CMS-10371 - Performance_Review-Data_Elements

Exchange Establishment - Performance Review Data Elements

Estimated Annualized Hours
Estimated Annual Line Items
Estimated Review Hours
Estimated Review Line Items
Estimated Avg Hours/Line Item

Report Section
2012-2017 Total
Activities
Per Review Average
Activities

172.5
68
115
68
0.59

Line
Items

68
68.0

Appendix A: Exchange, Administrative, and Associated Activities and Sub-activities for a Statebased Exchange
Below is a list of the Exchange, Administrative, and Associated Activities and Sub-Activities for a
State-based Exchange. Activities the State may choose not to carry out are identified as optional
by an asterisk (*) after the numerical ID. As this is updated in future guidance, please refer to the
most recent version posted on the CCIIO website.
=

Legal Authority and Governance
The State has enabling authority to operate an Affordable Insurance Exchange, including a Small Business
Health Options Program (SHOP), compliant with the Affordable Care Act § 1321(b) and implementing
regulations.
The Exchange has been established with an Exchange Board and governance structure in compliance with
Affordable Care Act § 1311(d) and 45 CFR 155.110.

Consumer and Stakeholder Engagement and Support
The Exchange has developed and implemented a stakeholder consultation plan and has and will continue to
consult with consumers, small businesses, State Medicaid and CHIP agencies, agents/brokers, employer
organizations, and other relevant stakeholders as required under 45 CFR § 155.130.
Applicable only to States with Federally-recognized Tribes: The Exchange has developed and implemented
a Tribal consultation policy or process, which has been submitted to HHS and approved by both the
Exchange and the Federally-recognized Tribe(s).

The Exchange provides culturally and linguistically appropriate outreach and educational materials,
including auxiliary aids and services, to the public regarding eligibility and enrollment options,
program information, benefits, and services available through the Exchange, the Insurance
Affordability Program(s), and the SHOP.
In addition, the Exchange has an outreach plan for populations including: individuals, entities with
experience in facilitating enrollment such as agents/brokers, small businesses and their employees, employer
groups, health care providers, community-based organizations, Federally-recognized Tribal communities,
advocates for hard-to-reach populations, and other relevant populations as outlined in 45 CFR § 155.130.

The Exchange provides for the operation of a toll-free telephone hotline (call center) to respond to requests
for assistance from the public, including individuals, employers, and employees, at no cost to the caller as
specified by 45 CFR § 155.205(a).
The Exchange has established and maintains an up-to-date Internet Web site that provides timely and
accessible information on Qualified Health Plans (QHPs) available through the Exchange, Insurance
Affordability Program(s), the SHOP, and includes requirements specified in 45 CFR § 155.205(b).
The Exchange has established or has a process in place to establish and operate a Navigator program that is
consistent with the applicable requirements of the program specified in 45 CFR § 155.210, including the
development of training and conflict of interest standards, and adherence to privacy and security standards
outlined in specified in 45 CFR § 155.210 and 45 CFR § 155.260.

If applicable: If the State permits such activities by agents and brokers pursuant to 45 CFR 155.220(a), the
Exchange has clearly defined the role of agents and brokers including evidence of licensure, training, and
compliance with 45 CFR § 155.220(c)-(e). The Exchange will have agreements with agents/brokers
consistent with 45 CFR § 155.220(d), which address agent/broker registration with the Exchange, training
on QHP options and Insurance Affordability Program(s), and adherence to privacy and security standards, as
specified in 45 CFR § 155.260.
If applicable: If the State permits such activities by agents and brokers pursuant to 45 CFR 155.220(a), the
Exchange has clearly defined the role of web brokers including evidence of licensure, training, and
compliance with 45 CFR § 155.220(c)-(e). More specifically, the Exchange will have agreements with web
brokers consistent with 45 CFR § 155.220(d), which address agent/broker registration with the Exchange,
training on QHP options and Insurance Affordability Program(s), and adherence to privacy and security
standards, as specified in 45 CFR § 155.260.

Eligibility and Enrollment
The Exchange has developed and will use an HHS-approved single, streamlined application for the
individual market – or will use the HHS-developed application – to determine eligibility and collect
information that is necessary for enrollment in a QHP and for insurance affordability programs as specified
in 45 CFR § 155.405. The Exchange has developed and will use an HHS-approved application for SHOP or
will use the HHS-developed application for SHOP.
The Exchange has developed and documented a coordination strategy with other agencies administering
Insurance Affordability Programs and the SHOP that enables the Exchange to carry out the eligibility and
enrollment activities.
The Exchange has the capacity to accept and process applications, updates, and responses to
redeterminations from applicants and enrollees, including applicants and enrollees who have disabilities or
limited English proficiency, through all required channels, including in-person, online, mail, and phone.
The Exchange has the capacity to send notices, including notices in alternate formats and multiple
languages; conduct periodic data matching, and conduct annual redeterminations and process responses inperson, online, via mail, and over the phone pursuant to 45 CFR part 155, subpart D.

