CMS-10637 Marketplace Operations Supporting Statementf

Supporting Statement for Marketplace Operations
(CMS-10637/OMB control number: 0938-1353)
A.

Background

On March 23, 2010, the Patient Protection and Affordable Care Act (PPACA; P.L. 111-148) was
signed into law and on March 30, 2010, the Health Care and Education Reconciliation Act of
2010 (P.L. 111-152) was signed into law. The two laws implement various health insurance
policies.
On June 19, 2013, HHS published the proposed rule CMS-9957-P: Program Integrity:
Exchanges, SHOP, Premium Stabilization Programs, and Market Standards (78 FR 37302)
(Program Integrity Proposed Rule). Among other things, the Program Integrity Proposed Rule
sets forth financial integrity provisions and protections against fraud and abuse. On January 30,
2013, CMS published Eligibility Appeals and Other Provisions Related to Eligibility and
Enrollment for Exchanges under the Affordable Care Act (CMS-2334-P) (E&E II Proposed
Rule). On August 30, 2013, HHS published the final rule CMS-9957-F: Program Integrity:
Exchanges, SHOP, Eligibility Appeals (Program Integrity final rule), finalizing a number of the
provisions from the Program Integrity and E&E II Proposed Rules. The third party disclosure
requirements and data collections in the Program Integrity final rule support the oversight of
qualified health plan (QHP) issuers in Federally-facilitated Exchanges (FFEs) and other
provisions.
This Information Collection Request (ICR) serves as the formal request for clearance for the
renewal of an existing data collection. The original approved ICR affiliated with this final rule
(OMB #: 0938-1213) was titled Program Integrity and Additional State Information Collections
and approved on 11/21/2013. This ICR also includes some of the information collection
requirements from the previously approved final rule. The other ICRs from the final rule that are
not included in this request will be submitted for OMB approval under separate collections.
B.

Justification

1.

Need and Legal Basis

Section 1321(c)(1) of the Affordable Care Act requires the Secretary to establish and operate an
FFE within States that either: do not elect to operate an Exchange; or, as determined by the
Secretary, will not have any required Exchange operational by January 1, 2014.
Section 1321(c)(2) of the Affordable Care Act authorizes the Secretary to enforce the Exchange
standards using civil money penalties (CMPs) on the same basis as detailed in section 2723(b) of
the Public Health Service Act (PHS Act). 1 Section 2723(b) of the PHS Act authorizes the
Secretary to impose CMPs as a means of enforcing the individual and group market reforms
contained in Title XXVII, Part A of the PHS Act when a State fails to substantially enforce these
provisions.
Section 1321(c) of the Affordable Care Act erroneously cites to section 2736(b) of the PHS Act instead of 2723(b)
of the PHS Act.

1

1

Section 1313 of the Affordable Care Act, combined with section 1321 of the Affordable Care
Act, provides the Secretary with the authority to oversee the financial integrity, compliance with
HHS standards, and efficient and non-discriminatory administration of State Exchange activities.
Section 1313(a)(6)(A) of the Affordable Care Act specifies that payments made by, through, or
in connection with an Exchange are subject to the False Claims Act (31 U.S.C. 3729, et seq.) if
those payments include any Federal funds.
Section 1401 of the Affordable Care Act amended the Internal Revenue Code (26 U.S.C.) to add
§ 36B, allowing a refundable premium tax credit to help individuals and families afford health
insurance coverage. Under sections 1401, 1411, and 1412 of the Affordable Care Act and 45
CFR part 155, subpart D, an Exchange will make a determination of advance payments of the
premium tax credit for individuals who enroll in QHP coverage through an Exchange and seek
financial assistance. Section 1402 of the Affordable Care Act provides for the reduction of cost
sharing for certain individuals enrolled in a QHP through an Exchange, and section 1412 of the
Affordable Care Act provides for the advance payment of these reductions to issuers.
Section 1411 of the Affordable Care Act, directs the Secretary to establish a program for
determining whether an individual meets the eligibility standards for Exchange participation,
advance payments of the premium tax credit, cost-sharing reductions, and exemptions from the
shared responsibility payment.
Sections 1412 and 1413 of the Affordable Care Act and section 1943 of the Social Security Act
(the Act), as added by section 2201 of the Affordable Care Act, contain additional provisions
regarding eligibility for advance payments of the premium tax credit and cost- sharing
reductions, as well as provisions regarding simplification and coordination of eligibility
determinations and enrollment with other health programs.
The Affordable Care Act directs issuers offering non-grandfathered health insurance coverage in
the individual and small group markets to ensure that plans meet an actuarial value (AV) level of
coverage specified in section 1302(a)(3) of the Affordable Care Act and as defined in 45 CFR
156.140(b). Consistent with section 1302(d)(2)(A) of the Affordable Care Act, AV is calculated
based on the provision of the essential health benefits (EHB) to a standard population and is a
measure of the percentage of expected health care costs a health plan will cover for a standard
population.
2.

