Supporting Statement for Paperwork Reduction Act Submissions: Establishment of an Exchange by a State and Qualified Health Plans
Supporting Statement A
Establishment of an Exchange by a State and Qualified Health Plans
CMS-10593, OMBI 0938-1312
The Patient Protection and Affordable Care Act, Public Law 111-148, enacted on March 23, 2010, and the Health Care and Education Reconciliation Act, Public Law 111-152, enacted on March 30, 2010 (collectively, “Affordable Care Act”), expand access to health insurance for individuals and employees of small businesses through the establishment of new Affordable Insurance Exchanges (Exchanges), including the Small Business Health Options Program (SHOP). The Exchanges, which became operational on January 1, 2014, enhance competition in the health insurance market, expand access to affordable health insurance for millions of Americans, and provide consumers with a place to easily compare and shop for health insurance coverage.
To offer insurance through an Exchange, a health insurance issuer must have its health plans certified as QHPs by the Exchange. A QHP must meet certain minimum certification standards, such as network adequacy, inclusion of Essential Community Providers (ECPs), and non-discrimination. The Exchange is responsible for ensuring that QHPs meet these minimum certification standards as described in the Exchange rule annually.1
The regulatory requirements are codified in 45 CFR parts 155, 156, and 157. Part 155 outlines the standards relative to the establishment, operation, and minimum functionality of Exchanges, including eligibility standards for insurance affordability programs. CMS rules establish requirements that various entities must meet for the establishment and operation of an Exchange; minimum requirements that health insurance issuers must meet for participation in a State-based or Federally-facilitated Exchange; and requirements that employers must meet to participate in the SHOP; as well as other provisions of the Affordable Care Act. While existing Exchanges must perform certain functions annually, any new State-based Exchange will need to perform certain one-time functions for implementation.
Section 1311(b) of the Affordable Care Act requires each State to establish an Exchange by January 1, 2014. Section 1311(d) of the Affordable Care Act requires an Exchange be a governmental agency or nonprofit entity established by a State; requires an Exchange make QHPs available to eligible individuals and employers; and identifies the minimum functions an Exchange must perform.
Pursuant to section 1311(d)(5), States had to ensure their Exchanges are self-sustaining beginning on January 1, 2015. A State may accomplish this by permitting its Exchange to charge assessments or user fees to participating health insurance issuers, or otherwise generate funding to support Exchange operations.
The requirements covered under this information collection requirement (ICR) include:
General Standards Related to the Establishment of an Exchange by a State (§155.100 through §155.150)
General Functions of an Exchange (§155.200 through §155.270)
Exchange Functions in the Individual Market: Eligibility Determinations for Exchange Participation and Insurance Affordability (§155.302 through §155.345)
Exchange Functions in the Individual Market: Enrollment in Qualified Health Plans (QHP) (§155.400 through §155.440)
Exchange Functions: Small Business Health Options Program (SHOP) (§155.700 through
§155.741)
The data collected from States operating State-based Exchanges (SBEs) will be used by CMS and other federal partners to determine Exchange compliance with Federal standards for operating the Exchange. The data collected by health insurance issuers and Exchanges will help to inform CMS, Exchanges, and health insurance issuers on the participation of individuals, employers, and employees in the individual Exchange and SHOP.
The process of establishing an SBE and compliance with the federal requirements covered by this ICR will be facilitated using existing IT systems for the collection of the State-specific data. CMS aims to lessen the burden on States and minimize the need for any additional costs for the required submission by using existing IT systems, and anticipates the majority of the processes will be automated.
This information collection does not duplicate any other Federal information collection.
We estimate minimal burden on small business, as they are not required to participate in the SHOP.2
This collection cannot be conducted less frequently. SBEs are required to complete certain activities only once to establish the Exchange, and other activities on an annual basis to be in compliance with federal requirements. Due to the required flow of information between multiple parties, it is necessary to collect information according to the indicated frequencies. If the information is collected less frequently, the result could mean non-compliance with the law or consumer harm.
There are no special circumstances for this information collection.
No payments and/or gifts will be provided to respondents.
To the extent of the applicable law and CMS policies, we will maintain respondent privacy with respect to the information collected.
There are no sensitive questions included in this information collection effort.
To derive average costs, we used data from the U.S. Bureau of Labor Statistics May 2018 National Occupational Employment and Wage Estimates for all salary estimates (https://www.bls.gov/oes/current/oes_nat.htm). The following table presents the mean hourly wage, the cost of fringe benefits (calculated at 100 percent of salary), and the adjusted hourly wage.
Table 1 – Wage Rates
Occupation Title |
Occupation Code |
Mean Hourly Wage ($/hr) |
Fringe Benefits and Overhead ($/hr) |
Adjusted Hourly Wage ($/hr) |
Management Analyst |
13-1111 |
$45.38 |
$45.38 |
$90.76 |
Computer and Information Systems Manager |
11-3021 |
$73.49 |
$73.49 |
$146.98 |
Computer Programmer |
15-1131 |
$43.07 |
$43.07 |
$86.14 |
Computer User Support Specialist |
15-1151 |
$26.46 |
$26.46 |
$52.92 |
Actuary |
15-2011 |
$55.89 |
$55.89 |
$111.78 |
Web Developer |
15-1134 |
$36.34 |
$36.34 |
$72.68 |
As indicated, we are adjusting our employee hourly wage estimates by a factor of 100 percent. This is necessarily a rough adjustment, both because fringe benefits and overhead costs vary significantly from employer to employer, and because methods of estimating these costs vary widely from study to study. Nonetheless, we believe that doubling the hourly wage to estimate total cost is a reasonably accurate estimation method.
Requirements and Associated Burden Estimates
CMS estimates 20 States, including the District of Columbia, will be operating a State-based Exchange (SBE) by plan year (PY) 2021. As of PY2019, there were 17 States operating an SBE, 5 of which operate and SBE-FP.CMS estimates three state will implement and be newly-operating as State-based Exchanges in PY 2020. For PY 2020 For PY 2021, CMS anticipates PA and NJ will be operating SBE-FPs.
Any state transitioning exchange models to become an SBE will need to perform one-time Exchange related functions; and all twenty SBEs will need to perform annual, recurring Exchange related functions. The estimates of burden recorded generally reflect burden hours and costs for the first year of operation. The associated burden for subsequent years may lessen since many of the standards in the regulation may be fulfilled through automated processes. Therefore, these estimates should be considered an upper bound of burden estimates for non-Federal entities.
In Part 155, subpart B of the regulation, we describe the standards related to the establishment of Exchanges by a State. Subpart B contains information collection requirements associated with determining whether a State is ready to operate an Exchange before 2014. There are additional information collection requirements associated with the development of Exchange operations after January 1, 2014.
Section 155.105 contains the requirements for the Exchange approval process. In order to have an Exchange approved by CMS, the State must develop and submit an Exchange Blueprint that demonstrates how the Exchange meets all legal requirements for successful operation of an Exchange. In addition to the Exchange Blueprint, the State must submit an operational readiness assessment to CMS to demonstrate readiness to execute the Exchange Blueprint. CMS published an Exchange Blueprint application that included an operational readiness section, subject to the notice and comment process under the Paperwork Reduction Act. The PRA package for the Exchange Blueprint application outlined the required components of the Exchange Blueprint, including the burden associated with completing an operational readiness assessment as well as the requirements regarding eligible contracting entities stated in §155.110. The burden associated with meeting the approval process requirements of §155.105 are reflected in the PRA package for the Blueprint approval application (CMS-10416 (OMB 0938-1172)).
