28/16) SHOP Enrollment/834 Q1: When will the final FFE (SHOP) Ground Enrollment layout be released? Could you provide a URL of where it will be posted? A1: Further guidance on group enrollment will be released shortly. (QHP SHOP FAQ 05/21/13) 891 Updated 1-31-17 2017--00991 Q2: Do the enrollment scenarios provided include all requirements for the issuers in terms of handling enrollment? If not, can we get all of the requirements and edits from the Companion Guide? A2: No, the enrollment scenarios do not provide all the requirements for issuers to handle every enrollment situation. Furthermore, the purpose of the Companion Guide is to assist issuers to successfully send a compliant 834 enrollment transaction when used in conjunction with the ASC X12 834 Bene?t Enrollment and Maintenance Transaction Implementation Guide/TR3 Version 5010. The Companion Guide provides speci?c rules for certain fields and data elements so that the 834 enrollment transaction can be used in the Marketplace, whether for individual or SHOP enrollment. (QHP Webinar Series SHOP FAQ #1 06/20/13; REGTAP FAQ Database - FAQ #106 06/20/13) Q4: Will you be releasing a SHOP-specific 834 Companion Guide? A4: No, the Enrollment Companion Guide includes individual and SHOP instructions (QHP Webinar Series SHOP FAQ #1 6/20/1; REG TAP FAQ Database - FAQ #108 06/20/13) Q14: In 45 CFR 156.270 of the Exchange Final Rule, it states that the QHP issuer is responsible for sending the enrollee a notice of termination of coverage that includes the reason for termination at least 30 days prior to the last day of coverage. Within the 834 Enrollment Companion Guide, it does not specify the codes that the FFE will transmit in the 2000 Loop INSO4. Will the FFE establish standard codes that will be transmitted for the termination reason? Will these codes be included in the next version of the companion guide? A14: Yes, the FFM will identify the codes for termination reasons, and will include these in future versions of the Companion Guide. Please check the CCIIO website at for the most recent copy of the Companion Guide. (QHP Webinar Series SHOP FAQ #1 06/20/13; REGTAP FAQ Database - FAQ #118 06/20/13) Q15: Will the FF-SHOP send 834 enrollment transactions prior to the issuer effectuating the group? A15: Yes, the FF-SHOP will send 834 enrollment transactions to the issuer prior to effectuation of groups in the FF-SHOP. (QHP Webinar Series SHOP FAQ #1 06/20/13; REGTAP FAQ Database - FAQ #119 06/20/13) 892 Updated 1-31-17 2017--00992 Q16: Will issuers be required to effectuate the group for year 1 and re-evaluate their enrollment for year 2? A16: The FF-SHOP makes all eligibility determinations and will pass this information on to participating QHP issuers. Similarly, annual renewals will be facilitated by the FF- SHOP. (QHP Webinar Series SHOP FAQ #1 06/20/13; REG TAP FAQ Database - FAQ #120 06/20/13) Q17: Will the marketplace enforce a minimum group size? For example, we cannot underwrite an Employer with less than 10 employees (by state statute) irrespective of the participation rate. A17: Our final regulations do not give us authority to enforce a minimum group size. However, as established in the Final Payment Notice, we are enforcing a 70% default minimum participation rate for the FF-SHOP. See (QHP Webinar Series SHOP FAQ #1 06/20/13; REG TAP FAQ Database - FAQ #121 06/20/13) Q18: What is the expected turnaround time from submission of group information to the issuer to group enrollment? A18: Group information will be submitted to the issuer two weeks before the effective date of coverage for the FF-SHOP. (QHP Webinar Series SHOP FAQ #1 06/20/13; REG TAP FAQ Database - FAQ #122 06/20/13) removed this FAQ from the REG TAP database on 09/02/14 022: In the group file request and response, the plan max occurrence is Are we getting multiple QHPs one request? A22: The group enrollment ?le IS employer and issuer speci?c and supports multiple plans from a single Issuer. - . - . ?le. (QHP Webinar Series? SHOP FAQ #1 06/20/13; REGTAP FAQ Database- FAQ #126 and #126a 06/20/13, updated 08/27/14) 893 Updated 1-31-17 2017--00993 026: If a QHP is added to a group in a subsequent group enrollment file, do you expect the original issuer group ID or a new one? A26: For the FF-SHOP, the decision to use original issuer identi?ers or new identifiers in future group enrollment files is based on the issuer?s preferences for maintaining continuity and tracking purposes. Any new numbers will need to be cross walked to the original number for reporting purposes, so issuers will need to be prepared to report on original identi?ers as well as new ones, and to be able to link those numbers for purposes of reporting and tracking. (QHP Webinar Series SHOP FAQ #1 06/20/13; REG TAP FAQ Database - FAQ #130 06/20/13) 027: How will we be notified of group size and employee status (retired, etc.) to effectively process Medicare? A27: We expect to provide information about group size and employee status in the group enrollment file and 834 enrollment ?le transfers. (QHP Webinar Series SHOP FAQ #1 06/20/13; REGTAP FAQ Database - FAQ #131 06/20/13) 028: Issuers need more clarification about the group information being sent using 834 (since 8343 are for membership, not group). Is there a companion guide or something that defines what segments/loops are going to be used to communicate group data? A28: CMS has provided information about the enrollment transaction, its contents, format and data elements through a variety of webinars and issuer calls. An updated version of the Group Enrollment File is being prepared and will be sent to issuers by late June or early July. (QHP Webinar Series - SHOP FAQ #1 06/20/13) Q30: Does an issuer ever receive a copy of the group application submitted to the FF- A30: Group enrollment information will be sent to the issuer prior to the coverage effective date, but the issuer does not receive a copy of an employer?s group application. (QHP Webinar Series SHOP FAQ #1 06/20/13; REG TAP FAQ Database - FAQ #133 06/20/13) Q31: How will an Issuer know how many people are enrolled in a group? We need this information in order to determine whether or not a small group has paid in full. A31: Premium information for each employee associated with a group will be sent to issuers on a regular basis via 834 enrollment transactions. (QHP Webinar Series SHOP FAQ #1 06/20/13; REGTAP FAQ Database - FAQ #134 06/20/13) 894 Updated 1-31-17 2017--00994 Q38: Will issuers receive a sample 834 ?le? And when will they be available? A38: Yes, sample 834 ?les will be made available through the testing and EDI work groups. For details about these groups and to participate in testing, contact the Help Desk at feps@cms.hhs.qov (QHP Webinar Series SHOP FAQ #1 06/20/13; REG TAP FAQ Database - FAQ #136 06/20/13) CMS removed this FAQ from the REGTAP database on 08/26/14 the REGTAP database on 08/26/14. Q1: How will the FF-SHOP prevent a new group from enrolling into an HMO plan when out-of-state? A1: There will not be a mechanism in place in 2014 or 2015 to prevent an employer from enrolling in a plan without network access. There will be a comparison tool on HealthCare.gov providing plan-specific information to enrollees. Employers and employees will be able to navigate to Issuers? websites for provider network information. CMS will work with Issuers to ensure educational information is provided to employers about the consequences of selecting a QHP for their employees that does not provide network access for an out-of-state employee?s primary worksite. (SHOP FAQ #2 07/05/13; REGTAP FAQ Database - FAQ #70 and #70a 07/05/13; updated 08/27/14) Q12: In cases where an employer is reapplying for coverage, and employees apply after the close of the employer?s open enrollment period, will all the other employees that previously applied need to reapply? A12: When a new offer of coverage is made, employees will need to reapply for coverage and respond to the new offer. However, any information saved during the initial application will remain saved and the employee can use this information when reapplying for FF-SHOP coverage. (SHOP FAQ #2 07/05/13; REG TAP FAQ Database - FAQ #81 07/05/13) Q18: In the March 27, 2013 webinar called ?Enrollment in the Federally Facilitated-SHOP Market? webinar, a new value is being sent in the 2750 loop - REQUEST SUBMIT TIMESTAMP. This value is not mentioned in the Companion Guide. What does this value represent? Should it be returned on the ASC X12 834 confirmations? If yes, should it be the same date/time as received on the inbound 834 to the carrier? A18: This data element will be included in the next version of the Companion Guide. It is the SUBMIT CurrentTimeStamp. This timestamp is captured at the time the Application Filer selects and presses the button on their enrollment choice. The timestamp was added to help maintain the correct order of transactions in daily ?les. (Enrollment FAQ #3 07/03/13; REGTAP FAQ Database - FAQ #158 07/24/13) 895 Updated 1-31-17 2017--00995 Q17: Employer Paid Amount: Is the employer paid amount a dollar amount or a percentagethe otherthe other, how is that designated on the 834 file? A17: The employer paid amount or employer responsibility amount is a dollar amount. Details about this field can be found in Section 9.6.2 SHOP Market: 2750 Member Reporting Categories Loop, Table 14. In the ASC X12 834 enrollment transaction, the SHOP Member Reporting Category Loop lists the format of the employer paid amount as: (Enrollment FAQ #3 07/03/13; REGTAP FAQ Database - FAQ #157 07/24/13) Q8: Will the termination dates for enrollees be populated on the ASC X12 834 enrollment transaction file or will they remain open until enrollees terminate? A8: No termination dates are sent on initial enrollment transactions. The termination date field in the ASC X12 834 enrollment transaction file will remain open until the enrollment is terminated. (SHOP FAQ #3 07/30/13; REGTAP FAQ Database - FAQ #55 07/30/13) Q9: Because CMS will not send the employer group number when issuers receive the original ASC X12 834 enrollment transaction file, how will issuers know which group to categorize them under? A9: Issuers may link Group enrollment information with ASC X12 834 enrollment transaction ?les using the Employer Identification Number (EIN). (SHOP FAQ #3 07/30/13; REGTAP FAQ Database - FAQ #56 07/30/13) Q10: A previous response stated that changes to enrollment and other member- level changes will be handled through the ASC X12 834 enrollment transaction. Will other changes at the group level be sent via an XML file broker, group contact information, etc.)? A10: When employer-level information included in the original Group Enrollment XML ?le changes, the updated information will be transmitted to the issuer via a subsequent Group Enrollment XML ?le. (SHOP FAQ #3 07/30/13; REGTAP FAQ Database - FAQ #57 07/30/13) Q12: Will the ASC X12 834 enrollment transactions contain the issuer?s group number? A12: Initial ASC X12 834 enrollment transactions sent by the FF-SHOP to a QHP issuer will not contain the issuer's Policy ID, as the FF- SHOP will not yet possess this data. The initial ASC X12 834 enrollment transaction will include an exchanqe- assigned a temporary Policy ID, generated by the FF- SHOP. Subsequent SHOP generated ASC X12 834 enrollment transactions for a group' policy will include the exchanqe assiqned Policy ID and issuer-generated Policy ID (once effectuation transaction is sent to FF- SHOP by issuers). (SHOP FAQ #4 08/28/13; REGTAP FAQ Database - FAQ #16 08/28/13; revised as FAQ #16a on 03/23/15) 896 Updated 1-31-17 2017--00996 this FAQ from the REGTAP database on 08/26/14. Q15: On the ASC X12 834 enrollment transaction, will CMS use the qualifier '1 group or policy number information) in the 2000 Loop in the member policy number segment? A15: No, the value note/segment indicates the submitter sent the payer's pre-assigned group or policy number. (SHOP FAQ #4 08/28/13; REGTAP FAQ Database - FAQ #19 08/28/13) Q16: Are SHOP ASC X12 834 enrollment transactions contained in the same files as ASC X12 834 enrollment transactions for individuals? A16: No, ASC X12 834 enrollment transactions related to FF-SHOPs will be sent separately from ASC X12 834 enrollment transactions for individuals. (SHOP FAQ #4 08/28/13; REGTAP FAQ Database - FAQ #20 08/28/13) CMS removed this FAQ from the REGTAP database on 08/26/14. 020: Are batched ASC X12 834 enrollment transactions all sent together? For example, are termination 834 transaction files, update 834 transaction files, and new enrollment 834 transaction ?les all sent together? A20: Yes, ASC X12 834 enrollment transactions are batched together by QHP ID. (SHOP FAQ #4 08/28/13; REG TAP FAQ Database - FAQ #24 08/28/13) 897 Updated 1-31-17 2017--00997 025: During the annual November 15th - December 15th special enrollment period (when no minimum participation rate will be calculated), will the FF-SHOP send issuers a single enrollment ?le or will enrollment files be sent piecemeal as employees enroll? A25: The Group Enrollment XML ?le transaction and associated ASC X12 834 enrollment transaction will not be sent until after the group's enrollment period has expired or all employees have responded to the offer of coverage. Thus, issuers will not be receiving ASC X12 834 enrollment transactions in a piecemeal manner. (SHOP FAQ #4 08/28/13; REG TAP FAQ Database - FAQ #29 08/28/13) 026: Since the FF-SHOP allows a rolling open enrollment period, will all the ASC X12 834 enrollment transactions be held until December 15th for January 1st coverage? A26: The transmission of SHOP enrollments, including Group Enrollment XML ?le transactions and ASC X12 834 enrollment transactions will start when open enrollment begins. Thus, the transmission of this information will not be held until December 151 2943? (SHOP FAQ #4 08/28/13; REGTAP FAQ Database - FAQ #30 and #30a 08/28/13; updated 08/27/14) Q31: Will the FF-SHOP provide women's preventive benefit information on the Group Enrollment XML file transaction sent to issuers? A31: No, the Group Enrollment XML ?le transaction will not contain information regarding this benefit. An issuer will need to communicate information regarding this bene?t directly with the group plan's administrator. (SHOP FAQ #4 08/28/13; REG TAP FAQ Database - FAQ #35 08/28/13) Q15: For SHOP, will there be a Payment Transaction ID on the Employer Group Enrollment transaction? Updated 1-31-17 A15: Yes, the Payment Transaction ID has been added to the Employer Group Enrollment XML file format, in version 13. This was posted on the on June 17, 2013. (Enrollment FAQ #7 Premium Payment Redirect 09/17/13; REG TAP FAQ Database - FAQ #202 09/09/13) 898 2017--00998 Q: For new FF-SHOP enrollments, are issuers able to collect the same documentation they ordinarily request for off-Marketplace enrollments, such as proof of the Federal Tax Identification Number (TIN), waiver forms for full-time employees, and quarterly wage details? A: Issuers may not ask for any more information from employers and employees seeking FF-SHOP coverage than is necessary to enroll quali?ed employees in a QHP or QDP. Until FF-SHOP online functionality is available, issuers may follow the enrollment process they currently use in the small group market to enroll FF-SHOP employer groups, so long as those processes are consistent with CMS requirements regarding FF- SHOP enrollment. (REGTAP FAQ Database - FAQ #651 01/16/14) Q: Can FF-SHOP QHP and QDP issuers work directly with employers to set enrollment timeframes and coverage effectuation dates? A: Issuers of QHPs and QDPs in the FF-SHOPs must adhere to policy on effectuating coverage by the first of the month if enrollment is completed by the enrollment deadline (generally the 15th of the month). However, issuers may extend enrollment deadlines beyond the 15th of the month as long as this flexibility is provided consistently to all applicants seeking coverage. (REGTAP FAQ Database - FAQ #657 01/16/14) Q: Does an employer contact the issuer directly to add employees or to make coverage changes in FF-SHOP coverage before the FF-SHOP begins accepting enrollments through the FF-SHOP website? A: Yes, employers should contact the issuer or agent/broker directly to make any changes in enrollment before the FF-SHOP begins accepting enrollments through the FF-SHOP website. (REGTAP FAQ Database - FAQ #661 01/16/14) Q: Are issuers expected to send enrollment files to the A: Yes, CMS regulations require issuers to reconcile enrollment files with the FF-SHOP. CMS will communicate the format of the ?le in the near future. (REGTAP FAQ Database - FAQ #662 01/16/14) Q: May issuers wait for an eligibility determination before enrolling a group in FF-SHOP coverage? A: Issuers may con?rm a group enrolling is eligible for FF-SHOP by contacting the SHOP Employer Call Center or by asking an employer to provide a copy of its FF-SHOP eligibility determination. As a reminder, an employer may enroll in a SHOP QHP prior to receiving an eligibility determination. (REGTAP FAQ Database - #740 02/10/14) Q: We've received tax credit information on an employer with 10 employees but only 8 enrolled. Do we go ahead and process the SHOP enrollment for 8 employees? What about the reverse (8 on application, 10 enroll)? A: Issuers do not administer the small business healthcare tax credit. 100% of employees offered coverage do not have to participate in order to enroll a group in FF- SHOP coverage. If more people enroll than what was originally on an employer's group 899 Updated 1-31-17 2017--00999 application, it is reasonable for the issuer to follow-up with the group to understand the discrepancy. (REGTAP FAQ Database - #741 02/10/14) Q: Where is it outlined what proof is required from a small group to enroll on the FFM A: Issuers are not required to collect any proof from a small employer prior to enrollment. Our SHOP eligibility application is available online at On the application, there are 4 attestation questions that employers have to agree to before the FF-SHOP is able to make an eligibility determination. Issuers may have employers attest to these eligibility requirements as well. (REGTAP FAQ Database - #742 02/10/14) Q: If an earlier version of the EDI form was completed, and we are a SHOP-only carrier, do we follow the "not completed" workflow? A: The only reason to complete a new Version 3.1 EDI Registration form is to obtain the Group Payee Number assigned to the issuer's organization(s) for the payments fees that are generated from the Financial Management (FM) area. (REGTAP FAQ Database - FAQ #1412 04/14/14) Q: Is the excel template only to gather FF-SHOP enrollment or also FFM enrollment information? A: The excel template is for FF-SHOP only. (REGTAP FAQ Database - FAQ #1413 04/14/14) Q: On the EDI form, how do we specify SHOP registration vs. Individual Marketplace registration? A: If an issuer chooses to group FF-SHOP products separately from Individual Marketplace Products, the issuer may do so by submitting two separate forms and requesting that there be a different suffix used for distinguishing the separate marketplaces (FF-SHOP versus Individual Marketplace). (REGTAP FAQ Database - FAQ #1414 04/14/14) Q: Can you confirm that 834 transactions will not be sent to issuers until an employee has made his or her plan selection and that the enrollment transaction will include the coverage effective date? A: Correct. 834 transactions will not be sent until an employee has made his or her plan selection, and the coverage effective date will be included in the 834 transaction. (REGTAP FAQ Database - FAQ #1422 04/14/14) Q: Where can issuers find the relationship codes referenced- ASC X12 834 Is the expectation that Issuers will send the closest match up to the CMS list of codes? A: CMS has updated the file template with new codes. Valid values now include: 01 - Subscriber, 02 - Spouse, and O3 - Dependent. (REGTAP FAQ Database - #1584 05/13/14) 900 Updated 1-31-17 2017--01000 Q: How many types of changes can a member report in their enrollment application? A: Enrollees can make multiple changes in a single enrollment application. (REGTAP FAQ Database - #1598 005/16/14) Q: How soon after an employee makes a plan selection will the Data Services Hub validate and send the enrollment data to the issuer? A: The Federally-facilitated Small Business Health Options Program (FF-SHOP) enrollment system holds employee plan selections until after an employer has completed the initial group enrollment process. Once this process is complete, the HUB will validate enrollment data and send files immediately to issuers. (REGTAP FAQ Database - #1980 05/30/14) Q: If an enrollee accidentally chose the wrong plan and needs to change to the correct plan with the same effective date as the original plan, would this change be a cancellation and addition? A: If the employee enrollment period is still open, an employee may change his or plan selection. After the employer has submitted the ?nal group enrollment, the only way to change a plan is for the employee to qualify for a special enrollment period. (REGTAP FAQ Database - FAQ #1996 5/30/14) Q: If a subscriber or member was enrolled in the Federally-facilitated Marketplace (FFM) and later enrolls in the Federally-facilitated Small Business Health Options Program (FF- SHOP), will the Subscriber ID or Member ID transfer to the A: No, numbers assigned by the FFM Individual Marketplace will not carry over to the FF-SHOP. (REGTAP FAQ Database - FAQ #2413 06/26/14) Q: Are the Centers for Medicare Medicaid Services (CMS) expecting all listed N1 associated information, such as the Application ID and Origin? In previous versions of the Companion Guide, these elements were not listed. A: The effectuated transaction has to return all the values passed in the initial ?le. The ID AND was not included in the previous version of the Companion Guide. These are new elements to the 2750 Loop. (REGTAP FAQ Database - FAQ #2416 06/26/14) Q: If a group does not pay the initial premium payment at initial submission, what Transaction ID would the issuer use to match the 834 transaction file? A: The Payment Transaction ID is a unique identi?er generated by the Federally- facilitated Small Business Health Options Program (FF-SHOP) upon initial enrollment, whether or not a payment is made at the time a group submits its final application for coverage. (REGTAP FAQ Database - FAQ #2419 06/26/14) 901 Updated 1-31-17 2017--01001 Q: Will the Federally-facilitated Small Business Health Options Program (FF-SHOP) separate segment values with or with as is currently used in 834 enrollment transactions in the A: The X12 ?les will use a separator element. The May 27, 2014 Federally- facilitated Small Business Health Options Program (FF-SHOP) Webinar slides only used the separator as an example. (REGTAP FAQ Database - FAQ #2420 06/26/14) Q: Will each functional group in the 834 for the Federally-facilitated Small Business Health Options Program (FF-SHOP) have transactions for a single Qualified Health Plan (QHP) A: Yes, transactions are grouped by the first 14 digits of the QHPID and belong to the same functional group. Every Functional Group will represent a unique 14 digit QHPID. (REGTAP FAQ Database - FAQ #2433 06/26/14) Q: Will 834 transactions for employees and dependents included in an issuer's daily batch process, or will the 834's be sent in real time? A: 834 enrollment transactions for employees and dependents are batched daily as a separate ?le in the Federally-facilitated Small Business Health Options Program (FF- SHOP) Marketplace. (REGTAP FAQ Database - FAQ #2857 07/16/14) Q: What is the definition of an 'enrollment group' in the Federally-facilitated Small Business Health Options Program does a group include members of an employer plan, or family members? A: Enrollment groups in FF-SHOPs include the employee and all enrollees in the employee's family group. (REGTAP FAQ Database - FAQ #2889 07/16/14) Q: Does the Federally-facilitated Small Business Health Options Program (FF-SHOP) require a response from an issuer after successful installation of a group? A: The FF-SHOP does not expect an issuer to send a group-level response after successful installation of a group. However, the FF-SHOP does require issuers to send effectuation 834 responses. (REGTAP FAQ Database - FAQ #3003 07/25/14) Q: How often will the Federally-facilitated Small Business Health Options Program (FF- SHOP) send 834 files to FF-SHOP issuers? A: The FF-SHOP will send 834 transaction files to issuers once per day (around 6PM EST), Monday through Friday. (REGTAP FAQ Database - FAQ #3456 08/01/14) Q: What will be the Sender ID at the interchange level for SHOP 834s A: The Centers for Medicare Medicaid Services (CMS) will use as the Sender ID for SHOP 834 transactions going to issuers. This is the same Sender ID used in the Individual Marketplace. (REGTAP FAQ Database - FAQ #3774 08/14/14) 902 Updated 1-31-17 2017-?01002 Q: The updated Companion guide states 'Financial Change' is transmitted in case of any change in amount fields due to any change in the contract. For the Small Business Health Options Program (SHOP), how will the FF-SHOP send this information to issuers? 1. ADD the new member 2. TERM transaction for existing contract 3. ADD with new effective date and with existing Member in Contract? A: Any life change, such as birth or marriage, which changes the premium of either the dependent or subscriber will be sent as 'Financial Change' as part of 'AdditionalMaintanenceReason'. (REGTAP FAQ Database - FAQ #3775 08/14/14) Q: Will the Federally-facilitated Small Business Health options Program (FF-SHOP) send waived employees on the 834 transaction along with the reason an employee is waiving coverage? A: No, the FF-SHOP will not send this information to issuers. (REGTAP FAQ Database - FAQ #3784 08/14/14) Q: Will employers have the option of allowing a 90-day waiting period? Will the intake form capture information about eligibility requirements or will the employer add eligibility date and hire date for new employees? A: To ensure an employer does not go over 90 days (because new hire coverage effective dates are always the first of the month following the waiting period), the available options for waiting periods aredays. The application will capture new employee hire date and determine the effective date of coverage based on the new hire waiting period policy established by the employer at the time of initial enrollment. (REGTAP FAQ Database - FAQ #3780 08/14/14) Q: What should an issuer do if the issuer receives a new Small Business Health Options Program (SHOP) group enrollment for an employer with an out-of-state business address? A: The Federally-facilitated Small Business Health Options Program (FF-SHOP) system has checks in place to prevent this scenario from occurring. Issuers may always contact the SHOP Call Center at 1-800-706-7893 (prompt with questions about 834 transactions received. (REGTAP FAQ Database - FAQ #4196 09/02/14) Q: What information will the Federally-facilitated Small Business Health Options Program (FF-SHOP) include in the ISA06 element on the 834 file? A: ISA06 value for the SHOP market will be the same as the Individual market. The value is (REGTAP FAQ Database - FAQ #4207 09/02/14) 903 Updated 1-31-17 2017--01003 Q: Will issuers receive two daily incremental 834 transactions, one for Individual Market and one for the Small Business Health Options Program If so, will the Centers for Medicare Medicaid Services (CMS) expect issuers to send two daily outbound transactions in return? A: Yes, CMS will send two (2) files for 834 transactions every day (one for SHOP and one for Individual Market). CMS expects to receive the con?rmation 834 ?les and the 999 ?les separately for each Marketplace. (REGTAP FAQ Database - FAQ #4209 09/02/14) Q: Will the Federally-facilitated Small Business Health Options Program (FF-SHOP) send initial enrollments and maintenance enrollments in a single 834 transaction file? A: Yes, issuers will receive one physical file at the end of the day (similar to the Individual Marketplace) containing all the initial enrollments and changes in the SHOP Marketplace for the issuer's plans. (REGTAP FAQ Database - FAQ #4210 09/02/14) Q: Will the Centers for Medicare Medicaid Services (CMS) expect Federally-facilitated Small Business Health Options Program (FF-SHOP) issuers to accept all transaction files (834 and XML) at all hours and days? A: The Centers for Medicare Medicaid Services (CMS) plans to deliver SHOP 834 files during the same timeframe as that of the Individual Marketplace (Sometime between 6 pm. - 9 pm). However, CMS will not send 834 ?les on weekends. CMS plans to send employer-level transactions (Group XML ?les) Monday through Friday from 8 am. to 6 pm. (REGTAP FAQ Database - FAQ #4429 09/05/14) Q: In the sample 834, how will the Federally-facilitated Small Business Health Options Program (FF-SHOP) arrange members of a family inside the functional group (GS) and transaction set and for multiple employers? A: The Centers for Medicare Medicaid Services (CMS) will group the enrollments based on the 14 characters of the Qualified Health Plan (QHP) ID at the GS level. CMS will send employee information in the ST-SE level. The member information will repeat as 2000 Loops within the ST-SE level. Please note, there could be multiple employees belonging to different employers under the same GS-GE. (REGTAP FAQ Database - FAQ #4433 09/05/14) Q: Can an FF-SHOP issuer receive an and file for the same member on the same day? A: While theoretically possible, the Centers for Medicare Medicaid Services (CMS) expects this scenario will be extremely rare in the Federally-facilitated Small Business Health Options Program (FF-SHOP) Marketplace. (REGTAP FAQ Database - FAQ #4436 09/05/14) 904 Updated 1-31-17 2017--01004 Q: If an employee makes changes to plan selection multiple times in the FF-SHOP, will the issuer see all plan selections or only the most recent plan when the 834 enrollment transaction is sent? A: Once an employee chooses a plan and the information is transmitted to an issuer, the employee is not able to choose a different plan during a plan year outside of a special enrollment period (SEP). It is possible, however, for an employee to have multiple ?les sent throughout the day. For example, an employee could enroll and then make a change to a phone number or address that would trigger a separate maintenance transaction. When this happens, the Federally-facilitated Small Business Health Options Program (FF-SHOP) will send both transactions separately. (REGTAP FAQ Database - FAQ #4437 09/05/14) Q: Does the Federally-Facilitated Small Business Health Options Program (FF-SHOP) intend to use the Health Insurance Casework System (HICS) for 834 transactions not supported on Day 1? A: The FF-SHOP will support transactions such as: - employee name change - updates to Date of Birth (DOB), Social Security Number (SSN), and gender The FF-SHOP will communicate these changes to issuers through 834 maintenance transactions. Thus, the FF-SHOP does not intend to use HICS for this purpose. If the Agency's thinking on this matter changes, the Centers for Medicare and Medicaid (CMS) will inform issuers in a timely manner. (REGTAP FAQ Database - FAQ #4679 09/11/14) Q: Do Federally-facilitated Small Business Health Options Program (FF-SHOP) issuers need to send effectuation 8345 for new hires and new members with existing FF-SHOP groups? A: FF-SHOP issuers must send effectuation 834 transactions whenever a new enrollee is added to a group's plan. (REGTAP FAQ Database - FAQ #5344 10/03/14) Q: Will each Small Business Health Options Program (SHOP) policy have the policy's own ST-SE and the entire groups ST-SE's rolled up under one A: Every 834 ST-SE will hold the employee and his or her dependent information. The enrollments for the plans that contains the ?rst 14 characters of the Quali?ed Health Plan (QHP) in common will be in the same GS-GE. (REGTAP FAQ Database - FAQ #5505 10/09/14) Q: If a newborn child would be the fourth (4th) dependent on a plan, would issuers receive a ?nancial change on the 834 transaction since a fourth dependent does not pay a premium? A: When a newborn child is not charged, the Federally-facilitated Small Business Health Options Program (FF-SHOP) will still send a ?nancial change on the 834 transaction. (REGTAP FAQ Database - FAQ #5507 10/09/14) 905 Updated 1-31-17 2017--01005 Q: What relationship code will the Federally-facilitated Small Business Health Options Program (FF-SHOP) use for Other Relationship Type on the 834: G8 or 69? A: The FF-SHOP will use G8 for other relationships. (REGTAP FAQ Database - FAQ #5513 10/09/14) Q: Are all shared transactions sent on the same file? A: If the transactions were sent on the same day by the Federally-facilitated Small Business Health Options Program (FF-SHOP) and have the same Quali?ed Health Plan (QHP) ID, then the FF-SHOP will send the transactions to issuers on the same file. (REGTAP FAQ Database - FAQ #8029 12/03/14) Q: Will the Centers for Medicare Medicaid Services (CMS) send a DMG segment in the Federally-facilitated Small Business Health Options Program (FF-SHOP) change transactions? A: CMS will not send a DMG segment in change transactions except for Date of Birth (DOB) or gender change. (REGTAP FAQ Database - FAQ #8031 12/03/14) O: For the Federally-Facilitated Small Business Health Options Program (FF-SHOP) inbound enrollment reconciliation file from issuers, issuers can put more than one Health Insurance Oversight System Identification (HIOS ID) in a single file, but Centers for Medicare and Medicaid Services (CMS) is requesting a total. Does CMS want detail records for HIOS ID followed by the total, then detail records for next ID, or all detail records followed by all totals? A: All total records (02) are expected to be placed at the end of the ?le after the detail records. (REGTAP FAQ Database - FAQ #10984 06/16/15) Q: What Federally-facilitated Small Business Health Options Program (FF-SHOP) 834 transactions will contain an enrollee's Date of Birth A: DOB is present on initial enrollment, cancellation, termination, gender change and DOB change transactions. (REGTAP FAQ Database - FAQ #11266 07/09/15) Q: When will the Federally-facilitated Small Business Health Options Program (FF-SHOP) Open Enrollment window begin for the 2016 Plan Year? When will issuers receive the first Open Enrollment/Renewal files? A: There is no de?ned Open Enrollment period for employers enrolling in FF-SHOPs. Employers may enroll at any time throughout the year. Issuers may receive 2016 files as early as November 1, 2015 for new enrollments, and about a week later for renewals (as employers must give employees at least seven (7) days to pick a plan for renewals). (REGTAP FAQ Database - FAQ #12162 08/27/15) 906 Updated 1-31-1 7 2017--01006 Q: When can Federally-facilitated Small Business Health Options Program (FF-SHOP) issuers expect to receive an acknowledgement response for an X12 834 effectuation file submitted in production today? A: FF-SHOP issuers can expect to receive responses to their X12 834 effectuations the same day. The responses are generated and sent back as soon as a ?le is received. (REGTAP FAQ Database - FAQ #12823 09/11/15) Enrollment - Dependents 025: If a subscriber already has insurance as a dependent, are they still eligible to obtain additional insurance via the A25: Yes, if an individual has insurance as a dependent, but is also eligible to obtain insurance through the SHOP, s/he may obtain additional insurance through the FF- SHOP. In this scenario, insurance industry coordination of bene?ts rules in a State would apply. (QHP Webinar Series SHOP FAQ #1 06/20/13; REG TAP FAQ Database - FAQ #129 06/20/13) Q: Is the permissible dependent mapping of domestic partner to life partner mandatory or optional on the Small Business Health Options Program A: The FF-SHOP enrollment system standardizes allowable dependents, and domestic partner coverage is one of the available options. When establishing their offer of coverage, employers determine if they will offer coverage to opposite sex and/or same sex domestic partners. Depending on the employer's offer of coverage, an employee may or may not be able to offer coverage to his or her life partner. (REGTAP FAQ Database - #1734 05/27/14) Q: Will the Federally-facilitated Small Business Health Options Program (FF-SHOP) verify dependent eligibility for 2015? For example, if a subscriber is enrolling a child over age 26, will the FF-SHOP verify that the child is eligible to continue past age 26 or will issuers have to verify this information? A: Based on information submitted to the Centers for Medicare Medicaid Services (CMS) on the Business Rules Template, the will not allow a child over age 26 (or whatever upper-threshold age is de?ned by an issuer based on State law/regulation) to enroll in a particular FF-SHOP. (REGTAP FAQ Database - FAQ #2415 06/26/14) CMS removed. this FAQ from the TAP database on 08/26/14. 907 Updated 1-31-17 2017--01007 Q: What is a qualified medical support order? A: A 1993 amendment to the Employee Retirement Income Security Act (ERISA) requires employment-based group health plans to extend health care coverage to the children of a parent-employee who is divorced, separated, or never married when ordered to do so by state authorities. A quali?ed medical support order documents this order by state authorities. (REGTAP FAQ Database - FAQ #2865 07/16/14) Q: Will the Federally-facilitated Small Business Health Options Program (FF-SHOP) support mid-month enrollment of newborns, or enrollment of newborns in general? A: Newborns trigger one of the required special enrollment periods that allow an individual to be added to an employee's plan outside of initial enrollment or a group's annual renewal period. The effective date of coverage for newborns is the date of birth, and premiums will be pro-rated accordingly. (REGTAP FAQ Database - FAQ #2866 07/16/14) Q: How will the Federally-facilitated Small Business Health Options Program (FF-SHOP) handle state mandates that require 31-day free coverage for newborns and adoptions charges? Will the FF-SHOP allow issuers to customize billing processes in these instances? A: The FF-SHOP cannot accommodate this state-level rating scenario and therefore will always charge for newborns. (REGTAP FAQ Database - FAQ #2880 07/16/14) Q: Will the Federally-facilitated Small Business Health Options Program (FF-SHOP) have an 'other' dependent category as a drop-down option when employees are adding dependents to the employer's plan? A: Yes, the will support an 'other' dependent category. Issuers can ?nd a list of dependent codes the FF-SHOP supports at: Slides 050814 5CR 052714.pdf. (REGTAP FAQ Database - FAQ #3764 08/14/14) Q: Who can issuers contact if 834 transactions, 820 transactions, or Group XML files are missing group or member information? A: Issuers should call the Small Business Health Option Program (SHOP) Call Center at 1-800-706-7893 and select prompt 5. (REGTAP FAQ Database - FAQ #4202 09/02/14) Enrollment Group Set-up/Group XMLs Q7: Will CMS send 834 enrollment transactions the same night as the group XML load file? A7: Yes, CMS will send 834 enrollment transactions the same night as the group XML load ?le. (SHOP FAQ #3 07/30/13; REGTAP FAQ Database - FAQ #54 07/30/13) 908 Updated 1-31-17 2017--01008 Q3: Will CMS generate a unique group ID on the Group Enrollment XML file transaction? A3: CMS will not generate a unique group ID on Group Enrollment XML file transactions for the FF-SHOPs. Instead, CMS will identify groups using their Employer Taxpayer Identi?cation Number (TIN)/Employer Identi?cation Number (EIN). (SHOP FAQ #7 08/28/13; REGTAP FAQ Database - FAQ #7 08/28/13) Q4: Will issuers receive one Group Enrollment XML file transaction containing all new employer applications submitted that day? A4: Group Enrollment XML file transactions are not batched on a daily basis. They will be sent to issuers throughout the day when an eligible employer signs and submits a completed application. (SHOP FAQ #4 08/28/13; REGTAP FAQ Database - FAQ #8 08/28/13) Q5: Are the Group Enrollment XML file transactions going to be available via Electronic File Transfer (EFT) similar to the Electronic Data Interchange (EDI) files? A5: Group Enrollment XML ?le transactions will be made available to issuers via Electronic File Transfer (EFT), similar to Electronic Data Interchange (EDI) files. Please refer to the zOne for the Federal Data Services Hub Employer Group Business Service Definition (BSD): RD BSD Employer Group.docx). (SHOP FAQ #4 08/28/13; REGTAP FAQ Database - FAQ #9 and #9a 08/28/13; reissued 08/27/14) 909 Updated 1-31-17 2017--01009 CMS removed this FAQ from the database on 08/26/14. 09: Since CMS will be sending a group enrollment file via XML, could the FF-SHOP also send member eligibility terminations via XML file? A9: No. The FF-SHOP and CMS will not use other conventions to send termination information. CMS will send terminations using the standard transaction in accordance with the ASC X12 834 enrollment transaction. (SHOP FAQ #4 08/28/13; REGTAP FAQ Database - FAQ #13 08/28/13) CMS removed this FAQ from the database on 08/26/14. 910 Updated 1-31-17 2017-?01010 CMS removed this FAQ from the REG TAP database on 08/26/14. Q27: What are the cycle time expectations for issuers to establish a new group and process an associated ASC X12 834 enrollment transaction? A27: The Group Enrollment XML ?le transaction is sent the same day as the ASC X12 834 enrollment transaction. We assume issuers will add both the employer group and the members as soon as possible within their established business processes. (SHOP FAQ #4 08/28/13; REG TAP FAQ Database - FAQ #31 08/28/13) CMS removed this FAQ from the REGTAP database on 08/26/14 Q: Will there be an Exchange Assigned Subscriber and Member A: For the 2014 plan year there will be no Exchange Assigned Subscriber and Member ID for SHOP enrollees. (REGTAP FAQ Database - #737 02/10/14) Q: What will be the process of receiving the group application Is there a time period of receiving this from the group or A: Issuers may request (but not require) this information from the employer enrolling in a The Marketplace Application ID is on the eligibility notice sent by the FF- SHOP when a group sends in the paper application. Our goal is to send out eligibility determinations within a week of receiving a completed employer application. An employer who has misplaced their Marketplace Application ID may call the SHOP Employer Call Center to obtain the ID, and issuers may contact the SHOP Employer Call Center to verify that a group is eligible to participate in SHOP before enrolling them in a SHOP (REGTAP FAQ Database - #738 02/10/14) Q: For plan years beginning on and after January 1, 2015, will the group XML and 834 be generated together at the same time or will there be a lag? A: These transactions will generally be sent on the same day. The group XML will be sent when a group has met any applicable minimum participation rate and an employer has completed the enrollment process. 834 enrollment transactions will follow the 911 Updated 1-31-17 2017-?01011 transmission of group ?les (batched at the end of each day). (REGTAP FAQ Database - #827 02/21/14) Q: Will effectuation guidelines for SHOP be updated in terms of what data is required on the 834 effectuation transaction? A: Yes, CMS will cover Group XML and 834 enrollment transactions and required data elements on future REGTAP calls. (REGTAP FAQ Database - #1572 05/08/14) Q: What is the difference between ?Issuer Policy and ?Group Number Assigned by Issuer?? A: If an Issuer does not assign a unique Policy ID, the Subscriber ID should be used to populate this element. (REGTAP FAQ Database - #1578 05/13/14) Q: The Excel template asks for dates in a format. Can CMS confirm that the form requires a format, and not a format, as these are not the same? vs A: The Excel template has been updated to require the format (REGTAP FAQ Database - #1579 05/13/14) Q: Will Group XML files be sent to carriers if their plans are not selected in the 'employee choice' model during initial enrollment? If not, should carriers assume a Group XML file will be sent if a carrier's plan is selected subsequently during the plan year by a new hire? A: Group XML ?les will not be sent to a carrier if a carrier's plans are not selected in the "employee choice" model during initial enrollment. A Group XML file will subsequently be sent during the plan year if a new hire picks that carrier's plan. (REGTAP FAQ Database - #1593 05/13/14) Q: Is the Insurance Policy Group Identification Number the issuer number, or the Qualified Health Plan (QHP) A: Group Identification Number will be the Issuer-assigned ID for the group. This sent in the Insurance Plan Identi?cation ?eld. (REGTAP FAQ Database - #1971 05/30/14) Q: Are issuers required to use the new fields added to the Group XML this?year? A: The Group Business Service Definition (BSD) identi?es which data elements are required and optional when validating elements coming in from the Federally-facilitated Small Business Health Options Program (FF-SHOP) enrollment system and issuers to the Data Services HUB. The HUB will not accept incoming transactions unless all required ?elds are populated in the correct format. (REGTAP FAQ Database - #1973 05/30/14; updated 01/19/17) 912 Updated 1-31-17 2017-?01o12 Q: Will the Insurance Group ID be included in the initial file? A: No. This data element will be an optional field for initial transactions. It will, however, be populated on subsequent maintenance transactions. (REGTAP FAQ Database - #1975 05/30/14) Q: What unique identifiers from the Group XML will the issuer be required to send back in the 834 effectuation transaction? A: Issuers are not required to send any speci?c information from Group XML transactions. However, the Group ID assigned by the issuer is required in the effectuated 834 transactions. (REGTAP FAQ Database - #1977 05/30/14) Q: Last?year it was stated in SHOP that the Employer Identification Number (EIN) would be the identi?er linking the Group Extensible Markup Lanquaqe (XML) XML to the initial 834 file. Will the EIN be provided or will the only common identifier be the Payment Transaction A: Both the EIN and Payment Transaction ID will be passed on initial Group XML and 834 transactions. (REGTAP FAQ Database - #1978 05/30/14; updated 01/19/17) Q: When are issuers expected to send 999 confirmation transactions? A: CMS expects issuers to send 999 con?rmation transactions in response to 834 enrollment transactions sent to them from the Data Services HUB. CMS does not expect issuers to send 999 con?rmation transactions in response to the Group XML file, since the Group XML ?le is not an Electronic Data Interchange (EDI) transaction. (REGTAP FAQ Database - #1979 05/30/14) Q: Will the employer Tax Identification Number (TIN) on the Group XML always be the same value as the Employer Identification Number (EIN) on 834 enrollment transactions? A: Yes, the employer TIN on the Group XML is always the same value as the EIN on 834 enrollment transactions. (REGTAP FAQ Database - #1982 05/30/14) Q: Are issuers required to send both TA1 and 999 confirmations? A: Yes. The acknowledgment model for Federally-facilitated Small Business Health Options Program (FF-SHOP) Marketplaces will follow the Federally-facilitated Marketplace (FFM). Both TA1 and 999 confirmations will be required for the transactions sent by the Centers for Medicare Medicaid Services (CMS). A 999 con?rmation is not required for Group XML transactions. (REG TAP FAQ Database - #1983 05/30/14) Q: If issuers do not send the Centers for Medicare Medicaid Services (CMS) the group number, how do issuers match the 834 to the group that the issuer set up? A: Issuers will use the Payment Transaction ID to tie together the initial Group XML, 834, and 820 transactions. (REG TAP FAQ Database - FAQ #2414 06/26/14) 913 Updated 1-31-17 2017--01013 Q: Can the Issuer Assigned Group Number and Policy ID Number be the same? Some issuers do not utilize Policy IDs. A: The Federally-facilitated Small Business Health Options Program (FF-SHOP) system does not check for uniqueness between Issuer Assigned Group Number and Policy ID Number, so these numbers can be the same. (REGTAP FAQ Database - FAQ #2421 06/26/14) Q: What are the specifications for the Application ID and Origin? A: ApplicationID Origin will be a combination of ApplicationlD a dash The Origin. Application ID Min 1 - Max 32 Origin Numeric - 1 digit (REGTAP FAQ Database - FAQ #2432 06/26/14) Q: Is the Employer ID a unique identifier, and what value should issuers use? A: The Employer ID is a unique combination of 12 digits with the following con?guration: digits)+State Code(2 digits). (REGTAP FAQ Database - FAQ #2434 06/26/14) Q: It is understood that issuers may pend claims prior to receipt of a group's initial binder payment from the Federally-facilitated Small Business Health Options Program (FF-SHOP) (subject to allowable state laws and regulations). If a group defers paying its initial binder payment, can the issuer hold the processing of the enrollment transactions (the until it receives the initial binder payment from the Centers for Medicare Medicaid Services 0r must the issuer immediately proceed with processing the and rely on CMS to convey any applicable cancelation transaction? A: Per Section issuers participating in FF-SHOP Marketplaces are required to effectuate SHOP coverage unless the issuer receives a cancellation transaction prior to the coverage effective date. Cancellation transactions will be sent to issuers if the FF-SHOP does NOT receive the initial binder payment by a specified date prior to the coverage effective date. The FF-SHOP will communicate the timing of these cancellation transactions on a future REGTAP call. CMS expects that some issuers will hold off on effectuating coverage until after this cancellation window has passed or until the issuer receives the initial binder payment from the FF-SHOP (prior to the cancellation window passing). (REGTAP FAQ Database - FAQ #2435 06/26/14) Q: Is the Policy ID a required field? A: The Policy ID is required either at the Member Level or at the Coverage Level. (REGTAP FAQ Database - FAQ #2437 06/26/14) Q: Is Policy ID unique per group, plan and subscriber or unique per group and plan? A: Issuers have flexibility in how to treat Policy IDs. The Federally-facilitated Small Business Health Options Program (FF-SHOP) system does not check for Policy ID uniqueness. (REGTAP FAQ Database - FAQ #2441 06/26/14) 914 Updated 1-31-17 2017-?01o14 Q: Can the Exchange-Assigned Policy Identi?er and Issuer-Assigned Policy Identi?er be optional in the Federally-facilitated Small Business Health Options Program (FF-SHOP) effectuation file? A: No, policy identi?ers are required fields. Issuers may send a dummy value or repeat another value so this ?eld is not left blank. (REGTAP FAQ Database - FAQ #2442 06/26/14) Q: Is the value in the SHOP 834 Transaction the same value as the Insurance Plan ID in the Group XML file? A: The Insurance Plan ID value will be sent in "Contract code" - Quali?er]. (REGTAP FAQ Database - FAQ #2551 07/03/14) Q: Why is the Federally-facilitated Small Business Health Options Program (FF-SHOP) using the in the 820 transaction for the Issuer Assigned Employer Group Identifier when in all the 834 transactions, the is used for the Exchange Assigned Policy Identi?er? Qualifier use should be consistent across Federally- facilitated Marketplace (FFM) transactions. A: The FF-SHOP is following the x306 ASC X12 implementation guide. . In the 820 306: the Reference Segment is named ASSIGNED EMPLOYER GROUP 0 In the 834 22OA1: the Reference Segment is POLICY Both use the Quali?er Group or Policy Number? (REGTAP FAQ Database - FAQ #2603 07/03/14) Q: Will the Federally-facilitated Small Business Health Options Program (FF-SHOP) include a status indicator on Group XML transactions? A: Yes, an element in the Employer Group XML file named EnrollmentAction will indicate the file's status. (REGTAP FAQ Database - FAQ #2853 07/16/14) Q: How can issuers identify Federally-facilitated Small Business Health Options (FF- SHOP) Group XML changes? A: The EnrollmentAction element will identify changes and action taken in the enrollment group. (REGTAP FAQ Database - FAQ #2855 07/16/14) Q: Is the Insurance Plan Element in the Group XML Schema is the Plan ID, and if so, should this element contain 16 characters? A: The Insurance Plan element is the Plan ID. Small Business Health Options Program (SHOP) plan IDs do not contain a Cost-Sharing Reduction (CSR) variant in the last two digits, so the last two digits remain static with the value Hence, the will only send the ?rst 14 characters of the Plan ID. (REGTAP FAQ Database - FAQ #2875 07/16/14 915 Updated 1-31-17 2017--01015 Q: What is the frequency of, or timing between 834 enrollment ?les and Group Set up Extensible Markup Language files (XMLs) in the Small Business Health Options Program A: CMS will generally send both the Group XML and 834 enrollment transactions on the same day. Issuers should hold 834 enrollment transactions until the issuer has successfully set up the group in the issuer's systems. (REGTAP FAQ Database - FAQ #2893 07/16/14) Q: Will Federally-facilitated Small Business Health Options Program (FF-SHOP) Group Extensible Markup (XML) files contain multiple groups? A: FF-SHOP Group XML transactions are sent for each employer per issuer. For example, if five (5) plans are selected by the employer group, three (3) issued by ABC insurance and the other two (2) issued by CD insurance, then ABC insurance will receive one (1) file for three (3) plans and CD will receive another ?le with the remaining two (2) plans. (REGTAP FAQ Database - FAQ #3015 07/25/14) Q: As the Companion Guide version 1.7 states, should the qualifier, which identifies the number of employee subscribers contained in the transaction set, always be one A: Yes. The FF-SHOP system will always send 1 employee and his family subscriber and his dependents) per enrollment request. Hence the QTY02 value for Quali?er will always have a value of within an loop. (REGTAP FAQ Database - FAQ #3016 07/25/14) Q: What are the "Application and "Origin" elements on the 834 enrollment transaction? A: The Application ID is an internally-generated data element that will be sent to issuers on 834 enrollment transactions. The Origin is the source from which the application was received. For Federally-facilitated Small Business Health Options Programs (FF- SHOPS), the source will always be an online application. Direct enrollment is not an option in FF-SHOPS as of 2015. (REGTAP FAQ Database - FAQ #3017 07/25/14) Q: Will the Federal Data Services Hub validate Group Extensible Markup Language (XML) files prior to transmitting the ?les to issuers, to ensure that all mandatory fields in the ?le are complete and valid? A: Yes, the Federal Data Services Hub will validate all transactions before sending the transactions to issuers. (REGTAP FAQ Database - FAQ #3004 07/25/14) Q: When is the earliest issuers operating in Federally-facilitated Small Business Health Options Program (FF-SHOP) Marketplaces can expect to receive Group XML files and 834 Enrollment transactions for the 2015 Plan Year? A: Issuers operating in FF-SHOPs can expect to receive Group XML files and 834 Enrollment transactions as early as November 15, 2014. (REGTAP FAQ Database - FAQ #3395 08/01/14) 916 Updated 1-31-17 2017--01016 Q: Will the Federally-facilitated Small Business Health Options Program (FF-SHOP) send waiting period information on Group XML files? A: No, the FF-SHOP will not send waiting period information on the Group XML ?le. The FF-SHOP calculates all coverage effective dates based on waiting periods established by employers at the time of initial group setup. (REGTAP FAQ Database - FAQ #3404 08/01/14) Q: In the Group XML file, will issuers receive Agent data or Broker data? A: Issuers will receive information for either one (1) Agent or one (1) Broker in the Group XML ?le. (REGTAP FAQ Database - FAQ #3411 08/01/14) Q: Will the Federally-facilitated Small Business Health Options Program (FF-SHOP) indicate Employee Retirement Income Security Act (ERISA) status on the Group XML file? A: Issuers can refer to the Group Business Service Definition (BSD) for information on group size information. The Group BSD document is posted to both and REGTAP. (REGTAP FAQ Database - FAQ #3412 08/01/14) Q: Will the Federally-facilitated Small Business Health Options Program (FF-SHOP) always send mandatory fields in Group Setup File? A: Unless the parent element is optional, The FF-SHOP will always send mandatory fields in the Group XML ?les. (REGTAP FAQ Database - FAQ #3417 08/01/14) Q: What is the purpose of the ?EnrollmentAction" element in the Federally-facilitated Small Business Health Options Program (FF-SHOP) Group XML file? A: The "EnrollmentAction" element conveys the type of action associated with the employer information. For example, if the enrollment group is initially enrolled, the EnrollmentAction is the "lnitialEnrollment." (REGTAP FAQ Database - FAQ #3418 08/01/14) Q: Is any response file required when issuers receive a Group XML file from the Federally-facilitated Small Business Health Options Program A: FF- SHOP does not current support or require a response file to the Group XML file. (REGTAP FAQ Database- FAQ #3420 08/01/14; updated 01/19/17) Q: Does the Centers for Medicare Medicaid Services (CMS) expect the Payment Transaction ID passed in the Group XML schema to be returned in the 834 Effectuation file? A: The 834 X12 ?le will also contain the Payment Transaction ID. This information should be returned in the 834 Effectuation File. (REGTAP FAQ Database - FAQ #3422 08/01/14) 917 Updated 1-31-17 2017-?01017 Q: Will the Federal Data Services HUB validate Group XML transactions to ensure that all mandatory fields are complete before sending the transaction to an issuer? A: Yes, the HUB will validate the XML schema to con?rm all mandatory fields are valid and complete prior to sending the XML ?le to an issuer. (REGTAP FAQ Database - FAQ #3423 08/01/14) Q: What is the purpose of the Termination Reason Code in the Federally-facilitated Small Business Health Options Program (FF-SHOP) Group XML file? A: Termination reason codes in the employer Group XML file is used to report if the termination happened voluntarily or involuntarily. (REGTAP FAQ Database - FAQ #3424 08/01/14) Q: In the Federally-facilitated Small Business Options Program (FF-SHOP) Group XML files, will the values in the 'Secondary Payer' section be yes or no indicators? A: The indicator values will be or N. Please refer to the Group Business Service Definition (BSD) on REGTAP and ZONE for additional information. (REGTAP FAQ Database - FAQ #3427 08/01/14) Q: When will the Centers for Medicare Medicaid Services (CMS) release the final XML schema for the Federally-facilitated Small Business Health Options Program A: Final draft Group Business Service De?nition (BSD), 834 Companion Guide, and 820 technical documents are already available on and REGTAP. Periodic updates will be made to these technical documents as new information becomes available. (REGTAP FAQ Database - FAQ #3429 08/01/14) Q: How will the Federally-facilitated Small Business Health Options Program (FF-SHOP) populate the required "LocationCountyText" field on the Group XML file? Specifically, will the employer select a county, or will the field populate using the business address? A: The FF-SHOP is planning to use the same United States Postal Service (USPS) county data as the Federally-facilitated Marketplace FFM Individual Market. When an employer enters the business address zip code, the corresponding Federal Information Processing Standards (FIPS) code is returned. If the zip code is associated with multiple counties, the employer will get a drop down of valid counties and must select the county, which will be sent to Issuers on the Group XML. (REGTAP FAQ Database - FAQ #3431 08/01/14) Q: Does the Employer Identification Number (EIN) field in the 2014 FF-SHOP reconciliation file need to contain the hyphen or can issuers omit the hyphen since it is a special character? Is the EIN field a number or a string? A: The employer EIN should not contain a hyphen. EIN data elements should be numeric characters only. (REGTAP FAQ Database - FAQ #3457 08/01/14) 918 Updated 1-31-17 2017-?01018 Q: Will the Federally-facilitated Small Business Health Options Program (FF-SHOP) generate a Group XML file automatically once all the employees for a employer group are enrolled or decline coverage? A: Employers must ?nalize group submissions before the FF-SHOP transmits the Group XMLs and 8343 to issuers. (REGTAP FAQ Database - FAQ #3768 08/14/14) Q: Does the issuer or the Federally-facilitated Small Business Health Options Program (FF-SHOP) enforce new hire waiting periods? A: The FF-SHOP will enforce waiting periods and send to Issuers applicable effective dates for new hire coverage. (REGTAP FAQ Database - FAQ #3769 08/14/14) Q: When an issuer receives a Group XML file mid-way through a plan year (when employee choice is available and a plan is chosen for the first time by a new hire), how can an issuer identify a group's initial effective date on the Group A: The Plan Maintenance Effective Date will always have a group's initial effective date on all Group XMLs. (REGTAP FAQ Database - FAQ #3770 08/14/14) Q: Is the Application ID an optional data element for the Federally-facilitated Small Business Health Options Program (FF-SHOP) as of the 2015 plan year? A: The FF-SHOP will send the Application ID to issuers for the 2015 plan year . The Application ID is an internally-generated data element that the FF-SHOP will send to issuers on 834 enrollment transactions. The Application ID is an optional field. The FF- SHOP will only send the ID upon initial enrollment for new enrollees or when an enrollee experiences a life status change. Issuers need to capture and return the Application ID on effectuated 834s. (REGTAP FAQ Database - FAQ #3772 08/14/14) Q: Is there a chance that the Federally-facilitated Small Business Health Options Program (FF-SHOP) will assign a new FF-SHOP member a Marketplace-assigned Subscriber or Member ID that the Federally-facilitated Marketplace (FFM) assigned to an FFM Individual Marketplace enrollee? A: No, the FF-SHOP format for Subscriber or Member IDs is different from the FFM Individual Marketplace. (REGTAP FAQ Database - FAQ #3785 08/14/14) Q: Will the Federally-facilitated Small Business Health Options Program (FF-SHOP) assign employees and the employee's dependent the same Exchange-assigned Subscriber A: SHOP will assign an employee and the employee?s dependents the same Exchange Assiqned Subscriber ID. Each employee and dependent will be assigned a unique Exchange Assigned Member ID. Database- FAQ #4136 08/26/14; Revised as FAQ 4136a 09/26/14) 919 Updated 1-31-17 2017--01019 Q: Will the Centers for Medicare Medicaid Services (CMS) share sample schemas of Federally-facilitated Small Business Health Options Program (FF-SHOP) 834 and Group XML files? A: CMS plans to provide sample ?les to issuers for both 834 and Group XML files. (REGTAP FAQ Database - FAQ #4208 09/02/14) Q: Will the Organization Member Quantity data element vary by plan in the Group Setup file, or will the value be repeated for each plan? A: The Organization Member Quantity will be the same value repeated for each plan. (REGTAP FAQ Database - FAQ #4211 09/02/14) Q: For?2045?, if an employer misses the initial payment deadline and reapplies for group coverage, how will the Federally-facilitated Small Business Health Options Program (FF- SHOP) indicate that the new Group XML file and 834 transaction are for the same employer group? A: Issuers will receive initial Group XML ?les. For non-payment, issuers will receive a cancellation Group XML. Reapplying will generate the same Group XML previously sent to the issuer. There is no indicator to identify the group as previously applying. (REGTAP FAQ Database - FAQ #4214 09/02/14; updated 01/19/17) Q: Will the Federally-facilitated Small Business Health Options Program (FF-SHOP) send Group XML and 834 transactions on federal holidays? A: CMS does not anticipate sending Group XML and 834 transactions on federal holidays. (REGTAP FAQ Database - FAQ #4221 09/02/14) Q: In the FF-SHOP Group XML file, is the OrganizationMemberQuantity the number of employees in the company, total employees in the employer group, or the total employees enrolling in a specific plan? A: OrganizationMemberQuantity ?eld will convey the total number of employees enrolling for a speci?c issuer. The OrganizationMemberQuantity does not represent the number of employees in the company. (REGTAP FAQ Database - FAQ #4434 09/05/14) Q: Will Group XML files be batched and sent as one file to FF-SHOP issuers daily or will issuers receive multiples, i.e. one Group XML file per group? A: CMS will send one employer group ?le per employer per Issuer per Trading Partner. The employer Group transactions will not be batched. The Group XML ?les are sent throughout the business day (M-F, 8am-6pm). (REGTAP FAQ Database - FAQ #4450 09/05/14) Q: Will the Centers for Medicare Medicaid Services (CMS) change the existing Small Business Health Options Program (SHOP) Exchange Subscriber IDs to meet the new field format? A: The FF-SHOP is not currently generating Exchange Assigned Subscriber IDs. Information about Exchange Assigned Subscriber IDs is already available in the 920 Updated 1-31-1 7 2017--01020 Library. CMS will update the next version of the Companion Guide to include the latest configuration for Exchange Assigned Subscriber IDs. (REGTAP FAQ Database - FAQ #4676 09/11/14) Q: How far in advance of the 834 transaction will the Federally-Facilitated Small Business Health Options Program (FF-SHOP) send the Group Extensible Markup Language (XML) file to issuers? A: FF-SHOP Issuers should plan on 834 transactions and Group XML files arriving on the same day. The 834 ?les will arrive after 6 pm. ET. The Group XML ?les are sent as groups submit final applications throughout the day from 8 am. to 6 pm. ET, Monday through Friday. (REGTAP FAQ Database - FAQ #4684 09/11/14) Q: If an employer in the FF-SHOP does not choose a Qualified Health Plan (QHP) during initial enrollment, and a Group Extensible Markup Language (XML) is sent in the middle of the year, is the mid-year enrollment considered a new enrollment or a maintenance transaction? A: This scenario is considered a new enrollment. The FF-SHOP will send issuers any subsequent changes for the group on a Group XML maintenance transaction. (REGTAP FAQ Database - FAQ #4904 09/17/14) Q: When will the Federally-facilitated Small Business Health Options Program (FF-SHOP) send Group Extensible Markup Language (XML) and 834 files if the 15th of the month falls on a weekend? A: The FF-SHOP will send Group XML and 834 ?les to FF-SHOP issuers on the first business day following the weekend. (REGTAP FAQ Database - FAQ #4913 09/17/14) Q: In situations where an employer group operates in multiple states, will issuers receive a single Group Extensible Markup Language (XML) file for the entire employer group or one Group XML file per state? A: The Centers for Medicare and Medicaid services (CMS) will send one employer group file, per employer, per issuer, per Trading Partner. (REGTAP FAQ Database - FAQ #4918 09/17/14) Q: If an issuer discovers a discrepancy in the issuer's Group Extensible Markup Language (XML) or 834 files, should issuers contact the Federally-facilitated Small Business Health Options Program (FF-SHOP) Call Center directly? A: Yes, FF-SHOP issuers may reach out to the FF-SHOP Call Center to reconcile discrepancies in enrollment transactions. (REGTAP FAQ Database - FAQ #4921 09/17/14) 921 Updated 1-31?17 2017-?01021 Q: Will subsequent Federally-facilitated Small Business Health Options Program (FF- SHOP) Group Extensible Markup Language (XML) files include the element after the issue receives the initial Group XML file? A: Yes, the element will be present in subsequent Group XML ?les. The Centers for Medicare Medicaid Services (CMS) will update the sample Group XML ?les with this information. (REGTAP FAQ Database - FAQ #5326 10/02/14) Q: For the Federally-facilitated Small Business Health Options Program (FF-SHOP), will issuers ever receive a Group Extensible Markup Language (XML) file, 834 transaction, and 820 transaction on the same day? A: For initial enrollments, FF-SHOP issuers will not receive all 3 transactions on the same day. Issuers will, however, receive the Group XML and associated 834 enrollment transactions on the same day. (REGTAP FAQ Database - FAQ #5327 10/02/14) Q: If a new employee enrolls in a plan at the family coverage level later in the year, how will the Federally-facilitated Small Business Health Options Program (FF-SHOP) notate the coverage type on the Group Extensible Markup Language (XML) file? A: The FF-SHOP does not allow employers to change available coverage levels in the middle of a plan year. For example, an employer who offers employee-only coverage upon initial enrollment may not add dependent coverage in the middle of a plan year; however, the employer could terminate the employer's existing coverage and reapply with a change in coverage levels. (REGTAP FAQ Database - FAQ #5502 10/09/14) Q: How will the Federally-facilitated Small Business Health Options Program (FF-SHOP) communicate the Plan Coverage Type Field on the Group Extensible Markup Language (XML) file? A: When a group is offering dependent coverage, the FF-SHOP will send FAM on the Group XML. When a group is offering employee-only coverage, the FF-SHOP will send EMP on the Group XML. (REGTAP FAQ Database - FAQ #5503 10/09/14) Q: If an issuer offers a plan with both family and employee coverage levels and two employees enroll in the employee level of coverage during open enrollment, will the Federally-facilitated Small Business Health Options Program (FF-SHOP) send issuers the plan as Employee coverage type or Family coverage type? A: If the employer is offering dependent coverage, the FF-SHOP will send FAM on the Group XML even if no dependents enroll during open enrollment. (REGTAP FAQ Database - FAQ #5504 10/09/14) 922 Updated 1-31-1 7 2017-?01022 Q: Will the Federally-facilitated Small Business Health Options Program (FF-SHOP) send 834 transactions and Group Extensible Markup Language (XML) files separately from 834 transactions and XML files from the Individual Marketplace? A: Only the FF-SHOP will send Group XML ?les. The FF-SHOP and Individual Marketplaces will send separate 834 transactions. (REGTAP FAQ Database - FAQ #5512 10/09/14) Q: What process is in place if a Federally-facilitated Small Business Health Options Program (FF-SHOP) Group XML file fails? A: The Centers for Medicare Medicaid Services (CMS) will validate all outbound Group XML transactions for Schema compliance. If issuers notice any schema validation errors, please create a help desk ticket. (REGTAP FAQ Database - FAQ #5514 10/09/14) Q: Will an employee have an Exchange Assigned Subscriber ID and an Exchange Assigned Member A: No. The Exchange Assigned Member ID will equal the Exchange Assigned Subscriber ID for employees. Both data elements will be populated with the Exchange Assigned Subscriber ID. (REGTAP FAQ Database - FAQ #5568 10/14/14) Q: Will the Exchange Assigned Policy ID for an employer group change between the initial 834 transaction and any 834 maintenance transaction? A: No, the Exchange Assigned Policy ID for an employer will not change as a result of 834 maintenance transactions. (REGTAP FAQ Database - FAQ #5679 10/17/14) Q: Under what circumstances would an Exchange Assigned Policy ID change during a plan year? A: The Centers for Medicare Medicaid Services (CMS) are unable to identify a circumstance when an Exchange Assigned Policy ID will change during a plan year. (REGTAP FAQ Database - FAQ #5680 10/17/14) Q: Will the Federally-facilitated Small Business Health Options Program (FF-SHOP) 834 transactions include the issuer's assigned group number in the transaction set? A: Issuer assigned group number will be present in 834 transactions where new members are getting enrolled after initial enrollment AND in termination transactions of dependents. The tag used for this information is ?ServiceContractNumber? (REGTAP FAQ Database - FAQ #6057 10/22/14) Q: In FAQ 3418, ?lnitialEnrollment? is listed as a value of the EnrollmentAction field. However this value is NOT listed in the latest Business Service Definition (BSD) for Group Extensible Markup Language (XML). Is this value still valid? A: The EnrollmentAction element is present in the latest version of the schema under File Information and is used to capture the type of transaction being sent. In the BSD, this element can be found in the attachment Employer Group Elements - v16 under: 923 Updated 1-31-17 2017--01023 Section 5: Data Element De?nitions Section 10: XML schema in the attachment Employer Group XSD (REGTAP FAQ Database - FAQ #6058 10/22/14) Q: How can issuers validate that issuers are receiving the correct number of employees for a new group enrolling in Federally-facilitated Small Business Health Options Program (FF-SHOP) coverage? A: The Organization Member Quantity in the Group Extensible Markup Language (XML) contains the number of employees enrolling within a Qualified Health Plan (QHP). Issuers can use this variable to verify if the total number of members reported in the Group XML for the employer matches the 834. Note: This veri?cation can only be done for initial transactions and not for subsequent transactions (since the employer group transaction is not sent when adding a new employee during a Special Enrollment Period if the employee chooses the plan previously sent in the Group XML). (REGTAP FAQ Database - FAQ #7787 11/21/14) Q: If issuers have a group enroll and its only participant terminates, how will issuers know if the employer information changes? If there is a subsequent new hire, would issuers receive a Group Enrollment Extensible Markup Language (XML) file with the updated information? A: Unless an employer terminates the entire group, the Federally-facilitated Small Business Health Options Program (FF-SHOP) will not send group-level terminations to impacted issuers. Whenever an employer changes any information related to group set- up, an updated Group XML ?le will be sent to Issuers. If a subsequent new hire joins a plan when a Group XML ?le was already sent, the issuer will not receive a new group set-up file because it was not previously terminated. (REGTAP FAQ Database - FAQ #8032 12/03/14) Q: If a group's employees do not select a plan initially, but an employee selects a plan mid-year, will the plan start date be populated on the Group Extensible Markup Language (XML) File? Will the start date be back-dated to the beginning of the year? A: Plan start dates will be sent in a PlanMaintenanceEffectiveDate tag. This date will be the current effective date for that member. (REGTAP FAQ Database - FAQ #12174 08/27/15) Q: If a group's employees do not select a plan initially, but an employee selects a plan mid-year due to employee choice, what will the Centers for Medicare and Medicaid Services (CMS) send to the issuer? A: CMS will send a Special Enrollment maintenance group ?le followed by an 834 for the group's employees and dependents. (REGTAP FAQ Database - FAQ #12175 08/27/15) Q: If an issuer's plan is not chosen initially but is added mid-year, what date will be populated on the Group Extensible Markup Language (XML) with the OriginalEffectiveDate tag? A: The group's original effective date will be populated in the OriginalEffectiveDate tag to 924 Updated 1-31-17 2017-?01024 reflect the beginning of the group's plan year. (REGTAP FAQ Database - FAQ #12176 08/27/15) Q: If a group selects two different plans from the same issuer, will the Federally- facilitated Small Business Health Options Program (FF-SHOP) issuer receive one Group Extensible Markup Language (XML) with both plans listed? A: If a group selects two different plans from the same issuer, the FF-SHOP issuer will receive one Group XML encompassing both plans. (REGTAP FAQ Database - FAQ #12219 08/27/15) Q: If a group file's purpose is to renew a group already on the Marketplace, will the Enrollment Action value be 'Open Enrollment'? A: Yes, the Centers for Medicare and Medicaid Services (CMS) will send Open Enrollment in the case of group renewal. (REGTAP FAQ Database - FAQ #12178 08/27/15) Group Application Q17: Will the FF-SHOP allow multiple billing addresses for an employer group? A17: No. The FF-SHOP will not allow multiple billing addresses for an employer group, however, a secondary contact may receive a copy of noti?cations sent to the primary contact. (SHOP FAQ #2 07/05/13; REGTAP FAQ Database - FAQ #86 07/05/13) Q18: Will the FF-SHOP collect ERISA status information for the group? A18: The FF-SHOP is collecting standardized data on the types of groups enrolling, private sector-C corporation, governmental, etc. but will not collect ERISA status information for each group. See QC. . A I (SHOP FAQ #2 07/05/13; REGTAP FAQ Database - FAQ #87 and #87a 07/05/13;. updated 08/27/14) Q19: Will the FF-SHOP allow multiple classes of employees (owners, salaried, hourly) for an employer group? A19: No. The FF-SHOP will not allow varying coverage for different classes of employees. (SHOP FAQ #2 7/5/1; REGTAP FAQ Database - FAQ #88 07/05/133) Q20: What business rules can the employer specify for enrolling employees? full- time only, no dependents, certain locations only, waiting period for new hires, etc.) How will the employer specify the business rules for enrolling employees? A20: Employers participating in the FF-SHOP are required to offer coverage to all full- time employees (those working on average 30+ hours per week). Depending on state law, dependent coverage is optional when an employer establishes a group policy. Thus, an employer may be able to choose to offer employee-only coverage in the FF-SHOP and exclude dependents from enrolling. In terms of limiting coverage to certain 925 Updated 1-31-17 2017--01025 geographic locations, the Patient Protection and Affordable Care Act requires all employers applying for FF-SHOP coverage to offer coverage to all full-time employees, regardless of geographic location, as a condition of FF-SHOP participation. (See 45 CFR 155.710 Eligibility standards for SHOP) As part of the initial application process, an employer will specify employees eligible for coverage on the employee roster. Issuers will only receive information on those employees who enroll from the roster. After the initial application, enrollment information passed to Issuers will already have factored in applicable new hire waiting periods and will specify when coverage must be effectuated. (SHOP FAQ #2 07/05/13; REGTAP FAQ Database - FAQ #89 07/05/13) 021: How will the FF-SHOP capture any paper documentation collected from an employer that needs to be provided to an Issuer and how will the FF-SHOP send the attachments (Example: Group Contract) to Issuers? A21: In?year?ene? Contractual documents will not be transmitted through the FF- SHOP and will be handled separately between the employer and Issuer. It?is?GMSs?intentien?te (SHOP FAQ #2 07/05/13; REGTAP FAQ Database - FAQ #90 and #90a 07/05/13; updated 08/27/14) Q: Once an employer completes the FF-SHOP paper application, should the employer send the application to the FF-SHOP or to the issuer or an agent or broker? A: Employers should send the FF-SHOP employer application to the FF-SHOP address located on the application. If an FF-SHOP QHP or QDP issuer receives a FF-SHOP application, the issuer or an agent or broker could forward the application to the FF- SHOP, or could advise the employer to submit the application him- or herself. The FF- SHOP will review the paper application and make a SHOP eligibility determination, which an employer that otherwise qualifies for the Small Business Health Care Tax Credit must have in order to be eligible for the credit. (REGTAP FAQ Database - FAQ #652 01/16/14) Q: Will employers be executing contracts with issuers as is the current practice? Updated 1-31-17 A: Nothing within the Affordable Care Act (ACA) or Small Business Health Options Program (SHOP) Marketplaces changes contractual relationships between Issuers and employer groups, which are based on State law and regulations. (REGTAP FAQ Database - #1976 05/30/14) CMS issued a clarifying FAQ on 09/05/14: Q: Clarifying FAQ 1976: Are issuers only responsible for contracts at the group- Ievel and not the employee-level? A: The Centers for Medicare Medicaid Services (CMS) has not regulated on this topic. Issuers should check with their respective state departments of insurance on what is required in a speci?c Small Business Health Options Program (SHOP) service area. (REGTAP FAQ Database - FAQ #4420 09/05/14) 926 2017-?01026 Direct Enrollment Q: Is the FF-SHOP supporting enrollments initiated through mechanisms other than the direct enrollment approach for coverage beginning in 2014? A: No. The FF-SHOP does not expect to begin accepting online enrollments before November 2014, for coverage beginning on or after January 1, 2015. (REGTAP FAQ Database - FAQ #648 01/16/14) Q: Is direct enrollment in FF-SHOPs the same as direct enrollment in the individual market A: The FF-SHOP direct enrollment approach is different from direct enrollment in the individual market Federally-facilitated Marketplaces (FFMs), because in the individual market FFM's consumers are being redirected from an issuer or a web-broker web site to the Marketplace to complete an online application and obtain an eligibility determination prior to returning to the issuer or web-broker site to select a QHP and/or QDP. The FF-SHOP direct enrollment approach enables issuers to enroll small employer groups utilizing existing small group processes and enrollment systems, subject to FF-SHOP requirements. Thus, employers and employees are never redirected to the Marketplace online portal in the FF-SHOP direct enrollment approach. (REGTAP FAQ Database - FAQ #649 01/16/14) Q: How can employers and agents/brokers identify FF-SHOP-certi?ed when seeking to enroll employees directly in a plan for 2014? A: Employers can utilize the Premium Estimation Tool on HealthCare.gov to ?nd certified FF-SHOP QHPs and QDPs along with their issuers' contact information. Issuers should ensure their contact information is up to date on HealthCare.gov so that employers can seek them out and enroll employees in coverage. Plan IDs for FF-SHOP QHPs and QDPs are available here: and (REGTAP FAQ Database - FAQ #659 01/16/14) Q: Can State-based Small Health Options Programs (SHOPs) allow direct enrollment for 2014 under an approach similar to the one announced for the Federally-facilitated Small Business Health Options Program Can employers who use direct enrollment to purchase a SHOP QHP in such circumstances access the Small Business Tax Credit, if they are otherwise eligible? A: CMS will consider requests from states that are not yet able to provide for enrollment through their online SHOP portals to utilize the same direct enrollment approach through QHP issuers that the Federally-facilitated SHOP implemented for 2014, as a transitional measure. However, outside of a transition period to a fully functioning online SHOP portal, direct enrollment in SHOP is not permitted. States taking this option should work with CMS and the Department of the Treasury to ensure that small employers who directly enroll in a state-based SHOP will be able to receive an eligibility determination in order to access the Small Business Health Care Tax Credit, if eligible. States should also make clear to both employers and issuers that enrollment in advance of the formal eligibility determination is an option, not a 927 Updated 1-31-17 2017-?01o27 requirement, and that in doing so, an employer could risk losing access to the Small Business Healthcare Tax Credit if the employer is later determined ineligible to participate in the SHOP. State-based SHOPs without a fully functioning online SHOP portal should contact CMS to determine how to establish direct enrollment as a transition policy to ensure eligible small businesses may claim the expanded small business healthcare tax credit for the 2014 tax year. State-based SHOPS should not implement such a policy absent CMS approval. (CMS FAQ 03/14/14) Q: What should issuers tell small employers about direct enrollment in A: In a state using SHOP direct enrollment during a transition period, small employers who wish to claim a Small Business Health Care Tax Credit will enroll in SHOP qualified health plans directly with SHOP issuers or by working with their agent or broker. SHOP health insurance issuers in a state where SHOP direct enrollment is permitted during a transition period can assist small employers in accessing the Small Business Health Care Tax Credit by making it clear which qualified health plan offerings are available through SHOP and providing information to inform small employers who enroll in SHOP qualified health plans of the next steps to access the tax credit. For additional information, please visit: health-care- tax-credits/. (CMS FAQ 03/14/14) Q: For 2015 Plan Year, will direct enrollment be an option for the Federally-facilitated Small Business Health Options Program A: No, direct enrollment will cease to be an option as of November 15, 2014, when groups wanting 2015 plan year coverage in the FF-SHOP must use the online system available at HealthCare.gov. (REGTAP FAQ Database - FAQ #4925 09/17/14) Q: How will issuers enroll existing Federally-facilitated Small Business Health Options Program (FF-SHOP) employer groups (those enrolling directly with an issuer in 2014) onto HealthCare.gov? Will those employer groups need to sign up for a plan at the next renewal time or sooner? A: Employer groups enrolled for the 2014 plan year must renew FF-SHOP group coverage using HealthCare.gov. Employers may not use direct enrollment with issuers and agents or brokers for the 2015 plan year. Employers may renew FF-SHOP group coverage when their 2014 plan year ends. (REGTAP FAQ Database - FAQ #5318 10/02/14) 2. Can states use existing, approved Section 1311 grant funds for the work of establishing SHOP online functionality and, if necessary, can states request a no cost extension? If the work of establishing SHOP online functionality is part of a state's approved work plan under its current Section 1311 grant award, states may use existing, approved grant funds for that work during an approved transition period so long as the funds are still available under the terms of the grant. States may also request a no cost extension to use grant funds on these activities in accordance with 1311 grants policy on the Use of 1311 Funds and No Cost Extensions extension-faqs-3-14-14.pdf Requests will be reviewed accordingly by CMS. CMS 928 Updated 1-31-17 2017--01028 FA 08 - Flexibilities for State-based SHOP Direct Enrollment 06/01/15) 3. What should issuers and a State-based SHOP tell small employers about direct enrollment in In a State-based Marketplace using SHOP direct enrollment during a transition period, small employers will enroll in SHOP QHPs directly with SHOP issuers or by working with their agent or broker. In such a state, to claim the Small Business Health Care Tax Credit, an otherwise eligible small business must enroll in a SHOP QHP, and must also ?le an application to participate in the SHOP and receive a favorable determination of eligibility. When a State-based SHOP using direct enrollment provides notice of a favorable eligibility determination, it should also provide information to the small employer about how to ?le for the Small Business Health Care Tax Credit with the Internal Revenue Service. SHOP QHP issuers in a state where SHOP direct enrollment is permitted during a transition period can assist small employers in accessing the Small Business Health Care Tax Credit by making clear which QHP offerings are available through the SHOP and providing information to inform small employers who enroll in SHOP QHPs of the next steps to access the tax credit. For additional information, please visit: business-tax-creditsl. CMS FA Qs - Flexibilities for State-based SHOP Direct Enrollment 06/01/15) SHOP Special Enrollment Periods Q19: Will the FF-SHOP validate Special Enrollment Period (SEP) reasons, such as legal guardianship? Is the issuer expected to maintain enrollment of plan members using the ASC X12 834 enrollment transaction, or is there additional validation for the issuer to perform? A19: No, the FF-SHOP will not validate SEP reasons at the time of enrollment. Information provided by an employee regarding their dependents is signed under the penalty of perjury. In addition, CMS may conduct dependent veri?cation audits. Any QHP issuer participating in the FF-SHOP must maintain enrollment of members in accordance with 45 C.F.R. ?156.285. (SHOP FAQ #3 07/30/13; REGTAP FAQ Database - FAQ #66 07/30/13) Q30: What is the length of special enrollment periods in the Updated 1-31-17 A30: In a March 11, 2013 proposed rule (78 FR 15553), we proposed aligning the length of special enrollment periods in the SHOPs with those set forth under HIPAA. Special enrollment periods in group markets, as provided for in rules implementing HIPAA, last for 30 days after loss of eligibility for other private insurance coverage or after a person becomes a dependent through marriage, birth, adoption, or placement for adoption. The proposed rule also would clarify that, consistent with HIPAA, there would be a 60-day special enrollment period for any qualified employee or dependent of a quali?ed employee who has become ineligible for Medicaid or CHIP or who has become eligible for state premium assistance under a Medicaid or CHIP program. These regulations were finalized as proposed. (QHP Webinar Series FAQ #10 05/09/13; REG TAP FAQ Database - FAQ #145 and #145a 08/02/13; updated 08/27/14) 929 2017-?01029 Q: For special enrollment periods in SHOP, does plan selection have to occur within 30 days of the triggering event? A: In most instances, yes, plan selection must occur within 30 days of the triggering event. The only exception is loss of Medicaid/CHIP. In that instance, an eligible individual must select a plan within 60 days. (REGTAP FAQ Database - #1561 05/08/14) Q: If an employee is granted a Special Enrollment Period (SEP) and the employee selects a plan, can the employee continue to make plan changes throughout the 30-day window or does the SEP window close when the employee selects a plan? A: Once an employee submits a plan selection and an 834 enrollment transaction is sent to the issuer, plan changes are not allowed as a part of that SEP. (REGTAP FAQ Database - FAQ #4139 08/26/14) SHOP Maintenance Transactions 029: Will there be additional information available regarding ongoing group enrollment maintenance during the plan year? Specifically, how will changes to enrollment (new hires/terminations, etc.) be handled? A29: Information included in the initial group enrollment may be updated during the year. Changes to enrollment and other member-level changes will be handled through the 834 enrollment transaction. (QHP Webinar Series SHOP FAQ #1 06/20/13; REGTAP FAQ Database - FAQ #132 06/20/13) 020: Can FF-SHOP enrollees make demographic and product-related changes directly with the issuers or should issuers direct enrollees to the A20: Enrollment and demographic changes should be made directly with the FF-SHOP, as it is the enrollment system of record. (SHOP FAQ #3 07/30/13; REGTAP FAQ Database - FAQ #67 07/30/13) Q: How will the Federally-facilitated Small Business Health Options Program (FF-SHOP) receive Group IDs from the Issuer for maintenance transactions? A: Issuers will send the Group ID on 834 effectuation confirmation transactions. (REGTAP FAQ Database - #1981 05/30/14) Q: Will the Federally-facilitated Small Business Health Options Program (FF-SHOP) send maintenance transactions as a termination transaction and an add transaction, similar to the Federally-facilitated Marketplace A: No, the plans to use Health Insurance Exchange (HIX) 834 maintenance transactions that will not require terminations and subsequent adds to reflect employee or dependent changes. (REGTAP FAQ Database - FAQ #2859 07/16/14) 930 Updated 1-31-17 2017--01030 Q: If a new employee is hired mid-year, will the new member enroll on an initial or maintenance 834 transaction? A: The FF-SHOP will process the new employee's initial enrollment on an 834 transaction with a maintenance type code of "021" and a maintenance reason code of (REGTAP FAQ Database - FAQ #2860 07/16/14) Q: When sending 834 maintenance transactions will the Federally-facilitated Small Business Health Options Program (FF-SHOP) send all members on the policy, or will the FF-SHOP only send the subscriber plus the member whose information that should be changed? A: The Centers for Medicare Medicaid Services (CMS) will only send information for the individual with the change; CMS will not send the entire member ?le. (REGTAP FAQ Database - FAQ #2864 07/16/14) Q: Appendix of the 834 Companion Guide mentions a new file type, the Change-in- Circumstance acknowledgement file. Does the file type apply in A: No. acknowledgement ?les only apply to the FFM Individual Marketplace. FF- SHOPs will use HIX 834 maintenance transactions to communicate changes to employee or dependent coverage. (REGTAP FAQ Database - FAQ #2868 07/16/14) Q: Will 834 maintenance transactions in the Federally-facilitated Small Business Health Options Program (FF-SHOP) always contain subscriber information? A: No. The subscriber information is sent only if the premium amount is impacted or when there is a change in subscriber information. (REGTAP FAQ Database - FAQ #2882 07/16/14) Q: For Federally-facilitated Small Business Health Options Program (FF-SHOP) maintenance transactions, if there are two changes (for example, both an address and phone number change), are both transactions sent on the same maintenance file, or are these changes sent separately on different days? A: The daily batched 834 file from the FF-SHOP may contain multiple transactions generated on a single day for an enrollee. For example, if the member changes his or her phone number in the first transaction and then updates his or her address in the next transaction, these 2 transactions will be batched in the same 834 ?le sent on the same day. (REG TAP FAQ Database - FAQ #2888 07/16/14) Q: When the Federally-facilitated Small Business Health Options Program (FF-SHOP) sends a maintenance transaction to make a change to a Group Extensible Markup Language (XML) file, will the FF-SHOP only send the changes, or the entire group file? A: When sending a maintenance transaction, the FF-SHOP will always send the entire Group XML ?le, including the changes that were made. (REGTAP FAQ Database - FAQ #3002 07/25/14) 931 Updated 1-31?17 2017--01031 Q: How will the Federally-facilitated Marketplace Individual Market and the Federally- facilitated Small Business Health Options Program (FF-SHOP) each send maintenance transactions to issuers? A: The FFM Individual Market will send maintenance transactions using the Change-in- Circumstance Termination Transaction followed by an Initial Enrollment Transaction. The will only send a single Maintenance 834 transaction for the conditions that are affected. (REGTAP FAQ Database - FAQ #3006 07/25/14) Q: If information on the Group XML file, such as an address or contact information, changes, will issuers receive a new XML file with the changes? A: Yes, issuers will receive group-level maintenance transactions when a group's contact information or broker changes. (REGTAP FAQ Database - FAQ #4135 08/26/14) Q17: Is the maintenance effective date considered the date of the transaction change or will it be the process date of the transaction? A17: The maintenance effective date is the process date of the transaction. (SHOP FAQ #4 08/28/1 3; REG TAP FAQ Database - FAQ #21 08/28/13) Q: If a member is removed from a group and another member is added to the group, how many transactions would issuers receive? Would the issuer receive one transaction for the cancel and another transaction for the addition? A: Every event will have a separate transaction. If a member is removed, the Federally- facilitated Small Business Health Options Program (FF-SHOP) will send a termination transaction. If a member is added, the FF-SHOP will send an add transaction. (REGTAP FAQ Database - FAQ #4212 09/02/14) Q: In 2015, will the Federally-facilitated Small Business Health Options Program (FF- SHOP) send issuers multiple transactions when the same employer group makes multiple changes on a single day? A: Every event will have separate transactions. Multiple changes on a single day will trigger multiple transactions. (REGTAP FAQ Database - FAQ #4213 09/02/14 Q: If an employer needs to update information (phone number, address, email address), do issuers need to direct the employer to the Federally-facilitated Small Business Health Options Program A: Yes, because the FF-SHOP is the sole enrollment system of record for 2015 and because the FF-SHOP has no way to receive maintenance transactions from issuers, all group and member-level changes must be made through the FF-SHOP online system (or by calling the SHOP Call Center). Issuers with in-house licensed Agents may utilize the FF-SHOP Agent/Broker portal to enroll groups and make changes after coverage has been effectuated. (REGTAP FAQ Database - FAQ #4428 09/05/14) 932 Updated 1-31-17 2017--01032 Q: If an employer makes multiple updates on the same day to information (phone number, address), will the issuer receive those changes as a single 834 transaction or multiple 834 transactions? A: The Federally-facilitated Small Business Health Options Program (FF-SHOP) will send all changes as separate transactions except for; 1) name changes of dependents, 2) mailing address changes of employees/dependents, and 3) contact information updates of employees/dependents. The FF-SHOP will combine these three transactions on a single transaction in 3 different loops because the changes are all entered on a single screen within the FF-SHOP user interface All other changes are initiated separately from life status change Ul screens. Because more than one life status change could be entered on a single day, issuers may receive multiple maintenance transactions when this scenario occurs. Each transaction is time-stamped, so issuers should assume the last maintenance transaction is the one that should be updated in an issuer's system. (REGTAP FAQ Database - FAQ #4438 09/05/14) Q: If an employer makes multiple updates to the business address and the issuer receives multiple Group XML maintenance transactions for that employer, how will issuers know which transaction is the correct information? A: The FF-SHOP will time stamp all transactions, so issuers should use the maintenance transaction with the latest time stamp. (REGTAP FAQ Database - FAQ #4439 09/05/14) Q: If an issuer effectuates a maintenance transaction or re-effectuates an initial enrollment transaction with a new group member, will the Federally-facilitated Small Business Health Options Program (FF-SHOP) replace the Issuer Assigned Group ID with the new number? A: Yes, the FF-SHOP will replace the Issuer Assigned Group ID with the new number. (REGTAP FAQ Database - FAQ #4688 09/11/14) Q: If an employee calls an issuer directly and provides the issuer with an update, could the issuer call the Federally-facilitated Small Business Health Options Program (FF- SHOP) Call Center to assist the employee with the change or do issuers have to direct the employee to the FF-SHOP Call Center? A: Issuers should direct employers and employees to the online system or the FF-SHOP Call Center to update account information or to make coverage changes. The FF-SHOP Call Center is also able to participate in 3 way calls between an issuer's help desk, the FF-SHOP Call Center and the employer wanting to make account changes. (REGTAP FAQ Database - FAQ #4914 09/17/14) Q: Should issuers reach out to the Federally-facilitated Small Business Health Options Program (FF-SHOP) to make corrections on behalf of an employer or must employers make corrections on the FF-SHOP Portal? A: Issuers should direct employers and employees to the online system or the FF-SHOP Call Center to update account information or to make coverage changes. The FF-SHOP Call Center is also able to participate in 3 way calls between an issuer's help desk, the 933 Updated 1-31-17 2017--01033 Call Center and the employer wanting to make account changes. (REGTAP FAQ Database - FAQ #4920 09/17/14) Q: How will the Federally-facilitated Small Business Health Options Program (FF-SHOP) Call Center validate the identity of an employer who calls to make changes? A: The Centers for Medicare and Medicaid Services (CMS) has established authentication data elements employers must provide before any FF-SHOP Call Center representatives will discuss the employer account or make any updates. (REGTAP FAQ Database - FAQ #4923 09/17/14) Q: If an employee changes demographic information online, will the Federally-facilitated Small Business Health Options Program (FF-SHOP) notify the employer of the change? A: Employees may only respond to an offer of coverage or a Special Enrollment Period (SEP) initiated by the employer. Thus, the employer will always know about coverage and demographic changes. The FF-SHOP will not notify employers when an employee changes contact information, such as a phone number or mailing address, using the employee's online account. (REGTAP FAQ Database - FAQ #5321 10/02/14) Q: Will Federally-facilitated Small Business Health Options Program (FF-SHOP) issuers receive a Maintenance Group Extensible Markup Language (XML) for every 834 maintenance transaction? A: No. In the FF-SHOP, every maintenance file of a member may not result in changes to the group information. If the member maintenance results in a new plan being added, the FF-SHOP will send an employer group maintenance ?le to issuers. (REGTAP FAQ Database - FAQ #5322 10/02/14) Q: Will the Federally-facilitated Small Business Health Options Program (FF-SHOP) send both Group Extensible Markup Language (XML) and 834 transactions for every event, for example, the removal of a member and the addition of another member to the group? A: The FF-SHOP will send 834 ?les for every maintenance transaction in the FF-SHOP, however, the FF-SHOP will only send Group XMLs when there is a change in group- level information, such as a change in broker, primary business address, or plan information not communicated on a previous Group XML. Thus, the FF-SHOP will not send a Group XML if an employee joins a plan for which information was already sent. (REGTAP FAQ Database - FAQ #5346 10/03/14) Q: Will the Federally-facilitated Small Business Health Options Program (FF-SHOP) send enrollment and maintenance transactions on the same 834 transaction or in the same ST- SE loop in the 834 transaction? A: If an employee (and his or her dependents) enroll and make changes on the same day, the FF-SHOP will send all enrollment and maintenance transactions on the same 834 transaction but on different ST-SE loops. (REGTAP FAQ Database - FAQ #5494 10/09/14) 934 Updated 1-31-17 2017--01034 Q: Which speci?c Maintenance 834 transactions do Federally-facilitated Small Business Health Options Program (FF-SHOP) issuers need to send effectuation 834 transactions? A: FF-SHOP issuers must send effectuation 834 transactions whenever a new enrollee is added to an employer group's plan. (REGTAP FAQ Database - FAQ #5508 10/09/14) Q: Can an employer change the employer's Employer Identification Number (EIN) after coverage has been effectuated? If yes, will issuers receive a Group Extensible Markup Language (XML) maintenance transaction for this scenario? A: No, employers cannot change their EIN once coverage has been effectuated. Employers could, however, terminate coverage for the entire group and reapply for coverage with the new EIN. (REGTAP FAQ Database - FAQ #5687 10/17/14) Q: Will there ever be a scenario when the Policy ID in will change for a family during the year? Or will a family maintain the original/same Policy ID throughout the year? A: If an employer disenrolls an employee from a plan and the employee is later added back to the roster and enrolls in a new plan, then only the Policy ID will change. In all other cases when an employee change is reported on a maintenance transaction, the Policy ID will remain the same. (REGTAP FAQ Database - FAQ #8030 12/03/14) Q: Will the Federally-facilitated Small Business Health Options Program (FF-SHOP) Maintenance Transaction be multiple transactions, or a single transaction change? A: No changes are happening for the 2016 Plan Year. For FF-SHOP, changes to an enrollment are covered with multiple maintenance transactions. There could simple change, or as many as seven (7) for more complex changes. (REGTAP FAQ Database - FAQ #12440 09/01/15) SHOP Effect/on Transation (834) Q: Can CMS confirm the type of dependent for which the relationship code 68 is used? A: The G8 Relationship code is used to describe a dependent who is not a child, or fitting any other description for the existing relationship codes. Additional information can be found using the link below; please review page 85: 201504.9df (REGTAP FAQ Database - FAQ #18505 01/09/17) Q: Where can FF-SHOP issuers find written information on the effectuation process? A: Issuers may find additional information on the 834 effectuation process in the following documents: Federally-facilitated Marketplace (FFM) and SHOP Enrollment Manual: Guidance/Downloads/ENR Manual 080916.pdf Section 10.2 in the 834 Companion Guide: 935 Updated 1-31-17 2017--01035 Dental Effectuation Guidance: Guidance/Downloads/FFM Dental Effectuation Bulletin 06012016.pdf (REGTAP FAQ Database - FAQ #18506 01/09/17) Q: Can CMS state when the deadline is for issuers to submit effectuation files, how long the time frame is for issuers to submit ?les and what steps must be taken if there are errors in the submission process? A: Issuers should submit effectuation ?les as soon as possible after the 26th of each month. Should errors arise during the submission process, please follow the guidance listed in the Electronic Data Interchange (EDI) 999 rejection ?le. If further assistance is needed please email enrollmentquidance@cms.hhs.qov (REGTAP FAQ Database - FAQ #18507 01/09/17) SHOP Renewal 020: Please explain how the group renewal process will work. A20: 90 days prior to the end of a plan year, the FF-SHOP will send out a notice to employers to renew coverage and obtain employee commitments for the next 12 months. Employers will have 30 days to make election decisions and employees will have 30 days to elect coverage and choose a QHP (including the choice to remain with the same QHP). (QHP Webinar Series SHOP FAQ #1 06/20/13; REGTAP FAQ Database - FAQ #124 06/20/13) Q37: How will renewals work in the A37: Renewal information in the FF-SHOP can found in the ?nal regulations at 45 CFR ?155.725. The FF-SHOP will be managing renewal noti?cations, and CMS intends to involve Brokers in the renewal process. Employers will be noti?ed of the option to renew SHOP coverage 90 days prior to the end of the plan year. At that time, the employer will be given a 30-day window to make employer-level changes. After the employer makes necessary changes, employees will be given the next 30 days of the 90-day renewal window to make their coverage selections for the new plan year. If the employer elects to have the same coverage for the following plan year, employees will be automatically renewed into the same QHP unless they take other action during their renewal timeframe. The remaining 15 days can be used to follow up with late renewals and process enrollment applications, which need to be submitted 15 days prior to the start of the new plan year. (SHOP FAQ #2 07/05/13; REGTAP FAQ Database - FAQ #99 07/05/13) Q: If an employer enrolls in SHOP during the 2014 plan year, how should we treat the group prior to renewal? Will we auto renew these groups or will they start from the beginning of the process? Updated 1-31-17 A: Groups enrolled in a FF-SHOP in 2014 will renew their coverage apply?and enrell?fer?the??rst?time using the FF- SHOP online portal at HealthCare. gov. Because qroups must do to HealthCare. qov to renew their coverage, auto renewals with issuers is not an option. when?it-gees?live-LateHn?ZOM. Issuers will not be able to renew qroups in a FF- SHOP for plan years beginning In 2015. All enrollments and payments 936 2017--01036 will take place usinq the FF-SHOP online portal. (REGTAP FAQ Database - #736 and 736a 02/10/14; updated 01/07/15) Q: Will coverage for small groups enrolled in the Federally-facilitated Small Business Health Options Program (FF-SHOP) automatically renew? A: Groups enrolled in FF-SHOP coverage must take action each year to renew coverage. The Centers for Medicare Medicaid Services (CMS) will outline the FF- SHOP renewal process on a 2015 REGTAP. (REGTAP FAQ Database - FAQ #2587 07/03/14) Q: For groups enrolled directly with an issuer for the 2014 plan year, should the issuer terminate coverage at the end of the 2014 plan year if the issuers has not received a Group XML, 834, or 820 for the group's 2015 coverage? A: Issuers should follow allowable business rules based on applicable State law. Groups are not able to claim the Small Business Health Care Tax Credit if the group maintains coverage with an issuer outside of the Federally-facilitated Small Business Health Options Program (FF-SHOP) online system as of the 2015 Plan Year. Direct Enrollment in FF-SHOP Quali?ed Health Plans (QHPs) and Qualified Dental Plans (QDPs) is not an option in 2015. (REGTAP FAQ Database - FAQ #3434 08/01/14) Q: What is the renewal process for employer groups currently enrolled in the Federally- facilitated Small Business Health Options Program A: Employers who want to renew SHOP coverage for the 2015 plan year may do so by enrolling using the FF-SHOP online portal as early as November 15, 2014. (REGTAP FAQ Database - FAQ #4203 09/02/14) Q: If an enrollee returns to the Marketplace (healthcare.gov) updates their application, and selects a new plan will they be able to keep their current SADP thus keeping with the spirit of the auto-enrollment process of allowing enrollees to stay with the policy they are currently enrolled in? A: During the 2015 Annual Open Enrollment period, if an enrollee returns to the Marketplace (healthcare.gov) updates their application and selects a new Qualified Health Plan (QHP), the enrollee will need to re-select their Stand-alone Dental Plan (SADP) at the same time since the Marketplace requires that QHPs and SADPs be confirmed simultaneously. If an enrollee does not return to the Marketplace to affirmatively select plans by midnight on December 15, 2014, the Marketplace will process the auto-renewal and enroll the person for 2015 coverage in a QHP and SADP per the business rules established for the 2015 Plan ID Crosswalk Template. In these instances, if the enrollee's 2014 SADP is still available for 2015, they will be auto- renewed into that same SADP even if the enrollee is auto-reenrolled to a different QHP for 2015. (REGTAP FAQ Database - FAQ #4500 09/05/14) Q: If an enrollee stays in their original QHP but changes their SADP and has APTC leftover from the purchase of their QHP, how should they ensure that the leftover APTC payments get made to the new A: During 2015 Annual Open Enrollment, if an enrollee visits the Marketplace 937 Updated 1-31-17 2017--01037 (healthcaregov) to change either his or her SADP or QHP, the Marketplace will follow existing rules to automatically redistribute any available APTC to each renewed policy. The Marketplace requires that SADP and QHP selections be confirmed at the same time to ensure proper allocation of APTC among policies. (REGTAP FAQ Database - FAQ #4501 09/05/14) Q: Are issuers required to send the Small Business Health Options Program (SHOP) small group renewal letter from 6/26 guidance, and if this is required, should issuers alter and edit any part of the letter, for example, to add issuer letterhead or phrasing? A: Please refer to the Bulletin published September 2, 2014 titled ?Form and Manner of Notices When Discontinuing or Renewing a Product in the Group or Individual Market.? FAQ Database - FAQ #4690 09/11/14) Q: What notices are issuers required to send to the Federally-Facilitated Small Business Health Options Program (FF-SHOP) enrollees who are turning 65? A: At this time the Centers for Medicare and Medicaid Services (CMS) does not require FF-SHOP issuers to send a notice to enrollees who are turning 65. (REGTAP FAQ Database - FAQ #4692 09/11/14) Q: What data elements will specify a renewal on the 834 transaction and Group Extensible Markup Language (XML) ?les in the Federally-facilitated Small Business Health Options Program A: The FF-SHOP will not send renewal transactions to issuers for employer groups enrolling directly with an issuer in 2014. The Centers for Medicare Medicaid Services (CMS) will review renewal transactions with issuers next year for employer groups that sign up for coverage in the 2015 plan year through the FF-SHOP. (REGTAP FAQ Database - FAQ #5316 10/02/14) Q: How can employers and employees make account and coverage changes through HealthCare.gov after enrolling in coverage in the Federally-facilitated Small Business Health Options Program (FF-SHOP) for the 2015 plan year? A: Employers and employees may make group-level and subscriber-level changes by logging into their HealthCare.gov account, working with the group's Agent or Broker, or calling the Small Business Health Options Program (SHOP) Call Center. (REGTAP FAQ Database - FAQ #5319 10/02/14) Q: If an employer group enrolled with an issuer for April 1, 2014, through Direct Enrollment, when is the employer group able to go online and enroll in a Federally- facilitated Small Business Health Options Program (FF-SHOP) plan for the 2015 plan year? A: Depending on the group's anniversary month, employers enrolled in coverage through the FF-SHOP for the 2014 plan year may renew at least one to two months prior to the end of the group's current plan year. For example, if an employer group's anniversary is February 1, 2015, the employer may begin the renewal process as early as November 15, 2014. If an employer group's anniversary is April 1, 2015, the soonest that the 938 Updated 1-31-17 2017--01038 employer may renew is February 16, 2015 because that date is the soonest the Centers for Medicare Medicaid Services (CMS) will load 2nd Quarter rates into the FF-SHOP online system. (REGTAP FAQ Database - FAQ #5320 10/02/14) Q: What is the process for carrying 2014 Federally-facilitated Small Business Health Options Program (FF-SHOP) employer groups over to the 2015 plan year? Are issuers responsible for member maintenance and other administrative tasks until the employer group's renewal date in 2015? A: Groups may renew their 2014 FF-SHOP coverage at HealthCare.gov when their current plan year ends. FF-SHOP issuers are responsible for member maintenance and other administrative items until a group renews coverage in 2015. As of the 2015 plan year, the FF-SHOP will take care of some administrative matters, such as billing, though issuers are still responsible for sending group contracts and member packets as required by state regulations. In addition, issuers are responsible for sending cancellation and termination notices to employers and employees (45 CFR (REGTAP FAQ Database - FAQ #5343 10/03/14) Q: Will the Centers for Medicare Medicaid Services (CMS) contact employer groups who are currently enrolled in the Federally-facilitated Small Business Health Options Program (FF-SHOP) regarding renewals? A: CMS will not send FF-SHOP employer group renewal noti?cations for the 2015 plan year because the is not the system of record for 2014 Qualified Health Plan (QHP) and Stand-alone Dental Plan (SADP) enrollments. CMS intends to e-mail employers who submitted an FF-SHOP paper application in 2014. The e-mail will instruct employers who enrolled in an FF-SHOP QHP or SADP to renew coverage by going to HealthCare.gov. CMS also plans to post renewal information on HealthCare.gov prior to November 15, 2014. On September 2, 2014, CMS issued a final bulletin on renewal noti?cations outlining requirements for issuer renewal notifications. The bulletin is posted at FAQ Database - FAQ #5498 10/09/14) Q: If an enrollee returns to the Federally-facilitated Marketplace (FFM) (for example, by accessing HealthCare.gov) updates his or her application, and selects a new medical QHP will s/he be able to keep his or her current SADP through the auto-enrollment process? Updated 1-31-17 A: During the Annual Open Enrollment period for the 2015 bene?t year, if an enrollee returns to the FFM (for example, by accessing HealthCare.gov) updates his or her application and selects a new medical Quali?ed Health Plan (QHP), the enrollee will need to re-select his or her Stand-alone Dental Plan QHP (SADP) at the same time, since the FFM requires that, if a consumer wants to select an SADP, the SADPs be selected simultaneously with a QHP. If upon returning to the FFM an enrollee wants to select the same SADP under which s/he is currently covered, s/he may use the SADP plan ID to search for his or her plan to ensure that s/he is selecting the same coverage. If an enrollee does not actively select a QHP or (QHP and SADP) by midnight on December 15, 2014, the Marketplace will process an auto-enrollment and enroll the person for 2015 coverage in a QHP and, if 939 2017--01039 applicable, SADP per the hierarchy set forth at 45 CFR 155.335(j) and the business rules established for the 2015 Plan ID Crosswalk Template. In these instances, if the enrollee can be auto-enrolled into 2015 QHP coverage, slhe also will be auto-enrolled in SADP coverage, if SADP coverage remains available for 2015, in accordance with the hierarchy set forth at 45 CFR 155.3350), as applied to SADPs, and the business rules established for the 2015 Plan ID Crosswalk Template. (REGTAP FAQ Database - FAQ #4500 10/07/14) Q: If an enrollee renews coverage through the FFM for 2015 in the same QHP under which s/he was covered in 2014, but changes his or her SADP enrollment and has APTC left over from the purchase of his or her QHP, how should slhe ensure that the leftover APTC payments get made to the new A: During Annual Open Enrollment period for the 2015 bene?t year, if an enrollee changes his or her SADP or QHP, the FFM will follow current regulations and FFM operational rules to automatically redistribute any available APTC to each renewed policy. The FFM requires that, if a consumer wants to select an SADP, the SADPs be selected simultaneously with a QHP to ensure proper allocation of APTC among policies. (REGTAP FAQ Database - FAQ #4501 10/07/14) Q: If a member switches plans (and therefore the first 5 digits of the Exchange Assigned Subscriber/Member ID changes), will the remaining ?10-Digit change? A: No, the 10-digit ID that is part of the Exchange Assigned Subscriber/Member ID will not change when a member switches plans. (REGTAP FAQ Database - FAQ #5683 10/17/14) Q: Will the Centers for Medicare Medicaid Services (CMS) send renewal Group Extensible Markup Language (XML) ?les, if a group renews in the Federally-facilitated Small Business Health Options Program A: Yes, CMS will be sending Group XML ?les for groups renewing in the Federally- facilitated Small Business Health Options Program (FF-SHOP). (REGTAP FAQ Database - FAQ #10783 05/27/15) Q: What are the Federally-facilitated Small Business Health Options Program (FF-SHOP) issuer requirements regarding Identification (ID) cards for A: The Centers for Medicare and Medicaid Services (CMS) has not released specific guidance regarding issuing ID cards for re-enrollments/renewals. (REGTAP FAQ Database - FAQ #12168 08/27/15) Q: If a group does not reselect a plan during renewal, but the group renews with the same issuer, will this plan be included on the Group Extensible Markup Language (XML) File sent to renew the group? A: The only plans that will be sent in a Group XML will be those plans, which are selected by members during renewal. (REGTAP FAQ Database - FAQ #12177 08/27/15) 940 Updated 1-31-17 2017--01040 Q: Are issuers permitted to match an Employer Taxpayer Identification Number (TIN) in order to determine if a file is a renewal versus a new enrollment? A: The Payment Transaction Identi?cation (ID) is the correct identi?er to determine renewals versus a new enrollment. (REGTAP FAQ Database - FAQ #12179 08/27/15) Q: During Federally-facilitated Small Business Health Options Program (FF-SHOP) renewals, will plans selected for the first time and renewal plans come on the same file? A: FF-SHOP renewals will include both first time employees as well as renewed employees. The difference will be the inclusion of Issuer-assigned Identifications (IDs) for renewed employees, and not ?rst time employees. (REGTAP FAQ Database - FAQ #12217 08/27/15) Q: Is it possible for a group to terminate and re-enroll by going through the application process at a later date within the Plan Year? A: Yes, this scenario is possible. (REGTAP FAQ Database - FAQ #12216 08/27/15) Q: If an issuer has a group that does not renew for the 2016 Plan Year and is included on the group switch file, will that group receive a termination letter? A: For groups NOT renewing in the Federally-facilitated Small Business Health Options Program (FF-SHOP), the FF-SHOP Marketplace will send a termination notice. If an employer continues on the Marketplace but changes to a different issuer (Employer Choice), the FF-SHOP Marketplace will not send a termination notice. (REGTAP FAQ Database - FAQ #13131 09/22/15) Q: Are Federally-facilitated Small Business Health Options Program (FF-SHOP) issuers required to send effective date notices to enrollees upon initial enrollment as well as upon renewal? A: No. The Centers for Medicare and Medicaid Services (CMS) only require effective date notices upon initial enrollment, so long as the enrollee renews coverage with the same plan. If an enrollee signs up for a different plan from the same issuer, the enrollee is considered a new enrollee within the meaning of because the change in plans has an effective date and the person would be new to that particular plan/coverage. Pursuant to 45 CFR issuers are required to notify new enrollees of their effective date of coverage consistent with 155.720(e) of this subchapter. This provision was intended to ensure that Qualified Health Plan (QHP) issuers participating in the SHOP Marketplace would provide notice to a new enrollee of the enrollee?s effective date of coverage. (REGTAP FAQ Database - FAQ #15020 03/02/16 Q: Do renewal notice requirements apply to Stand-alone Dental Plans A: No. SADPs are excepted benefits and therefore not subject to the Federal guaranteed renewability requirements. The Centers for Medicare and Medicaid Services (CMS) do not require SADP issuers to send renewal notices under Federal law, but issuers must adhere to any applicable State laws with respect to renewal and discontinuation notices. (REGTAP FAQ Database - FAQ #15021 03/02/16) 941 Updated 1-31-17 2017-?01o41 Q: Will my consumers need to reauthorize me as their agent or broker upon renewal in the Small Business Health options (SHOP) Marketplace? A: No; once the agent or broker and employer relationship has been established, that relationship will remain valid as long as the agent or broker has completed the registration and training requirements for the SHOP Marketplace for the current plan year. If an employer wants to end the relationship with the agent or broker and add a different one to the account, he or she can do that by logging into their SHOP account on HealthCare.gov. Otherwise the agent or broker will automatically remain on the application upon renewal. (REGTAP FAQ Database - FAQ #17981 10/28/16) Coverage Effective Dates 026: How will an employer select a new hire?s waiting period prior to effectuating coverage? A26: An employer will establish the group?s new hire waiting period policy during the initial application process. There will be a drop-down box in the online employer application where the employer will select the waiting period. The available options will days. Because coverage for new hires is always effectuated on the ?rst of the month, the maximum waiting period option will be 60 days to ensure an employee?s waiting period does not extend beyond the maximum allowable period of 90 days. Issuers will not receive the waiting period start and end dates. Only the effective dates of coverage for new hires (incorporating applicable waiting periods) will be sent to Issuers. (SHOP FAQ #2 07/05/13; REG TAP FAQ Database - FAQ #94 07/05/13) 027: Since the FF-SHOP will not be calculating participation rates during the November 15-December 15 special enrollment period, will Issuers receive a single enrollment file or a separate enrollment file for employers applying during this period of time? A27: The FF-SHOP will send Issuers groups? enrollment ?les during this period in the same manner as will occur during the rest of the open enrollment period. (SHOP FAQ #2 07/05/13; REGTAP FAQ Database - FAQ #95 07/05/13) 942 Updated 1-31-17 2017-?01o42 029: Will Issuers be allowed to pend employee enrollment until the employer meets the required participation threshold? A29: Pending employee enrollment will not be necessary since Issuers will not receive the group set up file or 834 enrollment transactions until the employer meets the participation rate. (SHOP FAQ #2 07/05/13; REGTAP FAQ Database - FAQ #97 07/05/ 13) Q37: Since employers will be determining waiting periods and effective dates at the level of the FF-SHOP, will the FF-SHOP ever set up a group with coverage effectuating on a day other than the first of a month? A37: Coverage for a group initially enrolling in the FF-SHOP will always be the ?rst of the month. New hire effective dates will also always be the ?rst of the month after any applicable waiting period has expired. (SHOP FAQ #4 08/28/13; REGTAP FAQ Database - FAQ #40 08/28/13) Q38: In the FF- SHOP, will the effective date of coverage always be the first of the following month if an initial enrollment application is received by the 15th of the month? Additionally, would the effective date of coverage be the first day of the following month if an enrollment application is received after the 15th of the month (with an exception for birth or adoption of a child where the effective date is the day of the qualifying event)? Will the FF-SHOP allow for retroactive enrollment? A38: For groups enrolling for the ?rst time, the effective date of coverage is based on when an employer submits the initial application. An employer must enroll by the 15th of the month to effectuate coverage on the ?rst of the following month. An employer that enrolls after the 15th will have their coverage effectuated on the ?rst day of the next month. For example, an employer that enrolls on March 17th will have an effective date of May 1st. For special enrollment periods, the effectuation date will depend on the employee?s speci?c situation. See 45 CFR 155.420(d) of the HHS Final Exchange Establishment Rule for applicable employee circumstances. There are instances where the effective date of coverage will be retroactive. For example, the effective date for the birth or adoption of a child is always the date of the qualifying event, regardless of when an issuer is notified, and as long as the FF-SHOP is noti?ed within 30 days of the event. (SHOP FAQ #4 08/28/13; REGTAP FAQ Database - FAQ #41 08/28/13) 943 Updated 1-31-17 2017--01043 Q: Will the FF-SHOP allow retroactive transactions in 2015 that go back to 2014, for groups that enroll using the FF-SHOP portal for the 2015 plan year? A: The FF-SHOP will not allow retroactive transactions to plan year 2014. All effective dates for enrollments generated through the FF-SHOP online portal will be January 1, 2015, and forward. (REGTAP FAQ Database - FAQ #831 02/21/14) Q: Per the current version of the companion guide ?last premium paid date? is required on effectuation. Will you please confirm that for plan years beginning on and after January 1, 2015, Issuers will have to effectuate coverage before receiving payments and 820 transactions for FF-SHOP coverage? A: Your understanding is confirmed. (REGTAP FAQ Database - FAQ #837 02/21/14) Q: Will issuers be sent the Group XML file prior to CMS receiving the full initial premium for the group? A: Issuers will be sent the Group XML ?le when an employer completes the group enrollment process on or before the 15th of the month. Employers will be given the opportunity to submit a payment online or mail a check into the FF-SHOP lockbox. Issuers will be sent the initial payment as soon as possible after it has been received by the (payments will generally be sent on a weekly basis). Issuers are expected to effectuate coverage if they do not receive a cancellation transaction from the FF- SHOP prior to the coverage effective date. (REGTAP FAQ Database - FAQ #1430 04/14/14) Q: If state rules dictate that Issuers cannot effectuate SHOP coverage unless they receive payment, will Federal regulation apply or will State rules be applicable in this situation? A: Pursuant to for initial payments, FF-SHOP issuers will be required to effectuate coverage unless the issuer has received a cancellation notice from the FF- SHOP prior to the coverage effective date. (REGTAP FAQ Database - FAQ #1436 04/14/14) Q: What is the effective date for adoptions and foster care? A: Pursuant to 45 ?155.420 (2) Special effective dates. In the case of birth, adoption, placement for adoption, or placement in foster care, the Exchange must ensure that coverage is effective for a qualified individual or enrollee on the date of birth, adoption, placement for adoption, or placement in foster care. (REGTAP FAQ Database - FAQ #1421 04/14/14) Q: 944 Updated 1-31-17 2017-?01044 1) Does the ?Coverage Effective Start Date? field refer to the member effective start date or the group effective start date? 2) Can CMS confirm that the file should not include any members with future effectuation or future termination dates? A: 1) The "Coverage Effective Start Date" refers to the member effective start date. 2) The file should only contain members with A) active coverage on the date that the ?le is extracted, and B) terminated coverage on the date the ?le is extracted. A future termination would be active when the file is extracted. (REG TAP FAQ Database - #1583 05/13/14) Q: Is CMS allowing groups to make retroactive changes? A: With few exceptions, birth/adoption/death, effective dates in FF-SHOPs are always the ?rst of the month, and termination effective dates are always the last day of the month. Retroactive changes are generally not allowed. (REGTAP FAQ Database - #1562 05/08/14) Q: When are Issuers expected to send 834 effectuation transactions? A: Per Federally-facilitated Small Business Health Options Program (FF-SHOP) regulations, issuers must effectuate coverage prior to the coverage effectuation date. Specifically, issuers should send 834 effectuations as soon as possible but no later than: 1) When payment is received from the FF-SHOP, or 2) When the initial binder payment deadline has passed. CMS will review the initial binder payment deadline on a future REGTAP call. (REGTAP FAQ Database - FAQ #2427 06/26/14) Q: Will the Centers for Medicare and Medicaid Services (CMS) test a scenario in which an employee selects a plan and makes a payment, then prior to the effectuation date, selects a new plan and pays for that plan? A: Operationally this scenario will not be supported, so CMS will not test this scenario. (REGTAP FAQ Database - FAQ #2429 06/26/14) Q: When employers or employees cancel coverage prior to the effectuation date, are issuers required to send noti?cations to the employers or employees? A: State law or regulation may require issuers to send notifications to employers or employees when cancellations occur. (REGTAP FAQ Database - FAQ #2604 07/03/14) Q: Can effectuations in Federally-facilitated Small Business Health Options Program (FF- SHOP) not take place unless the first month's premium is paid along with any unpaid premiums from direct enrollment SHOP coverage obtained from plan year 2014? A: No. The FF-SHOP will only collect and remit premium amounts owed for the 2015 plan year. Issuers are responsible for collecting any premium amounts owed from direct enrollments in 2014. (REGTAP FAQ Database - FAQ #2881 07/16/14) 945 Updated 1-31-17 2017--01045 Q: Are FF-SHOP Issuers required to hold enrollment confirmation/effectuations until after payment is received? A: Issuers participating in the FF-SHOP Marketplaces are not required to hold enrollment confirmation/effectuations until after payment is received. In fact, per Section issuers participating in FF-SHOP Marketplaces are required to effectuate SHOP coverage unless the issuer receives a cancellation transaction prior to the coverage effective date. Cancellation transactions will be sent to issuers if the FF- SHOP does NOT receive the initial binder payment by a speci?ed date prior to the coverage effective date. CMS will review initial and ongoing payment timelines as well as the timing of initial coverage effectuation transactions on an upcoming REGTAP call. (REGTAP FAQ Database - FAQ #3451 08/01/14) Q: What is the cut-off date for an employer group in the Federally-facilitated Small Business Health Options Program (FF-SHOP) to have coverage on the first day of the following month? A: The FF-SHOP must receive employer group applications by the 15th of the month for coverage to be effective on the 1st of the following month. (REGTAP FAQ Database - FAQ #3398 08/01/14) Q: What effective date will the Federally-facilitated Small Business Health Options Program (FF-SHOP) send on the Group XML file for an off cycle benefit change or when a new employee enrolls in a plan that was not selected during the initial enrollment period? A: The effective date for new hires and enrollees enrolled will vary depending on a variety of circumstances, however, rates are based on the quarter in which a group initially enrolled and the coverage end date for new enrollees is the end of a group's 12 month plan year. (REGTAP FAQ Database - FAQ #3433 08/01/14) Q: How will Federally-facilitated Small Business Health Options Program (FF-SHOP) issuers know when payments are made by employers to effectuate coverage A: Issuers will know a payment has been made when the issuer receives the payment and accompanying 820 transaction. Also, if an issuer does not receive a cancellation transaction for a new group by the 26th of the month, the issuer should assume the FF- SHOP received a payment and the issuer should proceed to effectuate the group's coverage. (REGTAP FAQ Database - FAQ #3793 08/14/14) Q: If an issuer effectuates the Small Business Health Options Program (SHOP) enrollments by the 26th of the month and did not receive the binder payment until a day before the coverage effective date, should issuers cancel the plan or provide coverage? A: The Federally-facilitated Small Business Health Options Program (FF-SHOP) must receive the initial binder payment by the 26th of the month. If a payment is not received by 26th of the month, the FF-SHOP will send a cancellation transaction to issuers prior to the coverage effective date. Issuers are required to effectuate coverage unless the issuer receives notice from the FF-SHOP. (REGTAP FAQ Database - FAQ #4205 09/02/14) 946 Updated 1-31-17 2017--01046 Q: What should Federally-facilitated Small Business Health Options Program (FF-SHOP) issuers enter for ?Premium Paid to End Date? and ?Last Premium Paid Date? on 834 effectuation transactions when an issuer has not yet received the initial payment because of end of the month timing issues? A: As documented in the 834 Companion Guide, these data elements are optional for FF-SHOP transactions. Thus, issuers should leave this data element blank if issuers have not yet received the initial payment when sending the 834 effectuation transaction. (REGTAP FAQ Database - FAQ #5567 10/14/14) Q: How will a Federally-facilitated Small Business Health Options Program (FF-SHOP) issuer know what benefit plan year (calendar vs contract year) is selected by a group? Will benefit plan year type be indicated on the Group Extensible Markup Language (XML) or834? A: Current CMS regulation allows issuers to establish benefit plan years based on a calendar year or a contract year (as allowed by state law and regulations). As a result, this data element is not contained within FF-SHOP issuer transactions. (REGTAP FAQ Database - FAQ #5677 10/17/14) Q: Can issuers omit the Last Premium Paid Date element on the effectuation 834 transaction? A: Yes, issuers should omit the 'Last Premium Paid Date' on 834 effectuation transactions. (REGTAP FAQ Database - FAQ #5678 10/17/14) Q: Are issuers required to send back the Exchange Assigned Policy ID in the 834 effectuation file? A: Yes, the Centers for Medicare Medicaid Services (CMS) expects Federally- facilitated Small Business Health Options Program (FF-SHOP) issuers to send back the Exchange Assigned Policy ID in the 834 effectuation ?le. (REGTAP FAQ Database - FAQ #5684 10/17/14) Q: When are issuers required to send effectuation 834 transactions? A: The Federally-facilitated Small Business Health Options Program (FF-SHOP) expects effectuation transactions for all outbound transactions where maintenance type code (INSOB) is 021. This includes plan changes during Special Enrollment, plan selection for new hires, renewals, etc. (REGTAP FAQ Database - FAQ #12182 08/27/15) Q: How quickly does the Centers for Medicare and Medicaid Services (CMS) require issuers to submit effectuation files? A: Federally-facilitated Small Business Health Options Program (FF-SHOP) issuers are required to send effectuation ?les, and CMS expects these files to be sent as soon as possible after the coverage effective date. After the 26th of the month prior to the coverage effective date, if issuers do not receive a cancellation transaction from the FF- SHOP, they are required to effectuate coverage even if they are not in receipt of the binder payment. (REGTAP FAQ Database - FAQ #12218 08/27/15) 947 Updated 1-31-17 2017-?01o47 COBRA Q32: Has there been a decision regarding how COBRA will be administered? When will a group need to submit payment for COBRA enrollees? A32: Employees eligible for COBRA may enroll at the time of initial enrollment and throughout the year for groups participating in the FF-SHOP. Full payment is expected for the entire group, including COBRA payments, at the time of initial enrollment and before the end of applicable grace periods each month. (QHP Webinar Series SHOP FAQ #1 06/20/13) 01/0543) CMS removed this FAQ from the REG TAP database on 08/26/14 025: If an employer is allowed to enroll employees in COBRA, who (employer or employee) will pay the COBRA premium? A25: Current insurance market standards and protocols for notifying employees and paying for COBRA coverage will remain unchanged in the FF-SHOP in 2014. For 2015 when the FF-SHOP will provide billing and payment services for all FF-SHOP employers, COBRA premiums will be included on the single employer invoice and employers will be expected to remit the full amount owed by the due date and no later than the end of the grace period. (SHOP FAQ #2 07/05/13) Q35: If an employer is allowed to enroll employees in COBRA, how do we know who (employer or employee) will pay the COBRA premium? A35: Requirements for premium payment with respect to COBRA are not modi?ed by FF-SHOPs. Thus, issuers should use standard COBRA billing practices allowed by state and federal regulations for plan years beginning in 2014. (SHOP FAQ #4 08/28/13) Q: How will Consolidated Omnibus Budget Reconciliation Act (COBRA) be handled in FF- SHOPs for plan years beginning on and after January 1, 2015? A: Centers for Medicare Medicaid Services' (CMS) desire is to communicate to issuers the status of enrollees with COBRA coverage for the 2015 plan year and beyond. CMS will communicate COBRA plans when the Companion Guide is updated for the 2015 plan year. (REGTAP FAQ Database - FAQ #913 03/05/14) 948 Updated 1-31-17 2017--01048 Q: If someone voluntarily disenrolls in COBRA during open enrollment, are they eligible for subsidies in the Individual Marketplace? A: During Marketplace open enrollment, a person can voluntarily drop their COBRA coverage and get a Marketplace plan instead, even if their COBRA hasn't expired. They also may be determined eligible for APTC in this case. Outside of Marketplace open enrollment, if a person's COBRA expires, they would qualify for a special enrollment period and may be eligible for APTC. If they are voluntarily dropping coverage outside of Marketplace open enrollment (their COBRA has not yet expired), they would not qualify for a special enrollment period. During the next open enrollment period or when their COBRA expires, they could enroll in a QHP and may be eligible for APTC. (REGTAP FAQ Database - FAQ #1496 4/21/14) Q: How will Consolidated Omnibus Budget Reconciliation Act (COBRA) transactions operate in the Federally-facilitated Small Business Health Options Program (FF-SHOP) Marketplace? A: The FF-SHOP will not support COBRA transactions as of November 15, 2014. The Centers for Medicare Medicaid Services (CMS) expects to support these transactions as part of a future release. (REGTAP FAQ Database - FAQ #1995 05/30/14) Q: How will the Federally-facilitated Small Business Health Options Program (FF-SHOP) handle Consolidated Omnibus Budget Reconciliation Act (COBRA) transactions when the online system is available? A: As of November 15, 2014, the FF-SHOP will not support COBRA transactions to issuers. Employers may still enroll COBRA enrollees by adding COBRA enrollees to the employer's employee roster. (REGTAP FAQ Database - FAQ #2851 07/16/14) Q: Since the Federally-facilitated Small Business Health Options Program (FF-SHOP) will not handle Consolidated Omnibus Reconciliation Act (COBRA) transactions on day one of the FF-SHOP portal rollout, will the FF-SHOP handle COBRA transactions in the future? A: The Centers for Medicare Medicaid Services (CMS) will communicate more information on the post go-live development schedule when the schedule is ?nalized. (REGTAP FAQ Database - FAQ #2870 07/16/14) Q: Are employers responsible for collecting premium payments for Consolidated Omnibus Reconciliation Act (COBRA) employees in the Federally-facilitated Small Business Health Options Program (FF-SHOP), as of 2015? A: An employer's FF-SHOP invoice will include COBRA charges. The method of collecting premiums for COBRA enrollees is up to the employer. (REGTAP FAQ Database - FAQ #2871 07/16/14) 949 Updated 1-31-17 2017--01049 Q: If the Federally-facilitated Small Business Health Options Program (FF-SHOP) will not support Consolidated Omnibus Reconciliation Act (COBRA) transactions as of the 2015 go-live, does this mean that a group that has COBRA enrollees cannot enroll through the online FF-SHOP portal? A: No, an employer group with COBRA enrollees may enroll through the online portal by adding the COBRA enrollees to the employer's employee roster. While issuer transactions will not identify these enrollees as COBRA, the group may still enroll in SHOP coverage. (REGTAP FAQ Database - FAQ #2874 07/16/14) Q: For Consolidated Omnibus Reconciliation Act (COBRA) enrollees, is the employer responsible for removing the enrollees once COBRA is exhausted? A: Yes, employers would remove COBRA enrollees from the employee roster when the employee is no longer eligible for COBRA coverage. (REGTAP FAQ Database - FAQ #2878 07/16/14) Q: Are issuers required to enroll Consolidated Omnibus Reconciliation Act (COBRA) enrollees in Federally-facilitated Small Business Health Options Programs (FF-SHOPS) as active employees until the FF-SHOP can support COBRA enrollment transactions? A: Yes, COBRA enrollees should be enrolled as active employees until the FF-SHOP can support COBRA enrollment transactions. (REG TAP FAQ Database - FAQ #2883 07/16/14) Q: How should issuers administer the Consolidated Omnibus Budget Reconciliation Act (COBRA) for 2014 Small Business Health Options Program (SHOP) enrollees? A: For the 2014 plan year, Federally-Facilitated Small Business Health Options Program (FF-SHOP) issuers should administer COBRA the way issuers do in the external small group market. (REGTAP FAQ Database - FAQ #4924 09/17/14) Q: Will the Small Business Health Options Program (SHOP) Marketplace handle Consolidated Omnibus Budget Reconciliation Act (COBRA) enrollments differently in 2016? A: No, the SHOP Marketplace will make no changes to COBRA enrollments for the 2016 Plan Year. (REGTAP FAQ Database - FAQ #12438 09/01/15) SHOP Billing database on 08/26/14. 950 Updated 1-31-17 2017--01050 QG: Will billing address and contact information for the employer be included in the group enrollment file? A6: Yes, employer contact information, such as billing address, will be included in the group enrollment file from the (QHP Webinar Series SHOP FAQ #1 06/20/13; REGTAP FAQ Database - FAQ #110 06/20/13) Q7: Some groups request that employees be split, for example by plant location, and bills be sent directly to the plant location for a subset of employees. What will be allowed in the A7: Employers can enroll in 1 SHOP per State, and the ratings will be based on the location of a company's primary business address in a State, and only 1 mailing address will be collected and sent to issuers. (QHP Webinar Series SHOP FAQ #1 06/20/13; REGTAP FAQ Database - FAQ #111 06/20/13) Q: Will issuers be responsible for sending invoices to Small Business Health Options Program (SHOP) employer groups in 2015? A: No, the Federally-facilitated Small Business Health Options Program (FF-SHOP) will be responsible for sending invoices to employers beginning in 2015. (REGTAP FAQ Database - FAQ #4198 09/02/14) Q: After a group has submitted its final initial application, when will the Federally- facilitated Small Business Health Options Program (FF-SHOP) invoice the employer for someone who is added after the initial submission but before the coverage effective date? For example, an employee gets married after the initial application is submitted but before the coverage effective date. A: The FF-SHOP will collect and remit to issuers the amount owed as of the initial application submission and back-charge the employer for the new enrollee (spouse) during the next invoicing cycle. (REGTAP FAQ Database - FAQ #8050 12/08/14) Q: When was the Federally-facilitated Small Business Health Options Program (FF-SHOP) under-billing issue fixed in production? A: The under-billing issue was fixed in production on August 1, 2015. (REGTAP FAQ Database - FAQ #12170 08/27/15) Q: Will issuers involved in the Federally-facilitated Small Business Health Options Program (FF-SHOP) under-billing issue receive an 834 file with financial changes in order to correct impacted rate calculations? A: When a State communicates a preference to the Centers for Medicare and Medicaid Services (CMS) to update impacted rate calculations, CMS will communicate the updates to issuers via re-publishing the initial enrollment 8345 with updated premiums. In addition, CMS will communicate employer/enrollment details to each of the impacted issuers through CMS Account Managers beginning as early as the week of August 24, 2015. (REGTAP FAQ Database - FAQ #12171 08/27/15) 951 Updated 1-31-17 2017--01051 SHOP Payments/820 Transactions 08: Will there be a version of the X12 820 transaction with premium information sent to issuers by the A8: In the ?rst year of the program (2014), there will not be any premium payment transaction reporting done with the FF-SHOP. However, when the premium aggregation program becomes available in the FF-SHOP, we anticipate using an X12 820 transaction to communicate information about premium payments. (QHP Webinar Series SHOP FAQ #1 06/20/13; REGTAP FAQ Database - FAQ #112 06/20/13) CMS removed this FAQ from the REGTAP database on 08/26/14. Q11: How does the Payment Discrepancy report apply to issuers in the FF-SHOPs in 2014? A11: The Payment Discrepancy report will not apply to issuers with FF-SHOP plans having effective dates beginning in 2014. (SHOP FAQ #3 07/30/13; REGTAP FAQ Database - FAQ #58 07/30/13) removed this FAQ from the REG TAP database on 08/26/14 952 Updated 1-31-17 2017--01052 Q13: Will CMS send issuers ASC X12 or HIX 820 premium payment transaction files for the FF-SHOP in 2014? A13: No, CMS will not be sending issuers any type of ASC X12 or HIX 820 premium payment transaction ?les in 2014. (SHOP FAQ #3 07/30/13; REGTAP FAQ Database - FAQ #60 07/30/13) removed this FAQ from the REG TAP database on 08/26/14. WW GMS removed this FAQ from the REG TAP database on 08/26/14. CMS removed this FAQ from the REGTAP database on 08/26/14. 953 Updated 1-31-17 2017--01053 Q34: The payment code listed as reflects ?Any commissions withheld by the exchange.? It is our understanding that issuers will be paying broker commissions. What commissions does the FF-SHOP plan to withhold? A34: This payment code will not be used by the FF-SHOP because no broker commissions will be withheld by the FF-SHOPs. (SHOP FAQ #4 08/28/13; REGTAP FAQ Database - FAQ #38 08/28/13CMS removed this FAQ om the REG TAP database on 08/26/14. Q: If an enrollment group has made their January payment but not the February payment by the January 15th cutoff date, should they only be reported on the January tab or both January and February? A: An enrollment is considered effectuated if the enrollment group has paid its ?rst premium payment. 80 the submitter should report the enrollment group on both the January and February tab, regardless of whether the enrollment group has paid the February premium by the January 15th cutoff date. (REGTAP FAQ Database - FAQ #665 01/16/14) Q: At what point does CMS expect submitters to report member level detail? Will CMS pay issuers based on enrollment group level data as opposed to aggregate payments? A: CMS does not intend to ask submitters to report member level detail using the template during this interim payment process. Once the system is fully functional, CMS will adjust the estimated payments made during this interim payment process with the actual enrollment group level data and make payments based on enrollment group level data. (REGTAP FAQ Database - FAQ #667 01/16/14) Q: Will a separate SHOP 820 Companion Guide be utilized for the State-Based Marketplace's remitting payment to the Issuer's and if so, please provide the that will be implemented. A: The CMS HIX 820 Companion Guide provides the supplemental instructions Issuers and SBMs will use when receiving HIX 820 transactions from CMS. For HIX 820 transactions between SBMs and their issuers, SBMs will work with their issuer community to establish their 820 procedures. CMS will not accept inbound 820$. (REGTAP FAQ Database - #723 02/04/14) 954 Updated 1-31-17 2017--01054 Q: For plan years beginning on and after January 1, 2015, are issuers required to accept premium payments from new groups if the group sends payment to the issuer instead of to the A: In this situation, we would expect the issuer to notify the group and FF-SHOP Call Center that a payment was received in error. The group may either cancel the check and resubmit the payment to the FF-SHOP or the issuer may send the payment to the FF- SHOP lock-box for processing. (REGTAP FAQ Database - #826 02/21/14) Q: For plan years beginning on and after January 1, 2015, will the 820 file allocate money to the employee and dependent level? A: The 820 ?le will allocate money to the employee and dependent level for each group. (REGTAP FAQ Database - #828 02/21/14) Q: Since employers usually short pay their bill to indicate that they are dropping coverage for a member, how is the FF-SHOP going to communicate and educate consumers about this since it is a very common behavior? A: For plan years beginning on and after January 1, 2015, employers will be expected to pay either 1) total invoiced amount, or 2) total account balance. The amount due at anytime will be available online within the FF-SHOP payment portal. (REGTAP FAQ Database - #834 02/21/14) Q: What is the schedule for 820-based payments for What about any late payments received by the Will these payments be sent on separate 820 transmissions? A: CMS plans to remit all payments received to Issuers on a weekly basis. 