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pdfSupporting Statement for Paperwork
Reduction Act Submissions: Establishment
of an Exchange by a State and Qualified
Health Plans
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”), expand 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 became operational
on January 1, 2014, 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.
As directed by the rule Establishment of Exchanges and Qualified Health Plans; Exchange Standards for
Employers (77 FR 18310) (Exchange rule), each Exchange will assume responsibilities related to the
certification and offering of Qualified Health Plans (QHPs). To offer insurance through an Exchange, a
health insurance issuer must have its health plans certified as QHPs by the Exchange. A QHP must meet
certain minimum certification standards, such as network adequacy, inclusion of Essential Community
Providers (ECPs), and non-discrimination. The Exchange is responsible for ensuring that QHPs meet these
minimum certification standards as described in the Exchange rule under 45 CFR 155 and 156, based on
the Affordable Care Act, as well as other standards determined by the Exchange. The reporting
requirements and data collection in the Exchange rule address Federal requirements that various entities
must meet with respect to the establishment and operation of an Exchange; minimum requirements that
health insurance issuers must meet with respect to participation in a State based or Federally-facilitated
Exchange; and requirements that employers must meet with respect to participation in the SHOP and
compliance with other provisions of the Affordable Care Act.
B.
Justification
1.
Need and Legal Basis
Section 1311(b) of the Affordable Care Act requires each State to establish an Exchange by January 1,
2014. Section 1311(d) of the Affordable Care Act requires that an Exchange be a governmental agency or
nonprofit entity established by a State; requires that an Exchange make QHPs available to eligible
individuals and employers; and identifies the minimum functions that an Exchange must perform.
Pursuant to section 1311(d)(5), States had to ensure that their Exchanges are self-sustaining beginning on
January 1, 2015. A State may accomplish this by permitting its Exchange to charge assessments or user
Supporting Statement for Paperwork Reduction Act Submissions: Establishment of an Exchange by a State
and Qualified Health Plans
fees to participating health insurance issuers, or otherwise generate funding to support Exchange
operations.
In order to consolidate similar requirements in the same collection, the following information collection
requirements (ICRs) currently approved under OMB Control Number 0938-1156 will now be included
under separate collections for which we are seeking OMB approval under new OMB Control Numbers:
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General Functions of an Exchange (§155.200 through §155.270)
Exchange Functions in the Individual Market: Eligibility Determinations for Exchange
Participation and Insurance Affordability (§155.302 through §155.345)
Exchange Functions in the Individual Market: Enrollment in Qualified Health Plans (§155.400
through §155.440)
Exchange Functions: Small Business Health Options Program (SHOP) (§155.700 through
§155.730)
Exchange Functions: Certification of Qualified Health Plans (§155.1000 through §155.1080)
QHP issuer notice of effective date (§156.260(b))
QHP issuer reconciliation of enrollment files with Exchange (§156.265(f))
QHP issuer termination notice to the enrollee and Exchange (§156.270(b))
QHP issuer notice of enrollee nonpayment of premium (§156.270(d))
QHP issuer notice to providers of the possibility for denied claims (§156.270(d)(3))
QHP issuer notice of payment delinquency to an enrollee (§156.270(e))
QHP issuers maintenance of records of terminations of coverage (§156.270(h))
QHP issuer notification of plan non-renewal (§156.290)
The following ICRs are currently approved under other OMB control numbers and are being removed
from this collection to avoid duplication:
• General Standards Related to the Establishment of an Exchange by a State (§155.100 through
§155.150), approved under OMB control number 0938-1172
• Data collection and reporting requirements for health insurance issuers related to the
certification of qualified health plans (§156.210, §156.230), approved OMB control number
0938-1187
• QHP transparency requirements (§156.220), approved OMB control number 0938-1187
• QHP Provider Directory (§156.230(b)), approved OMB control number 0938-1187
• QHP release of Accreditation survey (§156.275), approved OMB control number 0938-1187
The following requirement is being discontinued because it has not been implemented:
• QHP submission of information related to prescription drug dispensing, pricing and
management (§156.295)
2.
Information Users
The data collection and reporting requirements will further compliance with federal law and assist HHS in
operation of the Federally-facilitated Exchanges.
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Supporting Statement for Paperwork Reduction Act Submissions: Establishment of an Exchange by a State
and Qualified Health Plans
3.
Use of Information Technology
HHS anticipates that a majority of the systems, notices, and information collection required by this rule
will be automated.
4.
Duplication of Efforts
This information collection does not duplicate any other Federal effort.
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, it is necessary to collect information
according to the indicated frequencies. If the information is collected less frequently, the result could
mean non-compliance with the law or consumer harm.
7.
Special Circumstances
There are no special circumstances.
8.
Federal Register/Outside Consultation
A Federal Register notice was published on December 2, 2015 (80 FR 75463), providing the public with a
60-day period to submit written comments on the ICRs. Comments were received but did not impact
burden.
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 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 20 states,
including the District of Columbia in operating an Exchange. However, we recognize that not all states
have elected to operate their own Exchanges and that territories may participate in operating an
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Supporting Statement for Paperwork Reduction Act Submissions: Establishment of an Exchange by a State
and Qualified Health Plans
Exchange. We also note that these estimates generally reflect burden for the first year, and that the
associated burden in subsequent years will be lower because many of the standards in the regulation can
be fulfilled through automated processes. Therefore, these estimates should be considered an upper
bound of burden estimates for non-Federal entities. These estimates may be adjusted in future PRA
packages as states progress in their Exchange development processes.
Salaries for the positions cited in the labor category of the burden charts were obtained from the Bureau
of Labor Statistics (BLS) Web site by visiting this link: http://www.bls.gov/oes/current/oes_nat.htm and
the “May 2014 National Occupational Employment and Wage Estimates” report. Fringe benefit estimates
were taken from the BLS March June 2015 Employer Costs for Employee Compensation report.
General Standards Related to the Establishment of an Exchange by a State (§155.100 through
§155.150)
In Part 155, subpart B of the regulation, we describe the standards related to the establishment of
Exchanges by a State. Subpart B contains information collection requirements associated with
determining whether a State is ready to operate an Exchange before 2014. There are additional
information collection requirements associated with the development of Exchange operations after
January 1, 2014.
Section 155.105 contains the requirements for the Exchange approval process. In order to have an
Exchange approved by HHS, the State must develop and submit an Exchange Blueprint that demonstrates
how the Exchange meets all legal requirements for successful operation of an Exchange. In addition to the
Exchange Blueprint, the State must submit an operational readiness assessment to HHS to demonstrate
readiness to execute the Exchange Blueprint. HHS published an Exchange Blueprint application that
included an operational readiness section, subject to the notice and comment process under the
Paperwork Reduction Act. The PRA package for the Exchange Blueprint application outlined the required
components of the Exchange Blueprint, including the burden associated with completing an operational
readiness assessment as well as the requirements regarding eligible contracting entities stated in
§155.110. The burden associated with meeting the approval process requirements of §155.105 are
reflected in the PRA package for the template approval application, CMS-10416.
General Functions of an Exchange (§155.200 through §155.270)
Part 155, subpart C describes the information collection and reporting requirements that Exchanges are
required to perform to support the minimum functions of an Exchange. Section 155.200 sets out the basic
functions of the Exchange. Section 155.200(b) requires the Exchange to issue certificates of exemption
from the individual responsibility requirement and payment. Section 155.200(d) includes the required
quality activities that the Exchange will have to perform. The activities that will involve the collection of
information include the implementation of surveys, information disclosures, and data reporting. HHS will
conduct future rulemaking on both the certificate of exemption requirement and the quality activities. At
that time, and per the requirements outlined in the Paperwork Reduction Act, we will estimate the
burden on Exchanges of complying with these provisions of the rule.