Part 155, subpart C describes the information collection and reporting requirements that Exchanges are required to perform to support the minimum functions of an Exchange.
Section 155.205(b) requires the Exchange to maintain an up-to-date Internet Web site that provides information on available QHPs. The QHP information required to be posted on the Web site includes premium and cost-sharing information, the summary of benefits and coverage, levels of coverage (“metal levels”) for each QHP, results of the enrollee satisfaction survey, quality ratings, medical loss ratio information, transparency of coverage measures, and a provider directory. Additionally, the Exchange must maintain the Web site to publish financial information, provide information on Navigators and other consumer assistance services, and allow for eligibility determinations and enrollment in coverage. Finally, the Web site must provide a calculator for the comparison of plans and have a consumer assistance function.
The burden for this requirement may vary based on whether the Exchange decides to develop its own code to support the Internet Web site or utilize Federally-developed code provided pursuant to section 1311(c)(5)(B) of the Affordable Care Act. If the Exchange uses Federally-developed code, the burden of meeting this requirement may include customizing the code to meet the business practices of the State, developing security policies, and system testing. If the Exchange opts to develop new code, the burden will include the additional steps of designing the Web site template and writing the code for the Web site. After developing the Web site, the burden on the Exchange will be to maintain the Internet Web site by populating the Web site with information collected per information collection requirements in this rule and future rulemaking by CMS. We estimate that 3 States may plan to operate an Exchange Web site subject to these reporting requirements, and we assume that they will not opt to develop their own new code and that most will use Federally-developed code. We estimate that it will take 3,200 hours for an Exchange to meet these reporting requirements for a total of 9,600 hours.
Table 2 – Burden for Exchange Webpage Maintainence
Labor Category |
Staff Count |
Adjusted Hourly Wage ($/hr) |
Burden Hours |
Burden Costs (per respondent) |
Total Burden Costs (3 respondents) |
Health Policy Analyst 13-1111 |
1 |
$90.76 |
256 |
$23,234.56 |
|
Web Developer 15-1134 |
2 |
$72.68 |
256 |
$37,212.16 |
|
Senior Manager 11-3021 |
2 |
$146.98 |
64 |
$18,813.44 |
|
Database Administrator |
2 |
$88.50 |
384 |
$67,968 |
|
Computer Programmer |
4 |
$86.14 |
384 |
$132,311.04 |
|
Total |
|
|
3,200 |
$279,539.20 |
$5,590,784 |
The Exchange is required to develop and publicly disseminate two sets of standards for Navigators, one set of standards to govern conflict of interest and one set of standards for training. The Exchange may choose to use any method that would make the standards available to the general public if the Exchange does not exclusively rely on a method that places the burden on the public to request the standards. Such methods could, for example, include posting the standards on the Exchange Web site or disseminating them to appropriate stakeholders. The burden estimate related to this requirement includes the time and effort needed to develop the standards and make them available to the public. We estimate there will be 20 SBEs subject to these operating requirements. This estimate is an upper bound of burden. We estimate that it will take 192 hours for an Exchange to meet these reporting requirements for a total of 3,840 hours.
Table 3 – Burden for Navigation Program Standards
Labor Category |
Staff Count |
Adjusted Hourly Wage ($/hr) |
Burden Hours |
Burden Costs (per respondent) |
Total Burden Costs (20 respondents) |
Health Policy Analyst 13-111 |
2 |
$90.76 |
64 |
$11,617.28
|
|
Senior Manager 11-3021 |
2 |
$146.98 |
32 |
$9,406.72
|
|
Total |
|
|
192 |
$21,024.00 |
$420,480.00 |
Section 155.220(c) provides the option for an Exchange to allow an agent’s or broker’s Internet Web site to be used in the selection of a QHP, as long as the agent or broker’s Internet Web site meets certain conditions and the agent or broker complies with the terms of an agreement with the Exchange regarding access and use of Exchange data and systems by the agent or broker. In such instances, the agent or broker must ensure that applicants have their eligibility applications completed through the Exchange Internet Web site and the Exchange must transmit the enrollment information to the QHP issuer. For the agent or broker’s Internet Web site to be able to assist individuals in selecting a QHP, the Exchange would have to provide QHP data to the agent or broker’s Internet Web site so that the applicant could select a QHP. The Exchange would also need to develop an agreement with agents and brokers that intend to support an Internet web site that would assist individuals in selecting a QHP.
For Exchanges that elect to allow agents and brokers to use their Internet Web sites to help individuals select a QHP, the burden associated with this provision would be the development of electronic interfaces to provide QHP data to the agent or broker’s Internet Web site and receive QHP selection information from the agent or broker. There would also be additional burden on Exchanges to develop and execute agreements with applicable agents and brokers. We estimate there will be potentially 20 SBEs that plan to or do operate State Exchanges will be subject to these operating requirements. This estimate is an upper bound of burden. We estimate that it will take 164 hours for an Exchange to meet these reporting requirements for a total of 3,280 hours.
Table 4 – Burden hours for Enrollment through the Exchange
Labor Category |
Staff Count |
Adjusted Hourly Wage ($/hr) |
Burden Hours |
Burden Costs (per respondent) |
Total Burden Costs (20 respondents) |
Health Policy Analyst 13-111 |
1 |
$90.76 |
12 |
$1,089.12 |
|
Operations Analyst 13-111 |
1 |
$90.76 |
24 |
$2,178.24 |
|
Senior Manager 11-3021 |
1 |
$146.98 |
12 |
$1,763.76 |
|
Lawyer 23-1011 |
1 |
$138.68 |
16 |
$2,218.88 |
|
Database Administrator 15-1141 |
1 |
$88.50 |
40 |
$3,540.00 |
|
Computer Programmer 15-1131 |
1 |
$86.14 |
60 |
$5,168.40 |
|
Total |
|
|
164 |
$15,958.40 |
$319.168.00 |
The Exchanges must also develop privacy and security standards addressing the collection, use and disclosure of personally identifiable information. Section 155.260(d) states that the Exchange must develop policies and procedures regarding the use, disclosure, and disposal of personally identifiable information. These policies and procedures must be made available, in writing, to the Secretary of HHS upon request. This information will be used to verify that Exchanges have standards in place to protect personally identifiable information and that Exchanges are in compliance with all applicable privacy and security requirements. The burden associated with this requirement is the time and effort necessary for the Exchange to develop and transmit the information, in writing, to the Secretary of HHS. We estimate there will be States that plan to operate State Exchanges subject to these operating requirements. We estimate that it will take 95 hours for each of the 3 new SBEs to meet this requirement for a total estimate of 285 hours.