820 transactions will be sent every time a payment is remitted to Issuers. (REGTAP FAQ Database - FAQ #916 03/05/14) Q: How would an issuer know the FF-SHOP has the employer group payment? A: Issuers will be notified by the FF-SHOP prior to the coverage effectuation date if the initial binder payment was not received by the FF-SHOP. Following initial enrollment, the FF-SHOP will send a termination transaction to Issuers after the 31-day grace period has elapsed. (REGTAP FAQ Database - FAQ #918 03/05/14) Q: What is the tolerance level for initial and payments in 90% 80%, etc? A: We expect 100% payment for initial and payments. (REGTAP FAQ Database - FAQ #1427 04/14/14) Q: How are employers able to make initial payments? A: For initial and ongoing payments, employers will be able to make online EFT payments or mail checks to the FF-SHOP lockbox. Credit card payments will not be accepted. (REGTAP FAQ Database - FAQ #1431 04/14/14) 955 Updated 1-31-17 2017--01055 Q: Will only full payments be sent to Issuers or will partial payments be sent? Is there a payment threshold less than 100%? A: Only full payments will be sent to Issuers. Partial payments can be collected by the FF-SHOP until 100% payment is received from the employer. (REGTAP FAQ Database - #1553 05/08/14) Q: How will the FF-SHOP handle paper checks and ensure initial payments are received prior to the coverage effective date? A: The FF-SHOP must receive the initial binder check by the 26th of the month. If a payment is not received by this date, a cancellation transaction will be sent to Issuers prior to the coverage effective date. (REGTAP FAQ Database - #1554 05/08/14) Q: What is the effective date for death of an employee or dependent? A: The effective date for death of an enrollee is the date of the death. Premiums owed to Issuers when a death occurs will be pro-rated. When an employee dies, dependents will also be removed from the policy as of the date of death. Enrollees losing coverage will be eligible for a special enrollment period in the Individual Marketplace. (REGTAP FAQ Database - #1555 05/08/14) Q: Can a group receive a tax credit off of the SHOP in 2014 or is a group required to fill out the SHOP paper application and be considered a small group on the Are issuers required to pay the FFE fee for this group in 2014? A: In order to claim the expanded small business healthcare tax credit in 2014, eligible small groups must submit a paper application to the Marketplace and receive a positive eligibility determination. Employees must also enroll in a SHOP QHP directly from an Issuer in order to claim the tax credit in 2014. Issuers are required to pay FFE user fees for SHOP QHP and SADP enrollments in 2014. (REGTAP FAQ Database - #1556 05/08/14) Q: Issuers understand that the FF-SHOP will not accept credit card payments. Will the FF-SHOP accept prepaid debit cards? A: Debit cards will not be accepted. Only ACH direct debit transfers will be accepted. (REGTAP FAQ Database - #1560 05/08/14) Q: How will NSFs be handled in the payment file? A: NSFs will be handled as non-payment and adjustments will be noted on future payments made to Issuers. The speci?c 820 transaction scenario is still being ?nalized. This will involve a new payment type code in the REF segment. CMS will communicate this updated information on a future REGTAP call. (REGTAP FAQ Database - #1564 05/08/14) Q: Does the 820 218 act as the ACH transaction and contain money? A: The 820 218 is sent to the bank for payment, and the 820 306 is sent to the Issuer as the remittance advice. (REGTAP FAQ Database - #1567 05/08/14) 956 Updated 1-31-17 2017--01056 Q: Will the 820 218 be sent from CMS to Issuers or be sent directly to the bank? A: The FF-SHOP will send the 820 218 directly to the bank. The 820 306 will be sent to Issuers. (REGTAP FAQ Database - #1568 05/08/14) Q. How can Issuers contact the SHOP Call Center to receive payment status or to obtain answers to questions about a payment amount for a group enrolled in FF-SHOP beginning In 201520152. A. Issuers may contact the SHOP Call Center today with The number IS 1 8?00- 706- 7893 (TTY: 1 -800- 706- -7915). Issuers should choose prompt #5 when contacting the SHOP Call Center. (REGTAP FAQ Database- #1569 aned 15698 05/08/14) Q: Will the 820 have the exchange assigned group A: The FF-SHOP does not assign Group IDs. Only Issuers generate Group IDs in FF- SHOPS. Issuer assigned Group ID is an optional element for a group's initial premium payment. For the initial payment, the FF-SHOP will use the Payment Transaction ID (also sent on the Group XML file and 834 enrollment transaction) in HIX 820 transactions. The Payment Transaction ID is what connects the HIX 820 and the Group XML and 834 enrollment transaction. If the Issuer-assigned Group ID is known, then the FF-SHOP will transmit the Group ID with the Payment Transaction ID on the HIX 820. (REGTAP FAQ Database - #1570 05/08/14) Q: Will the FF-SHOP 820 be pushed to a different location than the Individual 820? A: The payee group set-up determines the ?le routing. If the Issuer ID for both SHOP and the Individual Market is the same, 820 HIX transactions will be sent to the same location but with a different function code. (REGTAP FAQ Database - #1574 05/08/14) Q: The requirement for a group to start with a zero balance does not make sense for a January enrollment for an existing SHOP group. When the group enrolls in November for January, issuers will still need to collect December premium at a minimum. A: This is correct. CMS expects there to be a zero balance as of the 2015 plan year. Issuers will collect any past-due balances from employers through their own delinquency process for plans that began in 2014. Issuers will refund any credits to employers' accounts at the end of a group's 2014 benefit year. (REGTAP FAQ Database - #1575 05/08/14) Q: The timeline indicates that issuers will send files to CMS starting in August 2014 through February 2016. Is this supposed to be 2016 or 2015? A: Issuers may be sending ?les as late as February 2016. This will accommodate plans for the 2014 plan year that run late into 2015. In addition, ?les should be sent for 1 cycle beyond the group termination date. For this reason, CMS anticipates that some terminations and other changes may need to be reflected on files running into 2016. (REGTAP FAQ Database - #1587 05/13/14) 957 Updated 1-31-17 2017--01057 Q: What is the purpose of the Payment Transaction A: The purpose of the Payment Transaction ID is to tie together initial and subseguent Group XML, 834, and 820 transactions. (REGTAP FAQ Database - #1972 05/30/14; updated 07/19/16) Q: For FF-SHOPs, is the Total Premium Amount divided equally among each family member in an enrollment group? A: No, the total premium amount is the sum of each per-member rate. Per-member rates may vary based upon age and tobacco use (if an issuer charges a tobacco surcharge). (REGTAP FAQ Database - FAQ #2417 06/26/14) Q: Where should employers send check payments? A: The Centers for Medicare Medicaid Services (CMS) will post the Federally- facilitated Small Business Health Options Program (FF-SHOP) lock-box national address at a later date. (REGTAP FAQ Database - FAQ #2422 06/26/14) Q: How often will 820 transactions be sent since there will be no payment con?rmations? A: Payments and related 8205 will be sent approximately one time per week. (REGTAP FAQ Database - FAQ #2425 06/26/14) Q: Are the Group XML indicator values Yes/No type for the Consolidated Omnibus Budget Reconciliation Act (COBRA), Multi-State Plans (MSPs), etc.? A: Yes, the values are of Yes/No type. or to be precise. Please refer to the Employer Group Business Service De?nition (BSD) documentation posted at and It contains the schema with all the required values. (REGTAP FAQ Database - FAQ #2431 06/26/14) Q: Is there a plan to test 820 transactions with all issuers? A: Yes, 820 transactions will be a part of end-to-end testing with all Issuers. (REGTAP FAQ Database - FAQ #2439 06/26/14) Q: How will the Federally-facilitated Small Business Health Options Program (FF-SHOP) handle a group payment with non-suf?cient funds A: The FF-SHOP will attempt to collect the outstanding payment owed from the group. In addition, the FF-SHOP will reduce any funds related to NSF that were already paid to an issuer and notate this adjustment on the corresponding 820 transaction. (REGTAP FAQ Database - FAQ #2440 06/26/14) 958 Updated 1-31-17 2017--01058 Q: Regarding the Payment Method Code for the Federally-facilitated Small Business Health Options Program (FF-SHOP), is it possible for the 820 to result in a net negative amount and if so, will the FF-SHOP use BAL in the BPRO4 field to set the balance to zero? A: The FF-SHOP may use the Payment Type Code to balance the BPR02 "Total Payment Amount" to zero, if necessary. (REGTAP FAQ Database - FAQ #2577 07/03/14) Q: Will payments roll up to the employer group level in Federally-facilitated Small Business Health Options Program (FF-SHOP) 820 transactions? A: The Total Payment Amount (BPR02) specifies the employer and member premium amounts SHOP received from multiple employers and any Non-Sufficient Funds (NSF) adjustments. At this time, SHOP is not considering payment at the employer group level. (REGTAP FAQ Database - FAQ #2578 07/03/14) Q: How do issuers receive the Payee Group ID that has been assigned by the Centers for Medicare Medicaid Services (CMS) for the issuer's Small Business Health Options Program (SHOP) transactions? A: SHOP issuers will receive training in an upcoming webinar on setting up Payee Group IDs. (REGTAP FAQ Database - FAQ #2579 07/03/14) Q: Will the Centers for Medicare Medicaid Services (CMS) separate Federally-facilitated Small Business Health Options Program (FF-SHOP) 820 transactions from Individual Marketplace 820 transactions? A: Yes, CMS will separate FF-SHOP 820 transactions from Individual Marketplace 820 transactions. However, CMS will still send Federally-facilitated Marketplace (FFM) SHOP user fees on the Individual Market HIX 820. (REGTAP FAQ Database - FAQ #2580 07/03/14) Q: Must issuers receive the 820 file for the initial payment before effectuating members in an Federally-facilitated Small Business Health Options Program (FF-SHOP) group? A: Issuers may effectuate coverage after receiving the Group XML and 834 enrollment transactions before receiving the initial payment and 820 transaction. (REGTAP FAQ Database - FAQ #2581 07/03/14) Q: Will the Federally-facilitated Small Business Health Options Program (FF-SHOP) provide reason codes when making adjustments, so that issuers know why an adjustment was applied? A: The FF-SHOP is not providing reason codes at this time. (REGTAP FAQ Database - FAQ #2582 07/03/14) 959 Updated 1-31-1 7 2017--01059 Q: Will the Federally-facilitated Small Business Health Options Program (FF-SHOP) send one payment file per subscriber (including dependents) or will one file include payment for several subscribers and dependents? A: The FF-SHOP will send 820 ?les which may include several subscribers including dependents. (REG TAP FAQ Database - FAQ #2583 07/03/14) Q: Will the 820 transaction represent one employer group, or multiple employer groups? A: Multiple employer groups may be represented on each 820 transaction. (REGTAP FAQ Database - FAQ #2584 07/03/14) Q: Would a Payment Reversal or ADJ always be for the entire previously paid amount for the employee, employer, and any dependents? A: Yes, Payment Reversal or ADJ is always for the entire previously paid amount for the employee, employer and any dependents. (REGTAP FAQ Database - FAQ #2590 07/03/14) Q: Are the Related Report Type values within the files, the only differentiation from the Individual 820 APTC payment files and the Federally-facilitated Small Business Health Options Program (FF-SHOP) employer payment files? A: SHOP and Individual Marketplace 820 transactions can be differentiated by function codes in the 820 transaction ?le name. For Individual 820 transactions, the function code is and for SHOP 820 transactions, the function code is FAQ Database - FAQ #2596 07/03/14) Q: Will the Federally-facilitated Small Business Health Options Program (FF-SHOP) group-level 820 transaction include group-level payment information? A: Yes, FF-SHOP 820 transactions will include group-level payment information. (REGTAP FAQ Database - FAQ #2858 07/16/14) Q: What are the TA1 and 999 requirements for Small Business Health Options Program (SHOP) 820 transactions? A: CMS expects TA1 and 999 acknowledgments within 48 hours of receiving the transaction. This aligns with the 834 transaction process used for the Individual Marketplace. (REG TAP FAQ Database - FAQ #2861 07/16/14) Q: For 2015, will the Federally-facilitated Small Business Health Options Program (FF- SHOP) deduct user fees FF-SHOP from premiums owed to the Issuer? A: CMS will not deduct user fees from FF-SHOP premiums owed to issuers. (REGTAP FAQ Database - FAQ #2886 07/16/14) 960 Updated 1-31-1 7 2017--01060 Q: Will Non-Sufficient Funds Transactions (NSFs) and refunds have a distinct payment type code, so issuers can distinguish NSFs and refunds from billing adjustments? A: NSFs are speci?ed using ADJ Payment Type Codes, and the FF-SHOP will recoup NSF amounts by adjusting the issuer total payment amount. In addition, the FF-SHOP will not request refunds from issuers; instead the FF-SHOP will recoup the amount from subsequent issuer payments. (REGTAP FAQ Database - FAQ #2892 07/16/14) Q: If an issuer has one Tax Identification Number (TIN) but two separate Trading Partner IDs, will the Issuer receive a separate 820x218 transaction and a separate 820x306 transaction? A: All payments are made at the Issuer level based on Issuer ID (HIOS ID). The Remittance Advice and Payment Advice do not use Tax ID Number (TIN) as a method of routing. The 820x218 is the Payment Advice that is sent to the bank based on the Routing Number/ Bank Account Number listed on the Trading Partner Agreement. The 820x306 is sent to the Issuer directly and relies on the Trading Partner ID to route it to the correct location. (REGTAP FAQ Database - FAQ #3005 07/25/14) Q: Since issuers receive separate 820 files for Federally-facilitated Marketplaces (FFM) Individual Market and Small Business Health Options Program (SHOP) payments, can issuers direct premium receipts from the two markets into two separate bank accounts? A: Issuers may establish only one bank account for payments from both the Individual Market and the SHOP. The Centers for Medicare Medicaid Services (CMS) will discuss this topic in greater detail on a future REGTAP call. (REGTAP FAQ Database - FAQ #3013 07/25/14) Q: Is the Federally-facilitated Small Business Health Options Program (FF-SHOP) responsible for billing and receiving initial payments for employer groups in 2015? A: Yes. Issuers will never bill or collect premium payments from FF-SHOP enrollees as of the 2015 plan year, even when employee choice is not available in a State. (REGTAP FAQ Database - FAQ #3397 08/01/14) Q: Is the payee group number required on the Electronic Data Interchange (EDI) Registration form? A: Yes, the payee group number is required on the EDI Registration form so issuers may receive 820 transactions. (REGTAP FAQ Database - FAQ #3421 08/01/14) Q: What information will the Federally-facilitated Small Business Health Options Program (FF-SHOP) include in the Exchange Policy ID field on initial payment transactions on the 820? A: Both the FF-SHOP and issuers assign employees an Insurance Policy Number. The Exchange Policy ID will have the policy number assigned by the FF-SHOP. (REGTAP FAQ Database - FAQ #3446 08/01/14) 961 Updated 1-31-17 2017--01061 Q: Will FF-SHOP payments be held for a certain amount of time to ensure funds are valid before sending to issuers? Or will Non-Sufficient Funds (NSFs) be sent on 820 transactions? A: The FF-SHOP will generally send payments to issuers each Friday for the prior week's payments received and paid in full. The FF-SHOP process allows for NSFs to occur before payments are made to issuers. If a payment made to an issuer is later deemed NSF, the FF-SHOP will re?ect the NSF on a future 820 transaction. (REGTAP FAQ Database - FAQ #3447 08/01/14) Q: Can issuers with separate Trading Partner IDs for the Individual Federally-facilitated Marketplace (FFM) and the Federally-facilitated Small Business Health Options Program (FF-SHOP) designate a separate bank account for payments from each Marketplace? A: The FFM can only accommodate one (1) bank account per issuer; however, the Centers for Medicare Medicaid Services will send separate 820 transactions for the Individual Marketplace and FF-SHOP. (REGTAP FAQ Database - FAQ #3458 08/01/14) Q: Will the Federally-facilitated Small Business Health Options Program (FF-SHOP) assign employees hired throughout the year the same Payment Transaction ID as employees who were active at the beginning of the coverage year? A: Yes, the FF-SHOP will assign employees hired through the plan year the same Payment Transaction ID as employees who were enrolled at the beginning of the FF- SHOP coverage year. (REGTAP FAQ Database - FAQ #4134 08/26/14) Q: When an employer group's coverage is renewed or reinstated, will the Payment Transaction ID change? A: The Payment Transaction ID will not change for reinstatements. The Centers for Medicare Medicaid Services (CMS) will communicate information for renewals at an appropriate time in 2015. (REGTAP FAQ Database - FAQ #4140 08/26/14) Q: How will the Federally-facilitated Small Business Health Options Program (FF-SHOP) reverse Non-Sufficient Funds (NSF) and distribute an earlier partial payment among employees and dependents? A: The FF-SHOP will only send payments to issuers when the employer makes the full premium payment. If the bank noti?es the FF-SHOP of an NSF of a full payment already sent to an issuer, the FF-SHOP will reverse the payment sent to the issuer on the next remittance. (REGTAP FAQ Database - FAQ #4142 08/26/14) Q: What is the deadline for editing scheduled payments? Does the Federally-facilitated Small Business Health Option Program designate a certain time during the day that a scheduled payment is closed to any edits? A: The employer can make changes to a scheduled payment up to 9:00 pm. ET. (REGTAP FAQ Database - FAQ #4143 08/26/14) 962 Updated 1-31-17 2017--01062 Q: If an issuer does not effectuate a new member but receives an 820 Payment transaction for the new member, will the 820 Transaction associate the new member with the correct issuer A: All 820 Payment transactions are sent to a single issuer and therefore, a single Issuer ID. If a member is found inside the remittance ?le for an issuer, then the member is associated with that Issuer ID. (REGTAP FAQ Database - FAQ #4144 08/26/14) Q: Will the Payment Transaction ID ever change during a plan year? A: No, the Payment Transaction ID will not change unless the Federally-facilitated Small Business Health Options Program terminates an employer group and the FF-SHOP sends a new application or group-setup to issuers. (REGTAP FAQ Database - FAQ #4145 08/26/14) Q: If an issuer does not receive a payment as part of the weekly FF-SHOP payment cycle to issuers, will an 820 be generated for that issuer? A: No, 820 Payment transactions are only sent to an issuer when payments are remitted to that issuer. (REGTAP FAQ Database - FAQ #4146 08/26/14) Q: Will the Federally-facilitated Small Business Health Options Program (FF-SHOP) always include the Payment Transaction IDs for employees and dependents in the 820 Payment transactions? A: Yes, the FF-SHOP will always include the Payment Transaction ID for both employees and dependents on FF-SHOP 820 Payment transactions. (REGTAP FAQ Database - FAQ #4147 08/26/14) Q: Will the Federally-facilitated Small Business Health Options Program (FF-SHOP) 820 Payment transactions include information for both the subscriber and dependents? A: Yes, the FF-SHOP 820 Payment transactions will contain information for both subscribers and dependents. For additional information on FF-SHOP 8203, please see the 820 Companion Guide. (REGTAP FAQ Database - FAQ #4148 08/26/14) Q: In the recently published 820 reverse and replace logic, the March entries are showing as adjustments and the February (replace) entries are not. Is this accurate? A: This is the correct behavior for reverse and replace. The reversing entry is the adjustment. The replacing entry is considered to be the correct entry. (REGTAP FAQ Database - FAQ #4215 09/02/14) Q: Will the 820 Payment transaction include the Issuer-assigned Employer Group Identifier for the Dependent A: The 820 Companion Guide states ?This segment will be transmitted when the information is available and it is not included at the header level.? (REGTAP FAQ Database - FAQ #4216 09/02/14) 963 Updated 1-31-17 2017--01063 Q: When scheduling a payment, can an employer select a payment date that is past the premium due date? A: If an employer group does not make a payment on time, the group will enter a 31-day grace period. The Federally-facilitated Small Business Health Options Program (FF- SHOP) will send a termination notice to issuers after the 31-day grace period has elapsed. If a qualified employer is terminated due to lack of premium payment, but within 30 days following the termination the quali?ed employer requests reinstatement, pays all premiums owed including any prior premiums owed for coverage during the grace period, and pays the premium for the next month's coverage, the FF-SHOP must reinstate the qualified employer in the previous coverage. (REGTAP FAQ Database - FAQ #4220 09/02/14) Q: Will the 820 Payment transactions have consistent Exchange-Assigned IDs to allow issuers to aggregate payments on the employer-group level? A: The Payment Transaction ID is the same for all members within an employer group and issuers can use the Payment Transaction ID to aggregate payments to the group level. (REGTAP FAQ Database - FAQ #4222 09/02/14) Q: Should issuers expect the Subscriber ID for the Employee Member record and the Dependent Member record to be different on the 820 Payment transaction? A: No, the Subscriber ID on the employee record will not differ from the Subscriber ID on the dependent record on the Federally-facilitated Small Business Health Options Program (FF-SHOP) 820 transaction ?le. (REGTAP FAQ Database - FAQ #4223 09/02/14) Q: What should FF-SHOP issuers do if rates sent for employer groups on the 834 and 820 transactions do not match the rates sent to the Centers for Medicare Medicaid Services A: Issuers should contact the SHOP Call Center (1-800-706-7893) and enter prompt #5 to speak with a customer service representative. (REG TAP FAQ Database - FAQ #4422 09/05/14) Q: How long will the Centers for Medicare Medicaid Services (CMS) give the employer to reconcile non-sufficient funds (NSF) on initial premium payments? A: The FF-SHOP must have a valid employer payment by the 26th of the month. If the does not have a valid payment for a group by the 26th of the month, the FF- SHOP will send a cancellation transaction to issuers at that time. (REGTAP FAQ Database - FAQ #4424 09/05/14) Q: Will either the FF-SHOP 834 or 820 transactions provide a premium Paid-to-Date amount for employer groups? A: FF-SHOP 820 transactions will communicate to issuers the coverage month for a payment. (REG TAP FAQ Database - FAQ #4430 09/05/14) 964 Updated 1-31-17 2017--01064 Q: Is there any situation when there would be enrollees across multiple employer groups in a single FF-SHOP 820 transaction? A: It is possible that one issuer could receive a payment for many Issuer Assigned Employer Group IDs. For example, the Federally-facilitated Small Business Health Options Program (FF-SHOP) could direct a single ?le to one issuer, containing payments for 10 employer groups, and those groups could contain a total of 100 employees. (REG TAP FAQ Database - FAQ #4441 09/05/14) Q: Is there any situation in FF-SHOP 820 payment transactions in which the Issuer Assigned Employer Group ID would not be in the transaction header or detail records? A: For initial payments, the Issuer Assigned Employer Group ID will never be present because the policy has not been effectuated. No 'lssuer Assigned' data is available until after effectuation. (REGTAP FAQ Database - FAQ #4442 09/05/14) Q: If an issuer received a misdirected 820 payment from the Small Business Health Options Program (SHOP), is the issuer responsible for distributing those funds back to the SHOP or would the SHOP recoup the funds through the 820 transaction process? A: While this scenario is highly unlikely, if this scenario were to occur, the Centers for Medicare Medicaid Services (CMS) would fix the situation on the next weekly issuer payment cycle and note the adjustments on associated 820 transactions. (REGTAP FAQ Database - FAQ #4443 09/05/14) Q: How will non-sufficient fund (NSF) transactions of initial premium payments appear to issuers? A: The Centers for Medicare Medicaid Services will document this scenario in the next version of the 820 Companion Guide. (REGTAP FAQ Database - FAQ #4444 09/05/14) Q: Can FF-SHOP issuers receive an example 820 transaction for a payment resulting in a non-sufficient funds (NSF) retroactively that would reduce the amount of the previous payment? A: The Centers for Medicare Medicaid Services will document this scenario in the next version of the 820 Companion Guide. (REGTAP FAQ Database - FAQ #4445 09/05/14) Q: In the 820 reverse/replace addendum, the last example was for a March invoice with a February adjustment. In this example, the March member records were adjustments and the February ones were not. Was this a typo? A: No, this was not a typo. The reverse and replace logic marks the incorrect records using adjustment codes. These codes usually have as part of the code. After the incorrect transaction is reversed, a replacement transaction is created using the Exchange Payment Type Code that re?ects the correct code that should have been used on the original payment date. (REGTAP FAQ Database - FAQ #4451 09/05/14) 965 Updated 1-31-17 2017--01065 Q: How will the Federally-Facilitated Small Business Health Options Program (FF-SHOP) determine an employer group's account has a $0.00 balance in order to interact with the FF-SHOP as of the 2015 plan year? A: The FF-SHOP will not ensure a group has a $0.00 account balance. The will begin with the 2015 plan year assuming a group has a zero account balance. Any outstanding balance for the 2014 plan year will be the responsibility of issuers to collect as part of the issuer's normal collections process as allowed by State law and regulations. (REGTAP FAQ Database - FAQ #4677 09/11/14) Q: The Centers for Medicare and Medicaid Services (CMS) will utilize the existing issuer Trading Partner Agreement (TPA). Will the source for the Federally-Facilitated Small Business Health Options Program (FF-SHOP) 820 files be the same as the current CD 834 enrollments from Federally-facilitated Marketplace (FFM) for VA enrollments? A: If the same trading partner onboarding form used for 834 enrollments has the payee group number tied to the form, then the source ID will be the same. (REGTAP FAQ Database - FAQ #4683 09/11/14) Q: If an FF-SHOP issuer is doing business in more than one state and using the same bank account, is the issuer required to have a unique Payee ID for each state? A: If an FF-SHOP issuer's business falls under the same Tax ID, then a single Payee ID is suf?cient. If an issuer's business falls under multiple Tax IDs, then a unique Payee ID is required for each Tax ID. (REGTAP FAQ Database - FAQ #4685 09/11/14) Q: Will the Centers for Medicare Medicaid Services (CMS) provide issuers with a sample 820 Payment transaction file? A: CMS has not posted any sample 820 payment transaction files at this time. Issuers should refer to the 820 Companion Guide for guidance. (REGTAP FAQ Database - FAQ #4693 09/11/14) Q: In the case that an issuer's products offered on the Individual and the Small Business Health Options Program (SHOP) Marketplaces are associated with the same Issuer Tax ID, how can issuers have separate 820 Payment transactions sent to clearinghouses for the Individual and SHOP Marketplaces, respectively? A: CMS will not send 820 files to two different locations for the and Federally- facilitated Marketplace (FFM). Although there are two separate 820 ?les generated, both Marketplace files will be sent to the same pick-up location. (REGTAP FAQ Database - FAQ #4694 09/11/14) Q: Will the Centers for Medicare Medicaid Services (CMS) send 820 files per state or per Health Insurance Oversight System (HIOS) Will each state receive an 820 file or would there be one 820 file for all states that have the same HIOS A: HIOS registrations are speci?c to a state. Each HIOS ID is registered to one specific state, and the will send payments at the HIOS ID level. (REGTAP FAQ Database - FAQ #4696 09/11/14) 966 Updated 1-31-1 7 2017--01066 Q: Is the Financial Authority Contact the same role as the Financial Reporting Contact noted on the Administrative Template? A: Similar to the Financial Authority Contact, the Financial Reporting Contact noted on the Administrative Template needs to be able to discuss Marketplace payments with CMS. (REGTAP FAQ Database - FAQ #4698 09/11/14) Q: Can issuers update the Electronic Data Interface (EDI) Registration format after the August 29, 2014 deadline if the issuer did not receive the Payee Group ID until after the deadline has passed? A: Issuers should send an email to vendor manaqement@cms.hhs.qov to ensure issuers are properly set up for the 2015 plan year. (REGTAP FAQ Database - FAQ #4699 09/11/14) Q: If issuers are already set up with a Payee Group and Bank Account, are currently receiving tax credit payments in the Individual Marketplace, and have no planned changes to the way issuers receive money from the Centers for Medicare and Medicaid Services (CMS), do issuers need to do anything now to prepare to receive payments in the Federally-Facilitated Small Business Health Options Program A: In general, there is nothing issuers need to do at this time. If the issuers health insurance company currently has multiple payee groups under a Taxpayer Identification Number (TIN), CMS will send issuers an email with a new Consolidated Payee Group ID for all of the Payee Groups. Issuers should email vendor manaqement@cms.hhs.qov with any additional questions on this matter. (REGTAP FAQ Database - FAQ #4700 09/11/14) Q: How do issuers ?nd out what the issuer's Payee ID is? A: Issuer's Payee IDs are listed as part of the issuers Trading Partner Agreement (TPA). Issuers should send an email to vendor manaqement@cms.hhs.qov to request the issuer Payee Group ID. (REGTAP FAQ Database - FAQ #4701 09/11/14) Q: If an issuer participating in the Individual and the Small Business Health Options Program (SHOP) Marketplaces has two (2) Payee IDs, will the Centers for Medicare Medicaid Services (CMS) require a consolidated Payee A: If there are two or more payee groups associated with a Taxpayer Identification Number (TIN), the Centers for Medicare and Medicaid Services (CMS) will send an email with a new consolidated payee group ID for these payee groups. (REGTAP FAQ Database - FAQ #4 702 09/11/14) 967 Updated 1-31-17 2017--01067 Q: Does the Centers for Medicare and Medicaid Services (CMS) plan to use payment codes for Advanced Premium Tax Credit (APTC), Cost Sharing Reduction (CSR), Federally Facilitated Marketplace (FFM) User Fees, or Retroactive Adjustments, in the Federally- Facilitated Small Business Health Options Program (FF-SHOP) 820 Files in 2015 in addition to the six SHOP specific payment codes? A: The 2015 FF-SHOP 820 ?les will only include the six SHOP-specific payment codes as SHOP does not make APTC, CSR, or FFM User Fee related-payments. (REGTAP FAQ Database - FAQ #4704 09/11/14) Q: What is the process of receiving the HIX 820 X12 files from the Marketplace (both Individual and Federally-facilitated Small Business Health Options Program Marketplace)? A: The FF-SHOP will send HIX 820 ?les to Marketplace issuers only after successfully submitting the Electronic Data Interchange (EDI) Registration form that ties the Payee Group Number with the Trading Partner ID This is a two-step process: 1. Obtaining a Payee Group Number from the Vendor Management (VM) Team 2. Submitting the EDI Onboarding forms to align the Payee groups to a Trading Partner ID (REGTAP FAQ Database - FAQ #4705 09/11/14) Q: Will issuers receive a single 820 transaction for all legal entities (under a single Tax Identification Number or a separate 820 for each legal entity? A: Payments are not made at the TIN level. Payments are made at the issuer's Health Insurance Oversight System (HIOS) ID level. Issuers will receive one 820 file for each HIOS ID. (REGTAP FAQ Database - FAQ #4709 09/11/14) Q: Can the Centers for Medicare and Medicaid Services (CMS) confirm the initial binder payment deadline for open enrollment is still December 20th? A: Employers are expected to submit their initial payment online or by mail by the 15th of the month. If the Federally-Facilitated Small Business Health Options Program (SHOP) does not have a valid payment for a new group by the 26th of the month, then issuers will receive a cancellation transaction. (REGTAP FAQ Database - FAQ #4710 09/11/14) Q: If an FF-SHOP issuer does not receive a weekly 820 file, how will the issuer know if they missed a file? A: A matching 820x218 Payment Order goes to the bank with an Electronic Funds Transfer (EFT) Trace Number. To detect a missing ?le, Federally-facilitated Small Business Health Options Program (FF-SHOP) issuers will notice a deposit to the issuer's bank account with an EFT Trace Number without an associated 820 Remittance. (REGTAP FAQ Database - FAQ #4915 09/17/14) 968 Updated 1-31-17 2017--01068 Q: If three employer groups are included in a single 820 payment transaction where one employer has paid in full and the other two employers have negative balances that exceed the payment of the first group, will the issuer receive the payment from the first group or will the Federally-facilitated Small Business Health Options Program (FF-SHOP) net all payments? A: The FF-SHOP will net the amounts together. In this instance, the will not send a payment for the week. The FF-SHOP will never send a payment to an issuer with an amount less than $0.00. The FF-SHOP will send payment history for these three groups on the next payment ?le when there is a positive balance. (REGTAP FAQ Database - FAQ #4916 09/17/14) Q: What payment code will issuers use for Federally-facilitated Small Business Health Options Program (FF-SHOP) payment amounts carried over to the next payment period? A: The FF-SHOP does not carry forward payment amounts in an 820. The Centers for Medicare and Medicaid Services (CMS) would carry forward negative amounts. CMS and issuer internal systems will see these negative amounts applied as off-setting positive amounts on a future 820 transaction when a positive balance exists. (REGTAP FAQ Database - FAQ #4917 09/17/14) Q: Will the updated 820 companion guide for the FF-SHOP include a scenario with a negative balance offsetting a positive amount? A: The updated 820 companion guide for the FF-SHOP will not contain an example of a negative balance spanning multiple payment cycles. Each time an offsetting positive amount is used to reduce the negative outstanding amount, issuers will receive an 820 transaction. (REGTAP FAQ Database - FAQ #4922 09/17/14) Q: Will Federally-facilitated Small Business Health Options Program (FF-SHOP) issuers receive weekly 820 files? A: The will send 820 ?les on Fridays when an FF-SHOP issuer has an incoming payment. If an issuer does not have any incoming payments during a given week, the FF-SHOP will not send an 820 file. (REGTAP FAQ Database - FAQ #4928 09/17/14) Q: Does a Federally-facilitated Small Business Health Options Program (FF-SHOP) payment amount represent the premium due for the month? A: An 820 ?le contains a DTM segment for each payment. Even though a payment period is often a month, it is not accurate to say the payment received represents the month's premium. Issuers should use the value listed in the DTM segment to determine the coverage start and end dates. (REGTAP FAQ Database - FAQ #4929 09/17/14) Q: If an issuer has a negative payment balance because the issuer's last group terminated from the Federally-facilitated Small Business Health Options Program (FF- SHOP), will the FF-SHOP invoice the issuer in this situation? A: If an issuer has a negative balance after the last group terminated from FF-SHOP, the Centers for Medicare Medicaid Services (CMS) will send the issuer 3 Demand Letter 969 Updated 1-31-17 2017--01069 for the balance due back to to clear the negative balance. (REGTAP FAQ Database - FAQ #4907 09/17/14) Q: How will issuers determine the overall invoice period in the Small Business Health Options Program (SHOP) 820 Payment transaction if both regular premium and 'replace' adjustments are coded as Will reinstatements appear as two payments for the group on the 820 Payment transaction? A: Each RMRO4 element is followed by a DTM element showing the dates that the payment amount covers. In the case of a reinstatement, the DTM segments are different. One DTM segment is for a previous period. (REGTAP FAQ Database - FAQ #5331 10/02/14) Q: Will payment deposit transactions to the bank include details from the FF-SHOP 820 payment transaction or only the whole amount? A: The FF-SHOP will not send transaction details in the 820x218 payment advice file sent to the bank. This ?le will only contain payment summary information. (REGTAP FAQ Database - FAQ #5332 10/02/14) Q: If an issuer has one Trading Partner ID and two Health Insurance Oversight System (HIOS) IDs, how many 820 Payment transactions will the issuer receive? A: The FF-SHOP makes all payments at the Issuer level based on the Issuer ID (HIOS ID). The 820x306 relies on the Trading Partner ID to route the transaction to the correct location. For this scenario, the issuer will receive two (2) 820 transactions from the FF- SHOP. (REGTAP FAQ Database - FAQ #5333 10/02/14) Q: Will the Marketplace Payee Group consolidation effort apply to issuers with multiple Payee Groups and separate Taxpayer Identification Numbers (TINs) for each legal entity? A: The Centers for Medicare Medicaid Services (CMS) set up the Payee Group consolidation process to combine multiple Payee Groups under one TIN to one Payee Group. If each Payee Group has a separate TIN, the consolidation effort will not apply. Issuers who want to con?rm the issuer's speci?c Issuer IDs can send an email to vendor FAQ Database - FAQ #5334 10/02/14) Q: Can an issuer have two different Trading Partner and Payee IDs in a single state: one for the Individual Marketplace and one for the Small Business Health Options Program (SHOP) Marketplace? A: No, an issuer's Payee Group IDs are the same for both the Individual and FF-SHOP Marketplaces in a single state. (REG TAP FAQ Database - FAQ #5335 10/02/14) Q: Since the Federally-facilitated Small Business Health Options Program (FF-SHOP) 820 payment transactions will not include user fee information, will the Centers for Medicare and Medicaid Services (CMS) provide a separate process for collecting SHOP user fees? A: The SHOP HIX 820 transaction will not include SHOP user fee information. Instead, the Financial Management/Individual Marketplace 820 Payment Reports will include SHOP user fee information with the SHOPUF Payment Type Code. Issuers who are 970 Updated 1-31-17 2017--01070 participating in only the SHOP will receive invoices for the amounts that the issuer owes to the Marketplace. For more information about SHOP user fees, please refer to the June 18, 2014 webinar posted on REGTAP at: Slides 061014 5CR FAQ Database - FAQ #5340 10/02/14) Q: The 820 Companion Guide for the Small Business Health Options Program (SHOP) states if a payment is an initial payment, the field will contain the value Will the FF-SHOP send this data element on subsequent 820 transactions when payments are remitted to FF-SHOP issuers? A: The FF-SHOP will send the Payment Transaction ID in initial and subsequent 820 transactions. The FF-SHOP will include the Payment Transaction ID in all 834 and Group XML transactions sent to Federally-facilitated Small Business Health Options Program (FF-SHOP) issuers. (REGTAP FAQ Database - FAQ #5349 10/03/14) Q: Will the Centers for Medicare Medicaid Services (CMS) hold premium payments from employers until the payment clears the bank or will CMS remit the payment on the 820 transaction the week the payment is received? A: FF-SHOP issuers will receive payments once a week for premiums received and successfully processed. As a result, CMS anticipates few payments will be returned for NSF. (REG TAP FAQ Database - FAQ #5493 10/09/14) Q: When will the Centers for Medicare Medicaid Services (CMS) provide issuers the 820 payment type code list for the Federally-facilitated Small Business Health Options Program A: The Centers for Medicare Medicaid Services (CMS) posted the complete list of Exchange payment type codes on (REGTAP FAQ Database - FAQ #5500 10/09/14) Q: In Example 11.2 from the 820 Companion Guide, the examples do not have an Issuer- assigned Group ID, Issuer-assigned Policy ID, or Issuer-assigned Subscriber ID. Is this true because the coverage for the example was not effectuated? A: The Federally-facilitated Small Business Health Options Program (FF-SHOP) will only send Issuer-assigned fields when the data is available. The data is not available in the example because coverage has not yet been effectuated. (REGTAP FAQ Database - FAQ #5506 10/09/14) Q: In the 820 Companion Guide, scenario 3 for SHOP shows non-sufficient funds (NSF) for January, but also a February payment. Why would the Federally-facilitated Small Business Health Options Program (FF-SHOP) apply the February payment if January was Issuers have to apply payments in order. A: Scenario 3 is an example where Company 1 has an NSF, but (new) Company 2 paid a premium. The FF-SHOP takes back the negative amount from the issuer and the FF- SHOP uses the payment from Company 2 to offset the amount. The payments are not from the same Employer Group. (REGTAP FAQ Database - FAQ #5516 10/09/14) 971 Updated 1-31-17 2017-?01o71 Q: In the 820 Companion Guide, what differentiates Example 11.1 from Example 11.2 that causes coverage to not effectuate in Example 11.2? When would Federally-facilitated Small Business Health Options Program (FF-SHOP) issuers effectuate coverage for Example 11.2? A: 820 transactions do not report that a policy has been effectuated; however, issuers will see issuer-assigned fields that contain data if the policy has been effectuated. (REGTAP FAQ Database - FAQ #5517 10/09/14) Q: Will the Federally-facilitated Small Business Health Options Program (FF-SHOP) send issuers the Exchange-Assigned Dependent Identifier on the FF-SHOP 820 file? A: The 820 Companion Guide published by CMS states that the FF-SHOP will send the Exchange-assigned Dependent Identifier. The Exchange Assigned Dependent ID in the 820 ?le is the same as the Exchange Assigned Member ID for dependents in the 834 file. (REGTAP FAQ Database - FAQ #5569 10/14/14) Q: How long will the payment transaction ID be on Group Extensible Markup Language (XML), 834 and 820 transactions? The Group Business Service Definition (BSD) says 2- 50. A: The payment transaction ID is a 13-digit alphanumeric, ?xed length identifier. (REGTAP FAQ Database - FAQ #5685 10/17/14) Q: Will the Federally-facilitated Small Business Health Options Program (FF-SHOP) send issuers ASC X12 or HIX 820 premium payment transaction files for the 2014 plan year? A: No, the FF-SHOP will not be sending issuers any type of ASC X12 or HIX 820 premium payment transaction files for the 2014 plan year. (REGTAP FAQ Database - FAQ #8048 12/04/14) Q: Does the Federally-facilitated Small Business Health Options Program (FF-SHOP) require issuers to complete new bank account information if the issuer's previously submitted bank account information did not change? A: No, if the issuer's bank account information did not change, the issuer does not have to resubmit its banking account information to the Federally-facilitated Small Business Health Options Program (FF-SHOP). (REGTAP FAQ Database - FAQ #10779 05/27/15) Q: How does the Federally-facilitated Small Business Health Options Program (FF-SHOP) assign a new Clearinghouse ID to an issuer? A: Issuers must submit a Electronic Data Interchange (EDI) Registration Form, identifying which Qualified Health Plan (QHP) IDs the FF-SHOP should route to the new clearinghouse, and the issuer must also submit a EDI Registration Form with the Clearinghouse information. (REG TAP FAQ Database - FAQ #10780 05/27/15) Q: Are SHOP Issuers required to process premium payment remittance information for SHOP subscribers? A: The SHOP program area has a HIX 820 transaction separate from the Policy-based 972 Updated 1-31-1 7 2017-?01o72 Payments (PBP) Process. Issuers should only expect the SHOP User Fee on the PBP HIX 820 and Preliminary Payment Report (PPR). (REGTAP FAQ Database - FAQ #15519 04/18/16) Q: What happens if an employer pays the SHOP Marketplace premium after the 15th of the month? Does the employer's late payment result in a loss of coverage for the entire group? A: The SHOP Marketplace payments are due in full by the 1st of the month. If the SHOP Marketplace does not receive a payment by the end of the month, coverage will be terminated the following day. There's a 31 calendar day grace period to make a full delinquent payment and continue plan coverage. (REGTAP FAQ Database - FAQ #16156 05/27/16) SHOP Grace Periods Q12: How long does an employer have to "make payment" prior to effectuation? A12: Employers are expected to make their full payment prior to the initial coverage effective date. After the initial enrollment, the SHOP will enforce a 31 d-ay standard qrace period. - . . (QHP Webinar Series? SHOP FAQ #1 06/20/13; REG TAP FAQ Database- FAQ #116 and #116a 06/20/13; updated 08/27/14) Q: If an Issuer contacts the SHOP at the end of a group's grace period, will the SHOP be able to tell the Issuer whether the group has made the required payment? A: As of November 2014, Issuers may contact the SHOP Call Center to receive the current payment status of FF-SHOP groups. (REG TAP FAQ Database - #1557 05/08/14) Q: Our state requires that issuers process claims during the grace period. How will plans bill for coverage during the FF-SHOP grace period? Issuers continue to bill plans for the grace period month today, and refer employers to collections if there is non-pay. A: FF-SHOP QHP and SADP Issuers will not be invoicing any groups with 2015 coverage effective dates. The FF-SHOP will continue to invoice a group during the 31 day FF-SHOP grace period and seek to collect outstanding balances during the grace period. CMS's collections process was outlined in a webinar conducted on 4-1-14. Please refer to the REGTAP library for this presentation. (REGTAP FAQ Database - #1576 05/08/14) Q: Is the Federally-facilitated Small Business Health Options Program (FF-SHOP) grace period 31 business days or 31 calendar days? A: The grace period in the FF-SHOP is 31 calendar days. (REG TAP FAQ Database - FAQ #4160 08/26/14) 973 Updated 1-31-17 2017--01073 Q: If a State's Department of Insurance (DOI) requires that issuers give consumers a 30- day grace period where issuers pay for claims, how can issuers make sure that the Federally-facilitated Small Business Health Options Program (FF-SHOP) sends notices that are consistent with state requirements? A: The FF-SHOP is sending standardized notices to all employers--regardless of the business address of the employer. Issuers are responsible for sending cancellation and termination notices for both employers and employees. (REGTAP FAQ Database - FAQ #4201 09/02/14) Q: After the FF-SHOP grace period and reinstatement windows have passed, are issuers accountable to collect outstanding payments or will the FF-SHOP collect payments? A: Once the grace period and reinstatement windows have passed, the FF-SHOP will no longer collect outstanding payments. Issuers may collect outstanding premium payments pursuant to applicable state law but only once the grace period and reinstatement windows have passed. (REGTAP FAQ Database - FAQ #4910 09/17/14) Reinstatement Transactions Q: Will the maintenance effective date for reinstatement transactions be the bene?t begin date, or the date when the member needs to be reinstated? A: Reinstatement effective dates will be retroactive back to when the members were terminated. Thus, if coverage was terminated as of May 31 and a group pays all back payments and pre-pays the next month, the reinstatement date will be June 1. (REGTAP FAQ Database - FAQ #2876 07/16/14) Q: For reinstatements that never went away, are the reinstatements the same as reinstatements without a lapse in coverage? A: Yes, Federally-facilitated Small Business Health Options Program (FF-SHOP) reinstatements mean that a group and all enrollees have coverage reinstated as if there was no lapse in coverage. (REGTAP FAQ Database - FAQ #2879 07/16/14) Q: Will the 820 transaction always list the Payment Transaction ID for each employee and dependent? A: The Payment Transaction ID uniquely ties an employer's Group XML, 834, and 820 transactions. The Payment Transaction ID will always be passed on each of these transactions. (REGTAP FAQ Database - FAQ #3786 08/14/14) Q: How will the Federally-facilitated Small Business Health Options Program (FF-SHOP) itemize payments on the 820 transactions? A: FF-SHOP will make payments to issuers at the issuer (trading partner) level. 820 transactions will itemize payments at the group-level and break the payments out down to the subscriber (employee) and dependent level. See the SHOP 820 Appendix located on and REGTAP at HIX 820 Transactions Draft Appendix 974 Updated 1-31-17 2017-?01o74 052714 5CR 052714.pdf for additional information. (REGTAP FAQ Database - FAQ #3787 08/14/14) Q: As of the 2015 plan year, will the Federally-facilitated Small Business Health Options Program (FF-SHOP) send an email confirmation of premium payment to employers? A: Yes, the will send a con?rmation email to the employer's SHOP inbox confirming the employer's premium payment. (REGTAP FAQ Database - FAQ #4151 08/26/14) Q: Will issuers be able to view an employer group's payment history? A: No, issuers will not be able to review the payment history of employer groups; however, issuers may call the Small Business Health Options Program (SHOP) Call Center (prompt to check on the payment status of an employer group. (REGTAP FAQ Database - FAQ #4152 08/26/14) Q: May an employer make a payment to the Federally-facilitated Small Business Health Options Program (FF-SHOP) after the due date? A: Yes, employers may pay up to the end of the grace period. The FF-SHOP grace period is 31 days following the due date. (REGTAP FAQ Database - FAQ #4153 08/26/14) Q: If the employer has a negative balance, is the negative balance rolled into the next invoice? A: Yes, negative amounts roll into future invoices until the negative amount is satisfied. (REGTAP FAQ Database - FAQ #4154 08/26/14) Q: Can employers make partial payments toward group coverage? A: Yes, employers may make partial payments; however, the Federally-facilitated Small Business Health Options Program (FF-SHOP) will only remit payments to issuers when the full owed amount has been paid. (REGTAP FAQ Database - FAQ #4155 08/26/14) Q: When scheduling a payment, can an employer select a payment date in the Federally- facilitated Small Business Health Options Program (FF-SHOP) payment portal that is past the premium due date? A: Yes, employers may select a payment date that is past the premium due date. The employer will receive a message stating that the selected payment date is later than the due date. (REGTAP FAQ Database - FAQ #4156 08/26/14) 975 Updated 1-31-17 2017-?01075 Enrollment/Reconciliation CMS removed this FAQ from the REGTAP database on 08/26/14. Q: Does CMS expect issuers to reconcile enrollment group level payments based on aggregate payments? Will the initial months get reconciled? A: CMS intends to adjust aggregate payments made during this interim payment process with the detailed enrollment group level data once that data is available back to January 1, 2014. (REGTAP FAQ Database - FAQ #668 01/16/14) Q: All of our plans, on and off Marketplace, are QHPs. How do issuers know what to send in the reconciliation file? Every group enrolled in a A: Issuers are not expected to send all QHP enrollments. We expect issuers to distinguish SHOP QHP enrollees from off-marketplace QHP enrollees and send only SHOP QHP enrollees. (REGTAP FAQ Database - #744 02/10/14) Q: Has CMS defined the reconciliation process for the Small Business Health Options Program A: The CMS Enrollment Team is working closely with the SHOP Team to ensure continuity for the reconciliation process. (REG TAP FAQ Database - #875 02/27/14) Q: When Issuers send the reconciliation file for 2014 for the first time, are they expected to include all enrollments and terminations back to January 1, 2014? A: Yes, Issuers are expected to send all enrollment and termination information back to January 1, 2014. (REGTAP FAQ Database - FAQ #920 03/05/14) 976 Updated 1-31-17 2017-?01076 Q: For the 2014 plan year, if an issuer has sold zero SHOP plans, will there be a need to send enrollment reconciliation files? A: It would be helpful to receive a null file if there are 0 SHOP plans in a given month. This will ensure we are not missing an Issuer's ?le. (REGTAP FAQ Database - FAQ #995 03/10/14) Q: Is the spread sheet with FF-SHOP enrollment data in lieu of the reconciliation 834 files for 2014? A: For the 2014 plan year, the Excel spread sheet is all issuers need to send for FF- SHOP enrollment/reconciliation purposes. (REGTAP FAQ Database - FAQ #1415 04/14/14) Q: When will the first SHOP enrollment/reconciliation file be due to A: The first file is due to CMS on August 15, 2014. (REGTAP FAQ Database - #1588 05/13/14) Q: What method will be used to send MS Excel spreadsheets to CMS, Email, File Transfer Protocol (FTP), etc.) for SHOP 2014 enrollment/reconciliation purposes? A: The SHOP 2014 Excel Format shall be sent to the Electronic File Transfer (EFT) Secure Point of Entry (SPOE) Mailboxing Folder using the EFT Function Code of EGRP in the ?lename. Upon receipt in the User's SPOE (EFT) Folder the MS Excel payload will be directed to the Marketplace Contractor for processing. (REGTAP FAQ Database - #1592 05/13/14) Q: Are "Total Employee Responsibility Amount" and "Total Employer Responsibility Amount" optional data elements for the 2014 SHOP enrollment/reconciliation reporting process? A: Yes, these are optional data elements. (REGTAP FAQ Database - #1581 05/13/14) Q: Should issuers include cancellations when reporting enrollment/reconciliation files for SHOP in 2014? A: Cancellations should not be included on the ?le. (REGTAP FAQ Database - #1582 05/13/14) Q: Does the Centers for Medicare Medicaid Services (CMS) require the Billed Premium, Earned Premium, or Collected Premium for the 2014 SHOP Enrollment Reconciliation Microsoft Excel Template and what is CMS's intent for capturing the premium information? A: CMS expects this ?eld to be populated with the cumulative billed premium amount for the 2014 plan year. (REGTAP FAQ Database - #1723 05/27/14) 977 Updated 1-31-1 7 2017-?01o77 Q: For issuers who operate in more than one state, will the Centers for Medicare Medicaid Services (CMS) expect one 2014 Enrollment/ReconciIiation File for each state or could issuers send all the information in one file? A: Federally-facilitated Small Business Health Options Program (FF-SHOP) issuers that operate in more than one state may either send one 2014 Enrollment/Reconciliation File for each state, or send one file with all the information for an issuer. (REGTAP FAQ Database - FAQ #2449 07/01/14) Q: If an issuer reported an enrollee as active on the Enrollment/Reconciliation File Template and the enrollee later retroactively cancels, should the issuer report the cancellation to the Federally-facilitated Small Business Options Program A: Yes, issuers should report these cancellations to the Federally-facilitated Small Business Health Options Program (FF-SHOP) to ensure the information the FF-SHOP has is accurate. (REGTAP FAQ Database - FAQ #2504 07/01/14) Q: If an issuer does not include late changes from the employer in year-end reporting, are issuers required to submit a 2014 Enrollment/Reconciliation report in February and possibly as late as March? A: Issuers should continue sending Federally-facilitated Small Business Health Options Program (FF-SHOP) Enrollment/Reconciliation Files until issuers have accurately and completely sent all 2014 enrollment activity to the Centers for Medicare Medicaid Services (CMS). (REGTAP FAQ Database - FAQ #2505 07/01/14) Q: For the 2014 Federally-facilitated Small Business Health Options Program (FF-SHOPS) Enrollment/Reconciliation process, should issuers include members with future effective dates Enrollment/Reconciliation File Template? For example, should the August file include people who do not become effective until September? A: Issuers should include on the 2014 Enrollment/Reconciliation File anyone with active coverage and anyone who has been terminated on the date that the file is extracted. (REGTAP FAQ Database - FAQ #2506 07/01/14) Q: Is the purpose of the 2014 interim Enrollment/Reconciliation reporting process for the Federally-facilitated Small Business Health Options Program (FF-SHOP) to report enrollments that issuers received directly from employers and employees? A: Yes, the FF-SHOP Enrollment/Reconciliation File should include a record for each enrollee who is or has been covered since 1/1/14. (REGTAP FAQ Database - FAQ #2507 07/01/14) Q: For the 2014 Federally-facilitated Small Business Health Options Program (FF-SHOP) Enrollment/Reconciliation reporting process, how should issuers classify wards? A: Issuers should classify wards as dependents (03). (REGTAP FAQ Database - FAQ #2508 07/01/14) 978 Updated 1-31-1 7 2017--01078 Q: For the 2014 Federally-facilitated Small Business Health Options Program (FF-SHOP) Enrollment/Reconciliation File, should issuers code domestic partners as 02 for spouse or 03 for dependents? A: Issuers should classify domestic partners as dependents (03). (REGTAP FAQ Database - FAQ #2510 07/01/14) Q: If issuers submit the Enrollment/Reconciliation file in a Comma Separated Value (CSV) file format, to whom should the issuer direct the email containing contact information? A: Issuers should direct the email containing contact information to shop@cms.hhs.qov with the subject line Recon 2014." Include the Enrollment/Reconciliation document ?le name in the email. (REGTAP FAQ Database - FAQ #2553 07/03/14) Q: If an issuer has no Small Business Health Options Program (SHOP) enrollees for 2014, does the issuer need to send a blank Enrollment/Reconciliation file to the Centers for Medicare Medicaid Services A: CMS encourages all 2014 FF-SHOP issuers to submit a test ?le with dummy data as part of the Enrollment/Reconciliation template ?le testing process. (REGTAP FAQ Database - FAQ #2554 07/03/14) Q: When can Federally-facilitated Small Business Health Options Program (FF-SHOP) issuers submit test ?les as part of the Enrollment/Reconciliation template ?le testing process? A: Issuers may submit test files between June 17 to August 1, 2014. (REGTAP FAQ Database - FAQ #2555 07/03/14) Q: Is the purpose of the Federally-facilitated Small Business Health Options Program (FF- SHOP) Enrollment/Reconciliation file template to identify employees and dependents enrolled directly in the 2014 plan year? A: Yes, the purpose of the Enrollment/Reconciliation file template is for issuers to report FF-SHOP enrollee data to the Centers for Medicare Medicaid Services (CMS) for the 2014 plan year. The file should include all enrollees who had coverage in 2014 (employees and dependents, both active and terminated). (REGTAP FAQ Database - FAQ #2556 07/03/14) Q: How should issuers report a break in coverage on the 2014 Enrollment/Reconciliation file? Should issuers create 1 row and have the cumulative premium displayed, or should issuers create 2 rows? A: To report a break in coverage (where coverage resumes after a lapse), issuers should fill out two rows in the 2014 Enrollment/Reconciliation ?le template and populate the coverage start and end dates for one period in each row. (REGTAP FAQ Database - FAQ #2557 07/03/14) 979 Updated 1-31-17 2017--01079 Q: How should issuers report terminations for non-payment of premium on the 2014 Enrollment/Reconciliation file, if an employer is billed for the last month's premium but the premium is never collected? A: Subsequent reports can re?ect the termination for non-payment of premium so that accurate information is reported to the Internal Revenue Service (IRS). (REGTAP FAQ Database - FAQ #2558 07/03/14) Q: Can Federally-facilitated Small Business Health Options Program (FF-SHOP) issuers submit the 2014 Enrollment Reconciliation file anytime between the 15th to 20th of the month? A: Issuers should extract and transmit 2014 plan data to the Centers for Medicare Medicaid Services (CMS) within 5 business days of the 15th of each month. (REGTAP FAQ Database - FAQ #2559 07/03/14) Q: What is the submission point for transmission of the 2014 FF-SHOP Enrollment/Reconciliation test and production ?les? A: Each issuer will post the Enrollment/Reconciliation file to the Federal Data Services HUB, using secure point of entry (SPOE), to a folder called nbound30. Once the file is dropped, the file will be picked up and transmitted to a Centers for Medicare Medicaid Services (CMS) contractor for processing. (REG TAP FAQ Database - FAQ #2560 07/03/14) Q: How should an issuer report a subscriber added in one month but retroactively cancelled the next month on the 2014 Enrollment/Reconciliation File Template? A: The 2014 Enrollment/Reconciliation file should include any enrollee who had coverage in 2014, and include employees and dependent both active and terminated. Cancelled (or never effectuated) policies should not be included on the file or may be removed on the next month's file. (REGTAP FAQ Database - FAQ #2561 07/03/14) Q: Is the intent of the Payment Transaction ID to tie the enrollment and payment information together for the initial enrollment only, until the Issuer IDs are present in the transaction? A: The Payment Transaction ID will be used to uniquely tie an employer's Group XML, 834, and 820 transactions for the initial ?le and all subsequent ?le transmissions. (REGTAP FAQ Database - FAQ #2562 07/03/14) Q: Are all issuers required to participate in 2014 Enrollment/Reconciliation File Testing? A: The Centers for Medicare Medicaid Services (CMS) recommend that all issuers test connectivity and send a sample file. (REGTAP FAQ Database - FAQ #2563 07/03/14) 980 Updated 1-31-17 2017--01080 Q: When and how often should issuers send 2014 Federally-facilitated Small Business Health Options Program (FF-SHOP) Enrollment/Reconciliation files? A: Issuers should extract and transmit the Enrollment/Reconciliation ?le data to the Centers for Medicare Medicaid Services (CMS) within 5 business days of the 15th of each month. (REG TAP FAQ Database - FAQ #2564 07/03/14) Q: For the 2014 Federally-facilitated Small Business Health Options Program (FF-SHOP) Enrollment/Reconciliation template, is the decimal assumed or physical for the Cumulative Billed Amount field, and does the field require leading zeroes? A: The decimal for the Cumulative Billed Amount field is physical, and no leading zeroes are required. (REGTAP FAQ Database - FAQ #2576 07/03/14) Q: If issuers choose not to provide the Employee Responsibility Amount and Employer Responsibility Amount on the 2014 Enrollment/Reconciliation template, should issuers populate the field with the value 0.00, or is NULL allowed? A: The Enrollment/Reconciliation will allow NULL in the Employee and Employer Responsibility Amount fields. (REGTAP FAQ Database - FAQ #2605 07/03/14) Q: Should issuers submit the 2014 Enrollment/Reconciliation File to the Electronic File Transfer (EFT) box? A: Yes, each issuer will post a ?le to the Data Services Hub (DSH) using a Secure Point of Entry (SPOE). Issuers will post the file to a folder called nbound30 using a Secure File Transfer Protocol (SFTP). Once the issuer posts the file into the folder, the DSH will pick up and transmit the ?le to the issuer. (REGTAP FAQ Database - FAQ #2850 07/16/14) Q: In the Federally-facilitated Small Business Health Options Program (FF-SHOP) 2014 Enrollment/Reconciliation File, does the Cumulative Billed Amount field require the year- to-date billed premium amount? A: Yes, the Cumulative Billed Amount field requires the year-to-date premium amount? (REGTAP FAQ Database - FAQ #2852 07/16/14) Q: When are issuers required to send production Enrollment/Reconciliation files to the Centers for Medicare Medicaid Services A: 2014 plan data should be extracted and transmitted to CMS within 5 business days of the 15th of each month beginning August 2014 and continue as long as the issuer has active 2014 FF-SHOP enrollments. (REGTAP FAQ Database - FAQ #2854 07/16/14) Q: On the 2014 Enrollment/Reconciliation Excel Template, should issuers send the template header (Sheet1) when sending the data, or should issuers only send data? A: Issuers should include both the template header and enrollment data on the submission sheet, and issuers should retain the name Sheet1 on the sheet containing the data. Issuers should also submit the file in Excel version 2007 or greater. (REGTAP FAQ Database - FAQ #2867 07/16/14) 981 Updated 1-31-17 2017--01081 Q: In states that require issuers to cover newborns for the first 30 days of life, regardless of whether the mother adds the newborn to the plan, should issuers include these newborns on the 2014 Federally-facilitated Small Business Health Options Program (FF- SHOP) Enrollment Reconciliation File Template? A: Yes, issuers should include these newborns in the enrollment data reported to the Centers for Medicare Medicaid Services (CMS) for the 2014 plan year. (REGTAP FAQ Database - FAQ #2872 07/16/14) Q: Should issuers include future enrollments on the Enrollment/Reconciliation File? A: The 2014 FF-SHOP enrollment/reconciliation ?le should include anyone with active coverage on the date the file is extracted and anyone who has been terminated. (REGTAP FAQ Database - FAQ #2877 07/16/14) Q: Will there be different reconciliation processes for the Federally-facilitated Small Business Health Options Program (FF-SHOP) in 2014 and 2015? A: Yes, the Centers for Medicare Medicaid Services (CMS) plan to have a different FF-SHOP reconciliation process for 2015. CMS will review the 2015 process on a future REGTAP call. (REGTAP FAQ Database - FAQ #2998 07/25/14) Q: Can the Centers for Medicare Medicaid Services (CMS) provide the naming convention for the 2014 Enrollment/Reconciliation Excel File? A: The reconciliation file naming format is as follows: Example: (REGTAP FAQ Database - FAQ #2891 07/16/14) Q: What is the deadline for issuers to submit 2014 Enrollment/Reconciliation test files? A: The deadline to submit 2014 Enrollment/Reconciliation test ?les is August 1, 2014. (REGTAP FAQ Database - FAQ #3007 07/25/14) Q: Will the 2014 Federally-facilitated Small Business Health Options Program (FF-SHOP) Enrollment/Reconciliation File process continue into 2015? A: The 2014 manual enrollment reconciliation process will continue for the entire 2014 plan year. Thus, FF-SHOP issuers may be sending ?les through the end of December 2015, for groups enrolling directly with issuers for December 1, 2014 FF-SHOP coverage. (REG TAP FAQ Database - FAQ #3008 07/25/14) Q: May issuers extract the data for the 2014 Enrollment/Reconciliation file prior to the 15th of each month? A: Issuers may extract Enrollment/Reconciliation file data prior to the 15th of the month, though the Centers for Medicare Medicaid Services (CMS) recommend that issuers extract data at the same time each month. (REGTAP FAQ Database - FAQ #3009 07/25/14) 982 Updated 1-31-17 2017?-01082 Q: If an issuer is already receiving 834 files, must the issuer resubmit connectivity forms for the 820? A: If the forms already have the Payee Group numbers 820 ?lled in, then there is no need to resubmit the forms. To receive more clarity on this topic, please contact the EDI help desk at (REGTAP FAQ Database - FAQ #3010 07/25/14) Q: Is there a separate Electronic File Transfer (EFT) folder exclusively for the 2014 Federally-facilitated Small Business Health Options Program (FF-SHOP) Enrollment/Reconciliation files? A: No, there is not a separate EFT file for the 2014 FF-SHOP enrollment/reconciliation files. (REGTAP FAQ Database - FAQ #3011 07/25/14) Q: The requirements for the Federally-facilitated Small Business Health Options Program (FF-SHOP) Enrollment/Reconciliation template state that issuers should report enrollment data for one (1) cycle after the end of the plan year. Therefore, if an issuer enrolls a group in December 2014, would the issuer send the final Enrollment/Reconciliation file in January 2016? A: Yes, if an issuer enrolls a Federally-facilitated Small Business Health Options Program (FF-SHOP) group in December 2014, the issuer should continue to report the group's enrollment data through January 2016. (REGTAP FAQ Database - FAQ #3012 07/25/14) Q: Where can issuers find instructions for filling out the Federally-facilitated Small Business Health Options Program (FF-SHOP) 2014 Enrollment/Reconciliation file? A: Issuers can ?nd instructions for filling out the 2014 Enrollment/Reconciliation ?le in the May 6, 2014 slide presentation, available in the REGTAP library at Slides 050614 5CR 050914.pdf (REGTAP FAQ Database - FAQ #3014 07/25/14) Q: If an issuer does not have 2014 Small Business Health Options Program (SHOP) enrollees, must the issuer send a blank Enrollment/Reconciliation file each month? A: No, if an issuer has not had any SHOP enrollees since January 1, 2014, the Centers for Medicare Medicaid Services (CMS) will not require the issuer to send a ?le. (REGTAP FAQ Database - FAQ #3019 07/25/14) Q: What is the naming convention for the 2014 FF-SHOP Enrollment/Reconciliation file? A: The file naming convention is as follows: 0 Trading Partner ID: ID number assigned to the Trading Partner . App ID: DSH . Function Code: A four character alpha numeric code that indicates the functional purpose of the file: EGRP 0 Date: Specifies date file was transferred in format 983 Updated 1-31-17 2017--01083 - The ?rst character is static text. . Time: Speci?es the timestamp of file created in format - The first character is static text. is in milliseconds. - Must be 9 characters. 0 Environment Code: A single character code is used to indicate what environment the ?le is transferred to. - Allowed values - for Production 0 for Test and Implementation 0 Direction: Indicates the direction in which the data is ?owing. towards CMS. (REG TAP FAQ Database - FAQ #3000 07/25/14) Q: For the 2014 plan year, since issuers are required to send Federally- facilitated Small Business Health Options Program (FF-SHOP) Enrollment/Reconciliation files within 5 business days of the 15th of each month, will the Centers for Medicare Medicaid Services (CMS) share with issuers a calendar marking business days? A: Business days are Monday through Friday with the exception of Federal holidays. Issuers can ?nd the calendar of federal holidays at (REGTAP FAQ Database - FAQ #3399 08/01/14) Q: In the 2014 Federally-facilitated Small Business Health Options Program (FF-SHOP) Enrollment/Reconciliation file, if the coverage effective end date is an open ended date, should issuers initialize this field with spaces? A: The coverage effective end date is an optional field and does not require data entry. (REGTAP FAQ Database - FAQ #3435 08/01/14) Q: What should issuers submit for the 2014 Enrollment/Reconciliation testing process ending on August 1, 2014? A: The Centers for Medicare Medicaid Services (CMS) discussed 2014 Reconciliation Test File submission process during the June 19, 2014 webinar located at library.php (REG TAP FAQ Database - FAQ #3436 08/01/14) Q: For the 2014 Federally-facilitated Small Business Health Options Program (FF-SHOP) Enrollment/Reconciliation process, what should issuers use to delimit the data in the Comma Separated Value (CSV) file? A: Excel is the preferred format for the 2014 FF-SHOP Enrollment/Reconciliation process, though issuers may use the CSV format. For Issuers using the CSV format, the ?les should be comma delimited. (REGTAP FAQ Database - FAQ #3437 08/01/14) 984 Updated 1-31-17 2017--01084 Q: If a group is currently enrolled with a FF-SHOP issuer and then signs up through the Marketplace portal for the 2015 plan year, the issuer will not have a termination date for the group or members. How should issuers show this termination on the 2014 FF-SHOP Enrollment/ Reconciliation ?le? A: The coverage effective end date is an optional field and does not require data entry. Thus, for 2014 plan year reporting purposes, issuers may leave the end date blank or enter the last day of the 2014 plan year when the plan year is over. The automated reporting process will pick up 2015 plan year information when all enrollments come through the online Federally-facilitated Small Business Health Options Program (FF- SHOP) system. (REGTAP FAQ Database - FAQ #3438 08/01/14) Q: Are issuers required to send a 2014 plan year Enrollment/Reconciliation test file if the issuer does not have any Federally-facilitated Small Business Health Options Program (FF-SHOP) enrollees? A: Issuers are not required to submit production files if the issuer has no FF-SHOP enrollees to report. The Centers for Medicare Medicaid Services (CMS) recommends, though, that all issuers submit a test file in preparation for receiving future SHOP enrollees. (REGTAP FAQ Database - FAQ #3439 08/01/14) Q: If an issuer does not distinguish between domestic partners and spouses, how should the issuer report these dependents on the 2014 Enrollment/Reconciliation file? A: Generally, domestic partners should be reported with the "03" dependent relationship code. For issuers who do not distinguish domestic partners from spouses, it is acceptable to report domestic partners with the "02" code for spouse. (REGTAP FAQ Database - FAQ #3440 08/01/14) Q: Where should issuers send a confirmation that the issuer has sent a 2014 Federally- facilitated Small Business Health Options Program (FF-SHOP) Enrollment/Reconciliation file? A: Issuers should email shop@cms.hhs.qov with the subject line Recon 2014." Please include the name of the ?le in this email. (REGTAP FAQ Database - FAQ #3441 08/01/14) Q: If an issuer does not have an enrollee's Social Security Number (SSN), can the issuer populate this field on the 2014 FF-SHOP Enrollment/Reconciliation file with zeroes? A: Yes, issuers can initialize this ?eld with zeroes. Issuers should send SSN information when it becomes available to ensure accurate reporting to the Internal Revenue Service (IRS). (REGTAP FAQ Database - FAQ #3442 08/01/14) O: For the FF-SHOP 2014 Enrollment/Reconciliation process, what value does the Centers for Medicare Medicaid Services (CMS) want Issuers to enter for optional fields when the issuer has no data? A: Optional ?elds do not require any data to be entered. (REGTAP FAQ Database - FAQ #3443 08/01/14) 985 Updated 1-31-17 2017--01085 Q: On the 2014 plan year Federally-facilitated Small Business Health Options Program (SHOP) Enrollment/Reconciliation file, for the dependent "Accumulated Billed Amount", should issuers initialize this field with zeroes, or leave this field blank? A: Issuers should enter zeroes for the accumulated amounts for dependents. (REGTAP FAQ Database - FAQ #3444 08/01/14) Q: What is the site name that we should access to submit the 2014 FF-SHOP enrollment] reconciliation file? A: Issuers can access the FF-SHOP Enrollment File Template for the 2014 Plan Year through REGTAP or Issuers will need to connect to the FFM EFT system through a common internet browser or secure FTP client. Each trading partner has an existing Source ID and Single Point of Entry ID (SPOE ID) to access the CMS Enterprise File Transfer (EFT) Server. (REGTAP FAQ Database - FAQ #3445 08/01/14) Q: For the 2014 Plan Year, if a FF-SHOP issuer has two legal entities with two Trading Partner IDs, must the issuer send two Excel Enrollment/Reconciliation Files? A: No, issuers can incorporate all the enrollment data into one spreadsheet. (REGTAP FAQ Database - FAQ #3448 08/01/14) Q: For the 2014 Federally-facilitated Small Business Health Options Program (FF-SHOP) Enrollment/Reconciliation process, can issuers sending files in Comma Separated Value (CSV) format, submit all data enclosed with quotes? A: The 2014 FF-SHOP Issuer Reconciliation CSV ?le should be comma delimited. Only the header row must have quotes around each column name. (REGTAP FAQ Database - FAQ #3449 08/01/14) Q: How should issuers report cancellations on the Federally-facilitated Small Business Options Program (FF-SHOP) Enrollment/Reconciliation file for the 2014 plan year? A: Issuers may remove groups or enrollees who are cancelled before coverage is effectuated from subsequent ?le template submissions. (REGTAP FAQ Database - FAQ #3450 08/01/14) Q: What should issuers include in the email to the Centers for Medicare Medicaid Services (CMS) after an issuer has sent a 2014 Federally-facilitated Small Business Health options Program (FF-SHOP) Enrollment/Reconciliation Test file? A: Issuers should include contact information and the name of the test ?le when the FF- SHOP Enrollment/Reconciliation test ?le is emailed to shop@cms.hhs.qov (REGTAP FAQ Database - FAQ #3452 08/01/14) 986 Updated 1-31-17 2017--01086 Q: For the FF-SHOP 2014 enrollment/reconciliation file, do Issuers need to create additional template tabs for each QHP ID and each state? A: No, issuers may submit data from multiple QHP IDs across different states in one file on one tab. (REGTAP FAQ Database - FAQ #3453 08/01/14) Q: Is the Application ID a constant, required portion of the filename for the FF- SHOP 2014 Enrollment/Reconciliation file? A: In order to ensure that the file is received correctly, The Centers for Medicare Medicaid Services (CMS) requests that issuers include the Application ID in the file name. This field is a constant required value. (REGTAP FAQ Database - FAQ #3454 08/01/14) Q: Are Federally-facilitated Small Business Health Options Program (FF-SHOP) Stand- alone Dental Plans (SADPs) required to submit SHOP reconciliation files for the 2014 plan year. A: All Qualified Health Plan (QHP) and SADP issuers with enrollment in 2014 are required to submit Enrollment/Reconciliation ?les on a basis beginning August 15, 2014, through the end of the 2014 plan year. (REGTAP FAQ Database - FAQ #3788 08/14/14) Q: Will the Federally-facilitated Small Business Health Options Program (FF-SHOP) accept '01 (three digits) instead of 01 (two digits) on the Enrollment/Reconciliation files for the 2014 plan year? A: FF-SHOP issuers need to enter the required number of digits (which is 2) for the relationship code ?eld. Relationship codes should be formatted as text so that Excel recognizes the O. (REGTAP FAQ Database - FAQ #3789 08/14/14) Q: Regarding the 2014 FF-SHOP Enrollment/Reconciliation process, excel does not recognize preceding/prefix 0. Thus, CEO1(three digits) instead of 01(two digits) will work. What should Issuers send to A: If you enter the information in the relationship code ?eld as text it will accept a zero. If you want to enter simply the number without the preceding zero that will be ?ne. (REGTAP FAQ Database - FAQ #3790 08/14/14) Q: Will Federally-facilitated Small Business Health Options Program (FF-SHOP) issuers need to send full 2014 Enrollment/Reconciliation files on a basis? Or should the files only contain changes from the previous month? A: Issuers should send the full 2014 FF-SHOP reconciliation file (REGTAP FAQ Database - FAQ #3791 08/14/14) 987 Updated 1-31-17 2017-?01087 Q: For the Federally-facilitated Small Business Health Options Program (FF-SHOP) Enrollment/Reconciliation file, should the first file in August 2014 be cumulative back to January 1, 2014, and moving forward only contain new data? A: All ?les beginning in August should be cumu lative back to January 1, 2014. (REGTAP FAQ Database - FAQ #3792 08/14/14) Q: If an issuer uses a different number for the Subscriber ID and Member ID in the issuer's system, must issuers reflect both numbers in the 2014 Enrollment file? A: The Subscriber ID and the Member ID are both required ?elds in the 2014 Enrollment/Reconciliation file template. The Enrollment/Reconciliation ?le should re?ect both numbers as the IDs appear in the issuer's system. (REGTAP FAQ Database - FAQ #4141 08/26/14) Q: Are issuers required to submit a 2014 Enrollment/Reconciliation file into the 2015 calendar year if the issuer does not include late changes from the employer in year-end reporting? What information is included in a late change? A: Issuers are required to continue submitting 2014 Enrollment/Reconciliation ?les into the 2015 calendar year (and potentially into the first two months of 2016) to fully report all 2014 plan year enrollments and changes. (REGTAP FAQ Database - FAQ #4149 08/26/14) Q: For the 2014 Enrollment/Reconciliation file, is the Issuer Policy Number needed to obtain the Employer Group Policy/Contract or the Employee's Individual Policy Number from the issuer? A: If assigned, the Issuer Policy ID identifies the employer group. The Issuer Policy ID is the Issuer-assigned ID for the employer group. (REGTAP FAQ Database - FAQ #4158 08/26/14) Q: Once the 2014 Enrollment/Reconciliation file is in production, will the Centers for Medicare Medicaid Services send a confirmation of receipt? A: After the initial month, CMS will not send e-mail con?rmations to issuers. Instead, CMS will alert an issuer if there is a problem with a ?le that the issuer sent. (REGTAP FAQ Database - FAQ #4217 09/02/14) Q: Is the cumulative billed amount on the 2014 FF-SHOP enrollment/reconciliation file the total amount billed since 1/1/2014 or the amount for all family members? A: It is the total billed premium for both employees and dependents since 1/1 2014. Issuers are asked to report the amount at the subscriber level. (REGTAP FAQ Database - FAQ #4218 09/02/14) 988 Updated 1-31-1 7 2017--01088 Q: On the 2014 Federally-facilitated Small Business Health Options Program (FF-SHOP) Enrollment/Reconciliation file, can issuers use blanks or the Trading Partner ID in the Secure Point of Entry (SPOE) field? A: SPOE ID is a required ?eld. Issuers may not use the Trading Partner ID in the SPOE ID field. (REGTAP FAQ Database - FAQ #4219 09/02/14) Q: Does the Centers for Medicare Medicaid Services (CMS) expect issuers to include tax credits in the billed amount in the 2014 Federally-facilitated Small Business Health Options Program (FF-SHOP) Enrollment/Reconciliation files? A: Cumulative billed amounts should represent the full premium amount charged to groups, excluding tax credits and other adjustments that reduce the full premium amount charged to groups. (REGTAP FAQ Database - FAQ #4446 09/05/14) Q: If an employer group is currently enrolled in a QHP or QDP directly through an FF- SHOP issuer and later enrolls through the FF-SHOP online Marketplace, how should issuers show the termination date on the FF-SHOP 2014 Enrollment/Reconciliation file? A: The termination date is not a required field on the 2014 FF-SHOP Enrollment/Reconciliation file, and issuers should not report terminations until the termination is in effect. Thus, groups enrolling online for plan year 2015 with the same FF-SHOP issuer and same QHP or QDP as the group did for the 2014 direct enrollment process will not have a termination date to report because it will be continuous coverage. (REGTAP FAQ Database - FAQ #4447 09/05/14) Q: Will Federally-facilitated Small Business Health Options Program (FF-SHOP) issuers receive confirmation that the issuer has submitted a 2014 FF-SHOP Enrollment/Reconciliation file? A: The Centers for Medicare Medicaid Services (CMS) will only contact an issuer if there is a problem with the Enrollment/Reconciliation file transmitted for the production month. (REGTAP FAQ Database - FAQ #5330 10/02/14) Q: If a Federally-facilitated Small Business Health Options Program (FF-SHOP) issuer sent Enrollment/Reconciliation ?les for August and September but has not received a response from the Centers for Medicare Medicaid Services (CMS), should the issuer assume that CMS accepted the files and will not require the issuer to submit an attestation form? A: FF-SHOP issuers who successfully submitted a production ?le in August or September should have received notification if CMS found any submission errors. If an issuer did not receive this email and is unsure if CMS received a 2014 Enrollment/Reconciliation file, the issuer should e-mail shop@cms.hhs.qov. (REGTAP FAQ Database - FAQ #5497 10/09/14) 989 Updated 1-31-1 7 2017--01089 Q: Are Federally-facilitated Small Business Health Options Program (FF-SHOP) issuers required to submit Enrollment/Reconciliation files if the issuers experienced no change in enrollment for the month? A: Yes, FF-SHOP issuers with 2014 enrollment must report enrollment ?les each month even if there is no change in enrollment. In addition, billed premium amounts are cumulative, so issuers should update those amounts each month. (REGTAP FAQ Database - FAQ #5510 10/09/14) Q: If a Federally-facilitated Small Business Health Options Program (FF-SHOP) issuer is submitting Enrollment/Reconciliation ?les, does the issuer need to complete the FF- SHOP 2014 Enrollment Attestation Form? A: No, FF-SHOP issuers who have submitted production enrollment data for August and September 2014 do not need to submit the FF-SHOP 2014 Enrollment Attestation Form. (REGTAP FAQ Database - FAQ #5511 10/09/14) Q: Since Federally-facilitated Small Business Health Options Program (FF-SHOP) issuers are handling billing for the 2014 plan year, are the Centers for Medicare Medicaid Services (CMS) requiring issuers to report premium payments to the FF-SHOP for 2014? A: Yes, as part of the FF-SHOP 2014 Enrollment/Reconciliation process, issuers are required to report cumulative billed premium amounts to CMS. For questions about this process, please e-mail FAQ Database - FAQ #8047 12/04/14) 2015 SHOP Reconciliation Q: Should Federally-Facilitated Small Business Health Options Program (FF-SHOP) issuers continue sending 2014 enrollment reconciliation files to the Centers for Medicare and Medicaid Services A: Yes, FF-SHOP issuers should continue sending 2014 enrollment reconciliation ?les to CMS until all 2014 plan year enrollments have ended. (REGTAP FAQ Database - FAQ #10859 06/05/15) Q: If a group enrolls in the Federally-Facilitated Small Business Health Options Program (FF-SHOP) and the FF-SHOP terminates the group prior to August, would the FF-SHOP include that group in the September 11 reconciliation file? A: No, since reconciliation in FF-SHOP begins for enrollments active August 1 to August 31, the FF-SHOP will not reconcile prior coverage. Issuers who have questions about previous enrollment files should either submit a ticket to CMS FEPS@cms.hhs.qov or contact the SHOP Call Center. (REGTAP FAQ Database - FAQ #10862 06/05/15) Q: Will the 2015 Federally-Facilitated Small Business Health Options Program (FF-SHOP) enrollment reconciliation process continue into 2016? A: Yes, the Centers for Medicare and Medicaid Services (CMS) expects that the 2015 FF-SHOP enrollment reconciliation process will continue into 2016. (REGTAP FAQ 990 Updated 1-31-17 2017--01090 Database - FAQ #10863 06/05/15) Q: Will the Federally- Facilitated Small Business Health Options Program (FF-SHOP) reconcile the Employer Group ID as part of the 2015 enrollment reconciliation process? A: No, the FF-SHOP will not reconcile group-speci?c information, because: a) the goal of the enrollment reconciliation process is not to reconcile every data element, b) the Centers for Medicare and Medicaid Services (CMS) is leveraging the Individual Marketplace speci?cations, which do not include group ?le information, c) reconciling group information is a significant effort for most issuers, and d) CMS can still reconcile the person, plan, and premium (primary goal for this process) without group-level information. (REGTAP FAQ Database - FAQ #10864 06/05/15) Q: Regarding field level dispositions, Centers for Medicare and Medicaid Services (CMS) stated that for code issuers should update their system with the Federally-Facilitated Small Business Health Options Program (FF-SHOP) value. On the Record Level Dispositions slide, CMS does not indicate issuer action for code (SHOP Orphans). What does CMS expect issuers to do with any SHOP orphans that may be identified? A: The FF-SHOP Enrollment Resolution and Reconciliation contractor will review orphans to determine any root cause problems. If the FF-SHOP and the Department of Health and Human Services (DHS) determine there are no issues, including transmission errors of these orphans to the issuer, it will be the issuer's responsibility to update its system of record. (REGTAP FAQ Database - FAQ #10977 06/16/15) Q: Please confirm that the Federally-Facilitated Small Business Health Options Program (FF-SHOP) issuers will use the existing Managed File Transfer (MFT) that is used today for the 2014 FF-SHOP enrollment reconciliation process for the new 2015 FF-SHOP enrollment reconciliation process. A: The same MFT process is applicable. Please note the function codes for the 2015 enrollment reconciliation process have changed. They are outlined in the Interface Control Document (ICD) posted on REGTAP. (REGTAP FAQ Database - FAQ #10978 06/16/15) O: For the Federally-Facilitated Small Business Health Options Program (FF-SHOP) 2015 enrollment reconciliation process, if technical or Enrollment Resolution and Reconciliation contacts change throughout the year, would we simply send notice to the appropriate email address? A: If contacts change, please send an email with relevant details to shoprecon@cms.hhs.qov Please be sure to include the issuer name, Health Insurance Oversight System Identification (HIOS ID), and whether the contact is functional or technical. (REGTAP FAQ Database - FAQ #10979 06/16/15) 991 Updated 1-31-17 2017--01091 Q: Will the Federally-Facilitated Small Business Health Options Program (FF-SHOP) issuers receive notice of files, such as outbound files or dispute resolution forms, sent through Managed File Transfer (MFT) from the FF-SHOP Enrollment Resolution and Reconciliation contractor to FF-SHOP issuers? A: The delivery and receipt of outbound files is dependent on how each FF-SHOP issuer's IT department handles Electronic File Transfers (EFT). Issuers should be able to set up alerts when such ?les are received. (REGTAP FAQ Database - FAQ #10980 06/16/15) Q: When will new Federally-Facilitated Small Business Health Options Program (FF- SHOP) issuers for the 2016 plan year be required to test enrollment reconciliation files? A: All FF-SHOP issuers are required to participate in the enrollment reconciliation process. All new and existing issuers should plan to participate in the testing process set to begin in August 2015. There will not be a separate testing process set up for new FF- SHOP issuers for the FF-SHOP enrollment reconciliation process beginning on 9/11/15. (REGTAP FAQ Database - FAQ #10981 06/16/15) Q: In the Federally-Facilitated Small Business Health Options Program (FF-SHOP) Interface Control Document (ICD) for enrollment reconciliation on page 21 (table 10) it indicates that there could be a dispute resolution outbound file. How will issuers know if a file has been sent? A: In most cases someone from the FF-SHOP Enrollment Resolution and Reconciliation contractor will reach out and note details are being sent in an outbound ?le. The actual delivery and receipt is dependent on how each issuer's IT department handles Electronic File Transfers (EFT). Issuers should be able to set up alerts when such files are received. (REGTAP FAQ Database - FAQ #10982 06/16/15) O: For the Federally-Facilitated Small Business Health Options Program (FF-SHOP) enrollment reconciliation process beginning on 9/11/15, what should issuers show for the addition of a 4th dependent child that will not be charged? A: For the 4th child, only the dependent record for that member should be added to the incoming reconciliation file with the relevant benefit start date. There will still only be one subscriber record sent since there is no impact to the financial record premium for the month being reconciled. If there is a plan change associated with the addition of the 4th child, then other rules concerning end dating records apply and the financial record would likely change the following month. (REGTAP FAQ Database - FAQ #10983 06/16/15) O: For the Federally-Facilitated Small Business Health Options Program (FF-SHOP) 2015enro lment reconciliation process, the inbound specifications have Exchange- Assigned-Subscriber-ID (field 17) and Exchange-Assigned-Member-ID (field 18) as minimum and maximum length of 10. For FF-SHOP, they are 15. Are the values on the examples valid? Shouldn't they be the Health Insurance Oversight System Identification (HIOS ID) (12345 on the examples) followed by 10 numeric? These questions also apply to corresponding fields 32 and 35 on the outbound specifications. 992 Updated 1-31-1 7 2017--01092 A: The exchange assigned lD's for subscribers and members are 10 digits once the HIOS ID is removed. To make this length 15 will diverge from the Federally-Facilitated Marketplaces (FFM) format, which the Centers for Medicare and Medicaid Services (CMS) has been careful to adhere to. (REGTAP FAQ Database - FAQ #10985 06/16/15) Q: For the 2015 Federally-Facilitated Small Business Health Options Program (FF-SHOP) enrollment reconciliation process, the inbound specifications say Benefit-End-Date (field 39) is "For termed employees only.? But it also says it is required. Should that not be conditional with the condition being required for termed employees and dependents? A: The Centers for Medicare and Medicaid Services (CMS) will add clari?cation to the Interface Control Document (ICD) that this is not a required ?eld. Issuers may leave this field blank. (REGTAP FAQ Database - FAQ #10986 06/16/15) Q: For the 2015 Federally-Facilitated Small Business Health Options Program (FF-SHOP) enrollment reconciliation process, Field 46 (Total-Premium-Amount) is marked as conditional (Leave blank for dependents. Mandatory for subscriber.) on the inbound speci?cations, but the corresponding Total-Premium-Effective-Date (field 47) is marked as required. Should it not have the same conditional criteria as Field 46? A: The Centers for Medicare and Medicaid Services (CMS) will add clari?cation to the Interface Control Document (ICD) that this is not a required ?eld. Issuers may leave this field blank. (REGTAP FAQ Database - FAQ #10987 06/16/15) Q: For the 2015 Federally-Facilitated Small Business Health Options Program (FF-SHOP) enrollment reconciliation process, is the Secure Point of Entry Identification (SPOE ID) (field 3) a required field? A: Like the Individual Marketplace, the SPOE ID (?eld 3) is a required field for the 2015 FF-SHOP enrollment reconciliation process. (REGTAP FAQ Database - FAQ #10988 06/16/15) Q: Are Federally-Facilitated Small Business Health Options Program (FF-SHOP) issuers required to submit 2015 enrollment reconciliation files on a basis as of September 11, 2015? A: Yes, FF-SHOP issuers are required to submit 2015 enrollment reconciliation files on a basis as of September 11, 2015. This requirement is a condition of Qualified Health Plans (QHP) certi?cation [See 45 CFR (REGTAP FAQ Database - FAQ #10989 06/16/15) Q: Will the Centers for Medicare and Medicaid Services (CMS) return a spreadsheet or a pipe-delimited file to Federally-facilitated Small Business Health Options Program (FF- SHOP) issuers in response to the submission of a Dispute Resolution Form? A: CMS will send an outbound Dispute Resolution Form in an Excel file through Managed File Transfer (MFT) in response to inbound Dispute Resolution Forms from issuers. (REGTAP FAQ Database - FAQ #12159 08/27/15) 993 Updated 1-31-1 7 2017--01093 Q: When an outbound Discrepancy Report is sent to Federally-facilitated Small Business Health Options Program (FF-SHOP) issuers, does the Enrollment/Reconciliation Contractor expect a response? A: The Enrollment/Reconciliation Contractor does not expect an acknowledgement of receipt once FF-SHOP issuers receive the outbound Discrepancy Report. (REGTAP FAQ Database - FAQ #12160 08/27/15) Q: Are Federally-facilitated Small Business Health Options Program (FF-SHOP) issuers required to use the Managed File Transfer (MFT) process, which includes the Electronic Data Interchange (EDI) naming standard, to submit Dispute Resolution Forms instead of sending the form in a password protected email? A: Since dispute resolution forms contain Protected Health Information (PHD/Personally Identi?able Information (PII), FF-SHOP issuers must send Dispute Resolution Forms through MFT only. Emails are for general communication only, and issuers must not send through email. (REGTAP FAQ Database - FAQ #12161 08/27/15) Q: For the 2015 Federally-facilitated Small Business Health Options Program (FF-SHOP) Enrollment/Reconciliation process, will issuers receive a discrepancy report if all entries match? A: No, if all entries match, FF-SHOP will not send a blank file back to issuers. (REGTAP FAQ Database - FAQ #12163 08/27/15) Q: Will the Federally-facilitated Small Business Health Options Program (FF-SHOP) Enrollment/Reconciliation file be in binary format or in ASCII format? A: The Centers for Medicare and Medicaid Services (CMS) expects ?les to be transmitted in the ASCII format. (REGTAP FAQ Database - FAQ #12180 08/27/15) Q: Is it possible for issuers to use Health Insurance Oversight System (HIOS) Identification (ID) numbers when issuers send the reconciliation files, in order to differentiate between the separate files required by the Federally-facilitated Small Business Health Options Program A: The will provide one outgoing ?le to each incoming ?le, each with a timestamp that will make the ?le names unique, or each ?le can be included in a single file with multiple Trading Partner IDs (TPls) in the ?le name. (REGTAP FAQ Database - FAQ #12183 08/27/15) Q: If an employee is added to a group plan on November 1, 2015 and the group renews in June 2016, would the effective date for the employee on the July 2016 Reconciliation begin on November 1 or would it begin on June 1, 2016; the beginning of the group's current benefit year? A: The Centers for Medicare and Medicaid Services (CMS) requires issuers to send plan start dates for the current plan year that were active during the month of reconciliation. (REGTAP FAQ Database - FAQ #12184 08/27/15) 994 Updated 1-31-1 7 2017--01094 Q: If the Federally-facilitated Small Business Health Options Program (FF-SHOP) sends an outbound response file to an issuer, what Record Level Disposition code will the team use if more time is necessary to research the file? A: The FF-SHOP will use as the Record Level Disposition for outbound files that need more research. (REGTAP FAQ Database - FAQ #12185 08/27/15) Q: To minimize discrepancies, when should Federally-facilitated Small Business Health Options Program (FF-SHOP) issuers extract data to send Enrollment/Reconciliation files to the Centers for Medicare and Medicaid Services (CMS) for purposes of the 2015 FF- SHOP Enrollment/Reconciliation process? A: CMS intends to extract data for comparison purposes at 9:00 pm. ET on the last business day of the month. For example, files due to CMS on 9/11/15 for the August snapshot file should be extracted as soon as possible after 9:00 pm. ET on 8/31/15. Before extracting, issuers should process all the files submitted on the last business day of the month and files should contain no changes after 9:00 pm. ET on the last business day of the month. Issuers are encouraged to send their Enrollment/Reconciliation ?les to CMS as soon as possible on or after 8/31/15 9:00 pm. ET but no later than the second Friday of the month or 11:59 pm. ET on 9/11/15. (REGTAP FAQ Database - FAQ #12186 08/27/15) Q: What if the last day of the month is on a Saturday or Sunday? Should issuers wait until Monday before pulling the SHOP 2015 Enrollment/Reconciliation data? A: When the last day of the month falls on a weekend, issuers should wait until they receive files processed over the weekend. (REGTAP FAQ Database - FAQ #12187 08/27/15) O: For the Federally-facilitated Small Business Health Options Program (FF-SHOP) 2015 Enrollment/Reconciliation process, are issuers to add blanks or pipes for fields that do not take up the maximum characters? Will the Centers for Medicare and Medicaid Services (CMS) require 15 spaces between pipes for a field with a minimum length of 1 and a maximum length of 15? A: If issuers are not sending a value for an optional data element, pipes need to be present for this speci?c element. Issuers should NOT send blanks between the pipes. If a speci?c data element has, for example, the requirement of 1 minimum and 15 maximum characters and the real value has only 4 characters, 4 characters will work for the issuer record. The remaining 11 characters (15 - 4 11) do not need to be ?lled in with spaces. (REGTAP FAQ Database - FAQ #12188 08/27/15) Q: For the Federally-facilitated Small Business Health Options Program (FF-SHOP) 2015 Enrollment/Reconciliation Process, will record trace numbers be assigned by an issuer per file, or must issuers use a Centers for Medicare and Medicaid Services (CMS) number? A: The issuer system needs to assign the value for this data element in each inbound detail record. Note that the corresponding outbound detail record, which will be sent by the reconciliation system to the issuer system, will have the same value. Issuers can use the value of this data element for correlation of records internally in their systems. 995 Updated 1-31-17 2017--01095 (REGTAP FAQ Database - FAQ #12189 08/27/15) Q: For the Inbound file field on the Qualified Health Plan (QHP) Identifier for the Federally-facilitated Small Business Health Options Program (FF-SHOP) Enrollment/Reconciliation Process, what are issuers required to enter for the 16 character Identification (ID) inclusive of the Variant A: The Standard Component ID generated by the Centers for Medicare and Medicaid Services (CMS) is 14 characters (alphanumeric): -Five digit Issuer ID -Two character State ID -Three digit Product Number -Four digit Standard Component Number -An example is as follows: Variant Component ID is 2 characters (Numeric) (REGTAP FAQ Database - FAQ #12190 08/27/15) Q: For the Federally-facilitated Small Business Health Options Program (FF-SHOP) 2015 Enrollment/Reconciliation Process, are issuers required to complete both the 'Detail' and 'Total' tabs on the 2015 inbound file? A: Issuers are required to complete both the 'Detail' and 'Total' records for the 2015 Enrollment/Reconciliation inbound ?le. (REGTAP FAQ Database - FAQ #12191 08/27/15) Q: For the Federally-facilitated Small Business Health Options Program (FF-SHOP) 2015 Enrollment/Reconciliation process, on the Inbound file, do fields 38 and 39 (Benefit-Start- Date/Benefit-End-Date) refer to coverage or to enrollment? A: Fields 38 and 39 refer to the coverage start and end dates. (REGTAP FAQ Database - FAQ #12192 08/27/15) Q: For the Federally-facilitated Small Business Health Options Program (FF-SHOP) 2015 Enrollment/Reconciliation process, do fields 47 and 48 (Total Premium Effective/End- Date) refer to Eligibility? A: Total Premium Effective Date refers to the effective date associated with the policy of the enrollment group. Total Premium End Date refers to the end date associated with the enrollment group's policy premium amount. (REGTAP FAQ Database - FAQ #12193 08/27/15) Q: For the Federally-facilitated Small Business Options Program (FF-SHOP) 2015 Enrollment/Reconciliation process, should issuers send data for on- and off-exchange enrollments? A: Issuers should only send on-exchange enrollments for FF-SHOP Marketplaces. (REGTAP FAQ Database - FAQ #12194 08/27/15) 996 Updated 1-31-1 7 2017--01096 Q: For the Federally-facilitated Small Business Options Program (FF-SHOP) 2015 Enrollment/Reconciliation process, should issuers send blanks or spaces between the pipes for optional items? A: Issuers should NOT send blanks between the pipes for optional items. (REGTAP FAQ Database - FAQ #12195 08/27/15) Q: Must Federally-facilitated Small Business Health Options Program (FF-SHOP) issuers provide residential or mailing Zone Improvement Plan (ZIP) Codes to the Centers for Medicare and Medicaid Services (CMS) for the Enrollment/Reconciliation process? A: CMS requires FF-SHOP issuers to submit mailing address ZIP codes. (REGTAP FAQ Database - FAQ #12196 08/27/15) Q: Is it acceptable for Federally-facilitated Small Business Health Options Program (FF- SHOP) issuers to only provide an email address to the Centers for Medicare and Medicaid Services (CMS) for the Electronic Data Interchange (EDI) technical contacts? A: CMS prefers FF-SHOP issuers to send both contact methods. However, if issuers have a preferred method of contact, issuers may indicate on the response, and CMS will use the preferred contact first. (REGTAP FAQ Database - FAQ #12197 08/27/15) Q: Should all terminated members, receive the termination dates for the 2015 Enrollment/Reconciliation process, and notjust subscribed members? A: All terminated members should receive termination dates for the 2015 Enrollment/Reconciliation process. (REGTAP FAQ Database - FAQ #12198 08/27/15) Q: Should Federally-facilitated Small Business Health Options Program (FF-SHOP) issuers send terminated enrollees in the new Enrollment/Reconciliation files? A: issuers must send only active enrollments in the new Enrollment/ Reconciliation ?les. If terminated members were active at any point during the reconciliation month, these members should be included in the Enrollment/Reconciliation ?les. (REGTAP FAQ Database - FAQ #12199 08/27/15) Q: When issuers submit new Enrollmentheconciliation files, should they include enrollments for the 2014 and 2015 Plan Years? A: All enrollments for the 2015 Plan Year and later should be included in the new Enrollment/Reconciliation files. 2014 Plan Year enrollments should continue to be submitted using the Excel ?le format through the end of the 2014 Plan Year. (REGTAP FAQ Database - FAQ #12200 08/27/15) Q: Can Federally-facilitated Small Business Health Options Program (FF-SHOP) issuers enter multiple rows on the new Enrollment/Reconciliation file if there are multiple Health Insurance Oversight System (HIOS) Identifications A: FF-SHOP issuers may enter multiple rows on the file, but the pattern cannot be 'Detail-Total-Detail-Total.' As the Interface Control Document (ICD) denotes, all total rows must be located at the end of the file. (REGTAP FAQ Database - FAQ #12201 08/27/15) 997 Updated 1-31-1 7 2017--01097 Q: How can Federally-facilitated Small Business Health Options Program (FF-SHOP) issuers file an appeal to the Centers for Medicare and Medicaid Services (CMS) regarding required changes on the new Enrollment/Reconciliation response file? A: FF-SHOP issuers should refer to the Enrollment/Reconciliation Interface Control Document (ICD) available on the Registration for Technical Assistance Portal (REGTAP). The ICD provides issuers with guidance on many questions, specifically the dispute resolution form. If the appeal in question relates to Enrollment/Reconciliation, issuers can challenge the disposition by sending a dispute resolution form to the reconciliation contractor. All details pertaining to the dispute resolution form are located in the ICD. (REGTAP FAQ Database - FAQ #12202 08/27/15) Q: What is the difference between Managed File Transfer (MFT) and Secure File Transfer Protocol A: MFT often encompasses the SFTP process, therefore if issuers use the it is equivalent to the MFT process. (REGTAP FAQ Database - FAQ #12203 08/27/15) Q: Does the Federally-facilitated Small Business Health Options Program (FF-SHOP) Enrollment/Reconciliation Interface Control Document (ICD) state that issuers cannot send multiple Health Insurance Oversight System (HIOS) Identifications (IDs) in the same file? A: The ICD states that issuers can send multiple HIOS IDs in the same ?le, but issuers are required to list total rows on the last three or four rows of the file. (REGTAP FAQ Database - FAQ #12204 08/27/15) Q: What date format are Federally-facilitated Small Business Health Options Program (FF-SHOP) issuers required to use on the new Enrollment/Reconciliation files submitted to the Centers for Medicare and Medicaid Services A: CMS requires issuers to use as the date format. (REGTAP FAQ Database - FAQ #12205 08/27/15) O: For the new Federally-facilitated Small Business Health Options Program (FF-SHOP) Enrollment/Reconciliation process, what is the Carriage Return/Line Feed (CRLF), and how will it be processed? A: Each line, including the last total row in the ?le, is expected to terminate by CRLF character. The Enrollment/Reconciliation module cannot process any ?les that do not contain this character. Functionally, it is a Carriage Return ASCII code 13) followed by a Line Feed ASCII code 10). (REGTAP FAQ Database - FAQ #12206 08/27/15) Q: Which files are due on the third Friday from the week of submission of the outbound files? A: Inbound Discrepancy Reports are due from issuers on the second Friday of each month. The Outbound Discrepancy Report is scheduled in response the following week, or the third Friday of the month. (REGTAP FAQ Database - FAQ #12207 08/27/15) 998 Updated 1-31-17 2017--01098 Q: For extensions, will each line read 'in progress,? or will the entire file reflect in- progress data? A: Reconciliation dispositions sent to Federally-facilitated Small Business Health Options Program (FF-SHOP) issuers are record-level. Whether further research will be performed, issuers can refer to the Interface Control Document (ICD) as to Enrollment Resolution Reconciliation assigned dispositions. (REGTAP FAQ Database - FAQ #12208 08/27/15) Q: For the first Federally-facilitated Small Business Health Options Program (FF-SHOP) Enrollment/Reconciliation file, if there have been enrollment or plan changes at a contract level, does the Centers for Medicare and Medicaid Services (CMS) require issuers to send the most recent effective date of the change which affected the premium sent on the first file? A: If changes have occurred before the August 2015 baseline, then the Enrollment/Reconciliation contractor expects the most recent dates for the changes to be re?ected in the reconciliation ?le. For example, if a dependent was added, the Enrollment/Reconciliation contractor would expect the subscriber coverage date on the record to be the date on which the dependent was added. (REGTAP FAQ Database - FAQ #12209 08/27/15) Q: Where can issuers locate the dispute resolution form for the new Federally-facilitated Small Business Health Options Program (FF-SHOP) Enrollment/Reconciliation process? A: The dispute resolution form is embedded in the Enrollment/Reconciliation Interface Control Document (ICD), which is available to registered Registration for Technical Assistance Portal (REGTAP) users on REGTAP. (REGTAP FAQ Database - FAQ #12210 08/27/15) Q: For benefit end dates on the new Federally-facilitated Small Business Health Options Program (FF-SHOP) Enrollment/Reconciliation file, does the Centers for Medicare and Medicaid Services (CMS) require issuers to send the effective date of termination, or the last active date of the current benefit that is ending? A: Unless there is explicit termination before coverage is scheduled to end, dates can be left blank. However, if the days are included, CMS requires the last day of coverage to be listed. For example, if the member goes off of coverage effective 7/1, issuers must list 6/30 as the last day of coverage. This field refers to the date on which the benefit for a speci?c member ends. (REGTAP FAQ Database - FAQ #12211 08/27/15) Q: For the field level disposition code, if dispositions are addressed within one week for Enrollment/Reconciliation review and subsequently changed to G, and before being sent to the issuer, will the issuer receive G, and but not A: If the Federally-facilitated Small Business Health Options Program (FF-SHOP) Enrollment/Reconciliation contractor reconciles an issue internally, then the field level disposition could be reported as G, or K. However, if the issue needs further research, then the field level disposition could be reported as N. The answer depends upon the speci?c issue. (REGTAP FAQ Database - FAQ #12212 08/27/15) 999 Updated 1-31-17 2017--01099 Q: For issuer-assigned member identi?cations (IDs), if a Federally-facilitated Small Business Health Options Program (FF-SHOP) issuer does not have a separate ID for each member but does have IDs for subscribers, should the issuer send the subscriber ID in the member ID associated with that subscriber? A: FF-SHOP issuers must provide the same issuer-assigned ID that issuers submitted on the 834 effectuation. The FF-SHOP will have previously stored the ID submitted on the 834, and will compare it to the ID submitted by issuers. (REGTAP FAQ Database - FAQ #12213 08/27/15) Q: For the new enrollment/reconciliation process, if there is a prorated premium within a given month, are Federally-facilitated Small Business Health Options Program (FF-SHOP) issuers to report both premiums for that month (for example: adding a newborn within the month)? A: At the subscriber level, the Total Premium Amount needs to be reported for that speci?c month. (REGTAP FAQ Database - FAQ #12439 09/01/15) Q: Will Federally-facilitated Small Business Health Options Program (FF-SHOP) issuers receive a notification if there are no discrepancies in the issuers' enrollment/reconciliation files? A: The Centers for Medicare and Medicaid Services (CMS) will not send a notification if all entries submitted on the enrollment/reconciliation match. (REGTAP FAQ Database - FAQ #12441 09/01/15) Q: Can one Enrollment/Reconciliation file contain multiple issuers? If so, will there be detail rows after the total row? A: When submitting data for multiple issuers in the same file, ensure detail rows related to these issuers are first and include the corresponding total rows at the end of the ?le. If multiple issuers are in the same ?le, all total rows must be at the end of the file vs. being throughout. (REGTAP FAQ Database - FAQ #12818 09/11/15) Q: Since Trading Partner ID (TPID) is a node in the file name, does this mean each ?le must contain data for only one Trading Partner A: Even though the file name can only have one TPID in the node of the Managed File Transfer (MFT) path, the contents of the ?le can be for multiple Health Insurance Oversight System (HIOS) IDs. (REGTAP FAQ Database - FAQ #12819 09/11/15) Q: Is the _Application Identification (App In the file name a required doe lfor the FF- SHOP Enrollment/Reconciliation processGan?yeu?please?elarify required node for all ?les sent. Please refer to the ICD located on the Registration for Technical Assistance Portal (REGTAP) for the prescribed file names. (REGTAP FAQ Database - FAQ #12820 09/11/15; updated 6/21/16) 1000 Updated 1-31-17 2017--01100 Q: Currently?wedo What will happen if an FF- SHOP issuer does not submit the Issuer Assigned Member ID on the X12 834 effectuation file, but does send them yet?it?is required on the Enrollment/Reconciliation file. Will-this?be?an?iseue? A: If CMS does not have the Issuer Assigned Member ID on effectuation ?les because?of the?reasen?montioned, it will show as a discrepancy during the enrollment/reconciliation process. It is critical that Issuer Assigned IDs are submitted on X12 834 effectuations for enrollment/reconciliation and renewal purposes. (REGTAP FAQ Database - FAQ #12821 09/11/15; updated 06/21/16) Q. When How will the Federally-facilitated Small Business Health Options Program (FF- SHOP) issuers begin submitting production Enrollment/Reconciliation files, how?wiil?they be notified if their file is rejected? A: CMS will send an email from shoprecon@cms.hhs.qov and advise an issuer thorn if a file has been rejected. (REGTAP FAQ Database - FAQ #12822 09/11/15; updated 06/21/16) Q: When must issuers new to the Federally-facilitated Small Business Health Options Program (FF-SHOP) for Plan Year 2016 begin submitting Enrollment] Reconciliation files? A: New FF-SHOP issuers must submit thei_r ?rst Enrollment/ Reconciliation ?le in the month following their first qroups coveraqae effective date. For example, if a new issuer had qroups enroll with a January 1 coverage effective date the issuer must submit their first enrollment/reconciliation in February. February?2046.1nis (REGTAP FAQ Database- FAQ #13385 09/29/15; updated 06/21/16) Q: Are Federally-facilitated Small Business Health Options Program (FF-SHOP) issuers able to submit Enrollment] Reconciliation files immediately after the last day of the month to align with the Centers for Medicare and Medicaid Services (CMS) timeline? How long do issuers have to resubmit a corrected file? A: Issuers can submit FF-SHOP Enrollment/ Reconciliation ?les from the 1st of the month through the 2nd Friday of the month. Valid ?les received during this timeframe are isolated in a secure location and held for processing until the 2nd Friday of the month. Note: All files submitted outside of this window will be rejected. (REGTAP FAQ Database - FAQ #13386 09/29/15) Q: In FAQ 11651, the Centers for Medicare Medicaid Services (CMS) stated that any claims incurred during the 2015 benefit year that did not result in a final payment by the data submission deadline of April 30, 2016 may be submitted in the following year reconciliation cycle. Will CMS also permit issuers to carry over claims for the 2015 benefit year that were paid but were not able to be submitted in time for the April 30, 2016 dead?ne? A: Yes. Claims incurred in the 2015 bene?t year that were not able to be submitted in time for the April 30, 2016 deadline may be submitted in the following year reconciliation cycle, whether the reason for the non-submission was because they had not been paid in time or because the issuer was not able to reconcile the claim in time. CMS expects 1001 Updated 1-31-17 2017-?01 101 issuers to reconcile cost-sharing reductions under a permitted methodology following payment. (REGTAP FAQ Database - FAQ #13418 10/01/15) Premium Proration Q: Do the FF-SHOP proration rules apply outside of A: Pursuant to for a Federally-facilitated SHOP, the premium for coverage lasting less than 1 month must equal the product of: (1) The premium for 1 month of coverage divided by the number of days in the month; and (2) The number of days for which coverage is being provided in the month described in paragraph of this section. This proration rule only applies to FF-SHOPs. (REGTAP FAQ Database - FAQ #1417 04/14/14) Q: The FF-SHOP prorating formula will use the number of days in that month as the divisor. Thus, a day of February coverage will cost more than a day in September. Is this statement correct? A: Yes, prorated premiums will be calculated by multiplying the number of days of coverage in the partial month by the premium for 1 month divided by the number of days in the month. Months with 30 or fewer days will effectively cost more than a month with 31 days. (REGTAP FAQ Database - FAQ #1419 04/14/14) Q: Will issuers have to prorate new hires depending on their effective date of coverage? A: No. All new hires will have an effective date of the 1st of the month. (REGTAP FAQ Database - FAQ #1420 04/14/14) Q: Under what circumstances would FF-SHOPs use proration? A: In FF-SHOPs, proration of premiums will occur for coverage lasting less than 1 month (generally only for a month when a birth/adoption or death occurs). (REGTAP FAQ Database - FAQ #1435 04/14/14) Q: What are the pro-rating rules for Federally-facilitated Small Business Health Options Program (FF-SHOP) enrollments? A: Based on regulations, the FF-SHOP will invoice and send issuers a pro-rated amount based on the number of days in a month an enrollee has coverage. (REGTAP FAQ Database - FAQ #2894 07/16/14) Q: Will the Federally-facilitated Small Business Health Options Program (FF-SHOP) prorate premiums for mid-month effective dates and indicate partial amounts on invoices sent to employers and on 820 transactions sent to issuers? A: Yes, the FF-SHOP will prorate premiums for mid-month effective dates and indicate partial amounts on invoices sent to employers and on 820 transactions sent to issuers. CMS will use a Reverse and Replace methodology that reverses any previous full-month charge and replace it with the partial-month prorated charge. Issuers will see the reversal as an adjustment code on the 820 transaction. The DTM segment will show 1002 Updated 1-31-17 2017-?01102 that the charge does not cover a full month. (REGTAP FAQ Database - FAQ #5341 10/02/14) Q: What happens if a Federally-facilitated Small Business Health Options Program (FF- SHOP) issuer cannot submit the Enrollment/Reconciliation file and correct all errors by the deadline? A: If an issuer misses the deadline, the Centers for Medicare and Medicaid Services (CMS) will not complete the Enrollment/Reconciliation process for the issuer for that month. CMS will follow up with issuers who consistently miss the deadline to ensure compliance with applicable regulations. (REGTAP FAQ Database - FAQ #14817 02/18/16) SHOP Payment: Employer Contributions Q14: Can an employer in the FF-SHOPs contribute a different amount to premiums for employees and their dependents based on whether the employee works full-time or part- time? A14: For 2014 and 2015, employers in the FF-SHOPs will not be able to contribute a different amount to premiums for employees and their dependents based on whether the employee works full-time or part-time. (SHOP FAQ #6 10/31/13; REGTAP FAQ Database - FAQ #354 and #354a 10/2/13; updated 08/27/14) Q15: Can employers in the FF-SHOPs contribute a different amount based on different employee classes, owners or salaried and hourly workers? A15: Employers in the FF-SHOPs will be able to contribute a uniform percentage to all employees and will not be able to vary the amount based on employee classes. (SHOP FAQ #6 10/31/13; REG TAP FAQ Database - FAQ #355 10/2/13) 1003 Updated 1-31-17 2017--01103 4042,43) CMS removed this FAQ from the REG TAP database on 09/02/14. Q13: Will tobacco usage be factored into calculating reference plan amounts in the FF- A13: No, when calculating reference plan premiums, applicable tobacco surcharges will not be factored into average group premium (SHOP FAQ #6 10/31/13; REGTAP FAQ Database- FAQ #353 10/2/13? The REGTAP version struck the language noted above) Q: Can employers make changes to plan or contribution amounts after the group enrollment process is complete? A: No. Employers will not be able to make changes to plan or contribution amounts after the group enrollment process is complete. To make changes after the group enrollment process is complete, an employer would need to cancel coverage prior to the original effective date and begin the process from the beginning. (REGTAP FAQ Database - FAQ #1424 04/14/14) Q: Will the Federally-facilitated Small Business Health Options Program (FF-SHOP) support a de?ned contribution (or ?xed dollar contribution) model? A: Employers may contribute a ?xed percentage amount towards employee and dependent medical and dental coverage. FF-SHOP Marketplaces will not support a fixed dollar contribution methodology. (REGTAP FAQ Database - FAQ #2594 07/03/14) 1004 Updated 1-31-17 2017-?01104 Q: Will the Federally-facilitated Small Business Health Options Program (FF-SHOP) Marketplaces allow employers to offer different contribution percentages based on employee class? A: No, FF-SHOP Marketplaces will not allow employers to contribute different percentages based on employee class. (REGTAP FAQ Database - FAQ #2595 07/03/14) Payment: Employee Contributions 1005 Updated 1-31-17 2017-?01105 WCMS removed this FAQ from the REG TAP database on 09/02/14. Payment: Examples of Contribution Calculations Below are examples depicting an employer that chooses to have employees contribute to premiums based on age and another that chooses to have employees contribute the same amount to premiums regardless of age by using composite rates. We have provided examples of the estimated versus actual contributions in both cases. Figure 1 shows how much an employer pays towards employee coverage based on estimated employee enrollment and the balance each employee would pay based on their ages. In this example, the employer decides to contribute 75% towards the reference plan average per- member rate of $387.50. The actual amounts contributed by the employer will vary per employee, and the entire calculation may change (as described above) based on the number and ages of employees who actually enroll. EXAMPLE 1: Contributions Based on Age Figure 1: Contributions based on Age Estimated Enrollment Example Employees Age Per-member Rate Employer Employee Expected to for Employer Contribution (75% Contribution (25% Enroll Chosen Reference of per member of per-member Plan premium) premium) Employee 1 22 $250.00 $187.50 $62.50 Employee 2 35 $350.00 $262.50 $87.50 Employee 3 58 $450.00 $337.50 $112.50 Employee 4 64 $500.00 $375.00 $125.00 $1,550.00 (total) $1,162.50 (total) $387.50 (total) TOTAL $387.50 (average) $290.63 (average) Figure 2 shows how much the employer above might pay towards employee coverage after employees actually enroll in coverage. Because employee contributions are based on age, this employer's contribution increases because the ages of employees actually enrolling are higher than what was originally estimated in Figure 1. Figure 2: Contributions based on Age Actual Enrollment Example Employees Age Per-member Employer Employee Actually Rate for Contribution Contribution Enrolled Employer (75% of per- (25% of per- Chosen member member Reference Plan premium) premium) Employee 1 58 $450.00 $337.50 $112.50 Employee 2 60 $475.00 $356.25 $118.75 Employee 3 62 $482.00 $361.50 $120.50 Employee 4 64 $500.00 $375.00 $125.00 $1,907.00 (total) 1,430.25 476.75 (total) TOTAL $476.75 (total) (average) $357.56 (average) Updated 1-31-17 2017-?01106 1006 EXAMPLE 2: Composite Premiums/Equal Contributions (Regardless of Age) Figure 3 shows how much an employer pays towards employee coverage based on estimated employee enrollment and the equal balance each employee would pay based on estimated enrollments. Figure 3: Equal Contributions Estimated Enrollment Example Employees Age Per-member Rate Employer Employee Expected to for Employer Contribution (75% Contribution Enroll Chosen Reference of calculated (25% of Plan average, $387.50) calculated average, $387.50) Employee 1 22 $250.00 $290.63 $96.87 Employee 2 35 $350.00 $290.63 $96.87 Employee 3 58 $450.00 $290.63 $96.87 Employee 4 64 $500.00 $290.63 $96.87 $1,550.00 (total) $1,162.52 (total) $387.48 (total) TOTAL $387.50 (average) $290.63 (average) Figure 4 shows how much the employer in Example 3 might pay towards employee coverage after employees actual enroll in coverage. In the FF-SHOPs, the employee contribution will not automatically change based on changes in which employees actually enroll. However, the employer contribution might increase, because the employees actually enrolling might be older than the original estimates. In this example, the employer would have an opportunity to determine if he or she is willing to contribute more. If not, the employer could notify employees that the offer of coverage is changing, and employees will be given an opportunity to reconsider their decision to elect coverage based on how much more they will have to pay to enroll in coverage. Once the application is submitted, the average rate of $476.75 is the composite premium that will be in place for the next 12 months. So regardless of how the group composition changes during the plan year, $476.75 is the amount a SHOP issuer agrees to accept for existing and new enrollees, such as a new hire added mid-year?regardless of how old the employee is. Thus, the SHOP issuer may benefit from younger employees enrolling and takes on the risk of older employees enrolling mid-year. Figure 4: Equal Contributions - Actual Enrollment Example Employees Age Per-member Employer Employee Actually Rate for Contribution Contribution Enrolled Employer (80% of new (25% of original Chosen calculated calculated Reference Plan average, average, $476.75) $387.50) Employee 1 58 $450.00 $379.88 $96.87 Employee 2 60 $475.00 $379.88 $96.87 Updated 1-31-17 2017--01 107 1007 Employees Age Per-member Employer Employee Actually Rate for Contribution Contribution Enrolled Employer (80% of new (25% of original Chosen calculated calculated Reference Plan average, average, $476.75) $387.50) Employee 3 62 $482.00 $379.88 $96.87 Employee 4 64 $500.00 $379.88 $96.87 Average/Total $1,907.00 (total) $1,519.52 (total) $387.48 (total) $476.75 $379.88 (average) (average) (SHOP FAQ #6 10/31/13) SHOP Terminations and Cancellations 09: Please explain the process to cancel groups that decide to terminate coverage prior totheenrollmenteffective date .-: e: :27 A9: If a group decides to cancel coverage prior to an effective date, the FF-SHOP will send an 834 enrollment transaction terminating coverage for the group and associated employees. Employers can make cancellation termination requests online at the FF- SHOP site or through the call center. (QHP Webinar Series SHOP FAQ #1 06/20/13; REGTAP FAQ Database - FAQ #113 and #113a 06/20/13; updated 08/27/14) CMS removed this FAQ from the REG TAP database on 08/26/14. Q17: What reasons may an issuer terminate a group in the A17: Issuers may terminate FF-SHOP group coverage for lack of payment and/or for instances of fraud. (SHOP FAQ #3 07/30/13) REG TAP database on 08/26/14. 1008 Updated 1-31-17 2017-?01108 Q: For what reasons may an issuer terminate an enrollee's coverage in a plan offered through the CMS removed this FAQ from the REG TAP database on 09/02/14. Q32: Can CMS please clarify how the ?Termination of coverage for qualified individuals? requirements in 45 CFR 156.270 of the HHS Final Exchange Establishment Rule applies to issuers offering QHPs in the Regulation 45 CFR 156.270 requires notifications to be sent to ?enrollees? 30 days prior to the last day of coverage. What is considered to be ?the last day of coverage?? A32: The pertinent regulatory citation, 45 CFR 155.270(b) of the HHS Final Exchange Establishment Rule has been updated to resolve this discrepancy. Under the new standard, for the termination reasons cited in the paragraph, such notice must be provided and without undue delay." (SHOP FAQ #4 08/28/13; REGTAP FAQ Database - FAQ #36 08/28/13) Q33: Can CMS please confirm that issuers are required to send termination notifications to each ?enrollee? and that billing timeframes, notices, and pending claims will be between issuers and employers. A33: Per 45 CFR 156.270(b) of the HHS Final Exchange Establishment Rule "If a QHP issuer terminates an enrollee?s coverage in accordance with 45 CFR or the QHP issuer must, and without undue delay: Provide the enrollee with a notice of termination of coverage that includes the termination effective date and reason for termination." In 2014, issuers should follow state rules pertaining to billing timeframes 1009 Updated 1-31-17 2017--01109 and pending claims. (SHOP FAQ #4 08/28/13; REGTAP FAQ Database - FAQ #37 08/28/13) Q41: Can CMS please clarify an employer?s appeal right for a group terminated by the FF- SHOP issuer for non-payment of the first month's premium? A41: The and Marketplace rules create no new appeal rights for an eligible employer who fails to make its first month?s premium payment before the coverage effective date. (SHOP FAQ #4 08/28/13; REG TAP FAQ Database - FAQ #44 and #44a 08/28/13; updated 08/27/14) Q: For plan years beginning on and after January 1, 2015, how will CMS notify issuers of non-payment within the grace period, ahead of termination? A: CMS will send a termination transaction after a group has been terminated for non- payment of premium after the 31-day grace period has expired. (REGTAP FAQ Database - FAQ #829 02/21/14) Q: For plan years beginning on and after January 1, 2015, because issuers are relying on the FF-SHOP to notify them that a group is being terminated because of non-payment of premium, how will issuers be protected from claims that may process between the delinquency of payment and the notice of termination from the A: Subject to state law and regulations, issuers may pend claims until they have been paid in full by a group via the FF-SHOP. (REGTAP FAQ Database - FAQ #832 02/21/14) Q: For plan years beginning on and after January 1, 2015, if a group is delinquent and we receive termination 8345 for their members, if the group later reinstates, will we receive regular 8345 for the members? What effective date would the 8345 have relative to the previous termination effective date? A: The reinstatement 834 transaction would have an effective date back to the termination date. We are working out what reinstatement transactions would be sent from the FF-SHOP to issuers and will communicate this information to issuers ASAP. (REGTAP FAQ Database - FAQ #836 02/21/14) Q: Will termination transactions be at the employee level or at the group level for the 2015 plan year? A: CMS current thinking is that terminations will be at the employee level. (REGTAP FAQ Database - FAQ #917 03/05/14) Q: Are Issuers allowed to pend claims during the FF-SHOP's 31-day grace period? A: Unless restricted by state law or regulation, Issuers may pend claims during the FF- SHOPs 31- day grace period. (REGTAP FAQ Database - FAQ #991 03/10/14) Q: When a group is terminated for non-payment of premium in FF-SHOPs, what will the termination effective date be? A: The termination effective date will be retroactive to the last month when premiums were paid in full. (REGTAP FAQ Database - FAQ #1426 04/14/14) 1010 Updated 1-31-17 2017-?01110 Q: For the Individual Marketplace, coverage can be cancelled after effectuation. Will this be allowed in A: In FF-SHOPs, coverage cannot be cancelled after it is effectuated. FF-SHOP coverage must be cancelled by 11:59 PM ET prior to the coverage effective date. Employers and employees may, however, voluntarily terminate coverage after coverage has been effectuated. (REGTAP FAQ Database - FAQ #1434 04/14/14) Q: If someone terminates employment mid-month, is the FF-SHOP policy to cover the enrollee thru the end of the month or would we prorate in this situation? A: An employee (and dependent) may voluntarily request to terminate their FF-SHOP coverage. The termination effective date will be the last day of the month when the FF-SHOP is notified. An employer may terminate coverage for all enrollees covered by the employer group health plan effective on the last day of any month, provided that the employer has given notice to the FF-SHOP on or before the 15th of the month. If notice is given after the 15th of the month, the FF- SHOP may terminate coverage on the last day of the following month. (REGTAP FAQ Database - FAQ #1437 04/14/14; updated 07/07/16) Q: How many reinstatement opportunities will a group have in a A: As long as a group reinstates within 30 days of the termination effective date, the FF- SHOP portal does not limit the number of times a group may reinstate. (REGTAP FAQ Database - FAQ #1423 04/14/14) Q: What are the employer reporting requirements for terminations? If someone leaves employment on the 30th of the month, how long does the group have to notify the FF- SHOP that the 30th is the last day of coverage? A: Terminations may be reported to the FF-SHOP on any day of the month, and the termination effective date will be the last day of that month regardless of when it is reported during the termination month. Retroactive terminations for employee/dependent terminations are generally not supported by the FF-SHOP system. (REGTAP FAQ Database - #1558 05/08/14; updated 07/07/16) Q: Wouldn't the death of an employee result in a retroactive termination and could that result in a negative amount for that employer if helshe was the only one that was on our plan? A: Yes, death of an employee or dependent may result in a retroactive termination and may result in a negative amount for that group. (REGTAP FAQ Database - #1577 05/08/14) Q: If a group does not pay their premium for a given month, does the coverage terminate at the end of that month rather than retroactively? A: When a group is terminated for non-payment of premium, the termination effective date on the 834 termination transaction will be the last day of the month when payment was received in full. (REGTAP FAQ Database - #1571 05/08/14) 1011 Updated 1-31-17 2017-?01111 Q: Some issuer systems require that members are paid through their termination date before they are terminated' In the system. Will the FF- SHOP ensure that transactions are sent in the right order beginning?with?plan?year?ZO45? A: Employers may voluntarily terminate their coverage in the FFSHOP system only when they have a zero balance. And termination transactions for nonpayment of premium are only sent to issuers after a group's grace period (31 days in FFSHOP) has expired without payment in full system. (REGTAP FAQ Database- #1580 05/13/14; updated 07/19/16) Q: If an employer is billed 4/10 and the employer notifies the FF-SHOP of an employee termination of 3/11 on 4/11, what is the employee term date? A: The termination effective date in this example will be 4/30. (REGTAP FAQ Database - #1563 05/08/14) Q: Will terminations for non-payment of premium be reported on both the Group XML and 834? A: Yes, the Centers for Medicare Medicaid Services (CMS) plans to send both group- Ievel and 834 termination transactions for non-payment of premium. (REGTAP FAQ Database - #1986 05/30/14) Q: If the Group XML fails validation at the HUB, will that prevent the 834 from being sent? A: If the Group setup ?le fails validation, the Federally-facilitated Small Business Health Options Program (FF-SHOP) will correct and send the Group setup ?le before sending 8343 to issuers. (REGTAP FAQ Database - #1987 05/30/14) Q: Are the enrollment action and the insurance policy status code tied together or are the two independent? A: The status of the enrollment action is for the entire employer ?le. For example, if the employer changes her address, a maintenance code is sent on the group ?le. On the other hand, an insurance plan code is used to indicate the status of the plan. Plan status is dependent on the enrollment action. (REGTAP FAQ Database - #1988 05/30/14) Q: Will all groups for an issuer be sent on the same 834 transaction file or will a separate 834 be sent for each group? A: 8343 will contain all the enrollment transactions for a day for that issuer trading partner. There will not be a separate 834 for each group. (REGTAP FAQ Database - #1989 05/30/14) 1012 Updated 1-31-17 2017-?01112 Q: Will the Payment Transaction ID be the same in the both the initial and subsequent group files, and initial and subsequent 834 files? A: Will the Payment Transaction ID be the same in both the initial and subsequent group files, and also the initial and subsequent 834 and 820 ?les? (REGTAP FAQ Database - #1990 05/30/14) Q: If a group pays after a cancellation transaction is sent, is there a reinstatement process? A: An employer who misses the initial payment deadline will have to re-apply and have coverage effectuated on a future month. There will not be a reinstatement process when a group does not pay the initial binder payment, however, the group may reapply using information stored in the Federally-facilitated Small Business Health Options Program (FF-SHOP) system. (REGTAP FAQ Database - FAQ #2423 06/26/14) Q: Will the Federally-facilitated Small Business Health Options Program (FF-SHOP) send group-level and member-level cancellation transactions? A: Yes, the FF-SHOP will send group-level and member-level cancellation transactions. (REGTAP FAQ Database - FAQ #2426 06/26/14) Q: Will the Centers for Medicare Medicaid Services (CMS) send cancellations for each family member or only the subscriber? A: When the employee cancels a plan selection prior to coveraqe effectuation, cancellations will be sent at the subscriber-level (as is the case in the FFM Individual Marketplace). (REGTAP FAQ Database - FAQ #2428 (revised as #2428a) 06/26/14; revised 9/30/14) Q: Regarding the FF-SHOP Eligibility Enrollment Notices Webinar (4/15/14), are issuers required to send terminations for every member termination or only if the group terminates? For example, if someone terminates because of being fired, must the issuer send a termination notice? A: Issuers are required to provide written notice to each plan sponsor (employer) and to all covered participants and beneficiaries. (REGTAP FAQ Database - FAQ #2573 07/03/14) Q: In addition to sending termination letters for non-payment of premiums, are issuers required to send termination notices for voluntary terminations, and at renewal if the employer group chooses another carrier? A: Issuers are required by Federally-facilitated Small Business Health Options Program (FF-SHOP) rules to send group-level termination notices if coverage is terminated for non-payment, or if the group's coverage is rescinded for a permissible reason (pursuant to 45 CFR Section 147.128). State law or regulation may require issuers to send termination notices for other reasons as well. (REGTAP FAQ Database - FAQ #2585 07/03/14) 1013 Updated 1-31-17 2017-?01113 Q: For dependent-level cancellations, will the Federally-facilitated Small Business Health Options Program (FF-SHOP) send issuers data for the entire employer contract (as is the case in the Individual Market) or will the FF-SHOP only send data from the dependent portion of the record? A: When a dependent's coverage is cancelled, the FF-SHOP will only send the dependent record. As applicable, the transaction may also include a financial change. (REGTAP FAQ Database - FAQ #2862 07/16/14) Q: After an issuer receives an 834 termination transaction from the Federally-facilitated Small Business Health Options Program (FF-SHOP), can the issuer use a Health Insurance Portability and Accountability Act (HIPAA) certified letter for termination notices to employers and employees, or are there specific data elements required for termination notices? A: When an Issuer terminates an employer for non-payment or because the coverage was rescinded, the termination notice must include the effective date of the termination and the reason for the termination. See 45 CFR which cites 45 CFR (REGTAP FAQ Database - FAQ #2884 07/16/14) Q: Who is responsible for sending termination or cancellation notifications to employees, or members of a Small Business Health Options Program (SHOP) employer group? A: Issuers are required to send all termination and cancellation notices to both employers and employees. (REGTAP FAQ Database - FAQ #2997 07/25/14) Q: The Centers for Medicare Medicaid Services (CMS) have stated that issuers are required to send all cancellation and termination notices in the Federally-facilitated Small Business Health Options Program (FF-SHOP), but the April 15, 2015 slides presentation (on notices) states that the FF-SHOP will generate a notice to inform an employer when an employee terminates FF-SHOP coverage. Can CMS clarify this apparent contradiction? A: When an employee (not the employer) terminates coverage in his or her online FF- SHOP account, the FF-SHOP will send the employer a courtesy noti?cation that the employee termination has occurred. Once the FF-SHOP sends the 834 termination transaction to an issuer, the issuer is required to send out a notice to the employee confirming that the coverage was terminated. (REGTAP FAQ Database - FAQ #2999 07/25/14) Q: Can the Centers for Medicare Medicaid Services (CMS) confirm that issuers are required to send all cancellation and termination notices to employer groups and employees, even for cancellations executed by the Federally-facilitated Small Business Health Options Program A: Yes, issuers must send all cancellation and termination notices, even for cancellations executed by the FF-SHOP. Also, issuers should note that only the FF-SHOP may cancel or terminate coverage as of the 2015 plan year. (REGTAP FAQ Database - FAQ #3000 07/25/14) 1014 Updated 1-31?17 2017-?01114 Q: Under what circumstances could an issuer initiate a cancellation for a Federally- facilitated Small Business Health Options Program (FF-SHOP) employer group and associated employees and dependents? A: Per Section 156.285 (0) issuers participating in Marketplaces are required to effectuate SHOP coverage unless the issuer receives an 834 cancellation transaction from the FF-SHOP prior to the coverage effective date. Cancellation transactions will be sent to issuers if the FF-SHOP does not receive the initial binder payment by a speci?ed date prior to the coverage effective date. Issuers will never generate cancellation or termination transactions for plans in the FF-SHOP Marketplaces. (REGTAP FAQ Database - FAQ #3396 08/01/14) Q: Section 9.6.1 of the 834 Companion Guide lists new cancellation and termination reason codes for the 2750 Reporting Loop. Are issuers required to identify and report on all of these codes? A: The Federally-facilitated Small Business Health Options Program (FF-SHOP) Marketplace does not allow issuers to report cancellations or terminations. As of the 2015 Plan Year, only the FF-SHOP will send cancellation and termination transactions to issuers. (REGTAP FAQ Database - FAQ #3402 08/01/14) Q: What effective date field should issuers use for Group XML file terminations and cancellations? A: The Federally-facilitated Small Business Health Options Program (FF-SHOP) will always generate these transactions and effective dates as of the 2015 Plan Year. Issuers will never send cancellation or termination transactions in the FF-SHOP for the 2015 Plan Year. (REGTAP FAQ Database - FAQ #3407 08/01/14) Q: What XML element will the Federally-facilitated Small Business Health Options Program (FF-SHOP) use to notify issuers of the ?Effective Date of Cancellation,? when an employer group is cancelled? A: Maintenance Effective Date will convey the group cancellation effective date. (REGTAP FAQ Database - FAQ #3408 08/01/14) Q: If an employer group is terminated for non-payment of premium, can an issuer send the premium due amount to the issuer's collection department? A: After the Federally-facilitated Small Business Health Options Program (FF-SHOP) reinstatement window has passed, issuers may collect outstanding premium amounts based on applicable state law. (REGTAP FAQ Database - FAQ #3414 08/01/14) Q: Can issuers use the Plan Maintenance Effective Date field for terminations? A: Issuers can use the Plan Maintenance Effective Date to determine the termination date of the plan. As of the 2015 Plan Year, issuers are not sending termination transactions to Federally-facilitated Small Business Health Options Program (FF-SHOP). The FF-SHOP will always generate termination transactions. (REGTAP FAQ Database - FAQ #3426 08/01/14) 1015 Updated 1-31-17 2017-?01115 Q: How will the Federally-facilitated Small Business Health Options Program (FF-SHOP) handle dependents who age out? A: For FF-SHOP, the Centers for Medicare Medicaid Services (CMS) is planning to send 834 termination transactions to issuers based on the maximum child dependent age issuers entered on the business rules template. (REGTAP FAQ Database - FAQ #3409 08/01/14) Q: What termination notices are Federally-facilitated Small Business Health Options Program (FF-SHOP) issuers required to send to employers and employees? A: Pursuant to 45 CFR Issuers are required to send group- level and member-level termination notices. (REGTAP FAQ Database - FAQ #3765 08/14/14) Q: With the addition of new maintenance reason codes for cancellations and terminations, can issuers send and on transactions? A: In Federally-facilitated Small Business Health Options Programs (FF-SHOPS), issuers are not sending termination or cancellation transactions. Only the FF-SHOP will initiate termination and cancellation transactions as of the 2015 plan year. (REGTAP FAQ Database - FAQ #3773 08/14/14) Q: Apart from the Centers for Medicare Medicaid Services (CMS) inbound transactions, is there any situation where issuers are expected to CANCEL or TERM a SHOP Subscriber or Member in a Small Business Health Options Program (SHOP) contract? A: No, as of 2015 plan year, issuers are not generating cancellation or termination transactions in FF-SHOPs. (REGTAP FAQ Database - FAQ #3782 08/14/14) Q: What will the Federally-facilitated Small Business Health Options Program (FF-SHOP) send to employers on the employer's invoice in the case of death or a retroactive termination of one member of the employer group? Would the FF-SHOP reverse the entire previously paid amount and then add the new amounts for the remaining employees and dependents? A: The FF-SHOP will give a credit on the next invoice for any amount due back to the employer due to a death or retroactive termination of one member within an employer group. The credit would show under the adjustment section on the invoice, listing the employee name and credit amount. The FF- SHOP will only reverse and replace the amount pertaining to the member within the employer group that was affected by the adjustment (REGTAP FAQ Database- FAQ #3794 and #37943 08/14/14, updated 09/10/14) Q: Will the Centers for Medicare Medicaid Services (CMS) publish a template for termination and cancellation notices to employer groups and employees? A: CMS anticipates posting model cancellation and termination notices for employers and employees. (REGTAP FAQ Database - FAQ #4133 08/26/14) 1016 Updated 1-31-17 2017-?01116 Q: When a dependent is terminated from an employer group, will the Federally-facilitated Small Business Health Options Program (FF-SHOP) include the Health Insurance Oversight System (HIOS) ID and Policy ID on the 834 Termination transaction? A: Yes, the FF-SHOP will send the Exchange Assigned Policy ID, HIOS Plan ID, Issuer Assigned Policy ID and Issuer Assigned Group ID in the HealthCoveragePolicyNumber loop of the 834 Enrollment transaction. (REGTAP FAQ Database - FAQ #4137 08/26/14) Q: When a dependent ages off of a medical plan and a dental plan, will the Federally- facilitated Small Business Health Options Program (FF-SHOP) send a separate 834 Termination transaction to the dental issuer? A: When a dependent ages off of a medical or dental plan in the FF-SHOP, both the medical and dental issuers will receive an 834 termination transaction. (REGTAP FAQ Database - FAQ #4138 08/26/14) Q: If an employer terminates an employee after the Federally-facilitated Small Business Health Options Program (FF-SHOP) generates an invoice and the employer pays the new amount, will the detailed 820 Payment transaction include the terminated employee? A: The answer to this question depends mostly on timing. The termination might occur quickly enough to show on the current 820 Payment transaction. In many cases, a termination reversal will show on a subsequent 820. (REGTAP FAQ Database - FAQ #4150 08/26/14) Q: If an employer groups does not pay a binder payment in full, when will the Federally- facilitated Small Business Health Options Program (FF-SHOP) send an 834 cancellation transaction? A: Issuers will receive an 834 Cancellation transaction by the 26th of the month if the FF- SHOP does not receive a group's initial binder payment. (REGTAP FAQ Database - FAQ #4157 08/26/14) Q: May issuers collect outstanding premium amounts based on applicable state law if a group is terminated for non-payment of premium? A: After the Federally-facilitated Small Business Health Options Program (FF-SHOP) grace period and reinstatement windows have passed, issuers may collect outstanding premium payments based on applicable state law. (REGTAP FAQ Database - FAQ #4161 08/26/14) Q: If an issuer receives a Group XML maintenance transaction to change the business address from an in-state address to an out-of-state address, will the Centers for Medicare Medicaid Services (CMS) subsequently cancel or terminate the employer group from the Small Business Health Options Program A: Issuers should not receive this type of transaction. Instead, issuers should receive a termination transaction because the group is no longer eligible for FF-SHOP coverage in that state. (REGTAP FAQ Database - FAQ #4197 09/02/14) 1017 Updated 1-31?17 2017-?01117 Q: After the Federally-facilitated Small Business Health Options Program (FF-SHOP) terminates an employer group, how long do issuers have to send termination notices to the employer and employees? A: Notices of termination must be sent without undue delay. (REGTAP FAQ Database - FAQ #4200 09/02/14) Q: If an FF-SHOP issuer does not enroll employees until the first payment for the group is received on an 820 transaction or the group is effectuated, is the issuer required to send cancellation notices when it receives a group cancellation transaction from the FF- A: Yes, issuers are required to send cancellation notices (for both employers and employees) when the issuer receives group-level cancellation transactions from the Federally-facilitated Small Business Health Options Program (FF-SHOP). (REGTAP FAQ Database - FAQ #4421 09/05/14) Q: How will Federally-facilitated Small Business Health Options Program (FF-SHOP) issuers request additional payments from cancelled or terminated employer groups for claims paid between the last payment received and when the FF-SHOP cancels or terminates the employer group? A: After the FF-SHOP 30-day reinstatement window has passed, issuers may collect outstanding money owed by groups as allowed by applicable State law and regulations. (REGTAP FAQ Database - FAQ #4423 09/05/14) Q: If an employer does not pay the initial premium payment and the Federally-facilitated Small Business Health Options Program (FF-SHOP) sends a cancellation transaction to the issuer, will the FF-SHOP send the cancellation at the member level, the group level, or both? A: When the FF-SHOP does not receive the initial binder payment in a timely manner, the FF-SHOP will send a cancellation transaction at the subscriber and group level. (REGTAP FAQ Database - FAQ #4425 09/05/14) Q: Since cancellations and terminations can be made at the group and member levels, what termination codes will the Federally-facilitated Small Business Health Options Program (FF-SHOP) send in the Group XML file? A: The employer group transaction has the termination codes in the schema. Please refer to the employer group schema located in the Group Business Service De?nition (BSD) document posted on REGTAP and ZONE. (REGTAP FAQ Database - FAQ #4432 09/05/14) 1018 Updated 1-31?17 2017-?01118 Q: Assuming an entire employer group is not terminating coverage, will Federally- Facilitated Small Business Health Options Program (FF-SHOP) issuers send termination notifications to a specific enrollee at any time and for any termination reason, including aging out? A: FF-SHOP issuers are required to send cancellation and termination notices to employers and employees, including single enrollees when the entire group is not terminating. (REGTAP FAQ Database - FAQ #4675 09/11/14) Q: When do FF-SHOP issuers need to terminate a group and send termination notices? A: FF-SHOP issuers must terminate a group and send termination notices when the issuer receives Group Extensible Markup Language (XML) and 834 termination transactions from the (REGTAP FAQ Database - FAQ #4678 09/11/14) Q: Will member e-mail addresses be included on 834 transactions in the Federally- Facilitated Small Business Health Options Program If so, can FF-SHOP issuers e-mail termination notices or must they be sent via U.S. mail? A: The FF-SHOP will send email addresses on subscriber 834 transactions when they are available. Issuer notices must meet the accessibility requirements described in (REGTAP FAQ Database - FAQ #4680 09/11/14) Q: Since groups have to renew their 2014 Federally-Facilitated Small Business Health Options Program (FF-SHOP) coverage online through HealthCare.gov for plan years beginning in 2015, will FF-SHOP issuers need to send termination notices to these groups when their 2014 plan year is ending? A: FF-SHOP Issuers will not need to send termination notices at the group or member level for enrollees with 2014 FF-SHOP coverage if a group enrolls in an Issuer's same plan in 2015. (REGTAP FAQ Database - FAQ #4681 09/11/14) Q: If an employer is terminating coverage, should FF-SHOP issuers only send termination notices after the issuer has received the Group termination and 834 transactions for all enrollees? A: FF-SHOP issuers should send termination letters once they have received a group termination and 834 termination transactions. Group XML and 834 transactions should arrive on the same day. (REGTAP FAQ Database - FAQ #4682 09/11/14) Q: Will the Federally-facilitated Small Business Health Options Program (FF-SHOP) transmit a speci?c reason for an employer group's termination in either an 834 transaction or Group Extensible Markup Language (XML) file? A: Yes, the will include the termination reason code in Group XML and 834 termination transactions. (REGTAP FAQ Database - FAQ #4687 09/11/14) Q: Do issuers have to wait for model termination notices to become available before issuers send out notices? A: Please refer to the Bulletin published September 2, 2014 titled ?Form and Manner of Notices When Discontinuing or Renewing a Product in the Group or Individual Market.? 1019 Updated 1-31?17 2017-?01119 FAQ Database - FAQ #4689 09/11/14) Q: Will the Federally-facilitated Small Business Health Options Program (FF-SHOP) list the date of termination on late payment notices sent to employers? A: Termination dates are not included on the late payment notices sent by the (REGTAP FAQ Database - FAQ #4695 09/11/14) Q: If an entire employer group is not terminated, are issuers required to send termination notices to all enrollees the issuer will terminate, including children who are dependents? A: The Centers for Medicare and Medicaid Services (CMS) expects issuers will generally send notices at the subscriber level. Issuers should ensure all notices comply with applicable state laws and regulations. (REGTAP FAQ Database - FAQ #4697 09/11/14) Q: After an FF-SHOP issuer receives an 834 transaction that terminates coverage, when should the issuer send termination notices to employers and employees? A: FF-SHOP issuers must send a notice of termination without undue delay. (REGTAP FAQ Database - FAQ #4708 09/11/14) Q: When a Federally-facilitated Small Business Health Options Program (FF-SHOP) enrollee changes plans after the FF-SHOP effectuates coverage, for example, when a new plan is chosen because of a special enrollment period, will the FF-SHOP send a Maintenance or Termination and an ADD transactions? A: If an enrollee changes plans after the FF-SHOP effectuates coverage, the FF-SHOP will send a termination transaction to end the first plan. Then FF-SHOP will generate a new enrollment transaction for the new plan. The will not re?ect this change on a maintenance transaction. (REGTAP FAQ Database - FAQ #4902 09/17/14) Q: Can Federally-Facilitated Small Business Health Options Program (FF-SHOP) issuers initiate a termination when an enrollee performs an act, practice or omission that constitutes fraud? A: No, the FF-SHOP cannot accept incoming termination transactions from FF-SHOP issuers. If issuers discover what may constitute a fraudulent act, issuers should contact the SHOP Call Center to report the alleged incident so the Centers for Medicare and Medicaid Services (CMS) may investigate further. (REGTAP FAQ Database - FAQ #4905 09/17/14) Q: When an employee cancels plan selection and a cancellation transaction is sent at the subscriber-level, does this mean that the member's coverage was not effectuated? A: Cancellation transactions are sent prior to the coverage effective date; however; this does not mean the issuer did not receive the initial Group XML or 834 enrollment transactions for the group. The Centers for Medicare and Medicaid Services (CMS) will send cancellations for initial coverage by the 26th of the month prior to the coverage effective date if the FF-SHOP does not receive a valid payment before this time. In addition, employers and enrollees may cancel coverage up to 11:59 pm. ET 1020 Updated 1-31-17 2017-?01120 prior to the month when coverage was to be effectuated. (REGTAP FAQ Database - FAQ #4911 09/17/14) O: For free-look periods, are Federally-facilitated Small Business Health Options Program (FF-SHOP) issuers expected to send model notice cancellation to the members? A: The FF-SHOP does not have free-look periods. (REGTAP FAQ Database - FAQ #4912 09/17/14) Q: Will the Centers for Medicare Medicaid Services (CMS) hold termination transactions that occur prior to the January 1 coverage effective date and will issuers receive cancellations effective on January 1, 2015? A: The Federally-facilitated Small Business Health Options Program (FF-SHOP) will not hold terminations until January 1, 2015 because terminations may not occur until after coverage has been effectuated. When an employer or employee wants to end coverage prior to the effective date of coverage, a cancellation transaction--not a termination transaction--wil be sent and be effective on the 1st of the coverage effective month. CMS will send these cancellation transactions as the cancellation transactions are initiated by employers and employees and not hold them until January 1. (REGTAP FAQ Database - FAQ #4931 09/17/14) Q: If an employer group is terminated for non-payment but is reinstated, will issuers receive a new Group Extensible Markup Language (XML) file to reinstate the employer group? A: Yes, the FF-SHOP will send issuers a Group XML and corresponding 834 transactions to reinstate an employer group. CMS will review the reinstatement process in greater detail on a future REGTAP call. (REGTAP FAQ Database - FAQ #5323 10/02/14) Q: If a Federally-facilitated Small Business Health Options Program (FF-SHOP) employer group selects an issuer's plan with only one employee enrolled and the employee later terminates coverage, will the issuer receive a termination Group Extensible Markup Language (XML) file as well as the 834 termination transaction for the employee? A: The does not plan to send a Group XML termination transaction in this instance. The FF-SHOP will only send a Group XML termination transaction when a group voluntarily terminates SHOP coverage or the group is involuntarily terminated for non-payment of premium. (REGTAP FAQ Database - FAQ #5347 10/03/14) Q: Will the Federally-facilitated Small Business Health Options Program (FF-SHOP) 834 enrollment transactions include individual and enrollee terminations in the Subscriber loop? A: If an entire family is terminated from coverage, then the FF-SHOP will communicate the termination in the Subscriber loop of the 834 transaction. If individual or dependents are terminated from coverage, the FF-SHOP will communicate the termination in the Member loop of the 834 transaction. (REGTAP FAQ Database - FAQ #5501 10/09/14) 1021 Updated 1-31-17 2017-?01 121 Q: What are the termination reasons on the 834 for the following reasons: - the enrollee is no longer eligible for coverage in a Qualified Health Plan (QHP) through the Marketplace - the enrollee's coverage is rescinded in accordance with 45 C.F.R. 147.128 A: There are two scenarios when an enrollee is no longer eligible for coverage in a QHP through the Marketplace, 1) group moves out of state 2) child dependent ages off a parent's plan. The Federally-facilitated Small Business Health Options Program (FF-SHOP) is not currently supporting a termination transaction to remove an enrollee because of fraud. (REGTAP FAQ Database - FAQ #5676 10/17/14) Q: If an entire group in the Federally-facilitated Small Business Health Options Program (FF-SHOP) is terminated, what transaction will the FF-SHOP send first; the Group Extensible Markup Language (XML) or 8345? A: While the FF-SHOP will send 834 terminations to the Data Services Hub ?rst followed by the Group XML terminating coverage, because of the 834 daily batching process, issuers may receive Group XML terminations before 834 terminations. (REGTAP FAQ Database - FAQ #5681 10/17/14) Q: When a group is reinstated in the Federally-facilitated Small Business Health Options Program (FF-SHOP) (after being terminated for non-payment of premium), are issuers expected to maintain the same issuer-assigned Group A: Yes, the Centers for Medicare Medicaid Services (CMS) expect FF-SHOP issuers to maintain the same issuer-assigned Group ID when a group is reinstated following non-payment of premium. (REGTAP FAQ Database - FAQ #5682 10/17/14) Q: Will Federally-facilitated Small Business Health Options Program (FF-SHOP) issuers ever receive a termination transaction to remove a disabled adult/ward? A: No, dependents classi?ed as 'ward' on an employee's application will not be removed from coverage when they would otherwise age off a parent's plan. If a ward is classi?ed as a child, step-child, or foster child on an employee's initial application, these dependents will be terminated when they reach the maximum child dependent age submitted by issuers on their business rules template. (REGTAP FAQ Database - FAQ #5686 10/17/14) Q: For what reasons may an issuer terminate an enrollee's coverage in a plan offered through the Federally-facilitated Small Business Health Options Program (FF-SHOP) for the 2014 plan year? A: For plan years beginning before January 1, 2015, issuers may terminate an enrollee's coverage in a plan offered through the FF-SHOP for the following reasons. See 45 C.F.R. 1) an enrollee is no longer eligible for coverage; 2) non-payment of premiums; or 1022 Updated 1-31-17 2017-?01122 3) the enrollee's coverage is rescinded in accordance with 45 CFR 147.128 (that is, the enrollee performs an act, practice or omission that constitutes fraud or makes an intentional misrepresentation of material fact, as prohibited by the terms of the plan or coverage). As of the 2015 plan year, FF-SHOP issuers may not send termination or cancellation transactions to the Centers for Medicare Medicaid Services (CMS). All termination and cancellation transactions must be initiated by the FF-SHOP for plan years beginning on and after January 1, 2015. (REGTAP FAQ Database - FAQ #8049 12/04/14) Q: Are retroactive terminations currently in scope as part of the new 2015 Federally- Facilitated Small Business Health Options Program (FF-SHOP) enrollment reconciliation process? A: No, retroactive terminations are not currently in scope as part of the FF-SHOP enrollment reconciliation process. The Centers for Medicare and Medicaid Services (CMS) is only reconciling a snapshot of active enrollments for the previous month. (REGTAP FAQ Database - FAQ #10860 06/05/15) Q: My client's SHOP Marketplace coverage was terminated due to non-payment. Is there a way for the group to be reinstated? A: If a group's coverage is terminated due to non-payment in the SHOP Marketplace, that group can be reinstated up to 30 days past the termination date. The group can be reinstated by paying its total premium owed. If the group's outstanding balance is not paid within the 30 -day reinstatement period, the group will need to complete a new SHOP Marketplace application and reenroll in SHOP Marketplace coverage. (REGTAP FAQ Database - FAQ #15723 05/02/16) SHOP Reporting/Notices Q38: As stated in 45 CFR the FF-SHOP is required to report to the IRS on employer participation, employer contribution, and employee enrollment information in a time and format to be determined by CMS. What employer contribution information are Issuers required to report to the How will this information be collected? A38: 45 CFR 155.720(i) does not place a reporting requirement on Issuers to the FF- SHOP. (SHOP FAQ #2 07/05/13; REGTAP FAQ Database - FAQ #100 07/05/13) Q40: The HHS Final Exchange Establishment Rule, 45 CFR requires the SHOP to report to the IRS employer participation, employer contribution, and employee enrollment information in a time and format to be determined by HHS. What information will issuers be required to report for purposes of employer contributions to the FF-SHOP and how will this information be collected? A40: 45 CFR 155.720(i) of the HHS Final Exchange Establishment Rule describes a reporting standard for SHOPs. This standard is limited to employers and does not include QHP issuers. All individuals providing health insurance, however, are subject to the standards for ?Reporting Health Insurance Coverage" under 26 U.S.C. 6055 1-title26- 1023 Updated 1-31-17 2017-?01123 The IRS will provide information regarding the implementation of these standards. (SHOP FAQ #4 08/28/13; REG TAP FAQ Database - FAQ #43 08/28/13) Q: Does the Centers for Medicare and Medicaid Services (CMS) allow carriers to interact with Small Business Health Options Program (SHOP) groups to gain information for reporting purposes? A: CMS is sending group size information to issuers on Group XML ?les. Thus, interaction with groups for reporting purposes should not be necessary. (REGTAP FAQ Database - FAQ #4707 09/11/14) Q: In the 'Getting Help in Other Languages' section in the Centers for Medicare and Medicaid Services (CMS) renewal notice, it is implied that issuers must include contact information in languages spoken by at least 10% of the population within a given State. Is this a firm requirement by A: The standard format, including the tagline, is not required for renewal and product discontinuation notices in the small group market. Per guidance issued by CMS on September 2, 2014, the Federal standard notices of product discontinuation and renewal in the individual market must include the tagline translated in the non-English language(s) spoken by 10% or more of the population in the country. For a list of languages spoken by 10% or more of the population in each county, please see CLAS-Countv-Data.pdf. (REGTAP FAQ Database - FAQ #12164 08/27/15) Q: If an issuer is participating in the Small Business Health Options Program (SHOP) and one of the issuer's products is discontinued in 2016, is the issuer required to send the discontinuation/termination notices to employers and employees, or does SHOP send the notices? A: Issuers are required to send discontinuation notices. See FAQ Database - FAQ #12214 08/27/15) Q: Is there a sample notice on giving a Small Business Health Options Program (SHOP) group a reminder for the group's 2016 Plan Year renewal? A: The Centers for Medicare and Medicaid Services (CMS) has not posted a 2016 Plan Year model notice for Federally-facilitated Small Business Health Options Program (FF- SHOP) renewals. CMS has, however, posted the following employer and employee annual notices: SHOP Employer Annual Election Notice SCR 062915.pdf SHOP Employee Annual Enrollment Period Notice 5CR FAQ Database - FAQ #12215 08/27/15) 1024 Updated 1-31-17 2017-?01124 Q: What are the renewal notice requirements for Federally-facilitated Small Business Health Options Program (FF-SHOP) issuers, and what information should be included in renewal notices that issuers send to employer groups? A: Under Public Health Service Act section 2703 and regulations at 45 CFR if an issuer in the small group market is renewing coverage (including a renewal with uniform modifications), the issuer must provide to each plan sponsor written notice of the renewal at least 60 calendar days before the date of the coverage will be renewed in a form and manner speci?ed by the Centers for Medicare and Medicaid Services (CMS). As stated in the CMS Bulletin released on September 2, 2014, CMS has not speci?ed the form and manner of the notices for the small group market at this time. Accordingly, until further guidance is issued, small group market issuers may use the draft Federal standard small group notices released in the CMS Bulletin on June 26, 2014, or any forms of the notice otherwise permitted by applicable law and regulation. CMS expects small group market issuers not using the form and manner of the draft Federal standard notices released in June 2014 to include relevant content from the September 2, 2014 Bulletin, including information about premiums for the plan in which the plan sponsor will be renewed in the next plan year, information about signi?cant changes to coverage, information about other health coverage options and contact information for the plan sponsor to call with questions. Please refer to the CMS Bulletin published September 2, 2014 titled ?Form and Manner of Notices When Discontinuing or Renewing a Product in the Group or Individual Market," available at and the CMS Bulletin published June 26, 2014 titled ?Draft Standard Notices When Discontinuing or Renewing a Product in the Small Group or Individual Market,? available at (REGTAP FAQ Database - FAQ #13536 10/07/15) Q: What action should a Federally-facilitated Small Business Health Options Program (FF-SHOP) issuer take if the issuer finds that the Issuer Assigned IDs on the reconciliation ?le do not match the FF-SHOP, for example: ?Issuer Assigned Member and ?Issuer Assigned Policy A: The issuer is the source of truth for the Issuer Assigned IDs. In order to resolve this type of discrepancy, the issuer must submit a new effectuation file to FF-SHOP with the updated information. Effectuation ?les can be sent at any time to update the Issuer Assigned IDs. Please do not add these discrepancies to the Dispute Resolution Form. (REGTAP FAQ Database - FAQ #14243 12/11/15) Employer Notice Proqram Q. What is the employer notice program? Updated 1-31-17 The Affordable Care Act and implementing regulations require each Health Insurance Marketplace to notify any employer whose employee was determined eligible for advance premium tax credits (APTC) and cost sharing reductions (CSRs) because the employee attested that he or she was neither enrolled in employer sponsored coverage nor eligible for employer coverage that is affordable and meets the minimum value standard. 1025 2017-?01125 Starting in 2016, the FFM will notify certain employers whose employees enrolled in Marketplace coverage with APTC. The FFM will send notices to employers if the employee received APTC for at least one month in 2016 and if the FFM has an address for the employer. (CMS FA Qs Regarding the FFM Employer Notice Program 09/18/15) Q. How is the FFM implementing the employer notice program in 2015? The FFM is phasing-in the employer notice program to improve operational ef?ciency and minimize confusion for employers and employees. In 2015, the FFM has been focusing on educating the public about the employer notice and appeals requirements, as well as conducting outreach to stakeholders to ensure effective implementation of the program. The FFM will begin sending notices to certain employers in 2016, and will expand to more employers in later years. As part of its efforts at public education in 2015, the FFM has used assister channels and consumer outreach to explain to consumers the importance of attesting correctly to eligibility for or enrollment in an employer sponsored plan. We have emphasized the bene?t of using the employer coverage tool and continue to examine ways to make it a more useful tool for consumers. Additionally, CMS representatives have met with various employer groups and large- and small- business stakeholders to discuss their concerns related to the employer notice and appeals process. These meetings have helped shape the program we will implement in 2016. (CMS FAQs Regarding the FFM Employer Notice Program 09/18/15) Q. Will employers be liable for the employer shared responsibility payment for 2015 if a full-time employee receives a premium tax credit for coverage received through a Marketplace in that year? Yes. The IRS will independently determine any liability for the employer shared responsibility payment without regard to whether the Marketplace issued a notice or the employer engaged in any appeals process. More information on the IRS process can be found at (CMS FAQs Regarding the FFM Employer Notice Program 09/18/15) Q. Which employers will be notified through the employer notice program in 2016? In 2016, the FFM will send notices to employers whose employees received APTC in 2016 and whose employees provided the Marketplace with a complete employer address. The notice will identify the specific employee and include a statement that the employee is enrolled in Marketplace coverage with APTC. The notices will not contain the employee?s personal health information or federal tax information. For 2016, the FFM will not notify employers when an employee who was bene?ting from APTC or CSRs terminates Marketplace coverage. (See (CMS FAQs Regarding the FFM Employer Notice Program 09/18/15) Q. How does this affect SBMs have the same flexibility to phase in their employer notices process in an effort to 1026 Updated 1-31-17 2017-?01126 enhance operational efficiency and improve stakeholder engagement. SBMs will continue to have the option to refer employer appeals to the HHS appeals entity. (CMS FAQs Regarding the FFM Employer Notice Program 09/18/15) Q. When can employers expect to receive notices? The FFM will send notices in batches. We expect to send the first batch in spring of 2016, following the close of Open Enrollment for the 2016 coverage year. This will likely be the largest batch of notices as it will include employers whose employees enrolled in Marketplace coverage with APTC during Open Enrollment which ends on January 31, 2016. The FFM will send additional batches of notices throughout 2016. (CMS FAQs Regarding the FFM Employer Notice Program 09/18/15) Q. Can employers receive notices by email or to a designated address? For 2016, the FFM will send notices to the mailing address of the employer provided by the employee on his or her application for Marketplace coverage. As the FFM continues implementation of the employer notice program, it will consider alternative ways of contacting employers. (CMS FA 03 Regarding the FFM Employer Notice Program 09/18/15) Q. What happens if the employer wants to appeal an employer notice from the An employer may appeal an employer notice and assert that it provides its employee access to affordable, minimum value employer sponsored coverage or that its employee is enrolled in employer coverage, and therefore that the employee is ineligible for APTC. If the employer is successful, the FFM will send a notice to the employee encouraging the employee to update his or her Marketplace application to re?ect that he or she has access to or is enrolled in other coverage. The notice will also explain that failure to update the application may result in a tax liability. (CMS FAQs Regarding the FFM Employer Notice Program 09/18/15) Q. How does an employer submit an appeal of an employer notice to the A. An employer has 90 days from the date of the notice it receives from the FFM to request an appeal. An employer appeal request form will be available on An employer must mail an appeal request to: Health Insurance Marketplace 465 Industrial Blvd. London, KY 40750-0061 They may also fax their appeal request to a secure fax line: 1-877-369-0129. (CMS FAQs Regarding the FFM Employer Notice Program 09/18/15) Q. When will CMS implement the process for all employers? We intend to evaluate the employer notice program phase-in for 2016, and determine the best means of expanding and improving that process in subsequent years. We will keep all relevant stakeholders aware of our plans and progress as it develops. (CMS 1027 Updated 1-31-17 2017-?01127 FAQs Regarding the FFM Employer Notice Program 09/18/15) SHOP Logos Q: Can issuers submit different Federally-facilitated Small Business Health Options Program (FF-SHOP) logos for different rating areas of the state? A: FF- SHOP issuers may submit one logo per Issuer ID. (REGTAP FAQ Database - FAQ #2566 07/03/14) Q: What is the deadline for the submission of Federally-facilitated Small Business Health Options Program (FF-SHOP) logos? A: The deadline for submitting logos to the FF-SHOP is July 15, 2014. (REGTAP FAQ Database - FAQ #2567 07/03/14) Q: Will issuers receive confirmation from the Federally-facilitated Small Business Options Program (FF-SHOP) that the portal will display the issuer's logo? A: Yes, issuers will receive a con?rmation that the issuer's FF-SHOP logo submissions meet Centers for Medicare Medicaid Services (CMS) requirements. (REGTAP FAQ Database - FAQ #2568 07/03/14) Q: What does the default Federally-facilitated Small Business Health Options Program (FF-SHOP) logo look like? A: The Centers for Medicare Medicaid Services (CMS) are currently con?rming the details of the default logos, but logos for both medical and dental plans will likely be plain, grayscale logos. (REGTAP FAQ Database - FAQ #2569 07/03/14) Q: What color will the background on the Federally-facilitated Small Business Health Options Program (FF-SHOP) logo page be? A: The background page will be white. (REGTAP FAQ Database - FAQ #2570 07/03/14) Q: Is there a limit to the numbers of characters in the Federally-facilitated Small Business Health Options Program (FF-SHOP) logo image filename? A: No, there is no character limit. (REGTAP FAQ Database - FAQ #2575 07/03/14) Q: Will both the Federally-facilitated Small Business Health Options Program (FF-SHOP) and the Individual Marketplace portals display issuer logos in 2015? A: Issuers who submit acceptable logos to the FF-SHOP before the July 15 deadline may have logos displayed on the online FF-SHOP portal for 2015. The Individual Marketplace portal for 2015 will not display issuer logos. (REGTAP FAQ Database - FAQ #2601 07/03/14) 1028 Updated 1-31-17 2017-?01128 Q: Do Issuers have to submit a logo for the Federally-facilitated Small Business Health Options Program (FF-SHOP) even if the issuer is already participating on the Federally- facilitated Marketplace (FFM) Individual Marketplace? A: The Federally-facilitated Marketplace (FFM) Individual Marketplace does not support logos for the 2015 Plan Year. FF-SHOP issuers may, but are not required to, submit a logo for the 2015 Plan Year. A default logo will be displayed for all issuers who do not submit a logo prior to the August 14 submission deadline. (REGTAP FAQ Database - FAQ #3403 08/01/14) Q: Where can issuers find instructions for submitting a logo for use in the Federally- facilitated Small Business Health Options Program A: The instructions for submitting a logo for use in the FF-SHOP can be found on REGTAP at Slides 061714 5CR 061914.pdf (REGTAP FAQ Database - FAQ #3405 08/01/14) Q: Will the Centers for Medicare Medicaid Services (CMS) contact issuers if there is a problem with an issuer's logo submission? A: Yes, CMS will contact issuers if there is a problem with the issuer's logo submission. (REGTAP FAQ Database - FAQ #3406 08/01/14) Q: If an issuer is not making changes to its previous year's logo, does the issuer have to re-submit a logo for the 2016 plan year? A: The Federally-facilitated Small Business Health Options Program (FF-SHOP) does not require issuers to resubmit a logo if the issuer makes no changes; however, the issuer must notify the FF-SHOP to use the previously submitted logo. (REGTAP FAQ Database - FAQ #10778 05/27/15) SHOP Dental Coverage Q: For plan years beginning on and after January 1, 2015, will all members of a family be required to enroll in only one dental plan, even if multiple SADPs are offered by an employer? A: Dependents in the FF-SHOP will be required to enroll in the same QHP and SADP of the employee. (REGTAP FAQ Database - #830 02/21/14) Q: In 2014 if a group purchases a FF-SHOP QHP directly with an issuer and that product doesn't contain pediatric dental, must the issuer of the medical plan obtain reasonable assurance that pediatric dental was purchased somewhere? A: For FF-SHOP direct enrollments in 2014, issuers do not have to obtain reasonable assurance that pediatric dental was purchased somewhere. This requirement applies only to off SHOP QHPs. (REGTAP FAQ Database - #835 02/21/14) 1029 Updated 1-31-17 2017-?01129 Q: For standalone dental plans, how will non-guaranteed rating work for FF-SHOPs and how does it integrate with the billing process since SHOP will be doing all the billing for plan years beginning in 2015? A: CMS current thinking is that employers and employees selecting standalone dental plans with non-guaranteed rates would be directed to an issuer's website to enroll in coverage. In this instance, the carrier would also be responsible for billing. (REGTAP FAQ Database - FAQ #919 03/05/14) Q: To display guaranteed rates for standalone dental plans on the FF-SHOP, would the carrier have to use the medical age rating factors? A: Because dental benefits are excepted bene?ts, in order for an employer to receive a guaranteed rate for standalone bene?ts and be allowed to enroll through the FF-SHOP portal, the issuer must use the medical age rating factors. (REGTAP FAQ Database - FAQ #994 03/10/14) Q: Can you confirm that the excel template for enrollment does not apply to FF-SHOP stand-alone dental carriers? A: If an issuer's organization is connected to the Federal Marketplace footprint for ?le exchange purposes, then the issuer must make the electronic points and obtain the Trading Partner IDs required to complete these functions/connections. Both medical and dental carriers are required to submit enrollment/reconciliation ?les to the FF- SHOP for the 2014 plan year. (REGTAP FAQ Database - FAQ #1433 04/14/14) Q: If an employer enrolling in FF-SHOP coverage does not elect a plan with dental coverage, will you require certification documentation that other pediatric dental coverage is being provided or offered to the employees and dependents? A: No, this is not a requirement in FF-SHOPs. (REGTAP FAQ Database - FAQ #1439 04/14/14) Q: Must all FF-SHOP QHPs contain pediatric dental benefits? A: FF-SHOP Quali?ed Health Plans (QHPs) do not have to contain pediatric dental benefits as long as an SADP that covers pediatric dental Essential Health Bene?ts (EHB) is available for employers to offer to their employees. (REGTAP FAQ Database - #1992 05/30/14) 024: If the QHP selected does not include pediatric dental, would a qualified dental plan be selected as well? A24. Employers will be able to select and offer employees and their dependents a stand- alone dental plan through the fF- SHOP. Webinar Series? SHOP FAQ #1 06/20/13, REGTAP FAQ Database - FAQ #128 and #12861 06/20/13, updated 08/27/14) 1030 Updated 1-31-17 2017--01130 Q: Will the Federally-facilitated Small Business Health Options Program (FF-SHOP) plan selection functionality identify which Qualified Health Plans (QHPs) include embedded dental coverage? A: The FF-SHOP plans will clearly display (to both employers and employees) if a plan includes embedded dental coverage. (REGTAP FAQ Database - FAQ #2588 07/03/14) Q: Are child-only dental plans the only dental plans allowed in the Federally-facilitated Small Business Health Options Programs A: Child-only plans are not allowed in FF-SHOPs for 2015. Issuers should plan to submit plans that cover both adults and children. Operationally, a dependent may not enroll in FF-SHOPs without an employee also enrolling. Additionally, if an employee enrolls a dependent in a SHOP Quali?ed Health Plan (QHP), and also elects to enroll in stand- alone dental coverage, both the employee and dependent will be enrolled in the same health and dental plans. (REGTAP FAQ Database - FAQ #2591 07/03/14) Q: If a State only allows high Actuarial Value (AV) dental plans, will only those plans display in Plan Compare for Federally-facilitated Small Business Health Options Program A: Yes, if a State only allows high AV dental plans, only high AV dental plans will display (because only high AV dental plans will be approved by the State/CMS as part of the FF- SHOP Quali?ed Health Plan (QHP) certi?cation process. (REGTAP FAQ Database - FAQ #2592 07/03/14) Q: Are Stand-alone Dental Plan (SADP) issuers in the Federally-facilitated Small Business Health Options Program (FF-SHOP) required to estimate rates for SADPs, or can issuers submit exact rates for display in the FF-SHOP portal? A: The FF-SHOP will only display and facilitate enrollment in Qualified Health Plans (QHPs) and SADPs with guaranteed rates. The FF-SHOP is not supporting plans with estimated rates in 2015. (REGTAP FAQ Database - FAQ #2599 07/03/14) Q: Will the Federally-facilitated Small Business Health Options Program (FF-SHOP) Marketplace display Stand-alone Dental Plans (SADPs) in 2015? A: Yes, the FF-SHOP Marketplace will display approved SADPs with guaranteed rates in 2015. (REGTAP FAQ Database - FAQ #2602 07/03/14) Q: On pediatric dental policies, will the policy subscriber be the youngest child, since no adults will be enrolled; and will the employee be the Responsible Party? A: Child-only plans are not allowed in FF-SHOPs for 2015. In addition, when employees enroll in dental coverage for 2015, the entire family will enroll in the same dental plan. (REGTAP FAQ Database - FAQ #2873 07/16/14 1031 Updated 1-31-17 2017-?01 131 Q: How does the Federally-facilitated Small Business Health Options Program (FF-SHOP) aging off policy apply to Stand-alone Dental Plans Are the ages of 19 and 26 treated any differently? A: The FF-SHOP will terminate dependents based on rules submitted by medical plans on the business rules template. Therefore, when a dependent ages off a medical plan, the dependent will also age off any dental plan the dependent is enrolled in. (REGTAP FAQ Database - FAQ #3001 07/25/14) Q: If an employer in the Federally-facilitated Small Business Health Options Program (FF- SHOP) is offering medical and dental products, can an employee decline the medical plan but enroll in a dental plan? A: No, the employee must select a medical plan in order to enroll in a dental plan. (REGTAP FAQ Database - FAQ #3401 08/01/14) Q: Will stand-alone dental plan (SADP) issuers who are participating only in the Small Business Health Options Program (SHOP) receive 820 payment transactions with the SHOPUF Exchange Payment type code? A: The SHOP HIX 820 transaction will not include SHOP user fee information. Instead, the Financial Management/Individual Marketplace 820 Payment Reports will include SHOP user fee information with the SHOPUF Payment Type Code. Issuers who are participating in only the SHOP will receive invoices for the amounts that the issuer owes to the Marketplace. For more information about SHOP user fees, please refer to the June 18, 2014 webinar posted on REGTAP at: Slides 061014 50R FAQ Database - FAQ #5329 10/02/14) Q: Are stand-alone dental plan issuers required to send termination and cancellation notices to employers and employees? A: Noti?cation requirements in the FF-SHOP are the same for health and dental issuers. (REGTAP FAQ Database - FAQ #5338 10/02/14) Q: Has the Centers for Medicare and Medicaid Services (CMS) created a marketing effort to inform existing Federally-facilitated Small Business Health Options Program (FF- SHOP) enrollees or potential new enrollees in 2016 that enrollees can elect dental coverage without enrolling in medical coverage? A: CMS has resources available on HealthCare. gov and Marketplace. cms. gov to provide information about the ability to enroll in dental coverage without also enrolling in medical coverage. All?ef?eur fer?2946? (REGTAP FAQ Database- FAQ #13132 09/22/15; updated 06/21/16) Q: Can employers offer dental coverage without having to offer health coverage through the SHOP Marketplace? A: New for plan year 2016, small employers may offer their employees dental coverage without also having to offer health coverage through the SHOP Marketplace. Unless the 1032 Updated 1-31-17 2017-?01132 employer decides to offer both health and dental coverage through the SHOP Marketplace, its employees can choose to enroll in health-only coverage, dental-only coverage, or both health and dental coverage. For the dependents of the employees electing SHOP Marketplace coverage, they may also choose which coverage they would like to enroll in. Dependents may choose to enroll in health-only, dental-only, or both, but they must always enroll in the same plan or plans chosen by the employee. (REGTAP FAQ Database - FAQ #15724 05/02/16) Q: How does vertical choice work for dental plans? A: Vertical choice, also referred to as employee choice by some insurance companies, works the same way for health and dental plans. Employers offering their employees a choice of health or dental plans by insurance company will pick one health and/or one dental insurance company. Then, their employees may choose any plan offered by the employer-selected insurance company. (REGTAP FAQ Database - FAQ #16158 05/27/16) Q: Is an employer able to offer only one health plan, but two dental plans for employees to choose from? A: In the SHOP Marketplace, employees have the option to offer their employees and, if applicable, their dependents a single health or dental plan, or a choice of health or dental plans. Employers may also choose to offer their employees a single health plan and multiple dental plans or a choice of health plans and a single dental plan. Employers are not required to offer both health and dental coverage to participate in the SHOP Marketplace. (REG TAP FAQ Database - FAQ #16159 05/27/16) PA CE Act on State Small Group Expansions Q1: What constitutes a State election to extend the definition of small employer? A1: Any State action that extends the de?nition of a small employer to include employers with up to 100 employees that is legally binding on health insurance issuers in the State will constitute an election to extend the small employer de?nition for purposes of the PACE Act. Such an election may be made through any State action within the authority of the applicable State regulatory agency that makes the de?nition legally binding on health insurance issuers in the State. If a State makes this election, the de?nition of small employer must be applied uniformly to all health insurance issuers in the State, including those in the Small Business Health Options Program (SHOP). States that elect to extend the small employer de?nition to up to 100 employees for coverage effective January 1, 2016, are requested to notify CMS of their election by October 30, 2015 at marketreform@cms.hhs.qov7 States that elect to extend the small employer definition with another coverage effective date are requested to notify CMS as soon as soon as practicable. (FAQs on the Impact of PACE Act on State Small Group Expansion 10/19/15) We to the federal definition of small employer promulgated 7 This information collection request is anticipated to affect fewer than 10 entities in a 12-month period. Accordingly, under 5 CFR it is not subject to the Paperwork Reduction Act of 1995. 