Response to Comment

Attachment E: 60 Day Comment and Response Summary – 3/10/16 – Page 3

CMS-10440 Marketplace Application Paperwork Reduction Act

Overview

The following is a summary of the comments received during the 60-day posting of the Marketplace Application Paperwork Reduction Act, as well as CMS responses.

Topic	Comments	CMS Response
Website Accounts	Commenters recommended providing additional enhancements to the account functionality including allowing the use of mobile phone numbers in place of email for usernames, or select an alternate username. Commenters also requested modifications to communication preferences features, including ability to view alerts and other features without completing ID proofing, and requiring consumers to reconfirm communication preferences (via email, text or paper) when returning to the Marketplace or during annual reenrollment.	CMS will add mobile phone numbers and consumer created usernames to the application PRA data collection to allow flexibility for the Marketplace to potentially use mobile numbers for account creation or for self-service features in the future such as password resets. While other proposed changes to online account management functionality are outside the scope of changes for this data collection, CMS will take them under consideration when making future system changes.
ID proofing	Commenters made several recommendations to provide greater flexibility in the account creation and identity proofing processes, with a focus on those individuals who don’t have sufficient credit history to verify their identity through the online automated process or otherwise are unable to verify their identity online. Recommendations included modifying the online security questions, providing a special enrollment period for those who are unable to verify their identity, expanding the list of allowable documents for identity verification, allowing consumers who are unable to pass identity proofing online and are unlikely to be able to complete proofing via phone to skip straight to uploading documents, allowing the use of documents submitted for data matching issues to be used for resolving identity proofing issues, as well allowing all consumers or those receiving in-person assistance to submit an application and receive an eligibility determination without verifying their identity. Commenters also requested clarifying language on who must be identity proofed, the use of social security numbers in identity proofing, and clarifying the option to apply via the Marketplace call center.	Identity proofing is a critical, industry-standard privacy and security protection for access to electronic systems. The process relies on a consumer entering core, identifying information like name, date of birth, and address, and then responding to knowledge-based questions that are generated from commercially available sources of data. (Note that a consumer’s sex is not part of the core information, and is not used anywhere in the electronic identity proofing process.) Currently, the majority of consumers are able to verify their identity quickly online through the automated process. Consumers who are unable to verify their identity electronically proceed to a telephone proofing step, and if that is unsuccessful, are directed to upload or mail documents to complete the proofing process. This identity proofing process is specific to the online process. CMS is evaluating ways to allow consumers who are unable to complete identity proofing online and are unlikely to be able to complete proofing via phone to move straight to document upload. CMS offers a robust list of documents that the minority of consumers who are unable to complete electronic identity proofing can submit to verify their identity. CMS remains open to suggestions for additional documentation that should be accepted, as well as other alternative, cost-effective, easily accessible electronic data sources that could be leveraged to provide a secure identity proofing process for consumers. Also, for those consumers who have submitted documents to resolve a data matching issue, CMS does allow the use of those documents to resolve an identity issue, if available. CMS also allows for a special enrollment period for people who are unable to select a plan online because they are in the process of completing identity proofing. Identity proofing is designed to ensure that people who create online accounts are who they say they are. Accordingly, in accordance with regulatory requirements regarding privacy and security, it is against CMS policy to provide electronic eligibility results (which are in part based on data obtained from trusted data sources) without prior proof of identity.
Additional Electronic Questions (Attachment A1)	Commenters recommended changes to the guided application tool which helps consumers navigate to the most appropriate application flow, including re-ordering the selection of household members. Commenters also inquired why the question about full-time students is asked for ages 18-22, as opposed to 18-21. Finally, they expressed concern that a question is asked about whether anyone is a naturalized or derived citizen, and commented that some consumers are confused or possibly offended by that question.	CMS clarifies that Attachment A1 is asking the full-time student question of individuals ages 18-22 so that full-time students can apply for coverage on the full Marketplace application using the Medicaid student residency rules. CMS clarifies that the system asks questions to guide consumers to a full or shorter application based on the complexity of their household situation. Not all naturalized citizens can be verified through the Social Security Administration and additional information is needed if verification will be attempted through the Department of Homeland Security. These up-front questions allow the FFM to direct consumers to the best application experience to increase their chances of verifying their information electronically.