Table 5 - Written policies and procedures
Labor Category |
Staff Count |
Adjusted Hourly Wage ($/hr) |
Burden Hours |
Burden Costs (per respondent) |
Total Burden Costs (3 respondents) |
Health Policy Analyst 13-1111 |
1 |
$90.76 |
40 |
$3,630.40 |
|
Senior Manager 11-3021 |
1 |
$146.98 |
15 |
$2,204.70 |
|
Information Security Officer 15-1122 |
1 |
$98.25 |
20 |
$1,965.00 |
|
Privacy Officer 15-1122 |
1 |
$98.25 |
20 |
$1,965.00 |
|
Total |
|
|
95 |
$9,765.10 |
$29,295.30 |
Section 155.302 of the regulation provides options for conducting eligibility determinations. Section 155.302(a) provides that the Exchange may satisfy the requirements of this subpart directly or through contracting arrangements or through a combination of the approach described in paragraph (a)(1) and one or both of the options, described in paragraphs (b) and (c), and certain standards are met. The burden associated with this provision is the time and effort necessary for the Exchange to establish or modify an agreement for eligibility determinations and coordination of eligibility functions. We do not have an estimate as to the number of States in which such an agreement will be executed; however, if one of the options, or combinations of options, described in paragraphs (b) and (c) is implemented, we estimate it will take a State an average of 105 hours to create a new agreement and a total of 315 hours for 3 new SBEs. This includes a mid-level health policy analyst drafting the agreement with managerial oversight and comprehensive review of the agreement.
Table 6 - Options for conducting eligibility determinations
Labor Category |
Staff Count |
Adjusted Hourly Wage ($/hr) |
Burden Hours |
Burden Costs (per respondent) |
Total Burden Costs (3 respondents) |
Health Policy Analyst 13-1111 |
1 |
$90.76 |
35 |
$3,176.60 |
|
Lawyer 23-1011 |
1 |
$138.68 |
30 |
$4,160.40 |
|
Operations Analyst 13-1111 |
1 |
$90.76 |
35 |
$3,176.60 |
|
Senior Manager 11-3021 |
1 |
$146.98 |
5 |
$634.90 |
|
Total |
|
|
105 |
$11,248.50 |
$33,745.50 |
Operating SPEs may modify existing agreements for eligibility determinations, however we estimate that no more than 3 SBEs each year would make such a change. We estimate that changing the agreement would be require no more than half the time of establishing a new agreement.
Annualized Hours and Costs Table
Labor Category |
Staff Count |
Adjusted Hourly Wage ($/hr) |
Burden Hours |
Burden Costs (per respondent) |
Total Burden Costs (3 respondents) |
Health Policy Analyst 13-1111 |
1 |
$90.76 |
17.5 |
$1,588.30 |
|
Lawyer 23-1011 |
1 |
$138.68 |
15 |
$2,080.20 |
|
Operations Analyst 13-1111 |
1 |
$90.76 |
17.5 |
$1,588.30 |
|
Senior Manager 11-3021 |
1 |
$146.98 |
2.5 |
$367.45
|
|
Total |
|
|
52.5 |
$5,624.25 |
$16,872.75
|
Section 155.310(d)(3) provides that to the extent that the Exchange determines an applicant eligible for Medicaid or CHIP, the Exchange must notify the State Medicaid or CHIP agency and successfully transfer all information from the records of the Exchange to the Medicaid agency to provide the applicant with coverage promptly and without undue delay. This applicant information will be transmitted electronically (via secure electronic interface) from the Exchange to the agency administering Medicaid or CHIP upon receiving an indication that the Exchange has determined an applicant eligible for such program. The purpose of this data transmission is to notify the agency administering Medicaid or CHIP that an individual is newly eligible and so the agency should facilitate enrollment in a plan or delivery system. We estimate the burden on the Exchange to execute data sharing agreements with State Medicaid and CHIP agencies to comply with this provision in §155.345.
Section 155.310(g) provides that the Exchange notifies individuals of their eligibility determination after it has been made, so that he or she may select a plan, appeal an eligibility determination, or follow up with Medicaid, CHIP, or the BHP, as applicable. The Exchange consolidate all eligibility determinations of a household into a single notice when multiple members of a household are applying together and receive an eligibility determination at the same time. The notice can be made available in paper or electronic format but must be in writing and sent after an eligibility determination has been made by the Exchange. We anticipate that half of enrollees will request electronic notification while the other half will receive the notice by mail. As a result, we estimated the associated mailing costs for the time and effort needed to mail notices in bulk to enrollees as appropriate. We expect that the electronic eligibility determination notice will be dynamic and include information tailored to all possible outcomes of an application throughout the eligibility determination process. To develop the paper and electronic notices, Exchange staff refer to eligibility rules and draft notice text for various decision points, follow up, referrals, and appeals procedures. A peer analyst, manager, and/or legal counsel would review and approve final language for the notice. The Exchange would then engage in review and editing to incorporate changes from the consultation and user testing including review to ensure compliance with plain writing, translation, and readability standards. The Exchange may also consult with the State Medicaid or CHIP agency in order to develop a coordinated, single notice. Finally, for the electronic notice, a developer would program the template notice into the eligibility system so that the notice may be populated and generated as the applicant moves through the eligibility process.
We estimate 20 Exchanges will be required to generate the various eligibility notices for applicants. We estimate that this notice development as outlined in the paragraph above, including the systems programming, would take each Exchange an estimated 196 hours to complete in the first year. We estimate the total estimated hour burden is 3,920 hours, however the number of hours to complete this activity will significantly reduce for operating Exchanges over time.
Annualized Hours and Costs Table
Labor Category |
Staff Count |
Adjusted Hourly Wage ($/hr) |
Burden Hours |
Burden Costs (per respondent) |
Total Burden Costs (20 respondents) |
Health Policy Analyst 13-1111 |
2 |
$90.76 |
69 |
$12,524.88 |
|
Lawyer 23-1011 |
1 |
$138.68 |
20 |
$2,773.60 |
|
Senior Manager 11-3021 |
1 |
$146.98 |
4 |
$587.92 |
|
Fulfillment Manager 15-1151 |
1 |
$52.92 |
2 |
$105.84 |
|
Computer Programmer 15-1131 |
1 |
$86.14 |
32 |
$2,756.48 |
|
Total |
|
|
196 |
$18,748.72 |
$374,974.40 |
Paragraph (h) specifies that the Exchange will notify an enrollee’s employer that an employee has been determined eligible for advance payments of the premium tax credits and/or cost-sharing reductions. Upon making such an eligibility determination, the Exchange will send a notice to the employer with information identifying the employee who was determined eligible for advance payments of the premium tax credit and cost-sharing reductions that the employer may be liable for the payment under section 4980H of the Code, and that the employer has a right to appeal this determination. The notice must be available in paper or electronic format. Unlike the eligibility notice, we expect the information on the employer notice to be minimal in comparison to the eligibility notice and therefore the burden on the Exchange to develop the notice to be substantially less.
To develop this employer notice, Exchange staff time would include learning the eligibility process and drafting notice text. A peer analyst, manager, and/or legal counsel would review the notice. The Exchange would then engage in review and editing to incorporate changes from the review and user testing, including review to ensure compliance with plain writing, translation, and readability standards. Finally, a developer would program the final notice into the eligibility system so that it can be populated and generated as the applicant moves through the eligibility process.
We estimate 20 Exchanges will be required to generate a notice to send to employers. We estimate that this notice development as outlined in the paragraph above would take each Exchange an estimated 168 hours in the first year and the total estimated hour burden across all Exchanges in the first year to be 3,360 hours. We expect that the burden on the Exchange to maintain this notice will be significantly lower than to develop it.
