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pdfBlueprint for Approval of Affordable Statebased and State Partnership Insurance
Exchanges
Introduction
The Affordable Care Act establishes Affordable Insurance Exchanges (Exchanges) to provide
individuals and small business employees with access to health insurance coverage beginning January
1, 2014.1 An Exchange is an entity that both facilitates the purchase of Qualified Health Plans (QHP)
by qualified individuals and provides for the establishment of a Small Business Health Options Program
(SHOP), consistent with Affordable Care Act 1311(b) and 45 CFR 155.20. Exchanges will provide
competitive marketplaces for individuals and small employers to directly compare and purchase private
health insurance options based on price, quality, and other factors. Exchanges are integral to the
Affordable Care Act’s goal of prohibiting discrimination against people with pre-existing conditions and
insuring all Americans.
The Affordable Care Act provides States with significant flexibility in the design and operation of their
Exchanges to best meet the unique needs of their citizens and their marketplace. States can choose to
operate as a State-based Exchange, or the Secretary of the United States Department of Health and
Human Services (HHS) will establish and operate a Federally-facilitated Exchange in any State that
does not elect to operate a State-based Exchange. In a Federally-facilitated Exchange, the State may
pursue a State Partnership Exchange, where a State may administer and operate Exchange activities
associated with plan management and/or consumer assistance. States that elect to participate in a
State Partnership Exchange will administer these functions in both the individual and the small group
market.
Regulations implementing the Affordable Care Act require HHS to Approve or Conditionally Approve
State-based Exchanges no later than January 1, 2013, for operation in 2014. In addition, the
Affordable Care Act 1321(c)(1) (B)(ii)(I) directs the Secretary to make a determination regarding
whether the State will operate reinsurance and/or risk adjustment programs or will use Federal
government services for these activities. To receive HHS Approval or Conditional Approval for a Statebased Exchange or a State Partnership Exchange, as well as reinsurance and risk adjustment
programs2, a State must complete and submit an Exchange Blueprint that documents how its
Exchange meets, or will meet, all legal and operational requirements associated with the model it
chooses to pursue. As part of its Exchange Blueprint, a State will also demonstrate operational
readiness to execute Exchange activities.3
1
Affordable Care Act 1311(b)(1)
Additional requirements for Risk Adjustment will be provided in the HHS Notice of Benefit and Payment Parameters.”
3
45 CFR 155.105, Establishment of Exchanges and Qualified Health Plans; Exchange Standards for Employers, 77 Fed. Reg.
18310, 18446 (Mar. 27, 2012)
2
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Flexible Exchange Options for States
In an effort to provide States with significant flexibility in the development of Exchanges to meet the
needs of their citizens, HHS has developed a program that offers multiple Exchange models as well as
a number of design alternatives within each model. A State also has the flexibility to transition between
models annually (see page 4 for details). See Figure 1 for a representation of the Exchange models,
and flexibility within those models.
Figure 1: Flexible Exchange Options for States
Exchanges will operate either as a State-based Exchange or a Federally-facilitated Exchange. A State
may also operate in partnership with HHS as a State Partnership Exchange, which provides States with
the option to administer and operate Exchange activities associated with plan management activities,
some consumer-assistance activities, or both. HHS, as the party responsible for Exchange
implementation, will provide as much flexibility as possible; however, HHS will need to ratify inherently
governmental decisions made by the State Partner.
Technical Assistance and Establishment Grant funding under Section 1311(a) of the Affordable Care
Act continues to be available to States through 2014 for State-based Exchanges, State Partnership
Exchanges, and States that are building linkages to the Federally-facilitated Exchange.4
4
http://www.grants.gov/search/search.do;jsessionid=0VqkQpTV3Z1fR74Z7rvnwjqf42vlsyw15Qp1FWKbqrQlJ8CQ7zJj!1406353995?oppId=180734&mode=VIEW
2
State-based Exchange
The Exchange final rule outlines the activities required to operate a State-based Exchange. Within the
required activities, a State-based Exchange has additional operational flexibility. It may choose to use
Federal government services for the following activities:
Determination of advance premium tax credit (APTC) and cost-sharing reduction (CSR)
Individual responsibility requirement and payment exemption as defined in future rulemaking
and guidance
Reinsurance
Risk adjustment
State Partnership Exchange
States have the option to operate as a State Partnership with HHS to administer and operate select
Exchange activities. Specifically, a State Partnership Exchange may assume primary responsibility for
activities including:
Plan Management: In a Plan Management Partnership, a State will conduct all analyses and
reviews necessary to support QHP certification, collect and transmit necessary data to HHS,
and manage certified QHPs.
Consumer Assistance: In a Consumer Assistance Partnership, a State will provide in-person
application and other assistance to consumers. In-person assistance may include supporting
consumers in filing an application, obtaining an eligibility determination, reporting a change in
status, comparing coverage options, and selecting and enrolling in a QHP.
Both Plan Management and Consumer Assistance: In a Plan Management and Consumer
Assistance Partnership, a State will perform all of the Partnership activities described above.
In addition to Plan Management and Consumer Assistance Partnership activities, Partnership States
may elect to perform the following Exchange activities:
Reinsurance
Medicaid and CHIP eligibility: A State may coordinate with the Center for Medicaid and CHIP
Services (CMCS) on decisions and protocols for either an assessment or determination model
for eligibility in the Exchange
Federally-facilitated Exchange without Partnership
For States that do not seek to operate a State-based Exchange or a Partnership with the Federallyfacilitated Exchange, HHS will establish and operate a Federally-facilitated Exchange. In such
instances, a State may elect to run reinsurance and may elect to coordinate with CMCS on decisions
and protocols for either an eligibility assessment or eligibility determination model in the Federallyfacilitated Exchange.
Regardless of a State’s Exchange model, HHS intends to work in collaboration with States, where
appropriate, to ensure the best, most effective experience for the State and its residents.
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Overview of Exchange Approval Requirements
HHS may approve States that seek to operate a State-based Exchange or participate in a State
Partnership Exchange based upon a State’s submission of its Blueprint. A Blueprint is made up of two
components:
Declaration Letter (Section 1)
Exchange Application (Section 2)
States seeking to operate a State-based Exchange must submit a Declaration Letter and a Blueprint
Application no later than 10 business days prior to January 1, 2013 (December 14, 2012 for plan year
2014). States seeking to operate in a State Partnership Exchange for plan year 2014 can submit their
Declaration Letter and a Blueprint Application any time before February 15, 2013 and may receive
approval on a rolling basis any time before March 1, 2013.
A State may submit its Declaration Letter at any time prior to this deadline. If a State’s Declaration
Letter is received more than 20 business days prior to the submission of its Blueprint, the State may
request an Exchange Application consultation with CMS regarding preparation of its application for
approval as a State-based Exchange or State Partnership Exchange.
States that plan to operate in the Federally-facilitated Exchange without Partnership that intend to
operate their own reinsurance programs—should submit a Declaration Letter addressing how they
meet or will meet the requirements of Section 5.2: Reinsurance program. They are invited to submit a
Declaration Letter otherwise, but they do not need to complete the Exchange Application.
In particular, HHS strongly encourages States that are considering operating a State-based Exchange
or a Plan Management Partnership to submit the Declaration Letter as soon as possible and to seek
technical assistance and consultation with HHS to ensure State readiness to operate Plan Management
activities in time for operational implementation.
States that seek HHS Approval to operate a State-based Exchange or State Partnership Exchange for
coverage years beginning after January 1, 2014 (e.g., January 1, 2015, January 1, 2016) should submit
an Exchange Blueprint in accordance with the same process and timeframe specified for those States
seeking to operate an Exchange on January 1, 2014, for the applicable year.
Initial Exchange Approval Determinations
HHS will approve a State-based Exchange once the State has demonstrated the ability to satisfactorily
perform all required Exchange activities.
HHS recognizes that States depend on HHS and other Federal agencies for guidance associated with
their Exchange establishment. In this regard, particularly in the first year of the program (plan year
2014), approval of State-based Exchanges will take into account timelines for guidance and
infrastructure development (e.g., Data Services Hub). Similarly, HHS expects that States will be in
various stages of the Exchange-development lifecycle when Blueprints are submitted. Many State
Exchange-development activities are likely to occur in 2013. HHS will utilize Conditional Approval for
State-based Exchanges and Partnership States whose Exchange establishment is not complete at the
time of Blueprint submission.
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Conditional Approval will be granted for State-based Exchanges and Partnership Exchanges that do
not meet all Exchange Approval requirements, but are making significant progress toward these
requirements and will be operationally ready for the initial open enrollment period beginning October 1,
2013. HHS will work with each State that receives Conditional Approval to develop a comprehensive
agreement that sets out expected future milestones and dates for operational readiness reviews. This
will allow HHS and the State to work jointly to ensure that the Exchange continues to develop at a pace
on track for operation during the initial open enrollment period beginning on October 1, 2013.
Conditional Approval will continue as long as a State continues to meet expected progress milestones
and until a State successfully demonstrates its ability to perform all required Exchange activities.
Provided that the State is meeting the milestones outlined in its Conditional Approval determination, a
State Exchange can maintain Conditional Approval. In this capacity, an Exchange must be able to:
Provide consumer support for coverage decisions
Facilitate eligibility determinations for individuals
Provide for enrollment in QHPs
Certify health plans as QHPs
Operate a SHOP
The technical assistance and grant funding available to States prior to Approval or Conditional Approval
will continue to be available under the terms and requirements of those programs.