Section 155.205(b) requires the Exchange to maintain an up-to-date Internet Web site that provides
information on available QHPs. The QHP information required to be posted on the Web site includes
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Supporting Statement for Paperwork Reduction Act Submissions: Establishment of an Exchange by a State
and Qualified Health Plans
premium and cost-sharing information, the summary of benefits and coverage, levels of coverage (“metal
levels”) for each QHP, results of the enrollee satisfaction survey, quality ratings, medical loss ratio
information, transparency of coverage measures, and a provider directory. Additionally, the Exchange
must maintain the Web site to publish financial information, provide information on Navigators and other
consumer assistance services, and allow for eligibility determinations and enrollment in coverage. Finally,
the Web site must provide a calculator for the comparison of plans and have a consumer assistance
function.
The burden for this requirement may vary based on whether the Exchange decides to develop its own
code to support the Internet Web site or utilize Federally-developed code provided pursuant to section
1311(c)(5)(B) of the Affordable Care Act. If the Exchange uses Federally-developed code, the burden of
meeting this requirement may include customizing the code to meet the business practices of the State,
developing security policies, and system testing. If the Exchange opts to develop new code, the burden
will include the additional steps of designing the Web site template and writing the code for the Web site.
After developing the Web site, the burden on the Exchange will be to maintain the Internet Web site by
populating the Web site with information collected per information collection requirements in this rule
and future rulemaking by HHS. We estimate that 3 states, may plan to operate an Exchange Web site
subject to these reporting requirements, and we assume that they will not opt to develop their own new
code and that most will use Federally-developed code. We estimate that it will take 3,200 hours for an
Exchange to meet these reporting requirements for a total of 9,600 hours.
Burden Costs
(per
respondent)
Respondents
Hour Rate
(incl fringe)
Burden
Hours
Health Policy Analyst
1
$58.66
256
$15,016.96
Web Developer
2
$44.35
256
$22,707.20
Senior Management
Network
Administrator/Database
Administrator
Computer Programmer
2
$78.81
64
$10,087.68
2
$54.86
384
$42,132.48
4
$61.52
384
$94,494.72
3200
$184,439.04
Labor Category
Total
Total Burden
Costs (all
respondents)
$553,317.12
As discussed in §155.210, the Exchange is required to develop and publically disseminate two sets of
standards for Navigators, one set of standards to govern conflict of interest and one set of standards for
training. The Exchange may choose to use any method that would make the standards available to the
general public as long as the Exchange does not exclusively rely on a method that places the burden on
the public to request the standards. Such methods could, for example, include posting the standards on
the Exchange Web site or disseminating them to appropriate stakeholders. The burden estimate related
to this requirement includes the time and effort needed to develop the standards and make them
available to the public. We estimate there will be 20 states, including the District of Columbia, potentially
operating State Exchanges subject to these operating requirements. This estimate is an upper bound of
burden. We estimate that it will take 192 hours for an Exchange to meet these reporting requirements for
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Supporting Statement for Paperwork Reduction Act Submissions: Establishment of an Exchange by a State
and Qualified Health Plans
a total of 3,840 hours.
Respondents
Hour Rate
(incl fringe)
Burden
Hours
Health Policy Analyst
2
$58.66
64
Burden Costs
(per
respondent)
$7,508.48
Senior Management
2
$78.81
32
$5,043.84
192
$12,552.32
Labor Category
Total
Total Burden
Costs (all
respondents)
$251,046.40
Section 155.220(c) provides the option for an Exchange to allow an Internet Web site of an agent or
broker to be used to select a QHP, as long as the agent or broker’s Internet Web site meets certain
conditions and the agent or broker complies with the terms of an agreement with the Exchange regarding
access and use of Exchange data and systems by the agent or broker. In such instances, the agent or
broker must ensure that applicants have their eligibility applications completed through the Exchange
Internet Web site and the Exchange must transmit the enrollment information to the QHP issuer. For the
agent or broker’s Internet Web site to be able to assist individuals in selecting a QHP, the Exchange would
have to provide QHP data to the agent or broker’s Internet Web site so that the applicant could select a
QHP. The Exchange would also need to develop an agreement with agents and brokers that intend to
support an Internet web site that would assist individuals in selecting a QHP.
For Exchanges that elect to allow agents and brokers to use their Internet Web sites to help individuals
select a QHP, the burden associated with this provision would be the development of electronic interfaces
to provide QHP data to the agent or broker’s Internet Web site and receive QHP selection information
from the agent or broker. There would also be additional burden on Exchanges to develop and execute
agreements with applicable agents and brokers. We estimate there will be potentially 20 states, including
the District of Columbia that plan to or do operate State Exchanges subject to these operating
requirements. We estimate that it will take 164 hours for an Exchange to meet these reporting
requirements for a total of 3,280 hours.
Burden Costs
(per
respondent)
Respondents
Hour Rate
(incl fringe)
Burden
Hours
Health Policy Analyst
1
$58.66
12
$703.92
Operations Analyst
1
$58.66
24
$1,407.84
Senior Manager
1
$84.09
12
$1,009.08
Attorney
Network
Administrator/Databas
e Administrator
Computer Programmer
Total
1
$86.18
16
$1,378.88
1
$54.86
40
$2,194.40
1
$61.52
60
$3,691.20
164
$10,385.32
Labor Category
6
Total Burden
Costs (all
respondents)
$207,706.40
Supporting Statement for Paperwork Reduction Act Submissions: Establishment of an Exchange by a State
and Qualified Health Plans
The Exchanges must also develop privacy and security standards addressing the collection, use and
disclosure of personally identifiable information. Section 155.260(d) states that the Exchange must
develop policies and procedures regarding the use, disclosure, and disposal of personally identifiable
information. These policies and procedures must be made available, in writing, to the Secretary of HHS
upon request. This information will be used to ensure that Exchanges have standards in place to protect
personally identifiable information and that Exchanges are in compliance with all applicable privacy and
security requirements. The burden associated with this requirement is the time and effort necessary for
the Exchange to develop and transmit the information, in writing, to the Secretary of HHS. We estimate
there will be states that plan to operate State Exchanges subject to these operating requirements. We
estimate that it will take 95 hours for each Exchange to meet this requirement for a total estimate of 285
hours.
$58.66
Burde
n
Hours
40
Burden Costs
(per
respondent)
$2,346.40
1
$84.09
15
$1,261.35
Systems security officer
1
$59.15
20
$1,183.00
Privacy Officer
1
$59.15
20
$1,183.00
95
$5,973.75
Labor Category
Responden
ts
Hour Rate
(incl fringe)
Health Policy Analyst
1
Senior Manager
Total
Total Burden
Costs (all
respondents)
$17,921.25
Exchange Functions in the Individual Market: Eligibility Determinations for Exchange Participation
and Insurance Affordability (§155.302 through §155.345)
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. 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 functions. We do not
have an estimate as to the number of States in which such an agreement will be executed; however, if
one of the options, or combinations of options, described in paragraphs (b) and (c) is implemented, we
estimate it will take a State an average of 105 hours to create a new agreement and a total of 315 hours
for the 3 potential new exchanges. This includes a mid-level health policy analyst drafting the agreement
with managerial oversight and comprehensive review of the agreement.