Annualized Hours and Costs Table
Labor Category |
Staff Count |
Adjusted Hourly Wage ($/hr) |
Burden Hours |
Burden Costs (per respondent) |
Total Burden Costs (20 respondents) |
Health Policy Analyst 13-1111 |
2 |
$90.76 |
69 |
$12,524.88 |
|
Lawyer 23-1011 |
1 |
$138.68 |
10 |
$1,386.80 |
|
Senior Manager 11-3021 |
1 |
$146.98 |
2 |
$293.96 |
|
Fulfillment Manager 15-1151 |
1 |
$52.92 |
2 |
$105.84 |
|
Computer Programmer 15-1131 |
1 |
$86.14 |
16 |
$1,378.24 |
|
Total |
|
|
99 |
$15,689.72 |
$313,794.40 |
The provisions in §155.315 and §155.320 set standards for verification of applicant information for determining eligibility for enrollment in a QHP and insurance affordability programs. Exchanges will set up data-sharing agreements with CMS to allow for the verification of applicant information with Federal agencies that maintain authoritative data. The attestations collected throughout the verification process in §155.315 and §155.320 are outlined in a separate Application PRA Package (CMS-10440, OMB Control Number: 0938-1191)
The primary burden associated with the verification process includes the written agreements necessary for data sharing between the Exchange and CMS in order for Exchanges to access the data maintained in Federal data sources, as well as with other State agencies to access data maintained by such entities. We estimate the time and effort necessary for the Exchange to create new agreements with CMS and other State agencies or entities for the collection of this information. We expect that 3 SBEs will be subject to this requirement. We estimate it will take a State an average of 105 hours to create new agreements. This includes a mid-level health policy analyst drafting the agreement with managerial oversight and comprehensive review of the agreement as well as operations work completed by an operations analyst. For 3 new SBEs, we estimate a total hour burden of 315 hours.
Annualized Hours and Costs Table
Labor Category |
Staff Count |
Adjusted Hourly Wage ($/hr) |
Burden Hours |
Burden Costs (per respondent) |
Total Burden Costs (3 respondents) |
Health Policy Analyst 13-1111 |
1 |
$90.76 |
35 |
$3,176.70 |
|
Operations Analyst 13-1111 |
1 |
$90.76 |
35 |
$3,176.70 |
|
Lawyer 23-1011 |
1 |
$138.68 |
30 |
$4,160.40 |
|
Senior Manager 11-3021 |
1 |
$146.98 |
5 |
$734.90 |
|
Total |
|
|
105 |
$11,248.50 |
$33,745.50 |
Section 155.315(f) outlines the process for resolving inconsistencies identified through the verification process. The Exchange will provide notice to an applicant, requests that the applicant provide documentation to support his or her attestation regarding the eligibility determination. Upon receipt of acceptable supporting information from the applicant, the Exchange updates the applicant’s account and predetermines his or her eligibility. While the electronic eligibility system will be able to process most applications in an automated fashion and that only the more complex cases will be handled through the paper-driven process to resolve inconsistencies. For these complicated cases, the manual adjudication of the documentation submitted by an applicant to the Exchange will be necessary. While there is minimal consumer burden associated with submitting documentation, it is difficult to provide estimates for the number of applicants for whom the adjudication of documentation will be necessary, but we anticipate that this number will decrease as applicants become more familiar with the eligibility process and as more data become available electronically.
Sections 155.330(b) and (c) indicate that the Exchange requires an individual to report certain changes that affect his or her eligibility for enrollment in a QHP and insurance affordability programs within 30 days of such change. Upon receipt of changes, the Exchange re-verifies the information in accordance with the rules described in §155.315 and §155.320.
A large volume of changes are reported electronically by the enrollee, but an enrollee would also be permitted to submit changes through any of the channels: via phone, mail, or in person. The burden for this collection includes the time necessary for an eligibility worker to process any changes submitted by an enrollee during the benefit year. It is difficult to provide estimates for the number of applicants for whom the adjudication of documentation will be necessary, but we anticipate that this number will decrease as applicants become more familiar with the eligibility process and as more data become available.
Section 155.330(d) provides that the Exchange will periodically examine certain data sources for changes impacting an enrollee’s eligibility. The final rule provides the Exchange the flexibility to go beyond the limited data matching required, as long as it acts within certain standards. Any such data matching would require new data sharing agreements or amendments to existing data sharing agreements. The estimate of the burden associated with establishing or amending such agreements is described in §155.315 and §155.320.
The Exchange is required to notify an enrollee that it has identified such a change and dependent upon the response, predetermine the enrollee’s eligibility. The burden associated with creating this notice is similar to that of the annual redetermination notice, discussed in §155.335.
Section 155.335 outlines the annual redetermination process and provides that the Exchange will predetermine the eligibility of an enrollee in a QHP on an annual basis. The burden associated with this requirement is the time and effort necessary for Exchanges to develop and automate the annual redetermination notice and perform the record keeping related to predetermining eligibility. In accordance with 155.335(d), the annual redetermination notice is sent along with the notice of annual open enrollment as specified in 155.410(d), in a single, coordinated notice. We anticipate that half of enrollees will request electronic notification while the other half will receive the notice by mail. Thus, we have estimated the associated mailing costs for the time and effort needed to mail notices in bulk to enrollees as appropriate.
Similar to the eligibility notice described in 155.310(g), the annual redetermination notice contains dynamic text and include information tailored to each applicant. Section 155.335(c) provides that the Exchange include in the annual redetermination notice 1) updated income and family size information from the IRS, 2) data regarding MAGI-based income as described in §155.320(c)(1), 3) data used in the enrollee’s most recent eligibility determination, and 4) the enrollee’s projected eligibility determination for the following year, including the amount of any advance payments of the premium tax credit and cost- sharing reductions.
Exchange staff time would include learning the eligibility process and drafting notice text to include relevant income information, as well as follow up and appeals procedure. A peer analyst, manager, and/or legal counsel would review the notice. The Exchange then engages in review and editing to incorporate changes from the review and user testing, including a review to ensure compliance with plain writing, translation, and readability standards. The Exchange also coordinates the text of the notice with other insurance affordability programs. Finally, a developer would program the notice template into the eligibility system so it can be incorporated into the streamlined eligibility process. The programming of the notice into the eligibility system would allow for updated tax information to be pre-populated into the notice of annual redetermination.
We estimate 20 Exchanges will be required to generate the annual redetermination notice for applicants. We estimate that this notice development as outlined in the paragraph above would take each Exchange an estimated 334 hours. We estimate the total estimated hour burden in the first year is 6,680 for all Exchanges. We expect that this cost will decrease significantly after the first year of development as the costs incurred will be for maintenance.
Annualized Hours and Costs Table
Labor Category |
Staff Count |
Adjusted Hourly Wage ($/hr) |
Burden Hours |
Burden Costs (per respondent) |
Total Burden Costs (20 respondents) |
Health Policy Analyst 13-1111 |
2 |
$90.76 |
138 |
$25,049.76 |
|
Lawyer 23-1011 |
1 |
$138.68 |
20 |
$2,773.60 |
|
Senior Manager 11-3021 |
1 |
$146.98 |
4 |
$587.92 |
|
Fulfillment Manager 15-1151 |
1 |
$52.92 |
2 |
$105.84 |
|
Computer Programmer 15-1131 |
1 |
$86.14 |
32 |
$2,756.48 |
|
Total |
|
|
334 |
$31,273.60 |
$625,472.00 |
Section§155.335(e), holds that the Exchange must require an individual to report changes on the notice of annual redetermination within 30 days. And the exchange has observed many enrollees will report changes at annual redetermination electronically (by updating their initial application for coverage). And some enrollees send in a paper annual redetermination notice or require manual review of documentation. However, it is difficult to provide estimates for the number of applicants for whom the manual adjudication of documentation will be necessary, but we anticipate that this number will decrease as applicants become more familiar with the eligibility process and as more data become available.
