CMS-10400 - Supporting Statement CCIIO clean

Medicaid and Children’s Health Insurance Programs: Essential Health Benefits in
Alternative Benefit Plans, Eligibility Notices, Fair Hearing and Appeal Processes, and
Premiums and Cost Sharing; Exchanges: Eligibility and Enrollment
Supporting Statement for Exchange Provisions

A. Background
The Patient Protection and Affordable Care Act, Public Law 111-148, enacted on March
23, 2010, and the Health Care and Education Reconciliation Act, Public Law 111-152, enacted
on March 30, 2010 (collectively, “Affordable Care Act”), expands access to health insurance for
individuals and employees of small businesses through the establishment of new Affordable
Insurance Exchanges (Exchanges), including the Small Business Health Options Program
(SHOP). The Exchanges, which will become operational by January 1, 2014, will enhance
competition in the health insurance market, expand access to affordable health insurance for
millions of Americans, and provide consumers with a place to easily compare and shop for
health insurance coverage.
The reporting requirements and data collection in Medicaid, Children’s Health Insurance
Programs, and Exchanges: Essential Health Benefits in Alternative Benefit Plans, Eligibility
Notices, Fair Hearing and Appeal Processes, and Premiums and Cost Sharing; Exchanges:
Eligibility and Enrollment (CMS-2334-F) address: (1) standards related to notices, (2)
procedures for the verification of enrollment in an eligible employer-sponsored plan and
eligibility for qualifying coverage in an eligible employer-sponsored plan; and (3) other
eligibility and enrollment provisions to provide detail necessary for state implementation.
The submission seeks OMB approval of the information collection requirements

1

associated with selected provisions in 45 CFR parts 155, 156 and 157.
It is important to note that these regulations involve several information collections that
will occur through the single, streamlined application for enrollment in a QHP and for insurance
affordability programs described in §155.405. We have accounted for the burden associated with
these collections in the Supporting Statement for Data Collection to Support Eligibility
Determinations for Insurance Affordability Programs and Enrollment through Health Benefits
Exchanges, Medicaid, and Children’s Health Insurance Program Agencies (CMS-10440).
We would also like to highlight that this supporting statement also includes several
information collections from regulatory provisions finalized in the Exchange final rule. We have
included these information collections in this PRA package to address PRA requirements related
to those provisions as they were not included in the information collection section of the
Exchange final rule.
Additionally, throughout this section, we reference notices, and include data elements
associated with these notices in Appendix A.
B. Justification
1.

Need and Legal Basis
Sections 1311(b) and 1321(b) of the Affordable Care Act provide that each state has the

opportunity to establish an Exchange that (1) facilitates the purchase of insurance coverage by
qualified individuals through QHPs; (2) assists qualified employers in the enrollment of their
employees in QHPs; and (3) meets other standards specified in the Affordable Care Act. Section
1311(k) of the Affordable Care Act specifies that Exchanges may not establish rules that conflict
with or prevent the application of regulations promulgated by the Secretary. Section 1311(d) of
the Affordable Care Act describes the minimum functions of an Exchange, including the

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certification of QHPs.
Section 1321 of the Affordable Care Act discusses state flexibility in the operation and
enforcement of Exchanges and related policies. Section 1321(c)(1) directs the Secretary to
establish and operate such Exchanges within states that either: (1) do not elect to establish an
Exchange, or (2) as determined by the Secretary on or before January 1, 2013, will not have an
Exchange operable by January 1, 2014. Section 1321(a) also provides broad authority for the
Secretary to establish standards and regulations to implement the statutory standards related to
Exchanges, QHPs, and other components of title I of the Affordable Care Act.
Section 1401 of the Affordable Care Act creates new section 36B of the Internal Revenue
Code (the Code), which provides for a premium tax credit for eligible individuals who enroll in a
QHP through an Exchange. Section 1402 of the Affordable Care Act establishes provisions to
reduce the cost-sharing obligation of certain eligible individuals enrolled in a QHP offered
through an Exchange, including standards for determining whether Indians are eligible for
certain categories of cost-sharing reductions.
Under section 1411 of the Affordable Care Act, the Secretary is directed to establish a
program for determining whether an individual meets the eligibility standards for Exchange
participation, advance payments of the premium tax credit, cost-sharing reductions, and
exemptions from the shared responsibility payment.
Sections 1412 and 1413 of the Affordable Care Act and section 1943 of the Social
Security Act (the Act), as added by section 2201 of the Affordable Care Act, contain additional
provisions regarding eligibility for advance payments of the premium tax credit and cost-sharing
reductions, as well as provisions regarding simplification and coordination of eligibility
determinations and enrollment with other health programs.

3

Unless otherwise specified, the provisions in this proposed rule related to the
establishment of minimum functions of an Exchange are based on the general authority of the
Secretary under section 1321(a)(1) of the Affordable Care Act.
These information collection requirements are set forth in 45 CFR Parts 155, 156, and
157.
2.

Information Users
The data collection and reporting requirements described below are critical to the basic

ability of Exchanges to facilitate enrollment in qualified health plans, and will also assist
Exchanges, health insurance issuers, and HHS in ensuring program integrity and quality
improvement.
3.

Use of Information Technology
HHS anticipates that a majority of the activities described below specified in this rule will

be automated. Exchanges and health insurance issuers are expected to develop automated notice
templates for many of the specified notices, and distribute the majority of these notices through
secure electronic accounts. The entities issuing notices or collecting information will develop the
initial template after which the templates will be automatically populated with the appropriate
information for the receiving party. A majority of the information that is collected in accordance
with this rule will be submitted electronically. Staff, or systems, will analyze, review, or process
the data through largely electronic means and communicate with individuals, states and health
insurance issuers using e-mail, telephone, or other electronic means whenever possible.
4.

Duplication of Efforts
These information collections do not duplicate any current information collections. They

contain information needed for a new program.

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5.

Small Businesses
We estimate minimal burden on small business as they are not required to participate in

the SHOP.
6.

Less Frequent Collection
Due to the required flow of information between multiple parties and flow of funds for

payments supporting health insurance coverage purchased through the Exchange, it is necessary
to collect information according to the indicated frequencies. If the information is collected less
frequently, the result would be less accurate, untimely or unavailable eligibility, enrollment or
payment information for Exchanges, insurers, employers and individuals. This would lead to
delayed payments to insurers; late charges to or payments by employers and enrollees; inaccurate
or inappropriate advance payments of the premium tax credit and cost sharing reductions; the
release of misleading information regarding health care coverage to potential enrollees; and an
overall stress on the organizational structure of the Exchanges and decrease in benefit to
individuals and employers.
7.

Special Circumstances
These information collections do not include any special circumstances.

8.

Federal Register/Outside Consultation
The proposed rule, Establishment of Exchanges and Qualified Health Plans, and the

associated collection of information were published on July 15, 2011 (76 FR 41905). The
proposed rule, Exchange Functions in the Individual Market: Eligibility Determinations;
Exchange Standards for Employers, was published on August 17, 2011 (76 FR 51202). The
comments for both of these proposed rules and the collection of information were due within 60
days of the publication. We received a number of comments on the proposed rules and one

5

comment on the collection of information. The commenter stated that the Collection of
Information was inadequate and recommended that HHS revise the Collection of Information.
HHS staff reviewed all received comments and questions on the proposed rules, revised the
document as appropriate, and forwarded revisions to the Office of the HHS Secretary for
submission to OMB. The final rule was published on March 27, 2012 (77 FR 18310). We also
published the proposed rule entitled 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 (CMS-2334-F). We are finalizing the proposed rule at the
time of publishing this Supporting Statement. We received a number of comments on the
proposed rule and received one comment related to the Exchange provision related to certified
application counselors, requesting that we include a burden estimate for this provision. We
intend to finalize the regulatory provisions regarding certified application counselors at a later
date, and will respond to that comment at that time.
As part of Exchange implementation to date, we have consulted with contractors,
academia, states, and industry of the feasibility of this information collection. We have based
many of the requirements in this information collection from the consultations with these outside
entities.
9.

Payments/Gifts to Respondents
No payments and/or gifts will be provided to respondents.

10. Confidentiality
To the extent of the applicable law and HHS policies, we will maintain respondent

6

privacy with respect to the information collected.
11. Sensitive Questions
There are no sensitive questions included in this information collection effort.
12. Burden Estimates (Hours & Wages)
For purposes of presenting an estimate of paperwork burden, we reflect the participation
of 18 State-based Exchanges. We also note that these estimates generally reflect burden for the
first year, and that the associated burden in subsequent years will be significantly lower because
many of the standards in the regulation will be fulfilled through the development of automated
processes that will involve only maintenance in future years. Therefore, these estimates should
be considered an upper bound of burden for non-federal entities. These estimates may be
adjusted in future PRA packages as Exchange development moves forward.
Salaries for the positions cited in the labor category of the burden charts were taken from
the May 2011 National Occupational Employment and Wage Estimate from the Bureau of Labor
Statistics (BLS) (http://www.bls.gov/oes/2011/may/oes_nat.htm). Additional employer costs are
based on the rate for management, professional, and related workers from the BLS’s June 2012
Employer Costs for Employee Compensation survey
(http://www.bls.gov/news.release/archives/ecec_09112012.htm).

Information Collections under Part 155
Subpart C—General Functions of an Exchange
A. Role of authorized representatives in the Exchange (§155.227)

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Section 155.227(a) provides that an applicant or enrollee, subject to applicable privacy
and security requirements, may designate an individual person or organization as his or her
authorized representative. One method for designating an authorized representative is by
submitting legal documentation of the representative’s authority. Exchanges have the option to
make available an “Appointment of Authorized Representative Form” at the time of application
or anytime thereafter for an individual to designate an authorized representative. Such a form
would collect identifying and contact information about the applicant, enrollee, and requested
authorized representative. Requested data elements would include the following for both the
applicant or enrollee and the requested representative: name, address, phone number, email
address, date of birth, and relationship. The applicant, enrollee, or authorized representative
could obtain the form from the Exchange website or from an assister (such as a Navigator, nonNavigator in-person assister, etc.), and could submit it to the Exchange by mail or online at any
time. We expect that the Exchange would use this information to authorize the authorized
representative to act on behalf of the applicant or enrollee. An authorized representative could
also submit this form if the applicant or enrollee is unable to do so.
HHS is currently developing a model Appointment of Authorized Representative Form to
be used by the Federally-facilitated Exchanges and will make that form available to State-based
Exchanges, which would also decrease the burden on State-based Exchanges to develop such a
form. If a state opts not to use the form provided by HHS, we estimate the burden associated for
the time and effort necessary for a State-based Exchange to develop the Appointment of
Authorized Representative Form to be 30 hours. This includes a 10 hours from a mid-level
health policy analyst at an hourly cost of $49.35 and 10 hours from an operations analyst at an
hourly cost of $54.45 for drafting the form with 4 hours of managerial oversight at an hourly cost

8

of $79.08 and 6 hours of legal review at an hourly cost of $90.14. The estimated cost per Statebased Exchange is $1,895, for a total cost of $34, 113 for 18 State-based Exchanges.

