Appendix B Data Elements for Notices Part 155 156 157

Appendix B: 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)

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*.
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))

Customer Service Information – Contact
information for the Exchange,
information regarding Navigators and
other customer service resources serving
the applicant’s area, Medicaid and CHIP
agency contact information* (45 CFR

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 documentation and information

Enrollment Information* – Instructions for
QHP plan selection, deadline for plan
selection based on enrollment period,
information about online tools.
If coverage in a QHP is being terminated,
information regarding the termination
reason and effective date.*
If Exchange determined or assessed an
applicant as eligible for Medicaid or
CHIP, information regarding what
steps the Medicaid/CHIP agency will
take.

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

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))

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 similar to

SHOP Required Notices to Employers

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

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 for
Election Information –
Name, address, account/unique ID
the Employer if applicableInstructions for plan and contribution
Determination of eligibility for the employer
election, deadline for election (based on
to participate in the SHOP (45 CFR
effective date of coverage), information
155.715(e)and 45 CFR
about online tools
155.715(d)(1)(iv)(A))
Customer Service Information –
Contact information for the
Exchange, information regarding
Navigators and other customer service
resources serving the employer’s area

Inconsistencies* Appeal rights and instructions (45 CFR
If an inconsistency exists for any applicant,
155.715(e))
the cause for the inconsistency, length
of the inconsistency period, and
directions for 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 for
Election Information –
Name, address, account/unique ID
the Employer if applicableInstructions for plan and selection, deadline
Eligibility determination of eligibility for the
for enrollment (based on enrollment
employee to enroll in coverage through
period length), information about
the SHOP (45 CFR 155.715(f)and 45
online tools (if completed application
CFR 155.715(d)(2)(iv))
on paper)
Customer Service Information –
Contact information for the
Exchange, information regarding
Navigators and other customer service
resources serving the employer’s area

Inconsistencies* If an inconsistency exists for any applicant,
the cause for the inconsistency, length
of the inconsistency period, and
directions for resolving
inconsistency (45 CFR

Appeal rights and instructions (45 CFR
155.715(f))

155.715(d)(2)(ii))
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.

Data elements for forms and notices related to appeals provisions.
Title of Form
Appeal Request Form

Appointment of Authorized Representative Form

Appeal Withdrawal Request Form

Data Elements
• Name
• Address
• Phone number
• Email address
• Date of birth
• Date of determination
• Reason for appeal
• Employer name and contact information
• Name of authorized representative
• Special considerations
• Date of request
• Appellant name
• Appellant address
• Appellant phone number
• Appellant email address
• Appellant date of birth
• Appellant date of determination
• Appellant case number
• Authorized representative name
• Authorized representative address
• Authorized representative phone number
• Authorized representative email address
• Authorized representative date of birth
• Relationship of authorized representative to appellant
• Appellant name
• Address
• Phone number
• Email address
• Date of birth
• Authorized representative name
• Case number

Title of Form

Request to Vacate Dismissal Form

Request for Special Considerations Form

Request for Additional Information Form

Data Elements
• Withdrawal appeal request reason
• Date of withdrawal
• Name
• Address
• Phone number
• Email address
• Date of birth
• Case number
• Authorized representative name
• Reason to reopen vacate dismissal
• Supporting documentation
• Date of request
• Name
• Address
• Phone number
• Email address
• Date of birth
• Employer name and contact information
• Case number
• Authorized representative name
• Special accommodations being requested
• Date of request
• Name
• Address
• Phone number
• Email address
• Date of birth
• Social Security number (optional)
• Case number
• Requesting entity
• Authorized representative name
• Additional information needed to supplement appeal request
• Date of request