Form CMS-10507 STATE-BASED MARKETPLACE ANNUAL REPORTING TOOL (SMART)

Department of Health & Human Services

Centers for Medicare & Medicaid Services

Center for Consumer Information and Insurance Oversight

7501 Wisconsin Avenue

Bethesda, MD 20814

State-based Marketplace Annual Reporting Tool (SMART)

Introduction

The Affordable Care Act (ACA) established State-based Marketplaces (SBMs) to provide individuals and small business employees with access to health insurance coverage beginning January 1, 2014. The ACA provides States with flexibility in the design and operation of their Marketplaces to best meet the unique needs of their residents and insurance markets.

The Centers for Medicare & Medicaid Services (CMS) is responsible for the oversight and monitoring of SBMs pursuant to 45 C.F.R. § 155.1200 (general program integrity and oversight responsibilities) and 45 C.F.R. § 155.1210 (maintenance of records). Under these provisions, SBMs are required to conduct a defined set of oversight activities to track and monitor how it is meeting ACA program integrity standards. In addition, SBMs are required to comply with Marketplace-related policy and operational requirements set forth in statute, regulations and guidance.

The State-based Marketplace Annual Reporting Tool (SMART) was developed to assist CMS in the collection of SBM reporting and auditing requirements and to monitor and evaluate, in coordination with other CMS oversight activities, SBM compliance with applicable regulations and guidance. SBMs must submit SMART on an annual basis to CMS. Submission of the SMART does not preclude an SBM from meeting other CMS reporting requirements not addressed in the SMART.

SBMs must submit or attest to the submission of these requirements by completing the following SMART elements: Executive Summary, Eligibility and Enrollment, Performance Monitoring Data, and Financial and Program Integrity. Directions for completing each attestation and/or document submission are contained in the element description.

SBMs should answer the SMART questions as they relate to Marketplace operations in place as of the last day of the previous plan year, unless otherwise noted.

SMART REPORTING ELEMENTS

I. Executive Summary 4

II. Eligibility and Enrollment 4

III. Performance Metrics 9

IV. Financial and Program Integrity 11

V. Attestation of Completion 15

1. Executive Summary

As the Executive Director or Chief Executive Officer (CEO), please provide an executive summary of SBM activities, accomplishments, and strategic priorities for the upcoming year. This can include:

• Highlights of accomplishments, key investments, and challenges faced during the past year.

• Strategic priorities for the coming year and any anticipated major changes to the strategic direction of the SBM.

2. Eligibility and Enrollment

1. Eligibility and Enrollment Overview

Under 45 C.F.R. § 155.1200(b)(2), Marketplaces are required to provide CMS with annual eligibility and enrollment reports. Please attest to whether the Marketplace is in compliance with the following Marketplace-related eligibility and enrollment policy and operational regulations and guidance, and submit the required information where noted. SBMs that use the federal platform for individual eligibility and enrollment, should select N/A.

2. Eligibility Standards

The Marketplace is in compliance with eligibility standards in accordance with 45 CFR 155 Subpart D.

	YES		NO		PARTIALLY		N/A (For SBM-FP only)

3. QHP Eligibility Verification: Social Security Number

The Marketplace verifies Social Security Number with the Social Security Administration through the Federal Data Services Hub under 45 CFR 155.315(b) unless otherwise authorized by CMS.	YES		NO		N/A (For SBM-FP only)

If yes, the Marketplace uses a non-hub, private, and/or state level data source in addition to or as a contingency for the Federal Data Services Hub for this eligibility verification procedure.

	YES		NO		N/A (For SBM-FP only)

4. QHP Eligibility Verification: Citizenship

The Marketplace verifies citizenship and lawful presence with the Social Security Administration and the Department of Homeland Security through the Federal Data Services Hub under 45 CFR 155.315(c) unless otherwise authorized by CMS.

	YES		NO		N/A (For SBM-FP only)

If yes, the Marketplace uses a non-hub, private, and/or state level data source in addition to or as a contingency for the Federal Data Services Hub for this eligibility verification procedure.