Labor Category
Health Policy
Analyst
Operations Analyst
Attorney
Senior Manager
Total

Hourly
Number of Labor
Employees Costs
1
1
1
1

$49.35
$54.45
$90.14
$79.08

Total Burden
Burden Costs (per
Hours Exchange)
10
10
6
4
30

Total Burden Costs
(per year)

$493.50
$544.50
$540.84
$316.32
$1,895.16

$493.50
$544.50
$540.84
$316.32
$34,112.88

For an applicant, enrollee, or prospective authorized representative, we estimate that it
will take up to 5 minutes to review instructions and complete a Appointment of Authorized
Representative Form. While we expect most applicants, enrollees, or prospective authorized
representatives to complete the Authorized Representative Form, an applicant, enrollee, or
prospective authorized representative may also comply with this provision by providing the
necessary information online, by phone, by mail or in-person. We expect a similar burden on the
applicant, enrollee, or authorized representative to comply with this provision through such
means.
Labor Category
Individual
Total per response

Number of
Individuals
1
1

Hourly Labor
Costs
---

Burden
Hours
0.08
0.08

Total Burden
Costs
---

. If the applicant, enrollee, or authorized representative chooses to submit an
“Appointment of Authorized Representative Form,” the burden for a State-based Exchange to
process the submitted information will be approximately 10 minutes at a cost of $3.39 per
submission. We anticipate that an eligibility support staff person will scan, digitize, and link the

9

form to an applicant’s or enrollee’s account, review the submitted information, and update the
authorized representative’s and applicant’s or enrollee’s account, if applicable.
Labor Category

Eligibility Support Staff
Total per response

Number of
Employees

Hourly
Labor Costs

Burden
Hours

1
1

$19.97

0.17
0.17

Total
Burden
Costs
$3.39
$3.39

B. General standards for Exchange notices.
Subpart D—Exchange Functions in the Individual Market: Eligibility Determinations for
Exchange Participation and Insurance Affordability (§155.302 through §155.345)
A. Options for conducting eligibility determinations (§155.302)
Section 155.302 of the regulation provides options for conducting eligibility
determinations. Section 155.302(a) provides that the Exchange may satisfy the requirements of
this subpart directly or through contracting arrangements or through a combination of the
approach described in paragraph (a)(1) and one or both of the options, described in paragraphs
(b) and (c), and certain standards are met. Section 155.302(b)(6) specifies that an Exchange that
uses the options specified in paragraphs (b) or (c) will enter in to agreements that reflect roles
and responsibilities. The burden associated with these provisions is the time and effort necessary
for the Exchange to establish or modify agreements for eligibility determinations and
coordination of eligibility functions. For 155.302(b)(6) this burden is captured in the agreements
associated with §155.345. For 155.302(c), since this agreement would involve a different
relationship, specifically, HHS and the Exchange, instead of the Exchange and Medicaid and
CHIP agencies, we have estimated to be the time and effort necessary for the Exchange to
develop and execute agreements with HHS, which we estimate will take 105 hours per
Exchange.
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Labor Category
Health Policy
Analyst
Operations Analyst
Attorney
Senior Manager
Total

Hourly
Number of Labor
Employees Costs
1
1
1
1

$49.35
$54.45
$90.14
$79.08

Total Burden
Burden Costs (per
Hours Exchange)
35
35
30
5
105

Total Burden Costs
(per year)

$1,727
$1,906
$2,704
$395
$6,733

$88,096
$97,200
$137,920
$20,166
$121,194

Section 155.302(b)(4) provides that if the Exchange conducts an assessment in
accordance with paragraph (b) of this section and finds that an applicant is not potentially
eligible for Medicaid and CHIP based on the applicable Medicaid and CHIP MAGI-based
income standards, the Exchange must consider the applicant as ineligible for Medicaid and CHIP
for purposes of determining eligibility for advance payments of the premium tax credit and costsharing reductions, notify the applicant, and provide the applicant with the opportunity to
withdraw his or her application for Medicaid and CHIP or request a full determination of
eligibility for Medicaid and CHIP by the applicable State Medicaid and CHIP agencies.
However, the provisions in §155.302 do not involve burden beyond what is already addressed in
§155.310(g), since each state will choose either an assessment or determination. In the case of an
assessment, the Exchange will substitute language described in this section with what would be
otherwise included.
In accordance with section 1413(b) of the Affordable Care Act, section 155.310(a)(1)
specifies that the Exchange use a single streamlined application, as specified in §155.405.
Section 155.405 also provides that the Exchange may choose to use an alternative application if
such application is approved by HHS and requests the minimum information necessary for the
purposes identified in §155.405(a). The application will include information that will be used to
determine the eligibility of an applicant for enrollment in a qualified health plan through the
11

Exchange and insurance affordability programs, as applicable. More detailed information on this
information collection requirement and the corresponding burden estimates is outlined in the
Supporting Statement for Data Collection to Support Eligibility Determinations for Insurance
Affordability Programs and Enrollment through Health Benefits Exchanges, Medicaid, and
Children’s Health Insurance Program Agencies (CMS-10440).
Throughout this subpart, we propose that the Exchange collect attestations from the
application filer. For the most part, these attestations will be collected as a data element or
incorporated in some way as part of the single streamlined application. As such, we have
accounted for the burden associated with these collections in the Supporting Statement for Data
Collection to Support Eligibility Determinations for Insurance Affordability Programs and
Enrollment through Health Benefits Exchanges, Medicaid, and Children’s Health Insurance
Program Agencies (CMS-10440).
C. Eligibility Process (§155.310)
Section 155.310(d)(3) provides that to the extent that the Exchange determines an
applicant eligible for Medicaid or CHIP, the Exchange must notify the state Medicaid or CHIP
agency and transmit all information from the records of the Exchange to the Medicaid or CHIP
agency to ensure that the Medicaid or CHIP agency can provide the applicant with coverage
promptly and without undue delay. This applicant information will be transmitted electronically
from the Exchange to the agency administering Medicaid or CHIP upon receiving an indication
that the Exchange has determined an applicant eligible for such program. The purpose of this
data transmission is to notify the agency administering Medicaid or CHIP that an individual is
newly eligible and so the agency should facilitate enrollment in a plan or delivery system. Data
will be transmitted through a secure electronic interface. The burden associated with this

12

provision is the burden of creating and executing agreements with State Medicaid and CHIP
agencies, which we estimate in §155.345.
Section 155.310(g) provides that the Exchange will notify an individual regarding his or
her eligibility determination after it has been made. This notice provides information necessary
to understand key next steps, including plan selection or appeal. We anticipate that the Exchange
will consolidate this notice when multiple members of a household are applying together and
receive an eligibility determination at the same time. The notice will be in writing, and may be in
paper or electronic format. We anticipate that a large volume of enrollees will request electronic
notification while others will opt to receive the notice by mail. As a result, we estimated the
associated mailing costs for the time and effort needed to mail notices in bulk to enrollees as
appropriate.
We expect that the eligibility determination notice will be dynamic and include
information tailored to all possible outcomes of an application. To develop the notice, Exchange
staff will need to learn eligibility rules and draft notice text for various decision points, along
with information regarding next steps, referrals, customer service, and appeals. A health policy
analyst, manager, and legal counsel will review the notice. The Exchange will then incorporate
changes from the consultation and user testing including review to ensure compliance with plain
writing, language access, and readability standards. The Exchange will also consult with the state
Medicaid or CHIP agency in order to develop coordinated notices. Finally, a developer
(occupation no. 15-1131) will program the template notice into the eligibility system so that the
notice may be populated and generated.
HHS is currently developing model notices for the eligibility determination notice and
several other notices described in this subpart which will also decrease the burden on Exchanges

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to provide such notices. If a state opts not to use the model notice provided by HHS, we estimate
that this notice development as outlined in the paragraph above, including the systems
programming, would take each Exchange an estimated 100 hours to complete in the first year if a
state opts to use the model notices provided by HHS. We estimate the cost for each Exchange
would be approximately $5,971 and a total cost of $107,478 for 18 State-based Exchanges. We
expect that the burden on the Exchange to maintain this notice will be significantly lower than
the estimate to develop it.

Labor Category

Health Policy Analyst
Attorney
Senior Manager
Computer Programmer
Total

Hourly
Number of
Labor
Employees
Costs

2
1
1
1

$49.35
$90.14
$79.08
$52.50

Total Burden
Total
Costs
Burden Burden
Hours Costs (per
Exchange)
(18
Exchanges)
44
$2,171
20
$1,803
4
$316
32
$1,680
100
$5,971
$107,478

We also include an estimate for the total printing and mailing costs related to sending
eligibility determination notices for all 18 State-based Exchanges. In the Supporting Statement
for Data Collection to Support Eligibility Determinations for Insurance Affordability Programs
and Enrollment through Health Benefits Exchanges, Medicaid, and Children’s Health Insurance
Program Agencies (CMS-10440), we estimated 5,348,297 total applications for 2014. This
estimate was based on analysis of Congressional Budget Office projections and Office of the
Assistant Secretary for Planning and Evaluation analysis of data from the Census indicating that
families with incomes less than 138% FPL had a family size of 3.88 and those with incomes
between 138% and 400% FPL had a family size of 3.61. It is difficult to estimate the number of
14

eligibility determination notices for 18 State-based Exchanges because the CBO estimates
present national figures and are not state-specific estimates. However, we estimate 297,128
notices will be sent for 18 State-based Exchanges. We use these assumptions to determine the
number of eligibility notices that we expect to be printed and distributed as described in
§155.310. We note, however, that since we expect that many individuals will choose electronic
notices instead of paper notices, this estimate is an upper bound.