1033 Updated 1-31-17 2017--01133 under the PACE Act, may States allow carriers to modify their rate filings for small group coverage for 2016? A2: States with a State-based SHOP that do not rely on the Federal platform have the discretion, consistent with state law and regulations, to allow resubmission of small group coverage rate ?lings, including changes to rates for the ?rst quarter of 2016. Due to technical constraints, issuers offering small group coverage in States with a Federally- facilitated SHOP (FF-SHOP), and in State-based SHOPS using the Federal platform, cannot make changes to rate ?lings for the first quarter of 2016. Consistent with 45 CFR issuers offering small group coverage in any State may adjust rates for the second quarter, for rates effective April 1, 2016, to the extent othenlvise allowed under applicable State and Federal law. (FAQs on the Impact of PACE Act on State Small Group Expansion 10/19/15) Q3. Does the enactment of the PACE Act affect the counting methodologies to be used by the SHOPs in accordance with Internal Revenue Code section 4980H(c)(2), and for purposes of the medical loss ratio (MLR), risk adjustment, and risk corridors programs? A3: No. The requirements regarding the employee counting methodologies for the FF- SHOPs and State-based SHOPS, and for the MLR, risk adjustment, and risk corridors programs remain the same, and are not changed by the PACE Act. (FAQs on the Impact of PACE Act on State Small Group Expansion 10/19/15) Q4: How does the PACE Act impact employer size for MLR, risk corridors, and risk adjustment reporting purposes? A4: The definition of a small employer for purposes of MLR, risk corridors, and risk adjustment will follow the State definition. Since States that elect to increase the upper limit of small employer must do so uniformly for all ACA programs, and given the greater distinction between the small and large group markets as a result of the 2014 market reforms, May 13, 2011 Guidance, in which we permitted States to increase the upper limit of a small employer for MLR reporting purposes only, is no longer applicable, beginning with the 2017 MLR reporting year. Nonetheless, it, for example, during a transition in the state definition of small employer from 100 employees to 50 employees, a small group policy is issued to a large employer, the experience of that large group employer should be reported with the small group market for that State for the purposes of those programs for the applicable reporting year. In other words, reporting for those programs during a transition in the state de?nition of small employer in the applicable reporting year should align with the policy issued to the employer, regardless of actual employer size. (FAQs on the Impact of PACE Act on State Small Group Expansion 10/19/15; updated 12/17/15) Q5. If a State with a SHOP that uses HealthCare.gov elects to extend the de?nition of small employer to 1-100 employees, when will CMS make the applicable changes to the employer eligibility screens on HealthCare.gov? Updated 1-31-17 A5: On November 1, 2015, the beginning of Open Enrollment for 2016 coverage, all FF- SHOP eligibility screens on HealthCare.gov will ask employers if they have 1-50 employees for purposes of SHOP eligibility. Because the PACE Act was signed into law so close to the start of Open Enrollment, CMS will be unable to change these eligibility screens for specific States until sometime after November 1. CMS intends to make the 1034 2017--01 134 applicable eligibility screen changes as quickly as possible and work with the SHOP Call Center and stakeholder groups to communicate options for employers in these States until the changes have been made to the online system. Moving forward, CMS will be able to make changes to the online system as soon as one month after being noti?ed by a State of its election to extend the de?nition of small employer. (FAQs on the Impact of PACE Act on State Small Group Expansion 10/19/15) HEALTH INSURANCE MARKET RULES General 10. How are Exchanges going to increase insurance market competition based on quality and cost? Some markets may be starting off from a position of having few local issuers. A: The introduction of Exchanges and the insurance market rules in 2014 will help promote competition based on quality and cost since consumers will have an unprecedented ability to compare similar products from different issuers and will be assured the right to purchase these products, regardless of their health condition. Further, consumers in many states will have new options such as the ability to purchase coverage from the Consumer Operated and Oriented Plans and Multi-State Plans created under the Affordable Care Act. Additionally, Exchanges can leverage market forces to drive further transformation in health care delivery. We anticipate that the number of individuals who will be eligible for advance payments of premium tax credits and cost-sharing reductions which are only available in connection with quali?ed health plan coverage purchased through an Exchange will attract issuers to Exchanges where the certi?cation process will encourage and reward high quality affordable insurance offerings. In addition, HHS is developing a Star Ratings system for quali?ed health plans purchased in an Exchange pursuant to section 131 of the Affordable Care Act. (FAQs on Exchanges, Market Reforms, and Medicaid (12/10/12)) 13. The Office of Personnel Management is required to certify Multi-State Plans that must be included in every Exchange. How will you ensure that Multi-State Plans compete on a level playing field and are compliant with state laws? Updated 1-31-17 A: The US. Office of Personnel Management released a proposed rule implementing the Multi-State Plan Program on November 30, 2012. To ensure that the Multi-State Plans are competing on a level playing ?eld with other plans in the marketplace, the proposed regulation largely defers to state insurance law and the standards promulgated by HHS and states related to quali?ed health plans. Under the proposal, Multi-State Plans will be evaluated based largely on the same criteria as other qualified health plans operating in Exchanges. The few areas in which the Office of Personnel Management proposes different regulatory standards from those applicable to qualified health plans are areas where the Office of Personnel Management has extensive experience through its administration of the Federal Employees Health Benefits Program. However, in order to ensure that these few differences will not create any unfair advantages, the Of?ce of Personnel Management seeks comment from states and other stakeholders on these proposals. The regulation appeared in the Federal Register on December 5, 2012, and 1035 2017-?01135 the comment period runs through January 4, 2013. (FAQs on Exchanges, Market Reforms, and Medicaid {12/10/12)} 11. When will we have final rules on essential health bene?ts, actuarial value, and rating? A: The proposed rules on essential health benefits and actuarial value and the market reforms ,including rating, were published on November 20, 2012. Public comments are due by December 26, 2012. On November 20, 2012, we also issued a state Medicaid directors letter on how we will propose essential health benefits be implemented in Medicaid. HHS will analyze the comments, adjust any policies accordingly, and publish final rules early next year. (FAQs on Exchanges, Market Reforms, and Medicaid (12/10/12)) Q: Do guaranteed availability standards apply to Catastrophic Plans? A: Yes, however, the only individuals eligible to enroll in catastrophic plans are individuals who have not attained the age of 30 before the beginning of the plan year and individuals who are certified as exempt from the requirement to maintain minimum essential coverage. See Affordable Care Act section 1302(e) and 45 CFR 156.155. (REGTAP FAQ Database - FAQ #3533 08/07/14) Q1: What standards for Medicaid managed care organizations are similar to Marketplace requirements for issuers of quali?ed health plans? Updated 1-31-17 The Affordable Care Act (ACA) and applicable regulations establish that issuers must meet a number of standards in order to be certi?ed as quali?ed health plans (QHPs). In several areas, federal law establishes comparable standards for entities that contract with states to provide coverage to bene?ciaries enrolled in Medicaid. In order to assist Medicaid managed care organizations (Medicaid MCOs) that may be interested in offering Marketplace QHPs, we are offering a general overview of selected QHP certification standards that are comparable to federal Medicaid managed care standards. Below are summaries of select QHP certi?cation standards with comparisons to Medicaid managed care standards. Other requirements may be applicable to QHPs or Medicaid MCOs under federal or State law, a State Medicaid Plan, or a State contract for Medicaid managed care. In addition, in limited circumstances, CMS may consider providing States ?exibility to allow greater continuity of coverage for certain populations that may transition between QHPs and Medicaid. Licensure - Marketplace standard: QHP issuers must be licensed and in good standing to offer health insurance coverage in each state in which the issuer offers health insurance coverage. (45 CFR - Comparable Medicaid managed care standard: Many Medicaid MCOs may already be licensed by a state, or meet the solvency standard required for licensure, due to the requirements at 42 CFR 438.116. Accreditation 1036 2017-?01136 Updated 1-31-17 Marketplace standard: QHP issuers must be accredited on the basis of local performance in a timeframe established by the Marketplace. For the Federally- facilitated Marketplaces (FFMs), an issuer?s QHP will be considered to meet the accreditation standard for the ?rst three years of participation in the Marketplace if the QHP uses the same policies and procedures as the issuer?s accredited Medicaid product. (45 CFR 155.1045 and 156.275) Comparable Medicaid managed care standard: While there is no federal standard that requires a Medicaid MCO to be accredited, many states have established such a standard. Thirty-three states and the District of Columbia require some form of accreditation or use accreditation to deem compliance with certain Medicaid standards.1 Medicaid MCOs must inform the state of their accreditation status, which the state must share on its website. (42 CFR 438.332) Benefits Marketplace standard: QHPs provide ten categories of essential health bene?ts (EHB) that are substantially equal to the state's EHB-benchmark plan. (45 CFR 156.20, 156.115, Comparable Medicaid managed care standard: States may elect to provide an Alternative Bene?t Plan (ABP) for some groups of Medicaid-eligible individuals, and individuals eligible for Medicaid as part of the ACA expansion eligibility group must receive bene?ts through an ABP. An ABP is de?ned by reference to a benchmark bene?t plan and must also include EHB and the full Early and Periodic Screening, Diagnosis, and Treatment bene?t for individuals under age 21. A state can determine EHB for an ABP using a different EHB-benchmark plan than the state?s individual and small group market EHB-benchmark plan, but the ABP must cover the same ten categories of EHB. The common EHB requirement provides a significant amount of alignment between QHP bene?t requirements and the benefits that a Medicaid MCO may already offer to beneficiaries, if it provides benefits through an ABP. (42 CFR 440.300, 440.330, 440.347) Network Adequacy and Essential Community Providers Marketplace standard: QHP issuers that use a provider network must ensure that the network is suf?cient in number and types of providers to assure that all services are accessible without unreasonable delay. In the FFMs, there are time and distance standards for certain provider types. Issuers that use provider networks must also ensure reasonable and timely access to a broad range of essential community providers (ECPs). (45 CFR 156,230-156,235) Comparable Medicaid managed care standard: Medicaid MCOs must currently maintain networks that are adequate to meet the needs of their enrollees and report on the adequacy of those networks (42 CFR 438.206 and 438.207). For rating periods beginning on or after July 1, 2018, Medicaid MCOs must maintain networks that meet state-defined time and distance standards for several provider types (42 CFR 438.68). Compliance with a state?s time and distance standards for Medicaid managed care may allow an issuer to satisfy QHP network adequacy standards for the geographic area it serves. While no federal standard exists for ECPs in Medicaid networks, networks designed to serve low-income Medicaid managed care bene?ciaries may already satisfy QHP ECP standards. Issuers of QHPs and MCOs should review state Medicaid standards and Marketplace QHP standards to determine if this is the case in each area. 1037 2017--01 137 Quality - Marketplace standard: QHP issuers must submit data for a quality rating system (QRS) after participating in the Marketplace for at least one year. QHPs must contract with an HHS-approved enrollee satisfaction survey vendor to conduct and report the results of an enrollee satisfaction survey. QHP issuers participating in an Exchange for two or more consecutive years must implement and report on quality improvement strategies. (45 CFR 156.1120, 156.1125, 156.1130) - Comparable Medicaid managed care standard: Medicaid managed care entities will be required to submit data for the state?s Medicaid QRS. For the Medicaid QRS, states must either adopt the CMS-developed system that aligns with the QHP QRS or operate a CMS-approved alternative. (42 CFR 438.334) 0 Issuers may be required to report similar data elements for both Medicaid managed care and QHPs. States are encouraged to align their Medicaid managed care quality improvement efforts with those underway for QHPs, while recognizing that differences in the types of populations served and benefits provided may require different approaches. (CMS FAQs on Health Insurance Marketplace Standards (01/03/17) 02: What resources are available for issuers, including Medicaid managed care organizations, seeking to offer QHPs in Health Insurance Marketplaces? To encourage greater competition in Marketplaces and to provide greater choice for consumers, particularly those who may transition between insurance affordability programs, CMS seeks to support Medicaid MCOs interested in participating in the Federally-facilitated Marketplaces (FFMs), including the Small Business Health Exchange Marketplaces, by offering certified QHPs. CMS Account Managers can provide organizations interested in offering QHPs in FFMs with information about QHP certification and answer questions about general FFM operations. Account Managers can also provide technical assistance and resources to Medicaid MCOs so they become more familiar with the FFMs. To learn more and connect with an Account Manager, interested entities, including Medicaid MCOs, are encouraged to contact Judith Associate Regional Administrator, at . (CMS FAQs on Health Insurance Marketplace Standards (01/03/17) Rating Q37: Are all non-grandfathered business renewing in 2014 new, and therefore would it not need to be submitted in A37: The FFE application requirements include submitting the entire risk pool using the URR module and templates, if even one plan in the risk pool is included in the QHP application. (QHP Webinar Series FAQ #7 04/24/13) Q38: If an issuer is modifying existing non-ACA compliant plans to be ACA compliant for 2014, how is the rate increase determined? Updated 1-31-17 A38: Rate increases take into account all reasons for the rate change, including State mandated benefits or compliance with EHB standards. (QHP Webinar Series FAQ #7 04/24/13) 1038 2017-?01138 Q44: Will the entire QHP application be rejected if rates are found to be unreasonable? A44: If unreasonable rate determinations are made, the Exchanges are required to take that information into account within their determination, but an automatic rejection is not required by rule or law. See Chapter 1, Section 3 of the Issuer Letter for more information on review of rates. If an issuer?s rates are declared "unreasonable" the State or HHS will generally provide the issuer a window to make corrections. (QHP Webinar Series FAQ #7 04/24/13) Q46: Is the index rate meant to be representative of specific plan richness, 60% actuarial value Similar to AV, is the index rate meant to be the 21 year old rate in an area that has a factor of 1.0 so that all other rating factors can be applied to it? A46: No. The index rate is an average rate based on the total combined claims experience derived from providing EHB to enrollees in all non-grandfathered health plans in a market. The index rate is utilized to set the base rate for all of an issuer?s products in a market. The index rate may be adjusted at the plan level to re?ect a plan's actuarial value and cost-sharing design; provider network; benefits in addition to administrative costs; and with respect to catastrophic plans, the speci?c eligibility categories of the plan. The premium rate for a given individual may further vary based on the premium rating factors in section 2701 of the PHS Act. (QHP Webinar Series FAQ #7 04/24/13) Q47: When deriving an index rate, what normalization factors are permitted? A47: The market reform final rule, published on February 27, 2013 at 78 FR 13406, does not allow for normalization, since the index rate must use the issuers? EHB claims experience in the market. The only plan-specific adjustments to the market-wide index rate are those described above. (QHP Webinar Series FAQ #7 04/24/13) Q48: The ?nal market reform rule says that the index rate cannot be adjusted for induced demand. Is this intended at the plan level, market level, or both? If not allowed at the plan level, would that mean that induced demand could be socialized across all plans based on an assumed distribution? A48: As stated in the market reform ?nal rule, 78 FR 13406, we exclude an induced demand factor from the plan-speci?c rate adjustments because of the actuarial dif?culty of measuring whether differences in total plan expenditures are due to risk selection or induced demand. However, for the purpose of developing an adjustment to the market- wide index rate for individual plans based on the plan?s actuarial value, issuers would use pooled allowable claims data as a basis for calculating the plan-speci?c actuarial value. (QHP Webinar Series FAQ #7 04/24/13) Updated 1-31-17 1039 2017-?01139 . . A 015/0343} This FAQ was cut from the 10/31/13 update to FAQ 061: Does validation compare the age 65 rate to the age 0-20 rate, or compare the age 65 rate to the age 21 rate? Is this because the age 65 rate cannot be more than 3x the age 21 rate? A61: The 3 to 1 age ratio factor requires that the 64+ age band be no more than 3 times the rate of a 21 year old who would be rated at 1.0. Validation is being done against the age 21 category. This validation is being done across non-smoking rates, and is also being applied between rates for smokers. Early versions of the template may have been built with incorrect references, but these have been corrected. The current rate table template version is 1.6. (QHP Webinar Series FAQ #9 05/03/13) Q36: For rate review, how is a ?new? product defined? A36: A ?new? product is one which had no previous enrollment, does not represent a previous plan with enrollment which is being modified to comply with State or Federal mandates or as de?ned by the appropriate state regulator. (QHP Webinar Series FAQ #7 04/24/13; note this is repeated as #28 in QHP Webinar Series FAQ #10 05/09/13) 021: Where and when will information about tobacco use be collected from applicants? A21: Consumers will answer a question regarding tobacco use as part of the plan selection process. (QHP Webinar Series FAQ #12 06/28/13) 023: Does one set of rates apply for the entire calendar year, or can an issuer provide rates that change by month or quarter due to trend assumption changes? A23: In the individual market, one set of rates applies for the entire calendar year. A rate is good until the end of a calendar year, so someone enrolling in June would have that rate until December 31 of that year. In SHOP, once a group has effectuated coverage, the rate is locked in for 12 months. If an issuer submitted trend increases during the initial QHP application window, approved rates will be applied as scheduled. (QHP Webinar Series FAQ #12 06/28/13; REG TAP FAQ Database - FAQ #142 06/28/13) 024: Will issuers have an opportunity to adjust rates throughout the year? A24: For individuals, the rates are set on a yearly basis. We intend to provide further guidance on rate updates for the SHOP at a future time. In the Program Implementation NPRM under ?156.80, we propose that issuers in the small group market (including SHOP) may make rate changes no more frequently than quarterly, effective as early as July 1, 2014. These rates would apply to both new and renewing businesses during the course of the year. (QHP Webinar Series FAQ #12 06/28/13; REG TAP FAQ Database - FAQ #143 06/28/13) 033: For a family of 5, with 19-year-old parents, how would the three-child cap apply? A33: The three-child cap refers to child dependents. In the case of two 19-year-old parents with three children, the parents would be rated as the primary and secondary 1040 Updated 1-31-17 2017-?01140 subscriber, and all three children would be rated. (QHP Webinar Series FAQ #12 06/28/13) Q34: In the question "Is there a maximum age for a dependent?" on the Business Rules template, should this be interpreted as up to and including the age? A34: This field is inclusive, so it should be considered up to and including that age. (QHP Webinar Series FAQ #12 06/28/13) Q41: Since issuers can vary distribution costs and administrative expenses by product, can an issuer offer all products with different distribution costs to a subset of the single risk pool groups? This FAQ was revised and reissued on 6/11/14. The new answer is as follows: A: Division of risk pool groups is not permitted. All plans are guaranteed available and an issuer must not limit the availability of any of the plans that are approved for sale in a market in a state. (REGTAP FAQ Database - FAQ #2162 06/11/14) Q: Will a thirty year-old ward receive a thirty year old rate? A: Yes, a 30 year-old ward will be charged the same rate as other 30 year-olds in the same rating area with the same tobacco status. (REGTAP FAQ Database - 1 1/22/13) Q: Do Non-Grandfathered Individual health plans, scheduled to be terminated in 2014, require placement on the Edge Server? A: Edge servers are used to collect data to support the HHS-operated risk adjustment and/or reinsurance programs which go into effect on January 1, 2014. Therefore, to be considered for these programs, enrollment and claim data submitted must only include non-grandfathered small group and individual market plans, both inside and outside the Marketplace, for plans effective January 1, 2014 or later. Grandfathered plans and large group plans would not be submitted to the edge server. (REGTAP FAQ Database - FAQ #513 12/02/13) Q9: Can an issuer adjust premiums to an individual or small group product when it becomes secondary to Medicare? Updated 1-31-17 No. In order to assure consumers have a consistent rate throughout the year, the rules provide that once an individual or employer enrolls in a plan at a set premium rate, the issuer generally may not change that rate during the plan or policy year, and must wait to do so until the plan or policy is renewed. Moreover, premiums may only be set based on index rates and adjustments set forth in PHS Act section 2701 and 45 CFR 156.80, which do not include any adjustment to account for an enrollee?s additional coverage. The issuer may, however, as consistent with current market practice, offer to replace the 1041 2017--01 141 individual or small group product with a Medicare supplemental Medigap plan that has a lower premium, which would be an excepted benefit and, therefore, not subject to the requirements of title XXVII of the PHS Act, provided that it is clear that such offer may be effected only at the option of the enrollee (such that it does not amount to a non-renewal or discontinuance of coverage under the guaranteed renewability requirements) and otherwise complies with applicable federal and state laws and regulations, including the Medicare supplemental health insurance policies requirements set forth in section 1882 of the Social Security Act. (CMS FA Qs Health Insurance Market Reforms Not Dated) Q: Is there Marketplace guidance on premium rating for underage dependents using tobacco, or will Issuers need to follow State rules on this matter? A: Per 45 CFR ?147.102 adjusting rates based on tobacco use may only be applied with respect to individuals who may legally use tobacco under federal and state law. (REGTAP FAQ Database - #897 02/27/14) Q: Can issuers rate beyond three dependents for Stand-alone Dental Plans (SADPs) on the Individual Marketplace? A: Yes, in the individual market, SADPs that meet the definition of excepted bene?ts are not subject to the market rating rules for QHPs. While the Business Rules Template imposes certain restrictions on the number of dependents that can be rated in the template, SADPs may adjust for rating factors not present in this template, increase the maximum number of children rated on a single contract, or remove this maximum altogether. Further, issuers can rate for each dependent on the policy as long as the issuer speci?es ?Estimated Rates? on the Plans and Bene?ts template. When the issuer receives the enrollment file, the issuer can generate the correct rates and communicate the rates to the consumer. (REG TAP FAQ Database - FAQ #2640 07/03/14) Q: How should issuers rate enrollees with birth date corrections? A: In most circumstances, when the Federally facilitated - Marketplace (FFM) receives a Change-in-Circumstance with a corrected DOB from the enrollee and it changes the rating/premium going fonrvard, the reconciliation process will update the DOB and the total premium amount retroactively to all policies/segments for that plan year. In most cases, the issuer will need to adjust their internal records to ensure they are correct, but they do not need to do anything to get it updated in the FFM. There are some cases that are not even-sided that cannot be updated using the reconciliation process and the issuer will need to file an enrollment dispute. Please refer to updated CMS Re-rating Policy clarified via a Monday Enrollment Policy Issuer Call on August 1, 2016 on Regtap here: UpdatedReratianFM 5CR O80816.pdf (REGTAP FAQ Database - FAQ #17839 10/18/16) 1042 Updated 1-31-17 2017-?01142 Geographic Rating Q3: If the family members do not all live in the same rating area, is the rate based off the subscriber's rating area? A3: Yes, the rating area and resulting premium for the enrollment group is determined by the subscriber's rating area, not the dependents on a policy. (Enrollment and Payment Processing Webinar Series 02/27/13; REGTAP FAQ Database - FAQ #319 02/27/13) Q55: Please clarify whether area rating can vary by network. A55: If an issuer offers two QHPs with the same benefit package and cost-sharing, but with two different networks (for example, a broad network vs. a narrow network), the issuer may make a plan-level adjustment to its market index rate to re?ect the expected cost differences resulting from network difference between those two QHPs. The state may place additional restrictions on rating ?exibility in the state, and all QHPs offered on the Exchange must comply with state law and be approved by the state. (QHP Webinar Series FAQ #5 04/18/13) 022: For the individual market, will the area rating be applied at the subscriber level? A22: The rating will be based on the subscriber address. (QHP Webinar Series FAQ #6 04/23/13) Q32: Because network design and structure is an allowable modifier to the Index Rate, can an issuer sell two plans with identical bene?t and cost-sharing designs where the only difference is the network type? A32: Yes, if there is a meaningful difference in the networks of the two plans, they can be identical in other ways and still be considered two different QHPs. Please see the 2014 Letter to Issuers for further information on meaningful difference in Chapter 1, Section 4. (QHP Webinar Series FAQ #7 04/24/13) 022: If a QHP is approved in a particular rating area to be sold on-Exchange, is that plan considered a QHP in all rating areas, even if it is not sold on the Exchange in those other rating areas? A22: If a proposed plan is approved for sale in a rating area, it can be considered a QHP for the rating area for which it is approved. (QHP Webinar Series FAQ #12 06/28/13) 028: How can an issuer offer a plan and rates for only a portion of a rating area? A28: Issuers should submit their service area using the Service Area template. The FFE does not require that an issuer's service area cover a complete rating area. However, issuers are also bound by State service area requirements, so issuers should carefully review their States? guidance on this topic to ensure that their proposed service areas comply with State requirements. In some states, issuers may be allowed to split service areas by submitting multiple applications. (QHP Webinar Series FAQ #12 06/28/13) 1043 Updated 1-31-17 2017-?01143 Q30: What correlation is there, if any, between the Rating Areas and the Service Areas created in the Service Area template? A30: The Service Area template de?nes the area (State-wide, a list of counties, or in rare cases partial counties) where a plan will be offered. In the FFE, a service area can cover one or more complete or partial rating areas. For each plan, issuers must submit rates for every rating area within its service area, and those rates will be displayed to the appropriate consumers within the plan?s service area on Plan Compare. Issuers should also refer to any additional State requirements on Service Area and ensure that the proposed Service Area is in compliance. (QHP Webinar Series FAQ #12 06/28/13) Q35: How can issuers ?nd the rating area IDs assigned for their State? A35: This information is available at gra.html. (QHP Webinar Series FAQ #12 06/28/13) Q58: Can a family plan cover family members who reside in different rating areas of the same State? A58: Yes, issuers can cover family members who live in different rating areas under the same plan. For the individual market family plan, all family members can be rated at the location of the subscriber, even if a family member is residing in a different rating area than the subscriber. (QHP Webinar Series FAQ #9 10/31/13) 059: In the individual market, if an enrollee permanently moves to a new geographic rating area mid-year, is he/she required to switch to a plan in the new rating area, or can he/she keep their other plan until the next renewal? A59: Whether or not an individual can remain on a plan depends on whether the individual still lives or resides within the service area of the plan upon moving to the new location. (QHP Webinar Series FAQ #9 10/31/13) 060: If the enrollee does re-enroll, per the previous question, are the rates based on age and tobacco use at the new enrollment date? A60: If the individual enrolls in a new plan, age and tobacco use would be determined at time of enrollment. (QHP Webinar Series FAQ #9 10/31/13) Q1: It seems like the rating area for a premium payment will be at the subscriber level only - does that mean rating by area is based on location of primary subscriber only and not based on location of dependents? A1: Yes, the rating area and resulting premium for the enrollment group is determined by the subscriber?s rating area, not the dependents on a policy. (Enrollment Transaction and Companion Guide Webinar 02/13/13) 1044 Updated 1-31-17 2017-?01144 Q3: Will small group market rating be based on employee or employer address? Will this approach apply only to plans offered through the FF-SHOP, or will it also apply to the small group market outside the Exchanges? We intend to propose in future rulemaking that the geographic rating factor and premiums will be based on the employer?s primary business location. This would apply both inside and outside of the SHOP. In the context of the FF-SHOP, we intend to propose that an employer generally may have only one SHOP account per state. This limitation would not apply to multi-state employers, however, which will still be able to establish either one SHOP account for all employees (primary business location will be used for rating purposes) or establish multiple SHOP accounts (primary business location in each state will be used for rating purposes). (CMS FAQs Health Insurance Market Reforms Not Dated) Q4: What rating areas should be used for individual market plans if family members live in multiple locations CMS believes that the location of the primary subscriber should be the rating area used for rating individual market plans, if purchased in the same state, regardless of the location of other individuals covered by the plan. (CMS FAQs - Health Insurance Market Reforms Not Dated) Q5: How many rating factors can an issuer have in a geographic rating area? An issuer can have one geographic rating factor per approved geographic rating area per single risk pool in a state. (CMS FAQs Health Insurance Market Reforms Not Dated) Q6: Can issuers vary their geographic rating factors within a rating area by product to reflect differences in network efficiency? No. To preserve the integrity of the single risk pool requirement, rating areas must apply uniformly within each market and may not vary by product in that market. (CMS FAQs Health Insurance Market Reforms Not Dated) Q7: We understand that some issuers need clarification on the rule prohibiting issuers from varying geographic area rating factors by product within a geographic rating area, and made plans to do so based on network cost differences. Would CMS consider a transitional period during which issuers that vary geographic rating factors on a plan-by- plan basis based on network cost differences would not be found to be out of compliance by CMS, until they make this conforming change? CMS understands that plans have operated in good faith with respect to these rules prior to the release of the clarifying FAQs Based on the timing of the release of these clarifying FAQs, CMS acknowledges that the rule could have been clearer with respect to varying geographic rating factors by product within a geographic rating area and understands that issuers may not have sufficient time to adjust their plans as would be necessary to comply with this speci?c requirement before the deadline for submission of applications to the Federally Facilitated Marketplaces for certification of QHPs. 1045 Updated 1-31-17 2017-?01145 Accordingly, for the 2014 plan or policy year only, issuers with plans subject to the rating rules imposed under the Affordable Care Act will not be found to have violated the Market Rule limitation on geographic rating if they implement geographic rating factors that vary by plan, provided that any variation in geographic rating factor by plan is based only on actuarially justi?ed network cost differences for each geographic rating area. Consistent with the Market Rule final rule and the FAQ, no other variation in geographic rating factor by plan will be permitted. Based on this guidance, all issuers submitting plans to the Federally Facilitated Marketplaces for certi?cation as QHPs will have the opportunity to make adjustments to their plans, as applicable. For those issuers that already have submitted plans to the Federally Facilitated Marketplaces or that will not have time before the deadline for submission to make such adjustments, CMS will provide an opportunity to make such adjustments during the period established for revising plans to correct any identified de?ciencies. (CMS FA Qs Health Insurance Market Reforms Not Dated) Rate Review Q1: The Centers for Medicare Medicaid Services (CMS) has specified the following uniform rate review timeline with respect to 2015 rate filings for single risk pool compliant coverage effective on or after January 1, 2016: issuers must submit initial rate ?lings by May 15, 2015 (ii) states with effective rate review programs must make publicly available proposed rate increases subject to review by June 1, 2015; and rates for plans in a single risk pool containing a Qualified Health Plan (QHP) must be finalized by August 25, 2015. Do these deadlines apply in states with a State-based Marketplace Updated 1-31-17 A1: Yes. The new uniform rate filing deadlines for single risk pool compliant plans apply in all states. However, for 2015 rate ?lings for coverage effective on or after January 1, 2016 only, CMS will not consider a state with an effective rate review program that operates an SBM and does not utilize the Federally Facilitated Marketplace (FFM) platform (and issuers offering coverage in such state) to be out of compliance with the uniform rate submission, posting, and finalization timeline for single risk pool compliant plans (including both QHPs and non-QHPs) offered in such state as long as the state meets all of the following conditions: 0 Sets a uniform submission deadline for proposed rate increases for single risk pool compliant plans no later than June 5, 2015; . Uniformly posts on the state?s website at least the information contained in Parts I, II, and of the Rate Filing Justification that CMS makes available on its website (or provides CMS's web address for such information) for all proposed rate increases for single risk pool compliant plans that are subject to review no later than June 19, 2015; . Finalizes all single risk pool compliant submissions in the Health Insurance and Oversight System (HIOS) by October 9, 2015; and Uniformly posts on the state?s website at least the information contained in Parts I, II, and of the Rate Filing Justification that CMS makes available on its website (or provides web address for such information) for all final rate increases for single risk pool compliant plans no later than November 1, 2015. 1046 2017-?01146 States with effective rate review programs that operate an SBM and elect to exercise this ?exibility must ensure that the information they release to the public is made available at a uniform time for all proposed and final rate increases for single risk pool compliant coverage (including QHPs and non-QHPs), as applicable, in the relevant market segment and without regard to whether coverage is offered through or outside of an Exchange. (Questions and Answers Regarding Rate Review Requirements (05/13/15) Q11: In the Final Letter to Issuers, there are footnotes that reference the risk pools with no Qualified Health Plans (QHPs), stating that risk pools with no QHPs must be final by October 9, 2015. Does this include transitional plans? A11: The October 9, 2015 non-QHP deadline applies only to single risk pool compliant plans and not to transitional plans or student health plans. The rate filing requirements and deadlines speci?c to transitional plans and student health plans can be found on the CCIIO website at (Issuer Outreach FAQ #1 (10/27/15)) Young Adults and the ACA Q: How does the Affordable Care Act help young adults? A: Before the President signed the Affordable Care Act into law, many health plans and issuers could remove adult children from their parents? policies because of their age, whether or not they were a student or where they lived. The Affordable Care Act requires plans and issuers that offer dependent coverage to make the coverage available until the adult child reaches the age of 26. Many parents and their children who worried about losing health insurance after they graduated from college no longer have to worry. (CMS FA 08 Young Adults and the ACA undated) Q: What plans are required to extend dependent coverage up to age 26? A: The Affordable Care Act requires plans and issuers that offer dependent coverage to make the coverage available until a child reaches the age of 26. Both married and unmarried children qualify for this coverage. This rule applies to all plans in the individual market and to new employer plans. It also applies to existing employer plans unless the adult child has another offer of employer-based coverage (such as through his or her job). Beginning in 2014, children up to age 26 can stay on their parent?s employer plan even if they have another offer of coverage through an employer. (CMS FAQs Young Adults and the ACA undated) Q: I?m a young adult under the age of 26 and I?m on my parents plan now, but I?m scheduled to lose coverage soon. How can I keep my health insurance? Updated 1-31-17 A: You have a number of options. First, check with your insurance company. Private health insurance companies that cover the majority of Americans have volunteered to provide coverage for young adults losing coverage as a result of graduating from college or aging out of dependent coverage on a family policy. This stop-gap coverage, in many cases, is available now. Second, watch for open enrollment. Young adults may qualify 1047 2017--01 147 for an open enrollment period to join their parents? family plan or policy on or after September 23, 2010. Insurers and employers are required to provide notice for this special open enrollment period. Watch for it or ask about it. Finally, expect an offer of continued enrollment for plans that begin on or after September 23, 2010. Insurers and employers that sponsor health plans will inform young adults of continued eligibility for coverage until the age of 26. Young adults and their parents need not do anything but sign up and pay for this option. (CMS FA Qs Young Adults and the ACA undated) Q: I?m under the age of 26, and I used to be on my parents? plan, but I recently lost this coverage because I graduated from college. Can I get coverage? A: Yes. Check with your insurance company to see if they will provide that coverage to you now. If not, watch for the special open enrollment period and sign up then. (CMS FAQs Young Adults and the ACA undated) Q: Now that the regulation is published, are plans required to immediately enroll eligible young adults in their parents? plan? A: No. The law says that the extension of dependent coverage for children is effective for plan years beginning on or after 6 months after the enactment of the law that means plan years beginning on or after September 23, 2010. However, the Administration has urged insurance companies and employers to prevent a gap in coverage for young adults aging off of their parents' policy prior to this effective date. To date, over 65 insurers have volunteered to do so. You should check with your insurance company or employer to see if they are offering this coverage option. (CMS FAQs Young Adults and the ACA undated) Q: Will young adults be given a special chance to enroll after September 23, 2010? A. Yes. For plan or policy years beginning on or after September 23, 2010, plans and issuers must give children who qualify an opportunity to enroll that continues for at least 30 days regardless of whether the plan or coverage offers an open enrollment period. This enrollment opportunity and a written notice must be provided not later than the first day of the ?rst plan or policy year beginning on or after September 23, 2010. Some plans may provide the opportunity before September 23, 2010 (CMS FAQs Young Adults and the ACA undated) Q: Will young adults have to pay more for coverage or accept a different benefit package? Updated 1-31-17 A: Any quali?ed individual must be offered all of the bene?t packages available to children who did not lose coverage because of loss of dependent status. The quali?ed young adult cannot be required to pay more for coverage than similarly situated individuals who did not lose coverage due to the loss of dependent status. (CMS FAQs Young Adults and the ACA undated) 1048 2017-?01148 Q: Can plans or issuers who offer dependent coverage continue to impose limits on who qualifies based upon financial dependency, marital status, enrollment in school, residency or other factors? A: No. Plans and issuers that offer dependent coverage must provide coverage until a child reaches the age of 26. There is one exception for group plans in existence on March 23, 2010. Those group plans may exclude adult children who are eligible to enroll in an employer-sponsored health plan, unless it is the group health plan of their parent. This exception is no longer applicable for plan years beginning on or after January 1, 2014. (CMS FAQs Young Adults and the ACA - undated) Q: Does the adult child have to purchase an individual policy? A: No. Eligible adult children wishing to take advantage of the new coverage will be included in the parents? family policy. (CMS FAQs Young Adults and the ACA undated) Q: Will Medicare cover adult children in the same way that private health insurance will? A: No. The provision does not apply to Medicare. (CMS FAQs Young Adults and the ACA undated) Q: Are both married and unmarried young adults covered? A: Yes (CMS FAQs Young Adults and the ACA undated) Q: Are plans or issuers required to provide coverage for children of children receiving the extended coverage? A: No (CMS FAQS Young Adults and the ACA undated) Q: Why is there a special exception for group plans in existence on March 23, 2010? A: Our goal is to cover as many young adults under the age of 26 as possible with the least amount of burden. If a young adult is eligible to purchase other employer-based health insurance such as through herjob, the law does not require the parent or parents? plan to enroll that child if the parents? plan is a grandfathered health plan in existence on March 23, 2010). Of course, all group plans have the option to cover all adult children until the age of 26 or beyond. In 2014, this exception will no longer apply. (CMS FAQs Young Adults and the ACA undated) Q: What happens if a young adult under the age of 26 is not eligible for employer- sponsored insurance and both parents have separate plans that offer dependent coverage? A: Neither parent?s plan can deny coverage. (CMS FAQs Young Adults and the ACA - undated) Q: Does the law apply to plans or issuers that do not provide dependent coverage? A: No. There is no federal requirement compelling a plan or issuer to offer dependent coverage at this time. However, the vast majority of group health plans offer dependent 1049 Updated 1-31-17 2017-?01149 Q: Are insurers doing anything to help young adults prior to the September 23rd coverage and many family policies exist in the individual market. (CMS FAQs Young Adults and the ACA undated) implementation date? Updated 1-31-17 A: Secretary Kathleen Sebelius called on leading insurance companies to begin covering young adults voluntarily before the September 23rd implementation date required by the Affordable Care Act. Early implementation would avoid gaps in coverage for new college graduates and other young adults and save on insurance company administrative costs of dies-enrolling and re-enrolling them between May 2010 and September 23, 2010. Many companies have responded including: Blue Cross and Blue Shield of Alabama Blue Cross Blue Shield of Delaware Blue Cross and Blue Shield of Arizona, Inc. Blue Cross and Blue Shield of Florida Arkansas Blue Cross and Blue Shield Blue Cross and Blue Shield of Hawaii Blue Shield of California Blue Cross of Idaho Health Service Regence Blue Shield of Idaho Wellmark Blue Cross and Blue Shield of Iowa Health Care Service Corporation Blue Cross and Blue Shield of Kansas Blue Cross Blue Shield Association Blue Cross and Blue Shield of Louisiana WeIIPoint, Inc. CareFirst BIueCross and BIueShield Blue Cross and Blue Shield of Massachusetts Blue Cross and Blue Shield of Kansas City Blue Cross and Blue Shield of Michigan Blue Cross and Blue Shield of Montana Blue Cross and Blue Shield of Minnesota Blue Cross and Blue Shield of Nebraska Blue Cross Blue Shield of Mississippi Horizon Blue Cross and Blue Shield of New Jersey, Inc. HealthNow New York, Inc. The Regence Group Excellus Blue Cross and Blue Shield Capital BIueCross Blue Cross and Blue Shield of North Carolina Independence Blue Cross BIueCross BIueShield of North Dakota Highmark, Inc. Blue Cross of Northeastern BIueCross and BlueShield of Tennessee Blue Cross and Blue Shield of Vermont Blue Cross Blue Shield of Rhode Island Premera Blue Cross Blue Cross and Blue Shield of South Carolina 2017-?01150 1050 Blue Cross and Blue Shield of Wyoming Kaiser Permanente Cigna Aetna United WellPoint Humana Capital District Physicians? Health Plan Albany, New York Capital Health Plan, Tallahassee, Florida Care Oregon, Portland, Oregon Emblem Health, New York, New York Fallon Community Health Plan, Worcester, Massachusetts Geisinger Health Plan, Danville, Group Health, Seattle, Washington Group Health Cooperative Of South Central Wisconsin, Madison, Wisconsin Health Partners, Minneapolis, Minnesota Independent Health, Buffalo, New York Kaiser Foundation Health Plan Oakland, California Martin's Point Health Care, Portland, Maine New West Health Services, Helena, Mt The Permanente Federation, Oakland, California Priority Health, Grand Rapids, Michigan Scott White Health Plan, Temple, Texas Security Health Plan, Marsh?eld, Wisconsin Tufts Health Plan, Waltham, Massachusetts UCARE, Minneapolis, Minnesota UPMC Health Plan, Pittsburgh, (CMS FAQs Young Adults and the ACA undated) Q: I understand that there are tax benefits related to the extension of dependent coverage. Can you explain these bene?ts? A. Under a change in tax law included in the Affordable Care Act, the value of any employer-provided health coverage for an employee's child is excluded from the employee?s income through the end of the taxable year in which the child turns 26. This tax bene?t applies regardless of whether the plan or the insurer is required by law to extend health care coverage to the adult child or the plan or insurer voluntarily extends the coverage. (CMS FAQs Young Adults and the ACA undated) Q: When does this tax benefit go into effect? A: The tax benefit is effective March 30, 2010. Consequently, the exclusion applies to any coverage that is provided to an adult child from that date through the end of the taxable year in which the child turns 26. (CMS FAQs Young Adults and the ACA undated) Q: Who benefits from this tax treatment? Updated 1-31-17 A: This expanded health care tax bene?t applies to various workplace and retiree health plans. It also applies to self-employed individuals who qualify for the self-employed 1051 2017--01 151 health insurance deduction on their federal income tax return. (CMS FAQs Young Adults and the ACA undated) Q: May employees purchase health care coverage for their adult child on a pre-tax basis through the employer?s cafeteria plan? A: Yes. In addition to the exclusion from income of any employer contribution towards qualifying adult child coverage, employees may pay the employee portion of the health care coverage for an adult child on a pre-tax basis through the employer?s cafeteria plan a plan that allows employees to choose from a menu of tax-free benefit options and cash or taxable bene?ts. The IRS provided in recent guidance [(Notice 2010-38)] that the cafeteria plan could be amended retroactively up until December 31, 2010 to permit these pre-tax salary reduction contributions. (CMS FAQs Young Adults and the ACA undated) Q: It seems like plans and insurers can terminate dependent coverage after a child turns 26, but employers are allowed to exclude from the employee?s income the value of any employer-provided health coverage through the end of the calendar year in which the child turns age 26. This is confusing. A. Under the law, the requirement to make adult coverage available applies only until the date that the child turns 26. However, if coverage extends beyond the 26th birthday, the value of the coverage can continue to be excluded from the employee?s income for the full tax year (generally the calendar year) in which the child had turned 26. For example, if a child turns 26 in March but is covered under the employer plan of his parent through December 31st (the end of most people?s taxable year), the value of the health care coverage through December 31st is excluded from the employee?s income for tax purposes. If the child stops coverage before December 31st, then the premiums paid by the employee up to the time the plan was stopped will be excluded from the employee?s income. (CMS FAQs Young Adults and the ACA undated) Q: If an enrollment group included an aging-off dependent, would an Issuer need to deny a policy for an entire enrollment group or can an Issuer enroll an entire enrollment group and then issue a termination for the over-aged dependent? A: CMS is currently working out technical design for aging-off terminations, along with concurrent eligibility redeterminations for remaining enrollees. (REG TAP FAQ Database - #906 02/27/14) Q: How will the Federally-facilitated Small Business Health Options Program (FF-SHOP) handle dependents aging off of a parent's plan? A: The FF-SHOP intends to send termination transactions to issuers when a dependent ages off a parent's plan. As an interim process, the Centers for Medicare Medicaid Services (CMS) may have employers remove dependents when the dependent ages off of a parent's plan. Either way, issuers will not need to take action to remove these dependents. (REGTAP FAQ Database - FAQ #2856 07/16/14) 1052 Updated 1-31-17 2017-?01152 Q: When and how is a 26 year old non-disabled dependent removed from the parents' policy? Will the Federally-facilitated Marketplace (FFM) send notification to the parents? A: When a dependent turns 26 during the year, the dependent should stay in the same enrollment as when they were 25. The individual will be auto-reenrolled at the end of the plan year into a separate policy. The family is required to update a life change if the adult attains coverage elsewhere. (REGTAP FAQ Database - FAQ #10759 05/27/15) Service Area 020: Should the partial county justification also be used to enter information on partial zip codes? A20: The service area template only requires that zip codes be entered when a county is not fully covered. If the partial zip code is part of a complete county being covered, no zip code information is required. If a zip code extends from a full county into a partial county, the zip code would only be entered on the partial county list. In this case, a partial county justification is required. If the zip code extends from one partial county to another, the issuer should enter the zip code under both counties. Partial county justi?cations will be required for both partial counties. (QHP Webinar Series FAQ #5 04/18/13) Q29: Can CMS provide additional guidance on service area requirements? Additionally, is it necessary to spell out pharmacy as part of the service area templates if the issuer is using a vendor to supply pharmacy benefits? A29: According to the ?nal rule ?Patient Protection and Affordable Care Act; Establishment of Exchanges and Quali?ed Health Plans; Exchange Standards for Employers? at 45 CFR 155.1055, the service area of a QHP must cover a minimum geographical area that is at least the entire geographic area of a county, or a group of counties defined by the Exchange, unless the Exchange determines that serving a smaller geographic area is necessary, nondiscriminatory, and in the best interest of the qualified individuals and employers. The service area of a QHP must be established without regard to racial, ethnic, language, or health status-related factors speci?ed under section 2705(a) of the PHS Act, or other factors that exclude specific high-utilizing, high- cost, or medically-underserved populations. The service area of a QHP is the geographic area in which an enrollee could access services and be covered under that particular QHP. To provide service area information in the QHP Application, the applicant must complete the Service Area template. The template requires the applicant to identify the service areas it will utilize for its QHPs. The applicant should input the county information for each service area that is covered by a QHP. Even if the issuer uses a contracted vendor for pharmacy services, the issuer is responsible for ensuring that pharmacy bene?ts are available in the issuer?s proposed service area. (QHP Webinar Series FAQ #5 04/18/13) Q8: If an issuer?s service area is the entire State, and the issuer wants to offer a plan that is only available in a certain part of the State, would that be another service area? A8: Yes. Each QHP must be associated with a single service area ID. If an issuer is applying to offer three QHPs, one available in service area A, a second available in service area B, and a third available across A and B, then the issuer should de?ne a 1053 Updated 1-31-17 2017--01153 service area by listing all of the counties included in both A and B, and use service area for the third QHP. Having an entire State service area for one QHP does not preclude also having one or more smaller service areas de?ned as a county or group of counties within the State for other QHPs. (QHP Webinar Series FAQ #7 04/24/13 and REGTAP FAQ Database - FAQ #2160 06/11/14) 09: Do the rating areas and service areas have to match? Will the service area be defined by the given State similar to the Rating Areas? A9: There is no FFE requirement that Service Area and Rating Areas have to match. See 45 CFR 147.102(b) and the preamble discussion in the final market rules at 78 FR 13410. States may have speci?c requirements related to Service Area, and issuers in the FFE are responsible for complying with these State requirements. Issuers will identify their service areas using the Service Area template. See the Chapter 9 of the Instructions for more information on ?lling out the Service Area template. (QHP Webinar Series FAQ #7 04/24/13 and REGTAP FAQ Database - FAQ #2159 06/11/14) Q10: If an issuer plans to offer individual coverage on the Exchange in 10 counties in a single State, will the 10 counties be considered 1 service area or 10 service areas? A10: Each QHP must be associated with a single service area ID. In this example, the ten counties would make up the QHP's single service area. (QHP Webinar Series FAQ #7 04/24/13) Q46: Are issuers required to have their service area cover the entire geographic area of their network? Updated 1-31-17 A46: Service areas in FFE States must satisfy 45 CFR 155.1055 of the Establishment of Exchanges and Quali?ed Health Plans ?nal rule, which requires: the service area of a QHP to cover a minimum geographical area that is at least the entire geographic area of a county, and (2) the service area to be established without regard to racial, ethnic, language, health status-related factors listed in section 2705(a) of the PHS Act, or other factors that exclude specific high utilizing, high cost, or medically-underserved populations.? As noted in the QHP Application Instructions, in most situations, the FFE will only approve service areas covering full counties. In the rare case in which the issuer is requesting to cover a service area containing a partial county, the issuer must provide the included ZIP codes, a justi?cation for why the entire county will not be served, and a detailed description that illustrates why the request is not discriminatory. Each QHP offered on the FFE must be approved or deemed for sale in the State (as applicable under state law) before final certi?cation. Upon application, the issuer will need to attest to adhering to all applicable State and Federal law. This would include compliance with service areas de?ned by the State. There is no requirement that the service area cover the entire geographic area of the issuer?s network. (QHP Webinar Series FAQ #9 05/03/13) 1054 2017--01 154 Q47: If a health plan will be offering QHPs in certain cities and counties in a State, instead of the entire State, do issuers have to designate and name a unique service area ID for each city and county in the drop down box of the service area template? Or, would an issuer designate and name one service area and list all of the cities from the drop down box that are included in the service area? A47: As noted in the QHP Application Instructions, within States where an issuer is licensed, they may offer plans in defined service areas which can include an entire State, certain counties within States, and under limited circumstances partial counties within a State. The template requires that an issuer's service area ID be generated (not user-assigned). Each plan must be associated with a single Service Area ID, so issuers should create enough service area to cover each unique combination of counties for which it intends to offer a QHP. A single Service Area ID can be used for multiple plans. Application Instructions are also posted on the REGTAP website at (QHP Webinar Series FAQ #9 05/03/13) Q: If a member moves to a different service area, can the Issuer update the QHP ID within a different QHP with the same type of plan and notify the Marketplace? A: No, the issuer cannot update the individuals status to a new QHP within the issuer's network, even if one is available through the same issuer. The individual may be able to select another QHP from the same issuer, however, s/he must first contact the FFM to provide information about the new address and service area, because this could impact the premiums and rates. Once the notification takes place, it may be necessary for the individual to go through the enrollment process again, and make a selection of a QHP - which may or may not be with the same issuer. (REG TAP FAQ Database - FAQ #640 01/09/14) Q: Should each county be in only one Service Area on the Service Area Template? A: Issuers should list a county in as many services areas as required to describe the products offered. (REGTAP FAQ Database - FAQ #2981 07/23/14) Q: Can the same county/zip code be used across multiple service areas? Updated 1-31-17 A: Yes, counties or zip codes can overlap within multiple service areas. Chapter 9 of the 2015 Quali?ed Health Plan (QHP) application instructions ("Instructions for the Service Area Application Section") located at nstructions-Ver2-05202014.pdf cites the following example: An issuer has five plans and four service areas. The ?rst plan has a service area (SA001) that covers the entire state. The second and third plans have a service area (SA002) that covers counties A and B. The fourth plan has a service area (SAOO3) that covers counties and D. The fifth plan has a service area (SAOO4) that covers counties A, B, C, and D. A QHP must always be associated with a single Service Area ID and with a single Network ID, but networks and service areas may be used for multiple QHPs. The issuer creates one template for all of its service areas and identi?es each service area with a unique Service Area ID. The issuer also completes the Network ID Template and creates a unique Network ID for each network. When the issuer 1055 2017-?01155 completes the Plans and Bene?ts Template, it maps each plan to a speci?c Service Area ID and Network ID as entered in the Service Area and Network ID Templates. Service Area IDs and Network IDs may both be used for multiple plans and do not have to correspond one to one (for example, an issuer may have a single state-wide network, identi?ed with a Network ID, assigned to all of its plans, but have two Service Area IDs, each made up of half the state and each assigned to a different plan). (REGTAP FAQ Database - FAQ #3493 08/06/14) Q: What is the deadline for submitting Service Area Change Requests (petitions)? A: Service Area change requests must be reviewed and approved by CMS prior to the September 4, 2014 deadline. In order to allow CMS adequate time to review your request, CMS recommends submitting your change request no later than August 18th, 2014. (REGTAP FAQ Database - FAQ #3513 08/07/14) Student Health Coverage Q: On February 11, 2011, the Department of Health and Human Services (HHS) published a Notice of Proposed Rulemaking in the Federal Register relating to Student Health Insurance Coverage. The proposed regulation clarifies the circumstances under which health insurance sold to students enrolled in colleges and universities is considered a type of individual health insurance coverage. It also provides that certain Public Health Service (PHS) Act requirements would be inapplicable to such coverage. The proposed policy set forth in the proposed rule would be applicable to policy years beginning on or after January 1, 2012. What is the status of student health insurance coverage with policy years starting prior to January 1, 2012? A: The proposed regulation clari?es the circumstances under which health insurance sold to students is considered individual health insurance coverage, as opposed to short-term limited duration insurance under 45 CFR 144.103. Insurance coverage that meets the de?nition of short-term limited duration insurance under 45 CFR 144.103 is not subject to PHS Act requirements. With respect to student policies that are individual health insurance coverage, HHS will not consider PHS Act requirements to apply to such coverage for policy years that begin before the ?rst policy year to which the ?nal regulation will be applicable. In addition, issuers that had a reasonable belief that the insurance coverage that they were providing to colleges and universities met the de?nition of short-term limited duration insurance will not, for purposes of federal law, be considered to be out of compliance pending the start of the ?rst policy year to which the ?nal regulation will be applicable. Starting with the ?rst policy year to which the final regulation will be applicable, any student health insurance coverage (that is, any insurance sold to students that does not meet the de?nition of short-term limited duration insurance set forth in 45 C.F.R. ?144.103) will be subject to all requirements that will apply to student health insurance coverage under the ?nal regulation. States currently enforce the individual market requirements of title XXVII of the PHS Act. HHS wishes to avoid disruption in the student health insurance market during the period before the applicability of the final rule. Therefore, HHS is also clarifying that, during this period, if a State is otherwise substantially enforcing the individual market requirements but the State does not enforce those requirements with respect to student health insurance coverage (as it would be de?ned by the proposed rule), the State is 1056 Updated 1-31-17 2017--01156 nevertheless considered to be substantially enforcing the individual market requirements. The federal enforcement policy described above does not preclude States from imposing State law requirements on student health insurance coverage for policy years beginning before the ?nal regulation?s effective date. In other words, States can continue to enforce relevant provisions relating to student health insurance coverage under State law and are not required to roll back any State law protections already applicable to student health insurance coverage. (CMS FAQs - Improving Health Insurance Protections for Students -not dated) Q4. How do student health insurance plans calculate AV since the population and bene?ts structure in these plan designs are generally different than the typical individual or small group market plan? A: Student health insurance plans are required to adhere to the EHB package requirements under section 1302 of the ACA and section 2707(a) of the PHS Act that include providing plans at a given level of coverage, which is determined by the plan?s AV. Speci?cally, under section 1302(d)(2), the level of coverage for a plan must be determined based on EHB provided to a standard population (and without regard to the population to which the plan may actually provide bene?ts). In the implementing regulation, under 45 CFR 156.135, we require issuers to use the AV Calculator to determine the level of coverage, as well as provide issuers with the option to use one of two alternate methods to calculate AV when the health plan?s design is not compatible with the AV Calculator. As is mentioned in the above question, this option is for use when the AV Calculator yields a materially different AV result from using the other approved methodologies. Student health insurance plans generally must use the AV Calculator to calculate AV, or they may use an alternative method under 45 CFR 156.135(b) when certain unique features of the student health insurance plan design might yield a materially different AV result from using other approved methodologies. Regardless of the use of an alternative method, the issuer should start with the data in the continuance tables when making adjustments to be re?ective of the standard population and must adhere to the regulatory requirements under 45 CFR Student health insurance plans should not use an alternative method under 45 CFR 156.135(b) solely as a means to account for a different population. We intend to monitor this issue and will consider further guidance or rulemaking for calculating AV for student health insurance plans as needed for policy years after 2015. (CMS FAQs on Health Insurance Market Reforms and Marketplace Standards 05/16/14) Q. Are student health plans required to make reinsurance contributions and are they eligible for the reinsurance payments?: Updated 1-31-17 A: Applicable to 2015 and 2016 Reinsurance Contribution Benefit Years: As we stated in the HHS Notice of Bene?t and Payment Parameters for 2015 Final Rule (79 FR 13779), in accordance with the policy established in the HHS Notice of Bene?t and Payment Parameters for 2014 Final Rule (78 FR 15466), we-elanfy?that-i-n ,student health plans are not eligible to receive reinsurance payments. Under student health 1057 2017--01 157 plans are not subject to the single risk pool requirement of section 1312(c) of the Affordable Care Act and ?156.80. Under ?153.234, a reinsurance-eligible plan's covered claims costs for an enrollee incurred prior to the application of the following provisions do not count towards either the uniform reinsurance payment parameters or the State supplemental reinsurance payment parameters: ?147.102 (fair premiums); ?147.104 (guaranteed availability); ?147.106 (guaranteed renewability); ?156.80 (single risk pool); and subpart of part 156 (essential health bene?ts). However, we-nete?that a student health plan would be considered part of a contributing entity's ?commercial book of business? and, to the extent that the plan provides major medical coverage, as defined in ?153.20, a contributing entity must make reinsurance contributions on behalf of their enrollees, absent another exception in ?153.400. (REGTAP FAQ Database - FAQ #4868; #4868a 09/18/14; updated 09/21/15 and 09/13/16) Student Health Plans and Rate Review Q: Are issuers of non-grandfathered Student Health Insurance Plans (SHPs) subject to federal rate review requirements? Updated 1-31-17 A: Yes, SHPs are subject to the federal rate review requirements codified under 45 CFR Part 154. While CMS issued guidance on February 25, 20131 indicating that SHPs would not have to submit rate increases using the Uni?ed Rate Review Template (URRT), since it did not accommodate non-single risk pool plans, CMS subsequently developed a process to accommodate SHPs in November 2013, and SHPs have been required to submit information on rate increases in accordance with the federal rate review requirements using that process. Specifically, in November 2013, CMS reinstituted the Rate Review Justi?cation (RRJ) module of the Health Insurance Oversight System (HIOS) that had been used to collect the Preliminary Justification for rate increases of 10% or greater prior to the January 1, 2014 applicability date of the single risk pool provision under 45 CFR 156.80. The related Paperwork Reduction Act (PRA) package was renewed on April 4, 2014, reiterating that the RRJ system and templates must be used for non-single risk pool rate ?lings that are subject to review. CMS also issued guidance in February 2015 providing form and rate filing instructions to issuers in the ?ve states where CMS has the responsibility to enforce provisions of title of the Public Health Service Act (PHS This document reminded issuers of the obligation to submit rate ?lings for SHP coverage in these ?ve states for: rate increases of 10 percent or more into the HIOS RRJ Module, and rate increases of less than 10 percent into the HIOS Document Collection Form Filing Module. On April 3, 2015, CMS released revised RRJ rate ?ling instructions for issuers proposing a rate increase of 10 percent or greater (or above a state-speci?c threshold) for a SHP to submit a Preliminary Justi?cation in the HIOS RRJ module. In states with ?ling requirements for rate increases for SHPs, the issuer must submit the Preliminary Justification to CMS on the same day that the issuer submits the rate filing to the 1058 2017-?01158 applicable state. In states without ?ling requirements for rate increases for SHPs, the issuer must submit the Preliminary Justi?cation to CMS prior to implementing the rate increase. In addition, CMS encourages issuers to submit the Preliminary Justi?cation for SHPs to CMS in the states where CMS is rate reviewer at least 60 days in advance of implementation of the rate increase so that CMS can complete its review and provide issuers with its review determination prior to the effective date of the rate increase. Because some issuers have expressed confusion regarding the ?ling requirements for SHPs, CMS is extending the deadline for submission of the Preliminary Justification to CMS for SHPs with a rate increase effective on or before December 31, 2015 as follows: Rate Increase Effective on or before December 31, Rate Increase Effective on or after January 1, 2015 2016 Rate Increases of 210%: Submit SHP Preliminary Rate Increases of 210%: Submit SHP Preliminary Justi?cations to CMS by the of: Justi?cations to CMS by the earlier of: The date that the issuer files the The date that the issuer ?les the Preliminary Justi?cation with the state Preliminary Justification with the state 0 A date prior to implementation of the rate 0 A date prior to implementation of the rate increase increase5 0 October 1, 2015 Rate Increases of Rate Increases of Not required for issuers in states with Effective Not required for issuers in states with Effective Rate Review (ERR) programs. In states without ERR Rate Review (ERR) programs. In states without ERR programs, submit Preliminary Justifications for all programs, submit Preliminary Justifications for all SHPs with rate increases (regardless of the size of SHPs with rate increases (regardless of the size of the increase) to CMS by the earlier of: the rate increase) to CMS by the latJ of: 0 The date that the issuer ?les the The date that the issuer files the Preliminary Justification with the state Preliminary Justi?cation with the state 0 A date prior to implementation of the 0 A date prior to implementation of the rate rate increase increase 0 October 1, 2015 Any questions regarding this guidance can be submitted to ratereview@cms.hhs.qov. (Rate Review Student Health Plans FAQ 08/12/15) Q. Will the Departments? enforcement relief to colleges and universities for certain health care premium reduction arrangements offered in connection with student health plans be extended? Yes. Colleges and universities have premium reduction arrangements for graduate student health coverage that are often part of a large and complex admission offer and acceptance process. Additionally, Congress evidenced an intent in the Affordable Care Act to preserve the ability of institutions of higher education to continue offering student health insurance plans othen/vise permitted under applicable Federal, State, or local law. Accordingly, pending further guidance, the Departments consider it appropriate to further extend the enforcement relief provided in the February 5, 2016 guidance and will not assert that a premium reduction arrangement offered by an institution of higher 1059 Updated 1-31-17 2017--01159 education fails to satisfy PHS Act section 2711 or 2713 if the arrangement is offered in connection with student health coverage (insured or self-insured). (FAQS on Premium Reduction Arrangements for Student Health Plan Coverage 10/21/16) Medical Loss Ratios Q1: The MLR interim final regulation, 45 CFR ?158.103, defines small employer as having up to 100 employees, but allows a state to substitute ?50? employees for ?100? employees until 2016, as provided in the Public Health Service Act and the Affordable Care Act. What actions should a state take to make an election to stay at 50 employees? A1: If a State uses 50 employees in its definition of small employer for other purposes, absent indication to the contrary, this will be deemed to be an election to use 50 as the upper limit for purposes of MLR reporting for that State?s experience. (Questions and Answers Regarding the Medical Loss Ratio Interim Final Rule {05/13/11) QZ: Must issuers of so-called mini-med plans and expatriate plans report the experience for those plans separately from other types of plans? A2: Yes. 45 CFR and (4) clearly require aggregating and reporting of mini-med and expatriate plans' experience separately from other types of policies, and 45 CFR requires quarterly reporting of such experience for the ?rst three quarters of 201 1. Aggregation and reporting of mini-med plans and expatriate plans are both addressed in separate 3 and Answers. Some have questioned whether and (4) allow issuers the ?option," at the issuer?s sole discretion, of applying the special adjustment to the numerator of the medical loss ratio. Such special adjustment under the regulation is not optional or permissive. For the 2011 MLR reporting year, it requires that the numerator for such mini-med and expatriate plans be multiplied by a factor of two. Similarly, for the 2011 MLR reporting year, requires quarterly reporting, and such quarterly reporting requirement is not optional or permissive. (Questions and Answers Regarding the Medical Loss Ratio Interim Final Rule {05/13/11) Q3: How should experience under so-called mini-med policies, 45 CFR be aggregated? A3: The experience of so-called mini-med policies (defined in the MLR IFR as policies with a total annual limit of $250,000 or less) is to be aggregated separately from other coverage, as stated in However, similar to other health insurance coverage and as specified in it should be aggregated by State, and by large group, small group, and individual market within each State. There is no national aggregation or other variation from the aggregation rules set forth in ?158.120 for mini- med policies. (Questions and Answers Regarding the Medical Loss Ratio Interim Final Rule {05/13/11) Q4: What aggregation should be used for calculating the MLR and rebates, if any, for so- called mini-med policies? A4: The experience of mini-med policies is to be aggregated separately from other 1060 Updated 1-31-17 2017--01160 coverage, as stated above and in 45 CFR An issuer?s MLR for its mini- med policies is also to be calculated separately from its MLR for other types of health insurance coverage. This is necessary in order for the issuer to apply the MLR calculation for mini-med coverage as set out in Sections and apply to the 2011 MLR reporting year only. However, like other types of health insurance coverage, an issuer?s MLR for its mini-med policies must be calculated separately for the large group, small group, and individual markets within each State, Thus, an issuer will have a separate mini-med MLR for each State and market (large group, small group, and individual) in which it issues these policies. Similarly, any rebates an issuer of mini-med policies must provide based upon its MLR must be calculated for each State and market in which it issues such policies. Questions and Answers Regarding the Medical Loss Ratio Interim Final Rule {05/13/11) 05: How should experience under expatriate group policies, 45 CFR be aggregated? A5: The experience of expatriate group policies is to be reported separately from other coverage. Because of the unique nature of expatriate plans as compared to plans that primarily provide coverage within the United States, such experience may be aggregated on a national basis. However, the large group market must meet an 85% MLR standard and the small group market must meet an 80% MLR standard, thus the experience of the large group market must be aggregated and reported separately from the experience of the small group market. Section applies only to group policies and not to individual policies. Individual expatriate policies are not included in the separate aggregation. This applies to the 2011 MLR reporting year only. (Questions and Answers Regarding the Medical Loss Ratio Interim Final Rule {05/13/11) 06: What aggregation should be used for calculating the MLR and rebates, if any, for expatriate group policies? Updated 1-31-17 A6: The experience of expatriate group policies is to be aggregated separately from other coverage as stated in An issuer?s MLR for its expatriate group policies is also to be calculated separately from its MLR for other types of health insurance coverage. This is necessary in order for the issuer to apply the MLR formula adjustment for expatriate plans as set forth in Sections and apply to the 2011 MLR reporting year only. However, unlike other types of health insurance coverage, an issuer?s MLR for its expatriate group plans may be calculated on a national basis for the large group and for the small group markets. (Section does not apply to individual expatriate policies.) Because the large group market must meet an 85% MLR standard and the small group market must meet an 80% MLR standard, an issuer?s MLR and any rebates for its expatriate policies in the large group market must be aggregated and reported separately from its MLR and any rebates for its expatriate policies in the small group market. Any rebates an issuer of expatriate large group policies must provide will be based upon the same MLR, and any rebates an issuer of expatriate small group policies must provide will be based upon the same MLR. (Questions and Answers Regarding the Medical Loss Ratio Interim Final Rule {05/13/11) 1061 2017--01 161 Q7: How should issuers report MLR data for expatriate policies where the employee is outside of the United States but his or her dependents are in the United States? A7: Section requires issuers to aggregate the experience from policies that cover employees working outside their country of citizenship, employees working outside of their country of citizenship and their employer?s country of domicile, and non- U.S. citizens working in their home country. The determining factor is the location of the employee, rather than the dependent. Thus, if a group policy covers a US. citizen working in France as well as that employee?s dependents living in the US, the experience of that employee and his/her dependents is included in the expatriate policy?s experience and data. (Questions and Answers Regarding the Medical Loss Ratio Interim Final Rule (05/13/1 1) Q8: Is the entire amount paid to a clinical provider in a capitation arrangement considered an incurred claim? A8: Generally, yes. Where an issuer has arranged with a clinical provider for capitation payments rather than fee-for-service reimbursement for covered services to enrollees, and such capitation payments include reimbursement for certain provider administrative costs, then the entire per member per month capitation payment paid to the provider may be included in incurred claims, as provided in 45 CFR The term ?provider? in this question and answer does not refer to or include third party vendors. (Questions and Answers Regarding the Medical Loss Ratio Interim Final Rule (05/13/1 1) 09: Is the entire payment to a non-physician clinical provider in a capitation arrangement considered an incurred claim? A9: Generally, yes. Although 45 CFR ?158.140(a) refers to the fact that it includes capitation arrangements with physicians, the intent was to include capitation arrangements with non-physician providers that are licensed, accredited, or certi?ed to perform clinical health services, consistent with State law, and who are engaged in the delivery of medical services to enrollees. (Questions and Answers Regarding the Medical Loss Ratio Interim Final Rule {05/13/11) Q10: Does 45 CFR or any other portion of the interim final rule require reporting of information on a claim-by-claim basis or pricing information? Updated 1-31-17 A10: Nothing in the IFR requires claim-by-claim reporting or for a third party vendor to disclose proprietary data concerning pricing arrangements. If an issuer seeks to include incurred claims paid through third party vendors in its MLR calculation, the issuer must obtain from the third party vendor the aggregate portion of the fees the vendor received from the issuer attributable to providing direct clinical services to enrollees. (Questions and Answers Regarding the Medical Loss Ratio Interim Final Rule {05/13/11) 1062 2017--01 162 Q11: Does 45 CFR -- which excludes from incurred claims amounts paid to third party vendors for network development, administrative fees, claims processing, utilization management and profits -- require issuers to disclose the administrative and other fees that they pay to particular third party vendors? A11: No. Issuers are not required to report at an individual vendor level the amount of payment that re?ects a vendor?s administrative expenses. The portion of the fees an issuer pays to a third party vendor for network development, administrative fees, claims processing, utilization management, and pro?t would simply be combined with, and reported as part of, the issuer?s overall administrative expenses. (Questions and Answers Regarding the Medical Loss Ratio Interim Final Rule {05/13/11) Q12: When a third party vendor provides clinical services directly to enrollees, how does 45 CFR -- which excludes from incurred claims amounts paid to third party vendors for network development, administrative fees, claims processing, and utilization management -- affect how an issuer reports payments to that third party vendor? A12: Section 158.140 treats payments to providers as reimbursement for clinical services to enrollees (also referred to as incurred claims). Section recognizes that issuers often pay third party vendors to perform services such as network development, administrative fees, claims processing, and utilization management, that are considered non-claims administrative costs if performed by the issuer and thus should be considered non-claims administrative costs if performed by a third party vendor. However, when a third party vendor, through its own employees, provides clinical services directly to enrollees, the entire portion of the amount the issuer pays to the third party vendor that is attributable to the third party vendor?s direct provision of clinical services should be considered incurred claims, even if such amount includes reimbursement for third party vendor administrative costs directly related to the vendor?s direct provision of clinical services. The term ?through its own employees? does not include a third party vendor?s contracted network of providers because such network providers are not considered employees of the third party vendor. For example, an issuer may contract with a PBM to provide clinical services directly to enrollees through a mail order pharmacy. The amount the issuer pays to the PBM for mail order pharmacy services provided directly by the employees, including administrative costs related to the PBM's direct provision of such mail order pharmacy services, would be included in the issuer?s incurred claims. (Questions and Answers Regarding the Medical Loss Ratio Interim Final Rule {05/13/11) Q13: Does 45 CFR -- which excludes from incurred claims amounts paid (including amounts paid to a provider) for professional or administrative services that do not represent compensation or reimbursement for covered services provided to an enrollee -- require issuers to separate out claims payments or providers to separate out their bills into their component parts for clinical services to enrollees and overhead costs? A13: No. This section of the IFR does not require any change in the way providers prepare or process their bills and it does not require providers to break out portions of 1063 Updated 1-31-17 2017--01163 claims attributable to administrative expenses or overhead. No modifications to claim preparation or process are required. This subsection simply clari?es that to the extent that there is a separate, identi?able charge in a bill or invoice that represents a separate charge for something other than reimbursement for clinical services to enrollees, payment for such a charge should be treated as a non-claim cost and is excluded from incurred claims. For example, a provider may charge for items such as medical record copying costs or attorneys? fees incurred as part of a payment dispute with the issuer. Such costs or payments are separate and apart from reimbursement for clinical services to enrollees and are to be treated as a non-claims cost and excluded from incurred claims. (Questions and Answers Regarding the Medical Loss Ratio Interim Final Rule (05/13/1 1) Q14: Does the IFR allow portions of the amounts paid to third party vendors to be counted as expenditures for activities that improve health care quality? A14: Yes. An issuer may count a vendor?s expenses as activities that improve health care quality to the extent that the issuer and vendor can show that these expenses were incurred for performing allowable quality improving activities on behalf of the issuer. Accordingly, the concept addressed specifically in 45 CFR regarding incurred claims and third party vendors applies, to the extent permitted under ?158.150 and ?158.151, to expenditures for activities that improve health care quality. For example, to the extent that a PBM performs functions that are designed primarily to identify quality concerns, such as potential adverse drug interactions, those costs may be reported, in aggregate, as expenditures for activities that improve health care quality. Questions and Answers Regarding the Medical Loss Ratio Interim Final Rule (05/13/1 Q15: Must an activity be speci?cally listed in 45 CFR ?158.150(b) in order to be included as an allowable quality improving activity A15: No. Section states that, in order to be reported as a QIA, the activity must be primarily designed to do one of four things: improve health outcomes including increasing the likelihood of desired outcomes compared to a baseline and reduce health disparities among speci?ed populations; (ii) prevent hospital readmission through a comprehensive program for hospital discharge; improve patient safety, reduce medical errors, and lower infection and mortality rates; or (iv) implement, promote, and increase wellness and health activities. Section provides a list of examples following each of these four things. Each list of examples is intended to be illustrative and not exhaustive. For example, activities that may be an allowable QIA (assuming that they also meet the criteria listed in that are not speci?cally listed in include blood glucose monitoring programs and medication adherence programs. (Questions and Answers Regarding the Medical Loss Ratio Interim Final Rule {05/13/11) 1064 Updated 1-31-17 2017-?01164 Q16: The interim final regulation was published on December 1, 2010, and the process for making a determination on a State?s request for an adjustment to the MLR standard for the individual market will mean that a determination will be made at least several weeks after January 1, 2011. Will the adjustment be retroactive to January 1, 2011? A16: Any request for adjustment of the MLR standard for a State?s individual market, if approved for MLR reporting year 2011, will be effective for the entire 2011 MLR reporting year. (Questions and Answers Regarding the Medical Loss Ratio Interim Final Rule {05/13/11) Q17: 45 CFR ?158.322 requires a State to provide its own proposal as to the adjustment it seeks to the MLR standard. May a State propose an adjustment to how the MLR is calculated? For example, may a State include or exclude factors that are not part of the federal formula for calculating the MLR, or substitute its State MLR definition or formula for the federal definitions and formula as well as an adjustment to the percentage? A17: A State may propose to substitute a lower minimum loss ratio standard for the 80 percent standard established in the Public Health Service Act as amended by Section 1001 of the Affordable Care Act, and by regulation codified at 45 CFR ??158.301 and A State may not propose an adjustment to how the MLR is calculated. By way of example, a State may not propose definitions or methods for calculating the MLR that differ from those established by the federal law and regulations. (Questions and Answers Regarding the Medical Loss Ratio Interim Final Rule (05/13/1 1) Q18: When reporting experience related to MLR, what method should issuers use for counting ?employees? in determining whether the data from a group policy should be reported as being issued in the large group market or small group market, as required by 45 CFR ?158.120, and for determining the minimum medical loss ratio required by 45 CFR ?158.210? A18: The large group and small group markets are defined as those where health insurance coverage is obtained through a large or small employer, respectively. A large employer and small employer are de?ned by the number of employees; a small employer has up to 100 employees, but a State may substitute ?50" employees for ?100? employees until 2016. (45 CFR ?158.103.) (Question and Answer 1 addresses how a State makes this election; 05 13 and a quidancepdf.) An employer's number of employees is determined by averaging the total number of all employees employed on business days during the preceding calendar year. (Section PHS Act ?2791(e)(2) and By way of example, this includes each full-time, part-time and seasonal employee. An employee is ?any individual employed by an employer.? This includes all full-time and part-time employees. (PHS Act Regarding the Medical Loss Ratio Interim Final Rule (07/18/1 1) 1065 Updated 1-31-17 2017--01165 Q19: How should an issuer report amounts paid to third party vendors who pay others to provide clinical services to enrollees and who perform network development, administrative functions, claims processing, and utilization management? A19: In general, an issuer may only include as reimbursement for clinical services (incurred claims) the amount that the vendor actually pays the medical provider or supplier for providing covered clinical services or supplies to enrollees. Where the third party vendor is performing an administrative function such as eligibility and coverage veri?cation, claims processing, utilization review, or network development, expenditures and pro?ts on these functions would be considered a non-claims administrative expense as provided in 45 CFR Some third party vendors provide reimbursement for clinical services to enrollees and provide administrative functions such as claims processing and network development. Payments by an issuer to a third party vendor to provide clinical services directly to enrollees through its own employees are considered to be incurred claims. However, the amounts paid by the issuer to a third party vendor for the functions that are not direct clinical services to enrollees through its own employees are governed by and only the amounts the third party vendor pays to providers may be included in incurred claims. (Questions and Answers 8 and 9 address what is meant by the term ?providers"; 05 13 and a quidancepdf .) The amounts attributable to network development, administrative fees, claims processing, and utilization management by the third party vendor and the third party vendor?s profits on those activities must not be included by an issuer in its incurred claims. For example, when a pharmacy benefit manager (PBM) pays a retail pharmacy one amount for prescription drugs covered by the plan and charges the issuer a higher amount (the retail spread), the issuer may only claim the amounts paid by the PBM to the retail pharmacy as incurred claims. As stated in the May 13, 2011 guidance posted on the internet at the third party vendor (in this example, the PBM) must report to the issuer only the aggregate amount it pays all providers (in this example, retail pharmacies) for clinical services to enrollees on behalf of the issuer, by market in each State. No claim-by-claim or provider by provider reporting is required. Regarding the Medical Loss Ratio Interim Final Rule (07/18/11) 020: Are payments by issuers to clinical risk-bearing entities, such as Independent Practice Associations (IPAs), Physician Hospital Organizations (PHOs), and Accountable Care Organizations (ACOS), incurred claims under 45 CFR 158.140? Updated 1-31-17 Answer #20: Generally, yes. We will consider such payments to be incurred claims provided that both the payment and risk-bearing entity meet all four factors stated here. 45 CFR 158.140 treats payments by issuers to providers as reimbursement for clinical services to enrollees (also referred to as incurred claims), but does not address situations in which issuers pay a third party, such as an IPA, to perform services that are considered provider services when performed by a provider?s medical practice. Payments to a clinical risk-bearing entity are considered incurred claims it the following 1066 2017-?01166 four factors are met: . The entity contracts with an issuer to deliver, provide, or arrange for the delivery and provision of clinical services to the issuer?s enrollees but the entity is not the issuer with respect to those services; The entity contractually bears financial and utilization risk for the delivery, provision, or arrangement of speci?c clinical services to enrollees; The entity delivers, provides, or arranges for the delivery and provision of clinical services through a system of integrated care delivery that, as appropriate, provides for the coordination of care and sharing of clinical information, and which includes programs such as provider performance reviews, tracking clinical outcomes, communicating evidence-based guidelines to the entity?s clinical providers, and other, similar care delivery efforts; and 0 Functions other than clinical services that are included in the payment (capitated or fee-for?service) must be reasonably related or incident to the clinical services, and must be performed on behalf of the entity or the entity?s providers. If the entity satis?es this four-part test, payments for clinical services for which the entity takes on the ?nancial risk for utilization as provided in prong two above will be considered incurred claims. Conversely, when an entity takes on only pricing risk, Question and Answer 19 in the July 18, 2011 guidance applies mlrguidancepdf #19 addresses payments to third party vendors who pay others to provide clinical services to enrollees and who perform administrative functions. It provides that the entirety of the payment by an issuer to an entity that only takes on pricing risk payments to pharmacy bene?t managers (PBMs) for retail pharmacy claims) should not be reported as incurred claims. Regarding the Medical Loss Ratio Interim Final Rule {02/10/12)} Q21: Are payments by issuers to such clinical risk-bearing entities that include payment for administrative functions performed on behalf of the entity?s providers incurred claims under 45 CFR 158.40? A21: Yes, if all four factors set forth in Answer #20 are met. For example, a bundled payment to an IPA or similar entity for providing clinical services to enrollees which includes: the IPA processing claims payments to its member providers and submitting claims reports to issuers on behalf of its providers; performing provider credentialing to determine a provider?s acceptability into the IPA network; and developing a network for its providers? bene?t, would be included in incurred claims. Regarding the Medical Loss Ratio Interim Final Rule {02/10/12)} 022: Are payments by issuers to clinical risk-bearing entities, such as Independent Practice Associations (IPAs), for administrative functions performed on behalf of the issuer, incurred claims under 45 CFR 158.140? Updated 1-31-17 A22: To the extent that administrative functions are performed on behalf of the issuer, that portion of the issuer?s payment that is attributable to the administrative functions may not be included in incurred claims (See Questions and Answers 11, 12 and 13 in the May 13, 2011 guidance at 05 13 MLR and A Guidancepdf . This is the case regardless of whether payment is made according to a separate, fee-for?service payment schedule or as part of a global, capitated fee payment for all services provided. 1067 2017--01 167 For example, payment for processing claims in order to issue explanations of bene?ts (EOBs) to enrollees and handling the any stage of enrollee appeals would not be included in incurred claims. Payments for non-clinical services for which the contract between the IPA and the issuer contains a ?clawback? provision are not considered incurred claims for MLR reporting purposes. Regarding the Medical Loss Ratio Interim Final Rule (02/10/12)) 023: Are self-funded plans subject to the MLR reporting and rebate requirements? A23: No. Section 2718(a) of the PHS Act and its implementing regulation, 45 CFR ?158.102, provide that the MLR requirements apply to health insurance issuers offering group or individual health insurance coverage. A self-funded plan (sometimes referred to as a self-insured plan) is not a health insurance issuer, as de?ned by 2791(b)(2) of the PHS Act, and thus is not subject to the MLR requirements. It does not matter if the self- funded plan is subject to the Employee Retirement Income Security Act of 1974 (ERISA) or if it is a plan. Regarding the Medical Loss Ratio Regulation (04/20/12)) 024: Is the experience for health insurance benefits provided through a Medicaid managed care organization (MCO) contract with a State Medicaid agency to provide bene?ts to Medicaid beneficiaries subject to the MLR reporting and rebate requirements? A 24: No. Section 2718(a) of the PHS Act applies to health insurance issuers offering employer group or individual health insurance coverage. Medicaid coverage offered under a contract with a State Medicaid agency is governed by Title XIX of the Social Security Act and regulations at 42 CFR Part 438, and not by State insurance law. Under these circumstances, issuers are not offering group health insurance coverage as de?ned under ?2791(b)(4) of the PHS Act because the coverage is not offered in connection with a group health plan, nor are they offering individual health insurance coverage as de?ned under ?2791(b)(5) of the PHS Act, because the coverage is not offered to individuals in the individual market. Congress recognized the inapplicability of Title 27 of the PHSA to MCO contracts when it enacted section 1932(b)(8) of the Social Security Act, which makes some, but not all, Title 27 requirements applicable to Medicaid MCO contracts. Regarding the Medical Loss Ratio Regulation (04/20/12)) 025: Is the experience for health insurance bene?ts provided through a contract with CMS that offers health insurance coverage through Medicare, such as Medicare Advantage plans (Medicare Part C) and Medicare prescription drug plans (Medicare Part D), subject to the commercial MLR reporting and rebate requirements? Updated 1-31-17 A 25: No. Section 2718(a) of the PHSA applies to health insurance issuers offering group or individual health insurance coverage. Medicare Advantage plans and Medicare Part prescription drug plans are not group health insurance coverage as de?ned under ?2791(b)(4) of the PHSA (because the coverage is primarily provided under a contract with the Medicare program not an employer group health plan) or individual health insurance coverage as de?ned under ?2791(b)(5) of the PHSA (because the coverage is not offered to individuals in the individual market). Such coverage is instead subject to a comprehensive regulatory scheme under Parts and of Title of the Social Security Act and regulations at 42 CFR Parts 422 and 423. Congress clearly recognized the inapplicability of the MLR requirements in section 2718 to Medicare Advantage plans 1068 2017-?01168 when it added separate and distinct MLR requirements to the Part statute. This answer applies even in cases in which the Medicare Part or Part plan is designed for members of an employer group under section 1857(i)(1) of the Social Security Act. Regarding the Medical Loss Ratio Regulation {04/20/12)} 026: Are blanket health insurance policies subject to the MLR reporting and rebate requirements? A 26: Some States categorize certain health insurance coverage as blanket health insurance policies distinct from group and individual health insurance coverage. Guidance issued under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) at 62 FR 16893, 16896 (April 8, 1997) addressed the interaction of Federal regulations with State law, and noted that federal law categorizes health insurance coverage into two markets, group market and individual market. The PHS Act does not include the term blanket coverage. The Affordable Care Act does not modify the types of coverage that fall within the PHS Act and the 1997 HIPAA guidance remains in effect. Even if a State law de?nes certain coverage as blanket coverage, an issuer offering such blanket coverage is subject to the MLR requirements if the coverage meets the de?nition of group or individual health insurance coverage under ?2791 of the PHS Act. Regarding the Medical Loss Ratio Regulation {04/20/12)} 027: The MLR regulation, 45 CFR 158.103, defines a small employer as having 1-100 (or at State option, 1-50) employees. When is a health plan a group of one and thus reported with small group market experience and when is it reported with individual market expe?ence? A27: PHS Act ?2791 de?nes the terms ?individual market," ?large group market," and ?small group market. ?We codi?ed those terms in 45 CFR ?158.103. To be considered a group health plan, the health plan must have ?employees? among its participants. For the purpose of determining whether a group health plan exists, Federal law does not classify an individual and his or her spouse as employees when the trade or business is wholly owned by the individual or by the individual and his or her spouse. Thus, where a sole proprietor and/or a spouse-employee are the only enrolled employees, the health plan would not be considered to be a group health plan. Thus its experience would be aggregated with the issuer?s individual market experience and not with the issuer?s small group market experience. However, if a sole proprietor enrolls a non-spouse employee, the experience of that plan is part of the small group market for MLR purposes. Even if the only enrollee is an employee who is not an owner or spouse, the plan is part of the small group market for MLR purposes. Regarding the Medical Loss Ratio Regulation (04/20/12)) 028: When reporting group MLR experience, what method should issuers use for counting ?employees? covered by a group policy that does not cover all of the employees of the employer, where the issuer does not have the information to determine the employer?s total number of employees, which it needs in order to determine whether the group policy should be treated as large group or small group, as required by 45 CFR ?158.120, and to determine the MLR standard required by 45 CFR ?158.210? Updated 1-31-17 A28: At the time of sale, issuers should make every attempt to accurately count the number of employees employed by the group policyholder so as to accurately categorize the group as belonging in the small or large group market. 1069 2017-?01169 If the policyholder does not make the issuer?s policy available in all of the States in which it has employees, the issuer may not be able to count all of the employees. For example, an employer may be based in New York with 150 employees in New York and 20 employees in Maryland. The Maryland employees may have health insurance with one issuer while the New York employees are covered by a different and separate (affiliated or unaffiliated) issuer. The issuer of the Maryland policy may not know the total number of the policyholder?s employees and may categorize the group in its systems to be in the small group market for purposes of the policy it issues, the rates it charges and so forth. In such a situation, the issuer may determine the group size for MLR reporting purposes and the minimum MLR standard based on the information available to the issuer. Unless the issuer has information which puts the issuer on notice that the total number of employees would cause the plan to be a large group for MLR purposes, the issuer may determine the number of employees solely based on the number of employees in Maryland and it may report the experience of the policy in the small group market or large group market based on the number of the plan?s Maryland employees. This guidance is intended to clarify prior guidance on Counting Employees for Determining Market Size (Question and Answer 18; mlrjuidancepdf) and amends the prior guidance only insofar as the situation presented by the scenario in this guidance is concerned. Regarding the Medical Loss Ratio Regulation (04/20/12)) 029: In what State should issuers report their MLR data for individual or non-group association policies? A29: Issuers should report their MLR data for individual or non-group association policies in the State where the individual resides at the time the certificate of coverage is issued. Some individual policies are issued through an association, such as the Automobile Association of America, to individual members of the association. In this instance, the association may be located in a different State than the insured resides. The association is the policyholder and the covered individual receives a certificate of coverage. 45 CFR ?158.120(d) instructs issuers to include the experience for individual market business sold through an association in the State report for the ?issue State of the certi?cate of coverage.? This is the State where the insured individual resides at the time the certificate of coverage is issued, not the State where the association or policyholder is located, or the State in which the issuer is located. This guidance is intended to clarify prior guidance on the Application of Individual and Group Market Requirements under Title of the Public Health Service Act when Insurance Coverage Is Sold to, or through, Associations coverage 9 1 2011.pdf.pdf). Regarding the Medical Loss Ratio Regulation {04/20/12)} Q30: If, during a MLR reporting year, an issuer finds that its MLR is lower than the standard required by 45 CFR ??158.210 and 158.211, may the issuer institute a ?premium holiday? in order to avoid having to pay rebates? Updated 1-31-17 A30: Neither the MLR regulation nor the PHS Act address whether an issuer may offer its policyholders a ?holiday? from owing premiums. Premiums are established and collected in accordance with State law and the terms of the policy or contract that, where required, is ?led with the applicable State regulatory agency. Thus, whether a premium ?holiday" is permissible is a matter of State law. 1070 2017-?01170 An issuer seeking to temporarily suspend or reduce premiums in a State?s individual, small and/or large group market should check with its State regulatory agency as to whether it may do so. However, if an issuer chooses to provide a premium holiday and its State regulator allows it to do so, HHS expects that the premium holiday would be provided in a non-discriminatory manner, meaning that it is offered to every policyholder in a State?s market and not based on product type or the experience of a particular policy. An issuer that offers a premium holiday is responsible for refunding any overpayment of premium by a policyholder who is offered a premium holiday but fails to accept or receive such premium holiday for any reason. Regarding the Medical Loss Ratio Regulation (04/20/12)) Q31: If an issuer reinsures 100 of a block of business by entering into reinsurance and administrative services agreements after March 23, 2010, even if the effective date of the agreement(s) is prior to March 23, 2010, is the ceding issuer or the assuming issuer responsible for filing the annual MLR Reporting Form? A31: The assuming issuer is responsible for filing the annual MLR Reporting Form only in the following circumstance. 45 CFR ?158.130 states: ?Reinsured earned premium for a block of business that was subject to indemnity reinsurance and administrative agreements effective prior to March 23, 2010, for which the assuming entity is responsible for 100 percent of the ceding entity?s ?nancial risk and takes on all of the administration of the block, must be reported by the assuming issuer and must not be reported by the ceding issuer." (Emphasis added.) However, the ceding issuer is responsible for ?ling the annual MLR Reporting Form and issuing any rebates if either of the agreements were entered into after March 23, 2010, even if they have an effective date prior to March 23, 2010. Regarding the Medical Loss Ratio Regulation (04/20/12)) Q32: 45 CFR states ?Reinsured earned premium for a block of business that was subject to indemnity reinsurance and administrative agreements effective prior to March 23, 2010, for which the assuming entity is responsible for 100 percent of the ceding entity?s financial risk and takes on all of the administration of the block, must be reported by the assuming issuer and must not be reported by the ceding issuer.? (Emphasis added.) If the ceding entity performs any administrative functions after the effective date of the reinsurance agreement, is the ceding issuer or the assuming issuer responsible for filing the annual MLR Reporting Form? A32: If the ceding issuer retains responsibility for any administrative functions, related to the reinsured block of business, after the effective date of the reinsurance agreement and administrative agreement, then for MLR reporting and rebate purposes, the ceding issuer remains responsible for ?ling the MLR Reporting Form and reporting the experience of the block of business that is the subject of the agreement. Regarding the Medical Loss Ratio Regulation {04/20/12)} 1071 Updated 1-31-17 2017-?01 171 Q33: If an issuer enters into a 100% indemnity reinsurance agreement and the ceding issuer is responsible for reporting the experience for MLR purposes, may the ceding issuer adjust premiums for taxes paid by the reinsurer on the ceding issuer?s MLR report? A33: No. General accounting principles require alignment between revenue and expenses. If the reinsurer receives the premium revenue for reinsured business and has the legal obligation to pay any tax due on it, and pays such tax, the ceding issuer may not report the tax amount and may not apply it as an adjustment to premiums when completing its MLR Annual Reporting Form and calculating its MLR. This is the case regardless of whether the reinsurer is an af?liate of the ceding issuer. The MLR regulation only permits issuers to deduct those taxes related to a reinsured block of business that were owed and paid by the reporting issuer. Therefore, if the ceding issuer did not owe or pay the related taxes or was reimbursed for premium taxes through any portion of commissions or allowance on reinsurance (see 45 CFR ?158.162(b) and the issuer is not allowed to deduct such taxes from premium when reporting its experience. Regarding the Medical Loss Ratio Regulation (04/20/12)) Q34: May an issuer include user fees paid to a State Exchange or a Federal Exchange in the Federal and State licensing and regulatory fees, as defined in 45 CFR that must be subtracted from premium in calculating an issuer?s MLR and rebate pursuant to 45 CFR ?158.221(c) and 45 CFR A34: Yes. Exchange user fees should be included in the licensing and regulatory fees that are subtracted from premium in the MLR calculations. 45 CFR ?158.161(a) - Reporting of Federal and State licensing and regulatory fees - requires issuers to report as an adjustment to premium ?statutory assessments to defray operating expenses of any State or Federal The Affordable Care Act ?1311(d)(5)(A) requires States to ensure that the Exchanges are self-sustaining beginning with 2015 and allows the Exchanges to charge assessments or user fees to participating health insurance issuers. implementing regulation, at 45 CFR ?155.160, provides that as of January 1, 2015, States must ensure that the Exchanges have sufficient funds to support ongoing operations and they may generate funding, such as through user fees on participating issuers, for Exchange operations. 45 CFR ?156.50 requires participating issuers to remit user fees and other assessments to the Exchange, whether State- or Federally-operated. Since the Exchanges are established as part of a State or Federal department and the user fees are intended to support operating expenses, user fees constitute statutory assessments that defray the operating expenses of such department and qualify for inclusion in the licensing and regulatory fees described in 45 CFR ?158.161 Regarding the Medical Loss Ratio Regulation {04/20/12)} Q35: If a State requires a higher minimum MLR for State rebate or rate filing purposes than that required by Federal law, does the State standard automatically apply to issuers in that State for purposes of the applicable Federal Updated 1-31-17 A35: No. 45 CFR ?158.211 states that ?[t]or coverage offered in a State whose law provides that issuers in the State must meet a higher MLR than that set forth in ?158.210, the State?s higher percentage must be substituted for the percentage stated in ?158.210 of this subpart.? However, 45 CFR ?158.211(b) requires that before a State sets a higher minimum MLR to apply for purposes of the Federal MLR, it ?must seek to ensure adequate participation by health insurance issuers, competition in the health 1072 2017--01 172 insurance market in the State, and value for consumers so that premiums are used for clinical services and quality improvements.? Since it would not have been possible for a State to have considered whether its MLR standard should be higher than the Federal MLR standard prior to the passage of the Affordable Care Act, HHS will only apply a higher MLR to issuers in States that have taken affirmative action since March 23, 2010 indicating that they have exercised their option pursuant to 45 CFR ?158.211 to require issuers to meet a higher MLR standard for Federal MLR purposes. Examples of States that have taken such affirmative action are Massachusetts, New Mexico and New York. Regarding the Medical Loss Ratio Regulation {04/20/12)} Q36: Beginning with the 2013 experience, when issuers of mini-med policies calculate their MLR according to the formula in 45 CFR ?158.221, should they apply the applicable adjustment (multiplier) for each year to the reported experience from each year and then add each of those adjusted numerators together, or, should the reported experience for each MLR year be added together and then apply the adjustment (multiplier) for the current MLR reporting year to the aggregated experience? A36: 45 CFR ?158.220(b) provides that, beginning with the 2013 MLR Reporting year, an issuer?s MLR is calculated according to the formula in ?158.221, aggregating the data reported for three years. On December 7, 2011, the Department issued an MLR Final Rule amending ?158.221 and providing mini-med issuers with an adjustment (or multiplier) to the numerator of the MLR the total of claims and quality improving activities) as follows: a factor of 1.75 for 2012; 1.50 for 2013; and 1.25 for 2014. The multiplier is applied to the numerator of the issuer?s MLR formula. For non-mini-med experience, each year?s experience is added together to obtain the numerator for purposes of calculating the Federal MLR. Similarly, issuers of mini-med policies should add the reported experience for each MLR year together to obtain the numerator and then apply the multiplier for the current MLR reporting year to the aggregated experience. This is consistent with how other experience is aggregated for purposes of calculating the Federal MLR. Regarding the Medical Loss Ratio Regulation {04/20/12)} Q37: When providing MLR rebates to current or former enrollees in the individual, small group or large group markets pursuant to 45 CFR ?158.241, may issuers use a pre-paid debit card as a means of rebate distribution? Updated 1-31-17 A37: Generally, yes. 45 CFR ?158.241 states that an issuer may provide rebates in the form of a premium credit, lump-sum check or, if the enrollee paid the premium using a credit or debit card, by returning the entire rebate to the account used to pay the premium. CMS believes that an alternative, such as a debit or credit card, is a reasonable alternative as long as it is as convenient to use as a check and meets all of the conditions described below. An issuer may provide rebates in the form of a pre-paid debit card (presumably by arrangement with a bank or other ?nancial institution) provided all of the following conditions are met: 0 The applicable policyholder?s or subscriber?s name must be on the card in order to ensure that the rebate reaches the intended policyholder or subscriber and is not stolen or diverted to a creditor or other third party; 0 The card must not have an expiration date; 1073 2017-?01173 The policyholder or subscriber must not incur any fees in association with the use or non-use of the card. If the institution that issues the card does not have any locations within a reasonable distance to the policyholder?s or subscriber?s mailing address and the policyholder or subscriber incurs a fee from another financial institution in order to cash the card, any such fees imposed by the other financial institution must be reimbursed by the issuing institution; . At the policyholder?s or subscriber?s request, the entire balance on the card must be convertible to cash; 0 The policyholder or subscriber must be able to contact the issuer or the issuing institution in order to opt out of receiving the rebate in the form of a pre-paid debit card and request a paper check. Such check must be mailed within ten (10) calendar days of the request; . The policyholder or subscriber must be able to contact the issuing institution during normal business hours to obtain the cash value, or balance, on the card; and The policyholder or subscriber must be provided with an easy-to-understand notice of their rights and an explanation of the terms of the card at the time the cards are mailed. Regarding the Medical Loss Ratio Regulation {04/20/12)} Q38: Must an issuer that offers only excepted benefit plans submit a Medical Loss Ratio (MLR) Reporting Form? A 38: No. Section 2718(a) of the PHS Act and its implementing regulation, 45 CFR ?158.102, provide that the MLR requirements apply only to a health insurance issuer offering group or individual health insurance coverage. PHS Act ?2722(b) provides that excepted benefits, as de?ned in PHS Act ?2791(c), are exempt from the requirements of subparts 1 and 2 of the PHS Act for individual coverage or any group health plan. PHS Act ?2718 is in Subpart 2 of the PHS Act and, therefore, an issuer of only excepted benefits is not subject to the MLR filing and rebate requirements. However, an issuer that offers health insurance coverage that is subject to ?2718 of the PHS Act and also has experience that is not subject to ?2718 of the PHS Act is required to ?le an MLR Reporting Form that includes the issuer?s experience that is not subject to the MLR requirements. Regarding the Medical Loss Ratio Reporting Form {05/24/12)} Q39: How should an issuer determine the number of employees of an employer, for the purpose of determining if an employer is a large employer or a small employer? Updated 1-31-17 A #39: An issuer should determine the number of employees of an employer in accordance with Public Health Service Act (PHS Act) ?2791(e), as referenced in 45 CFR ?158.103. PHS Act ?2791(e) defines a ?large employer" as one that ?employed an average of at least 101 employees on business days during the preceding calendar year and who employs at least 2 employees on the first day of the plan year," and a ?small employer" as one that ?employed an average of at least 1 but not more than 100 employees on business days during the preceding calendar year and who employs at least 1 employee on the ?rst day of the plan year." On May 16, 2012, CMS published Interim Final Rule, Correcting Amendment (77 FR 28789), which indicated that we were revising the preamble language of the Medical Loss Ratio Interim Final Rule (75 FR 74864 (December 1, 2010)) to ?eliminate any ambiguity resulting from the fact that Federal and State law may differ on how an issuer 1074 2017--01 174 determines the number of employees an employer has . . The Correcting Amendment had inadvertently identi?ed the incorrect Federal standard (using the last day of the year to determine the number of employees), instead of using the correct standard set forth in PHS Act ?2791 Regarding the Medical Loss Ratio Reporting Form {05/24/12)} Q40: Which individuals may act as the primary attesters for an issuer?s MLR Reporting Form? A 40: A health insurance issuer offering group or individual health insurance coverage must designate four separate individuals who may attest to the information being submitted on the issuer?s MLR Reporting Form: two primary attesters and two back-up attesters. Using the HIOS registration form, the issuer must designate the Chief Executive Officer (CEO) or President as one primary attester and the Chief Financial Officer (CFO) as the other primary attester. If the issuer does not have such officers, the next highest ranking of?cers acting in the capacity of either the CEO or President, and the CFO should be designated as the primary attesters. Regarding the Medical Loss Ratio Reporting Form {05/24/12)} Q41: Which individuals may act as back-up attesters for an issuer?s MLR Reporting Form? A 41: The next highest ranking officers that are designated by the issuer to act in the capacity of either the CEO or President, and the CFO should be designated as the back- up attesters. If the issuer does not have four of?cers, the issuer may request an exception to the requirement that it designate four officers two as primary attesters and two as back-up attesters. The exception process should be initiated by an email from the issuer?s CEO or President which af?rms that the issuer has fewer than four of?cers. The email should be addressed to HIOS Helpdesk at insuranceoversiqht@hhs.qov. Regarding the Medical Loss Ratio Reporting Form (05/24/12)) Q42: May an issuer designate a primary attester as a back-up attester? A 42: No. An issuer must be designate four different individuals two as primary attesters and two separate individuals as back-up attesters. Regarding the Medical Loss Ratio Reporting Form {05/24/12)} Q43: May the CEO of a parent company act as an attester for a subsidiary? A 43: A subsidiary without a CEO or President, or without a CFO, may designate its next highest ranking of?cers as one of its primary attesters. A subsidiary without a CEO or President, or without a CFO may also designate its holding company?s chief officers (CEO or President, and CFO) as back-up attesters for the subsidiary. Regarding the Medical Loss Ratio Reporting Form {05/24/12)} Q44: May an issuer?s primary attesters and back-up attesters act as the issuer?s ?up- loaders,? i.e. the individuals authorized to upload the issuer?s MLR Report to the HIOS system? A 44: An issuer must designate two individuals as MLR Reporting Form ?up-loaders.? These individuals are responsible for uploading the issuer?s completed MLR Reporting Form to HIOS. An issuer?s up-loader and back-up loader may not be a primary attester 1075 Updated 1-31-17 2017-?01175 or back-up attester. Regarding the Medical Loss Ratio Reporting Form {05/24/12)} Q45: May an issuer designate an employee of its third party administrator as one of its authorized up- loaders? A 45: Yes. The issuer may designate an employee of its third party administrator as one of its authorized up-loaders. Regarding the Medical Loss Ratio Reporting Form {05/24/12)} Q46: How many HIOS registration numbers may an issuer have for any one State? A 46: Each issuer must have only one HIOS registration number for each State in which the issuer offers health insurance coverage. An issuer with multiple HIOS registration numbers in a State should contact the HIOS Helpdesk at insuranceoversiqht@hhs.qov. Regarding the Medical Loss Ratio Reporting Form {05/24/12)} Q47: How many MLR forms must each issuer file? A 47: Each company will download a HIOS-created zip ?le that contains an MLR Reporting Form for each State in which the issuer indicated, on its HIOS registration form, that it offered health insurance coverage, as well as a Grand Total report that the issuer will use to aggregate its experience nationwide. One MLR Reporting Form must be prepared and submitted for each State in which the issuer has written direct health insurance coverage or has direct amounts paid, incurred or unpaid for the provision of health care services. In addition, each issuer that offers health insurance coverage and is subject to the MLR reporting requirements must submit a Grand Total report. Regarding the Medical Loss Ratio Reporting Form (05/24/12)) Q48: How should an issuer report ?dual contract group health coverage? in the ?12l31? column of the MLR Reporting Form, since the instructions indicate that the 12/31 column matches the Supplemental Health Care Exhibit (SHCE) but the SHCE does not allow an issuer the option to include the dual contract group health coverage in its report? A 48: CMS recognizes that some cells in the ?3/31" columns cannot be edited by the issuer and are based on information that is entered into the corresponding ?12l31? columns. For such data elements, an issuer must enter into the ?12/31? column the experience as instructed by the ?3/31" column instructions, to ensure that the ?3/31" column has accurate data and yields correct MLR and rebate calculations. The MLR regulation and MLR Reporting Form allow an issuer the option to aggregate dual contract group health coverage, and the SHCE does not allow that option. Thus, entering on the MLR reporting form the amount reported by the issuer on the SHCE would not accurately capture the data required by the MLR regulation and MLR Reporting Form. For an issuer that chooses to aggregate dual contract group health coverage on its MLR Reporting Form: 0 The in-network issuer should, in the ?12/31? column cells which correspond to the ?3/31? column cells that cannot be edited by the issuer, report premium and other required data including the experience of the af?liated issuer providing the out-of- 1076 Updated 1-31-17 2017-?01176 network coverage along with the in-network experience being reported; and . The out-of?network affiliated issuer should, in the ?12/31? column cells which correspond to the ?3/31? column cells that cannot be edited by the issuer, report premium and other required data excluding that out-of-network experience being reported by the in-network issuer. We recognize that in such cases the ?12/31? column will not match the NAIC SHCE. Regarding the Medical Loss Ratio Reporting Form {05/24/12)} Q49: The MLR Reporting Form Instructions (Instructions) direct an issuer to report ?experience rating refunds? in both the premium and claims sections of Part 2. Is this correct? A 49: Yes. 45 CFR states that incurred claims, which are included in the MLR numerator, must include experience rating refunds. However, CMS recognizes that issuers traditionally report this experience as premium, which is included in the MLR denominator. Therefore, the Instructions direct an issuer to report experience rating refunds separately in both the Premium and Claims sections of Part 2 of the MLR Reporting Form, but to exclude experience rating refunds from written premium. An issuer?s MLR and MLR rebates are calculated with experience rating refunds factored into only the issuer?s incurred claims as provided in 45 CFR Regarding the Medical Loss Ratio Reporting Form (05/24/12)) Q50: When the regulation requires that notice be sent to ?each policyholder and subscriber of a group health plan,? does the term ?subscriber? refer to an employee enrolled in the group health plan? A 50: Yes. 45 CFR ?158.251, published on May 16, 2012 (77 FR 28790), requires an issuer in a group market to send the MLR information notice to the group policyholder (typically an employer) and to each subscriber of the group policyholder (typically an employee). If there are multiple enrollees in the same household enrolled in the same health plan, an issuer needs to provide only one subscriber notice to the household. In addition, as stated in ?158.251, the ?notice may be included with other plan documents" sent to employees. Regarding the Medical Loss Ratio Reporting Form {05/24/12)} 051: There are various MLR provisions that apply to aggregating experience that require issuers to report information in a different manner than they have been required to do in the past, or in some cases under current State law, for example, how to report policies sold to sole proprietors. If issuers do not have accurate information to classify sole proprietor policies, what should they do now? Updated 1-31-17 A 51: CMS is working together with stakeholders to help them come into compliance with the MLR provisions as well as other provisions of the Affordable Care Act. We expect issuers to make reasonable efforts, in good faith, to obtain and accurately categorize the information issuers are required to report regarding the experience of sole proprietors. However, we recognize that for the 2011 MLR reporting year, certain information that is necessary to attribute this experience to the small group or individual market may not be known to the issuer. For the 2011 MLR reporting year, an issuer may not know whether a policy that under State law may be considered a group of one and thus a small group policy has as its only insured a sole proprietor?s spouse, and thus should be considered an individual policy under Federal law that should be aggregated 1077 2017--01 177 with the issuer?s individual market experience. Under this circumstance, an issuer should make a good faith effort to submit an accurate ?ling based on the information it has at the time of the ?ling. Regarding the Medical Loss Ratio Reporting Form (05/24/12)) 52: Will CMS grant extensions of the June 1, 2012 deadline for issuers to submit their MLR annual report or the August 1, 2012 deadline for issuers to provide rebates for the 2011 MLR reporting year? A 52: No. 45 CFR ?158.110(b) establishes ?June 1 of the year following the end of an MLR reporting year? as the date by which an issuer must submit the MLR report, and 45 CFR ?158.240(d) establishes ?August 1 following the end of the MLR reporting year? as the date by which an issuer must provide any rebate owing. Therefore, because the MLR regulation does not provide for extensions to either deadline, no extensions will be granted for these deadlines. We sent emails to issuers reminding them of the June 1 MLR submission deadline, on March 30, April 6, April 12addition, we held a weekly webinar for issuers on using our HIOS computer system to submit MLR data to HHS, every Tuesday from April 10 through May 22, and have held a weekly telephone conference call to answer issuers? questions regarding completing the MLR reporting form, every Thursday beginning April 19. Information about the weekly webinar and the weekly telephone conference was emailed to issuers on April 6 and April 12 and is posted on our HIOS website. Regarding the Medical Loss Ratio Reporting Requirements {05/30/12) 53: Will CMS accept 2011 MLR Report submissions beyond June 1, 2012? Answer 53: Our Health Insurance Oversight System (HIOS) will accept the submission of a 2011 MLR Report beyond June 1, 2012. However, the deadline to submit a timely 2011 MLR Report remains June 1, 2012. 45 CFR ??158.602 and 158.606 authorize civil monetary penalties for failure to submit to HHS the required MLR report by the June 1 deadline. Regarding the Medical Loss Ratio Reporting Requirements {05/30/12) 54: For an issuer that must provide the rebate directly to the group policyholder, must the notice of rebate to the policyholder?s subscribers be provided to those enrolled during the MLR reporting year, or to those who are current subscribers at the time of the rebate? Updated 1-31-17 A 54: In accordance with the rules in 45 CFR ?158.242 describing who is entitled to the rebate under a group health plan, an issuer must provide notice of rebate to all subscribers enrolled in the group. This means that all subscribers enrolled in the group during the MLR reporting year except those who are no longer enrolled at the time the issuer provides the notice of rebate will receive a notice of rebate. For notice of rebates that must be provided by August 1, 2012, this means that the notice must be sent to all subscribers enrolled in the group at the time in 2012 that the notice is sent. In addition to providing notice of rebate to all subscribers enrolled in a group plan at the time the issuer provides the notice of rebate, issuers may choose to include subscribers enrolled in the group plan during the MLR reporting year even if the subscribers are no longer enrolled at the time the issuer provides the notice of rebate, based on the 1078 2017-?01178 instructions for the notice of rebate, but is not required. Regarding the Medical Loss Ratio Reporting and Rebate Requirements {07/17/12)} 55: For an issuer whose MLR meets or exceeds the applicable MLR standard, may the notice under 45 CFR ?158.251 be provided separately from the first plan document that the issuer provides to enrollees on or after July 1, 2012? A55: Yes. The regulation does not prohibit issuers who prefer to provide the one-time notice of MLR separately from any other plan documents provided that they do so prior to or concurrent with the first plan documents that are provided to enrollees on or after July 1, 2012. Regarding the Medical Loss Ratio Reporting and Rebate Requirements (07/1 7/12)) 056: 45 CFR ?158.251 directs an issuer whose MLR meets or exceeds the applicable MLR standard to provide policyholders and group subscribers a notice of MLR information with the first ?plan document? that the issuer provides to enrollees on or after July 1, 2012. What is a ?plan document? for purposes of 45 CFR ?158.251? Answer 56: For the purposes of 45 CFR ?158.251, a plan document can be considered a document pertaining to the plan or policy that is distributed to all policyholders in individual and group markets and all subscribers in group markets. Examples of plan documents include policies, summary plan descriptions, benefits summaries, and group contracts. Regarding the Medical Loss Ratio Reporting and Rebate Requirements (07/1 7/12)) 057: May an issuer exclude from premium in its MLR and rebate calculation the fees it must pay under the Affordable Care Act, such as those required by the risk adjustment program (ACA and 1343, along with the Independent Offices Appropriations Act (IOAA) authority found at 31 U.S. C. 9701), for funding the Patient Centered Outcomes Research Institute (ACA ?6301), and on an issuer?s net premium (ACA ?9010)? A57: Yes. For MLR purposes, issuers may exclude from premium all ?Federal taxes and assessments allocated to health insurance coverage reported under section 2718 of the PHS Act,? as well as State taxes and assessments, which include ?[a]ny industry-wide (or subset) assessments (other than surcharges on specific claims) paid to the State 45 CFR and ACA assessments or fees are a state or federal assessment and therefore may be excluded from premium under the MLR reporting and rebate requirements. 45 CFR and This MLR treatment is similar to the MLR treatment of Exchange user fees, which is addressed in Technical Guidance Bulletin 2012-02, dated April 20, 2012, Question and A34 However, an issuer?s operating costs or any administrative costs associated with taxes or fees, such as those related to implementing and operating data submission and validation systems for the risk adjustment program, are not part of a state or federal assessment and therefore may not be deducted from premium for purposes of the MLR calculation. Regarding the Medical Loss Ratio Reporting and Rebate Requirements (04/05/13)) 1079 Updated 1-31-17 2017-?01179 058: In a state market in which different MLR standards apply to different MLR reporting years, may an issuer account for the difference in standards when aggregating multiple years of data in MLR and rebate calculations? A58: Yes. While the MLR regulation does not explicitly address the interaction of the requirement to aggregate multiple years of data (45 CFR with HHS adjustments to the MLR standard in the individual market (PHS Act ?2718(b)(1)(A)(ii) and 45 CFR ?158.301), or higher state MLR standards substituted for the federal minimum MLR standard (45 CFR ?158.211), we believe that a method that prevents issuers from being penalized for pricing to the applicable MLR standard each year is permissible. The permitted method allows issuers in state markets with MLR standards that change over time to scale the prior year experience included in the current year MLR numerator, to account for the higher MLR standard of the current reporting year. The scaling adjustment is the reporting year standard minus the applicable prior year standard, multiplied by the applicable prior year adjusted premium. That amount is then added to the experience from the applicable prior year that is included in the current year MLR numerator. This scaling adjustment is optional for issuers in state markets with MLR standards that change over time. For example, for an issuer subject to a 75% MLR standard in 2011 and an 80% MLR standard in 2012, who has $100 in adjusted premium in 2011, the 2011 claims and quality improving activities data would have an adjustment of $100] or $5 added to the 2012 MLR numerator, which scales the 2011 experience by the change in the MLR standard. Regarding the Medical Loss Ratio Reporting and Rebate Requirements (04/05/13)) 059: Will CMS initiate an enforcement action against an issuer of health insurance coverage for failure to file a complete MLR report if that issuer has only grandfathered plans in small closed blocks of business? Updated 1-31-17 A59: No, but only under the limited circumstances stated here. Based on its enforcement discretion, CMS will not initiate an enforcement action if an issuer of group or individual health insurance coverage fails to submit a full MLR report and its only health insurance coverage exists in grandfathered plans in small closed blocks. To qualify, the issuer?s CFO and CEO must attest to and provide all the following information regarding the applicable MLR reporting year: 1. The issuer has ceased offering health insurance coverage, as de?ned by ?2791 of the Public Service Health Act, in the small group, large group, and individual health insurance markets in every state in which it is licensed to offer health insurance coverage; 2. The issuer has only grandfathered health plans (as defined in 45 CFR in closed blocks of business that are in run-off; 3. The issuer did not submit a Supplemental Health Care Exhibit (SHCE) or other similar state filing for business during the applicable MLR reporting year, has been exempt from filing a SHCE or similar state filing by the state in which it is domiciled, and submits to CMS evidence of this exemption on state letterhead. If the issuer is not subject to a SHCE or similar state ?ling requirement, this criterion is not applicable; 1080 2017-?01180 4. The issuer has less than 1,000 life years nationwide (combined for all health insurance coverage) for the MLR reporting year; and 5. The issuer has non-credible experience in each state market in which it provides coverage. The issuer must report the number of life-years in each state market for each MLR reporting year that is aggregated to determine whether the issuer has non-credible experience. For example, an issuer with 700 life-years in the 2011 MLR reporting year and 600 life-years in the 2012 MLR reporting year for the same state market would be partially credible in the 2012 MLR reporting year. (45 CFR ??158.230 and 158.231.) Issuers that meet the criteria for this policy have the option of submitting a completed MLR reporting form, as required by 45 CFR ?158.110, instead of this information. If CMS determines that an issuer does not satisfy the criteria in Question and A59, CMS will notify the issuer that it must complete the full MLR reporting form as speci?ed in 45 CFR Part 158. Regarding the Medical Loss Ratio Reporting and Rebate Requirements {04/05/13)} 060: How should an issuer notify CMS that its health insurance coverage exists only in grandfathered plans in small closed blocks of business? A60: Like all issuers subject to the MLR reporting requirements, a company that meets the criteria described in Question and A59 must register with the MLR module of Health Insurance Oversight System (HIOS), and complete or con?rm the ?company issuer association" form in HIOS. The company should check the ?small closed blocks of business? box, download the MLR reporting form from HIOS, and for the 2012 MLR reporting year, complete only Part 4, Line 3.1 of the MLR reporting form. The complete instructions are in the MLR Reporting Form Instructions, available through the HIOS MLR module and on the CCIIO website. Registration instructions for HIOS are available at: If CMS determines that an issuer does not satisfy the criteria in Question and A59, CMS will notify the issuer that it must complete the full MLR reporting form as speci?ed in 45 CFR Part 158. Regarding the Medical Loss Ratio Reporting and Rebate Requirements {04/05/13)} 061: Must an issuer of plans that the issuer had categorized as ?fixed indemnity? policies, but which in fact fail to satisfy the criteria for fixed indemnity policies described in the Affordable Care Act Implementation FAQs, Set 11, Question and Answer #7 (January 24, 2013), report the medical loss ratio (MLR) experience of those plans to the Secretary for the 2012 reporting year? A61: No. Issuers do not need to report the experience of these policies for the 2012 MLR reporting year. Regarding the Requirement that Issuers of Certain Health Insurance Coverage sold as Fixed Indemnity Insurance submit an annual Medical Loss Ratio (MLR) report to the Secretary {05/30/13)} 062: When may an issuer exclude Affordable Care Act fees, such as those required by ACA ?9010, from premium in its MLR and rebate calculations? Updated 1-31-17 A62: Issuers may exclude ACA assessments or fees from MLR calculations for a reporting year only if such assessments or fees were incurred in that reporting year. 1081 2017--01 181 Issuers may not exclude ACA assessments or fees they expect to incur in future MLR reporting years. Specifically, an issuer may not report such amounts as assessments and fees described in 45 CFR ?158.161(a) and and or as unearned premium described in 45 CFR As discussed in the HHS Notice of Benefit and Payment Parameters for 2014, published on March 11, 2013, Act section 2718 does not provide for estimated regulatory fees for future years to be deducted from premium used in MLR and rebate calculations for the reporting year.? 78 FR 15410 at 15505-15506. Regarding the Medical Loss Ratio Reporting and Rebate Requirements (07/02/13). Q63: May an issuer defer including premium collected during 2013 for 2014 Affordable Care Act (ACA) fees on non-calendar year policies in its 2013 MLR and rebate calculations? A63: Yes. For the 2013 MLR reporting year, issuers may defer including in their MLR and rebate calculations the portion of 2013 premiums collected for 2014 ACA assessments or fees on non-calendar year policies. If issuers elect to defer this portion of premium in the 2013 MLR and rebate calculations, they must disclose the deferred amount for each respective state and market. In addition, issuers must disclose and reduce the MLR tax adjustment to premium by the amount of federal and state taxes and fees associated with the deferred portion of premium. Regarding the Medical Loss Ratio Reporting and Rebate Requirements (12/30/13) 064: May an issuer for MLR reporting purposes, exclude from earned premium agent and broker fees or commissions paid in connection with a health insurance policy? Updated 1-31-17 A: No, unless all of the conditions stated in this guidance exist. 45 CFR. ?158.130 requires health insurance issuers to report earned premium for each MLR reporting year. The regulation states that earned premium ?means all monies paid by a policyholder or subscriber as a condition of receiving coverage from the issuer, including any fees or other contributions associated with the health plan." 45 CFR. requires issuers to report ?Agents and brokers fees and commissions? as a non-claims cost part of an issuer?s administrative costs) because such fees and commissions are generally a condition of receiving coverage and an expense of the issuer and not a separate cost incurred by the policyholder. CMS has become aware that some issuers have been seeking ways to exclude agent and broker fees and commissions from premium in order to increase their MLRs and reduce or eliminate rebates. Speci?cally, some issuers have been trying to assert that payment of agent or broker fees or commissions is not a condition of coverage, and that the policyholder owes these amounts directly to the agent or broker, while issuers merely pass these amounts through. In some cases, issuers have required policyholders, as a condition of coverage, to sign a statement that the policyholder retained the agent or broker and negotiated the fee independently of the issuer, even where it appears that such statement was not factually accurate. In recognition of the fact that there may be instances where the policyholder does in fact retain the agent or broker and negotiate and pay the agent or broker?s fee or commission, CMS is issuing this guidance to clarify when it may be acceptable for an issuer to exclude agent or broker fees and commissions from premium for MLR reporting purposes. Accordingly, if all of the following seven conditions are met, an issuer may 1082 2017--01 182 exclude these agent or broker fees and commissions from premium in the applicable state/market for MLR reporting purposes: 1. The law of the state in which the policy is sitused does not deem the agent or broker to be a representative of the issuer; 2. The policyholder is not required to utilize an agent or broker to purchase insurance and may purchase a policy directly from the issuer; 3. The policyholder selects, retains, and contracts with the agent or broker on his or her own accord; 4. The policyholder negotiates and is responsible for the fee or commission separate and apart from premium; 5. The issuer does not include these agent or broker commissions and fees in rate ?lings submitted to the applicable regulatory agency; 6. The policyholder voluntarily chooses to pass the fee or commission through the issuer and is not required to do so, or the policyholder pays the fees or commission directly to the agent or broker; and, 7. The policyholder issues the 1099 to the agent or broker, if a 1099 is required. If any condition in the above list is not met, then the issuer must include the agent or broker fees and commissions in earned premium for MLR reporting purposes. 2015?000 1): Regarding the Medical Loss Ratio (MLR) Reporting and Rebate Requirements {05/27/15) Q65: How will CMS enforce the above guidance on earned premiums and the treatment of agent and broker fees and commissions? A: The Affordable Care Act and implementing regulations at 45 C.F.R. Part 158 require health insurance issuers to submit data on the proportion of premium revenues spent on clinical services and quality improvement, also known as the Medical Loss Ratio (MLR), in accordance with CMS guidance and instructions. Issuers are also required to issue rebates to enrollees if this percentage does not meet minimum standards. CMS will review issuer compliance with this guidance as part of its ongoing MLR monitoring efforts, including examination as part of an audit pursuant to 45 C.F.R. 158.402. If CMS determines that an issuer has incorrectly calculated rebates or has incorrectly reported MLR data, it may require issuers to take appropriate corrective actions, such as paying any difference in rebates owed (with interest) to enrollees, and reporting the corrected amounts to CMS. Technical Guidance 2015? 0001): Regarding the Medical Loss Ratio (MLR) Reporting and Rebate Requirements {05/27/15) 066: If an issuer is required to provide a rebate because the MLR standard was not met for a given reporting year, and a portion or all of that policyholder?s health insurance premium obligation was paid with advance payments of the premium tax credit, to whom must the issuer provide the rebate? Updated 1-31-17 A: The Affordable Care Act established a refundable health insurance premium tax credit to help eligible individuals and families afford health insurance coverage. An eligible enrollee may choose to pay his or her health insurance premiums to the issuer during the year, and claim the full amount of the premium tax credit when he or she files an income tax return for that year. Alternatively, the eligible enrollee may choose to have 1083 2017-?01183 some or all of the estimated premium tax credit paid in advance, directly to the insurance issuer, if he or she enrolls in coverage through the Marketplaces. If an enrollee chooses this latter option, he or she must reconcile the advance payments of the estimated premium tax credit with the actual premium tax credit that the enrollee is eligible to claim when his or her income tax return is filed. For purposes of the MLR rebate, there is no distinction between an enrollee who chooses to pay the entire amount of premium to the issuer and claim the full amount of the premium tax credit when he or she files an income tax return for that year, and an enrollee who chooses to apply the premium tax credit against the premium obligation to the issuer in advance of ?ling an income tax return. Therefore, when a policyholder is owed an MLR rebate, and a portion or all of that policyholder?s health insurance premium obligation was paid with a premium tax credit, the issuer must provide the rebate to the policyholder. Technical Guidance 2015?0001): Regarding the Medical Loss Ratio (MLR) Reporting and Rebate Requirements (05/27/15) 067: May an issuer that timely submitted its 2014 MLR and Risk Corridors Reporting Forms but was required to resubmit those forms in September 2015, have until October 30, 2015 to distribute MLR rebates for the 2014 reporting year? A67: Yes. The Centers for Medicare Medicaid Services (CMS) communicated with certain issuers during August and September, 2015, requesting them to perform data validation and reconciliation of their risk corridors results and, in some cases, revise and resubmit their 2014 MLR and Risk Corridors Reporting Forms. In addition, CMS directed a number of issuers to revise and resubmit these forms due to certain changes to risk adjustment data. As a result, and in recognition of the fact that there may be instances where these issuers will be unable to distribute rebates for the 2014 reporting year by the MLR regulation deadline of September 30, 2015, CMS will not find such an issuer to be out of compliance with the MLR rebate deadline for the 2014 reporting year if the issuer disburses any and all rebates for the 2014 reporting year by October 30, 2015. Issuers who were required to resubmit their 2014 MLR and Risk Corridor Reporting Forms that elect to use the extra time for rebate disbursement should revise their 2014 MLR notices to policyholders and subscribers by changing the due date in template notices from September 30, 2015 to October 30, 2015. Regarding the MLR Reporting and Rebate Requirements for the 2014 MLR Reporting Year {09/18/15)} Q: Will the Centers for Medicare Medicaid Services (CMS) provide new templates for the Medical Loss Ratio (MLR) Annual Form that have the correct definition of allowable administrative costs? Updated 1-31-17 A: Yes. Issuers can now download corrected MLR Annual Form templates from the HIOS MLR module. CMS has also updated the MLR Calculator and Form Tool available on the home page of the MLR module, as well as on the Center for Consumer Information and Insurance Oversight (CCIIO) website at Loss Ratio. (REGTAP FAQ Database - FAQ #11031 06/18/15) 1084 2017--01 184 Other Q: To the extent an insurer provides information about PCIP to a prospective enrollee, is that insurer in violation of the anti-dumping provisions in 45 (CFR) 152.28? A: No. This provision pertains exclusively to existing enrollees who have been discouraged by a health insurance issuer or group health plan from remaining enrolled in coverage offered by such issuer or health plan based on the individual?s health status. For purposes of this provision, a prospective enrollee is not considered to be enrolled. (Anti-Dumping Provisions Related to the Pre-Existing Condition Insurance Plan Program (05/31/1 1) Q9: To what extent should multi-State plans contracting with the Of?ce of Personnel Management (0PM) adhere to State-based standards, including State insurance standards solvency, prompt payment, market conduct) as well as Exchange- speci?c qualified health plan certification standards in a State network adequacy standards)? A9. While the proposed rule on Establishment of Exchange and Qualified Health Plans deems OPM-approved multi-State plans as certi?ed by an Exchange, we recognize States? concerns about the need to apply State insurance requirements and State- speci?c certi?cation standards to multi-State plans. We also note that Section 1324 requires a level playing ?eld in connection with certain State and Federal legal requirements for health plans. We seek to ensure that implementation of section 1324 does not disrupt existing markets both inside and outside the Exchanges in the States. HHS and OPM will work with the National Association of Insurance Commissioners to address these questions. We will explore this issue by further identifying existing State standards as well as speci?c issues of greatest concern for multi-State plans and States including reduction of adverse risk selection, the risks to multi-State plans and States, and potential alternatives. (State Exchange Implementation Questions and Answers (11/29/11)) 15. Does the federal government intend to maintain the Pre-Existing Condition Insurance Plan program beyond 2014? How will state high risk pools be affected by the affordability and insurance market reforms in 2014? Under the Affordable Care Act, coverage for persons under the Pre-Existing Condition Insurance Plan program (whether federally-run or state-run in a state) will generally not extend beyond January 1, 2014, which is when all individuals will be able to access coverage without any pre-existing condition exclusions in the individual market. The transitional reinsurance program is expected to help stabilize premiums in the individual market by reimbursing issuers who enroll high cost individuals, such as those currently enrolled in the Pre-Existing Condition Insurance Plan, as they enter that market. In the notice of proposed rulemaking on the health insurance market rules (77 Fed. Reg.70584; November 26, 2012), we noted that we are exploring ways in which states could continue to run their existing high risk pools separate from the Pre-Existing Condition Insurance Pool program) beyond 2014. (FAQs on Exchanges, Market Reforms, and Medicaid (12/10/12)) 1085 Updated 1-31-17 2017--01185 09: May an issuer elect to discontinue offering all products in the small group market in a state but continue to offer products in the large group market in that state (and vice versa)? A9: Yes. Although the ?nal rule implementing PHS Act section 2703, as added by the Affordable Care Act, addressed the market withdrawal exception to guaranteed renewability only with reference to the individual and ?group" market, we intend to propose amendments in future rulemaking that recognize the distinction between the large group and small group market segments for purposes of PHS Act section 2703. Accordingly, an issuer could, in accordance with applicable state law and subject to the other requirements of 45 CFR satisfy the requirement in 45 CFR 147.106(d) to discontinue offering all coverage by doing so with respect to either the large group or small group market without being required to withdraw from both segments of the group market. (CMS FAQs - Health Insurance Marketplaces 07/29/13) Q1: If a health insurance issuer?s product includes both grandfathered and non- grandfathered business, can the health insurance issuer use the Health Insurance Portability and Accountability Act (HIPAA) product withdrawal (discontinuance) procedures for the non-grandfathered business, but maintain the grandfathered business related to that product? Yes, so long as the issuer meets the guaranteed renewability requirements under HIPAA (implemented in 45 CFR 146.152), including offering substitute coverage for enrollees of the non-grandfathered products. Enrollees of the non-grandfathered products can either be offered a ?new? 2014 compliant product or a non-grandfathered product that has been modified to comply with the 2014 provisions. A ?new? product is one that has no previous enrollment and does not represent a previous plan with enrollment which is being modified to comply with state or federal requirements or is one which is defined as new by the appropriate state regulator. Enrollees of the grandfathered product can maintain that coverage if that coverage continues to be offered and the coverage does not make a change that would cause the product to cease to be grandfathered as provided for under the interim ?nal regulations. (CMS FAQs Health Insurance Market Reforms Not Dated) Q2: Given the guaranteed availability requirement in 2014, what does this mean for states with alternative mechanisms? Updated 1-31-17 In general, most state high-risk pool coverage is not provided through insurance and is not group health plan coverage. Such state high-risk pool coverage is not subject to title XXVII of the PHS Act. However, some states, as their state alternative mechanism, require issuers (or certain issuers of last resort) to guarantee the availability of a product or specific bene?t design. If the state alternative mechanism is individual market insurance coverage, it is subject to title XXVII of the PHS Act, to the extent that it is not grandfathered. In 2014, individuals enrolled in state high-risk pools will have the same rights as others to guaranteed availability of any individual market products offered inside and outside of the Health Insurance Marketplace or Exchange, and states may not prevent individuals from moving to other products or to an Exchange in a state. Note that state high-risk pools may continue past 2014. 1086 2017-?01186 PHS Act section 2702, which requires guaranteed availability of all products in the individual and small group markets, has rendered section 2741 moot with regard to non- grandfathered plans. Accordingly, beginning in 2014, states will no longer be required to maintain their alternative mechanisms for the purpose of guaranteeing coverage to HIPAA eligible individuals. CMS also will no longer be reviewing the state alternative mechanism for compliance with PHS Act section 2741. States will have the discretion to determine how long beyond January 2014 their state alternative mechanisms can continue to exist or, if it was a ?federal fallback" state that did not have an alternative mechanism, whether health insurance issuers in the individual market must continue to offer certain products to HIPAA eligible individuals. (CMS FAQs Health Insurance Market Reforms Not Dated) Q8: Can states de?ne coverage sold to individuals and small groups through an association as large group coverage and hence avoid subjecting such coverage to the single risk pool and other requirements of the individual and small group market? No. For purposes of Title XXVII of the PHS Act, including the market reforms, any state law that de?nes coverage sold to individuals and small groups through an association as large group coverage would be preempted by federal law. As stated in previous guidance[3], the test for determining whether association coverage is individual or group market coverage for purposes of Title XXVII of the PHS Act is the same test that applied to health insurance offered directly to individuals or employers. Coverage that is provided to associations but is not related to employment is not considered group coverage under 45 CFR part 144 through 148. The coverage is considered coverage in the individual market, regardless of whether it is considered group coverage under state law.[4] If the health insurance coverage is offered in connection with an association group health plan as de?ned at section 2791 of the PHS Act, it is considered group health insurance coverage.[5] To the extent an association has any covered members that are small employers, the issuer is subject to the requirements that apply to small group coverage with respect to any small employer in the association. If the coverage is issued through an association, but not in connection with a group health plan, the coverage is considered individual health insurance coverage. In a ?mixed? association where different members have coverage that is subject to the individual market, small group market, and/or large group market rules under the PHS Act, as determined by each member?s circumstances, each association member must receive coverage that complies with the requirements arising out of its status as an individual, small employer, or large employer.[6] For example, it is not permissible under the PHS Act for mixed association coverage to comply only with the large group market rules, even with respect to its individual and small employer members. (CMS FAQs Health Insurance Market Reforms Not Dated) Q: A health insurance issuer has received from HHS a waiver of the annual dollar limit requirements pursuant to section 2711 of the PHS Act for a group health insurance product. Can this issuer sell that product to a self-insured grandfathered group health plan that has itself been granted a waiver and wishes to switch from being a self-insured plan to a fully insured plan? Updated 1-31-17 A: Yes, if the group health plan and the health insurance coverage satisfy the criteria below. In the December 9, 2010, CCIIO Supplemental Guidance: ?Sale of New 1087 2017--01 187 Business by Issuers Receiving Waivers,? HHS stated that it is permissible for a group health plan that is fully insured with a waiver of the annual limit requirement to purchase a new policy from a different issuer that has also obtained a waiver of the annual limit requirement. The December 9, 2010 guidance was published in light of an amendment to the interim ?nal rule concerning grandfathered health plans. The amendment permits a group health plan to maintain its grandfathered status despite entering into a new insurance contract, 26 CFR 29 CFR 45 CFR The amendment permits a self-insured group health plan to become a fully insured plan while maintaining its grandfathered status, so long as the group health plan is not altered in a way that would violate paragraph 1) of the grandfathering rule. While the December 9, 2010, guidance only addressed the scenario of switching from one fully-insured insurance policy to another, the same policy rationale for permitting the change of insured policies applies to a self?insured group health plan that received a waiver of the annual limits requirement pursuant to section 2711 of the PHS Act and wishes to purchase a new policy from a health insurance issuer that has obtained a waiver of the annual limit requirement for that policy. Accordingly, a self-insured group health plan that has obtained a waiver can purchase a group health policy with a waiver from a health insurance issuer under the following conditions, which are similar to those established in the December 9, 2010, guidance: 1) In all cases, the plan sponsor must have been offering group health coverage to its employees before September 23, 2010, for which it obtained from HHS a waiver of the annual limits requirement; 2) The issuer from which the group health plan is now obtaining the insured policy must have obtained a waiver from HHS for the newly purchased policy; 3) The annual limits of the new policy may not be lower than the annual limits of the previous policy, except in the situation outlined in 1) 4) The plan sponsor may obtain a replacement policy with a lower annual limit only if other comparable coverage is not available. If a plan purchases a lower annual limit policy due to lack of comparable coverage, this change would cause a loss of status under 45 CFR relating to status as a grandfathered health plan. 4) The health insurance issuer must obtain from the plan sponsor an attestation that the criteria outlined above are satis?ed, and the attestation must be accompanied by documentation outlining the terms of the prior coverage. Issuers shall retain this information in accordance with the data retention requirements of the September 3, 2010 and November 5, 2010 annual limits guidance documents. 