Section 155.340 provides that in the event a tax filer is determined eligible for advance payments of the premium tax credit and/or cost-sharing reductions, the Exchange notifies CMS and the relevant QHP issuer. This notification is made via secure, electronic transmission automatically sent by the system.
Paragraph (a) provides that the Exchange transmits eligibility and enrollment information necessary to enable CMS to begin, end, or change an individual’s advance payments of the premium tax credit or cost- sharing reductions. This applicant information is transmitted from the Exchange to CMS and includes information such as the individual’s name, the dollar amount of the individual’s advance payment, and the individual’s cost-sharing reductions eligibility category, among other information. This information is transmitted when an individual’s advance payment of the premium tax credit or cost-sharing reductions begins, ends, or changes. This electronic data transmission is automatically sent by the system. The burden estimate for this information collection is addressed in the discussion of enrollment transactions in §155.400(b).
Based on Section 155.345(a), the Exchange has entered into written agreements with agencies administering other insurance affordability programs. These provisions are necessary to minimize burden on individuals, ensure prompt determinations of eligibility and enrollment in the appropriate program without undue delay, and to provide standards for transferring an application from an insurance affordability program to the Exchange. Agencies will also develop agreements to share data between insurance affordability programs. The specific number of agreements needed may vary depending on how States choose to divide responsibilities regarding eligibility determinations.
The burden associated with this provision is the time and effort necessary for the Exchange to establish or modify an agreement for eligibility determinations and coordination of eligibility and enrollment functions. We expect that 3 SBEs will be subject to this requirement and that one agreement would include standards for all insurance affordability programs. If a State chooses to draft separate agreements for each insurance affordability program or a subset of insurance affordability programs, then the estimate would likely increase. We estimate it will take a State an average of 105 hours to create new agreements. This includes a mid-level health policy analyst and an operations analyst developing the agreement with managerial oversight and comprehensive review of the agreement an operations analyst. For 3 new SBEs, we expect a total hour burden in the first year of 315 hours.
Annualized Hours and Costs Table
Labor Category |
Staff Count |
Adjusted Hourly Wage ($/hr) |
Burden Hours |
Burden Costs (per respondent) |
Total Burden Costs (3 respondents) |
Health Policy Analyst 13-1111 |
1 |
$90.76 |
35 |
$3,176.60 |
|
Operations Analyst 13-1111 |
1 |
$90.76 |
35 |
$3,176.60 |
|
Lawyer 23-1011 |
1 |
$138.68 |
30 |
$4,160.40 |
|
Senior Manager 11-3021 |
1 |
$146.98 |
5 |
$734.90 |
|
Total |
|
|
105 |
$11,248.50 |
$33,745.50 |
Section 155.345(d)(1) provides that when the Exchange identifies an applicant as potentially eligible for Medicaid by accessing information on the application or an applicant requests a full determination for Medicaid, the Exchange must transmit all information provided on the application and any information or verifies by the Exchange to the State Medicaid agency. Section 155.345(d)(2) also provides that the Exchange must notify the applicant of such transmittal. This notification is part of the eligibility notice described in 155.310(f) and the burden associated with this information collection requirement is referenced in that section.
The burden associated with this ICR for information disclosure is the time and effort necessary to transmit the application data from the Exchange to the appropriate insurance affordability program. This data transmission is via secure, electronic transmission automatically sent by the system. No personnel are needed to enact this transmission and therefore we do not estimate any burden associated with the data transmitted as specified by this provision. The Exchange will enter into agreements to fulfill this provision as specified in §155.345(a).
In Part 155, subpart E of the regulation, we describe the requirements for Exchanges in connection with enrollment and disenrollment of qualified individuals through the Exchange.
Section 155.400(a) requires Exchanges to notify QHP issuers of an applicant’s selected QHP and transmit any information necessary to enroll the applicant. Section 155.400(b) requires Exchanges to send eligibility and enrollment information to QHP issuers and to CMS promptly, without undue delay. Additionally, Exchanges are required to establish a process by which a QHP issuer acknowledges receipt of the eligibility and enrollment information. We expect that all plan selection, eligibility and enrollment information will be maintained electronically by Exchanges, QHP issuers and CMS alike. We expect the transmission of such data to be fully automated. Therefore, we estimate that it will take an Exchange less than one minute to transmit plan selection and necessary enrollment information concurrently to QHP issuers and CMS. As a result, we expect that most of the burden will initially reflect programming of the enrollment feeds to QHP issuers and CMS.
We estimate that 3 new SBEs would be subject to these reporting requirements. This estimate is an upper bound of burden. We estimate that it will take 142 hours for an Exchange to meet these reporting requirements for a total of 426 hours.
Annualized Hours and Costs Table
Labor Category |
Staff Count |
Adjusted Hourly Wage ($/hr) |
Burden Hours |
Burden Costs (per respondent) |
Total Burden Costs (3 respondents) |
Health Policy Analyst 13-1111 |
1 |
$90.76 |
10 |
$907.60 |
|
Computer Programmer 15-1131 |
1 |
$86.14 |
100 |
$8,614.00 |
|
Operations Analyst 13-1111 |
1 |
$90.76 |
32 |
$2,904.32 |
|
Total |
|
|
142 |
$12,425.92 |
$37,277.76 |
Section 155.400(c) states that Exchanges must maintain records of all enrollments in QHPs through the Exchange. The information will be used to make sure that the Exchange has up to date information on the individuals covered through the Exchange and to ensure that individuals are not covered by more than one QHP. It is expected that the information will be maintained in an electronic data system. We expect that most of the burden will reflect programming to retain enrollment information on the Exchange’s electronic data system. We estimate that the 20 SBEs would be subject to these reporting requirements. This estimate is an upper bound of burden. We estimate that it will take 142 hours for an Exchange to meet these record requirements for a total of 2,840 hours.
Annualized Hours and Costs Table
Labor Category |
Staff Count |
Adjusted Hourly Wage ($/hr) |
Burden Hours |
Burden Costs (per respondent) |
Total Burden Costs (20 respondents) |
Health Policy Analyst 13-1111 |
1 |
$90.76 |
10 |
$907.60 |
|
Computer Programmer 15-1131 |
1 |
$86.14 |
100 |
$8,614.00 |
|
Operations Analyst 13-1111 |
1 |
$90.76 |
32 |
$2,904.32 |
|
Total |
|
|
142 |
$12,425.92 |
$248,518.40 |
Section 155.400(d) states that Exchanges must reconcile enrollment information with QHP issuers and CMS on no less than a monthly basis. The purpose of reconciling enrollment information between the Exchange and the QHP issuers and CMS is to ensure that both entities have accurate records of the number of enrollees and persons enrolled in each QHP. It is expected that the information will be maintained in an electronic data system. We estimate that it will take 27 hours per month for an Exchange to reconcile information, for a total of 6,480 hours across 20 Exchanges. We estimate that it will take 324 hours for each Exchange to reconcile information over the course of a year if information is reconciled on a monthly basis. This estimate is similar to estimates provided by Medicare Part D in their rule on data submissions. For example, Medicare Part D estimated that it would take plan sponsors approximately 10 hours annually for plan sponsors to submit data on aggregated negotiated drug pricing from pharmaceutical companies described in §423.104. We provided a higher estimate for the submission of data due to the complexity of enrollment data.