Total Burden
Cost (18 StateNumber of
Printing/Mailing Costs
based
Notices
per notice
Exchanges)
Printing/Mailing
297,128
$.50 $148,564
Section 155.310(h) specifies that the Exchange will notify an enrollee’s employer that an
employee has been determined eligible for advance payments of the premium tax credits and/or
cost-sharing reductions. Upon making such an eligibility determination, the Exchange will send a
notice to the employer with information identifying the employee, along with a notification that
the employer may be liable for the payment under section 4980H of the Code, and that the
employer has a right to appeal this determination. Because this notice will be sent to an employer
at the address as provided by an application filer on the application, we anticipate all of these
notices will be sent by mail. As a result, we estimated the associated mailing costs for the time
and effort needed to mail notices in bulk to employers. Like the eligibility notice, the employer
notice above will be developed and programmed into the eligibility system. However, unlike the
eligibility notice, we expect the information on the employer notice to be minimal in comparison
to the eligibility notice and therefore the burden on the Exchange to develop the notice to be
substantially less. Further, as with the individual eligibility notice, HHS will provide model
15

notice text for Exchanges to use in developing this notice.
To develop this notice, Exchange staff time would include learning the eligibility process
and drafting notice text. A peer analyst, manager, and/or legal counsel would review the notice.
The Exchange would then engage in user testing, along with review and editing to incorporate
changes and ensure compliance with plain writing, language access, and readability standards.
Finally, a developer would program the final notice into the eligibility system so that it can be
populated and generated as the applicant moves through the eligibility process.
We expect that 18 State-based Exchanges will be subject to this requirement. We
estimate that this notice development as outlined in the paragraph above will take each Exchange
an estimated 97 hours in the first year, with a cost burden of approximately $5,304 per Exchange
and a total cost of $95,472 for 18 Exchanges. We expect that the burden on the Exchange to
maintain this notice will be significantly lower than to develop it.

Labor Category
Health Policy
Analyst
Attorney
Senior Manager
Computer
Programmer
Total

Hourly
Number of Labor
Employees Costs

Burden
Hours

Total Burden
Total Burden Costs Costs (18
(per Exchange)
Exchanges)

2
1
1

$49.35
$90.14
$79.08

69
10
2

$3,405
$901
$158

1

$52.50

16
97

$840
$5,304

$95,472

We believe it is difficult to estimate the number of employer notices that will be sent as it
requires an estimate of the number of individuals who will be determined eligible for advance
payments of the premium tax credit who will be employed. We therefore provide an estimate of
the cost to print and mail each notice below.

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Number of
Notices

Printing/Mailing Costs
Total Burden Cost
per notice
(per notice)
1
$.50 $.50

Printing/Mailing

D. Verification process related to eligibility for enrollment in a QHP through the Exchange
(§155.315)
The primary burden associated with the verification process includes the written
agreements necessary for data sharing between the Exchange and HHS in order for Exchanges to
access the data maintained in Federal data sources, as well as with other State agencies to access
data maintained by such entities. We estimate the time and effort necessary for the Exchange to
create new agreements with HHS and other State agencies or entities for the collection of this
information. We expect that 18 State-based Exchanges will be subject to this requirement. We
estimate it will take a State an average of 105 hours to create new agreements. This includes a
mid-level health policy analyst drafting the agreement with managerial oversight and
comprehensive review of the agreement as well as operations work completed by an operations
analyst. For all 18 Exchanges, we expect a total hour burden in the first year of 1,890 hours, and
a cost of $6,733 per Exchange, for a total cost of $121,194 for 18 State-based Exchanges.

Labor Category
Health Policy
Analyst
Operations Analyst
Attorney
Senior Manager
Total

Hourly
Number of Labor
Employees Costs
1
1
1
1

$49.35
$54.45
$90.14
$79.08

Total Burden
Burden Costs (per
Hours Exchange)
35
35
30
5
105

$1,727
$1,906
$2,704
$395
$6,733

Total Burden Costs
(per year)
$88,096
$97,200
$137,920
$20,166
$121,194

In addition to the agreements necessary to support §155.315, we expect there to be no
transactional burden associated with the electronic transactions needed to implement §155.315
17

and §155.320. As these transmission functions will all be electronic, we do not expect for there
to be any additional burden than that which is required to design the overall eligibility and
enrollment system. Those costs are described in the section detailing capital costs.
Section 155.315(f) outlines the process for resolving inconsistencies identified through
the verification process. We anticipate that the Exchange eligibility system will be able to
process most applications in an automated fashion and that only the more complex cases will
necessitate the resolution of inconsistencies through an offline process. For these cases, the
manual adjudication of documentation submitted by an individual to the Exchange will be
necessary. Given the fact that the Exchange eligibility process is entirely new and involves the
use of new electronic data sources in combination with a new application, it is not possible to
provide estimates for the number of applicants for whom we expect to have an inconsistency.
However, we anticipate that this number will decrease as applicants become more familiar with
the eligibility process, as more data become available electronically, and as customer service
resources evolve based on experience.
In §155.315(f)(2)(i), we specify that the Exchange will provide notice to an applicant
regarding any inconsistencies identified through the verification process. This notice of
inconsistency is a part of the notice in §155.310(g), and so we do not include a separate burden
estimate here.
Section 155.315(f)(2)(ii) provides that in the case of an inconsistency that cannot be
resolved through action by the Exchange, the Exchange must request that the individual provide
satisfactory documentation or otherwise resolve the inconsistency. Our estimates below reflect
the time and cost for an individual to collect information and provide it to the Exchange, as well
as time needed for eligibility support staff (occupation no. 43-4061) to review the

18

documentation. For the reasons noted above, we are unable to estimate the number of individuals
who will receive such a notice. We expect that this will take an individual one hour to gather the
relevant documentation, five minutes to upload or mail the relevant documentation, and 12
minutes for eligibility support staff to review the documentation, which reflects our expectation
that each individual who is required to submit documentation will submit approximately 2
documents for review. Our estimate that it will take an individual one hour to gather the relevant
documentation depends on whether or not the individual already has the necessary
documentation on hand, or whether the documents are unavailable and the individual needs to
spend additional time to gather the documentation. As such, it could take significantly less time
if an individual already had the documents on hand, or potentially more time if certain
documents were unavailable at the time an individual needed to resolve an inconsistency.

Individual
Eligibility Support Staff
Total

Number of
Total Burden
Individuals Hourly Labor
Burden
Costs (per
/Employees Costs
Hours
individual)
1
-1
-1
$28.66
.20
$5.73
2
1.2
$6

Section 155.315(f)(5)(i) provides that if after that the period described in paragraph
(f)(2)(ii) of this section, the Exchange remains unable to verify the applicant’s attestation, the
Exchange must determine the applicant’s eligibility based on the information available from the
data sources specified in subpart D, unless such applicant qualified for the exception for special
circumstances under paragraph (g) of this section, and notify the applicant of such determination
in accordance with the notice requirements specified in §155.310(g), including notice that the
Exchange is unable to verify the attestation. We do not include a separate burden estimate for
this notice because the burden for this notice is described and accounted for in §155.310(g).

19

E. Verification process related to eligibility for insurance affordability programs (§155.320)
Section 155.320(c)(3)(iv) outlines standards for the notice described in paragraph
(c)(3)(vi)(E) and (c)(3)(vi)(F) provided at the end of the inconsistency period for inconsistencies
related to income. We do not include a separate burden estimate for this notice because the
burden for this notice is described and accounted for in §155.310(g).
Section 155.320(d) proposes the process for the verification of enrollment in an eligible
employer-sponsored plan and eligibility for qualifying coverage in an eligible employersponsored plan. Paragraph (d)(2) proposes the data sources the Exchange will use to verify
access to employer-sponsored coverage. This will involve the development and execution of data
sharing agreements; however, this burden is already captured in the data sharing agreements
described in §155.315. As these data exchanges will be electronic, we do not expect for there to
be any additional burden than that which is required to design the overall eligibility and
enrollment system.
Paragraph (d)(3) proposes applicable verification procedures. Paragraph (d)(3)(ii)
specifies that if an applicant’s attestation is not reasonably compatible with the information
specified in paragraphs (d)(2)(i) through (d)(2)(iii) of this section, other information provided by
the application filer, or other information in the records of the Exchange, the Exchange must
follow the procedures specified in §155.315(f) of this subpart. Consequently, the burden
associated with this is captured in the section describing §155.315(f). Paragraph (d)(3)(iii)
proposes that when specified as needed to resolve verification issues, the Exchange will select a
statistically significant sample of individuals and provide notice to them indicating that the
Exchange will be contacting any employer identified on the application for the applicant and the
members of his or her household to verify whether the applicant is enrolled in an eligible

20

employer-sponsored plan or is eligible for qualifying coverage in an eligible employer-sponsored
plan for the benefit year for which coverage is requested. The burden associated with this notice
is addressed in 155.310(g) as this will not be a separate notice, but incorporated into the
eligibility determination notice described in the above paragraph.
In paragraph (d)(3)(iii)(D), we propose that for the statistically significant sample, the
Exchange make reasonable attempts to contact any employer identified on the application for the
applicant and the members of his or her household to verify whether the applicant is enrolled in
an eligible employer-sponsored plan or is eligible for qualifying coverage in an eligible
employer-sponsored plan for the benefit year for which coverage is requested. It is difficult to
estimate the burden associated with this information collection as the calculation involves
identifying the number of individuals for whom data will be unavailable. As such, below, we
estimate the time and cost associated with the Exchange making a reasonable attempt to contact
one employer.