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Supporting Statement for Paperwork Reduction Act Submissions: Establishment of an Exchange by a State
and Qualified Health Plans
Burden Costs
(per
respondent)
Respondents
Hour Rate
(incl fringe)
Burden
Hours
Health Policy Analyst
1
$58.66
35
$2,053.10
Attorney
1
$86.18
30
$2,585.40
Operations Analyst
1
$58.66
35
$2,053.10
Senior Manager
1
$84.09
5
$420.45
105
$7,112.05
Labor Category
Total
Total Burden
Costs (all
respondents)
$21,336.15
In accordance with section §1413(b) of the Affordable Care Act, §155.310(a)(1), the Exchange uses 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 includes all
information necessary to determine the eligibility of an applicant for enrollment in a qualified health plan
through the Exchange and insurance affordability programs, as applicable. More detailed information on
this information collection requirement and the corresponding burden estimate is outlined in a separate
Application PRA Package (CMS-10440, OMB Control Number: 0938-1191)
Throughout this subpart, we 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. We will discuss the burden of these attestations in further detail in a separate
PRA package associated with the single streamlined application.
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 successfully transfer
all information from the records of the Exchange to the Medicaid agency to provide the applicant with
coverage promptly and without undue delay. This applicant information will be transmitted electronically
(via secure electronic interface) 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. We estimate
the burden on the Exchange to execute data sharing agreements with State Medicaid and CHIP agencies
to comply with this provision in §155.345.
Section 155.310(g) provides that the Exchange notifies individuals of their eligibility determination after it
has been made, so that he or she may select a plan, appeal an eligibility determination, or follow up with
Medicaid, CHIP, or the BHP, as applicable. The Exchange consolidate all eligibility determinations of a
household into a single notice when multiple members of a household are applying together and receive
an eligibility determination at the same time. The notice can be made available in paper or electronic
format but must be in writing and sent after an eligibility determination has been made by the Exchange.
We anticipate that half of enrollees will request electronic notification while the other half 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. We expect that the electronic eligibility determination
notice will be dynamic and include information tailored to all possible outcomes of an application
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Supporting Statement for Paperwork Reduction Act Submissions: Establishment of an Exchange by a State
and Qualified Health Plans
throughout the eligibility determination process. To develop the paper and electronic notices, Exchange
staff refer to eligibility rules and draft notice text for various decision points, follow up, referrals, and
appeals procedures. A peer analyst, manager, and/or legal counsel would review and approve final
language for the notice. The Exchange would then engage in review and editing to incorporate changes
from the consultation and user testing including review to ensure compliance with plain writing,
translation, and readability standards. The Exchange may also consult with the State Medicaid or CHIP
agency in order to develop a coordinated, single notice. Finally, for the electronic notice, a developer
would program the template notice into the eligibility system so that the notice may be populated and
generated as the applicant moves through the eligibility process.
We estimate 20 Exchanges will be required to generate the various eligibility notices for applicants. We
estimate that this notice development as outlined in the paragraph above, including the systems
programming, would take each Exchange an estimated 196 hours to complete in the first year. We
estimate the total estimated hour burden is 3,920 hours, however this will significantly reduce for
operating exchanges.
Burden Costs
(per
respondent)
Respondents
Hour Rate
(incl fringe)
Burden
Hours
Health Policy Analyst
2
$58.66
69
$8,095.08
Attorney
1
$86.18
20
$1,723.60
Senior Manager
1
$84.09
4
$336.36
Fulfillment Manager
1
$34.61
2
$69.22
Computer Programmer
1
$61.52
32
$1,968.64
196
$10,155.04
Labor Category
Total
Total Burden
Costs (all
respondents)
$203,100.80
Paragraph (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 who was determined eligible for advance payments of the premium
tax credit and cost-sharing reductions 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. The notice must be
available in paper or electronic format. 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.
To develop this employer 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 review and editing to incorporate changes from the review and user testing,
including review to ensure compliance with plain writing, translation, 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 estimate 20 Exchanges will be required to generate a notice to send to employers. We estimate that
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Supporting Statement for Paperwork Reduction Act Submissions: Establishment of an Exchange by a State
and Qualified Health Plans
this notice development as outlined in the paragraph above would take each Exchange an estimated 99
hours in the first year and the total estimated hour burden across all Exchanges in the first year to be
1,980 hours. We expect that the burden on the Exchange to maintain this notice will be significantly lower
than to develop it.
$58.66
$86.18
$84.09
Burde
n
Hours
69
10
2
Burden Costs
(per
respondent)
$8,095.08
$861.80
$168.18
1
$34.61
2
$69.22
1
$61.52
16
$984.32
99
$9,125.06
Respondent
s
Hour Rate
(incl fringe)
Health Policy Analyst
Attorney
Senior Manager
2
1
1
Fulfillment Manager
Labor Category
Computer
Programmer
Total
Total Burden Costs
(all respondents)
$182,501.20
The provisions in §155.315 and §155.320 set standards for verification of applicant information for
determining eligibility for enrollment in a QHP and insurance affordability programs. Exchanges will set up
data-sharing agreements with HHS to allow for the verification of applicant information with Federal
agencies that maintain authoritative data. The attestations collected throughout the verification process
in §155.315 and §155.320 will be collected as data elements of the single streamlined application and
discussed in further detail in a separate PRA package.
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 20 Exchanges, including
the District of Columbia 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 the 3 potential new Exchanges, we expect a total hour
burden of 315 hours.
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Supporting Statement for Paperwork Reduction Act Submissions: Establishment of an Exchange by a State
and Qualified Health Plans
Labor Category
Health Policy
Analyst
Operations
Analyst
Attorney
Senior Manager
Total
Burden Costs
(per
respondent)
Respondents
Hour Rate
(incl fringe)
Burden
Hours
1
$58.66
35
$2,053.10
1
$58.66
35
$2,053.10
1
1
$86.18
$84.09
30
5
105
$2,585.40
$420.45
$7,112.05
Total Burden Costs
(all respondents)
$21,336.15
Section 155.315(f) outlines the process for resolving inconsistencies identified through the verification
process. The Exchange will provide notice to an applicant, requests that the applicant provide
documentation to support his or her attestation regarding the eligibility determination. Upon receipt of
acceptable supporting information from the applicant, the Exchange updates the applicant’s account and
predetermines his or her eligibility. While the electronic eligibility system will be able to process most
applications in an automated fashion and that only the more complex cases will be handled through the
paper-driven process to resolve inconsistencies. For these complicated cases, the manual adjudication of
the documentation submitted by an applicant to the Exchange will be necessary. While there is minimal
consumer burden associated with submitting documentation, it is difficult to provide estimates for the
number of applicants for whom the adjudication of documentation will be necessary, but we anticipate
that this number will decrease as applicants become more familiar with the eligibility process and as more
data become available electronically.
Sections 155.330(b) and (c) indicate that the Exchange requires an individual to report certain 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, the Exchange re-verifies the information in accordance
with the rules described in §155.315 and §155.320.
A large volume of changes are reported electronically by the enrollee, but an enrollee would also be
permitted to submit changes through any of the channels via phone, mail, or in person. The burden for
this collection includes the time necessary for an eligibility worker to process any changes submitted by
an enrollee during the benefit year. It is difficult to provide estimates for the number of applicants for
whom the adjudication of documentation will be necessary, but we anticipate that this number will
decrease as applicants become more familiar with the eligibility process and as more data become
available.
Section 155.330(d) provides that the Exchange will periodically examine certain data sources for changes
impacting an enrollee’s eligibility. The final rule provides the Exchange the flexibility to go beyond the
limited data matching required, as long as it acts within certain standards. Any such data matching would
require new data sharing agreements or amendments to existing data sharing agreements. The estimate
of the burden associated with establishing or amending such agreements is described in §155.315 and
§155.320.