Questions Regarding the Exchange Blueprint and Technical Assistance
States should contact their CMS Center for Consumer Information and Insurance Oversight (CCIIO)
State Officer for specific questions regarding their Exchange Blueprints. Additionally, all States are
encouraged to contact CCIIO’s State Exchange Group for information about technical assistance
consultations, available resources, and funding opportunities available to States for Exchange-build
activities. General questions may be directed to [email protected].
PRA Disclosure Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection
of information unless it displays a valid OMB control number. The valid OMB control number for this
information collection is 0938-1172. The time required to complete this information collection is
estimated to average (211 hours) or (12,660 minutes) per response, including the time to review
instructions, search existing data resources, gather the data needed, and complete and review the
information collection. If you have comments concerning the accuracy of the time estimate(s) or
suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports
Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
Section I: Declaration Letter
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A State seeking to operate a State-based Exchange or participate in a State Partnership Exchange in
plan year 2014 will declare the type of Exchange Model it intends to pursue through an Exchange
Declaration Letter as part of its Exchange Blueprint. States that plan to operate in the Federallyfacilitated Exchange without Partnership, and that intend to operate their own reinsurance programs,
should submit a Declaration Letter addressing how they meet the requirements of Section 5.2:
Reinsurance program. To facilitate coordination, States seeking to participate in a Federally-facilitated
Exchange without Partnership and not electing to operate reinsurance are also invited, at their option,
to complete a Declaration Letter.
A State’s Declaration Letter must be signed by the State’s Governor5. As described below, the Letter’s
contents should include basic information associated with its designated Exchange Model. The Letter
should include a designation of the individual(s) (i.e., Designee(s)) who should serve as the primary
point of contact for HHS regarding the Exchange. The individual(s) should be authorized to bind the
State regarding the State’s Exchange, as well as to complete and sign the Exchange Application. In the
case of State-based Exchanges and State Partnership Exchanges, this should be the individual(s)
authorized to electronically attest to the facts in the Exchange Application.
States are encouraged to submit their Exchange Declaration Letters early, but a Declaration Letter
must be sent to the Centers for Medicare & Medicaid Services (CMS) Center for Consumer Information
and Insurance Oversight (CCIIO) at least 10 business days prior to the required Approval date of
January 1 (December 14, 2012 for plan year 2014) for State-based Exchanges and by February 15th
(February 15, 2013, for plan year 2014) for State Partnership Exchanges. Declaration Letters may be
sent to the CMS Center for Consumer Information and Insurance Oversight (CCIIO), 200 Independence
Avenue SW, Suite 739H, Washington DC, 20201. In addition, please email a copy to the
[email protected]. To support HHS’ goal of public transparency, States must post
their Model Declaration Letter to the State (or other appropriate) website.
Contents of Exchange Declaration Letters
A State’s Declaration Letter must include the following contents based on the Exchange Model that the
State chooses to pursue.
State-based Exchange
Confirmation of the State’s intention to apply to operate a State-based Exchange
Indication of whether the State intends to administer a risk adjustment program in the first year
of operations or if it will be using Federal government services. If yes,
o What is the State’s risk adjustment entity?
o Is the State planning to use the Federal risk adjustment methodology?
o What is the proposed data model (i.e., intermediate or distributed)?
5
CMS has been advised that in some States, the Governor does not have the authority to enter into a State
Partnership Exchange. Please contact your CCIIO State Officer if the Governor of your State believes that
another entity is the appropriate authority to sign the State’s Model Declaration Letter so that we can work with
your State on an appropriate arrangement.
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Indication of whether the State intends to administer its own reinsurance program by
establishing or contracting with a nonprofit reinsurance entity. If yes, provide the name of the
selected entity.
Indication of whether the State-based Exchange will perform its Advance Premium Tax Credit
(APTC)/Cost-Sharing Reduction (CSR) eligibility determinations or if it will use Federal
government services for this activity.
Designation of the individual(s) (i.e., Designee(s)) authorized to act as primary point of contact
and authorized to bind the State with HHS regarding the State’s Exchange, as well as to
complete and sign the Exchange Application.
State Partnership Exchange
Confirmation of the State’s intention to participate in a State Partnership Exchange, including
which Partnership the State intends to pursue:
o Plan Management
o Consumer Assistance
o Plan Management and Consumer Assistance
Indication of whether the State intends to administer its own reinsurance program by
establishing or contracting with a nonprofit reinsurance entity. If yes, provide the name of the
selected entity.
Designation of the individual(s) (i.e., Designee) authorized to act as primary point of contact and
authorized to bind the State with HHS regarding the State’s Exchange, as well as to complete
and sign the Exchange Application. The State Medicaid Director will be assumed to be the
primary contact on issues related to eligibility determination and coordination, unless otherwise
indicated by the State Governor or the authorized personnel in the Declaration Letter. In States
with a separate Children’s Health Insurance Program (CHIP), the State’s CHIP Director will be
assumed to serve as the point of contact for CHIP-related eligibility issues, unless otherwise
indicated.
Federally-facilitated Exchange
Confirmation of the State’s intention to elect for the Secretary to establish and operate a
Federally-facilitated Exchange.
Designation of the State agency or official who is authorized by the State to collaborate with
HHS on issues related to Exchange issues in that State’s Federally-facilitated Exchange in that
State. The State Medicaid Director will be assumed to be the primary contact on issues related
to eligibility determination and coordination unless otherwise indicated by the State Governor or
the authorized personnel in the Declaration Letter. In States with separate CHIP programs, the
State’s CHIP Director will be assumed to serve as the point of contact for CHIP-related eligibility
issues unless otherwise indicated.
Indication of whether the State intends to administer its own reinsurance program by
establishing or contracting with a nonprofit reinsurance entity. If yes, indicate how the State
meets or will meet the requirements of Section 5.2: Reinsurance program..
If a Declaration Letter is not received 10 business days prior to January 1, 2013 (i.e., December 14th,
2012) for State-based Exchanges or by February 15, 2013 for State Partnership Exchanges, HHS will
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plan to implement a Federally-facilitated Exchange for the State. In the absence of a Declaration Letter,
HHS will operate a Federally-facilitated Exchange for the State under the following assumptions:
The State will not administer its own reinsurance program;
The State’s small group and individual markets will be merged in the Federally-facilitated
Exchange only if the current individual and small-group markets are merged. If a State does not
merge the individual and small-group-market risk pools, the SHOP will permit each qualified
employee to enroll only in QHPs in the small-group market; and
The State’s current definition of “small-group” employer (e.g., “up to 50” or “up to 100”
employees) will be followed, while the method of determining employer size will be based on
full-time equivalent employees consistent with other Affordable Care Act policies.
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Section II: Application for Approval of
Affordable State-based and State Partnership
Insurance Exchanges
Table of Contents
Application Instructions ...................................................................................................................... 10
Attestation ......................................................................................................................................... 17
State Background Information for Application Submission ................................................................. 18
1.0 Legal Authority and Governance.................................................................................................. 19
2.0 Consumer and Stakeholder Engagement and Support ................................................................ 20
3.0 Eligibility and Enrollment .............................................................................................................. 25
4.0 Plan Management........................................................................................................................ 31
5.0 Risk Adjustment and Reinsurance ............................................................................................... 35
6.0 Small Business Health Options Program (SHOP) ........................................................................ 36
7.0 Organization and Human Resources ........................................................................................... 37
8.0 Finance and Accounting .............................................................................................................. 38
9.0 Technology .................................................................................................................................. 38
10.0 Privacy and Security .................................................................................................................. 39
11.0 Oversight and Monitoring ........................................................................................................... 39
12.0 Contracting, Outsourcing, and Agreements ............................................................................... 40
13.0 State Partnership Exchange Activities ....................................................................................... 40
The Exchange Application must be completed online. Beginning September 14, 2012, the Exchange
Application will be available for online completion and submission on CMS’ Center for Consumer
Information and Insurance Oversight’s (CCIIO) State Exchange Resource and Virtual Information
System (SERVIS) system https://servis.cms.gov.6 The online Exchange Application has been designed
so only the questions relevant to the Exchange Model the State has selected will be presented to the
applicant.
6
SERVIS and the Collaborative Application Lifecycle Tool (CALT) are password protected. To receive a CALT/SERVIS user
ID and password please contact [email protected] or [email protected].
9
Application Instructions
Introduction
In addition to a Declaration Letter, a complete Exchange Blueprint requires submission of an Exchange
Application. This Exchange Application is used to document a State’s completion, or progress towards
completion, of all Exchange requirements, either as a State-based Exchange or State Partnership
Exchange.
Exchange Application: Overview of Exchange Activities
The Exchange Application is comprised of a list of activities that a State-based Exchange or State
Partnership Exchange must perform to comply with the Affordable Care Act and associated regulations.
In some instances, a State may use Federal services to perform an Exchange activity. Table 1 outlines
all of the Exchange activities that an Exchange must perform and can serve as a roadmap for
Exchange development.