Information Users

The data collections and third-party disclosure requirements will assist HHS in determining
Exchange compliance with Federal standards and monitoring QHP issuers in FFEs for
compliance with Federal QHP issuer standards. The data collection will assist HHS in
monitoring Web-brokers for compliance with Federal Web-broker standards. The data collected
by health insurance issuers and Exchanges will help to inform HHS, Exchanges, and health
insurance issuers as to the participation of individuals, employers, and employees in the
individual Exchange, the SHOP, and the premium stabilization programs.

2

3.

Use of Information Technology

HHS anticipates that a majority of the systems, notices, and information collection required will
be automated. A majority of the information that is required by the collection of information will
be submitted electronically. HHS staff will analyze or review the data in the same manner by
which it was submitted and communicate with states, health insurance issuers, and other entities
using e-mail, telephone, or other electronic means.
4.

Duplication of Efforts

This information collection does not duplicate any other Federal effort.
5.

Small Businesses

This information collection will not have a significant impact on small businesses.
6.

Less Frequent Collection

Due to the required flow of information between multiple parties and flow of funds for payments
for health insurance coverage within the Exchange, it is necessary to collect information
according to the indicated frequencies. If the information is collected less frequently, the result
would be less accurate, untimely or unavailable eligibility, enrollment or payment information
for Exchanges, insurers, employers, and individuals. This would lead to delayed payments to
insurers; late charges to or payments by employers and enrollees; inaccurate or inappropriate
payments of advance premium tax credits and cost sharing reductions; the release of misleading
information regarding health care coverage to potential enrollees; and an overall stress on the
organizational structure of the Exchanges. If the information is not collected in the timeframe,
HHS will not be able to properly ensure the financial integrity of Federal funds.
7.

Special Circumstances

There are no special circumstances.
8.

Federal Register/Outside Consultation

A 60-day Federal Register Notice was published in the Federal Register on 06/02/2021 (V.86,
No. 104) for the public to submit written comment on the information collection requirements.
No comments were received.
A 30-day Notice will be published in the Federal Register on XX/XX/2021 for the public to
submit written comment on the information collection requirements.
No additional outside consultation was sought.
9.

Payments/Gifts to Respondents

3

No payments and/or gifts will be provided to respondents.
10.

Confidentiality

To the extent of the applicable law and HHS policies, we will maintain respondent privacy with
respect to the information collected. Nothing in the information collection should be interpreted
as preventing a State from being allowed to disclose its own data.
11.

Sensitive Questions

There are no sensitive questions included in this information collection effort.
12.

Burden Estimates (Hours & Wages)

The following section of this document contains an estimate of the burden imposed by the
associated ICRs. Average labor costs (including 100% fringe benefits) used to estimate the costs
are calculated using data available from the May 2020 National Industry-Specific Occupational
Employment and Wage Estimates from the Bureau of Labor Statistics (BLS).
Table 1: Adjusted Hourly Wages Used in Burden Estimates
Occupational
Title
Database
Administrator
and Architect
Actuary
General and
Operations
Manager
Compliance
Officer
Lawyer
Insurance
Claims and
Policy
Processing Clerk
Software
Developer

Occupational
Code
15-1245

Mean Hourly
Wage ($/hour)
$48.60

Fringe Benefits
(100%) ($/hour)
$48.60

Adjusted Hourly
Wage ($/hour)
$97.20

15-2011
11-1021

$59.22
$60.45

$59.22
$60.45

$118.44
$120.90

13-1041

$36.35

$36.35

$72.70

23-1011
43-9041

$71.59
$21.67

$71.59
$21.67

$143.18
$43.34

15-1256

$54.94

$54.94

$109.88

State Specific Standard Population (§ 156.135)
This information collection is not directly tied to the provisions in the Program Integrity final
rule. In 45 CFR § 156.135(d), HHS established that beginning in 2015, a State may submit a
State-specific standard population, to be used for AV calculations, so long as the criteria
described in § 156.135(d)(1) through (6) are met. A State that applies must submit to HHS