Privacy	Commenters recommended the inclusion of the anti-discrimination clause in the online application, as well a statement that application information will not be used for immigration enforcement purposes, and enrollment in a Qualified Health Plan with advance payments of the premium tax credit (APTC) will not make an applicant a “public charge” or affect their eligibility to become a Lawful Permanent Resident (i.e., green card holder).	CMS clarifies that the online application currently has the following link with information on the anti-discrimination policy. https://www.cms.gov/About-CMS/Agency-Information/Aboutwebsite/CMSNondiscriminationNotice.html. CMS further clarifies that the online application currently indicates that this information will not be used for immigration enforcement: https://www.healthcare.gov/individual-privacy-act-statement/. CMS will consider making this information available to consumers in other areas of the application.
Contact Information	Commenters recommended changes to the contact information, including recommending all consumers be required to enter email addresses, while others recommending more flexibility to use other forms of contact such as mobile phone numbers. Commenters recommended more flexibility on the requirement that household contacts must be age 18 or over, to allow for homeless youth or emancipated minors under age 18 to be able to submit an application on their own behalf. Commenters recommended asking preferred and spoken language preferences of all applicants, not just the household contact, and providing and option to enter the specific “other” language. Commenters recommended making the default option mail and electronic communication, but give consumers the option to receive electronic notices only, in line with current banking and other industry standards.	CMS may consider providing additional on-screen text or functionality to encourage consumers to provide email addresses and/or phone numbers, if available. Current regulations require an application filer to be a responsible adult to apply on behalf of a minor child (45 CFR 155.20 and 42 CFR 435.907). Currently the system asks language preferences only of the household contact (aka application filer) since he or she is the only person the Marketplace sends notices. If a consumer contacts the Marketplace call center for assistance, they may request language assistance in a large number of additional languages. At a later date, CMS will explore adding functionality to collect the “other” language. CMS does not currently plan on modifying the default options for receiving mail and electronic notices.
Help Applying for Coverage	Commenters recommended that questions about help applying for coverage should be required.	CMS currently only has one application used by consumers and those assisting consumers in applying for coverage. As such, the question must remain optional so consumers can proceed when applying on their own. CMS will explore additional help text and training of assisters/navigators around this issue to reduce confusion and improve data collection.
Help paying for coverage	Commenters recommended changing "you'll need to file next year if you want to get a premium tax credit…" to clarify that they will need to file taxes for the year they receive coverage with advance payments of the premium tax credit. Other commenters recommended adding language to indicate who will be eligible, such as, “you may qualify for financial assistance if you earn up to $xx/year.”	CMS agrees with this issue and will explore the next opportunity to make a change, as well as exploring providing additional help text.
Tell us about each person – Race/Ethnicity	Commenters recommend asking race/ethnicity (optionally) and other demographic data of all individuals on the application, not just applicants. Commenters also recommended modifying the Latino/Hispanic Ethnicity questions to include locations in Central and South America as places of origin, and remove the word “ethnicity”.	Currently CMS asks race/ethnicity of all individuals applying for coverage on the application as outlined in Section 4302 of the Affordable Care Act and in line with federal standards. Currently, there are no plans to change this data collection.
Tell us about each person –Other demographic information	Several commenters recommended the Marketplace make changes and add questions to improve data collection on LGBT applicants to assist with outreach to LGBT populations, help prevent discrimination in the provision of health services, and address health disparities. Commenters recommended modifying the current question asking “What is [FNLNS]’s sex?” to ask the consumer’s sex at birth, or sex listed on their birth certificate. Commenters also recommended ensuring the application logic asks the question about whether a person is pregnant of those individuals who indicate “female” is their sex at birth (or on their birth certificate). Commenters also recommended adding optional questions about a consumer’s gender identity and sexual orientation. Some commenters also recommended asking questions about whether applicants have been diagnosed with an intersex condition or difference of sex development.	CMS agrees that new wording of the question collecting applicants’ sex, and the addition of optional questions for applicants on gender identity and sexual orientation, are in line with Sections 1557 (non-discrimination) and 4302 (health disparities data collection) of the Affordable Care Act. CMS has added placeholder language to the application data collection and will consider these changes in the future. Specific language changes to the application data collection are to be determined based on research and forthcoming guidance. CMS clarifies that currently the online application lists individuals on the pregnancy question if the individual selected “female” in response to the “What is [FNLNS]’s sex?” question.