States that are seeking Approval of their State-based Exchange or State Partnership Exchange should
use Table 1 to complete the Application accordingly. Required activities within an Exchange model are
designated with an “X.” Select activities are also described as “if applicable,” “can use Federal
government services,” “may elect to perform,” and “optional.” States may attest to activities being
completed by the Exchange or a Designee—through contract, agreement, or other arrangement.
However, the Exchange is ultimately responsible for successful performance of the activity.
Approval requirements for a State Partnership Exchange will mirror State-based Exchange Approval
requirements for those activities a State elects to perform within a Federally-facilitated Exchange.
Therefore, all States that seek Approval of a State-based Exchange or a State Partnership Exchange
can use this list of activities and common elements as part of the Exchange Approval process. The
activities associated with the State Partnership Exchanges are similarly designated in Table 1 below.
States that are applying to be State-based Exchanges are also encouraged to complete the subset of
activities associated with the Partnership models. By also completing the Partnership activities, a State
can assure that if it receives Conditional Approval but is ultimately unable to achieve operational
milestones in other areas it will be able to participate as a State Partnership Exchange in plan year
2014.
If you are interested in additional requirements associated with a Regional or Subsidiary Exchange,
please contact your State Officer or email CCIIO at [email protected].
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Table 1: Roadmap for Completing the Exchange Application
Section of Exchange Blueprint
Exchange Activity
Required Activities
State-based
Exchange
State Partnership
Exchange—Plan
Management
State Partnership
Exchange—
Consumer
Assistance
1.0 Legal Authority and Governance
1.1 Enabling authority for Exchange and
X
SHOP
1.2 Board and governance structure
X
2.0 Consumer and Stakeholder Engagement and Support
2.1 Stakeholder consultation plan
2.2 Tribal-consultation plan
2.3 Outreach and education
2.4 Call center
2.5 Internet website
2.6 Navigators
2.7 In-person assistance program
X
X
(if applicable)
X
X
X
X
X
(if applicable)
2.8 Agents/brokers
X
(if applicable)
2.9 Web brokers
X
(if applicable)
3.0 Eligibility and Enrollment
3.1 Single streamlined application(s) for
Exchange and SHOP
3.2 Coordination strategy with Insurance
Affordability Programs and the SHOP
3.3 Application, updates, acceptance, and
processing, and responses to
redeterminations
3.4 Notices, data matching, annual
redeterminations, and response
processing
3.5 Verifications
3.6 Document acceptance and processing
3.7 Eligibility determination
3.8 Eligibility determinations for APTC and
CSR
3.9 Applicant and employer notification
3.10 Individual responsibility requirement
and payment exemption determinations
3.11 Eligibility appeals
X
X
X
X
X
X
X
X
(can use Federal
service)
X
X
(can use Federal
service)
X
11
Section of Exchange Blueprint
Exchange Activity
3.12 QHP selections and terminations,
and APTC/advance CSR information
processing
3.13 Electronically report results of
eligibility assessments and determinations
3.14. In accordance with section
155.345(i) of the Exchange Final Rule, the
Exchange must follow procedures
established in accordance with 45 CFR
152.45 related to the Pre-Existing
Condition Insurance Plan (PCIP)
transition
4.0 Plan Management
Required Activities
State-based
Exchange
State Partnership
Exchange—Plan
Management
X
X
X
X
(as applicable)
X
X
4.2 QHP certification process
4.3 Plan management system(s) or
processes that support the collection of
QHP issuer and plan data
X
X
X
X
4.4 Ensure ongoing QHP compliance
4.5 Support issuers and provide technical
assistance
4.6 Issuer recertification, decertification,
and appeals
4.7 Timeline for QHP accreditation
4.8 QHP quality reporting
5.0 Risk Adjustment & Reinsurance
X
X
X
X
X
X
X
X
X
X
4.1 Appropriate authority to perform and
oversee certification of QHPs
State Partnership
Exchange—
Consumer
Assistance
5.1 Risk adjustment program
X
(can use Federal
service)
5.2 Reinsurance program
X
(can use Federal
service)
X
(may elect to
perform
or can use Federal
service)
X
(as applicable)
X
(may elect to
perform
or can use Federal
service)
6.0 SHOP
6.1 SHOP compliance with 45 CFR 155
Subpart H
X
6.2 SHOP premium aggregation
X
6.3 Electronically report results of
eligibility assessments and determinations
for SHOP
7.0 Organization & Human Resources
X
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Section of Exchange Blueprint
Exchange Activity
Required Activities
State-based
Exchange
7.1 Organizational structure and staffing
resources to perform Exchange activities
State Partnership
Exchange—Plan
Management
State Partnership
Exchange—
Consumer
Assistance
X
8.0 Finance & Accounting
8.1 Long-term operational cost, budget,
and management plan
9.0 Technology
X
9.1 Compliance with HHS IT Guidance
9.2 Adequate technology infrastructure
and bandwidth
9.3 IV&V, quality management and test
procedures
10.0
Privacy & Security
X
X
X
X
X
X
10.1 Privacy and Security standards
policies and procedures
X
X
10.2 Safeguards based on HHS IT
guidance
X
X
10.3 Safeguard protections for Federal
information
11.0 Oversight, Monitoring, & Reporting
X
11.1 Routine oversight and monitoring of
the Exchange’s activities
13.1 Plan Management
13.2 Capacity to interface with the
Federally-facilitated Exchange
13.3 Consumer Assistance
X
(if applicable)
X
X
X
X
X
(if applicable)
X
X
X
(if applicable)
X
X
X
(if applicable)
Optional
X
Optional
X
11.2 Track/report performance and
outcomes metrics related to Exchange
activities
11.3 Uphold financial integrity provisions
including accounting, reporting, and
auditing procedures
12.0 Contracting, Outsourcing, and Agreements
12.1 Contracting and outsourcing
agreements
13.0 State Partnership Exchange Activities
X
(if applicable)
Optional
X
X
13
Relationship between Exchange Application and the Establishment Grant
Review Process
HHS has developed an Establishment Review Process to monitor and assist States that have received
grant(s) through the Cooperative Agreements for Establishment of Exchanges under the Affordable
Care Act 1311(a). While the Establishment Review Process is intended to support States as they work
toward Exchange Approval, the Establishment Review Process is independent of the Exchange
Approval process. However, to streamline data collection requirements, HHS has aligned requirements
so that a State may utilize information submitted during the Establishment Review Process to complete
a State’s Exchange Blueprint. If a State successfully completes a portion of an activity requirement
during its Establishment Review, the State may waive out of re-submitting testing files or supporting
documentation as part of the Exchange Application requirements. As referenced in the Exchange
Application, a State may upload and submit a letter(s) from HHS confirming successful completion of
documentation requirements instead of re-submitting documentation.
Completion of the Exchange Application
In completing the Exchange Application, States are asked to submit the elements described below.
Attestations
The individual(s) designated in the Declaration Letter (the Designee(s)) must attest, on behalf of the
State, to either completion or expected completion of an Exchange activity. Specifically, the State can
attest to their Exchange’s current ability to meet specified Exchange requirements. Alternatively, if the
State is unable to meet requirements by the time of the Exchange Application submission date, the
State may attest to expected completion and its expected ability to meet the specified activity
requirements by a future date.
As appropriate, for attestations related to expected completion, the State should provide a timeline and
work plan that includes key milestones, including any vendor-related agreements, so that HHS
understands the State’s expected ability to complete the activity by a future date. The State may
choose to provide one comprehensive work plan that outlines all applicable activities or a set of work
plans that logically bundle activities (e.g., a work plan for all Eligibility activities). However, the work
plan(s) must clearly reference the specific activities required as part of the Exchange Application.
Supporting Documentation
For some activities, supporting documentation is required. States must upload requested
documentation associated with the Exchange activity. Alternatively a State may submit a letter(s) from
HHS confirming successful demonstration of the associated supporting document through the
Establishment Review process. In such cases, the State does not need to provide
documentation/descriptions, and HHS will confirm the State’s submitted documentation from the
Establishment Review.
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Testing Files
As part of a standard systems development process, States and their vendors will develop and
implement testing and validation plans. For some activities, the Application requires submission of
these files.
Three different types of testing files may be required:
Summary of results of State-developed testing: These summaries should document Statedefined and executed system testing, including details of Exchange activities tested, the scope of
testing activities conducted, and metrics detailing the results of that testing as it relates to each
designated Exchange Application requirement.
Results of State execution of HHS-developed test scenarios: HHS, in collaboration with States,
developed test scenarios to confirm implementation of those Exchange activities that require
standardization across all State Exchanges. These scenarios will be released to a central Test
Library on the Collaborative Application Lifecycle Tool (CALT)7. For CALT login and password
assistance, please send a request to [email protected].
Summary of Independent Verification & Validation (IV&V) of applicable system components:
A report by an independent third party which provides verification and validation that designated
Exchange activities are built and operating as designed and in compliance with documented
requirements.
Upload Relevant Files
Files are requested to be uploaded, as applicable. The files should be clearly labeled with the
appropriate activity or activities). Activities requiring additional documentation in the form of uploaded
files are specifically identified in the Exchange Application. Depending on the Exchange activity being
tested, a given document or file may encompass multiple activities. In such cases, please note any file
cross-referencing and clearly label the activities within the attachments. States do not need to upload
the same file multiple times. Instead referencing, will allow HHS to identify files provided, as
appropriate.