4

summary evidence that the requirements described in §156.135 are met and that the dataset is in
a format that will support the use of the AV calculator.
Given that no States have elected to pursue this option to date, we expect this trend to continue
and that a limited number of States will pursue this option in the near future. For the purposes of
calculating burden, we estimate that one State will pursue this option during the next three years.
This burden will therefore not be subject to PRA requirements and will not be included in total
burden calculations. We expect that for each State choosing this option, the data submission will
require 15 hours from a database administrator and architect at $97.20 an hour, 4 hours from an
actuary at $118.44 an hour, and 1 hour from a general and operations manager at $120.90 an
hour. Therefore, the total burden cost associated with this reporting requirement is estimated to
be $2,052.66.
Pursuant to 45 CFR § 156.135(d), a State may submit a State-specific standard population, to be
used for AV calculations. The State must submit summary evidence to show the requirements in
§ 156.135 are being met. The table below displays the burden for a State submitting this
standard.
Table 2: State Burden in Submitting Information Required for State Specific Standard
Population Option
Labor
Category
Database
Administrator
and Architect
Actuary
General and
Operations
Manager
Total

Number of
Respondents

Burden
Hours

Total Burden
Costs (Per
Respondent)

Total Burden
Costs (All
Respondents)

1

Hourly Labor
Costs (Hourly
Rate + 100%
Fringe Benefits)
$97.20

15

$1,458.00

$1,458.00

1
1

$118.44
$120.90

4
1

$473.76
$120.90

$473.76
$120.90

20

$2,052.66

$2,052.66

Enforcement Remedies in Federally-facilitated Exchanges (§ 156.800 to § 156.810)
Subpart I of Part 156 discusses the enforcement remedies in the FFEs. Section 156.800
authorizes HHS to impose sanctions on QHP issuers in an FFE that are not in compliance with
Federal standards. These sanctions may be in the form of a civil money penalty (CMP), as set
forth in §156.805; or decertification of QHPs, as set forth in §156.810. The burden estimates for
the collections of information in this Part reflect our assumption that there will be 361 QHP
issuers and 4,312 plans QHPs in all FFEs based on the number of QHP issuers and QHPs in Plan
Year 2021.
Section 156.805(a) states the general process and bases for imposing a CMP on issuers offering
QHPs in an FFE. CMPs will be imposed only for serious issues of non-compliance. We expect to

5

provide technical assistance to issuers, as appropriate, to assist them in maintaining compliance
with the applicable standards. We also plan to coordinate with States in our oversight and
enforcement activities to avoid inappropriately duplicative enforcement efforts. Subsequently,
we anticipate that CMPs will be imposed infrequently. Based on the fact that no CMPs have
been imposed in the last several years, we estimate that this trend will continue in the near future.
For the purposes of calculating burden, we estimate that one issuer will receive and appeal a
CMP in the next three years. This burden will therefore not be subject to PRA requirements and
will not be included in total burden calculations. We estimate that each issuer receiving and
appealing a CMP will utilize a compliance officer at $72.70 an hour for 60 hours, a lawyer at
$143.18 an hour for 60 hours, and a general and operations manager at $120.90 an hour for 30
hours. In total, we estimate the cost for an issuer receiving and appealing a CMP to be
$16,579.80.
Pursuant to 45 C.F.R. § 156.805 (a), HHS may impose a sanction on QHP Issuers in an FFE that
are not in compliance with Federal standards. The table below displays the burden for an issuer
that receives and appeals this sanction.
Table 3: Issuer Burden in Receiving and Appealing Civil Money Penalty
Labor
Category
Compliance
Officer
Lawyer
General and
Operations
Manager
Total

Number of
Respondents

Burden
Hours

Total Burden
Costs (Per
Respondent)

Total Burden
Costs (All
Respondents)

1

Hourly Labor
Costs (Hourly
Rate + 100%
Fringe Benefits)
$72.70

60

$4,362.00

$4,362.00

1
1

$143.18
$120.90

60
30

$8,590.80
$3,627.00

$8,590.80
$3,627.00

150

$16,579.80

$16,579.80

Section 156.810 sets forth the bases for the decertification of a QHP in an FFE and the general
process for decertification. Decertification is reserved for only serious instances of
noncompliance with applicable standards. Subsequently, HHS expects that decertification will
occur infrequently. Based on the fact that no issuers’ QHPs have been decertified in the last
several years, we estimate that this trend will continue in the near future. For the purposes of
calculating burden, we estimate that one issuer will be decertified and will appeal said
decertification in the next three years. This burden will therefore not be subject to PRA
requirements and will not be included in total burden calculations. We estimate an issuer that is
decertified and that appeals this decertification will utilize a compliance officer at $72.70 for 40
hours, a lawyer at $143.18 for 40 hours, and a general and operations manager at $120.90 for 20
hours. In total, we estimate the cost for an issuer that is decertified and appeals this
decertification to be $11,053.20.
Pursuant to 45 C.F.R. § 156.810, HHS may decertify a QHP in an FFE for serious instances of
noncompliance with applicable standards. The table below displays the burden for an issuer who