	YES		NO		N/A (For SBM-FP only)

5. QHP Eligibility Verification: State Residency

The Marketplace verifies state residency through attestation or electronic data sources under 45 CFR 155.315(d) unless otherwise authorized by CMS.

	YES		NO		N/A (For SBM-FP only)

If yes, the Marketplace uses a non-hub, private, and/or state level data source in addition to or as a contingency for the Federal Data Services Hub for this eligibility verification procedure.

	YES		NO		N/A (For SBM-FP only)

6. QHP Eligibility Verification: Incarceration Status

The Marketplace verifies incarceration status through electronic data sources or attestation under 45 CFR 155.315(e) unless otherwise authorized by CMS.

	YES		NO		N/A (For SBM-FP only)

If yes, the Marketplace uses a non-hub, private, and/or state level data source in addition to or as a contingency for the Federal Data Services Hub for this eligibility verification procedure.

	YES		NO		N/A (For SBM-FP only)

7. Affordability Program Eligibility Verification: Household Income and Size

The Marketplace verifies household income and family/household size through the Federal Data Services Hub under 45 CFR 155.320(c) and other CMS-approved electronic data sources.

	YES		NO		N/A (For SBM-FP only)

8. Affordability Program Eligibility Verification: Employer-sponsored Plan

The Marketplace verifies eligibility related to enrollment in an eligible employer-sponsored plan and eligibility for qualifying coverage in an eligible employer-sponsored plan under 45 CFR 155.320(d).

	YES		NO		N/A (For SBM-FP only)

9. Inconsistency Resolution

In cases where the Marketplace cannot verify information required to determine eligibility for enrollment in a QHP through the Marketplace, advance payments of the premium tax credit, and cost-sharing reductions, the Marketplace has a process in place to identify inconsistencies, notify consumers of an inconsistency and resolve inconsistencies in accordance with 45 CFR 155.315(f) relating to the following eligibility factors:

	Annual Income
	Citizenship/Immigration Status
	Incarceration Status
	American Indian/Alaskan Native Status
	Minimum Essential Coverage: Non-Employer Sponsored Coverage
	Minimum Essential Coverage: Employer Sponsored Coverage

10. Benefit Year Eligibility Redetermination and Verification

The Marketplace conducts eligibility redeterminations and verifies reported changes during the benefit year in accordance with 45 CFR 155.330.

	YES		NO		N/A (For SBM-FP only)

11. Periodic Data Matching

The Marketplace conducts periodic data matching in accordance with 45 CFR 155.330(d).

	YES		NO		N/A (For SBM-FP only)

12. Annual Eligibility Redeterminations and Verification

The Marketplace performs annual eligibility redeterminations and verifies reported changes in accordance with 45 CFR 155.335. Submit the procedures for redeterminations for the next open enrollment period per 45 CFR 155.335(2).

	YES		NO		N/A (For SBM-FP only)

13. Eligibility Determinations: Right to Appeal

The Marketplace includes the notice of the right to appeal and instructions regarding how to file an appeal in any eligibility determination notice issued to the applicant in accordance with 45 CFR 155.355.

	YES		NO		N/A (For SBM-FP only)

14. Enrollment Standards

The Marketplace is in compliance with enrollment standards in accordance with 45 CFR 155 Subpart E.

	YES		NO		PARTIALLY		N/A (For SBM-FP only)

15. Single Streamlined Application: Approved Alternative

The Marketplace has an HHS approved alternative Single Streamlined Application with no outstanding CMS conditions for approval in accordance with 45 CFR 155.405.

	YES		NO		N/A (For SBM-FP only)

If no, the Marketplace has developed and communicated a plan for resolving any outstanding conditions to CMS.

	YES		NO		N/A (For SBM-FP only)

16. Single Streamlined Application: Substantial Changes

The Marketplace has made substantial changes to its alternative Single Streamlined Application since CMS provided approval.

	YES		NO		N/A (For SBM-FP only)

If yes, the Marketplace has notified CMS of any substantial changes to its approved alternative Single Streamlined Application.