Supporting Documentation
Testing Files
Letter(s) from HHS allowing an applicant to waive out of any requirements successfully
completed in an Establishment Review(s)
Expected Completion Work Plan
Operational Readiness Assessment and Additional Information Requests
In addition to reviewing the completed Exchange Application, HHS may conduct on-site or virtual
Exchange assessments as part of its verification of an Exchange’s Operational Readiness. Operational
Readiness entails HHS’ and its Federal agency partners’ assessment to determine the capacity of an
7
Test scenarios will be available on the Collaborative Application Lifecycle Tool (CALT) site (https://calt.hhs.gov);
a more specific link to the site will be provided at a future date
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Exchange to conduct Exchange business. The objective of the Operational Readiness assessment is
to assure that an Exchange’s policies, procedures, operations, technology, and other administrative
capacities have been implemented and scaled to meet the needs of the State’s Exchange population.
HHS will use the information in a State’s Exchange Application, including results from a State’s Testing
Files, to determine the need for, and timing of, an on-site or virtual Operational Readiness assessment.
In addition, the State may be asked to provide supplemental information after the Exchange Application
has been submitted, as determined necessary by HHS and its Federal agency partners.
Public Transparency
The Affordable Care Act envisions a significant role for consumers and other stakeholders in the
design, implementation and on-going operations of Exchanges. For example, an Exchange that is an
independent State agency or a non-profit established by a State will include consumer representatives
on its board and hold regular public governing board meetings. In addition, Exchanges will develop and
implement a comprehensive stakeholder engagement plan that includes meaningful engagements with
consumers, advocates, employers, and members of Federally-recognized Tribes (where applicable).
In that spirit, as part of a State’s Approval or Conditional Approval decision, States should post the
following sections (excluding test data) of a State’s Exchange Application on the appropriate State
website within ten (10) business days of an Approval or Conditional Approval decision:
Section 1.2: Exchange board and governance structure
Section 2.1: Stakeholder consultation plan
Section 2.2: Tribal consultation policy
Section 2.3: Outreach and education plan
Section 2.6: Navigators
Section 2.7: Role of in-person assistance programs
Section 2.8: Role of agents and brokers
Section 2.9: Role of Web agents and brokers
Section 3.1: State-developed single-streamlined application (if applicable)
Section 3.2: Coordination strategy
Section 3.14: Pre-Existing Condition Insurance Plan (PCIP) transition
Section 4.4: Integration between Exchange and other State entities with respect to QHP-issuer
oversight
Section 8.1: Long-term operational cost plan
If a State is concerned that the publication of the above information may jeopardize an active
procurement process, it may contact their State Officer or email CCIIO at
[email protected] to discuss the timing of the publication of this information.
Application Format and Availability
The Exchange Application will be electronically available for States to complete on HHS’ Center for
Consumer Information and Insurance Oversight’s (CCIIO) State Exchange Resource and Virtual
Information System (SERVIS) system (https://servis.cms.gov) beginning September 14, 2012.
16
Attestation
ON THIS DATE, I ATTEST THAT THE STATEMENTS AND INFORMATION CONTAINED IN
THIS EXCHANGE BLUEPRINT AND DOCUMENTS SUBMITTED IN CONJUNCTION WITH
THIS EXCHANGE BLUEPRINT ACCURATELY REPRESENT THE STATUS OF MY STATE’S
INSURANCE EXCHANGE BEING DEVELOPED UNDER TITLE I OF THE PATIENT
PROTECTION AND AFFORDABLE CARE ACT OF 2010 (Pub. L. 111-148), AS AMENDED
BY THE HEALTH CARE AND EDUCATION RECONCILIATION ACT OF 2010 (Pub. L. 111152), AND REFERRED TO COLLECTIVELY AS THE AFFORDABLE CARE ACT; AND
REGULATIONS AT 45 CFR PARTS 153, 155, AND 156.
State: _____________________________________________________________________________
(Name of State)
__________________________________________________________________________________
(Signature of Governor Designee of the State, Date Signed)
17
State Background Information for Application Submission
1. STATE NAME
2. DESIGNATED EXCHANGE OFFICIAL(S) TO COMPLETE EXCHANGE APPLICATION &
CONTACT INFORMATION
NAME:
TELEPHONE:
EMAIL ADDRESS:
NAME:
TELEPHONE:
EMAIL ADDRESS:
3. STATE EXCHANGE MODEL (Can check more than one. States applying for a State-based
Exchange are encouraged to also select and complete partnership requirements.)
__STATE-BASED EXCHANGE
__STATE PARTNERSHIP EXCHANGE
__PLAN MANAGEMENT
__CONSUMER ASSISTANCE
4. If you are pursuing a State-based Exchange, indicate if you will be using any of the following
Federal services: (check all that apply)
__3.8 Eligibility determinations for APTC and CSR
__3.10 Individual responsibility requirements and payment exemption determinations
__5.1 Risk adjustment program
__5.2 Reinsurance program
5. If you are pursuing a State Partnership Exchange, indicate if you will be using any of the
following Federal services:
__5.2 Reinsurance program
18
Legend:
Blank fields require response from applicant
Shaded fields require no response from applicant
* Supporting Documentation and Testing Files eligible for waive out given an applicant’s successful completion of an Establishment Review(s)
Exchange Activity
Attestation
Supporting Documentation*
Testing Files*
Expected
State
HHSCompleted
Completion Summary Developed
(X)
(date)
(X)
(X)
HHS Approval
Letter for
Waive Out
(X)
IV&V
(X)
1.0 Legal Authority and Governance
1.1
The State has enabling authority to operate an Affordable
Insurance Exchange, including a Small Business Health Options
Program (SHOP), compliant with Affordable Care Act Section
1321(b) and implementing regulations.
Copy of current law and/or regulation that indicates that
the State has necessary legal authority to establish an
Exchange or that establishes the Exchange.
OR
Other legislation or general authority (e.g., Executive
Order) that the State has determined provides the
necessary legal authority to establish an Exchange.
Note: If the SHOP was separately authorized from the
Exchange, pursuant to Affordable Care Act § 1321(b),
provide documentation demonstrating that the State has
enabling authority to establish and operate a SHOP.
AND
If authority is not clear on its face, provide a Statement
from the legal counsel of the office of the applicant, the
Governor’s legal counsel, or the State’s Attorney
General’s Office (correspondence or a formal legal
opinion) certifying that the State is authorized to
establish an Exchange under State law.
1.2
The Exchange has been established in compliance with
Affordable Care Act 1311(d) and 45 CFR 155.110. If State
agency, please proceed to Section 2.
Brief description of governance structure (e.g., State
agency, nonprofit organization). If State agency, please
proceed to Section 2.
1.2a
The Exchange board and governance structure has been
established in compliance with Affordable Care Act 1311(d) and
Brief description of board composition, including board
members’ affiliations and any consumer representation.
19
Exchange Activity
Attestation
Testing Files*
Expected
State
HHSCompleted
Completion Summary Developed
(X)
(date)
(X)
(X)
45 CFR 155.110.
1.2b
The Exchange has a formal, publicly-adopted charter or bylaws.
1.2c
The Exchange has established governance policies in
compliance with 45 CFR 155.110(d) and obtained conflict of
interest disclosures from board members, including disclosures of
financial interest.
1.2d
The governing board has at least one voting member who is a
consumer representative, and does not have a majority of voting
representatives with a conflict of interest.
1.2e
The majority of the voting members have relevant experience in
health benefits administration, health care finance, health plan
purchasing, health care delivery system administration, public
health, or health policy issues related to the individual and small
group markets and the uninsured.
1.2f
The Exchange holds regular, public governing-board meetings
that are announced in advance.
Supporting Documentation*
HHS Approval
Letter for
Waive Out
(X)
IV&V
(X)
Note any differences in board composition and
governance structure for SHOP.
2.0 Consumer and Stakeholder Engagement and Support
2.1
The Exchange has developed and implemented a stakeholder
consultation plan and has consulted with, and will continue to
consult with, consumers, small businesses, State Medicaid and
CHIP agencies, agents/brokers, employer organizations, and
other relevant stakeholders as required under 45 CFR 155.130.
2.2
Applicable only to States with Federally-recognized Tribes: The
Exchange, in consultation with the Federally-recognized Tribes,
Brief description of the stakeholder consultation plan that
addresses how consultation will occur on an ongoing
basis with consumers, small businesses, State Medicaid
and CHIP agencies, agents/brokers, employer
organizations, and other relevant stakeholders as
required under 45 CFR 155.130.
20
Exchange Activity
Attestation
Testing Files*
Expected
State
HHSCompleted
Completion Summary Developed
(X)
(date)
(X)
(X)
Supporting Documentation*
HHS Approval
Letter for
Waive Out
(X)
IV&V
(X)
has developed and implemented a Tribal consultation policy or
process, which has been submitted to HHS.
2.3
The Exchange provides culturally and linguistically appropriate
outreach and educational materials to the public, including
auxiliary aids and services for people with disabilities, regarding
eligibility and enrollment options, program information, benefits,
and services available through the Exchange, the Insurance
Affordability Program(s), and the SHOP.
Brief description of the outreach plan(s) and targeted
efforts that address each population or type of
stakeholder, including those identified in 45 CFR
155.130.
