Individual - Essential Health Benefits in Alternative Benefit Plans, Eligibility Notices, Fair Hearing andAppeal Processes, and Premiums and Cost Sharing; Exchanges: Eligibility and Enrollment

OMB Control Number: 0938-1207 Expiration Date: XX/XXXX

Appendix A: Data Elements for Notices Under 45 CFR Part 155, Part 156, and Part 157

Data Elements for Eligibility Determination Notice (45 CFR 155.310(g))- Sent after the processing of an initial application, as well as after the processing of self-reported changes, or changes identified through periodic data matching or annual redetermination.
Household Contact Information – Name, address(es)	Eligibility Determination Information, For Each Applicant that applied together, if applicable- Eligibility determination or assessment for each applicant for enrollment in a QHP and insurance affordability programs, as applicable. Maximum APTC amount*, CSR category*, qualification for enrollment period for enrollment in a QHP*. If Exchange conducted an assessment for Medicaid/CHIP and individual is not assessed as potentially eligible for Medicaid or CHIP based on MAGI, information about withdrawal of application for Medicaid/CHIP and right to a full Medicaid determination* (45 CFR 155.302(b)(4)) If an individual meets the criteria specified in 155.320(d)(3)(iii), an indication that the Exchange will be contacting the employers listed on the application for additional information.	Enrollment Information* – Instructions for QHP plan selection, deadline for plan selection based on enrollment period, information about online tools. If coverage in a QHP is being terminated, information regarding the termination reason and effective date.* If Exchange determined or assessed an applicant as eligible for Medicaid or CHIP, information regarding what steps the Medicaid/CHIP agency will take.
Customer Service Information – Contact information for the Exchange, information regarding Navigators and other customer service resources serving the applicant’s area, Medicaid and CHIP	Inconsistencies* - If an inconsistency exists for any applicant, the cause for the inconsistency, length of the inconsistency period, and directions for resolving inconsistency, including acceptable	Citation to regulation for action, including the reason for the action (45 CFR 155.230(a)(3))

agency contact information* (45 CFR 155.230(a)(1))	documentation and information to assist Exchange in matching documentation to person (45 CFR 155.315(f)(2)(i))
Right to request a full Medicaid determination (45 CFR 155.345(c))	Account transfer - If account is being transferred to Medicaid for a full determination* (45 CFR 155.345(d))	Reminder to report changes within 30 days of a change related to eligibility throughout the year* (45 CFR 155.330(b))
Appeal rights and instructions (45 CFR 155.355 and 155.230(a)(2))	Accessibility- Taglines in other languages for how to obtain assistance interpreting the notice, and information about availability and access to oral interpretation, written translation, and other services for individuals living with disabilities or who are limited English proficient (45 CFR 155.205(c))	Disclosure statement (45 CFR 155.260(iii) and (iv)) Instructions for how to receive electronic notices* (§155.230(d))
Other Exchange Notices to Individuals
Pre-populated notice resulting from Periodic Data Matching (45 CFR 155.330(e)(2)(i) and (e)(3)(i)) – The updated information found about the individual, the projected eligibility determination, timeframe and instructions for how the individual can respond to the Exchange to confirm or refute the updated information found by the Exchange, includes additional data elements similar to those included in the eligibility determination notice identified previously (as applicable)
Pre-Populated notice resulting from Annual Redetermination (45 CFR 155.335(c)) - The updated information found about the individual, projected eligibility determination, timeframe and instructions for how the individual can respond to the Exchange to refute the updated information found by the Exchange, in 2014 and beyond this notice includes information about the annual open enrollment period (45 CFR 155.410(d)), includes additional data elements similar to those included in the eligibility determination notice identified previously (as applicable)
Employer Notice (45 CFR 155.310(h)) - Notice Unique ID, employer contact information, name of employee and that the employee qualified for APTC/CSR, Information about potential liability for the employer responsibility payment, appeal rights, contact information for the Exchange, disclosure statement, employee protections
Electronic Reminder Notice (45 CFR 155.330(c)(2)) – Notice Unique ID, reminder to report changes about information related to eligibility standards, includes additional data elements similar to those included in the eligibility determination notice identified previously (as applicable)
Notice of Decertification and SEP (45 CFR 155.1080(e)) – Notice Unique ID, Plan ID/information, primary subscriber/contact information and identification of other policy members/enrollees affected by the decertification, effective dates, qualification for a special enrollment period, includes additional data elements similar to those included in the eligibility determination notice identified previously (as applicable)