	YES		NO		N/A (For SBM-FP only)

17. Policy Level Enrollment Reports

The Marketplace is in compliance with applicable requirements regarding submission of monthly Policy Level Enrollment Reports to CMS based on the monthly IRS report to support the reconciliation of aggregated payments of Advance Premium Tax Credits and cost-sharing reductions to issuers under 45 CFR 155.340(a) and 45 CFR 155.400(b).

	YES		NO		N/A (For SBM-FP only)

18. Enrollment and Payment Data Workbook Reports

The Marketplace is in compliance with applicable requirements regarding submission of monthly Enrollment and Payment Data Workbook reports to CMS support administration of Advance Premium Tax Credits and cost-sharing reductions under 45 CFR 155.340(a).

	YES		NO		N/A (For SBM-FP only)

19. IRS and Taxpayer Reporting

The Marketplace is in compliance with applicable requirements regarding reporting to the IRS and to taxpayers in accordance with 45 CFR 155.340(c).

	YES		NO		N/A (For SBM-FP only)

20. Non-Discrimination Policies and Standards

The Marketplace has policies and clear enforcement standards to safeguard against discrimination in health insurance determinations and practices including notices, complaint processes, training of Marketplace personnel in accordance with Section 1557 of the Affordable Care Act. If yes, submit the Marketplace’s non-discrimination policies and standards.

	YES		NO		N/A (For SBM-FP only)

21. Consumer Assistance Tools

The Marketplace has policies and procedures in place to provide all consumers with information and assistance that is timely and accessible in accordance with 45 CFR 155.205..

	YES		NO

22. Self-Reporting: Eligibility and Enrollment Opportunity for Comments

Please provide information on any identified discrepancies and/or concerns with eligibility and enrollment and, if applicable, the steps that were taken to resolve such discrepancies and/or concerns. Please also address strengths, lessons learned, and best practices, and identify operational or policy issues ,if any, which have caused significant and/or recurring problems in making accurate eligibility determinations or enrollments.

3. Performance Monitoring Data

1. Performance Monitoring Data Overview

Under 45 CFR §155.1200(a)(3), Marketplaces are required to collect and report to CMS performance monitoring data. SBMs that operate an individual eligibility and enrollment system and/or a Small Business Health Options Program (SHOP) must, based on prescribed timelines, submit: open enrollment indicator metrics, quarterly metrics reports, and a cumulative final plan year metrics report, as applicable. Please attest to submission of these metrics and reports. SBM-FPs that also use the federal platform for SHOP should select N/A.

2. Open Enrollment Indicator Metrics

The Marketplace submitted the weekly indicator metrics reports that, as applicable, included data pertaining to individual coverage applications received, Medicaid Assessments, Qualified Health Plan (QHP) eligibility, QHP plan selections during open enrollment, consumer demographics and income levels, effectuated enrollment premiums, and employer and employee enrollment in SHOP.

	YES		NO		N/A

3. Quarterly Outcome Metrics Reports

The Marketplace submitted the quarterly outcomes metrics reports that, as applicable, included data pertaining to QHP eligibility, QHP effectuated enrollments, financial assistance, consumer demographics and income levels, and employer and employee enrollment in SHOP.

	YES		NO		N/A

4. Final Plan Year Outcome Metrics Report

The Marketplace submitted the final plan year cumulative quarterly metrics report.. If no, upload the final plan year quarterly metrics report.

	YES		NO		N/A

5. Self-Reporting: Performance Monitoring Data Opportunity for Comments

Please identify best practices exhibited by the Marketplace, trends that demonstrate the impact of the Marketplace on the health market, and areas of improvement where technical assistance regarding completing the performance monitoring data requirements may be necessary for the Marketplace.

4. Financial and Program Integrity

1. Financial and Program Integrity Overview

Under 45 CFR 155.1200 Marketplaces are required to report to CMS on financial and program integrity and engage an independent qualified auditing entity to conduct a financial and a programmatic audit. Please attest to having completed the applicable activities and submit any requested documentation.