Annualized Hours and Costs Table
Labor Category |
Staff Count |
Adjusted Hourly Wage ($/hr) |
Burden Hours |
Burden Costs (per respondent) |
Total Burden Costs (20 respondents) |
Health Policy Analyst 13-1111 |
2 |
$90.76 |
72 |
$13,069.44 |
|
Computer Programmer 15-1131 |
2 |
$86.14 |
60 |
$10,336.80 |
|
Operations Analyst 13-1111 |
1 |
$90.76 |
60 |
$5,445.60 |
|
Total |
|
|
324 |
$28,851.84 |
$577,036.80 |
Section 155.405(b) states that Exchanges have the option of using an alternative application that includes information to determine the eligibility of an applicant and process plan selection for enrollment in a QHP and insurance affordability programs, as applicable. If the Exchange opts to use an alternative application, the Exchange must submit the alternative application to CMS for approval. The burden estimate associated with this requirement includes the time and effort needed to develop the alternative application and submit the application for approval by CMS. We believe that most Exchanges, in the interest of avoiding duplication of existing work, will choose to use the model single, streamlined application being developed by CMS. We assume that the number of Exchanges choosing to develop an alternate application will be less than ten in a twelve-month period. We will review each alternative application that is submitted to CMS and, if the number of Exchanges opting to use an alternative application approaches ten, then we will seek OMB approval.
As discussed in §155.410, the Exchange must provide written notice to each enrollee about annual open enrollment between September 1 and September 30 of each year, beginning in 2014. The notice will include the date of annual open enrollment and information regarding where individuals may obtain information about available QHPs. The Exchange will send the notice of annual open enrollment via mail or electronic means depending on the preference of the enrollee. The burden estimate associated with this requirement includes the time and effort needed to develop the notice template and distribute the notice through an automated process when appropriate via the enrollee’s preferred method. We anticipate that half of enrollees will request electronic notification while the other half will receive the notice by mail. As a result, we estimated the associated mailing costs for the time and effort needed to mail notices in bulk to enrollees as appropriate. We estimate that 20 SBEs plan to or do operate an Exchange will be subject to these reporting requirements. This estimate is an upper bound of burden. As such, we estimate that it will take approximately 42 hours annually for the time and effort to develop and transmit the notice when appropriate for a total of 840 hours.
Annualized Hours and Costs Table
Labor Category |
Staff Count |
Adjusted Hourly Wage ($/hr) |
Burden Hours |
Burden Costs (per respondent) |
Total Burden Costs (20 respondents) |
Health Policy Analyst 13-1111 |
1 |
$90.76 |
4 |
$363.04 |
|
Senior Manager 11-3021 |
1 |
$146.98 |
1 |
$146.98 |
|
Operations Analyst 13-1111 |
1 |
$90.76 |
3 |
$272.28 |
|
Computer Programmer 15-1131 |
1 |
$86.14 |
32 |
$2,756.48 |
|
Fulfillment Manager 15-1151
|
1 |
$52.92 |
2 |
$105.84 |
|
Total |
|
|
42 |
$3,644.62 |
$72892.40 |
Section 155.430(c) requires Exchanges to retain and track coverage termination information, including information to identify the individuals terminating coverage, the date of coverage termination, and the reason for termination. The Exchange will collect and retain the coverage termination information. The Exchange will submit the coverage termination information to CMS. The information will help provide CMS an accurate record of enrollment in the Exchange, so that CMS can inform the IRS when to cease advance payments of premium tax credits. We expect that all termination information will be maintained electronically by Exchanges. We also expect the transmission of data to be automated. We estimate that it will take Exchanges less than one minute to transmit the termination information to CMS. We anticipate a similar initial burden on Exchanges for establishing a system for automated tracking, maintenance and transmittal of termination information. The burden estimates associated with the maintenance and transmission of coverage termination information includes the time and effort needed to develop the system to collect and store the information. Additionally, the burden estimates include the time and effort needed to develop an automated process to submit termination information when appropriate. We estimate that 20 SBEs plan to or do Exchange operations will be subject to these reporting requirements. This estimate is an upper bound of burden. As such, we estimate that it will take approximately 70 hours annually for the time and effort to meet this requirement for a total of 1,400 hours.
Annualized Hours and Costs Table
Labor Category |
Staff Count |
Adjusted Hourly Wage ($/hr) |
Burden Hours |
Burden Costs (per respondent) |
Total Burden Costs (20 respondents) |
Health Policy Analyst 13-1111 |
1 |
$90.76 |
30 |
$2,722.80 |
|
Computer Programmer 15-1131 |
1 |
$86.14 |
20 |
$1,722/80 |
|
Operations Analyst 13-1111 |
1 |
$90.76 |
20 |
$1,815.20 |
|
Total |
|
|
70 |
$6,260.80 |
$125,216.00
|
Section 155.430(c) requires Exchanges to establish procedures for QHP issuers to maintain records of termination of coverage and requires Exchanges to send termination information to the QHP issuer and CMS in accordance with §155.400(b). We expect that Exchanges and QHP issuers will manage termination records and related procedures the same way they do the enrollment records described in §155.400. We therefore do not estimate any additional burden for Exchanges to meet the requirements in §155.430.
In subpart H of part 155, we describe information collection and reporting requirements that pertain to the SHOP.
Section 155.712 states that the SHOP must maintain records of all employer and employee enrollments in QHPs through the SHOP for at least 10 years. This information will be used to facilitate reconciliation functions of the SHOP. Section 155.720(g) states that the SHOP must reconcile enrollment and employer participation information with QHP issuers on no less than a monthly basis. The purpose of reconciling enrollment information between the SHOP and QHP issuers is to ensure that both entities have accurate records of the participating employers, number of enrollees, and persons enrolled in each QHP. It is expected that the information will be maintained in an electronic data system. The burden estimates associated with these requirements includes the time and effort needed to develop processes for the collection and retention of record information, and reconcile the enrollment information with CMS. We estimate that one new SBE would be subject to these reporting requirements. This estimate is an upper bound of burden. We estimate that it will take 142 hours for an Exchange to meet the record maintenance requirement.
Annualized Hours and Costs Table
Labor Category |
Staff Count |
Adjusted Hourly Wage ($/hr) |
Burden Hours |
Burden Costs (per respondent) |
Total Burden Costs (3 respondents) |
Health Policy Analyst 13-1111 |
1 |
$90.76 |
10 |
$907.60 |
|
Computer Programmer 15-1131 |
1 |
$86.14 |
100 |
$8,614.0 |
|
Operations Analyst 13-1111 |
1 |
$90.76 |
32 |
$2,904.32 |
|
Total |
|
|
142 |
$12,425.92 |
$12,425.92 |
We further estimate that it will take 264 hours annually for 20 SBEs that plan or do operate an Exchange to meet the reconciliation requirements for a total of 5,280 hours across all Exchanges.
Annualized Hours and Costs Table
Labor Category |
Staff Count |
Adjusted Hourly Wage ($/hr) |
Burden Hours |
Burden Costs (per respondent) |
Total Burden Costs (20 respondents) |
Health Policy Analyst 13-1111 |
1 |
$90.76 |
84 |
$7,623.84 |
|
Computer Programmer 15-1131 |
1 |
$86.14 |
120 |
$10,336.80 |
|
Operations Analyst 13-1111 |
1 |
$90.76 |
60 |
$5,445.60 |
|
Total |
|
|
264 |
$23,406.24 |
$468,124.80 |
Section 155.715(e) requires the SHOP to provide an employer requesting eligibility to purchase coverage with a notice of approval or denial of eligibility and the employer’s right to appeal the eligibility determination. The burden estimates associated with the notice requirement includes the time and effort needed to develop the notice and make the notice an automated process to be sent out when appropriate. We anticipate that nearly all employers will request electronic notification. As a result, we did not estimate the associated mailing costs. We estimate that 20 SBEs that plan to or do operate an Exchange will be subject to these reporting requirements. This estimate is an upper bound of burden. As such, we estimate that it will take approximately 40 hours annually for the time and effort to develop the two notices and transmit each notice when appropriate for a total of 800 hours.