Pregnancy	Commenters requested the addition of help text for pregnant applicants to clarify that they are not required to apply for Medicaid coverage and can choose to stay enrolled in a QHP, if currently enrolled when they become pregnant. Commenters also urged the use of accurate and neutral language to describe pregnancy in the application instructions.	CMS agrees that additional help text and educational materials are needed to clarify coverage and financial assistance options available to consumers who become pregnant while enrolled in a Qualified Health Plan through the Marketplace and receiving APTC and CSRs. CMS will explore adding help text to guide pregnant women in better understanding their options. CMS made wording changes to the instructions in Attachment A to reflect language in federal regulations regarding calculating the household size for pregnant women when determining Medicaid and CHIP eligibility.
Citizenship/ Immigration Status	Commenters made several recommendations to modify or add to the data collection for immigrants on the application, including asking an additional, optional question about applicants’ immigration status with a drop-down list of all statuses considered lawfully present under the ACA for applicants whose immigration status cannot be verified immediately through the Department of Homeland Security. Commenters also recommended adding another question to better ascertain if an applicant is subject to the 5-year bar. Commenters also recommended allowing applicants to attest when immigration status is pending or documents are in the mail. Further, commenters suggested providing help text/educational information on immigration document types and the use of SSN for verification purposes, and clarifying that there is no eligibility difference for US born and naturalized/derived citizens, and that CMS distinguishes between these groups only for verification purposes.	CMS is not making any application PRA related changes to the immigration data collection at this time. However, CMS is actively exploring alternatives or additional methods in which it might collect immigration information from applicants. We will continue to explore the proposed changes and their effectiveness for improving the accuracy of the application eligibility determinations and consumer experience, and reduce immigration data matching issues. CMS will also consider improvements to help text and educational materials to further clarify policy and processes for consumers.
Family and Household	Commenters made a number of suggestions on how to improve data collection in the family and household section of the application, including: changing how Social Security Numbers (SSN) are collected to ensure that consumers who have an SSN provide it on their application to help reduce data matching issues; requesting addresses of all individuals applying for coverage; adding clarifying language for individuals who file their federal income taxes as married filing separately, but may qualify for APTC due to qualifying for an exception (e.g., victims of domestic abuse and spousal abandonment, filing as head of household); asking domestic partners if they are married; modifying the parent/caretaker question logic so that it’s not asked of parents who live with the child; collecting information to determine student status for non-tax filers given that MAGI applies different rules for determining non-filers' household based on age and student status; and, modifying the follow-up question when a consumer indicates he or she doesn’t plan to file taxes to clarify the consequences of not filing a federal income tax return on eligibility.	CMS is continually working to improve data collection with the goal of increasing verification of SSNs through the application. CMS will consider additional consumer testing, and will continue to explore providing educational materials or other help text to encourage consumers to provide their SSN, when available. CMS currently collects addresses for all applicants on the application. CMS currently provides help text for consumers who indicate that they are not “married filing jointly”, and provides a link to more help text regarding exceptions to consumers who may still qualify for APTC. CMS will explore adding functionality to accommodate exceptions to the married filing jointly rule and provide additional tax filing statuses, such as head of household, to help consumers better respond to the family and household questions for their given situation. CMS agrees with the proposed change to the display of the parent/caretaker question and will explore making changes in the future. For the remaining comments on this section, CMS does not plan on making changes to the data collection, but will consider adding help text/educational materials to clarify and research functionality to ensure accurate eligibility is being provided.
Family and Household – Tax Dependents	Commenters recommended asking applicants if someone could claim them as a dependent, as opposed to whether someone will claim them as a dependent, and to confirm that tax dependents have the consent of their claiming tax filer when applying for APTC. Commenters recommended these changes to ensure that applicants are correctly being determined eligible for APTC.	Overall, CMS agrees with the comments raised and will explore providing additional educational materials and/or help text to clarify.