5) To the extent not superseded here, all prior HHS guidance regarding annual limits waivers continues to apply to the plan and policies described here. (CMS FAQs Annual Limit Waivers not dated) Q: What is the distinction between on-Marketplace and off-Marketplace plans? Updated 1-31-17 A: If CMS has not registered an Issuer as a Quali?ed Health Plan (QHP) Issuer in the Health Insurance Marketplace, then that Issuer is an off-Marketplace or non-Marketplace Issuer. Additionally, a registered QHP Issuer may offer both Marketplace and non- Marketplace products to enrollees. However, the QHP Issuer must display the non- Marketplace products in a separate section that does not include information on Direct 1088 2017-?01188 Updated 1-31-17 Enrollment or Plan Compare. Even if the QHP is not registered as being offered off- Marketplace, it must be available to individuals who request it off-Marketplace although it does not have to be marketed off-Marketplace. (REGTAP FAQ Database - #907 02/27/14) Q: If a health insurance issuer in the group or individual market offers coverage of an opposite-sex spouse, may the issuer refuse to offer coverage of a same-sex spouse? No. Federal regulations at 45 CFR 147.104(e) provide that a health insurance issuer offering non-grandfathered group or individual health insurance coverage cannot employ marketing practices or bene?t designs that discriminate on the basis of certain speci?ed factors. One such factor is an individual?s sexual orientation. As CMS has used the terms in this regulation, an issuer is considered to employ marketing practices or bene?t designs that discriminate on the basis of sexual orientation if: (1) The issuer offers coverage of an opposite-sex spouse; and (2) The issuer chooses not to offer, on the same terms and conditions as those offered to an opposite-sex spouse, coverage of a same-sex spouse based on a marriage that was validly entered into in a jurisdiction 3 where the laws authorize the marriage of two individuals of the same sex, regardless of the jurisdiction in which the insurance policy is offered, sold, issued, renewed, in effect, or operated, or where the policyholder resides. This section does not require a group health plan (or group health insurance coverage provided in connection with such plan) to provide coverage that is inconsistent with the terms of eligibility for coverage under the plan, or otherwise interfere with the ability of a plan sponsor to de?ne a dependent spouse for purposes of eligibility for coverage under the plan. Instead, this section prohibits an issuer from choosing to decline to offer to a plan sponsor (or individual in the individual market) the option to cover same-sex spouses under the coverage on the same terms and conditions as opposite sex- spouses. CMS is issuing this guidance to clarify the current regulations? prohibition against discrimination based on sexual orientation. This guidance operates to clarify these terms as CMS has used them in 45 CFR This clarification is consistent with the policy of ensuring that all individuals have access to health coverage. At the same time, we recognize that some issuers may not have understood the prohibition as described in this guidance when designing their policies for the 2014 coverage year. Accordingly, while issuers are encouraged to implement this clari?cation for the 2014 coverage year, we expect issuers to come into full compliance with the regulations as clari?ed in this guidance no later than for plan or policy years beginning on or after January 1, 2015. We also expect States4 to begin enforcing the regulations in accordance with this clari?cation no later than for plan or policy years beginning on or after January 1, 2015. CMS will not consider a State to be failing to substantially enforce PHS Act section 2702 in connection with this clari?cation for earlier policy years. (FAQ on Coverage of Same Sex Spouses (03/14/14)) 1089 2017-?01189 05. Can a health insurance issuer ?le a plan for State approval in the individual or small group market that is intended to be offered only as a QHP in the Marketplace? A: Issuers may ?le plans that they only market through the Marketplace to qualified individuals or the SHOP to quali?ed employers eligible to participate in a Marketplace, provided the marketing does not violate applicable discrimination standards, including those set forth in 45 CFR 156.125 and 45 CFR 156.225, and otherwise complies with applicable federal and state laws and regulations. However, such plans would be considered to be offered in the individual or group market, respectively, in the State. If, despite the fact that the issuer has not advertised the plan other than through the Marketplace, an individual or employer (as applicable) seeks to enroll in the plan directly with the issuer (outside the Marketplace), the issuer may instruct the individual or employer to complete enrollment through the Marketplace. However, if the individual or employer declines to enroll through the Marketplace, or is ineligible to do so, and wishes to enroll directly with the issuer, issuers of health insurance coverage subject to the guaranteed availability requirements of section 2702 of the PHS Act must accept every individual or employer in the state that applies for such coverage, unless an exception applies. We note that form ?ling requirements generally are a matter of state law, and issuers should follow applicable State laws and regulations. The guaranteed availability requirements of PHS Act section 2702 require that, to the extent a plan uses a contract that is designed to apply only for sale through a Marketplace, such contracts must also be valid for use in cases where the plan is subject to enrollment directly with the issuer (meaning outside the Marketplaces). For example, if permitted under applicable state authorities, issuers could ?le contracts that include alternative language that can be selected depending on whether enrollment occurs through or outside the Marketplaces. (CMS FAQs on Health Insurance Market Reforms and Marketplace Standards 05/16/14) 1. What actions are issuers required to take to ensure that QHPs intended for the individual market Marketplace meet the guaranteed availability standards, consistent with the May 16, 2014 As we explained in our FAQ of May 16, 2014, all non-grandfathered individual market health insurance products must be guaranteed available to all individuals, unless an exception applies. Issuers may direct consumers who wish to enroll in a QHP to the Marketplace for enrollment, and are not required to market any QHP for sale outside of the Marketplace. Issuers who intend a QHP to be primarily for sale in the Marketplace are not required to create a designated pathway for off-Marketplace enrollment, and will satisfy the guaranteed availability standard if they enroll consumers who wish to enroll outside of the Marketplace using a process employed entirely on an ad hoc basis. (CMS FAQs on QHPs and Guaranteed Availability Standards 06/03/2014) Q: What is the guidance concerning Guaranteed Availability, and where can written guidance outside of the Enrollment Manual be found? Updated 1-31-17 A: Please refer to Title 45 8594; Subtitle A 8594; Subchapter 8594; Part 147 8594; ?147.104 Guaranteed availability of coverage, in the Code of Federal Regulations (CFR): e45.1.147 1104 (REGTAP FAQ Database - FAQ #15250 03/23/16) 1090 2017-?01190 Transitional Policy Q1. Can health insurance issuers modify or customize the notices that were in the November 21, 2013 guidance? A1. No. The notices in the November 21, 2013 guidance cannot be modi?ed in any way by a health insurance issuer and are required to be used by issuers in informing policyholders of their rights in order for the plan to meet the criteria of the transitional policy. These notices satisfy the notice requirement outlined in the November 14, 2013 letter to the State Insurance Commissioners. Issuers can include a cover letter with the notices providing additional information regarding the renewals, such as issuer contact and premium information. (FAQs on Standard Notices for Transition to ACA Compliant Policies (1 1/21/31)) 02. Can States develop their own notices and require health insurance issuers in their State to substitute their notices for the notices in the November 21, 2013 guidance? A2. Yes, with CMS approval. State Insurance Commissioners can develop required notices that are more consumer protective and more informative than the notices in the November 21, 2013 guidance. If they choose to do so, however, the State notices must be reviewed and approved by CMS before they are sent out by the health insurance issuers. Once the State notices are approved by CMS, they cannot be modi?ed or customized by the health insurance issuers. (FAQs on Standard Notices for Transition to ACA Compliant Policies (11/21/31)) Q3. Can the required notices be combined or inserted in other plan materials or correspondence that is being sent to policyholders? A3. The required notices, regardless of whether they are from the November 21, 2013 guidance or developed by a State (and approved by CMS), must be sent to policyholders separately from any other plan material or correspondence, except for information related to changes in premium associated with the renewal. As stated in the response to Q1, however, issuers can include a cover letter with the notices providing additional information regarding the renewals. And, issuers can include material related to any premium changes associated with the renewal along with the required notices. (FA OS on Standard Notices for Transition to ACA Compliant Policies (11/21/31)) CMS has received a number of questions from States and issuers about the Extended Transition to Affordable Care Act-Compliant Policies bulletin, released March 5, 2014 . The extended transitional policy speci?ed that no Federal enforcement actions would be taken with respect to issuers that elect to continue to offer certain coverage that would otherwise have to be cancelled as non-compliant with speci?ed 2014 market reform requirements. The bulletin also encouraged States to adopt a similar non-enforcement policy. Under this policy, the coverage at issue would not be treated as out of compliance with the speci?ed market reforms if certain speci?c conditions are met. Like the March 5, 2014 bulletin, these FA OS are specifically applicable to the individual and small group markets, and large employers who renew insurance in the large group market for policy years beginning on or after January 1, 2016, and who will be rede?ned as of January 1, 2016 as small employers (those employers with 51-100 employees). 1091 Updated 1-31-17 2017-?01 191 Q7. Would a large employer with 51-100 employees who is a large group policyholder be covered by the March 5, 2014 bulletin with respect to a renewal of its 2013 plan at its 2014 renewal date if the policy is not compliant with the provisions of the ACA that apply to the large group market? A: No. The extended transitional policy for eligible large group plans applies only to plans that an employer renews for a plan year beginning on or after January 1, 2016 and on or before October 1, 2016 the year in which the law applies small group market rules to employers with 51 to 100 employees. Prior to January 1, 2016, all insurance coverage sold to large employers, whether they have 51-100 employees or greater than 100 employees must meet all applicable ACA requirements (note that few new requirements went into effect for such employers in 2014). The extended transitional policy is effective as of January 1, 2016 for eligible large employers with 51-100 employees that originally purchased the insurance in the large group market. (CMS FAQs on Health Insurance Market Reforms and Marketplace Standards 05/16/14) 08. Is a large group employer who employs 51-100 employees required to remain with the same insurer between 2013 and 2016 in order to be eligible for transitional relief in 2016? A: No. A large group employer is not required to remain with the insurer from which it had coverage in 2013 in order to be eligible for the extended transitional relief in 2016 and thus may shop for alternative coverage with a different insurer. The key is that the extended transitional policy for eligible large group plans applies to the large employer plan that the employer has at the time of the renewal that will occur on or after January 1, 2016 and on or before October 1, 2016. Speci?cally, on January 1, 2016, employers who employ between 51-100 employees and thus will be rede?ned as small employers would be covered by the non-enforcement provisions in the March 5, 2014 bulletin through October 1, 2016 with respect to a large employer policy that does not conform to small employer rules if permitted by their State and offered by the health insurance issuer. (CMS FAQs on Health Insurance Market Reforms and Marketplace Standards 05/16/14) 09. Are individual policyholders and small employers who changed carriers between October 2, 2013 and December 31, 2013 eligible for extended transitional relief? A: At the option of the States, and if permitted by the health insurance issuer, the extended transitional policy relief applies to health insurance coverage in the individual and/or small group market that renews between January 1, 2014 and December 31, 2014. However, as outlined in the March 5, 2014 extension of transitional policy bulletin, States have flexibility to limit the duration of the extended transition policy. (CMS FAQs on Health Insurance Market Reforms and Marketplace Standards 05/16/14) Q10. If an individual or small employer purchased a 2014 ACA-compliant plan, are there circumstances where the policyholder can have the 2013 plan reinstated and be eligible for the transitional policy relief? Updated 1-31-17 A: No. If an individual or small employer has purchased a new plan on or after January 1, 2014, the transitional policy would not apply if an individual or small employer attempted to reinstate their previous 2013 non-ACA compliant plan. (CMS FAQs on Health Insurance Market Reforms and Marketplace Standards 05/16/14) 1092 2017--01 192 Q11. Does the large employer transitional policy starting in 2016 apply to large employers with 51-100 employees who did not have health insurance coverage at the time the transitional policy extension bulletin was issued March 5, 2014, but who purchase a large employer policy after March 5, 2014 but before January 1, 2016? A: Yes. The extended transitional policy in 2016 applies to large employers with 51-100 employees that purchase health insurance coverage any time before January 1, 2016. (CMS FAQs on Health Insurance Market Reforms and Marketplace Standards 05/16/14) Q12. Are transitional policies considered minimum essential coverage? A: Yes. Since transitional policies are offered in the individual and small group markets, they are considered to be minimum essential coverage, and individuals enrolled in these plans would satisfy the individual shared responsibility requirement. (CMS FAQs on Health Insurance Market Reforms and Marketplace Standards 05/16/14) Privacy and Security Q: What does the 2015 QHP Agreement require QHP Issuers to comply with in terms of reporting incidents involving personally identifiable information (Pll) to A: The 2015 QHP Agreement requires QHP issuers to report ?any Incident or Breach of to the CMS IT Service Desk by telephone or email noti?cation within seventy-two (72) to ninety-six (96) hours after discovery of the Incident or Breach. The 2015 QHP Agreement de?nes Incident, or Security Incident, as the ?act of violating an explicit or implied security policy, which includes attempts (either failed or successful) to gain unauthorized access to a system or its data, unwanted disruption or denial of service, the unauthorized use of a system for the processing or storage of data; and changes to system hardware, firmware, or software characteristics without the owner's knowledge, instruction, or consent." This definition is generally consistent with the de?nition of security incident under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). (REGTAP FAQ Database - FAQ #7205 11/12/14) Q: Under this definition, do QHP Issuers have to report all failed attempts to gain unauthorized access to a system or its data within 72-96 hours? A: No. CMS acknowledges that there may be some unintentional disruptions to a QHP issuer's system or its data which may not be unlawful and/or pose a risk to a consumer's PII, the QHP issuer, and CMS. A QHP Issuer may be able to leverage existing protocols and processes it utilizes to comply with privacy and security standards under HIPAA, state privacy and security laws, and the Affordable Care Act risk assessment and risk management procedures), to determine what constitutes a failed attempt to access QHP Issuer's system that may not be reasonable to report for every occurrence; versus an incident or pattern of activities that warrants reporting. QHP issuers should also consider numerous factors in the context of its business operations when considering whether to report failed attempts to gain unauthorized access to its systems to CMS, including the probability of potential risks to CMS and individuals and the QHP issuer's technical infrastructure, hardware, and software security capabilities. (REGTAP FAQ 1093 Updated 1-31-17 2017--01193 Database - FAQ #7206 11/12/14) Q: Can CMS provide any examples of when a QHP issuer should report a failed attempt to access its systems to A: The following examples are provided to assist QHP issuers in determining whether a failed attempt to gain unauthorized access to its systems must be reported to CMS. They are for consideration only, are meant to promote review of a QHP issuer's environment in relation to the CMS Incident reporting requirement, and should not be construed to change the terms of the 2015 QHP Agreement. A QHP issuer may decide that a single ?ping? (a request-response utility used to determine whether a speci?c Internet Protocol (IP) address, or host, exists or is accessible) on its communications network initiated from an external source does not amount to a failed attempt to gain unauthorized access to its systems that must be reported to CMS. Notwithstanding, the QHP issuer may also determine that a suspicious pattern of ?pings? on the communications network initiated from an external source or a speci?c malicious attempt to access its systems would require a report to CMS. Further examples of incidents that should be considered for reporting to CMS include: . A sudden unexpected increase in network traf?c; An unexpected or abnormal increase in the number of bad or malformed packets; Systems rebooting for unknown reasons; Discovery of a virus or malware; Loss of equipment; Network scans by unknown sources; A large increase in internet requests that degrades or disables the QHP issuer's system from communicating; and 0 Unknown users being added, or known users' privileges increasing without knowledge or approval. (REGTAP FAQ Database - FAQ #7207 11/12/14) Wellness Programs Q1: May an issuer limit its offering of a wellness program in connection with a particular health insurance product to only certain employer groups enrolling in that product, such as employers in certain industry classi?cations? Updated 1-31-17 No. If an issuer offers a wellness program in connection with a particular product that is approved for sale in a market within a State, and the rewards under the program affect the health insurance coverage for that product, including the premiums, bene?ts, cost sharing, provider network or service area, then the offering of the wellness program would be considered a part of the plan design, and that plan design must generally be made available to every employer in the State and market that applies for such coverage, in accordance with the requirements of section 2702 of the PHS Act. The issuer cannot make a wellness program selectively available only to certain employers. For example, if an issuer?s wellness program that offered a premium discount was only made available to employer groups who perform of?ce work and not those who perform physical labor, that would not be permissible and the issuer would be in violation of the guaranteed availability requirements of section 2702 of the PHS Act. 1094 2017--01 194 This applies only to issuers offering health insurance coverage that is governed by the guaranteed availability provisions of section 2702 of the PHS Act, as added by the Affordable Care Act. It does not affect the ability of an employer to de?ne the terms of the group health plan, including the employer's decision to offer wellness programs as part of the plan that are independent of those offered by the issuer. It also does not apply to excepted benefits under section 2791(0) of the PHS Act employee assistance programs) or wellness programs with rewards that do not affect the coverage memberships). Issuer marketing of wellness programs should be consistent with applicable nondiscrimination standards, including those set forth at 45 CFR (CMS FA OS on Health Insurance Market Reforms and Wellness Programs - 04/16/15) 02: Do the rating rules of section 2701 of the PHS Act prevent an issuer from offering premium discounts, rebates or other incentives for wellness programs other than those designed to prevent or reduce tobacco use? No. Although providing a premium discount, rebate or other reward under a non- tobacco-related wellness program effectively varies the premium based on a factor not described in section 2701 of the PHS Act, the law speci?cally permits such rewards in connection with a wellness program meeting the standards of section 27050) of the PHS Act. (CMS FA OS on Health Insurance Market Reforms and Wellness Programs - 04/16/15) Q3: When establishing the index rate and plan-level adjustments under the single risk pool provision, may an issuer take into account the penalties or rewards expected to be provided under a wellness program (whether health-contingent or participatory)? No. The penalties or rewards associated with participation in a wellness program (participatory or health-contingent) may be applied to individual participants? premiums or contributions (or otherwise accrue to individuals), but may not be used to establish an issuer?s index rate for a market, or any permitted plan-level adjustments, under the single risk pool provision at 45 CFR 156.80. Any such penalties or rewards may be retained or paid out by the issuer or by the employer, as applicable, pursuant to the terms of the wellness program and in accordance with the wellness program regulations. This guidance is applicable to health insurance issuers subject to the single risk pool requirement for rates effective on or after January 1, 2016. Issuers subject to the single risk pool requirement must establish rates consistent with this guidance and without regard to the rewards or penalties expected to be provided under a wellness program. (CMS FAQs on Health Insurance Market Reforms and Wellness Programs - 04/16/15) Uniform Modi?cation and Plan/Product Withdrawal Q: From a system perspective, what data field links plans following uniform modification from year to year? Updated 1-31-17 A: The unique HIOS Plan ID (Standard Component) persists from year to year for plans that are within the uniform modi?cation of coverage standards as described in 45 CFR Thus a plan with the same HIOS-generated 14-character plan ID number in 2015 as 2014 is understood by the system to be the same plan. (REGTAP FAQ Database - FAQ #2038 06/05/14) 1095 2017-?01195 Q: If an issuer chooses to divide a 2014 plan to accommodate the Geographic Rating Area (GRA) factor variation, can all of the plan's ?break-out? plans have the same HIOS Plan A: No. If an issuer wants to address the specific costs of multiple networks within a GRA, they can either combine the costs within a plan, spreading them across all consumers who buy the plan, or set up network specific plans, to demonstrate the pricing variations speci?c to each network. If issuers divide a 2014 plan into multiple plans, it will lead to more "new" plans that require new HIOS Plan IDs. The issuer would persist one plan with the 2014 HIOS Plan ID that follows the de?nition of uniform modi?cation as described in 45 CFR This means that an issuer will need to acquire new HIOS plan IDs for the number of ?break-out" components minus 1. CMS would expect that these ?new? plans would all be under the same product and that the product ID components as part of the plan ID would be the same. (REGTAP FAQ Database - FAQ #2039 06/05/14) Q: How does the definition of uniform modification of coverage apply to stand-alone dental plans A: As excepted bene?ts, dental coverage offered by stand-alone dental plans (SADPs) is not subject to the uniform modification of coverage de?nition. However, as outlined in the 2015 Exchange and Insurance Market Standards for 2015 and Beyond (2015 Market Standards) Final Rule, we are using the uniform modification standard for the purpose of identifying SADPs that can be recertified and renewed. We are establishing a process by which renewing SADPs could be considered the same plan for the purposes of continued enrollment and continued use of an SADP's HIOS ID. SADP issuers wishing to automatically renew and enroll consumers would then complete the Plan ID Cross Walk template discussed above. CMS anticipates that auto enrollment would occur only for those consumers that did not actively select different coverage during open enrollment. SADP issuers have been concerned about the changes in the dental MOOP and corresponding changes to cost-sharing structures and whether or not these changes would allow them to be considered the same plan. We interpret any uniform cost- sharing changes made to conform to the new national annual limit on cost sharing as meeting the uniform modi?cation standard, because these modi?cations would meet the requirements under of the 2015 Market Standards ?nal rule, which provides that modifications made uniformly and solely pursuant to applicable Federal or State requirements are considered a uniform modi?cation of coverage." We would consider an SADP that is uniformly modified to reduce its annual limitation on cost sharing as being a renewal with a uniform modi?cation of the same plan for the purposes of recertification. (REGTAP FAQ Database - FAQ #2040 06/05/14) Q1: An issuer stops offering Product at the end of 2015, and in 2016 begins offering Product Y. ls Product a new product? It depends. If the differences between Product and Product qualify as a uniform modi?cation of coverage, then, for purposes of federal law, Product is not a new product. Rather, it is a continuation of Product (even if a new Product ID has been 1096 Updated 1-31-17 2017--01196 assigned by the issuer), and it should be reviewed as if it is the same product, including with respect to rate review. Only if the changes are outside the scope of changes contemplated by the uniform modification rules would, for purposes of federal law, Product be considered to have been discontinued, and Product be considered a new product. HHS guaranteed renewability regulations at 45 CFR 146.152, 147.106, and 148.122 set forth standards for uniform modi?cations of coverage and discontinuation of a product (as defined in 45 CFR 144.103). For example, Issuer offers Product in the individual market in 2015 (Product ID: 39854QQ042). Issuer stops offering Product effective at the end of 2015, and, for 2016 coverage, begins offering Product (Product ID: 3985400043). The only changes between Product and Product are cost-sharing changes to maintain metal tier levels for each Plan in the Product. For purposes of federal law, Product is not a new product because the changes satisfy the conditions of a uniform modification of coverage they are cost-sharing changes made to a plan to maintain the same metal tier level.2 The uniform modification rules give issuers substantial room to adjust product portfolios. Changes to covered bene?ts, outside of those made pursuant to applicable federal or state requirements, may cumulatively impact the plan-adjusted index rate for any plan within the product by :2 percentage points without falling outside the scope of the uniform modi?cation of coverage rules. In addition, under 45 CFR regulators may broaden standards relating to service area and cost-sharing structure, giving issuers room to adjust plans within products, and stay within the parameters for uniform modi?cation. If product changes fall within the uniform modi?cation standards, including pursuant to the state discretion under 45 CFR the product is subject to the ACA rate review requirements under 45 CFR Part 154 as a continuation of the product that was modi?ed. CMS encourages states to exercise this discretion to ensure that product changes are considered uniform modifications of coverage where appropriate. (Uniform Modification and Plan/Product Withdrawal FAQ 06/15/15) 02: An issuer makes changes within a product but submits it as a new product. The state determines that the product changes are within the standards for uniform modification of coverage. Is the issuer required to revert to the product?s former Health Insurance Oversight System (HIOS) product identifier Updated 1-31-17 HIOS product IDs should change only when a new product is being submitted, as determined by the uniform modification of coverage standards. If a product remains the same product, consistent with the uniform modi?cation standards, it should continue to use the same HIOS product ID. If a product is a different product based on the uniform modi?cation standards, the new product should use a different HIOS product ID. However, for products that will be offered for plan years beginning in 2016, issuers that submitted product IDs in a manner inconsistent with this guidance will not be expected to update their HIOS product IDs, unless otherwise required by the applicable state regulator. Nonetheless, we note that the HIOS ID assigned by the issuer is not determinative of compliance with any applicable provision of federal law, including the guaranteed renewability and rate review requirements. The discrete package of health insurance coverage benefits that the health insurance issuer offers using a particular product network type within a service area comprising the product, rather than the HIOS ID, will determine an issuer?s obligations under those provisions of federal law. 1097 2017--01 197 For example, as discussed in Issuer offers Product in the individual market in 2015 (Product ID: 3985400042). Issuer stops offering Product effective at the end of 2015 and, for 2016 coverage, begins offering Product (Product ID: 3985400043). The only changes between Product and Product are cost-sharing changes to maintain metal tier levels for each Plan in the Product. For purposes of federal law, Product is not considered a new product because the changes satisfy the conditions of a uniform modi?cation of coverage they are cost-sharing changes made to a plan to maintain the same metal tier level. In this example, under this guidance the issuer would othen/vise be directed to maintain the same Product ID for Products and Y, but for 2016, CMS will not require the issuer to revert back to the 2015 product ID (Product ID: 3985400042). Uniform Modi?cation and Plan/Product Withdrawal FAQ 06/15/15) 03: If an issuer removes a plan from a product or adds a plan to a product, would such a change be considered a discontinuance of that product? An issuer will not trigger a product discontinuance by removing a plan from a product or adding a plan to a product, unless by removing a plan, the issuer exceeds the scope of a uniform modi?cation for the product the product no longer covers a majority of the same service area). For example, Issuer offers Product in a state that de?nes service area based on enrollment-weighted geographic coverage. Product includes 3 Plans - Bronze Plan (constituting 20 percent of the product?s enrollment), Silver Plan (constituting 75 percent of the product?s enrollment), and Gold Plan (constituting 5 percent of the product?s enrollment). Issuer removes Bronze Plan X. The removal of Bronze Plan can be considered a uniform modi?cation of Product under 45 CFR which does not result in the discontinuance of Product because Product continues to cover a majority of the same service area based on covered population. (Uniform Modi?cation and Plan/Product Withdrawal FAQ 06/15/15) 04: If an issuer makes minor changes to a plan?s cost sharing, has it changed the plan?s ?cost-sharing structure? such that the change will not be considered a uniform modification, and a product discontinuance is triggered under 45 CFR Updated 1-31-17 Because the regulations do not de?ne the term ?cost-sharing structure," CMS will defer to a state's reasonable interpretation of this provision. Furthermore, a state has the discretion to broaden the standards in 45 CFR as stated in 45 CFR such that changes in cost sharing within the same metal tier level could be considered a uniform modification rather than a product discontinuance. CMS intends to be flexible when determining whether a cost-sharing structure is ?the same? for the 2016 plan year as it was in the 2015 plan year. Note that the magnitude of a change in cost-sharing structure does not affect whether the change is considered a uniform modi?cation if the change was solely related to changes in cost and utilization of medical care, or to maintain the same metal tier, as set forth in 45 CFR Any changes in cost-sharing structure for such reasons would be considered a uniform modi?cation that would not trigger a product discontinuance. (Uniform Modi?cation and Plan/Product Withdrawal FA 0 06/1 5/1 5) 1098 2017-?01198 05: If an issuer changes all of its products in a market such that the changes do not qualify under the uniform modification rules (resulting in a product discontinuance), will the issuer be considered to have performed a market withdrawal, and be subject to the 5- year prohibition on market reentry? Yes. For purposes of federal law, market withdrawal occurs when a carrier discontinues all of its products4 within the applicable market in a state (individual market, small group market, or large group market). This is true even if a carrier files new products, if those new products would not be available for coverage effective until after the current products are discontinued. Therefore, if an issuer?s entire offering of products within a market has been discontinued or substituted with new products such that each substituted product has undergone changes that are not uniform modi?cations, then the issuer has effectuated a market withdrawal under federal law, and will be subject to the five-year prohibition on market reentry, beginning on the date of discontinuation of the last coverage not renewed. Therefore, the issuer will be prohibited from offering the newly filed products. The issuer would be required to provide notice of the discontinuation at least 180 days prior to the date coverage would be discontinued. Because product filings for coverage beginning in 2016 already have been filed in many states, CMS will apply this policy prospectively, effective for coverage beginning on or after January 1, 2017. If, however, the changes to any product are determined to include only uniform modi?cations, then those changes would not result in the discontinuance of the product, and the continuation of that product would mean that the issuer did not effectuate a market withdrawal. States have the discretion to broaden the scope of what is considered a uniform modi?cation with respect to the service area and cost-sharing structure. (Uniform Modi?cation and Plan/Product Withdrawal FAQ 06/15/15) CO-OP PROGRAM Q1: Can the Centers for Medicare Medicaid Services (CMS) provide additional guidance on the establishment of the Private Purchasing Council, such as: a. Are there any limitations on functions performed beyond those mentioned in the statute? b. Does a separate entity need to be established? If so, are there limitations on form, such as LLC, Partnership, Schedule C, or Non-Profit? c. Could the council act as a management organization for multiple CO-OPs to achieve development or administrative efficiencies? d. If a separate entity needs to be established, could external organizations own all or part of the council, if not otherwise subject to any of the predecessor or related entity regulations? Updated 1-31-17 A1: The statute provides wide latitude in the operation of purchasing councils to buy services such as third-party administrative services, reinsurance or IT functions for CO- OPs that would result in lower administrative costs. The statute envisions that purchasing councils are formed by the CO-OPs as separate organizations. In addition, there is no barrier to a purchasing council providing management functions for a CO-OP or group of CO-OPs, but a CO-OP in its application would need to clearly describe the management functions performed directly by the CO-OP, what functions it anticipates 1099 2017-?01199 delegating to a purchasing council or other third party, and what the effects would be on the overall management and governance of the CO-OP. (CMS FAQs CO-OP Program 03/12/12) 02: Please provide additional guidance on what is included in the 75 page limit. a. Are the Excel spreadsheets for the pro-forma ?nancial statements and other supporting models bylaws) considered part of the 75-page limit, or can they be considered as attachments? b. If an applicant intends to set up a multi-state CO-OP, are they limited to this 75 page limit? A2: a. Under the Funding Opportunity Announcement of December 9, 2011, the application narrative may not exceed 75 pages. This includes: the application cover letter, the application abstract, the project narrative, and the business plan (not including pro forma ?nancials, resumes, and any other supporting Excel documents). This 75 page limit does not include: Standard Forms SF 424), the feasibility study certi?cation and analysis, organizational charts, position descriptions, resumes, proforma ?nancials and other business plan attachments, supporting excel documents, governance and licensure requirements, evidence of nonpro?t status, relevant statutory and regulatory citations regarding state licensure, eligibility af?davit and application certi?cation, af?davit(s) of criminal and/or civil proceedings, affidavit of eligibility to participate in federal programs, and evidence of private support. Applicants may upload these additional appendices as separate attachments. c. If an applicant intends to set up a multi-state CO-OP, they are expected to discuss their overall feasibility study and business plan within the 75-page limit. However, applicants may use appendices to further describe their State specific feasibility studies and business plans. Such appendices would not be included in the 75-page limit. (OMS FA Qs CO-OP Program 03/12/12) Q3: Is it acceptable to incorporate generic nonpro?ts that have the mission to develop a CO-OP plan but that do not have a stated explicit insurance purpose and are not incorporated as an insurance entity so as to meet timeline? A3: As finalized at 45 CFR 156.515, applicants must be incorporated as a non-pro?t member organization. However, applicants need not be incorporated or licensed as an insurance entity provided that the applicant entity is able to become a licensed issuer within the prescribed time period. The applicant must be the entity that ultimately becomes a CO-OP. Under the Final Rule, applicants should have a plan for achieving licensure and offering a quali?ed health plan in the Affordable Insurance Exchanges within three years of receiving Start-up Loan funds or within one year of receiving Solvency Loan funds. (CMS FAQs CO-OP Program 03/12/12) Q4: Must an eligible applicant be incorporated as a non-profit member organization speci?cally within the State it intends to organize a future CO-OP in order to be awarded a CO-OP loan? A4: Under the Final Rule, an applicant is not required to be incorporated as a non-profit member organization in each State in which it intends to organize a CO-OP. It must, however, be authorized to do business in any State where it intends to offer coverage. A 1100 Updated 1-31-17 2017--01200 successful applicant must eventually be licensed by the State insurance agency, either as a domicile issuer or a foreign issuer operating with an expansion license in every State in which it intends to provide health insurance coverage. (CMS FAQs CO-OP Program 03/12/12) Q5: Is it permissible to set up a relationship between the sponsoring organization and the CO-OP entity whereby the sponsoring organization applies for the loan on behalf of the future CO-OP, with a plan for transitioning the loan to the CO-OP entity once created? A5: No, under the Final Rule, the nonpro?t entity that will become the CO-OP after receiving funds will need to submit the application. As stated in response to Question applicants need not be incorporated as an insurance entity provided that the applicant entity is able to become a licensed issuer within the prescribed time period. (CMS FAQs CO-OP Program 03/12/12) 06: What does CMS expect applicants to have in place with vendor partners at the time of the application Letters of Intent with networks, reinsurers, etc.)? A6: Consistent with the Funding Opportunity Announcement, we expect that applicants will either have identi?ed strategic operational partners or be able to describe a plan for developing speci?c partnerships with provider networks, reinsurers, etc., and provide documentation of existing relationships with vendor partners. This could be demonstrated with a Letters of Intent or Support. It is not expected that formal obligations will be in place at the time of application or that negotiations will be completed. (CMS FAQs CO-OP Program 03/12/12) Q7: What happens if the CO-OP time-line changes as a result of State Department of Insurance (DOI) concerns? A7: Consistent with recommendations of the CO-OP Advisory Board, CO-OPs should begin discussions with the State DOI as soon as possible and prior to submitting an application in order to be able to provide solvency information as required in the application and comply with any State requirements that will be essential to formation, operation, and licensure of the CO-OP. Successful applicants will have three years from the ?rst drawdown of Start-up Loans to work with their State DOI to become licensed in order to offer qualified health plans. Successful applicants will be unable to draw down solvency loan funds until such funds are required by the State DOI to complete the licensure process. (CMS FAQs CO-OP Program 03/12/12) Q8: Would the standard in the Final Rule that two-thirds of contracts must be in the individual or small group markets, prevent a CO-OP from offering coverage to large groups or medical groups or hospitals that want to offer the coverage to their employees? Is a Medicaid or Medicare contract counted as one contract? A8: Under the Final Rule, as long as two-thirds of the policies and contracts issued by a CO-OP in each State are quali?ed health plans in the individual or small group markets, the CO-OP is not prevented from offering coverage to large groups or medical groups that want to offer coverage to their employees. Each insurance policy or contract that an issuer sells constitutes a single activity regardless of the group size. For example, a ?rm of 40 insured workers and an individual Exchange enrollee each count as single activity. 1101 Updated 1-31-17 2017-?01201 Therefore, a Medicaid or Medicare contract or an employer group contract would be counted as one single activity. (CMS FAQs CO-OP Program 03/12/12) Q9: Can a business plan and budget include funding for private purchasing council administration and governance activities? A9: According to the Funding Opportunity Announcement, the costs of establishing private purchasing councils as provided for in section 1322(d) of the Affordable Care Act may be considered start-up costs. (CMS FAQs CO-OP Program 03/12/12) Q10: How is ?part of State or local government and practice groups? defined in the Final Rule? Would a hospital that is a separate, private, not-for-profit entity that provides training for medical students of a State university medical school be prohibited from sponsoring a Could such a hospital or related entity sponsor a CO-OP so long as the chief executive and board members are not shared? A10: Consistent with the Final Rule, a private, non-profit hospital that provides training to State university medical students or residents, but does not receive funding other than as payment for services from an instrumentality of a State or local government may sponsor a CO-OP. The Final Rule clarifies that a CO-OP may receive limited grants (less than 40% of its total funding, excluding CO-OP loans) and other funding from a State or local government as long as the CO-OP or its sponsor is not controlled by a governmental entity. (CMS FAQs CO-OP Program 03/12/12) Q11: Would a conversion to a for-profit entity be prohibited in all situations? What if the CO-OP Members voted in favor of such a conversion if it meant that coverage would be preserved? What happens if, after several years of operations, the CO-OP needs additional financial support and the most suitable alternative is private equity? Would a conversion be prohibited? A11: Under the Final Rule, a CO-OP conversion to a for-profit entity is prohibited in all circumstances. (CMS FAQs CO-OP Program 03/12/12) Q12: Is the (Treasury rate minus a fixed or adjustable rate for the loan repayment? A12: According to the Funding Opportunity Announcement, Start-up Loan recipients will be charged an interest rate equal to the average interest rate on marketable Treasury securities of similar maturity minus 1 percentage point (but no less than at the time of award. This interest rate will be determined at the time of the award and remain ?xed for the life of the loan. Similarly, Solvency Loan recipients will be charged an interest rate equal to the average interest rate on marketable Treasury securities of similar maturity minus 2 percentage points (but no less than at the time of award. This interest rate will be determined at the time of the award and remain fixed for the life of the loan. (CMS FAQs CO-OP Program 03/12/12) 1 102 Updated 1-31-17 2017-?01202 Q13: Can a person that is a member of an existing health cooperative that is an existing licensed issuer be on the Board of Directors (BOD) of a CO-OP or otherwise involved with the governance of that A13: Under the Final Rule, a member of an existing health cooperative that is a licensed issuer may serve on the BOD of a CO-OP or otherwise participate in the governance of a CO-OP if the member is not a representative of the existing health cooperative. Therefore, the member cannot participate employee of the existing health cooperative or otherwise serves as a ?representative? of the organization. A ?representative" means an individual who stands or acts for an organization or group of organizations through a formal agreement or ?nancial compensation such as a contractor, broker, lobbyist, official, or employee. The member must not serve in a position that would create a conflict of interest or allow the existing health cooperative to exert undue influence on the governance of the CO-OP. (CMS FAQs CO-OP Program 03/12/12) Q14: Can an employee from a current health insurance issuer also be an employee for a A14: Consistent with the Final Rule, an employee may work for both a current health insurance issuer and a CO-OP, provided that the employee does not serve in a position of leadership or management for either organization that would create a con?ict of interest or allow the current health insurance issuer to exert undue in?uence on the governance or activities of the CO-OP. (CMS FA 03 CO-OP Program 03/12/12) Q15. After receiving the Letters of Intent (LOI) to apply for CO-OP loans, will CMS be releasing this information publicly? A15: Because the loan award process is competitive, CMS does not anticipate publicly posting the names or locations of organizations that submit a Letter of Intent (LOI). (CMS FAQs CO-OP Program 03/12/12) Q16: Will CMS approve Start-Up Loan modifications necessary to satisfy the capital requirements associated with unexpected rapid growth or high enrollment? A16: Consistent with the FOA, applicants should estimate their funding needs as accurately as possible in the business plan submitted as a part of the application. Applicants should not assume that loan modi?cations will be available to provide additional funding. (CMS FAQs CO-OP Program 03/12/12) Q17: Will CMS allow applicants to submit detailed budgets only for the limited Start-Up period and less detailed forecasts for the periods after that? A17: Consistent with the FOA, the budget and budget narrative must account for all uses of Start-Up Loan funds and cover the full period through which start-up funds are expended. The budget template attached to the funding opportunity announcement (FDA) is intended to be a sample of what CO-OP applicants should provide with their business plans. Applicants are expected to submit a budget plan for Start-Up and Solvency Loans with as much speci?city as is feasible, with the expectation that CO-OPs will be updating their business plan as they become operational. (CMS FAQs CO-OP Program 03/12/12) 1 103 Updated 1-31-17 2017--01203 Q18: What would preclude a CO-OP from offering insurance prior to 2014? A18: As described in Section 1322(c)(6) of the Affordable Care Act, an entity cannot be a quali?ed nonprofit health insurance issuer unless it ?does not offer a health plan in a State until that State has in effect (or the Secretary has implemented for the State) the market reforms required by part A of title XXVII of the Public Health Service Act." (CMS FAQs CO-OP Program 03/12/12) Q19: Can an organization partner with an existing health insurance issuer to develop a A19: As a statutory requirement under section 1322(c)(2)(A)the Affordable Care Act, if an organization is a health insurance issuer that was in existence on July 16, 2009, a related entity, or any predecessor of either pre-existing issuer), that organization is not eligible for loans under the program and cannot become a The Final Rule also prohibits pre-existing issuers from sponsoring a CO-OP. (CMS FAQs CO- OP Program 03/12/12) 020: Will CMS allow a Third Party Administrator develop a A20: Consistent with the statute and Final Rule, a Third Party Administrator may develop a CO-OP unless the Third Party Administrator was also a licensed health insurance issuer on July 16, 2009. (CMS FAQs CO-OP Program 03/12/12) 021: If CMS is unlikely to fund applicants with overlapping service areas and two applicants submit Letters of Intent (LOI) to apply for funds, is the first applicant?s application held until the second applicant?s application is reviewed? A21: The statute permits the funding of multiple CO-OPs in any State, provided that there is sufficient funding to capitalize at least one CO-OP in each State. Consistent with the FDA, we expect applications to be reviewed within approximately 75 days of notice of an application being complete. Accordingly, applications will be evaluated on their own merits, and awards will be made in the time-table outlined in the FDA. Final award decisions will be made by a CMS program official. In making these decisions, the CMS program official will take into consideration: recommendations of the external reviewers; reviews for programmatic compliance; the reasonableness of the size of the loan request and anticipated results of funding the application; ability to repay the loan, and the likelihood that the proposed project will result in the bene?ts expected. (CMS FAQs CO-OP Program 03/12/12) 022: Does the prohibition in the statute on provider rate setting by a private purchasing council prevent CO-OPs from arranging for their provider contract rates to be used by other CO-OPs for out-of-network care? Updated 1-31-17 A22: Under the statute, CO-OPs will be allowed to establish private purchasing councils. As described in the statute, private purchasing councils may not ?set payment rates for health care facilities or providers participating in health insurance coverage provided by qualified nonprofit health insurance issuers,? and relevant antitrust law continues to apply. However, CO-OPs ?may establish a private purchasing council to enter into collective purchasing arrangements for items and services other than those directly with 1104 2017-?01204 health care providers that increase administrative and other cost ef?ciencies, including claims administration, administrative services, health information technology, and actuarial services.? CO-OPs should work with State insurance regulators to establish service areas that meet all applicable State laws. (CMS FAQs CO-OP Program 03/12/12) Q23: Can the CO-OP use a management services organization to provide services for the benefit of the CO-OP, including providing executives for the organization? A23: Consistent with the Final Rule, 3 CO-OP must demonstrate that the management is controlled by the CO-OP members and is accountable to them. Applicants must show how they will achieve this accountability when transitioning from the Formation Board to Operational Board. Boards are permitted to include experts who are not plan members in order to obtain knowledge in areas such as ?nance, actuarial functions, and medical management. (CMS FAQs CO-OP Program 03/12/12) 024: Does CMS have any objection to a CO-OP paying reasonable fees to the members of the formation board of directors (BOD) or to the members of the operational board of directors A24: The statute, Final Rule, and FDA do not prohibit reasonable compensation. Applicants should consider that salaries will affect the size of the loans and premium rates in their business plan, which will be evaluated to ensure that they are viable in the CO-OP's target market. (CMS FAQs CO-OP Program 03/12/12) 025: Does the 80% individual/small group Medical Loss Ratio (MLR) requirement under the Affordable Care Act is, apply to CO-OPs, especially in the early years of their development? A25: Under the statute, the Medical Loss Ratio (MLR) standards that appear in Section 2718 of the Public Health Service Act apply to CO-OPs. These rules include a ?credibility adjustment? when the insurer?s medical loss ratio for a market within a State is based on less than 75,000 people enrolled for an entire calendar year. The credibility adjustment, recommended by the National Association of Insurance Commissioners (NAIC) and adopted in the regulation, addresses the statistical unreliability of experience based on a small number of people covered. In addition, consistent with NAIC recommendations, certain insurers that have newly joined the insurance market may be able to delay reporting their medical loss ratio until the next year. When 50% or more of an insurer's premium income accounts for policies that have not been effective for an entire calendar, they are eligible to delay reporting until the following year. A fact sheet on MLR standards is available here: loss ratio.html. (CMS CO- OP Program 03/12/12) Q26: Does CMS determine if a CO-OP is tax-exempt at the State level? Updated 1-31-17 A26: Under the statute and Final Rule, an applicant and a CO-OP must be ?organized under State law as a nonpro?t, member corporation,? which is defined as ?a nonpro?t, not-for-pro?t, public bene?t, or similar membership entity organized as appropriate under State law." State tax-exempt status is not an eligibility criterion; it is possible that an 1105 2017-?01205 organization may be a nonprofit organization but not tax-exempt under State law. (CMS FAQs CO-OP Program 03/12/12) 027: Does an existing non-profit entity have to form a separate entity to apply for funds and become a A27: First, as a statutory requirement under the Affordable Care Act, a health insurance issuer that was in existence on July 16, 2009 cannot sponsor a CO-OP. Under the Final Rule, the applicant must be the entity that will eventually become a CO-OP. Unless the sponsor wants to become a CO-OP, it should form a separate entity. (CMS FAQS CO- OP Program 03/12/12) 028: Can a CO-OP be founded by a consumer-run nonprofit self-insured Multiple Employer Welfare Arrangement (MEWA) that does not have an insurance license, but that is currently licensed in its domiciliary state as a non-pro?t, self-funded A28: Under the statute and Final Rule, entities not licensed as issuers on July 16, 2009 are permitted to apply. If a MEWA was licensed as an issuer in a State on July 16, 2009, it cannot receive a loan under the CO-OP program. (CMS FAQs CO-OP Program 03/12/12) 029: If an applicant is applying to operate in multiple States, are separate loan applications required? If an application covers more than one State, can the $100,000 available for preparing the business plan and feasibility study be multiplied by the number of States? A29: Consistent with the Final Rule and FDA, submitting multiple applications for CO- OPs operating in multiple States depends on the management team and governance of each CO-OP. Separate loan applications can be submitted if the CO-OPs are independently organized under State law, the management teams differ, or the CO-OPs are independent and governed by separate boards of directors by State but share the same sponsor. An applicant intending to create a single CO-OP that operates in more than one state need only submit a single loan application. The FDA speci?es that, for applicants ?approved to operate in more than one State, an additional $50,000 attributable to the cost of preparing feasibility studies and business plans per additional State in which the applicant is approved to operate will be considered eligible costs for Start-Up Loans for up to four additional States amounting to a maximum of $300,000." (CMS FAQs CO-OP Program 03/12/12) Q30: We anticipate filing as an applicant for two States initially. Each of these States will have a separate legal entity. Should we anticipate making two applications, even though we anticipate sharing administrative and management functions between the two legal entities? If we do file two applications, how could we best reflect this in the budget narrative and forms? A30: If the applicant intends to create a single CO-OP that operates in more than one State, it need only submit a single loan application. On the other hand, if the two entities will be functioning as separate CO-OPs with separate governing boards but are sharing some services in common, an applicant ?ling for a CO-OP in two States should file two applications. The application should indicate the names and locations of the applicants 1106 Updated 1-31-17 2017-?01206 sharing services in the project narrative. The budget narrative should clearly describe how expenses for shared services will be allocated between the two applicants. (CMS FAQs CO-OP Program 03/12/12) Q31: Which parts of our application can we mark proprietary to protect the identity of potential managers and other sensitive information such as enrollment strategy? Are there specific areas that we may or may not designate as confidential? A31: In accordance with the Department?s Freedom of Information Act (FOIA) implementing regulation at 45 C.F.R. you may designate part or all of the information you submit as exempt from disclosure under Exemption 4 of the FOIA if you believe the information is commercial or financial information that is con?dential or privileged. If there is a FOIA request for your submitted information, we will follow the pre-disclosure notification procedures found at 45 C.F.R. to seek your input on the applicability of Exemption 4 before disclosure is made. If the information has previously been published or made generally available to the public, it will not be considered con?dential or privileged for purposes of Exemption 4. For more information on the applicability of Exemption 4, please visit quideOQ/exemption4pdf. (CMS FAQs CO-OP Program 03/12/12) Q32: Can interest be earned on Solvency Loans awarded under the CO-OP program? A32: The statute, Final Rule, and FDA require that reserves are held in appropriate accounts structured and invested in compliance with standards approved by State insurance regulatory agencies. (CMS FAQs CO-OP Program 03/12/12) Q33: Is there any limitation on using the infrastructure created with CO-OP Start-Up or Solvency-Loans to serve non-exchange business? A33: Neither the statute nor the Final Rule restricts loans to only lines of business operating in the Exchanges. CO-OPs are further required to offer plans ?in every individual market Exchange that serves the geographic regions in which the organization is licensed and intends to provide health care coverage," and, if the CO-OP serves the small group market, to offer plans ?in each SHOP that serves the geographic regions in which the organization offers coverage in the small group market." The Final Rule requires that ?at least two-thirds of the policies or contracts for health insurance coverage issued by a in each State in which it is licensed must be qualified health plans offered in the individual and small group markets.? (CMS FAQs CO-OP Program 03/12/12) Q34: If an individual has family coverage through the CO-OP (either through the individual's employer or the individual's purchase of a non-group policy), are the individual's dependents spouse) also members with the right to vote and serve as a director? Updated 1-31-17 A34: The Final Rule de?nes a member as an ?individual covered under health insurance policies issued by a loan recipient.? However, voting rights are limited to members over 18 years old. This de?nition of ?member? does not permit the plan to exclude adult dependents spouses) from governance because every adult covered by the CO OP must be eligible to vote and serve on the board of directors in order to ensure that 1107 2017-?01207 decisions are made in the best interest of all covered lives. (CMS FAQs CO-OP Program 03/12/12) Q35: Can the Solvency Loans be requested over a ramp-up period (Le. 2014 through 2016)? A35: As stated in the FOA, applicants should request the total amount they anticipate requiring during the life of the loan. However, as further stated in the FOA, anticipates that Solvency Loan recipients may need to draw down the loan in multiple phases." (CMS FAQs CO-OP Program 03/12/12) Q36: Can applications be supplemented after submission? A36: No. As required in the FDA, all loan applications must be submitted electronically as complete and be received through by 11:59 pm. Eastern Time on October 17, 2011, or by 8:00pm Eastern Time on the quarterly application due dates thereafter: January 3, 2012, April 2, 2012, July 2, 2012, October 1, 2012 and December 31, 2012. It is important to make sure that applications are complete at the time of submission according to the requirements set forth in the FOA. Appendix A on page 55 of the FDA serves as an organizational tool to assist the applicant in preparing a complete application package. Applicants are strongly encouraged not to wait until the due date to submit their application package in case of technical or other unforeseen difficulties. Applicants should register on grants.gov at least one month prior to the due date to be sure that they have registration numbers and other information needed to submit an application. Incomplete or late applications will not be considered for award in that submission round. (CMS FAQs CO-OP Program 03/12/12) Q37: Can the application ask for a range of funding (minimum/max with two different plans for growth?) A37: As indicated in the FOA, an applicant should submit its most accurate projection of its funding needs based on its expected growth trajectory as re?ected in its business plan. (CMS FAQs CO-OP Program 03/12/12) Q38: How long does the grants.gov registration process take if our organization has never used this process before? Updated 1-31-17 A38: The time required to complete the registration process varies by applicant and it is possible that it may take over a month. Therefore, we strongly encourage you to start this process as early as possible. In order to use grants.gov you will be required to have an Employee Identification Number and a Data Universal Numbering System (DUNS) number; you also will need to register with the Central Contractor Registration (CCR) database. For speci?c information about these various numbers and databases please go to faqs.isp. (CMS FAQs CO-OP Program 03/12/12) 1108 2017-?01208 Q39: The FDA encourages applicants to secure private support, including but not limited to, committed funding, committed in-kind support, letters of intent from key stakeholders or partners, and letters of support from key community leaders. Do letters of support from key community leaders need to be submitted with my application? A39: Yes. The funding opportunity announcement states that an applicant should include any evidence of private support (which includes letters of support from key community leaders) as an attachment when submitting a completed application on grantsgov. All materials should be submitted with the application to grantsgov. If letters of support for an applicant are sent directly to CMS, we cannot guarantee that they will be considered as part of that application. (CMS FAQs - CO-OP Program 03/12/12) Q40: The Funding Opportunity Announcement lists ?Evidence of Private Support? as a required document under the Start-up Loan and Solvency Loan Application Check List on page 56. However, the Review Criteria listed on page 40 of the FDA states that ?Evidence of Private Support? is a statutory preference and not a requirement. If an applicant does not have any evidence of private support, do they need to provide this document? A40: No. As stated in the Amended FOA released on December 9, 2011, evidence of private support is a recommended document. Evidence of private support should only be provided if an applicant has private support such as committed funding, or committed in-kind provision of services. As discussed in Q39, evidence of private support also includes letters of intent from key stakeholders provider groups) to participate in the CO-OP or its formation, and/or letters of support from key community leaders. Applicants who do not have private support should indicate this in their application. (CMS FAQs CO-OP Program 03/12/12) Q41: Who is conducting the external review process for CO-OP applications? A41: To assist CMS in awarding CO-OP loans, we have obtained services from Deloitte Consulting, LLP to establish, and manage quali?ed expert, objective technical panels responsible for reviewing applications and providing recommendations to CMS staff. The technical review panels review all applications to determine applicant eligibility. As stated in the FDA, the final award decisions are made by CMS program of?cials with private insurance expertise and who are walled off from CMS CO-OP program staff. (CMS FAQs CO-OP Program 03/12/12) Q42: How many applications did CMS receive for the CO-OP program on October 17th and January 3, 2012 and what States do these applications cover? Updated 1-31-17 A42: Consistent with established Departmental policy in the administration of a competitive award process, CMS does not anticipate publicly posting the names or locations of organizations that submit an application. This information will be posted for successful applicants that receive loans. We can say that applications received re?ect proposals to operate in most states, with multiple applications for a number of states. However, applicants should keep in mind that all materials submitted to CMS are subject to the Freedom of Information of Act (FOIA), 5 USC 552. Certain information in the materials may be exempt from release (for example con?dential business information and personal privacy information), as outlined in the FOIA and in the Department?s FOIA regulation. Individuals who wish to submit a FOIA request for CMS records may do so by 1109 2017-?01209 utilizing the following link to the CMS FOIA webpage: (CMS FAQs CO-OP Program 03/12/12) Q43: If a representative of a for-profit health care provider sits on the Board of Directors of a pre-existing Issuer, is the for-profit health care provider barred from sponsoring a A43: No. The health care provider could sponsor a CO-OP as long as the representative of the provider resigns from the Board of Directors of the issuer. The CO-OP board cannot have any members that also represent pre-existing issuers that are a related entity to the for-profit sponsoring organization. (CMS FAQs - CO-OP Program 03/12/12) Q44: Can Start-up Loans be used to fund costs associated with clinical functions and/or physical construction of offices and facilities? A44: No. Start-up Loans cannot be used to fund costs associated with construction of facilities, including clinical facilities, nor can Start-up Loans be used for clinical expenses, such as salaries of or payments to treating providers, provider clinical space or administrative staff associated with clinical functions, or clinical equipment. CO-OPs should be self-sustaining, meaning these costs are paid for by member premiums and reflected in the reimbursement to providers. However, start-up funds can be used to develop integrated administrative and clinical IT and to provide other functions typically associated with the business of insurance such as quality improvement and disease management programs. (CMS FAQs CO-OP Program 03/12/12) Q45: After submitting my application via I received an error message saying that ?one or more of my documents failed to upload.? How should I resolve this issue? Updated 1-31-17 A45: At the website, you will ?nd information about submitting an application electronically through the site. Technical support is available 24 hours a day, 7 days a week [1-800-518-4726 We strongly recommend that that all applicants register and receive their DUNS number as early as possible. In addition, we strongly recommend that applicants begin the process of uploading the application through as early as possible because technical dif?culties in the application submission that cannot be resolved within the deadline may result in your application being denied review until re-submitted in the next application submission cycle. Applicants can submit their applications at any time up to the deadline. In addition, please follow this guidance to ensure that you upload your application successfully: . The applicant must submit all documents electronically in PDF format or Microsoft Excel (Please use Microsoft Of?ce 2007), including all information included on the SF 424 and all necessary assurances and certifications, and all other attachments. 0 Please upload each required and recommended document from the Start-up Loan and Solvency Loan Application Check List as a separate attachment. The checklist can be found on page 55 of the Funding Opportunity Announcement. . Please include a table of contents page with your application that lists all required and recommended documents in your submission. The table of contents should list each attachment with a brief explanation of what the document is and how many pages it contains (including the number of worksheets within an Excel workbook). 1110 2017-?01210 0 Please include a header at the top of each attachment clearly indicating what the document is. For example, the Feasibility Study (a required document) should have a header at the top of each page of the document that says ?Feasibility Study" as well as the name of the applicant organization. If a document cannot have a header one of the Standard Forms or the resumes) please use a cover page for this attachment indicating what the ?le is. 0 Please use a file name for each attachment that indicates what the document is. For example, the Feasibility Study should be saved as CO-OP. Feasibility Study.PDF? and not saved as ?Attachment . Please use page numbers for the application and separate page numbers for each Attachment. For example, the page numbers in the feasibility study should be labeled ?Feasibility Study, page 0 Please do not save ?les or zipped ?les that are embedded within a PDF or Excel ?le. Please save all documents as a separate PDF or Excel ?le and upload them separately. (CMS FAQs CO-OP Program 03/12/12) Q46: The Funding Opportunity Announcement lists ?Evidence of Nonprofit Status? as a required document under the Start-up Loan and Solvency Loan Application Check List on page 56. What type of evidence is needed to prove that an applicant has obtained nonprofit status in their State? A46: In order to ful?ll this requirement, the applicant must submit a copy of the organization?s of?cial certificate of organization or similar document, such as articles of incorporation, showing the State or tribal seal that clearly establishes that nonprofit status has been conferred or recognized by the appropriate State department or of?cial. Applicants must submit evidence of nonpro?t status that is certified or approved as provided under State law or the entire application will be rejected. Rejected applicants can re-apply in the next round. An application for nonpro?t status submitted to the State but that has not been approved and certi?ed by the State is not suf?cient. (CMS FAQs CO-OP Program 03/12/12) Q47: Are Multiple Employer Welfare Arrangements (MEWAs) eligible to apply for CO-OP loans? A47. Consistent with the FOA and the Final Rule section 156.510, MEWAs are eligible to apply for a loan under the CO-OP Program if they are not pre-existing issuers and they meet all eligibility requirements. Therefore, if on July 16, 2009, a MEWA was licensed as an issuer in a State and was subject to State law that regulates insurance, it is not eligible to become or sponsor a CO-OP. The laws for MEWAs vary from State to State; accordingly, some MEWAs may be eligible to apply to be a CO-OP and others may not. (CMS FAQs CO-OP Program 03/12/12) Q: What happened to the CO-OP money appropriated by the Affordable Care Act? Updated 1-31-17 A: The American Taxpayer Relief Act of 2012 (Pub. L. 112-240) transfers 10 percent of the unobligated balance of funds appropriated by section 1322(9) of the Affordable Care Act to a new CO-OP contingency fund and rescinds the remaining 90 percent of the unobligated funds. The law directs the Secretary of Health and Human Services (HHS) to use the contingency fund to provide assistance and oversight to CO-OP loan recipients that have received a loan or grant award prior to the date of enactment. These 1111 2017-?01211 remaining CO-OP funds remain available until expended. on Consumer Operated and Oriented Plan (CO-OP) Program Contingency Fund (04/04/13)) Q: What happens to current CO-OP loan recipients? A: To date, 24 private, nonprofit entities have been awarded loans to establish CO-OPs across 24 states. Because such funds are considered to be obligated when the awards are made upon execution of a loan agreement, loan or grant awards issued to CO-OPs prior to enactment of the American Taxpayer Relief Act of 2012 are not subject to or affected by the rescission. The Centers for Medicare Medicaid Services (CMS) will continue to provide assistance and oversight to these CO-OPs as they work to achieve program milestones, receive licensure from their respective state Departments of Insurance, qualify as a Qualified Health Plan (QHP), and prepare to participate in the new Health Insurance Marketplace. This assistance may include additional loan funds, as needed, to cover costs of speci?c systems, contracts or work not anticipated and budgeted during loan closing or to extend operations to a new state conditioned on approval of a separate request speci?cally for that proposed expansion. This financial assistance will be important to each success and allow them to respond to changing market conditions. on Consumer Operated and Oriented Plan (CO-OP) Program Contingency Fund {04/04/13)} Q: What happens to CO-OP applicants that were in active negotiations with CMS to complete a CO-OP loan agreement, submitted a request for reconsideration of a previous application, or were given the option to reapply? A: CMS no longer has the authority to make loan awards to new borrowers or enter into loan agreements with new borrowers. on Consumer Operated and Oriented Plan (CO-OP) Program Contingency Fund {04/04/13)} Q: The last application deadline for the Funding Opportunity announcement was December 31, 2012. What happens to the applicants who applied for the last round of funding? A: CMS no longer has the authority to make loan awards to new borrowers. This applies to both new applications and applications received, but not awarded, during earlier application rounds. However, CMS has the authority to provide additional funding to existing borrowers, including funds for expansions to new states. CMS is currently accepting and reviewing the applications submitted by existing borrowers. on Consumer Operated and Oriented Plan (CO-OP) Program Contingency Fund {04/04/13)} Q: How does the rescission affect state Departments of Insurance (DOIs), which are making the determination whether or not to grant licensure to Updated 1-31-17 A: The statute does not rescind funding from the 24 existing CO-OP loan recipients and CMS will continue to disburse funds to CO-OPs as they reach milestones outlined in the loan agreements. Solvency loans will continue to be available to CO-OPs to complete the state licensure process and to support the regulatory capital of the CO-OPs as they begin providing health insurance coverage. A CO-OP must meet all the requirements of state law and regulations in order to successfully complete the licensure process. on Consumer Operated and Oriented Plan (CO-OP) Program Contingency Fund 1112 2017-?01212 (04/04/13)) Q: Will CO-OPs be financially viable? A: Yes, CMS believes the CO-OPs will be financially viable. Each of the 24 CO-OP awardees has undergone a thorough application review process and extensive loan negotiations. Loans have been made only to entities demonstrating a high probability of financial viability, and we expect that these CO-OPs will become active participants in the new health insurance marketplaces. CMS will closely monitor CO-OPs to ensure they are meeting program goals and will be able to repay loans. To ensure strong financial management, CO-OPs are required to submit quarterly ?nancial statements, including cash ?ow and enrollment data, receive site visits, and undergo annual external audits. This monitoring is initially conducted by CMS and will continue concurrently with the financial and operational oversight by state insurance regulators once the CO-OP is approved for state licensure. on Consumer Operated and Oriented Plan (CO-OP) Program Contingency Fund {04/04/13)} Q: Can the Secretary use the new CO-OP contingency fund to provide additional loans to CO-OPs that have received a loan award prior to the date of enactment? A: Yes. Congress authorized the remaining CO-OP funds to be used for ?assistance and oversight" for entities awarded loans under section 1322 of the Affordable Care Act. It has been determined that providing additional funds to existing CO-OPs is a permitted activity under the American Taxpayer Relief Act of 2012 (Pub. L. 112-240). Additional funds may be provided to existing CO-OPs to meet constraints in their start-up activities or to expand their operations to another State. The assessment process for additional funding is rigorous. The available program funds will be prioritized ?rst to ensure the viability of the existing business plans, and secondly to fund modifications to business plans for the purpose of expanding to new states. Expansion requests will be reviewed against the same scoring criteria as were the original loan applications. Preference will be given to expansions that align with the program goal of increasing consumer choice in states that may otherwise face limited issuer competition in their Health Insurance Marketplace. We note that, under the Affordable Care Act, administrative costs related to CO-OPs are supported by the CO-OP fund. on Consumer Operated and Oriented Plan (CO- OP) Program Contingency Fund (04/04/13)) Q1. What does it mean that ?substantially all? of a business be sales of Can CO-OPs sell large group policies or participate in other health programs? Updated 1-31-17 A1. The requirement that substantially all of a sales be QHPs ensures that the CO-OP program retains its focus on providing competitive, high-quality health plan choices to American consumers in the individual and small group markets. The regulation does not preclude CO-OPs from offering other products such as large group policies, Medicaid Managed Care products, Medicare Advantage products, or ancillary products such as dental or vision plans. The limitation on the array of policies issued only restricts the percentage of policies other than QHPs offered in the individual and small group markets. Under our regulations, at least two-thirds of the policies or contracts for health insurance coverage issued by a in each State 1113 2017-?01213 must be QHPs. (CMS FAQs on the COOP Program 1-27?16) 02. When a loans are converted to a surplus note, what does that mean for repayment of the loan? A2. Each CO-OP has two Federal loans: a start-up loan and a solvency loan. The solvency loans have always been treated as surplus notes in the sense that payment is not due to CMS until the State Department of Insurance determines repayment will not adversely impact the CO-OP. The start-up loans were all issued as general obligations to be repaid at a speci?c time. In 2015, CMS agreed to convert CO-OP start-up loans to surplus notes, on a case-by-case basis, if a CO-OP could demonstrate the need and bene?t of a conversion. This conversion was designed to increase financial ?exibility for CO-OPs and allow them to leverage private financial markets. Under the terms of a surplus note, CO-OPs are not required to make any payments that could lead to distress or default. When a creditor accepts a surplus note, the debt becomes comprehensively subordinate, pursuant to National Association of Insurance Commissioners Statement of Statutory Accounting Principles No. 41. Speci?cally, a surplus note renders a debt subordinate to claims of policyholders, beneficiary claims, and all other classes of creditors other than another surplus note. The debt cannot be repaid, and interest cannot accrue, without the prior written approval of the state insurance commissioner. (CMS FAQs on the COOP Program 1-27-16) Q3. Is it true that a CO-OP will be considered to be in default if it has risk-based capital (RBC) below 500%? What are the implications if a CO-OP has an RBC below 500%? Updated 1-31-17 A3. Under our regulations and guidance, a CO-OP that has an RBC below 500% is not automatically considered to be in default. Under the terms of the loan agreement, the RBC level that a CO-OP must maintain is speci?ed in its business plan. For all CO-OPs this level is 500% RBC. Failure to maintain an RBC level that is within at least ten percent of this RBC level is a potential Event of Default under the loan agreement, subject to all terms and conditions thereof. However, CMS evaluates CO-OPs that fall below 500% RBC on a case-by-case basis to determine whether the CO-OP should be placed on a Corrective Action Plan or notified that the drop in RBC constitutes an Event of Default, per the loan contract. Beyond the case-by-case review, there are no automatic actions that CMS initiates if a CO-OP has an RBC level below 500%, assuming the CO-OP remains solvent under state regulatory requirements and has no other substantial issues. We encourage CO-OPs to maintain an RBC level of 500% or higher, but a CO-OP with an RBC below that level may still be in good standing. Providing a CO-OP with the ?exibility to operate at an RBC level below 500% assists consumers by allowing a CO-OP to more easily manage changes in business operations. In addition, in most states, suf?cient RBC levels are between 200% and 300%. (CMS FAQs on the COOP Program 1-27-16) 1114 2017-?01214 Q4. Can CMS waive or change the requirements for serving on a CO-OP board, which could help CO-OPs diversify board membership? A4. Existing standards are described in 45 C.F.R. They require that all board members be elected by a majority vote of a quorum of the CO-OP membership and that a majority of voting directors be CO-OP members covered by policies issued by the CO-OP. The regulation also prohibits any representative of a pre-existing insurance company or state government from serving on the board of a CO-OP. CMS is exploring what changes could be made to help CO-OPs diversify their boards and grow and raise capital, while still preserving the fundamentally member-run nature of the CO-OP program. (CMS FAQs on the COOP Program 1-27?16) MEDICARE AND THE MARKETPLACE Q1: May an issuer request documentation from an applicant or enrollee to establish that the individual falls within the scope of this bulletin? A1: Yes. For individuals who identify themselves as Medicare beneficiaries who come within the scope of this bulletin, an issuer may ask for documentation showing that he or she was enrolled in the state?s high risk pool as of the last day he or she was able to be enrolled in the high risk pool. Examples of documentation include: (1) a copy of the high risk pool plan identification card; (2) an explanation of bene?ts; or (3) a letter from CMS or the state high risk pool to the individual stating that he or she is losing high risk pool coverage. In addition, it is possible that some states? high risk pools or insurance departments may be able to verify a person?s prior high risk pool enrollment with an issuer directly. (FAQs on Bulletin Entitled The Sale of Individual Market Policies to Medicare Bene?ciaries Under-65 Losing Coverage Due to High Risk Pool Closures (01/31/14)) 02: When can Medicare beneficiaries enroll in individual market plans pursuant to the bulletin? Updated 1-31-17 A2: A Medicare bene?ciary who falls within the scope of this bulletin will have a 60-day SEP, measured from the date the individual or dependent loses eligibility for high risk pool coverage, to enroll in an individual market plan under 45 CFR and which provide a SEP for loss of minimum essential coverage. CMS expects issuers selling coverage to such individuals to accept applications suf?ciently in advance of applicants? loss of high risk pool coverage to ensure they do not experience a gap in supplemental coverage. Under 45 CFR 156.602, state high risk pools are designated as minimum essential coverage for policy years beginning on or before December 31, 2014. With respect to state high risk pool coverage beginning after December 31, 2014, a state will need to apply to CMS to have the high risk pool coverage be recognized as minimum essential coverage under 45 CFR 156.604. (FAQs on Bulletin Entitled The Sale of Individual Market Policies to Medicare Bene?ciaries Under-65 Losing Coverage Due to High Risk Pool Closures (01/31/14)) 1115 2017-?01215 Q3: When can Medicare bene?ciaries enroll in Medicare Advantage or Prescription Drug plans? A3: Affected beneficiaries who do not have ESRD and are otherwise eligible to enroll in an MA plan will also have a SEP to enroll in a Medicare Advantage plan. This SEP begins two months prior to the loss of high-risk pool coverage and ends two months after. (FA 03 on Bulletin Entitled The Sale of Individual Market Policies to Medicare Bene?ciaries Under-65 Losing Coverage Due to High Risk Pool Closures {01/31/14)} Q4: Can these Medicare beneficiaries who enroll in individual market plans pursuant to the bulletin receive a tax credit under Code section 363? A4: No. These bene?ciaries cannot receive a tax credit under Code section 368 because they also are enrolled in Medicare Part A: Q5: How will coordination of benefits occur between Medicare and the individual market plan issuer in these circumstances? A5: Medicare will be the primary payer and the individual market issuer will be the secondary payer. The individual market issuer can accept claims billed via the Medicare crossover process, to the extent there are co-insurance balances remaining. (FAQs on Bulletin Entitled The Sale of Individual Market Policies to Medicare Bene?ciaries Under- 65 Losing Coverage Due to High Risk Pool Closures {01/31/14)} 06: Are issuers required to sell individual market coverage to Medicare beneficiaries in this specific circumstance? A6: No. While the bulletin allows issuers to sell individual market coverage to Medicare bene?ciaries in these circumstances, CMS does not have the authority to require such sales, because the statute still provides that doing so is ?unlawful." (FAQs on Bulletin Entitled The Sale of Individual Market Policies to Medicare Bene?ciaries Under-65 Losing Coverage Due to High Risk Pool Closures (01/31/14)) Q1: Can individuals who have Medicare enroll in coverage through the Marketplace? A1: No. Consistent with the longstanding prohibitions on the sale and issuance of duplicate coverage to Medicare bene?ciaries (section 1882(d) of the Social Security Act), it is illegal to knowingly sell or issue a Quali?ed Health Plan (QHP) to a Medicare beneficiary. This prohibition does not apply in the Small Business Health Options Program (SHOP) market or to employer coveraqe offered outside of the SHOP market. (Enrollment FAQ #9 10/04/13; CMS FAQs Regarding Medicare and the Marketplace 08/01/14 note: the underlined language was added by the 08/11/14 revision.) 02: What should Agents and Brokers do to comply with this guidance? A2: Consistent with the longstanding prohibitions on the sale of duplicate coverage to Medicare bene?ciaries (section 1882(d) of the Social Security Act), agents and brokers are prohibited from knowingly selling a Medicare bene?ciary a Marketplace plan. Agents and brokers may wish to protect themselves by asking each applicant about Medicare status. CCIIO will update the training materials provided to agents and brokers to re?ect this clari?cation. (Enrollment FAQ #9 10/04/13) 1116 Updated 1-31-17 2017-?01216 Q3: What do Medicare bene?ciaries need to know about Medicare and the Marketplace? A3: Individuals with Medicare need to know that if they have Medicare, a Marketplace plan is not appropriate for them. If individuals are seeking supplemental coverage for their Medicare, and do not have retiree coverage, they should consult Medicaregov about enrolling in a Medicare Advantage plan or purchasing a Medigap policy. CMS will continue to work to have these messages included in our outreach for Medicare?s annual open enrollment. (Enrollment FAQ #9 10/04/13) Note: This FAQ was revised and re-re/eased in the CMS FA 03 Regarding Medicare and the Marketplace 08/01/14: C2. Individuals with Medicare need to know that if they have Medicare, an Individual Marketplace plan is not appropriate for them. If individuals want coverage designed to supplement Medicare, they can visit Medicaregov to learn more about Medigap policies. They can also visit Medicaregov to learn more about other Medicare options, like Medicare Advantage Plans Q4: Can Medicare beneficiaries whose employer purchases insurance coverage through the SHOP be enrolled in a SHOP Qualified Health Plan? A4: Yes, Medicare bene?ciaries whose employer purchases SHOP coverage are treated the same as any other person with employer coverage. The prohibition only applies to coverage sold by an Issuer to an individual. SHOP coverage is sold to the employer. For Medicare bene?ciaries who have coverage based on their or a spouse's current employment and are enrolled in SHOP coverage, the Medicare Secondary Payer rules, which govern the coordination of benefits between Medicare and the employer coverage, apply to employers with at least 20 employees. (Enrollment FAQ #9 10/04/13) Note: This FAQ was revised and re-re/eased in the CMS FA Qs Regarding Medicare and the Marketplace 08/01/14: A2. Yes, Medicare bene?ciaries whose employers purchase SHOP coverage are treated the same as any other person with employer Group Health Plan coverage. The statute (Section 1882(d) of the Social Security Act) prohibits the sale or issuance of duplicate coverage to an individual with Medicare, but employer-sponsored coverage is explicitly exempted from this prohibition. SHOP coverage is sold to the employer. Note that for Medicare bene?ciaries who are active employees and are enrolled in SHOP coverage, the Medicare Secondary Payer rules, which govern the coordination of bene?ts between Medicare and the employer coverage, apply to employers with 20 or more employees. Q9: For enrollees who are also Medicare beneficiaries, may a plan charge different premiums for enrollees based on whether their Medicare coverage is primary vs. secondary? Updated 1-31-17 A9: No, as described at 2013.htm : Health insurance issuers may vary premiums only based on age (within a 3:1 ratio for adults), tobacco use (within a 1.521 ratio for adults and subject to wellness program requirements in the small group market), family size, and geography. Since factors related to Medicare and the coordination of Medicare bene?ts are not amongst 1117 2017-?01217 the allowable rating factors, then plans may not charge the enrollees different premiums based on these factors. (QHP Webinar Series FAQ #12 06/28/13) Q: Is a person who is eligible for Medicare who is less than age 65 (SSDI eligible) also eligible to apply for the Exchange? A: Consistent with the longstanding prohibitions on the sale and issuance of duplicate coverage to Medicare bene?ciaries (section 1882(d) of the Social Security Act), it is illegal to knowingly sell or issue a Qualified Health Plan (QHP) to a Medicare bene?ciary. This is a correction of previously issued guidance. This prohibition does not apply in the SHOP market. (REGTAP FAQ Database FAQ #418 11/22/13) Q: How will Issuers distribute the notification to individuals who are aging-off at 65 due to Medicare eligibility? A: Issuers do not need to generate a notice to individuals who are aging-off at 65 due to Medicare eligibility. The FFM will generate a notice to these individuals based on the FFM periodic data match. (REGTAP FAQ Database - FAQ #638 01/09/14) A.3. Does the prohibition against the sale or issuance of duplicate coverage to an individual with Medicare apply to selling or issuing coverage to someone eligible for Medicare but not yet signed up? No. The prohibition, set forth in Section 1882(d) of the Social Security Act applies to selling or issuing coverage to someone who is entitled to Medicare Part A or enrolled in Part B. If an individual is collecting Social Security, they are entitled to Medicare, even if they have not signed up for Medicare. (CMS FAQs Regarding Medicare and the Marketplace 08/01/14) A.4. Do beneficiaries with Part only meet the Affordable Care Act?s requirement to maintain Minimum Essential Coverage? Medicare Part alone does not constitute Minimum Essential Coverage. (CMS FAQs Regarding Medicare and the Marketplace 08/01/14) A.5. Does it make any difference to the Affordable Care Act?s requirement to maintain Minimum Essential Coverage if an individual with Part only is required to pay the Income Related Adjustment Amount for Part No, the same principles apply. (CMS FAQs Regarding Medicare and the Marketplace 08/01/14) AG. The Individual Marketplace Qualified Health Plans (QHPs) may be cheaper than Medicare for individuals who have to pay a premium for Part A. Can someone with Premium Part A drop Medicare and enroll in the Individual Marketplace? Yes. Individuals who are not eligible to get Medicare Part A for free may drop both their Premium Part A and their Part coverage (or choose not to enroll when first eligible). An individual who does not have Medicare (either Part A or Part B) can enroll in a QHP. Note that individuals who get free Part A cannot drop it without dropping their retiree 1118 Updated 1-31-17 2017-?01218 bene?ts (social security or railroad retirement) and paying back all retirement benefits received and costs incurred by the Medicare program as well. Before making this choice, there are 2 important points for individuals to consider: 0 Individuals who do not enroll in Medicare when ?rst eligible (during their initial enrollment period) may have to pay late enrollment penalties if they later apply for both Premium Part A and Part B. In addition, individuals who enroll in Medicare after their initial enrollment period ends can enroll in Medicare only during the Medicare general enrollment period (from January 1 to March 31) and coverage does not begin until July of that year. (CMS FAQs Regarding Medicare and the Marketplace 08/01/14) A.7. Can a Medicare beneficiary purchase a stand-alone dental plan through the Individual Marketplace? Even though Medicare does not provide dental coverage, and therefore a stand-alone dental plan would not duplicate Medicare bene?ts, the Federally-facilitated Marketplaces (FFMs) require that individuals buy a comprehensive medical Quali?ed Health Plan (QHP) before they can purchase a separate dental plan. Because it is illegal to sell or issue a comprehensive medical QHP to a Medicare beneficiary, Medicare bene?ciaries cannot currently buy a stand-alone dental plan through the FFMs. Nothing in federal law prohibits issuers from generally selling or issuing stand-alone dental plans through State Based Marketplaces that can support this functionality, or outside the Marketplaces, to Medicare bene?ciaries. (CMS FA 03 Regarding Medicare and the Marketplace 08/01/14) A.8. If you have coverage in an Individual Marketplace Qualified Health Plan (QHP) and later enroll in Medicare, can you keep your Marketplace coverage? Yes. The prohibition on selling or issuing duplicative coverage set forth in Section 1882(d) of the Social Security Act applies to the sale or issuance of a (QHP) or other individual market coverage to a Medicare beneficiary. It does not require an individual who was not a Medicare bene?ciary when the QHP was purchased to drop coverage when he or she becomes a Medicare beneficiary. Once Medicare Part A coverage begins, however, any premium tax credits and reduced cost-sharing the individual receives through the Marketplace will be discontinued. See the chart below for details. (CMS FAQs Regarding Medicare and the Marketplace 08/01/14) 1119 Updated 1-31-17 2017-?01219 Chart A: Maintaining Enrollment in an Individual Marketplace Quali?ed Health Plan HP) Once Medicare Coverage Begins li?youare: Individual Marketplace receiving tax credit: and reduced QHP after enrolling in coat-sharing? Medicare? Currently enrolled in a Yes No. Any tax credits the individual QHP and become entitled is receiving in the QHP will be to free Part A discontinued once Part A coverage begins. Currently enrolled in a Yes Yes, if you only enroll in Part B, QHP and become eligible because Part does not constitute to buy Premium Part A Minimum Essential Coverage. and Part No, if you enroll in Premium Part A. A.9. Will individuals enrolled in an Individual Marketplace Qualified Health Plan (QHP) be subject to the Part or Premium Part A late enrollment penalty if they delay enrollment into Medicare? Yes. Individuals who do not enroll in Medicare during their Initial Enrollment Period (either for Part or Premium Part A) will only be able to enroll in Medicare during the Medicare General Enrollment Period and may be subject to the late enrollment penalties. i A.10. Can Medicare beneficiaries with coverage under SHOP plans delay enrollment in Medicare Part without penalty? Yes. A Medicare bene?ciary who is enrolled in employer purchased SHOP coverage is treated the same as any other person with employer group health plan coverage. Individuals can delay enrollment if they are covered under a group health plan based on their or their spouse?s current employment. These individuals have a special enrollment period to sign up for Part without penalty: 0 Any time they are still covered by the group health plan. 0 During the 8-month period that begins the month after the employment ends or the coverage ends, whichever happens first. If the individual does not sign up during this special enrollment period, late enrollment penalties may apply, and enrollment will only be possible during the General Enrollment Period which occurs annually from January through March with coverage beginning July FAQs Regarding Medicare and the Marketplace 08/01/14) A.11. ls prescription drug coverage in an Individual Marketplace or SHOP Quali?ed Health Plan (QHP) considered creditable prescription drug coverage for purposes of Medicare Part While prescription drug coverage is an essential health bene?t, there is no requirement under the Affordable Care Act or its implementing regulations that prescription drug coverage in an Individual Marketplace or SHOP QHP be at least as good as Medicare Part coverage, which is the general test for whether coverage is creditable. However, 1 120 Updated 1-31-17 2017-?01220 all private insurers offering prescription drug coverage, including Individual Marketplace and SHOP QHPs, are required to determine annually if their prescription drug coverage is creditable and notify CMS and their Medicare-eligible enrollees in writing of the determination. All private insurers offering prescription drug coverage are required to notify their Medicare-eligible enrollees of the plan?s creditable coverage status in writing annually prior to the start of the Medicare open enrollment period that begins on October 15, and in the following situations: 0 Prior to an individual?s Initial Enrollment Period for Part 0 Prior to the effective date of enrollment in the insurer?s prescription drug coverage; . Upon any change that affects whether the coverage is creditable; and 0 Upon request by the individual. (CMS FAQs Regarding Medicare and the Marketplace 08/01/14) A.12. Is prescription drug coverage through the Marketplace considered creditable prescription drug coverage for the purposes of determining whether an individual must pay the late enrollment penalty upon enrollment in Medicare Part While prescription drug coverage is an essential health bene?t, prescription drug coverage in a Marketplace or SHOP plan isn?t required to be expected to pay, on average, at least as much as Medicare?s standard prescription drug coverage (creditable). All private plans offering prescription drug coverage, including Marketplace and SHOP plans, must determine if their prescription drug coverage is creditable each year and let you know in writing. (CMS FAQs Regarding Medicare and the Marketplace 08/01/14) A.13. If a person is enrolled in Part A and has chosen not to enroll in Part B, can that person purchase a QHP (or other individual market coverage) until their Part is effective? Updated 1-31-17 For bene?ciaries who would purchase their plan on the individual market, no. Consistent with the longstanding prohibitions on the sale and issuance of duplicate coverage to Medicare bene?ciaries (section 1882(d) of the Social Security Act), it is illegal for an insurer to sell or issue to a Medicare bene?ciary a QHP (or other individual market coverage) that the insurer knows would duplicate Medicare bene?ts. This is true even if the beneficiary has only Part A or only Part B. This prohibition does not apply in the small group market, including plans sold through the Small Business Health Options Program (SHOP). Medicare bene?ciaries whose employers purchase SHOP coverage are treated the same as any other person with employer-sponsored Group Health Plan (GHP) coverage. The statute (Section 1882(d) of the Social Security Act) prohibits the sale or issuance of coverage that the insurer knows duplicates Medicare bene?ts to an individual with Medicare, but employer-sponsored (GHP) coverage is explicitly exempted from this prohibition. SHOP coverage is sold to the employer. Note that for Medicare beneficiaries who are active employees and are enrolled in SHOP coverage, the Medicare Secondary Payer rules govern the coordination of benefits between Medicare and the employer coverage as appropriate. (CMS FAQs Regarding Medicare and the Marketplace 08/01/14) 1121 2017-?01221 AM. If an individual is over age 65 and eligible for premium-free Part A, but is not collecting Social Security benefits and has not enrolled in either Part A or Part B, can that person purchase a QHP (or other individual market coverage)? Yes. If the individual is not collecting Social Security bene?ts, and is not covered by Medicare, then she/he is not ?entitled? to Medicare Part A benefits. If the individual is also not enrolled in Part B, then the insurer would not be prohibited from issuing or selling coverage that the insurer knows would duplicate Medicare coverage to the individual. This means that she/he can purchase individual market coverage (including QHPs). (CMS FA 03 Regarding Medicare and the Marketplace 08/01/14) A.15. ls purchasing a QHP (or other individual market plan), instead of enrolling in Medicare Part B, an option for individuals who fail to enroll in Part in a timely manner and must pay a Part premium penalty, especially in those situations where the higher premium resulting from the penalty may be more than the individual would pay for a QHP?with or without a tax credit? Generally, no. If an individual already has Medicare coverage (including Part A and/or Part coverage), consistent with the longstanding prohibitions on the sale and issuance of duplicate coverage to Medicare beneficiaries (section 1882(d) of the Social Security Act), it is illegal for an insurer to knowingly sell or issue to a Medicare bene?ciary an individual market plan that the insurer knows would duplicate Medicare bene?ts, regardless of the cost of the Part premium amount. An individual who does not have Medicare (neither Part A nor Part B) and who is otherwise eligible can enroll in a QHP. An individual who does not enroll in Medicare during his or her Medicare Initial Enrollment Period (either for Part or Premium Part A) will only be able to enroll in Medicare during the Medicare General Enrollment Period, and may be subject to the late enrollment penalties if he or she chooses to enroll later. (CMS FAQs Regarding Medicare and the Marketplace 08/01/14) A.16. A Quali?ed Health Plan (QHP) may be cheaper than Medicare for individuals who get Part A for free but have to pay a late enrollment penalty or Income-Related Adjustment Amount (IRMAA) for Part B. Can someone with free Part A drop Medicare and enroll in a Generally, no. Individuals generally can choose to stop Medicare coverage only if they?re paying a premium for Part A or have only Part B. Individuals with free Part A can?t drop Medicare without also dropping their retiree bene?ts (Social Security or Railroad retirement) and paying back all retirement or disability benefits they received and all costs spent for their care by the Medicare program. Before making this choice, there are two important points for individuals to consider: Individuals who do not enroll in Medicare when ?rst eligible (during their Medicare Initial Enrollment Period) may have to pay late enrollment penalties if they later apply for both Premium Part A and Part B. In addition, individuals who enroll after their Medicare Initial Enrollment Period ends can enroll in Medicare only during the Medicare General Enrollment Period (from January 1 to March 31) for coverage that begins on July 1 of that year. (CMS FAQs Regarding Medicare and the Marketplace 08/01/14) 1 122 Updated 1-31-17 2017-?01222 Q: If a member has both Medicare and a Qualified Health Plan (QHP), which plan will be the primary payer if the QHP did not submit as a supplemental plan to the Office of Superintendent of Insurance Updated 1-31-17 A: Appropriate coordination of bene?ts (COB) requires the member to notify medical providers and insurance companies about all health insurance coverage. Whether Medicare is primary or secondary depends on the age and disability status of the member, if coverage is through current employment and the number of employees covered under the plan. Please note that the following situations do not constitute a complete list of scenarios for dual coverage with Medicare. Under the provisions of Title of the Social Security Act, if the member is a Medicare bene?ciary, Medicare is secondary if the QHP is covering the member as a dependent and primary if the QHP is covering the member as other than a dependent employee, member, subscriber or retired employee). If the member is covered by both Medicare and Medicaid, then Medicare will be the primary payer. If the member is 65 years of age or older and covered by a group QHP, because the member or the member's spouse is still working, the group QHP will pay ?rst, unless the employer has less than 20 employees. If the member has an employer group QHP through a former employer after retiring and the member is 65 years of age or older, then Medicare will be the primary payer. If the member is disabled and covered by a large employer group QHP through employment work or through a family member spouse, domestic partner, son, daughter, or grandchild) who is employed, the QHP will be the primary payer unless the employer has less than 100 employees. If the member has End-Stage Renal Disease (ESRD) (permanent kidney failure requiring dialysis or a kidney transplant) and coverage through a group QHP (including a retirement plan), then the group QHP will be the primary payer within the first 30 months of eligibility or entitlement to Medicare. Medicare will become the primary payer after the ?rst 30 months of eligibility or entitlement. If the member has ESRD and coverage under the Consolidated Omnibus Budget Reconciliation Act (COBRA) coverage, COBRA will be the primary payer for the ?rst 30 months of eligibility or entitlement to Medicare based on having ESRD. After the first 30 months, Medicare is the primary payer. If the member is 65 years of age or older or has a disability other than ESRD and has coverage under Medicare and COBRA, Medicare will be the primary payer. If the member is a veteran and has veteran benefits, Medicare will pay for Medicare- covered services or items, while Veterans' Affairs (VA) pays for VA?authorized services or items. If the member is covered under TRICARE, then Medicare will pay for Medicare-covered services or items, and TRICARE will pay for services or items from a military hospital or any other federal provider. (REGTAP FAQ Database - FAQ #16839 09/09/16) 1123 2017-?01223 Q: Can a medical claim be active in two (2) different enrollment groups? A: In order for a claim to be active in two (2) different enrollment groups, a member would have to have coverage in two (2) different enrollment groups, resulting in dual coverage. The legality and legitimacy of a member's dual coverage depends on the member and the issuer honoring the terms of the member's policy. Insurance companies require policyholders to notify them of changes in coverage, such as the addition of coverage under a second plan. Most health insurance contracts have a coordination of bene?ts (COB) clause that allows the bene?ts of one (1) policy to be coordinated with the bene?ts of other policies. The issuer might require the member to submit a coordination of benefits form to report the coverage and provide the name and contact information for the second plan in order to prevent duplicate payment of health care services. The member cannot choose which health plan is primary, meaning the one that pays first. However, if the first issuer does not cover a certain treatment, or only covers it partially, the member can then submit the remainder of the claim to the secondary issuer for payment, assuming the treatment is covered under the second plan. Coverage provided under employment is typically primary. Special rules exist for COB when Medicare is one (1) of the health insurance plans. Although 65 is the usual age for Medicare eligibility, young people with end-stage renal disease or certain disabilities are eligible, regardless of age. Whether Medicare is primary depends on the age and disability status of the covered individual and, if coverage is through current employment, the number of employees covered under the plan. An agreement must be in place between the Benefits Coordination Recovery Center (BCRC) and private insurance companies for the BCRC to automatically cross over claims. In the absence of an agreement, a member with Medicare is required to coordinate secondary or supplemental payment of bene?ts with any other issuers he or she may have in addition to Medicare. Appropriate COB requires the member to notify issuers about all of his or her health insurance coverage. Special rules also apply to dependent children covered under two (2) plans, such as coverage under both parents' employment-based plans. For instance, the birthday rule determines the primary plan when the parents living together. Physical custody or a court order determines primary plan when the parents live apart. (REGTAP FAQ Database - FAQ #16840 09/09/16) Q: If a consumer turning 65 years old is the primary account holder on the account with other family members, when does the family need to contact the Marketplace to remove the Medicare-eligible person? Updated 1-31-17 A: Regardless of whether or not the consumer is the primary account holder, he or she should contact the Marketplace at least 15 days before his or her Medicare coverage will begin to end Marketplace coverage. To reach the Marketplace Call Center call 1-800- 318-2596 (TTY: 1-855-889-4325). (REGTAP FAQ Database - FAQ #17398 09/09/16) 1124 2017-?01224 Q: I work with a consumer who called the Marketplace Call Center to cancel his health coverage because he was turning 65 years old. He called on the 10th of the month and was told that his Marketplace coverage would end that day and was told to wait until the end of the month to cancel his coverage. Is this correct? A: Please refer to for more information about transitioning from Marketplace to Medicare coverage. (REGTAP FAQ Database - FAQ #17399 09/09/16) Q: Does the Medicare periodic data matching (PDM) process also apply to Medicare beneficiaries who are under age 65? A: For the initial round of Medicare PDM, consumers receiving PDM notices will only be those who are age 65 and older, and dually enrolled in minimum essential coverage (MEC) Medicare and a Marketplace plan with ?nancial assistance. (REGTAP FAQ Database - FAQ #17400 09/09/16) Q: What coverage is considered minimal essential coverage (MEC) Medicare? A: Enrollment in Medicare Part A and Part is considered MEC Medicare. Consumers enrolled in Medicare Part A or Medicare Part are not eligible for ?nancial assistance for Marketplace coverage, but may remain enrolled in Marketplace plans without ?nancial assistance, if they wish. There are a small number of consumers who are eligible for Medicare because of age, but who did not work the necessary quarters of coverage to be eligible for premium-free Medicare. For consumers eligible for, but not enrolled in Medicare Part A with the premium, that is not considered MEC, they can enroll in Marketplace coverage and still be eligible for ?nancial assistance. However, if consumers who pay a premium for Medicare Part A coverage choose to enroll in Medicare coverage and pay the premium, they are now no longer eligible for financial assistance on the Marketplace. All of these instructions are included in the Periodic Data Matching (PDM) notice consumers receive who are affected by Medicare PDM, depending on what type of Medicare coverage the consumer may have. The notice includes instructions for what consumers should do in those various situations. (REGTAP FAQ Database - FAQ #17401 09/09/16) Q: What if a consumer is enrolled in Medicare Part A only not enrolled in Medicare Part or Part and does not have Part B) will they receive a periodic data matching (PDM) notice? A: Consumers aged 65 and up that are dually enrolled in minimal essential coverage (MEC) Medicare and Marketplace coverage with ?nancial assistance will receive the Medicare PDM notice. Enrollment in Medicare Part A is considered MEC and a consumer enrolled in Medicare Part A (but not Part B, C, or D) will receive the PDM notice if they are aged 65 and up and also enrolled in a Marketplace plan with ?nancial assistance. (REGTAP FAQ Database - FAQ #17402 09/09/16) 1 125 Updated 1-31-17 2017-?01225 Q: What is the difference between Medicare eligibility prior to Marketplace enrollment and Medicare eligibility after Marketplace enrollment? A: If a consumer is eligible for or enrolled in minimal essential coverage (MEC) Medicare, they are not eligible for financial assistance on the Marketplace. If a consumer is eligible for MEC Medicare, he or she should enroll in Medicare coverage and does not need to enroll in Marketplace coverage. If a consumer is already enrolled in Marketplace coverage and later becomes eligible for or enrolled in MEC Medicare, he or she should return to the Marketplace and report this change on their application. A consumer enrolled in a Marketplace plan and eligible for or enrolled in MEC Medicare is not eligible to receive ?nancial assistance to help pay for plan premiums or covered services. (REGTAP FAQ Database - FAQ #17403 09/09/16) Q: When will the Medicare periodic data matching (PDM) notices be sent out? A: Medicare PDM notices should reach consumers mailboxes in early September. The Medicare PDM notice will not be uploaded to a consumers online Marketplace account. (REGTAP FAQ Database - FAQ #17404 09/09/16) Q: If a consumer is enrolled in Medicare Part A, is he or she able to drop the coverage to enroll in Marketplace coverage with or without financial assistance? A: If a consumer is eligible for or enrolled in premium-free Medicare Part A he or she is not eligible to receive advance payments of the premium tax credit (APTC) or income- based cost-sharing reductions (CSR). If a consumer is enrolled in Medicare Part A with a premium, he or she can compare plans to see what best meets their needs and budget. In either case the consumer should also follow the instructions listed on his or her Medicare periodic data matching (PDM) notice. (REGTAP FAQ Database - FAQ #17405 09/09/16) Q: Do consumers have to pay back advance payments of the premium tax credit (APTC) or income-based cost-sharing reductions (CSR) back for periods when they are dually eligible for or enrolled in Marketplace plans and Medicare? A: If consumers were dually-enrolled in minimal essential coverage (MEC) Medicare and Marketplace coverage with financial assistance, they may have to pay back some or all of the APTC they received during the time they were dually enrolled. The purpose of receiving the periodic data matching (PDM) notice is to notify consumers of that possibility, and to remind them they should end their ?nancial assistance to avoid paying a larger penalty. (REG TAP FAQ Database - FAQ #17406 09/09/16) Q: How is the consumer's coverage canceled: prospective or retrospectively? A: Consumers who receive Medicare periodic data matching (PDM) notices will need to take action to end their coverage. The coverage termination will be prospective. (REGTAP FAQ Database - FAQ #17407 09/09/16) 1 126 Updated 1-31-17 2017-?01226 Q: What if Medicare-eligible consumers want to keep their Federally-facilitated Marketplace (FFM) coverage? Can they keep the Marketplace coverage? A: If consumers receive the Medicare periodic data matching (PDM) notice, CMS advises they follow the instructions listed on the notice; however, if consumers are enrolled in both minimal essential coverage (MEC) Medicare and a Marketplace plan with financial assistance, they can terminate just their ?nancial assistance and remain enrolled in their Marketplace plan. The consumer would have to pay the full price for his or her plan premium and covered services. (REGTAP FAQ Database - FAQ #17408 09/09/16) Q: What happens if a consumer is eligible for Medicare coverage, but wants to remain enrolled in his or her Marketplace plan? A: Consumers eligible for minimal essential coverage (MEC) Medicare are no longer eligible for ?nancial assistance to help pay for his or her Marketplace plan premium and covered services. A consumer eligible for MEC Medicare can choose to remain enrolled in their Marketplace plan without ?nancial assistance if they so desire. (REGTAP FAQ Database - FAQ #17409 09/09/16) Q: If I am a consumer who has Marketplace coverage, but is eligible for Medicare, do I wait until the day before I am eligible for Medicare to terminate my Marketplace plan, or should I terminate the Marketplace coverage before the 15th of the month so it will end on the last day of month? A: Please refer to for more information about transitioning from Marketplace to Medicare coverage. (REGTAP FAQ Database - FAQ #17410 09/09/16) B. ESRD B.1. Are Individuals with ESRD required to sign up for Medicare? No. Individuals with ESRD are not required to sign up for Medicare; it is voluntary. In order to get Medicare coverage, the individual must meet the necessary eligibility requirement and apply. If you don?t apply, you do not get Medicare coverage. (CMS FAQs Regarding Medicare and the Marketplace 08/01/14) 32. Are individuals with ESRD who do not have Medicare coverage eligible to enroll in a Marketplace Qualified Health Plan Individuals with ESRD who do not have either Medicare Part A or Part are eligible to enroll in individual market coverage because the Medicare anti-duplication statute does not apply; therefore, individual market guaranteed issue rights apply under the ACA. In order to enroll in a QHP through the Marketplace, the individual must meet the eligibility requirements for enrollment criteria related to citizenship, lawful presence, incarceration, and residency). (CMS FAQs Regarding Medicare and the Marketplace 08/01/14) 1 127 Updated 1-31-17 2017-?01227 B.3. Are individuals with ESRD who do not have Medicare coverage eligible for the health care Premium Tax Credit? An individual may be eligible for the health care Premium Tax Credit if he or she is not eligible for minimum essential coverage, as outlined in the IRS Notice 2013-41 at the following web link: However, individuals will lose their eligibility for the health care Premium Tax Credit when coverage in Medicare Part A begins. (CMS FAQs Regarding Medicare and the Marketplace 08/01/14) 3.4. Can bene?ciaries who currently have Medicare coverage due to ESRD opt out of or disenroll from Medicare? Generally, no. Following the application for Medicare, the law provides that Medicare coverage ends one year after the termination of regular dialysis or 36 months after a successful kidney transplant. However, a bene?ciary may withdraw their original Medicare application. The individual is required to repay all costs covered by Medicare, pay any outstanding balances, and refund any benefits received from the SSA or RRB. Once all repayments have been made, the withdrawal can be processed as though the individual was never enrolled in Medicare at all retroactively). (CMS FAQs Regarding Medicare and the Marketplace 08/01/14) 3.5. Is there a mechanism for individuals to cancel ESRD Medicare enrollment if applications are initiated on their behalf without complete information about their options for A dialysis facility or attending physician may not complete an application for Medicare entitlement on behalf of the bene?ciary. While these providers may submit the medical evidence form for an individual applying for Medicare based on ESRD, the individual must also contact the Social Security Administration (SSA) to complete the Medicare application. If an individual wants to enroll in a QHP after the medical evidence form is submitted by the provider, the individual can choose to not complete his or her application for Medicare. If the individual has Medicare currently based on ESRD, he or she may withdraw their original Medicare application. The individual is required to repay all costs covered by Medicare, pay any outstanding balances, and refund any bene?ts received from the SSA or RRB. Once all repayments have been made, the withdrawal can be processed as though the individual was never enrolled in Medicare at all retroactively). (CMS FAQs Regarding Medicare and the Marketplace 08/01/14) 3.6. Please clarify whether individuals with ESRD who are currently enrolled in Medicare based on ESRD can disenroll from both Part A and Part B. If yes, please specify the requirements for doing so and the potential ramifications of this choice. Generally, individuals with ESRD who are currently enrolled in Medicare based on ESRD cannot disenroll prospectively. Following the application for Medicare, the law provides that Medicare coverage ends one year after the termination of regular dialysis or 36 months after a successful kidney transplant. However, a bene?ciary may withdraw their original Medicare application. The individual is required to repay all costs covered by Medicare, pay any outstanding balances, and refund any bene?ts received from the 1 128 Updated 1-31-17 2017-?01228 SSA or RRB. Once all repayments have been made, the withdrawal can be processed as though the individual was never enrolled in Medicare at all retroactively). (CMS FAQs Regarding Medicare and the Marketplace 08/01/14) C. Consumer Messaging C.1. What is the message to Medicare beneficiaries who have questions about how the Marketplace affects them? Medicare isn?t part of the Health Insurance Marketplace. If you have Medicare, you are covered, and do not need to do anything about the Marketplace. The Marketplace won't affect your Medicare choices and bene?ts. No matter how you get Medicare, whether through Original Medicare or a Medicare Advantage Plan, you won?t have to make any changes. (CMS FAQs Regarding Medicare and the Marketplace 08/01/14) C.3. I want to purchase health insurance through the Marketplace. What if I have Medicare? Medicare isn?t part of the Health Insurance Marketplace, so you don?t need to do anything. If you have Medicare, you?re considered covered. The Marketplace won?t affect your Medicare choices or benefits. No matter how you get Medicare, whether through Original Medicare or a Medicare Advantage Plan (like an HMO or PPO), you won?t have to make any changes. Note: The Marketplace doesn?t offer Medicare supplement (Medigap) insurance or Part drug plans. (CMS FAQs Regarding Medicare and the Marketplace 08/01/14) 0.4. Can I get a Marketplace plan if I already have Medicare? No. It?s against the law for someone who knows that you have Medicare to sell or issue you a Marketplace policy. This is true even if you have only Medicare Part A or only Part B. If you want coverage designed to supplement Medicare, you can find out more about Medigap policies. You can also learn about other Medicare options, like Medicare Advantage Plans. For prescription drug coverage, you can buy a Medicare Part drug plan. (CMS FA Qs Regarding Medicare and the Marketplace 08/01/14) 0.5. Can I choose Marketplace coverage instead of Medicare? Updated 1-31-17 Generally, no. It?s against the law for someone who knows you have Medicare to sell you a Marketplace plan. But there are a few situations where you can choose a Marketplace private health plan instead of Medicare: 0 If you?re paying a premium for Part A. In this case you can drop your Part A and Part coverage and get a Marketplace plan instead. 0 If you?re eligible for Medicare but haven?t enrolled in it. This could be because: 0 You?d have to pay a premium 0 You have a medical condition that quali?es you for Medicare, like end- stage renal disease (ESRD), but haven't applied for Medicare coverage 0 You?re not collecting Social Security retirement or disability bene?ts before you're eligible for Medicare Before choosing a Marketplace plan over Medicare, there are 2 important points to consider: 0 If you enroll in Medicare after your initial enrollment period ends, you may have to pay a late enrollment penalty for as long as you have Medicare. 1129 2017-?01229 0 Generally you can enroll in Medicare only during the Medicare general enrollment period (from January 1 to March 31 each year). Your coverage won?t start until July. This may cause a gap in your coverage. (CMS FA Qs Regarding Medicare and the Marketplace 08/01/14) C.6. If I?m getting Medicare Part A for free, can I drop Medicare to enroll in a Marketplace plan? Generally, no. You can choose to have your Medicare stop only if you?re paying a premium for Part A or have only Part B. If you get Part A for free, you can?t drop Medicare without also dropping your retiree or disability bene?ts (Social Security or railroad retirement) and paying back all retirement or disability bene?ts you?ve received and all costs spent for your care by the Medicare program. Before making this choice, there are 2 important points to consider: 0 If you enroll in Medicare after your initial enrollment period ends, you may have to pay a late enrollment penalty for as long as you have Medicare. . Generally you can enroll in Medicare only during the Medicare general enrollment period (from January 1 to March 31 each year). Your coverage won?t start until July. This may cause a gap in your coverage. (CMS FAQs Regarding Medicare and the Marketplace 08/01/14) C.7. I have coverage through an Individual Marketplace Qualified Health Plan (QHP) and then I enroll in Medicare. Once my coverage in Medicare starts, can the QHP disenroll me without my consent? No, issuers may not terminate enrollees whom they subsequently ?nd to be eligible for or enrolled in Medicare, unless the enrollee requests the termination. (CMS FAQs Regarding Medicare and the Marketplace 08/01/14) Q8. Can an individual market health insurance issuer disenroll someone if it learns that individual is a Medicare beneficiary prior to the individual's coverage effective date? Updated 1-31-17 Consistent with the longstanding prohibitions on the sale and issuance of duplicate coverage to Medicare bene?ciaries (section 1882(d) of the Social Security Act), it is illegal to knowingly sell or issue an Individual Marketplace Quali?ed Health Plan (or an individual market policy outside the Marketplace) to a Medicare bene?ciary. The issuer should cancel an enrollment prior to the policy being issued if the issuer learns that the enrollment is for someone who has Medicare coverage. That is, the start date for the individual?s Part A and/or Part was before the effective date of the individual market coverage. However, if the applicant?s Medicare coverage has not started yet, then the issuer issue the coverage on a guaranteed available basis. Issuers may not, however, terminate the individual market coverage of enrollees who they ?nd to be eligible for or enrolled in Medicare after the coverage has been issued, even if the individual was eligible for or enrolled in Medicare before enrollment into the individual market coverage, unless the enrollee requests the termination or another legal basis for termination applies. (CMS FAQs Regarding Medicare and the Marketplace 08/01/14) 1130 2017-?01230 C.9. What if I have only Medicare Part If you have only Medicare Part B, you are not considered to have minimum essential coverage. This means you may have to pay the penalty that people who don't have coverage may have to pay. If you have Medicare Part A only, you are considered covered. If you have both Medicare Part A and Part 8, you are also considered covered. (CMS FAQs Regarding Medicare and the Marketplace 08/01/14) C.10. What if I have a Marketplace plan but will be eligible for Medicare soon? If you have a Marketplace plan, you can keep it until your Medicare coverage starts. Then you can cancel it without penalty. If you like, you can keep your Marketplace plan too. But if you've been getting tax credits or lower out-of-pocket costs on a plan you bought through the Marketplace, these savings will end once your Medicare Part A coverage starts. You'd have to pay full price for the Marketplace plan. Let?s assume you have a Marketplace plan and are turning 65 sometime this year. Once you?re eligible for Medicare, you?ll have an initial enrollment period to sign up for Medicare. For most people, the initial enrollment period starts 3 months before their 65th birthday and ends 3 months after their 65th birthday. In most cases it?s to your advantage to sign up for Medicare when you?re ?rst eligible because: . Once your Medicare Part A coverage starts, you won?t be able to keep any premium tax credits or lower out of pocket costs for a Marketplace plan based on your income. You?ll have to pay full price for the Marketplace plan. 0 If you enroll in Medicare after your initial enrollment period ends, you may have to pay a late enrollment penalty for as long as you have Medicare. In addition, you can enroll in Medicare Part (and Part A if you have to pay a premium for it) only during the Medicare general enrollment period (from January 1 to March 31 each year). Coverage doesn?t start until July of that year. This may create a gap in your coverage. If you want coverage to supplement Medicare, you can get Medicare supplement (Medigap) insurance. For prescription drug coverage, you can buy a Medicare Part drug plan. You can learn about other Medicare options, like Medicare Advantage Plans. Once your Medicare coverage starts, you can cancel your Marketplace health plan without penalty. You can do this by contacting the Marketplace call center or cancelling your coverage online. If you have Medicare coverage, you?re considered covered under the health care law. You won?t have to pay the fee that some people without insurance must pay. Be sure not to cancel your Marketplace plan before your Medicare coverage begins. Otherwise you may have a gap in coverage. (CMS FAQs Regarding Medicare and the Marketplace 08/01/14) C.11. Medicare beneficiaries under age 65 don?t have federal guaranteed issue rights to purchase Medicare Supplement (Medigap) insurance coverage. Can these beneficiaries enroll in the Individual Marketplace to supplement their Medicare coverage? Updated 1-31-17 No, consistent with the longstanding prohibitions on the sale and issuance of duplicate coverage to Medicare bene?ciaries (section 1882(d) of the Social Security Act), it is illegal to knowingly sell or issue a Qualified Health Plan (QHP) to a Medicare bene?ciary. If individuals are seeking supplemental coverage for their Medicare, and do not have retiree coverage, they should consult Medicaregov about enrolling in a Medicare Advantage plan, or check with their State department of insurance to see if their state 1131 2017-?01231 requires the sale of Medigap policies to people under age 65. (CMS FAQs Regarding Medicare and the Marketplace 08/01/14) D. Coordination of Benefits Policy D.1. If someone is enrolled in both Medicare and an Individual Marketplace Qualified Health Plan (QHP), will there be coordination of benefits? If someone is enrolled in both Medicare and an Individual Marketplace QHP, Medicare is the primary payer. Medicare does not provide coordination of benefits. (CMS FAQs Regarding Medicare and the Marketplace 08/01/14) 02. Will Coordination of Benefits apply to someone who is enrolled in Medicare and a SHOP Quali?ed Health Plan Medicare bene?ciaries whose employer purchases SHOP coverage are treated the same as any other person with employer coverage. If the employer has 20 or more employees, the employer-provided health coverage generally will be primary for a Medicare bene?ciary who is covered through active employment. (CMS FAQs Regarding Medicare and the Marketplace 08/01/14) 0.3. What do employers participating in SHOP need to know about the Medicare Secondary Payer rules? An employer participating in SHOP will be impacted by the Medicare Secondary Payer (MSP) rules if the employer has 20 or more employees, and any of its employees are Medicare bene?ciaries. When offering health coverage to its employees, the employer cannot ?take Medicare into account? when determining if an individual is eligible for enrollment in the employer-sponsored plan. This means that the employer can?t exclude the individual?s opportunity to participate in the employer-sponsored Group Health Plan coverage on the basis that the employee is a Medicare bene?ciary. (CMS FAQs Regarding Medicare and the Marketplace 08/01/14) D.4. What do SHOP Qualified Health Plans (QHPs) need to know about the Medicare Secondary Payer rules? If the employer has 20 or more employees, the SHOP QHP insurer will be required to participate in the Medicare program?s ?Section 111 Group Health Plan Reporting? program, which is mandated by applicable Medicare Secondary Payer (MSP) regulations. Insurers under these circumstances will be required to register with Medicare Secondary Payer Coordination of Benefits Contractor and report its coverage of the working people with Medicare to CMS under the MSP reporting requirements. (CMS FAQs Regarding Medicare and the Marketplace 08/01/14) 0.5. Will SHOP plans be required to inform beneficiaries of any benefit coordination? Yes. SHOP insurers are required to notify their enrollees of the coordination of bene?ts between Medicare and the employer coverage. (CMS FAQs Regarding Medicare and the Marketplace 08/01/14) 1132 Updated 1-31-17 2017-?01232 D.6. Will Marketplace coverage purchased prior to an individual enrolled in and/or entitled to Medicare affect that individual?s eligibility for the Medicare Part Low-Income Subsidy (LIS) program? Having Marketplace coverage is not a factor in determining whether or a bene?ciary is eligible for the Low-Income Subsidy (LIS) program. (CMS FAQs Regarding Medicare and the Marketplace 08/01/14) E. Enrollment Operations E.1. Does the FFM application screen for Medicare enrollment? The FFM application verifies enrollment in Medicare for individuals who have requested financial assistance. However, the FFM systems are not currently set up to prevent Medicare bene?ciaries from enrolling in a Quali?ed Health Plan. (CMS FAQs Regarding Medicare and the Marketplace 08/01/14) E.2. Will the Marketplace add a note to the Individual Marketplace paper application telling people not to apply if they have Medicare? Specific Medicare messaging isn?t included in the online or paper applications; however, in the 2014 Medicare You Handbook, the Medicare call center, Medicaregov, and HealthCaregov, we have reassured bene?ciaries that they are covered, their Medicare bene?ts aren?t changing, and the Marketplace doesn?t require them to do anything differently. In our public messaging, individuals are informed that Medicare isn?t part of the Health Insurance Marketplace. If you have Medicare, you are covered, and do not need to explore coverage through the Marketplace. The Marketplace won?t affect your Medicare choices, and your bene?ts won't be changing. No matter how you get Medicare, whether through Original Medicare or a Medicare Advantage Plan, you?ll still have the same bene?ts and security you have now. You won?t have to make any changes. (CMS FAQs Regarding Medicare and the Marketplace 08/01/14) Q: How should an Issuer handle a situation where an individual on Medicare has been unknowingly enrolled in a Marketplace plan? Updated 1-31-17 A: Consistent with the prohibition on the sale and issuance of duplicate coverage to people with Medicare (section 1882(d) of the Social Security Act, referred to as the Medicare anti-duplication provision), it is illegal to knowingly sell or issue a qualified health plan (QHP) to a Medicare beneficiary. Issuers may not terminate enrollees whom they subsequently find to be eligible for or enrolled in Medicare based on their Medicare coverage. However, consistent with the Medicare anti-duplication provision, if an issuer learns an individual is a Medicare beneficiary prior to the individuals coverage effective date, the issuer may cancel the enrollment. The current work around for cancellations is via the 834 non-payment transaction. Once the coverage is effectuated, consumers can request a prospective termination in accordance with 45 C.F.R. 155.430, or, if their state has a free look period, they can retroactively cancel their coverage in accordance with the state policy. To request prospective termination, consumers can call or log into healthcaregov and select 'End All Coverage.? If there are other applicants on the consumers' application who wish to retain their coverage, the consumer can remove speci?c applicants Medicare-eligible applicants) by selecting 'Report a Life FAQ Database - FAQ #2845 08/11/14) 1133 2017-?01233 Q: What should an Issuer do if it learns a consumer is enrolled in a Marketplace plan with advance payments of the premium tax credit and/or cost-sharing reductions (APTCICSR), and is also covered by Medicare? A: Consistent with the longstanding prohibitions on the sale and issuance of duplicate coverage to Medicare bene?ciaries (section 1882(d) of the Social Security Act), it is illegal to knowingly sell or issue an individual market plan that duplicates Medicare benefits, such as a qualified health plan, to a Medicare beneficiary. However, in a case in which a QHP enrollee later enrolls in Medicare, an Issuer may not terminate the QHP enrollment solely on the basis that the enrollee has Medicare coverage. Issuers should advise consumers receiving APTC that they may be required to repay the APTC when they ?le their tax return because they may no longer be eligible for the APTC based on their Medicare coverage and should remind them of their obligation to report to the Marketplace any changes that may affect their eligibility for enrollment in coverage through the Marketplace or for insurance affordability programs, including APTC. (REGTAP FAQ Database - FAQ #4264 08/28/14; CMS FAQs on Casework 08/28/14) Q: How will the Federally-facilitated Small Business Health Options Program (FF-SHOP) handle employees who are eligible for Medicare? A: Employees eligible for Medicare are able to enroll in SHOP. When a Medicare-eligible employee enrolls in SHOP, the FF-SHOP will send a Medicare-enrollee ?ag for the employee on the associated 834 enrollment transaction. (REGTAP FAQ Database - FAQ #4195 09/02/14) Q: Can a consumer keep his or her premium tax credit (PTC) when also covered by Medicare? A: A consumer who is enrolled in Medicare is not eligible for advance payments of the premium tax credit (APTC) or PTC. The Internal Revenue Service (IRS) reporting process will show the IRS that a consumer enrolled in Medicare is also receiving APTC. That consumer may be required to pay back APTC received during the period he or she was dually enrolled, but that is ultimately the decision. (REGTAP FAQ Database - FAQ #16094 05/24/16) Q: If a consumer becomes eligible for Medicare due to disability, I understand that he or she can keep the quali?ed health plan (QHP) in which currently enrolled. Can they change plans during the next Open Enrollment period? A: If an individual has coverage in an Individual Marketplace QHP and later enrolls in Medicare, the individual can keep the Marketplace coverage. Once Medicare Part A coverage begins, the individual will become ineligible for any premium tax credits and cost-sharing reductions the individual receives through the Marketplace. However, consistent with the longstanding prohibitions on the sale and issuance of duplicate coverage to Medicare bene?ciaries, it is illegal to knowingly sell or issue an Individual Marketplace QHP (or an individual market policy outside the Marketplace) to an individual enrolled in Medicare. This prohibition does not apply in the Small Business Health Options Program (SHOP) Marketplace, or to employer coverage outside of the SHOP Marketplace. (REGTAP FAQ Database - FAQ #16098 05/24/16) 1 134 Updated 1-31-17 2017-?01234 Q: If a tax household takes care of and claims a consumer's elderly mother, is the mother's income included in the total family income reported to the Federally-facilitated Marketplaces even though she is on Medicare and does not need FFM coverage? A: In general, an application for Marketplace coverage should include the tax ?ler, spouse, and any tax dependents. These individuals should be included even if they aren't applying for health coverage. The Marketplace counts the estimated income of all members of the tax household who are required to ?le a tax return. For more information on who to include on your Marketplace application, visit and (REGTAP FAQ Database - FAQ #16101 05/24/16) Q: Will the process for termination of advance payments of the premium tax credit (APTC) or income-based cost sharing reductions (CSR) be the same for consumers who are enrolled in Medicare? A: This noticing effort is the ?rst step the Federally-facilitated Marketplace (FFM) is taking to make sure consumers take action to end their Marketplace coverage with APTC because they are receiving Minimum Essential Coverage (MEC) Medicare. The FFM does expect to turn off for consumers who are found to be dually- enrolled in a Marketplace plan with financial assistance and Medicare once it is operationally feasible. (REGTAP FAQ Database - FAQ #17682 09/30/16) COMPLIANCE OVERSIGHT Compliance Q7: Will HHS make a template or preferred form available for the compliance plan? A7: HHS expects that most issuers already have compliance plans in place which support their ongoing lines of business. HHS will be providing a cover sheet that issuers can use to identify the elements of their compliance plans. The cover sheet should be submitted along with the issuer's compliance plan, as part of the application process. Issuers should design their compliance plans to meet their speci?c organizational needs and structure, and should use the compliance plan cover sheet to assist CMS in identifying where in their existing structure the requested elements can be found. The compliance plan cover sheet is available in the QHP Application Instructions posted on the REGTAP portal. (Plan Management Webinar QHP FAQ #2 04/09/13) 08: Do issuers have to submit a compliance plan? If so, do issuers have to submit the entire compliance plan orjust attest that it has one? Updated 1-31-17 A8: HHS expects that most issuers already have compliance plans in place which support their ongoing lines of business. HHS is requesting that a compliance plan be submitted as part of the QHP issuer application process. These compliance plans will be used for base-lining purposes, and will not be used as a criterion for assigning de?ciencies during the certi?cation process. (Plan Management Webinar QHP FAQ #2 04/09/13) 1135 2017-?01235 09: Do the compliance plans need to be specific to the Exchange? Can issuers submit their existing compliance plan? A9: HHS understands that compliance plans are subject to change as an entity evolves, and HHS assumes that an effective compliance strategy encompasses an issuer's full lines of business. We would expect issuers to update their existing compliance plans to reflect new Federal standards that may apply as a result of the issuer's participation in the FFE. If Exchange-specific updates are not presently made, we recommend that an issuer submit the existing compliance plan to assist HHS in offering future guidance. (Plan Management Webinar QHP FAQ #2 04/09/13) Q10: Will HHS be issuing guidance on compliance plans? A10: HHS has not published requirements specific to FFM compliance plans and does not expect to do so for plan year 2014. (Plan Management Webinar QHP FAQ #2 04/09/13) Q32: For the organizational chart submission, our assumption is that you are looking for an organizational chart with the CEO and key leaders versus Corporate Entity/Issuer Org Chart. Is that correct? A32: Yes, that is correct. (QHP Webinar Series FAQ #5 04/18/13) Q33: For the QHP compliance plan, do you prefer our current plan with acknowledgement that it will be adjusted for ACA, or do you want the current draft of our plan knowing it is only a draft? When do you expect to have our approved compliance plan? A33: HHS understands that compliance plans are subject to change as an entity evolves, and HHS assumes that an effective compliance strategy encompasses an issuer's full lines of business. We would expect issuers to update their existing compliance plans to reflect new Federal standards that may apply as a result of the issuer's participation in the FFE. If Exchange-speci?c updates are not presently made, we recommend that an issuer submit the existing compliance plan to assist HHS in offering future guidance. For issuers that are currently drafting a compliance plan that would include Exchange-specific information, we suggest submitting the revised compliance plan that is pending approval. This will better help us to see the Exchange- speci?c information. (QHP Webinar Series FAQ #5 04/18/13) Q3: When will the Centers for Medicare Medicaid Services (CMS) release the Cover Sheet and the checklist for the Attestations, Compliance Plan, and Organization chart? A3: The cover sheet has not changed from last year and is included in Chapter 2 of the Instructions at . (QHP Certification Process FAQs #4 {09/29/15)} 1 136 Updated 1-31-17 2017--01236 Oversight Oversight of Premium Stabilization Proqrams, APTC, and CSRs Q1: What oversight activities does the Centers for Medicare Medicaid Services (CMS) intend to propose with respect to the state-operated risk adjustment and reinsurance programs, cost-sharing reductions, and advance payments of the premium tax credit? A1: We intend to propose monitoring and oversight measures related to the premium stabilization programs applicable to both states and issuers. With respect to state- operated risk adjustment programs, we intend to propose a standard under which the state would maintain an accurate accounting for each bene?t year of risk adjustment expenditures, receipts, and administrative expenses, and the state would provide to CMS and make public an annual summary of the program. We also intend to propose that each state-operated risk adjustment program provide for an annual external financial and programmatic audit, and maintain relevant records for ten years. We intend to propose oversight standards applicable to states operating reinsurance programs that are substantially similar to those discussed above for state-operated risk adjustment programs. With respect to advance payments of the premium tax credit and cost-sharing reductions, we intend to propose standards for reimbursement to eligible enrollees, and providers as applicable, when a QHP issuer incorrectly applies cost-sharing reductions or advance payments of the premium tax credit with respect to an enrollee. We also intend to propose standards relating to record retention, annual reporting, and audits. (CMS FAQs - Health Insurance Marketplaces 07/29/13) Q2: How will CMS ensure that issuers of a risk-adjustment covered plan or reinsurance- eligible plan establish a distributed data environment? A2: We intend to propose enforcement of distributed data environment standards through civil money penalties. In addition, with respect to risk adjustment, we intend to propose a default risk charge that would apply to plans that fail to establish a secure, distributed data environment or otherwise fail to provide risk adjustment data required for the calculation of risk adjustment payment transfers. (CMS FAQs - Health Insurance Marketplaces 07/29/13) Issuer Oversight Q3: How does the Federally Facilitated Marketplace intend to enforce issuers? ongoing compliance with Marketplace-specific standards? Updated 1-31-17 A3: We expect that state departments of insurance will continue to oversee issuers in the health insurance market pursuant to the respective states? existing law and regulations. We intend to coordinate with state monitoring and oversight efforts to avoid duplicating such efforts, to the extent feasible and appropriate. As mentioned in prior FAQS, implementation we intend to continue assisting issuers to maintain compliance with Marketplace standards. To that end, we expect to release guidance reflecting this approach in the near future. (CMS FA Qs - Health Insurance Marketplaces 07/29/13) 1137 2017-?01237 Q4: Under what circumstances are issuers in the Federally-facilitated Marketplace subject to enforcement actions, including decertification of their A4: We intend to take an enforcement approach that would take into consideration various factors, including any past or concurrent state determinations and indications of the issuer?s good faith efforts in maintaining compliance with standards speci?c to the Federally-facilitated Marketplace. We note the need to coordinate with states on issuer oversight to avoid duplicative enforcement or investigative actions for the same issue, to the extent feasible and appropriate. We will generally look to the states to enforce standards applicable to issuers in the Federally-facilitated Marketplace. Where a state has elected not to enforce a standard or lacks the regulatory or enforcement authority to do so, we intend to propose enforcement of Federally-facilitated Marketplace-specific standards through civil money penalties (CMPs) and decertification. Absent any extraordinary circumstances, we expect decerti?cation would be uncommon. We also intend for issuers to be able to appeal the issuance of CMPs or decertifications. (CMS FAQs - Health Insurance Marketplaces 07/29/13) State-based Marketplace Reporting 05: Will State-based Marketplaces be required to provide reports to CMS on Marketplace activities? A5: Yes, we intend to propose requiring State-based Marketplaces to submit reports to CMS at least annually, including but not limited to financial statements and summary- Ievel statistical reports regarding eligibility determinations, enrollments, appeals, eligibility determination errors, privacy and security safeguards, and fraud and abuse determinations. Additionally, we intend for State-based Marketplaces to submit performance monitoring data including financial sustainability, operational ef?ciency, consumer satisfaction, and quality of care data. (CMS FAQs - Health Insurance Marketplaces 07/29/13) 06: Are there any recordkeeping requirements for State-based Marketplaces? A6: Yes, we intend to propose that State-based Marketplaces will be required to maintain for a minimum of 10 years records related to external audits, annual financial reports, error rate testing, consumer complaints, and other data sources in anticipation of targeted audits. (CMS FAQs - Health Insurance Marketplaces 07/29/13) Q7: What types of audits will State-based Marketplaces be required to conduct? Updated 1-31-17 A7: We intend to propose that State-based Marketplaces engage an independent qualified auditing entity to perform an independent audit of their annual financial statements and a review of the process/internal controls associated with their eligibility determinations and enrollments. We further intend to propose that State-based Marketplaces will be required to provide the results of this ?nancial and programmatic audit to CMS. (CMS FAQs - Health Insurance Marketplaces 07/29/13 1138 2017-?01238 SMART Governing Authority Q1: What is the purpose of the State-based Marketplace Annual Reporting Tool A1: The SMART is intended to capture in one document all reporting requirements for approved SBMs. In addition, we expect all conditionally-approved SBMs to collect this data and submit the SMART in 2015 and every year thereafter. This integrated reporting document streamlines compliance and will make it easier for SBMs to demonstrate their adherence to the regulations and standards of CMS. (State- based Marketplaces Annual Reporting Tool (SMART) 12/30/13) 02: Where is the SMART stored? A2: The SMART is currently open for comment under the Paperwork Reduction Act of 1995 (PRA). The Federal Register notice can be found at until January 14, 2014. A copy of the SMART can be found at 10507.htm . Following final approval by the Of?ce of Management and Budget (OMB), the SMART will be available on SERVIS at (State-based Marketplaces Annual Reporting Tool (SMART) 12/30/13) Q3: What authority does the CMS have to require an SBM to complete the A3: Section 1313(a)(1) of the ACA requires an Exchange (Marketplace) to keep an accurate accounting of all activities, receipts, and expenditures and annually submit to the Secretary a report concerning such accounting. Section 155.1200 of Title 45 of the Code of Federal Regulations, ?nalized in the Program Integrity Rule ll, 78 FR. 65046 (October 30, 2013) (PI Reg II), requires SBMs to monitor and report to HHS on Exchange-related activities, complete an annual report, and engage an independent qualified auditing entity to perform an annual independent external ?nancial and programmatic audit to ensure each Marketplace is in compliance with CMS regulations and standards. CMS received numerous requests from SBMs that CMS develop a tool that lists all SBM reporting requirements and enables SBMs to search one document to determine what reports are required. In response to those requests and as a procedural matter, the SMART is an electronic system CMS has developed to receive SBM reporting. (State-based Marketplaces Annual Reporting Tool (SMART) 12/30/13 Q4: What requirements must be addressed in the Updated 1-31-17 A4: SBMs are required to submit documents or attest to the submission of documents for the five components described in the table below. Smart Component Description Executive Summary 0 The executive summary captures activities and accomplishments for the given year. This information can include, data, highlights of accomplishments, key investments, challenges, priorities for the coming year, and major changes to 1139 2017-?01239 Updated 1-31-17 Smart Component Description the strategic direction of the SBM. The SBM will be expected to complete a text box or upload the executive summary if additional characters are needed Performance Metrics The performance metrics which can be found in the Appendix to the SMART were created to provide insight into the performance and impact of SBMs. This limited set of standardized metrics ensures basic transparency and allows consistent cross- state comparisons of the impact of varying approaches to SBM implementation. . Performance metrics are submitted on a quarterly and annual basis by the SBMs to CMS via the Outcomes Metrics Template ?at ?le. SBMs must attest to each quarterly and annual submission in the SMART. State-Blueprint Profiles and Updates . State-Blueprint Pro?les are created through data collected from SBMs from various reports, submissions, and reviews on policy and operational decisions. These profiles will be used to track and analyze varying approaches to implementation of each Marketplace. 0 The SBM must review the State-Blueprint Profiles through SERVIS. The SBM must attest that all of the information contained in the State-Blueprint Pro?le is accurate and current in the SMART. Additionally, the SBM must note any changes to the Blueprint. Eligibility and Enrollment 0 Eligibility and enrollment requirements were created to enhance transparency and ensure fairness for consumers. These requirements focus on eligibility determination errors, nondiscrimination safeguards, accessibility of information, and fraud and abuse incidences. . SBMs should submit reports regarding eligibility and enrollment to CMS as part of the SMART. The SBM must attest to the activities speci?ed, as well as submit documentation, as noted in the SMART. Financial and Program Integrity 0 Requirements on ?nancial and program integrity were developed to ensure proper oversight, accurate accounting of all activities, receipts, and expenditures, and assurance for identifying and addressing incidences of fraud, waste, and abuse. 0 Financial and program integrity reporting requirements include attestations and document submission. The SBM must attest to the activities speci?ed, as well as submit documentation from an independent external auditor. 1140 2017-?01240 (State-based Marketplaces Annual Reporting Tool (SMART) 12/30/13) Q5: Why do some questions require the SBM to upload a document or report while other questions only require an attestation? A5: For those questions where the response or document has already been captured in another document or system, an attestation is required. For example, the State is required to review the State Blueprint pro?les through SERVIS and con?rm that the profile is accurate and up-to-date. When a document does not exist, it must be uploaded. SERVIS will serve as that repository for the documents and enable CMS to confirm that the SBM has met the requirement. (State-based Marketplaces Annual Reporting Tool (SMART) 12/30/13) Q6: The SBM has already submitted the reports listed and believes this work is duplicative. Why does the SBM have to verify and/or resubmit the information again? A6: CMS is not asking states to report to CMS again, but rather to attest that they have completed the necessary reports. For example, States have to submit the Outcomes Metrics ?at file quarterly and annually. In this instance CMS is asking States to attest to the submission and not to submit the report again. CMS received many requests from SBMs to develop a tool that lists all reporting requirements and enables them to search one document to determine what reports are required. This tool responds to the request. (State-based Marketplaces Annual Reporting Tool (SMART) 12/30/13) Q7: How should SBMs attach the results of the independent external audit? A7: The audit ?ndings report and statements from the external auditor should be uploaded to SERVIS. Additional attestations will be required as well. Additional information on the independent external audit will be provided in future guidance. (State- based Marketplaces Annual Reporting Tool (SMART) 12/30/13) Q8: When must SBMs submit the SMART to A8: The SMART must be submitted to CMS by April 1 each year, with the first report due April 1, 2015. (State-based Marketplaces Annual Reporting Tool (SMART) 12/30/13) QQ: The SBM was conditionally approved in 2014. When must the SBM submit the SMART to A9: Conditionally-approved SBMs must meet all early 2014 reporting requirements which will be posted on SERVIS and submit the SMART in 2015. (State-based Marketplaces Annual Reporting Tool (SMART) 12/30/13) Q10: What will the SBM need to report in 2014? A10: As in past years, all States that received grants under section 1311 of the ACA must submit grant reports. In 2014, quarterly and annual metrics are required under 45 CFR SBMs will also be required to revisit their State-Blueprint Profiles and make any changes, based on new or updated policies and procedures. Additional information regarding 2014 reporting requirements will be made available to States in a 1141 Updated 1-31-17 2017-?01241 webinar and on SERVIS. (State-based Marketplaces Annual Reporting Tool (SMART) 12/30/13) Q11: How should the SBM submit the SMART to A11: The SMART must be completed and submitted to CMS using SERVIS at (State-based Marketplaces Annual Reporting Tool (SMART) 12/30/13) Q12: Can the SBM submit the SMART Guide and required documents in lieu of submitting responses on A12: The SMART Guide should only serve as an of?ine planning tool to help the SBM to prepare for submission of the SMART through SERVIS. SERVIS will be the only mechanism through which responses will be accepted as it will serve as a centralized location to track SMART requirements. (State-based Marketplaces Annual Reporting Tool (SMART) 12/30/13) Q13: Who will be required to sign the A13: The SMART must be electronically signed by the SBM executive director or CEO. (State-based Marketplaces Annual Reporting Tool (SMART) 12/30/13) Q14: What guidance and resources are available to assist SBMs with completing and submitting the A14: The table below provides resources available to SBMs as guidance for completing and submitting the SMART. As always, feel free to contact your State Officer for more information. Resource Use Location State-based An off-line planning tool that Marketplace outlines all the requirements 27305 Annual each SBM must complete as and Report Tool outlined in the PI Reg II that (SMART) simulates SERVIS. Guide uctionActof1995/PRA-Listinq- temleMS-10507.htm State Created through data collected Blueprint from SBMs on policy and Pro?le operational decisions. The SBM must review the State-Blueprint Pro?les through SERVIS. Program Grants authority to CMS to Integrity (PI) require each SBM to submit a Data/2013-25326 P .pdf Regulation SMART on an annual basis. Outcome Metrics are submitted by the Metrics SBMs to the US. Department Template of Health and Human Services (HHS) via the Outcomes 1142 Updated 1-31-17 2017-?01242 Resource Use Location Metrics Template flat ?le on a quarterly and annual basis, as speci?ed in the Pl Reg ll. (State-based Marketplaces Annual Reporting Tool (SMART) 12/30/13) QUALITY Quality Rating System (QRS) QHP Enrollee Survey Q: Can QHP issuers include off-Marketplace enrollees (those enrolled in coverage outside of the Marketplace that would be considered the same as coverage certified as a QHP and offered through the Marketplace) in the data submissions for the Quality Rating System (QRS) and the QHP Enrollee Experience Survey (QHP Enrollee Survey) reporting for the 2015 beta test? Updated 1-31-17 A: Pursuant to 45 CPR. and QHP issuers participating in the Marketplace must include information in their respective QRS and QHP Enrollee Survey data submissions only for those enrollees at the level specified by HHS. For the 2015 beta test, this reporting is speci?ed at the product level HMO, PPO, POS, EPO). For each product, QHP issuers should include enrollees in eligible QHPs. An eligible QHP must meet all 3 of the following criteria: 1) have a 14-digit Standard Component ID number (SCID) that was assigned in the HIOS database, 2) be offered on an Individual Marketplace and/or a SHOP Marketplace, and 3) provide family and/or adult-only medical coverage. This could result in the inclusion of off-Marketplace enrollee information in the 2015 beta test, based on our understanding that the assignment of enrollees to variants of the same SCID was not consistently applied and that it may not be feasible to separate enrollees who purchased off-Marketplace coverage from those who purchased coverage through the Marketplace. Based on the guidance outlined in this FAQ, all enrollees included in an eligible QHP meeting the 3 criteria above should be included in reporting for the QRS and QHP Enrollee Survey. This approach differs from the one outlined in the 2015 QRS and QHP Enrollee Survey Technical Guidance. QHP issuers that already completed programming for 2015, based on the previous guidance issued in the 2015 QRS and QHP Enrollee Survey Technical Guidance, are permitted to provide a data submission that excludes off-Marketplace enrollees from eligible QHPs. However, QHP issuers must apply the same approach for identifying its eligible populations and sampling for the QHP Enrollee Survey and QRS clinical measure set. Therefore, if a QHP issuer excluded off- Marketplace enrollees for the QHP Enrollee Survey, then it should also exclude such enrollees for the QRS clinical measure set. CMS previously stated (79 FR 30318) that during the 2015 beta testing period data from QHPs outside the Marketplace will not be used. CMS has since learned that data submissions may inevitably reflect a mix of on- and off-Marketplace enrollees based on the inconsistent application of SCID variants. Therefore, the 2015 beta test quality ratings calculated for each product will be based on enrollees in each eligible QHP and may include information from enrollees who purchased the coverage outside of the Marketplace. The 2015 beta test quality ratings once calculated will be assigned to each eligible QHP within the product offered through the Marketplace. 