6

is decertified and then appeals this decision.
Table 4: Issuer Burden in Decertification and Appeal of Certification Action
Labor
Category
Compliance
Officer
Lawyer
General and
Operations
Manager
Total

Number of
Respondents

Burden
Hours

Total Burden
Costs (Per
Respondent)

Total Burden
Costs (All
Respondents)

1

Hourly Labor
Costs (Hourly
Rate + 100%
Fringe Benefits)
$72.70

40

$2,908.00

$2,908.00

1
1

$143.18
$120.90

40
20

$5,727.20
$2,418.00

$5,727.20
$2,418.00

100

$11,053.20

$11,053.20

Consumer Cases Related to Qualified Health Plans and Qualified Health Plan Issuers (§
156.1010)
In subpart K of part 156, we describe the information collection requirements that pertain to the
resolution of consumer cases related to QHPs and QHP issuers. Section 156.1010(g)(1) states
that QHP issuers must include the date of case resolution, § 156.1010(g)(2) states that QHP
issuers must record a clear and concise narrative documenting the resolution of a consumer case
in the HHS-developed casework tracking system, and § 156.1010(g)(3) states that QHP issuers
must provide information about compliance issues found by a State during the investigation of a
case.
The burden associated with this requirement is the time and effort necessary for the staff of a
QHP issuer to gather information related to the consumer complaint, draft the narrative, and
enter the narrative into the electronic HHS-developed case tracking system. For the purpose of
estimating burden, we estimate 361 issuers will be subject to this requirement based on the
number of QHP issuers in Plan Year 2021. We estimate that each issuer will utilize insurance
claims processing clerks for 4,800 hours at $43.34 an hour and a general and operations manager
for 800 hours at $120.90 an hour for a total annual cost of $304,752 per issuer, with the total
annual cost for all issuers amounting to $110,015,472. Over the course of three years, the
estimated cost of this reporting requirement is $914,256 per issuer and $330,046,416 for all
issuers.
Pursuant to 45 C.F.R. § 156.1010(g)(1), QHP issuers must include the date of consumer case
resolutions. 45 C.F.R. § 156.1010(g)(2) states that QHP issuers must record a narrative
documenting the resolution of a case in the HHS-developed casework tracking system. 45 C.F.R.
§ 156.1010(g)(3) states that QHP issuers must provide information about compliance issues
during the investigation of a case. The table below displays the burden for an issuer to comply
with these regulations around consumer cases, including maintaining the HHS-developed
tracking system.

7

Table 5: Issuer Burden in Maintaining Records of Consumer Case Resolution and
Inputting into HHS-Developed Casework Tracking System
Labor
Category
Insurance
Claims and
Policy
Processing
Clerk
General and
Operations
Manager
Total - Annual
Total - Three
Years

Number of
Respondents

Burden
Hours

Total Burden
Costs (Per
Respondent)

Total Burden
Costs (All
Respondents)

361

Hourly Labor
Costs (Hourly
Rate + 100%
Fringe Benefits)
$43.34

4,800

$208,032

$75,099,552

361

$120.90

800

$96,720

$34,915,920

2,021,600
6,064,800

$304,752
$914,256

$110,015,472
$330,046,416

Enrollment Process for Qualified Individuals (§ 156.1230)
Under § 156.1230(a)(1)(ii), issuers must provide information on available QHPs when they use
their Web sites to directly enroll qualified individuals into QHPs in a manner considered to be
through the Exchange, a process known as direct enrollment (DE). The QHP information
required to be posted on the DE Web sites includes premium and cost-sharing information, the
summary of benefits and coverage, metal level, results of the enrollee satisfaction survey, quality
ratings, medical loss ratio information, transparency in coverage measures, and a provider
directory.
Additionally, § 156.1230(a)(1)(iv) requires issuers’ DE Web sites to inform applicants about the
availability of other QHP products available through an Exchange through an HHS-approved
universal disclaimer and to display a Web link to the appropriate Exchange Web site. Issuers are
also required to distinguish between QHPs for which a consumer is eligible and other non-QHPs
that an issuer may offer pursuant to § 156.1230(a)(1)(iii). Finally, an issuer must allow a
consumer to select and attest to an APTC amount pursuant to § 156.1230(a)(1)(v).
The burden for these requirements relates to issuers developing and maintaining DE Web sites in
accordance with the requirements described above. Approximately 60 issuers currently utilize
DE and are thus subject to the disclosure requirements described above. Based on current yearto-date DE issuer participation and future potential market size, we estimate the number of
participating issuers will increase to 75 total in subsequent years. This is the number of issuers
used in calculating burden estimates. We expect that it will take a software developer 15 hours at
$109.88 an hour to develop and maintain the required QHP information on their Web sites in
accordance with §156.1230(a)(1) each year. We estimate that these disclosure requirements will