The Exchange has the capacity to conduct verifications pursuant to 45 CFR part 155, subpart D,
and is able to connect to data sources, such as the Federal Data Services Hub, and other sources as
needed.
The Exchange has the capacity to accept, store, associate, and process documents received from individual
applicants and enrollees electronically, and the ability to accept, image, upload, associate, and process paper
documentation received for applicants and enrollees via mail and/or fax.
The Exchange has the capacity to determine individual eligibility for enrollment in a QHP through the
Exchange and for employee and employer participation in the SHOP. In addition, the Exchange has the
capacity to assess or determine eligibility for Medicaid and CHIP based on MAGI.

The Exchange has the capacity to determine eligibility for Advance Payments of the Premium Tax
Credit (APTC) and Cost Sharing Reductions (CSR), including calculating maximum APTC,
independently or through the use of a Federally-managed service.

The Exchange has the capacity to electronically report results of eligibility assessments and determinations,
and associated information, including information necessary to support administration of the advance
premium tax credit and cost sharing reductions as well as to support the employer responsibility provisions
of the Affordable Care Act to HHS, IRS, and other agencies administering Insurance Affordability
Programs, as applicable. The SHOP Exchange has the capacity to electronically report information to the
IRS for tax administration purposes.
The Exchange has the capacity to independently notify applicants and employers as necessary pursuant to 45
CFR §155 subpart D to support eligibility and enrollment activities through notices that are in plain
language, that address the appropriate audience, and that meet content requirements.
The Exchange has the capacity to accept applications and updates, conduct verifications, and determine
eligibility for exemptions independently or through the use of Federally-managed services.
The Exchange has the capacity to support the eligibility appeals process and to implement appeals decisions,
as appropriate, for individuals, employers, and employees.
The Exchange and SHOP have the capacity to process QHP selections and terminations in accordance with
45 CFR § 155.400 and § 155.430, compute actual APTC, and report and reconcile QHP selections,
terminations, and APTC/advance CSR information in coordination with issuers and CMS. This includes
exchanging relevant information with issuers and CMS using electronic enrollment transaction standards.

The Exchange has received HHS approval of its PCIP Transition Plan and has the capacity to
transition individuals to the Exchange, as defined in the Affordable Care Act 101g(3).
Plan Management
The Exchange has the appropriate authority to perform the certification of QHPs and to oversee QHP issuers
consistent with 45 CFR § 155.1010(a).
The Exchange has a process in place to certify QHPs pursuant to 45 CFR § 155.1000(c) and according to
QHP certification requirements contained in 45 CFR § 156.
The Exchange uses a plan management system(s) or processes that support the collection of QHP issuer and
plan data; facilitates the QHP certification process; manages QHP issuers and plans; and integrates with
other Exchange business areas, including the Exchange Internet Web site, call center, quality, eligibility and
enrollment, and premium processing.
The Exchange has the capacity to ensure QHPs’ ongoing compliance with QHP certification requirements
pursuant to 45 CFR § 155.1010(a)(2), including a process for monitoring QHP performance and collecting,
analyzing, and resolving enrollee complaints.
The Exchange has the capacity to support issuers and provides technical assistance to ensure ongoing
compliance with QHP issuer operational standards.
The Exchange has a process for QHP issuer recertification, decertification, and appeal of decertification
determinations pursuant to 45 CFR § 155.1075 and § 155.1080.
The Exchange has set a timeline for QHP issuer accreditation in accordance with 45 CFR § 155.1045. The
Exchange also has systems and procedures in place to ensure QHP issuers meet accreditation requirements
(per 45 CFR § 156.275) as part of QHP certification in accordance with applicable rulemaking and guidance.

The Exchange has systems and procedures in place to ensure that QHP issuers meet the minimum
certification requirements pertaining to quality reporting and provide relevant information to the Exchange
and HHS pursuant to Affordable Care Act § 1311(c)(1), 1322(e)(3), and as specified in rulemaking.

Financial Management, Risk Adjustment, and Reinsurance
The State has the legal authority to operate the risk adjustment program per 45 CFR § 153 and Affordable
Care Act 1343, if the State chooses to administer its own risk adjustment program.
The State operates its own reinsurance program per Affordable Care Act § 1341 requirements, if the State
elects to operate its reinsurance program.

Small Business Health Options Program (SHOP)
The SHOP is compliant with regulatory requirements pursuant to 45 CFR § 155 Subpart H.
The Exchange has the capacity for SHOP premium aggregation pursuant to 45 CFR § 155.705.

Organization and Human Resources
The Exchange has organizational structure and staffing resources to perform Exchange activities.

Finance and Accounting
The Exchange has a long-term operational cost, budget, and management plan.