Employer
Eligibility Support Staff
Total

Number of
Total Burden
Individuals Hourly Labor
Burden
Costs (per
/Employees Costs
Hours
individual)
1
-1
-1
$28.66
1.20
$34.39
2
2.2
$34.39

In paragraph (d)(3)(iii)(E), we propose that if the Exchange receives any information
from an employer relevant to the applicant’s enrollment in an eligible employer-sponsored plan
or eligibility for qualifying coverage in an eligible employer-sponsored plan, the Exchange will
determine the applicant’s eligibility based on such information and in accordance with the
effective dates. If such information changes his or her eligibility determination, the Exchange
will notify the applicant and his or her employer or employers of such determination in

21

accordance with the notice requirements specified in 155.310(g) and (h) of this subpart. The
burden associated with this provision is the time and effort necessary to notify the applicant and
his or her employer if information from an employer changes the applicant’s eligibility. The time
and effort associated with this provision is accounted for in the estimate discussed in 155.310(g)
and (h) of this subpart.
F. Eligibility redetermination during a benefit year (§155.330)
Section 155.330(b) provides that the Exchange specify that an individual will report
changes that affect his or her eligibility for enrollment in a QHP and insurance affordability
programs within 30 days of such change. Upon receipt of changes reported by an individual,
§155.330(c) provides the Exchange will verify the information in accordance with the standards
described in §155.315 and §155.320.
In §155.330(b)(1), we specify that except as specified in paragraphs (b)(2) and (b)(3) of
this section, the Exchange must require an enrollee to report any change with respect to the
eligibility standards specified in §155.305 within 30 days of such change. Our estimates reflect
the time that it would take for an enrollee to collect and report to the Exchange any information
related to a change that impacts their eligibility. Enrollees will be permitted to submit changes
via phone, mail, in person, or electronically. We expect that a majority of enrollees will
electronically report changes to the Exchange. As such, we estimate that it will take an enrollee
ten minutes on average to report a change to the Exchange. The burden associated with the
collection and processing of any documentation that is needed to support reported changes is
accounted for in the estimate for §155.330(c)(1).

Number of
Individuals

Hourly Labor
Costs

Burden
Hours

Total Burden
Costs (per
22

Individual
Total

1

--

.16
.16

change)
---

In §155.330(c)(1), we state that the Exchange will verify any information reported by an
enrollee in accordance with the processes specified in §§155.315 and 155.320 prior to using such
information in an eligibility redetermination. It is not possible at this time to provide estimates
for the number of applicants for whom a reported change will necessitate the adjudication of
documentation, but we anticipate that this number will decrease as applicants become more
familiar with the eligibility process and as more data become available. As such, we note that
the burden associated with this provision is one hour for an individual to collect and submit
documentation, and 12 minutes for eligibility support staff to review the documentation.

Individual
Eligibility
Support Staff
Total

Number of
Individuals
Total Burden
/
Hourly Labor
Burden
Costs (per
Employees Costs
Hours
inconsistency)
1
-1
-1
1

$28.66

.2
1.2

$5.73
$6

In §155.330(c)(2), we describe the that the Exchange will provide periodic electronic
notifications regarding the requirements for reporting changes and an enrollee’s opportunity to
report any changes as described in paragraph (b)(3) of this section, to an enrollee who has
elected to receive electronic notifications, unless he or she has declined to receive notifications
under this paragraph. We expect that 18 State-based Exchanges will be subject to this
requirement. For each Exchange, we estimate that it will take 21 hours total, 20 hours for an
operations analyst to integrate this electronic notification into the Exchange eligibility system,
and one hour for a computer programmer to program the electronic notifications into the
23

eligibility system. We estimate a cost burden of $1,040 per Exchange and a total cost of $53,015
for 18 State-based Exchanges.

Labor Category
Operations Analyst
Computer
Programmer
Total

Total
Burden
Number of Hourly Labor
Burden
Costs (per
Employees Costs
Hours
Exchange)
1
$49.35
20
$987
1
2

$52.50

1
21

Total
Burden
Costs (18
Exchanges)

$52
$1,040

$53,015

In §155.330(d), we describe that the Exchange will periodically examine available data
sources described in §155.315(b)(1) and §155.320(b) to identify changes related to death and
eligibility determinations for Medicare, Medicaid, CHIP, or the BHP, if a BHP is operating in
the service area of the Exchange for an applicant on whose behalf advance payments of the
premium tax credit or cost-sharing reductions are being provided. The Exchange will develop
electronic data exchanges to support obtaining this information in order to determine the
applicant’s eligibility at the point of application and reuse those data exchanges here.
Consequently, we do not expect there to be additional burden associated with those data
exchanges for the purposes of this paragraph.
In §155.330(e), we describe the redetermination and notification procedures for changes
reported by enrollees or identified by the Exchange. Section 155.330(e)(1) states that if the
Exchange verifies updated information reported by an enrollee, the Exchange will redetermine
the enrollee’s eligibility in accordance with the standards specified in §155.305, notify the
enrollee regarding the determination in accordance with the requirements specified in
§155.310(g), and notify the enrollee’s employer, as applicable, in accordance with the
requirements specified in §155.310(h). The burden for this notice is identical to the burden

24

associated with the eligibility notice described in §155.310(g). Similarly, we do not include a
separate burden estimate here for the notice to the enrollee’s employer because the burden for
this notice is described and accounted for in §155.310(h). Section 155.330(e)(2) describes that
the Exchange will notify an enrollee if it identifies updated information through periodic data
matching, and dependent upon the response, will redetermine the enrollee’s eligibility or if
necessary proceed with the inconsistency process in §155.315(f). We do not include a separate
burden estimate for this notice because we expect that the burden associated with creating and
sending this notice will be similar to that of the annual redetermination notice, which is discussed
in §155.335 below. Furthermore, the burden on an enrollee to notify the Exchange that such
information is potentially inaccurate is the same as that in relation to reporting changes as
described in §155.330(b), and the burden estimate related reviewing the response and the
inconsistency process is explained above in §155.315(f). We are unable to estimate the number
of notices that will be sent based on this provision for the reasons stated previously, along with
the fact that it is not possible to determine the share of individuals who will enroll in a QHP with
advance payments and then gain eligibility for another insurance affordability program and not
report it to the Exchange.
G. Annual eligibility redetermination (§155.335)
Section 155.335 outlines the annual redetermination process and provides that the
Exchange will redetermine the eligibility of a qualified individual on an annual basis. In
§155.335(c) we propose that the Exchange will provide a qualified individual with an annual
redetermination notice including the qualified individual’s projected eligibility determination for
the following year, and if applicable, the amount of any advance payments of the premium tax
credit and the level of any cost-sharing reductions or eligibility for other insurance affordability

25

programs. The burden associated with this requirement is the time and effort necessary for
Exchanges to develop and automate the annual redetermination notice and perform associated
record keeping. In accordance with 155.335(d), we expect the annual redetermination notice be
sent along with the notice of annual open enrollment as specified in 155.410(d), as a single,
coordinated notice. We anticipate that the majority of applicants will request electronic
notification while others will receive the notice by mail. As a result, we estimated the associated
mailing costs for the time and effort needed to mail notices in bulk to enrollees as appropriate.
To develop this notice, Exchange staff will learn the eligibility process and draft
appropriate notice text. A peer analyst, manager, and/or legal counsel will review the notice. The
Exchange staff would then conduct user testing, and engage in review and editing to incorporate
changes, and to ensure compliance with plain writing, language access, and readability standards.
The Exchange staff would also coordinate the text of the notice with other insurance affordability
programs. Finally, a developer would program the notice template into the eligibility system so it
can be incorporated into the streamlined eligibility process.
We provide estimates for an Exchange to develop this notice, and assume that it will not
vary significantly by Exchange. We estimate that this notice development as outlined in the
paragraph above would take each Exchange an estimated 100 hours in the first year, at a cost of
$5,971 and a total cost of $107,478 for 18 State-based Exchanges. We expect that this cost will
decrease significantly after the first year of development as the costs incurred will be for
maintenance. We also note that HHS intends to provide model notice text that should limit
Exchange burden.

26

Hourly
Number of
Labor
Employees
Costs

Labor Category

Health Policy Analyst
Attorney
Senior Manager
Computer Programmer
Total

2
1
1
1

$49.35
$90.14
$79.08
$52.50

Total Burden
Total
Costs
Burden Burden
Hours Costs (per
Exchange)
(18
Exchanges)
44
$2,171
20
$1,803
4
$316
32
$1,680
100
$5,971
$107,478

We believe it is difficult to estimate the number of redetermination notices that will be
sent as it requires an estimate of the number of individuals who will be determined eligible for
enrollment in a QHP through the Exchange. We therefore provide an estimate of the cost to print
and mail one redetermination notice below.

Number of
Notices
Printing/Mailing

Printing/Mailing Costs
Total Burden Cost
per notice
(per notice)
1
$.50 $.50

Section 155.335(e) provides that the Exchange will require a qualified individual to
report any changes with respect to the information listed in the notice described in §155.335 (c)
of this section within 30 days from the date of the notice. We specify in §155.335(e)(2) that the
Exchange will allow a qualified individual or an application filer, on behalf of the qualified
individual, to report changes via the channels available for the submission of an application.
Similar to the estimate in §155.330(b)(1), our estimates reflect the time that it would take for a
qualified individual to collect information related to a change that impacts their eligibility, as
well as the time it would take to report these changes to the Exchange. We expect that a large
volume of changes would be reported electronically by qualified individuals. We expect that it
27

will take an enrollee ten minutes to report a change to the Exchange. The burden associated with
the collection and processing of any documentation that is needed to support reported changes is
accounted for in the estimate for §155.335(f).
Number of
Individuals Hourly Labor
/Employees Costs
1
--

Individual
Total

Burden
Hours
.16
.16

Total Burden
Costs (per
change)
---

Section 155.335(f) states that the Exchange will verify any information reported by an
enrollee with respect to their annual eligibility redetermination in accordance with the processes
specified in §§155.315 and 155.320 prior to using such information to determine eligibility. It is
not possible at this time to provide estimates for the number of applicants for whom a change
reported will necessitate the adjudication of documentation, but we anticipate that this number
will decrease as applicants become more familiar with the eligibility process and as more data
become available. As such, for now, we note that the burden to process documentation
associated with an inconsistency that arises as a result of an annual eligibility redetermination is
one hour for an individual to collect and submit documentation, and 12 minutes for eligibility
support staff to review the documentation.