1143 2017-?01243 We will assess the impact of this approach in the beta test and will consider the feasibility of alternative approaches for 2016. Please see the 2015 Quality Rating System and QHP Enrollee Survey Technical Guidance for additional details about the beta test reporting requirements, including eligible product types and coverage types. (REGTAP FAQ Database - FAQ #8206 12/16/14) Q: Some QHP issuers either do not offer a pediatric dental benefit or carve out the pediatric dental benefit. How should such QHP issuers report data for the Quality Rating System (QRS) Annual Dental Visit (ADV) measure and how will a QHP issuer's ratings be impacted if data are not reported for this measure? A: If the QHP issuer does not offer or administer the dental benefit, the issuer should report an NB (?Bene?t Not Offered?) for the ADV measure. If a dental bene?t is a carved- out benefit, then the QHP issuer has the option to report data for the ADV measure. Some organizations can obtain the necessary information from a carved-out entity and may include these enrollees in their measure reporting. If the QHP issuer is unable to obtain the necessary information for the measure due to carved-out benefits, the plan should report an NB for the ADV measure. CMS anticipates issuing guidance on how NB and NR Not Reportable" due to the issuer not reporting the rate, or the rate being materially biased) results will be handled for QRS scoring, including impacts to the QRS hierarchy, once beta test analyses are completed in fall 2015. (REGTAP FAQ Database - FAQ #8207 12/16/14) Q: If a QHP issuer offers multiple products EPO, HMO, POS, PPO) in the Marketplace, can products be combined for the Quality Rating System (QRS) and the QHP Enrollee Experience Survey (QHP Enrollee Survey) reporting? A: Product types EPO, HMO, POS, PPO) cannot be combined for reporting. QHP issuers must collect and submit QRS clinical measure data and QHP Enrollee Survey response data separately for each product type offered through a Marketplace in the previous year that meets the minimum enrollment size threshold for data collection. For the 2015 QRS and QHP Enrollee Survey beta test, CMS will calculate quality ratings at the product level for QHP issuers within in each Marketplace and these ratings will be applied to each product's respective QHPs. (REGTAP FAQ Database - FAQ #8208 12/16/14) Q: With regard to the minimum enrollment threshold for the Quality Rating System (QRS) and the QHP Enrollee Experience Survey (QHP Enrollee Survey), which enrollees should be included for purposes of calculating the ?more than 500 enrollees? minimum? Updated 1-31-17 A: QHP issuers are required to collect and submit QRS clinical measure data and QHP Enrollee Survey response data at the product level EPO, HMO, POS, PPO). To determine if a product meets the minimum enrollment threshold, QHP issuers must include enrollees in the individual market offered through a Marketplace, as well as enrollees from the Small Business Health Options Program (SHOP) enrolled as of July 1, 2014. A QHP issuer that offers both a QHP and a Multi-State Plan option of the same product type in the same Marketplace must include enrollees in both plan types when determining product enrollment size. (REGTAP FAQ Database - FAQ #8209 12/16/14) 1144 2017-?01244 Q: During the 2015 Quality Rating System (QRS) beta test preview period, will QHP issuers be able to view other issuers' quality scores and ratings in order to understand how they are performing comparatively? A: The QRS and QHP Enrollee Survey data preview period will allow QHP issuers and Marketplaces to review their respective QHP quality scores and ratings; however, QHP issuers will not be able to view other QHP issuers' scores and ratings during the preview period. CMS will provide further details in advance of the preview period including the type of quality ratings information that will be available and how QHP issuers and Marketplaces will be able to access their information. (REGTAP FAQ Database - FAQ #8210 12/16/14) Q: Do the Quality Rating System (QRS) and the QHP Enrollee Experience Survey (QHP Enrollee Survey) requirements only apply to QHP issuers participating in State-based Marketplaces A: QRS and QHP Enrollee Survey requirements apply to all QHP issuers offering family and/or adult-only health insurance coverage through the Marketplaces, regardless of the Marketplace model in which they operate Federally-facilitated Marketplace State Partnership Marketplace or State-based Marketplace as part of QHP certification to operate in the Marketplace. (REGTAP FAQ Database - FAQ #8211 12/16/14) Q: What are the deadlines for QHP issuers to contract with data validators and survey vendors in preparation for Quality Rating System (QRS) and the QHP Enrollee Experience Survey (QHP Enrollee Survey) data submission? Are these deadlines flexible? A: QHP issuers should contract with a data validator (Healthcare Effectiveness Data and Information Set Compliance Auditor) by December 1, 2014 and with a CMS- approved QHP Enrollee Survey vendor by January 5, 2015. CMS expects QHP issuers to meet the contracting deadlines so that data validators and survey vendors can effectively support QHP issuers with meeting the data collection and data submission requirements. For additional questions about the contracting process for data validators HEDIS Compliance Auditors), please submit questions labeled HEDIS to the National Committee for Quality Assurance's (NCQA's) Policy Clarification Support (PCS) system at For additional questions about the contracting process for survey vendors, please contact the QHP Enrollee Survey team via e-mail at ghpcahps@air.org. (REGTAP FAQ Database - FAQ #8212 12/16/14) Q: Where can I find more information on the QHP Enrollee Experience Survey (QHP Enrollee Survey)? A: The QHP Enrollee Survey questionnaire and additional resources for preparing for the survey are available on QHP Enrollee Survey website at (REGTAP FAQ Database - FAQ #8213 12/16/14) 1 145 Updated 1-31-17 2017-?01245 Q: At what level(s) in the Quality Rating System (QRS) hierarchy will CMS produce QRS star ratings? Will it only be at the global level? A: CMS will calculate both a numeric score and a star rating for each QRS hierarchy component (composites, domains, summary indicators), as well as a single global score and rating. Numeric scores and star ratings will be calculated by product and applied to each product's respective QHPs. (REGTAP FAQ Database - FAQ #8214 12/16/14) Q: Will CMS accept state-mandated quality measure data to meet Quality Rating System (QRS) requirements? A: QHPs issuers are required to meet QRS and QHP Enrollee Survey requirements as part of QHP certi?cation to operate in the Marketplace. QHP issuers are required to collect and submit QRS clinical measure data and QHP Enrollee Survey data as outlined in the Quality Rating System and Quali?ed Health Plan Enrollee Experience Survey: Technical Guidance for 2015 in addition to any quality measures their respective states may require. (REGTAP FAQ Database - FAQ #8215 12/16/14) Quality Improvement Strategy (QIS) Q: Does an issuer need to submit a separate quality improvement strategy (QIS) for each eligible product type Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), Point of Service (POS) plans, Exclusive Provider Organizations (EPOs), and indemnity plans) within a Marketplace? A: No. An issuer may choose to implement a single QIS to cover all of its eligible health plans and product types, or may choose to implement multiple quality improvement strategies. (REGTAP FAQ Database - FAQ #14717 01/28/16) Q: Criterion 21b of the Quality Improvement Strategy (QIS) Implementation Plan and Progress Report form asks issuers to ?specify all QHPs covered by the QIS by listing each plan's unique 14-digit HIOS Plan ID (Standard Component ID Indicate if each one is a new or existing Since issuers submit their strategies during the 2016 QHP Application and Review Period, issuers will know their 2016 SCIDs, but may not know the entirety of their 2017 SCIDs. Should issuers indicate their 2016 SCIDs, 2017 SCIDs, or both in Criterion 21b? A: Criterion 21b of the QIS Implementation Plan and Progress Report form includes space for issuers to input their existing health plan SCIDs as well as new health plan SCIDS. The SCle listed in Criterion 21 should include those the issuer intends to offer during the 2017 coverage year. If the health plan has been offered in previous years and will be offered again in 2017, the SCID listed in Criterion 21b should be marked as ?existing health plan.? If the health plan is new for the 2017 coverage year, the SCID listed in Criterion 21 should be marked as ?new health plan.? (REGTAP FAQ Database - FAQ #14718 01/28/16) Q: When calculating quality improvement strategy (QIS) minimum enrollment, should an issuer include both Small Business Health Options Program (SHOP) enrollees and individual Marketplace enrollees? A: Yes. When calculating minimum enrollment, issuers should include both SHOP and 1 146 Updated 1-31-17 2017-?01246 individual Marketplace enrollees within a product type. If an issuer has 501+ enrollees within a product type including SHOP and individual Marketplace enrollees, then all eligible health plans within that product type must be covered by a QIS. (REGTAP FAQ Database - FAQ #14719 01/28/16) Q: If an issuer's 14-digit HIOS Plan ID (Standard Component ID changes after it submits its Quality Improvement Strategy (QIS) Implementation Plan and Progress Report form, how will that information be transmitted to A: Issuers do not need to report any changes in the 80le that were included in their QIS Implementation Plan to CMS as they occur during the course of the year. When issuers submit a QIS Progress Report via the QIS Implementation Plan and Progress Report form, during the following QHP Application Period, they should then provide an updated list of the SCle included in each QIS. (REGTAP FAQ Database - FAQ #14720 01/28/16) Q: The Quality Improvement Strategy (QIS) Technical Guidance and User Guide for the 2017 Coverage Year specifies a SOD-character limit for an issuer's response to Element 17, QIS Title. However, the QIS Implementation Plan and Progress Report form specifies 200 characters. What is the correct character limit for an issuer's response to Element 17, QIS Title? A: Element 17, QIS Title, has a ZOO-character limit, which is correctly speci?ed in the QIS Implementation Plan and Progress Report form. (REGTAP FAQ Database - FAQ #14721 01/28/16) Q1: Criterion 21a of the Quality Improvement Strategy (QIS) Implementation Plan and Progress Report form states, ?Indicate if this QIS is applicable to all qualified health plans (QHPs) you offer or are applying to offer through the Marketplaces, or to a subset of Does ?all mean only QHPs within product type(s) that meet the minimum enrollment threshold eligible QHPs), or all QHPs offered through the Marketplaces? A1: Criterion 21a of the QIS Implementation Plan and Progress Report form asks each issuer to indicate if its QIS applies to all QHPs or a subset of QHPs. In this case, the term ?all refers to eligible QHPs only; it does not refer to all QHPS offered through the Marketplaces. Eligible QHPs are health plans within a product type that meets the minimum enrollment threshold the product type had more than 500 on- Marketplace enrollees per state as of July 1, 2015). QHPs within product types that do not meet the minimum enrollment threshold non-eligible QHPs) are not required to be covered by a QIS. For more information about QHP eligibility with respect to an issuer?s QIS, please see Section 5.2 of the QIS Technical Guidance and User Guide for the 2017 Coverage Year. (REGTAP FAQ QIS Criterion 21 8 03/30/16) Q1: Do product types and health plans offered for less than two consecutive years on the Marketplace need to be covered by a quality improvement strategy A1: The QIS two-consecutive-year requirement is based on the number of years an issuer has offered coverage on the Marketplace, not the number of years a product type or health plan has been offered. For example, if an issuer offered coverage on the Marketplace in 2014 and 2015, the issuer is required to develop at least one QIS for the 1 147 Updated 1-31-17 2017-?01247 2017 coverage year to cover all eligible health plans. An issuer that meets the two- consecutive-year requirement has the option of implementing one QIS that covers multiple health plans and product types, or having multiple quality improvement strategies to cover all eligible health plans and product types. Additional details on health plan eligibility can be found in Section 5.1 of the QIS Technical Guidance and User Guide for the 2017 Coverage Year. (REGTAP FAQ QIS Two Consecutive Years 03/30/16) Q1: Element 19 of the Quality Improvement Strategy (QIS) Implementation Plan and Progress Report form requires an issuer to indicate the type(s) of market-based incentive(s) used in its QIS. Is an issuer required to select both a provider-based incentive and an enrollee-based incentive? A1: No. Issuers are not required to select both a provider-based incentive and an enrollee-based incentive, but may choose to do so if they wish. An issuer has the ?exibility to develop a QIS that includes only a provider-based incentive, only an enrollee-based incentive, or both. (REGTAP FAQ QIS Provider Enrollee Incentives 03/30/16) Q1: When an issuer uploads its Quality Improvement Strategy (QIS) to the Health Insurance Oversight System (HIOS) Accreditation module or System for Electronic Rate and Form Filing (SERFF), what should it name the file? A1: Issuers should name their QIS submissions according to the following naming convention: Issuer where the is a numerical identifier of the issuer?s submissions. For example, an issuer with one QIS submission would submit a single ?le with the ?le name ending in ?1 an issuer with two QIS submissions would submit two files with the ?le names ending in and respectively. (REGTAP FAQ QIS Naming Convention 03/30/16) Q1: When an issuer uploads its Quality Improvement Strategy (QIS) to the Health Insurance Oversight System (HIOS) Accreditation module, what should the issuer select as the ?Document Type?? A1: In the HIOS Accreditation module, an issuer should use the ?Upload File(s)? function to upload its QIS as part of its ?Supplementary Documentation.? When asked to select the document type, the issuer should use the dropdown menu to select FAQ QIS HIOS Upload 03/30/16) Q1: What is the difference between the Quality Rating System and Qualified Health Plan Enrollee Experience Survey: Technical Guidance for 2016 version published in September 2015 and Version 2.0 published in January 2016? A1: The Quality Rating System and Quali?ed Health Plan Enrollee Experience Survey: Technical Guidance for 2016 specifies requirements for QHP issuers offering coverage through the Health Insurance Marketplaces (Marketplaces) in 2016, which include data submission in the 2016 calendar year for ratings to be displayed for the 2017 plan year. Version 2.0, published in January 2016, is the final version of the technical guidance. This version supersedes the initial version published in September 2015. The key differences include: 1 148 Updated 1-31-17 2017-?01248 1. The and QHP Enrollee Survey Requirements" section (beginning on page 6) includes more details regarding on- and off-Marketplace scenarios to aid in determining which enrollees to include in the reporting unit. 2. The Rating Methodology? section (beginning on page 15) reflects the finalized rating methodology for 2016 based on the results of the 2015 beta test data analysis, and it includes additional details such as the scoring speci?cations for QRS survey measures. 3. The ?Quality Rating Information Preview Process" section (beginning on page 18) includes additional details about the process and timing for the QRS preview period in August 2016. 4. The ?Marketplace Display Guidelines for QHP Quality Rating Information? section (beginning on page 19) includes additional details about the required display of QHP quality rating information in time for the individual market open enrollment period for 2017. For more information, download the QRS and QHP Enrollee Survey: Technical Guidance for 2016 Version 2.0 at Marketplace Quality Initiatives website. (REGTAP FAQ - QIS Updated 2016 Guidance 03/30/16) Q: For Federally-facilitated Marketplaces (FFMs), including FFMs where States perform plan management, what happens to issuers' Quality Improvement Strategy (QIS) Implementation Plan and Progress Report forms (QIS forms) following submission during the Qualified Health Plan (QHP) Application Submission and Review Period (QHP Application Period)? A: For FFMs, including FFMs where States perform plan management, QIS forms submitted during the QHP Application Period are ?rst assessed for completeness, and then undergo full evaluation by the Centers for Medicare Medicaid Services (CMS). Issuers participating in the FFMs whose QIS forms were not received as required, were missing information, or contained blank ?elds receive Correction Notices during the QHP Application Period that specify any QIS de?ciencies. Issuers participating in the FFMs that receive Correction Notices must correct and resubmit their QIS forms. If issuers participating in the FFMs do not receive Correction Notices that list QIS de?ciencies, their QIS forms are complete and will undergo full evaluation. For FFM states where States perform plan management functions, the submission is jointly reviewed by CMS and the State, with the final determination being made by CMS. Issuers operating in these FFM states should contact the State for details on the State's process for evaluating QIS submissions. (REGTAP FAQ Database - FAQ #17315 08/30/16) Q: When will the Centers for Medicare Medicaid Services (CMS) notify issuers operating in Federally-facilitated Marketplaces (FFMs), including FFMs where States perform plan management, of their full Quality Improvement Strategy (QIS) evaluation results? Updated 1-31-17 A: For the FFMs, including FFMs where States perform plan management, CMS noti?es issuers of any concerns with their QIS submissions based on their full QIS evaluation results at the end of the calendar year, after the conclusion of the annual Qualified 1149 2017-?01249 Health Plan (QHP) Application Submission and Review Period (QHP Application Period) in which the QIS submissions were made. For example, issuers participating in the FFMs will receive notice of de?ciencies or concerns at the end of calendar year 2016 for QIS submissions made during 2017 QHP Application Period. An issuer participating in an FFM that receives outreach regarding de?ciencies or concerns with its QIS must work with CMS to address these concerns. CMS does not provide affirmative notification of ful?llment of the QIS requirements. Issuers participating in the FFMs that do not receive notification of deficiencies or concerns by the end of the calendar year following the conclusion of the applicable QHP application period should continue their QIS implementation. For FFM states where States perform plan management functions, the submission is jointly reviewed by CMS and the State, with the final determination being made by CMS. Issuers operating in these FFM states should contact the State for details on the State's process for evaluating QIS submissions. (REGTAP FAQ Database - FAQ #17316 08/30/16) OTHER Shared Responsibility Payments Q: Will any individual who enrolls in coverage through the Marketplace by the end of the open enrollment period for 2014 have to make a shared responsibility payment in 2015 for the months prior to the effective date of the individual?s coverage? Updated 1-31-17 A: Starting in 2014, the individual shared responsibility provision requires each individual to maintain health coverage (known as minimum essential coverage), qualify for an exemption from the requirement to maintain minimum essential coverage, or make a shared responsibility payment when ?ling a federal income tax return. To help make coverage affordable for millions of individuals and families, the Affordable Care Act provides, among other things, a premium tax credit to eligible individuals and families to help pay for the cost of health insurance coverage purchased through Health Insurance Marketplaces. The shared responsibility payment generally applies to people who have access to affordable coverage during a taxable year but who choose to spend a substantial portion of that year uninsured. The Affordable Care Act gives the Secretary of the US. Department of Health and Human Services (HHS) the authority to establish hardship exemptions from the shared responsibility payment for individuals who ?have suffered a hardship with respect to the capability to obtain coverage under a quali?ed health plan Under this authority, HHS has enumerated several situations that constitute such a hardship. Furthermore, the Affordable Care Act provides the Secretary of HHS the authority to determine the initial open enrollment period for individuals to enroll in coverage through the Marketplaces for 2014. Pursuant to this authority, the ?nal rule entitled ?Patient Protection and Affordable Care Act; Establishment of Exchanges and Quali?ed Health Plans; Exchange Standards for Employers" and published on March 27, 2012, at 45 1150 2017-?01250 Updated 1-31-17 CFR 155.410(b) (?Exchange Final Rule?) speci?es that the initial open enrollment period for individuals begins on October 1, 2013, and extends into 2014. The Exchange Final Rule also provides the coverage effective dates for individuals enrolling in coverage through the Marketplaces during the initial open enrollment period. For plan selections made between the 1st and the 15th of a given month, the coverage effective date is the ?rst day of the immediately following month, and for plan selections made between the 16th and end of a given month, the coverage effective date is the ?rst day of the second following month. To ensure that the shared responsibility payment generally applies only to the limited group of people who have access to affordable coverage during a year but who nonetheless choose to spend a substantial portion of that year uninsured, the Affordable Care Act provides nine statutory exemptions relating to the individual shared responsibility provision within the Internal Revenue Code. The short coverage gap exemption speci?es that an individual is exempt for ?[any] month the last day of which occurred during a period in which the applicable individual was not covered by minimum essential coverage for a continuous period of less than 3 months.? The length of the initial open enrollment period and the coverage effective dates, in tandem with the terms of the short coverage gap exemption, created the possibility that an individual who enrolled in coverage through a Marketplace during the initial open enrollment period could nonetheless be liable for a shared responsibility payment for months prior to the effective date of that coverage, if the individual were not othenivise exempt. More speci?cally, under this structure, an individual who enrolls between February 16, 2014 and the close of the initial open enrollment period will have coverage effective as of April 1 or later. As a result, such an individual would not be eligible for the short coverage gap exemption, which applies only when the coverage gap is less than (but not equal to) 3 months. HHS recognizes that the duration of the initial open enrollment period implies that individuals have until the end of the initial open enrollment period to enroll in coverage through the new Marketplaces while avoiding liability for the shared responsibility payment. Yet, unless a hardship exemption is established, individuals who purchase insurance through the Marketplaces towards the end of the initial open enrollment period could be required to make a shared responsibility payment when filing their federal income tax returns in 2015. HHS has determined that it would be unfair to require individuals in this situation to make a payment. Accordingly, HHS is exercising its authority to establish an additional hardship exemption in order to provide relief for individuals in this situation. Specifically, if an individual enrolls in a plan through the Marketplace prior to the close of the initial open enrollment period, when filing a federal income tax return in 2015 the individual will be able to claim a hardship exemption from the shared responsibility payment for the months prior to the effective date of the individual?s coverage, without the need to request an exemption from the Marketplace. Additional detail will be provided in 2014 on how to claim this exemption. (CMS FAQs - Shared Responsibility Provision 10/28/13) 1151 2017-?01251 Q: Will any individual who submits an application during the open enrollment period for 2014 and is found eligible for Medicaid or the Children?s Health Insurance Program (CHIP) have to make a shared responsibility payment in 2015 for the months prior to the effective date of the individual?s coverage? Updated 1-31-17 A: Starting in 2014, the individual shared responsibility provision requires each individual to maintain health coverage (known as minimum essential coverage), qualify for an exemption from the requirement to maintain minimum essential coverage, or make a shared responsibility payment when ?ling a federal income tax return. To help make coverage affordable for millions of individuals and families, the Affordable Care Act provides, among other things, a premium tax credit to eligible individuals and families to help pay for the cost of health insurance coverage purchased through Health Insurance Marketplaces. The shared responsibility payment generally applies to people who have access to affordable coverage during a taxable year but who choose to spend a substantial portion of that year uninsured. To ensure that the shared responsibility payment generally applies only to the limited group of people who have access to affordable coverage during a year but who nonetheless choose to spend a substantial portion of that year uninsured, the Affordable Care Act provides nine statutory exemptions relating to the individual shared responsibility provision within the Internal Revenue Code, including exemptions for hardship and an exemption for a short coverage gap.1 Hardship exemptions apply to individuals who ?have suffered a hardship with respect to the capability to obtain coverage under a qualified health plan Under this authority, HHS has enumerated several situations that constitute such a hardship.3 The short coverage gap exemption speci?es that an individual is exempt for ?[any] month the last day of which occurred during a period in which the applicable individual was not covered by minimum essential coverage for a continuous period of less than 3 months.? The Affordable Care Act provides the Secretary of HHS the authority to determine the initial open enrollment period for individuals to enroll in coverage through the Marketplaces for 2014.5 Pursuant to this authority, the ?nal rule entitled ?Patient Protection and Affordable Care Act; Establishment of Exchanges and Quali?ed Health Plans; Exchange Standards for Employers" and published on March 27, 2012, at 45 CFR 155.410(b) (?Exchange Final Rule?) speci?es that the initial open enrollment period for individuals begins on October 1, 2013, and extends through March 31, 2014. The length of the initial open enrollment period and the coverage effective dates for enrollment in a QHP through the Marketplace, in tandem with the terms of the short coverage gap exemption, created the possibility that an individual who enrolled in coverage through a Marketplace during the initial open enrollment period could nonetheless be liable for a shared responsibility payment for months prior to the effective date of that coverage, if the individual were not otherwise exempt. Accordingly, on October 28, 2013, HHS specified that, ?if an individual enrolls in a plan through the Marketplace prior to the close of the initial open enrollment period, when ?ling a federal income tax return in 2015 the individual will be able to claim a hardship exemption from the shared responsibility payment for the months prior to the effective date of the individual?s coverage, without the need to request an exemption from the Marketplace.? 1152 2017-?01252 The October 28, 2013 guidance did not address an individual who applies for coverage during the initial enrollment period and is determined eligible for Medicaid or CHIP. This guidance addresses that situation. . First, in accordance with 42 CFR 435.915, the effective date of coverage for an individual who is determined eligible for Medicaid is the date of his or her application (and may be up to three months before the month the individual ?led his or her application, in some circumstances). Accordingly, an individual who applies for coverage on or before March 31, 2014 and is found eligible for Medicaid based on that application will have Medicaid on or before March 31, 2014. Under these circumstances, even if such an individual did not have coverage before March 31st he or she will qualify for a short coverage gap exemption for the period of time before his or her Medicaid coverage was not yet effective, back to January 1, 2014. 0 Second, because CHIP effective dates typically follow the same rules as private insurance (meaning that an application date of March 31st may not yield a March 31st effective date), HHS is exercising its authority to extend the hardship exemption described in the October 28, 2013 guidance, to include individuals who apply for coverage during the initial open enrollment period and are found eligible for CHIP based on that application. The IRS and Treasury Department intend to publish guidance allowing an individual to claim a hardship exemption from the individual shared responsibility payment for the months in 2014 prior to the effective date of the individual's CHIP coverage if the individual submits a coverage application prior to the close of the open enrollment period and is found eligible for CHIP. (Shared Responsibility Provision (03/31/14)) 06. Are conversion policies offered to individuals losing group health insurance coverage considered to be minimum essential coverage under section 5000A(f) of the Internal Revenue Code? A: Yes, as long as the conversion coverage is offered by a health insurance issuer (within the meaning of section 2791(b)(2) of the PHS Act) and is an individual market policy subject to the consumer protections that apply to such coverage (notwithstanding that under section 2741 of the PHS Act, the issuer is not deemed to be a health insurance issuer offering individual health insurance coverage solely because such issuer offers a conversion policy). (CMS FA OS on Health Insurance Market Reforms and Marketplace Standards 05/16/14) Q: Can a State-based Marketplace (SBM) continue to utilize the option provided for under 45 CFR 155.625(b) to have the Department of Health and Human Services (HHS) process exemption applications for the shared responsibility payment? Updated 1-31-17 Yes. In the Eligibility for Exemptions ?nal rule (78 FR 39494, July 1, 2013), HHS established in 45 CFR 155.625(b) an option under which a SBM could adopt eligibility determinations for exemptions from the shared responsibility payment made by HHS, provided certain conditions are met by the SBM, for any applications submitted prior to October 15, 2014. The May 27, 2014 Exchange and Insurance Market Standards for 2015 and Beyond ?nal rule extended the ?155.625(b) option for exemption applications submitted before the start of the open enrollment period for 2016. Based on operation of this service, we have determined that the HHS exemption option is an ef?cient process for SBMs that has minimized confusion for consumers. We, 1153 2017-?01253 therefore, intend to propose regulations that would authorize this option on a permanent basis, and, in the interim, will not take any enforcement action against SBMs that continue to use the HHS service for exemptions beyond the start of open enrollment for 2016. (FAQs on State-based Marketplace Options for Implementing Exemptions from the Shared Responsibility Payment 07/28/15) Q: Does 45 CFR 155.625(b) apply only to This option applies only to SBMs utilizing their own eligibility and enrollment platform. States that did not establish SBMs or use their own eligibility platforms do not have the option to process their own exemptions. (FAQs on State-based Marketplace Options for Implementing Exemptions from the Shared Responsibility Payment 07/28/15) Q: How does an SBM notify HHS that it intends to elect the HHS exemptions option under 45 CFR An SBM must inform HHS in writing whether it will process its own exemption applications or adopt HHS exemption eligibility determinations. An SBM should contact its CCIIO State Officer for more information. If electing to use the HHS exemption option, the SBM must meet the conditions under 45 CFR which include: 1) Adhering to the HHS eligibility determination; 2) Furnishing to HHS any information available through the Exchange that is necessary for an applicant to utilize the process administered by and 3) Providing information to a consumer via the SBM call center and Internet Web site specified in 155.205(a) and regarding the exemption eligibility process. If an SBM elects to develop the capacity to grant certificates of exemption, HHS remains committed to providing technical assistance to SBMs to support their implementation of these capabilities. HHS has developed and released a set of model paper applications that can be adopted by SBMs and will consider providing additional guidance, such as example standard operating procedures, to assist SBMs as they develop their own exemption processing capabilities. (FAQs on State-based Marketplace Options for Implementing Exemptions from the Shared Responsibility Payment 07/28/15) Q: If electing to use the HHS option for exemptions under 45 CFR what information must an SBM furnish to Updated 1-31-17 As a condition of using the HHS exemption option, the SBM must furnish HHS with ?any information available through the Exchange that is necessary for an applicant to utilize the process administered by under 45 CFR For example, a consumer submitting a prospective affordability exemption application to HHS under may need information including the cost of the lowest cost bronze plan net of advance payments of the premium tax credit (APTC). We encourage SBMs to make information available to consumers about the applicable lowest cost bronze plan and any applicable APTC to help facilitate affordability exemption processing. However, if a consumer cannot access this information directly, the SBM may need to provide the information to HHS directly. (FAQs on State-based Marketplace 1154 2017-?01254 Options for Implementing Exemptions from the Shared Responsibility Payment 07/28/1 5) Q: Must an SBM that elects to set up its own exemption process use an electronic system? Electronic exemption application capabilities are not a requirement. At this time, an SBM may use a paper and manual process to handle exemption applications. (FAQs on State-based Marketplace Options for Implementing Exemptions from the Shared Responsibility Payment 07/28/15) Exchange Coverage for Members of Congress and staff Q. How will Members of Congress and Congressional staff access health insurance coverage through an Exchange as directed by Office of Personnel Management (OPM) regulations implementing the Affordable Care Act? A. Section 1312(d)(3)(D) of the Affordable Care Act provides that the only health plans that the federal government may make available to Members of Congress and certain congressional staff with respect to their service as such are health plans offered through an Exchange, also known as a Health Insurance Marketplace. Section 1312 further de?nes congressional staff as those employed by the official of?ce of a Member of Congress. A ?nal rule published by OPM provides that Members of Congress will designate those on their staff who are eligible to purchase their health insurance from an Exchange and establishes the Small Business Health Options Program (SHOP) as the channel through which such staff and Members of Congress may enroll in qualified health plans. Consistent with the OPM rule, this guidance clari?es that of?ces of the Members of Congress are considered quali?ed employers eligible to offer coverage to Members and designated Congressional staff through the appropriate SHOP as determined by OPM. CMS clarifies that of?ces of the Members of Congress, as qualified employers, are eligible to participate in a SHOP regardless of the size and offering requirements set forth in the definition of ?qualified employer" in the Exchange ?nal rule1, provided that the office offers coverage to those full-time employees who are determined by statute to purchase health insurance from an Exchange for the purpose of the government contribution. (CMS FAQs - Members of Congress and staff Accessing Coverage through Exchanges (Marketplaces) 09/30/13) Model Language for Individual Market Renewal Notices Issuers can use to following to provide notice to their existing customers about the new coverage options in the individual market, including QHPs, premium tax credits, and cost sharing reductions through Health Insurance Marketplaces, beginning January 1, 2014. CMS will consider the use of this language acceptable under the requirements set forth in 45 C.F.R. 147.104(e) and provided that it is provided uniformly to all applicable enrollees. Issuers may wish to provide this notice before 10/1/13, either: 1) with non-grandfathered individual policy renewal notices; or 2) as a stand-alone notice sent to non-grandfathered individual market customers. 1155 Updated 1-31-17 2017--01255 Use of this notice does not preclude issuers from providing additional information concerning the issuer?s QHP, a web link to the issuer's direct enrollment website or its other products. ?You and your family may soon have new options for health care coverage. Starting on October 1, 2013, the Health Insurance Marketplace will offer a new alternative for purchasing health insurance plans. You can preview your premium, deductibles, and co-payment costs before you make a decision to enroll in a plan, and determine whether you qualify for assistance to reduce these costs. You can continue to purchase coverage from us in the Marketplace. You may ?nd your premiums are lower due to a new kind of tax credit in the Marketplace. You might also qualify for plans with reduced deductibles and co-payments. Even though help with premiums, deductibles, and co-payments isn?t available outside the Marketplace, the health care law also guarantees that you can choose a new plan outside the Marketplace even if you have a preexisting condition. Find out more at (Insurance Standards Bulletin Series Model Language for Individual Market Renewal Notices, April 30, 2013 Outreach by Medicaid Managed Care contractors and Health Insurance Issuers to Former Enrollees Medicaid managed care organizations (MCOs) provide coverage of Medicaid benefits to Medicaid bene?ciaries on a risk basis, and have been in existence since before the enactment of the Affordable Care Act. Many individuals who were once enrolled in a Medicaid managed care plan may no longer be eligible for Medicaid as determined by a State. Many issuers that contract with the State as MCOs are now involved in offering Quali?ed Health Plans (QHPs) on the Federally-facilitated Marketplace or in State-based Marketplaces offering coverage to individuals who were previously uninsured. Q. May an issuer with a Medicaid MCO contract reach out to former Medicaid MCO enrollees who have been disenrolled by the state due to loss of Medicaid eligibility, to assist them in enrolling in health coverage offered by the issuer through the Marketplace (or, if they are Medicaid eligible again, through the issuer?s MCO contract)? A. Yes. An issuer with a Medicaid MCO contract can reach out to former Medicaid MCO enrollees to assist them in enrolling in health coverage, provided it does not violate applicable marketing rules prohibiting discrimination, doesn?t attempt to enroll only healthy individuals. An issuer with a Medicaid MCO contract also would not be in violation of the marketing restrictions of the HIPAA Privacy Rule in sending communications to its former enrollees about their options for health care coverage through Medicaid or other government programs and government sponsored programs, and/or their options for coverage it offers, including through the Marketplace. Under the Privacy Rule, communications about government programs and government-sponsored programs and about a plan?s own health plan products are not considered ?marketing.? This analysis also applies to health insurance issuers with respect to their former enrollees providing information regarding government programs, government- 1156 Updated 1-31-17 2017--01256 sponsored programs, and the issuer?s own health plan products available through the Marketplace) in addition to Medicaid managed care organizations. This activity by a Medicaid MCO contractor would not violate Medicaid marketing rules at 42 CFR 438.104 because the activity is not marketing to enrolled Medicaid bene?ciaries. - a - (Outreach by Medicaid Managed Care contractors and Health Insurance Issuers to Former Enrol/ees, 02/21/14; updated 01/15/16) The Use of 1311 Funds and No-cost Extensions Q: May grantees whose State-based Marketplace (SBM) or State Partnership Marketplace (SPM) provide coverage in 2014 seek an extension of their grant project period beyond the first year of operations, and if so, for what types of activities? A: Yes, consistent with existing HHS grant rules and policies, grantees may request No Cost Extensions (NCEs) to extend the project period beyond the first year of operations (December 31, 2014) where the grantee reasonably requires additional time to complete the design, development, and implementation of activities that were part of the grantees? approved work plan under a speci?c grant. CMS will review each NCE request for allowability, allocability, and reasonableness of costs based on section 1311 of the Affordable Care Act and HHS grant rules and policies. (CMS FAQ 03/14/14) Q: Are there activities that may not be supported with funds made available to a grantee pursuant to an A: Yes, where funds are made available during a project period that was extended pursuant to an NCE, the funds may not be used to cover maintenance and operating costs, including but not limited to rent, software maintenance, telecommunications, utilities, and base operational personnel/contractors. CMS will thoroughly review all NCE requests to ensure that project periods are extended only for approved and permissible establishment activities. (CMS FAQ 03/14/14) Q: If I am a 2014 SPM or SBM currently offering coverage and I apply for funds during 2014, how long is my project period? A: All project periods for 2014 SPMs and SBMs end on December 31, 2014 (CMS FAQ 03/14/14) Q: If a grantee-state?s Marketplace is transitioning from Federally- Funded Marketplace (FFM) to an SPM, how long is the project period? A: For those Marketplaces transitioning from an SPM to an SBM or from an FFM to an SPM, per the Funding Opportunity Announcement, and the Notice of Award (NOA), the project period may be 1 or 3 years, based on eligibility criteria. All project periods are listed in the NOA provided the awardee, per AAGAM See previous FAQs on funding of transitioning activities. and (CMS FAQ 03/14/14) 1 157 Updated 1-31-17 2017-?01257 Q1: Ifl am a 2014 State Partnership Marketplace (SPM) or State-based Marketplace (SBM) currently offering coverage and I apply for a new section 1311 grant award during 2014, how long is my project period? A1: Current funding opportunities for which SPMs and SBMs are eligible allow for project periods of up to one year. Please refer to the Funding Opportunity Announcement (FDA) for guidance on project periods and grant funding for costs related to establishment activities. Also, note that the FDA de?nes establishment activities and that a 2014 SPM or SBM may not apply for grant funding for on-going operations. For more information, see: Insurance Marketplaces. (CMS FAQ 09/19/14) 02: If a state has not completed the SPM or SBM Blueprint approval process, can that state apply for 1311(a) funding for consumer assistance activities? A2: Yes. A state may apply for 1311(a) funding for consumer assistance establishment activities, including the establishment of consumer assistance programs like an in- person assister program, if the application includes a letter from the Governor indicating that the state anticipates completing the Blueprint approval process. All requests for funding are reviewed for allowability, allocability, and reasonableness and other requirements set forth in the FAQ. (CMS FAQ 09/19/14) Q3: How often does CMS require a state to update the cost allocation methodology between the Marketplace and the state Medicaid agency for jointly funded activities? A3: Whenever, a state seeks additional 1311 funding and/or Advance Planning Document (APD) funding, they must provide an updated cost allocation methodology in the application. It is important for states to reassess the initial cost allocation that was approved prior to open enrollment based on projections, now that actual enrollment and transactional volume data is available. In addition, CMS strongly recommends that states continue to reassess their cost allocation on an annual basis and/or if there is a substantive change in program participation or the scope of the jointly-funded activities. (CMS FAQ 09/19/14) Q: For current Marketplace Grantees, including those who have or are applying for a No Cost Extension, are there any activities that are not allowable? Updated 1-31-17 A: Yes. Per section 1311(d)(5) of the Affordable Care Act, Marketplaces must be self- sustaining beginning January 1, 2015, and funds may not be used for ongoing operations. Marketplaces demonstrate self-sustainability by, among other things, having a source of funding other than 1311 in place for ongoing operations. Allowable uses of 1311 funds after January 1, 2015 are for establishment activities that were speci?cally described in the grantee?s approved work plan, including: . Stabilizing Marketplace IT Systems through the design, development, and testing of IT functionality; . Instituting financial and programmatic audit policies and procedures to comply with the State-based Marketplace Annual Reporting Tool (SMART), including establishment of data systems that support compliance; 0 Outreach and education, including in-person assistance, to support increasing total enrollment to designated targets in a grantee?s approved work plan that re?ect a 1158 2017-?01258 documented level of participation that was not achieved by January 1, 2015, and is necessary for the viability of the Marketplace; . Call center activities to support establishment-related outreach or to provide manual support while IT functionality is developed; and 0 Long-term capital planning to support the successful establishment of the Marketplace. Grantees are reminded that allowable establishment activities that may be supported with 1311 funds after January 1, 2015, during an initial project period under a 1311 award or during an extended project period under a No Cost Extension, must have been speci?cally described in a grantee?s approved work plan. In addition, portions of indirect costs, such as salaries, that support establishment activities may be allowable. Grantees should have accounting systems that adequately track activities and costs in a manner that will enable accurate allocation of indirect costs to allowable establishment activities. Examples of unallowable costs related to ongoing operations include but are not limited to: rent, hardware/software maintenance and operations, telecommunications, utilities, and call center operations that do not constitute establishment activities or indirect costs ?owing from allowable establishment activities. CMS recognizes that in some situations grantees will have questions regarding whether a particular activity constitutes an allowable establishment activity. Grantees should present these questions to the grants of?cial identi?ed in the grant award and to their state officers prior to expending funds on such activities. CMS grants officials will continue to work closely with states to address questions regarding allowable costs on a case-by-case basis. (CMS FAQs - Clari?cation of the Use of 1311 Funds for Establishment Activities 06/08/15) Q: May Marketplace Grantees seek an extension of their grant project period? Updated 1-31-17 A: Yes, consistent with existing Department of Health and Human Services? (HHS) grant rules and policies, grantees may request No Cost Extensions (NCE) to extend the project period in order to complete establishment activities that were part of the grantees? approved work plan under a speci?c grant where the grantee reasonably requires additional time to complete those activities. CMS reviews each NCE request for allowability, allocability, and reasonableness of costs based on section 1311 of the Affordable Care Act and HHS grant rules and policies. When submitting a request for a NCE, the grantee should submit a budget and a spend plan/drawdown plan for each budget category on the Standard Form 424A, as well as for the Exchange Core Areas. When submitting a budget for the Exchange Core Areas, the request should clearly identify the grants funds for which an NCE is being requested. This budget should also identify non-1311 funds that will support the Marketplaces? ongoing operations. If grantees receive a NCE: 1) the grantee must use 1311 funds only for establishment activities that are speci?cally described in its approved work plan; and 2) the grantee must have internal controls in place to assure that 1311 funding and the other identified funding sources are properly separated and documented in support of these allowable 1159 2017-?01259 activities. CMS will thoroughly review all NCE requests to ensure that project periods are extended only for approved and permissible establishment activities. (CMS FAQs - Clari?cation of the Use of 1311 Funds for Establishment Activities 06/08/15) Exchange Implementation - Funding and Other Issues Q1: What funding is available to assist States in the establishment of an Exchange under a fully State-based Exchange, a Partnership Exchange, and a Federally-facilitated Exchange? A1: The Affordable Care Act provides funding for States establishing an Exchange through grants described in section 1311. Such grants are available for establishing a State-based Exchange, to build functions that a State elects to operate under a Partnership Exchange, and to support State activities to build interfaces with a Federally- facilitated Exchange. Grants may be awarded through the end of 2014, and grant funds are available for approved and permissible establishment activities. The process of ?establishing? an Exchange may extend beyond the first date of operation and may include improvements and enhancements to key functions over a limited period of time. Generally, grants can be used to establish Exchange functions and operating systems and to test and improve systems and processes. We have determined that a State that does not have a fully certi?ed State-based Exchange on January 1, 2013 can continue to qualify for and receive a grant award, subject to the Funding Opportunity Announcement (FOA) eligibility criteria. A State can also use grant funds to build and test interfaces with HHS to support certain functions of a Federally- facilitated Exchange, such as information needed for certification of quali?ed health plans. As such, HHS anticipates modifying and extending the schedule for States to apply for establishments grants in future guidance to accommodate this schedule. (State Exchange Implementation Questions and Answers (1 1/29/1 02: What costs are States expected to assume in establishing an Exchange, and can these costs be covered by grant funding? A2: Under the Affordable Care Act, States must ensure that their Exchanges are self- sustaining by January 1, 2015. Therefore, the costs to States for implementing a State- based Exchange and testing Exchange operations during 2014 may be allowed under section 1311(a). Additionally, grants under section 1311 may be awarded until December 31, 2014, for approved establishment activities after that date. Therefore, it is also permissible that under a Partnership Exchange, 3 State may receive a grant for activities to establish and test functions that the State performs in support of a Federally- facilitated Exchange. (State Exchange Implementation Questions and Answers (11/29/1 Q3: Will States be charged for administrative expenses when a Federally-facilitated Exchange makes a Medicaid eligibility determination? Updated 1-31-17 A3: State Medicaid and CHIP programs will not be required to contribute to the costs associated with the Federally-facilitated Exchange, including the costs associated with a Federally-facilitated Exchange making a Medicaid or CHIP determination. However, State Medicaid and CHIP programs will have to transfer information and cases to, and accept information and cases from, the Federally-facilitated Exchange; the costs of 1160 2017-?01260 establishing, testing and maintaining those interfaces will be shared between the State Medicaid and CHIP programs and the Federally-facilitated Exchange, consistent with current cost allocation rules. HHS has provided additional help to States to build and maintain a shared eligibility service that allows for the Exchange, the Medicaid agency, and the CHIP agency to share common components, technologies and processes to evaluate applications for insurance affordability programs. This includes enhanced funding under Medicaid and opportunities for other State programs to reuse the information technology (IT) infrastructure without having to contribute funding for development costs related to shared services. This additional help is available to defray State costs related to establishing an efficient and effective shared eligibility service regardless of whether a Federally-facilitated Exchange or a State-based Exchange is operating in a State. (State Exchange Implementation Questions and Answers (1 1/29/1 Q4: Will CMS charge States for use of the data services hub? A4: CMS is establishing a Federally-managed data services hub to support information exchanges between States (Exchanges, Medicaid and CHIP agencies) and relevant Federal agencies. In many cases, Federal agencies other than CMS will be providing information through the hub. Additional information about the services available through the hub and the terms for accessing those services is under development. While the agency is considering the treatment of charges for ?scal year 2014, we do not anticipate charging fully State-based Exchanges for the use of the hub. (State Exchange Implementation Questions and Answers (1 1/29/11)) 05: Under what circumstances may Exchange planning grant dollars or the Exchange establishment grant dollars be used by a State exploring or establishing a Basic Health Program under section 1331 of the Affordable Care Act? Updated 1-31-17 A5: Planning grants: Planning grant funds may be used to support research and explore health insurance coverage options permitted under the Affordable Care Act, including the option of a Basic Health Program. Establishment grants: Establishment grant funds may be used for Exchange establishment activities that would coordinate or overlap with activities undertaken pursuant to the establishment of an optional Basic Health Program. For example, a call center may provide consumer information on a range of coverage options including the Basic Health Program, and could therefore be funded through Establishment grant funds. However, funding under the Establishment grants cannot be used to support operations of the Basic Health Program or to investigate the feasibility of the Basic Health Program. Other funding sources: States electing to establish a Basic Health Program may opt to fund administrative or establishment activities for the Basic Health Program through user fees or other State funding. (State Exchange Implementation Questions and Answers (11/29/11)) 1161 2017-?01261 06: How will the Federally-facilitated Exchange coordinate with State insurance departments? Updated 1-31-17 A6: A Federally-facilitated Exchange will operate in States electing not to pursue a State- based Exchange. To the greatest extent possible, HHS intends to work with States to preserve the traditional responsibilities of State insurance departments when establishing a Federally-facilitated Exchange. Additionally, HHS will seek to harmonize Exchange policy with existing State programs and laws wherever possible. For example, quali?ed health plans (QHP) that will be offered in the Federally-facilitated Exchange must meet State licensure and solvency requirements and be in good standing in the State (section 1301(a)(1)(C) of the Affordable Care Act). Accordingly, States continue to maintain an important responsibility with respect to health plans licensed and offered in their State, regardless of whether the Exchange is Federally- facilitated or fully State-based. With respect to review of network adequacy, which is commonly a responsibility of State insurance departments or State health agencies in consultation with State insurance departments, HHS would rely on the State for advice and recommendations regarding network adequacy standards where HHS is operating a Federally-facilitated Exchange. Network adequacy standards must ensure enrollees a suf?cient choice of providers, consistent with HHS regulations. We expect that if a State has not adopted such a standard, HHS would develop it for the purposes of the Federally-facilitated Exchange using a commonly recognized and accepted standard such as the National Association of Insurance Commissioners (NAIC) Network Adequacy Model Act. Similarly, HHS is also currently working to determine the extent to which activities like the review of rates and benefit packages are already conducted by State insurance departments and how these responsibilities could be recognized as part of the certification of QHPs by a Federally-facilitated Exchange. For example, most States currently have an effective rate review program in place and HHS will rely on such processes to the extent practicable and where legally permissible. In States with a Federally-facilitated Exchange, HHS will also apply existing State standards on marketing materials, assuming issuers will be required to convey information about premiums, bene?ts and cost sharing that ?ow from data used for plan approval, and HHS will work with States to harmonize procedures for responding to consumer complaints. We recognize that most State insurance departments already have procedures in place for addressing consumer complaints, and we will work with States to utilize existing processes for consumer complaints as efficiently as possible to the extent practicable. Pursuant to our goal to preserve the traditional responsibilities of State insurance departments when establishing a Federally-facilitated Exchange, we are planning to establish one or more working groups with representatives from State insurance departments to start working through issues related to plan management functions in the coming weeks. Successful operation of the Federally-facilitated Exchange will depend on successfully harmonizing State and HHS work?ows so that the annual QHP certification process can be effectively completed in time to adequately support open enrollment including 1162 2017-?01262 preparation and release of an insurance web portal. We look fonivard to conversations with and suggestions from States in pursuit of this harmonization. (State Exchange Implementation Questions and Answers (1 1/29/11)) Q11: What quality activities must States engage in to meet Exchange approval and certification requirements? A11: The Exchange establishment grant funding opportunity announcement indicates that State-based Exchanges must develop and report a quality rating for however, the current expectation is that further guidance will be released before Exchanges are required to implement the quality rating system. At this time, States should focus on developing and establishing other Exchange operational capacities. When focusing on quality, States should consider their strategy for using quality information to certify QHPs, including when to require issuer accreditation and how to assess the quality of plans seeking to participate in Exchanges. States will also need to determine what quality information or metrics the Exchange will display to consumers and build capacity in the development of Exchange systems to accept this quality data and report it on the website. States should also consider how the Exchange will monitor QHP quality during the plan year, including performance monitoring of complaints, appeals and network adequacy. HHS intends to propose a phased approach to the quality rating provisions in which quality ratings in 2014 would be predicated on generally available and collected metrics and measures, transitioning to a QHP-speci?c rating in 2016. (State Exchange Implementation Questions and Answers (11/29/11)) Q12: Will individuals who are enrolled in coverage through a Federally-facilitated Exchange have access to premium tax credits, as well as the advance payments of tax credits that will be authorized by Exchanges? A12: Yes. The proposed regulations issued by the Treasury Department, and the related proposed regulations issued by the Department of Health and Human Services, are clear on this point and supported by the statute. Individuals enrolled in coverage through either a State-based Exchange or a Federally-facilitated Exchange may be eligible for tax credits, including advance payments. Additionally, neither the Congressional Budget Office score nor the Joint Committee on Taxation technical explanation discussed limiting the credit to those enrolled through a State-based Exchange. (State Exchange Implementation Questions and Answers (1 1/29/11)) Q13: How will HHS ensure that States that adopt procedures, consistent with Federal policy and rulemaking, to streamline Medicaid and CHIP eligibility and perform real-time determinations, will not be penalized as a result of subsequent audits or error-reduction programs? Updated 1-31-17 A13: In 2010, CMS issued new regulations establishing the principle that in applying the Payment Error Rate Measurement (PERM) program to Medicaid and CHIP, PERM reviews should measure the extent to which State policies and procedures are consistent with Federal policy and regulations. As long as Federally-approved State procedures are followed, PERM classifies the case as an accurate determination. For example, where States rely on self-attestation to establish certain facts regarding eligibility, PERM audits also rely on those self-attestations to establish those facts. If Federally-approved State policies require additional veri?cations and data collection, auditors will review cases against those standards. 1163 2017-?01263 We will review and analyze all of our error rate measurement programs to ensure consistent application of this principle. While we are still evaluating how we will apply the Improper Payments Elimination and Recovery Act in the case of eligibility determinations involving advance payments of the premium tax credit, our intention is to follow the same general principle. (State Exchange Implementation Questions and Answers (11/29/11)) 1. Does HHS plan to further extend deadlines for states to decide on their level of involvement in implementing Exchanges? A: No. As mentioned in the two letters that Secretary Sebelius sent to governors in November2012, states have been and will continue to be partners in implementing the health care law and we are committed to providing states with the ?exibility, resources and time they need to deliver the bene?ts of the health care law to the American people. In response to various governors? requests for additional time, we extended the deadline for a Blueprint Application to operate a State-Based Exchange from November 16, 2012 to December 14, 2012. If a state is pursuing a State Partnership Exchange, we will accept Declaration Letters and Blueprint Applications and make approval determinations for State Partnership Exchanges on a rolling basis. A state that plans to operate the Exchange in its state in partnership with the federal government starting in 2014 will need to submit its Declaration Letter and Blueprint Application declaring what partnership role they would like to have by February 15, 2013. A state may apply at any time to run an Exchange in future years. (FAQs on Exchanges, Market Reforms, and Medicaid {12/10/12)} 2. What federal funding is available to assist a state in creating and maintaining a State- Based Exchange? Will a state have to return federal funding if it decides not to implement a State-Based Exchange? A: By law, states operating Exchanges in 2014 must ensure that their Exchanges are financially self-sustaining by January 1, 2015. The costs to states for establishing a State-Based Exchange and testing Exchange operations during 2014 may be funded by grants under section 1311(a). Additionally, grants under section 1311 may be awarded until December31, 2014, for approved establishment activities that fund ?rst year start- up activities activities in 2014). It is also permissible that under a State Partnership Exchange, a state may receive grants for activities to establish and test functions that the state performs in support of a Federally-Facilitated Exchange. This applies whether or not a state is a State Partnership Exchange. Generally, states will not be required to repay funds, provided funds are used for activities approved in the grant and cooperative agreement awards. (FAQs on Exchanges, Market Reforms, and Medicaid (12/10/12)) 3. Will HHS charge fees to a state that utilizes federal data in connection with its State- Based Exchange? Updated 1-31-17 A: No. HHS is establishing a federally-managed data services hub to support information exchanges between states (Exchanges, Medicaid and CHIP agencies) and relevant federal agencies. In many cases, federal agencies other than HHS will be providing information through the hub. As stated in previous guidance, no charge will be imposed 1164 2017-?01264 on states for use of the hub, nor for the required data accessed there. (FAQs on Exchanges, Market Reforms, and Medicaid (12/10/12)) 4. What is the approval process for a state that would like to participate in a State Partnership Exchange? A: To operate a State Partnership Exchange in 2014, a state must submit a declaration letter, complete the relevant portions of the Exchange Blueprint and be approved or conditionally approved by HHS for participation in a State Partnership Exchange. State Partnership Exchange approval standards mirror State-Based Exchange approval standards for plan management and the relevant consumer activities, where applicable, and include standards related to sharing data and coordinating processes between the state and a Federally-Facilitated Exchange. States have until February 15, 2013 to submit a declaration and Blueprint Application for approval as a State Partnership Exchange. (FAQs on Exchanges, Market Reforms, and Medicaid (12/10/12)) 5. How will HHS work with state policymakers to make sure that the Federally-Facilitated Exchange accounts for the needs of a particular state? How will the Federally-Facilitated Exchange for each state ensure that it accurately incorporates state-specific laws and procedures into its business processes? Updated 1-31-17 A: To the greatest extent possible, HHS intends to work with states to preserve the traditional responsibilities of state insurance departments when establishing a Federally- Facilitated Exchange for a particular state. Additionally, HHS will seek to harmonize Exchange policy with existing state programs and laws wherever possible. For example, qualified health plans that will be offered in a Federally-Facilitated Exchange must be offered by issuers that meet state licensure and solvency requirements and are in good standing in the state (section 1301(a)(1)(C) of the Affordable Care Act; 45 C.F.R. section In addition, qualified health plans will be subject to requirements that apply to all individual and small group market products such as the proposed market rules. Accordingly, states continue to maintain an important responsibility with respect to qualified health plans licensed and offered in their states, regardless of whether the Exchange is Federally-Facilitated or State-Based. HHS is currently working to determine the extent to which activities conducted by state insurance departments such as the review of rates and policy forms could be recognized as part of the certi?cation of qualified health plans by a Federally-Facilitated Exchange. For example, most states currently have an effective rate review program in place and HHS will rely on such processes in connection with quali?ed health plan certi?cation decisions and oversight by a Federally-Facilitated Exchange. HHS will work with regulators in each state with a Federally-Facilitated Exchange to identity these ef?ciencies. HHS is working with the National Association of Insurance Commissioners to enable states to use the System for Electronic Rate and Form Filing as part of the qualified health plan submission and certification process in a State Partnership Exchange. This will help ensure that state and federal regulators are using the same data for their reviews and simplify issuer compliance responsibilities. HHS also will collect state-speci?c Medicaid and CHIP policy data so that the Federally- Facilitated Exchange is able to evaluate Medicaid and CHIP eligibility. (FAQs on Exchanges, Market Reforms, and Medicaid {12/10/12)} 1165 2017-?01265 6. Will Federally-Facilitated Exchange customer support personnel be familiar with state rules so that they can advise consumers adequately? A: Yes. HHS will operate the Federally-Facilitated and State Partnership Exchange call center and website, and personnel will be trained on relevant state insurance laws and Medicaid and CHIP eligibility standards so that they can advise consumers. In a state operating in a State Partnership Exchange, a state will be responsible for the day-to- day management of the Exchange Navigators and the development and management of another separate in-person assistance program, and may elect to conduct additional outreach and educational activities. The Affordable Care Act directs Navigators to conduct public education to target Exchange-eligible populations, assist quali?ed consumers in a fair and impartial manner with the selection of quali?ed health plans and distribute information on tax credits and cost-sharing reductions, and refer consumers to any consumer assistance or ombudsman programs that may exist in the state. Navigators must provide this information in a manner that is culturally and linguistically appropriate and accessible by persons with disabilities. (FAQs on Exchanges, Market Reforms, and Medicaid (12/10/12)) 7. What restrictions will there be on a state regulator's authority to enforce state laws when consumers purchase coverage through a Federally-Facilitated Exchange? Will states retain their ability to protect consumers? A: States have signi?cant experience and the lead role in insurance regulation, oversight, and enforcement. We will seek to capitalize on existing state policies, capabilities, and infrastructure that can also assist in implementing some of the components of a Federally-Facilitated Exchange. We also encourage states interested in improving this alignment to apply to conduct plan management through a State Partnership Exchange. A Federally-facilitated Exchange?s role and authority are limited to the certi?cation and management of participating quali?ed health plans. Its role and authority do not extend beyond the Exchange or affect otherwise applicable state law governing which health insurance products may be sold in the individual and small group markets. Several qualified health plans certification standards rely on reviews that some state departments of insurance may not currently conduct. Therefore, HHS will evaluate each potential QHP against applicable certification standards either by deferring to the outcome of a state?s review in the case of licensure) or by performing a review necessary to verify compliance with QHP certification standards. Federally-facilitated Exchanges will consider completed state work to support this evaluation to the extent possible. (FAQs on Exchanges, Market Reforms, and Medicaid {12/10/12)} 8. How will the Federally-Facilitated Exchange be funded? A: To fund the operation of the Federally-Facilitated Exchange, we proposed for comment in the draft Payment Notice that participating issuers pay a user fee to support the operation of the Federally-Facilitated Exchange. For the 2014 bene?t year, we proposed a user fee rate that is aligned with rates charged by State- Based Exchanges. While we proposed that this rate be 3.5 percent of premium, it may be adjusted in the final Payment Notice to take into account State-Based Exchange rates. Exchange user fees will support activities such as the consumer outreach, information and assistance activities that health plans currently pay themselves. This 1 166 Updated 1-31-17 2017--01266 policy does not affect the ability of a state to use grants described in section 1311 of the Affordable Care Act to develop functions that a state elects to operate under a State Partnership Exchange and to support state activities to build interfaces with a Federally-Facilitated Exchange. (FAQs on Exchanges, Market Reforms, and Medicaid (12/10/12)) 9. If a state chooses to provide some services to a Federally-Facilitated Exchange, will the state be reimbursed for its costs? A: Yes in certain circumstances. HHS expects that states supporting the development of a Federally-Facilitated Exchange may choose to seek section 131 1 Exchange Establishment cooperative agreement funding for activities including, but not limited to: 0 Developing data system interfaces with the Federally-Facilitated Exchange; 0 Coordinating the transfer of plan information licensure and solvency) from the state insurance department to the Federally-Facilitated Exchange; and . Other activities necessary to support (and related to the establishment of) the effective operations of a Federally-Facilitated Exchange. After section 131 1 funds are no longer available, HHS anticipates continued funding, under a different funding vehicle, for state activities performed on behalf of the Federally-Facilitated Exchange. To the extent permissible under applicable law, HHS intends to make tools and other resources used by the Federally-Facilitated Exchange available to state partners in State Partnership Exchanges, as well as to State-Based Exchanges. (FAQs on Exchanges, Market Reforms, and Medicaid {12/10/12)} 17. How does HHS plan to conduct outreach about the Exchanges and new coverage options? Will outreach materials be tailored to each state? Will states be able to provide HHS with input in developing materials? A: Education and outreach are high priorities for implementing the changes coming in 2014.HHS plans to conduct outreach to consumers in a variety of ways, including the Navigator program, in-person assistance, the internet, and call centers. States and other stakeholders de?nitely will be able to provide input in developing its outreach approach to consumers. (FAQs on Exchanges, Market Reforms, and Medicaid {12/10/12)} 18. How does HHS plan to operate the Navigator program for the Federally-Facilitated Exchanges? How many and what types of Navigators will there be in a particular state? What will their roles be? Can states require Navigators to hold a producer license? If not, what type of training or certification will they receive? Updated 1-31-17 A: Section 1311(i) of the Affordable Care Act directs an Exchange whether a State- Based Exchange or a Federally-Facilitated Exchange to establish a program under which it awards grants to Navigators. Section 1311(i) and 45 C.F.R. section 155.210 articulate the required duties of a Navigator. In addition, section directs that the Exchange select two different types of entities as Navigators, one of which must be a community and consumer-focused non-pro?t group. This program is further described in the ?General Guidance on Federally-facilitated Exchanges.? The number of Navigators per state served by a Federally-Facilitated Exchange will be contingent upon the total amount of funding available as well as the number of applications that we receive in each state in response to the forthcoming Navigator 1167 2017-?01267 Grant Funding Opportunity Announcement that we plan to issue early next year to support the Federally Facilitated Exchanges. Additionally, a state or Exchange cannot require Navigators to hold a producer license a license as an agent or broker) for the purpose of carrying out any of the duties required of Navigators in section 1311(i)(3) of the Affordable Care Act and 45 C.F.R. section Because the law directs Navigators to carry out all required duties, linking a producer license to any one of those speci?c duties would have the effect of requiring all Navigator entities, their employees, and their sub-grantees to hold a producer license. As described above, this would prevent the application of the standard set forth in 45 C.F.R. section that at least two different types of entities must serve as Navigators. As such, and as provided by section 1321 of the Affordable Care Act, any state laws which would require all Navigators to hold a producer license would be preempted by 45 C.F.R. section In Federally-Facilitated Exchanges and State Partnership Exchanges, individuals selected to receive Navigator grants or working for entities selected to receive Navigator grants must successfully participate in an HHS-developed and administered training program, which will include a certi?cation examination pursuant to 45 C.F.R. section In addition, under state law, states may impose Navigator-speci?c licensing or certi?cation requirements upon individuals and entities seeking to operate as Navigators, so long as such licenses or certi?cations are not preempted by the requirement to award to different types of entities identi?ed in 45 C.F.R. section such as producer licenses. (FAQs on Exchanges, Market Reforms, and Medicaid {12/10/12)} 19. What does HHS expect that states in a State Partnership Exchange must do to fulfill their obligations regarding in-person consumer assistance? How will the state-specific in-person consumer assistance programs be integrated with the Navigator program? A: ln-person assistance programs are an additional mechanism through which Exchanges may meet the consumer assistance responsibilities of the Exchange under 45 C.F.R. section155.205(d) and As described in the Federally-facilitated Exchange Guidance, states operating under a State Partnership Exchange will build and operate an in-person assistance program, for which grant funding is available under section 1311 of the Affordable Care Act, distinct from the Navigator program for that Exchange. State- Based Exchanges may do so as well. The purpose of providing multiple tools for in- person assistance is to ensure that all consumers can receive help when accessing health insurance coverage through an Exchange. (FAQs on Exchanges, Market Reforms, and Medicaid {12/10/12)} 38. How can states use premium assistance to help families that are split among the Exchange, Medicaid, and the Children?s Health Insurance Program (CHIP) enroll in the same plans? Updated 1-31-17 A: In 2014, some low-income children will be covered by Medicaid or CHIP while their parents obtain coverage on the Exchange with advance payments of the premium tax credit. Premium assistance, an option under current law, provides an opportunity for state Medicaid and CHIP programs to offer coverage to such families through the same coverage source, even if supported by different payers. Under Medicaid and CHIP statutory options, states can use federal and state Medicaid and CHIP funds to deliver 1168 2017-?01268 Medicaid and CHIP coverage through the purchase of private health insurance. Most commonly, states have used premium assistance to help Medicaid/CHIP eligible families pay for available employer-based coverage that the state determines is cost effective. There are cost sharing assistance and bene?t wrap-around coverage requirements, to the extent that the insurance purchased with Medicaid and/or CHIP funds does not meet Medicaid or CHIP standards. In both Medicaid and CHIP, premium assistance is authorized for group health coverage and, under some authorities, for health plans in the individual market, which, in 2014 would include qualified health plans available through the Exchange. Please note that advance payments of the premium tax credit and cost- sharing reductions are not available for an individual who is eligible for Medicaid or CHIP. The statutory authorities that permit use of title XIX or title XXI funds to be used for premium assistance for health plans in the individual market, including quali?ed health plans in the Exchange, are sections 1905(a) and 2105(c)(3) of the Social Security Act. For example, beginning in 2014, when a child is eligible for Medicaid/CHIP and the parent is enrolled in a qualified health plan through the Exchange, 3 state Medicaid or CHIP program could use existing premium assistance authority to purchase coverage for a Medicaid or CHIP-eligible child through that quali?ed health plan. The premium tax credit would not be available to help cover the cost of coverage for these children. As noted above, with respect to the children, the state would adhere to federal standards for premium assistance, including providing wrap-around bene?ts, cost sharing assistance, and demonstrating cost effectiveness, as appropriate. A State-Based Exchange may be able to support such an option, and in states where a Federally?Facilitated Exchange is operating, a State Medicaid or CHIP agency may be able to take this approach by making arrangements with quali?ed health plans to pay premiums for individuals. We will be working with states interested in this option to consider how the state Medicaid and CHIP agency can coordinate with the Exchange to establish and simplify premium assistance arrangements. (FAQs on Exchanges, Market Reforms, and Medicaid (12/10/12)) 39. How can states use premium assistance to promote continuity of care when individuals move between Exchange, CHIP, and Medicaid coverage? Updated 1-31-17 A: The Affordable Care Act envisions and directs that there be a coordinated system for making eligibility determinations between Medicaid, CHIP and the Exchange to avoid gaps in coverage as individuals? income fluctuates. Smooth eligibility transitions will not necessarily prevent people from having to select a new plan and/or provider when they lose eligibility for one insurance affordability program and gain eligibility for another. The extent to which such changes in plans and providers occur will depend on whether and to what degree plans participate in both the Exchange and in Medicaid and CHIP, and the networks in such plans. Premium assistance can help address this issue, while encouraging robust plan participation in Medicaid, CHIP, and the Exchange. As discussed above, this option permits state Medicaid or CHIP programs to use premium assistance to enroll a Medicaid or CHIP eligible individual or family in a quali?ed health plan through the Exchange. States may be most interested in this option for families close to the top of the Medicaid income limit. Under this arrangement, if a family?s income changes such that some or all members of the family become ineligible for Medicaid or CHIP and eligible for a premium tax credit to help cover the cost of a quali?ed health plan through 1169 2017-?01269 the Exchange, it would be less likely that members moving into Exchange coverage would need to change plans or providers. Similarly, premium assistance could help increase the likelihood that individuals moving from Exchange coverage into Medicaid or CHIP may remain in the same quali?ed health plan in which they had been enrolled through the Exchange. As discussed above, premium assistance options in Medicaid and CHIP are subject to federal standards related to wrap around benefits, cost sharing and cost effectiveness. There may also be an opportunity for states to promote continuity of coverage through ?bridge plans? as described earlier. (FAQs on Exchanges, Market Reforms, and Medicaid (12/10/12)) Transparency Reporting Q: When do plans and issuers have to comply with the transparency in coverage reporting requirements under section 1311(e)(3) of the Affordable Care Act and section 2715A of the PHS Act? A: We do not intend to enforce the transparency requirements until we provide further guidance. (REGTAP FAQ Database - FAQ #5850 10/20/14) Q: For the purposes of transparency in coverage data for the 2017 plan year, should issuers submit the number of claims and appeals for services rendered in 2015 or claims processed in 2015? A: Issuers must submit the numbers for claims and appeals, for services rendered in 2015, not claims processed in 2015. The intent and focus of the collection is to provide information on claims and appeals numbers for calendar year 2015. Example: An enrollee has a claim for date of service 12/31/14, which the issuer receives on 1/5/15. The issuer should not include this claim as part of its data submission for the 2017 plan year, as the service was not rendered in calendar year2015. The 2017 plan year transparency in coverage reporting requirements extend to QHP (and SADP) issuers in the Federally-facilitated Marketplaces (FFMs), including issuers in states performing plan management functions, and State-based Marketplaces on the Federal Platform (SBM-FPs). For more information, please refer to the Transparency in Coverage QHP Issuer Instruction Guide for Plan Year, available at (REGTAP FAQ Database - FAQ #17070 08/03/16) Q: Does a QHP issuer offering a QHP for the first time in plan year (FY) 2017 need to submit a Transparency in Coverage reporting template for 2017 FY data submission? Updated 1-31-17 A: Yes. When an issuer is offering a QHP for the ?rst time in PY 2017, it is required to submit a template that includes all of the required contact information and an active URL for claims payment policies and other information. Issuers should mark on the template for the remaining ?elds for 2017 data since the plan was not offering coverage in 2015. 1170 2017-?01270 The 2017 plan year transparency in coverage reporting requirements extend to QHP (and SADP) issuers in the Federally-facilitated Marketplaces (FFMs), including issuers in states performing plan management functions, and State-based Marketplaces on the Federal Platform (SBM-FPs). For more information, please refer to the Transparency in Coverage QHP Issuer Instruction Guide for Plan Year, available at (REGTAP FAQ Database - FAQ #17071 08/03/16) Q: Can SADP issuers that offered coverage through the Marketplace(s) in 2015 leave any fields in the Transparency in Coverage reporting template blank for 2017 plan year data submission? A: SADP issuers that offered coverage through the Marketplace(s) in 2015 are generally subject to the same transparency in coverage reporting obligations as QHP issuers for major medical coverage. However, SADP issuers? claims payment policies and other information URL does not need to include information for the data element on ?drug exceptions timeframes and enrollee responsibilities". The 2017 plan year transparency in coverage reporting requirements extend to QHP (and SADP) issuers in the Federally-facilitated Marketplaces (FFMs), including issuers in states performing plan management functions, and State-based Marketplaces on the Federal Platform For more information, please refer to the Transparency in Coverage QHP Issuer Instruction Guide for Plan Year, available at (REGTAP FAQ Database - FAQ #17072 08/03/16) Q: Does the information required in the URL landing page need to be live at the time issuers submit the Transparency in Coverage reporting template for 2017 plan year data submission? A: Yes. The webpage must be live at the time of submission and remain active for the entire plan year. (REGTAP FAQ Database - FAQ #17073 08/03/16) Q: What does CMS mean by submitting a template for each Updated 1-31-17 A: QHP and SADP issuers are required to complete and submit separate templates for each HIOS ID for 2017 plan year data submissions. The reference to each means the issuer's Health Insurance Oversight System (HIOS) ID number (issuer ID). The 2017 plan year transparency in coverage reporting requirements extend to QHP (and SADP) issuers in the Federally-facilitated Marketplaces (FFMs), including issuers in states performing plan management functions, and State-based Marketplaces on the Federal Platform (SBM-FPs). For more information, please refer to the Transparency in Coverage QHP Issuer Instruction Guide for Plan Year, available at (REGTAP FAQ Database - FAQ #17074 08/03/16) 1171 2017-?01271 Q: Will issuers be given additional time to submit the transparency data reporting template for the 2017 plan year data submission? A: Yes. Issuers subject to these reporting requirements will be given until Friday, September 2 to submit completed templates for the 2017 plan year. The timeline is as follows: 0 Initial QHP Transparency Submission Window: 08/01/2016?09/02/2016 . CMS Reviews Initial QHP Data Submissions as of 09/02/2016: 09/05/2016- 09/09/2016 . CMS Sends First Correction/Non-submission Notice: 09/12/2016 0 Deadline for Submission of Revised QHP Data: 09/23/2016 0 CMS Reviews Revised QHP Data as of 09/23/2016: 09/26/2016?10/03/2016 (REGTAP FAQ Database - FAQ #17075 08/03/16) Q: When will CMS post the transparency in coverage 2017 plan year data reported by issuers? A: CMS intends to publish transparency data with the other Marketplace public use ?les (PUFs) this fall. (REGTAP FAQ Database - FAQ #17076 08/03/16) Q: For the purposes of transparency in coverage data for the 2017 plan year, should issuers submit the number of claims and appeals for services rendered in 2015 or claims processed in 2015? A: Issuers must submit the numbers for claims and appeals, for services rendered in 2015, not claims processed in 2015. The intent and focus of the collection is to provide information on claims and appeals numbers for calendar year 2015. Example: An enrollee has a claim for date of service 12/31/14, which the issuer receives on 1/5/15. The issuer should not include this claim as part of its data submission for the 2017 plan year, as the service was not rendered in calendar year 2015. The 2017 plan year transparency in coverage reporting requirements extend to QHP (and SADP) issuers in the Federally-facilitated Marketplaces (FFMs), including issuers in states performing plan management functions, and State-based Marketplaces on the Federal Platform (SBM-FPs). For more information, please refer to the Transparency in Coverage QHP Issuer Instruction Guide for Plan Year, available at Certify-and-Offer-Plans-.html (Transparency, QHP Obligations, and QRS Marketing Guidelines FAQS 08/04/16) Q: Does a QHP issuer offering a QHP for the first time in plan year (PY) 2017 need to submit a Transparency in Coverage reporting template for 2017 FY data submission? A: Yes. When an issuer is offering a QHP for the ?rst time in PY 2017, it is required to submit a template that includes all of the required contact information and an active URL for claims payment policies and other information. Issuers should mark on the template for the remaining ?elds for 2017 data since the plan was not offering coverage 1 172 Updated 1-31-17 2017-?01272 in 2015. The 2017 plan year transparency in coverage reporting requirements extend to QHP (and SADP) issuers in the Federally-facilitated Marketplaces (FFMs), including issuers in states performing plan management functions, and State-based Marketplaces on the Federal Platform (SBM-FPs). For more information, please refer to the Transparency in Coverage QHP Issuer Instruction Guide for Plan Year, available at Certify-and-Offer-Plans-.html (Transparency, QHP Obligations, and QRS Marketing Guidelines FAQS 08/04/16) Q: Can SADP issuers that offered coverage through the Marketplace(s) in 2015 leave any fields in the Transparency in Coverage reporting template blank for 2017 plan year data submission? A: SADP issuers that offered coverage through the Marketplace(s) in 2015 are generally subject to the same transparency in coverage reporting obligations as QHP issuers for major medical coverage. However, SADP issuers? claims payment policies and other information URL does not need to include information for the data element on ?drug exceptions timeframes and enrollee responsibilities?. The 2017 plan year transparency in coverage reporting requirements extend to QHP (and SADP) issuers in the Federally-facilitated Marketplaces (FFMs), including issuers in states performing plan management functions, and State-based Marketplaces on the Federal Platform (SBM-FPs). For more information, please refer to the Transparency in Coverage QHP Issuer Instruction Guide for Plan Year, available at Certify-and-Offer-PIans-.html (Transparency, QHP Obligations, and QRS Marketing Guidelines FAQS 08/04/16) Q: Does the information required in the URL landing page need to be live at the time issuers submit the Transparency in Coverage reporting template for 2017 plan year data submission? A: Yes. The webpage must be live at the time of submission and remain active for the entire plan year. (Transparency, QHP Obligations, and QRS Marketing Guidelines FAQS 08/04/16) Q: What does CMS mean by submitting a template for each Updated 1-31-17 A: QHP and SADP issuers are required to complete and submit separate templates for each HIOS ID for 2017 plan year data submissions. The reference to each means the issuer?s Health Insurance Oversight System (HIOS) ID number (issuer ID). The 2017 plan year transparency in coverage reporting requirements extend to QHP (and SADP) issuers in the Federally-facilitated Marketplaces (FFMs), including issuers in states performing plan management functions, and State-based Marketplaces on the Federal Platform (SBM-FPs). For more information, please refer to the Transparency in Coverage QHP Issuer Instruction Guide for Plan Year, available at Certify-and-Offer-Plans-.html (Transparency, QHP Obligations, and QRS Marketing 1173 2017-?01273 Guidelines FAQS 08/04/16) Q: Will issuers be given additional time to submit the transparency data reporting template for the 2017 plan year data submission? A: Yes. Issuers subject to these reporting requirements will be given until Friday, September 2 to submit completed templates for the 2017 plan year. The timeline is as follows: Activity Dates Initial QHP Transparency Submission Window 08/01/2016-09/02/2016 CMS Reviews Initial QHP Data Submissions as of 09/05/2016-09/09/2016 09/02/2016 CMS Sends First Correction/Non-submission Notice 09/12/2016 Deadline for Submission of Revised QHP Data 09/23/2016 CMS Reviews Revised QHP Data as of 09/23/2016 09/26/2016-10/03/2016 (Transparency, QHP Obligations, and QRS Marketing Guidelines FAQS 08/04/16) Q: When will CMS post the transparency in coverage 2017 plan year data reported by issuers? A: CMS intends to publish transparency data with the other Marketplace public use ?les (PUFs) this fall. (Transparency, QHP Obligations, and QRS Marketing Guidelines FAQS 08/04/16) The Health Insurance Marketplace and Employer-sponsored Coverage As an employer, what can I do to help my employees who are not eligible for coverage through my company find health coverage through the Marketplace? Employers can help their employees ?nd health coverage through the Marketplace by providing them with contact information for the Marketplace in their state, and making sure that they have the information about coverage available through the employer so that the employee can provide it on the Marketplace application. By ?lling out the Employer Coverage Tool Application 508 130615.pdf an employer will give an employee all the information helshe needs to apply for coverage through the Marketplace. Providing your employees a completed Employer Coverage Tool before open enrollment (beginning October 1, 2013 and going until March 31, 2014 for the first year, and from October 15 to December 7 starting in 2014 and each following year) and when employer plan options change can help reduce the number of questions you get from employees about the new health care law. (CMS Technical Assistance Resources FA Qs About the Health Insurance Marketplace and Employer-sponsored Coverage - no date) Why does the Marketplace need information about the coverage I offer to my employees? After an individual submits their application to the Marketplace, we use the information about any employer coverage available to determine whether the individual is eligible for a new tax credit to help lower health insurance costs. If the Marketplace ?nds that an 1174 Updated 1-31-17 2017-?01274 individual will be either enrolled in employer-sponsored coverage or eligible for employer-sponsored coverage that is affordable and meets the minimum value standard, then he/she would not be eligible for the new tax credit. (CMS Technical Assistance Resources FAQs About the Health Insurance Marketplace and Employer-sponsored Coverage no date) Why does the Marketplace need my contact information? The health care law speci?es that when an employee (or someone in their tax household) has been determined eligible for the new tax credit, the Marketplace will notify that person?s employer. This notification will allow the employer to provide updated information about coverage available to the employee (if applicable) and provide an early indication of potential liability for the employer shared responsibility payment assessed by IRS for 2015. (CMS Technical Assistance Resources FAQs About the Health Insurance Marketplace and Employer-sponsored Coverage no date) How does the Marketplace calculate whether employer coverage is affordable? Affordability is determined by calculating the employee?s share of the annual premium for the lowest- cost self-only plan the employer offers that meets the minimum value standard (factoring in certain discounts for wellness programs) and comparing that amount to the employee?s annual household income. A plan is considered affordable if the employee?s share of the annual premium is less than 9.5% of annual household income. An individual is not eligible to receive a tax credit if he or she is eligible for coverage that is deemed affordable and that meets minimum value. (CMS Technical Assistance Resources FA 03 About the Health Insurance Marketplace and Employer- sponsored Coverage no date) How does the Marketplace treat wellness incentives that affect premium cost? The premium amount for the plan offered by the employer is calculated by assuming that the employee received the maximum discount for any tobacco cessation programs the employer offers, and doesn?t include any other discounts from wellness programs. This net premium amount is compared to the employee?s annual household income to determine affordability. (CMS Technical Assistance Resources FA Qs About the Health Insurance Marketplace and Employer-sponsored Coverage no date) What is the minimum value standard? An employer plan is considered to meet the minimum value standard if the plan?s share of the total allowed bene?t costs covered by the plan is no less than 60 percent of such costs. You should contact your plan administrator or use the minimum value calculator on the CCIIO website to ?nd out if the plans you offer meet the minimum value standard. (CMS Technical Assistance Resources FAQs About the Health Insurance Marketplace and Employer-sponsored Coverage no date) How will the Marketplace verify whether an individual has access to employer-sponsored coverage that is affordable and meets the minimum value standard? Updated 1-31-17 The Marketplace will verify the attested information provided by an individual on the Marketplace application first by comparing the information with any available electronic data sources. For 2014, the Federally-facilitated Marketplace will use data from the 1175 2017-?01275 federal Of?ce of Personnel Management and the Small Business Health Options Program. For 2015 and beyond, we continue to work closely with employers to explore additional opportunities for electronic data matching to streamline the veri?cation process. In the event no data is found in available electronic data sources, for a statistically significant sample of individuals, the Marketplace will reach out to employers directly to verify the individual?s attested information regarding employer coverage. (CMS Technical Assistance Resources FAQs About the Health Insurance Marketplace and Employer-sponsored Coverage no date) How will the sample-based review be conducted? If the Marketplace does not have any information in available data sources to verify whether an individual has access to employer-sponsored coverage that is affordable and meets the minimum value standard, the Marketplace will take a statistically signi?cant sample of such individuals and reach out to employers directly to verify the individual?s attested information regarding employer coverage. In the Federally-facilitated and State Partnership Marketplace, a contractor will contact the employer by phone to obtain information the employee. The information requested will be the same as what is captured on the employer coverage tool. State-based Marketplaces have the ?exibility to begin performing this sample-based review for eligibility determinations for insurance affordability programs that are effective starting January 1, 2015.option to start this sample-based review on October 15, 2014. (CMS Technical Assistance Resources FA 03 About the Health Insurance Marketplace and Employer-sponsored Coverage - no date) How will I know if the Marketplace has determined one of my employees to be eligible for the new tax credit? When an employee (or someone in their tax household) has been determined eligible for the new tax credit, the Marketplace will notify the employee?s employer. In recent rulemaking, we clari?ed that the Marketplace can either send the employer notice on an employee-by-employee basis as eligibility determinations are made, or send it to employers for groups of employees.1 Similarly, when an employee (or someone in their tax household) is no longer eligible for the tax credit, the Marketplace will notify the employee?s employer. (CMS Technical Assistance Resources FAQs About the Health Insurance Marketplace and Employer-sponsored Coverage no date) How is employer-sponsored coverage information used for determining whether one of my employees is exempt from the shared responsibility payment for individuals who don?t maintain minimum essential coverage? Updated 1-31-17 Starting in 2014, each individual needs to have minimum essential coverage to qualify for an exemption, or make a shared responsibility payment on his or her tax return. There are several exemptions from this payment described in the Affordable Care Act and supporting regulations, including one for individuals who are unable to afford coverage based on projected household income. In order to evaluate whether someone is eligible for this exemption, the Marketplace will need information about available employer-sponsored coverage. The exemption application includes an exemption- speci?c employer coverage tool, which is very similar to the employer coverage tool that is used as a part of the eligibility process for health coverage; the only changes are those required by regulation. 1176 2017-?01276 Specifically, in addition to asking for the cost of self-only coverage, the exemptions tool also asks for the cost of family coverage, if it is offered. It also asks for the cost of coverage without any discounts for wellness programs. (CMS Technical Assistance Resources FAQs About the Health Insurance Marketplace and Employer-sponsored Coverage no date) What if my company only offers plans where the premium is low but the out of pocket costs are high? Out-of-pocket costs are not specifically considered when the Marketplace calculates affordability. The Marketplace will determine affordability by comparing the employee?s share of the annual premium of the lowest-cost self-only plan offered by the employer that meets the minimum value standard (factoring in certain discounts for wellness programs) to the employee?s annual household income. A plan is considered affordable if the employee?s share of the annual premium is less than 9.5% of annual household income. We note that for purposes of the employer shared responsibility provision, a plan is deemed affordable for the employer affordability safe harbor from shared responsibility payment if the cost to the employee of a self-only coverage is not more than 9.5% of his/her wages as reported in Box 1 of the employee?s Form W-2. (CMS Technical Assistance Resources FAQs About the Health Insurance Marketplace and Employer-sponsored Coverage - no date) What Should I Do Next? 0 Decide how you will provide information about the coverage you offer to your employees 0 Proactively or as requested ?ll out Employer Coverage Tool, or opt to include information on FLSA 18B notice 0 Determine contact to address limited number of Marketplace inquiries 0 To what address do you prefer notices be sent? . Help us ?nd a solution to streamline employer-sponsored coverage veri?cation process 0 Let us know what you think! (CMS Technical Assistance Resources FAQs About the Health Insurance Marketplace and Employer-sponsored Coverage no date) The 2017 Moratorium on Health Insurance Provider Fee Q1: Does the 2017 moratorium apply to the 2017 fee year or the 2017 data year? Under the recent legislation, the moratorium applies to the payment that would be due in the 2017 calendar year based on 2016 data. [Treasury regulations refer to this as the payment for the 2017 fee year.] (CMS FA OS on the 2017 Moratorium on the Health Insurance Provider Fee 02-29-16) 02: What is the 2017 fee amount that would have been collected but for the moratorium? The applicable amount for the 2017 fee year is $13.9 billion. (CMS FAQs on the 2017 Moratorium on the Health Insurance Provider Fee 02-29-16) 1177 Updated 1-31-17 2017-?01277 Q3: Will the 2017 moratorium affect the fee amount for the 2018 fee year? No. The moratorium has no effect on the fee amount for the 2018 fee year. The legislation enacting the moratorium limited it to one year. (CMS FAQs on the 2017 Moratorium on the Health Insurance Provider Fee 02-29-16) Q4: What is the expected impact on 2017 plan year rate changes as a result of the moratorium? The Fee is part of administrative costs for health insurance plans. Because the Fee is not being collected for the 2017 fee year, administrative costs for plans in all impacted markets are expected to be adjusted appropriately to account for the moratorium. With regard to single risk pool ?lings in the individual and small group markets, administrative costs are one of the permissible plan-level adjustments to the index rate.4 It is expected that the 2017 plan adjusted index rate will be adjusted downward to account for the moratorium of the Fee where appropriate. (CMS FAQs on the 2017 Moratorium on the Health Insurance Provider Fee 02-29-16) Other Q: Does the guidance for Medicare Creditable Prescription Drug Coverage notices apply to both the Individual and the Small Business Health Options Program (SHOP) Marketplaces? A: Yes, the creditable prescription drug notice guidance applies to both the SHOP and Individual Marketplaces as well as markets outside Exchanges. (REGTAP FAQ Database - FAQ #4440 09/05/14) Q. May an issuer with a Medicaid MCO contract reach out to former Medicaid MCO enrollees who have been disenrolled by the state due to loss of Medicaid eligibility, to assist them in enrolling in health coverage offered by the issuer through the Marketplace (or, if they are Medicaid eligible again, through the issuer?s MCO contract)? A. Yes. An issuer with a Medicaid MCO contract can reach out to former Medicaid MCO enrollees to assist them in enrolling in health coverage, provided it does not violate applicable marketing rules prohibiting discrimination, doesn?t attempt to enroll only healthy individuals. An issuer with a Medicaid MCO contract also would not be in violation of the marketing restrictions of the HIPAA Privacy Rule in sending communications to its former enrollees about their options for health care coverage through Medicaid or other government programs and government sponsored programs, and/or their options for coverage it offers, including through the Marketplace. Under the Privacy Rule, communications about government programs and government-sponsored programs and about a plan?s own health plan products are not considered ?marketing." This analysis also applies to health insurance issuers with respect to their former enrollees providing information regarding government programs, government- sponsored programs, and the issuer?s own health plan products available through the Marketplace) in addition to Medicaid managed care organizations. 1 178 Updated 1-31-17 2017-?01278 This activity by a Medicaid MCO contractor would not violate Medicaid marketing rules at 42 CFR 438.104 because the activity is not marketing to enrolled Medicaid bene?ciaries. Former Enrol/ees; 02-21-14, updated 01-15-15) Q: What is the applicability of MARS-E 2.0 to QHP issuers? A: CMS recently published the MARS-E 2.0, which will replace the MARS-E 1.0, to address updates in the NIST SP 800-53 rev. 4 series, CMS regulations since 2012, and IRS Pub 1075. The MARSE-E 2.0 establishes the privacy and security standards for all Marketplaces and Medicaid/CHIP agencies to meet federal laws and regulations for the information and information technology systems that support their eligibility and enrollment platforms. The MARS-E 2.0 does not introduce a change for QHP issuers. On September 23, 2015, CMS published the CMCS Informational Bulletin Minimum Acceptable Risk Standards for Exchanges (The MARS-E) 2.0 Informational Bulletin") to introduce the updated MARS-E 2.0 requirements to state Medicaid and Children?s Health Insurance Program (CHIP) agencies. Since publication of the CMCS Informational Bulletin, CMS has received inquiries on whether the bulletin alters any CMS privacy and security standards applicable to QHP issuers. The CMCS Informational Bulletin does not alter any existing CMS privacy and security standards for QHP issuers participating in State-Based Marketplaces (SBMs) or the Federally facilitated Marketplaces (FFMs). FFMs and each SBMs are required under 45 CFR and (3) to execute agreements with all entities, including QHP issuers, who obtain access to information about applicants or enrollees to comply with speci?c privacy and security standards. Q: How can Form 1094-C be filed electronically? A: Pub. 5165, Guide for Electronically Filing Affordable Care Act (ACA) Information Returns (AIR) for Software Developers and Transmitters (Processing Year 2016), speci?es the communication procedures, transmission formats, business rules and validation procedures for returns ?led electronically for calendar year 2015 through the AIR system. To develop software for use with the AIR system, software developers, transmitters and issuers (employers filing their own Forms 1094-C and 1095-C) should use the guidelines provided in Pub. 5165 along with the Extensible Markup Language (XML) Schemas published on RS.gov. Visit to find out the address to mail paper returns based on the employer's state. (REGTAP FAQ Database - FAQ #15244 03/23/16) Q: Does the Enrollment Weekly Issuer Call Series VI provide content that is applicable to off-Exchange plans? A: The Enrollment Weekly Issuer Call Series VI mainly presents content concerning on- Exchange plans. Issuers should refer to state regulations for off-Exchange content. (REGTAP FAQ Database - FAQ #15247 03/23/16) 1 179 Updated 1-31-17 2017-?01279 CMS ENTERPRISE IDENTITY MANAGEMENT SYSTEM What is CMS EIDM is the acronym for Enterprise Identity Management system which includes Remote Identity Proofing, Access Management (Multi-Factor Authentication), Authorization Assistance Work?ow Tools, and Identity Lifecycle Management functions Password Reset, Forgot User ID, etc.). (EIDM FAQ 04/03/2013) What is a CMS EIDM User account? A CMS EIDM account verifies the identity of the user and ensures that only authorized/registered users can access protected information and systems through the CMS Enterprise Portal. (EIDM FAQ 04/03/2013) Who is eligible to have a CMS EIDM User Account? All US citizens who are over 18 years of age and have a current or previous valid US residential address are eligible to have a CMS EIDM User Account. (EIDM FAQ 04/03/2013) I am new to CMS Enterprise Portal. How should I create my user account? Once you are on the CMS Enterprise portal, select the ?New User Registration? hyperlink. You are required to enter your personal information and answer the knowledge-based questions. Choose desired User lD/Password as per the guidelines provided. Once the details have been successfully updated in EIDM, the system will display a message con?rming the creation of the user account. (EIDM FAQ 04/03/2013) Why should I submit personal information at the time of registering my user account and how safe is it? EIDM needs your personal information to verify your identity. During the registration process EIDM initiates a remote identity proofing call with one of the identity service providers and, based upon the information provided, you are allowed to create a user account. For security level information please visit: (EIDM FAQ 04/03/2013) What will you do with my Personal Identifiable Information (Pll)? EIDM uses an external authentication service provider, Experian, to help us verify your identity based on the information that you have provided. Experian veri?es your information against its records to successfully identify you. CMS provides, on the public- facing websites, the Terms Conditions of how your information will be handled when registering for a CMS EIDM user account. (EIDM FAQ 04/03/2013) 1180 Updated 1-31-17 2017--01280 Will my Social Security Number (SSN) be shared with any federal or private agency? Your SSN will be used for verification purposes only. EIDM does not share your SSN with any other federal or private agency. (EIDM FAQ 04/03/2013) Why does Experian require my personal information? Experian uses your personal information to verify your identity against your personal information record; this may result in what is known as a ?soft inquiry? on your Experian report. (EIDM FAQ 04/03/2013) Does verifying my identity by Experian affect my credit score? No. These kinds of inquiries are termed as ?soft inquiry?. Soft inquiries do not affect your credit score, and you do not incur any charges related to them. Soft inquiries are displayed in the version of the credit profile viewable only to consumers and are not reported to lenders. If you order a credit report from Experian, you will see an entry of inquiry by the Centers for Medicare Medicaid Services with our address and the date of request. (EIDM FAQ 04/03/2013) What if I have problems? Is there an Experian Help Desk? Yes, Experian Proo?ng Support Services is a dedicated call center for individuals who have failed being proofed on-Iine while attempting to obtain a CMS EIDM credential. (EIDM FAQ 04/03/2013) What happens if the Experian Help Desk cannot proof my identity? If you cannot be proofed even with assistance from the Experian Help desk, EIDM will create user credentials for you, but your access to CMS applications may be limited. (EIDM FAQ 04/03/2013) Why am I not able to change my User The User ID identi?es you uniquely to therefore, you cannot change your User ID. (EIDM FAQ 04/03/2013) What is Multi-Factor Authentication It is an approach to security authentication which requires users of a system to provide more than one form of veri?cation in order to prove their identity and be allowed access to the system. It includes veri?cation by something a user knows (such as a password) and something a user has (such as a Security Token), before getting access to an online application. (EIDM FAQ 04/03/2013) When I try to login I get an error message ?Your information cannot be verified please try again?. What should I do? Please check the entered User ID, Password or Symantec Secure Code (VIP Security Token if you have registered the MFA device to your account). An incorrect combination of these can result in this error message. (EIDM FAQ 04/03/2013) 1181 Updated 1-31-17 2017-?01281 When I try to login, I get the error message stating ?Your account is disabled. Contact the Help Desk to enable your account?. Why? A user?s account can be disabled by Application Helpdesks or EIDM Administrators for possible reasons linked to security violations or fraud detection. In order to enable your disabled account, you are required to contact the application helpdesk. (EIDM FAQ 04/03/2013) When I try to login, I get the error message stating ?Your account has been locked. Please try again later.? Why? How can I get my account unlocked? If you make three unsuccessful attempts to login, your account will be locked out. You can unlock your account after 60 minutes have elapsed since your third consecutive failed authentication attempt. You are required to enter valid credentials associated to user account to unlock the account. (EIDM FAQ 04/03/2013) The application that I?m attempting to access requires me to login again with User ID, Password and Security Code. Why should I login again and how do I get the Security Code? The application that you are trying to access requires a higher level of security to include a Security Code from a Multi-Factor Authentication (MFA) device. You can obtain the security codes by registering your computer or smart phone. Once you are successfully authenticated, you can add MFA devices by selecting ?Register your Smartphone/Computer? hyperlink on the ?My Profile? page. You are required to submit the valid Credential ID, Security Code, Credential Type and Credential Description on the ?Register your Smartphone or Computer' view. Upon successful validation, EIDM displays a message con?rming addition of the MFA device to the user account. You can now access your application by providing the User ID, Password and the Security Code from the Symantec VIP software installed on your computer or smartphone. Please refer to the EIDM User Manual for more information. (EIDM FAQ 04/03/2013) Are there any specific MFA service providers? What Multi-Factor Authentication (MFA) devices can I link to my CMS User account? Yes. There are various MFA service providers. Symantec is the MFA service provider for EIDM accounts. Symantec provides validation and identity protection through the Computer and Smartphone. (EIDM FAQ 04/03/2013) How do I get a Multi-Factor Authentication (MFA) application on my device? You can download and install the following applications: Computer: The MFA application can be downloaded from: and Smartphone: The MFA application can be downloaded from: (EIDM FAQ 04/03/2013) How do I register my Multi-Factor Authentication Smartphone or Computer to my EIDM user account? Once your identity is verified at a higher level, EIDM will display the ?Register your Smartphone or Computer? screen. You need to enter the Credential Type (such as 1182 Updated 1-31-17 2017-?01282 Computer or a Smartphone), Credential ID, Credential Description, and Security Code (VIP Security Token) as displayed on your Smartphone or Computer to complete the registration. (EIDM FAQ 04/03/2013) How many MFA devices can I link to my EIDM user account? EIDM allows you to link a maximum of three distinct devices which can either be a Computer or a Smartphone. (EIDM FAQ 04/03/2013) What is a Credential How do I find it on my MFA device? A Credential ID is a unique 12-character alphanumeric code that displays under the label Credential ID on your MFA device. The Credential ID is required to be submitted only when linking an MFA device to the user account. (EIDM FAQ 04/03/2013) What is a Security Code? A Security Code is a six digit numeric code that appears under the label ?Security Code? on your MFA device. This Security Code is mapped to your User ID and is used as a second-factor authentication to con?rm your identity. Please remember, this Security Code changes every 30 seconds. Make sure you enter and submit the Security Code within 30 seconds. (EIDM FAQ 04/03/2013) Do I need to use my MFA device every time I log in? How do I know if I need MFA is required for speci?c applications that require higher level of authentication. Not all applications require MFA for a user. This is decided on the basis of application access a user has. For example: A user has access to App1 and App2. App1 requires MFA and App2 does not. A user logs in using single factor authentication, i.e. the user id and password. A user is allowed to access App2, but the moment user tries to access App1, EIDM triggers second factor authentication; that is, the user has to submit the User ID, Password and Security Code. (EIDM FAQ 04/03/2013) Can I access multiple applications if I?m Multi-Factor Authenticated? Yes, you can work on multiple applications if you have been Multi-Factor Authenticated. MFA serves as a Single Sign On (880) and allows you to work on multiple CMS applications during a valid EIDM session. (EIDM FAQ 04/03/2013) How do I use my Multi-Factor Authentication device to log into my CMS EIDM user account? In order to access a CMS MFA protected application; you are required to link your Symantec Multi-Factor Authentication device with your user account. EIDM displays a login screen once you select a protected application hyperlink. You must enter your User ID, Password and Security Code. (EIDM FAQ 04/03/2013) How do I register additional devices to my CMS EIDM user account? To access this feature you must be successfully authenticated to the CMS Portal. You can register additional Multi-Factor Authentication devices by selecting ?Register your 1 183 Updated 1-31-17 2017--01283 Smartphone or Computer? hyperlink on the ?My Pro?le? page. You are required to submit the valid Credential ID, Security Code, Credential Type and Credential Description on the ?Register your Smartphone or Computer? view. Upon successful validation, EIDM displays a message, con?rming addition of the MFA device to the user account. (EIDM FAQ 04/03/2013) I lost all my MFA devices linked to my EIDM user account. How do I deactivate the linked devices and link new devices to my user account? Your application helpdesk should be able to assist you in removing/deactivating the registered devices and registering new devices to your user account. (EIDM FAQ 04/03/2013) If my Credential ID is copied or stolen, can someone else access my CMS EIDM User account? No. A Credential ID cannot be used to access an EIDM user account. Why does the Security Code keep changing on a Multi-Factor Authentication device? For your protection, Multi-Factor Authentication device automatically generates a new Security Code each time it counts down from a 30-second timer. (EIDM FAQ 04/03/2013) When I try to login, I get an error message stating ?It?s been over 60 days since we last saw you.? How do I unlock my account? EIDM locks your user account if no activity is reported in the account for 60 or more days. When you login after 60 days the system will display the ?Unlock my Account? view; enter your User ID and correctly answer all challenge questions on the next page; enter your new password in the input ?elds of ?New Password? and ?Confirm New Password? to unlock your account. (EIDM FAQ 04/03/2013) Why do I need to answer all four challenge questions when unlocking my user account? EIDM needs to verify your identity. Your response to the set of four challenge questions will enable EIDM to con?rm your identity and help you proceed in getting your account unlocked. This also protects you from identity theft. (EIDM FAQ 04/03/2013) How do I request access to applications now that I have an EIDM account? After setting up an EIDM account, you will have to request access to the applications that you previously used. This is a one-time setup process per application. Select the ?My Access? link located on the CMS Portal Home page and then click on the ?Request New Application Access? hyperlink. Follow the on-screen instructions. Once your request has been approved, a link to the application will appear on your ?My Home? page. (EIDM FAQ 04/03/2013) How long does it take to get approved for an access to a requested application or a role? It can take up to 30 days to be granted access to an application or role. After 30 days, your request will expire. In the unlikely event that this happens, please contact the respective Application Help Desk. (EIDM FAQ 04/03/2013) 1184 Updated 1-31-17 2017-?01284 What is Identity Proofing? Identity proofing is the process of providing suf?cient information identity history, credentials, or documents) to a service provider for the purpose of proving that a person or object is the same person or object it claims to be. Individuals requesting electronic access to CMS protected information or systems must be identity proofed. (EIDM FAQ 04/03/2013) Where can I find information on who has the right to request a Social Security Number Federal law mandates that state departments of motor vehicles, tax authorities, welfare offices, and other governmental agencies request your SSN as proof that you are who you claim to be. However, the Privacy Act of 1974 requires that any government agency requesting your SSN provide details on how this information will be used, and what law or authority requires its use. For information on who has the right to request your SSN, see Number The text of the Privacy Act can be found at (EIDM FAQ 04/03/2013) I already provided my personal information during Registration to setup an EIDM user account. Why do I have to provide it again to access certain applications? When you have selected an application or role that requires a higher level of security than you currently have, you are required to complete identity proo?ng again. In most cases, you may need to provide a few more details SSN, Date of Birth) to be able to request access to the selected application or role. (EIDM FAQ 04/03/2013) How do I add another role to an application to which I already have access? After you have access to an application role, you can request access for additional roles by selecting the ?My Access? hyperlink and then selecting the ?Add a Role? hyperlink next to the desired application on the ?View and Manage My Applications? view. You will be required to select a new role and possibly provide additional information before submitting your request. For some applications, you may receive immediate approval based on the information entered. (EIDM FAQ 04/03/2013) How do I remove a role that I no longer need? Updated 1-31-17 Select the ?My Access? hyperlink and then select the ?Remove a Role? hyperlink next to the desired application on the ?View and Manage My Applications? view. Next, select the ?Remove? link next to the role that you want to remove. The system will ask you to confirm that you want to remove the role. You can cancel the request or continue by selecting ?Submit?. If you are a user with approval authority, you may not be able to remove your approval role, if you are the only approver for your end users you are the only approver for users in the Eastern Region). However, approval may take up to 30 days. (EIDM FAQ 04/03/2013) 1185 2017-?01285 Will CMS make improvements to the Identity proofing process? Identity proofing for electronic accounts seeks to balance security concerns and usability. As users undergo ID proo?ng, the systems are constantly tuned to achieve an appropriate balance that can account for the types of users that are entering the system. We are already seeing a signi?cant rise in the number of users successfully completing ID proofing and will continue to monitor the solution until the appropriate measures are reached. If you were unsuccessful during your first attempt, we thank you for your patience and encourage you to try again in 24-48 hours. (EIDM FAQ 04/03/2013) Length of Marketplace Coverage Does a Marketplace plan last for 12 months, or does it need to be renewed at the end of every calendar year? Marketplace plans sold in the individual market must be on a calendar year cycle, meaning that they generally start on January 1 and end on December 31. The calendar year for which a Quali?ed Health Plan (QHP) provides coverage for health bene?ts is called the ?benefit year." That said, because Open Enrollment extended into 2014 and special enrollment periods are available throughout the year, not all coverage lasts the full 12 months. For example, a consumer who enrolled in a QHP that has a coverage effective date of May 1, 2014 would have their coverage last only 8 months (through December 31, 2014), and the coverage would need to be renewed on a calendar year cycle, beginning January 1, 20158 The new bene?t year for QHPs will begin January 1, 2015, which means that cost-sharing features of a QHP, such as deductibles and out-of- pocket limits, for current QHP enrollees will start over for that bene?t year. (CMS Technical Assistance Resources on the Length of Marketplace Coverage 07/16/14) How are consumers informed about the start and end dates of their QHP coverage? A consumer?s ?My Account" page indicates both the start date and end date of their Marketplace QHP coverage. The page will display a coverage end date of December 31, 2014, regardless of when in 2014 the consumer purchased QHP coverage. Consumers who do not have an online account can con?rm their QHP coverage start and end dates by calling their insurance company, checking the plan?s Summary of Benefits and Coverage, or referring to welcome package documents the insurance company mailed to them. Because Marketplace plans operate on a calendar year, these documents should display the coverage end date as December 31, 2014. (CMS Technical Assistance Resources on the Length of Marketplace Coverage 07/16/14) How should consumers renew their Marketplace coverage and tax credit? The vast majority of consumers will be automatically re-enrolled in coverage and will have their tax credit continued. Consumers are encouraged to visit the Marketplace during Open Enrollment to make sure their information is up to date and they are getting the right amount of ?nancial assistance, and to make sure they are enrolled in the right plan for them. The exact process for renewal will vary depending on the state where the 8 See 45 CFR 144.103 (definition of ?policy year"); 45 CFR 45 CFR 155.20 (de?nition of ?bene?t year?); see also . 1 186 Updated 1-31-17 2017--01286 consumer lives. For consumers who are automatically re-enrolled in their plan, their new plan year will begin January 1, 2015. However, these enrollees have until the end of the Open Enrollment Period (February 15, 2015) to shop and switch their plans. Consumers who have been re-enrolled in their plan and then switch to a new plan should keep in mind that the cost-sharing features, such as deductibles and out-of?pocket limits, will generally start over with their new plan. (CMS Technical Assistance Resources on the Length of Marketplace Coverage 07/16/14 How long will coverage purchased through the Small Business Health Options (SHOP) Marketplace be effective? SHOP Marketplace coverage is generally based on a 12-month plan year cycle that could begin (and end) at any point during the calendar year, rather than on a calendar year cycle. The 12-month plan year in most SHOPS begins with the employer?s initial coverage effective date, not the individual enrollee?s initial coverage effective date. For example, an employee who enrolled in a SHOP QHP under which their employer has an initial effective start date of July 1, 2014, would have coverage that ends as of June 30, 2015. If an employer?s plan year begins on July 1, 2014, but a newly hired employee's coverage doesn?t begin until September 1, 2014, then the employee?s coverage will still end on June 30, 2015. (CMS Technical Assistance Resources on the Length of Marketplace Coverage 07/16/14) How long are the bene?t years for Medicaid and the Children?s Health Insurance Program Consumers who are enrolled in Medicaid or CHIP based on their Modi?ed Adjusted Gross Income (MAGI) are generally eligible for 12 months, unless they experience a change in their income or other circumstances that may affect their eligibility. Eligibility is renewed on a 12-month cycle starting from the beginning date of coverage (rather than on a calendar-year cycle). For 2014, some states are temporarily delaying their renewals, so if consumers have questions about the length of their eligibility period, they should call their state Medicaid or CHIP agency to confirm their status. Additionally, the typical 12-month Medicaid cycle may not apply to all consumers. A consumer who is eligible for Medicaid for a reason, such as for a disability, may have a more frequent renewal cycle. Regularly scheduled renewals are also not the only time state Medicaid and CHIP agencies redetermine eligibility. For example, Medicaid and CHIP agencies redetermine a consumer?s eligibility for coverage if a consumer provides new information or changes that may affect their eligibility, or if the agencies ?nd new information resulting from periodic data matching efforts. (CMS Technical Assistance Resources on the Length of Marketplace Coverage 07/16/14) How should consumers renew their Medicaid or CHIP coverage? Updated 1-31-17 Renewals for current Medicaid and CHIP bene?ciaries will happen only through the state Medicaid or CHIP agency. New applicants can continue to submit initial applications for Medicaid and CHIP through HealthCare.gov. Medicaid and CHIP bene?ciaries should pay close attention to the instructions on their renewal notice. Some families will not need to take any action to continue their coverage, while some families will need to ?ll in missing information on the renewal form that the state sends, and sign and return the 1187 2017-?01287 form to the state. Individuals should also directly contact their state Medicaid or CHIP agency to report any changes that may affect their eligibility during the year to receive a mid-year renewal. The Medicaid and CHIP agencies in each state can help bene?ciaries understand what they are required to report and the procedures for doing so. (CMS Technical Assistance Resources on the Length of Marketplace Coverage 07/16/14) Appeals Help - Timely Eligibility Appeals Pending on or Requested after March 31, 2014 1. What happens to a timely eligibility appeal filed with the Federally Facilitated Marketplace (Marketplace) before March 31, 2014, that is still pending after March 31, 2014? If you ?led an eligibility appeal on or before March 31, 2014 that remains pending after March 31, 2014, your appeal will continue to be processed. We will provide you with our decision, which will be responsive to your appeal. If you receive a favorable appeal decision, you will be provided a special enrollment period to enroll in, or to switch plans within the Marketplace, and to apply any subsidies for which you are found eligible. If you receive an unfavorable decision and have not enrolled into a plan, unless you have another special or other enrollment period available, you may not be able to enroll in a plan until the next open enrollment period, which is set to begin November 15, 2014, for a January 1, 2015 effective date. If our decision is favorable you may also choose to have your insurance coverage, and any subsidies you are eligible for apply retroactively. You may be able to select a retroactive date based upon the date of your original application to the Marketplace. (CMS Technical Assistance Resources Appeals Help Time/y Eligibility Appeals Pending or Requested after March 31, 2014 no date) 2. What happens to a timely eligibility appeal that is filed with the Marketplace after March 31, 2014? Updated 1-31-17 Generally, a consumer has 90 days after the date of an eligibility determination, to submit an appeal. Other time limits might apply to cases involving state Medicaid-related appeals. This means that the time limit for a consumer to submit an appeal can go beyond March 31st. In these circumstances, we will process your appeal according to normal eligibility appeals procedures. We will provide you with our decision, which will be responsive to your appeal. If you receive a favorable appeal decision, you will be provided a special enrollment period to enroll in, or to switch plans within the Marketplace, and to apply any subsidies for which you are found eligible. If you receive an unfavorable decision and have not enrolled into a plan, unless you have another special or other enrollment period available, you may not be able to enroll in a plan until the next open enrollment period, which is set to begin November 15th, 2014, for a January 1, 2015 effective date. If our decision is favorable you may also choose to have your insurance coverage, and any subsidies for which you are eligible, apply either prospectively or retroactively. You may be able to select a retroactive date based upon the date of your original application 1188 2017-?01288 to the Marketplace, assuming you pay, or have paid, your premiums back to the retroactive effective date. (CMS Technical Assistance Resources Appeals Help Timely Eligibility Appeals Pending or Requested after March 31, 2014 no date) 3. What will my eligibility effective date be if the appeal decision is favorable? Will I be able to enroll retroactively? If you receive a favorable appeal decision, you will be provided a special enrollment period to enroll in, or to switch plans within the Marketplace, and to apply any subsidies for which you are found eligible. If our decision is favorable you may also choose to have your insurance coverage, and any subsidies for which you are eligible, apply either prospectively or retroactively. If you choose a prospective date, Marketplace rules will apply. For example, if you choose to enroll into a different plan based on the appeals decision, on May 23rd, the effective date of coverage in the new plan will be July 1. Or you may select a retroactive date based upon the date of your original application to the Marketplace, assuming you pay, or have paid, your premiums back to the retroactive effective date. For example, if you receive a favorable appeals decision on April 5th but you received your original determination, which you are disputing, on February 28th, the effective date of coverage would be April 1. If you receive an unfavorable decision and have not enrolled into a plan, unless you have another special or other enrollment period available, you may not be able to enroll in a plan until the next open enrollment period, which is set to begin November 15th, 2014, for a January 1, 2015 effective date. (CMS Technical Assistance Resources Appeals Help Time/y Eligibility Appeals Pending or Requested after March 31 2014 no date) 4. Will I have to pay a penalty ifl have not signed-up for coverage by March 31, 2014, if my eligibility appeal is still pending? Updated 1-31-17 We will continue to work on your eligibility appeal after March 31st. This applies even if you were still in the process of applying on March 31st. If you receive a favorable eligibility appeal decision, you will not be assessed a shared responsibility payment. You will be provided a special enrollment period to enroll in, or to switch, plans within the Marketplace, and to apply any subsidies for which you are found eligible. You may choose to have your insurance coverage, and any subsidies for which you are eligible, apply either prospectively or retroactively. Please be sure to keep all of the paperwork that you receive from CMS, including any appeals decision, and from your health plan, to ensure that you can demonstrate your coverage and coverage effective dates to any review entities, if need be. You may receive an eligibility appeal decision that finds the Marketplace made the right determination. An eligibility appeal decision that doesn't change your original eligibility determination will not give you a special period to enroll after the March 31st deadline, and you will be assessed a shared responsibility payment. If you receive an unfavorable decision and have not enrolled into a plan, unless you have another special or other enrollment period available, you may not be able to enroll in a plan until the next open 1189 2017-?01289 enrollment period, which is set to begin November 15th, 2014, for a January 1, 2015 effective date. (CMS Technical Assistance Resources Appeals Help Timely Eligibility Appeals Pending or Requested after March 31, 2014 no date) 5. Will I be able to enroll in or switch plans once a decision is made regarding my appeal if my appeal is still pending after March 31, 2014? Updated 1-31-17 Yes, if you filed an eligibility appeal on or before March 31st, it?s pending after March 31st, and you receive a favorable decision after March 31, 2014, you will be able to enroll in, or switch, plans. If our decision is favorable you may also choose to have your insurance coverage, and any subsidies for which you are eligible applied either prospectively or retroactively. You may be able to select a retroactive date based upon the date of your original application to the Marketplace. An eligibility appeal decision that doesn't change your original eligibility determination will not give you a special period to enroll after the March 31st deadline. If you receive an unfavorable decision and have not enrolled into a plan, unless you have another special or other enrollment period available, you may not be able to enroll in a plan until the next open enrollment period, which is set to begin November 15th, 2014, for a January 1, 2015 effective date. (CMS Technical Assistance Resources Appeals Help Timely Eligibility Appeals Pending or Requested after March 31 2014 no date) 1190 2017-?01290 DOL FAQS ABOUT ACA IMPLEMENTATION Compliance Q1: Under the Affordable Care Act, there are various provisions that apply to group health plans and health insurance issuers and various protections and benefits for consumers that are beginning to take effect or that will become effective very soon. What is the Departments? basic approach to implementation? The Departments are working together with employers, issuers, States, providers and other stakeholders to help them come into compliance with the new law and are working with families and individuals to help them understand the new law and bene?t from it, as intended. Compliance assistance is a high priority for the Departments. Our approach to implementation is and will continue to be marked by an emphasis on assisting (rather than imposing penalties on) plans, issuers and others that are working diligently and in good faith to understand and come into compliance with the new law. This approach includes, where appropriate, transition provisions, grace periods, safe harbors, and other policies to ensure that the new provisions take effect smoothly, minimizing any disruption to existing plans and practices. (DOL FAQs Part I 09/20/10) Grandfathered Health Plans 02: After the interim final regulations on grandfathered health plans were issued, some issuers commented that they do not always have the information needed to know whether (or when) an employer plan sponsor changes its rate of contribution towards the cost of group health plan coverage. (Generally, the interim final regulations provide that a group health plan or health insurance coverage will cease to be a grandfathered health plan if the employer decreases its contribution rate based on cost of coverage towards the cost of coverage by more than 5 percentage points below the contribution rate on March 23, 2010.) For purposes of determining whether an insured group health plan is a grandfathered health plan, what steps should issuers and employer plan sponsors take to communicate regarding changes to the plan sponsor's contribution rate? The Departments have determined that, until the issuance of final regulations, they will not treat an insured group health plan that is a grandfathered plan as having ceased to be a grandfathered health plan immediately based on a change in the employer contribution rate if the employer plan sponsor and issuer take the following steps: . Upon renewal, an issuer requires a plan sponsor to make a representation regarding its contribution rate for the plan year covered by the renewal, as well as its contribution rate on March 23, 2010 (if the issuer does not already have it); and . The issuer's policies, certificates, or contracts of insurance disclose in a prominent and effective manner that plan sponsors are required to notify the issuer if the contribution rate changes at any point during the plan year. For policies renewed prior to January 1, 2011, issuers should take these steps no later than January 1, 2011. If these steps are taken, an insured group health plan that is a grandfathered health plan will continue to be considered a grandfathered health plan. 1191 Updated 1-31-17 2017-?01291 The relief in this will no longer apply as of the earlier of the ?rst date on which the issuer knows that there has been at least a 5-percentage-point reduction or the first date on which the plan no longer qualifies for grandfathered status without regard to the 5- percentage-point reduction. Moreover, nothing in the Affordable Care Act or the interim final regulations prevents a policy, certi?cate, or contract of insurance from requiring a plan sponsor to notify an issuer in advance 30 or 60 days in advance) of a change in the contribution rate. (DOL FAQs Part I 09/20/10) Q3: Similarly, multiemployer plans do not always know whether (or when) a contributing employer changes its contribution rate as a percentage of the cost of coverage. What steps should multiemployer plans take to communicate with contributing employers regarding employer contributions towards coverage? If multiemployer plans and contributing employers follow steps similar to those outlined in above, the same relief will apply to the multiemployer plan unless or until the multiemployer plan knows that the contribution rate has changed. (DOL FAQs Partl 09/20/10) Q4: Also with respect to multiemployer plan coverage, some multiemployer plans have stated that it is common for such plans to have either a fixed-dollar employee contribution or no employee contribution towards the cost of coverage. In such cases, is it relevant if a contributing employer's contribution rate changes (for example, after making up a funding deficit in the prior year or to reflect a surplus), provided any changes in the coverage terms would not otherwise cause the plan to cease to be grandfathered and there continues to be no employee contribution or no increase in the fixed-dollar employee contribution towards the cost of coverage? In this circumstance, if there is no increase in the employee contribution towards coverage and any changes in the coverage terms would not otherwise cause the plan to cease to be grandfathered, a change in a contributing employer's contribution rate will not, in and of itself, cause a plan that is otherwise a grandfathered health plan to cease to be a grandfathered health plan. (DOL FAQs Part I 09/20/10) 05: Are the Departments receiving other comments and questions regarding the grandfather regulations? ls more guidance expected? The Departments invited comments on their interim ?nal grandfather regulations, as well as on the appeals regulations and other provisions whose applicability is affected by status as a grandfathered health plan. The Departments have issued some sub- regulatory guidance on the appeals regulations and will continue to review and evaluate comments on these and other regulations, and might issue further sub-regulatory guidance on selected issues as comments are evaluated. Final regulations on the various interim final regulations recently issued under the Affordable Care Act are expected to be published beginning next year. (DOL FAQs Part I 09/20/10) 1192 Updated 1-31-17 2017-?01292 06: Will the Departments change the current rules so that a grandfathered group health plan that changes carriers does not relinquish its status as a grandfathered health plan? The Departments anticipate that they will shortly address the circumstances under which grandfathered group health plans may change carriers without relinquishing their status as grandfathered health plans. (DOL FAQs Part I 09/20/10) Claims, Internal Appeals, and External Review Q7: My plan already provided an external review process before the Affordable Care Act was enacted. Can my already-existing external review process be deemed to comply with Public Health Service Act (PHS Act) section 2719(b)? If your plan existed prior to enactment of the Affordable Care Act, you should ?rst check to see if your plan is a grandfathered health plan. If it is, the new external review provisions of PHS Act section 2719(b) do not apply to your plan. If your plan is not a grandfathered health plan and it is insured, the Departments have provided transitional relief under which plans can use existing State external processes, in one of the States in which they operate, to comply with the new Federal requirements. This transitional relief applies regardless of whether the plan already existed on March 23, 2010 or is a new plan. If your plan is not a grandfathered health plan and it is self-insured, relief is also provided. On August 23, 2010, the Department of Labor issued Technical Release 2010- 01, which sets forth an enforcement safe harbor. If the plan complies with one of the methods set forth in the release, the Department of Labor and the IRS will not take any enforcement action with respect to PHS Act section 2719(b) during the transition period. See also below. (DOL FAQs Part I 09/20/10) Q8: What if a self-insured plan's external review process does not satisfy the safe harbor in the DOL technical release? Updated 1-31-17 The technical release provides a safe harbor from enforcement by the Departments. For plans that do not strictly comply with all the standards set forth in the technical release, compliance will be determined on a case-by-case basis under a facts and circumstances analysis. Thus, a plan that does not satisfy all of the standards of the technical release's safe harbor may in some circumstances nonetheless be considered to be in compliance with PHS Act section 2719(b). For example, one of the standards set forth in the technical release requires self-insured plans to contract with at least three independent review organizations (IROs) and to rotate claims assignments among them (or to incorporate other independent, unbiased methods for selection of lROs, such as random selection). However, a self-insured group health plan's failure to contract with at least three IROs does not mean that the plan has automatically violated PHS Act section 2719(b). Instead, a plan may demonstrate other steps taken to ensure that its external review process is independent and without bias. (DOL FAQS Part 09/20/10) 1193 2017-?01293 Q9: Similarly, what if a self-insured plan does not contract directly with any independent review organization (IRO), but contracts with a third-party administrator (TPA) that, in turn, contracts with an The technical release does not require a plan to contract directly with any IRO. Where a self-insured plan contracts with a TPA that, in turn, contracts with an IRO, the standards of the technical release can be satisfied in the same manner as if the plan had contracted directly. Of course, such a contract does not automatically relieve the plan from responsibility if there is a failure to provide an individual with external review. Moreover, ?duciaries of plans that are subject to ERISA have a duty to monitor the service providers to the plan. (DOL FAQs Part I 09/20/10) Q10: What if there is no IRO in my plan's State? The IRO is not required to be in the same State as the plan. Plans may contract with an IRO even if it is located in another State. (DOL FAQs Part 09/20/10) Q11: The Departments' regulations make changes to shorten the times for making initial determinations with respect to urgent care claims, but did not make any changes to the times for making internal appeals decisions. The Departments' model notice of adverse benefit determination issued on August 23, 2010, was unclear as to which times have been shortened. What is the rule? Only the times for making the initial bene?t determination were changed. The Departments have revised the model notice to eliminate confusion. The revised notice includes a header that reads, "Revised as of September 20, 2010." (DOL FAQs Pan?l 09/20/10) Q12: I anticipate that my plan will no longer be a grandfathered plan and will have a hard time making systems changes in time to comply with some of the new standards for claims and internal appeals. Is there any relief? Yes, on September 20, 2010 the Department of Labor issued Technical Release 2010- 02 at providing an enforcement grace period until July 1, 2011 to give plans and issuers necessary time to make certain procedural and computer system changes to comply with the new requirements. (DOL FAQs Part I 09/20/10) Q13: The September 20, 2010 technical release, among other things, gives plans and issuers additional time (as an enforcement grace period until July 1, 2011) before they have to provide new content (such as coding information) on notices of adverse benefit determination and notices of final adverse benefit determination. Does this mean that notices are not required during the grace period? No. The Technical Release 2010-02 provides that the standards of the Department of Labor's claims procedure regulation issued on November 21, 2000 (29 CFR 2560.503-1) apply. A grace period is given only for the new content required under paragraph of the Departments' July 23, 2010 interim ?nal claims and appeals regulations. In addition, under existing regulations, claimants may obtain coding and other information relevant to the claimant's claim for benefits free of charge upon request. See 29 CFR (DOL FAQs Part 09/20/10) 1 194 Updated 1-31-17 2017-?01294 Q1: Our company sponsors a group health plan for our employees that has been in effect since March 23, 2010. We and the issuer of the policy under the plan are considering whether we could make various changes to the plan without losing grandfathered status. If we avoid making any of the six speci?c changes described in paragraph of the interim final regulations relating to grandfathered health plans, are there other changes to our existing plan/policy that we need to be concerned could cause it to relinquish grandfathered status?(1) No. Paragraph of the Departments? interim final grandfather regulations provides that any of six changes (measured from March 23, 2010) are considered to change a health plan so significantly that they will cause a group health plan or health insurance coverage to relinquish grandfather status. Brie?y stated, these six changes are: 1. Elimination of all or substantially all bene?ts to diagnose or treat a particular condition. 2. Increase in a percentage cost-sharing requirement raising an individual?s coinsurance requirement from 20% to 3. Increase in a deductible or out-of?pocket maximum by an amount that exceeds medical in?ation plus 15 percentage points. 4. Increase in a copayment by an amount that exceeds medical inflation plus 15 percentage points (or, if greater, $5 plus medical inflation). 5. Decrease in an employer?s contribution rate towards the cost of coverage by more than 5 percentage points. 6. Imposition of annual limits on the dollar value of all benefits below specified amounts For a plan that is continuing the same policy, these six changes are the only changes that would cause a cessation of grandfather status under the interim ?nal regulations. (As noted, the Departments are separately considering under what circumstances otherwise grandfathered plans may change issuers without relinquishing their status as grandfathered health plans.) (DOL FAQs Pan? II 10/08/10) 02: My plan offers three benefit package options - a PPO, a POS arrangement, and an HMO. If the HMO relinquishes grandfather status, does that mean that the PPO and POS arrangement must also relinquish grandfather status? No. The grandfather analysis applies on a basis. In this situation, it is permissible to treat the PPO, POS arrangement, and HMO as separate bene?t packages. Accordingly, if any benefit package ceases grandfather status, it does not affect the grandfather status of the other bene?t packages. (DOL FAQs Part II 10/08/10) Q3: How do the Departments? interim final grandfather rules regarding changes in employer contributions apply where an employer restructures its tiers of coverage? The interim final grandfather regulations provide that the standards of paragraph for employer contributions (listed above as item (5) in apply on a tier- by-tier basis. As a result, if a group health plan modifies the tiers of coverage it had on March 23, 2010 (for example, from self-only and family to a multi-tiered structure of self- only, self-plus-one, self-plus-two, and self-plus-three-or-more), the employer contribution for any new tier would be tested by comparison to the contribution rate for the corresponding tier on March 23, 2010. In this example, if the employer contribution rate for family coverage was 50 percent on March 23, 2010, the employer contribution rate 1195 Updated 1-31-17 2017--01295 for any new tier of coverage other than self-only self-plus-one, self-plus-two, self- plus-three or more) must be within 5 percentage points of 50% at least 45 percent). If, however, the plan adds one or more new coverage tiers without eliminating or modifying any previous tiers and those new coverage tiers cover classes of individuals that were not covered previously under the plan, the new tiers would not be analyzed under the standards of paragraph Therefore, for example, if a plan with only a self-only coverage tier added a family coverage tier, the level of employer contribution toward the family coverage would not cause the plan to lose grandfather status. (DOL FAQs Part II 10/08/10) Q4: If an employer plan sponsor raises the copayment level for a category of services (such as outpatient or primary care) by an amount that exceeds the standards set forth in paragraph of the interim final regulations, but retains the copayment level for other categories of services (such as inpatient care or specialty care), will that cause the plan to relinquish grandfather status? Yes. Each change in cost sharing is separately tested against the paragraph standards of the Departments? interim ?nal grandfather regulations. (DOL FAQs Part II 10/08/10) Q5: How do the Departments? interim final grandfather regulations affect wellness programs sponsored by group health plans? Group health plans may continue to provide incentives for wellness by providing premium discounts or additional benefits to reward healthy behaviors by participants or beneficiaries, by rewarding high quality providers, and by incorporating evidence-based treatments into benefit plans.(2) However, penalties (such as cost-sharing surcharges) may implicate the paragraph standards listed above in and should be examined carefully. In addition, plans should take steps to ensure compliance with applicable nondiscrimination rules (such as the nondiscrimination rules for group health plans and group health insurance coverage with respect to an individual based on a health status related factor) and any other applicable Federal or State law. (DOL FAQs Part II 10/08/10) Q1: The Departments? interim final grandfather regulations provide that, to maintain status as a grandfathered health plan, a group health plan or health insurance coverage must include a statement, in any plan materials provided to a participant or beneficiary describing the bene?ts provided under the plan or health insurance coverage, that the plan or coverage believes it is a grandfathered health plan. Must a grandfathered health plan provide the disclosure statement every time it sends out a communication, such as an EOB (explanation of benefits), to a participant or beneficiary? If not, how does a grandfathered health plan comply with this disclosure requirement? A grandfathered health plan will comply with this disclosure requirement if it includes the model disclosure language provided in the Departments' interim ?nal grandfather regulations (or a similar statement) whenever a summary of the benefits under the plan is provided to participants and bene?ciaries. For example, many plans distribute summary plan descriptions upon initial eligibility to receive bene?ts under the plan or coverage, during an open enrollment period, or upon other opportunities to enroll in, renew, or change coverage. While it is not necessary to include the disclosure statement with each plan or issuer communication to participants and beneficiaries (such as an 1 196 Updated 1-31-17 2017--01296 EOB), the Departments encourage plan sponsors and issuers to identify other communications in which disclosure of grandfather status would be appropriate and consistent with the goal of providing participants and bene?ciaries information necessary to understand and make informed choices regarding health coverage. (DOL FAQs Part IV 10/29/10) 02: If an individual health insurance policy that was in place on March 23, 2010 included a feature that allowed a policy holder to elect an option under which he or she would pay a reduced premium in exchange for higher cost sharing, could such an election be made after March 23 without affecting the policy's grandfather status even if the increase in cost sharing for the individual would exceed the limits under the grandfather rule on increases in cost sharing? Yes. The cost-sharing level that would apply under this option would be grandfathered as part of the policy in place on March 23, 2010 even if it did not apply for the particular individual at that time. As long as the policy holder had that option available on March 23 under the policy, he or she could exercise the option after March 23 without affecting grandfather status, even if the result would be that the particular individual?s cost-sharing would increase as a result of electing this option by an amount in excess of the grandfather rule limits. (DOL FAQs Part IV 10/29/10) 03: An employer has maintained a plan since before enactment of the Affordable Care Act that reimburses expenses for special treatment and therapy of eligible employees? children with physical, mental, or developmental disabilities. The treatment or therapy is not covered by the employer?s primary medical plan or plans. Reimbursable expenses may include expenses for special treatment or therapy from licensed clinics or practitioners, day or residential special care facilities, special education facilities for learning-disabled children, or camps offering medically oriented programs that are part of a child?s continued treatment, or for special devices. The plan is operated separately from the employer?s primary medical plans; employees who are otherwise eligible may participate in the plan without participating in those primary medical plans. The plan limits the total benefits for any eligible child to a speci?ed lifetime dollar limit. Would it be a reasonable good faith interpretation of the Affordable Care Act and the regulations thereunder for the plan sponsor to take the position that the plan does not violate the prohibition, under section 2711 of the Public Health Service Act (PHS Act) and the related interim final regulations, on imposing a lifetime dollar limit on ?essential health bene?ts,? as de?ned in section 1302(b) of the Affordable Care Act (the lifetime limit prohibition)? Yes. In accordance with the preamble to the Departments? interim final regulations implementing PHS Act section 2711, for plan years beginning before the issuance of final regulations defining ?essential health bene?ts,? for purposes of enforcement, the Departments will take into account good faith efforts to comply with a reasonable interpretation of the term ?essential health benefits." (Of course, the regulations may differ in their definition of ?essential health benefits? from reasonable interpretations used before the regulations are issued.) Accordingly, in the case of plans described above, for such plan years: the Departments will treat as a reasonable good faith interpretation of section 2711 of the PHS Act and the regulations thereunder the position that the imposition of the per-child lifetime dollar limit on bene?ts provided under such plans does not violate the lifetime limit prohibition, and (ii) the imposition by such plans of such a 1 197 Updated 1-31-17 2017-?01297 limit will not result in an enforcement action by the Departments against such plans under PHS Act section 2711. (DOL FAQs Pan? IV 10/29/10) Q7: My plan terms include out-of-pocket spending limits that are based on a formula (a fixed percentage of an employee?s prior year compensation). If the formula stays the same, but a change in earnings results in a change to the out-of-pocket limits such that the change exceeds the thresholds allowed under paragraph of the interim final regulations relating to grandfathered health plans, will my plan relinquish grandfather status? No. The Departments have determined that if a plan or coverage has a ?xed-amount cost-sharing requirement other than a copayment (for example, a deductible or out-of- pocket limit) that is based on a percentage-of-compensation formula, that cost-sharing arrangement will not cause the plan or coverage to cease to be a grandfathered health plan as long as the formula remains the same as that which was in effect on March 23, 2010. Accordingly, if the percentage-of?compensation formula for determining an out-of- pocket limit is unchanged and an employee?s compensation increases, then the employee could face a higher out-of-pocket limit, but that change would not cause the plan to relinquish grandfather status. (DOL FAQs Part 12/22/10) Q1: What is the scope of the anti-abuse rule in paragraph of the interim final regulations relating to grandfather status? In particular, what is a "bona fide employment-based reason" for employees enrolled in a benefit package that is being eliminated to be transferred into another benefit package? Updated 1-31-17 The interim final regulations relating to status as a grandfathered health plan generally state that transferring employees from one grandfathered plan or benefit package (transferor plan) to another (transferee plan) will cause the transferee plan to relinquish grandfather status if amending the transferor plan to replicate the terms of the transferee plan would have caused the transferor plan to relinquish grandfather status. However, the interim final regulations also provide that this rule applies only if there was no bona ?de employment-based reason to transfer the employees. For purposes of paragraph of the interim final regulations relating to status as a grandfathered health plan, the Departments interpret the term "bona fide employment- based reason" to embrace a variety of circumstances. These circumstances (under which a transfer would not cause cessation of grandfather status) include, but are not limited to, any of the following: 1. When a bene?t package is being eliminated because the issuer is exiting the market; 2. When a bene?t package is being eliminated because the issuer no longer offers the product to the employer (for example, because the employer no longer satis?es the issuer's minimum participation requirement); 3. When low or declining participation by plan participants in the benefit package makes it impractical for the plan sponsor to continue to offer the bene?t package; 4. When a bene?t package is eliminated from a multiemployer plan as agreed upon as part of the collective bargaining process; or 5. When a bene?t package is eliminated for any reason and multiple bene?t packages covering a signi?cant portion of other employees remain available to the employees being transferred. 1198 2017-?01298 The foregoing is not intended to be an exhaustive list of circumstances that will be deemed to satisfy the bona ?de employment-based reason condition. There may be many other circumstances in which a benefit package is considered to be eliminated for a bona ?de employment-based reason. (DOL FAQs Pan? VI 04/01/11) 02: My plan bases the level of cost sharing for brand-name prescription drugs on the classification of the drugs under the plan as having or not having generic alternatives. The classification of a drug that had no generic alternative changes because a generic alternative becomes available and is added to the formulary, with a resulting increase in the cost-sharing level for the brand-name drug. Does that increase cause my plan to relinquish its grandfather status? No. For example, if, on March 23, 2010, the terms of the plan included prescription drug benefits with different cost sharing divided into tiers as follows: Tier 1 includes generic drugs only; Tier 2 includes brand name drugs with no generic available; Tier 3 includes brand name drugs with a generic available in Tier 1; and Tier 4 includes lV chemotherapy drugs. A drug was previously classi?ed in Tier 2 as a brand name drug with no generic available. However, a generic alternative for the drug has just been released and is added to the formulary. Since the generic is now available, the plan moves the brand name drug into Tier 3 and adds the generic to Tier 1. This movement of the brand name drug into a higher cost-sharing tier does not cause the plan to relinquish grandfather status. (DOL FAQs Pan? VI 04/01/11) 03: A previous FAQ addressed the interaction of value-based insurance design (VBID) and the no cost-sharing preventive care services requirements. See In that example, a group health plan did not impose a copayment for colorectal cancer preventive services when performed in an in- network ambulatory surgery center. In contrast, the same preventive service provided at an in-network outpatient hospital setting generally required a $250 copayment, although the copayment was waived for individuals for whom it would be medically inappropriate to have the preventive service provided in the ambulatory setting. The FAQ indicated that this VBID did not cause the plan to fail to comply with the no cost-sharing preventive care requirements. A question about a different situation has been raised. Under a group health plan, similar preventive services are available both at an in-network ambulatory surgery center and at an in-network outpatient hospital setting, but currently no copayment is imposed for these services in either setting. This has been the case since March 23, 2010. If this plan wished to adopt the VBID approach described in the example above by imposing a $250 copayment for these preventive services only when performed in the in-network outpatient hospital setting not when performed in an in-network ambulatory surgery center), and with the same waiver of the copayment for any individuals for whom it would be medically inappropriate to have these preventive services provided in the ambulatory setting, would implementation of that new design now cause the plan to relinquish grandfather status? 