2. Accurate Accounting

The Marketplace keeps accurate accounting of all activities, receipts, and expenditures in accordance with GAAP under 45 CFR Subpart M, §155.1200(a)(1).

	YES		NO

3. Financial Independent External Audit

An independent, qualified auditing entity that follows generally accepted governmental auditing standards (GAGAS) has performed an annual independent external financial audit of the Marketplace, under 45 CFR Subpart M, §155.1200(c), and submitted the results to CMS.

	YES		NO

4. Accurate Accounting and Financial Statement: Independent External Auditor Attestation

The Marketplace has prepared an annual financial statement in accordance with GAAP under 45 CFR Subpart M, §155.1200(b)(1) and provided the financial statement to CMS.

	YES		NO

An independent, external auditor attests that the Marketplace has demonstrated to CMS accurate accounting of all activities, receipts, and expenditures and has prepared an accurate annual financial statement in accordance with GAAP. If yes, upload the auditor attestation confirming the Marketplace has demonstrated accurate accounting and prepared an accurate annual financial statement.

	YES		NO

5. Programmatic Independent External Audit

An independent, qualified auditing entity that follows generally accepted governmental auditing standards (GAGAS) has performed an annual independent external programmatic audit of the Marketplace, under 45 CFR Subpart M, §155.1200(c) in compliance with the standards in 45 CFR Subpart M, §155.1200(d). If yes, upload results of the annual programmatic independent external audit.

	YES		NO		WILL SUBMIT AT LATER DATE

6. Material Weaknesses

The programmatic independent external audit identified a material weakness or significant deficiency.

	YES		NO

If yes, the Marketplace has informed CMS of any material weakness or significant deficiency and any intended corrective action identified by the independent external audit.

	YES		NO

If yes, upload corrective action plan (CAP) addressing the material weakness or significant deficiency identified by the external audit.

7. Summary of Audit Results Available to Public

The Marketplace has made a summary of the results from the independent financial and programmatic external audits available to the public.

	YES		NO

If yes, include a link to where the independent external audit results are located.

8. Maintenance of Records

The Marketplace adheres to the maintenance of records requirements as stated under 45 CFR Subpart M §155.1210(a)(b)(c).

	YES		NO

9. Fraud, Waste, and Abuse: Marketplace Operations

The Marketplace has policies and procedures in place to identify incidents of fraud, waste, and abuse within its operations under 45 CFR Subpart M, §155.1200(b). If yes, upload the Fraud, Waste, and Abuse policies and procedures.

	YES		NO

10. Fraud, Waste and Abuse: Consumer Assistance

The Marketplace has processes in place to identify, adjudicate, and report on fraud, waste and abuse incidents associated with Issuers, Agents/Brokers, Navigators, In-Person Assisters, Certified Application Counselors, and other entities associated with providing consumer assistance for applying for QHPs through the Marketplace. If yes, submit the Marketplace’s processes.

	YES		NO

11. Oversight and Monitoring Plan

The Marketplace has a process in place to perform required activities related to routine oversight and monitoring of Marketplace activities under Blueprint Application requirement 11.1. If yes, upload the updated oversight and monitoring plan.

	YES		NO

12. Self-Reporting: Financial and Program Integrity Opportunity for Comments

Please identify any new initiatives related to the SBM management of financial and programmatic integrity, provide explanations of problematic issue areas identified, and a description of any areas the auditor identified as at risk and the SBM mitigation strategies to address those issues.

5. Attestation of Completion

On this date, I attest that the statements and information contained in this State-based Marketplace Annual Reporting Tool (SMART) and the documents submitted in conjunction with this report accurately represent the SBM’s compliance with the regulatory requirements.

		YES		NO
STATE:					<Enter Name of State>
ELECTRONIC SIGNATURE:					<Enter Electronic Signature of Executive Director or Chief Executive Officer>
DATE:					<Enter MM/DD/YYYY>

PRINT NAME: ­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­ ______________________________________________________________­­­­­­

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