Individual
Eligibility
Support Staff
Total

Number of
Individuals
Total Burden
/
Hourly Labor
Burden
Costs (per
Employees Costs
Hours
inconsistency)
1
-1
-1

$28.66

.2
1.2

$5.73
$6

Section 155.335(g) provides that the Exchange will require a qualified individual, or an
application filer, on behalf of the qualified individual, to sign and return the annual
28

redetermination notice. Our estimates reflect the time that it would take for a qualified
individual, or an application filer on behalf of the qualified individual to sign and return the form
to the Exchange. We expect that a large volume of individuals will sign and return the form
electronically, but a qualified individual will also be permitted to sign the form via phone, mail,
or in person. The burden for this collection also includes the time necessary for eligibility
support staff to process any forms submitted via mail. We expect that this process will take one
individual one hour to submit the form, and for an individual who submits the form via mail, it
will also take 12 minutes for eligibility support staff to handle intake. For those individuals that
complete this process through paper, we estimate a cost burden per individual of $6. We note
that to the extent that an individual is reporting a change in response to the annual
redetermination notice, the change report would likely be consolidated with the response to the
notice described in this paragraph.

Individual
Eligibility Support
Staff
Total

Number of
Individuals/
Employees
1

Hourly Labor Costs
--

1

$28.66

Burden
Hours
1

Total Burden
Costs (per
respondent)
--

.2
1.2

$5.73
$5.73

Section 155.335(h)(1)(ii) provides that after the 30-day period for an individual to report
changes and/or sign and return the redetermination notice, the Exchange will notify a qualified
individual in accordance with the requirements specified in §155.310(g) and notify his or her
employer, as applicable, in accordance with the requirements specified in §155.310(h). We
expect that the burden associated with this requirement is identical to the burden estimates
associated with §155.310(g) and §155.310(h), and is thus already incorporated in the estimates
provided for those provisions. In section 155.335(k) we provide that the Exchange must have
29

authorization from a qualified individual to obtain updated tax return information for the
purposes of conducting an annual redetermination. The burden associated with this information
collection is included in the Supporting Statement for Data Collection to Support Eligibility
Determinations for Insurance Affordability Programs and Enrollment through Health Benefits
Exchanges, Medicaid, and Children’s Health Insurance Program Agencies (CMS-10440).
Section 155.335(l) provides that if the Exchange does not have an active authorization
from a qualified individual to obtain updated tax information for use in the annual
redetermination process, the Exchange must notify the qualified individual in accordance with
the timing described in paragraph (d) of this section, and redetermine his or her eligibility for
enrollment in a QHP through the Exchange. This notice is in place of the regular annual
redetermination notice, and as such, the burden associated with this requirement is included in
the burden estimate associated with 155.335(c).
H. Administration of advance payments of the premium tax credit and cost-sharing reductions
(§155.340)
This section specifies that the Exchange will provide the relevant information related to
enable advance payments of the premium tax credit and cost-sharing reductions, reconciliation of
advance payments of the premium tax credit, and employer responsibility. As these reporting
functions will all be electronic, we do not expect for there to be any additional burden than that
which is required to design the overall eligibility and enrollment system outside of the
requirements in section 155.340(b)(3)(ii).
Section 155.340(b)(3)(ii) states that in the event that an individual for whom advance
payments of the premium tax credit are made or who is receiving cost-sharing reductions
terminates coverage from a QHP through the Exchange during a benefit year, the Exchange will

30

transmit the individual’s name and the effective date of the termination of coverage to his or her
employer. We anticipate that this burden on this transmission will be identical to that of
§155.310(h).
We estimate that this development as outlined in the paragraph above will take each
Exchange an estimated 97 hours in the first year, with a cost burden of approximately $5,304 per
Exchange and a total cost of $95,472 for 18 Exchanges. We expect that the burden on the
Exchange to maintain this process will be significantly lower than to develop it.

Labor Category
Health Policy
Analyst
Attorney
Senior Manager
Computer
Programmer
Total

Hourly
Number of Labor
Employees Costs

Burden
Hours

Total Burden Costs
(per Exchange)

2
1
1

$49.35
$90.14
$79.08

69
10
2

$3,405
$901
$158

1

$52.50

16
97

$840
$5,304

Total Burden
Costs (18
Exchanges)

$95,472

We believe it is difficult to estimate the number of employer notices that will be sent as it
requires an estimate of the number of individuals who will be employed and then terminate
coverage after receiving advance payments of the premium tax credit or cost-sharing reductions.
We therefore provide an estimate of the cost to print and mail each notice below.
Number of
Notices
Printing/Mailing

Printing/Mailing
Costs per notice
1

Total Burden
Cost (per notice)
$.50 $.50

Section 155.340(c) states that the Exchange must comply with the requirements specified
under section 36B of the Code to provide information related to reconciliation of advance
payments of the premium tax credit, and as this is an IRS requirement, consequently IRS will
account for this burden.
31

I. Coordination with Medicaid, CHIP, the Basic Health Program, and the Pre-existing Condition
Insurance Plan (§155.345)
Section 155.345(a) specifies that Exchanges will enter into written agreements with
agencies administering other insurance affordability programs. These agreements will include
provisions necessary to minimize burden on individuals, ensure prompt determinations of
eligibility and enrollment in the appropriate program without undue delay, and to provide
standards for transferring an application from an insurance affordability program to the
Exchange. Agencies will also develop MOUs to outline responsibilities and coordinate between
insurance affordability programs. The specific number of agreements needed may vary
depending on how States choose to divide responsibilities regarding eligibility determinations.
The burden associated with this provision is the time and effort necessary for the
Exchange to establish or modify an agreement for eligibility determinations and coordination of
eligibility and enrollment functions. If a State chooses to draft separate agreements for each
insurance affordability program or a subset of insurance affordability programs, then the estimate
would likely increase. We estimate it will take each Exchange an average of 105 hours to create
new agreements per state. This includes a mid-level health policy analyst and an operations
analyst developing the agreement with managerial oversight and comprehensive review of the
agreement by an attorney and a senior manager. We estimate a cost burden of $6,733 per
Exchange and a total cost of $121,194 for 18 State-based Exchanges.

Labor Category
Health Policy
Analyst
Operations Analyst
Attorney
Senior Manager

Number of Hourly
Employees Labor Costs
1
1
1
1

$49.35
$54.45
$90.14
$79.08

Burden
Hours
35
35
30
5

Total Burden
Costs (per
Exchange)

Total Burden
Cost (18
Exchanges)

$1,727
$1,906
$2,704
$395
32

Total

105

$6,733

$121,194

Section §155.345(c) specifies that an Exchange must provide an applicant with the
opportunity to request a full determination for Medicaid. We do not include a separate burden
estimate for this notice because the burden for this notice is described and accounted for in
§155.310(g).
Section §155.345(d) specifies standards in the case where the Exchange identifies an
applicant as potentially eligible for Medicaid or an applicant requests a full determination for
Medicaid. In paragraph (d)(1), we specify that in such a situation, the Exchange will transmit all
information provided on the application and any information obtained or verified by the
Exchange to the State Medicaid agency. In paragraph (d)(2), we specify that the Exchange will
notify the applicant of such transmittal. Because information will be transmitted electronically
and through interfaces that will exist for other purposes, we do not account for any additional
burden for paragraph (d)(1) and only account for the burden of sending the notice to the
applicant as described in paragraph (d)(2). We expect that the burden associated with this
requirement is identical to the burden estimates associated with §155.310(g), and is thus already
incorporated in the estimate provided for that provision.
Section 155.345(f) specifies that the Exchange will provide the applicant with any
information regarding income used in the Medicaid and CHIP eligibility determination for the
special rule described in this paragraph. We do not include a separate burden estimate for this
notice because the burden for this notice is described and accounted for in §155.310(g).
J. Special eligibility standards and process for Indians (§155.350)
Section 155.350(c) specifies that the Exchange will verify an attestation by an applicant
that he or she is an Indian to the extent that the approved data sources are unavailable, an

33

individual is not represented in available data sources, or data sources are not reasonably
compatible with an applicant’s attestation through the inconsistency procedures specified in
§155.315(f) As we have already accounted for this burden above, we are not including a
separate burden estimate for this provision.
K. Right to Appeal (§155.355)
Section 155.355 provides that the Exchange must include the notice of the right to appeal
and instructions regarding how to file an appeal in the eligibility determination notice. We do not
include a separate burden estimate for this notice because the burden for this notice is described
and accounted for in §155.310(g).
Subpart E –Exchange Functions in the Individual Market
A. Enrollment of Qualified Individuals into QHPs.
In Part 155, subpart E of the Exchange final rule, we describe the requirements for
Exchanges in connection with enrollment and disenrollment of qualified individuals through the
Exchange. Section 155.400(a) requires Exchanges to notify QHP issuers of an applicant’s
selected QHP and transmit any information necessary to enroll the applicant. Section 155.400(b)
requires Exchanges to send eligibility and enrollment information to QHP issuers and to HHS
promptly, without undue delay. Additionally, Exchanges are required to establish a process by
which a QHP issuer acknowledges receipt of the eligibility and enrollment information. We
expect that all plan selection, eligibility and enrollment information will be maintained
electronically by Exchanges, QHP issuers and HHS alike. We expect the transmission of such
data to be fully automated. As a result, we expect that most of the burden will initial reflect
programming of the enrollment feeds to QHP issuers and HHS. These costs are reflected in the
capital costs of building enrollment systems.

34

In addition to the IT development, we estimate that 18 State-based Exchanges are subject
to these reporting requirements. This estimate is an upper bound of burden. We estimate that it
will take 142 hours for an Exchange to meet these reporting requirements for a total of 2,556
hours for a total cost of $136,314 for 18 State-based Exchanges.

Labor Category
Health Policy
Analyst
Computer
Programmer
Operations Analyst
Total

Hourly Labor
Costs (Hourly
Number of rate + 35%
Employees Fringe benefits

Burden
Hours

Total
Burden
Total Burden
Costs (per
Costs (all
respondent) respondents)

1

$58.05

10

$581

1
1

$52.50
$54.45

100
32
142

$5,250
$1,742
$7,573

$136,314

Section 155.400(c) of the Exchange final rule specifies that Exchanges must maintain
records of all enrollments in QHPs through the Exchange. The information will be used to make
sure that the Exchange has up to date information on the individuals covered through the
Exchange and to ensure that individuals are not covered by more than one QHP. It is expected
that the information will be maintained in an electronic data system. We expect that most of the
burden will reflect programming to retain enrollment information on the Exchange’s electronic
data system. We estimate that 18 State-based Exchanges will be subject to these reporting
requirements. This estimate is an upper bound of burden. We estimate that it will take 142 hours
for an Exchange to meet these record requirements for a total of 2,556 hours for a total cost of
$136,314 for 18 State-based Exchanges.