1199 Updated 1-31-17 2017--01299 No. This increase in the copayment for these preventive services solely in the in-network outpatient hospital setting (subject to the waiver arrangement described above) without any change in the copayment in the in-network ambulatory surgery center setting would not be considered to exceed the thresholds described in paragraph of the interim final regulations on grandfather status and thus would not cause the plan to relinquish grandfather status. The Departments are seeking further information on VBID and wellness programs and are planning to address issues relating to those designs and programs in future regulations. Comments from plan sponsors have expressed an interest in being able to retain grandfather status notwithstanding certain changes in plan terms that are intended to implement VBID and wellness programs. As the regulatory process progresses, the Departments will be giving close attention to these comments, and further guidance may be issued addressing other circumstances in which plan changes implementing those designs and programs may be made without relinquishing grandfather status. (DOL FA 08 Part VI 04/01/11) Q4: A plan operating on a calendar plan year is considering an amendment to plan terms that will exceed the thresholds described in paragraph of the interim final regulations and cause it to relinquish grandfather status. If the plan sponsor decides to adopt this amendment on July 1, 2011, and the change becomes effective for the plan year beginning on January 1, 2012, at what point in time does the plan relinquish grandfather status? A plan or coverage will cease to be a grandfathered health plan when an amendment to plan terms, which exceeds the thresholds described in paragraph of the interim final regulations, becomes effective regardless of when the amendment is adopted. Therefore, in this example, the plan would cease to be a grandfathered health plan on January 1, 2012, the first day of the ?rst plan year for which the change is effective. (DOL FAQs Part VI 04/01/11) 05: A plan operating on a calendar plan year is considering an amendment to plan terms that will cause it to relinquish grandfather status, but wants the amendment to become effective before the ?rst day of the next plan year. If the plan sponsor decides to make this amendment effective on July 1, 2011, does the plan relinquish grandfather status in the middle of the plan year? Yes. A plan or coverage will cease to be a grandfathered health plan when a plan amendment becomes effective. Therefore, if a plan sponsor chooses to make an amendment to plan terms effective in the middle of a plan year, the plan will cease to be a grandfathered health plan at that time. If a plan sponsor wishes to avoid relinquishing grandfathered status in the middle of a plan year, any changes that will cause a plan or coverage to relinquish grandfather status should be made effective the first day of a plan year that begins after the change is adopted. (DOL FAQs Part VI 04/01/11) 1200 Updated 1-31-17 2017--01300 06: A plan covers both retirees and active employees and is subject to the market reform requirements of the Affordable Care Act. For retirees, the employer that sponsors the plan contributes $300 per year multiplied by the individual's years of service for the employer, capped at $10,000 per year. As the cost of coverage increases over time, how is it determined whether the employer's contribution rate has decreased for purposes of maintaining grandfather status? In this example, the employer makes contributions based on a formula. Accordingly, the plan will cease to be a grandfathered health plan if the employer decreases its contribution rate towards the cost of coverage by more than five percent below the contribution rate on March 23, 2010. If the formula does not change, the employer is not considered to have reduced its contribution rate, regardless of any increase in the total cost of coverage. However, if the dollar amount that is multiplied by years of service decreases by more than five percent (or if the $10,000 maximum employer contribution cap decreases by more than ?ve percent), the plan will cease to be a grandfathered health plan. (DOL FAQs Part VI 04/01/11) Dependent Coverage of Children Q14: Will a group health plan or issuer fail to satisfy section 2714 of the Public Health Service Act (PHS Act) and its implementing interim final regulations merely because it conditions health coverage on support, residency, or other dependency factors for individuals under age 26 who are not described in section 152(f)(1) of the Internal Revenue Code (Code)? (That section of the Code de?nes children to include only sons, daughters, stepchildren, adopted children (including children place for adoption), and foster children.) No. A plan or issuer does not fail to satisfy the requirements of PHS Act section 2714 or its implementing regulations because the plan limits health coverage for children until the child turns 26 to only those children who are described in section 152(f)(1) of the Code. For an individual not described in Code section 152(f)(1), such as a grandchild or niece, a plan may impose additional conditions on eligibility for health coverage, such as a condition that the individual be a dependent for income tax purposes. (DOL FAQS Part/ 09/20/10) 05: My group health plan normally charges a copayment for physician visits that do not constitute preventive services. The plan charges this copayment to individuals age 19 and over, including employees, spouses, and dependent children, but waives it for those under age 19. Is this permissible? Yes. The Departments? regulations implementing PHS Act section 2714 provide that the terms of a group health plan or health insurance coverage providing dependent coverage of children cannot vary based on age (except for children who are age 26 or older). While this generally prohibits distinctions based upon age in dependent coverage of children, it does not prohibit distinctions based upon age that apply to all coverage under the plan, including coverage for employees and spouses as well as dependent children. In this case, the copayments charged to dependent children are the same as those charged to employees and spouses. Accordingly, the Departments will not consider the arrangement described in this question (including waiver, for individuals under age 19, of the generally applicable copayment) to violate PHS Act section 2714 or its implementing regulations. (DOL FAQs Part 12/22/10) 1201 Updated 1-31-17 2017--01301 Q: Is there further guidance regarding how dependents will age off their parents plans? A: At this time, CMS does not have additional guidance about dependents who reach the maximum age identi?ed by the issuer. During the initial and special enrollment periods, the Federally-facilitated Marketplace (FFM) applies the age limits submitted by Issuers in the business rules section of the Qualified Health Plan (QHP) application for children of subscribers (the maximum age is at minimum 26, and higher for some States and Issuers). The FFM does not apply age limits to dependents that are wards. The FFM will provide guidance regarding aging off in the near future. (REGTAP FAQ Database FAQ #424 11/22/13) Out-of?Network Services Q3: My plan does not have any in-network providers to provide a particular preventive service required under PHS Act section 2713. Ifl obtain this service out-of-network, can the plan impose cost-sharing? No. While nothing in the interim ?nal regulations generally requires a plan or issuer that has a network of providers to provide benefits for preventive services provided out-of- network, this provision is premised on enrollees being able to access the required preventive services from in-network providers. Thus, if a plan or issuer does not have in its network a provider who can provide the particular service, then the plan or issuer must cover the item or service when performed by an out-of?network provider and not impose cost-sharing with respect to the item or service. (DOL FAQs Part XII 02/20/13) Q15: Public Health Service Act (PHS Act) section 2719A generally provides, among other things, that if a group health plan or health insurance coverage provides any benefits for emergency services in an emergency department of a hospital, the plan or issuer must cover emergency services without regard to whether a particular health care provider is an in-network provider with respect to the services, and generally cannot impose any copayment or coinsurance that is greater than what would be imposed if services were provided in network. At the same time, the statute does not require plans or issuers to cover amounts that out-of-network providers may "balance bill". Accordingly, the interim final regulations under section 2719A set forth minimum payment standards in paragraph to ensure that a plan or issuer does not pay an unreasonably low amount to an out-of-network emergency service provider who, in turn, could simply balance bill the patient. Are the minimum payment standards in paragraph of the regulations intended to apply in circumstances where State law prohibits balance billing? (Similarly, what if a plan or issuer is contractually obligated to bear the cost of any amounts balance billed, so that the patient is held harmless from those costs?) No. As stated in the preamble to the interim final regulations under section 2719A, the minimum payment standards set forth in paragraph of the regulations were developed to protect patients from being financially penalized for obtaining emergency services on an out-of?network basis. If a State law prohibits balance billing, plans and issuers are not required to satisfy the payment minimums set forth in the regulations. Similarly, if a plan or issuer is contractually responsible for any amounts balance billed by an out-of-network emergency services provider, the plan or issuer is not required to satisfy the payment minimums. In both situations, however, patients must be provided 1202 Updated 1-31-17 2017--01302 with adequate and prominent notice of their lack of ?nancial responsibility with respect to such amounts, to prevent inadvertent payment by the patient. Nonetheless, even if State law prohibits balance billing, or if the plan or issuer is contractually responsible for amounts balance billed, the plan or issuer may not impose any copayment or coinsurance requirement that is higher than the copayment or coinsurance requirement that would apply if the services were provided in network. (DOL FAQs Part I 09/20/10) Q4: Is a plan or issuer required to disclose how it calculated the amount under the minimum payment standards, including the method the plan or issuer generally uses to determine payments for out-of-network services the UCR amount)? Yes. For plans subject to the Employee Retirement Income Security Act (ERISA), documentation and data used to calculate each of the minimum payment standards, including the UCR amount, for out-of?network emergency services are considered to be instruments under which the plan is established or operated and would be subject to the disclosure provisions under ERISA section 104(b) and 29 CFR 2520.104b-1, which generally require such information be furnished to plan participants (or their authorized representatives) within 30 days of In addition, the DOL claims procedure regulations, as well as the internal claims and appeals and external review requirement under PHS Act section 2719, which apply to non-grandfathered group health plans and issuers of non-grandfathered group or individual coverage, set forth rules regarding claims and appeals, including the right of a claimant (or the claimant's authorized representative) upon appeal of an adverse benefit determination (or a ?nal internal adverse bene?t determination) to be provided upon request and free of charge, reasonable access to and copies of all documents, records, and other information relevant to the claimant's claim for bene?tsl?l A failure to provide or make payment in whole or in part is an adverse benefit (DOL FAQs Part 31 04/20/16) Highly Compensated Employees Q16: Are the Departments planning to issue any guidance regarding the provisions of Public Health Service Act (PHS Act) section 2716 (which prohibits discrimination in favor of highly compensated individuals in insured group health plans)? Yes, on September 20, 2010 the Internal Revenue Service released Notice 2010-63, to be published in Internal Revenue Bulletin 2010-41, October 12, 2010. This bulletin provides background information on the statutory provisions of PHS Act section 2716 that has been reviewed and approved by the three Departments. In addition, it invites comments to be considered in the development of future guidance. (DOL FAQs Part I 09/20/10) Limitations on Cost-Sharing Q1: Who must comply with the deductible limitations under PHS Act section 2707(b)? Updated 1-31-17 The HHS ?nal regulation on standards related to essential health bene?ts implements the deductible provisions described in section 1302(c)(2) for non-grandfathered[1] health insurance coverage and qualified health plans offered in the small group market, including a provision implementing section 1302(c)(2)(C) so that such small group 1203 2017--01303 market health insurance coverage may exceed the annual deductible limit if it cannot reasonably reach a given level of coverage (metal tier) without exceeding the deductible imit.[2] With respect to self?insured and large group health plans, as explained in the preamble to the HHS ?nal regulations, the Departments intend to engage in future rulemaking to implement PHS Act section 2707(b). The Departments continue to believe that only plans and issuers in the small group market are required to comply with the deductible limit described in section 1302(c)(2). Public input is welcome in advance of a future rulemaking, which will implement that only plans and issuers in the small group market will be subject to the deductible limit. Please send comments by April 22, 2013 to Until that rulemaking is promulgated and effective, the Departments have determined that a self?insured or large group health plan can rely on the Departments' stated intention to apply the deductible limits imposed by section 1302(c)(2) of the Affordable Care Act only on plans and issuers in the small group market. (DOL FAQs Part XII 02/20/13) 02: Who must comply with the annual limitation on out-of-pocket maximums under PHS Act section 2707(b)? Updated 1-31-17 As stated in the preamble to the HHS ?nal regulation on standards related to essential health bene?ts, the Departments read PHS Act section 2707(b) as requiring all non- grandfathered group health plans to comply with the annual limitation on out-of?pocket maximums described in section 1302(c)(1) of the Affordable Care Act.[3] The Departments recognize that plans may utilize multiple service providers to help administer bene?ts (such as one third-party administrator for major medical coverage, a separate pharmacy bene?t manager, and a separate managed behavioral health organization). Separate plan service providers may impose different levels of out-of- pocket limitations and may utilize different methods for crediting participants' expenses against any out-of-pocket maximums. These processes will need to be coordinated under section 1302(c)(1), which may require new regular communications between service providers. The Departments have determined that, only for the first plan year beginning on or after January 1, 2014, where a group health plan or group health insurance issuer utilizes more than one service provider to administer bene?ts that are subject to the annual limitation on out-of?pocket maximums under section 2707(a) or 2707(b), the Departments will consider the annual limitation on out-of-pocket maximums to be satisfied if both of the following conditions are satis?ed: a. The plan complies with the requirements with respect to its major medical coverage (excluding, for example, prescription drug coverage and pediatric dental coverage); and b. To the extent the plan or any health insurance coverage includes an out-of-pocket maximum on coverage that does not consist solely of major medical coverage (for example, if a separate out-of?pocket maximum applies with respect to prescription drug coverage), such out-of-pocket maximum does not exceed the dollar amounts set forth in section 1302(c)(1). 1204 2017-?01304 The Departments note, however, that existing regulations implementing Mental Health Parity and Addiction Equity Act of 2008 prohibit a group health plan (or health insurance coverage offered in connection with a group health plan) from applying a cumulative ?nancial requirement or treatment limitation, such as an out-of-pocket maximum, to mental health or substance use disorder bene?ts that accumulates separately from any such cumulative financial requirement or treatment limitation established for medical/surgical bene?ts. Accordingly, under MHPAEA, plans and issuers are prohibited from imposing an annual out-of?pocket maximum on all medical/surgical bene?ts and a separate annual out-of?pocket maximum on all mental health and substance use disorder bene?ts. (DOL FAQs Part 02/20/13) 02: After this ?rst year of applicability, are plans and issuers subject to PHS Act section 2707 required to apply the out-of-pocket maximum across all essential health benefits? Yes. For plan years beginning on or after January 1, 2015, non-grandfathered group health plans and group health insurance coverage must have an out-of?pocket maximum which limits overall out-of?pocket costs on all essential health benefits (EHB). Because cost-sharing limits in section 1302(c) of the Affordable Care Act apply only to EHB, plans are not required to apply the annual limitation on out-of-pocket maximums to bene?ts that are not EHB. To determine which bene?ts are EHB for purposes of complying with PHS Act section 2707, the Departments will consider self-insured group health plans or large group health plans to have used a permissible de?nition of EHB under section 1302(b) of the Affordable Care Act if the de?nition is one that is authorized by the Secretary of Furthermore, the Departments intend to use their enforcement discretion and work with large group market and self-insured plans that make a good faith effort to apply an authorized de?nition of EHB. This approach is consistent with the approach the Departments have taken with respect to annual and lifetime limits under PHS Act section 2711.(9) (DOL FAQs Part 01/09/14) Q3: Some plans, such as those with multiple service providers, may find it easier to divide the annual limit on out-of-pocket costs across multiple categories of benefits, rather than reconcile claims across multiple service providers. Is this permitted, if the combined out-of-pocket maximum for the year does not exceed the annual limitation under section 1302(c) of the Affordable Care Act? Yes. Plans and issuers are permitted to structure a benefit design using separate out-of- pocket limits, provided that the combined amount of any separate out-of?pocket limits applicable to all EHBs under the plan does not exceed the annual limitation on out-of- pocket maximums for that year under section 1302(c) of the Affordable Care Act.(10) (DOL FAQs Part 01/09/14) Q4: If a plan includes a network of providers, is the plan required to count an individual's out-of-pocket expenses for out-of-network items and services toward the plan's annual maximum out-of?pocket limit? Updated 1-31-17 No. A plan may, but is not required to, count out-of?pocket spending for out-of-network items and services towards the plan's annual maximum out-of?pocket limit. PHS Act section 2707 sets limits on cost sharing with reference to the limitations set forth in section 1302(c) of the Affordable Care Act. Under HHS regulations at 45 CFR 156.130(c) implementing Affordable Care Act section 1302(c), cost-sharing requirements 1205 2017--01305 for benefits that are EHB from a provider outside a plan's network of providers are not required to be counted toward the annual limitation on out-of?pocket costs. With respect to health insurance issuers offering quali?ed health plans (QHPs) through a Health Insurance Marketplace (Marketplace) only, as noted in the Interim Final Rule on Maximizing January 1, 2014 Coverage Opportunities, 78 Fed. Reg. 76212 (Dec. 17, 2013), HHS strongly encourages QHP issuers to allow enrollees to receive in-network benefits with respect to any provider listed in the version of the provider directory as of the date of that enrollee's enrollment for the beginning months of coverage, in cases where issuers are unable to maintain provider directories in a current status. HHS also urges QHP issuers to temporarily cover non-formulary drugs, as well as drugs that are on a QHP issuer's formulary but typically require prior authorization or step therapy prior to being covered, during the ?rst 30 days of coverage, starting on January 1, 2014. Accordingly, under these limited circumstances, HHS strongly encourages QHP issuers to count enrollees' out-of?pocket expenses on these services and items toward the annual maximum out-of-pocket limits. (DOL FAQs Pan? 01/09/14) Q5: Is a plan required to count an individual's out-of-pocket costs for non-covered items or services (such as cosmetic services) toward the plan's annual maximum out-of-pocket limit? No. A plan may, but is not required to, count out-of?pocket spending for non-covered services towards the plan's annual maximum out-of?pocket costs. The term "cost- sharing" does not include spending for non-covered services. Under section 1302(c)(3) of the Affordable Care Act, the term "cost-sharing" includes: 0 Deductibles, coinsurance, copayments, or similar charges; and . Any other expenditure required of an individual which is a qualified medical expense (within the meaning of section 223(d)(2) of the Internal Revenue Code (the Code)) with respect to EHB covered under the plan. The term "cost-sharing" does not include premiums, balance billing amounts for non- network providers, or spending for non-covered services. Nothing, however, prohibits a plan or issuer from counting such expenses toward the plan's annual maximum out-of- pocket limit, particularly in the circumstances described in Q4 above with respect to QHP issuers. (DOL FAQs Part 01/09/14) 02: If an out-of-network provider charges an amount greater than the plan's or issuer's allowed amount, does individual spending for the amount in excess of the allowed amount (also known as balance billing) count toward the out-of-pocket maximum? Updated 1-31-17 The Departments previously stated in an that if a plan includes a network of providers, the plan may, but is not required to, count out-of-pocket spending for out-of- network items and services towards the plan's annual out-of-pocket maximum. A plan that counts such spending towards the out-of?pocket maximum may use any reasonable method for doing so. For example, if the plan covers 75% of the usual, customary, and reasonable amount (UCR) charged for services provided out-of-network and the participant pays the remaining 25% of UCR plus any amount charged by the out-of- network provider in excess of UCR, the 25% of UCR paid by the participant may reasonably be counted, in full or in part, toward the out-of-pocket maximum without including any amount charged above UCR paid by the participant. . (DOL FAQs Part XIX 05/02/14) 1206 2017--01306 Q3: With respect to the annual out-of-pocket maximum, how should large group market coverage and self-insured group health plans treat an individual's out-of-pocket costs for a brand name prescription drug, in circumstances in which a generic was available and medically appropriate? As the Departments previously stated in guidance on how to apply annual and lifetime dollar limits under section 2711 of the Public Health Service Act,(8) large group market coverage and self-insured group health plans have discretion to de?ne "essential health benefits." For example, a plan may include only generic drugs, if medically appropriate (as determined by the individual's personal physician) and available, while providing a separate option (not as part of essential health bene?ts) of electing a brand name drug at a higher cost sharing amount. If, under this type of plan design, a participant or beneficiary selects a brand name prescription drug in circumstances in which a generic was available and medically appropriate (as determined by the individual's personal physician), the plan may provide that all or some of the amount paid by the participant or beneficiary the difference between the cost of the brand name drug and the cost of the generic drug) is not required to be counted towards the annual out-of?pocket maximum. For ERISA plans, the SPD must explain which covered bene?ts will not count towards an individual's out-of?pocket maximum. In determining whether a generic is medically appropriate, a plan may use a reasonable exception process. For example, the plan may defer to the recommendation of an individual's personal physician, or it may offer an exceptions process meeting the requirements of 45 CFR For non-grandfathered health plans in the individual and small group markets that must provide coverage of the essential health bene?t package under section 1302(a) of the Affordable Care Act, additional requirements apply. (DOL FAQs Part XIX 05/02/14) Q4: If large group market coverage or self-insured group health plan has a reference- based pricing structure, under which the plan pays a fixed amount for a particular procedure (for example, a knee replacement), which certain providers will accept as payment in full, how does the out-of-pocket limitation apply when an individual uses a provider that does not accept that amount as payment in full? Updated 1-31-17 Reference pricing aims to encourage plans to negotiate cost effective treatments with high quality providers at reduced costs. At the same time, the Departments are concerned that such a pricing structure may be a subterfuge for the imposition of otherwise prohibited limitations on coverage, without ensuring access to quality care and an adequate network of providers. Accordingly, the Departments invite comment on the application of the out-of?pocket limitation to the use of reference based pricing. The Departments are particularly interested in standards that plans using reference-based pricing structures should be required to meet to ensure that individuals have meaningful access to medically appropriate, quality care. Please send comments by August 1, 2014 to E-OHPSCA- FAQ.ebsa@dol.qov. Until guidance is issued and effective, with respect to a large group market plan or self- insured group health plan that utilizes a reference-based pricing program, the Departments will not consider a plan or issuer as failing to comply with the out-of?pocket 1207 2017-?01307 maximum requirements of PHS Act section 2707(b) because it treats providers that accept the reference amount as the only in-network providers, provided the plan uses a reasonable method to ensure that it provides adequate access to quality providers. For non-grandfathered health plans in the individual and small group markets that must provide coverage of the essential health bene?t package under section 1302(a) of the Affordable Care Act, additional requirements apply. (DOL FAQs Part XIX 05/02/14) Limitations on Cost-sharing is also addressed in DOL FAQs Part XXI issued 10//10/14) Public Health Service (PHS) Act section 2707(b), as added by the Affordable Care Act, provides that a non-grandfathered group health plan shall ensure that any annual cost-sharing imposed under the plan does not exceed the limitations provided for under section 1302(c)(1) of the Affordable Care Act. Section 1302(c)(1) limits an enrollee's out-of?pocket costs?) For plan or policy years beginning in 2015, the annual limitation on an individual's maximum out-of-pocket (MOOP) costs in effect under Affordable Care Act section 1302(c)(1) is $6,600 for self-only coverage and $13,200 for coverage other than self-only coverage?gl Beginning with the 2015 plan or policy year and for plan or policy years thereafter, the annual limitation on out-of? pocket costs is increased by the premium adjustment percentage described under Affordable Care Act section 1302(c)(4). Previous FAQs provided guidance on the MOOP requirements under PHS Act section The FAQs clarified that if a plan includes a network of providers, the plan may, but is not required to, count an individual's out-of-pocket spending for out-of-network items and services toward the annual limitation on cost sharing. The FAQs also addressed reference- based pricing in non-grandfathered large group insurance market and self-insured group health plans,(4) under which the plan pays a fixed amount for a particular procedure (for example, a knee replacement), which certain providers will accept as payment in In the FAQ, the Departments explained that reference-based pricing is designed to encourage plans to negotiate treatments with high-quality providers at reduced costs. At the same time, the Departments expressed concerns that such a pricing structure could be a subterfuge for the imposition of otherwise prohibited limitations on coverage, without ensuring access to quality care and an adequate network of providers. The FAQ further stated that, until guidance was issued and effective, with respect to a large group market plan or self-insured group health plan that utilizes a reference-based pricing design, the Departments would not consider a plan or issuer as failing to comply with the MOOP requirements of PHS Act section 2707(b) because the plan or issuer treats providers that accept the reference amount as the only in-network providers, as long as the plan or issuer uses a reasonable method to ensure that it offers adequate access to quality providers. The FAQ also solicited comments on the application of the MOOP requirements to such bene?t designs, indicating a particular interest in standards that plans or issuers using reference-based pricing should be required to meet to ensure that individuals have meaningful access to medically appropriate, quality care. The Departments received a range of comments and questions on the application of the MOOP requirements to various provider network bene?t designs. Many comments suggested that plans and issuers should be permitted to limit counting an individual's out-of-pocket costs exceeding the reference price towards the MOOP only with respect to certain types of services (such as non-emergency services or routine procedures). Other comments suggested network adequacy 1208 Updated 1-31-17 2017--01308 and quality standards or procedures that a plan or issuer should be required to meet if the plan or issuer wants to utilize a network design under which less-than-full credit is given against the MOOP for non-preferred providers. Many of these comments also suggested that plans establish an exceptions process in certain circumstances to allow an enrollee's full cost sharing for non-reference based providers to count toward the MOOP. Additional comments addressed disclosure issues, to ensure that individuals had timely and adequate information to make informed treatment decisions. Based on comments received, set forth below is an additional FAQ regarding the MOOP requirements. This FAQ addresses only group health plans? and group health insurance issuers' obligations under section 2707(b) of the PHS Act. For non-grandfathered health plans in the individual and small group markets that must provide coverage of the essential health benefit package under section 1302(a) of the Affordable Care Act, additional requirements apply. Compliance with section 2707(b) of the PHS Act is not determinative of compliance with any other provision of law, including PHS Act section 2713, relating to coverage of preventive services, and PHS Act section 2719A, relating to choice of a health care professional and bene?ts for emergency services (incorporated by reference into the Employee Retirement Income Security Act (ERISA) section 715 and Internal Revenue Code (Code) section 9815) and implementing regulations. Q: Under PHS Act section 2707(b), what specific factors will the Departments consider when evaluating whether a non-grandfathered plan that utilizes reference-based pricing (or similar network design) is using a reasonable method to ensure that it provides adequate access to quality providers at the reference-based price? Pending issuance of future guidance, for purposes of enforcing the requirements in PHS Act section 2707(b), the Departments will consider all the facts and circumstances when evaluating whether a plan's reference-based pricing design (or similar network design) that treats providers that accept the reference-based price as the only in-network providers and excludes or limits cost-sharing for services rendered by other providers is using a reasonable method to ensure adequate access to quality providers at the reference price, including: 1. Type of service. Plans should have standards to ensure that the network is designed to enable the plan to offer bene?ts for services from high-quality providers at reduced costs, and does not function as a subterfuge for othenlvise prohibited limitations on coverage. For this purpose: a. In general, reference-based pricing that treats providers that accept the reference amount as the only in-network providers should apply only to those services for which the period between identi?cation of the need for care and provision of the care is long enough for consumers to make an informed choice of provider. b. Limiting or excluding cost-sharing from counting toward the MOOP with respect to providers who do not accept the reference-based price would not be considered reasonable with respect to emergency Furthermore, any provision in a non-grandfathered plan that involves a more restrictive network cannot be applied to emergency services pursuant to PHS Act section 2719A (incorporated by reference into ERISA section 715 and Code section 9815) and its implementing regulations?l 1209 Updated 1-31-17 2017--01309 2. Reasonable access. Plans should have procedures to ensure that an adequate number of providers that accept the reference price are available to participants and bene?ciaries. For this purpose, plans are encouraged to consider network adequacy approaches developed by States, as well as reasonable geographic distance measures, and whether patient wait times are reasonable. (Insured coverage is also subject to any applicable requirements under State law.) 3. Quality standards. Plans should have procedures to ensure that an adequate number of providers accepting the reference price meet reasonable quality standards. 4. Exceptions process. Plans should have an easily accessible exceptions process, allowing services rendered by providers that do not accept the reference price to be treated as if the services were provided by a provider that accepts the reference price if: a. Access to a provider that accepts the reference price is unavailable (for example, the service cannot be obtained within a reasonable wait time or travel distance). b. The quality of services with respect to a particular individual could be compromised with the reference price provider (for example, if co-morbidities present complications or patient safety issues). 5. Disclosure. Plans should provide the following disclosures regarding reference- based pricing (or similar network design) to plan participants free of charge. a. Automatically. Plans should provide information regarding the pricing structure, including a list of services to which the pricing structure applies and the exceptions process. (This should be provided automatically, without the need for the participant to request such information, for example through the plan's Summary Plan Description or similar document.) b. Upon Request. Plans should provide: i. A list of providers that will accept the reference price for each service; ii. A list of providers that will accept a negotiated price above the reference price for each service; and Information on the process and underlying data used to ensure that an adequate number of providers accepting the reference price meet reasonable quality standards. The Departments will continue to monitor the use of reference-based pricing and may provide additional guidance in the future, including guidance relating to requirements other than those under section 2707(b) that is applicable to non-grandfathered health plans in the individual and small group markets that must provide coverage of the essential health bene?t package under section 1302(a) of the Affordable Care Act. Footnotes 1. Updated 1-31-17 This annual limitation is also applied to non-grandfathered individual market coverage through the essential health benefits package requirements of PHS Act section 2707(a). On April 1, 2014, Public Law No. 113-93 was enacted. Section 213 of that law repeals the limitation on deductibles in the small group market that was previously required in this market under section 2707(b) of the PHS Act and section 1302(c)(2) of the Affordable Care Act. 1210 2017-?01310 7. Patient Protection and Affordable Care Act; Exchange and Insurance Market Standards for 2015 and Beyond; Final Rule, 79 FR 30240 (May 27, 2014). See Affordable Care Act Implementation FA Qs, Part XII, Q2, available at dol. qo v/ebsa/faqs/faq- aca 12.html cms. qo FAQs/aca implementation faqs12.htm/; Affordable Care Act Implementation FAQs, Part 02-05, available at aca18.html and cms. qo FAQs/aca implementation faqs18.html; Affordable Care Act Implementation FAQs, Part XIX, Q2-Q4, available at aca19.html cms. qo FA Qs/aca implementation faqs19.html. The FAQ stated that, for non-grandfathered health plans in the individual and small group markets that must provide coverage of the essential health bene?t package under section 1302(a) of the Affordable Care Act, additional requirements apply. Grandfathered health plans are exempt from both section 1302(a) of the Affordable Care Act and section 2707(b) of the PHS Act. Affordable Care Act Implementation FAQs, Part XIX, Q4, available at dol. qov/ebsa/faqs/faq- aca19.html cms. qo FA Qs/aca implementation faqs19.html. For this purpose, "emergency services" has the same meaning as the term in the Departments' interim ?nal regulations related to coverage of emergency services, which is defined generally in accordance with the meaning of the term under the Emergency Medical Treatment and Labor Act (EMTALA), section 1867 of the Social Security Act. See 29 CFR 2590. 715-2719A(b) and 45 CFR Q1. The 2016 Payment Notice clarified that under section 1302(c)(1) of the Affordable Care Act, the self-only maximum annual limitation on cost sharing applies to each individual, regardless of whether the individual is enrolled in self-only coverage or in coverage other than self-only. Does PHS Act section 2707(b) apply this requirement to all non-grandfathered group health plans? Updated 1-31-17 Yes. PHS Act section 2707(b) applies this requirement to all non-grandfathered group health plans, including non-grandfathered self-insured and large group health plans. The Departments read section 2707(b) as requiring non-grandfathered group health plans to comply with the maximum annual limitation on cost sharing promulgated under section 1302(c)(1) of the Affordable Care Act,(3) including the HHS clarification that the self-only maximum annual limitation on cost sharing applies to each individual, regardless of whether the individual is enrolled in self-only coverage or in coverage other than self- only. Accordingly, the self-only maximum annual limitation on cost sharing applies to an individual who is enrolled in family coverage or other coverage that is not self-only coverage under a group health plan. Example: Assume that a family of four individuals is enrolled in family coverage under a group health plan in 2016 with an aggregate annual limitation on cost sharing for all four enrollees of $13,000 (note that a plan is permitted to set an annual limitation below the maximum established under section 1302(c)(1), which is an aggregate $13,700 limitation for coverage other than self-only for 2016). Assume that individual #1 incurs claims associated with $10,000 in cost sharing, and that individuals and #4 each incur 1211 2017-?01311 claims associated with $3,000 in cost sharing (in each case, absent the application of any annual limitation on cost sharing). In this case, because, under the clari?cation discussed above, the self-only maximum annual limitation on cost sharing ($6,850 in 2016) applies to each individual, cost sharing for individual #1 for 2016 is limited to $6,850, and the plan is required to bear the difference between the $10,000 in cost sharing for individual #1 and the maximum annual limitation for that individual, or $3,150. With respect to cost sharing incurred by all four individuals under the policy, the aggregate $15,850 ($6,850 $3,000 $3,000 $3,000) in cost sharing that would otherwise be incurred by the four individuals together is limited to $13,000, the annual aggregate limitation under the plan, under the assumptions in this example, and the plan must bear the difference between the $15,850 and the $13,000 annual limitation, or $2,850. (DOL FAQs Part XXVII 05/26/15) 02. Does the clari?cation of section 1302(c)(1) of the Affordable Care Act apply for plan or policy years that begin in 2015? No. The Departments will apply this clarification only for plan or policy years that begin in or after 2016. (DOL FAQs Part XXVII 05/26/15) Q3. Does the clarification of section 1302(c)(1) of the Affordable Care Act apply to self- only coverage or other coverage that is not self-only coverage under a high-deductible health plan (HDHP) as defined at section 223(c)(2) of the Internal Revenue Code? Yes. The clarification of section 1302(c)(1) also applies to non-grandfathered (DOL FAQs Part XXVII 05/26/15) Q7: If a non-grandfathered large group market or self-insured group health plan has a pricing structure in which the plan pays a ?xed amount (sometimes called a reference price) for a particular procedure, but the plan does not ensure that participants have adequate access to quality providers that will accept the reference price as payment in full, is the plan required to count an individual's out-of-pocket expenses for providers who do not accept the reference price toward the individual's MOOP limit? Updated 1-31-17 Yes. The Departments' previous guidance explained that, for purposes of PHS Act section 2707(b), a plan that utilizes a reference-based pricing design (or similar network design) may treat those providers that accept the reference-based price as the only in- network providers and not count an individual's out-of-pocket expenses for services rendered by other providers towards the MOOP limit only if the plan is using a reasonable method to ensure adequate access to quality providers at the reference price?? A plan that merely establishes a reference price without using a reasonable method to ensure adequate access to quality providers at the reference price will not be considered to have established a network for purposes of PHS Act section 2707(b). This guidance does not affect the Departments' previously issued regarding speci?c factors that the Departments will consider when evaluating whether a non- grandfathered plan that utilizes reference-based pricing (or similar network design) is using a reasonable method to ensure that it provides adequate access to quality providers at the reference-based price. Under the standards set out by the Departments, it continues to be the case that, under PHS Act section 2707(b), a non-grandfathered plan that utilizes reference-based pricing (or similar network design) may treat providers that accept the reference based-price as the only in-network providers for purposes of 1212 2017-?01312 determining what counts towards an individual's MOOP limit as long as the non- grandfathered plan uses a reasonable method to ensure that it provides adequate access to quality providers at the reference-based price. This FAQ addresses only group health plans' and group health insurance issuers' obligations under section 2707(b) of the PHS Act. For non-grandfathered health plans in the individual and small group markets that must provide coverage of the EHB package under section 1302(a) of the Affordable Care Act, additional requirements apply. (DOL FAQs Part 31 04/20/16) Coverage of Preventive Services Q8: Some of the recommendations and guidelines of the United States Preventive Services Task Force (USPTF), the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention (Advisory Committee) and the Health Resources and Services Administration (HRSA) do not definitively state the scope, setting, or frequency of the items or services to be covered. What should my plan do if an individual requests, for example, daily counseling for diet? The interim final regulations regarding preventive health services provide that if a recommendation or guideline for a recommended preventive health service does not specify the frequency, method, treatment, or setting for the provision of that service, the plan or issuer can use reasonable medical management techniques (which generally limit or exclude benefits based on medical necessity or medical appropriateness using prior authorization requirements, concurrent review, or similar practices) to determine any coverage limitations under the plan. Thus, to the extent not specified in a recommendation or guideline, a plan or issuer may rely on the relevant evidence base and these established techniques to determine the frequency, method, treatment, or setting for the provision of a recommended preventive health service. (DOL FAQs Part II 10/08/10) Q1: My group health plan does not impose a copayment for colorectal cancer preventive services when performed in an in-network ambulatory surgery center. In contrast, the same preventive service provided at an in-network outpatient hospital setting would generally require a $250 copayment. Is this permissible under PHS Act section 2713? Yes, this plan design is permissible. PHS Act section 2713 and its implementing regulations allow plans to use reasonable medical management techniques to control costs. The regulations the Departments issued to implement the preventive health bene?ts in the Affordable Care Act recognized the important role that VBID can play in promoting the use of appropriate, high value preventive services and providers. Plans may use reasonable medical management techniques to steer patients towards a particular high-value setting such as an ambulatory care setting for providing preventive care services, provided the plan accommodates any individuals for whom it would be medically inappropriate to have the preventive service provided in the ambulatory setting (as determined by the attending provider) by having a mechanism for waiving the otherwise applicable copayment for the preventive services provided in a hospital. (DOL FAQs Pan? 12/22/10) 1213 Updated 1-31-17 2017--01313 Q1: On September 24, 2013, the issued new recommendations with respect to breast cancer.(5) What changes must plans make to comply with the new recommendations? The recently revised its recommendation regarding medications for risk reduction of primary breast cancer in women. The September 2013 recommendation now says: The recommends that clinicians engage in shared, informed decision- making with women who are at increased risk for breast cancer about medications to reduce their risk. For women who are at increased risk for breast cancer and at low risk for adverse medication effects, clinicians should offer to prescribe risk-reducing medications, such as tamoxifen or raloxifene. Accordingly, for plan or policy years beginning one year after the date the recommendation or guideline is issued (in this case, plan or policy years beginning on or after September 24, 2014), non-grandfathered group health plans and non- grandfathered health insurance coverage offered in the individual or group market will be required to cover such medications for applicable women without cost sharing subject to reasonable medical management. (DOL FAQs Part 01/09/14) Q: My closely held for-profit corporation's health plan will cease providing coverage for some or all contraceptive services mid-plan year. Does this reduction in coverage trigger any notice requirements to plan participants and bene?ciaries? Yes. For plans subject to the Employee Retirement Income Security Act (ERISA), ERISA requires disclosure of information relevant to coverage of preventive services, including contraceptive coverage. Specifically, the Department of Labor's longstanding regulations at 29 CFR provide that, the summary plan description (SPD) shall include a description of the extent to which preventive services (which includes contraceptive services) are covered under the plan. Accordingly, if an ERISA plan excludes all or a subset of contraceptive services from coverage under its group health plan, the plan's SPD must describe the extent of the limitation or exclusion of coverage. For plans that reduce or eliminate coverage of contraceptive services after having provided such coverage, expedited disclosure requirements for material reductions in covered services or bene?ts apply. See ERISA section 104(b)(1) and 29 CFR which generally require disclosure not later than 60 days after the date of adoption of a modi?cation or change to the plan that is a material reduction in covered services or bene?ts. Other disclosure requirements may apply, for example, under State insurance law applicable to health insurance issuers. (DOL FAQs Pan? XX 7/17/14) 1214 Updated 1-31-17 2017-?01314 United States Preventive Services Task Force Q4: The recommends the use of aspirin for certain men and women when the potential bene?t due to a reduction in myocardial infarctions outweighs the potential harm. Aspirin is generally available over-the-counter (OTC) to patients. Are group health plans and health insurance issuers now required to pay for OTC methods such as aspirin? Aspirin and other OTC recommended items and services must be covered without cost- sharing only when prescribed by a health care provider. (DOL FAQs Part XII 02/20/13) 05: If a colonoscopy is scheduled and performed as a screening procedure pursuant to the recommendation, is it permissible for a plan or issuer to impose cost- sharing for the cost of a polyp removal during the colonoscopy? No. Based on clinical practice and comments received from the American College of Gastroenterology, American Gastroenterological Association, American Society of Gastrointestinal Endoscopy, and the Society for Gastroenterology Nurses and Associates, polyp removal is an integral part of a colonoscopy. Accordingly, the plan or issuer may not impose cost-sharing with respect to a polyp removal during a colonoscopy performed as a screening procedure. On the other hand, a plan or issuer may impose cost-sharing for a treatment that is not a recommended preventive service, even if the treatment results from a recommended preventive service. (DOL FAQs Part XII 02/20/13) 06: Does the recommendation for genetic counseling and evaluation for routine breast cancer susceptibility gene (BRCA) testing include the BRCA test itself? Updated 1-31-17 Yes. HHS believes that the scope of the recommendation includes both genetic counseling and BRCA testing, if appropriate, for a woman as determined by her health care provider. PHS Act section 2713 addresses coverage for evidence-based items or services with a rating of or in the current recommendations of the as well as coverage for preventive care and screenings as provided for in comprehensive guidelines released by HRSA. The recommends with a rating that "women whose family history is associated with an increased risk for deleterious mutations in the BRCA1 or BRCA2 genes be referred for genetic counseling and evaluation for BRCA testing." The HRSA Guidelines, released by HHS in August 2011, incorporate by reference relevant portions of an Institute of Medicine (IOM) Report, released on July 19, 2011. In some instances, the IOM Committee Report provides additional interpretation of recommendations. For the BRCA recommendation, the IOM Committee interpreted the recommendation to include "referral for genetic counseling and BRCA testing, if appropriate." Thus, genetic counseling and BRCA testing, if appropriate, must be made available as a preventive service without cost-sharing. (DOL FA 08 Part XII 02/20/13) 1215 2017-?01315 Q7: Some recommendations apply to certain populations identified as high-risk. Some individuals, for example, are at increased risk for certain diseases because they have a family or personal history of the disease. It is not clear, however, how a plan or issuer would identify individuals who belong to a high-risk population. How can a plan or issuer determine when a service should or should not be covered without cost-sharing? Identi?cation of "high-risk" individuals is determined by clinical expertise. Decisions regarding whether an individual is part of a high-risk population, and should therefore receive a speci?c preventive item or service identified for those at high-risk, should be made by the attending provider. Therefore, if the attending provider determines that a patient belongs to a high-risk population and a recommendation applies to that high-risk population, that service is required to be covered in accordance with the requirements of the interim final regulations (that is, without cost-sharing, subject to reasonable medical management). (DOL FAQs Part XII 02/20/13) Q5: The recommends that clinicians ask all adults about tobacco use and provide tobacco cessation interventions for those who use tobacco products. What are plans and issuers expected to provide as preventive coverage for tobacco cessation interventions? As stated earlier, plans may use reasonable medical management techniques to determine the frequency, method, treatment, or setting for a recommended preventive service, to the extent not speci?ed in the recommendation or guideline regarding that preventive service. Evidence-based clinical practice guidelines can provide useful guidance for plans and issuers.(13) The Departments will consider a group health plan or health insurance issuer to be in compliance with the requirement to cover tobacco use counseling and interventions, if, for example, the plan or issuer covers without cost- sha?ng: 1. Screening for tobacco use; and, 2. For those who use tobacco products, at least two tobacco cessation attempts per year. For this purpose, covering a cessation attempt includes coverage for: 0 Four tobacco cessation counseling sessions of at least 10 minutes each (including telephone counseling, group counseling and individual counseling) without prior authorization; and All Food and Drug Administration (FDA)?approved tobacco cessation medications (including both prescription and over-the-counter medications) for a 90-day treatment regimen when prescribed by a health care provider without prior authorization. This guidance is based on the Public Health Service-sponsored Clinical Practice Guideline, Treating Tobacco Use and Dependence: 2008 Update, available at: (DOL FAQs Part XIX 05/02/14) In 2009, the recommended with an rating ?tobacco cessation interventions? for non-pregnant adults who use tobacco. On May 2, 2014, the Departments provided a safe harbor in FAQs stating that the Departments will consider plans and issuers to be in compliance with the requirement to cover tobacco use counseling and interventions based on the 2009 recommendation, if for example, the plan or issuer covers without cost sharing: 1) screening for tobacco use; and (2) for those who use tobacco products, at least two tobacco 1216 Updated 1-31-17 2017--01316 cessation attempts per year. For this purpose, covering a cessation attempt includes coverage for: four tobacco cessation counseling sessions of at least 10 minutes each (including telephone counseling, group counseling and individual counseling) without prior authorization; and (ii) all Food and Drug Administration (FDA)-approved tobacco cessation medications (including both prescription and over-the-counter medications) for a 90-day treatment regimen when prescribed by a health care provider, without prior authorization. Q1: The updated its recommendation for tobacco cessation interventions on September 22, 2015. Did the recommendation for tobacco cessation for non- pregnant adults change? Updated 1-31-17 Yes. On September 22, 2015, the extended its recommendation for non- pregnant adults and recommended with an rating that ?clinicians ask all adults about tobacco use, advise them to stop using tobacco, and provide both behavioral interventions and FDA-approved pharmacotherapy for cessation to adults who use tobacco." The Final Recommendation Statement states that ?[b]oth intervention types (pharmacotherapy and behavioral interventions) are effective and recommended; combinations of interventions are most effective, and all should be offered.? The Final Recommendation Statement provides additional detail on individual, group, and telephone behavioral interventions. It also describes the seven FDA-approved over- the-counter (OTC) and prescription medications for treating tobacco dependence that are now available. These include three types of OTC nicotine replacement products (transdermal nicotine patches, nicotine lozenges, and nicotine gum), two prescription- only nicotine replacement products (nicotine inhaler or nasal spray and prescription-only bupropion hydrochloride sustained release (Zyban? or generic) and varenicline tartrate (Chantix?), which do not contain nicotine. Since the issuance of the updated recommendation, stakeholders have asked the Departments to clarify what items and services must be provided without cost sharing to comply with the updated recommendation, applicable for plan years (in the individual market, policy years) beginning on or after one year from the date of issuance of the updated recommendation (in this case, plan years or policy years beginning on or after September 22, 2016). The Departments are seeking comments in advance of providing future guidance. Speci?cally, the Departments seek comment on: a) Whether all seven categories of FDA-approved pharmacotherapy interventions must be covered without cost sharing when prescribed by a health care provider or whether plans and issuers may use reasonable medical management techniques to determine which specific categories of FDA-approved pharmacotherapy interventions will be covered without cost sharing. b) Whether plans and issuers may use reasonable medical management techniques to: i. Limit the number of quit attempts per year or the duration of the interventions prescribed; ii. Manage the categories of FDA-approved pharmacotherapy interventions that may be covered without cost sharing when used in combination; or Limit the types of behavioral interventions that are covered without cost sharing. This request for comment seeks input to inform any future guidance on tobacco cessation coverage. It does not supplement or clarify the recommendation, and 1217 2017-?01317 plans and issuers must offer coverage consistent with the speci?c recommendation made by the Please send comments to marketreform@cms.hhs.qov by January 3, 2017. All comments will be shared among the Departments. (DOL FAQs Part 34 10/27/16) Advisory Committee on Immunization Practices 08: Which ACIP recommendations are required to be covered without cost-sharing by non-grandfathered group health plans and health insurance coverage? PHS Act section 2713 and the interim final regulations require coverage for immunizations for routine use in children, adolescents, and adults that have in effect a recommendation by the ACIP for routine use. The vaccines must be covered without cost?sharing requirements when the service is delivered by an in-network provider. The ACIP makes routine immunization recommendations for children, adolescents, and adults that are population-based age-based), risk-based underlying medical conditions, work-related, or other special circumstances that increase risk of illness), or are catch?up recommendations. In some circumstances, the ACIP makes a recommendation that applies for certain individuals rather than an entire population. In these circumstances, health care providers should determine whether the vaccine should be administered, and if the vaccine is prescribed by a health care provider consistent with the ACIP recommendations, a plan or issuer is required to provide coverage for the vaccine without cost-sharing. New ACIP recommendations will be required to be covered without cost-sharing starting with the plan year (in the individual market, policy year) that begins on or after the date that is one year after the date the recommendation is issued. An ACIP recommendation is considered to be issued on the date on which it is adopted by the Director of the Centers for Disease Control and Prevention (CDC), which is the earlier of: the date the recommendation is published in the Mortality and Morbidity Weekly Report, or the date the recommendation is re?ected in the Immunization Schedules of the CDC. Therefore plans or issuers with respect to a plan can determine annually what vaccines recommended by ACIP must be covered by checking prior to the beginning of each plan year. (DOL FAQs Part XII 02/20/13) 09: Do the recommendations for women's preventive services in the HRSA Guidelines promote multiple visits for separate services? Updated 1-31-17 No. Section 2713 of the PHS Act and its implementing regulations allow plans and issuers to use reasonable medical management techniques to determine the frequency, method, treatment, or setting for a recommended preventive item or service, to the extent this information is not specified in a recommendation or guideline. Although the HRSA Guidelines list services individually, nothing in PHS Act section 2713 or the regulations requires that each service be provided in a separate visit. Ef?cient care delivery and the delivery of multiple prevention and screening services at a single visit is a reasonable medical management technique, permissible under the regulations. For 1218 2017-?01318 example, HIV screening and counseling and Sexually Transmitted Infections counseling could occur as part of a single well-woman visit. (DOL FAQs Part X/l 02/20/13) Q10: What is included in a "well-woman" visit? The HRSA Guidelines recommend at least one annual well-woman preventive care visit for adult women to obtain the recommended preventive services that are age- and developmentalIy-appropriate, including preconception and prenatal care. The HRSA Guidelines recommend that well-woman visits include preventive services listed in the HRSA Guidelines, as well as others referenced in section 2713 of the PHS Act. HHS understands that additional well-woman visits, provided without cost-sharing, may be needed to obtain all necessary recommended preventive services, depending on a woman's health status, health needs, and other risk factors. If the clinician determines that a patient requires additional well-woman visits for this purpose, then the additional visits must be provided in accordance with the requirements of the interim ?nal regulations (that is, without cost-sharing and subject to reasonable medical management). (DOL FAQs Pan? XII 02/20/13) Q11: What do health care providers need to know to conduct a screening and counseling for interpersonal and domestic violence, as recommended in the HRSA Guidelines? Screening may consist of a few, brief, open-ended questions. Screening can be facilitated by the use of brochures, forms, or other assessment tools including chart prompts. One option is the five-question Abuse Assessment Screening tool available here: page 22). Counseling provides basic information, including how a patient's health concerns may relate to violence and referrals to local domestic violence support agencies when patients disclose abuse. Easy-to-use tools such as patient brochures, safety plans, and provider educational tools, as well as training materials, are available through the HHS- funded Domestic Violence Resource Network, including the National Resource Center on Domestic Violence (DOL FAQs Pan? XII 02/20/13) Q12: In the discussion of "Identified Gaps" within the Cervical Cancer section of the IOM report, the IOM recognized "co-testing with cytology and high-risk Human Papillomavirus (HPV) DNA testing among women 30 years of age and older as a strategy to increase screening intervals to every three years." When should the HPV DNA test be administered? The HRSA Guidelines recommend high-risk HPV DNA testing for women with normal cytology results who are 30 years of age or older to occur no more frequently than every 3 years. (DOL FAQs Part X/l 02/20/13) Q13: The HRSA Guidelines include a recommendation for annual HIV counseling and screening for all sexually active women. Is the term "screening" in this context defined as actual testing for Yes. In this context, "screening" means testing. (DOL FAQs Part XII 02/20/13) 1219 Updated 1-31-17 2017--01319 Q14: The HRSA Guidelines include a recommendation for all Food and Drug Administration (FDA) approved contraceptive methods, sterilization procedures, and patient education and counseling for all women with reproductive capacity, as prescribed by a health care provider. May a plan or issuer cover only oral contraceptives? No. The HRSA Guidelines ensure women's access to the full range of FDA-approved contraceptive methods including, but not limited to, barrier methods, hormonal methods, and implanted devices, as well as patient education and counseling, as prescribed by a health care provider. Consistent with PHS Act section 2713 and its implementing regulations, plans and issuers may use reasonable medical management techniques to control costs and promote efficient delivery of care. For example, plans may cover a generic drug without cost-sharing and impose cost-sharing for equivalent branded drugs. However, in these instances, a plan or issuer must accommodate any individual for whom the generic drug (or a brand name drug) would be medically inappropriate, as determined by the individual's health care provider, by having a mechanism for waiving the otherwise applicable cost-sharing for the branded or non-preferred brand version. This generic substitution approach is permissible for other pharmacy products, as long as the accommodation described above exists.[9] If, however, a generic version is not available, or would not be medically appropriate for the patient as a prescribed brand name contraceptive method (as determined by the attending provider, in consultation with the patient), then a plan or issuer must provide coverage for the brand name drug in accordance with the requirements of the interim final regulations (that is, without cost- sharing, subject to reasonable medical management). (DOL FAQs Part Xl/ 02/20/13) Q15: Do the HRSA Guidelines include contraceptive methods that are generally available over-the-counter (OTC), such as contraceptive sponges and spermicides? Contraceptive methods that are generally available OTC are only included if the method is both FDA-approved and prescribed for a woman by her health care provider. The HRSA Guidelines do not include contraception for men.[10] (DOL FAQs Part 02/20/13) Q16: Do the HRSA Guidelines include services related to follow-up and management of side effects, counseling for continued adherence, and for device removal? Yes. Services related to follow-up and management of side effects, counseling for continued adherence, and device removal are included under the HRSA Guidelines and required to be covered in accordance with the requirements of the interim ?nal regulations (that is, without cost-sharing, subject to reasonable medical management). (DOL FAQs Part 02/20/13) Q17: Are intrauterine devices and implants contraceptive methods under the HRSA Guidelines and therefore required to be covered without cost-sharing? Yes, if approved by the FDA and prescribed for a woman by her health care provider, subject to reasonable medical management. (DOL FAQs Part XII 02/20/13) 1220 Updated 1-31-17 2017--01320 Q18: The already recommends breastfeeding counseling. Why is this part of the HRSA Guidelines? Under the topic of "Breastfeeding Counseling" the recommends interventions during pregnancy and after birth to promote and support breastfeeding. The HRSA Guidelines specifically incorporate comprehensive prenatal and postnatal lactation support, counseling, and equipment rental. Accordingly, the items and services described in the HRSA Guidelines are required to be covered in accordance with the requirements of the interim ?nal regulations (that is, without cost-sharing, subject to reasonable medical management, which may include purchase instead of rental of equipment). (DOL FAQs Pan? XII 02/20/13) Q19: How are certified lactation consultants reimbursed for their services under the HRSA Guidelines? Reimbursement policy is outside of the scope of the HRSA Guidelines and the Departments' regulations. (DOL FAQs Pan? XII 02/20/13) 020: Under the HRSA Guidelines, how long after childbirth is a woman eligible for lactation counseling? Are breastfeeding equipment and supplies unlimited? Coverage of comprehensive lactation support and counseling and costs of renting or purchasing breastfeeding equipment extends for the duration of breastfeeding. Nonetheless, consistent with PHS Act section 2713 and its implementing regulations, plans and issuers may use reasonable medical management techniques to determine the frequency, method, treatment, or setting for a recommended preventive item or service, to the extent not speci?ed in the recommendation or guideline. (DOL FAQs Part XII 02/20/13) Coveraqe of BRCA Testing Q1: Must a plan or issuer cover without cost sharing recommended genetic counseling and BRCA genetic testing for a woman who has not been diagnosed with BRCA-related cancer but who previously had breast cancer, ovarian cancer, or other cancer? Updated 1-31-17 Yes. The recommends that "primary care providers screen women who have family members with breast, ovarian, tubal, or peritoneal cancer with 1 of several screening tools designed to identify a family history that may be associated with an increased risk for potentially harmful mutations in breast cancer susceptibility genes (BRCA1 or BRCA2). Women with positive screening results should receive genetic counseling and, if indicated after counseling, BRCA testing." The Final Recommendation Statement related to BRCA testing indicates that the recommendation "applies to women who have not been diagnosed with BRCA-related Therefore, as set out in the recommendations described above, as long as the woman has not been diagnosed with BRCA-related cancer, a plan or issuer must cover preventive screening, genetic counseling, and genetic testing without cost sharing, if appropriate, for a woman as determined by her attending provider, consistent with PHS Act section 2713 and its implementing regulations.(9) (DOL FAQS Part XXVI 05/11/15) 1221 2017-?01321 Q10: Which women must receive coverage without cost sharing for genetic counseling, and if indicated, testing for harmful BRCA mutations? Women found to be at increased risk using a screening tool designed to identify a family history that may be associated with an increased risk of having a potentially harmful gene mutation must receive coverage without cost sharing for genetic counseling, and, if indicated, testing for harmful BRCA mutations. This is true regardless of whether the woman has previously been diagnosed with cancer, as long as she is not currently of or receiving active treatment for breast, ovarian, tubal, or peritoneal cancer For questions about this guidance, contact Centers for Medicare Medicaid Services, Center for Consumer Information and Insurance Oversight at 1-888-393-2789, or the Department of Labor at or 1-866-444-3272. (DOL FAQs Part XXIX 10/23/15) FDA-approved Contraceptives Coverage and User Fee Adjustment Submission 02: If a plan or issuer covers some forms of oral contraceptives, some types of IUDs, and some types of diaphragms without cost sharing, but excludes completely other forms of contraception, will the plan or issuer comply with PHS Act section 2713 and its implementing regulations? No. Plans and issuers must cover without cost sharing the full range of FDA-identified methods. Thus, plans and issuers must cover without cost sharing at least one form of contraception in each method that is identified by the FDA. The FDA currently has identi?ed 18 distinct methods of contraception for women. A plan or issuer generally may use reasonable medical management techniques and impose cost sharing (including full cost sharing) to encourage an individual patient to use speci?c services or FDA- approved items within the chosen contraceptive method. If utilizing reasonable medical management techniques, plans and issuers must have an easily accessible, transparent, and sufficiently expedient exceptions process that is not unduly burdensome on the individual (or a provider or other individual acting as a patient's authorized representative) to ensure coverage without cost sharing of any service or FDA-approved item within the specified method of contraception as described in below. In this example, even though the plan provides coverage in multiple methods, the plan's exclusion of some of the methods for women currently identified by the FDA means the plan fails to comply with PHS Act section 2713 and its implementing regulations. (DOL FAQs Part XXVI 05/11/15) Q3: If multiple services and FDA-approved items within a contraceptive method are medically appropriate for an individual patient, what is a plan or issuer required to cover without cost sharing? Updated 1-31-17 If multiple services and FDA-approved items within a contraceptive method are medically appropriate for an individual, the plan or issuer may use reasonable medical management techniques to determine which speci?c products to cover without cost sharing with respect to that individual. However, if the individual's attending provider recommends a particular service or FDA-approved item based on a determination of medical necessity with respect to that individual, the plan or issuer must cover that service or item without cost sharing. The plan or issuer must defer to the determination 1222 2017--01322 of the attending provider with respect to the individual involved. As previously stated, the plan or issuer must cover at least one service or item within each of the methods (currently 18) identified by the FDA for women. (DOL FAQs Part XXVI 05/11/15) Q4: If a plan or issuer covers oral contraceptives (such as the extended/continuous use contraceptive pill), can it impose cost sharing on all items and services within other FDA- identified hormonal contraceptive methods (such as the vaginal contraceptive ring or the contraceptive patch)? No. The FDA currently identifies 18 distinct methods of contraception for women, and the HRSA Guidelines are designed to provide women?s access to the full range of these contraceptive methods identi?ed by the FDA, as prescribed by a health care provider. Thus, plans and issuers must cover without cost sharing at least one form of contraception within each method the FDA has identified. For the hormonal contraceptive methods, coverage therefore must include (but is not limited to) all 3 oral contraceptive methods (combined, progestin-only, and extended/continuous use), injectables, implants, the vaginal contraceptive ring, the contraceptive patch, emergency contraception (Plan B/Plan One Step/Next Choice), emergency contraception (Ella), and lUDs with progestin. Accordingly, a plan or issuer may not impose cost sharing on the ring or the patch. (DOL FAQs Part XXVI 05/11/15) 09: I am a qualifying non-profit or closely held for-profit employer who sponsors an ERISA-covered self-insured plan, and I have a sincerely held religious objection to providing coverage of contraceptive services. How do I effectuate the religious accommodation, relieving myself of any obligation to contract, arrange, pay, or refer for that coverage? There are two methods: Updated 1-31-17 Complete the EBSA Form 700 (accessible at and provide it to the plan?s third party administrator(s); or Provide appropriate notice of the objection to the Department of HHS. A model notice is available at In the ?rst instance, the EBSA Form 700 will be a plan instrument that relieves you from any obligation to contract, arrange, or pay for contraceptive services to which you object, and that has the legal effect of designating the third party administrator as the ERISA plan administrator responsible for separately providing payments for those services. In the second instance, HHS will forward the information to the Department of Labor, which will send a notification to the third party administrator, designating it as the ERISA plan administrator responsible for separately providing coverage for any contraceptive services to which you object. In that instance, the notice of your objection sent to HHS will be a plan instrument that relieves you from any obligation to contract, arrange, or pay, or refer for contraceptive services to which you object, but will not have the legal effect of designating the third party administrator as the ERISA plan administrator for those services. Instead, the notification sent from the Department of Labor to the third party administrator will be a separate plan instrument, and that separate instrument will serve to designate the third party administrator as the ERISA plan administrator responsible for separately providing payments for any contraceptive services to which you object. (DOL FAQs Part XXIX 10/23/15) 1223 2017-?01323 02: If a plan or issuer utilizes reasonable medical management techniques within a specified method of contraception, can the plan or issuer develop and utilize a standard exception form and instructions as part of its steps to ensure that it provides an easily accessible, transparent, and sufficiently expedient exceptions process that is not unduly burdensome on the individual or a provider (or other individual acting as a patient's authorized representative)? Yes. Plans and issuers may develop a standard exception form with instructions that an attending provider may use to prescribe a particular service or FDA-approved item based on a determination of medical necessity with respect to the individual involved. The Medicare Part Coverage Determination Request Form may serve as a model for plans and issuers when developing a standard exception (DOL FAQs Part 31 04/20/16) Q: ARE THE DEPARTMENTS MAKING CHANGES TO THE ACCOMMODATION AT THIS No. As described in more detail below, the comments reviewed by the Departments in response to the RFI indicate that no feasible approach has been identified at this time that would resolve the concerns of religious objectors, while still ensuring that the affected women receive full and equal health coverage, including contraceptive coverage. The comments demonstrate that a process like the one described in the Court?s supplemental brie?ng order would not be acceptable to those with religious objections to the contraceptive-coverage requirement. Further, a number of comments illustrate that the administrative and operational challenges to a process like the one described in the Court?s order are more significant than the Departments had previously understood and would potentially undermine women?s access to full and equal coverage. For these reasons, the Departments are not modifying the accommodation regulations at this time. As the government explained in its briefs in Zubik, the Departments continue to believe that the existing accommodation regulations are consistent with RFRA for two independent reasons. First, as eight of the nine courts of appeals to consider the issue have held, by virtue of objecting employers? ability to avail themselves of the accommodation, the contraceptive-coverage requirement does not substantially burden their exercise of religion. Second, as some of those courts have also held, the accommodation is the least restrictive means of furthering the government?s compelling interest in ensuring that women receive full and equal health coverage, including contraceptive coverage. (DOL FAQs Pan? 36, -1/12/17) FAQs for Federally-facilitated Marketplace (FFM) User Fee Adjustment Submission Requirements (for reporting of contraceptive claims) (08/22/16) FAQs 5CR O82216.pdf Purpose: For the 2015 benefit year, the Centers for Medicare Medicaid Services (CMS) is releasing a web-based form through which Third-Party Administrators (TPAs), including Pharmacy Benefit Managers (PBMs) that provide services to a self-insured group health plan offered by an eligible organization, and Federally-facilitated Marketplace (FFM) issuers that have entered into an 1224 Updated 1-31-17 2017-?01324 agreement with these TPAs (including PBMs) can report contraceptive claims costs incurred by plan participants and bene?ciaries. Completion of the web-based form for the 2015 benefit year will allow CMS to: 1) determine the reduction to the FFM user fee for the participating FFM issuer; 2) ensure that these adjustments to the FFM user fee reflect payments for contraceptive services paid for under this accommodation under 45 C.F.R. 147.131(b) and and 3) ensure that the adjustment, equal to cost of contraceptive claims incurred during the applicable bene?t year plus a 15 percent administrative margin, is applied to the appropriate FFM issuer. The FAQs below are intended to assist issuers and TPAs (including PBMs) with navigating the submission requirements and understanding the mechanism through which CMS will apply the FFM user fee adjustment to FFM issuers. Submission Process Deadlines Q: How will CMS collect 2015 data for the Federally-facilitated Marketplace (FFM) User Fee Adjustment? A: For the 2015 FFM User Fee Adjustment, CMS will collect data through a web-based form which will be available on the Center for Consumer Information and Insurance Oversight (CCIIO) website and will be described on the Registration for Technical Assistance Portal (REGTAP). An e-mail will be sent to participants that participated for the 2014 bene?t year FFM user fee adjustment. TPAs (including, as discussed below, PBMs) will also be required to submit the Notice of Intent Disclosure Form through the web-based form. We note that this is different from the 2014 benefit year data collection where CMS collected information through forms submitted to a CMS email address. (FAQs for FFM User Fee Adjustment Submission Requirements (for reporting of contraceptive claims) {08/22/16) Q: When is the submission window for the 2015 FFM User Fee Adjustment and Notice of Intent Disclosure Form? A: The data submission window for the 2015 FFM User Fee Adjustment, including submission of the Notice of Intent Disclosure Form by TPAs (including PBMs), will be August 22, 2016 - September 20, 2016 at 11:59 PM. ET. (FAQs for FFM User Fee Adjustment Submission Requirements (for reporting of contraceptive claims) {08/22/16) Q: How should TPAs (including PBMs) submit the Notice of Intent Disclosure Form indicating that they intend to partner with an FFM issuer to seek a user fee adjustment for the 2015 bene?t year? A: TPAs (including PBMs) should submit the Notice of Intent Disclosure Form through the web-based form from August 22, 2016 through September 20, 2016. The web-based form is the same form that they will use to report contraceptive claims costs incurred in the 2015 bene?t year. (FAQs for FFM User Fee Adjustment Submission Requirements (for reporting of contraceptive claims) (08/22/16) Q: How should FFM issuers and TPAs (including PBMs) submit the required information 1225 Updated 1-31-17 2017--01325 to Is this data collected through the Health Insurance Oversight System (HIOS) or the External Data Gathering Environment (EDGE) server? What format should be used? A: CMS will not be collecting this information through HIOS or through the EDGE server. CMS has a web-based form that will be used to collect the information necessary to process the user fee adjustment. FFM issuers and TPAs (including PBMs) should complete the information requested for their respective circumstances by completing the web-based form by September 20, 2016. (FAQs for FFM User Fee Adjustment Submission Requirements (for reporting of contraceptive claims) (08/22/16) Q: Will CMS provide training on how to use the web-based form? Is there a resource for additional questions? A: Yes, CMS will conduct a webinar to train issuers and TPAs (including PBMs) on successfully completing and submitting the web-based form. A training will be held on August 22, 2016, with a repeat training session on August 31, 2016. Details will be announced through Policy questions can be emailed to (FAQs for FFM User Fee Adjustment Submission Requirements (for reporting of contraceptive claims) {08/22/16) Eliqible Submitters Q: Can a Pharmacy Bene?t Manager (PBM) enter into an identical arrangement with an issuer in order to receive reimbursement for contraceptive services that it has provided to participants and beneficiaries of a self-insured group health plan of an eligible organization? A: Yes. Like other TPAs, PBMs that perform these functions for participants and beneficiaries of a self-insured group health plan of an eligible organization can enter into an arrangement with an issuer to receive reimbursement for contraceptive services that it has provided. If a PBM intends to enter into this arrangement with an FFM issuer for reimbursement for contraceptive services provided, it will be subject to all of the requirements that apply to TPAs generally, including, but not limited to, submission of the ?Noti?cation of Intent? to HHS through the web-based form. (FAQs for FFM User Fee Adjustment Submission Requirements (for reporting of contraceptive claims) {08/22/16) Q: If the TPA (including a PBM) and the FFM issuer are part of the same entity parent company or holding group), do the TPA and FFM issuer each have to submit separate web-based forms to CMS in order to receive the user fee adjustment? A: If the TPA (including a PBM) is part of the same entity or parent company as the FFM issuer, the TPA does not need to submit the TPA submission form. If part of the same entity, the submitter should only complete the portion of the web-based form that applies to FFM issuers. (FAQs for FFM User Fee Adjustment Submission Requirements (for reporting of contraceptive claims) {08/22/16) Q: Can an FFM issuer simply include the paid claims amount on the participating issuer form without the TPA (including a PBM) needing to also complete and submit the separate form applicable to A: If the TPA (including a PBM) and FFM issuer are not part of the same entity, the TPA 1226 Updated 1-31-17 2017--01326 must still ?ll out a web-based form indicating the total value of eligible contraceptive claims that were paid. The FFM issuer must also submit the total dollar value of eligible contraceptive claims incurred during the applicable benefit year and the total amount that was paid, or that it has agreed to pay, to the TPA. Receiving the information from both entities will help CMS ensure that the amounts are being reported consistently and that the FFM issuer is reporting eligible claims for which it has actually reimbursed the TPA, or will do so. (FAQs for FFM User Fee Adjustment Submission Requirements (for reporting of contraceptive claims) {08/22/16) Claims Reportinq FFM User Fee Calculation Q: Can the FFM issuer or TPA (including a PBM) include claims costs incurred in 2016 as part of its claims submission for the 2015 benefit year? A: For the 2015 benefit year, FFM issuers and TPAs (including PBMs) should report the total dollar amount for payments for contraceptive claims provided consistent with the guidelines identified at 45 CFR incurred by plan participants and bene?ciaries as of December 31, 2015. FFM issuers and TPAs (including PBMs) should count the dollar value of payments for claims incurred by December 31, 2015 in the total amount reported, even if the claims were not paid by December 31, 2015. (FAQs for FFM User Fee Adjustment Submission Requirements (for reporting of contraceptive claims) {08/22/16) Q: Can HHS conduct the FFM user fee adjustment data collection earlier in the year, so that FFM issuers and TPAs (including PBMs) do not have to carry claims costs over for an additional benefit year before receiving reimbursement? A: The data collection window for the 2015 benefit year will be August 22, 2016 through September 20, 2016, and only applies to claims that were incurred during the 2015 benefit year. However, HHS will consider beginning data submission for the 2016 benefit year user fee adjustment earlier in the 2017 calendar year. We intend to publish future guidance regarding the manner and timeframe of data submission for the FFM user fee adjustment for the 2016 benefit year. (FA 03 for FFM User Fee Adjustment Submission Requirements (for reporting of contraceptive claims) {08/22/16) Q: Is the FFM user fee adjustment amount limited to the dollar amount of contraceptive claims? Is there a way that the FFM issuer can be reimbursed for the administrative costs associated with entering into an agreement with a TPA (including a A: Yes, the user fee adjustment amount that is credited toward an FFM issuer?s user fee obligation is equal to the dollar amount of contraceptive claims reimbursement paid to the TPA (including a PBM), plus an additional 15 percent for administrative costs incurred. For example, if the FFM issuer paid $100,000 in reimbursement for contraceptive claims to a TPA for claims incurred through December 31, 2015, the issuer?s total user fee adjustment amount would be $115,000. (FAQs for FFM User Fee Adjustment Submission Requirements (for reporting of contraceptive claims) {08/22/16) Q: Can a TPA (including a PBM) be reimbursed for the administrative costs associated with entering into an agreement with a FFM issuer? A: CMS has not established a mechanism through which TPAs (including PBMs) can be 1227 Updated 1-31-17 2017-?01327 directly reimbursed for the administrative costs associated with administering contraceptive claims for eligible organizations. However, the agreement between the FFM issuer and the TPA (including a PBM) may provide that the FFM issuer will share a portion of its administrative margin with the TPA in order to help offset the administrative costs. (FA 08 for FFM User Fee Adjustment Submission Requirements (for reporting of contraceptive claims) {08/22/16) Transfer of FFM User Fee Adjustment Amount to FFM Issuers Q: How will issuers receive payment for the contraceptive claims costs and associated administrative costs that they have incurred? Does an FFM issuer need to do something to ensure that CMS can properly transfer the monies to the issuer?s account? A: After an FFM issuer has submitted the required data to CMS through the web-based form, the FFM issuer does not need to take any further action to ensure that the user fee adjustment is applied. CMS will not make direct payments to FFM issuers for the user fee adjustment amount. Instead, CMS will automatically deduct the user fee adjustment amount from the user fee amount that the issuer othenivise owes for a given month. CMS collects FFM user fees by automatically deducting the user fee amount from issuers? Advance Payment of Premium Tax Credits (APTCs) and Cost-sharing Reductions (CSRs). (FAQs for FFM User Fee Adjustment Submission Requirements (for reporting of contraceptive claims) {08/22/16) Q: When will the FFM issuer receive the FFM user fee adjustment? A: CMS anticipates applying the FFM user fee adjustment for the 2015 bene?t year on a basis beginning in the Fall of 2016, and will automatically deduct the user fee adjustment amount from the issuer?s user fee obligation. We will provide future guidance on the timing of the user fee adjustment for forthcoming bene?t years. CMS will credit the user fee adjustment amount for a month against an FFM issuer?s user fee obligation until the user fee obligation for that month has been completely offset. Any remaining user fee adjustment amount will be credited towards the issuer?s user fee obligation for the next month. CMS will continue this process until the user fee adjustment amount is fully exhausted. (FAQs for FFM User Fee Adjustment Submission Requirements (for reporting of contraceptive claims) (08/22/16) Q: What happens if the FFM user fee adjustment amount is greater than the FFM issuer?s total user fee obligation for the year? Updated 1-31-17 A: CMS will credit the user fee adjustment amount against the FFM issuer?s user fee obligation on a basis. If the FFM issuer?s user fee obligation has been fully offset at the end of the year and a user fee adjustment amount still remains, CMS will roll-over the amount of the adjustment to the next year and will credit the remaining amount against the next year?s user fees. (FAQs for FFM User Fee Adjustment Submission Requirements (for reporting of contraceptive claims) (08/22/16) 1228 2017-?01328 Coverage of Sex-specific Recommended Preventive Services Q5: Can plans or issuers limit sex-specific recommended preventive services based on an individual's sex assigned at birth, gender identity or recorded gender? No. Whether a sex-speci?c recommended preventive service that is required to be covered without cost sharing under PHS Act section 2713 and its implementing regulations is medically appropriate for a particular individual is determined by the individual's attending provider. Where an attending provider determines that a recommended preventive service is medically appropriate for the individual such as, for example, providing a mammogram or pap smear for a transgender man who has residual breast tissue or an intact cervix and the individual othenivise satisfies the criteria in the relevant recommendation or guideline as well as all other applicable coverage requirements, the plan or issuer must provide coverage for the recommended preventive service, without cost sharing, regardless of sex assigned at birth, gender identity, or gender of the individual otherwise recorded by the plan or issuer. (DOL FAQs Part XXVI 05/11/15) Coverage of Well-woman Preventive Care for Dependents 06: If a plan or issuer covers dependent children, is the plan or issuer required to cover without cost sharing recommended women's preventive care services for dependent children, including recommended preventive services related to pregnancy, such as preconception and prenatal care? Yes. Non-grandfathered group health plans and health insurance issuers offering non- grandfathered group or individual health insurance coverage must cover speci?ed recommended preventive care services without cost sharing, consistent with PHS Act section 2713 and its implementing regulations, for all participants and bene?ciaries under a group health plan (and all individuals enrolled in individual market coverage). If the plan or issuer covers dependent children, such dependent children must be provided the full range of recommended preventive services applicable to them for their age group) without cost sharing and subject to reasonable medical management techniques, in accordance with the requirements of PHS Act section 2713 and its implementing regulations?) For example, the HRSA Guidelines recommend well-woman visits for adult women to obtain the recommended preventive services that are age- and developmentaIIy-appropriate, including preconception care and many services necessary for prenatal Therefore, consistent with PHS Act section 2713 and its implementing regulations, plans and issuers must cover without cost sharing these recommended preventive services for dependent children where an attending provider determines that well-woman preventive services are age- and developmentally- appropriate for the dependent. (DOL FAQs Part XXVI 05/11/15) 1229 Updated 1-31-17 2017--01329 Coverage of Colonoscopies Pursuant to Recommendations Q7: If a colonoscopy is scheduled and performed as a preventive screening procedure for colorectal cancer pursuant to the recommendation, is it permissible for a plan or issuer to impose cost sharing with respect to anesthesia services performed in connection with the preventive colonoscopy? No. The plan or issuer may not impose cost sharing with respect to anesthesia services performed in connection with the preventive colonoscopy if the attending provider determines that anesthesia would be medically appropriate for the individual. (DOL FAQs Part XXVI 05/11/15) Q7: If a colonoscopy is scheduled and performed as a screening procedure pursuant to the recommendation, is it permissible for a plan or issuer to impose cost sharing for the required specialist consultation prior to the screening procedure? No. The plan or issuer may not impose cost sharing with respect to a required consultation prior to the screening procedure if the attending provider determines that the pre-procedure consultation would be medically appropriate for the individual, because the pre-procedure consultation is an integral part of the colonoscopy. As with any invasive procedure, the consultation before the colonoscopy can be essential in order for the consumer to obtain the full benefit of the colonoscopy safely. The medical provider examines the patient to determine if the patient is healthy enough for the procedure and explains the process to the patient, including the required preparation for the procedure, all of which are necessary to protect the health of the patient. Because the Departments' prior guidance may reasonably have been interpreted in good faith as not requiring coverage without cost sharing of consultation prior to a colonoscopy screening procedure, the Departments will apply this clarifying guidance for plan years (or, in the individual market, policy years) beginning on or after the date that is 60 days after publication of these FAQs. (DOL FAQs Part XXIX 10/23/15) Q8: After a colonoscopy is scheduled and performed as a screening procedure pursuant to the recommendation, is the plan or issuer required to cover any pathology exam on a polyp biopsy without cost sharing? Yes, such services performed in connection with a preventive colonoscopy must be covered without cost sharing. The Departments view such services as an integral part of a colonoscopy, similar to polyp removal during a colonoscopy?). The pathology exam is essential for the provider and the patient to obtain the full bene?t of the preventive screening since the pathology exam determines whether the polyp is malignant. Since the primary focus of the colonoscopy is to screen for malignancies, the pathology exam is critical for achieving the primary purpose of the colonoscopy screening. Because the Departments' prior guidance may reasonably have been interpreted in good faith as not requiring coverage without cost sharing of a pathology exam on a polyp biopsy performed in connection with a colonoscopy screening procedure, the Departments will apply this clarifying guidance for plan years (or, in the individual market, policy years) beginning on or after the date that is 60 days after publication of these FAQs. (DOL FAQs Part XXIX 10/23/15) 1230 Updated 1-31-17 2017--01330 Q1: If a colonoscopy is scheduled and performed as a screening procedure pursuant to the recommendation, can a plan or issuer impose cost sharing for the bowel preparation medications prescribed for the procedure? No. Consistent with a previous the required preparation for a preventive screening colonoscopy is an integral part of the procedure. Bowel preparation medications, when medically appropriate and prescribed by a health care provider, are an integral part of the preventive screening colonoscopy, and therefore, are required to be covered in accordance with the requirements of PHS Act section 2713 and its implementing regulations (that is, without cost sharing, subject to reasonable medical management). (DOL FAQs Pan? 31 04/20/16) Preventive Services Other Q1: Are plans and issuers required to provide a list of the lactation counseling providers within the network? Updated 1-31-17 Yes. The HRSA guidelines provide for coverage of comprehensive prenatal and postnatal lactation support, counseling, and equipment rental as part of their preventive service recommendations, including lactation counselingf?l) While the preventive services requirements under PHS Act section 2713 do not include specific disclosure requirements, provisions of other applicable law require disclosure of lactation counseling providers available under the plan or coverage. Under PHS Act section 2715 and implementing regulations, group health plans and health insurance issuers offering group or individual health insurance coverage must provide a Summary of Bene?ts and Coverage (SBC) that includes an Internet address (or other contact information) for obtaining a list of the network providers.(5> With respect to group health plans subject to the Employee Retirement Income Security Act (ERISA), ERISA section 102 and the Department of Labor?s implementing regulations provide that a group health plan must provide a Summary Plan Description (SPD) that describes provisions governing the use of network providers, the composition of the provider network, and whether, and under what circumstances, coverage is provided for out-of-network For those plans with provider networks, the listing of providers can be furnished in a separate document accompanying the SPD, as long as the SPD describes the provider network and states that provider lists are furnished automatically, without charge, as a separate document?i Finally, issuers of quali?ed health plans (QHPs) in the individual market Exchanges and the SHOPS currently must make their provider directories available online. For plan years beginning on or after January 1, 2016, a QHP issuer must publish an up-to-date provider directory, including information on which providers are accepting new patients, as well as the provider?s contact information, specialty, medical group, and any institutional affiliations, in a manner that is easily accessible to plan enrollees, prospective enrollees, the State, the Exchange, HHS, and (DOL FAQs Part XXIX 10/23/15) 1231 2017-?01331 02: My group health plan has a network of providers and covers recommended preventive services without cost sharing when such services are obtained in-network. However, the network does not include lactation counseling providers. Is it permissible for the plan to impose cost sharing with respect to lactation counseling services obtained outside the network? No. As stated in a previous while nothing in the preventive services requirements under section 2713 of the PHS Act or its implementing regulations requires a plan or issuer that has a network of providers to provide benefits for preventive services provided out-of?network, these requirements are premised on enrollees being able to access the required preventive services from in-network providers. The FAQ also stated that if a plan or issuer does not have in its network a provider who can provide a particular service, then the plan or issuer must cover the item or service when performed by an out-of?network provider and not impose cost sharing with respect to the item or service. Therefore, if a plan or issuer does not have in its network a provider who can provide lactation counseling services, the plan or issuer must cover the item or service when performed by an out-of-network provider without cost sharing. (DOL FAQs Part XXIX 10/23/15) Q3: The State where I live does not license lactation counseling providers and my plan or issuer will only cover services received from providers licensed by the State. Does that mean that I cannot receive coverage of lactation counseling without cost sharing? No. Subject to reasonable medical management techniques, lactation counseling must be covered without cost sharing by the plan or issuer when it is performed by any provider acting within the scope of his or her license or certi?cation under applicable State law. Lactation counseling could be provided by another provider type acting within the scope of his or her license or certi?cation (for example, a registered nurse), and the plan or issuer would be required to provide coverage for the services without cost sharing. (DOL FAQs Part XXIX 10/23/15) Q4: A plan or issuer provides coverage for lactation counseling without cost sharing only on an inpatient basis. Is it permissible for the plan or issuer to impose cost sharing with respect to lactation counseling received on an outpatient basis? Updated 1-31-17 No. If a recommendation or guideline does not specify the frequency, method, treatment, or setting for the provision of a recommended preventive service, then the plan or issuer may use reasonable medical management techniques to determine any such coverage limitations. However, it is not a reasonable medical management technique to limit coverage for lactation counseling to services provided on an in-patient basis. Some births are never associated with a hospital admission home births assisted by a nurse midwife), and it is not permissible to deny coverage without cost sharing for lactation support services in this case. Moreover, coverage for lactation support services without cost sharing must extend for the duration of the breastfeedingllo) which, in many cases, extends beyond the in-patient setting for births that are associated with a hospital admission. (DOL FAQs Part XXIX 10/23/15) 1232 2017-?01332 05: Are plans and issuers permitted to require individuals to obtain breastfeeding equipment within a specified time period (for example, within 6 months of delivery) in order for the breastfeeding equipment to be covered without cost sharing? No. The requirement to cover the rental or purchase of breastfeeding equipment without cost sharing extends for the duration of breastfeeding, provided the individual remains continuously enrolled in the plan or coverage. (DOL FAQs Part XXIX 10/23/15) 06: My non-grandfathered group health plan or coverage contains a general exclusion for weight management services for adult obesity. Is this permissible? No. Consistent with PHS Act section 2713, its implementing regulations, and current recommendations, non-grandfathered plans and issuers must cover, without cost sharing, screening for obesity in adults. In addition to such screening, the currently recommends, for adult patients with a body mass index (BMI) of 30 kg/m2 or higher, intensive, multicomponent behavioral interventions for weight management. The recommendation speci?es that intensive, multicomponent behavioral interventions include, for example, the following: Group and individual sessions of high intensity (12 to 26 sessions in a year), Behavioral management activities, such as weight-loss goals, Improving diet or nutrition and increasing physical activity, Addressing barriers to change, Self-monitoring, and Strategizing how to maintain lifestyle changes. While plans and issuers may use reasonable medical management techniques to determine the frequency, method, treatment, or setting for a recommended preventive service, to the extent not speci?ed in the recommendation or guideline regarding that preventive service, plans are not permitted to impose general exclusions that would encompass recommended preventive services. Additionally, with respect to individual and small group market issuers subject to the essential health bene?ts (EHB) requirements under section 1302(b) of the Affordable Care Act and section 2707(3) of the PHS Act, to the extent the applicable EHB- benchmark plan does not include coverage of the required preventive services, including obesity screening and counseling, the issuer must nonetheless provide coverage for such preventive services consistent with PHS Act section 2713 and its implementing regulations, and with the regulation implementing the EHB requirements at 45 CFR (DOL FAQs Part XXIX 10/23/15) 02: HRSA updated its Women?s Preventive Services Guidelines on December 20, 2016. When must non-grandfathered group health plans and health insurance issuers begin offering coverage for preventive services without cost sharing based on the updated guidelines? Women?s preventive services are required to be covered without cost sharing in accordance with the updated guidelines for plan years (or, in the individual market, policy years) beginning on or after December 20, 2017.9 Until the new guidelines become applicable, non-grandfathered group health plans and health insurance issuers are required to provide coverage without cost sharing consistent with the previous HRSA 1233 Updated 1-31-17 2017--01333 guidelines and PHS Act section 2713 for any items or services that continue to be recommended. updated women?s preventive services guidelines were recently released based on recommendations developed by the Women?s Preventive Services Initiative (WPSI), a coalition of national health professional organizations and consumer and patient groups with expertise in women?s health. The update is available at . WPSI is led, through a competitive cooperative agreement, by the American College of Obstetricians and Gynecologists. In developing these guidelines, WPSI engaged its coalition of health professional organizations and consumer and patient advocates to develop, review, and update recommendations for women?s preventive services. These updated guidelines complement and build upon recommendations from entities such as the These recommendations update prior work by the Institutes of Medicine (IOM) to develop the initial Women?s Preventive Service Guidelines, meet a recommended ?ve-year benchmark for updates (by the IOM), and help ensure the guidelines remain current with the existing science and evidence-based practices. Similar to the processes of the ACIP, and Bright Futures10 for developing evidence-based guidelines, WPSI established a process for stakeholders to provide public comment that included de?ning the scope of the recommended guidelines, identifying and assessing the evidence base, and disseminating the ?nal HRSA- supported guidelines. (DOL FAQs Part 35 - SEPs, Preventive Services, and Small Employer HRAs 12/20/16) Dental and Vision Benefits 06: What if my dental (or vision) benefits are structured as excepted bene?ts under Does that exemption except my dental (or vision) plan from the Affordable Care Act?s market reforms? Updated 1-31-17 Yes. If benefits constitute excepted bene?ts under HIPAA, the requirements of the Affordable Care Act?s market reforms do not apply. Under HIPAA, dental (and vision) bene?ts generally constitute excepted bene?ts if they: 0 Are offered under a separate policy, certi?cate, or contract of insurance; or Are not an integral part of the plan. For dental (or vision) benefits to be considered not an integral part of the plan (whether insured or self-insured), participants must have a right not to receive the coverage and, if they do elect to receive the coverage, must pay an additional premium. Accordingly, if a plan provides its dental (or vision) bene?ts pursuant to a separate election by a participant and the plan charges even a nominal employee contribution towards the coverage, the dental (or vision) bene?ts would constitute excepted bene?ts, and the market reform provisions would not apply to that coverage. (DOL FAQs Part II 10/08/10) 1234 2017-?01334 Rescissions Q7: The Affordable Care Act (through Public Health Service Act section 2712) generally provides that plans and issuers must not rescind coverage unless there is fraud or an individual makes an intentional misrepresentation of material fact. A rescission is defined as it is commonly understood under the law a cancellation or discontinuance of coverage that has a retroactive effect, except to the extent attributable to a failure to pay timely premiums towards coverage. Is the exception to the statutory ban on rescission limited to fraudulent or intentional misrepresentations about prior medical history? What about retroactive terminations of coverage in the ?normal course of business?? The statutory prohibition related to rescissions is not limited to rescissions based on fraudulent or intentional misrepresentations about prior medical history. An example in the Departments' interim final regulations on rescissions clari?es that some plan errors (such as mistakenly covering a part-time employee and providing coverage upon which the employee relies for some time) may be cancelled prospectively once identi?ed, but not retroactively rescinded unless there was some fraud or intentional misrepresentation by the employee. On the other hand, some plans and issuers have commented that some employers? human resource departments may reconcile lists of eligible individuals with their plan or issuer via data feed only once per month. If a plan covers only active employees (subject to the COBRA continuation coverage provisions) and an employee pays no premiums for coverage after termination of employment, the Departments do not consider the retroactive elimination of coverage back to the date of termination of employment, due to delay in administrative record-keeping, to be a rescission. Similarly, if a plan does not cover ex-spouses (subject to the COBRA continuation coverage provisions) and the plan is not notified of a divorce and the full COBRA premium is not paid by the employee or ex-spouse for coverage, the Departments do not consider a plan?s termination of coverage retroactive to the divorce to be a rescission of coverage. (Of course, in such situations COBRA may require coverage to be offered for up to 36 months if the COBRA applicable premium is paid by the quali?ed bene?ciary.) (DOL FAQs Part 10/08/10) Q3: I am a school teacher who was employed by a school district through a 10-month teaching contract from August 1 to May 31. My health coverage through the school district health plan was for the plan year from August 1 to July 31, and the full premium was paid during that period. I provided my resignation on July 31 indicating that I did not intend to continue my employment with the school district for the following school year. The plan terminated my coverage retroactively to May 31. I did not request that my coverage be retroactively terminated, or commit fraud or make an intentional misrepresentation of a material fact. Is the retroactive termination of coverage permissible? No. The plan's termination of health coverage retroactive to May 31 is a rescission that is prohibited under PHS Act section 2712 and the implementing regulations, because it is a cancellation or discontinuance of coverage that has retroactive effect, (ii) it is not attributable to a failure to timely pay premiums toward coverage, there was no fraud 1235 Updated 1-31-17 2017--01335 or intentional misrepresentation of material fact, and (iv) the other limited circumstance exceptions speci?ed in the implementing regulations do not apply. The plan may terminate coverage prospectively, subject to other applicable Federal and State laws or collective bargaining agreements. (DOL FAQs Pan? 31 04/20/16) Clarification Relating to Policy Year and Effective Date of the Affordable Care Act for Individual Health Insurance Policies 09: Some States and issuers have interpreted the definition of a policy year in the interim final regulation on dependent coverage of children to age 26(4) to mean that if an issuer establishes a policy year for the insured under an individual policy on a basis other than the effective date of coverage (such as a calendar year beginning January 1, 2012), then the provisions of the Affordable Care Act do not apply to those policies before the start of the policy year. Can compliance with the Affordable Care Act requirements for policies in the individual market sold on or after September 23, 2010 be effective on a date other than the date that coverage begins? Updated 1-31-17 No. We understand that carriers in the health insurance individual market may designate a fixed policy year, but continue to issue policies throughout the year. For example, a carrier may designate a policy year of January 1 through December 31 for an individual policy under which coverage begins on October 1. However, the statute and regulations contemplate implementation of the Affordable Care Act requirements at the beginning of the ?rst new period of coverage that begins on or after September 23, 2010, whether this new coverage period is a full or shortened period of coverage. If a policy begins to cover an individual effective on a date that is on or after September 23, 2010, the initial policy year for that individual, for purposes of determining the effective date of the Affordable Care Act requirements, begins on the ?rst date on which the coverage is effective. This initial period of coverage might be an abbreviated policy year. For example, it may run from October 1, 2010 through December 31, 2010, with a new calendar-based policy year beginning on January 1, 2011 (assuming the individual renews the policy), or from December 1, 2010 through June 30, 2011, with a new policy year beginning each July 1 (again, assuming the policy is renewed). It would be a ?policy year? for purposes of the Affordable Care Act effective date if it is a new period of coverage, regardless of when (or whether) the ?rst subsequent 12 month policy year begins. If issuers, however, have relied in good faith on guidance or instructions from a state insurance regulator indicating that the provisions of the Affordable Care Act are not applicable until the beginning of the ?rst full policy year of the individual coverage, then carriers will be afforded a reasonable period of time after the issuance of this guidance to come into compliance with the law. Nonetheless, subsequent to the issuance of this guidance, issuers may not rely in good faith on any contrary guidance or instruction issued by a state insurance regulator. (DOL FAQs Part II 10/08/10) 1236 2017--01336 Exemption for Group Health Plans with Less than Two Current Employees Q1: Do the HIPAA statutory exemptions in effect since 1997 for group health plans with ?less than two participants who are current employees? apply to the Affordable Care Act?s group market reforms? Yes. The preamble to the interim ?nal regulations on grandfathered plans1 noted that statutory provisions in effect since 1997 exempting group health plans with ?less than two participants who are current employees? from HIPAA also exempt such plans from the group market reform requirements of the Affordable Care Act. Accordingly, under the terms of these statutory provisions, group health plans that do not cover at least two employees who are current employees (such as plans in which only retirees participate) are exempt from the Affordable Care Act's market reform requirements. (DOL FAQs Part 10/12/10) 02: I am an employer who sponsors a number of plans including one for both my retirees and individuals on long-term disability. Before the Affordable Care Act, we treated our plan covering retirees and those on long-term disability as exempt under HIPAA. Can we continue to treat that plan as exempt? The Departments have not issued guidance on this specific issue. In order to fully analyze the issue, and balance the goal of ensuring that the Affordable Care Act?s market reforms and patient protections are provided to eligible enrollees of group health plans with the goal of preventing disruption of existing coverage, the Departments will be issuing a request for information (RFI) very soon. The RFI will solicit comments from employers and other stakeholders to inform future guidance. After reviewing the comments submitted, the Departments intend to publish guidance on this issue in 2011. Until guidance is issued, the Departments will treat plans described above as satisfying the exemption from HIPAA and the Affordable Care Act?s group market reforms for plans with less than two participants who are current employees. To the extent future guidance on this issue is more restrictive with respect to the availability of the exemption than this interim relief, the guidance will be prospective, applying to plan years that begin some time after its issuance. Pending such further guidance, a plan may adopt any or all of the HIPAA and Affordable Care Act market reform requirements without prejudice to its exemption. The Departments encourage such voluntary compliance. (DOL FAQs Part II 10/08/10) Value-Based Insurance Design in Connection with Preventive Care Benefits Updated 1-31-17 Section 2713 of the Public Health Service Act (PHS Act) generally requires group health plans and group and individual health insurance issuers that are not grandfathered health plans to provide coverage for recommended preventive services without cost sharing. A complete list of the current recommended preventive services is available at The Departments will also develop guidelines to permit a group health plan or group or individual health insurance issuer to utilize value-based insurance designs. Generally speaking, value-based insurance designs (VBID) are health plan designs that provide incentives for enrollees to utilize higher-value and/or higher-quality services or venues of 1237 2017-?01337 care. On or about the date of issuance of these FAQs, the Departments will be issuing a Request for Information on ways the Departments can encourage VBID in the context of preventive care services. (DOL FAQs Part 12/22/10) Automatic Enrollment in Health Plans 02: The Affordable Care Act amended the Fair Labor Standards Act (FLSA) by adding a new section 18A, requiring employers with more than 200 full-time employees to automatically enroll new full-time employees in the employer?s health benefits plans and continue enrollment of current employees. What Agency is responsible for guidance under this new FLSA provision? The Secretary of Labor has delegated responsibility for FLSA section 18A rulemaking, and for regulations under new section 188 of the FLSA, Notice to Employees of Coverage Options, to the Employee Bene?ts Security Administration (EBSA) within the Department of Labor. EBSA and the Department of the Treasury will coordinate to develop the rules that will apply in determining full-time employee status for purposes of the amendments to the FLSA and the rulemaking by the Treasury Department under the Internal Revenue Code to develop the rules that will apply in determining full-time employee status for purposes of the amendments made by the Affordable Care Act to the Internal Revenue Code. (DOL FAQs Part 12/22/10) Q3: When do employers have to comply with the new automatic enrollment requirements in section 18A of the Section 18A provides that employer compliance with the automatic enrollment provisions of that section shall be carried out accordance with regulations promulgated by the Secretary [of Labor]." Accordingly, it is the view of the Department of Labor that, until such regulations are issued, employers are not required to comply with section 18A. The Department of Labor expects to work with stakeholders to ensure that it has the necessary information and data it needs to develop regulations in this area that take into account the practices employers currently use for auto-enrollment and to solicit the views and practices of a broad range of stakeholders, including employers, workers, and their families. The Department of Labor intends to complete this rulemaking by 2014. (DOL FAQs Part 12/22/10) Q1. What is the current timeline for issuing guidance on automatic enrollment under FLSA section Updated 1-31-17 A1. The Department of Labor has been working with stakeholders to ensure that it has the necessary information and data to develop regulations relating to automatic enrollment, and is sensitive to stakeholder concerns regarding the need for adequate time to comply with any regulations that are ultimately issued. In addition, the Department of Labor is aware of the need to coordinate the work it will be undertaking to develop guidance relating to automatic enrollment with the guidance being developed regarding other related Affordable Care Act provisions, including the employer shared responsibility provision and the 90-day limitation on waiting periods, described above. In view of the need for coordinated guidance and a smooth implementation process, including an applicability date that gives employers suf?cient time to comply, the Department of Labor has concluded that its automatic enrollment guidance will not be 1238 2017--01338 ready to take effect by 2014. It remains the Department of Labor?s view that, until ?nal regulations under FLSA section 18A are issued and become applicable, employers are not required to comply with FLSA section 18A. (DOL Technical Release 2012-01 02/09/12) Q1. What is the current timeline for issuing guidance on automatic enrollment under FLSA section A1. The Department of Labor has been working with stakeholders to ensure that it has the necessary information and data to develop regulations relating to automatic enrollment, and is sensitive to stakeholder concerns regarding the need for adequate time to comply with any regulations that are ultimately issued. In addition, the Department of Labor is aware of the need to coordinate the work it will be undertaking to develop guidance relating to automatic enrollment with the guidance being developed regarding other related Affordable Care Act provisions, including the employer shared responsibility provision and the 90-day limitation on waiting periods, described above. In view of the need for coordinated guidance and a smooth implementation process, including an applicability date that gives employers suf?cient time to comply, the Department of Labor has concluded that its automatic enrollment guidance will not be ready to take effect by 2014. It remains the Department of Labor?s view that, until ?nal regulations under FLSA section 18A are issued and become applicable, employers are not required to comply with FLSA section 18A. (FAQs from Employers Regarding Automatic Enrollment, Employer Shared Responsibility, and Waiting Periods (02/09/12) 02. Do Treasury and the IRS intend to issue proposed regulations or other guidance permitting employers to use an employee?s W-2 wages as a safe harbor in determining the affordability of employer coverage, as outlined in IRS Notice 2011-73? A2. Yes. As described in Notice 2011-73, Treasury and the IRS intend to issue proposed regulations or other guidance permitting employers to use an employee?s Form W-2 wages (as reported in Box 1) as a safe harbor in determining the affordability of employer coverage. (FA 03 from Employers Regarding Automatic Enrollment, Employer Shared Responsibility, and Waiting Periods (02/09/12) Q3. Do Treasury and the IRS intend to issue proposed regulations or other guidance addressing how the employer shared responsibility provisions under Code section 4980H and the 90-day waiting period limitation under PHS Act section 2708 are coordinated? Updated 1-31-17 A3. Yes. Treasury and the IRS intend to issue proposed regulations or other guidance under Code section 4980H (which imposes shared responsibility on large employers with respect to coverage of full-time employees). That guidance is expected to address the intersection of the Code section 4980H rules and the PHS Act section 2708 rules applicable to the 90-day waiting period limitation and will be coordinated with upcoming tri-Department proposed rules under PHS Act section 2708 (discussed below). Treasury and the IRS are mindful of employers? requests for safe harbors and simplicity and will seek to accommodate those requests to the extent feasible and consistent with the terms of the statute. The upcoming guidance is expected to provide that, at least for the ?rst three months following an employee?s date of hire, an employer that sponsors a group health plan will 1239 2017--01339 not, by reason of failing to offer coverage to the employee under its plan during that three-month period, be subject to the employer responsibility payment under Code section 4980H. (FAQs from Employers Regarding Automatic Enrollment, Employer Shared Responsibility, and Waiting Periods {02/09/12) Q4. For purposes of determining whether an employee (other than a newly-hired employee) is a full-time employee for purposes of Code section 4980H, do Treasury and the IRS intend to issue proposed regulations or other guidance allowing employers to use a look-back/stability period safe harbor, based on the approach outlined in IRS Notice 2011-36? A4. Yes. Having reviewed the comments in response to IRS Notice 2011-36, Treasury and the IRS intend to issue proposed regulations or other guidance that would allow employers to use a ?look-back/stability period safe harbor? method based on the approach outlined in the Notice for purposes of determining whether an employee (other than a newly-hired employee) is a full-time employee. Accordingly, it is anticipated that the guidance will allow look-back and stability periods not exceeding 12 months. For a description of anticipated guidance regarding newly-hired employees, see (FA 08 from Employers Regarding Automatic Enrollment, Employer Shared Responsibility, and Waiting Periods {02/09/12) Q5. For purposes of determining whether a newly-hired employee is a full-time employee, do Treasury and the IRS intend to issue proposed regulations or other guidance under Code section Updated 1-31-17 A5. Yes. Treasury and the IRS also intend to issue proposed regulations or other guidance that will address how to determine whether a newly-hired employee is a full- time employee for purposes of Code section 4980H. As stated in the upcoming guidance is expected to provide that, at least for the ?rst three months following an employee?s date of hire, an employer that sponsors a group health plan will not, by reason of failing to offer coverage to the employee under its plan during that three-month period, be subject to the employer responsibility payment under Code section 4980H. The guidance is also expected to provide that, in certain circumstances, employers have six months to determine whether a newly-hired employee is a full-time employee for purposes of section 4980H and will not be subject to a section 4980H payment during that six-month period with respect to that employee. Treasury and the IRS intend to propose an approach under which the period of time that an employer will have to determine whether a newly-hired employee is a full-time employee (within the meaning of section 4980H) will depend upon whether, based on the facts and circumstances, the employee is reasonably expected as of the time of hire to work an average of 30 or more hours per week on an annual basis and the employee?s first three months of employment are reasonably viewed, as of the end of that period, as representative of the average hours the employee is expected to work on an annual basis. Specifically, it is intended that the upcoming proposed regulations or other guidance would provide, for purposes of section 4980H, that: . If a newly-hired employee is reasonably expected to work full-time on an annual 1240 2017-?01340 Updated 1-31-17 basis and does work full?time during the ?rst three months of employment, the employee must be offered coverage under the employer?s group health plan as of the end of that period in order to avoid the possibility that the employer would be subject to a section 4980H payment after the end of that three-month period. If, based on the facts and circumstances as of the time of hire, it cannot reasonably be determined that a newly-hired employee is expected to work full-time, the following rules will apply for purposes of determining whether the newly-hired employee is considered a full-time employee in applying section 4980H with respect to the employer?s group health plan: 0 If the employee works full-time during the first three months of employment, and the employee?s hours during that period are reasonably viewed, as of the end of that period, as representative of the average hours the employee is expected to work on an annual basis, the employee will ?rst be considered a full-time employee for purposes of section 4980H as of the end of that three-month period. (If the employee works part-time during the ?rst three months of employment, then no section 4980H penalty applies during the ?rst or second three month period.) 0 If the employee works full-time during the first three months of employment, but the employee?s hours during that period are reasonably viewed, as of the end of that period, as not representative of the average hours the employee is expected to work on an annual basis, the plan is permitted an additional three-month period to determine the employee?s status, and no section 4980H payment would be required with respect to that employee during the ?rst or second three-month periods. (If the employee works part-time during the second three months of employment, then no section 4980H penalty applies during the ?rst, second, or third three-month period.) This policy describes the applicability of a potential section 4980H payment with respect to newly-hired employees. Forthcoming guidance is expected also to coordinate the rules for newly-hired employees with those applicable to other employees (including employees who are transferred from one employment classi?cation or status to another). The following examples illustrate the intended approach described above: Example 1: Newly-hired employee expected to work full time. Facts: Employer D, an applicable large employer an employer with at least 50 full- time equivalent employees), hires Employee as a computer programmer on December 1. Employee is expected to work full-time on an annual basis and does work full-time for the months of December, January, and February. Employer offers health coverage to its full-time workers (and their dependents). Conclusion: Employee must be able to enroll in coverage beginning in March or the employer potentially would be subject to a section 4980H payment. However, failure to offer coverage to Employee during the ?rst three months (December-February) would not subject Employer to a potential section 4980H payment. 1241 2017-?01341 Example 2: Newly-hired employee who seasonally works full-time Facts: Same as Example 1 except that Employer hires Employee as a salesperson who is expected to work full-time during the holiday season and part-time the rest of the year. Employee works an average of 35 hours per week in December, January, and February and 20 hours per week in March, April, and May. Conclusion: If, based on the facts and circumstances at the end of the period, the three-month period of December through February is reasonably viewed as not representative of the average hours Employee is reasonably expected to work on an annual basis, Employer may use a second three-month period (March-May) as a look- back period. Failure to offer coverage under Employer D?s group health plan to Employee during the ?rst (December-February) and the second (March-May) three- month periods would not subject Employer to a potential section 4980H payment. (Failure to offer coverage to Employee for June also would not subject Employer to a potential section 4980H payment because Employee was determined to be part-time during the March-May look-back period.) (FA OS from Employers Regarding Automatic Enrollment, Employer Shared Responsibility, and Waiting Periods {02/09/12) 06. When PHS Act section 2708 (which imposes a 90-day limitation on waiting periods) becomes effective in 2014, will it require an employer to offer coverage to part-time employees or to any other particular category of employees? A6. No. Many employers make distinctions in eligibility for coverage based on full-time or part-time status, as de?ned by the employer's group health plan (which may differ from the standard under Code section 4980H). PHS Act section 2708 does not require the employer to offer coverage to any particular employee or class of employees, including part-time employees. PHS Act section 2708 merely prohibits requiring an othen/vise eligible employee to wait more than 90 days before coverage is effective. Furthermore, nothing in the Affordable Care Act penalizes small employers for choosing not to offer coverage to any employee, or large employers for choosing to limit their offer of coverage to full-time employees, as defined in the employer shared responsibility provisions. (FAQS from Employers Regarding Automatic Enrollment, Employer Shared Responsibility, and Waiting Periods {02/09/12) Q7. How do the Departments intend to address the application of the 90-day waiting period limitation in PHS Act section 2708 to an offer of coverage by an employer? Updated 1-31-17 A7. Having reviewed the comments in response to IRS Notice 2011-36, the Departments intend to retain, for purposes of PHS Act section 2708, the de?nition in existing regulations that the 90-day waiting period begins when an employee is othenlvise eligible for coverage under the terms of the group health plan. This is the de?nition of waiting period used for purposes of Title XXVII of the PHS Act, Part 7 of ERISA, and chapter 100 of the Code.6 Under this approach, if a plan were to provide that full-time employees are eligible for coverage without satisfying any other condition, and an employee were hired as a full-time employee, the waiting period (if the employer were to choose to impose one) for that employee would begin on the date of hire and could not exceed 90 days. Consistent with PHS Act section 2708, eligibility conditions that are based solely on the lapse of a time period would be permissible for no more than 90 days. Other conditions for eligibility under the terms of a group health plan would generally be 1242 2017-?01342 Updated 1-31-17 permissible under PHS Act section 2708, unless the condition is designed to avoid compliance with the 90-day waiting period limitation. For example, eligibility conditions such as full-time status, a bona fide job category, or receipt of a license would be permissible. The upcoming guidance under section 2708 is also expected to address situations in which, under the terms of an employer?s plan, employees (or certain classes of employees) are eligible for coverage once they complete a speci?ed cumulative number of hours of service within a specified period (such as 12 months). It is anticipated that, under the upcoming guidance, such eligibility conditions will not be treated as designed to avoid compliance with the 90-day waiting period limitation so long as the required cumulative hours of service do not exceed a number of hours to be speci?ed in that guidance. Comments are requested on how this possible approach would apply to plans that credit hours of service from multiple different employers and plans that use hours banks. Example 3: Employee ineligible under terms of plan by reason ofjob classification Facts: Same as Example 1 except that Employer D?s plan does not cover computer programmers. Conclusion: Unlike Code section 4980H, in which the determination of full-time status is governed by a statutory standard (working an average of 30 hours per week), the waiting period limitation under PHS Act 2708 applies only to employees who are otherwise eligible under the terms of the plan. Because Employee is excluded under the plan?s eligibility criteria, and the plan?s terms are not designed to avoid compliance with PHS Act section 2708, the plan?s eligibility provision does not violate PHS Act section 2708. Example 4: Part-time employee, hours of service requirement Facts: Employer hires Employee to work 20 hours per week. Employer E?s plan requires part-time employees to complete 750 hours of service in order to participate. Solely for purposes of illustration in this example, it is assumed that upcoming guidance under PHS Act section 2708 permits plans to require part-time employees to complete up to, but no more than, 750 hours of service in order to participate. Conclusion: Part-time employees who work 20 hours per week will complete 750 hours of service in 37 weeks orjust under 9 months. The waiting period under PHS Act section 2708 begins when Employee satisfies the cumulative service requirement, thereby becoming eligible (but for the waiting period) for coverage under the plan. Employer must provide coverage to Employee no later than 90 days after Employee completes 750 hours of service, which is about one year after Employee 2 is hired and begins working part-time. (No Code section 4980H payment applies because Employee is part-time.) (FAQs from Employers Regarding Automatic Enrollment, Employer Shared Responsibility, and Waiting Periods (02/09/12) 1243 2017-?01343 Disclosure under PHSA 2715(d)(4) Q4: When are group health plans and health insurance issuers required to comply with the notice requirement in PHS Act section 2715 which generally requires a 60-day prior notice for material modifications to the plan or coverage? PHS Act section 2715 as added by the Affordable Care Act generally provides, among other things, that not later than 12 months after the date of enactment of the Affordable Care Act, the Departments must develop standards for use by group health plans and health insurance issuers in compiling and providing a summary of benefits and coverage explanation that accurately describes the bene?ts and coverage under the applicable plan or coverage and, not later than 24 months after the date of enactment, plans and issuers must begin to provide the summary pursuant to the standards. PHS Act section 2715(d)(4) generally provides that if a group health plan or health insurance issuer makes any material modi?cation in any of the terms of the plan or coverage involved (as de?ned for purposes of section 102 of the Employee Retirement Income Security Act that is not reflected in the most recently provided summary of bene?ts and coverage, the plan or issuer must provide notice of such modi?cation to enrollees not later than 60 days prior to the date on which such modi?cation will become effective. Accordingly, it is the view of the Departments that group health plans and health insurance issuers are not required to comply with the 60-day prior notice requirement for material modi?cations in PHS Act section 2715 until plans and issuers are required to provide the summary of bene?ts and coverage explanation pursuant to the standards issued by the Departments.(1) The Departments have not yet issued the standards. (DOL FAQs Part 12/22/10) Preexisting Condition Exclusions for Children in the Individual Market 06: Some States have expressed an interest in permitting issuers to screen applicants for eligibility for alternative coverage options before offering a child-only policy. Is this allowed? Updated 1-31-17 Yes, under certain circumstances, issuers may screen applicants for eligibility for alternative coverage options before offering a child-only policy, provided this practice is permitted under State law. Screening is limited to circumstances in which all child-only applicants, regardless of health status, undergo the same screening process, and the alternative coverage options include options for which healthy children would potentially be eligible, such as the Children?s Health Insurance Program (CHIP) and group health insurance. Screening may not be limited to programs targeted to individuals with a pre-existing condition, such as the state high-risk pool or Pre-existing Condition Insurance Plan (PCIP). Note that Medicaid policy, under 42 U.S.C.A. 1396a prohibits participating States from allowing health issuers to consider whether an individual is eligible for, or is provided medical assistance under, Medicaid in making enrollment decisions. Furthermore, issuers may not implement a screening process that by its operation signi?cantly delays enrollment or artificially engineers eligibility of a child for a program targeted to individuals with a pre-existing condition. Additionally, the screening 1 244 2017-?01344 process may not be applied to offers of dependent coverage for children given the new Affordable Care Act requirement of offering coverage to dependents up to age 26. States are encouraged, subject to State law, to require issuers that screen for other coverage to enroll and provide coverage to the applicant effective on the first date that the child-only policy would have been effective had the applicant not been screened for an alternative coverage option. States are also encouraged to impose a reasonable time limit, such as 30 days, at which time the issuer would have to enroll the child regardless of pending applications for other coverage. Finally, nothing in this FAQ should be construed to relieve the issuer of its obligation to enroll a child applicant in coverage. (DOL FAQs Part 12/22/10) Mental Health Parity 08: After the amendments made by the Affordable Care Act, are small employers still exempt from the MHPAEA requirements? How is ?small employer? defined? Yes, small employers are still exempt. Although there were changes to the de?nition of ?small employer? for other purposes under the Affordable Care Act, ERISA and the Code continue to de?ne a small employer as one that has 50 or fewer employees. Accordingly, for group health plans and health insurance issuers subject to ERISA and the Code, the Departments will continue to treat group health plans of employers with 50 or fewer employees as exempt from the MHPAEA requirements under the small employer exemption, regardless of any State insurance law de?nition of small employer. For nonfederal governmental plans, the PHS Act was amended by the Affordable Care Act to define a small employer as one that has 100 or fewer employees. (DOL FAQs Part 12/22/10) 09: I am an in-network health care provider and one of my patients is having trouble getting benefits paid for a mental health condition or substance use disorder. Am I entitled to receive a copy of the criteria for medical necessity determinations made by the patient?s plan or health insurance coverage? Yes. MHPAEA and its implementing regulations state that the criteria for medical necessity determinations made under a plan or health insurance coverage with respect to mental health or substance use disorder bene?ts must be made available by the plan administrator or health insurance issuer to any current or potential participant, beneficiary, or contracting provider upon request. (DOL FAQs Part 12/22/10) Q10: was denied benefits for mental health treatment by my plan because the plan determined that the treatment was not medically necessary. I requested and received a copy of the criteria for medical necessity determinations for mental health and substance use disorder treatment, and the reason for denial. I think my plan is applying medical necessity standards more strictly to benefits for mental health and substance use disorder treatment than for medical/surgical benefits. How can I obtain information on the medical necessity criteria used for medical/surgical benefits? Under ERISA, documents with information on the medical necessity criteria for both medical/surgical bene?ts and mental health/substance use disorder benefits are plan documents, and copies of plan documents must be furnished within 30 days of your 1245 Updated 1-31-17 2017--01345 request. See ERISA regulations at 29 CFR 2520.104b-1. Additionally, if a provider or other individual is acting as a patient?s authorized representative in accordance with the Department of Labor's claims procedure regulations at 29 CFR 2560.503-1, the provider or other authorized representative may request these documents. If your plan is not subject to ERISA (for example, a plan maintained by a State or local government), you should check with your plan administrator. (DOL FAQs Part 12/22/10) Q11: MHPAEA contains an increased cost exemption. How does a plan claim this exemption? MHPAEA contains an increased cost exemption that is available for plans that make changes to comply with the law and incur an increased cost of at least two percent in the ?rst year that MHPAEA applies to the plan (the ?rst plan year beginning after October 3, 2009) or at least one percent in any subsequent plan year (generally, plan years beginning after October 3, 2010). If such a cost is incurred, the plan is exempt for the plan year following the year the cost was incurred. Thus, the exemption lasts one year. After that, the plan is required to comply again; however, if the plan incurs an increased cost of at least one percent in that plan year, the plan could claim the exemption for the following plan year. The Departments' interim ?nal regulations implementing MHPAEA did not provide guidance for implementing the increased cost exemption. Accordingly, during an interim enforcement safe harbor until future regulatory guidance is effective, a plan that has incurred an increased cost of two percent during its ?rst year of compliance can obtain an exemption for the second plan year by following the exemption procedures described in the Departments? 1997 MHPA regulations (62 FR 66932, December 22, 1997)(4), except that, as required under MHPAEA, for the ?rst year of compliance the applicable percentage of increased cost is two percent and the exemption lasts only one year. Calculations of increased costs due to MHPAEA should include increases in a plan's share of cost sharing. Moreover, any non-recurring administrative costs (such as adjustments to computer software) attributable to complying with MHPAEA must be appropriately amortized. Plans applying for an exemption must demonstrate that increases in cost are attributable directly to implementation of MHPAEA and not otherwise to occurring trends in utilization and prices, a random claims experience that is unlikely to persist, or seasonal variation typically experienced in claims submission and payment patterns. (DOL FAQs Part 12/22/10) 02: For all mental health and substance use disorder benefits, my group health plan requires prior authorization from the plan?s utilization reviewer that a treatment is medically necessary, but the plan does not require such prior authorization for any medical/surgical benefits. Is this permissible? Updated 1-31-17 No. The plan is applying a nonquantitative treatment limitation to mental health and substance use disorder benefits that is not applied to medical/surgical benefits. This violates prohibition on separate treatment limitations that are applicable only to mental health or substance use disorder bene?ts. (DOL FAQs Part 11/17/11) 1246 2017-?01346 Q3: My group health plan requires prior authorization from the plan?s utilization reviewer that a treatment is medically necessary for all inpatient medical/surgical benefits and for all inpatient mental health and substance use disorder benefits. In practice, inpatient bene?ts for medical/surgical conditions are routinely approved for seven days, after which a treatment plan must be submitted by the patient?s attending provider and approved by the plan. On the other hand, for inpatient mental health and substance use disorder benefits, routine approval is given for only one day, after which a treatment plan must be submitted by the patient?s attending provider and approved by the plan. Is this permissible? No. The plan is applying a stricter nonquantitative treatment limitation in practice to mental health and substance use disorder bene?ts than is applied to medical/surgical benefits. While some differences in prior authorization practices with respect to individual conditions or treatments might be permissible based on recognized clinically appropriate standards of care, the interim final regulations do not permit a plan to apply stricter nonquantitative treatment limitations to all benefits for mental health or substance use disorders than those applied to all medical/surgical bene?ts. The application of nonquantitative treatment limitations -- both with respect to the plan?s benefits and its care management practices -- must comply with the nonquantitative treatment limitation rules. (DOL FAQs Pant 11/17/11) Q4: My group health plan considers a wide array of factors in designing medical management techniques for both mental health/substance use disorder benefits and medical/surgical bene?ts, such as cost of treatment; high cost growth; variability in cost and quality; elasticity of demand; provider discretion in determining diagnosis, or type or length of treatment; clinical efficacy of any proposed treatment or service; licensing and accreditation of providers; and claim types with a high percentage of fraud. Based on application of these factors in a comparable fashion, prior authorization is required for some (but not all) mental health and substance use disorder benefits, as well as for some medical/surgical benefits, but not for others. For example, under my plan, prior authorization is required for: outpatient surgery; speech, occupational, physical, cognitive and behavioral therapy extending for more than six months; durable medical equipment; diagnostic imaging; skilled nursing visits; home infusion therapy; coordinated home care; pain management; high-risk prenatal care; delivery by cesarean section; mastectomy; prostate cancer treatment; narcotics prescribed for more than seven days; and all inpatient services beyond 30 days. The evidence considered in developing its medical management techniques includes consideration of a wide array of recognized medical literature and professional standards and protocols (including comparative effectiveness studies and clinical trials). This evidence and how it was used to develop these medical management techniques is also well documented. Has my plan complied with the nonquantitative treatment limitation rules? Yes. It appears that, under the terms of the plan as written and in practice, the processes, strategies, evidentiary standards, and other factors considered by the plan in implementing its prior authorization requirement with respect to mental health and substance use disorder benefits are comparable to, and applied no more stringently than, those applied with respect to medical/surgical bene?ts. (DOL FAQs Part VII 1 1/17/1 1) 1247 Updated 1-31-17 2017-?01347 05: I am an employer considering several health insurance policy options. One health insurance policy requires prior authorization for all outpatient mental health benefits but only a few types of outpatient medical/surgical benefits (outpatient surgery; speech, occupational and physical therapy; and skilled home nursing visits.) Is this permissible? While some differences in plan requirements for prior authorization might be permissible based on recognized clinically appropriate standards of care, it is unlikely that the processes, strategies, evidentiary standards, and other factors considered by the plan in determining that those three (and only those three) outpatient medical/surgical bene?ts require prior authorization would also result in all outpatient mental health and substance use disorder outpatient bene?ts needing prior authorization. (DOL FAQs Pan? VII 1 1/17/1 1) 06: A plan applies concurrent review to inpatient care where there are high levels of variation in length of stay (as measured by a coefficient of variation exceeding 0.8). In practice, the application of this standard affects 60 percent of mental health conditions and substance use disorder conditions, but only 30 percent of medical/surgical conditions. Is this permissible? Yes. The evidentiary standard used by the plan is applied no more stringently for mental health and substance use disorder bene?ts than for medical/surgical benefits, even though it results in an overall difference in the application of concurrent review for mental health conditions or substance use disorders than for medical/surgical conditions. (DOL FAQs Part VII 11/17/11) Q7: Is my group health plan always limited in the amount that it can charge for all mental health/substance use disorder providers to the same rate as medical/surgical generalists? No. The standard for determining the maximum copayment that can be applied to mental health/substance use disorder benefits is determined by the predominant copayment that applies to substantially all medical/surgical bene?ts within a classi?cation. If the copayment that meets this standard is the one charged for a medical/surgical specialist, that copayment can be charged for all mental health/substance use disorder bene?ts within that classi?cation. On the other hand, if the copayment that meets this standard is the one charged for a medical/surgical generalist, then that is the copayment that can be charged to all mental health/substance use disorder benefits within that classi?cation. (DOL FAQs Part 11/17/11) Q12: What was the effect of the Affordable Care Act on The Affordable Care Act builds on MHPAEA and provides that mental health and substance use disorder services are one of ten EHB categories. Under the EHB rule, non-grandfathered health plans in the individual and small group markets are required to comply with the requirements of the parity regulations to satisfy the requirement to provide EHB. In addition, section 1563 of the Affordable Care Act extends the protections of MHPAEA to the entire individual market, both with respect to grandfathered and non-grandfathered coverage.(19) Therefore: 1248 Updated 1-31-17 2017--01348 For non-grandfathered individual market coverage: For policy years beginning on or after January 1, 2014, all non-grandfathered individual market coverage that is not othen/vise subject to the HHS transitional policy(20) must include coverage for mental health and substance use disorder benefits, and that coverage must comply with the Federal parity requirements set forth in the interim ?nal regulations issued in February 2010. The final regulations apply for policy years beginning on or after July 1, 2014 (which, for calendar year policies, is January 1, 2015). For grandfathered individual market coverage: Grandfathered individual health insurance coverage is not subject to the EHB requirements and therefore is not required to cover mental health or substance use disorder bene?ts. However, to the extent mental health or substance use disorder benefits are covered under the policy, coverage must comply with the Federal parity requirements set forth in ?nal regulations for policy years beginning on or after July 1, 2014 (which, for calendar year policies, is January 1, 2015). For non-grandfathered small group market coverage: For plan years beginning on or after January 1, 2014, all non-grandfathered small group market coverage that is not othen/vise subject to the HHS transitional policy must include coverage for mental health and substance use disorder benefits, and that coverage must comply with the Federal parity requirements set forth in the interim ?nal regulations issued in February 2010. The final regulations apply for plan years beginning on or after July 1, 2014 (which, for calendar year plans, is January 1, 2015). Grandfathered small group market coverage is not required to comply with either the EHB provisions or MHPAEA. HHS has also released guidance explaining how the Federal parity requirements will be applied to the Children's Health Insurance Program (CHIP), Medicaid managed-care organizations, and to Alternative Benefit Plans. See the January 16, 2013 letter from CMS to State Medicaid Directors.(21) (DOL FAQs Part 01/09/14) Q1: When are the final rules effective for group coverage? MHPAEA's statutory provisions generally became effective for plan years beginning after October 3, 2009. Interim ?nal rules under MHPAEA generally became applicable for plan years beginning on or after July 1, 2010. The ?nal rules generally apply to group health plans and health insurance issuers offering group health insurance coverage for plan years beginning on or after July 1, 2014. Until the applicability date of the ?nal rules, plans and issuers subject to MHPAEA must continue to comply with the interim ?nal rules. (DOL FAQs Pan? 11/08/13) 02: When do the ?nal rules apply to individual health insurance coverage? Updated 1-31-17 The Affordable Care Act amended the PHS Act to apply MHPAEA to health insurance issuers offering individual health insurance coverage (both through the Health Insurance Marketplaces, also known as Exchanges, and outside the Marketplaces). These changes are effective for policy years beginning on or after January 1, 2014. The final rules apply to individual health insurance coverage for policy years beginning on or after July 1, 2014 and apply to both grandfathered and non-grandfathered plans. (DOL FAQs Pan? XVII 1 1/08/13) 1249 2017-?01349 Q3: What new protections do the final rules provide for individuals? The interim final rules contained an exception for differences in nonquantitative treatment limitations between medical/surgical benefits and mental health or substance use disorder bene?ts based on "clinically appropriate standards of care." This exception has been determined to be confusing, unnecessary, and subject to potential abuse. The underlying requirements regarding nonquantitative treatment limitations (even without this exception) are sufficiently ?exible to allow plans and issuers to take into account clinical and other appropriate standards when applying nonquantitative treatment limitations such as medical management techniques to medical/surgical benefits and mental health or substance use disorder bene?ts. Thus, the ?nal rules have eliminated this exception. The ?nal rules also apply parity requirements to bene?ts for intermediate levels of care for mental health conditions and substance use disorders. The ?nal rules accomplish this by providing that plans and issuers ?rst identify what is meant by an intermediate service for mental health and substance use disorder care and medical/surgical care and requiring that such intermediate level services be treated comparably within the structure of plan benefits. Under the final rules, parity requirements for nonquantitative treatment limitations also apply to restrictions based on geographic location, facility type, provider specialty, and other criteria that limit the scope or duration of bene?ts for services (including access to intermediate level services). Finally, the final rules clarify the disclosure rights of plan participants with respect to both mental health and substance use disorder bene?ts and medical/surgical bene?ts. See QB regarding the type of information that individuals can receive from their plans and issuers under Federal law. (DOL FAQs Part XVII 11/08/13) Q4: What are the Departments doing to promote compliance? Updated 1-31-17 The Departments are working with plans, issuers, and their service providers to help them understand and come into compliance with MHPAEA and to ensure that individuals receive the bene?ts they are entitled to under the law. The Departments also coordinate with State regulators both individually and through the National Association of Insurance Commissioners to ensure compliance and issue guidance to address frequently asked questions from stakeholders. Compliance assistance is a high priority and the Departments' approach to implementation is marked by an emphasis on assisting plans and issuers that are working diligently and in good faith to comply with the requirements of the law. The Departments receive complaints from group health plan participants and bene?ciaries, enrollees in individual market health coverage, providers, and other stakeholders and work with these individuals and the regulated community to correct violations. The Departments also engage in extensive outreach and compliance assistance activities throughout the year on MHPAEA. For a copy of MHPAEA outreach publications, and to get information on upcoming events, see and factsheet.html. (DOL FAQs Part XVII 11/08/13) 1250 2017--01350 Q5: Do the ?nal rules address multiple provider network tiers? Yes. The final rules permit plans and issuers to use multiple provider network tiers, provided they are consistent with the parity requirements. (DOL FAQs Part XVII 1 1/08/13) 06: Are there plans that are exempt from Yes. MHPAEA applies to most employment-based group health coverage, but there are a few exceptions. MHPAEA contains an exemption for a group health plan of a small employer.(4) Nevertheless, under HHS final rules governing the Affordable Care Act requirement to provide essential health benefits (EHBs), non-grandfathered health insurance coverage in the individual and small group markets must provide all categories of EHBs, including mental health and substance use disorder bene?ts. The ?nal EHB rules require that such bene?ts be provided in compliance with the requirements of the MHPAEA rules.(5) MHPAEA also contains an increased cost exemption available to plans that meet the requirements for the exemption. The ?nal rules establish standards and procedures for claiming an increased cost exemption under MHPAEA. Additionally, plans for State and local government employees that are self-insured may opt-out of MHPAEA's requirements if certain administrative steps are taken.(6) Finally, MHPAEA does not apply to retiree-only plans. (DOL FAQs Part XVII 11/08/13) Q7: For a plan or issuer claiming the increased cost exemption, where should the plan or issuer send its notice to the Departments? Updated 1-31-17 The increased cost exemption is not effective until 30 days after notice has been sent to group health plan participants and bene?ciaries, enrollees in individual market health coverage, and to the appropriate Federal agency. For notice to the Federal Government: 0 An ERISA plan, or a health insurance issuer offering coverage in connection with such plan, must notify the Department of Labor at: Of?ce of Health Plan Standards and Compliance Assistance Employee Benefits Security Administration US. Department of Labor ATTN: Increased Cost Exemption for MHPAEA 200 Constitution Avenue, NW. Suite N-5653 Washington, DC 20210 . A group health plan that is a non-Federal governmental plan (or a health insurance issuer offering coverage in connection with such plan) or a health insurance issuer offering health insurance coverage in the individual market must notify HHS at: Centers for Medicare Medicaid Services (CMS) Center for Consumer Information and Insurance Oversight (CCIIO) ATTN: Increased Cost Exemption for MHPAEA 200 Independence Avenue, SW Room 737F Washington, DC 20201 1251 2017-?01351 Or via facsimile to 301-492-4462 or via e-mail to marketreform@cms.hhs.qov. . A group health plan that is a church plan (as de?ned in section 414(e) of the Code), or a health insurance issuer offering coverage in connection with such plan, must notify the Department of the Treasury. Notice should be sent to: MHPAEA Increased Cost Exemption Notice Of?ce of Division Counsel/Associate Chief Counsel (TEGE) Room 4300 1111 Constitution Avenue, NW Washington, DC 20224 (DOL FAQs Pan? XVII 11/08/13) 08: My plan uses medical management techniques (such as preauthorization) to manage care for mental health and substance use disorder services, and my mental health bene?ts were denied. What information am I entitled to receive from my plan? Updated 1-31-17 MHPAEA provides that the criteria for medical necessity determinations with respect to mental health or substance use disorder bene?ts must be made available by the plan administrator or the health insurance issuer to any current or potential participant, bene?ciary, or contracting provider upon request. In addition, under MHPAEA, the reason for any denial of reimbursement or payment for services with respect to mental health or substance use disorder bene?ts must be made available to participants and bene?ciaries. Furthermore, under the internal appeals and external review requirements added by the Affordable Care Act, non-grandfathered group health plans and health insurance issuers must provide to an individual (or a provider or other individual acting as a patient's authorized representative), upon request and free of charge, reasonable access to and copies of all documents, records, and other information relevant to the individual's claim for benefits consistent with the Department of Labor claims procedure regulation.