Form CMS-10633 Appendix A - Agents and Brokers

OMB Control Number: 0938-NEW
Expiration Date: XX/XX

Appendix A: Data Elements for General Function of an Exchange (Part 155, Subpart C)
The data elements for the collections of information included in Part 155, Subpart C– General
Function of an Exchange, are as follows:
Ability of States to Permit Agents and Brokers to Assist Qualified Individuals, Qualified
Employers, or Qualified Employees Enrolling in Qualified Health Plans in the Federallyfacilitated Exchange (§155.220)
Section 155.220(c)(4) requires a Web-broker who permits other agents and brokers to use
its Web site to enroll a consumer through the FFE, pursuant to a contractual or other
arrangement, to provide to the FFE a list of those agents or brokers who enter into such an
arrangement, if requested by HHS. We assume Web-brokers already have the necessary
data to list each of the other agents or brokers accessing their Web site, and the information
they provide to HHS will include:
1. Other agent’s or broker’s name
2. Other agent’s or broker’s address and contact information (address)
3. Other agent’s or broker’s FFM User ID
4. Other agent’s or broker’s National Producer Number

Section 155.220(g) describes the process for HHS to terminate and agent’s or broker’s
agreement with the Federally-facilitated Exchange for cause. HHS will notify the agent or
broker of the specific finding of noncompliance or pattern of noncompliance. We assume the
agent or broker may acknowledge receipt of this notice by providing a written statement that
includes the following issuer information:
1.
2.
3.
4.
5.

Agent or broker name
Agent or broker address
Date of receipt of notice
Date of submission of acknowledgement
Type of notice received

Section 155.220(h) explains how an agent or broker whose agreement has been terminated can
request a reconsideration of such action. The agent or broker must submit a written request within
30 calendar days of the date of the written notice from HHS. No information is given as to what
the request should contain; it is our assumption that the request needs to contain all the
information necessary for the agent or broker to explain their situation and receive a favorable
response from the reconsideration entity. This information may include the following:
1.
2.
3.
4.
5.
6.

Agent or broker name
Agent or broker address
Date of receipt of notice
Date of submission of request
Type of notice received
Evidence to counteract any specific details specified in the notice from HHS that give
grounds for terminating the agreement, and explanation for why the agreement should not
be terminated
7. Evidence that shows the agent or broker’s overall financial and regulatory good standing