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/XXX

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)

Customer Service Information –
Contact information for the Exchange,
information regarding Navigators and
other customer service resources serving
the applicant’s area, Medicaid and CHIP

Eligibility Determination Information, For
Each Applicant that applied together, if
applicableEligibility 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*.

Enrollment Information* –
Instructions for QHP plan selection,
deadline for plan selection based on
enrollment period, information about
online tools.

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 Exchange determined or assessed an
applicant as eligible for Medicaid or
CHIP, information regarding what steps
the Medicaid/CHIP agency will take.

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.
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

If coverage in a QHP is being
terminated, information regarding the
termination reason and effective date.*

Citation to regulation for action,
including the reason for the action
(45 CFR 155.230(a)(3))

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agency contact information* (45 CFR
155.230(a)(1))
Right to request a full Medicaid
determination (45 CFR 155.345(c))

Appeal rights and instructions (45 CFR
155.355 and 155.230(a)(2))

documentation and information to assist
Exchange in matching documentation to
person (45 CFR 155.315(f)(2)(i))
Account transfer - If account is being
transferred to Medicaid for a full
determination* (45 CFR 155.345(d))

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))

Reminder to report changes within
30 days of a change related to
eligibility throughout the year* (45
CFR 155.330(b))
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)
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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 –
Election Information –
Eligibility Determination Information
Instructions for plan and contribution
Name, address, account/unique ID
for the Employer if applicableelection, deadline for election (based on
Determination of eligibility for the
effective date of coverage), information
employer to participate in the SHOP (45
about online tools
CFR 155.715(e)and 45 CFR
155.715(d)(1)(iv)(A))

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Inconsistencies* Appeal rights and instructions (45 CFR
If an inconsistency exists for any applicant, 155.715(e))
the cause for the inconsistency, length of
the inconsistency period, and directions for
resolving inconsistency (45 CFR
155.715(d)(1)(ii))
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
Customer Service Information –
Contact information for the Exchange,
information regarding Navigators
and other customer service
resources serving the employer’s area

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 –
Election Information –
Eligibility Determination Information
Instructions for plan and selection,
Name, address, account/unique ID
for the Employer if applicabledeadline for enrollment (based on
Eligibility determination of eligibility for
the employee to enroll in coverage through enrollment period length), information
the SHOP (45 CFR 155.715(f)and 45 CFR about online tools (if completed
application on paper)
155.715(d)(2)(iv))
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))

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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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