Annualized Hours and Costs Table
Labor Category |
Staff Count |
Adjusted Hourly Wage ($/hr) |
Burden Hours |
Burden Costs (per respondent) |
Total Burden Costs (20 respondents) |
Health Policy Analyst 13-1111 |
1 |
$90.76 |
4 |
$363.04 |
|
Senior Manager 11-3021 |
1 |
$146.98 |
1 |
$146.98 |
|
Operations Analyst 13-1111 |
1 |
$90.76 |
3 |
$272.28 |
|
Computer Programmer 15-1131 |
1 |
$86.14 |
32 |
$2,756.48 |
|
Total |
|
|
40 |
$3,538.78 |
$70,775.60 |
Section 155.715(f) provides the same notice of approval or denial of eligibility for employees seeking to enroll in a QHP offered through the SHOP. The burden estimates associated with the notice requirement includes the time and effort needed to develop the notice and make the notice an automated process to be sent out when appropriate. We anticipate that half of enrollees will request electronic notification while the other half will receive the notice by mail. As a result, we estimated the associated mailing costs for the time and effort needed to mail notices in bulk to enrollees as appropriate. As a result, we have not estimated associated mailing costs. We estimate that 20 SBEs that plan to or do operate an Exchange will be subject to these reporting requirements. This estimate is an upper bound of burden. As such, we estimate that it will take approximately 42 hours annually for the time and effort to develop the two notices and transmit each notice when appropriate for a total of 840 hours.
Annualized Hours and Costs Table
Labor Category |
Staff Count |
Adjusted Hourly Wage ($/hr) |
Burden Hours |
Burden Costs (per respondent) |
Total Burden Costs (20 respondents) |
Health Policy Analyst 13-1111 |
1 |
$90.76 |
4 |
$363.04 |
|
Senior Manager 11-3021 |
1 |
$146.98 |
1 |
$146.98 |
|
Operations Analyst 13-1111 |
1 |
$90.76 |
3 |
$272.28 |
|
Computer Programmer 15-1131 |
1 |
$86.14 |
32 |
$2,756.48 |
|
Fulfillment Manager 15-1151
|
1 |
$52.92 |
2 |
$105.84 |
|
Total |
|
|
42 |
$3,644.62 |
$72,892.40 |
Section 155.716 discusses several notices related to the eligibility process that SHOP must provide to employers and employees. If the SHOP finds any inconsistencies in the application submitted by the employer, the SHOP, in accordance with section 155.716(d)(2), must notify the employer of the inconsistency and give the employer 30 days to submit documentary evidence to support the application. If after the 30-day period the SHOP does not receive satisfactory documentary evidence, the SHOP, must notify the employer of its denial of eligibility and the employer’s right to appeal such determination. The burden estimates related to the two notices includes the time and effort needed to develop each of the notices and make it an automated process to be sent out when appropriate. We anticipate that nearly all employers will request electronic notification. We estimate that 20 SBEs will be subject to these reporting requirements. This estimate is an upper bound of burden. As such, we estimate that it will take approximately 80 hours annually for the time and effort to develop the two notices and transmit each notice when appropriate for a total of 1,600 hours.
Annualized Hours and Costs Table
Labor Category |
Staff Count |
Adjusted Hourly Wage ($/hr) |
Burden Hours |
Burden Costs (per respondent) |
Total Burden Costs (20 respondents) |
Health Policy Analyst 13-1111 |
1 |
$90.76 |
8 |
$726.08 |
|
Senior Manager 11-3021 |
1 |
$146.98 |
2 |
$293.96 |
|
Operations Analyst 13-1111 |
1 |
$90.76 |
6 |
$544.56 |
|
Computer Programmer 15-1131 |
1 |
$86.14 |
64 |
$5,512.96 |
|
Total |
|
|
80 |
$7,077.56 |
$141,551.20 |
Section 155.731 states that the SHOP may use an alternative employer application, if such application is approved by CMS and collects the information required in §155.731(b) by including identifying information about the employer and a list of qualified employees with social security numbers. The alternative application includes the information necessary to establish eligibility of the employee as a qualified employee and to complete the enrollment of a qualified employee. The alternative employer applications must be submitted to CMS. The burden estimate associated with this requirement includes the time and effort needed to develop the alternative applications and submit the applications for approval by CMS. We believe that most Exchanges, in the interest of not duplicating existing work, will choose to use the model employer application being developed by CMS. We presume that the number of Exchanges choosing to develop an alternate employer application will be less than ten in a twelve- if the number of Exchanges opting to use an alternative application approaches ten, then we will seek OMB approval.
In subpart K of Part 155, we describe a number of data collection and reporting requirements for Exchanges related to the certification of qualified health plans (QHPs).
Section 155.1075 requires that an Exchange notify a QHP seeking recertification by the Exchange, of the Exchange’s determination. We assume that the Exchange will notify QHP issuers by using a standardized notice that provides information about the recertification process. The burden estimate associated with this requirement includes the time and effort needed to develop the notice and distribute the notice to QHP issuers. We expect that this notice will be distributed electronically to all QHP issuers. We estimate that 20 states will distribute recertification notices on an annual basis. This estimate is an upper bound of burden. As such, we estimate that it will take approximately 40 hours annually for each Exchange to develop and transmit the notice when appropriate, and a total of 800 hours across all Exchanges.
Annualized Hours and Costs Table
Labor Category |
Staff Count |
Adjusted Hourly Wage ($/hr) |
Burden Hours |
Burden Costs (per respondent) |
Total Burden Costs (20 respondents) |
Operations analyst |
1 |
$89.84 |
4 |
$359.36 |
|
Senior manager |
1 |
$138.02 |
1 |
$138.02 |
|
Health Policy Analyst |
1 |
$89.84 |
3 |
$269.52 |
|
Computer Programmer |
1 |
$84.16 |
32 |
$2,693.12 |
|
Total |
|
|
40 |
$3,460.02 |
$69,200.40 |
Section 155.1080(e) requires that an Exchange must provide notification of decertification to all affected parties, including the QHP issuer, the enrollees in the QHP who enrolled through the Exchange, CMS, and the State department of insurance. The decertification notice needs to be provided to CMS so that the IRS can cease payment of tax credits and cost-sharing reductions, as appropriate. The notice will advise affected enrollees to enroll in other available QHPs during a special enrollment period and provide information about how enrollees may select a new QHP. The burden estimate for notifying all of the affected parties of the decertification of a QHP includes the time and effort needed to develop the decertification notice and transmit the notice to the affected parties. We expect that the decertification notice will be distributed electronically to CMS and the State department of insurance. We anticipate that half of enrollees will prefer to receive electronic notification while the other half of enrollees will receive the notice by mail. As such, the burden includes the time and effort needed to mail notices, in bulk, to enrollees electing to receive notice by mail. For the purposes of this estimate, we assume that Exchanges in 20 states will issue a decertification notice annually. This is an upper bound of burden. Accordingly, we estimate that it will take 42.5 hours for each Exchange to meet this requirement for a total estimate of 850 hours.