In addition, the Exchange has an outreach plan for populations
including: individuals, entities with experience in facilitating
enrollment such as agents/brokers, small businesses and their
employees, employer groups, health care providers, communitybased organizations, Federally-recognized Tribal communities,
advocates for hard-to-reach populations, and other relevant
populations as outlined in 45 CFR 155.130.
2.3a
The Exchange has developed and provides culturally and
linguistically appropriate outreach and educational materials and
auxiliary aids and services to people with disabilities (including
information in alternate format), regarding eligibility and
enrollment options, program information, benefits, and services
available through the Exchange, SHOP, and other Insurance
Affordability Programs, as required in 45 CFR 155.205(c).
2.3b
The Exchange has an outreach plan for populations including:
individuals, entities with experience in facilitating enrollment such
as agents/brokers, small businesses and their employees,
employer groups, health care providers, community-based
organizations, Federally-recognized Tribal communities,
advocates for hard-to-reach populations, and other relevant
populations as outlined in 45 CFR 155.130.
21
Exchange Activity
Attestation
Testing Files*
Expected
State
HHSCompleted
Completion Summary Developed
(X)
(date)
(X)
(X)
2.4
The Exchange provides for the operation of a toll-free telephone
hotline (call center) to respond to requests for assistance from the
public, including individuals, employers, and employees, at no
cost to the caller as specified by 45 CFR 155.205(a).
2.4a
The Exchange provides for the operation of a toll-free telephone
hotline (call center) which acts as a central line to handle
seamless application support, coordinates with other Insurance
Affordability Program(s) and with other State and Federal
agencies, and responds to requests for assistance from the
public, including individuals, employers, and employees, at no
cost to the caller as specified by 45 CFR 155.205(a).
2.4b
The Exchange provides translation and oral interpretation
services and auxiliary aids and services to the public, including
individuals, employers, and employees, at no cost to the caller.
2.4c
The Exchange provides adequate training and resources to
operate the call center, including an operating plan and
procedures.
2.5
The Exchange has established and maintains an up-to-date
Internet Web site that provides timely and accessible information
on Qualified Health Plans (QHPs) available through the
Exchange, Insurance Affordability Program(s), and the SHOP,
and includes requirements specified in 45 CFR 155.205(b).
2.5a
The Exchange has established and maintains an up-to-date
Internet Web site that provides timely and accessible information
on Qualified Health Plans (QHPs) available through the
Exchange, Insurance Affordability Program(s), and the SHOP,
and includes requirements specified in 45 CFR 155.205(b).
2.5b
The Exchange’s Internet Web site provides information on
premium and cost-sharing, QHP comparison, metal level of QHP
Supporting Documentation*
HHS Approval
Letter for
Waive Out
(X)
IV&V
(X)
Brief description of the call center’s strategy for
managing call volume, plan for translation services, and
toll-free telephone number.
Internet Web site URL address for the Exchange and the
SHOP, if different.
22
Exchange Activity
Attestation
Testing Files*
Expected
State
HHSCompleted
Completion Summary Developed
(X)
(date)
(X)
(X)
Supporting Documentation*
HHS Approval
Letter for
Waive Out
(X)
IV&V
(X)
coverage, transparency of coverage measures, and a provider
directory.
2.5c
The Exchange’s Internet Web site provides information in a
manner that is accessible to individuals with disabilities and
individuals with limited English proficiency, as required in 45 CFR
155.205(b) and (c).
2.6
The Exchange has established or has a process in place to
establish and operate a Navigator program that is consistent with
the applicable requirements of 45 CFR 155.210, including the
development of training and conflict of interest standards, and
adherence to privacy and security standards specified in 45 CFR
155.210 and 45 CFR 155.260.
2.6a
The Exchange has established or has a process in place to
establish and operate a Navigator program that is consistent with
the applicable requirements specified in 45 CFR 155.210 and 45
CFR 155.260.
2.6b
The Exchange has a plan for the ongoing funding of an Exchange
Navigator program, in order to award at least two (2) types of
entities, one of which is a community or consumer-focused
organization or non-profit entity. Grant agreements ensure that
Navigator grantees (“Navigators”) will conduct the five (5) duties
outlined in 45 CFR 155.210(e).
2.6c
The Exchange has begun to develop training and conflict of
interest standards for Navigators.
Brief description of Exchange’s plan to operate a
Navigator program, including documentation outlining
the Exchange’s progress in developing conflict of
interest and training standards; how it will ensure
Navigators are appropriately trained and meet the
Exchange’s conflict of interest, privacy and security
standards; and a timeline and strategy for funding for the
Navigator program and making the program fully
operational.
23
Exchange Activity
Attestation
Supporting Documentation*
Testing Files*
Expected
State
HHSCompleted
Completion Summary Developed
(X)
(date)
(X)
(X)
IV&V
(X)
2.7
If applicable: The Exchange has established an in-person
assistance program distinct from the Navigator program and has
a process in place to operate the program consistent with the
applicable requirements of 45 CFR 155.205(c), (d), and (e).
Brief description of Exchange’s plan to operate an inperson assistance program distinct from the Navigator
program, which provides in-person assistance to
consumers, including documentation outlining the
Exchange’s progress in developing conflict of interest
and training standards; how it will ensure in-person
assistance program staff are appropriately trained and
meet the Exchange’s conflict of interest, accessibility,
and privacy and security standards; and a timeline and
strategy for funding for the in-person assistance program
and making the program fully operational.
2.8
If applicable: If the State permits activities by agents and brokers
pursuant to 45 CFR 155.220(a), the Exchange has clearly defined
the role of agents and brokers including evidence of licensure,
training, and compliance with 45 CFR 155.220(c)-(e). The
Exchange will have agreements with agents/brokers consistent
with 45 CFR 155.220(d), which address agent/broker registration
with the Exchange, training on QHP options and Insurance
Affordability Program(s), and adherence to privacy and security
standards, as specified in 45 CFR 155.260.
If applicable: Brief description of the strategy, including
the Exchange’s compensation policy for agents/brokers,
including web brokers, as it relates to their enrollment of
individuals through the Exchange.
2.8a
If applicable: The Exchange has a process to verify that
agents/brokers are in compliance with State law, including
licensure requirements consistent with 45 CFR 155.220(e).
2.9
If applicable: If the State permits activities by agents and brokers
pursuant to 45 CFR 155.220(a), the Exchange has clearly defined
the role of web brokers including evidence of licensure, training,
and compliance with 45 CFR 155.220(c)-(e). Specifically, the
Exchange has agreements with web brokers consistent with 45
CFR 155.220(d), which address agent/broker registration with the
HHS Approval
Letter for
Waive Out
(X)
AND
If applicable: Brief description of the Exchange’s policy
for ensuring compliance with 45 CFR 155.220(d) and
(e), including how it will ensure agents/brokers are
appropriately trained and meet the Exchange’s privacy
and security standards.
If applicable: Brief description of how the Exchange’s
Internet Web site will interface with web brokers’ Web
sites.
AND
If applicable: Brief description of Exchange’s policy for
24
Exchange Activity
Attestation
Expected
State
HHSCompleted
Completion Summary Developed
(X)
(date)
(X)
(X)
Exchange, training on QHP options and Insurance Affordability
Program(s), and adherence to privacy and security standards, as
specified in 45 CFR 155.260.
2.9a
If applicable: The Exchange has a process to verify that web
brokers are in compliance with State law including licensure
requirements consistent with 45 CFR 155.220(e).
2.9b
If applicable: The Exchange has agreements with web brokers,
consistent with 45 CFR 155.220(d), which address web broker
registration with the Exchange, training on QHP options and
Insurance Affordability Program(s), and adherence to privacy and
security standards, as specified in 45 CFR 155.260.
Supporting Documentation*
Testing Files*
HHS Approval
Letter for
Waive Out
(X)
IV&V
(X)
ensuring compliance with 45 CFR 155.220(c)(3),(d) and
(e), including how it will ensure web brokers are
appropriately trained and meet the Exchange’s privacy
and security standards.
3.0 Eligibility and Enrollment
3.1
3.1a1
The Exchange has developed and will use an HHS-approved
single, streamlined application for the individual market – or will
use the HHS-developed application – to determine eligibility and
collect information that is necessary for enrollment in a QHP for
the individual market and for Insurance Affordability Programs as
specified in 45 CFR 155.405. The Exchange has developed and
will use an HHS-approved application for SHOP or will use the
HHS-developed application for SHOP employers and employees
as specified in 45 CFR 155.730.
If applicable: State-developed single-streamlined
application to determine eligibility for the individual
market.
AND
If applicable: State-developed single-streamlined
application to determine eligibility for the SHOP.
The Exchange has developed and will use a HHS-approved
single, streamlined application for the individual market to
determine eligibility and collect information that is necessary for
enrollment in a QHP and for Insurance Affordability Programs as
specified in 45 CFR 155.405.
OR
25
Exchange Activity
Attestation
Testing Files*
Expected
State
HHSCompleted
Completion Summary Developed
(X)
(date)
(X)
(X)
3.1a2
The Exchange will use the HHS-developed single, streamlined
application for the individual market to determine eligibility and
collect information that is necessary for enrollment in a QHP and
for Insurance Affordability Programs as specified in 45 CFR
155.405.