Labor Category
Health Policy Analyst

Number of
Employees

Hourly Labor
Costs (Hourly
rate + 35%
Fringe benefits

1

$58.05

Burden
Hours
10

Total Burden
Costs (per
respondent)

Total Burden
Costs (all
respondents)

$580.50
35

Computer
Programmer
Operations Analyst
Total

1
1

$52.50
$54.45

100
32
142

$5,250
$1,742
$7,573

$136,314

Section 155.400(d) states that Exchanges must reconcile enrollment information with
QHP issuers and HHS on no less than a monthly basis. The purpose of reconciling enrollment
information between the Exchange and the QHP issuers and HHS is to ensure that both entities
have accurate records of the number of enrollees and persons enrolled in each QHP. It is
expected that the information will be maintained in an electronic data system. We estimate that it
will take 27 hours per month for an Exchange to reconcile information, for a total of 1,296 hours
per month across 18 State-based Exchanges. We estimate that it will take 324 hours for each
Exchange to reconcile information over the course of a year if information is reconciled on a
monthly basis. This estimate is similar to estimates provided by Medicare Part D in their rule on
data submissions. For example, Medicare Part D estimated that it would take plan sponsors
approximately 10 hours annually for plan sponsors to submit data on aggregated negotiated drug
pricing from pharmaceutical companies described in §423.104. We provided a higher estimate
for the submission of data due to the complexity of enrollment data.

Labor Category

Number of
Employees

Hourly Labor
Costs (Hourly
rate + 35%
Fringe benefits

Burden
Hours

Total
Burden
Costs (per
respondent)

Health Policy Analyst
Computer
Programmer

2

$58.05

144

$8,359

2

$52.50

120

$6,300

Operations Analyst

1

$54.45

60

$3,267

324

$17,926

Total

Total Burden
Costs (all
respondents)

$322,668

As discussed in §155.405(a), the Exchange must use a single streamlined application to
determine eligibility and to collect information necessary for enrollment. The application will
36

include information to determine eligibility of an applicant and process plan selection for
enrollment in a qualified health plan through the Exchange and insurance affordability programs.
The information will be required of each applicant upon initial application with subsequent
information collections for the purposes of confirming accuracy of previous submissions or
updating information from previous submissions. Information collection will start during initial
open enrollment in October 2013. As indicated in §155.405(c)(2), the information will be
submitted by the applicant to the Exchange through the internet, call center, in-person assistance,
or a paper application. After collecting the information, the Exchange will either house the
information in an Exchange data repository or purge the information after it is used to make an
eligibility determination. At this time, HHS is currently developing the model single streamlined
application for the States. A detailed estimate of the burden associated with this information
collection was included in the Supporting Statement for Data Collection to Support Eligibility
Determinations for Insurance Affordability Programs and Enrollment through Health Benefits
Exchanges, Medicaid, and Children’s Health Insurance Program Agencies (CMS-10440).
Section 155.405(b) states that Exchanges have the option of using an alternative
application which includes information to determine the eligibility of an applicant and process
plan selection for enrollment in a QHP and insurance affordability programs, as applicable. If the
Exchange opts to use an alternative application, the Exchange must submit the alternative
application to HHS for approval. The burden estimate associated with this requirement includes
the time and effort needed to develop the alternative application and submit the application for
approval by HHS. We believe that most Exchanges, in the interest of avoiding duplication of
existing work, will choose to use the model single, streamlined application being developed by
HHS. We assume that the number of Exchanges choosing to develop an alternate application will

37

be less than ten in a twelve month period. We will review each alternative application that is
submitted to HHS and, if the number of Exchanges opting to use an alternative application
approaches ten, then we will seek OMB approval.
B. Initial and Annual Open Enrollment Periods (§155.410)
As discussed in §155.410, the Exchange will provide written notice to each enrollee
about annual open enrollment between September 1 and September 30 of each year, beginning in
2014. The notice will include the date of annual open enrollment and information regarding
where individuals may obtain information about available QHPs. The Exchange will send the
notice of annual open enrollment via mail or electronic means depending on the preference of the
enrollee. In accordance with §155.335(c), we expect the notice of annual open enrollment as
specified in §155.410(d), will be sent along with the annual redetermination notice as a single,
coordinated notice. Therefore, the burden estimate associated with this requirement is described
in §155.335(d).
C. Termination of Coverage (§155.430)
Section 155.430(c) requires Exchanges to retain and track coverage termination
information, including information to identify the individuals terminating coverage, the date of
coverage termination, and the reason for termination. The Exchange will collect and retain the
coverage termination information. The Exchange will submit the coverage termination
information to HHS. The information will help provide HHS an accurate record of enrollment in
the Exchange, so that HHS can inform the IRS when to cease advance payments of premium tax
credits. We expect that all termination information will be maintained electronically by
Exchanges. We also expect the transmission of data to be automated. We estimate that it will
take Exchanges less than one minute to transmit the termination information to HHS. We

38

anticipate a similar initial burden on Exchanges for establishing a system for automated tracking,
maintenance and transmittal of termination information. The burden estimates associated with
the maintenance and transmission of coverage termination information includes the time and
effort needed to develop the system to collect and store the information. Additionally, the burden
estimates includes the time and effort needed to develop an automated process to submit
termination information when appropriate. We estimate that 18 State-based Exchanges will be
subject to these reporting requirements. This estimate is an upper bound of burden. We estimate
that it will take 30 hours of a health policy analyst at an hourly rate of $58.05, 20 hours for a
computer programmer at an hourly rate of $52.50, and 20 hours from a operations analyst at an
hourly rate of $54.45 for a total of 70 hours annually and a total of 1,260 hours for the time and
effort to meet this standard. We estimate a cost of $3,881 for one Exchange and a total cost of
$69,858 for 18 State-based Exchanges.

Labor Category
Health Policy
Analyst
Computer
Programmer
Operations Analyst
Total

Number of
Employees

Hourly Labor
Costs (Hourly
rate + 35%
Fringe benefits

Burden
Hours

Total
Burden
Costs (per
respondent)

1

$58.05

30

$1,742

1

$52.50

20

$1,050

1

$54.45

20
70

$1,089
$3,881

Total Burden
Costs (all
respondents)

$69,858

Section 155.430(c) requires Exchanges to establish procedures for QHP issuers to
maintain records of termination of coverage, and requires Exchanges to send termination
information to the QHP issuer and HHS in accordance with §155.400(b). We expect that
Exchanges and QHP issuers will manage termination records and related procedures the same
way they do the enrollment records described in §155.400. We therefore do not estimate any
additional burden for Exchanges to meet the requirements in §155.430.
39

Subpart H- Exchange Functions: Small Business Health Options Program (SHOP)
A. Exchange Functions: Small Business Health Options Program (SHOP) (§§155.715, 155.720,
155.725)
Subpart H of 45 CFR part 155 includes several notices that the SHOP Exchange will send
to employers and employees in relation to their participation in the SHOP Exchange. We have
included the data elements for the SHOP Exchange issued notices in Appendix A of this PRA
package. We expect that the SHOP Exchange will send notices to employers and employees in
paper or electronic format, in accordance with the preference of the recipient; further, as in the
individual market Exchange, we anticipate that a large share of notices in the SHOP Exchange
will be sent electronically. We estimate that the associated printing and mailing costs for paper
notices will be approximately $0.50 per notice; however, we do not have a reasonable way to
estimate total printing and mailing costs for the SHOP Exchange due to uncertainty regarding the
number of employers and employees who will choose to receive paper notices, as well as some
uncertainty regarding the frequency of circumstances that will trigger notices in accordance with
this part.
First, under §155.715, the SHOP Exchange will notify an employer of an eligibility
determination, which will inform the employer of their eligibility to participate in the SHOP
Exchange. This notice will include information such as instructions for plan and contribution
elections, the deadline for making elections, appeal rights, and customer service contact
information for the SHOP Exchange. Second, §155.725(d) provides that the SHOP Exchange
provide employers with a notice of annual election period. This notice will include information
about current plan and contribution election information, and will alert the employer about
potential actions the employer may want to take. Third, §155.720(h) provides that the SHOP

40

Exchange provide employers with a notice of employee termination, which informs an employer
if an employee has elected to terminate his or her coverage, including information about the date
the employee elected to terminate and the effective date of the termination.
As it relates to employees of an employer participating in the SHOP Exchange, in
§155.715, we provide that the SHOP Exchange send an eligibility determination notice to an
employee. This notice will explain the employee’s eligibility to enroll in a QHP through the
SHOP Exchange. Second, if an employer withdraws from participation in the SHOP, the SHOP
Exchange will provide a notice to the employer’s employees, as described under §155.715(g).
Lastly, the SHOP Exchange will provide a notice regarding the annual enrollment period to
employees in accordance with §155.725(f). This notice will include information about current
plan and contribution election information, and potential actions the employee may want to take
related to renewing plans, change plans, and terminating enrollment.
We expect that the notices provided by the SHOP Exchange, and particularly the
eligibility determination notices, will be dynamic and include information tailored to all possible
outcomes for employers applying to participate in, or employees seeking coverage through, the
SHOP Exchange. To develop the required notices, the SHOP Exchange staff will need to learn
eligibility rules and draft notice text for various decision points, follow up, referrals, and appeals
procedures. Similar to notices that will be issued by the individual market Exchange, we expect
that for SHOP Exchange-issued notices, an analyst will develop text, and a peer analyst,
manager, and legal counsel will review the notices, including a review to ensure compliance with
plain writing, language access, and readability standards as required under §156.250(c). Finally,
a developer will program the template notice into the eligibility system so that the notice may be
populated and generated. Accordingly, we expect that the burden hours for creating each of the