8

have an annual burden of 15 hours with a cost of approximately $1,648.20 per issuer and 1,125
hours with a cost of approximately $123,615 for all issuers. We estimate the total cost for three
years to be $4,944.60 for each issuer and $370,845 for all issuers.
Pursuant to 45 C.F.R.156.1230(a)(1)(ii), issuers must provide information on available QHPs
when they use their Web sites to directly enroll qualified individuals into QHPs in a manner
considered to be through the Exchange. 45 C.F.R. 156.1230(a)(1)(iv) requires issuers’ DE Web
sites to inform applicants about the availability of other QHP products available through an
Exchange. Issuers are also required to distinguish between QHPs for which a consumer is
eligible and other non-QHPs that an issuer may offer pursuant to 45 C.F.R. 156.1230(a)(1)(iii).
An issuer must allow a consumer to select and attest to an APTC amount pursuant to 45 C.F.R.
156.1230(a)(1)(v). The table below displays the burden for an issuer to maintain a DE Web site.
Table 6: Issuer Burden in Maintaining DE Web Site
Labor
Category

Number of
Respondents

Software
Developer

75

Hourly Labor
Costs (Hourly
Rate + 100%
Fringe Benefits)
$109.88

Total - Annual
Total - Three
Years

Burden
Hours

Total Burden
Costs (Per
Respondent)

Total Burden
Costs (All
Respondents)

15

$1,648.20

$123,615

1,125
3,375

$1,648.20
$4,944.60

$123,615
$370,845

Table 7 – Summary of Total Burden
Table Number: Name
Table 5: Issuer Burden in
Maintaining Records of Consumer
Case Resolution and Inputting into
HHS-Developed Casework
Tracking System
Table 6: Issuer Burden in
Maintaining DE Web Site
Total - Annual
Total - Three Years
13.

CFR Section

Burden
Hours

Burden Cost

45 C.F.R.
156.1010(g)(1)-(3)

2,021,600

$110,015,472

45 C.F.R.
156.1230(a)(1)(ii)(iv)

1,125

$123,615

2,022,725
6,068,175

$110,139,087.00
$330,417,261.00

Capital Costs

There are no anticipated capital costs associated with these information collections.

9

14.

Cost to Federal Government

The burden to the Federal government for maintaining the systems and policies associated with
this information collection is $315,654. The calculations for the Center for Consumer
Information and Insurance Oversight (CCIIO) employees’ hourly salary was obtained from the
OPM website: https://www.opm.gov/policy-data-oversight/pay-leave/salaries-wages/salarytables/pdf/2020/DCB_h.pdf
Table 8: Administrative Burden Costs for the Federal Government Associated with the
Program Integrity and Additional State Collections
Task
Maintenance of Program Integrity Information
Collections
15 GS-13: 15 x $49.19 x 200 hours

Estimated Cost
$147,570

Technical Assistance to States
15 GS-13: 15 x $49.19 x 200 hours

$147,570

Managerial Review and Oversight
2 GS-15: 2 x $68.38 x 150 hours

$20,514

Total Costs to Government
15.

$315,654

Changes to Burden

The number of total annual responses have been reduced from 2,930 to 437, a total reduction of
2,494 respondents. The total number of annual burden hours has been reduced from 2,339,000 to
2,022,745, a total reduction of 316,275 hours. The number of issuers used in these estimates has
been adjusted to reflect the 361 issuers currently offering QHPs in Plan Year 2021. In addition,
burden hours have decreased because the Web sites have already been developed and now
simply require maintenance for most issuers.
16.

Publication/Tabulation Dates

Results of the collection will not be made public.
17.

Expiration Date

The expiration date and OMB control number will appear on the first page of the instrument (topright corner).

10