3.1b1
The Exchange has developed and will use HHS-approved
applications for SHOP employers and employees as specified in
45 CFR 155.730.
OR
3.1b2
The Exchange will use the HHS-developed applications for SHOP
employers and employees as specified in 45 CFR 155.730.
3.2
The Exchange has developed and documented a coordination
strategy with other agencies administering Insurance Affordability
Programs and the SHOP that enables the Exchange to carry out
the eligibility and enrollment activities.
3.3
The Exchange has the capacity to accept and process
applications, updates, and responses to redeterminations from
applicants and enrollees, including applicants and enrollees who
have disabilities or limited English proficiency, through all
required channels, including in-person, online, mail, and phone.
3.3a
The Exchange has the capacity to accept and process
applications, updates, and responses to redeterminations from
applicants and enrollees in-person.
3.3b
The Exchange has the capacity to accept and process
applications, updates, and responses to redeterminations from
applicants and enrollees online.
Supporting Documentation*
HHS Approval
Letter for
Waive Out
(X)
IV&V
(X)
Brief description of the Exchange’s coordination strategy
with other agencies administering Insurance Affordability
Programs and the SHOP related to eligibility and
enrollment activities.
26
Exchange Activity
Attestation
Testing Files*
Expected
State
HHSCompleted
Completion Summary Developed
(X)
(date)
(X)
(X)
3.3c
The Exchange has the capacity to accept and process
applications, updates, and responses to redeterminations from
applicants and enrollees via mail.
3.3d
The Exchange has the capacity to accept and process
applications, updates, and responses to redeterminations from
applicants and enrollees via phone.
3.3e
The Exchange has the capacity to conduct the activities set out in
3.3a – 3.3d for applicants and enrollees who have disabilities or
limited English proficiency.
3.4
The Exchange has the capacity to send notices, including notices
in alternative formats and multiple languages; conduct periodic
data matching; and conduct annual redeterminations and process
responses in-person, online, via mail, and over the phone
pursuant to 45 CFR 155, subpart D.
3.4a
The Exchange has the capacity to generate and send notices,
including notices in alternative formats and multiple languages,
pursuant to 45 CFR 155, subpart D.
3.4b
The Exchange has the capacity to conduct periodic data
matching pursuant to 45 CFR 155, subpart D and act on the
results of the data matching.
3.4c
The Exchange has the capacity to conduct annual
redeterminations and process responses through all channels
pursuant to 45 CFR 155, subpart D.
3.5
The Exchange has the capacity to conduct verifications pursuant
to 45 CFR 155, subpart D, and is able to connect to data sources,
such as the Data Services Hub, and other sources as needed.
Supporting Documentation*
HHS Approval
Letter for
Waive Out
(X)
IV&V
(X)
If the Exchange will conduct additional periodic data
matching in accordance with 45 CFR 155.330(d)(2),
provide brief description of the data sources to be used.
Comprehensive list of data sources that the State is
connecting to or interfacing with, including a description
of the data types and information associated with each
source (including data sources that are used as primary
verification methods or are used when information is not
27
Exchange Activity
Attestation
Supporting Documentation*
Testing Files*
Expected
State
HHSCompleted
Completion Summary Developed
(X)
(date)
(X)
(X)
HHS Approval
Letter for
Waive Out
(X)
IV&V
(X)
reasonably compatible).
AND
Brief description of how verifications will be conducted in
the following areas: residency, citizenship and
immigration status, incarceration, household income,
family/household size, whether an individual is an
Indian, enrollment in an eligible employer-sponsored
plan (if applicable), eligibility for qualifying coverage in
an eligible employer-sponsored plan, and eligibility for
non-employer-sponsored minimum essential coverage.
If applicable, describe any of the verifications listed
above that may require the support of Federal agencies.
3.6
The Exchange has the appropriate privacy protections and
capacity to accept, store, associate, and process documents
received from individual applicants and enrollees electronically,
and the ability to accept, image, upload, associate, and process
paper documentation received from applicants and enrollees via
mail and/or fax.
3.6a
The Exchange has the appropriate privacy protections and
capacity to accept, store, associate, and process documents
received from applicants and enrollees electronically.
3.6b
The Exchange has the appropriate privacy protections and
capacity to accept, image, upload, associate, and process paper
documentation received from applicants and enrollees via mail
and/or fax.
28
Exchange Activity
Attestation
Testing Files*
Expected
State
HHSCompleted
Completion Summary Developed
(X)
(date)
(X)
(X)
3.7
The Exchange has the capacity to determine individual eligibility
for enrollment in a QHP through the Exchange and for employee
and employer participation in the SHOP. In addition, the
Exchange has the capacity to assess or determine eligibility for
Medicaid and CHIP based on Modified Adjusted Gross Income
(MAGI).
3.7a
The Exchange has the capacity to determine individual eligibility
for enrollment in a QHP through the Exchange.
3.7b1
The Exchange has the capacity to determine eligibility for
Medicaid and CHIP based on MAGI.
OR
3.7b2
The Exchange has the capacity to assess eligibility for Medicaid
and CHIP based on MAGI.
3.7c
The Exchange has the capacity to determine eligibility for
employee and employer participation in SHOP.
3.7d
The Exchange has the capacity to accept and process
applications that have been transferred from other agencies
administering Insurance Affordability Program(s).
3.8
The Exchange has the capacity to determine eligibility for
Advance Payments of the Premium Tax Credit (APTC) and Cost
Sharing Reductions (CSR), including calculating maximum APTC,
independently or through the use of a Federally-managed
service.
3.9
The Exchange has the capacity to independently send notices, as
necessary, to applicants and employers pursuant to 45 CFR 155,
subpart D that are in plain language, address the appropriate
audience, and meet content requirements.
Supporting Documentation*
HHS Approval
Letter for
Waive Out
(X)
IV&V
(X)
If the Exchange is using Federally-managed Services:
Provide a description of the end-to-end process,
including activities conducted by the Exchange and
integration points with the Federally-managed service.
29
Exchange Activity
Attestation
Testing Files*
Expected
State
HHSCompleted
Completion Summary Developed
(X)
(date)
(X)
(X)
3.10
The Exchange has the capacity to accept applications and
updates, conduct verifications, and determine eligibility for
individual responsibility requirement and payment exemptions
independently or through the use of Federally-managed services.
3.11
The Exchange has the capacity to support the eligibility appeals
process and to implement appeals decisions, as appropriate, for
individuals, employers, and employees.
3.12
The Exchange and SHOP have the capacity to process QHP
selections and terminations in accordance with 45 CFR 155.400
and 155.430, compute actual APTC, and report and reconcile
QHP selections, terminations, and APTC/advance CSR
information in coordination with issuers and CMS. This includes
exchanging relevant information with issuers and CMS using
electronic enrollment transaction standards.
3.12a
The Exchange has the capacity to process QHP selections and
terminations using electronic enrollment transaction standards in
coordination with issuers and CMS.
3.12b
The Exchange has the capacity to compute actual APTC.
3.12c
The Exchange has the capacity to report and reconcile QHP
selections, terminations, and APTC/advance CSR information in
coordination with issuers and CMS.
3.12d
The SHOP has the capacity to process QHP selections and
terminations, including reporting and reconciling selection and
termination information.
3.13
The Exchange has the capacity to electronically report results of
eligibility and exemption assessments and determinations, and
provide associated information to HHS, IRS, and other agencies
administering Insurance Affordability Programs, as applicable.
Supporting Documentation*
HHS Approval
Letter for
Waive Out
(X)
IV&V
(X)
If the Exchange is using Federally-managed Services:
Provide brief description of the end-to-end process,
including activities conducted by the Exchange and
integration points with the Federally-managed service.
30
Exchange Activity
Attestation
Supporting Documentation*
Testing Files*
Expected
State
HHSCompleted
Completion Summary Developed
(X)
(date)
(X)
(X)
HHS Approval
Letter for
Waive Out
(X)
IV&V
(X)
This includes information necessary to support administration of
the APTC and CSR as well as to support the employer
responsibility provisions of the Affordable Care Act.
3.14
In accordance with section 155.345(i) of the Exchange Final Rule,
the Exchange must follow procedures established in accordance
with 45 CFR 152.45 related to the Pre-Existing Condition
Insurance Plan (PCIP) transition.
4.0 Plan Management
If applying for Plan Management Partnership, the appropriate State entity, rather than the “Exchange,” will complete this section.
4.1
The Exchange has the appropriate authority to perform the
certification of QHPs and to oversee QHP issuers consistent with
45 CFR 155.1010(a).
Citation of the State’s applicable statutory and/or
regulatory authority(ies).
4.2
The Exchange has a process in place to certify QHPs pursuant to
45 CFR 155.1000(c) and according to QHP certification
requirements contained in 45 CFR 156.
Brief description of how the Exchange will ensure that
the issuers and health plans meet each of the QHP
certification standards. Include the process that the
Exchange will use to evaluate issuers and health plans
against each of the QHP certification standards,
including any differences specific to SHOP.
AND
Brief description of entities responsible for QHP
certification and briefly describe the roles and
responsibilities of each entity as they relate to each of
the QHP certification standards.
AND
Brief description of the integration between the
Exchange and the State Department of Insurance.