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Supporting Statement for Paperwork Reduction Act Submissions: Establishment of an Exchange by a State
and Qualified Health Plans
The Exchange is required to notify an enrollee that it has identified such a change and dependent upon
the response, predetermine the enrollee’s eligibility. The burden associated with creating this notice is
similar to that of the annual redetermination notice, discussed in §155.335.
Section 155.335 outlines the annual redetermination process and provides that the Exchange will
predetermine the eligibility of an enrollee in a QHP on an annual basis. The burden associated with this
requirement is the time and effort necessary for Exchanges to develop and automate the annual
redetermination notice and perform the record keeping related to predetermining eligibility. In
accordance with 155.335(d), the annual redetermination notice is sent along with the notice of annual
open enrollment as specified in 155.410(d), in a single, coordinated notice. We anticipate that half of
enrollees will request electronic notification while the other half will receive the notice by mail. Thus, we
have estimated the associated mailing costs for the time and effort needed to mail notices in bulk to
enrollees as appropriate.
Similar to the eligibility notice described in 155.310(g), the annual redetermination notice contains
dynamic text and include information tailored to each applicant. Section 155.335(c) provides that the
Exchange include in the annual redetermination notice 1) updated income and family size information
from the IRS, 2) data regarding MAGI-based income as described in §155.320(c)(1), 3) data used in the
enrollee’s most recent eligibility determination, and 4) the enrollee’s projected eligibility determination
for the following year, including the amount of any advance payments of the premium tax credit and costsharing reductions.
Exchange staff time would include learning the eligibility process and drafting notice text to include
relevant income information, as well as follow up and appeals procedure. A peer analyst, manager, and/or
legal counsel would review the notice. The Exchange then engages in review and editing to incorporate
changes from the review and user testing, including a review to ensure compliance with plain writing,
translation, and readability standards. The Exchange also coordinates 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. The programming of
the notice into the eligibility system would allow for updated tax information to be pre-populated into the
notice of annual redetermination.
We estimate 20 Exchanges will be required to generate the annual redetermination notice for applicants.
We estimate that this notice development as outlined in the paragraph above would take each Exchange
an estimated 196 hours. We estimate the total estimated hour burden in the first year is 3,920 for all
Exchanges. We expect that this cost will decrease significantly after the first year of development as the
costs incurred will be for maintenance.
12
Supporting Statement for Paperwork Reduction Act Submissions: Establishment of an Exchange by a State
and Qualified Health Plans
Labor Category
Health Policy
Analyst
Attorney
Senior Manager
Fulfillment
Manager
Computer
Programmer
Total
Respondents
Hour Rate
(incl fringe)
Burden
Hours
Burden Costs
(per
respondent)
2
$58.66
138
$16,190.16
1
1
$86.18
$84.09
20
4
$1,723.60
$336.36
1
$34.61
2
$69.22
1
$61.52
32
$1,968.64
196
$18,250.12
Total Burden
Costs (all
respondents)
$365,002.40
Section§155.335(e), holds that the Exchange must require an individual to report changes on the notice of
annual redetermination within 30 days. And the exchange has observed many enrollees will report
changes at annual redetermination electronically (by updating their initial application for coverage). And
some enrollees send in a paper annual redetermination notice or require manual review of
documentation. However, it is difficult to provide estimates for the number of applicants for whom the
manual adjudication of documentation will be necessary, but we anticipate that this number will decrease
as applicants become more familiar with the eligibility process and as more data become available.
Section 155.340 provides that in the event that a tax filer is determined eligible for advance payments of
the premium tax credit and/or cost-sharing reductions, the Exchange notifies HHS and the relevant QHP
issuer. This notification is made via secure, electronic transmission automatically sent by the system.
Paragraph (a) provides that the Exchange transmits eligibility and enrollment information necessary to
enable HHS to begin, end, or change an individual’s advance payments of the premium tax credit or costsharing reductions. This applicant information is transmitted from the Exchange to HHS and includes
information such as the individual’s name, the dollar amount of the individual’s advance payment, and
the individual’s cost-sharing reductions eligibility category, among other information. This information is
transmitted when an individual’s advance payment of the premium tax credit or cost-sharing reductions
begins, ends, or changes. This electronic data transmission is automatically sent by the system. The
burden estimate for this information collection is addressed in the discussion of enrollment transactions
in §155.400(b).
Based on Section 155.345(a), the Exchange has entered into written agreements with agencies
administering other insurance affordability programs. These provisions are 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 agreements to share data 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. We expect that 3 Exchanges will be subject to this requirement and that one agreement would
13
Supporting Statement for Paperwork Reduction Act Submissions: Establishment of an Exchange by a State
and Qualified Health Plans
include standards for all insurance affordability programs. 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 a State an average of 105 hours to create new
agreements. This includes a mid-level health policy analyst and an operations analyst developing the
agreement with managerial oversight and comprehensive review of the agreement an operations analyst.
For the 3 potential new Exchanges, we expect a total hour burden in the first year of 315 hours.
Labor Category
Health Policy
Analyst
Operations Analyst
Attorney
Senior Manager
Total
Burden
Hours
Burden Costs
(per
respondent)
Respondents
Hour Rate
(incl fringe)
1
$58.66
35
$2,053.10
1
1
1
$58.66
$86.18
$84.09
35
30
5
105
$2,053.10
$2,585.40
$420.45
$7,112.05
Total Burden
Costs (all
respondents)
$21,336.15
Section 155.345(d)(1) provides that when the Exchange identifies an applicant as potentially eligible for
Medicaid by accessing information on the application or an applicant requests a full determination for
Medicaid, the Exchange must transmit all information provided on the application and any information or
verifies by the Exchange to the State Medicaid agency. Section 155.345(d)(2) also provides that the
Exchange must notify the applicant of such transmittal. This notification is part of the eligibility notice
described in 155.310(f) and the burden associated with this information collection requirement is
referenced in that section.
The burden associated with this ICR for information disclosure is the time and effort necessary to transmit
the application data from the Exchange to the appropriate insurance affordability program. This data
transmission is via secure, electronic transmission automatically sent by the system. No personnel are
needed to enact this transmission and therefore we do not estimate any burden associated with the data
transmitted as specified by this provision. The Exchange will enter into agreements to fulfill this provision
as specified in §155.345(a).
Exchange Functions in the Individual Market: Enrollment in Qualified Health Plans (§155.400
through §155.440)
In Part 155, subpart E of the regulation, 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. Therefore, we estimate that it will take an Exchange less than one minute to transmit
plan selection and necessary enrollment information concurrently to QHP issuers and HHS. As a result, we
14
Supporting Statement for Paperwork Reduction Act Submissions: Establishment of an Exchange by a State
and Qualified Health Plans
expect that most of the burden will initially reflect programming of the enrollment feeds to QHP issuers
and HHS.
We estimate that the 3 potential exchanges plan would 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 reporting requirements for a total of 426 hours.
Labor Category
Burden Costs
(per
respondent)
Respondents
Hour Rate
(incl fringe)
Burden
Hours
1
$58.66
10
$586.60
1
$61.52
100
$6,152.00
1
$58.66
32
142
$1,877.12
$8,615.72
Health Policy
Analyst
Computer
Programmer
Operations Analyst
Total
Total Burden Costs
(all respondents)
$25,847.16
Section 155.400(c) states 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 the 3 potential exchanges plan would 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 426 hours.