41

above notices, including systems programming, will be similar to that which we estimate for the
eligibility determination notice described under §155.310(g). However, we believe that the
burden estimate described under §155.310(g) likely represents an upper bound estimate of the
burden on the SHOP Exchange to develop these notices as in some cases the notice described
under §155.310(g) will need to be somewhat more dynamic in order to address the additional
eligibility criteria associated with eligibility for enrollment in a QHP and insurance affordability
programs. Please see appendix A for the data elements that we expect to be included in the
notices required under subpart H. We expect that the burden on the SHOP Exchange to maintain
the notices will be significantly lower than to develop them.
Labor Category

Number
Hourly
of
Labor
Employees Costs

Health Policy Analyst
Attorney
Senior Manager
Computer Programmer
Total

2
1
1
1

$49.35
$90.14
$79.08
$52.50

Burden Total
Hours Burden
Costs (per
Exchange)
44
20
4
32
100

Total
Burden
Costs (18
Exchanges)

$2,171
$1,803
$316
$1,680
$5,971

$107,478

Information Collections under Part 156
A. ICRs Regarding Notices to QHP Issuers_(§§156.260, 156.265, 156.270, 156.290).
MPLOYER INTERACTIONS WITH EXCHANGES AND SHOP PARTICIPATIONwill be
manually generated by a human resources specialist4242424242424242424242
45 CFR part 156 includes several notices that qualified health plan (QHP) issuers will
send to qualified individuals and enrollees. We have included the data elements for these notices
in Appendix A of this PRA package. As mentioned previously, we anticipate that a large share of
enrollees will elect to receive electronic notices while the rest will receive notices by mail. We
42

believe that this will be the case for notices sent by the Exchange as well as notices sent by QHP
issuers. We estimate that the associated printing and mailing costs for paper notices will be
approximately $0.50 per notice; however, we do not have a reasonable way to estimate total
printing and mailing costs for issuers due to uncertainty regarding the number of individuals who
will choose to receive paper notices, as well as some uncertainty regarding the frequency of
circumstances that will trigger notices in accordance with this part.
First, section 156.260(b) provides that QHP issuers will notify a qualified individual of
his or her effective date of coverage, in accordance with the effective dates of coverage
established by the Exchange in accordance with §155.410(c) and (f). Second, under §156.270(b),
QHP issuers will send a notice of termination of coverage to an enrollee if the enrollee’s
coverage in the QHP is being terminated in accordance with §155.430(b)(1)(i), (b)(2)(ii) or
(b)(2)(iii).. Third, §156.270(f) provides that QHP issuers will provide enrollees with a notice
about the grace period for non-payment of premiums. QHP issuers will send this notice to
enrollees who are delinquent on premium payments. Fourth, §156.265(e) provides that QHP
issuers will provide new enrollees with an enrollment information package, which we anticipate
that issuers may combine with the notification of coverage effective date described in
§156.260(b). Lastly, under §156.290(b), QHP issuers will provide a notice to enrollees if the
issuer elects not to seek recertification of a QHP.
We anticipate that some of the above QHP issuer required notices are similar in nature to
the notices that issuers currently send to enrollees. For example, it is standard practice for issuers
to provide new enrollees with information about their enrollment in a plan, their effective date of
coverage, and if and when their coverage is terminating. Accordingly, we anticipate that QHP
issuers will review, update, and revise notice templates that they utilize currently as they work to

43

address the notice requirements described below and to ensure that the notices include the
appropriate information. Similar to notices that will be issued by the Exchange, we expect that
for QHP-issued notices, an analyst will develop text, and a peer analyst, manager, and legal
counsel for the issuer will review the notices, including a review to ensure compliance with plain
writing, language access, and readability standards as required under §156.250(c). Finally, a
developer will need to incorporate programming changes into the issuer’s noticing system to
account for the changes and updates that will be necessary to ensure that the QHP issuer is in
compliance with the notice standards set forth in this rule and to ensure the notice can be
populated and generated according to an individual’s preference to receive notices.
Accordingly, we expect that the burden hours for creating the above notices, including
taking into account systems programming, will be similar to that which we estimate for the
eligibility determination notice described under §155.310(g). However, we believe that the
burden estimate described under §155.310(g) likely represents an upper bound estimate of the
burden on issuers to develop each of these notices as in some cases the notice described under
§155.310(g) will be somewhat more dynamic in order to address the additional information we
expect to be included in that notice. We expect that the burden on the QHP issuers to maintain
the notices will be significantly lower than to develop them.
Labor Category

Health Policy Analyst
Attorney
Senior Manager
Computer Programmer
Total

Number
Hourly
of
Labor
Employees Costs

2
1
1
1

$49.35
$90.14
$79.08
$52.50

Burden Total
Hours Burden
Costs (per
Exchange)
44
20
4
32
100

$2,171
$1,803
$316
$1,680
$5,971

Total
Burden
Costs (18
Exchanges)

$107,478

44

We estimate a total burden cost of $87,105 for the notices described under part 156. Due
to uncertainty regarding the number of individuals who will choose to receive paper notices, as
well as some uncertainty regarding the frequency of circumstances that will trigger notices in
accordance with this part, we have only included an estimate of the printing and mailing costs for
a QHP issuer to send one notice to a qualified individual or enrollee.

Number of
Notices
Printing/Mailing

Printing/Mailing Costs
Total Burden Cost
per notice
(per notice)
1
$.50 $.50

Information Collections under Part 157
A. ICRs Regarding Notices and Third-Party Disclosures in the SHOP (§§157.205(e) and (f))
45 CFR part 157 includes several instances in which qualified employers participating in
the SHOP Exchange will need to provide information to employees or to the SHOP Exchange.
We include the data elements for these notifications in appendix A of this PRA package. For the
individual market Exchange, we anticipate that a large share of enrollees will elect to receive
electronic notices while the rest will receive notices by mail. We do not make this assumption for
notices described here as we expect that qualified employers will provide notices to employees in
whatever format the qualified employer usually provides notices to employees; in paper,
electronically, or in a combination of both formats. We estimate that the associated printing costs
for paper notices will be approximately $0.10 per notice. We do not take mailing costs into
consideration for notices provided by qualified employers, as we expect that if qualified
employers provide notices in paper format, the employer may provide the employee with the
notice in person, as opposed to mailing the notice. We do not have a reasonable way to estimate
total printing costs for notices provided by qualified employers in the SHOP Exchange due to
45

uncertainty regarding the number of employees who will choose to receive paper notices, as well
as some uncertainty regarding the frequency of circumstances that will trigger notices in
accordance with this part.
First, §157.205(e) provides that a qualified employer provide an employee with
information about the enrollment process. A qualified employer will inform each employee that
he or she has an offer of coverage through the SHOP Exchange, and instructions for how the
employee can apply for and enroll in coverage. We anticipate that the qualified employer will
also provide information about the acceptable formats in which an employee may submit an
application; online, on paper, or by phone, as described under §157.205(c). If the employee
being offered coverage was hired outside an initial or annual enrollment period, the notice will
also inform the employee if he or she is qualified for a special enrollment period. Second, in
§157.205(f) we provide that a qualified employer will notify the SHOP Exchange regarding an
employee’s change in eligibility for enrollment in a QHP through the SHOP Exchange, including
when a dependent or employee is newly eligible, or is no longer eligible.
We expect that the information that qualified employers will be providing to employees
and the SHOP Exchange, as described above, will be somewhat standardized. Additionally, we
anticipate that qualified employers will generate notices using a manual process. We expect that
for notices that will be issued by qualified employers, a human resources specialist will develop
the text, and a human resources manager and legal counsel will review the notices. We do not
anticipate that a developer will be needed to develop the notices described in this part since we
expect that in most cases, these notices will be manually generated on demand. We expect that
the burden hours for developing each of the notices will be approximately 34 hours for each of
the two notices that will be provided by a qualified employer. We expect that the burden on the

46

qualified employer to maintain the notices will be significantly lower than to develop the notices.

Labor Category
Human Resources
Specialist
Attorney
Human Resources
Manager
Total

Number of Hourly
Burden
Employees Labor Costs Hours

Total Burden Costs
(per Exchange)

1
1

$40.68
$90.14

20
10

$814
$901

1

$75.01

4
34

$300
$2,015

In total, we estimate $4,030 in burden costs for the two notices described above.
13. Capital Costs
We anticipate that the majority of capital costs associated with these information
collections, as well as the burden and costs associated with the transactions described in
§155.315 and §155.320 related to verification, will be related to the implementing regulations
found in Subparts D and E of the proposed rule that provide for a streamlined eligibility and
enrollment system. To support this new eligibility structure, States seeking to operate Exchanges
will build new or modify existing information technology systems. We believe that how each
State constructs and assembles the components necessary to support its Exchange and Medicaid
infrastructure will vary and depend on the level of maturity of current systems, current
governance and business models, size, and other factors. Any administrative costs incurred in
the development of information technology infrastructure to support the Exchange may be
funded wholly through State Exchange Planning and Establishment Grants. The Federal
government expects that these grants will fund the development of IT systems that can be used
by many States who either develop their own Exchanges or who partner with the Federal
government to provide a subset of Exchange services. Costs for information technology
infrastructure that will also support Medicaid must be allocated to Medicaid, but are eligible for a

47

90 percent Federal matching rate to assist in development.[1]
Table 1 includes estimates of grants from 2013 to 2017. We include estimated federal
government payments and receipts related to grants for Exchange startup. States’ initial costs
due to the creation of Exchanges will be funded by these grants. Eligibility determination is a
minimum function of the Exchange; therefore the Exchange costs to develop the infrastructure
for the provisions included in this proposed rule are covered by these grant outlays.
Table 1. Estimated Total Outlays for the Affordable Insurance Exchanges FY 2013 - FY2017, in billions of dollars
Year

2013

Grant Authority for
Exchange Start upa
1.5
a
FY 2014 President’s Budget

2014

2015

2016

2017

2013-2017

2.1

1.7

0.8

0.2

6.2

Other administrative costs to support the streamlined and coordinated eligibility and
enrollment process and the associated information collections will also vary for each State
depending on the specific approaches taken, including how the State chooses to support the
review of paper documentation and the resolution of eligibility and enrollment issues. We also
believe that overall administrative costs may increase in the short term as States build
information technology systems; however, in the long-term States will see savings through the
use of more efficient systems and consolidation across programs.
14. Cost to Federal Government
We anticipate costs to the Federal government to include costs related to implementation
of the federally-facilitated Exchange. As the FFE, costs related to implementation would be the
same as the costs, described in the burden estimates for each State-based Exchange above and
would vary depending on the number of states that opt to participate as an FFE.
[1]

Federal Funding for Medicaid Eligibility Determination and Enrollment Activities. Final Rule. April 19, 2011 [42
CFR Part 433, 75 FR 68583, pg 21950]

48

15. Changes to Burden
There are no changes to the burden. This is a new data collection.
16. Publication/Tabulation Dates
TBD
17. Expiration Date
Not Applicable
18. Certification Statement
There is no exception to the certification statement identified in Item 19, "Certification for
Paperwork Reduction Act Submissions," of OMB Form 83-I.