31
Exchange Activity
Attestation
Expected
State
HHSCompleted
Completion Summary Developed
(X)
(date)
(X)
(X)
4.2a
The Exchange has the capacity to certify QHPs in advance of the
annual open enrollment period pursuant to 45 CFR 155.1010(a)
(1).
4.2b
The Exchange has the capacity to ensure QHPs comply with the
QHP certification standards contained in 45 CFR 156 including,
but not limited to, standards relating to licensure, solvency,
service area, network adequacy, essential community providers,
marketing and discriminatory benefit design, accreditation, and
consideration of rate increases.
4.2c
The Exchange has the capacity to collect, analyze, and if
required, submit to the Federal government for review QHPs’ plan
variations for cost-sharing reductions, advance payment
estimates for such reductions, and any supporting documentation
needed to ensure compliance with applicable regulations and
accuracy of the cost-sharing reduction advance payments.
4.2d
The Exchange has the capacity to ensure QHPs meet actuarial
value and essential health benefit standards in accordance with
applicable regulations and guidance.
4.2e
4.3
Supporting Documentation*
Testing Files*
HHS Approval
Letter for
Waive Out
(X)
IV&V
(X)
The Exchange has the capacity to ensure QHPs’ compliance with
market reform rules in accordance with applicable regulations and
guidance.
The Exchange uses a plan management system(s) or processes
that support the collection of QHP issuer and plan data; facilitate
the QHP certification process; manage QHP issuers and plans;
and integrate with other Exchange business areas, including the
Exchange Internet Web site, call center, quality, eligibility and
enrollment, and premium processing.
Brief description of the anticipated number of health
plans expected to participate in the Exchange.
AND
Brief description of the collection method and applicable
systems that will be used to support the business
operations of Plan Management.
32
Exchange Activity
Attestation
Testing Files*
Expected
State
HHSCompleted
Completion Summary Developed
(X)
(date)
(X)
(X)
Supporting Documentation*
HHS Approval
Letter for
Waive Out
(X)
IV&V
(X)
4.3a
The Exchange has the capacity to collect and analyze information
on plan rates, covered benefits, and cost-sharing requirements
pursuant to 45 CFR 155.1020.
4.3b
The Exchange has the capacity to use plan rate data and rules
for purposes such as generating consumer-facing premiums and
determining the second-lowest cost silver plan for premium tax
credit calculations.
4.4
The Exchange has the capacity to ensure QHPs’ ongoing
compliance with QHP certification requirements pursuant to 45
CFR 155.1010(a)(2), including a process for monitoring QHP
performance and collecting, analyzing, and resolving enrollee
complaints.
4.4a
The Exchange has the capacity to ensure QHPs’ ongoing
compliance with QHP certification requirements pursuant to 45
CFR 155.1010(a) (2) and Exchange operational requirements.
4.4b
The Exchange has a process to monitor QHP performance and to
collect, analyze, and resolve enrollee complaints in conjunction
with any applicable State entities (e.g., State Department of
Insurance, consumer assistance programs, and ombudsmen).
4.5
The Exchange has the capacity to support issuers and provides
technical assistance to ensure ongoing compliance with QHP
issuer operational standards.
Description of issuer technical assistance and support
activities to be provided by the Exchange and examples
where applicable.
4.6
The Exchange has a process for QHP issuer recertification,
decertification, and appeal of decertification determinations
pursuant to 45 CFR 155.1075 and 155.1080.
Brief description of the process for transitioning
enrollees to new QHPs in the event of a QHP
decertification, including any differences specific to
SHOP.
Brief description of approach to ensuring QHP
compliance and monitoring of QHP performance,
including any integration between Exchange and other
State entities.
33
Exchange Activity
Attestation
Supporting Documentation*
Testing Files*
Expected
State
HHSCompleted
Completion Summary Developed
(X)
(date)
(X)
(X)
HHS Approval
Letter for
Waive Out
(X)
IV&V
(X)
AND
Brief description of general approach for decertification,
recertification, and appeals of decertification.
4.6a
The Exchange has a process for recertification of QHP issuers
and QHPs including the annual receipt and review of QHP rate,
benefit, and cost sharing information pursuant to 45 CFR
155.1020(c).
4.6b
The Exchange has a process for decertification of QHPs and
QHP issuers and a process for transitioning enrollees into new
QHPs pursuant to 45 CFR 155.1080.
4.6c
The Exchange has a process for the QHP issuer appeal of a
decertification of a QHP pursuant to 45 CFR 155.1080 and any
necessary appeal of QHP certification determinations consistent
with any applicable State laws or regulations.
4.7
The Exchange has set a timeline for QHP issuer accreditation in
accordance with 45 CFR 155.1045. The Exchange also has
systems and procedures in place to ensure QHP issuers meet
accreditation requirements (per 45 CFR 156.275) as part of QHP
certification in accordance with applicable rulemaking and
guidance.
4.8
The Exchange has systems and procedures in place to ensure
that QHP issuers meet the minimum certification requirements
pertaining to quality reporting and provide relevant information to
the Exchange and HHS pursuant to Affordable Care Act
1311(c)(1), 1322(e)(3), and as specified in rulemaking.
34
Exchange Activity
Attestation
Testing Files*
Expected
State
HHSCompleted
Completion Summary Developed
(X)
(date)
(X)
(X)
Supporting Documentation*
HHS Approval
Letter for
Waive Out
(X)
IV&V
(X)
5.0 Risk Adjustment and Reinsurance
Additional requirements for Risk Adjustment will be provided in the HHS Notice of Benefit and Payment Parameters.
5.1
The State has the legal authority to operate the risk adjustment
program per 45 CFR 153 and Affordable Care Act 1343, if the
State chooses to administer its own risk adjustment program.
5.1a
If applicable: will be overseeing the risk adjustment program. This risk
adjustment entity must meet the requirements outlined in 45 CFR
155.110 and can include Departments of Insurance (DOIs). Note:
The entity cannot be a health insurance issuer. Options include
DOI, Medicaid, or “Other Entity.”
5.2
The State operates its own reinsurance program per 45 CFR 153
and Affordable Care Act 1341.
5.2a
If applicable: The reinsurance entity will be a not-for-profit entity
If the State plans to administer its own risk adjustment
program: Indicate the entity(s) that will be operating the
risk adjustment program, and provide a brief description.
and will have the legal authority and capacity to receive selfinsured market reinsurance contributions from HHS, determine
payment amounts, distribute payments, and perform data
collection and auditing functions regarding reinsurance payments.
5.2b
If the entity collects contributions in the fully insured market in the
State: The reinsurance entity will have the legal authority and
capacity to identify all issuers in the State's fully insured market
that owe reinsurance contributions, determine appropriate
contribution amounts from issuers, and ensure the collection of
reinsurance contributions.
Brief description of how the State’s reinsurance entity
intends to collect contributions from the fully insured
market and identify sub-contractors that will be involved
in collecting contributions from the fully insured market.
Note: State must inform HHS of its intent to collect
contributions from the fully insured market no later than
December 1, 2012. HHS will collect contributions from
the self-insured market.
35
Exchange Activity
Attestation
Testing Files*
Expected
State
HHSCompleted
Completion Summary Developed
(X)
(date)
(X)
(X)
5.2c
If the State opts to modify the Federal reinsurance parameters,
collect reinsurance contributions in the fully-insured market,
collect additional reinsurance contributions, modify HHS
requirements for data collection or collection frequency for issuers
receiving reinsurance payments, and/or use more than one
reinsurance entity: The State will publish its reinsurance
modifications in a State notice of benefit and payment parameters
by March 1, 2013.
Supporting Documentation*
HHS Approval
Letter for
Waive Out
(X)
IV&V
(X)
Timeline under which the State will submit its
modifications in the State notice of benefit and payment
parameters.
6.0 Small Business Health Options Program (SHOP)
6.1
The SHOP is compliant with regulatory requirements pursuant to
45 CFR 155 Subpart H.
6.1a
The SHOP has capacity to allow a qualified employer to select a
level of coverage as described in the Affordable Care Act 1302(d)
(1), in which all QHPs within that level are made available to the
qualified employees of the employer.
6.1b
The SHOP has capacity to ensure that all QHP issuers make rate
changes at a uniform time that is either quarterly, monthly, or
annually, and has the capacity to prohibit all QHP issuers from
varying rates for a qualified employer during the employer’s plan
year.
6.1c
The SHOP has capacity to offer small employers only QHPs that
meet the requirements for the State’s small group market.
6.1d
If the SHOP decides to implement minimum participation
requirements, the SHOP has capacity to authorize uniform group
participation rules for the offering of health insurance coverage in
the SHOP.
Brief description of how the size of a small business is
determined in the Exchange and whether the small
group market includes employers with 51 to 100
employees in 2014 and 2015.
36
Exchange Activity
Attestation
Expected
State
HHSCompleted
Completion Summary Developed
(X)
(date)
(X)
(X)
6.1e
The SHOP has established a premium calculator, as described in
45 CFR 155.205(b) (6), to facilitate the comparison of available
QHPs after the application of any applicable employer
contribution in lieu of any advance payment of the premium tax
credit and any cost-sharing reductions.
6.2
The Exchange has the capacity for SHOP premium aggregation
pursuant to 45 CFR 155.705.