Annualized Hours and Costs Table
Labor Category |
Staff Count |
Adjusted Hourly Wage ($/hr) |
Burden Hours |
Burden Costs (per respondent) |
Total Burden Costs (20 respondents) |
Operations Analyst |
1 |
$89.84 |
6 |
$539.04 |
|
Senior Manager |
1 |
$138.02 |
2.5 |
$345.05 |
|
Computer Programmer |
1 |
$84.16 |
32 |
$2,693.12 |
|
Fulfillment Manager |
1 |
$47.14 |
2 |
$94.28 |
|
Total |
|
|
42.5 |
$3,671.49 |
$73,429.80 |
In accordance with Section 1311(c)(3) and (c)(4) of the Patient Protection and Affordable Care Act and 45 C.F.R. §§ 155.1400 and 155.1405, all Exchanges are required to publicly report 2019 quality rating information on their websites beginning with the individual market OEP for the 2020 plan year (PY) to help consumers compare and shop for qualified health plans (QHPs). The term “QHP quality rating information” includes the Quality Rating System (QRS) scores and ratings and the Qualified Health Plan (QHP) Enrollee Survey results. Exchanges can satisfy the requirement to display the QHP Enrollee Survey results by displaying the QRS star ratings (which incorporate member experience data from the QHP Enrollee Survey).
To support CMS’s strategic goals of empowering consumers through data, minimizing cost and burden on QHP issuers, and supporting state flexibility, CMS developed a phase-in approach to display QHP quality rating information across the Exchanges. During PY 2017, 2018, and 2019, we displayed QRS star ratings on HealthCare.gov in select FFE states as part of a limited pilot program. Additionally, multiple SBEs have elected to display QRS star ratings on their state websites (California, Colorado, District of Columbia, Maryland, Minnesota, New York, Rhode Island, and Washington).
SBEs have some flexibility to customize the form and manner to display their QHP quality rating information. SBEs that do not rely on the federal eligibility and enrollment platform (for example, SBEs whose consumers do not use HealthCare.gov) should display QHP quality rating information in the form and manner specified by CMS. SBEs are generally required to display the federally calculated QRS global ratings and summary indicator ratings. However, SBEs have flexibility to adjust the names of the QRS global rating and summary indicator ratings, similar to CMS’s approach for HealthCare.gov in Section 1.1, such that the names appropriately reflect the underlying data in the QRS hierarchy. For example, a state may choose to refer to the “Clinical Quality Management” summary indicator as “Medical Care.” SBEs also will continue to have flexibility to display additional state or local quality information for their QHPs and, as noted above, SBEs will have some flexibility to customize the display of their QHP quality information. For example, some SBEs have customized the summary indicator ratings for Plan Efficiency, Affordability and Management based on regional benchmarks.
The QRS ratings reflect QHP performance by product type, which includes QHPs in both the SHOP and individual market. SBEs should display ratings for all QHPs in the product type, including QHPs in the SHOP and individual market, as applicable. If a QHP is not eligible for scoring or does not receive a rating for other reasons, CMS encourages SBEs to follow the same approach as the FFE and display “New plan – quality ratings unavailable” or “Not Rated” in place of the QHP quality rating information. SBEs that display federally calculated QRS ratings must prominently display the following disclaimer language on the SBE website or the static website that displays the QHP quality ratings information:
Plan quality ratings and enrollee survey results are calculated by CMS using data provided by health plans in 2019. The ratings are being displayed for health plans for the 2020 plan year. Learn more about these ratings. [Link to appropriate explanatory/Help text on HealthCare.gov.]
SBEs that customize the display of their QHP quality rating information should not display this disclaimer on their SBE website or static website that displays QHP quality information.
CMS will provide a State Ratings Data File that includes ratings down to the QRS composite level. CMS will publish the State Ratings Data Files on the Marketplace Quality Module (MQM) within the Health Insurance Oversight System (HIOS) in September, after the annual QRS and QHP Enrollee Survey preview period.
We estimate that 20 SBEs will operate an Exchange subject to these requirements. This estimate is an upper bound of burden. CMS will provide the QRS data for states to display on their websites. Eight SBEs have already included QRS information on the websites. The estimate is the burden for SBEs to publish the data on their websites.
As such, we estimate that it will take approximately 33 hours annually per Exchange for the time and effort to comply with this requirement for a total of 660 hours for 20 Exchanges.
Annualized Hours and Costs Table
Labor Category |
Respondents |
Adjusted Hourly Wage ($/hr) |
Burden Hours |
Burden Costs (per respondent) |
Total Burden Costs (20 respondents) |
Operations Analyst (13-1111) |
1 |
$90.76
|
7 |
$635.32 |
|
Computer Programmer (15-1131)
|
1 |
$86.14 |
5 |
$430.70 |
|
Web Developer (15-1134) |
1 |
$72.68 |
20 |
$1,453.60 |
|
Senior Manager (11-3021) |
1 |
$146.98 |
1 |
$146.98 |
|
Total |
|
|
33 |
$2,666.60 |
$53,332.00 |
There are no additional record keeping/capital costs.
CMS staff provide guidance and technical support to SBE staff developing written notices, collecting rate justifications, and on the display of QRS data on the website. CMS has made improvements that reduce burden on the states, as well as increase staff efficiencies. The total estimated time for CMS staff to perform these activities is 7,090.5 hours annually, with 6,525 hours performed by staff at an average grade and step of a GS-13, step 2 (hourly salary of $49.10 in the Washington D.C. area) and 565.5 hours performed by staff at the GS-15, step 2 level (hourly salary is $68.25 in Washington D.C. area), for a total cost of $358,972.88.
The hourly salary data for federal employees in the Washington D.C. area were obtained from the OPM Web site, at the following link: https://www.opm.gov/policy-data-oversight/pay-leave/salaries-wages/salary-tables/19Tables/html/DCB_h.aspx.
Staff |
Estimated Cost |
Certification of Exchanges |
|
15 GS-13: 15 x $49.10 x 193.6 hours |
$ 140,966.10 |
Review of State/Exchange data |
|
15 GS-13: 15 x $49.10 x 264.4 hours |
$ 179,411.40 |
Managerial Review and Oversight |
|
2 GS-15: 2 x $68.25 x 286 hours |
$ 38,595.38 |
Total Costs to the Federal Government |
$ 358,972.88 |
The majority of information collected under these requirements will be not be made public but used in the operations of the SBEs, and for CMS oversight purpose. SBEs will be display justifications for each rate increase by a QHP prior to the implementation of the rate increase on its website. SBEs are also required to provide public display of quality on the SBE website beginning during the Open Enrollment Period (OEP) for the 2020 plan year.
This collection does not have associated data collection instruments.
1 Establishment of Exchanges and Qualified Health Plans; Exchange Standards for Employers” (77 FR 18310) and any subsequent updates to the final rule.
2 Patient Protection and Affordable Care Act; HHS Notice of Benefit and Payment Parameters for 2019, https://www.federalregister.gov/documents/2018/04/17/2018-07355/patient-protection-and-affordable-care-act-hhs-notice-of-benefit-and-payment-parameters-for-2019
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Courtney Williams |
| File Modified | 0000-00-00 |
| File Created | 2021-01-13 |