(7) This includes documents of a comparable nature with information on medical necessity criteria for both medical/surgical bene?ts and mental health and substance use disorder bene?ts, as well as the processes, strategies, evidentiary standards, and other factors used to apply a nonquantitative treatment limitation with respect to medical/surgical bene?ts and mental health or substance use disorder bene?ts under the plan. In addition, the plan or issuer must provide the claimant with any new or additional evidence considered, relied upon, or generated by the plan or issuer (or at the direction of the plan or issuer) in connection with a claim. If the plan or issuer is issuing an adverse benefit determination on review based on a new or additional rationale, the claimant must be provided, free of charge, with the rationale. Additionally, under ERISA, documents with information on medical necessity criteria for both medical/surgical and mental health or substance use disorder bene?ts, as well as the processes, strategies, evidentiary standards, and other factors used to apply a nonquantitative treatment limitation, are instruments under which the plan is established or operated, and copies must be furnished to a participant within 30 days of request. (DOL FAQs Part XVII 11/08/13) 1252 2017-?01352 09: How can I obtain more information about my health plan benefits and As stated in Q8, the ?nal rules clarify that participants and bene?ciaries in ERISA group health plans are entitled to request certain speci?c information with respect to both mental health and substance use disorder bene?ts and medical/surgical bene?ts, which may be helpful in determining whether or not a plan is complying with MHPAEA. Additional information and FAQs regarding MHPAEA are available on the Department of Labor's MHPAEA webpage at and the Department of Health and Human Services' webpage at factsheet.htm . If you have additional questions regarding compliance with MHPAEA, you may contact HHS by calling toll free at 1-877-267-2323 extension 6-1565 or emailinqphiq@cms.hhs.qov, or you may contact a benefit advisor in one of the Department of Labor's regional offices at or by calling toll free at 1-866-444-3272. Regardless of which number you call, the Federal Departments will work together and with the States, as appropriate, to ensure MHPAEA violations are addressed. The Departments request comments on what additional steps, consistent with the statute, should be taken to ensure compliance with MHPAEA through health plan transparency, including what other disclosure requirements would provide more transparency to participants, beneficiaries, enrollees, and providers, especially with respect to individual market insurance, non-Federal governmental plans, and church plans. Please send comments by January 8, 2014 to (DOL FAQs Part XVII 11/08/13) Q12: I am a participant in a group health plan that provides treatment for anorexia as a mental health benefit. In accordance with the plan terms, my provider, on my behalf, requested prior authorization for a 30-day inpatient stay to treat my anorexia. The request was denied based on the plan?s determination that a 30-day inpatient stay is not medically necessary under the plan terms. I then requested from the plan administrator a copy of its medical necessity criteria for both medical/surgical and benefits (including anorexia), as well as any information regarding the processes, strategies, evidentiary standards, or other factors used in developing the medical necessity criteria and in applying them. May the plan administrator deny me this information based on an assertion that the information is ?proprietary? and/or has ?commercial value?? No. The criteria for making medical necessity determinations, as well as any processes, strategies, evidentiary standards, or other factors used in developing the underlying NQTL and in applying it, must be disclosed with respect to both bene?ts and medical/surgical bene?ts, regardless of any assertions as to the proprietary nature or commercial value of the information. Whether a plan that is subject to ERISA can refuse to provide ?instruments under which the plan is established or operated" on the basis that the information is ?proprietary? was speci?cally addressed in the Department of Labor?s Advisory Opinion The 1253 Updated 1-31-17 2017--01353 Advisory Opinion rejected that basis for refusal. In that Advisory Opinion, the Department of Labor stated that any documents or instruments that specify formulas, methodologies, or schedules to be applied in determining or calculating a participant's or bene?ciary?s bene?t entitlement under an employee bene?t plan (in that case, a schedule of a plan's usual and customary fees) would constitute ?instruments under which the plan is established or operated,? and must be provided, notwithstanding that the plan asserted that such fee schedules are of a proprietary? nature. Such information must be disclosed, even in cases where the source of the information is a third-party commercial vendor. (DOL FAQs Part XXIX 10/23/15) Q13: Can my plan, upon request, provide a summary description of the medical necessity criteria for both benefits and medical/surgical benefits that is written to be understandable for a layperson? Yes. Although not required to do so, group health plans and issuers can provide a document that provides a description of the medical necessity criteria in layperson?s terms. However, providing such a summary document is not a substitute for providing the actual underlying medical necessity criteria, if such documents are requested. (DOL FAQs Part XXIX 10/23/15) 08: When performing "substantially all" and "predominant" tests for financial requirements and quantitative treatment limitations under MHPAEA, may a plan or issuer base the analysis on an issuer's entire overall book of business for the year? Updated 1-31-17 No. Basing the analysis on an issuer's entire overall book of business expected to be paid for the year or book of business in a specific region or State is not a reasonable method to determine the dollar amount of all plan payments under MHPAEA. To the extent group health plan-speci?c data is available, each self-insured group health plan must use such data in making their projections. For large fully-insured group health plans, for which the premiums are determined on an experience-rated basis, the issuer should generally have group health plan-speci?c data to make projections. If a large, fully-insured plan does not have suf?cient group health plan-specific data to make projections, data from other similarly-structured group health plans with similar demographics can be utilized for the analysis. For insured small group and individual market plans, the health insurance issuer should use data at the "plan" level (as opposed to the "product" level) to perform the substantially all and predominant analyses, as such terms are defined in 45 CFR 144.1031?) If an issuer does not have suf?cient data to calculate the substantially all and predominant tests at the plan level, it can use data at the product level to inform its projections of expected spending in the bene?t classification at issue (provided that the issuer can demonstrate the validity of the projection method based on the best available data). (DOL FAQs Part 31 04/20/16) 1254 2017-?01354 09: I am a provider acting as an authorized representative for an ERISA group health plan participant. The health plan has requested that I complete a pre-authorization form after the patient's 9th visit for the treatment of depression. I understand that there are a number of documents that plans must provide upon request. Which of those documents would generally be most helpful for me to request regarding the plan's compliance with Updated 1-31-17 You may request the following documents and plan information, which could be helpful in evaluating the plan's compliance with MHPAEA. While it may not be necessary to review all of the following documents and plan information, the plan must provide any of these documents and plan information to you if requested, when you as a provider are acting as an individual's authorized representative: 1. A Summary Plan Description (SPD) from an ERISA plan, or similar summary information that may be provided by plans; 2. The speci?c plan language regarding the imposition of the NQTL (such as a preauthorization requirement); 3. The speci?c underlying processes, strategies, evidentiary standards, and other factors (including, but not limited to, all evidence) considered by the plan (including factors that were relied upon and were rejected) in determining that the NQTL will apply to this particular bene?t; 4. Information regarding the application of the NQTL to any medical/surgical bene?ts within the bene?t classification at issue; 5. The speci?c underlying processes, strategies, evidentiary standards, and other factors (including, but not limited to, all evidence) considered by the plan (including factors that were relied upon and were rejected) in determining the extent to which the NQTL will apply to any medical/surgical bene?ts within the bene?t classification at issue; and 6. Any analyses performed by the plan as to how the NQTL complies with MHPAEA. For example, if the plan can demonstrate that it imposes pre-authorization requirements for both and medical/surgical benefits in the outpatient, in-network classification when the length of treatment for a condition exceeds the national average length of treatment by 10% or more, it has identi?ed a factor on which the NQTL is based. Furthermore, to the extent the plan can document, via studies, schedules or similar documents that contain relevant information or data, that the national average length of outpatient treatment for depression is eight visits, it has identi?ed an evidentiary standard used to evaluate the factor. Finally, by applying the eight visit standard to the case at hand, it demonstrates how the evidentiary standard is applied and the result. Accordingly, to be in compliance with the MHPAEA and ERISA disclosure requirements, the plan must furnish to the provider suf?cient documentation of the NQTL factor, evidentiary standard and the analysis outlined above. Additionally, it must produce documentation of how the factor, evidentiary standard and analysis is applied in the outpatient, in-network classi?cation for medical/surgical bene?ts to demonstrate that the NQTL is not being applied to bene?ts more stringently than to medical/surgical bene?ts in the classification. As the Departments indicated in prior guidance, the fact that any information (including factors and evidentiary standards used for 1255 2017--01355 medical/surgical bene?ts) may be characterized as proprietary or commercially valuable is not legitimate grounds for not providing the information.l38> The information outlined in 1-6 above must also be provided by non-grandfathered health plans under PHS Act section 2719 in instances of internal claims and appeals related to the application of an NQTL to a benefit. (DOL FAQs Part 31 04/20/16) Q10: I'm reviewing my individual market health insurance coverage options. I requested a copy of the medical necessity criteria for coverage of mental health conditions from an issuer, but was told that because I was not enrolled in its coverage, the issuer did not have to provide the criteria to me. Is this correct? No. Under MHPAEA, the criteria for medical necessity determinations under a group health plan or health insurance coverage with respect to benefits must be made available to any current or potential enrollee or contracting provider upon request. (DOL FAQs Part 31 04/20/16) Q11: Does MHPAEA apply to any benefits a plan may offer for Medication Assisted Treatment for opioid use disorder? Yes. Medication Assisted Treatment (MAT) is any treatment for opioid use disorder that includes medication that is FDA-approved for detoxi?cation or maintenance treatment in combination with behavioral health servicesf?) The Departments' ?nal regulations implementing MHPAEA define "substance use disorder bene?ts" as benefits with respect to items or services for substance use disorders, as de?ned under the terms of the plan or health insurance coverage and in accordance with applicable Federal and State law which must be defined to be consistent with generally recognized independent standards of current medical practice.l4?0) Opioid use disorder is a type of substance use disorder and MAT is a "substance use disorder benefit" within the meaning of the term as defined by MHPAEA. Group health plans and issuers that offer MAT benefits must do so in accordance with the requirements of MHPAEA and, accordingly, any financial requirements and treatment limitations may not be more restrictive than the predominant financial requirements and quantitative treatment limitations that apply to substantially all medical and surgical benefits in a classification. In addition, the special rule for multi-tiered prescription drug bene?ts also applies to the medication component of MATE) The behavioral health services components of MAT should be treated as outpatient bene?ts and/or inpatient benefits as appropriate for purposes of MHPAEA. (DOL FAQs Pan? 31 04/20/16) 02: After having a benefit denied by my plan, I?ve asked my plan for documents to show whether the plan is treating benefits differently than medical/surgical benefits, and I haven?t received them (or I don?t know how to interpret them). Is there a government agency that can help? Yes. Depending on the type of plan you have, there may be more than one government agency, including both Federal and State agencies, that can help you to obtain documents or understand the information you receive. There is a now a Parity Consumer Web Portal that can connect you to the appropriate agency to help you. You 1256 Updated 1-31-17 2017--01356 can use to identify the agency that can help you. While different Federal and State agencies may be responsible for providing oversight for and assistance with respect to different plans, the agencies work together to ensure that any MHPAEA violations are corrected. In addition, if your plan is a non-grandfathered individual or group health plan and your claim for bene?ts has been denied for a reason that involves medical judgment (including if you have been denied a benefit and you are challenging the plan?s or issuer?s compliance with respect to parity in the application of its medical management techniques), you can seek external review after exhausting your internal appeals.13 This gives you the right to review of your claim by an independent review organization, without deference to the decision of your plan or issuer. This review will determine whether the plan?s or issuer?s decision was correct. Your plan or issuer will be required to accept a favorable decision for you by the independent review organization. General information regarding requirements is also available on the web at and protections/mhpaea Financial Requirements and Quantitative Treatment Limitations Q3: If a group health plan or health insurance issuer does not have sufficient claims data to do either the MHPAEA substantially all or predominant analyses, what data can the plan or issuer use to conduct the analyses? Updated 1-31-17 In general, if a group health plan or issuer has sufficient claims data for a reasonable projection of future claims costs for the substantially all or predominant analyses as described above, such claims data should be used for these analyses. An issuer?s or third party administrator?s broader book of business should not be used for the analysis, as the broader book of business includes many plans that may have bene?t designs that bear little resemblance to the specific group health plan for which the MHPAEA analysis is being conducted. In certain circumstances, however, there may be insuf?cient reliable claims data for a group health plan, in which case the analyses will require utilizing reasonable data from outside the group health plan. Under the Departments? MHPAEA regulations, group health plans and issuers must use a ?reasonable method? for the substantially all and predominant analyses, which includes using reasonable data to produce reasonable projections. Group health plans and issuers should not use claims data from an issuer?s or third party administrator?s entire book of business in an unreasonable manner to calculate the amount of a particular group health plan?s or issuer?s payments under MHPAEA. A plan or issuer must always use appropriate and sufficient data to perform the analysis in compliance with applicable Actuarial Standards of Practice. For example, if there is not enough claims data, a group health plan significantly changed its bene?t package, a group health plan experienced a signi?cant workforce change that would impact claims costs, or a group health plan (or the plan design) is new, using only group health plan data also may be unreasonable. Accordingly, the Departments clarify that, for large group market and self-insured group health plans, a group health plan or issuer must consider group health plan-level claims 1257 2017-?01357 data to perform the substantially all and predominant analyses and must rely on such data if it is credible to perform the required projections. Similarly, for small group and individual market plans, an issuer must consider ?plan?-leve (as opposed to the ?product?-level) claims data to perform the substantially all and predominant analyses, as such terms are de?ned in 45 CFR 144.103, and must rely on such data if it is credible to perform the required projections.16 However, if an actuary who is subject to and meets the quali?cation standards for the issuance of a statement of actuarial opinion in regard to health plans in the United States,17 including having the necessary education and experience to provide the actuarial opinion, determines that a group health plan or issuer does not have sufficient data at the plan or product level for a reasonable projection of future claims costs for the substantially all or predominant analyses, the group health plan or issuer should utilize other reasonable claims data to make a reasonable projection to conduct actuarially-appropriate analyses. Data from other similarly- structured products or plans with similar demographics may be utilized for the analyses if actuarially appropriate. In addition, to the extent possible, the claims data should be customized to reflect the characteristics of the group health plan to which the substantially all and predominant analyses are being applied. As part of using a ?reasonable method? to make these projections, plans and issuers should document the assumptions used in choosing a data set and making projections. Furthermore, as stated in the preamble to the ?nal regulations, a plan or issuer is not required to perform the parity analysis each plan year unless there is a change in plan bene?t design, cost-sharing structure, or utilization that would affect a ?nancial requirement or treatment limitation within a classi?cation (or (DOL FAQs Part 34 10/27/16) Nonquantitative Treatment Limitations Q4: Prior to authorizing admission to an inpatient, in-network facility for a mental health condition, my group health plan requires that a plan representative examine the individual in person to determine whether inpatient care is medically necessary. For all medical and surgical inpatient, in-network admissions, my plan also requires prior authorization but it is conducted over the phone without an in-person examination. Is this in-person prior authorization requirement for mental health inpatient admissions permissible? Updated 1-31-17 No. The plan is imposing a prior authorization NQTL more stringently with respect to inpatient mental health bene?ts than to inpatient medical/surgical bene?ts. While some differences in prior authorization practices with respect to individual conditions or treatments might be permissible based on recognized clinically appropriate standards of care, the MHPAEA regulations do not permit a plan or issuer to apply stricter to all benefits for mental health conditions in a classification than those applied to all medical/surgical bene?ts in the same classi?cation. In this case, in order to receive prior authorization for any inpatient, in-network mental health benefits, a participant must undergo an in-person examination whereas prior authorization may be obtained more easily and quickly over the phone for any inpatient, in-network medical/surgical bene?ts. Accordingly, the plan?s in-person prior authorization requirement for these mental health benefits does not comply with MHPAEA. (DOL FAQs Pan? 34 10/27/16) 1258 2017--01358 05: Before authorizing coverage for inpatient treatment for a substance use disorder, my plan requires that I first enroll in an intensive outpatient program. My plan applies similar requirements to medical/surgical benefits. However, unlike medical/surgical benefits for which the requirements can be satisfied by programs offered in my geographic area, no intensive outpatient programs are available to treat my substance use disorder in my geographic area. I alerted my plan that no outpatient program is available in my geographic area, but the plan indicated that there are no exceptions. Is this permissible? No. The requirement to try an intensive outpatient program before being admitted for inpatient treatment is a type of NQTL, often referred to as a fail-first or step-therapy requirement. The Departments? regulations require that a plan or insurance issuer may not impose an NQTL with respect to bene?ts in a bene?t classification unless, under the terms of the plan as written and in operation, the processes, strategies, evidentiary standards, or other factors used in applying the NQTL are comparable and applied no more stringently with respect to benefits than with respect to medical/surgical bene?ts in the same classi?cation. If a fail-first requirement that applies to bene?ts includes a condition that an individual cannot reasonably satisfy (in this case, a condition to ?rst attempt an intensive outpatient program, although there are no programs available), and the lack of access to programs necessary to satisfy the requirement exists only with respect to benefits, then the fail-first requirement is, in operation, applied more stringently with respect to bene?ts than medical/surgical benefits. Because the Departments' prior guidance did not address the application of fail-first requirements in situations involving lack of access and may have reasonably been interpreted in an alternative manner, the Departments will apply this clarifying guidance for plan years (or, in the individual market, policy years) beginning on or after March 1, 2017. (DOL FAQs Part 34 10/27/16) Medication Assisted Treatment for Opioid Use Disorder 06: My plan requires prior authorization from the plan?s utilization reviewer that buprenorphine is medically necessary for the treatment of my opioid use disorder. The plan says the prior authorization requirement is imposed due to safety risks associated with buprenorphine. Although there are prescription drugs to treat medical/surgical conditions that have similar safety risks, my plan does not impose similar prior authorization requirements on those drugs. Is this permissible? No. A plan may impose an NQTL, including a prior authorization requirement for buprenorphine, if, under the terms of the plan as written and in operation, the processes, strategies, evidentiary standards, and other factors considered by the plan in implementing its prior authorization requirement with respect to buprenorphine to treat an opioid use disorder are comparable to, and applied no more stringently than, those used in applying its prior authorization requirement with respect to medical/surgical benefits in the prescription drug classi?cation under MHPAEA. In this scenario, the plan imposes the prior authorization requirement due to stated safety concerns. However, the prior authorization requirement is applied more stringently to buprenorphine when used to treat opioid use disorder than it is applied to prescription drugs with similar safety risks to treat medical/surgical conditions. Accordingly, the plan?s 1259 Updated 1-31-17 2017--01359 prior authorization requirement on buprenorphine does not comply with MHPAEA. (DOL FAQs Part 34 10/27/16) Q7: My plan requires that I meet specific non-pharmacological fail-?rst requirements (for example, that I have tried counseling alone, failed at recovery, and resumed substance use) before it will authorize coverage for buprenorphine to treat my opioid use disorder. While comparable evidentiary standards and other factors indicate that similar fail-first requirements could be imposed on certain prescription drugs covered by my plan for medical/surgical conditions, the plan does not impose fail-first requirements in these instances. Is this permissible? No. A fail-?rst requirement is an NQTL that must comply with the requirements of MHPAEA. A plan or issuer cannot impose a fail-?rst requirement on coverage for buprenorphine for opioid use disorder unless, under the terms of the plan as written and in operation, the processes, strategies, evidentiary standards, and other factors considered by the plan in designing and imposing this fail-first requirement are comparable to, and applied no more stringently than the processes, strategies, evidentiary standards, or other factors used in applying fail-?rst requirements to medical/surgical bene?ts in the prescription drug classification under MHPAEA. In this case, the plan is imposing a non-pharmacological requirement that the individual fail ?rst at recovery with counseling alone before the plan will authorize coverage of bene?ts for buprenorphine. While comparable evidentiary standards and other factors indicate that similar fail-?rst requirements could be appropriate before authorizing coverage for certain other prescription drugs covered by the plan for medical/surgical conditions, the plan does not in fact impose fail-?rst requirements in any of these instances. Accordingly, the fail-first requirement imposed on buprenorphine is an NQTL that the plan applies more stringently to a substance use disorder condition than medical/surgical conditions. This disparity violates MHPAEA. (DOL FAQs Part 34 10/27/16) Q8: My group health plan states that it follows nationally-recognized treatment guidelines for setting prior authorization requirements for prescription drugs, but requires prior authorization for my buprenorphine/naioxone combination at each refill (every 30 days) for my opioid use disorder, which is not consistent with nationally-recognized treatment guidelines. Is this permissible? No. In setting the NQTL of prior authorization for the substance use disorder medication, buprenorphine/naloxone, a plan or issuer must apply comparable processes, strategies, evidentiary standards, and other factors no more stringently to buprenorphine/naloxone than those applied to medical/surgical medications. The plan states that it follows nationally-recognized guidelines. However, these guidelines,26 such as the American Society of Addiction Medicine (ASAM) national practice guidelines,27 do not support 30- day authorization practices for buprenorphine/naloxone. Furthermore, the plan does not deviate from nationally-recognized treatment guidelines when establishing prior authorization requirements for any prescription drugs to treat medical/surgical conditions. Accordingly, although the plan asserts that its process of setting the NQTL of prior authorization -- following nationally-recognized treatment guidelines -- is comparable as written, in operation, the plan?s process departs from and provides less coverage than recommended under nationally-recognized treatment guidelines for buprenorphine/naloxone, in violation of MHPAEA. 1260 Updated 1-31-17 2017--01360 However, as an alternative to simply mirroring nationally-recognized treatment guidelines, many plans? and issuers? use Pharmacy and Therapeutics committees in deciding how to cover prescription drugs and evaluating whether to follow or deviate from nationally-recognized treatment guidelines for setting the prior authorization requirements. The Departments? note that while the use of committees to inform prior authorization requirements for prescription drugs in this manner may not violate MHPAEA per se, these processes must also comply with NQTL standard in operation. For example, if the plan deviates from nationally-recognized treatment guidelines for buprenorphine/naloxone based on committee reports, then use of the committee would be evaluated for compliance with NQTL requirements (for example, by evaluating whether the committee is comprised of comparable experts for conditions, as compared to the experts for medical/surgical conditions, and how such experts evaluated nationally-recognized treatment guidelines in setting prior authorization for medications for both and medical/surgical conditions). Under nationally-recognized treatment guidelines, authorization for a prescription drug intended for extended use to treat a chronic or medical/surgical condition is often appropriate at six or 12 months; as a result, even in a plan that uses a committee to set standards, an authorization of buprenorphine/naloxone that is limited to 30 days could be inconsistent with authorization practices for chronic medical/surgical conditions. Therefore, in such a plan, absent comparable restrictions on medications for medical/surgical conditions, this 30-day limit is a ?red ?ag" or ?warning sign" that the plan may be imposing an impermissible NQTL. Unless the plan provides evidence from committee reports regarding the 30-day limit to substantiate its compliance, the plan?s prior authorization requirement on buprenorphine would not be in compliance with MHPAEA. (DOL FAQs Pan? 34 10/27/16) Court-Ordered Treatment Plans and policies may sometimes exclude coverage of court-ordered treatment. MHPAEA prohibits separate treatment limitations in a plan or coverage that are applicable only with respect to bene?ts.29 It has come to the Departments? attention that there are questions regarding whether exclusions for court-ordered treatment are subject to MHPAEA, and how the MHPAEA analysis would apply. 09: Is an exclusion of court-ordered treatment for substance use disorders permissible under MHPAEA for a plan or coverage that does not exclude court-ordered treatment for medical/surgical conditions? Updated 1-31-17 No, if the exclusion applies only to court-ordered treatment for substance use disorders. MHPAEA prohibits separate treatment limitations in a plan or coverage that are applicable only with respect to bene?ts. Alternatively, plans often apply medical necessity criteria to all treatment requests, and may do so in the case of court-ordered treatment for substance use disorders, if that is consistent with parity requirements for If the plan determines that court-ordered treatment is not medically necessary and denies a claim for bene?ts, then an individual would be informed of his or her right to appeal and request external 1261 2017-?01361 medical necessity review, consistent with the Departments? regulations for claims, appeals, and external review. (DOL FAQs Part 34 10/27/16) Wellness Programs Q12: Are all employment-based wellness programs required to check for compliance with the HIPAA nondiscrimination provisions? No. Many employers offer a wide range of programs to promote health and prevent disease. For example, some employers may choose to provide or subsidize healthier food choices in the employee cafeteria, provide pedometers to encourage employee walking and exercise, pay for memberships, or ban smoking on employer facilities and campuses. A wellness program is subject to the HIPAA nondiscrimination rules only if it is, or is part of, a group health plan. If an employer operates a wellness program as an employment policy separate from its group health plan(s), the program may be covered by other Federal or State nondiscrimination laws, but it is not subject to the HIPAA nondiscrimination regulations. (DOL FAQS Part 12/22/10) Q13: My group health plan gives an annual premium discount of 50 percent of the cost of employee-only coverage to participants who adhere to a wellness program which consists of attending a health seminar. Does this reward violate the HIPAA nondiscrimination regulations? No. This wellness program is not based on an individual satisfying a standard that is related to a health factor, so it does not have to satisfy the ?ve criteria (set forth above) in the HIPAA nondiscrimination regulations. (The rule limiting the amount of the reward for health-contingent wellness programs to 20 percent of the cost of coverage applies only to programs that require satisfaction of a standard related to a health factor in order to qualify for the reward.) (DOL FAQs Part 12/22/10) Q14: My group health plan gives an annual premium discount of 20 percent of the cost of employee-only coverage to participants who adhere to a wellness program. The wellness program consists of giving an annual cholesterol exam to participants; participants who achieve a cholesterol count of 200 or lower receive the annual premium discount. The plan also provides that if it is unreasonably dif?cult or medically inadvisable to achieve the targeted cholesterol count within a 60-day period, the plan will make available a reasonable alternative standard that takes the relevant medical condition into account. Does this wellness program violate the HIPAA nondiscrimination regulations? No. The wellness program is based on a health factor (achieving a cholesterol count of 200 or lower) and is subject to the HIPAA nondiscrimination regulations, including the five criteria described in paragraph of the regulations. In general, among other things, a wellness program subject to the HIPAA nondiscrimination regulations must be available to all similarly situated individuals, provide a reasonable alternative standard, and the reward must be limited to no more than 20 percent of the total cost of coverage. The wellness program described above satis?es the requirement of being available to all similarly situated individuals because the plan provides a reasonable alternative standard and the premium discount is limited to 20 percent of the cost of employee-only coverage. (DOL FAQs Part 12/22/10 1262 Updated 1-31-17 2017--01362 Q15: My group health plan offers two different wellness programs, both of which are offered to all full-time employees enrolled in the plan. The first program requires participants to take a cholesterol test and provides a 20 percent premium discount for every individual with cholesterol counts under 200. The second program reimburses participants for the cost of a membership to a fitness center. If I participate in both wellness programs and receive both rewards (the 20 percent premium discount and the reimbursement for the cost of a fitness center membership), is my plan violating the HIPAA nondiscrimination regulations? No. In this scenario, the first program is subject to the requirements of the HIPAA nondiscrimination regulations because the premium discount reward is based on an individual satisfying a standard that is related to a health factor (having a cholesterol count under 200). Therefore, the first program must meet the five criteria in the regulations, including the 20 percent limit on the amount of the reward. The second program is not based on an individual satisfying a standard that is related to a health factor, so it does not have to satisfy the ?ve criteria in the regulations. Furthermore, it is permissible to offer both programs at the same time because the rule limiting the amount of the reward for health-contingent wellness programs to 20 percent of the cost of coverage only applies to programs that require satisfaction of a standard related to a health factor. As previously noted, the Departments intend to propose regulations that use existing regulatory authority under HIPAA to raise the percentage for the maximum reward that can be provided under a health-contingent wellness program to 30 percent before the year 2014 and are also considering what accompanying consumer protections may be needed to prevent the program from being used as a subterfuge for discrimination based on health status. More guidance is expected early next year. (DOL FAQs Part 12/22/10) 08: A group health plan charges participants a tobacco premium surcharge but also provides an opportunity to avoid the surcharge if, at the time of enrollment or annual re- enrollment, the participant agrees to participate in (and subsequently completes within the plan year) a tobacco cessation educational program. A participant who is a tobacco user initially declines the opportunity to participate in the tobacco cessation program, but joins in the middle of the plan year. Is the plan required to provide the opportunity to avoid the surcharge or provide another reward to the individual for that plan year? No. If a participant is provided a reasonable opportunity to enroll in the tobacco cessation program at the beginning of the plan year and qualify for the reward avoiding the tobacco premium surcharge) under the program, the plan is not required (but is permitted) to provide another opportunity to avoid the tobacco premium surcharge until renewal or reenrollment for coverage for the next plan year. Nothing, however, prevents a plan or issuer from allowing rewards (including pro-rated rewards) for mid- year enrollment in a wellness program for that plan year. (DOL FAQs Part 01/09/14) 1263 Updated 1-31-17 2017--01363 09: A plan participant's doctor advises that an outcome-based wellness program's standard for obtaining a reward is medically inappropriate for the plan participant. The doctor suggests a weight reduction program (an activity-only program) instead. Does the plan have a say in which one? Yes. The plan must provide a reward for individuals who qualify by satisfying a reasonable alternative standard. If an individual's personal physician states that the outcome-based wellness program is not medically appropriate for that individual and recommends a weight reduction program (an activity-only program) instead, the plan must provide a reasonable alternative standard that accommodates the recommendations of the individual?s personal physician with regard to medical appropriateness. Many different weight reduction programs may be reasonable for this purpose, and a participant should discuss different options with the plan. (DOL FAQs Part 01/09/14) Q10: Paragraph of the final regulations provides sample language that may be used to satisfy the requirement to provide notice of the availability of a reasonable alternative standard. Are plans and issuers permitted to modify this language? Yes. The final regulations state that the sample language provided in paragraph or substantially similar language, can be used to satisfy the notice requirement. Plans and issuers may modify the sample language to re?ect the details of their wellness programs, provided that the notice includes all of the required content described in paragraphs or as applicable, of the final regulations. Additional sample language is available in examples illustrating the ?nal regulations' requirements for outcome-based wellness programs.(13) (DOL FAQs Part 01/09/14) Q1: What does it mean that a health-contingent wellness program must be ?reasonably designed?? Updated 1-31-17 Under section 2705 of the PHS Act and the wellness program regulations, a health- contingent wellness program must be reasonably designed to promote health or prevent disease. A program complies with this requirement if it (1) has a reasonable chance of improving the health of, or preventing disease in, participating individuals; (2) is not overly burdensome; (3) is not a subterfuge for discrimination based on a health factor; and (4) is not highly suspect in the method chosen to promote health or prevent disease. The determination of whether a health-contingent wellness program is reasonably designed is based on all the relevant facts and circumstances. The wellness program regulations are intended to allow experimentation in diverse and innovative ways for promoting wellness. While programs are not required to be accredited or based on particular evidence-based clinical standards, practices such as those found in the Guide to Community Preventive Services or the United States Preventive Services Task Force's Guide to Clinical Preventive Services, may increase the likelihood of wellness program success and are encouraged. Wellness programs designed to dissuade or discourage enrollment in the plan or program by individuals who are sick or potentially have high claims experience will not be considered reasonably designed under the Departments? wellness program regulations. A program that collects a substantial level of sensitive personal health information without assisting individuals to make behavioral changes such as stopping 1264 2017-?01364 smoking, managing diabetes, or losing weight, may fail to meet the requirement that the wellness program must have a reasonable chance of improving the health of, or preventing disease in, participating individuals. Programs that require unreasonable time commitments or travel may be considered overly burdensome. Such programs will be scrutinized and may be subject to enforcement action by the Departments. The wellness program regulations also state that, in order to be reasonably designed, an outcome-based wellness program must provide a reasonable alternative standard to qualify for the reward or all individuals who do not meet the initial standard that is related to a health factor. This approach is intended to ensure that outcome-based wellness programs are more than mere rewards in return for results in biometric screenings or responses to a health risk assessment, and are instead part of a larger wellness program designed to promote health and prevent disease, ensuring the program is not a subterfuge for discrimination or underwriting based on a health factor. (DOL FAQs Part XXV 04/16/15) 02: Is compliance with the Departments? wellness program regulations determinative of compliance with other laws? No. The fact that a wellness program that complies with the Departments? wellness program regulations does not necessarily mean it complies with any other provision of the PHS Act, the Code, ERISA, (including the COBRA continuation provisions), or any other State or Federal law, such as the Americans with Disabilities Act or the privacy and security obligations of the Health Insurance Portability and Accountability Act of 1996, where applicable. Satisfying the rules for wellness programs also does not determine the tax treatment of rewards provided by the wellness program. The Federal tax treatment is governed by the Code. For example, reimbursement for ?tness center fees is generally considered an expense for general good health. Thus payment of the fee by the employer is not excluded from income as the reimbursement of a medical expense and should generally be added to the employee wages reported on the Form W- 2, Wage and Tax Statement. In addition, although the Departments? wellness program regulations generally do not impose new disclosure obligations on plans and issuers, compliance with the wellness program regulations is not determinative of compliance with any other disclosure laws, including those that require accurate disclosures and prohibit intentional misrepresentation. (DOL FAQs Part XXV 04/16/15) Q11: My group health plan gives rewards in the form of non-financial (or in-kind) incentives (for example, gift cards, thermoses, and sports gear) to participants who adhere to a wellness program. Are these non-financial incentives subject to the wellness program regulations issued by the Departments? Updated 1-31-17 Yes. If a group health plan provides a ?reward" based on an individual satisfying a standard that is related to a health factor, the wellness program is subject to the Department?s wellness regulations. As provided in the regulations, a reward may be financial or non-?nancial (or in-kind). More speci?cally, the regulations provide that reference to an individual obtaining a reward includes both ?obtaining a reward (such as a discount or rebate of a premium or contribution, a waiver of all or part of a cost-sharing mechanism (such as a deductible, copayment, or coinsurance), an additional bene?t, or any financial or other incentive) and avoiding a penalty (such as the absence of a surcharge or other ?nancial or non?nancial (DOL FAQs Part 10/23/15) 1265 2017--01365 Summary of Benefits and Coverage Q1: On August 22, 2011, the Departments issued proposed regulations and proposed templates in connection with implementation of the Summary of Benefits and Coverage and Uniform Glossary requirements of PHS Act 2715. An applicability date ?beginning March 23, 2012? was proposed. At the same time, the Departments invited comments generally, as well as on a range of discrete issues, including the timing of the application of the SBC requirement. My plan anticipates that preparation of the summary of benefits and coverage will take several months and require significant resources. In light of the March 23, 2012 proposed applicability date, we are considering moving forward with implementation of the Summary of Benefits and Coverage requirements, using the proposed rules and templates, but are concerned that the final rules and templates will differ from the proposed rules and templates, which would prompt additional implementation costs. What is the timeline for the issuance of future guidance on the summary of benefits and coverage? What actions should my plan be taking now, if any? The Departments received many comments on the proposed regulations and templates and intend to issue, as soon as possible, final regulations that take into account these comments and other stakeholder feedback. PHS Act section 2715 provides that group health plans and health insurance issuers shall provide the Summary of Bene?ts and Coverage and Uniform Glossary pursuant to standards developed by the Departments. Accordingly, until ?nal regulations are issued and applicable, plans and issuers are not required to comply with PHS Act section 2715. It is anticipated that the Departments? ?nal regulations, once issued, will include an applicability date that gives group health plans and health insurance issuers suf?cient time to comply. (DOL FAQs Part VII 11/17/11) Q1: When must plans and issuers begin providing the For group health plan coverage, the regulations provide that, for disclosures with respect to participants and bene?ciaries who enroll or re-enroll through an open enrollment period (including late enrollees and re-enrollees), the SBC must be provided beginning on the first day of the first open enrollment period that begins on or after September 23, 2012. For disclosures with respect to participants and bene?ciaries who enroll in coverage other than through an open enrollment period (including individuals who are newly eligible for coverage and special enrollees), the SBC must be provided beginning on the first day of the first plan year that begins on or after September 23, 2012. For disclosures from issuers to group health plans, and with respect to individual market coverage, the SBC must be provided beginning September 23, 2012. (DOL FAQs Part 003/19/12) 02: What is the Departments' basic approach to implementation of the SBC requirement during the first year of applicability? The Departments' basic approach to ACA implementation, as stated in a previous FAQ (see is: "[to work] together with employers, 1266 Updated 1-31-17 2017--01366 issuers, States, providers and other stakeholders to help them come into compliance with the new law and [to work] with families and individuals to help them understand the new law and bene?t from it, as intended. Compliance assistance is a high priority for the Departments. Our approach to implementation is and will continue to be marked by an emphasis on assisting (rather than imposing penalties on) plans, issuers and others that are working diligently and in good faith to understand and come into compliance with the new law. This approach includes, where appropriate, transition provisions, grace periods, safe harbors, and other policies to ensure that the new provisions take effect smoothly, minimizing any disruption to existing plans and practices." In addition to the general approach to implementation, in the instructions for completing the SBC, we stated: "To the extent a plan's terms do not reasonably correspond to these instructions, the template should be completed in a manner that is as consistent with the instructions as possible, while still accurately re?ecting the plan's terms. This may occur, for example, if a plan provides a different structure for provider network tiers or drug tiers than is represented in the SBC template and these instructions, if a plan provides different benefits based on facility type (such as hospital inpatient versus non-hospital inpatient), in a case where a plan is denoting the effects of a related health ?exible spending arrangement or a health reimbursement arrangement, or if a plan provides different cost sharing based on participation in a wellness program." Consistent with this guidance, during this ?rst year of applicability, the Departments will not impose penalties on plans and issuers that are working diligently and in good faith to provide the required SBC content in an appearance that is consistent with the final regulations. The Departments intend to work with stakeholders over time to achieve maximum uniformity for consumers and certainty for the regulated community. (DOL FAQs Part 003/19/12) Q3: Are plans and issuers required to provide a separate SBC for each coverage tier self-only coverage, employee-plus-one coverage, family coverage) within a benefit package? No, plans and issuers may combine information for different coverage tiers in one SBC, provided the appearance is understandable. In such circumstances, the coverage examples should be completed using the cost sharing deductible and out-of-pocket limits) for the self-only coverage tier (also sometimes referred to as the individual coverage tier). In addition, the coverage examples should note this assumption. (DOL FAQs Pan? 03/19/12) Q4: If the participant is able to select the levels of deductible, copayments, and co- insurance for a particular benefit package, are plans and issuers required to provide a separate SBC for every possible combination that a participant may select under that bene?t package? Updated 1-31-17 No, as with the response to Q-3, plans and issuers may combine information for different cost-sharing selections (such as levels of deductibles, copayments, and co-insurance) in one SBC, provided the appearance is understandable. This information can be presented in the form of options, such as deductible options and out-of?pocket maximum options. In these circumstances, the coverage examples should note the assumptions used in creating them. An example of how to note assumptions used in creating 1267 2017-?01367 coverage examples is provided in the Departments' sample completed (DOL FAQs Part 03/19/12) 05: If a group health plan is insured and utilizes "carve-out arrangements" (such as pharmacy benefit managers and managed behavioral health organizations) to help manage certain benefits, who is responsible for providing the SBC with respect to the plan? The Departments recognize that different combinations of plans, issuers, and their service providers may have different information necessary to provide an SBC, including the coverage examples. The Departments have determined that, until further guidance is issued, where a group health plan or group health insurance issuer has entered into a binding contractual arrangement under which another party has assumed responsibility (1) to complete the SBC, (2) to provide required information to complete a portion of the SBC, or (3) to deliver an SBC with respect to certain individuals in accordance with the final regulations, the plan or issuer generally will not be subject to any enforcement action by the Departments for failing to provide a timely or complete SBC, provided the following conditions are satisfied: - The plan or issuer monitors performance under the contract, 0 If a plan or issuer has knowledge of a violation of the ?nal regulations and the plan or issuer has the information to correct it, it is corrected as soon as practicable, and If a plan or issuer has knowledge of a violation of the ?nal regulations and the plan or issuer does not have the information to correct it, the plan or issuer communicates with participants and bene?ciaries regarding the lapse and begins taking signi?cant steps as soon as practicable to avoid future violations. (DOL FAQs Pan? 03/19/12) 06: If a plan offers participants add-ons to major medical coverage that could affect their cost sharing and other information in the SBC (such as a health flexible spending arrangement (health FSA), health reimbursement arrangement (HRA), health savings account (HSA), or wellness program), is the plan permitted to combine information for all of these add-ons and re?ect them in a single Updated 1-31-17 Yes. As stated in the preamble to the final regulations and the instructions for completing the SBC template,(3) plans and issuers are permitted to combine such information in one SBC, provided the appearance is understandable. That is, the effects of such add- ons can be denoted in the appropriate spaces on the SBC for deductibles, copayments, coinsurance, and benefits otherwise not covered by the major medical coverage. In such circumstances, the coverage examples should note the assumptions used in creating them. (The Departments' sample completed provides an example of how to denote the effects of a diabetes wellness program.) (DOL FAQs Part 03/19/12) 1268 2017--01368 Q7: The final regulations require the SBC to be provided in certain circumstances within 7 business days. Does that mean the plan or issuer has 7 business days to send the SBC, or that the SBC must be received within 7 business days? In the context of the ?nal regulations, the term "provided" means sent. Accordingly, the SBC is timely if sent out within 7 business days, even if it is not received until after that period. (DOL FAQs Part 03/19/12) Q8: Are plans and issuers required to provide SBCs to individuals who are COBRA qualified beneficiaries? Yes. While a qualifying event does not, itself, trigger an SBC, during an open enrollment period, any COBRA quali?ed beneficiary who is receiving COBRA coverage must be given the same rights to elect different coverage as are provided to similarly situated bene?ciaries. See 26 CFR 54.49808-5, (requirement to provide election) and 54.498OB-3, (definition of similarly situated beneficiary). In this situation, a COBRA qualified bene?ciary who has elected coverage has the same rights to receive an SBC as a similarly situated bene?ciary. There are also limited situations in which a COBRA quali?ed bene?ciary may need to be offered different coverage at the time of the qualifying event than the coverage he or she was receiving before the qualifying event and this may trigger the right to an SBC. See 26 CFR 54.498OB-5, (DOL FAQs Part 03/19/12) 09: What circumstances will trigger the requirement to provide an SBC to a participant or beneficiary in a group health plan? In particular, how do the terms "application" and "renewal" apply to a self-insured plan? Updated 1-31-17 The final regulations require that the SBC be provided in several instances: 0 Upon application. If a plan (including a self-insured group health plan) or an issuer distributes written application materials for enrollment, the SBC must be provided as part of those materials. For this purpose, written application materials include any forms or requests for information, in paper form or through a website or email, that must be completed for enrollment. If the plan or issuer does not distribute written application materials for enrollment (in either paper or electronic form), the SBC must be provided no later than the ?rst date on which the participant is eligible to enroll in coverage. . By ?rst day of coverage (if there are any changes). If there is any change in the information required to be in the SBC that was provided upon application and before the ?rst day of coverage, the plan or issuer must update and provide a current SBC no later than the ?rst day of coverage. 0 Special enrollees. The SBC must be provided to special enrollees no later than the date on which a summary plan description is required to be provided (90 days from enrollment). 0 Upon renewal. If a plan or issuer requires participants and beneficiaries to actively elect to maintain coverage during an open season, or provides them with the opportunity to change coverage options in an open season, the plan or issuer must provide the SBC at the same time it distributes open season materials. If there is no requirement to renew (sometimes referred to as an "evergreen" election), and no opportunity to change coverage options, renewal is considered to be automatic and 1269 2017--01369 the SBC must be provided no later than 30 days prior to the ?rst day of the new plan or policy year.(5) . Upon request. The SBC must be provided upon request for an SBC or summary information about the health coverage as soon as practicable but in no event later than seven business days following receipt of the request. (DOL FAQs Pan? 03/19/12) Q10: What are the circumstances in which an SBC may be provided electronically? Updated 1-31-17 With respect to group health plan coverage, an SBC may be provided electronically: (1) by an issuer to a plan, and (2) by a plan or issuer to participants and bene?ciaries who are eligible but not enrolled for coverage, if: . The format is readily accessible (such as in an html, MS Word, or PDF format); . The SBC is provided in paper form free of charge upon requestprovided via an Internet posting (including on the HHS web portal), the issuer timely advises the plan (or the plan or issuer timely advises the participants and beneficiaries) that the SBC is available on the Internet and provides the Internet address. Plans and issuers may make this disclosure (sometimes referred to as the "e-card" or "postcard" requirement) by email. An SBC may also be provided electronically by a plan or issuer to a participant or beneficiary who is covered under a plan in accordance with the Department of Labor's disclosure regulations at 29 CFR 2520.104b-1. Those regulations include a safe harbor for disclosure through electronic media to participants who have the ability to effectively access documents furnished in electronic form at any location where the participant is reasonably expected to perform duties as an employee and with respect to whom access to the employer's or plan sponsor's electronic information system is an integral part of those duties. Under the safe harbor, other individuals may also opt into electronic delivery. With respect to individual market coverage, a health insurance issuer must provide the SBC, in either paper or electronic form, in a manner that can reasonably be expected to provide actual notice. The SBC may not be provided in electronic form unless: a The format is readily accessible; . If the SBC is provided via an Internet posting, it is placed in a location that is prominent and readily accessible; The SBC is provided in an electronic form which can be retained and printed; and The issuer noti?es the individual that the SBC is available free of charge in paper form upon request. In addition, a health insurance issuer offering individual market coverage, that provides HealthCare.gov with all the content required to be provided in the SBC, will be deemed compliant with the requirement to provide an SBC upon request prior to application. However, issuers must provide the SBC in paper form upon request for a paper copy, and at all other times as specified in the regulations. In addition, as stated in the regulations, unless the plan or issuer has knowledge of a separate address for a bene?ciary, the SBC may be provided to the participant on behalf of the bene?ciary (including by furnishing the SBC to the participant in electronic form). (DOL FAQs Part 03/19/12) 1270 2017-?01370 Q11: Are issuers who have provided individual market plan information to HealthCare.gov in compliance with PHS Act section 2715 and its implementing regulations already? The deemed compliance provision in the regulation requires issuers in the individual market to provide all of the data elements that are needed to complete the SBC template to HealthCare.gov. If the issuer fails to provide all of the data elements, it would not be deemed to be in compliance with the regulation. Today, HealthCare.gov does not collect all of the elements of an SBC, such as information necessary to complete the coverage examples. However, HHS will collect this information and display it in the format of the SBC template by September 23, 2012, so that providing information to HealthCare.gov fulfills the deemed compliance provision. (DOL FAQs Part 03/19/12) Q12: Can the Departments provide model language to meet the requirement to provide an e-card or postcard in connection with evergreen website postings? Yes. Plans and issuers have ?exibility with respect to the postcard and may choose to tailor it in many ways. One example is: Availability of Summary Health Information As an employee, the health bene?ts available to you represent a signi?cant component of your compensation package. They also provide important protection for you and your family in the case of illness or injury. Your plan offers a series of health coverage options. Choosing a health coverage option is an important decision. To help you make an informed choice, your plan makes available a Summary of Bene?ts and Coverage (SBC), which summarizes important information about any health coverage option in a standard format, to help you compare across options. The SBC is available on the web at: A paper copy is also available, free of charge, by calling (a toll-free number). (DOL FAQS Part 3/19/12) Q13: The regulations state that in order to satisfy the requirement to provide the SBC in a culturally and linguistically appropriate manner, a plan or issuer follows the rules in the claims and appeals regulations under PHS Act section 2719. Does this mean that the SBC must include a sentence on the availability of language assistance services? Yes, if the notice is sent to an address in a county in which ten percent or more of the population is literate only in a non-English language. The final SBC regulations provide that a plan or issuer is considered to provide the SBC in a culturally and linguistically appropriate manner if the thresholds and standards of the claims and appeals regulations are met.(6) The claims and appeals regulations outline three requirements that must be satis?ed for notices sent to an address in a county in which ten percent or more of the population is literate only in a non-English language. In such cases, the plan or issuer is generally required to provide oral language services in the non-English language, provide notices upon request in the non-English language, and include in all 1271 Updated 1-31-17 2017-?01371 English versions of the notices a statement in the non-English language clearly indicating how to access the language services provided by the plan or issuer. Accordingly, plans and issuers must include, in the English versions of SBCs sent to an address in a county in which ten percent or more of the population is literate only in a non-English language, a statement prominently displayed in the applicable non-English language clearly indicating how to access the language services provided by the plan or issuer. In this circumstance, the plan or issuer should include this statement on the page of the SBC with the "Your Rights to Continue Coverage" and "Your Grievance and Appeals Rights" sections. Sample language for this statement is available on the model notice of adverse benefit determination at Current county-by- county data can be accessed at data.html. Even in counties where no non-English language meets the ten percent threshold, a plan or issuer can voluntarily include such a statement in the SBC in any non-English language. Moreover, nothing in the SBC regulations limits an individual's rights to meaningful access protections under other applicable Federal or State law, including Title VI of the Civil Rights Act of 1964. (DOL FAQs Part 03/19/12) Q14: Where can plans and issuers ?nd the written translations of the SBC template and the uniform glossary in the non-English languages? Written translations in Spanish, Chinese, Tagalog and Navajo will be available at (DOL FAQs Part 03/19/12) Q15: Is an SBC permitted to simply substitute a cross-reference to the summary plan description (SPD) or other documents for a content element of the No, an SBC is not permitted to substitute a reference to the SPD or other document for any content element of the SBC. However, an SBC may include a reference to the SPD in the SBC footer. (For example, "Questions: Call 1-800-[insert] or visit us at for more information, including a copy of your plan's summary plan description") In addition, wherever an SBC provides information that fully satisfies a particular content element of the SBC, it may add to that information a reference to speci?ed pages or portions of the SPD in order to supplement or elaborate on that information. (DOL FAQs Part 03/19/12) Q16: Can a plan or issuer add premium information to the SBC form voluntarily? Yes. If a plan or issuer chooses to add premium information to the SBC, the information should be added at the end of the SBC form. (DOL FAQs Part 03/19/12) Q17: Must the header and footer be repeated on every page of the No. If a plan or issuer chooses, it may include the header only on the first page of the SBC. In addition, a plan or issuer may include the footer only on the ?rst and last page of the SBC, instead of on every page. 1272 Updated 1-31-17 2017-?01372 The OMB control numbers (which were displayed on the SBC template and the Departments' sample completed SBC to inform plans and issuers that the Departments had complied with the Paperwork Reduction Act) should not be displayed on SBCs provided by plans or issuers. (DOL FAQs Part 03/19/12) Q18: For group health plan coverage, may the coverage period in the SBC header reflect the coverage period for the group plan as a whole, or must the coverage period be the period applicable to each particular individual enrolled in the plan? The SBC may reflect the coverage period for the group health plan as a whole. Therefore, if a plan is a calendar year plan and an individual enrolls on January 19, the coverage period is permitted to be the calendar year. Plans and issuers are not required to individualize the coverage period for each individual's enrollment. (DOL FAQs Part 03/19/12) Q19: Can issuers and plans make minor adjustments to the SBC format, such as changing row and column sizes? What about changes such as rolling over information from one page to another, which was not permitted by the instructions? Minor adjustments are permitted to the row or column size in order to accommodate the plan's information, as long as the information is understandable. The deletion of columns or rows is not permitted. Rolling over information from one page to another is permitted. (DOL FAQs Part 03/19/12) 020: Can plan names be generic, such as "Standard Option" or "High Option"? Yes, generic terms may be used. (DOL FAQs Part 03/19/12) Q21: Can the issuer's name and the plan name be interchangeable in order? Yes. (DOL FAQs Part 03/19/12) Q22: Can barcodes or control numbers be added to the SBC for quality control purposes? Yes, they can be added. (DOL FAQs Part 03/19/12) 023. Is the SBC required to include a statement about whether the plan is a grandfathered health plan? No, although plans may voluntarily choose to add a statement to the end of the SBC about whether the plan is a grandfathered health plan. (DOL FAQs Part 03/19/12) 024. My plan is moving forward to implement the SBC template for the first year of applicability. Are significant changes anticipated for 2014? No. The Departments identified in the preamble to the ?nal regulations certain discrete changes that would be necessary for plan years (or, in the individual market, policy years) beginning after the first year of applicability. These changes include the addition of a minimum value statement and a minimum essential coverage statement, changes to 1273 Updated 1-31-17 2017--01373 be consistent with the Affordable Care Act's requirement to eliminate all annual limits on essential health bene?ts, and the Departments' intent to add additional coverage examples. The Departments are also considering making some re?nements consistent with these FAQs and other requests from plans and issuers for clari?cation and to promote operational efficiencies. No other changes are planned at this time. (DOL FAQs Part 03/19/12) Q1: A previous FAQ outlined the circumstances in which an SBC may be provided electronically. The FAQ discussed a safe harbor for providing the SBC to participants or beneficiaries covered under the plan who are able to effectively access documents provided in electronic form at the worksite. Are there any additional safe harbors for electronic delivery of Yes. The Departments have adopted the following additional safe harbor?. 8808 may be provided electronically to participants and bene?ciaries in connection with their online enrollment or online renewal of coverage under the plan. 8803 also may be provided electronically to participants and bene?ciaries who request an SBC online. In either case, the individual must have the option to receive a paper copy upon request. (In addition, for individual market issuers that offer online enrollment or renewal, the SBC may be provided electronically, at all issuances, to consumers who enroll or renew online, consistent with the regulations.) (DOL FAQs Part IX 05/11/12) Q2: What are the circumstances that will trigger the requirement for an issuer to provide an SBC to an individual applying for coverage in the individual market, or to a group health plan or its sponsor applying for coverage? In particular, how do the terms ?upon application? and ?first day of coverage (if there are changes)? apply to an individual (or a plan or its sponsor) shopping for coverage? The regulations state that a health insurance issuer must provide the SBC upon application for health coverage. For this purpose, a plan or issuer must provide the SBC as soon as practicable, but no later than seven business days after receiving a substantially complete application for a health insurance product. If an individual, plan, or plan sponsor is negotiating coverage terms after an application has been ?led and the information required to be in the SBC changes, an updated SBC is not required to be provided (unless an updated SBC is requested) until the ?rst day of coverage. The updated SBC should re?ect the ?nal coverage terms under the contract, certificate, or policy of insurance that was purchased. (DOL FAQs Part IX 05/11/12) Q3: If an individual (or a plan or its sponsor) receives an SBC prior to application for coverage, must an issuer automatically provide another SBC upon application, if the information required to be in the SBC has not changed? Updated 1-31-17 No. A duplicate SBC is generally not required to be provided at the time of application unless requested by the applicant. However, if by the time the application is ?led, there is a change in the information required to be in the SBC, the issuer or plan must update and provide a current SBC to the individual (or plan or its sponsor) as soon as practicable following receipt of the application, but in no event later than seven business days following receipt of the application. Similarly, if an SBC is provided upon application, there is no requirement to provide the SBC again on the ?rst day of 1274 2017-?01374 coverage, unless there is a change to the information that is required requested by the applicant. (DOL FAQs Part IX 05/11/12) Q4: Are issuers required to provide SBCs to group health plans (or their sponsors) who are ?shopping? for coverage, but have not yet submitted an application for coverage? Yes, but only in certain circumstances. The regulations generally provide that an SBC must be provided upon request for an SBC or ?summary information about a health insurance product.? The latter phrase is intended to ensure that persons who do not ask exactly for a ?summary of bene?ts and coverage? still receive one when they explicitly ask for a summary document with respect to a speci?c health product. Other, general questions about coverage options or discussions about health products do not trigger the requirement to provide an SBC. (See also, Q1 regarding electronic delivery options for providing (DOL FAQs Part IX 05/11/12) Q5: A previous FAQ stated that an SBC provided in connection with a group health plan may include a reference to the summary plan description For SBCs provided in connection with coverage in the individual market, can the SBC refer to other documents associated with the coverage? Yes. While it is not permitted to substitute a reference to any other document for any content element of the SBC, an SBC may include a reference to another document in the SBC footer. In addition, wherever an SBC provides information that fully satis?es a particular content element of the SBC, it may add to that information a reference to speci?ed pages or portions of other documents in order to supplement or elaborate on that information. (DOL FAQs Pan? IX 05/11/12) Q6: Are certain electronic features (such as scrolling and expansion of columns) permitted when displaying the SBC electronically? Updated 1-31-17 Yes. Minor adjustments are permitted to accommodate the plan?s or issuer?s information and electronic display method, such as expansion of columns. Additionally, it is permissible to display the SBC electronically on a single webpage, so the viewer can scroll through the information required to be in the SBC without having to advance through pages (as long as a printed version is available that meets the formatting requirements of the SBC). However, the deletion of columns or rows is not permitted when displaying a complete SBC. (For more on minor adjustments, see FAQs Part at implementation faqs8.html. Specifically, Q3 and Q4 state that ?plans and issuers may combine information the appearance is understandable? and Q19 states that ?minor adjustments are long as the information is understandable") (DOL FAQs Part IX 05/11/12) 1275 2017-?01375 Q7: Some plans or issuers provide web-based or print materials to illustrate the differences between benefit package options (including comparison charts and broker comparison websites). Is it permissible to ?combine? SBCs or SBC elements to provide a side-by-side comparison? Yes. Issuers and plans (and agents and brokers working with such plans) may display 8803, or parts of $803, in a way that facilitates comparisons of different benefit package options by individuals and employers shopping for coverage. For example, on a website, viewers could be allowed to select a comparison of only the deductibles, out-of- pocket limits, or other cost sharing of several bene?t package options. This could be achieved by providing the ?deductible row? of the SBC for several benefit packages, but without having to repeat the ?rst one or two columns, as appropriate, of the SBC for each of the bene?t packages. However, such a chart, website, or other comparison does not, itself, satisfy the requirements under PHS Act section 2715 and the ?nal regulations to provide the SBC. The full SBC for all the bene?t packages included in the comparison view/tool must be made available in accordance with the regulations and other guidance. (DOL FAQs Part IX 05/11/12) Q8: Under what circumstances can penalties be imposed for failure to provide the SBC or the uniform glossary? PHS Act section 2715(f) states that an entity is subject to a ?ne if the entity ?willfully fails to provide the information required under this section." As stated in previous the Departments? basic approach to ACA implementation is: ?[to work] together with employers, issuers, States, providers and other stakeholders to help them come into compliance with the new law and [to work] with families and individuals to help them understand the new law and benefit from it, as intended. Compliance assistance is a high priority for the Departments. Our approach to implementation is and will continue to be marked by an emphasis on assisting (rather than imposing penalties on) plans, issuers and others that are working diligently and in good faith to understand and come into compliance with the new law.? Accordingly, consistent with this guidance, during this ?rst year of applicability, the Departments will not impose penalties on plans and issuers that are working diligently and in good faith to comply. (DOL FAQs Part IX 05/11/12) 09: For the first year of applicability,(4) can the Departments provide further assistance with regard to the coverage examples, such as a streamlined calculator? Updated 1-31-17 Yes. The Departments are developing a calculator that plans and issuers can use as a safe harbor for the ?rst year of applicability to complete the coverage examples in a streamlined fashion; because this approach will be less accurate, it will be allowed as a transitional tool for the ?rst year of applicability.(5) The calculator will allow plans and issuers to input a discrete number of elements about the bene?t package. Calculator inputs generally are expected to be taken from data ?elds used to populate the front portion of the SBC template. (See for a list of calculator inputs.) The output will be a coverage example that can be added to the corresponding SBC. The Departments will also provide the algorithm that was used to create the calculator. The calculator and algorithm will be posted at 1276 2017-?01376 soon. (DOL FAQs Part IX 05/11/12) Q10: A previous FAQ discussed the utilization of ?carve-out arrangements? under which a plan or issuer contracts with a service provider to help manage certain benefits under the plan or policy.(6) In another type of ?carve-out arrangement,? a plan sponsor may purchase an insurance product for certain coverage from a particular issuer and purchase a separate insurance product or self-insure with respect to other coverage (such as outpatient prescription drug coverage). In these circumstances, the first issuer may or may not even know of the existence of other coverage, or whether the plan sponsor has arranged the two benefit packages as a single plan or two separate plans. What are an issuer?s obligations to provide an SBC with respect to bene?ts it does not insure? Unless it contracts otherwise, an issuer has no obligation to provide coverage information for bene?ts that it does not insure. However, group health plan administrators are responsible for providing complete SBCs with respect to a plan. A plan administrator that uses two or more insurance products provided by separate issuers with respect to a single group health plan may the information into a single SBC, or may contract with one of its issuers (or other service providers) to perform that function. Due to the administrative challenges of combining benefit package information from multiple issuers, during the first year of applicability, for enforcement purposes, with respect to a group health plan that uses two or more issuers, the Departments will consider the provision of multiple partial 8803 that, together, provide all the relevant information to meet the SBC content requirements. In such circumstances, the plan administrator should take steps (such as a cover letter or a notation on the 8803 themselves) to indicate that the plan provides coverage using multiple different insurers and that individuals who would like assistance understanding how these products work together may contact the plan administrator for more information (and provide the contact (DOL FAQs Part IX 05/11/12) Q11: A previous FAQ provided a link where written translations for the SBC template and the uniform glossary would be available in the future.(8) Are these translations available? Written translations in Spanish, Chinese, and Tagalog are now available. Navajo translations will be available shortly. For more information, see CCIIO website at (DOL FAQs Pan? IX 05/11/12) Q12: Are health insurance issuers required to provide SBCs for insurance products that are no longer being offered for purchase? The Departments understand that most plans and issuers have to develop new databases and technology systems in order to extract information about coverage terms and provide SBCs. The Departments also understand that, with respect to insurance products that are no longer being offered for purchase (sometimes referred to as closed blocks of business), there is a significant volume of data that is not stored in electronic form or is not stored in an information system that that is compatible with the new 1277 Updated 1-31-17 2017-?01377 electronic systems being developed for the SBC. Accordingly, due to the additional administrative complexities with respect to providing SBCs with respect to closed blocks of business, the Departments will not take any enforcement action against a plan or issuer for failing to provide an SBC before September 23, 2013 with respect to an insured product that is no longer being actively marketed for business, provided the SBC is provided no later than September 23, 2013 (at which time, enrollees and small employers will have new opportunities to compare coverage options available through an Exchange). (DOL FAQs Part IX 05/11/12) Q13: Expatriate plans and policies face special circumstances and considerations in complying with the SBC requirements. Can the Departments provide any assistance or relief with respect to expatriate coverage? Yes. The Departments recognize that expatriate coverage carries additional administrative costs and barriers in ?lling out SBCs, including benefit and claims systems that are distinct from those for domestic coverage, which makes compliance more dif?cult. Therefore, for purposes of enforcement, the Departments will not take any enforcement action against a group health plan or group health insurance issuer for failing to provide an SBC with respect to expatriate coverage during the ?rst year of applicability. (DOL FAQs Part IX 05/11/12) Q14: Other than the FAQs, are there any updates to the SBC template and related documents on the Departments? websites that I need to know about? Yes. In the diabetes treatment scenario, the version originally posted contained a typographical error, listing the allowed amount for insulin as $11.92, rather than $119.20 a difference that impacts the total cost of care for diabetes in the coverage example calculations. To correct this error, the Departments have posted updated versions of the SBC template, the sample completed SBC, and the guide for coverage examples calculations diabetes scenario. The updated SBC template and sample completed SBC also include sample taglines for obtaining translated documents, to be included if appropriate consistent with paragraph of the regulations, as well as updated Sample Care Costs amounts for the diabetes coverage example, due to more accurate rounding in making these calculations. Finally, the updated versions include some appearance modi?cations (such as changes in bolding, underlining, shading, capitalization, margin justi?cation, use of hyphens, and row and column sizing) to ensure the document is accessible to individuals with disabilities, consistent with section 508 of the Rehabilitation Act. Plans and issuers may use either version, or may make similar modi?cations to their own SBCs, without violating the appearance requirements for an SBC. (DOL FAQs Part IX 05/11/12) Q1: I am an employer sponsoring a group health plan. One of the bene?t packages is a Medicare Advantage plan. Am I required to provide an SBC for the Medicare Advantage package? Updated 1-31-17 No. Medicare Advantage bene?ts are Medicare benefits (?nanced by the Medicare Trust fund and equivalent to Medicare A and benefits, which are set by Congress and regulated by the Centers for Medicare Medicaid Services They are, therefore, not health insurance coverage and Medicare Advantage organizations are not required to provide an SBC with respect to such benefits. Pending further guidance, the 1278 2017-?01378 Departments will not take any enforcement action against a group health plan because it does not provide an SBC with respect to a Medicare Advantage benefit package.(1) This enforcement policy does not affect other disclosure requirements administered by CMS that apply to Medicare Advantage organizations. These separately required disclosures will ensure that enrollees in these plans receive the necessary information about their coverage and benefits. Nor does this policy affect the obligation of group health plans that offer Medicare Advantage benefit options to ensure that 8803 are provided with respect to other bene?t packages that they offer. (DOL FAQs PartX 08/07/12) Q1: What templates should plans and issuers use for the $805 and the uniform glossary required to be provided after the first year of applicability? An updated SBC template (and sample completed SBC) are now available at and . These documents are authorized for use with respect to group health plans and group and individual health insurance coverage for 8803 provided with respect to coverage beginning on or after January 1, 2014, and before January 1, 2015 (referred to in this guidance document as ?the second year of applicability?). The only change to the SBC template and sample completed SBC is the addition of statements of whether the plan or coverage provides MEC (as defined under section 5000A(f) of the Internal Revenue Code 1986) and whether the plan or coverage meets the MV requirements (that is, the plan?s or coverage?s share of the total allowed costs of bene?ts provided under the plan or coverage is not less than 60 percent of such costs). On page 4 of the SBC template (and illustrated on page 6 of the sample completed SBC), a plan or issuer should indicate in the designated entry on the SBC template that the plan or coverage ?does" or ?does not" provide MEC and whether the plan or coverage ?does? or ?does not? meet applicable MV requirements. There are no changes to the uniform glossary. There are also no changes to the Instructions for Completing the SBC (for either group or individual health coverage), ?Why This Matters? language for the SBC, or to the coverage examples. (DOL FAQs Part XIV 04/23/13) Q2: Our plan is already working on the process of preparing SBCs for issuance in the second year of applicability and it would be an administrative burden to add the new data element to the template at this point in the process. Is any relief available to provide information about MEC and MV without changing the SBC template? Updated 1-31-17 Yes. To the extent a plan or issuer is unable to modify the SBC template for disclosures required to be provided with respect to the second year of applicability, the Departments will not take any enforcement action against a plan or issuer for using the template authorized for the ?rst year of applicability, provided that the SBC is furnished with a cover letter or similar disclosure stating whether the plan or coverage does or does not provide MEC and whether the plan's or coverage?s share of the total allowed costs of bene?ts provided under the plan or coverage does or does not meet the MV requirement under the Affordable Care Act. The language for these statements is as follows: Does this Coverage Provide Minimum Essential Coverage? 1279 2017-?01379 The Affordable Care Act requires most people to have health care coverage that qualifies as ?minimum essential coverage." This plan or policy [does/does not] provide minimum essential coverage. Does this Coverage Meet the Minimum Value Standard? The Affordable Care Act establishes a minimum value standard of bene?ts of a health plan. The minimum value standard is 60% (actuarial value). This health coverage [does/does not] meet the minimum value standard for the bene?ts it provides. (DOL FA 05 Part XIV 04/23/13) Q3: A previous FAQ stated that the Departments intended to make changes to the SBC template for 2014 to be consistent with the Affordable Care Act?s requirement to eliminate all annual limits on essential health benefits.(4) Have the Departments made any changes related to this requirement? Updated 1-31-17 No. As stated earlier, the only change to the SBC template and sample completed SBC is the addition of information to indicate whether the plan or coverage provides MEC and whether the plan?s or coverage's share of the total allowed costs of bene?ts provided under the plan or coverage meets applicable MV requirements under the Affordable Care Act. Plans and issuers should continue to complete the SBC template consistent with the Instructions for Completing the SBC (for either group or individual health coverage, as applicable) for the Important Questions chart that appears on page 1 of the SBC: In the Answers column, the plan or issuer should respond where the template asks, ?Is there an overall annual limit on what the plan pays??, as plans and issuers are generally prohibited from imposing annual limits on the dollar value of essential health benefits for plan years (in the individual market, policy years) beginning on or after January 1, 2014.(5) In the Why This Matters column, the plan or issuer must show the following language: ?The chart starting on page 2 describes any limits on what the plan will pay for speci?c covered services, such as of?ce Additionally, as applicable, plans and issuers should continue to include information regarding annual or lifetime dollar limits on specific covered bene?ts as required in the chart starting on page 2 of the SBC (in the Limitations Exceptions column), as described in the Instructions for Completing the SBC (for either group or individual health coverage, as applicable). To the extent a plan or issuer wishes to modify the SBC template for disclosures required to be provided for the second year of applicability to remove this information, the Departments will not take any enforcement action against a plan or issuer for removing the entire row in the Important Questions chart on page 1 of the SBC (with the question: ?Is there an overall annual limit on what the plan pays??). (DOL FAQs Part XIV 04/23/13) 1280 2017--01380 Q4: A previous FAQ stated that the Departments intended to add additional coverage examples for 2014. Have the Departments made any changes related to this requirement? To help transition to new market changes in 2014, the Departments believe it is prudent to maintain the current coverage examples. Additional coverage examples are not required as part of the SBC at this time. As with the SBC authorized for the first year of applicability, the documents authorized for the second year of applicability continue to require the same two coverage examples authorized for the first year of applicability having a baby (normal delivery) and managing type 2 diabetes (routine maintenance of a well-controlled condition). (DOL FAQs Part 04/23/13) QS: Safe harbors and other enforcement relief were provided by the Departments related to the requirement to provide an SBC and a uniform glossary for the first year of applicability. Will this relief be extended? Updated 1-31-17 Yes. As stated in previous the Departments? basic approach to ACA implementation is: ?[to work] together with employers, issuers, States, providers and other stakeholders to help them come into compliance with the new law and [to work] with families and individuals to help them understand the new law and bene?t from it, as intended. Compliance assistance is a high priority for the Departments. Our approach to implementation is, and will continue to be, marked by an emphasis on assisting (rather than imposing penalties on) plans, issuers and others that are working diligently and in good faith to understand and come into compliance with the new law.? In recognition of and to ensure a smooth transition to new market changes in 2014, the Departments believe it is prudent to extend the following enforcement relief to apply through the end the second year of applicability: 0 Affordable Care Act Implementation FAQs Part QZ (regarding the Departments? basic approach to implementation of the SBC requirements during the first year of . Affordable Care Act Implementation FAQs Part IX, Q1 (regarding the circumstances in which an SBC may be provided 0 Affordable Care Act Implementation FAQs Part IX, Q8 (regarding penalties for failure to provide the SBC or uniform 0 Affordable Care Act Implementation FAQs Part IX, 09 (regarding the coverage examples and related information related to use of the coverage examples calculator;(13) 0 Affordable Care Act Implementation FAQs Part IX, Q10 (regarding an issuer's obligation to provide an SBC with respect to bene?ts it does not and 0 Affordable Care Act Implementation FAQs Part IX, Q13 (regarding expatriate In addition, the following enforcement relief continues to apply through the second year of applicability, consistent with existing guidance: . The Special Rule contained in the Instruction Guides for Group and Individual Coverage;(16) . Affordable Care Act Implementation FAQs Part IX, Q1 (regarding the circumstances in which an SBC may be provided and 0 Affordable Care Act Implementation FAQs Part X, 01 (regarding Medicare 1281 2017-?01381 Additionally, Affordable Care Act Implementation FAQs Part Q5 (regarding use of carve-out arrangements) applies ?until further guidance is issued.? The relief provided in this Affordable Care Act Implementation FAQs Part Q5 continues to apply, and plans and issuers may rely on this relief at least through the end of 2014. This guidance supersedes any previous subregulatory guidance (including FAQs) stating that enforcement relief for the SBC and uniform glossary requirements is limited to the first year of applicability. (DOL FAQs Part 04/23/13) 06: A previous FAQ provided an enforcement safe harbor until September 23, 2013 for plans and issuers with respect to insurance products that are no longer being offered for purchase (?closed blocks of business?). Will this relief be extended? Yes. The relief provided in this FAQ extends this date to September 23, 2014 for plans and issuers with respect to an insured product that meets three conditions: 0 The insured product is no longer being actively marketed; The health insurance issuer stopped actively marketing the product prior to September 23, 2012, when the requirement to provide an SBC was ?rst applicable to health insurance issuers; and The health insurance issuer has never provided an SBC with respect to the insured product. That is, if a health insurance product is not being actively marketed and the health insurance issuer has not actively marketed the product at any time on or after September 23, 2012, the Departments will not take any enforcement action against the plan or issuer for failing to provide an SBC before September 23, 2014 with respect to a product, provided the SBC is provided for that product no later than September 23, 2014. However, if an insured product was actively marketed for business on or after September 23, 2012, and is no longer being actively marketed for business, or if the plan or issuer ever provided an SBC in connection with the insured product, the plan and issuer must provide the SBC with respect to such coverage, as required by PHS Act section 2715 and the final regulations. (DOL FAQs Part XIV 04/23/13) Q7: The final regulations regarding the SBC included an anti-duplication provision for group health coverage clarifying that an entity required to provide an SBC would be considered to have satisfied that requirement with respect to an individual if another party provides a timely and complete SBC. Is a similar anti-duplication rule applicable for student health insurance coverage? Updated 1-31-17 Yes. On March 21, 2012, HHS issued a ?nal rule establishing requirements for student health insurance coverage.(21) The final rule de?nes student health insurance coverage as a type of individual health insurance coverage provided pursuant to a written agreement between an institution of higher education and a health insurance issuer.(22) HHS is extending the anti-duplication rule for group health coverage set forth in the final SBC regulations to student health insurance coverage, as de?ned in 45 CFR Therefore, the requirement to provide an SBC with respect to an individual will be considered satis?ed for an entity (such as an institution of higher education) if another party (such as a health insurance issuer) provides a timely and complete SBC to the individual. (DOL FAQs Part XIV 04/23/13) 1282 2017-?01382 Q7: What templates should plans and issuers use for the SBCs and the uniform glossary required to be provided after the second year of applicability? An updated SBC template (and sample completed SBC) were made available at and in April 2013 for the second year of applicability. Until further guidance is issued, these documents continue to be authorized. There are no changes to the uniform glossary or the "Why This Matters" language for the SBC. There are also no changes to the Instructions for Completing the SBC (for either group or individual health coverage, as applicable), including the special rule providing that, the extent a plan's terms that are required to be described in the SBC template cannot reasonably be described in a manner consistent with the template and instructions, the plan or issuer must accurately describe the relevant plan terms while using its best efforts to do so in a manner that is still as consistent with the instructions and template format as reasonably possible." (DOL FAQs Part XIX 05/02/14) Q8: Certain speci?c safe harbors and other enforcement relief were provided by the Departments related to the requirement to provide an SBC and a uniform glossary for the first and second years of applicability.(21) Will this relief be extended? Updated 1-31-17 Yes. As stated in previous the Departments' basic approach to Affordable Care Act implementation is to work together with employers, issuers, States, providers and other stakeholders to help them come into compliance with the new law and [to work] with families and individuals to help them understand the new law and bene?t from it, as intended. Compliance assistance is a high priority for the Departments. Our approach to implementation is, and will continue to be, marked by an emphasis on assisting (rather than imposing penalties on) plans, issuers and others that are working diligently and in good faith to understand and come into compliance with the new law." Until further guidance is provided, previously issued enforcement and transition relief guidance continues to apply with respect to: 0 Affordable Care Act Implementation FAQs Part 02 (regarding the Departments' basic approach to implementation of the SBC requirements during the first year of . Affordable Care Act Implementation FAQs Part Q5 (regarding use of carve-out 0 Affordable Care Act Implementation FAQs Part IX, Q1 (regarding the circumstances in which an SBC may be provided 0 Affordable Care Act Implementation FAQs Part IX, Q8 (regarding penalties for failure to provide the SBC or uniform 0 Affordable Care Act Implementation FAQs Part IX, 09 (regarding the coverage examples and related information related to use of the coverage examples calculator;(28) 0 Affordable Care Act Implementation FAQs Part IX, Q10 (regarding an issuer's obligation to provide an SBC with respect to bene?ts it does not 0 Affordable Care Act Implementation FAQs Part IX, Q13 (regarding expatriate 0 Affordable Care Act Implementation FAQs Part X, Q1 (regarding Medicare 1283 2017--01383 0 Affordable Care Act Implementation FAQs Part XIV, QZ (regarding providing information about MEC and MV without changing the SBC 0 Affordable Care Act Implementation FAQs Part XIV, QB (removal of the row on the SBC template related to annual limits . Affordable Care Act Implementation FAQs Part XIV, Q6 (an enforcement safe harbor related to closed blocks of . Affordable Care Act Implementation FAQs Part XIV, Q7 (regarding the anti- duplication rule for student health insurance and The Special Rule contained in the Instruction Guides for Group and Individual Coverage.(36) This guidance supersedes any previous subregulatory guidance (including FAQs) stating that certain enforcement relief for the SBC and uniform glossary requirements is limited to the ?rst or second year of applicability. (DOL FAQs Part XIX 05/02/14) Q1. In the December 2014 notice of proposed rulemaking, the Departments proposed changes to the SBC regulations, as well as a new SBC template and associated documents. Changes to the SBC regulations, template, and associated documents were proposed to apply beginning September 1, 2015. When do the Departments intend to finalize changes to the regulations, SBC template, and associated documents? The Departments intend to ?nalize changes to the regulations in the near future, which are intended to apply in connection with coverage that would renew or begin on the ?rst day of the ?rst plan year (or, in the individual market, policy year) that begins on or after January 1, 2016 (including open season periods that occur in the Fall of 2015 for coverage beginning on or after January 1, 2016). The Departments also intend to utilize consumer testing and offer an opportunity for the public, including the National Association of Insurance Commissioners, to provide further input before ?nalizing revisions to the SBC template and associated documents. The Departments anticipate the new template and associated documents will be finalized by January 2016 and will apply to coverage that would renew or begin on the first day of the ?rst plan year (or, in the individual market, policy year) that begins on or after January 1, 2017 (including open season periods that occur in the Fall of 2016 for coverage beginning on or after January 1, 2017). The Departments are fully committed to updating the template and associated documents (including the uniform glossary) to better meet consumers' needs as quickly as possible. (DOL FAQs Part XXIV 03/30/15) What is the intended implementation date for SBCs using the new template and associated documents? Updated 1-31-17 After the close of the public comment period on March 28, 2016, regarding the proposed SBC template and associated documents that were published on February 26, 2016, the Departments intend to review the comments and finalize the new SBC template and associated documents expeditiously. The Departments intend that health plans and issuers that maintain an annual open enrollment period will be required to use the new SBC template and associated documents beginning on the ?rst day of the first open enrollment period that begins on or after April 1, 2017 with respect to coverage for plan 1284 2017-?01384 years (or, in the individual market, policy years) beginning on or after that date. For plans and issuers that do not use an annual open enrollment period, the new SBC template and associated documents would be required beginning on the first day of the ?rst plan year (or, in the individual market, policy year) that begins on or after April 1, 2017. (DOL FAQs Part Summary of Bene?ts and Coverage 03/11/16) Notice of Coverage Options Available Through the Exchanges Q1: When do employers have to comply with the new notice requirements in section 18B of the Section 18B of the FLSA provides that employer compliance with the notice requirements of that section must be carried out accordance with regulations promulgated by the Secretary [of Labor]." Accordingly, it is the view of the Department of Labor that, until such regulations are issued and become applicable, employers are not required to comply with FLSA section 188. The Department of Labor has concluded that the notice requirement under FLSA section 188 will not take effect on March 1, 2013 for several reasons. First, this notice should be coordinated with educational efforts and Internal Revenue Service (IRS) guidance on minimum value. Second, we are committed to a smooth implementation process including providing employers with suf?cient time to comply and selecting an applicability date that ensures that employees receive the information at a meaningful time. The Department of Labor expects that the timing for distribution of notices will be the late summer or fall of 2013, which will coordinate with the open enrollment period for Exchanges. The Department of Labor is considering providing model, generic language that could be used to satisfy the notice requirement. As a compliance alternative, the Department of Labor is also considering allowing employers to satisfy the notice requirement by providing employees with information using the employer coverage template as discussed in the preamble to the Proposed Rule on Medicaid, Children's Health Insurance Programs, and Exchanges: Essential Health Benefits in Alternative Benefit Plans, Eligibility Notices, Fair Hearing and Appeal Processes for Medicaid and Exchange Eligibility Appeals and Other Provisions Related to Eligibility and Enrollment for Exchanges, Medicaid and CHIP, and Medicaid Premiums and Cost Sharing (78 FR 4594, at 4641 which will be available for download at the Exchange web site as part of the streamlined application that will be used by the Exchange, Medicaid, and CHIP. Future guidance on complying with the notice requirement under FLSA section 18B is expected to provide flexibility and adequate time to comply. (DOL FAQs Part XI 01/24/13) Q1: Is it permissible for another entity (such as an issuer, multiemployer plan, or third- party administrator) to send the Notice of Coverage Options on behalf of an employer to satisfy the employer's obligations under FLSA section 183? Updated 1-31-17 Yes, an employer will have satis?ed its obligation to provide the notice with respect to an individual if another party provides a timely and complete notice. The Department of Labor notes that, as explained in Technical Release 2013-02, FLSA section 188 requires employers to provide notice to all employees, regardless of whether an employee is enrolled in, or eligible for, coverage under a group health plan. Accordingly, 1285 2017--01385 an employer is not relieved of its statutory obligation to provide notice under FLSA section 188 if another entity sends the notice to only participants enrolled in the plan, if some employees are not enrolled in the plan. When providing notices on behalf of employers, multiemployer plans, issuers, and third party administrators should take proper steps to ensure that a notice is provided to all employees regardless of plan enrollment, or communicate clearly to employers that the plan, issuer, or third party administrator will provide notice only to a subset of employees employees enrolled in the plan) and advise of the residual obligations of employers with respect to other employees employees who are not enrolled in the plan). (DOL FAQs Part XVI 09/04/13) Health Reimbursement Arrangements (HRAs) 02: May an HRA used to purchase coverage on the individual market be considered integrated with that individual market coverage and therefore satisfy the requirements of PHS Act section 2711? No. The Departments intend to issue guidance providing that for purposes of PHS Act section 2711, an employer-sponsored HRA cannot be integrated with individual market coverage or with an employer plan that provides coverage through individual policies and therefore will violate PHS Act section 2711. (DOL FAQs Part XI 01/24/13) Q3: If an employee is offered coverage that satisfies PHS Act section 2711 but does not enroll in that coverage, may an HRA provided to that employee be considered integrated with the coverage and therefore satisfy the requirements of PHS Act section 2711? No. The Departments intend to issue guidance under PHS Act section 2711 providing that an employer-sponsored HRA may be treated as integrated with other coverage only if the employee receiving the HRA is actually enrolled in that coverage. Any HRA that credits additional amounts to an individual when the individual is not enrolled in primary coverage meeting the requirements of PHS Act section 2711 provided by the employer will fail to comply with PHS Act section 2711. (DOL FAQs Pan? XI 01/24/13) Q4: How will amounts that are credited or made available under HRAs under terms that were in effect prior to January 1, 2014, be treated? Updated 1-31-17 The Departments anticipate that future guidance will provide that, whether or not an HRA is integrated with other group health plan coverage, unused amounts credited before January 1, 2014, consisting of amounts credited before January 1, 2013 and amounts that are credited in 2013 under the terms of an HRA as in effect on January 1, 2013 may be used after December 31, 2013 to reimburse medical expenses in accordance with those terms without causing the HRA to fail to comply with PHS Act section 2711. If the HRA terms in effect on January 1, 2013, did not prescribe a set amount or amounts to be credited during 2013 or the timing for crediting such amounts, then the amounts credited may not exceed those credited for 2012 and may not be credited at a faster rate than the rate that applied during 2012. (DOL FAQs Part XI 01/24/13) 1286 2017--01386 Question 1: The HRA FAQs provide that an employer-sponsored HRA cannot be integrated with individual market coverage, and, therefore, an HRA used to purchase coverage on the individual market will fail to comply with the annual dollar limit prohibition. May other types of group health plans used to purchase coverage on the individual market be integrated with that individual market coverage for purposes of the annual dollar limit prohibition? Answer 1: No. A group health plan, including an HRA, used to purchase coverage on the individual market is not integrated with that individual market coverage for purposes of the annual dollar limit prohibition. For example, a group health plan, such as an employer payment plan, that reimburses employees for an employee?s substantiated individual insurance policy premiums must satisfy the market reforms for group health plans. However the employer payment plan will fail to comply with the annual dollar limit prohibition because (1) an employer payment plan is considered to impose an annual limit up to the cost of the individual market coverage purchased through the arrangement, and (2) an employer payment plan cannot be integrated with any individual health insurance policy purchased under the arrangement. (DOL Technical Release 2013-03 09/13/13) Question 2: How do the preventive services requirements apply to an HRA that is integrated with a group health plan? Answer 2: Similar to the analysis of the annual dollar limit prohibition, an HRA that is integrated with a group health plan will comply with the preventive services requirements if the group health plan with which the HRA is integrated complies with the preventive services requirements. (DOL Technical Release 2013-03 09/13/13) Question 3: The HRA FAQs provide that an employer-sponsored HRA cannot be integrated with individual market coverage, and, therefore, an HRA used to purchase coverage on the individual market will fail to comply with the annual dollar limit prohibition. May a group health plan, including an HRA, used to purchase coverage on the individual market be integrated with that individual market coverage for purposes of the preventive services requirements? Answer 3: No. A group health plan, including an HRA, used to purchase coverage on the individual market is not integrated with that individual market coverage for purposes of the preventive services requirements. For example, a group health plan, such as an employer payment plan, that reimburses employees for an employee?s substantiated individual insurance policy premiums must satisfy the market reforms for group health plans. However, the employer payment plan will fail to comply with the preventive services requirements because (1) an employer payment plan does not provide preventive services without cost-sharing in all instances, and (2) an employer payment plan cannot be integrated with any individual health insurance policy purchased under the arrangement. (DOL Technical Release 2013-03 09/13/13) 1287 Updated 1-31-17 2017--01387 Question 4: Under what circumstances will an HRA be integrated with another group health plan for purposes of the annual dollar limit prohibition and the preventive services requirements? Answer 4: An HRA will be integrated with a group health plan for purposes of the annual dollar limit prohibition and the preventive services requirements if it meets the requirements under either of the integration methods described below. Pursuant to this Technical Release, under both methods, integration does not require that the HRA and the coverage with which it is integrated share the same plan sponsor, the same plan document or governing instruments, or ?le a single Form 5500, if applicable. (DOL Technical Release 2013-03 09/13/13) Question 5: May an employee who is covered by both an HRA and a group health plan with which the HRA is integrated, and who then ceases to be covered under the group health plan that is integrated with the HRA, be permitted to use the amounts remaining in the Answer 5: Whether or not an HRA is integrated with other group health plan coverage, unused amounts that were credited to an HRA while the HRA was integrated with other group health plan coverage may be used to reimburse medical expenses in accordance with the terms of the HRA after an employee ceases to be covered by other integrated group health plan coverage without causing the HRA to fail to comply with the market reforms. Note that coverage provided through an HRA, other than coverage consisting solely of excepted bene?ts, is an eligible employer-sponsored plan and, therefore, minimum essential coverage under Code 5000A. (DOL Technical Release 2013-03 09/13/13) Question 6: Does an HRA impose an annual limit in violation of the annual dollar limit prohibition if the group health plan with which an HRA is integrated does not cover a category of essential health benefits and the HRA is available to cover that category of essential health benefits (but limits the coverage to the maximum benefit)? Updated 1-31-17 Answer 6: In general, an HRA integrated with a group health plan imposes an annual limit in violation of the annual dollar limit prohibition if the group health plan with which the HRA is integrated does not cover a category of essential health benefits and the HRA is available to cover that category of essential health benefits and limits the coverage to the maximum benefit. This situation should not arise for a group health plan funded through non-grandfathered health insurance coverage in the small group market, as small group market plans must cover all categories of essential health bene?ts, with the exception of pediatric dental bene?ts, if pediatric dental bene?ts are available through a stand-alone dental plan offered in accordance with 45 C.F.R. ?155.1065. However, under the integration method available for plans that provide minimum value described under 4 of this Technical Release, if a group health plan provides minimum value under Code an HRA integrated with that group health plan will not be treated as imposing an annual limit in violation of the annual dollar limit prohibition, even if that group health plan does not cover a category of essential health bene?ts and the HRA is available to cover that category of essential health bene?ts and limits the coverage to the HRA's maximum benefit. (DOL Technical Release 2013-03 09/13/13) 1288 2017--01388 Guidance Under the Sole Jurisdiction of the Treasury Department and the IRS on HRAs and Code 125 Plans Question 10: Is an HRA that has fewer than two participants who are current employees on the first day of the plan year (for example, a retiree-only HRA) minimum essential coverage for purposes of Code 5000A and 363? Answer 10: Yes. The Treasury Department and the IRS understand that some employers are considering making amounts available under standalone retiree-only HRAs to retired employees so that the employer would be able to reimburse medical expenses, including the purchase of an individual health insurance policy. For this purpose, the standalone HRA would constitute an eligible employer-sponsored plan under Code ?5000A(f)(2), and therefore the coverage would constitute minimum essential coverage under Code for a month in which funds are retained in the HRA (including amounts retained in the HRA during periods of time after the employer has ceased making contributions). As a result, a retiree covered by a standalone HRA for any month will not be eligible for a Code 368 premium tax credit for that month. Note that unlike other HRAs, the market reforms generally do not apply to a retiree-only HRA and therefore would not impact an employer?s choice to offer a retiree-only HRA. (DOL Technical Release 2013-03 09/13/13) Question 11: How are amounts newly made available under an HRA treated for purposes of Code 363? Updated 1-31-17 Answer 11: An individual is not eligible for individual coverage subsidized by the Code 368 premium tax credit if the individual is eligible for employer-sponsored coverage that is affordable (premiums for self-only coverage do not exceed 9.5 percent of household income) and that provides minimum value (the plan?s share of costs is at least 60 percent). If an employer offers an employee both a primary eligible employer-sponsored plan and an HRA that would be integrated with the primary plan if the employee enrolled in the plan, amounts newly made available for the current plan year under the HRA may be considered in determining whether the arrangement satisfies either the affordability requirement or the minimum value requirement, but not both. Amounts newly made available for the current plan year under the HRA that an employee may use only to reduce cost-sharing for covered medical expenses under the primary employer- sponsored plan count only toward the minimum value requirement. See Minimum Value of Eligible Employer?Sponsored Plans and Other Rules Regarding the Health Insurance Premium Tax Credit, 78 Fed. Reg. 25909, 25916 (May 3, 2013) (proposed regulations, to be codified, in part, once ?nal, at 26 Amounts newly made available for the current plan year under the HRA that an employee may use to pay premiums or to pay both premiums and cost?sharing under the primary employer- sponsored plan count only toward the affordability requirement. See Minimum Value of Eligible Employer-Sponsored Plans and Other Rules Regarding the Health Insurance Premium Tax Credit, 78 Fed. Reg. 25909, 25914 (May 3, 2013) (proposed regulations; to be codified, in part, once ?nal, at 26 CPR. Even if an HRA is integrated with a plan offered by another employer for purposes of the annual dollar limit prohibition and the preventive services requirements (see 4 of this Technical Release), the HRA does not count toward the affordability or minimum value requirement of the plan offered by the other employer. Additionally, if an employer 1289 2017--01389 offers an HRA on the condition that the employee does not enroll in non-HRA coverage offered by the employer and instead enrolls in non-HRA coverage from a different source, the HRA does not count in determining whether the employer?s non-HRA coverage satis?es either the affordability or minimum value requirement. For purposes of the Code 368 premium tax credit, the requirements of affordability and minimum value do not apply if an employee enrolls in any employer-sponsored minimum essential coverage, including coverage provided through a Code ?125 plan, an employer payment plan, a health FSA, or an HRA, but only if the coverage offered does not consist solely of excepted bene?ts. See 26 If an employee enrolls in any employer-sponsored minimum essential coverage, the employee is ineligible for individual coverage subsidized by the Code 368 premium tax credit. (DOL Technical Release 2013-03 09/13/13) Question 12: Section 125(f)(3) of the Code, effective for taxable years beginning after December 31, 2013, provides that the term ?qualified benefit? does not include any QHP (as defined in ACA 1301(a)) offered through an Exchange. This prohibits an employer from providing a QHP offered through an Exchange as a benefit under the employer?s Code ?125 plan. Some states have already established Exchanges and employers in those states may have Code 125 plan provisions that allow employees to enroll in health coverage through the Exchange as a benefit under a Code ?125 plan. If the employer's Code ?125 plan operates on a plan year other than a calendar year, may the employer continue to provide the Exchange coverage through a Code ?125 plan after December 31, 2013? Answer 12: For Code 125 plans that as of September 13, 2013 operate on a plan year other than a calendar year, the restriction under Code 125(f)(3) will not apply before the first plan year of the Code 125 plan that begins after December 31, 2013. Thus, for the remainder of a plan year beginning in 2013, a QHP provided through an Exchange as a benefit under a Code 125 plan will not result in all benefits provided under the Code 125 plan being taxable. However, individuals may not claim a Code 368 premium tax credit for any month in which the individual was covered by a QHP provided through an Exchange as a benefit under a Code 125 plan. (DOL Technical Release 2013-03 09/13/13) Q3: The Cures Act, enacted on December 13, 2016, includes provisions allowing small employers to offer arrangements similar to an HRA or EPP that may be used to pay or reimburse for medical expenses, including coverage on the individual market. How do these provisions of the Cures Act affect the Departments? previous guidance regarding HRAs and To address concerns raised by application of the group market provisions to certain arrangements of small employers, section 18001 of the Cures Act introduces a new type of tax-preferred arrangement that small employers may use to help their employees pay for medical expenses the ?qualified small employer health reimbursement arrangement? (QSEHRA). The Cures Act amends Code section 9831, ERISA section 733, and PHS Act section 2791, and provides that a QSEHRA is not a group health plan. 1290 Updated 1-31-17 2017--01390 Updated 1-31-17 Under the Cures Act, a QSEHRA is an arrangement offered by an eligible employer that meets the following criteria: (1) The arrangement is funded solely by an eligible employer, and no salary reduction contributions may be made under the arrangement; (2) The arrangement provides, after the employee provides proof of coverage, for the payment to, or reimbursement of, an eligible employee for expenses for medical care (as de?ned in Code section 213(d)) incurred by the eligible employee or the eligible employee?s family members (as determined under the terms of the arrangement); (3) The amount of payments and reimbursements described in (2) for any year do not exceed $4,950 ($10,000 in the case of an arrangement that also provides for payments or reimbursements for family members of the employee) (with amounts to be indexed for increases in cost of living); and (4) The arrangement is provided on the same terms17 to all eligible employees of the eligible employer. To be an eligible employer that may offer a QSEHRA, the employer may not be an applicable large employer (ALE) as de?ned in Code section 4980H(c)(2) (and thus may not be an employer that, generally, employed at least 50 full-time employees, including full-time equivalent employees, in the prior calendar year) and may not offer a group health plan to any of its employees. The Departments? prior guidance concluded that EPPs and non-integrated HRAs are group health plans that fail to comply with the group market reform requirements that prohibit annual dollar limits under PHS Act section 2711 and that require the provision of certain preventive services without cost sharing under PHS Act section 2713. Because a QSEHRA is statutorily excluded from the de?nition of a group health plan, the group market reform requirements do not apply to a QSEHRA. With respect to EPPs and HRAs that do not qualify as QSEHRAs, the Departments' prior guidance continues to apply. The statutory exclusion of QSEHRAs from the group health plan de?nition is effective for plan years beginning after December 31, 2016. With respect to plan years beginning on or before December 31, 2016, the Cures Act provides that the relief under Notice 2015- 1718 applies. 1 of Notice 2015-17 provides that the excise tax under Code section 4980D will not be asserted with respect to employers that are not ALEs for any failure to satisfy the market reforms by EPPs that pay, or reimburse employees for, individual health policy premiums or Medicare Part or Part premiums. That relief was limited to periods before July 1, 2015. Employers eligible for that relief were not required to ?le IRS Form 8928 (regarding failures to satisfy requirements for group health plans under chapter 100 of the Code, including the market reforms) solely as a result of having such an arrangement for the periods prior to July 1, 2015. Pursuant to the extension provided under the Cures Act, for plan years beginning on or before December 31, 2016, the excise tax under Code section 4980D will not be asserted for any failure to satisfy the market reforms by EPPs that pay, or reimburse employees for, individual health policy premiums or Medicare Part or Part premiums, with respect to employers othenNise eligible for the relief under 1 of Notice 2015-17. Such employers are also not required to ?le IRS Form 8928 solely as a 1291 2017-?01391 result of having such an arrangement for the plan years beginning on or before December 31, 2016. As noted in 1 of Notice 2015-17, the relief does not extend to stand-alone HRAs or other arrangements to reimburse employees for medical expenses other than insurance premiums. Consequently, the extension of the relief by the Cures Act is similarly limited to EPPs and does not extend to stand-alone HRAs or other arrangements to reimburse employees for medical expenses other than insurance premiums. In addition, as an employer-provided group health plan, coverage by an HRA or EPP that is not a QSEHRA and that is eligible for the extended relief under the Cures Act would be minimum essential coverage. Consequently, a taxpayer would not be allowed a premium tax credit under Code section 368 for the Marketplace coverage of an employee, or an individual related to the employee, who is covered by an HRA or EPP other than a QSEHRA. 2 of Notice 2015-17 clarifies the treatment of certain corporation healthcare arrangements for 2-percent shareholder employees, generally providing that, until additional guidance provides othenivise, taxpayers may continue to rely on Notice 2008- 120 for all federal income and employment tax treatment of such arrangements, and that such arrangements will not be treated as failing to satisfy the market reforms. As additional guidance with respect to these arrangements has not been issued, the guidance under 2 of Notice 2015-17 continues to apply. The Cures Act's extension of the relief under Notice 2015-17 to plan years beginning on or before December 31, 2016 does not modify 2 of Notice 2015-17, which continues to apply to such arrangements until additional guidance provides otherwise. As noted above, the Departments? prior regulations and guidance continue to apply with respect to EPPs and HRAs that do not qualify as QSEHRAs, including such arrangements offered by employers that are not eligible employers as defined under the Cures Act. An employer that is considered an applicable large employer as defined in Code section 4980H(c)(2) is not permitted to offer a QSEHRA. (DOL FA 03 Part 35 SEPs, Preventive Services, and Small Employer HRAs 12/20/16 Q1: MAY A FAMILY HRA BE INTEGRATED WITH A NON-HRA GROUP HEALTH PLAN SPONSORED BY THE EMPLOYER OF THE SPOUSE THAT COVERS ALL OF THE INDIVIDUALS COVERED BY THE FAMILY HRA IF THAT NON-HRA GROUP HEALTH PLAN OTHERWISE MEETS THE APPLICABLE INTEGRATION Yes. For purposes of determining whether a family HRA is ?integrated" with a non-HRA group health plan, an employer may rely on the reasonable representation of an employee that the employee and other individuals covered by the family HRA are also covered by another non-HRA group health plan that otherwise meets the applicable integration requirements (a qualifying non-HRA group health plan). 1292 Updated 1-31-17 2017--01392 02: MAY A FAMILY HRA BE INTEGRATED WITH A COMBINATION OF (1) SELF-ONLY COVERAGE OF THE EMPLOYEE BY A QUALIFYING NON-HRA GROUP HEALTH PLAN SPONSORED BY THE EMPLOYER AND (2) QUALIFYING NON-HRA GROUP HEALTH PLAN COVERAGE SPONSORED BY THE EMPLOYER OF THE SPOUSE THAT COVERS ALL MEMBERS OF THE FAMILY COVERED BY THE FAMILY HRA (OTHER THAN THE Yes. A family HRA is permitted to be integrated with a combination of coverage under other qualifying non-HRA group health plans for purposes of the group market reforms, provided that all of the individuals who are covered under the family HRA are also covered under other qualifying non-HRA group health plan coverage. The integration rules do not require that the HRA and the non-HRA group health plan with which it is integrated share the same plan sponsor, or that all of the individuals are covered under the same non-HRA group health plan, provided that all of the individuals covered by the HRA are also enrolled in other qualifying non-HRA group health plan coverage. For example, a family HRA covering an employee, spouse, and one dependent child may be integrated with the combination of (1) the employee?s self-only coverage under the non- HRA group health plan of the employee?s employer, and (2) the spouse and dependent child?s coverage under the non-HRA group health plan of the spouse?s employer, provided that both non-HRA group health plans are qualifying non-HRA group health plans. Health FSAs Question 7: How do the market reforms apply to a health FSA that does not qualify as excepted benefits? Updated 1-31-17 Answer 7: The market reforms do not apply to a group health plan in relation to its provision of bene?ts that are excepted bene?ts. Health FSAs are group health plans but will be considered to provide only excepted benefits if the employer also makes available group health plan coverage that is not limited to excepted benefits and the health FSA is structured so that the maximum benefit payable to any participant cannot exceed two times the participant?s salary reduction election for the health FSA for the year (or, if greater, cannot exceed $500 plus the amount of the participant?s salary reduction See 26 C.F.R. 29 C.F.R. and 45 C.F.R. Therefore, a health FSA that is considered to provide only excepted bene?ts is not subject to the market reforms. If an employer provides a health FSA that does not qualify as excepted bene?ts, the health FSA generally is subject to the market reforms, including the preventive services requirements. Because a health FSA that is not excepted benefits is not integrated with a group health plan, it will fail to meet the preventive services The Departments understand that questions have arisen as to whether HRAs that are not integrated with a group health plan may be treated as a health FSA as defined in Code Notice 2002-45, 2002-02 CB 93, states that, assuming that the maximum amount of reimbursement which is reasonably available to a participant under an HRA is not substantially in excess of the value of coverage under the HRA, an HRA is a health FSA as de?ned in Code 106(c)(2). This statement was intended to clarify 1293 2017--01393 the rules limiting the payment of long-term care expenses by health FSAs. The Departments are also considering whether an HRA may be treated as a health FSA for purposes of the exclusion from the annual dollar limit prohibition. In any event, the treatment of an HRA as a health FSA that is not excepted bene?ts would not exempt the HRA from compliance with the other market reforms, including the preventive services requirements, which the HRA would fail to meet because the HRA would not be integrated with a group health plan. This analysis applies even if an HRA reimburses only premiums. (DOL Technical Release 2013-03 09/13/13) Question 8: The interim final regulations regarding the annual dollar limit prohibition contain an exemption for health FSAs (as defined in Code See 26 C.F.R. 29 C.F.R. and 45 C.F.R. Does this exemption apply to a health FSA that is not offered through a Code 125 plan? Answer 8: No. The Departments intended for this exemption from the annual dollar limit prohibition to apply only to a health FSA that is offered through a Code ?125 plan and thus subject to a separate annual limitation under Code 125(i). There is no similar limitation on a health FSA that is not part of a Code 125 plan, and thus no basis to imply that it is not subject to the annual dollar limit prohibition. To clarify this issue, the Departments intend to amend the annual dollar limit prohibition regulations to conform to this 8 retroactively applicable as of September 13, 2013. As a result, a health FSA that is not offered through a Code 125 plan is subject to the annual dollar limit prohibition and will fail to comply with the annual dollar limit prohibition. (DOL Technical Release 2013?03 09/13/13) Q6: How is a permissible carryover amount for a health FSA taken into account with regards to the maximum benefits payable limit for health FSAs under the excepted bene?t regulations? Unused carry over amounts remaining at the end of a plan year in a health FSA that satisfy the modified "use-or-lose" rule should not be taken into account when determining if the health FSA satisfies the maximum benefit payable limit prong under the excepted bene?ts regulations. (DOL FAQs Part XIX 05/02/14) Compliance of Premium Reimbursement Arrangements On September 13, 2013, DOL and the Treasury published guidance on the application of the market reforms and other provisions of the Affordable Care Act to health reimbursement arrangements (HRAs), certain health ?exible spending arrangements (health FSAs) and certain other employer health care arrangements.(1lHHS issued contemporaneous guidance to re?ect that HHS concurs in the application of the laws under its jurisdiction as set forth in the DOL and Treasury Department guidance}? Subsequently, on May 13, 2014, two FAQs were made available on the IRS website addressing employer health care arrangementsf?) The Departments' prior guidance explains that employer health care arrangements, such as HRAs and employer payment plans, are group health plans that typically consist of a promise by an employer?) to reimburse medical expenses up to a certain amount. The Departments' guidance clarifies that such arrangements are subject to the group market reform provisions of the Affordable Care Act, including the prohibition on annual limits under Public Health Service Act (PHS Act) section 2711 and the requirement to provide certain preventive services without 1294 Updated 1-31-17 2017--01394 cost sharing under PHS Act section 271319 The Departments' guidance further clarifies that such employer health care arrangements will not violate these market reform provisions when integrated with a group health plan that complies with such provisions. However, an employer health care arrangement cannot be integrated with individual market policies to satisfy the market reforms. Consequently, such an arrangement may be subject to penalties, including excise taxes under section 498GB of the Internal Revenue Code (Code). Q1: My employer offers employees cash to reimburse the purchase of an individual market policy. Does this arrangement comply with the market reforms? No. If the employer uses an arrangement that provides cash reimbursement for the purchase of an individual market policy, the employer's payment arrangement is part of a plan, fund, or other arrangement established or maintained for the purpose of providing medical care to employees, without regard to whether the employer treats the money as pre-tax or post-tax to the employee. Therefore, the arrangement is group health plan coverage within the meaning of Code section 9832(a), Employee Retirement Income Security Act (ERISA) section 733(a) and PHS Act section 2791(a), and is subject to the market reform provisions of the Affordable Care Act applicable to group health plans. Such employer health care arrangements cannot be integrated with individual market policies to satisfy the market reforms and, therefore, will violate PHS Act sections 2711 and 2713, among other provisions, which can trigger penalties such as excise taxes under section 49800 of the Code. Under the Departments' prior published guidance, the cash arrangement fails to comply with the market reforms because the cash payment cannot be integrated with an individual market (DOL FAQs Part XXII 11/06/14) 02: My employer offers employees with high claims risk a choice between enrollment in its standard group health plan or cash. Does this comply with the market reforms? Updated 1-31-17 No. PHS Act section which was incorporated by reference into ERISA section 715 and Code section 9815, as well as the nondiscrimination provisions of ERISA section 702 and Code section 9802 originally added by the Health Insurance Portability and Accountability Act (HIPAA), prohibit discrimination based on one or more health factors. Offering, only to employees with a high claims risk, a choice between enrollment in the standard group health plan or cash, constitutes such discrimination. While the Departments' regulations implementing this provisionl?) permit more favorable rules for eligibility or reduced premiums or contributions based on an adverse health factor (sometimes referred to as benign discrimination), in the Departments' view, cash-or- coverage arrangements offered only to employees with a high claims risk are not permissible benign discrimination. Accordingly, such arrangements will violate the nondiscrimination provisions, regardless of whether (1) the cash payment is treated by the employer as pre-tax or post-tax to the employee, (2) the employer is involved in the selection or purchase of any individual market product, or (3) the employee obtains any individual health insurance. Such offers fail to qualify as benign discrimination for two reasons. First, if an employer offers a choice of additional cash or enrollment in the employer's plan to a high-claims- risk employee, the opt-out offer does not reduce the amount charged to the employee with the adverse health factor. Rather, the employer's offer of cash to a high-claims-risk employee who opts out of the employer's plan effectively increases the premium or contribution the employer's plan requires the employee to pay for coverage under the plan because, unlike other similarly situated individuals, the high-claims-risk employee 1295 2017--01395 must accept the cost of forgoing the cash in order to elect plan coverage. For example, if the employer's group health plan requires all employees to pay $2,500 toward the cost of employee-only coverage under the plan, but the employer offers a high-claims-risk employee $10,000 in additional compensation if the employee declines the coverage, for purposes of discrimination analysis, the effective required contribution by that high- claims-risk employee for plan coverage is $12,500 that is, the $2,500 required employee contribution for employee-only coverage under the employer's plan plus the $10,000 of additional compensation that the employee would forgo by enrolling in the plan. Because a high-claims-risk employee must effectively contribute more to participate in the group health plan, the arrangement violates the rule that a group health plan may not on the basis of a health factor require any individual (as a condition of enrollment) to pay a premium or contribution which is greater than the premium or contribution for a similarly situated individual enrolled in the plan. Second, the Departments' regulations generally permit providing, based on an adverse health factor, enhancements to eligibility for coverage under the plan itself but not cash as an alternative to the plan. In particular, the regulations permit providing plan eligibility criteria that offer extended coverage within the plan and subsidization of the cost of coverage within the plan based on an adverse health factorl?) An example in the Departments' regulations illustrates that a plan may have an eligibility provision that provides coverage to disabled dependent children beyond the age at which non-disabled dependent children become ineligible for coverageml Another example in the regulations illustrates that a plan may provide coverage free of charge to disabled employees, while other employees pay a participant contribution towards coverageml However, in the Departments' view, providing cash as an alternative to health coverage for individuals with adverse health factors is an eligibility rule that discourages participation in the group health plan. This type of arrangement differentiates based on a health factor and is outside the scope of the Departments' regulations on benign discrimination, which permit only discrimination that helps individuals with adverse health factors to participate in the health coverage being offered to other plan participants. The Departments intend to initiate rulemaking in the near future to clarify the scope of the benign discrimination provisions. Finally, because the choice between taxable cash and a tax-favored quali?ed benefit (the election of coverage under the group health plan) is required to be a Code section 125 cafeteria plan, imposing an effective additional cost to elect coverage under the group health plan could, depending on the facts and circumstances, also result in discrimination in favor of highly compensated individuals in violation of the Code section 125 cafeteria plan nondiscrimination rules. (DOL FAQs Part XXII 11/06/14) Q3: A vendor markets a product to employers claiming that employers can cancel their group policies, set up a Code section 105 reimbursement plan that works with health insurance brokers or agents to help employees select individual insurance policies, and allow eligible employees to access the premium tax credits for Marketplace coverage. Is this permissible? Updated 1-31-17 No. The Departments have been informed that some vendors are marketing such products. However, these arrangements are problematic for several reasons. First, the arrangements described in this QB are themselves group health plans and, therefore, employees participating in such arrangements are ineligible for premium tax credits (or cost-sharing reductions) for Marketplace coverage. The mere fact that the employer does not get involved with an employee's individual selection or purchase of an 1296 2017--01396 individual health insurance policy does not prevent the arrangement from being a group health plan. DOL guidance indicates that the existence of a group health plan is based on many facts and circumstances, including the employer's involvement in the overall scheme and the absence of an unfettered right by the employee to receive the employer contributions in cash?) Second, as explained in DOL Technical Release 2013-03, IRS Notice 2013-54, and the two IRS FAQs addressing employer health care arrangements referenced earlier, such arrangements are subject to the market reform provisions of the Affordable Care Act, including the PHS Act section 2711 prohibition on annual limits and the PHS Act 2713 requirement to provide certain preventive services without cost sharing. Such employer health care arrangements cannot be integrated with individual market policies to satisfy the market reforms and, therefore, will violate PHS Act sections 2711 and 2713, among other provisions, which can trigger penalties such as excise taxes under section 49800 of the Code. (DOL FAQs Part XXII 11/06/14) Disclosure of Information Related to Firearms Q5: Does PHS Act section 2717(c) restrict communications between health care professionals and their patients concerning firearms or ammunition? No. While we have yet to issue guidance on this provision, the statute prohibits an organization operating a wellness or health promotion program from requiring the disclosure of information relating to certain information concerning firearms. However, nothing in this section prohibits or otherwise limits communication between health care professionals and their patients, including communications about ?rearms. Health care providers can play an important role in promoting gun safety. (DOL FAQs Part Xl 01/24/13) Self-Insured Employer Prescription Drug Coverage Supplementing Medicare Part Coverage Provided through Employer Group Waiver Plans 06: Must self-insured prescription drug coverage that supplements the standard Medicare Part coverage through EGWPs comply with the health coverage requirements? Updated 1-31-17 Pending further guidance, the Departments will not take any enforcement action against a group health plan that is an EGWP because the non?Medicare supplemental drug benefit does not comply with the health coverage requirements of title XXVII of the PHS Act, part 7 of ERISA, and chapter 100 of the Code. This enforcement policy does not affect other requirements administered by the Centers for Medicare Medicaid Services that apply to providers of such coverage. The Centers for Medicare Medicaid Services intends to issue related guidance concerning insured coverage that provides non- Medicare supplemental drug bene?ts shortly. (DOL FAQs Part XI 01/24/13) 1297 2017-?01397 Fixed Indemnity Insurance Q7: What are the circumstances under which fixed indemnity coverage constitutes excepted benefits? The Departments' regulations provide that a hospital indemnity or other ?xed indemnity insurance policy under a group health plan provides excepted bene?ts only if: . The benefits are provided under a separate policy, certi?cate, or contract of insurance; . There is no coordination between the provision of the bene?ts and an exclusion of bene?ts under any group health plan maintained by the same plan sponsor; and The benefits are paid with respect to an event without regard to whether bene?ts are provided with respect to the event under any group health plan maintained by the same plan sponsor. The regulations further provide that to be hospital indemnity or other ?xed indemnity insurance, the insurance must pay a ?xed dollar amount per day (or per other period) of hospitalization or illness (for example, $100/day) regardless of the amount of expenses incurred. Various situations have come to the attention of the Departments where a health insurance policy is advertised as fixed indemnity coverage, but then covers doctors' visits at $50 per visit, hospitalization at $100 per day, various surgical procedures at different dollar rates per procedure, and/or prescription drugs at $15 per prescription. In such circumstances, for doctors' visits, surgery, and prescription drugs, payment is made not on a per-period basis, but instead is based on the type of procedure or item, such as the surgery or doctor visit actually performed or the prescribed drug, and the amount of payment varies widely based on the type of surgery or the cost of the drug. Because office visits and surgery are not paid based on "a fixed dollar amount per day (or per other period)," a policy such as this is not hospital indemnity or other ?xed indemnity insurance, and is therefore not excepted benefits. When a policy pays on a per-service basis as opposed to on a per-period basis, it is in practice a form of health coverage instead of an income replacement policy. Accordingly, it does not meet the conditions for excepted benefits. The Departments plan to work with the States to ensure that health insurance issuers comply with the relevant requirements for different types of insurance policies and provide consumers with the protections of the Affordable Care Act. (DOL FAQs Part XI 01/24/13) Q11: If insurance labeled as ?xed indemnity insurance provides benefits other than on a per-period basis, may the insurance nonetheless qualify as excepted benefits? Updated 1-31-17 Yes. With respect to group health insurance coverage that does not meet the de?nition of ?xed indemnity excepted bene?ts, coverage that supplements other group health plan coverage may, nonetheless, qualify as supplemental excepted benefits under sections 2722(c)(3) and 2791(c)(4) of the PHS Act, sections 732(c)(3) and 733(c)(4) of ERISA, and sections 9831(c)(3) and 9832(c)(4) of the CodeCFR the Department of Labor's Employee Bene?ts Security Administration's Field Assistance Bulletin No. 2007-04 (available at HHS Centers for Medicare Medicaid 1298 2017--01398 Services Insurance Standards Bulletin 08-01 (available at 08 01 508.pdf and Internal Revenue Service Notice 2008-23 (available at 07 Furthermore, HHS intends to propose amendments to 45 CFR that would allow ?xed indemnity coverage sold in the individual health insurance market to be considered to be an excepted bene?t if it meets the following conditions: 1) It is sold only to individuals who have other health coverage that is minimum essential coverage within the meaning of section 5000A(f) of the Code; 2) There is no coordination between the provision of bene?ts and an exclusion of bene?ts under any other health coverage; 3) The benefits are paid in a ?xed dollar amount regardless of the amount of expenses incurred and without regard to the amount of bene?ts provided with respect to an event or service under any other health coverage; and 4) A notice is displayed prominently in the plan materials informing policyholders that the coverage does not meet the de?nition of minimum essential coverage and will not satisfy the individual responsibility requirements of section 5000A of the Code. If these proposed revisions are implemented, ?xed indemnity insurance in the individual market would no longer have to pay benefits solely on a per-period basis to qualify as an excepted benefit. Until HHS ?nalizes this rulemaking related to these proposed amendments, HHS will treat fixed indemnity coverage in the individual market as excepted bene?ts for enforcement purposes if it meets the conditions above in States where HHS has direct enforcement authority. For States with primary enforcement authority, HHS encourages those States to also treat this coverage as an excepted benefit and will not consider that a State is not substantially enforcing the individual market requirements merely because it does so. (DOL FAQs Part 01/09/14) previous FAQ provided guidance reiterating that, in order for a ?xed indemnity policy to be considered an excepted bene?t, it must pay on a per-period basis, and that a fixed indemnity policy that pays on a per-service basis does not meet the conditions for excepted bene?ts. 15)] Payment of PCORI Fees 08: Does Title I of ERISA prohibit a multiemployer plan's joint board of trustees from paying the Code section 4376 fee from assets of the plan? Updated 1-31-17 In the case of a multiemployer plan defined in ERISA section 3(37), the plan sponsor liable for the fee would generally be the independent joint board of trustees appointed by the participating employers and employee organization, and directed pursuant to a collective bargaining agreement to establish the employee benefit plan. Normally, such a joint board of trustees has no function other than to sponsor and administer the multiemployer plan, and it has no source of funding independent of plan assets to satisfy the Code section 4376 statutory obligation. The fee involved is not an excise tax or similar penalty imposed on the trustees in connection with a violation of federal law or a breach of their ?duciary obligations in connection with the plan. Nor would the joint board be acting in a capacity other than as a fiduciary of the plan in paying the fee.(4) In such 1299 2017--01399 circumstances, it would be unreasonable to construe the fiduciary provisions of ERISA as prohibiting the use of plan assets to pay such a fee to the Federal government. Thus, unless the plan document speci?es a source other than plan assets for payment of the fee under Code section 4376, such a payment from plan assets would be permissible under ERISA. There may be rare circumstances where sponsors of employee bene?t plans that are not multiemployer plans would also be able to use plan assets to pay the Code section 4376 fee, such as a VEBA that provides retiree-only health bene?ts where the sponsor is a trustee or board of trustees that exists solely for the purpose of sponsoring and administering the plan and that has no source of funding independent of plan assets. The same conclusion would not necessarily apply, however, to other plan sponsors required to pay the fee under Code section 4376. For example, a group or association of employers that act as a plan sponsor but that also exist for reasons other than solely to sponsor and administer a plan may not use plan assets to pay the fee even if the plan uses a VEBA trust to pay benefits under the plan. The Department of Labor would expect that such an entity or association, like employers that sponsor single employer plans, would have to identify and use some other source of funding to pay the Code section 4376 fee. (DOL FAQs Part XI 01/24/13) Expatriate Health Plans Q1: To what extent is expatriate group health insurance coverage subject to the provisions of the Affordable Care Act? Updated 1-31-17 The Departments recognize that expatriate health plans may face special challenges in complying with certain provisions of the Affordable Care Act. In particular, challenges in reconciling and coordinating the multiple regulatory regimes that apply to expatriate health plans might make it impossible or impracticable to comply with all the relevant rules at least in the near term. For example, independent review organizations may not exist abroad, and it may be dif?cult for certain preventive services to be provided, or even be identi?ed as preventive, when such services are provided outside the United States by clinical providers that use different code sets and medical terminology to identify services. Further, expatriate issuers may face challenges and delays in communicating with enrollees living abroad, and, due to the complex nature of these plans, standardized benefits disclosures can be difficult for issuers to produce. Expatriate health plans may require additional regulatory approvals from foreign governments, and, in some circumstances, it is possible that domestic and foreign law requirements con?ict. While the Departments gather further information and analyze these challenges to determine what actions may be appropriate regarding the current requirements under the Affordable Care Act, the Departments have determined that, for plans with plan years ending on or before December 31, 2015, with respect to expatriate health plans, the Departments will consider the requirements of subtitles A and of Title of the Affordable Care Act satis?ed if the plan and issuer comply with the pre-Affordable Care Act version of Title XXVII of the Public Health Service Act. 1300 2017-?01400 References to subtitles A and of Title of the Affordable Care Act also include the corresponding provisions imported into section 715 of the Employee Retirement Income Security Act (ERISA) and section 9815 of the Internal Revenue Code. For purposes of this temporary transitional relief, an expatriate health plan is an insured group health plan with respect to which enrollment is limited to primary insureds who reside outside of their home country for at least six months of the plan year and any covered dependents, and its associated group health insurance coverage. This definition is also the de?nition of ?expatriate health coverage? under 45 CFR during this temporary transitional period (that is, for plans with plan years ending on or before December 31, 2015). Expatriate health plans must, as a condition of this transitional relief, comply with the pre?Affordable Care Act version of Title XXVII of the PHS Act and other applicable law under ERISA and the Internal Revenue Code, including, for example, the mental health parity provisions, the HIPAA nondiscrimination provisions, the ERISA section 503 requirements for claims procedures, and any reporting and disclosure obligations under ERISA Part 1. The Departments note that coverage provided under an expatriate group health plan is a form of minimum essential coverage under section 5000A of the Internal Revenue Code. The Departments request comments on and information about the unique challenges that expatriate health plans may face in complying with provisions of the Affordable Care Act, including information about which particular types of plans face these challenges and with respect to which particular provisions of the Affordable Care Act. Please send comments by May 8, 2013 to (DOL FAQs Part X/l/ 03/18/13) 06: Can the Departments provide any additional clarification of the definition of an insured expatriate health plan for purposes of the temporary transitional relief, as well as additional clarification of the scope of the relief provided? Updated 1-31-17 Yes. For purposes of the temporary transitional relief, an insured expatriate health plan is an insured group health plan with respect to which enrollment is limited to primary insureds for whom there is a good faith expectation that such individuals will reside outside of their home country or outside of the United States for at least six months of a 12?month period and any covered dependents, and also with respect to group health insurance coverage offered in conjunction with the expatriate group health plan. The 12- month period can fall within a single plan year or across two consecutive plan years. Also, the earlier guidance only mentioned subtitles A and of title of the Affordable Care Act, but the Departments will also consider the requirements of subtitle of title of the Affordable Care Act to be satis?ed if a plan and issuer of an insured expatriate health plan complies with the pre-Affordable Care Act version of title XXVII of the PHS Act. The Departments note that coverage provided under an insured expatriate health plan generally is minimum essential coverage under section 5000A of the Code. (DOL FAQs Part 01/09/14) 1301 2017-?01401 previous FAQ provided guidance and temporary transitional relief regarding the extent to which expatriate health coverage is subject to the provisions of the Affordable Care Act.] Q7: Do the Departments intend to issue regulations or provide additional guidance on insured expatriate health plans? The Departments continue to consider narrowly tailored guidance with respect to insured expatriate health plans that takes into account the ability of such coverage to reasonably comply with the requirements of subtitles A, C, and of title I of the Affordable Care Act. The Departments intend that any new regulations or guidance that is more restrictive on plans or issuers will not be applicable to plan years ending on or before December 31, 2016. Insured expatriate health plans may continue to rely on the temporary transitional relief set forth in Affordable Care Act Implementation FAQs Part Q1 at least through those plan years. (DOL FAQs Part 01/09/14) Annual Limit Waiver Expiration Date based on a Change to a Plan or Policy Year Q1: If a group health plan or health insurance issuer that was granted a waiver from the annual limits requirements under Public Health Service Act (PHS Act) section 2711 changes its plan year (or, in the individual market, policy year) prior to the waiver expiration date, can that change modify the expiration date of the waiver? No. Changing the plan year (or, in the individual market, policy year) does not change the waiver expiration date. Annual limit waivers under PHS Act section 2711(1) were approved by HHS for the plan or policy year in effect when the plan or issuer applied for the waiver. The same holds true for waiver extensions. They extended the waiver based on the date of the plan or policy year in effect when the initial application was submitted. As a result, waiver recipients that change their plan or policy years will not extend the expiration date of their waivers. For example, if a waiver approval letter states that a waiver is granted for an April 1, 2013 plan or policy year, the waiver will expire on March 31, 2014, regardless of whether the plan or issuer later amends its plan or policy year. That said, waiver recipients may terminate the waiver at any time prior to its approved expiration date, for example, on December 31, 2013 rather than on March 31, 2014. Additionally, HHS requested that each plan or issuer provide its effective dates of coverage as part of its annual limit waiver application, in part so that HHS would have a record of the waiver's expiration date. As noted in the Technical nstructions,(2) waiver recipients must retain all records pertaining to their waiver applications to permit HHS to conduct audits of waiver applications. If there is a discrepancy between the plan or policy year in an original application and a subsequent annual update, HHS may review the waiver to determine whether the group health plan or health insurance issuer is in compliance with policy on annual limit waivers. (DOL FAQs Part XV 4/29/13) 1302 Updated 1-31-17 2017-?01402 Provider Non-Discrimination 02: Will the Departments be issuing regulations addressing PHS Act section 2706(a) prior to its effective date? No. The statutory language of PHS Act section 2706(a) is self-implementing and the Departments do not expect to issue regulations in the near future. PHS Act section 2706(a) is applicable to non-grandfathered group health plans and health insurance issuers offering group or individual health insurance coverage for plan years (in the individual market, policy years) beginning on or after January 1, 2014. Until any further guidance is issued, group health plans and health insurance issuers offering group or individual coverage are expected to implement the requirements of PHS Act section 2706(a) using a good faith, reasonable interpretation of the law. For this purpose, to the extent an item or service is a covered benefit under the plan or coverage, and consistent with reasonable medical management techniques speci?ed under the plan with respect to the frequency, method, treatment or setting for an item or service, a plan or issuer shall not discriminate based on a provider's license or certification, to the extent the provider is acting within the scope of the provider's license or certi?cation under applicable state law. This provision does not require plans or issuers to accept all types of providers into a network. This provision also does not govern provider reimbursement rates, which may be subject to quality, performance, or market standards and considerations. The Departments will work together with employers, plans, issuers, states, providers, and other stakeholders to help them come into compliance with the provider nondiscrimination provision and will work with families and individuals to help them understand the law and bene?t from it as intended. For questions about the provider nondiscrimination provision, including complaints regarding compliance with the statutory provision by health insurance issuers, contact your state department of insurance (contact information is available by visiting or the Centers for Medicare Medicaid Services, Center for Consumer Information and Insurance Oversight at 1-888-393-2789. For employment-based group health plan coverage, you also may contact the Department of Labor at or 1- 866-444-3272. (DOL FA Qs Pan? XV 4/29/13) Q4. What is the Departments? approach to PHS Act section 2706(a)? Updated 1-31-17 In light of the breadth of issues identi?ed in the comments to the RFI, the Departments are re-stating their current enforcement approach to PHS Act section 2706(a). Until further guidance is issued, the Departments will not take any enforcement action against a group health plan, or health insurance issuer offering group or individual coverage, with respect to implementing the requirements of PHS Act section 2706(a) as long as the plan or issuer is using a good faith, reasonable interpretation of the statutory provision, which states: A group health plan and a health insurance issuer offering group or individual health insurance coverage shall not discriminate with respect to participation under the plan or coverage against any health care provider who is acting within the scope of that 1303 2017-?01403 provider?s license or certi?cation under applicable State law. This section shall not require that a group health plan or health insurance issuer contract with any health care provider willing to abide by the terms and conditions for participation established by the plan or issuer. Nothing in this section shall be construed as preventing a group health plan, a health insurance issuer, or the Secretary from establishing varying reimbursement rates based on quality or performance measures. (DOL FAQs Part XXVII 05/26/15) 05. Does 02 in FAQs about Affordable Care Act Implementation Part XV continue to apply? No. 02 in FAQs about Affordable Care Act Implementation Part XV, which previously provided guidance from the Departments on PHS Act section 2706(a), is superseded by this FAQ and notation will be made on the Departments? websites to re?ect this modi?cation. The Departments will continue to work together with employers, plans, issuers, states, providers, and other stakeholders to help them comply with the provider nondiscrimination provision and will work with families and individuals to help them understand the law and bene?t from it as intended. (DOL FAQs Part XXVII 05/26/15) Coverage for Individuals Participating in Approved Clinical Trials Q3: Will the Departments be issuing regulations addressing PHS Act section 2709 prior to its effective date? Updated 1-31-17 No. The statutory language of PHS Act section 2709 is self-implementing and the Departments do not expect to issue regulations in the near future. PHS Act section 2709 is applicable to non-grandfathered group health plans and health insurance issuers offering group or individual health insurance coverage for plan years (in the individual market, policy years) beginning on or after January 1, 2014. Until any further guidance is issued, group health plans and health insurance issuers are expected to implement the requirements of PHS Act section 2709 using a good faith, reasonable interpretation of the law. The Departments will work together with employers, plans, issuers, states, providers, and other stakeholders to help them come into compliance with the law and will work with families and individuals to help them understand the coverage for clinical trials provision and bene?t from it as intended. For questions about the coverage for clinical trials provision, including complaints regarding compliance with the statutory provision by health insurance issuers, contact your state department of insurance (contact information is available by visiting or the Centers for Medicare Medicaid Services, Center for Consumer Information and Insurance Oversight at 1-888-393-2789. For employment-based group health plan coverage, you also may contact the Department of Labor at or 1- 866-444-3272. (DOL FAQs Part XV 4/29/13) 1304 2017-?01404 05: If a plan or issuer generally covers chemotherapy to treat cancer, can the plan or issuer limit coverage of chemotherapy for an individual due to the fact that it is provided in connection with the individual's participation in an approved clinical trial for a new anti-nausea medication? No. PHS Act section 2709 generally provides that a plan or issuer may not deny (or limit or impose additional conditions on) the coverage of routine patient costs for any items or services furnished in connection with participation in an approved clinical trial. If the plan (or coverage) typically covers chemotherapy for a quali?ed individual who is not enrolled in a clinical trial, the plan or issuer cannot deny (or limit or impose additional conditions on) the coverage of such item or service on the basis that it is furnished in connection with participation in an approved clinical trial. Under PHS Act section 2709(a)(2)(B), routine patient costs do not include the investigational item, device, or service being studied in the approved clinical trial; (ii) an item or service provided solely to satisfy the clinical trial's data collection and analysis needs and that is not used in the direct clinical management of the patient; or a service that is clearly inconsistent with widely accepted and established standards of care for a particular diagnosis. These exceptions do not apply to chemotherapy in this case. However, note that PHS Act section 2709 does not require a plan or issuer to provide bene?ts for routine patient care services provided outside of the plan's (or coverage's) health care provider network unless out-of?network bene?ts are otherwise provided under the plan (or coverage). (DOL FAQs Part 31 04/20/16) 06: If a plan or issuer typically covers items and services to diagnose or treat certain complications or adverse the plan or issuer deny coverage of such items and services when provided to diagnose or treat complications or adverse events side effects) in connection with an individual's participation in an approved clinical trial? No. PHS Act section 2709 generally provides that a plan or issuer may not deny (or limit or impose additional conditions on) the coverage of routine patient costs for any items or services furnished in connection with participation in an approved clinical trial. Routine patient costs for items and services to diagnose or treat complications or adverse events arising from participation in an approved clinical trial are items and services furnished in connection with participation in an approved clinical trial, and accordingly, are required to be covered in accordance with PHS Act section 2709, if the plan typically covers such items or services for a qualified individual who is not enrolled in a clinical trial. (DOL FAQs Part 31 04/20/16) Transparency Reporting Q4: When do plans and issuers have to comply with the transparency in coverage reporting requirements under section 1311(e)(3) of the Affordable Care Act and section 2715A of the PHS Act? Section 1311(e)(3) of the Affordable Care Act, as implemented at 45 CFR 155.1040(a) and 156.220, requires QHP issuers to submit specified information to the Marketplace and other entities in a timely and accurate manner. However, because QHP issuers will not have some of the data necessary for reporting under this requirement until during or 1305 Updated 1-31-17 2017--01405 after the ?rst year of operation of their QHPs QHP enrollment and disenrollment), HHS is clarifying that, in order to comply with section 1311(e)(3) as implemented at 45 CFR 155.1040(a) and 156.220, QHP issuers will begin submitting information only after QHPs have been certified as QHPs for one bene?t year. Similarly, because section 2715A of the PHS Act simply extends the transparency provisions set forth in section 1311(e)(3) of the Affordable Care Act to group health plans and health insurance issuers offering group and individual health insurance coverage, the Departments clarify that the reporting requirements under section 2715A of the PHS Act will become applicable to group health plans and health insurance issuers offering group and individual health insurance coverage no sooner than when the reporting requirements under section 131 of the Affordable Care Act become applicable. As previously stated, the Departments will coordinate regulatory guidance on the transparency in coverage standards for coverage offered inside and outside of the Marketplaces. (DOL FAQs Part XV 4/29/13) 02: Will the Departments be issuing ?nal regulations under PHS Act section 2708 that give plans and issuers suf?cient time to comply with the waiting period limitation? Yes. As stated in the proposed rules, plans and issuers can rely on guidance provided in the March 2013 proposed rules at least through 2014. To the extent ?nal regulations are more restrictive on plans or issuers than the proposed regulations, they will not be effective prior to January 1, 2015 and the Departments expect they will give plans and issuers suf?cient time to comply. Under the proposed rules, to the extent plans and issuers impose substantive eligibility requirements not based solely on the lapse of time, these eligibility provisions are permitted if they are not designed to avoid compliance with the 90-day waiting period limitation. Therefore, for example, if a multiemployer plan operating pursuant to an arms- length collective bargaining agreement has an eligibility provision that allows employees to become eligible for coverage by working hours of covered employment across multiple contributing employers (which often aggregates hours by calendar quarter and then permits coverage to extend for the next full calendar quarter, regardless of whether an employee has terminated employment), the Departments would consider that provision designed to accommodate a unique operating structure, (and, therefore, not designed to avoid compliance with the 90-day waiting period limitation). (DOL FAQs Part XVI 09/04/13) Q: How do the Departments intend to propose transparency reporting for non-QHP issuers and non-grandfathered group health plans? Updated 1-31-17 The Departments intend to propose transparency reporting for non-QHP issuers and non-grandfathered group health plans in the future. The proposed reporting requirements may differ from those prescribed in the August 11, 2015 HHS proposal under section 1311(e)(3) of the Affordable Care Act, and will take into account differences in markets, reporting requirements already in existence for non-QHPs (including group health plans), and other relevant factors. The Departments also intend to streamline reporting under multiple reporting provisions and reduce unnecessary duplication. The Departments intend to implement any transparency reporting requirements applicable to non-QHP issuers and non-grandfathered group health plans only after reasonable notice and comment, and after giving those issuers and plans 1306 2017-?01406 suf?cient time, following the publication of ?nal rules, to come into compliance with those requirements. (DOL FAQs Part 08/11/15) Guidance an Employee Assistance Programs Question 9: Are bene?ts under an employee assistance program or EAP considered to be excepted benefits? Answer 9: The Departments intend to amend 26 C.F.R. 29 C.F.R. and 45 C.F.R. ?146.145(c) to provide that bene?ts under an employee assistance program or EAP are considered to be excepted benefits, but only if the program does not provide signi?cant bene?ts in the nature of medical care or treatment. Excepted benefits are not subject to the market reforms and are not minimum essential coverage under Code 5000A. Until rulemaking is ?nalized, through at least 2014, the Departments will consider an employee assistance program or EAP to constitute excepted benefits only if the employee assistance program or EAP does not provide significant benefits in the nature of medical care or treatment. For this purpose, employers may use a reasonable, good faith interpretation of whether an employee assistance program or EAP provides signi?cant bene?ts in the nature of medical care or treatment. (DOL Technical Release 2013-03 09/13/13) Employer Shared Responsibility, and Waiting Periods 02. Do Treasury and the IRS intend to issue proposed regulations or other guidance permitting employers to use an employee?s W-2 wages as a safe harbor in determining the affordability of employer coverage, as outlined in IRS Notice 2011-73? A2. Yes. As described in Notice 2011-73, Treasury and the IRS intend to issue proposed regulations or other guidance permitting employers to use an employee?s Form W-2 wages (as reported in Box 1) as a safe harbor in determining the affordability of employer coverage. (DOL Technical Release 2012-01 02/09/12) Q3. Do Treasury and the IRS intend to issue proposed regulations or other guidance addressing how the employer shared responsibility provisions under Code section 4980H and the 90-day waiting period limitation under PHS Act section 2708 are coordinated? Updated 1-31-17 A3. Yes. Treasury and the IRS intend to issue proposed regulations or other guidance under Code section 4980H (which imposes shared responsibility on large employers with respect to coverage of full-time employees). That guidance is expected to address the intersection of the Code section 498OH rules and the PHS Act section 2708 rules applicable to the 90-day waiting period limitation and will be coordinated with upcoming tri-Department proposed rules under PHS Act section 2708 (discussed below). Treasury and the IRS are mindful of employers? requests for safe harbors and simplicity and will seek to accommodate those requests to the extent feasible and consistent with the terms of the statute. The upcoming guidance is expected to provide that, at least for the ?rst three months following an employee?s date of hire, an employer that sponsors a group health plan will not, by reason of failing to offer coverage to the employee under its plan during that 1307 2017-?01407 three-month period, be subject to the employer responsibility payment under Code section 4980H. (DOL Technical Release 2012-01 02/09/12) Q4. For purposes of determining whether an employee (other than a newly-hired employee) is a full-time employee for purposes of Code section 4980H, do Treasury and the IRS intend to issue proposed regulations or other guidance allowing employers to use a look-back/stability period safe harbor, based on the approach outlined in IRS Notice 2011-36? A4. Yes. Having reviewed the comments in response to IRS Notice 2011-36, Treasury and the IRS intend to issue proposed regulations or other guidance that would allow employers to use a ?look-back/stability period safe harbor? method based on the approach outlined in the Notice for purposes of determining whether an employee (other than a newly-hired employee) is a full-time employee. Accordingly, it is anticipated that the guidance will allow look-back and stability periods not exceeding 12 months. For a description of anticipated guidance regarding newly-hired employees, see (DOL Technical Release 2012-01 02/09/12) Q5. For purposes of determining whether a newly-hired employee is a full-time employee, do Treasury and the IRS intend to issue proposed regulations or other guidance under Code section Updated 1-31-17 A5. Yes. Treasury and the IRS also intend to issue proposed regulations or other guidance that will address how to determine whether a newly-hired employee is a full- time employee for purposes of Code section 4980H. As stated in the upcoming guidance is expected to provide that, at least for the ?rst three months following an employee?s date of hire, an employer that sponsors a group health plan will not, by reason of failing to offer coverage to the employee under its plan during that three-month period, be subject to the employer responsibility payment under Code section 4980H. The guidance is also expected to provide that, in certain circumstances, employers have six months to determine whether a newly-hired employee is a full-time employee for purposes of section 4980H and will not be subject to a section 4980H payment during that six-month period with respect to that employee. Treasury and the IRS intend to propose an approach under which the period of time that an employer will have to determine whether a newly-hired employee is a full-time employee (within the meaning of section 4980H) will depend upon whether, based on the facts and circumstances, the employee is reasonably expected as of the time of hire to work an average of 30 or more hours per week on an annual basis and the employee's first three months of employment are reasonably viewed, as of the end of that period, as representative of the average hours the employee is expected to work on an annual basis. Specifically, it is intended that the upcoming proposed regulations or other guidance would provide, for purposes of section 4980H, that: If a newly-hired employee is reasonably expected to work full-time on an annual basis and does work full-time during the ?rst three months of employment, the employee must be offered coverage under the employer?s group health plan as of the end of that period in order to avoid the possibility that the employer would be subject to a section 4980H payment after the end of that three-month period. 