Burden Costs
(per
respondent)
Respondents
Hour Rate
(incl fringe)
Burden
Hours
Health Policy Analyst
1
$58.66
10
$586.60
Computer Programmer
1
$61.52
100
$6,152.00
Operations Analyst
Total
1
$58.66
32
142
$1,877.12
$8,615.72
Labor Category
Total Burden
Costs (all
respondents)
$172,314.40
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 6,480 hours across 20 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
15
Supporting Statement for Paperwork Reduction Act Submissions: Establishment of an Exchange by a State
and Qualified Health Plans
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.
Burden Costs
(per
respondent)
Respondents
Hour Rate
(incl fringe)
Burden
Hours
Health Policy Analyst
2
$58.66
72
$8,447.04
Computer Programmer
2
$61.52
60
$7,382.40
Operations Analyst
1
$58.66
60
$3,519.60
324
$19,349.04
Labor Category
Total
Total Burden
Costs (all
respondents)
$386,980.80
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 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 starting 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, inperson 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. In the near future, HHS will publish the model application and will solicit public
comment. At that time, and per the requirements outlined in the Paperwork Reduction Act, we will
estimate the burden on Exchanges of complying with this provision of the rule.
Section 155.405(b) states that Exchanges have the option of using an alternative application that 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 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.
As discussed in §155.410, the Exchange must 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. The burden estimate associated with
16
Supporting Statement for Paperwork Reduction Act Submissions: Establishment of an Exchange by a State
and Qualified Health Plans
this requirement includes the time and effort needed to develop the notice template and distribute the
notice through an automated process when appropriate via the enrollee’s preferred method. We
anticipate that half of enrollees will request electronic notification while the other half 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. We estimate that 20 states, including the District of
Columbia plan to or do operate an Exchange subject to these reporting requirements. This estimate is an
upper bound of burden. As such, we estimate that it will take approximately 42 hours annually for the
time and effort to develop and transmit the notice when appropriate for a total of 840 hours.
Burden Costs
(per
respondent)
Respondents
Hour Rate
(incl fringe)
Burden
Hours
Health Policy Analyst
1
$58.66
4
$234.64
Senior Manager
1
$84.09
1
$84.09
Operations Analyst
Computer
Programmer
1
$58.66
3
$175.98
1
$61.52
32
$1,968.64
Fulfillment Manager
1
$34.61
2
$69.22
42
$2,532.57
Labor Category
Total
Total Burden
Costs (all
respondents)
$50,651.40
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 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 20 states, including the District of Columbia, plan to or do Exchange operations subject to
these reporting requirements. This estimate is an upper bound of burden. As such, we estimate that it will
take approximately 70 hours annually for the time and effort to meet this requirement for a total of 1,400
hours.
17
Supporting Statement for Paperwork Reduction Act Submissions: Establishment of an Exchange by a State
and Qualified Health Plans
Labor Category
Health Policy
Analyst
Computer
Programmer
Operations Analyst
Total
Burden Costs
(per
respondent)
Respondents
Hour Rate
(incl fringe)
Burden
Hours
1
$58.66
30
$1,759.80
1
$61.52
20
$1,230.40
1
$58.66
20
70
$1,173.20
$4,163.40
Total Burden
Costs (all
respondents)
$83,268.00
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.
Exchange Functions: Small Business Health Options Program (SHOP) (§155.700 through §155.730)
In subpart H of part 155, we describe information collection and reporting requirements that pertain to
the SHOP. Section 155.705(b)(4) states that the SHOP must perform certain functions related to premium
payment administration. On a monthly basis, the SHOP is required to provide a bill to each employer
participating in the SHOP. The bill will inform the employer of the amount of the employer and employee
contributions, as well as provide a total amount that is due to the QHP issuers from the qualified
employer. The SHOP will have to develop the bill and transmit it to the qualified employer by either
electronic or paper means. The SHOP will have to maintain books, records, documents, and other
evidence related to the premium aggregation program for a minimum of ten years. The information will
be used to facilitate audit functions of the SHOP. The burden estimates associated with these
requirements include the time and effort needed to develop automated processes for creating and
transmitting the monthly bills to qualified employers. Additionally, the burden includes the time and
effort needed to develop processes for the collection of discrepancy information and information
retention. We estimate that the 3 potential exchanges plan would be subject to these reporting
requirements. This estimate is an upper bound of burden. As such, we estimate that it will take
approximately 60 hours annually for the time and effort to develop and transmit the notice when
appropriate for a total of 1,200 hours.
Labor Category
Computer
Programmer
Senior Manager
Operations Analyst
Total
Burden Costs
(per
respondent)
Respondents
Hour Rate
(incl fringe)
Burden
Hours
3
$61.52
15
$2,768.40
1
2
$84.09
$58.66
5
5
60
$420.45
$586.60
$3,775.45
18
Total Burden
Costs (all
respondents)
$11,326.35
Supporting Statement for Paperwork Reduction Act Submissions: Establishment of an Exchange by a State
and Qualified Health Plans
Section 155.715(b) states that the SHOP must accept a SHOP single employer application form. The
application, which will be submitted by an employer when applying to participate in the Exchange, will
include information to determine employer eligibility to participate in the Exchange and to collect
information necessary to purchase coverage. As stated in §155.730(b), the application must, at a
minimum, include identifying information about the employer and a list of employees with social security
numbers. The burden associated with complying with the requirement to accept a SHOP single employer
application form includes the time and effort to accept and process the information provided by the
employer in the application. Per §155.730(d), HHS is developing a model single employer application for
States that will include the minimum data elements that the Exchanges will be required to collect. In the
near future, HHS will publish the model application and will solicit public comment. At that time, and per
the requirements outlined in the Paperwork Reduction Act, we will estimate the burden on Exchanges of
complying with this provision of the rule.
Section 155.715(b) also states that the SHOP must accept a SHOP single employee application form from
employees wishing to elect coverage through SHOP. As per §155.730(b), the application will include
information to determine the eligibility of an applicant and process plan selection for enrollment in a
qualified health plan through the SHOP. Employees will submit the application to the Exchange upon
applying to participate in the Exchange. Per §155.730(d), HHS is developing a model single employee
application for States that will include the minimum data elements that the Exchanges will be required to
collect. In the near future, HHS will publish the model application and will solicit public comment. At that
time, and per the requirements outlined in the Paperwork Reduction Act, we will estimate the burden on
Exchanges of complying with this provision of the rule.
Section 155.715 discusses several notices related to the eligibility process that SHOP must provide to
employers and employees. If the SHOP finds any inconsistencies in the application submitted by the
employer, the SHOP, in accordance with section 155.715(d)(1), must notify the employer of the
inconsistency and give the employer 30 days to submit documentary evidence to support the application.
If after the 30 day period the SHOP does not receive satisfactory documentary evidence, the SHOP, must
notify the employer of its denial of eligibility and the employer’s right to appeal such determination. The
burden estimates related to the two notices includes the time and effort needed to develop each of the
notices and make it an automated process to be sent out when appropriate. We anticipate that nearly all
employers will request electronic notification. We estimate that 20 States will operate an Exchange
subject to these reporting requirements. This estimate is an upper bound of burden. As such, we estimate
that it will take approximately 80 hours annually for the time and effort to develop the two notices and
transmit each notice when appropriate for a total of 1,600 hours.