Income	Commenters made several suggestions to clarify or modify the way the application collects income from consumers to make it easier for consumers to accurately enter their income, including specifying the income tax return year on the income guiding question when consumer is asked to enter the number of people they’ll include on their federal income tax return, providing a calculator with income questions to help consumers better estimate their income, clarifying countable and not countable income types for the purposes of Modified Adjusted Gross Income and Medicaid eligibility (such as social security disability, taxable scholarship income) and deductions, and providing greater flexibility for frequencies such as income received one-time only and providing options for reporting income received less than a full year. Commenters also requested clarification on how tax dependents’ income counted or not counted toward the household income.	CMS will consider providing additional help text to clarify for consumers how they might enter or estimate their income, including information regarding which tax year the consumer should reference when completing income estimation questions. CMS will consider making help text changes at the next opportunity to make a change. CMS will also explore options to provide additional educational materials and help text to better assist consumers in completing the application such as clarify income types, deductions and income frequencies on the application. CMS also will take these recommendations into consideration, along with findings from consumer testing when making future updates to the application.
APTC Eligible – Other Health Coverage	Commenters recommended adding help text explaining that applicants who pay a premium for Medicare or CHIP should not indicate that they have coverage through Medicare or CHIP, respectively. Commenters also recommended preventing Medicare eligible consumers from enrolling in a Qualified Health Plan through screening, pop-up messages as well as verification against data sources. Commenters also recommended asking all applicants the name of their prior insurer, the type of coverage, and policy ID number to help with coordination of coverage.	CMS is planning to display on-screen messages to appear for consumers who are age 65 or older, notifying them that if they are entitled to benefits under Medicare, they should not enroll in a Marketplace plan. The application also displays an on-screen message for individuals who are approaching age 65 to alert them that if they become eligible for Medicare they should report a life change and tell the Marketplace about their Medicare coverage. CMS does not have plans to modify the data collection on the other health coverage page. However, CMS will explore providing additional on-screen text or help text to clarify who should indicate if they currently are enrolled in coverage, including Medicare and CHIP.
Medicaid	Commenters made a range of comments on Medicaid related data collection, including: modifying the “Medicaid Block” question to clarify that it refers to denials of Medicaid/CHIP for failure to meet program requirements, but not denials for procedural reasons; modifying or adding questions related to functional limitations to current disability questions; adding questions to assess or determine eligibility for limited-scope Medicaid family planning programs; and adding language to explain the reason for asking the former foster care information and how it will be used.	The Federally-facilitated Marketplace (FFM) application is designed to only ask questions necessary to make a MAGI-based eligibility determination. Questions intended to identify individuals who may be eligible on a basis other than MAGI serve as a screening tool and are not intended to capture sufficient information to make a determination on a non-MAGI basis. Individuals who answer affirmatively to any of the screening questions are referred to the Medicaid agency, which will follow-up with the consumer to collect more detailed information in order to make a final determination. CMS does not believe detailed questions need to be asked of the majority of applicants, as this may increase applicant burden. CMS agrees that individuals with functional limitations may not identify as having a disability, and will consider providing educational materials and/or adding help text to clarify. The FFM application does not consider eligibility for all limited-scope state benefit programs as the availability of such programs and their rules vary from state to state. CMS will consider adding clarifying help text or other educational materials to clarify who should respond to the “Medicaid Block” question and the purpose of the foster care questions.
Medicare	Commenters recommended modifications to the application, including attestations, help text and on-screen messaging, to prevent individuals who are eligible for benefits under Medicare from enrolling in a Marketplace Qualified Health Plan. Commenters also recommended that the application should make eligibility determinations for Medicare Savings Programs (QMB, SLMB, Q1-1).	CMS agrees that consumers should be informed that they shouldn’t be enrolling in a Qualified Health Plan if they are eligible for benefits under Medicare. CMS is planning to display an on-screen message which appears to consumers who are age 65 or older, notifying them that if they are entitled to benefits under Medicare, they should not enroll in a Marketplace plan. The application also displays an on-screen message for individuals who are approaching age 65 to alert them that if they become eligible for benefits under Medicare they should report a life change and tell the Marketplace about their Medicare coverage. Consumers who indicate they are eligible for benefits under Medicare are determined ineligible for APTC and individuals that data sources find are enrolled in Medicare are given a data matching issue to prevent APTC eligibility. It should be noted, however, that Medicare eligible or enrolled consumers are not blocked completely from enrolling in a QHP. CMS will continue to look for ways to provide education and help text regarding this and will explore possible additional functionality in the future. The Medicare Savings Program (MSP) is run by state Medicaid agencies. The FFM application does not make non-MAGI Medicaid or Medicare determinations. It does not align with CMS policy, or required under statute or regulations to make MSP eligibility determinations.