49

Appendix A: Data Elements for Notices Under 45 CFR Part 155, Part 156, and Part 157
Data Elements for Eligibility Determination Notice (45 CFR 155.310(g))- Sent after the processing of an initial application, as
well as after the processing of self-reported changes, or changes identified through periodic data matching or annual redetermination.
Household Contact Information –
Name, address(es)

Customer Service Information –
Contact information for the Exchange,
information regarding Navigators and
other customer service resources serving
the applicant’s area, Medicaid and CHIP

Eligibility Determination Information, For
Each Applicant that applied together, if
applicableEligibility determination or assessment for
each applicant for enrollment in a QHP and
insurance affordability programs, as
applicable. Maximum APTC amount*, CSR
category*, qualification for enrollment period
for enrollment in a QHP*.

Enrollment Information* –
Instructions for QHP plan selection,
deadline for plan selection based on
enrollment period, information about
online tools.

If Exchange conducted an assessment for
Medicaid/CHIP and individual is not assessed
as potentially eligible for Medicaid or CHIP
based on MAGI, information about
withdrawal of application for Medicaid/CHIP
and right to a full Medicaid determination*
(45 CFR 155.302(b)(4))

If Exchange determined or assessed an
applicant as eligible for Medicaid or
CHIP, information regarding what steps
the Medicaid/CHIP agency will take.

If an individual meets the criteria specified in
155.320(d)(3)(iii), an indication that the
Exchange will be contacting the employers
listed on the application for additional
information.
Inconsistencies* If an inconsistency exists for any applicant,
the cause for the inconsistency, length of the
inconsistency period, and directions for
resolving inconsistency, including acceptable

If coverage in a QHP is being
terminated, information regarding the
termination reason and effective date.*

Citation to regulation for action,
including the reason for the action
(45 CFR 155.230(a)(3))

50

agency contact information* (45 CFR
155.230(a)(1))
Right to request a full Medicaid
determination (45 CFR 155.345(c))

Appeal rights and instructions (45 CFR
155.355 and 155.230(a)(2))

documentation and information to assist
Exchange in matching documentation to
person (45 CFR 155.315(f)(2)(i))
Account transfer - If account is being
transferred to Medicaid for a full
determination* (45 CFR 155.345(d))

Accessibility- Taglines in other languages
for how to obtain assistance interpreting the
notice, and information about availability and
access to oral interpretation, written
translation, and other services for individuals
living with disabilities or who are limited
English proficient (45 CFR 155.205(c))

Reminder to report changes within 30
days of a change related to eligibility
throughout the year* (45 CFR
155.330(b))
Disclosure statement
(45 CFR 155.260(iii) and (iv))
Instructions for how to receive
electronic notices* (§155.230(d))

Other Exchange Notices to Individuals
Pre-populated notice resulting from Periodic Data Matching (45 CFR 155.330(e)(2)(i) and (e)(3)(i)) –
The updated information found about the individual, the projected eligibility determination, timeframe and instructions for how the
individual can respond to the Exchange to confirm or refute the updated information found by the Exchange, includes additional data
elements similar to those included in the eligibility determination notice identified previously (as applicable)
Pre-Populated notice resulting from Annual Redetermination (45 CFR 155.335(c)) The updated information found about the individual, projected eligibility determination, timeframe and instructions for how the
individual can respond to the Exchange to refute the updated information found by the Exchange, in 2014 and beyond this notice
includes information about the annual open enrollment period (45 CFR 155.410(d)), includes additional data elements similar to those
included in the eligibility determination notice identified previously (as applicable)
Employer Notice (45 CFR 155.310(h)) Notice Unique ID, employer contact information, name of employee and that the employee qualified for APTC/CSR, Information
about potential liability for the employer responsibility payment, appeal rights, contact information for the Exchange, disclosure
statement, employee protections
Electronic Reminder Notice (45 CFR 155.330(c)(2)) –
Notice Unique ID, reminder to report changes about information related to eligibility standards, includes additional data elements
51

similar to those included in the eligibility determination notice identified previously (as applicable)
Notice of Decertification and SEP (45 CFR 155.1080(e)) –
Notice Unique ID, Plan ID/information, primary subscriber/contact information and identification of other policy members/enrollees
affected by the decertification, effective dates, qualification for a special enrollment period, includes additional data elements similar
to those included in the eligibility determination notice identified previously (as applicable)
Notices Sent by QHP Issuers to Individuals
Notice of Grace Period for Non-Payment of Premium (45 CFR 156.270(f)) –
Notice Unique ID, Plan ID/Information, primary subscriber/contact information and identification of other policy members/enrollees
affected by the non-payment, information about the non-payment and 90-day grace period including dates of the period, amount of
unpaid premiums, that the grace period does not reset, implications of not having coverage (i.e., individual responsibility requirement,
inability to get special enrollment period/enroll until next open enrollment period), customer service contact information
Termination of Coverage (45 CFR 156.270(b)) Notice Unique ID, Plan ID/Information, primary subscriber/contact information and identification of other policy members/enrollees
affected by the termination, reason for the termination, effective dates, implications of not having coverage (i.e., individual
responsibility requirement, inability to get special enrollment period/enroll until next open enrollment period, customer service contact
information)*, customer service contact information
Notification of effective date (45 CFR 156.260(b))–
Household contact/primary subscriber information, qualified individual’s effective date of coverage, customer service contact
information (may be combined with enrollment information package)
Enrollment information package (45 CFR 156.265(f)) –
Welcome package about individual’s enrollment, information regarding how to access covered services, customer service contact
information
Plan decertification notice (45 CFR 156.290(b)) –
Unique ID, plan ID/Information, primary subscriber/contact information and identification of other policy members/enrollees affected
by the decertification, effective dates, implications of not having coverage (i.e., individual responsibility requirement, inability to get
special enrollment period/enroll until next open enrollment period), if the individual can choose to remain enrolled in the QHP outside
of the Exchange (without APTC/CSR), customer service contact information
Appointment of Authorized Representative Form
Appointment of Authorized Representative Form (§155.227(a)) –
Name, address, phone number, email address, date of birth, and relationship.

52

SHOP Required Notices to Employers
Data Elements for Employer Eligibility Determination Notice (45 CFR 155.715)- Sent after the processing of an initial
application, as well as after the processing of employer-reported changes or as part of annual redetermination
Employer Contact Information –
Eligibility Determination Information
Election Information –
Name, address, account/unique ID
Instructions for plan and contribution
for the Employer if applicableDetermination of eligibility for the
election, deadline for election (based on
employer to participate in the SHOP (45
effective date of coverage), information
CFR 155.715(e)and 45 CFR
about online tools
155.715(d)(1)(iv)(A))
Appeal rights and instructions (45 CFR
Customer Service Information –
Inconsistencies* Contact information for the
If an inconsistency exists for any applicant, 155.715(e))
Exchange, information regarding
the cause for the inconsistency, length of
Navigators and other customer service
the inconsistency period, and directions for
resources serving the employer’s area
resolving inconsistency (45 CFR
155.715(d)(1)(ii))
Notice of annual election period -- Current plan and contribution election information, potential actions the employer may want to
take – renew at same level, modify election, terminate participation (45 CFR 155.725(d))
Notice of employee termination – Notification to the employer of an employee’s termination of coverage. Includes date employee
elected to terminate and effective date of termination (45 CFR 155.720(h)
SHOP Required Notices to Employees
Data Elements for Employee Eligibility Determination Notice (45 CFR 155.715)- Sent at initial application, to confirm employee
eligibility determination resulting from changes or annual redetermination
Employee Contact Information –
Eligibility Determination Information
Election Information –
Name, address, account/unique ID
Instructions for plan and selection,
for the Employer if applicableEligibility determination of eligibility for
deadline for enrollment (based on
the employee to enroll in coverage through enrollment period length), information
the SHOP (45 CFR 155.715(f)and 45 CFR about online tools (if completed
155.715(d)(2)(iv))
application on paper)
Customer Service Information –
Contact information for the
Exchange, information regarding
Navigators and other customer service
resources serving the employer’s area

Appeal rights and instructions (45 CFR
Inconsistencies* If an inconsistency exists for any applicant, 155.715(f))
the cause for the inconsistency, length of
the inconsistency period, and directions for
resolving inconsistency (45 CFR
155.715(d)(2)(ii))

53

Notice of employer withdrawal –
Notification to the employee of its employer’s termination of participation in coverage. Includes date of termination of coverage (45
CFR 155.715(g) and information regarding other coverage options through the Exchange, as well as contact information for the
Exchange and information regarding Navigators and other customer service resources serving the employee’s area
Notice of annual enrollment period Current plan and contribution election information, potential actions the employee may want to take – renew plan, change plans,
terminate enrollment (45 CFR 155.725(f))
Qualified Employer Required Notices to Employees
Notice of enrollment process – A qualified employer must inform each employee that they are being offered coverage through the
SHOP and inform each employee of the instructions about how to enroll in health insurance coverage through the SHOP, including
information about what formats the employee may submit an application: online, on paper, or by phone (45 CFR 157.205(c)). If the
employee being offered coverage was hired outside an initial or annual enrollment period, the notice will include information about
whether the employee may qualify for a special enrollment period (45 CFR 157.205(e))
Qualified Employer Required Notices to a SHOP
Notice of change in eligibility for coverage – A qualified employer must provide the SHOP with an update the application if an
employee and his or her dependents have a change in eligibility status. For an employee, this consists of an application update
including, the employee’s name, SSN, and DOB. For dependents, this is a yes/no question. Information submission may be completed
online, by phone, or by paper (45 CFR 157.205(f))
*Information will only be included in the notice if applicable.

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