1308 2017-?01408 Updated 1-31-17 0 If, based on the facts and circumstances as of the time of hire, it cannot reasonably be determined that a newly-hired employee is expected to work full-time, the following rules will apply for purposes of determining whether the newly-hired employee is considered a full-time employee in applying section 4980H with respect to the employer?s group health plan: 0 If the employee works full-time during the first three months of employment, and the employee?s hours during that period are reasonably viewed, as of the end of that period, as representative of the average hours the employee is expected to work on an annual basis, the employee will ?rst be considered a full-time employee for purposes of section 4980H as of the end of that three-month period. (If the employee works part-time during the ?rst three months of employment, then no section 4980H penalty applies during the ?rst or second three-month period.) 0 If the employee works full-time during the first three months of employment, but the employee?s hours during that period are reasonably viewed, as of the end of that period, as not representative of the average hours the employee is expected to work on an annual basis, the plan is permitted an additional three-month period to determine the employee?s status, and no section 4980H payment would be required with respect to that employee during the ?rst or second three-month periods. (If the employee works part-time during the second three months of employment, then no section 4980H penalty applies during the ?rst, second, or third three-month period.) This policy describes the applicability of a potential section 4980H payment with respect to newly-hired employees. Forthcoming guidance is expected also to coordinate the rules for newly-hired employees with those applicable to other employees (including employees who are transferred from one employment classi?cation or status to another). The following examples illustrate the intended approach described above: Example 1: Newly-hired employee expected to work full time Facts: Employer D, an applicable large employer an employer with at least 50 full- time equivalent employees), hires Employee as a computer programmer on December 1. Employee is expected to work full-time on an annual basis and does work full-time for the months of December, January, and February. Employer offers health coverage to its full-time workers (and their dependents). Conclusion: Employee must be able to enroll in coverage beginning in March or the employer potentially would be subject to a section 4980H payment. However, failure to offer coverage to Employee during the ?rst three months (December-February) would not subject Employer to a potential section 4980H payment. Example 2: Newly-hired employee who seasonally works full-time Facts: Same as Example 1 except that Employer hires Employee as a salesperson who is expected to work full-time during the holiday season and part-time the rest of the year. Employee works an average of 35 hours per week in December, January, and February and 20 hours per week in March, April, and May. 1309 2017-?01409 Conclusion: If, based on the facts and circumstances at the end of the period, the three-month period of December through February is reasonably viewed as not representative of the average hours Employee is reasonably expected to work on an annual basis, Employer may use a second three-month period (March-May) as a look- back period. Failure to offer coverage under Employer D?s group health plan to Employee during the first (December-February) and the second (March-May) three- month periods would not subject Employer to a potential section 4980H payment. (Failure to offer coverage to Employee for June also would not subject Employer to a potential section 4980H payment because Employee was determined to be part-time during the March-May look-back period.) (DOL Technical Release 2012-01 02/09/12) 06. When PHS Act section 2708 (which imposes a 90-day limitation on waiting periods) becomes effective in 2014, will it require an employer to offer coverage to part-time employees or to any other particular category of employees? A6. No. Many employers make distinctions in eligibility for coverage based on full-time or part-time status, as de?ned by the employer?s group health plan (which may differ from the standard under Code section 4980H). PHS Act section 2708 does not require the employer to offer coverage to any particular employee or class of employees, including part-time employees. PHS Act section 2708 merely prohibits requiring an othenivise eligible employee to wait more than 90 days before coverage is effective. Furthermore, nothing in the Affordable Care Act penalizes small employers for choosing not to offer coverage to any employee, or large employers for choosing to limit their offer of coverage to full-time employees, as defined in the employer shared responsibility provisions. (DOL Technical Release 2012-01 02/09/12) Q7. How do the Departments intend to address the application of the 90-day waiting period limitation in PHS Act section 2708 to an offer of coverage by an employer? Updated 1-31-17 A7. Having reviewed the comments in response to IRS Notice 2011-36, the Departments intend to retain, for purposes of PHS Act section 2708, the de?nition in existing regulations that the 90-day waiting period begins when an employee is otherwise eligible for coverage under the terms of the group health plan. This is the de?nition of waiting period used for purposes of Title XXVII of the PHS Act, Part 7 of ERISA, and chapter 100 of the Code. Under this approach, if a plan were to provide that full-time employees are eligible for coverage without satisfying any other condition, and an employee were hired as a full-time employee, the waiting period (if the employer were to choose to impose one) for that employee would begin on the date of hire and could not exceed 90 days. Consistent with PHS Act section 2708, eligibility conditions that are based solely on the lapse of a time period would be permissible for no more than 90 days. Other conditions for eligibility under the terms of a group health plan would generally be permissible under PHS Act section 2708, unless the condition is designed to avoid compliance with the 90-day waiting period limitation. For example, eligibility conditions such as full-time status, a bona fide job category, or receipt of a license would be permissible. The upcoming guidance under section 2708 is also expected to address situations in which, under the terms of an employer?s plan, employees (or certain classes of employees) are eligible for coverage once they complete a speci?ed cumulative number 1310 2017-?01410 of hours of service within a specified period (such as 12 months). It is anticipated that, under the upcoming guidance, such eligibility conditions will not be treated as designed to avoid compliance with the 90-day waiting period limitation so long as the required cumulative hours of service do not exceed a number of hours to be speci?ed in that guidance. Comments are requested on how this possible approach would apply to plans that credit hours of service from multiple different employers and plans that use hours banks. Example 3: Employee ineligible under terms of plan by reason ofjob classification Facts: Same as Example 1 except that Employer D?s plan does not cover computer programmers. Conclusion: Unlike Code section 4980H, in which the determination of full-time status is governed by a statutory standard (working an average of 30 hours per week), the waiting period limitation under PHS Act 2708 applies only to employees who are otherwise eligible under the terms of the plan. Because Employee is excluded under the plan?s eligibility criteria, and the plan's terms are not designed to avoid compliance with PHS Act section 2708, the plan?s eligibility provision does not violate PHS Act section 2708. Example 4: Part-time employee, hours of service requirement Facts: Employer hires Employee 2 to work 20 hours per week. Employer E?s plan requires part-time employees to complete 750 hours of service in order to participate. Solely for purposes of illustration in this example, it is assumed that upcoming guidance under PHS Act section 2708 permits plans to require part-time employees to complete up to, but no more than, 750 hours of service in order to participate. Conclusion: Part-time employees who work 20 hours per week will complete 750 hours of service in 371/2 weeks or just under 9 months. The waiting period under PHS Act section 2708 begins when Employee satisfies the cumulative service requirement, thereby becoming eligible (but for the waiting period) for coverage under the plan. Employer must provide coverage to Employee no later than 90 days after Employee 2 completes 750 hours of service, which is about one year after Employee 2 is hired and begins working part-time. (No Code section 4980H payment applies because Employee is part-time.) (DOL Technical Release 2012-01 02/09/12) DOL Model Notices Q1: Where can I get a copy of the Department of Labor's newest model notices? Updated 1-31-17 A1: The model general notice and model election notice are available on the DOL website at and the model CHIPRA notice is available at assistancehtml. (The model notices are available in modi?able, electronic form). As with the earlier model notices, in order to use the model properly, the plan administrator must complete it by ?lling in the blanks with the appropriate plan information. Contemporaneous with the issuance of these FAQs, DOL is also issuing a notice of proposed rulemaking to update its regulations with respect to the COBRA model notices. 1311 2017-?01411 Until rulemaking is ?nalized and effective, DOL will consider use of the model notices available on its website, appropriately completed, to constitute compliance with the notice content requirements of COBRA. (DOL FAQs Part 05/02/14) Excepted Benefits The Departments have become aware of health insurance issuers selling supplemental products that provide a single bene?t. At least one issuer is characterizing this type of coverage as an excepted bene?t. These issuers claim that the products meet the criteria for supplemental coverage to qualify as an excepted bene?t outlined in the Departments' guidance and are designed to ?ll in the gaps of primary coverage in the sense that they are providing a benefit that is not covered under the primary group health plan. Q: Can health insurance coverage that supplements group health coverage by providing additional categories of bene?ts, be characterized as supplemental excepted benefits? Updated 1-31-17 It depends. The Departments' prior guidancelz) provided an enforcement safe harbor for supplemental insurance products that are speci?cally designed to ?ll gaps in primary coverage, such as coinsurance or deductibles. In determining whether insurance coverage sold as a supplement to group health coverage can be considered "similar supplemental coverage" and an excepted benefit, the Departments will continue to apply the applicable regulations and the four criteria indicated in the guidance discussed above. In addition, the Departments intend to propose regulations clarifying the circumstances under which supplemental insurance products that do not fill in cost- sharing under the primary plan are considered to be specifically designed to ?ll gaps in primary coverage. Specifically, the Departments intend to propose that coverage of additional categories of coverage would be considered to be designed to "?ll in the gaps" of the primary coverage only if the bene?ts covered by the supplemental insurance product are not an essential health bene?t (EHB) in the State where it is being marketed. If any benefit in the coverage is an EHB in the State where it is marketed, the insurance coverage would not be an excepted benefit under our intended proposed regulations, and would have to comply with the applicable provisions of title of PHS Act, part 7 of ERISA, and chapter 100 the Code. We note that this standard applies to coverage that purports to qualify as an excepted benefit as "similar supplemental coverage provided to coverage under a group health plan" under PHS Act section 2791(c)(4), ERISA section 733(c)(4), and Code section 9832(c)(4). This standard does not apply to other circumstances where the coverage may qualify as another category of excepted bene?ts, such as limited excepted benefits under section 2791(c)(2), ERISA section 733(c)(2), and Code section 9832(c)(2). Pending publication and ?nalization of the above proposed regulations, the Departments will not initiate an enforcement action if an issuer of group or individual health insurance coverage fails to comply with the provisions of the PHS Act, ERISA, and the Code, as amended by the Affordable Care Act, with respect to health insurance coverage that (1) provides coverage of additional categories of benefits that are not EHB in the applicable State (as opposed to ?lling in cost-sharing gaps under the primary plan); (2) complies with the applicable regulatory requirements and meets all of the criteria in the existing guidance on "similar supplemental coverage"; and (3) has been ?led and approved with the State (as may be required under State law). As noted above, for purpose of the second criterion of the existing guidance, coverage would be considered designed to "?ll 1312 2017-?01412 gaps in primary coverage" even if it does not include coverage of cost-sharing under the group health plan, only if the benefits are not covered by the group health plan and are not EHBs in the State. The Departments encourage States that have primary enforcement authority over the provisions of the PHS Act, as amended by the Affordable Care Act, to utilize the same enforcement discretion under such circumstances. (DOL FAQs Part 02/13/15) Women ?s Health Care and Cancer Rights Act Q12: Are group health plans and issuers offering group or individual health insurance coverage that cover mastectomies required to provide coverage for nipple and areola reconstruction as a required stage of breast reconstruction under Yes. If a group health plan or health insurance issuer offering group or individual coverage provides medical and surgical bene?ts with respect to a mastectomy, the plan or issuer is required to provide coverage for all stages of reconstruction of the breast on which the mastectomy was performed, in a manner determined in consultation with the attending physician and the patientl??l This includes coverage for nipple and areola reconstruction, including nipple and areola repigmentation to restore the physical appearance of the breast, as a required stage of reconstruction. Under WHCRA, plans and issuers may impose deductibles and coinsurance for these bene?ts only if such cost-sharing requirements are consistent with those established for other benefits under the plan or coverage. (DOL FAQs Part 31 04/20/16) COBRA Q: The COBRA model election notice contains information about enrollment in the Marketplaces. Is it permissible for a group health plan administrator to include additional information about Marketplace coverage in or along with this notice? Updated 1-31-17 Yes. An individual who experiences a qualifying event and therefore becomes eligible for COBRA continuation coverage (for example, a covered dependent who ages out of her parents? health plan or a covered worker who loses his job), also becomes eligible to apply for Marketplace coverage as a result of the same event. As explained in the COBRA model election notice, for certain quali?ed bene?ciaries, coverage obtained through a Marketplace may be a less expensive healthcare coverage option than enrollment in COBRA continuation coverage. In Technical Release 2013-02, DOL indicated that the COBRA election notice may be used by plan administrators to assist qualified bene?ciaries in understanding their health coverage options upon experiencing a qualifying event, including information regarding enrollment in Marketplace coverage (including the Marketplace website and phone number). current model election notice is accessible at: In addition, plan administrators may include with the COBRA election notice other information about the Marketplaces, such as: how to obtain assistance with enrollment (including special enrollment), the availability of financial assistance, information about Marketplace websites and contact information, general information regarding particular products offered in the Marketplaces, and other information that may help quali?ed bene?ciaries choose between COBRA and other coverage options. We encourage plan administrators to consider how they can help individuals maintain the coverage that would best suit their needs through these transitions. COBRA election notices may be 1313 2017-?01413 tailored to particular groups like young adults aging out of dependent coverage on their parents? health plan. In all cases, they are required to be ?easily understood by the average plan participant" and, therefore, information should not be too or difficult to understand. (DOL FAQs Part 32 06/21/16) Special Enrollment for Group Health Plans Under HIPAA, group health plans and health insurance issuers providing group health insurance coverage are required to provide special enrollment periods to current employees and dependents during which othen/vise eligible individuals who previously declined health coverage have the option to enroll under the terms of the plan (regardless of any open enrollment period). Generally, a special enrollment period must be offered for circumstances in which an employee or dependents lose eligibility for any group health plan or health insurance coverage in which the employee or their dependents were previously enrolled, and upon certain life events such as when a person becomes a dependent of an eligible employee by birth, marriage, or adoption.3 The Children?s Health Insurance Program (CHIP) Reauthorization Act added other special enrollment rights to group health plan coverage for circumstances in which an employee or dependents lose Medicaid or CHIP, or become eligible for assistance for group health plan coverage under Medicaid or CHIP. Special enrollment periods are available in several circumstances set forth in the Departments? regulations, including when (subject to certain exceptions) an individual loses eligibility for coverage under a group health plan or other health insurance coverage (such as an employee and dependents' loss of coverage under the spouse?s plan), when an employer terminates contributions toward health coverage (other than COBRA continuation coverage), or when coverage is no longer offered to a group of similarly situated individuals.4 The Departments' regulations require that employees receive a notice of special enrollment at or before the time they are ?rst offered the opportunity to enroll in the group health plan. Q1: If an individual who enrolled in individual market health insurance coverage, including coverage purchased through a Marketplace, loses eligibility for that coverage, is the individual entitled to a special enrollment period in an employer-sponsored group health plan for which the individual is otherwise eligible and had previously declined to enroll? Yes. Employees and their dependents are eligible for special enrollment in a group health plan if they are otherwise eligible to enroll in the plan, and at the time coverage under the plan was previously offered, they had other group health plan or health insurance coverage (regardless of whether the coverage was obtained inside or outside of a Marketplace) for which they have lost eligibility. Accordingly, if an individual loses eligibility for coverage in the individual market, including coverage purchased through a Marketplace (other than loss of eligibility for coverage due to failure to pay premiums on a timely basis or termination of coverage for cause, such as making a fraudulent claim or an intentional misrepresentation of a material fact), that individual is entitled to special enrollment in group health plan coverage for which he or she is otherwise eligible. These individuals will be eligible for special enrollment in the group health plan coverage regardless of whether they may enroll in other individual market coverage, through or outside of a Marketplace. (DOL FAQs Part 35 SEPs, Preventive Services, and Small Employer HRAs 12/20/16) 1314 Updated 1-31-17 2017-?01414 Interpretation Of ?Health Insurance Coverage? 03: DOES A CLINICAL RISK-BEARING ENTITY THAT IS A LICENSED HEALTH INSURER UNDER STATE LAW PROVIDE HEALTH INSURANCE COVERAGE WITHIN THE MEANING OF CODE SECTION ERISA SECTION AND PHS ACT SECTION WITH RESPECT TO ITS PROVISION OF MEDICAID COVERAGE TO MEDICAID RECIPIENTS AS AN MCO UNDER CONTRACT WITH A STATE No. Notwithstanding that a clinical risk-bearing entity is a licensed health insurer under State law, the provision Of Medicaid coverage tO Medicaid recipients as an MCO is not the provision Of health insurance coverage within the meaning of Code section 9832(b)(1), ERISA section 733(b)(1), and PHS Act section 2791(b)(1), because the coverage is governed by SSA Title XIX and underlying regulations and not by otherwise applicable State insurance law. (DOL FAQs Part 37 01/12/17) Q4: DOES A CLINICAL RISK-BEARING ENTITY THAT IS A LICENSED HEALTH INSURER UNDER STATE LAW PROVIDE HEALTH INSURANCE COVERAGE WITHIN THE MEANING OF CODE SECTION ERISA SECTION AND PHS ACT SECTION WITH RESPECT TO ITS PROVISION OF COVERAGE UNDER A MEDICARE ADVANTAGE ORGANIZATION OR PLAN OR A MEDICARE PRESCRIPTION DRUG NO. Notwithstanding that a clinical risk-bearing entity is a licensed health insurer under State law, the provision Of coverage under a Medicare Advantage organization or plan or a Medicare prescription drug plan is not the provision Of health insurance coverage within the meaning of Code section 9832(b)(1), ERISA section 733(b)(1), and PHS Act section 2791(b)(1), because the coverage provided by such an entity is governed by Parts and of SSA Title and regulations at 42 CFR Parts 422 and 423, rather than otherwise applicable State insurance law. This FAQ does not address the ERISA status of, or any obligations under ERISA with respect to, any such arrangement. (DOL FAQS Part 37 01/12/17) Footnotes For DOL FAQS Many of the DOL FAQS have their own footnotes. To see these, go to the Affordable Care Act FAQ page, at and click on the appropriate FAQ Part Part or Part IV) to see the footnotes for a particular FAQ. HHS OFFICE OF CIVIL RIGHTS (OCR) FAQS SEC. 1557 NON- General Questions About Section 1. What is Section 1557? Section 1557 is the nondiscrimination provision Of the Affordable Care Act (ACA). The law prohibits discrimination on the basis of race, color, national origin, sex, age, or 1315 Updated 1-31?17 2017-?01415 disability in health programs or activities that receive Federal financial assistance or are administered by an Executive agency or any entity established under Title of the ACA. Section 1557 has been in effect since enactment of the ACA. (OCR FAQs General Questions about Section 155710/27/16) 2. In what ways does Section 1557 protect consumers? Section 1557 makes it unlawful for any health care provider that receives funding from the Federal government to refuse to treat an individual or to othenivise discriminate against the individual - based on race, color, national origin, sex, age or disability. Section 1557 imposes similar requirements on health insurance issuers that receive federal ?nancial assistance. Health care providers and insurers are barred, among other things, from excluding or adversely treating an individual on any of these prohibited bases. The Section 1557 final rule applies to recipients of financial assistance from the Department of Health and Human Services (HHS), the Health Insurance Marketplaces and health programs administered by HHS. (OCR FAQs - General Questions about Section 155710/27/16) 3. How is the ?nal rule under Section 1557 different from rules under the other civil rights laws the Office for Civil Rights already enforces? The ?nal rule is consistent with existing, well-established Federal civil rights laws and clari?es the standards HHS will apply in implementing Section 1557 of the ACA. These standards provide that individuals cannot be denied access to health care or health coverage or otherwise be subject to discrimination because of race, color, national origin, sex, age, or disability. Building on long-standing and familiar civil rights principles, the final rule is an important step toward eliminating unlawful discrimination in federally funded programs and HHS programs. Section 1557 is the ?rst Federal civil rights law to broadly prohibit discrimination on the basis of sex in all federally funded health care programs. The ?nal rule extends nondiscrimination protections to individuals enrolled in coverage through the Health Insurance Marketplaces and certain other health coverage. It also applies to own health programs. (OCR FAQs General Questions about Section 155710/27/16) 4. Is Section 1557 currently being enforced? Section 1557 has been in effect since the enactment of the ACA in 2010. Since that time, the Of?ce for Civil Rights (OCR) has been receiving and investigating discrimination complaints under Section 1557. (OCR FAQs General Questions about Section 155710/27/16) 5. What is the effective date for the ?nal rule? Updated 1-31-17 The ?nal rule is effective 60 days after publication in the Federal Register. There are three situations in which covered entities have additional time to comply with the rule?s requirements: posting notices of consumer rights and taglines; accessibility standards for buildings not previously covered by the Americans with Disabilities Act; and design changes to health coverage. (OCR FAQs General Questions about Section 155710/27/16) 1316 2017-?01416 6. What can I do if I believe my civil rights under Section 1557 have been violated? If you feel that you have been subject to discrimination in health care or health coverage, you may file a complaint of discrimination under Section 1557. Please visit website at to ?le a complaint or to request a complaint package, or call toll free number at (800) 368-1019 or (800) 537-7697 (TDD) to speak with someone who can answer your questions and guide you through the process. complaint forms are available in a variety of languages. Individuals can also ?le lawsuits under Section 1557. (OCR FAQs General Questions about Section 155710/27/16) 7. Why is OCR issuing a final rule addressing Section 1557? OCR is issuing this final rule to educate consumers about their rights and to help covered entities understand their legal obligations under Section 1557. The ?nal rule builds on the standards of the four Federal civil rights laws referenced in Section 1557 and their implementing regulations: Title VI of the Civil Rights Act of 1964, Title IX of the Education Amendments of 1972, Section 504 of the Rehabilitation Act of 1973, and the Age Discrimination Act of 1975. Among other things, the ?nal rule implements prohibitions against sex discrimination in federally funded health care programs and establishes standards that apply to the Health Insurance Marketplaces and health programs administered by HHS. (OCR FAQs General Questions about Section 155710/27/16) 8. Who does the final rule apply to? The ?nal rule applies to every health program or activity that receives HHS funding, every health program or activity administered by HHS, such as the Medicare Part program, and the Health Insurance Marketplaces and all plans offered by issuers that participate in those Marketplaces. Covered entities may include hospitals, health clinics, health insurance issuers, state Medicaid agencies, community health centers, physician?s practices and home health care agencies. While the ?nal rule applies only to HHS and the health programs and activities it funds, the Section 1557 statute applies more broadly to health programs and activities that receive financial assistance from any Federal department or agency. (OCR FAQs General Questions about Section 155 71 0/2 7/1 6) 9. Does the final rule apply to the Marketplaces? Yes, both the Federally-facilitated Marketplaces and the State-based Marketplaces are covered by Section 1557. (OCR FAQs General Questions about Section 155710/27/16) 10. How are covered entities supposed to let consumers know about their rights? Updated 1-31-17 The ?nal rule requires all covered entities to post a notice of consumer civil rights; covered entities with 15 or more employees are also required to have a civil rights grievance procedure and an employee designated to coordinate compliance. Under a new requirement, covered entities are required to post information telling consumers about their rights and telling consumers with disabilities and consumers with limited English pro?ciency (LEP) about the right to receive communication assistance. They are also required to post taglines in the top 15 languages spoken by individuals with LEP in 1317 2017-?01417 the states in which the covered entity operates, advising consumers of the availability of free language assistance services To minimize burden on covered entities, OCR has prepared a model notice and model nondiscrimination statement that covered entities can use if they choose to do so; covered entities are free to create their own notices or statements if they wish. For more information about translated notices and taglines, visit (OCR FAQs General Questions about Section 155710/27/16) 11. What does the final rule require for individuals with limited English pro?ciency The final rule adopts the longstanding civil rights principle that covered entities must take reasonable steps to provide meaningful access to each individual with LEP. The standards incorporated into the final rule are ?exible and context-speci?c, taking into account factors such as the nature and importance of the health program and the communication at issue and other relevant considerations, such as whether an entity has developed and implemented an effective language access plan appropriate to its circumstances. (OCR FAQs General Questions about Section 155710/27/16) 12. What does the final rule require concerning individuals with disabilities? The ?nal rule is consistent with existing directives implementing the requirements under the Americans with Disabilities Act and Section 504 of the Rehabilitation Act of 1973. It requires effective communication, including through the provision of auxiliary aids and services; establishes standards for accessibility of buildings and facilities; requires that health programs provided through electronic and information technology be accessible; and requires covered entities to make reasonable modi?cations to their policies, procedures, and practices to provide individuals with disabilities access to a covered entity?s health programs and activities. (OCR FAQs General Questions about Section 155710/27/16) 13. What types of discrimination constitute discrimination on the basis of sex? Updated 1-31-17 Under the ?nal rule, sex discrimination includes, but is not limited to, discrimination on the basis of pregnancy, gender identity and sex stereotyping. More than 25 years ago, the US. Supreme Court held that discrimination based on stereotypical ideas about gender is unlawful sex discrimination. While the ?nal rule does not resolve whether discrimination on the basis of an individual?s sexual orientation status alone is a form of sex discrimination under Section 1557, the rule makes clear that OCR will evaluate complaints that allege sex discrimination related to an individual's sexual orientation to determine if they involve the sorts of stereotyping that can be addressed under 1557. HHS supports prohibiting sexual orientation discrimination as a matter of policy and will continue to monitor legal developments on this issue. (OCR FAQs General Questions about Section 155710/27/16) 1318 2017-?01418 14. Why did OCR choose to include provisions that speci?cally address equal program access on the basis of sex in health programs and activities? Many of the provisions of the final rule incorporate long-standing principles and protections of civil rights law and thus will be familiar to entities governed by the final rule. The ?nal rule provides additional guidance in areas for which application of these principles may not be as familiar. Because Section 1557 is the first Federal civil rights law that broadly prohibits sex discrimination in all federally funded health care programs and activities, the ?nal rule contains provisions designed to educate consumers and covered entities specifically about sex discrimination in the health care context. OCR is also providing additional information about the application of nondiscrimination principles to health insurance and other health coverage. (OCR FAQs General Questions about Section 155710/27/16) 15. What does the provision that specifically addresses equal program access on the basis of sex in health programs and activities require? The ?nal rule requires covered entities to provide individuals equal access to health programs and activities without discrimination on the basis of sex and to treat individuals consistent with their gender identity. This provision applies to all health programs and activities, including with regard to access to facilities, administered by the covered entity. OCR FAQs - General Questions about Section 155710/27/16) 16. What does the provision regarding nondiscrimination in health insurance and other health coverage prohibit? Updated 1-31-17 The final rule prohibits covered entities from discriminating on the basis of race, color, national origin, sex, age or disability when providing or administering health-related insurance or other health-related coverage. This prohibition applies to all health insurance issuers that are recipients of Federal ?nancial assistance, which includes premium tax credits and cost sharing reductions associated with coverage offered through the Health Insurance Marketplaces or Medicare Parts A, and payments. Under the ?nal rule, a covered entity cannot: deny, cancel, limit, or refuse to issue or renew a health-related insurance policy or other health-related coverage; deny or limit coverage of a claim, or impose additional cost sharing or other limitations or restrictions; or employ marketing practices or bene?t designs that discriminate on the basis of race. color, national origin, sex, age, or disability. The ?nal rule does not require plans to cover any particular bene?t or service or prohibit issuers from determining whether a particular health service is medically necessary, but a covered entity cannot have a coverage policy that operates in a discriminatory manner. The ?nal rule also prohibits a covered entity from denying or limiting coverage, denying or limiting a claim, or imposing additional cost sharing or other limitations, on any health services that are ordinarily or exclusively available to individuals of one gender, based on the fact that an individual?s sex assigned at birth, gender identity, or recorded gender is different than the one to which the health care services are ordinarily or exclusively available. For example, when a plan covers medically appropriate pelvic exams, coverage cannot be denied for an individual for whom a pelvic exam is medically appropriate based on the fact that the individual either identi?es as a transgender man or is enrolled in the health plan as a man. 1319 2017-?01419 Under the ?nal rule, categorical coverage exclusions or limitations for all health services related to gender transition are discriminatory. Also, a covered entity cannot deny or limit coverage, deny or limit a claim, or impose additional cost sharing or other limitations or restrictions, for any specific health services related to gender transition if such denial, limitation or restriction results in discrimination against a transgender individual. (OCR FAQs General Questions about Section 155710/27/16) 17. Does the final rule cover employment discrimination? The ?nal rule provides limited coverage of employment discrimination. The ?nal rule prohibits an employer that receives Federal ?nancial assistance that is principally engaged in providing health care or health coverage, such as a hospital or nursing home, from discriminating in employee health bene?ts. The final rule also applies to employee health bene?ts offered by an entity that is not principally engaged in providing health care or health coverage if the entity receives Federal funding that is speci?cally for the employee health bene?t program itself or for a particular health program. In the latter situation, however, only the employees who work for the health program would be covered by the rule. The ?nal rule?s treatment of employment discrimination under Section 1557 does not change the protections under Title VII of the Civil Rights Act, the Americans with Disabilities Act, the Age Discrimination in Employment Act, or the other civil rights statutes referenced in Section 1557. (OCR FAQs General Questions about Section 155710/27/16) 18. Does the final rule include a religious exemption? The final rule on Section 1557 does not include a religious exemption; however, the final rule does not displace existing protections for religious freedom and conscience. (OCR FAQs General Questions about Section 155710/27/16) 19. Can I review the final regulation? Yes. You can review a copy of the final regulation at (OCR FAQs General Questions about Section 155710/27/16) 20. Can I get a copy of the regulation in large print, Braille, or some other alternative format? Yes. To get a copy in an alternative format, please contact the Of?ce for Civil Rights and provide the specifications for the format. To contact us, call our toll-free number at (800) 368-1019 or (800) 537-7697 (TDD) for assistance. (OCR FAQs General Questions about Section 155710/27/16) 21. Would the enactment of a state benefit mandate for a specific age group (for example, children) violate Section 1557? No. Enacting a mandate for a speci?c age group does not violate Section 1557. As clari?ed in the preamble to the Section 1557 regulation, under 92.101 of subpart B, ?age distinctions contained in Federal, State, or local statutes or ordinances adopted by an elected, general purpose legislative body are not covered by the final rule. States may adopt new laws that contain age distinctions; those distinctions would not violate the final rule.? OCR notes that age limits may violate Centers for Medicare Medicaid 1320 Updated 1-31-17 2017-?01420 (CMS) regulations under the Affordable Care Act and covered entities are responsible for ensuring compliance with all applicable CMS regulations and other Federal laws.[1] OCR FAQs General Questions about Section 1557 10/27/16) In November 2016, the Of?ce for Civil Rights (OCR) added five new FAQs on its Section 1557 website. The new FAQs are numbered 21 -25. Please note that the FA Qs release earlier have been renumbered to 26-35 on the OCR website. 21. What is the date by which a covered entity must comply with the posting requirements in 92.8 of the Section 1557 regulation? The effective date for these speci?c requirements is October 17, 2016[1_1. In general, covered entities may satisfy these requirements either by including the required notice and taglines on the significant publication or communication itself or by creating an insert to be enclosed with the publication or communication. For covered entities with current stock of hard copy signi?cant publications and communications that were printed before the effective date of the Section 1557 regulation (July 18, 2016), such entities may exhaust existing stock but should consider enclosing an insert of the required notice and taglines with the publication or communication. (OCR FAQs General Questions about Section 1557 11/16/16) 22. Section 1557 and its implementing regulation (Section 1557) require covered entities to post in their significant publications and communications nondiscrimination notices in English, as well as taglines in at least the top 15 languages spoken by individuals with limited English proficiency (LEP) in the State(s) served [21. What are some examples of documents that are not considered significant publications or communications? The following are not signi?cant publications and signi?cant communications under Section 1557: . Radio or television ads; . Identi?cation cards (used to access benefits or services); . Appointment cards; . Business cards; . Banners and banner-like ads; 0 Envelopes; or . Outdoor advertising, such as billboard ads. (OCR FAQs General Questions about Section 1557 11/16/16) 23. For significant publications and communications that are small-sized, covered entities must post at least a nondiscrimination statement in English and taglines in at least the top two languages spoken by individuals with LEP of the State(s) What are publications and communications that are small-sized? Examples of documents that are ?small-sized? include: . Postcards, . Tri-fold brochures, and . Pamphlets. 1321 Updated 1-31-17 2017-?01421 Signi?cant publications and signi?cant communications that are presented on 8.5 11 inch paper are not considered ?small-sized," even if the information conveyed ?ts on one side of a page. (OCR FAQs General Questions about Section 1557 11/16/16) 24. Is the Notice of Privacy Practices required by the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule at 45 C.F.R. 164.520 a communication that is ?significant? under 92.8 of the Section 1557 regulation? If so, does a Section 1557 covered entity?s inclusion of the nondiscrimination notice and taglines with the entity?s Notice of Privacy Practices constitute a ?material thus requiring the entity to revise and distribute its Notice of Privacy Practices? The Notice of Privacy Practices required by the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule is a communication that is ?signi?cant" under 92.8 of the Section 1557 regulation. The inclusion of the Section 1557 nondiscrimination notice and taglines with the entity?s Notice of Privacy Practices does not constitute a ?material change? of that entity?s Notice of Privacy Practices. Section 1557?s nondiscrimination notice advises individuals of their Section 1557 civil rights and therefore does not constitute a change in privacy policies and practices regulated under the HIPAA Privacy Rule. Therefore, revision and distribution, in accordance with 45 C.F.R. 164.520, of an entity?s Notice of Privacy Practices is not required. (OCR FAQs General Questions about Section 1557 11/16/16) 25. Is the written Summary of Benefits and Coverage (SBC) required by 45 C.F.R. 147.200(a) a publication that is ?significant? under 92.8 of the Section 1557 regulation? If so, Federal regulations limit the length to four double-sided pages._Does a Section 1557 covered entity?s inclusion of the nondiscrimination notice and taglines with its SBC count against the regulatory page limit? The written summary of bene?ts and coverage required by 45 C.F.R. 147.200(a) is a publication that is ?significant" under 92.8 of the Section 1557 regulation. The Centers for Medicare Medicaid Services (CMS) requires the use of an addendum to the SBC to accommodate applicable language access standards[?1. Accordingly, covered entities required to provide a SBC must include the nondiscrimination notice and taglines required by in its addendum along with other applicable language access standards. This addendum must contain only the Section 1557 nondiscrimination notice and taglines and other applicable language access information. (OCR FAQs General Questions about Section 1557 11/16/16) 45 C.F.R. The notice and taglines must also be posted in conspicuous physical locations where the entity interacts with the public and in a conspicuous location of the covered entity?s website, accessible from the home page. The October 17th date applies to all covered entities, even those that have until January 1, 2017, or later, to comply with other provisions, such as those requiring the revision of benefit designs. 45 C.F.R. An entity covered by the HIPAA Privacy Rule must revise and distribute its Notice of Privacy Practices when there is a material change to any of the entity's privacy practices described in the notice, including changes to the entity?s uses or disclosures of protected health information, an individual?s rights, the covered entity?s legal duties, or other privacy practices. See 45 C.F.R. See 45 C.F.R. See, US. Dept of Health Human Servs., Ctrs. for Medicare Medicaid Servs., Guidance and Population Data for Exchanges, Qualified Health Plan Issuers, and Web-Brokers to Ensure Meaningful Access by Limited-English Proficient Speakers Under 45 CFR 155.205(c) and 1322 Updated 1-31-17 2017-?01422 156.250 (Mar. 30, 2016), - US. Dep?t of Health Human Servs., Centers for Medicare Medicaid Servs., Final 2017 Letter to Issuers in the Federally- Facilitated Marketplaces, 80 (Feb. 29, 2016), to-Issuers-2-29-16.pdf - PDF. Independent of the tagline requirement of the Section 1557 regulation, issuers of quali?ed health plans are required by other authorities to include taglines with the SBC. See, 45 C.F.R. (requiring the SBC to be provided in a culturally and linguistically appropriate manner in accordance with the standards at 22. Does Section 1557 require a covered entity with multiple locations throughout the country to have a coordinator at each of its locations to coordinate compliance with Section 1557? It depends. Section 927(3) of the Section 1557 regulation requires each covered entity with 15 or more employees to designate at least one employee to coordinate efforts to comply with and implement the entity?s responsibilities under Section 1557, including the investigation of grievances. Whether each physical location is its own covered entity under Section 1557 is a question of fact that OCR would need to evaluate on a case-by- case basis. OCR recognizes that not all covered entities are organized and operate the same way; OCR is not managing how covered entities ensure their compliance. To this end, the Section 1557 regulation aims to preserve covered entities? ?exibility by specifying that each covered entity must have ?at least one employee.? This language ?at least one? read in light of the preamble at 81 Fed. Reg. 31376, 31394-95 (May 18, 2016), does, however, contemplate that in some circumstances, a covered entity may need to designate more than one employee to fulfill the substantive coordination, implementation, and investigation responsibilities stated in (OCR FAQs General Questions about Section 155 71 0/2 7/1 6) 23. By what date are covered entities required to make changes to address gender- coding issues? Updated 1-31-17 July 18, 2016 was the effective date for making necessary modi?cations in claims processing systems to address problems with gender-based coding. OCR does recognize, however, that some issuers use computer systems that accommodate only binary gender billing codes that ?ag a gender mismatch for coverage of certain sex- speci?c services. This is permissible on an interim basis if it does not result in a delay of services or processing of a claim for services. OCR expects issuers to use feasible interim methods, until their computer systems are updated, for correcting initial coverage denials due to computer systems flagging a gender mismatch. Issuers have ?exibility in designing such interim methods for processing claims for sex-specific services by transgender individuals as long as the process is not overly burdensome and provides timely access to care and coverage. See the discussion in the Preamble to the Final Rule. 81 Fed. Reg.31376, 31436 (May 18, 2016). (OCR FAQs General Questions about Section 155710/27/16) 1323 2017-?01423 24. Where can I ?nd the Assurance of Compliance form (Form HHS 690)? The Assurance of Compliance Form (HHS 690) can be found on OCR's website, at (Form HHS-690 - PDF). (OCR FAQs General Questions about Section 155710/27/16) 25. When does a covered entity have to submit the Assurance of Compliance form? Covered entities that are recipients of Federal ?nancial assistance from HHS and have a form 690 on ?le with HHS do not need to submit a new form to replace the form on ?le. However, when a covered entity applies or reapplies for Federal ?nancial assistance from HHS on or after July 18, 2016, the entity will need to sign, date, and submit the new Assurance of Compliance Form. (OCR FAQs General Questions about Section 155710/27/16) 26. Is there just one Assurance of Compliance Form that each covered entity must sign, or do different types of covered entities, or entities from different States, sign different forms? There is just one Assurance of Compliance form (Form HHS 690), and each covered entity is required to sign, date, and submit the same form. (OCR FAQs General Questions about Section 155710/27/16) 26. Which publications and communications are ?significant? with respect to the posting requirements in 92.8? Covered entities are in the best position to determine, within reason, which of their communications and publications are signi?cant in the context of their own health programs and activities. Examples of publications and communications that OCR considers to be ?signi?cant? include applications to participate in, or receive bene?ts or services from, a covered entity?s health program or activity, as well as written correspondence related to an individual?s rights, bene?ts, or services, including correspondence requiring a response. In contrast, OCR would not generally view all of an entity?s outreach, education, and marketing materials to be categorized as ?signi?cant.? Specifically, OCR clari?es that the following marketing publications and communications are not ?signi?cant? for purposes of the posting requirements in 92.8: radio or television ads; banner and banner like ads; envelopes; or outdoor advertising such as billboard ads. (OCR FAQs General Questions about Section 1557 12/14/16) 27. What is the difference between a ?covered entity? and a ?recipient?? The 1557 regulation includes definitions of both terms at Section 92.4. A recipient is an entity that receives Federal ?nancial assistance and operates a health program or activity. A covered entity includes recipients, entities established under Title I of the Affordable Care Act, and the Department of Health Human Services. (OCR FAQs General Questions about Section 155710/27/16) 1324 Updated 1-31-17 2017-?01424 28. Some covered entities participate in Medicare Advantage (MA) plans (Medicare Part plans). Others do not and therefore do not receive direct reimbursement from an MA plan; their patients pay providers directly for services and submit claims to an MA plan based on the provider?s fees. If an MA plan reimburses the patient rather than the entity, is it covered by Section 1557? Entities that receive reimbursement from an MA plan (including dental practices) must comply with Section 1557. Funds provided under the Medicare program (except for funds provided under Medicare Part B) constitute Federal ?nancial assistance. The entity must comply with the regulation regardless of whether the MA plan reimburses the patient or the entity. (OCR FA Qs General Questions about Section 155710/27/16) 29. Is claims processing considered a part of health insurance and health plan benefit design or administration? What is the effective date for compliance with the Section 1557 regulation for claims processing? The effective date for the provisions of the final Section 1557 regulation, including those concerning the administration of health insurance or other health-related coverage, is July 18, 2016. Claims processing is considered to be administration of health plans or health coverage, not plan design. Thus, it is not affected by the January 1, 2017, application date for benefit design changes in the regulation. See the discussion in the Preamble to the Final Rule. 81 Fed Reg. 31431 (May 18, 2016). (OCR General Questions about Section 155710/27/16) 30. Are Medicaid agencies subject to the July 18, 2016, effective date or the January 1, 2017 applicability date? What if they contract with Managed Care Organizations or other entities to operate Medicaid managed care plans? Are the Medicaid managed care plans subject to the July 18, 2016 effective date or January 1, 2017 applicability date? Medicaid agencies are subject to the July 18, 2016 effective date. They are not health insurance issuers under Section 1557, and thus the applicability date of January 1, 2017 for health insurance and group health plan bene?t design changes does not apply to them, whether or not they have contracted with other entities to administer Medicaid managed care plans. Managed Care Organizations and other entities that operate Medicaid managed care plans are not operating as insurers when they contract to operate these plans, so these plans are also subject to the July 18, 2016 effective date, and not the applicability date of January 1, 2017. (OCR FAQs General Questions about Section 155710/27/16) 37. What resources or funding are available to covered entities to provide language assistance services? There is no dedicated funding available to covered entities to implement the nondiscrimination provisions of Title VI and Section 1557 that prohibit discrimination on the basis of national origin and require covered entities to take reasonable steps to provide meaningful access to individuals with limited English proficiency. Under the Medicaid and Children's Health Insurance Programs, States can elect to reimburse health providers for the cost of written translation and oral interpretation services and receive Federal matching funds for these services when claimed as administrative expenses or as medical assistance-related expenses. However, not all States provide such reimbursements.[8] 1325 Updated 1-31-17 2017-?01425 HHS OCR has training materials, technical assistance materials, and sample policies and procedures on its website see, for instance, Covered entities can also call OCR at 1-800-368-1019 if they have questions about the Section 1557 resources on our website, or entities can email 1557@hhs.gov. (OCR FAQs General Questions about Section 1557 12/27/16) 38. If a covered entity provides a significant publication or significant communication in a non-English language, does the entity still have to post a nondiscrimination notice (or statement, as applicable) and taglines, with such publication or communication? If so, does the entity have to provide the nondiscrimination notice in the non-English language in which the significant publication or significant communication is written? The nondiscrimination notice and tagline posting requirements in 45 C.F.R. 92.8 apply to signi?cant publications or communications written in any language. For example, a covered entity that provides a signi?cant publication written in Chinese must include the nondiscrimination notice (or statement, as applicable) and taglines. The regulations permit a covered entity to provide the nondiscrimination notice (or statement, as applicable) in English or in the non-English-language in which the covered entity provides the signi?cant publication or communication. For example, it would be suf?cient for a covered entity to provide a nondiscrimination notice in English even if the notice accompanies a significant publication or communication translated into Spanish. Regardless of the language in which the entity provides the signi?cant publication or the nondiscrimination notice, the entity must post taglines with the signi?cant publication. OCR FAQs - General Questions about Section 1557 12/27/16) 39. Is a covered entity required by 45 C.F.R. 92.8 to post the notice of nondiscrimination (or nondiscrimination statement, as applicable) in non-English languages? If not, why does OCR make available the nondiscrimination notice and statement in 64 languages? Under 92.8, it is suf?cient for the covered entity to provide the nondiscrimination notice (or statement, as applicable) in English only. OCR encourages covered entities to post the notice (or statement, as applicable) in one or more of the most prevalent non-English languages frequently encountered by covered entities in their geographic service areas. To this end, OCR makes available the notice and statement in 64 languages for entities? use: resources/index.html. (OCR FAQS General Questions about Section 1557 12/27/16) 40. To meet its obligations under Section 1557, can a health program or activity receiving Federal financial assistance from the US. Department of Health and Human Services (HHS) use the HHS call center number and thus rely on HHS to provide oral interpretation for an individual with limited English proficiency who is eligible to be served or likely to be encountered by the health program? It is not role, or the purpose of the HHS call center, to provide oral interpretation services for all entities covered by Section 1557 and its implementing regulation (Section 1557). OCR encourages covered entities to work together to leverage their resources to provide language assistance services in the most cost-effective and ef?cient ways to meet their respective obligations under 92.201. OCR also encourages professional associations and organizations to consider what role they can play in helping their members meet the requirements of 92.201. 1326 Updated 1-31-17 2017-?01426 For example, the Washington State Medicaid Interpreter Services Program centralizes the provision of language assistance services to achieve economies of scale.[g1 Similarly, through Effective Communication in Hospitals Initiative, the Kentucky Hospital Association built the capacity to offer its approximately 120 member hospitals access to a telephonic interpretation service contract that offers a volume-based discount rate Although OCR cannot certify that these approaches uniformly enable entities to meet the requirements of Section 1557, they do represent examples of the types of collaborative action that covered entities may consider. (OCR FAQs General Questions about Section 1557 12/27/16) 41. The sample tagline OCR makes available on its website and in appendix to the Section 1557 regulation includes a placeholder for a telephone number and directs individuals to call the number to obtain language assistance services, free of charge. What telephone number is a covered entity supposed to provide? Should the covered entity insert its own telephone number? Or, should the covered entity provide the number of a telephonic oral interpretation vendor that provides qualified interpreters for the entity?s health programs or activities? The phone number included in the tagline should be the covered entity?s phone number. As soon as the covered entity identifies that the caller has a limited ability to speak English and is speaking a non-English language, the covered entity should access a qualified interpreter via a telephonic oral interpretation vendor who can orally interpret the conversation between the caller with limited English pro?ciency and the covered entity. If the covered entity has dif?culty identifying the language that a caller speaks, the telephonic oral interpretation service should be able to assist in identifying the language spoken by the caller to obtain the appropriate qualified interpreter. (OCR FAQs General Questions about Section 1557 12/27/16) 42. If a covered entity has arranged to provide a qualified interpreter for an appointment, and the individual with limited English proficiency fails to attend the appointment, is the covered entity responsible for paying for the language assistance services it arranged to be provided? Can the covered entity charge a ?no show? fee to persons with limited English proficiency who fail to cancel or do not show for an appointment? Whether the covered entity is charged a fee by its telephonic interpretation vendor when an individual with limited English proficiency fails to attend an appointment is a contractual matter between the vendor and the covered entity. However, under Section 1557 and its implementing regulation, an individual cannot be charged for oral interpretation services, even if such services were scheduled for an appointment that an individual with limited English proficiency missed. (OCR FAQs General Questions about Section 1557 12/27/16) 43. Does the use of an electronic program that translates written content satisfy the requirements of Section 1557? For example, some apps for written translation are marketed as translating written content on demand. Section 1557 and its implementing regulation do not prohibit the use of automated translation technologies. However, because written translation must be provided by a qualified translator, automated translation alone likely would not be sufficient. Machine translation, which is one type of automated translation technology, translates text by 1327 Updated 1-31-17 2017-?01427 performing simple substitution of words using statistical techniques. Given differences across languages in syntax, figures of speech, and vocabulary, the simple substitution of words using statistical techniques may produce highly unreliable translations for certain languages and written content. A quality check performed by a qualified translator, such as reviewing the translation for accuracy and editing the translation if needed, would likely be necessary. OCR encourages covered entities to understand the and weaknesses of the technology and software programs that qualified translators use. OCR FAQs - General Questions about Section 1557 12/27/16) 44. Does Section 1557 permit covered entities to limit some health research to only males or females? Sex-speci?c programs or activities (those in which participation is limited to one sex only), including health research, are allowed only where a covered entity can show an exceedingly persuasive justification for the limitation to one sex. To establish an exceedingly persuasive justification, a covered entity must show that the sex-based classification is substantially related to the achievement of an important health-related or scienti?c objective. A covered entity must supply objective evidence, and empirical data if available, to justify the need to restrict participation in a health program to only one sex. Justi?cations that rely on overly broad generalizations about the sexes are not acceptable. Health researchers will typically be able to show an exceedingly persuasive justification for a sex-speci?c clinical trial based on research protocols. These include protocols that target or exclude certain populations in order to account for the health or safety of the subjects, the study design, or the purpose of the research. For example, certain drugs are known to affect women and men differently; men?s kidneys tend to ?lter certain antianxiety medication more rapidly than women. Based on this scienti?c knowledge, a medical research institution that is a covered entity and that runs a clinical trial to test a modi?ed release mechanism to slow the drug filtration and excretion in men?s kidneys may permissibly exclude women from the trial under the standards set forth above. (OCR FA Qs General Questions about Section 1557 01/03/17) 45. What does Section 1557 require with regard to general medical care for transgender individuals? Updated 1-31-17 Under Section 1557, discrimination on the basis of sex includes discrimination on the basis of gender identity; the law thus prohibits discrimination against transgender individuals. This prohibition imposes several types of obligations on covered entities. For example, covered entities, as a general matter, must provide transgender individuals equal access to programs, including facilities, without discrimination and consistent with an individual's gender identity. Moreover, health care professionals may not deny treatment to a transgender individual based on the fact that the individual is transgender, if the health care professional would provide the same treatment for a non-transgender individual. For example a general practitioner may not refuse to treat a transgender male for a broken arm, based on the individual?s transgender status, if he or she would treat the broken arm of individuals who are not transgender. (OCR FAQs General Questions about Section 1557 01/03/17) 1328 2017-?01428 46. What does Section 1557 require with regard to the provision of, or coverage for, sex- specific health services for transgender individuals? As a general matter, if a transgender individual needs a sex-specific health service, covered entities may not deny that service because the individual is transgender. For example, if a transgender woman has a prostate, and prostate exams are recommended for men of her age and/or risk factors, an internal medicine practice may not refuse to provide a medically indicated prostate exam to her because she identifies as a woman or because her records or identi?cation identify her as female. Similarly, covered health insurance plans may not deny or limit claims for sex-speci?c health services for a transgender individual based on the fact that an individual?s sex assigned at birth, gender identity, or gender otherwise recorded in a record does not correspond to the gender of individuals to whom the service is typically provided. For example, a covered health insurance plan could not deny coverage of a claim for a medically indicated pap smear based on the fact that the patient identi?es as a transgender man. Covered entities must determine coverage of a claim for health services by applying the same nondiscriminatory terms and conditions to everyone, regardless of the individual?s sex assigned at birth, gender identity, or recorded gender. Notably, Section 1557 also prohibits categorical exclusions or limitations of all gender transition- related services in health insurance plans or other health coverage covered by Section 1557. In addition, in relation to coverage for speci?c health services related to gender transition, covered entities must utilize a neutral nondiscriminatory rule or principle in deciding whether to deny or limit claims for speci?c health services for a transgender individual. For example, if a health insurance plan denies coverage for hormone therapy that a patient?s provider says is medically necessary to treat gender while approving coverage for medically necessary hormones used to treat different conditions, OCR would evaluate the reasons why coverage for the same treatment is available to individuals with different health conditions and expect the covered entity to provide a neutral, nondiscriminatory reason for the denial that is not a pretext for discrimination. (OCR FAQs - General Questions about Section 1557 01/03/17) 47. Does Section 1557 prohibit harassment based on sex, including on the basis of sex stereotyping? Updated 1-31-17 Consistent with longstanding principles of Federal civil rights principles, Section 1557 prohibits harassment based on race, color, national origin, sex, age or disability. Covered entities must respond and effectively to sex-based harassment of individuals in their health programs or activities, by taking action to eliminate the harassment, prevent its recurrence and address its effects. For example, if a male nursing home resident is harassed by staff based on his non-conformity with stereotypical notions of how a man is expected to act or appear (including mannerisms, apparel, or grooming choices), that may constitute discrimination on the basis of sex that must be addressed by the entity. The nursing home must take action to stop the staff harassment, prevent it from recurring and address the effects of the harassment. In addition, the nursing home should adopt policies addressing sex-based harassment to make clear that such harassment is not tolerated in the workplace. (OCR FAQs General Questions about Section 1557 01/03/17) 1329 2017-?01429 48. Is it prohibited under Section 1557 to treat married men differently than married women? Section 1557 prohibits discrimination on the basis of sex in health programs or activities. Thus, a covered entity may not apply a rule concerning marital status that treats individuals differently on the basis of sex. For example, a hospital may not have a policy or practice that automatically assigns a male spouse as the sole ?nancially responsible party for a female spouse?s health care, but does not also automatically assign a female spouse as the sole ?nancially responsible party for a male spouse?s medical services. OCR FAQs General Questions about Section 1557 01/03/17) 49. Does Section 1557 prohibit discrimination in health insurance and other health coverage? Section 1557 and the Department?s implementing regulation prohibit discrimination on the basis of race, color, national origin, sex, age, or disability in the provision or administration of health-related insurance or other health-related coverage offered by recipients of Federal financial assistance or the Health Insurance Marketplaces or provided by the Department of Health and Human Services (HHS or the Department). In addition, covered entities are prohibited from having or using marketing practices or bene?t designs that unlawfully discriminate. Although Section 1557 does not require an issuer to cover a particular type of care or service, covered entities must use neutral, nondiscriminatory criteria in making decisions as to which bene?ts and services to cover, and their health coverage cannot operate in a discriminatory manner. (OCR FAQs General Questions about Section 1557 01/03/17) 50. What constitutes ?Federal financial assistance? under Section 1557? Under the Section 1557 regulation, ?Federal financial assistance" means any grant, loan, credit, subsidy, contract (other than a procurement contract, but including a contract of insurance), or any other arrangement by which the Federal government provides or otherwise makes available funds or other types of assistance. It includes all tax credits the Department plays a role in providing under Title of the ACA, including payments extended by the Department to or on behalf of an individual to help pay for health-related insurance coverage. Thus, if a health insurance issuer provides health insurance on the MarketplaceSM for which tax credits or premium assistance are provided, the issuer must ensure that its plans comply with Section 1557. (OCR FAQs General Questions about Section 1557 01/03/17) 51. Do Federal employment nondiscrimination laws also apply to insurance discrimination? Updated 1-31-17 Several laws prohibit covered employers, unions, and other entities from discriminating based on race, color, national origin, religion, sex, age, disability, or genetic information when providing bene?ts to their employees, including insurance. These laws include Title VII of the Civil Rights Act of 1964, the Age Discrimination in Employment Act, the Equal Pay Act, Title of the Americans with Disabilities Act, Section 501 of the Rehabilitation Act, and Title II of the Genetic Information Nondiscrimination Act. The Equal Employment Opportunity Commission (EEOC) enforces these laws, which pre- date the Affordable Care Act (ACA) and which apply separate and apart from the ACA's nondiscrimination requirements. Thus, both Section 1557 and employment nondiscrimination laws may apply in some circumstances where health bene?ts are 1330 2017-?01430 offered through an employee health plan. By contrast, some activities may be subject to either Section 1557 or employment nondiscrimination laws but not both. For example, outside the employment context, Section 1557, but not the employment laws, applies to federally funded health programs and activities, including those offered by insurance issuers. On the other hand, the employment nondiscrimination laws apply to a universe of employers that is broader than those to which Section 1557 applies. Claims under Section 1557 may be ?led with HHS OCR by going to this link: For information about ?ling a charge of discrimination with the EEOC against an employer under statutes that the EEOC enforces, including concerning discrimination with respect to employer- provided health or life insurance, go to OCR and the EEOC will coordinate to ensure that claims are handled by the appropriate agency. (OCR FAQs General Questions about Section 1557 01/03/17) 52. What issuers are prohibited from discriminating in health insurance or health coverage under Section 1557? Updated 1-31-17 Section 1557 of the ACA, and the Department's implementing regulation, apply to: All health programs or activities that receive HHS funding; 0 All health programs or activities administered by HHS itself by the Centers for Medicare Medicaid Services or the Substance Abuse and Mental Health Services Administration); and, The Health Insurance Marketplaces and plans offered by issuers that participate in those Marketplaces. A ?health program or activity" is defined as ?the provision or administration of health- related services or health related insurance coverage or other health-related coverage, and the provision of assistance to individuals in obtaining health-related services or health related insurance Thus, covered entities include entities that provide or administer health insurance or other health coverage[29]. These entities are prohibited from discriminating in the provision or administration, including marketing and design, of health insurance or other health coverage under Section 1557. Issuers participating in the Marketplaces are receiving Federal ?nancial assistance through advanced premium tax credits and cost-sharing reduction subsidies and therefore must comply with Section 1557 in the plans that they offer. Absent any defense, issuers that are principally engaged in providing health insurance are covered for all of their activities, including off-Marketplace plans.lssuers participating in the Marketplaces are receiving Federal financial assistance through advanced premium tax credits and cost-sharing reduction subsidies and therefore must comply with Section 1557 in the plans that they offer. Absent any defense, issuers that are principally engaged in providing health insurance are covered for all of their activities, including off- Marketplace plans.[30] Third party administrators are covered by Section 1557 for the health benefits they administer if they receive Federal ?nancial assistance either directly or because they are part of a recipient organization that is principally engaged in health services, health insurance or health coverage. 1331 2017-?01431 However, if the decision that resulted in discrimination relates to the design, rather than the administration, of a plan, OCR will typically investigate a complaint against the employer providing the benefits rather than against the third party administrator. If OCR lacks jurisdiction over the employer, it will typically refer or transfer the matter to the EEOC. (OCR FA 08 General Questions about Section 1557 01/03/17) 53. Under what circumstances are employers liable for discriminating in health insurance or health coverage under Section 1557? Employers will be held accountable under Section 1557 for discrimination in the employee health bene?t programs they provide to employees and/or dependents in three circumstances: (1) the employer receives Federal financial assistance and is principally engaged in providing or administering health services, health insurance, or other health coverage; or (2) the employer receives Federal financial assistance, a primary purpose of which is to fund the entity's employee health benefit program; or (3) the employer is not principally engaged in providing or administering health services, health insurance, or other health coverage but operates a health program or activity, which is not an employee health bene?t program, that receives Federal ?nancial assistance; in this situation the employer must comply with Section 1557 in the provision or administration of employee health benefits only to the employees in that health program or For example, a hospital that provides health bene?ts to its employees is covered by Section 1557 in the health bene?ts it provides to all employees, including employees who work in the cafeteria, because the hospital is principally engaged in providing health services. By contrast, where a housing program receives Federal ?nancial assistance to operate a diabetes screening program for housing residents, but is not principally engaged in providing health services or coverage, its employee health bene?ts are covered by Section 1557 only with respect to the employees of the diabetes screening program. (OCR FAQs General Questions about Section 1557 01/03/17) 54. If a covered entity that provides or administers health insurance or other health coverage complies with other Federal civil rights laws, such as Title VII of the Civil Rights Act and Title VI of the Civil Rights Act, is it automatically in compliance with Section 1557? Section 1557 is independent of and in addition to other requirements of other Federal civil rights laws. However, OCR coordinated with other Federal agencies in drafting the Section 1557 regulation and will continue to work with other Federal agencies to ensure consistency to the extent appropriate. (OCR FA Qs General Questions about Section 1557 01/03/17) 1332 Updated 1-31-17 2017-?01432 55. Are non-spousal dependents who receive health coverage through a parent?s employer protected under Section 1557 from discrimination in the health coverage they receive? Section 1557 prohibits discrimination against an ?individual,? including non-spousal dependents who are covered by another individual?s health plan. The purpose of Section 1557 is to ensure that ?individuals? have access to health insurance and health services and to eliminate discriminatory and other barriers to accessing coverage and care. Thus, whether or not discrimination against non-spousal dependents is covered under other laws, such as Title or Title IX, an employer?s health bene?t plan may not discriminate against non-spousal dependents under Section 1557. (OCR FAQs General Questions about Section 1557 01/03/17) 56. If an employer or health issuer is required to make changes in the design of its health insurance or other health coverage to comply with Section 1557, what is the deadline for doing so? Section 1557 went into effect on March 23, 2010.. The ?nal regulation was published by the Department on May 18, 2016.. The ?nal regulation became effective on July 18, 2016, with the exception of provisions of the regulation that require changes to health insurance or group health plan benefit design, which apply as of the ?rst day of the first plan year (or, in the individual market, policy year) beginning on or after January 1, 2017. As noted in the preamble to the ?nal rule, OCR recognizes that some covered entities will have to make changes to their health coverage to bring that coverage into compliance with the ?nal rule; OCR is ?sensitive to the difficulties that making changes in the middle of a plan year could pose for some covered entities and is committed to working with covered entities to ensure that they can comply with the final rule without causing excessive disruption for the current plan year.? (OCR FAQs General Questions about Section 1557 01/03/17) 57. What is a gender-coding mismatch? Updated 1-31-17 Covered entities offering private health insurance or health coverage through the Medicare and Medicaid programs may use automated billing practices to process claims for services, including procedure codes and diagnosis codes to identify which service was performed and why it was performed. As part of this process, some services are coded as sex-specific, meaning that they are only provided for one sex. The automated billing process then denies claims for services when there is a gender mismatch between the gender of the individual receiving the treatment or service and the billing code associated with the biological sex that typically receives that service. For example, a gender-coding mismatch can occur when a transgender male seeks coverage for treatment of ovarian cancer, due to the fact that the individual?s gender (male) does not align with the gender (female) that typically receives that service. A gender-coding mismatch can also occur when the gender of the individual receiving the treatment or service is different from the gender identified in the covered entity?s records. For example, this can occur when a transgender male seeks coverage for a broken arm, but the computer system denies the claim because the individual?s gender (male) does not align with the individual?s gender (female) that had been originally recorded in the system. (OCR FA Qs General Questions about Section 1557 01/03/17) 1333 2017-?01433 58. How can a covered entity address gender-coding mismatch issues? OCR recognizes that covered entities have certain requirements as to their claims processing systems. Issuers are free to develop their own methods for addressing gender-coding mismatches, but as an example, OCR suggests that covered entities consider using a unique billing code modifier that a health care provider could submit, along with a claim for sex-speci?c services for a transgender patient, which would alert the issuer that it should override any sex-specific billing codes. This modi?er could be similar to the condition code 45 under Medicare Part A or the KX modi?er under Medicare Part that is used by the Centers for Medicare Medicaid Services to address inappropriate denials of coverage for care and services typically thought of as gender-speci?c. When used alongside standard billing codes for speci?c procedures, this additional code alerts Medicare?s computer system to ignore an apparent gender mismatch and thus allows the claim to be processed. The Section 1557 rule preamble speci?es that covered entities should develop methods for correcting coverage denials due to computer systems flagging a gender mismatch. Such ?agging by itself would not be impermissible if it does not result in a delay or denial of services or a claim for services. However, as the preamble makes clear, once a covered entity is aware that a gender code mismatch is causing a delay or denial of services or a claim for services, the entity must develop a another method to process claims for sex-specific services by transgender individuals. The method developed may not be overly burdensome and must provide timely access to care. Thus, requiring transgender employees to repeatedly go through internal appeals processes to obtain coverage for certain services would subject these enrollees to a burdensome process that is likely to delay their receipt of coverage or timely payment of a claim. Instead, issuers could notate in the individual?s file that the individual is transgender to ensure that such services are approved in the future or utilize a billing code modifier as discussed above. (OCR FA Qs General Questions about Section 1557 01/03/17) 59. Does a doctor?s office have to provide a qualified interpreter for a visit with a patient who is deaf or hard of hearing? Updated 1-31-17 In accordance with 92.202 of the Section 1557 regulation, a covered entity must take appropriate steps to ensure that communications with individuals with disabilities are as effective as communications with individuals without disabilities in health programs and activities. In evaluating its obligations, the covered entity should consider several factors: . The covered entity has an obligation to take appropriate steps to ensure effective communication in its telecommunications, which includes the initial phone contact. . The covered entity may not rely on a companion of an individual with a disability to interpret for that individual except in very narrow circumstances. . Where the individual requests a quali?ed interpreter in advance of the appointment in suf?cient time for the covered entity to arrange for a qualified interpreter and a qualified interpreter is necessary for effective communication, the quali?ed interpreter must be available at the time of the appointment. 1334 2017-?01434 . The duty to take appropriate steps to ensure effective communication applies to communications with deaf or hard of hearing companions of patients, as well as patients. . If the covered entity knows from past interactions or should know from available records that a quali?ed interpreter is needed for effective communication in an upcoming patient visit, the covered entity needs to provide a quali?ed interpreter. (OCR FAQs General Questions about Section 1557 01/23/17) 60. Can a nursing home exclude from admission individuals with certain conditions? A covered entity may not deny an individual the opportunity to participate in or benefit from an aid, benefit, or service on the basis of his or her disability when the individual meets all of the essential eligibility requirements for the health program or activity. For example, an eligible individual may not be denied admission to an assisted living facility based on his or her HIV status (a disability under Federal civil rights laws). (OCR FAQs General Questions about Section 155 7 01/23/17) 61. May covered entities use health research protocols that target or exclude individuals with disabilities? A covered entity conducting health research may design research protocols that target or exclude certain populations when necessary to protect the health or safety of the subjects or serve the purpose of the research. For example, a medical research institution that is a covered entity may exclude individuals who are deaf from a clinical trial designed to investigate a new brain imaging technology for assessing cognitive functioning where that trial relies on auditory stimulation as the test stimulus. This research design would not be discriminatory on the basis of disability because there is a nondiscriminatory justi?cation for excluding individuals who are deaf. On the other hand, if an individual?s disability does not interfere with the purpose of the study or the health or safety of the participants, an individual with a disability may not be excluded on the basis of his or her disability. (OCR FAQs General Questions about Section 1557 01/23/17) 62. Must a health provider that is a covered entity have accessible medical equipment? Updated 1-31-17 A covered entity may not deny an individual with a disability an equal opportunity to participate in and bene?t from its health programs and activities. That means that a covered entity must provide access to medical services, including diagnostic services, to an individual with a disability. A covered entity has ?exibility in how it meets this obligation. For example, the covered entity can use different types of accessible medical diagnostic equipment or have enough staff to assist the patient to transfer from a wheelchair to an examination table, if that approach is effective for an individual with the disability. For more information, please see joint HHS and DOJ guidance that addresses these issues in greater detail, Access to Medical Care for Individuals with Mobility Disabilities, mobility ta/medcare ta.htm. (OCR General Questions about Section 1557 01/23/17) 1335 2017-?01435 63. Must a covered health plan ensure that providers in its network have accessible medical equipment? A covered managed care plan or other covered plan does not have to ensure that all providers in the network have accessible medical and diagnostic equipment. However, the plan should: ensure that a sufficient number of providers in its network have accessible medical and diagnostic equipment to allow individuals with disabilities to receive necessary diagnostic exams, or, take other steps to provide accessible services, such as ensuring that a process is available for allowing an individual with a disability to go out of network at no additional charge to receive these services. (OCR FAQs General Questions about Section 1557 01/23/17) 64. Does the website of a covered entity have to be accessible? A covered entity must ensure that its health programs or activities provided through electronic and information technology are accessible to individuals with disabilities, unless doing so would result in undue ?nancial and administrative burdens or a fundamental alteration in the nature of the health programs or activities. For example, a Health Insurance Marketplace creating a website for application for health insurance coverage must ensure that individuals with disabilities have access to the bene?t of the website?s tool that allows comparison of health insurance coverage options, quick determination of eligibility, and facilitation of timely access to health insurance coverage by making its new website accessible to individuals who are blind or who have low vision. (OCR FAQs General Questions about Section 1557 01/23/17) 65. If a patient requests to be treated only by staff persons of a particular racial group, would it be a violation of the Section 1557 regulation if the covered entity honored that request? It is unlawful discrimination for a covered entity to assign staff on the basis of race, color, or national origin, even if such a request is made by a patient or resident. (OCR FAQs General Questions about Section 1557 01/23/17) 66. May a Section 1557 covered entity decide not to serve a particular geographic area whose residents are predominantly of a particular racial group based on concerns about the safety of the area? Updated 1-31-17 Covered entities may not refuse or limit services on the basis of race in determining the geographic area where they will provide a health program or activity. This prohibition includes situations in which covered entities make assumptions about safety based on the race of the neighborhood's residents. For example, a home health agency may not decline to serve certain streets or housing complexes, where the areas are selected based on assumptions that the areas are unsafe because of the race or national origin of the area's residents. (OCR FA 08 General Questions about Section 1557 01/23/17) 1336 2017-?01436 67. Are immigrants protected from discrimination on the basis of national origin under Section 1557? Yes. The protections of Section 1557 do not differ based on a person?s immigration status. Further, covered entities may not administer their health programs in a manner that has a discriminatory impact on individuals of any particular national origin, even if the policy or practice is facially neutral. For example, a State Medicaid agency should consider whether a requirement to disclose the immigration status of non-applicant parents applying for health bene?ts on behalf of eligible children discriminates against the eligible children on the basis of national origin because the requirement may deter parents from seeking benefits for their eligible children. Section 1557 does not alter programmatic laws and regulations that restrict eligibility for particular health programs to persons of certain immigration or citizenship statuses. Section 1557 allows covered entities to make requests for such information when required by federal or state law for purposes of determining eligibility. But where individuals are legally eligible for benefits, they may not be subject to discrimination in those benefit programs on the basis of national origin and the other bases prohibited under Section 1557. (OCR FAQs General Questions about Section 1557 01/23/17) 68. How can a covered entity meet its obligation to take reasonable steps to provide meaningful access to individuals with limited English proficiency (LEP) in its health programs and activities? Updated 1-31-17 OCR will evaluate an entity?s compliance by using a fact-dependent, contextualized analysis. OCR will give substantial weight to the nature and importance of the health program and the particular communication at issue. OCR will also consider other relevant factors, such as: the length, complexity, and context of the communication; the prevalence of the language in which the individual communicates among those eligible to be served or likely to be encountered; the frequency with which a covered entity encounters the language in which the individual communicates; all resources available to the covered entity; the cost of language assistance services and whether a covered entity has availed itself of cost-saving opportunities; and whether a covered entity has explored the individual?s preference, if any, for a type of language assistance service. OCR will also take into account whether the entity developed and implemented an effective, written language access plan. For example, if a Spanish-speaking individual with LEP seeks a surgery consultation regarding a gallbladder removal procedure with a physician at a large hospital, the hospital should evaluate the appropriate level, type and manner of language assistance services to be provided by considering and giving substantial weight to the nature and importance of the health care. If the population of Spanish-speaking individuals with LEP is large and the hospital?s contacts with such individuals are frequent, and if the resources available to a large hospital are considerable, the hospital will likely have to provide the Spanish-speaking individual with LEP interpretation services from a staff interpreter, contracted interpreter or other qualified interpreter or through a bilingual physician. (OCR FA 08 General Questions about Section 1557 01/23/17) 1337 2017-?01437 69. How can a covered entity meet its obligation to take reasonable steps to provide meaningful access if an individual speaks an uncommon language? The underlying approach outlined above is the same even if the individual speaks an uncommon language. For example, if an individual with LEP who speaks Urdu seeks information about Medicaid eligibility from a State Medicaid agency, that agency should consider and give substantial weight to the nature and importance of health insurance enrollment. The State Medicaid agency may consider the proportion of Urdu-speaking individuals with LEP served or encountered by the agency; the frequency with which Urdu-speaking individuals with LEP come in contact with the agency; and the resources available to the agency and costs of the language assistance services. Even if the population of, and frequency with which the State Medicaid agency serves or encounters Urdu-speaking individuals with LEP is small and relatively infrequent, these factors could be outweighed by the nature and importance of Medicaid program enrollment. Although an agency is permitted to consider the resources it has available, low-cost commercial language services, such as telephonic oral interpretation services, are now widely available. As a result, OCR may ?nd that the State Medicaid agency was capable of providing the Urdu-speaking individual with LEP telephonic interpretation services to ensure meaningful access to the program. (OCR FAQs General Questions about Section 1557 01/23/17) 70. Does a covered entity have any flexibility in its provision of language assistance to individuals with Yes, depending on the circumstances, so long as it takes reasonable steps to provide meaningful access to a health program or activity. The covered entity should analyze the facts in light of the factors set forth in the question above. For instance, if a small clinic discharges an individual with LEP who speaks Tagalog (a language rarely encountered by the clinic) after providing treatment for a sprained ankle and the individual requests a translated brochure on healthy eating, the covered entity would not be required to translate the brochure for that individual primarily because the subject of the brochure is unrelated to the condition for which the patient was seeking treatment and the clinic rarely serves individuals with LEP who speak Tagalog. However, the entity would be required to take other reasonable steps to provide meaningful access to the individual. Such steps could include, depending on the facts, using a telephonic interpretation service to orally walk the individual with limited English proficiency through the information in the brochure in Tagalog. (OCR FAQs General Questions about Section 1557 01/23/17) 71. Does Section 1557 require covered entities to have a language access plan? Updated 1-31-17 Section 1557 does not require covered entities to have a language access plan. Nonetheless, the regulation encourages covered entities to develop and implement an effective written language access plan, appropriate to its circumstances, that addresses the needs of the limited English pro?cient population in the service area of its health programs or activities. A written language access plan has long been recognized as a helpful tool to ensure adequate and timely provision of language assistance services and often may be necessary to meet the requirements of the law in a timely manner. A language access plan need not be long, complex, or burdensome. The nature and extent of the voluntary planning in which a covered entity may choose to engage will vary depending on the entity?s particular health programs and activities, its 1338 2017-?01438 size, its geographic location, and other factors. Effective language access plans often, among other components, address how the entity will determine an individual?s primary language, particularly if the language is an unfamiliar one; identify a telephonic oral interpretation service to be able to access quali?ed interpreters when the need arises; identify a translation service to be able to access quali?ed translators when the need arises; identify the types of language assistance services that may be required under particular circumstances; and identify any documents for which written translations should be routinely available. (OCR FAQs General Questions about Section 1557 01/23/17) 72. When is it permissible to treat people differently on the basis of age? Under the Section 1557 regulation, the general rule prohibiting the denial or limitation of access based on age is limited by the following exception: A covered entity may reasonably take age into account if it is a factor necessary to the normal operation or achievement of a statutory objective of a health program or activity. Even then, the entity is only permitted to consider age as one factor as part of its overall decision- making. For example, the US. Preventive Services Task Force recommends screening for colorectal cancer beginning at age 50 and continuing until age 75. If a 25 year old requests screening for colon cancer, a medical practice should conduct an individualized assessment of the patient, including whether the patient presents any risk factors, such as family history, the presence of or other medical conditions, or lifestyle factors that might make the patient an appropriate candidate for this screening. If the assessment demonstrates that the screening is not medically appropriate, the practice may decline to conduct the screening, even if the practice would have conducted the assessment, based on the Task Force guidelines, had the patient been 50 years old or older. This approach would be permissible since the entity reasonably took age into account as one factor, among other factors that it considered. Furthermore, waiving cost sharing only for individuals age 50 to 75 in accordance with the preventive service requirements of the Affordable Care Act would be permissible, because age distinctions contained in Federal statutes which describe intended bene?ciaries or target groups in age-related terms are not covered by the Section 1557 regulation. On the other hand, suppose an organ transplant center has a policy that automatically disallows heart transplants to all individuals aged 65 or older. While it would be permissible for the transplant center to consider age as one factor in assessing the allocation of transplants, the entity?s blanket exclusion of individuals based solely on age is discriminatory. (OCR FAQs General Questions about Section 1557 01/23/17) 73. How does the regulation apply to age rating in health insurance? Updated 1-31-17 Under the regulation, any age distinction contained in a regulation issued by HHS is presumed to be necessary to the achievement of a statutory objective of the program. For example, regulations issued by HHS implementing the Affordable Care Act permit health insurance issuers in the individual and small group markets to charge premiums based on age, within a 3:1 ratio. Thus, age rating within these parameters is permissible under the Section 1557 regulation. (OCR FAQs General Questions about Section 1557 01/23/17) 1339 2017-?01439 74. May a State have age limits on certain benefits provided by issuers? The regulation does not apply to age distinctions contained in State or local statutes that were adopted by an elected, general purpose legislative body. For instance, some State statutes permit health insurance issuers to limit coverage of hearing aids to individuals of a certain age. This age limit would not violate Section 1557 because it is authorized under State law. However, covered entities should be mindful of other legal requirements, including those issued by the Centers for Medicare Medicaid Services that prohibit age limits and distinctions. (OCR FAQs General Questions about Section 1557 01/23/17) Estimates of at Least the Top 15 Languages Spoken by Individuals with Limited English Proficiency 1. Regulations implementing Section 1557 of the ACA require each covered entity to ?post taglines in at least the top 15 languages spoken by individuals with limited English proficiency of the relevant State or States.? 45 C.F.R. What are these languages in each State? Updated 1-31-17 As a resource for covered entities, OCR has made available a table displaying list of the top 15 languages spoken by individuals with limited English proficiency (LEP) in each State, the District of Columbia, Puerto Rico and each U.S. Territory. OCR created this list for covered entities? use in identifying languages in which to provide translated taglines in implementing list is organized first by State with the US. Territories at the end of the table and then by language. Languages estimated to be spoken by the most individuals with LEP are ranked as number 1. Covered entities may use the information in this list to implement although nothing in the Section 1557 regulation requires covered entities to use particular resource in doing so. In implementing covered entities may refer to sources other than list if covered entities have a reasonable basis for relying on such sources when considering characteristics such as the currency, reliability, and stability of the data. Covered entities may use such sources even if the list of languages produced from those sources is different from list or has variations in the relative rank of the languages. As a reminder, nothing in the Section 1557 regulation bars a covered entity from including taglines in languages beyond those triggered by For instance, a covered entity may choose to include taglines in additional languages to maximize the breadth of national origin populations informed about the availability of language assistance services. Please be aware that providing taglines as requires does not ful?ll the covered entity?s obligation for complying with the prohibition of national origin discrimination under Section 1557 and the rule. Under covered entities must also take reasonable steps to provide meaningful access to each individual with LEP eligible to be served or likely to be encountered in the entity?s health programs or activities. Independent of the tagline requirement at covered entities are responsible for providing timely and accurate language assistance services, such as oral interpretation and written translation, in non-English languages, even if the language is 1340 2017-?01440 not shown on list, when doing so is a reasonable step to provide meaningful access to an individual with LEP. View the table created for OCR. - PDF OCR FAQs FAQs to Accompany the Estimates of at Least the Top 15 Languages Spoken By Individuals with Limited English Pro?ciency Under Section 1557 of the ACA 10/2 7/1 6) 2. What data did OCR use to compile its list of the top 15 languages spoken by individuals with LEP in each of the 50 States, the District of Columbia, and Puerto Rico? OCR used the US. Census Bureau's (Bureau) American Community Survey?s (ACS) data set entitled ?Language Spoken at Home by Ability to Speak English for the Population 5 Years and Older.? The tables for this data set display, among other variables and geographic units, the estimated number of individuals, who speak non- English languages in each State,who speak English less than ?very well,? which OCR used as a proxy for the population with LEP. OCR used the most recent State-based data set available to OCR during the development of the Section 1557 rule the 2014 ACS 5-year estimates, available as one of the Bureau?s American FactFinder tables.[i] The American FactFinder tables include estimates on a total of 39 individual languages and language groups. The language groups on the American FactFinder tables ?bundle" more than one language in the groups? estimates. For instance, the American FactFinder tables estimate the prevalence of individuals who speak English less than ?very well? who speak ?Other lndic languages," ?Other Paci?c Island Languages, African Languages,? and ?Other and unspecified languages,? among other groups. For these groups where more detail was needed to identify the languages represented, OCR used the detailed State-based data set from the 2013 ACS 5-year estimates which were the most recent estimates available during the development of the Section 1557 The detailed tables display approximately 380 languages and language groups. 1! (I On list, an asterisk after the language denotes that the estimate came from the Bureau?s detailed 2013 ACS 5-year estimates rather than from the 2014 ACS 5?year estimates. (OCR FA 08 FA 03 to Accompany the Estimates of at Least the Top 15 Languages Spoken By Individuals with Limited English Pro?ciency Under Section 1557 of the ACA 10/27/16) 3. Why did OCR rely on the ACS 5-year estimates rather than the 1-year estimates? Updated 1-31-17 OCR used the 5-year estimates (which average five years of data) rather than the 1-year estimates (which represent one year of data). This choice best balanced the currency of the estimates with their reliability and stability. In analyzing small populations, such as some LEP populations, a data source that averages ?ve years of data is more reliable and stable than a source that includes only one year of (OCR FAQs FAQs to Accompany the Estimates of at Least the Top 15 Languages Spoken By Individuals with Limited English Pro?ciency Under Section 1557 of the ACA 10/27/16) 1341 2017-?01441 4. What data did OCR use to compile its estimates of the top languages spoken by individuals with LEP for each of the U.S. Territories, other than Puerto Rico? For the US. Territories other than Puerto Rico, OCR used the data available from the US. Census Bureau, 2010 Census of Population and Housing.ji_v] OCR used this data source instead of the ACS because the ACS does not include data on the US. Territories, other than Puerto Rico. The language data available from the 2010 Census of Population and Housing for the US. Territories do not allow for a one-to-one comparison to the data available from the Bureau?s ACS for the 50 States, the District of Columbia, and Puerto Rico. In contrast to the Bureau?s ACS data estimating the number of individuals who speak non-English languages who speak English less than ?very well,? the data available for Guam, the Commonwealth of Northern Mariana Islands, and American Samoa show the number of individuals who speak a non-English language. These estimates do not indicate how many individuals who speak a non-English language also speak English and whether that English-speaking ability is limited. The language estimates available for the US. Virgin Islands show individuals who speak a non-English language who speak English ?not well." These estimates do not indicate how many individuals speak a particular non- English language who also speak English less than ?very well." (OCR FAQs FAQs to Accompany the Estimates of at Least the Top 15 Languages Spoken By Individuals with Limited English Pro?ciency Under Section 1557 of the ACA 10/27/16) 5. Did OCR make any technical adjustments to the data? For example, how did OCR address the fact that even the detailed 2013 ACS 5-year estimates by State contain information on language groups, as opposed to individual languages? Updated 1-31-17 In compiling its list for covered entities? use in implementing OCR made two main types of technical adjustments to the data OCR used. First, OCR omitted languages from the detailed language tables that still represented a language group rather than a single language or list of single languages for which covered entities could identify a speci?c language in which to provide a translated tagline in implementing This technical adjustment resulted in the omission of language groups, such as ?African? and ?Mayan language,? from list. Second, OCR omitted any spoken languages that do not have a written equivalent in which a translated tagline could be provided. This technical adjustment resulted in the omission of speci?c languages, such as Crow, Dakota, and Inupik, from list. These technical adjustments made by OCR are limited to the provision of this particular resource. Consequently, the omission from this speci?c resource of language groups such as ?African? and ?Mayan language? does not relieve a covered entity from the separate obligation to take reasonable steps to provide meaningful access to an individual with LEP whose primary language for communication is a specific African or Mayan language. Similarly, the omission from this specific resource of spoken languages that do not have a written equivalent does not relieve a covered entity from the separate obligation to take reasonable steps to provide meaningful access to an individual with LEP whose primary language for communication is a spoken language that does not have a written equivalent. (OCR FAQs FAQs to Accompany the Estimates of at Least the Top 15 Languages Spoken By Individuals with Limited English Pro?ciency Under Section 1557 of the ACA 10/27/16) 1342 2017-?01442 6. Why do some of the States on list have more than 15 languages listed? Four States (Colorado, Maryland, Rhode Island, and Virginia) and the District of Columbia have 17 languages listed because the detailed 2013 ACS language tables identify an estimate of language speakers for a grouping of three languages - Kru, Ibo, and Yoruba. The detailed ACS language estimates do not further disaggregate the number of individuals speaking English less than ?very well? who speak Kru, Ibo, and Yoruba, respectively. Although all three languages are grouped as one entry on the detailed 2013 ACS 5-year language tables with one combined estimate of language speakers, OCR counted each of these three languages separately because they are distinct languages. As a result, these four States and the District of Columbia have 15 estimates displayed but more than 15 languages listed. OCR recommends that covered entities that rely on list in implementing and that serve individuals in these States or the District of Columbia post taglines in 17 languages. This recommendation is informed by the purpose underlying the ACA to expand access to health care, reduce barriers, and address health disparities. (OCR FAQs FAQs to Accompany the Estimates of at Least the Top 15 Languages Spoken By Individuals with Limited English Proficiency Under Section 1557 of the ACA 10/27/16) 7. In list, why are there significantly fewer than 15 languages listed for each of the US. Territories other than Puerto Rico? For instance, only one language is listed for Guam. Updated 1-31-17 OCR has listed fewer than 15 languages for the US. Territories other than Puerto Rico because the data OCR used to estimate the languages spoken by individuals with LEP in the US. Territories other than Puerto Rico identify a mere handful of languages or language groups. Using Guam as an example, the table of estimates for ?Language Spoken at Home, Frequency of English Usage, and Sex by Ethnic Origin or Race" from the 2010 Census of Population and Housing provides data on the number of individuals in Guam who speak one language (Chamorro) and the four language groups: ?Philippine languages," ?Other Paci?c Island languages,? ?Asian languages,? and ?Other Because the language groups listed are not further disaggregated to identify the specific languages into which a tagline or other materials could be translated, OCR made technical adjustments to omit the aggregated language groups. Consequently, the only individual language estimated to be spoken by individuals with LEP in Guam that OCR could identify for inclusion in this speci?c resource is Chamorro. Covered entities operating health programs or activities that serve individuals in the US. Territories may be in a better position to identify speci?c languages spoken by individuals with LEP in which to provide translated taglines to meet their obligations under The technical adjustments made by OCR are limited to the provision of this particular resource. Consequently, the omission from this speci?c resource of language groups, such as ?Philippine languages," ?Other Paci?c Islands languages," and ?Asian languages? for Guam, does not relieve a covered entity that serves individuals in Guam through a health program or activity from the separate obligation under ?92.201 to take reasonable steps to provide meaningful access to an individual with LEP whose primary language for communication is not shown on list. (OCR FAQs FAQs to 1343 2017-?01443 Accompany the Estimates of at Least the Top 15 Languages Spoken By Individuals with Limited English Pro?ciency Under Section 1557 of the ACA 10/27/16) 8. Some languages listed in the table that OCR has made available have more than one spoken or written dialect, which means that the grammar, vocabulary, pronunciation, or usage may differ for the same language. For these languages, into which dialects did OCR translate its sample taglines and other materials? For the following languages with more than one dialect, OCR translated its sample taglines and other materials into the dialects as follows: . For Spanish, materials are translated into neutral Spanish for the United States. For Chinese, materials are translated into traditional Chinese. For French Creole, materials are translated into Haitian Creole. For French, materials are translated into the European dialect. For Portuguese, materials are translated into the European dialect. For Persian, materials are translated into Farsi. For Cushite, materials are translated into Oromo. For Serbo-Croatian, materials are translated into Serbian. For Syriac, materials are translated into Assyria. For Kru, materials are translated into Bassa. For Micronesian, materials are translated into Pohnpeian. For Bantu, materials are translated into Kirundi. For Sudanic, materials are translated into Fulfulde For Nilotic, materials are translated into Dinka. OCR FAQs to Accompany the Estimates of at Least the Top 15 Languages Spoken By Individuals with Limited English Pro?ciency Under Section 155 7 of the ACA 10/27/16) 9. The population with LEP may change in future years, affecting the languages spoken by individuals with LEP that are ranked within the top 15. Will OCR update its list of the top 15 languages in the future based on newer data? If so, will OCR release the sample tagline, sample notice of nondiscrimination, and sample nondiscrimination statement in languages not captured within the 64 languages in which OCR has already made such translated materials available? The Section 1557 rule does not specify when to revisit the languages triggered by the standard in As newer data from the Bureau?s American Community Survey becomes available for the dataset entitled ?Language Spoken at Home by Ability to Speak English for the Population 5 Years and Older,? OCR will determine if and when the standard in triggers languages in addition to the 64 already triggered by this standard. When additional languages are warranted, OCR will make available the sample tagline, nondiscrimination notice, and nondiscrimination statement in the additional non-English languages. (OCR FAQs FAQs to Accompany the Estimates of at Least the Top 15 Languages Spoken By Individuals with Limited English Proficiency Under Section 1557 of the ACA 10/27/16) Applying the Tagline Requirement to Covered Entities that Operate Health Programs or Activities in More than One State Section 1557 and its implementing regulation (Section 1557) require a covered entity to inform individuals with limited English pro?ciency (LEP) about the availability of language assistance 1 344 Updated 1-31-17 2017-?01444 services by providing taglines. Taglines are short statements written in non-English languages that indicate the availability of language assistance services free of charge? Section of the regulation requires a covered entity to post taglines in ?at least the top 15 languages spoken by individuals with limited English pro?ciency of the relevant State or States? in significant publications and communications, in physical locations, and in a location accessible from the home page of the covered entity?s websitelzl For publications and communications that are significant and small-sized, requires taglines to be posted in ?at least the top two languages spoken by individuals with limited English pro?ciency of the relevant State or States.?l31 Nothing in the regulation bars entities from posting taglines in additional languages beyond those required by these standards. 1. How does the requirement to post taglines apply to a covered entity that operates a health program in more than one State, or that operates one health program with a multi-State service area? Updated 1-31-17 A covered entity that operates health programs or activities in more than one State, or that operates one health program or activity with a multi-State service area, may add together the number of individuals with LEP who speak the same language in the collective States served to determine the top languages required by In doing so, entities may use OCR's list of the top 15 languages spoken by individuals with LEP in each State, the District of Columbia, and each U.S. Territory For example, an entity that operates a health program or activity in Minnesota, North Dakota, and Wisconsin may add together the number of individuals with LEP who speak each of the non-English languages for each of these States using list. Based on the total, the covered entity would be able to rank the aggregated number of speakers for each language, and thus identify the top languages required by The table below illustrates this example, using the languages and estimates from OCR's list released August 2016. 1345 2017-?01445 MINNESOTA NORTH DAKOTA WISCONSIN AGGREGATED LIST LANGUA ESTIMA LANGUA ESTIMA LANGUA ESTIMA LANGUA ESTIMA 83,799 1,948 103,109 188,973 SH SH SH 2.HMON 24,584 2.GERMA 1,452 2.HMON 17,202 2.HMON 41,786 3.CUSHI 18,500 807 8,142 3.CUSHI 19,185 TE SE TE 13.241 4.CUSHIT 685 4.GERM 4. 18,871 MESE AN CHINESE 9,992 497 5. 6,583 15,889 SE MESE ARABIC MESE 6,463 6.BANTU 410 2,816 6.GERM 12,067 AN AN AN 5,053 331 7.KOREA 2,398 9,188 AN 8.AMHAR 4,395 245 2,151 6,820 IC AMESE 9.KAREN 4,045 243 9.PENN. 1,970 6,398 DUTCH 10.GERM 4,032 10.JAPAN 210 1,767 10.FREN 5,049 AN ESE AN CH 11.MON- 3,691 11.NEPAL 190 11.FREN 1,678 11.KORE 4,725 KHMER CH AN CAMBOD IAN 12. 3,251 12.FREN 184 1,666 12.AMHA 4,395 ARABIC CH RIC 13.FREN 3,187 13.KORE 181 1,472 13.KARE 4,045 CH AN 14.KORE 2,146 14.TAGAL 173 14.ALBA 1,460 14. MON- 3,691 AN OG NIAN KHMER CAMBOD IAN 15.TAGA 1,500 15. 170 15.TAGA 1,336 15.TAGA 3,909 LOG NORWEG LOG LOG IAN (OCR FAQs FAQs on Section 1557 of the Applying the Tag/ine Requirement to Covered Entities that Operate Health Programs or Activities in More than One State 10/27/16) 2. The ?aggregated list? column displays the estimated number of individuals with LEP who speak each respective language when that language falls within the top 15 languages spoken by individuals with LEP of MN, ND, or WI. In this example, there are 24 unique languages ranked among the top 15 languages spoken by individuals with LEP for Minnesota, North Dakota, and Wisconsin. Of the 24 languages, nine (in all capsthe States but are not in the top 15 when the languages spoken by LEP individuals in all three states are 1346 Updated 1-31-17 2017-?01446 combined. In this example, a covered entity would not be required under to include taglines in the nine languages in all caps because none are in the top 15 when the estimates from all three States are combined. (A covered entity, however, is still responsible for providing timely and accurate language assistance services, even for those languages for which taglines are not provided, when doing so is a reasonable step to provide meaningful access to an individual who is LEP.) [i1 (OCR FAQs FAQS on Section 1557 of the ACA: Applying the Tag/ine Requirement to Covered Entities that Operate Health Programs or Activities in More than One State 10/27/16) 3. Is a covered entity required to post taglines tailored for the State in which it has a physical location when that entity operates health programs or activities in more than one State? When a covered entity identifies the top 15 languages by aggregating populations with LEP, it may post taglines in the top 15 languages identified by its aggregated list in all required locations, documents, and websites. Covered entities may, however, choose to provide taglines in the top 15 languages spoken by individuals with LEP of each of the States in which the entity has a physical location. (OCR FAQs FAQs on Section 1557 of the ACA: Applying the Tag/ine Requirement to Covered Entities that Operate Health Programs or Activities in More than One State 10/27/16) 4. How does the tagline requirement in apply to a covered entity that operates health programs or activities nationwide and in the U.S. Territories? Under Section 1557, a covered entity serving individuals nationally may aggregate populations with LEP in all 50 States, the District of Columbia, and the US. Territories. OCR has used its estimates showing the languages spoken by populations with LEP by State to create a list for covered entities operating nationwide and in the US. Territories.161 This list is as follows: Spanish, Chinese, Vietnamese, Korean, Tagalog, Russian, Arabic, French Creole, French, Polish, Portuguese, Italian, German, Japanese, and Persian Covered entities may use this list or may instead calculate the top 15 languages spoken by individuals with LEP nationally through other reasonable methods. (OCR FAQS FA OS on Section 1557 of the ACA: Applying the Tag/ine Requirement to Covered Entities that Operate Health Programs or Activities in More than One State 10/27/16) 1347 Updated 1-31-17 2017-?01447 SOURCE DOCUMENTS Dates for all documents are the release dates [Items in red are additions since the previous update. Note: Starting in November, CMS has changed the way it released FAQs. Instead of releasing them as separate documents organized by subject matter, they have created a searchable database on the REG TAP website at form.php ?stakeholderview=v and identify FA 03 by number and date released rather than by subject area. Enrollment and Eligibility Enrollment FAQ #1 04/24/13 [updated 09/04/13] Enrollment FAQ #2 07/02/13 Enrollment FAQ #3 07/03/13 [updated 07/24/13] Enrollment FAQ #5 07/12/13 Enrollment FAQ #6 7/22/13 Enrollment FAQ #7 Premium Payment Redirect 09/17/13 Enrollment FAQ #8 Disabled Dependents, Wards, and Enrollment in the FFM 09/19/13 Enrollment FAQ #9 Medicare and the Marketplace 10/04l13 Enrollment Transaction and Companion Guide Webinar 02/13/13 Enrollment March 8th and 11th, 2013 [Note: there?s an attachment to this document that isn?t included here a chart of ?Identi?ers? in exchange transactions] 0 Enrollment and Payment Processing Webinar Series 02/27/13 [updated05/24/13] QHPs QHP Dental FAQ #1 05/13/13 [updated 05l31/13] QHP SHOP FAQ 05/21/13 SHOP FAQ #1 06/20/13 SHOP FAQ #2 07/05/13 SHOP FAQ #3 07/30/13 SHOP FAQ #4 08/28/13 SHOP FAQ #5 09/13/13 SHOP FAQ #6 10/2/13 [updated 10/31/13] QHP webinar series Plan Management Webinar 01/24/13 FAQ #1 04/08/13 FAQ #2 04/09/13 FAQ #3 04/11/13 FAQ #4 04/16/13 FAQ #5 04/18/13 FAQ #6 04/23l13 FAQ #7 04/24/13 FAQ #8 04/23/13 FAQ #9 4/20/13 [updated 05/03/13, updated 10/31/13] FAQ #10 5/2/13 [updated 5/10/13, updated 08/02/13] 1348 Updated 1-31-17 2017-?01448 FAQ #11 05/22/13 [updated 5/28/13] FAQ #12 06/28/13 FAQ #13 7/29/13 FAQ #14 09/04/13 Distributed Data Collection for RI and Server Distributed data collection for Reinsurance and Risk Adjustment FAQ #1 05/09/13 Distributed data collection for Reinsurance and Risk Adjustment FAQ #2 07/15/13 Distributed data collection for Reinsurance and Risk Adjustment FAQ #3 07/23/13 Distributed data collection for Reinsurance and Risk Adjustment FAQ #4 08/16/13 Distributed data collection for Reinsurance and Risk Adjustment FAQ #5 09/23/13 HHS-Operated Data Collection Policy FAQs 06/26/13 Other EIDM FAQ 04/03/2013 ASC X12 Exchange Related Payments (820) Implementation Guide 05/14/13 Payments FAQ #1 06/28/13 Payments FAQ #2 10/07/13 Agent/Broker FAQ 09/19/13 Insurance Standards Bulletin Series Model Language for Individual Market Renewal Notices 04/30/13 REGTAP FAQs Issued in Groups Plan Preview FAQs (06/30/14) PIanPreviewFAQs 063014 5CR 063014.pdf Note: CMS issued the same FAQs included in this document as separately numbered REGTAP FAQs on 06/30/14. The individual FAQs are numbered: 2447-2468, 2499, and 2470-2482) FAQs Regarding Medicare and the Marketplace (08/01/14) Medicare FAQ 5CR 080814.pdf Casework FAQs FAQs by HIM Issuers (09/18/14) FAQ HIM Issuers Part4 091814 50R 0918 14.pdf Data Submission for CSR Reconciliation (10/02/14) CSR Recon FAQ 5CR 100214.pdf Calculation of member months for the Cost-Sharing Reductions (CSRs) Reconciliation simplified methodology (1 1/21/ 14) 112114 50R 112114.pdf Frequently Asked Questions about Form 1095-A for Assisters (first issued 01/12/15; updated 02/09/15) FAQs for Handling Health Insurance Casework System (HICS) Casework (4/21/15) HICSCaseworkFAQs 042215 50R 042215.p df Risk Corridors and Medical Loss Ratio (MLR) Resubmissions for the 2014 Benefit Year (08/14/15) MLR ResubmissionFAQ 50R 081415.pdf 1349 Updated 1-31-17 2017-?01449 0 Risk Adjustment Charges FAQ (08/14/15) RAShortfallFAQ 50R 081415.pdf . FAQ: Re-adjudication of claims under the Cost-sharing Reduction Reconciliation Standard Methodology (08/25/15) CSR 5CR 082415.pdf . FAQs: Cost-Sharing Reduction Reconciliation Simplified Methodology (08/25/15) CSRRecon qv 50R 082415.pdf 0 Health Insurance Casework System (HICS) FAQs - August 2015 (08/31/15) HICSFAQs 5CR 083115.pdf QHP Certification Process FAQs #1 (09/29/15) CertProcessFAQ1 092515 5CR 092915.pdf QHP Certification Process FAQs #2 (09/29/15) CertProcessFAQ2 092515 5CR 092915.pdf QHP Certification Process FAQs #3 (09/29/15) CertProcessFAQ3 092515 50R 092915.pdf QHP Certification Process FAQs #4 (09/29/15) CertProcessFAQ4 092515 50R 092915.pdf 0 QHP Certification Process FAQs #5 (09/29/15) CertProcessFAQS 092515 5CR 092915.pdf . QHP Certification Process FAQs #6 (09/29/15) CertProcessFAQG 092515 5CR 092915.pdf . QHP Certification Process FAQs #7 (09/29/15) CertProcessFAQ7 092515 5CR 092915.pdf - QHP Certification Process FAQs #8 (09/29/15) CertProcessFAQB 092515 5CR 092915.pdf QHP Certification Process FAQs #9 (09/29/15) CertProcessFAQQ 092515 5CR 092915.pdf QHP Certification Process FAQs #10 (09/29/15) CertProcessFAQ1O 092515 5CR 092915.pdf 0 FAQ: Claims run-out deadline for Cost-sharing Reduction Reconciliation (09/30/15) CSRRecon FAQCIaimsRunOutDate 093015 v1 50R 100115.9df . FAQs: Dental Plan Preview and Plan Compare display (10/09/15) DentalPIanFAQ 100815 CR 100915.pdf 0 Dental Plan Preview and Plan Compare Display Frequently Asked Questions (10/09/15) DentalPIanFAQ 100815 CR 100915.pdf . Issuer Outreach Frequently Asked Questions (FAQ) #1 (10/27/15) IssuerOutreachFAQ1 102715 50R 102715.p df Issuer Outreach Frequently Asked Questions (FAQ) #2 (10/27/15) IssuerOutreachFAQ2 102715 5CR 102715.p df Enrollment FAQs (10/28/15) 0713 0720 15 5CR 102815.pdf . FAQs on Reconciliation of the Cost-Sharing Reduction Component of Advance Payments for Benefit Years 2014 and 2015 (FAQS 1350 Updated 1-31-17 2017--01450 CSRRecon FAQs v1 50R 022416.pdf (Note - these FAQs also were released sing/y in the REG TAP database) 0 FAQs on Reconciliation of the Cost-Sharing Reduction (CSR) Component of Advance Payments for Benefit Years 2014 and 2015 FAQ SET #2 :Accounting for non-issuer enrollee subsidies (03/08/11) CSR Recon FAQs 2 031116 5CR 031116.pdf 0 Risk Adjustment Payment Update for the 2014 Benefit Year (03/08/16) PaymentUpdateFAQ 5CR 030916.pdf 0 Summary of Benefits and Coverage (SBC) Related to Rate Filing and QHP Certification (03/11/16) . FAQs on Reconciliation of the Cost-Sharing Reduction (CSR) Component of Advance Payments for Benefit Years 2014 and 2015 (FAQ SET (03/23/16; updated 05/06/16) 0 Quality Improvement Strategy - Criterion 21a FAQ (03/30/16) QISCriterion21aFAQ 033016 5CR 033016.p df . Quality Improvement Strategy - 2 Consecutive Years FAQ (03/30/16) QISZConsecutiveYearsFAQ 033016 50R 03 3016.9df 0 Quality Improvement Strategy - Provider Enrollee Incentives (03/30/16) 033016 5CR 033016.pdf 0 Quality Improvement Strategy - Naming Convention FAQ (03/30/16) QISNaminqunventionFAQ 033016 5CR 03 3016.pdf 0 Quality Improvement Strategy - HIOS Upload FAQ (03/30/16) QISNaminqunventionFAQ 033016 50R 03 3016.9df - Quality Improvement Strategy QIS Updated 2016 Guidance FAQ (03/30/16) QISUpdated2016GuidanceFAQ 033016 v1 5 CR 033016.pdf 0 FAQs on Reconciliation of the Cost-Sharing Reduction (CSR) Component of Advance Payments for Benefit Years 2014 and 2015 (FAQ SET (04/19/16; updated 05/06/16) CSRRecon FAQs 6 041916 v1 50R 041916. p_df CSRRecon FAQs 6 041916 5CR 050616.pdf 0 FAQs on Quality Improvement Strategy (QIS) 04/15/16 QISZCriterion21 FAQ 041316 50R 041516 and QISZCriterion24eFAQ 033016 v1 50R 0415 16.pdf Enrollment FAQs 1095-A (05-17-16) Form1095AFaqs 051716 5CR 051716.pdf . FAQs on Cost-sharing Reduction Component of Advance Payments for Bene?t Years 2014 and 2015 (Set (05/03/16) CSRRecon FAQs 7 050316 50R 050316.pdf 0 FAQs on Cost-sharing Reduction Component of Advance Payments for Benefit Years 2014 and 2015 (Set (05/09/16) 1351 Updated 1-31-17 2017-?01451 0 QHP Provider Directory Requirements and OIG List of Excluded Individuals and Entities (05-20-16) ProvDirOlGExList 5CR CSRRecon FAQs 8 050916 5CR 050916.pdf 0 FAQs on Health Insurance Market Reforms and Marketplace Standards (05-26-16) WaitianeriodFAQ 5CR 052616.pdf 0 Alternative Schedule for Payment of Charges for Reconciliation of the Cost-sharing Reduction Portion of Advance Payments for the 2014 and 2015 Bene?t Years (06/17/16) CSRRecon paymentplanFAQ 5CR 061716.pdf . REGTAP DDC for RI RA Edge Server 2015 Archive Questions 07/14/16 0 FAQ regarding Agents and Brokers (including Web-brokers) and Application Fees (07/18/16) FAQABAppIicationFees 50R 071816.pdf 0 FAQ Regarding Agents and Brokers (Including Web-brokers) and Federally-facilitated Marketplace (FFM) Online Consumer Functionality (07/18/16) FAQABConsumerFunctionaIity 5CR 071816. 0 FAQ regarding Agents and Brokers (Including Web-brokers) and Federally-facilitated Marketplace (FFM) Online Enrollment Functionality (07/18/16) SC 071816.pdf 0 FAQ Regarding FFE User ID Submission (07/18/16) FAQFFEUserIDSubmission 5CR 071816.pdf QHP Enrollment Partner FAQ (12/06/16) Enrollment Partner FAQ 120616 v1 5CR 1 20616.9df - Quality Rating System (QRS) FAQ (12/06/16) QRSDisclaimerFAQ 120616 50R 120616.pdf 0 FAQs on Agent/Broker Compensation and Discriminatory Marketing Practices (12/16/16) Compensation and Descriminatory Marketinq Practices FAQs 5CR 122116.pdf . Marketplace Learning Management System (MLMS) Plan Year 2017 FAQs (01/12/17) PY2017 011217 5CR 011217.pdf 0 Quality Rating System FAQ (01/06/17) QRSDisclaimerFAQ 010617 vl 5CR 010617.pdf CMS FAQs 0 State Evaluation of Plan Management Activities of Health Plans and Issuers (02/20/13) 2013.9df CO-OP Program (03/08/12) Opportunities/coop foa faq.htm 0 Use of Exchange for Ancillary Products (03/29/13) 0 Essential Community Providers (05/13/13) 1352 Updated 1-31-17 2017-?01452 0 Assessment Fees (07/10/13) FAQs/Downloads/7 10 13-Fee Assessment FAQ mc.pdf 0 Health Insurance Marketplaces (07/29/13) . Health Insurance Marketplaces and Income Verification (08/05/13) 0 Members of Congress and staff Accessing Coverage through Exchanges (Marketplaces) (09/30/13) 0 Shared Responsibility Provision (10/28/13) 0 Third Party Payment of Premiums for QHPs in the Marketplaces (11/04/13) 1- 04-2013.pdf Reinsurance Enrollment Count (11/08/13) 1-08-2013.pdf . Choice of Methodology for CSR Reconciliation (12/13/13) methodoloqy-qa-12-13-2013.pdf EHB FAQ (02/17/12) 508.9df State-based Marketplaces Annual Reporting Tool (SMART) (12/30/13) . Affordable Care Act Implementation FAQs (Set of 18) (01/09/14) [Note these are the same as the DOL FAQs released on the same day: Part (01/09/14) (see below) 0 Risk Adjustment Implementation Issues (not dated) Resources/risk adjustment implementation 0 Health Insurance Market Reforms (not dated) Sheets-and-FAQs/qa hmr.htm 0 Annual Limit Waivers (not dated) 0 Young Adults and the ACA (not dated) child faq.htm 0 Improving Health Insurance Protections for Students (not dated) FAQs/student healthinsurance faqs.htm 0 Third Party Payments of Premiums for QHPs in the Marketplaces (02/07/14) Outreach by Medicaid Managed Care contractors and Health Insurance Issuers to Former Enrollees . The Use of 1311 Funds and No-cost Extensions (2/27/14) extension-faqs-3-14-14.pdf 1353 Updated 1-31-17 2017--01453 0 CMS Bulletin to Marketplaces on Availability of Retroactive Advance Payments of the Premium Tax Credit and Cost Sharing Reductions in 2014 Due to Exceptional Circumstances, and Related SHOP Issues - Frequently-Asked Questions (03/14/14) 0 Risk Corridors and Budget Neutrality (4/11/14) 04-11-2014.Qdf Casework (4/18/14) CaseworkFAQs 041814 5CR 041814.pdf . Cost-Sharing Reductions for Contract Health Services (05/09/14) FAQs/Downloads/CSRs and Contract Health Services QA.pdf Reinsurance Contributions Process (05/22/14) . Health Insurance Market Reforms and Marketplace Standards (05/16/14) QHPs and Guaranteed Availability Standards (6/3/14) FAQs/Downloads/faq on and quaranteed availability 6314.pdf 0 Essential Community Providers (6/12/14) 0 Uniform Modification and Plan/Product Withdrawal FAQ (06/15/15) and-plan-wd-FAQ-06-15-2015.pdf . FAQs on Casework (6/17/14) Casework FAQs 061714 v1 5CR 061714.pd 0 FAQs on Casework: (08/28/14) CaseworkFAQsZ 5CR 082814.pdf Note: These FA 03 were also released separately on 08/28/14 as FAQs #s 4262 - 4265 0 FAQs on the use of 1311 Funds, Project Periods, and Updating the cost Allocation Methodology (9/19/14) FAQs/Downloads/FAQ 1311 proiect FAQs periods.pdf 0 Frequently Asked Questions (FAQs) regarding Reporting Certain Incidents CMS under the 2015 QHP Certification Agreement and Privacy and Security Agreement (2015 QHP Agreement (11/12/13) Reportinq Security Incidents 50R 111214.pd I [Also issued as REGTAP FAQs 7214, 7215, and 7216] . FAQs on Health Insurance Market Reforms and Wellness Programs (04/16/15) Flexibilities for State-based SHOP Direct Enrollment - Frequently-Asked Questions (FAQs) (06/01/15) 0 FAQs on the Clarification of the Use of 1311 Funds for Establishment Activities (06/08/15) 1354 Updated 1-31-17 2017-?01454 0 Uniform Modification and Plan/Product Withdrawal FAQ (06/15/15) plan-wd-FAQ-06-15-2015.pdf 0 Frequently Asked Questions on State-based Marketplace Options for Implementing Exemptions from the Shared Responsibility Payment (07/28/15) Processinq-FAQ-7-21-15.pdf 0 Summary of Benefits and Coverage Online Posting of Policy and Certi?cate of Coverage Documents (09/08/15) . Frequently Asked Questions (FAQ) Regarding Agents and Brokers Operating in the SHOP Marketplace (09/18/15) 0 Frequently Asked Questions (FAQ) Regarding the FFM Employer Notice Program (09/18/15) . Periodic Data Matching in the Federally-facilitated Marketplaces (Marketplaces) FAQ (09/18/15) O/Resources/Fact-Sheets-and- . Frequently Asked Questions on the Impact of PACE Act on State Small Group Expansion (10/19/15) Expansionpdf updated 12-17-15 12-17-15.pdf 0 Frequently Asked Question regarding the applicability of the Minimum Acceptable Risk Standards for Exchanges (MARS-E) 2.0 to Quali?ed Health Plan (QHP) issuers(10/23I15) final 102315.pdf . FAQs on the 2017 Moratorium on Health Insurance Provider Fee (02-29-16) FAQs/Downloads/FINAL 9010 FAQ 2-29-16.pdf 0 FAQs on the Consumer Operated and Oriented Plan (CO-OP) Program (01/27/16) Questions-FinaI-1-27-16.pdf INCARCERATION AND THE MARKETPLACE FAQs (05/03/16) 0 Auto Re-enrollment for QHPs no longer available in the Marketplace: External FAQs (06/24/16) Re-issued 08/08/16) 0 Annual Income Threshold Adjustment FAQ (07/21/16) Datamatchinq-FAQ-7-21-16.pdf 0 on the Summary of Benefits and Coverage Applicability Date (07/08/16) 07072016-finaI-MM-508.pdf 0 FAQs on Health Insurance Marketplace Standards (10/14/16) 1355 Updated 1-31-17 2017--01455 0 Second Lowest Cost Silver Plan Technical FAQs (12/16/16) 0 FAQ on Compliance Safe Harbor for Issuers Affected by the Extension of the Enrollment Deadline to December 19, 2016 (12/23/16) FAQs/Downloads/FAQ on Compliance Safe Harbor Extension 122316.pdf 0 Machine Readable Data FAQs (01/19/17) CMS Technical Assistance Website - In December 2014, we found a new CMS resource for FAQs that includes one new set of FAQS and a number of older FAQs documents, at the website 0 Eligibility and Enrollment Resources about Re-enrollment (December 2014) . Shared Responsibility Payment and Exemptions Information FAQs on Exemptions (09/30/14) 0 Eligibility and Enrollment Resources - on the length of marketplace coverage (7-16-14) marketplace-coveraqepdf 0 Appeals Help - Timely Eligibility Appeals Pending on or Requested after March 31, 2014 (no date) 0 Application Process Assistance Miscellaneous FAQs (no date) Assister Training Frequently Asked Questions (no date) . Certified Application Counselor (CAC) Certification and Training (01/17/14) 0 Common Questions and Answers on Designation of Certification Application Counselor (CAC) Organizations in FFMs (no date) SHOP FAQs - (no date) for Assisters about Form 1095-A Second Lowest Cost Silver Plan? Issue (February 2015) planpdf CMS Regulations and Guidance FAQs site: In June 2015, we found yet another CMS resource for FAQs at We found three new sets of FAQs and many older sets of FAQs as well. . CCIIO Guidance - Questions and Answers Regarding Rate Review Requirements (05/13/15) CCIIO Technical Guidance (CCIIO 2015?0001): Questions and Answers 1356 Updated 1-31-17 2017--01456 Regarding the Medical Loss Ratio (MLR) Reporting and Rebate Requirements (05/27/15) . Spring 2016 Periodic Data Matching in the FFM FAQ (05/16/16) This is an update of a September 18, 2015 FAQ, and is discussed under the updated FAQs section, above. OLDER Sets of FAQs from this site: . Shared Responsibility Provision Question and Answer (03/31/14) 0 Frequently Asked Question on Coverage of Same-Sex Spouses (03/14/14) . Frequently Asked Questions on the Bulletin Entitled The Sale of Individual Market Policies to Medicare Beneficiaries Under-65 Losing Coverage Due to High Risk Pool Closures (01/31/14) Risk-PooI-FAQs.pdf . Questions and Answers on Options Available for Consumers with Cancelled Policies (01/13/14) - Questions and Answers Regarding the Medical Loss Ratio Reporting and Rebate Requirements (12/30/13) 0 Frequently Asked Questions on Standard Notices for Transition to ACA Compliant Policies (11/21/13) 0 Questions and Answers Regarding the Medical Loss Ratio Reporting and Rebate Requirements (07/02/13) - Questions and Answers Regarding the Requirement that Issuers of Certain Health Insurance Coverage sold as Fixed Indemnity Insurance submit an annual Medical Loss Ratio (MLR) report to the Secretary (05/30/13) 5-30-2013pdf - Questions and Answers Regarding the Medical Loss Ratio Reporting and Rebate Requirements (04/05/13) - Questions and Answers on Consumer Operated and Oriented Plan (CO-OP) Program Contingency Fund (04/04/13) . Frequently Asked Questions on Exchanges, Market Reforms, and Medicaid (12/10/12) - Questions and Answers Regarding the Medical Loss Ratio Reporting and Rebate Requirements (07/17/12) 07172012.pdf 1357 Updated 1-31-17 2017-?01457 0 Questions and Answers Regarding the Medical Loss Ratio Reporting Requirements (05/30/12) 30-2012.pdf - Questions and Answers Regarding the Medical Loss Ratio Reporting Form (05/24/12) 5-24-2012.pdf . Questions and Answers Regarding the Medical Loss Ratio Regulation (04/20/12) 0 Questions and Answers Regarding the Medical Loss Ratio Interim Final Rule (02/10/12) Frequently-Asked-Questions from Employers Regarding Automatic Enrollment, Employer Shared Responsibility, and Waiting Periods (02/09/12) faq bulletin 2 9 12 ?nalpdf . State Exchange Implementation Questions and Answers (11/29/11) and A:pdf 0 Questions and Answers Regarding the Medical Loss Ratio Interim Final Rule (07/18/11) guidancepdf Anti-Dumping Provisions Related to the Pre-Existing Condition Insurance Plan Program (05/31/11) policy letter 7.pdf . Questions and Answers Regarding the Medical Loss Ratio Interim Final Rule (05/13/11) 20110513.pdf 0 Rate Review Student Health Plans FAQ (08/12/14) Guidance/Downloads/Rate Review Student Health Plans FAQ 20150812 Final.pdf 0 FAQs Regarding Crosswalk of Enrollees into Plans Offered by Other Issuers (09/02/16) 0 FAQ on Compliance Safe Harbor for Issuers Affected by an Increase in Enrollment for the 2017 Plan Year (09/16/16) 0 Frequently Asked Questions Regarding Veri?cation of Special Enrollment Periods (09/06/16) 0 FAQs on Health insurance Marketplace Standards (10/14/16) NOTE: CMS also has released separate FA 08 that focus on Medicaid-related ACA issues. 0 A listing of the separate FAQs documents can be found at It appears that these documents include over 600 separate FAQs. 1358 Updated 1-31-17 2017--01458 A searchable Medicaid-related FAQ database can be found at As with the REGTAP database, this site allows searches by text or by FAQ number. DOL FAQs Part I - 09/20/10 (implementation topics including compliance, grandfathered health plans, claims, internal appeals and external review, dependent coverage of children, out-of- network emergency services, and highly compensated employees. Part II 10/08/10 (grandfathered health plans, dental and vision bene?ts, rescissions, preventive health services, and ACA effective date for individual health insurance policies) Part 10/12l10 (the exemption for group health plans with less than two current employees) Part IV - 10/29/10 (grandfathered health plans) Part 12/22/10 (A variety of ACA implementation topics, the HIPAA nondiscrimination and wellness program rules, and the Mental Health Parity and Addiction Equity Act of 2008) Part VI- 04/01/11 (grandfathered health plans) Part VII- (SBC and Uniform Glossary requirements of PHS Act ?2715 and the Mental Health Parity and Addiction Equity Act of 2008) Part 03/09/12 (SBC requirements) Part IX- 05/11/12 (SBC requirements) Part 08/07/12 (SBC requirements) Part Xl- 01/24/13 (employer notice of coverage options, HRAs, disclosure of information related to ?rearms, employer group waiver plans supplementing Medicare Part D, ?xed indemnity insurance and payment of PCORI fees) Part 02/20/13 (imitations on cost-sharing under the ACA 02/20/13) Part (expatriate health plans) Part XIV- 04I23I13 (SBC requirements Note: Some of the guidance in FAQs Parts IX, and has been superseded by guidance contained in FAQs Part XIV.) Part XV- 04/29/13 (annual limit waiver expiration date based on a change to a plan or policy year, provider non-discrimination, coverage for individuals participating in approved clinical trials and transparency reporting) Part XVI - 09/04/13 (Notice of coverage options available through exchanges, 90-day waiting period limitation) Part XVII (ACA Implementation and Mental Health Parity Implementation) Part 01/09/14 (Coverage of preventive services, limits on cost-sharing, expatriate health plans, wellness programs, ?xed indemnity insurance, and mental health parity) DOL Technical Release 2013-03 ?Application of Market Reform and other Provisions of the Affordable Care Act to HRAs, Health FSAs, and Certain other Employer Healthcare Arrangements,? 09/13/13 DOL Technical Release 2012-01 ?Automatic Enrollment, Employer Shared Responsibility, and Waiting Periods, 02/09/12 Part XIX - (DOL model notices, limits on cost?sharing, coverage of preventive services, FSAs, SBCs) Part XX 7/16/14 ?Disclosure with Respect to Preventive Services" Part XXI - 10l10/14 Limitations on Cost-sharing Under the .pdf 1359 Updated 1-31-17 2017-?01459 0 Part XXII - 11/06/14 (Compliance with Premium Reimbursement Arrangements) Part - 02l13/15 (Excepted Benefits) Part XXIV 03/30/15 (Summary of Benefits and Coverage) 0 Part XXV - 04l16/15 Wellness Programs 0 Part XXVI 05/11/15 Coverage of Preventive Services . Part XXVII - 05/26/15 Limitations on Cost-sharing under the ACA 0 Part 08/11l15 Future Tri-Department Transparency Reporting Rulemaking for Coverage 0 Part XXIX - 10/23/15 - FAQs about ACA and Mental Health Parity Implementation 0 Part - 03/11/16 - Summary of Bene?ts and Coverage . Part 31 04/20/16 - Preventive Coverage . Part 32 - 06/21/16 Notice of Coverage Options?COBRA and Health Insurance Marketplace Coverage FAQs/Downloads/FAQS-32 Final-6-21-16.pdf 0 Part 33 - FAQs About ACA Implementation - Premium Reduction Arrangements for Student Health Plan Coverage (October 21, 2016) 0 Part 34 - FAQS ABOUT AFFORDABLE CARE ACT IMPLEMENTATION PART 34 AND MENTAL HEALTH AND SUBSTANCE USE DISORDER PARITY IMPLEMENTATION (October 27, 2016) 0 Part 35 - FAQs on ACA Implementation - Special Enrollment for Group Health Plans (12/20/16) . Part 36 - COVERAGE OF PREVENTIVE SERVICES (01/12/17) . Part 37 - HEALTH REIMBURSEMENT ARRANGEMENTS (01/12/17) HHS Office of Civil Rights FAQs [Re: Sec. 1557 Nondiscrimination Requirements] 0 General Questions About Section 1557 (10/27/16) . Frequently Asked Questions to Accompany the Estimates of at Least the Top 15 Languages Spoken by Individuals with Limited English Proficiency under Section 1557 of the Affordable Care Act (ACA) (10/27/16) . Frequently Asked Questions on Section 1557 of the Affordable Care Act (ACA): Applying the Tagline Requirement to Covered Entities that Operate Health Programs 1360 Updated 1-31-17 2017--01460 or Activities in More than One State (10/27/16) taqline/index.htm 1361 Updated 1-31-17 2017-?01461 From: HHS Secretary Sent: 27 Feb 2017 18:50:23 +0000 To: HHS Secretary Ann John Carla Wade (CTR);Keith Nahigian;Kouzoukas, Demetrios Lance Matt Ryan Brian Caitlin B. Randy Nina Kristin Paula Amanda Subject: Daily Health Care Reform Meeting NOTE: The Secretary will not be here but Kris will run the meeting on his behalf. 2017-?01462 From: Khosla, Jay (Finance) Sent: 3 Feb 2017 19:01:33 +0000 To: Khosla, Jay (Finance) Cc: Prater, Mark (Finance);Campbell, Chris (Finance);Kuskowski, Jennifer (Finance) Subject: Chairman Hatch on Obamacare Repeal Importance: High Happy Friday all First and foremost, apologies for sending you all more emails on a Friday afternoon. After 8 years of Chairman Hatch?s clear position on Obamacare, thought we would have moved past restatements but DC has a funny way of losing itself in a sea of analogies. Since, time is a very valuable commodity in all of our lives and in a sincere effort to save you all time on calls and emails, we thought this would be a much more efficient. Here is the Chairman in his own words: believe that we need to repeal Obamacare immediately, and provide for a stable transition We need to advance replacement policies in tandem with the repeal process.? If folks need even more clarity, please free to look at statements from the last 8 years on his website. Now that we have put that past us, we hope you have a great Superbowl weekend. To get you ready, here is the perfect hype video we can all get behind highlights of the Puppy Bowl XII: From: Rep-Press, Finance (Finance) Sent: Friday, February 03, 2017 12:23 PM To: Breinig, Amelia (Finance) Subject: Republicans Committed to Repealing Replacing Obamacare: A Look at What They?re Saying Importance: High ITED STATES SENATE COMMITTEE ON FINANCE U.S. SENATOR ORRIN HATCH (R-UT), CHAIRMAN I A 2017-?01463 FOR IMMEDIATE RELEASE CONTACT: Aaron Fobes/Julia Lawless February 3, 2017 (202) 224-4515 Republicans Committed to Repealing Replacing Obamacare: A Look at What They? re Saying As Republicans continue to work towards righting the many wrongs of Obamacare, one thing remains clear: Republicans are committed to repealing and replacing the law. Republicans continue to work to produce a bill that will repeal the law and include as many replace policies as possible given the constraints of the reconciliation process. At the same time, Republicans are working to ensure a responsible transition period to move away from the harms of Obamacare and toward responsible reforms that will put patients first and address costs. As Senate Finance Committee Chairman Orrin Hatch (R-Utah) said in a speech before the U.S. Chamber of Commerce this week, believe that we need to repeal Obamacare immediately, and provide for a stable transition We need to advance replacement policies in tandem with the repeal process.? (Hatch Unveils Finance Committee Agenda for 115th Congress, February 1, 2017) -Here?s a look at what others are saying: Vice President Mike Pence: ?We are absolutely committed to follow through on President Trump '5 directive to repeal and replace (Washington Examiner: Pence: 'We are absolutely committed' to Obamacare repeal? February 3, 2017) Senate Majority Leader Mitch McConnell: ?Repealing and replacing Obamacare is a big challenge. It isn?t going to be easy. Nonetheless, we?re committed to fulfilling our promise to the American people and we will.? (The Senate Now Has the Tools to Repeal Obamacare, January 12, 2017) House Speaker Paul Ryan: ?This law is collapsing?we have to rescue people from the failure of this law. And that is why, step by step, we are going to keep our promise to repeal and replace this law. 50 that consumers can do better, and so they can have more choices.? (House Progress on Regulatory and Health Care Reform: Remarks from Weekly Press Briefing, February 2, 2017) House Ways and Means Chairman Kevin Brady: ?Ways and Means Republicans are focused on providing immediate relief and peace of mind to all of the workers, families, and small businesses that have been forced to buy insurance they do not like and cannot the process of repealing and replacing Obamacare moves forward, it is critical that we not lose sight of the reason we are doing this in the first place. It is to help all [individuals, families, and small business owners] who are hurting because of the law?s broken promises. And it?s to ensure 2017-?01464 that all Americans have access to high-quality, affordable healthcare options that meet their needs.? (Chairman Brady Op-Ed in Washington Examiner: Putting patients back in control of healthcare, 2017-?01465 From: Sent: 7 Mar 2017 14:31:56 +0000 To: Ann John Carla Jessica Wade (CTR);Keith;Kouzoukas, Demetrios Lance Matt Ryan Brian Caitlin B. Randy Nina Kristin Amanda John K. Subject: Daily Health Care Reform Meeting NOTE: Participants to include staff from Legislative Affairs and Public Affairs, and appropriate policy personnel. Lance Leggitt determines the appropriate staff for inclusion. 2017-?01466 From: Sent: 7 Mar 2017 14:31:39 +0000 To: Ann John Carla Jessica Wade (CTR);Keith;Kouzoukas, Demetrios Lance Matt Ryan Brian Caitlin B. Randy Nina Kristin Amanda John K. Subject: Daily Health Care Reform Meeting NOTE: Participants to include staff from Legislative Affairs and Public Affairs, and appropriate policy personnel. Lance Leggitt determines the appropriate staff for inclusion. 2017-?01467 From: Twomey, John K. Sent: 28 Feb 2017 13:19:40 +0000 To: Twomey, John K.;Agnew, Ann John Carla Wade (CTR);Leggitt, Lance Matt Ryan Brian Randy Nina Kristin Paula Amanda Demetrios Subject: Daily Health Care Reform Meeting The Secretary has to go to the White House at 5:00 PM today so he asked to move up the daily health care reform meeting so he could participate. 2017-?01468 From: HHS Secretary Sent: 24 Feb 2017 16:30:46 +0000 To: HHS Secretary Ann John Kouzoukas Carla Wade (CTR);Keith Nahigian;Kouzoukas, Demetrios Lance Matt Ryan Brian Caitlin B. Randy Nina Kristin Paula Amanda Subject: Daily Health Care Reform Meeting 2017-?01469 From: HHS Secretary Sent: 13 Feb 2017 22:19:37 +0000 To: HHS Secretary John Paula Nina Ryan Matt Caitlin 8. Subject: Daily Health Care Reform Meeting 2017-?01470 From: Sent: 17 Mar 2017 13:07:50 +0000 To: Ann Jeffrey Sarah John Brady John Carla Jessica Wade (CTR);Kouzoukas, Demetrios Lance Matt Ryan Brian Caitlin B. Randy Diana Nina Kristin Paula Amanda John K. Subject: Daily Health Care Reform Meeting Attachments: Untitled, Untitled, Untitled, Untitled, Untitled 2017-?01471 From: Klimczak, Kate Sent: 22 Mar 2017 13:54:25 +0000 To: Klimczak, Kate Jen John Maggie Paula Heather Nina Wade Kristin Lance Mary-Sumpter Amanda Norris Janis Rachel Jessica Subject: Secretary Price House LHHS Appropriations Subcommittee Hearing Prep Session - Hearing Overview Strategy Attachments: Agenda3.22.17.docx, House LLHS Hearing Prep Memo.pdf, Enclosure A IEnclosure House LHHS Hearing Prep Papers 3.21.17 Enclosure Member Profiles.docx The meeting has been moved to 4pm; a meeting agenda is attached. Also included below are the hearing prep materials that went to the Secretary last night. He received a hearing memo, draft written testimony for review, brie?ng papers, and Member pro?les. 2017-?01472 Secretary Price House LHHS Appropriations Subcommittee Hearing Prep Session Hearing Overview Strategy Session March 4pm 4:30pm Agenda: 1. Hearing logistics 0 Hearing Structure Staffing needs Press De?nition of success Other Budget hearings 0000 11. Member Call Time 111. Testimony 0 Written testimony 0 Oral testimony IV. Guidance on hearing prep Brie?ng papers 0 sessions 0 AHCA Prep 0 Member Polling V. Hearing Strategy 0 OMB guidance on budget hearings Questions about speci?c cuts Ask from Members for commitments on speci?c programs Getbacks Tough QA Staff interaction 2017-?01473 r? .n ?1 DEPARTMENT OF HEALTH HUMAN SERVICES Of?ce of the Secretary ?Wm 0? a? Washington, DC. 20201 DATE: March 21, 2017 TO: Thomas E. Price, M.D., Secretary FROM: Jen Moughalian, Acting Assistant Secretary for Financial Resourcesqw CC: John Brooks Heather Flick Wade Horn Mary-Sumpter Lapinski Lance Leggitt Nina Schaefer Kristin Paula Stannard Amanda Street Maggie Wynne SUBJECT: Appropriations Hearing Preparation - INFORMATION Details House Labor/HHS Subcommittee Appropriations Hearing Date: Wednesday, March 29 Time: l0:00 am. Attendees: Jen Moughalian, Norris Cochran Overview On Wednesday, March 29th you are scheduled to testify before the House Appropriations Subcommittee for Labor, Health and Human Services, Education, and Related Agencies (?Labor/HHS?) on the President?s FY 2018 Budget Blueprint. We have prepared brie?ng materials for you based on key themes in the HHS chapter of the Budget Blueprint and current hot topics in health and human services policy, as well as issues of speci?c interest to Committee Members based on incoming letters and staff interaction. In this brie?ng book you will ?nd: . (MS) 0 Briefing papers on select policy issue areas; and 0 House Labor/HHS Appropriations Subcommittee Member Profiles. Your brie?ng papers are organized by issue area (HHS cross-cutting issues, public health, and human services). Prior to the hearing, ASFR will engage with subcommittee staff on potential topics and questions that may come up at the hearing (we refer to this as ?member polling?). Based on those conversations, ASFR will provide additional papers or talking points as needed. -1- 2017--01474 We currently have four brie?ngs scheduled to help you prepare for this hearing: Wednesday, March 22, 1 1:30am 12:00pm to discuss overall hearing strategy; Friday, March 24, 3 :30-4:3 0pm to answer any questions you have from the brie?ng book and conduct practice 0 Monday, March 27, 3:30-4:30pm to conduct practice and 0 Tuesday, March 28, 3:30-4:00pm to review member polling and address any ?nal concerns. We also have set aside time on your calendar on Monday, March 2'7th for you to make calls to all the members of the subcommittee. Reaching out to Members of Congress before your hearing allows you the opportunity to check in before the hearing and take the temperature of members. These calls are informal and may be placed personally or arranged through your scheduler. Committee Activity in the 115"l Congress Last week, the House Labor/HHS Subcommittee held a hearing entitled ?Investing in the Future?Early Childhood Education Programs at the Department of Health and Human Services.? There were no government witnesses. During that hearing, members expressed concern over the possibility of deep cuts to Head Start and the impacts those cuts would have to the current waitlist for Head Start programs. Members were also concerned that cuts to Early Head Start and Head Start would undermine the results experts hoped to see in those programs. Members also asked questions about Federal funding for Head Start and the Child Care Block Grant. Enclo ures A B. Brie?ng Papers C. 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In addition, the subcommittee oversees the Social Security Administration, Medicaid and Payment and Access Commission, Medicare Payment Advisory Commissions, and several other related, smaller agencies. Members in the 115th Congress Majority (8 Republicans) Minority (5 Democrats) Tom Cole, OK - Chairman Rosa DeLauro, CT - Ranking Member Mike Simpson, lD Lucille Roybal-Allard, CA Steve Womack, AK, Vice Chair Barbara Lee, CA Chuck Fleischmann, TN Mark Pocan, WI Andy Harris, MD Katherine Clark, MA Martha Roby, AL Nita Lowey, NY (ex of?cio) Jamie Herrera Bcutler, WA John Moolenaar, MI Rodney Frelinghuysen, NJ (ex of?cio) 2017-?01512 Majority REP. TOM COLE (R), CHAIRMAN 4th District of Oklahoma South central Norman, Lawton, part of Oklahoma City Residence: Moore Born: April 28, 1949; Shreveport, Louisiana Religion: Methodist Family: Wife, Ellen Cole; one child Education: Grinnell College, BA. 1971 (history); Yale U., MA. 1974 (British history); U. of Oklahoma, 1984 (19th Century British history) Military Service: None Career: Political consultant; party of?cial; congressional district director; professor First Elected: 2002 (8th term) Latest Election: 2016 General (69.63%) Political Highlights: Okla. Republican Party chairman, 1985-89; Okla. Senate, 1989-91; Okla. secretary of state, 1995-99 Committees: Appropriations (LHHS Chairman, Defense, Interior); Budget; and Ru] 2017-?01513 2017-?01514 REP. MIKE SIMPSON (R) 2nd District of Idaho East -- Pocatello, Idaho Falls, part of Boise Residence: Idaho Falls Born: Sept. 8, 1950; Burley, Idaho Religion: Mormon Family: Wife, Kathy Simpson Education: Utah State U., attended 1968-72 (pre-dentistry); Washington U. (M0.), D.M.D. 1977; Utah State U., BS. 2002 (pre-dentistry) Military Service: None Career: Dentist First Elected: 1998 (10th term) Latest Election: 2016 General (62.93%) Political Highlights: Blackfoot City Council, 1980-84; Idaho House, 1984-98 (speaker, 1992- 98) Committees: Appropriations (Energy-Water - chairman; Interior-Environment; Labor-HHS- Education) 2017-?01515 REP. STEVE WOMACK (R), 3rd District of Arkansas Northwest Fort Smith, Fayetteville Residence: Rogers Born: Feb. 18, 1957; Russellville, Arkansas Religion: Southern Baptist Family: Wife, Terri Womack; three children Education: Arkansas Tech, BA. 1979 (speech) Military Service: Ark. National Guard 1979-2009 Career: Securities broker; college ROTC program director; radio station manager; National Guard First Elected: 2010 (4?h term) Latest Election: 2016 General (77.32 Political Highlights: Rogers City Council, l983-84, 1997-98; mayor of Rogers, 1999-2010 Committees: Appropriations Defense; Financial Services); Budget 2017-?01516 REP. CHUCK FLEISCHMANN (R) 3rd District of Tennessee East Chattanooga, Oak Ridge Residence: Ooltewah Born: Oct. 1 1, 1962; Manhattan, New York City, New York Religion: Roman Catholic Family: Wife, Brenda Fleischmann; three children Education: U. ofIllinois, B.A.L.A.S. 1983 (political science); U. of Tennessee, JD. 1986 Military Service: None Career: Attorney First Elected: 2010 (44lh term) Latest Election: 2016 General (66.39%) Political Highlights: No previous of?ce Committees: Appropriations Energy Water; Homeland Security) 2017-?01517 REP. ANDY HARRIS (R) 1st District of Maryland Northeast and Eastern Shore Residence: Cockeysville Born: Jan. 25, 1957; Brooklyn, New York Religion: Roman Catholic Family: Widowed; ?ve children Education: U. of attended 1973-75; Johns Hopkins U., BA. 1977 (human biology), MD. 1980, M.H.S. 1995 (health ?nance management) Military Service: Navy Reserve 1988-2005 Career: Physician (Anesthesiologist) First Elected: 2010 (3rd term) Latest Election: 2016 General (66.99%) Political Highlights: MD Senate, 1999-2010 (Republican whip, 2003-06); Republican nominee for US. House, 2008 Committees: Appropriations (LHHS, Commerce, Justice, and Related Agencies) 2017-?01518 2017-?01519 REP. MARTHA ROBY (R) 2nd District of Alabama Southeast part of Montgomery, Dothan Residence: Montgomery Born: July 26, 1976; Montgomery, AL Religion: Presbyterian Family: Husband, Riley Roby; two children Education: New York U., BM. 1998 (music, business and technology); Samford U., JD. 200] Military Service: None Career: Lawyer First Elected: 2010 (3rd term) Latest Election: 2016 General (48.77%) Political Highlights: Montgomery City Council, 2004-] Committees: Appropriations (LHHS, Legislative Branch, Military Construction/VA); Benghazi Attack 2017-?01520 REP. JAMIE HERRERA BEUTLER (R) 3rd District of Washington, Southwest Washington Residence: Battle Ground Born: November 3, 1978; Glendale, CA Religion: Christian Family: Husband, Daniel Beutler; two children Education: University of Washington, BA. 2004 (Communications) Military Service: None Career: Congressional aide First Elected: 2010 (4th term) Latest Election: 2016 General Political Highlights: Congressional aide for Congresswomen Cathy McMorris Rodgers (R- WA), State Representative (R-WA, District l8) Committees: Appropriations Energy and Water; Financial Services) 2017-?01521 REP. JOHN MOOLENAAR (R) 4th District of Michigan, Midland, Mt. . Pleasant Residence: Midland Born: May 18, 1961; Midland, MI Religion: Christian Family: Wife, Amy Moolenaar; six children Education: Hope College, BS. 1983 (Chemistry); Harvard University, MPA 1989 Military Service: None. Career: Chemist, worked at Dow Chemical Company First Elected: 2014 (2rd term) Latest Election: 2016 General Political Highlights: State Representative District 98), Michigan House of Representatives; State Senator (R-MI, District 36), Michigan Senate Committees: Appropriations Financial Services; Legislative Branch) 2017-?01522 REP. RODNEY FRELINGHUYSEN (R) 11th District of New Jersey, North Central?eastern Morris Country, Wayne Residence: Harding Born: April 29, 1946; Manhattan, NY Religion: Episcopalian Family: Wife, Virginia; two children Education: Hobart College, BA. 1969 (American History) Military Service: Army, 1969 1971 Career: County board aide First Elected: 1994 (12th term) Latest Election: 2016 General Political Highlights: Morris County Board of Freeholders (I974 1983); New Jersey Assembly, 1983 1994 Committees: Appropriations, Chairman 2017-?01523 Minority REP. ROSA DELAURO (D) 3rd District of Connecticut - South -- New Haven, Milford Residence: New Haven Born: March 2, 1943; New Haven, Conn. Religion: Roman Catholic Family: Husband, Stanley Greenberg; three children Education: London School of Economics, attended 1962-63; Marymount College (N.Y.), BA. 1964; Columbia U., MA. 1966 (international politics) Military Service: None Career: Political activist; congressional and mayoral aide First Elected: 1990 (14?h term) Latest Election: 2016 General Political Highlights: No previous of?ce Committees: Appropriations (LHHS - ranking member; Agriculture) 2017-?01524 REP. LUCILLE ROYBAL-ALLARD (D) 40th District of California East Los Angeles; Downey Residence: Downey Born: June 12, 1941; Boyle Heights, Calif. Religion: Roman Catholic Family: Husband, Edward Allard; four children Education: California State U., Los Angeles, BA. 1965 (speech therapy) Military Service: None Career: Nonpro?t worker First Elected: 1992 (13?h term) Latest Election: 2016 General Political Highlights: Calif. Assembly, 1987-92 Committees: Appropriations Homeland Security ranking member) 2017-?01525 REP. BARBARA LEE (D) 13th District of California Northwest Alameda County -- Oakland, Berkeley Residence: Oakland Born: July 16, 1946; El Paso, Texas Religion: Baptist Family: Divorced; two children Education: Mills College, BA. 1973 U. of California, Berkeley, M.S.W. 1975 Military Service: None Career: Congressional aide First Elected: 1998 (9th full term) Latest Election: 2014 General (88.48%) Political Highlights: Calif. Assembly, 1990-96; Calif. Senate, 1996-98 Committees: Appropriations Military Construction-VA; State-Foreign Operations); Budget 2017-?01526 REP. MARK POCAN (D) 2nd District of Wisconsin, South?Madison Residence: Madison Born: August 14, 1964; Kenosha, WI Religion: Unspeci?ed Family: Husband, Philip Frank Education: University of Wisconsin, BA. 1986 (journalism) Military Service: None Career: Sign manufacturing company owner First Elected: 2012 (3ml full term) Latest Election: 2014 General Political Highlights: Dane County Board ofSupervisors, 1991-96; Wis. Assembly, 1999-2013 Committees: Appropriations Agriculture) :Ma Or. 2017-?01527 REP. KATHERINE CLARK (D) 5th District of Massachusetts, North and west Boston suburbs; ramingham Residence: Melrose Born: July 17, 1963; New Haven, Connecticut Religion: Protestant Family: Husband, Rodney Dowell; three children Education: St. Lawrence University BA. 1985 (history); Cornell University JD. 1989; Harvard University, M.P.A. 1997 Military Service: None Career: Attorney; state assistant attorney general First Elected: 2013 (2nd full term) Latest Election: 2016 General Political Highlights: Mass. House, 2008-1 1; Mass. Senate, 201 1-13 Committees: Appropriations Transportation-HUD) 2017-?01528 REP. NITA LOWEY (D) 18th District of New York Rockland and part of Westchester counties White Plains, Peekskill Residence: Born: July 5, 1937; Bronx, New York Religion: Jewish Family: Husband, Stephen Lowey; three children Education: Mount Holyoke College, BA, 1955-59 (political science) Military Service: None Career: State government aide; homemaker First Elected: 1988 (15?h term) Latest Election: 2016 General Political Highlights: N.Y. Assistant Secretary of State, 1985-87 Committees: Appropriations Ranking Member (State Foreign Ops - Ranking Member) 2017-?01529 From: Sent: 7 Mar 2017 14:33:47 +0000 To: W6) Ann John John Carla Jessica Wade (CTR);Kouzoukas, Demetrios Lance Matt Ryan Brian Caitlin B. Randy Nina Kristin Paula Amanda John K. Subject: Daily Health Care Reform Meeting 2017--01530 From: Sent: 7 Mar 2017 14:33:25 +0000 To: (W6) Ann John Carla Jessica Wade (CTR);Keith;Kouzoukas, Demetrios Lance Matt Ryan Brian Caitlin B. Randy Nina Kristin Paula Amanda John K. Subject: Daily Health Care Reform Meeting 2017-?01531 From: (Me) Sent: 16 Mar 2017 14:23:56 +0000 To: Anderson, Jeffrey Subject: FW: Daily Health Care Reform Meeting "i in' A From (W6) Sent: Tuesday, March 07, 2017 9:34 AM To- Agnew, Ann Bardis, John Brooks, John DiBlasio, Carla Harrison, Jessica Horn, Wade Kouzoukas, Demetrios Leggitt, Lance Lloyd, Matt Murphy, Ryan Neale, Brian Oakley, Caitlin B. Pate, Randy Schaefer, Nina Kristin Stannard, Paula Street. Amanda Twomey, John K. Subject: Daily Health Care Reform Meeting When: Thursday. March 16, 2017 4:00 PM Eastern Time (US Canada). Where: 2017-?01532 From: Pate, Randy Sent: 23 Mar 2017 17:27:18 +0000 To: Pate, Randy Wade (CTR);Agnew, Ann Jeffrey Nina John Paula Marie Amanda John Matthew Ryan Brady Emily Jane Laura Kristina Chanda L. Keagan Cc: Lloyd, Matt Jen Subject: ACA Regulatory Reform Huddle Attachments: Untitled, Untitled, Untitled, Untitled, Untitled, Untitled, Untitled, Untitled, Untitled, Untitled, Untitled, Untitled, Untitled, Untitled, Untitled, Untitled, Untitled Note: This meeting will occur three times a week and will have to be changed frequently due to possible con?icts with everyone?s schedules. PARTICIPANTS ade Horn andy Pate nn Agnew eff Anderson ina Schaefer ohn Brooks aula Stannard arie Meszaros manda Street ohn O?Brien att Bowman rady Brookcs yan Murphy mily Wilkinson ane Lucas aura Trueman 2017--01533 From: Sent: 17 Mar 2017 20:18:00 +0000 To: (W6) (05/ IOS);Agnew, Ann Jeffrey Sarah John John Carla Jessica Wade (CTR);Kouzoukas, Demetrios Lance Matt Ryan Brian Caitlin B. Randy Nina Kristin Paula Amanda John K. Subject: Canceled: Daily Health Care Reform Meeting 2017-?01534 From: (W6) Sent: 20 Mar 2017 15:12:51 +0000 To: (Me) Ann Jeffrey Sarah John John Carla Jessica Wade (CTR);Kouzoukas, Demetrios Lance Matt Ryan Brian Caitlin B. Randy Nina Kristin Paula Amanda John K. Lea Subject: Canceled: Daily Health Care Reform Meeting Attachments: Untitled, Untitled 2017--01535