Burden Costs
(per
respondent)
Respondents
Hour Rate
(incl fringe)
Burden
Hours
Health Policy
Analyst
1
$58.66
8
$469.28
Senior Manager
1
$84.09
2
$168.18
Operations Analyst
1
$58.66
6
$351.96
Labor Category
19
Total Burden
Costs (all
respondents)
Supporting Statement for Paperwork Reduction Act Submissions: Establishment of an Exchange by a State
and Qualified Health Plans
Labor Category
Computer
Programmer
Burden Costs
(per
respondent)
Respondents
Hour Rate
(incl fringe)
Burden
Hours
1
$61.52
64
$3,937.28
80
$4,926.70
Total
Total Burden
Costs (all
respondents)
$98,534.00
Section 155.715(d)(2) provides a similar notification process for any inconsistent information in an
employee application. If the SHOP finds that information on the application is inconsistent with
information provided by the employer, the SHOP must notify the individual of the inconsistency and
provide the individual with 30 days to provide documentary evidence to the SHOP to support the
employee application. If after the 30 day period the SHOP does not receive satisfactory documentary
evidence, the SHOP, must notify the employee of denial of eligibility. The burden estimates associated
with the two notices includes the time and effort needed to develop each of the notices and make it an
automated process to be sent out when appropriate. We anticipate that half of enrollees will request
electronic notification while the other half 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.
We estimate that 20 states, including the District of Columbia, plan to or do operate an Exchange subject
to these reporting requirements. This estimate is an upper bound of burden. As such, we estimate that it
will take approximately 84 hours annually for the time and effort to develop the two notices and transmit
each notice when appropriate for a total of 1,680 hours.
Respondents
Hour Rate
(incl fringe)
Burden
Hours
Health Policy Analyst
1
$58.66
8
Burden Costs
(per
respondent)
$469.28
Senior Manager
Operations Analyst
Computer Programmer
Fulfillment Manager
Total
1
1
1
1
$84.09
$58.66
$61.52
$34.61
2
6
64
4
84
$168.18
$351.96
$3,937.28
$138.44
$5,065.14
Labor Category
Total Burden
Costs (all
respondents)
$101,302.80
Section 155.715(e) requires the SHOP to provide an employer requesting eligibility to purchase coverage
with a notice of approval or denial of eligibility and the employer’s right to appeal the eligibility
determination. The burden estimates associated with the notice requirement includes the time and effort
needed to develop the notice and make the notice an automated process to be sent out when
appropriate. We anticipate that nearly all employers will request electronic notification. As a result, we
did not estimate the associated mailing costs. We estimate that 20 States, including the District of
Columbia, plan to or do operate an Exchange subject to these reporting requirements. This estimate is an
upper bound of burden. As such, we estimate that it will take approximately 40 hours annually for the
time and effort to develop the two notices and transmit each notice when appropriate for a total of 800
hours.
20
Supporting Statement for Paperwork Reduction Act Submissions: Establishment of an Exchange by a State
and Qualified Health Plans
Labor Category
Health Policy
Analyst
Senior Manager
Operations Analyst
Computer
Programmer
Total
Respondents
Hour Rate
(incl fringe)
Burden
Hours
Burden Costs
(per
respondent)
1
$58.66
4
$234.64
1
1
$84.09
$58.66
1
3
$84.09
$175.98
1
$61.52
32
$1,968.64
40
$2,463.35
Total Burden
Costs (all
respondents)
$49,267.00
Section 155.715(f) provides the same notice of approval or denial of eligibility for employees seeking to
enroll in a QHP offered through the SHOP. The burden estimates associated with the notice requirement
includes the time and effort needed to develop the notice and make the notice an automated process to
be sent out when appropriate. We anticipate that half of enrollees will request electronic notification
while the other half 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. As a result, we have not
estimated associated mailing costs. We estimate that 20 states, including the District of Columbia, plan to
or do operate an Exchange subject to these reporting requirements. This estimate is an upper bound of
burden. As such, we estimate that it will take approximately 42 hours annually for the time and effort to
develop the two notices and transmit each notice when appropriate for a total of 840 hours.
Labor Category
Respondents
Hour Rate
(incl fringe)
Burden
Hours
Burden Costs
(per
respondent)
Health Policy Analyst
1
$58.66
4
$234.64
Senior Manager
1
$84.09
1
$84.09
Operations Analyst
Computer
Programmer
1
$58.66
3
$175.98
1
$61.52
32
$1,968.64
Fulfillment Manager
1
$34.61
2
$69.22
42
$2,532.57
Total
Total Burden
Costs (all
respondents)
$50,651.40
Section 155.715(g) requires the SHOP to notify enrolled employees when their employer terminates its
participation in the SHOP. The purpose of the notice is to inform the employee of the termination of the
employee’s coverage and to provide the employee with information on potential other sources of
coverage. The burden estimate related to the notice includes the time and effort needed to develop a
single notice template and which would be distributed through an automated process when appropriate.
We anticipate that half of employees will request electronic notification while the other half of employees
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 employees as appropriate. As a result, we have not estimated
21
Supporting Statement for Paperwork Reduction Act Submissions: Establishment of an Exchange by a State
and Qualified Health Plans
associated mailing costs. We estimate that 20 states, including the District of Columbia, plan to or do will
operate an Exchange subject to these reporting requirements. This estimate is an upper bound of burden.
As such, we estimate that it will take approximately 42 hours annually for the time and effort to develop
and transmit the notice when appropriate for a total of 840 hours.
Labor Category
Health Policy
Analyst
Senior Manager
Operations Analyst
Computer
Programmer
Fulfillment Manager
Total
Burden Costs
(per
respondent)
Respondents
Hour Rate
(incl fringe)
Burden
Hours
1
$58.66
4
$234.64
1
1
$84.09
$58.66
1
3
$84.09
$175.98
1
$61.52
32
$1,968.64
1
$34.61
2
42
$69.22
$2,532.57
Total Burden
Costs (all
respondents)
$50,651.40
Section 155.720(c) requires the SHOP to transfer enrollment information on behalf of qualified employees
to QHP issuers in order to enroll qualified employees of a qualified employer participating in the SHOP.
We estimate that 20 States, including the District of Columbia, plan to or do operate an Exchange subject
to these reporting requirements. This estimate is an upper bound of burden. We expect that the
transmission of SHOP enrollment information will leverage the enrollment feeds to issuers developed by
Exchanges for the individual market. As a result, we expect only incremental development costs
associated with incorporating SHOP specific information. We estimate that it will take 28 hours for an
Exchange to meet the requirement for a total of 560 hours.
Burden Costs
(per
respondent)
Respondents
Hour Rate
(incl fringe)
Burden
Hours
Health Policy
Analyst
1
$58.66
5
$293.30
Senior Manager
1
$84.09
2
$168.18
Operations Analyst
Computer
Programmer
1
$58.66
5
$293.30
1
$61.52
16
$984.32
28
$1,739.10
Labor Category
Total
Total Burden
Costs (all
respondents)
$34,782.00
Section 155.720(f) states that the SHOP must maintain records of all employer and employee enrollments
in QHPs through the SHOP. This information will be used to facilitate reconciliation functions of the SHOP.
Section 155.720(g) states that the SHOP must reconcile enrollment and employer participation
information with QHP issuers on no less than a monthly basis. The purpose of reconciling enrollment
information between the SHOP and QHP issuers is to ensure that both entities have accurate records of
22
Supporting Statement for Paperwork Reduction Act Submissions: Establishment of an Exchange by a State
and Qualified Health Plans
the participating employers, number of enrollees, and persons enrolled in each QHP. It is expected that
the information will be maintained in an electronic data system. The burden estimates associated with
these requirements includes the time and effort needed to develop processes for the collection and
retention of record information, and reconcile the enrollment information with HHS. We estimate that
the 3 potential exchanges plan would 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 the record
maintenance requirement for a total of 426 hours.
