Form CMS-10507 2016 - SMART Tool

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 CFR § 155.1200 (general program integrity and oversight responsibilities) and 45 CFR § 155.1210 (maintenance of records). Under these provisions, SBMs are required to conduct a defined set of oversight activities to track and monitor how they are 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, in coordination with other CMS oversight activities, to monitor and evaluate 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: 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.

Unless otherwise noted, SBMs should answer the SMART questions, as they relate to Marketplace operations in place, on the last day of the previous open enrollment period.

SMART REPORTING ELEMENTS

I. Eligibility and Enrollment 3

II. Performance Monitoring Data 7

III. Financial and Program Integrity 8

IV. Attestation of Completion 11

1. Eligibility and Enrollment

SBMs using the Federal Platform (SBM-FPs) for individual eligibility and enrollment, should skip this section.

1. Eligibility and Enrollment Overview

Under 45 CFR § 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, operational regulations, and guidance, and submit the required information where noted. Answer the questions as they relate to Marketplace operations in place as of the last day of the previous open enrollment period, unless otherwise noted.

2. Qualified Health Plan (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

3. QHP Eligibility Verification: Citizenship and Lawful Presence

The Marketplace verifies citizenship with the Social Security Administration through the Federal Data Services Hub under 45 CFR § 155.315(c) unless otherwise authorized by CMS.

	YES		NO

The Marketplace verifies lawful presence with the Department of Homeland Security through the Federal Data Services Hub Verify Lawful Presence (VLP) Service Steps 1, 2, and 3 under 45 CFR § 155.315(c) or through an alternative process approved by CMS.

	YES		NO

4. QHP Eligibility Verification: State Residency

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

	YES		NO

The Marketplace verifies state residency through a non-Federal Data Services Hub, private, and/or state-level data source for this eligibility verification procedure.

	YES		NO

If yes, please list data source(s):____________________________

5. QHP Eligibility Verification: Standards and Process for American Indian/Alaska Natives

The Marketplace verifies attestations of American Indian/Alaska Native status utilizing relevant documentation and/or an electronic data source as provided under 45 CFR § 155.350(c) unless otherwise authorized by CMS.

	YES		NO

If yes, please list documentation type and/or data source(s):____________________________

6. QHP Eligibility Verification: Incarceration Status

The Marketplace verifies incarceration status through the Federal Data Services Hub or attestation under 45 CFR § 155.315(e) unless otherwise authorized by CMS.

	YES		NO

The Marketplace uses a non-Federal Data Services 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

If yes, please list data source(s):____________________________

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) unless otherwise authorized by CMS.

	YES		NO

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

If yes, please list data source(s):____________________________

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 through the Federal Data Services Hub Office of Personnel Management Service under 45 CFR § 155.320(d) unless otherwise authorized by CMS.

	YES		NO

The Marketplace uses a non-Hub, private, and/or state-level data source, and/or employs an alternative verification process (including a statistically significant random sample) for this eligibility verification procedure.

	YES		NO

If yes, please list data source(s) and/or alternative process:____________________________

9. Affordability Program Eligibility Verification: Medicaid, Children’s Health Insurance Program (CHIP) and Basic Health Program (BHP)

The Marketplace verifies eligibility related to enrollment in Medicaid, CHIP, and BHP (if applicable) through a state-level data source under 45 CFR § 155.320(b)(1)(ii).

	YES		NO

10. Affordability Program Eligibility Verification: Non Employer-sponsored Plan

The Marketplace verifies eligibility related to enrollment in minimum essential coverage, other than through an eligible employer-sponsored plan, Medicaid, CHIP, and BHP (if applicable), through the Federal Data Services Hub under 45 CFR § 155.320(b)(1)(i).

	YES		NO

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

If yes, please list data source(s):____________________________

11. Inconsistency Resolution

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

Y	N	Partial
			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

11. 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

11. Periodic Data Matching

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

	YES		NO

11. 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

11. QHP Eligibility Process: Employer Notices

The Marketplace notifies an employer that an employee has been determined eligible for APTCs and CSRs and has enrolled in a QHP through the Marketplace within a reasonable timeframe under 45 CFR 155.310(h).

	YES		NO

11. 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

11. 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

11. 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 Internal Revenue Service [IRS] report) to support the reconciliation of aggregated payments of APTCs and CSRs to issuers under 45 CFR § 155.340(a) and 45 CFR § 155.400(b).

	YES		NO

11. 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, including instances where the Marketplace has delegated this activity to its issuers on its behalf, to support the administration of APTCs and CSRs under 45 CFR § 155.340(a).

	YES		NO

11. 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

11. Monthly Reconciliation of Enrollment Information with QHP issuers and HHS

The Marketplace reconciles their enrollment information, including historical dates of coverage, with QHP issuers no less than on a monthly basis in accordance with 45 CFR § 155.400. Submit the internal and external procedures for reconciliation with issuers per 45 CFR § 155.400(d).

	YES		NO

The Marketplace has begun testing with HHS, in accordance with the state’s plan as approved by CMS, to transmit eligibility and enrollment information to HHS using the State-based Marketplace Inbound (SBMI) file in support of the administration of APTCs and CSRs per 45 CFR § 155.340(a) and 45 CFR § 155.400(d).

	YES		NO

11. 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, that have caused significant and/or recurring problems in making accurate eligibility determinations or enrollments.

2. 
   
   

   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 for the previous plan year.

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, 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. Monthly and Quarterly Outcome Metrics Reports

The Marketplace submitted the monthly and 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. 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.

3. 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 generally accepted accounting principles (GAAP) under 45 CFR § 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 § 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 § 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 GAGAS has performed an annual independent external programmatic audit of the Marketplace, under 45 CFR § 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

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 a 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 § 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 § 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 enrollment in 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. 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, and training of Marketplace personnel in accordance with Section 1557 of the Affordable Care Act. If yes, upload the Marketplace’s non-discrimination policies and standards.

	YES		NO

13. 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. For SBM-FPs, the Marketplace has, at a minimum, an informational website and toll free hotline that directs consumers to the Federal platform for eligibility and enrollment.

	YES		NO

14. Financial Information

The Marketplace publishes on its website average licensing costs, regulatory fees, administrative costs, and any other additional fees required by the Marketplace, along with any monies lost to waste, fraud, and abuse, in accordance with 45 CFR § 155.205(b)(2).

	YES		NO

If yes, include a link to where the information is posted:____________________________

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

Please identify any new initiatives related to the SBM management of financial and programmatic integrity, and 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.

4. 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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