Notices Sent by QHP Issuers to Individuals
Notice of Grace Period for Non-Payment of Premium (45 CFR 156.270(f)) – Notice Unique ID, Plan ID/Information, primary subscriber/contact information and identification of other policy members/enrollees affected by the non-payment, information about the non-payment and 90-day grace period including dates of the period, amount of unpaid premiums, that the grace period does not reset, implications of not having coverage (i.e., individual responsibility requirement, inability to get special enrollment period/enroll until next open enrollment period), customer service contact information
Termination of Coverage (45 CFR 156.270(b)) - Notice Unique ID, Plan ID/Information, primary subscriber/contact information and identification of other policy members/enrollees affected by the termination, reason for the termination, effective dates, implications of not having coverage (i.e., individual responsibility requirement, inability to get special enrollment period/enroll until next open enrollment period, customer service contact information)*, customer service contact information
Notification of effective date (45 CFR 156.260(b))– Household contact/primary subscriber information, qualified individual’s effective date of coverage, customer service contact information (may be combined with enrollment information package)
Enrollment information package (45 CFR 156.265(f)) – Welcome package about individual’s enrollment, information regarding how to access covered services, customer service contact information
Plan decertification notice (45 CFR 156.290(b)) – Unique ID, plan ID/Information, primary subscriber/contact information and identification of other policy members/enrollees affected by the decertification, effective dates, implications of not having coverage (i.e., individual responsibility requirement, inability to get special enrollment period/enroll until next open enrollment period), if the individual can choose to remain enrolled in the QHP outside of the Exchange (without APTC/CSR), customer service contact information
Appointment of Authorized Representative Form
Appointment of Authorized Representative Form (§155.227(a)) – Name, address, phone number, email address, date of birth, and relationship.
SHOP Required Notices to Employers
Data Elements for Employer Eligibility Determination Notice (45 CFR 155.715)- Sent after the processing of an initial application, as well as after the processing of employer-reported changes or as part of annual redetermination
Employer Contact Information – Name, address, account/unique ID	Eligibility Determination Information for the Employer if applicable- Determination of eligibility for the employer to participate in the SHOP (45 CFR 155.715(e)and 45 CFR 155.715(d)(1)(iv)(A))	Election Information – Instructions for plan and contribution election, deadline for election (based on effective date of coverage), information about online tools

Customer Service Information – Contact information for the Exchange, information regarding Navigators and other customer service resources serving the employer’s area	Inconsistencies* - If an inconsistency exists for any applicant, the cause for the inconsistency, length of the inconsistency period, and directions for resolving inconsistency (45 CFR 155.715(d)(1)(ii))	Appeal rights and instructions (45 CFR 155.715(e))
Notice of annual election period -- Current plan and contribution election information, potential actions the employer may want to take – renew at same level, modify election, terminate participation (45 CFR 155.725(d))
Notice of employee termination – Notification to the employer of an employee’s termination of coverage. Includes date employee elected to terminate and effective date of termination (45 CFR 155.720(h)
SHOP Required Notices to Employees
Data Elements for Employee Eligibility Determination Notice (45 CFR 155.715)- Sent at initial application, to confirm employee eligibility determination resulting from changes or annual redetermination
Employee Contact Information – Name, address, account/unique ID	Eligibility Determination Information for the Employer if applicable- Eligibility determination of eligibility for the employee to enroll in coverage through the SHOP (45 CFR 155.715(f)and 45 CFR 155.715(d)(2)(iv))	Election Information – Instructions for plan and selection, deadline for enrollment (based on enrollment period length), information about online tools (if completed application on paper)
Customer Service Information – Contact information for the Exchange, information regarding Navigators and other customer service resources serving the employer’s area	Inconsistencies* - If an inconsistency exists for any applicant, the cause for the inconsistency, length of the inconsistency period, and directions for resolving inconsistency (45 CFR 155.715(d)(2)(ii))	Appeal rights and instructions (45 CFR 155.715(f))

Notice of employer withdrawal –

Notification to the employee of its employer’s termination of participation in coverage. Includes date of termination of coverage (45

CFR 155.715(g) and information regarding other coverage options through the Exchange, as well as contact information for the Exchange and information regarding Navigators and other customer service resources serving the employee’s area

Notice of annual enrollment period -

Current plan and contribution election information, potential actions the employee may want to take – renew plan, change plans, terminate enrollment (45 CFR 155.725(f))

Qualified Employer Required Notices to Employees

Notice of enrollment process – A qualified employer must inform each employee that they are being offered coverage through the SHOP and inform each employee of the instructions about how to enroll in health insurance coverage through the SHOP, including information about what formats the employee may submit an application: online, on paper, or by phone (45 CFR 157.205(c)). If the employee being offered coverage was hired outside an initial or annual enrollment period, the notice will include information about whether the employee may qualify for a special enrollment period (45 CFR 157.205(e))

Qualified Employer Required Notices to a SHOP

Notice of change in eligibility for coverage – A qualified employer must provide the SHOP with an update the application if an employee and his or her dependents have a change in eligibility status. For an employee, this consists of an application update including, the employee’s name, SSN, and DOB. For dependents, this is a yes/no question. Information submission may be completed online, by phone, or by paper (45 CFR 157.205(f))

*Information will only be included in the notice if applicable.

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