Labor Category
Health Policy
Analyst
Computer
Programmer
Operations Analyst
Total
Burden Costs
(per
respondent)
Respondents
Hour Rate
(incl fringe)
Burden
Hours
1
$58.66
10
$586.60
1
$61.52
100
$6,152.00
1
$58.66
32
142
$1,877.12
$8,615.72
Total Burden
Costs (all
respondents)
$25,847.16
We further estimate that it will take 264 hours annually for an Exchange to meet the reconciliation
requirements for a total of 5,280 hours across all Exchanges.
Labor Category
Health Policy
Analyst
Computer
Programmer
Operations Analyst
Total
Burden Costs
(per
respondent)
Respondents
Hour Rate
(incl fringe)
Burden
Hours
1
$58.66
84
$4,927.44
1
$61.52
120
$7,382.40
1
$58.66
60
264
$3,519.60
$15,829.44
Total Burden
Costs (all
respondents)
$316,588.80
Section 155.720(h) states that the SHOP must provide notice to a qualified employer if any employee
terminates coverage from a QHP. The purpose of the notice is to inform the employer of the termination
of an employee’s coverage. The burden estimate associated with this requirement includes the time and
effort needed to develop the notice and distribute it through an automated process when appropriate.
We anticipate that nearly all employers will request electronic notification. As a result, we have not
estimated associated mailing costs. We estimate that 20 States will operate an Exchange subject to these
reporting requirements. This estimate is an upper bound of burden. As such, we estimate that it will take
approximately 40 hours annually for the time and effort to develop and transmit the notice when
appropriate for a total of 800 hours.
23
Supporting Statement for Paperwork Reduction Act Submissions: Establishment of an Exchange by a State
and Qualified Health Plans
Burden Costs
(per
respondent)
Respondents
Hour Rate
(incl fringe)
Burden
Hours
Health Policy Analyst
1
$58.66
4
$234.64
Senior Manager
1
$84.09
1
$84.09
Operations Analyst
Computer
Programmer
1
$58.66
3
$175.98
1
$61.52
32
$1,968.64
40
$2,463.35
Labor Category
Total
Total Burden
Costs (all
respondents)
$49,267.00
Section 155.725(d) states that the SHOP must provide notice to a qualified employer of the annual
election period. The Exchange will send the notice of annual election period via mail or electronic means
depending on the preference of the qualified employer. The burden estimate associated with this
requirement includes the time and effort needed to develop the notice and distribute the notice through
an automated process when appropriate. We anticipate that nearly all employers will request electronic
notification. As a result, we have not estimated associated mailing costs. We estimate that 20 States will
operate an Exchange subject to these reporting requirements. This estimate is an upper bound of burden.
As such, we estimate that it will take approximately 40 hours annually for the time and effort to develop
and transmit the notice when appropriate for a total of 800 hours.
Burden Costs
(per
respondent)
Respondents
Hour Rate
(incl fringe)
Burden
Hours
Health Policy Analyst
1
$58.66
4
$234.64
Senior Manager
1
$84.09
1
$84.09
Operations Analyst
Computer
Programmer
1
$58.66
3
$175.98
1
$61.52
32
$1,968.64
40
$2,463.35
Labor Category
Total
Total Burden
Costs (all
respondents)
$49,267.00
Section 155.725(f) requires that the SHOP provide notice to a qualified employee of the annual open
enrollment period. The Exchange will send the notice of the annual open enrollment period via mail or
electronic means depending on the preferences of the qualified employee. The burden estimate
associated with this requirement includes the time and effort needed to develop the notice and distribute
the notice through an automated process when appropriate. We anticipate that half of employees will
request electronic notification while the other half of employees 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
employees as appropriate. As a result, we have not estimated associated mailing costs. We estimate that
20 States will operate an Exchange subject to these reporting requirements. This estimate is an upper
bound of burden. As such, we estimate that it will take approximately 42 hours annually for the time and
24
Supporting Statement for Paperwork Reduction Act Submissions: Establishment of an Exchange by a State
and Qualified Health Plans
effort to develop and transmit the notice when appropriate for a total of 840 hours.
Labor Category
Health Policy
Analyst
Senior Manager
Operations Analyst
Computer
Programmer
Fulfillment Manager
Total
Burden Costs
(per
respondent)
Respondents
Hour Rate
(incl fringe)
Burden
Hours
1
$58.66
4
$234.64
1
1
$84.09
$58.66
1
3
$84.09
$175.98
1
$61.52
32
$1,968.64
1
$34.61
2
42
$69.22
$2,532.57
Total Burden
Costs (all
respondents)
$50,651.40
Section 155.730(e) states that the SHOP may use an alternative employer application, other than the
model application being developed by HHS. The alternative application must adhere to §155.730(b) by
including identifying information about the employer and a list of qualified employees with social security
numbers. This section also states that the SHOP may use an alternative employee application, other than
the model application being developed by HHS. The alternative application includes the information
necessary to establish eligibility of the employee as a qualified employee and to complete the enrollment
of a qualified employee. The alternative employer applications must be submitted to HHS. The burden
estimate associated with this requirement includes the time and effort needed to develop the alternative
applications and submit the applications for approval by HHS. We believe that most Exchanges, in the
interest of not duplicating existing work, will choose to use the model employer application being
developed by HHS. We presume that the number of Exchanges choosing to develop an alternate
employer application will be less than ten in a twelve month period. We will review each alternative
employer 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.
Exchange Functions: Certification of Qualified Health Plans (§155.1000 through §155.1080)
In subpart K of Part 155, we describe a number of data collection and reporting requirements for
Exchanges related to the certification of qualified health plans (QHPs). As described in §155.1010, we
require Exchanges to establish procedures for the certification of QHPs. The Exchange will have to
develop procedures to collect information from QHPs that will be used to determine whether a QHP
complies with the minimum certification standards seen in subpart C of part 156 and, based on
§155.1000(c), is in the interest of the qualified individuals and qualified employers. HHS is developing a
model application for the certification of QHPs that will include the data elements needed to inform the
Exchange’s certification process in determining whether an issuer meets the minimum standards for QHP
certification. HHS will publish the model QHP certification application and will solicit public comment. At
that time, and per the requirements outlined in the Paperwork Reduction Act, we will estimate the
burden on Exchanges for complying with this provision of the regulation.
As discussed in §155.1020(a), the Exchange will be required to collect justifications for each rate increase
by a QHP prior to the implementation of the rate increase. The Exchange must also make the justification
25
Supporting Statement for Paperwork Reduction Act Submissions: Establishment of an Exchange by a State
and Qualified Health Plans
available on its Web site. The burden estimate related to the collection of rate increase justifications
includes the time and effort needed to develop standards related to the format and content of the rate
increase justification, collect the justification from the QHP issuer, and provide access to the justification
on the Exchange Web site. We estimate that 20 States will operate an Exchange subject to these
requirements. This estimate is an upper bound of burden. We note that 42 States and the District of
Columbia have rate review programs under section 2794 of the PHS Act (“Effective Rate Review
programs”) in both the individual and small group markets; an additional two States have programs for
one market. We expect the Exchange to leverage standards for rate increase justifications provided to the
Effective Rate Review program where available, thus reducing the burden on the Exchange in developing
standards related to this information collection. We also anticipate that each Exchange will automate the
collection of the rate increase justification. As such, we estimate that it will take approximately 41.5
hours annually per Exchange for the time and effort to comply with this requirement for a total of 830
hours for all Exchanges.