6.2a
The Exchange has the systems in place for billing employers,
receiving employer and employee contributions toward premiums,
and making aggregated premium payments to issuers.
6.2b
The Exchange has a process for managing non-payment or late
premiums; including how and when notices are sent to
employers.
6.3
The SHOP Exchange has the capacity to electronically report
information to the IRS for tax administration purposes.
Supporting Documentation*
Testing Files*
HHS Approval
Letter for
Waive Out
(X)
IV&V
(X)
7.0 Organization and Human Resources
7.1
The Exchange has an appropriate organizational structure and
staffing resources to perform Exchange activities.
Organizational chart
AND
Brief description of the hiring strategy that addresses
competencies, roles, and responsibilities needed to
perform key Exchange activities.
7.1a
The Exchange has an organizational structure that includes
leadership/key staff and encompasses key Exchange activities.
37
Exchange Activity
Attestation
Expected
State
HHSCompleted
Completion Summary Developed
(X)
(date)
(X)
(X)
7.1b
Supporting Documentation*
Testing Files*
HHS Approval
Letter for
Waive Out
(X)
IV&V
(X)
The Exchange has a hiring strategy that addresses
competencies, roles, and responsibilities needed to perform key
Exchange activities.
8.0 Finance and Accounting
8.1
The Exchange has a long-term operational cost, budget, and
management plan.
Brief description of the methods the Exchange will use to
generate revenue and how the Exchange will address
any financial deficits.
AND
Model budget entailing expected operating costs,
revenues, and expenditures.
8.1a
The Exchange has a long-term operational budget and
management plan, monitors its finances, and is able to track its
costs and revenues.
8.1b
The Exchange has defined methods for generating revenue (e.g.,
user fees) pursuant to Affordable Care Act 1311(d) (5) (A), and
has the appropriate legal authority.
9.0 Technology
9.1
The Exchange technology and system functionality complies with
relevant HHS information technology (IT) guidance.
9.2
The Exchange has the adequate technology infrastructure and
bandwidth required to support all of the Exchange activities.
9.3
The Exchange effectively implements IV&V, quality management,
and test procedures for Exchange-development activities and
demonstrates it has achieved HHS-defined essential functionality
for each required activity.
Brief description of any areas of significant variation
between Exchange technology and system functionality
and HHS IT guidance.
Brief description of the front-end system engineering
work including IT, quality assurance processes and
IV&V services used to validate requirements, business
processes and development of the Exchange.
38
Exchange Activity
Attestation
Testing Files*
Expected
State
HHSCompleted
Completion Summary Developed
(X)
(date)
(X)
(X)
Supporting Documentation*
HHS Approval
Letter for
Waive Out
(X)
IV&V
(X)
10.0 Privacy and Security
10.1
The Exchange has established and implemented written policies
and procedures regarding the Privacy and Security standards set
forth in 45 CFR 155.260(a) – (g).
10.2
The Exchange has established and implemented safeguards that
(1) ensure the critical outcomes in 45 CFR 155.260(a) (4),
including authentication and identity proofing functionality, and (2)
incorporates HHS IT requirements as applicable.
10.3
The Exchange has adequate safeguards in place to protect the
confidentiality of all Federal information received through the Data
Services Hub, including but not limited to Federal tax information.
10.3a
The Exchange has adequate safeguards in place to protect the
confidentiality of all Federal information received through the Data
Services Hub, including but not limited to Federal tax information.
10.3b
The Exchange has developed and received a letter of acceptance
from the IRS on its Safeguard Procedures Report related to the
protection of Federal tax information.
11.0 Oversight and Monitoring
11.1
The Exchange has a process in place to perform required
activities related to routine oversight and monitoring of Exchange
activities (and will supplement those policies and procedures to
implement regulations promulgated under the Affordable Care Act
1313).
11.1a
The Exchange has in effect policies and procedures for
performing routine oversight and monitoring of Exchange
activities.
11.1b
The Exchange has in effect quality controls as part of oversight
Brief description of the oversight and monitoring plan for
the Exchange, including any specific protocols for quality
monitoring of Exchange activities (e.g., Eligibility and
Enrollment, Plan Management).
39
Exchange Activity
Attestation
Testing Files*
Expected
State
HHSCompleted
Completion Summary Developed
(X)
(date)
(X)
(X)
Supporting Documentation*
HHS Approval
Letter for
Waive Out
(X)
IV&V
(X)
and monitoring of Exchange activities.
11.2
The Exchange has the capacity to track and report performance
and outcome metrics related to Exchange Activities in a format
and manner specified by HHS necessary for, but not limited to,
annual reports required by Affordable Care Act 1313(a).
Brief description of data-collection and reporting
processes and Exchange activity-related performance
metrics that the Exchange intends to track for internal
purposes as part of ongoing quality controls and
improvement plan.
11.3
The Exchange has instituted procedures and policies that
promote compliance with the financial integrity provisions of
Affordable Care Act 1313 (and will supplement those policies and
procedures to implement regulations promulgated under the
Affordable Care Act 1313), including the requirements related to
accounting, reporting, auditing, cooperation with investigations,
and application of the False Claims Act.
Indicate the financial or accounting standards with which
the Exchange is in compliance (e.g., Government
Accounting Standards Board, Government
Accountability Office (GAO) Government Auditing
Standards (Yellow Book), OMB Circular A-123
“Management’s Responsibility for Internal Control”).
12.0 Contracting, Outsourcing, and Agreements
12.1
The Exchange has executed appropriate contractual,
outsourcing, and partnership agreements with vendors and/or
State and Federal agencies for all Exchange activities and
functionality as needed, including data and privacy agreements.
Exchange contracting entities meet the requirements for eligible
contracting entities outlined in 45 CFR 155.110.
List of all contractor(s) with which Exchange has
contracted and a notation of the services that the
contractor(s) will support.
13.0 State Partnership Exchange Activities
13.1
The State has appropriate agreements in place to operate the
Plan Management activities for a State Partnership Exchange.
13.1a
The State and applicable entities have agreed to a process for
timely plan management data submission in the specified format
to the Federally-facilitated Exchange.
40
Exchange Activity
Attestation
Testing Files*
Expected
State
HHSCompleted
Completion Summary Developed
(X)
(date)
(X)
(X)
13.1b
The State and applicable entities have signed and agreed to
adhere to the terms and conditions of all necessary agreement(s)
required to carry out required Exchange activities.
13.1c
The State and applicable entities have agreed on a process for
coordination with Federally-facilitated Exchange account
managers and oversight.
13.2
The State has the capacity to interface with the Federallyfacilitated Exchange, as necessary, to ensure a seamless
consumer experience.
13.2a
The State and the applicable State agencies have the capacity to
conduct necessary coordination with the Exchange regarding
customer service, outreach, and education.
13.2b
The applicable State agencies have the capacity to share data
with the Exchange that is needed to support the eligibility process
for Insurance Affordability Programs.
13.3
The appropriate State entity has appropriate agreements in place
and capacity to manage and operate a Navigator program and to
establish and operate an in-person assistance program for a
State Partnership Exchange.
13.3a
The appropriate State entity has established or has a process in
place to support, administer, and oversee (as applicable) aspects
of the Federally-facilitated Exchange Navigator program
consistent with the applicable requirements of 45 CFR 155.210,
including ensuring that Navigators are adhering to the training
and conflict of interest standards established by the Federallyfacilitated Exchange and to the privacy and security standards
developed by the Federally-facilitated Exchange pursuant to 45
Supporting Documentation*
HHS Approval
Letter for
Waive Out
(X)
IV&V
(X)
Brief description of the appropriate State entity’s plan to
operate a Navigator program, including how it will
ensure Navigators are appropriately trained and meet
the Federally-facilitated Exchange’s conflict of interest,
privacy and security standards.
41
Exchange Activity
Attestation
Testing Files*
Expected
State
HHSCompleted
Completion Summary Developed
(X)
(date)
(X)
(X)
Supporting Documentation*
HHS Approval
Letter for
Waive Out
(X)
IV&V
(X)
CFR 155.260.
13.3b
Brief description of the appropriate State entity’s plan to
operate an in-person assistance program including
documentation outlining how it will meet the
requirements set out in Federally-facilitated Exchange
guidance, policies, and procedures.
The appropriate State entity has established an in-person
assistance program distinct from the Navigator program, and has
a process in place to operate the program consistent with
Federally-facilitated Exchange guidance, policies, and
procedures.
Relevant File Uploads
The following files should be uploaded as applicable. Files should be clearly labeled with the appropriate activity(ies). Depending on the
Exchange activity being tested, a given document or file may encompass multiple activities. In such cases, please note any file crossreferencing and clearly label the activities within the attachments. States do not need to upload the same file multiple times.
Testing Files
Browse
Supporting Documentation
Browse
Letter(s) from HHS allowing an applicant to waive out of any
supporting documentation and/or testing file requirements
given successful completion of an activity through
Establishment Review(s)
Expected Completion Work Plan and Timeframes
Browse
Browse
Please provide any additional comments related to
completion of this Application
42
| File Type | application/pdf |
| File Title | Draft Blueprint for Approval of Affordable State-based and State Partnership Insurance Exchanges |
| Subject | Affordable Health Care Act |
| Author | Department of Health and Human Services |
| File Modified | 2012-11-15 |
| File Created | 2012-11-15 |