APTC eligible – Employer Sponsored health coverage (ESC)	Commenters recommended improvements to the ESC section, including: clarifying the importance of attesting correctly and using the employer coverage tool, defining “self-only coverage” with more consumer-friendly language, and moving the help-text “Most plans offered by employers meet the minimum value standard” from the affordability question to the minimum value question. Commenters recommended asking consumers who attest to being enrolled in COBRA for the date when COBRA coverage ends. Commenters also recommended deleting the reference to eligibility for insurance through a parent or guardian in the following question: “Is [FNLNS] currently eligible for health coverage through a job (even if it’s through COBRA or from another person’s job, like a spouse [display if person is under age 26: or parent/guardian])?” because a non-tax dependent child under age 26 may be eligible for APTC if the child is eligible for (but not enrolled in) ESC through his or her parent/guardian.	CMS clarifies that the application currently asks about future changes in eligibility and enrollment from applicants who attest to being eligible for or enrolled in ESC, and from current employees (i.e. ESC that is not COBRA or retiree coverage). CMS agrees that further clarification for this section would be useful and will consider changes to functionality and amending existing help text and providing additional educational materials to clarify.
QHP Enrollment – Legal Relationships	Commenters request clarification for the "dependent" legal relationship.	CMS currently has help text that defines the legal relationships, but will explore options to clarify and/or provide additional educational materials.
Special Enrollment Periods (SEP)	Commenters recommended a variety of changes to Special Enrollment Period (SEP) questions on the application, including: editing the loss of Minimum Essential Coverage (MEC) and permanent move questions to clarify the SEP eligibility parameters; reordering all SEP questions on the application; adding questions for SEPs only currently available through the Marketplace Call Center, including the SEPs for consumers moving out of the coverage gap and for exceptional circumstances; and, amending the permanent move question and FFM system functionality to accommodate moves across states and within zip codes. Some commenters recommended that the FFM verify consumers’ eligibility for several existing SEPs, including the loss of MEC, permanent move, and gaining or becoming a dependent SEPs, while other commenters cautioned against verifying eligibility for SEPs without evidence that they’re being granted improperly. Several commenters requested that the FFM begin offering advanced availability of the permanent move SEP, which includes release from incarceration. Lastly, commenters requested that additional information be added for enrollees who return to the Marketplace to update their information, so that they know which changes may qualify them for a SEP and/or a change in eligibility for advance payments of the premium tax credit or cost-sharing reductions.	CMS is modifying the data collection to make clarifying changes to both the loss of MEC and permanent move SEP questions on the application and will consider providing additional educational materials and help text to clarify both the eligibility parameters and application questions for these and other SEPs, as needed. In addition, the FFM intends to conduct an assessment of Qualified Health Plan enrollments that have been made through SEPs in the FFM to ensure that consumers properly accessed coverage outside of an open enrollment period and may require documentation for select SEPs going forward, as described in recent guidance posted on February 24, 2016. In line with this new guidance, CMS is modifying the data collection to collect an agreement from the consumer that they understand they may have to provide documentation to provide proof of their eligibility for a SEP should they qualify. CMS may add SEP questions to align with current policy, in the future. CMS will consider providing help text and other education materials to improve accurate eligibility determinations for SEPs.
Paper application	Several commenters recommended changes for the online version of the application should also be updated as appropriate for the paper application.	CMS will update the paper applications as appropriate to match the online application prior to Open Enrollment cycles.
Direct Enrollment	Commenters recommended providing issuers using the direct enrollment channel and web-based entities the flexibility to make changes to the application language or sequence to allow them to provide the best enrollment experience to consumers.	CMS does not plan to provide such an option by Open Enrollment Period for 2017 coverage, but will consider a measured approach to implementation of expanded direct enrollment and those activities in a future year while ensuring consistent and accurate eligibility determinations for all consumers regardless of the channel(s) they choose to apply and enroll through.