Respondents
Hour Rate
(incl fringe)
Burden
Hours
Operations analyst
1
$58.66
13.25
Burden Costs
(per
respondent)
$777.25
Actuary
Computer
Programmer
1
$60.88
3
$182.64
1
$61.52
24
$1,476.48
Web developer
1
$44.35
0.25
$11.09
Senior Manager
Total
1
$84.09
1
41.5
$84.09
$2,531.54
Labor Category
Total Burden
Costs (all
respondents)
$50,630.85
As discussed in §155.1020(c), the Exchange must collect information, at least annually, from QHPs about
rates, covered benefits, and cost-sharing requirements. The burden estimate for collecting the rate and
benefit information includes the time and effort expended by the Exchange in collecting and reviewing
the rate, benefit, and cost-sharing information provided by QHP issuers. HHS is developing a model QHP
certification application for the States that will include data elements for uploading rate and benefit
information. HHS will publish the model QHP certification application and will solicit public comment. At
that time, and per the requirements outlined in the Paperwork Reduction Act, we will estimate the
burden on QHP issuers for complying with this provision of the regulation.
As discussed in §155.1040, Exchanges will be required to collect from QHP issuers information relating to
coverage transparency as described in §156.220(a). The information will include claims payment policies
and practices, data on enrollment, data on disenrollment, the number of claims that are denied, and
rating practices. Finally, the Exchange must collect information on cost-sharing and payments with
respect to any out-of-network coverage and information on enrollee rights under title I of the Affordable
Care Act. The information collected by the Exchange from the QHP issuers may be used by Exchanges
during the QHP certification process or when considering the past performance of the health insurance
issuers. HHS will be providing future guidance on the collection of coverage transparency information. At
that time, and per the requirements outlined in the Paperwork Reduction Act, we will estimate the
burden on Exchanges for complying with this provision of the regulation.
26
Supporting Statement for Paperwork Reduction Act Submissions: Establishment of an Exchange by a State
and Qualified Health Plans
Section 155.1055 requires the Exchange to have a process to establish or evaluate the service areas of
QHPs to ensure such service areas meet minimum criteria. The Exchange will collect information related
to service area through the QHP certification application. As previously stated, HHS is developing a model
QHP certification application for the States that will include data elements related to service area
standards. HHS will publish the model QHP certification application and will solicit public comment. At
that time, and per the requirements outlined in the Paperwork Reduction Act, we will estimate the
burden on QHP issuers for complying with this provision of the regulation.
Section 155.1065 describes the requirements on an Exchange to allow stand-alone dental plans. The
Exchange will have to collect information from an issuer of a stand-alone dental plan to ensure that it
meets the Exchange’s certification requirements that apply to dental plans. The information may be
collected through an application similar to the QHP certification application previously mentioned.
However, the burden estimate related to certifying a stand-alone dental plan will be less due to the
limited nature of the benefits offered by a stand-alone dental plan compared to a full QHP. Furthermore,
in order to ensure sufficient child-only coverage of the pediatric essential health benefit, as described in
155.1065(e), the Exchange will have to ensure collection of benefit information from potential QHP
issuers regarding whether the QHPs it offers will cover the pediatric dental essential health benefit. The
burden for this information is included in the overall estimate of benefit reporting included under
155.1020(c). As previously stated, HHS is developing a model QHP certification application. HHS will
publish the model QHP certification application and will solicit public comment. At that time, and per the
requirements outlined in the Paperwork Reduction Act, we will estimate the burden on QHP issuers for
complying with this provision of the regulation.
Section 155.1075 requires that an Exchange notify a QHP, seeking recertification by the Exchange, of the
Exchange’s determination. We assume that the Exchange will notify QHP issuers by using a standardized
notice that provides information about the recertification process. The burden estimate associated with
this requirement includes the time and effort needed to develop the notice and distribute the notice to
QHP issuers. We expect that this notice will be distributed electronically to all QHP issuers. We estimate
that 20 States will distribute recertification notices on an annual basis. This estimate is an upper bound of
burden. As such, we estimate that it will take approximately 40 hours annually for each Exchange to
develop and transmit the notice when appropriate, and a total of 800 hours across all Exchanges.
Burden Costs
(per
respondent)
Respondents
Hour Rate
(incl fringe)
Burden
Hours
Operations analyst
1
$58.66
4
$234.64
Senior manager
Health Policy
Analyst
Computer
Programmer
Total
1
$84.09
1
$84.09
1
$58.66
3
$175.98
1
$61.52
32
$1,968.64
40
$2,463.35
Labor Category
Total Burden
Costs (all
respondents)
$49,267.00
Section 155.1080(e) requires that an Exchange must provide notification of decertification to all affected
27
Supporting Statement for Paperwork Reduction Act Submissions: Establishment of an Exchange by a State
and Qualified Health Plans
parties, including the QHP issuer, the enrollees in the QHP who enrolled through the Exchange, HHS, and
the State department of insurance. The decertification notice needs to be provided to HHS so that the IRS
can cease payment of tax credits and cost-sharing reductions, as appropriate. The notice will advise
affected enrollees to enroll in other available QHPs during a special enrollment period and provide
information about how enrollees may select a new QHP. The burden estimate for notifying all of the
affected parties of the decertification of a QHP includes the time and effort needed to develop the
decertification notice and transmit the notice to the affected parties. We expect that the decertification
notice will be distributed electronically to HHS and the State department of insurance. We anticipate that
half of enrollees will prefer to receive electronic notification while the other half of enrollees will receive
the notice by mail. As such, the burden includes the time and effort needed to mail notices, in bulk, to
enrollees electing to receive notice by mail. For the purposes of this estimate, we assume that Exchanges
in 20 States will issue a decertification notice annually. This is an upper bound of burden. Accordingly, we
estimate that it will take 42.5 hours for each Exchange to meet this requirement for a total estimate of
850 hours.
Burden Costs
(per
respondent)
Respondents
Hour Rate
(incl fringe)
Burden
Hours
Operations Analyst
1
$58.66
6
$351.96
Senior Manager
Computer
Programmer
Fulfillment Manager
Total
1
$84.09
2.5
$210.23
1
$61.52
32
$1,968.64
1
$34.61
2
42.5
$69.22
$2,600.05
Labor Category
13.
Total Burden
Costs (all
respondents)
$52,000.90
Capital Costs
There are no additional record keeping/capital costs.
14.
Cost to Federal Government
The initial burden to the Federal Government for the management of qualified health plans and
Exchanges is $390,088.00. The calculations for CCIIO employees’ hourly salary were obtained from the
OPM Web site, at the following link: https://www.opm.gov/policy-data-oversight/pay-leave/salarieswages/2015/general-schedule/.
28
Supporting Statement for Paperwork Reduction Act Submissions: Establishment of an Exchange by a State
and Qualified Health Plans
Task
Certification of Exchanges
15 GS-13: 15 x $46.42 x 220 hours
Review of State/Exchange data
15 GS-13: 15 x $46.42 x 280 hours
Managerial Review and Oversight
2 GS-15: 2 x $64.52 x 325 hours
Total Costs to Government
Estimated Cost
$ 153,186.00
$ 194,964.00
$ 41,938.00
$ 390,088.00
15. Explanation for Program Changes or Adjustments
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.
29
| File Type | application/pdf |
| Author | COURTNEY WILLIAMS |
| File Modified | 2016-03-04 |
| File Created | 2015-11-13 |