Technology
The Exchange technology and system functionality complies with relevant HHS information technology
(IT) guidance.
The Exchange has the adequate technology infrastructure and bandwidth required to support all of the
Exchange activities.
The Exchange effectively implements IV&V, quality management, and test procedures for Exchange
activities and demonstrates it has achieved HHS-defined essential functionality for each required activity.

Privacy and Security
The Exchange has established and implemented written policies and procedures regarding the Privacy and
Security standards set forth in 45 CFR § 155.260(a)-(g).
The Exchange has established and implemented safeguards that (1) ensure the critical outcomes in 45 CFR §
155.260(b)(4), including authentication and identity proofing functionality, and (2) incorporates HHS IT
requirements as applicable.
The Exchange has adequate safeguards in place to protect the confidentiality of all Federal information
received through the Data Services Hub, including but not limited to Federal tax information.

Oversight, Monitoring, and Reporting

The Exchange has a process in place to perform required activities related to routine oversight and
monitoring of Exchange activities (and will supplement those policies and procedures to implement
regulations promulgated under § 1313 of the Affordable Care Act.
The Exchange has the capacity to track and report performance and outcome metrics related to Exchange
Activities in a format and manner specified by HHS necessary for, but not limited to, annual reports required
by Affordable Care Act §1313(a).
The Exchange has instituted procedures and policies that promote compliance with the financial integrity
provisions of Affordable Care Act § 1313 (and will supplement those policies and procedures to implement
regulations promulgated under § 1313), including the requirements related to accounting, reporting,
auditing, cooperation with investigations, and application of the False Claims Act.

Contracting, Outsourcing, and Agreements
The Exchange has executed appropriate contractual, outsourcing, and partnership agreements with vendors
and/or State and Federal agencies for all Exchange activities and functionality as needed, including data and
privacy agreements.

A.
Activities eligible for funding in a Federally-facilitated Exchange, including State
Partnership Model

Plan Management State Partnership Exchange Activities
State Partnership Exchange Activities
The State agrees to operate the Plan Management activity for its State Partnership Exchange.
The State has the capacity to interface with the Federally-facilitated Exchange, as necessary.

Eligibility and Enrollment
Assess or determine processing of Medicaid and CHIP eligibility in the Federally-facilitated
Exchange
Plan Management
The Exchange has the appropriate authority to perform the certification of QHPs and to oversee QHP issuers
consistent with 45 CFR § 155.1010(a).
The Exchange has a process in place to certify QHPs pursuant to 45 CFR § 155.1000(c) and according to
QHP certification requirements contained in 45 CFR § 156.
The Exchange uses a plan management system(s) or processes that support the collection of QHP issuer and
plan data; facilitates the QHP certification process; manages QHP issuers and plans; and integrates with
other Exchange business areas, including the Exchange Internet Web site, call center, quality, eligibility and
enrollment, and premium processing.

The Exchange has the capacity to ensure QHPs’ ongoing compliance with QHP certification requirements
pursuant to 45 CFR § 155.1010(a)(2), including a process for monitoring QHP performance and collecting,
analyzing, and resolving enrollee complaints.
The Exchange has the capacity to support issuers and provides technical assistance to ensure ongoing
compliance with QHP issuer operational standards.
The Exchange has a process for QHP issuer recertification, decertification, and appeal of decertification
determinations pursuant to 45 CFR § 155.1075 and § 155.1080.
The Exchange has set a timeline for QHP issuer accreditation in accordance with 45 CFR § 155.1045. The
Exchange also has systems and procedures in place to ensure QHP issuers meet accreditation requirements
(per 45 CFR § 156.275) as part of QHP certification in accordance with applicable rulemaking and guidance.
The Exchange has systems and procedures in place to ensure that QHP issuers meet the minimum
certification requirements pertaining to quality reporting and provide relevant information to the Exchange
and HHS pursuant to Affordable Care Act § 1311(c)(1), 1322(e)(3), and as specified in rulemaking.

Financial Management, Risk Adjustment, and Reinsurance
The State operates its own reinsurance program per Affordable Care Act § 1341 requirements, if the State
elects to operate its reinsurance program.
The State elects to operate, and has a plan for providing the Consumer Assistance activity(ies) for its State
Partnership Exchange consistent with 45 CFR 155.205 (d) and (e).
The State has the capacity to interface with the Federally-facilitated Exchange, as necessary.

Consumer and Stakeholder Engagement and Support
The Exchange has established or has a process in place to establish and operate a Navigator program that is
consistent with the applicable requirements of the program specified in 45 CFR § 155.210, including the
development of training and conflict of interest standards, and adherence to privacy and security standards
outlined in specified in 45 CFR § 155.210 and 45 CFR § 155.260.

Eligibility and Enrollment
Assess or determine processing of Medicaid and CHIP eligibility in the Federally-facilitated
Exchange
Financial Management, Risk Adjustment, and Reinsurance
The State operates its own reinsurance program per Affordable Care Act § 1341 requirements, if the State
elects to operate its reinsurance program.