CMS-10416 Blueprint for Approval of Affordable Healthcare Marketpl

DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
Center for Consumer Information and Insurance Oversight
200 Independence Avenue SW
Washington, DC 20201

Form Approved- exp. XX/XX/2021
OMB Control Number: 0938-1172

BLUEPRINT FOR APPROVAL
OF STATE-BASED HEALTH
INSURANCE EXCHANGES
Coverage Years Beginning
on or after 2022

PRA Disclosure Statement: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a
valid OMB control number. The valid OMB control number for this information collection is 0938-1172.

DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
Center for Consumer Information and Insurance Oversight
200 Independence Avenue SW
Washington, DC 20201

Table of Contents for Blueprint for Approval of
State-Based Health Insurance Exchanges
SECTION I: OVERVIEW OF BLUEPRINT APPLICATION AND APPROVAL REQUIREMENTS ......... i
Introduction ............................................................................................................................................................... i
Exchange Blueprint Application Review and Approval Process ................................................................................ iv
Questions Regarding the Exchange Blueprint Application and Technical Assistance ................................................. v
PRA Disclosure Statement .......................................................................................................................................... v

SECTION II: DECLARATION OF INTENT LETTER ................................................................................ vi
Contents of Declaration of Intent Letter .................................................................................................................... vi

SECTION III: APPLICATION FOR APPROVAL OF STATE-BASED HEALTH INSURANCE
EXCHANGES ............................................................................................................................................... vii
Application Instructions ........................................................................................................................................... vii
PART A. APPLICATION ATTESTATION .............................................................................................................. ix
PART B. EXCHANGE DECLARATIONS ................................................................................................................ x
PART C. STATE-BASED EXCHANGE BLUEPRINT APPLICATION ...................................................................1
Legal Authority and Governance.............................................................................................................................. 1
Consumer Assistance Tools and Programs............................................................................................................... 2
Eligibility and Enrollment ........................................................................................................................................ 7
Plan Management ................................................................................................................................................... 11
SHOP ...................................................................................................................................................................... 12
Finance and Accounting ......................................................................................................................................... 14
Technology ............................................................................................................................................................. 15
Privacy and Security ............................................................................................................................................... 16
Program Integrity and Oversight ............................................................................................................................ 18
Contingency Planning............................................................................................................................................. 19
PART D: STATE-BASED EXCHANGE ON THE FEDERAL PLATFORM BLUEPRINT APPLICATION............1
Legal Authority & Governance ................................................................................................................................ 1
Consumer Assistance Tools and Programs............................................................................................................... 2
Eligibility and Enrollment ........................................................................................................................................ 6
Plan Management ..................................................................................................................................................... 7
SHOP ........................................................................................................................................................................ 9
Finance and Accounting ......................................................................................................................................... 11
Technology ............................................................................................................................................................. 11
Privacy and Security ............................................................................................................................................... 12
Program Integrity and Oversight ............................................................................................................................ 12
User Fee .................................................................................................................................................................. 13

APPENDIX: EXCHANGE BLUEPRINT APPLICATION UPDATE REFERENCE FOR TRANSITION OF
A STATE-BASED EXCHANGE TO A STATE-BASED EXCHANGE ON THE FEDERAL PLATFORM ... i

DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
Center for Consumer Information and Insurance Oversight
200 Independence Avenue SW
Washington, DC 20201

SECTION I: OVERVIEW OF BLUEPRINT APPLICATION AND
APPROVAL REQUIREMENTS
Introduction
The Patient Protection and Affordable Care Act (P.L. 111-148) and the Health Care and Education
Reconciliation Act of 2010 (P.L. 111-152) (together referred to as the ACA) established American Health
Benefit Exchanges, beginning January 1, 2014, to provide individuals and small business employees access to
health insurance coverage. ACA § 1311(b) and 45 CFR § 155.100 describe an Exchange as an entity that both
facilitates the purchase of Qualified Health Plans (QHP) by qualified individuals and provides for the
establishment of a Small Business Health Options Program (SHOP).
The ACA and its implementing regulations provide states with flexibility in the design and operation of
Exchanges to ensure states are implementing Exchanges that best meet the needs of their consumers. States
can choose to establish and operate a State-based Exchange (SBE) or a State-based Exchange on the
Federal Platform (SBE-FP). States electing to operate as an SBE-FP rely on the Federal HealthCare.gov
platform to carry out eligibility and enrollment functions but operate other Exchange functions, including
consumer assistance and outreach. For states that do not elect to operate either an SBE or SBE-FP, the
Secretary of the U.S. Department of Health and Human Services (HHS) operates a Federally-facilitated
Exchange (FFE) in those states. FFE states can also work with CMS to undertake certain Plan Management
functions for their individual and SHOP markets.
Pursuant to 45 CFR §§ 155.105 and 155.106, states that elect to operate an SBE or SBE-FP must complete
and submit an Exchange Blueprint Application. The Exchange Blueprint Application documents that an
Exchange will meet the legal and operational requirements associated with the Exchange model a state
chooses to pursue. As part of its Exchange Blueprint Application submission, a state will also agree to
demonstrating operational readiness to implement and execute the required Exchange activities described in
the Exchange Blueprint Application.
This document includes the Exchange Blueprint Application for states seeking approval to operate either an
SBE or SBE-FP for coverage years beginning on, or after, January 1, 2022, and includes the following
application components:
•

Declaration of Intent Letter (Section II)

•

Exchange Blueprint Application (Section III)
Part A: Application Attestation
Part B: Exchange Declarations
Parts C or D: SBE or SBE-FP Application

This Exchange Blueprint Application replaces previous versions. All FFE states electing to operate a SBE or
SBE-FP must submit a Declaration of Intent Letter and the applicable sections of the Exchange Blueprint
Application. States that already have a conditionally-approved Exchange Blueprint Application as an SBE or
SBE-FP for a coverage year prior to January 1, 2022 and wish to transition to a new state Exchange model,
must submit an updated Declaration of Intent Letter and Exchange Blueprint Application for the applicable
model.
An SBE transitioning to an SBE-FP should also refer to the Appendix in this document for further information.

DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
Center for Consumer Information and Insurance Oversight
200 Independence Avenue SW
Washington, DC 20201

A state operating as an SBE or SBE-FP that is electing to transition to the FFE should follow the process
described in 45 CFR § 155.106(b).
Figure 1 provides an illustrative representation of the Exchange models, the flexibility within each, as well as
the associated CMS application timeline requirements.
Figure 1. State Exchange Model Options and Exchange Blueprint Application Requirements and
Timelines for Coverage Years Beginning On, or After, January 1, 2022
SBE

SBE-FP

FFE

State performs all Exchange
functions, including coordination
with state Medicaid and
Children’s Health Insurance
Program (CHIP).

State performs the following
Exchange functions:
• Plan Management
• Consumer Assistance
• SHOP

CMS performs all Exchange
functions through HealthCare.gov

State may rely on CMS for the
following functions:
• Exemptions processing (45
CFR § 155 Subpart G)
• Risk adjustment (45 CFR §
153 Subpart D)
• Employer appeal upon notice
of employee’s receipt of
APTC/CSR (45 CFR §
155.555)

State relies on CMS for the following
functions:
• Eligibility and enrollment
functions (Individual Market)
• Related eligibility support
functions, such as consumer call
center and consumer casework
(Individual Market)

State elects whether CMS
(through the HealthCare.gov
eligibility platform) will perform
Medicaid and Children’s Health
Insurance Program (CHIP)
assessments or determinations.
(Notification is through CMS’s
Center for Medicaid and CHIP
Services (CMCS)).

State may elect to perform certain
PM functions.1

State elects whether CMS (through
the HealthCare.gov eligibility
platform) will perform Medicaid and
Children’s Health Insurance
Program (CHIP) assessments or
determinations. (Notification is
through CMS’s Center for Medicaid
and CHIP Services (CMCS)).

1

A state electing to perform certain PM functions does not have to complete an Exchange Blueprint Application. For additional information, contact
the Center for Consumer Information and Insurance Oversight (CCIIO) via the FFE Plan Management State Coordination (PMSC) mailbox at
[email protected].

DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
Center for Consumer Information and Insurance Oversight
200 Independence Avenue SW
Washington, DC 20201

State Must Submit:
• Declaration of Intent Letter

State Must Submit:
• Declaration of Intent Letter

Not applicable.

•

•

SBEs or SBE-FPs that wish to
transition to the FFE should notify
CMS in accordance with timelines
in 45 CFR § 155.106(b).

SBE Exchange Blueprint
Application at least 15 months
prior to the beginning of an
SBE’s first Open Enrollment2

SBE-FP Exchange Blueprint
Application at least three months
prior to the beginning of an SBEFP’s first Open Enrollment3

Additionally, a state must have an
executed Federal Platform
Agreement with CMS prior to the
beginning of an SBE-FP’s first Open
Enrollment4

2

45 CFR § 155.106(a)(3)
45 CFR § 155.106(c)(2)
4 CMS will provide states with the Federal Platform Agreement required for signature for the relevant coverage years. 45 CFR § 155.106(c)(4)
3

DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
Center for Consumer Information and Insurance Oversight
200 Independence Avenue SW
Washington, DC 20201

Exchange Blueprint Application Review and Approval Process
Upon a state’s submission of its Declaration of Intent Letter, HHS’ Centers for Medicare & Medicaid Services’
(CMS) will engage the state and provide technical assistance on the completion of the state’s Exchange
Blueprint Application, if not already submitted, and the process toward approval or conditional approval. HHS
recognizes that states depend on HHS/CMS, other Federal agencies, and contractors for guidance associated
with their Exchange establishment. In consideration of this dependency, CMS’s approval of a SBE and SBE-FP
will take into account that states will be in various stages of development at the time in which an Exchange
Blueprint Application is submitted to CMS. As a result, CMS will grant conditional approval for an SBE or SBEFP that does not meet all applicable Exchange requirements at the time of Exchange Blueprint Application
submission, but that has: 1) attested to meeting all applicable requirements in the Exchange Blueprint
Application; 2) is making significant progress toward meeting the requirements with projected dates of
completion, and; 3) is anticipated to be operationally ready for the applicable Open Enrollment Period.
Once a state has been conditionally approved, CMS will work closely with each Exchange to monitor state
progress and ensure that proposed dates of completion for Exchange Blueprint Application activities and other
project milestones are met in accordance with the state’s projected completion dates.

Monitoring of State Progress and Readiness Reviews
CMS will utilize regular calls with the state in addition to implementation and/or operational readiness reviews
to monitor and provide guidance to states on their Exchange information technology (IT) system build and
implementation of programmatic requirements as defined in the Exchange Blueprint Application. Operational
readiness entails CMS’s and its Federal agency partners’ assessment of the capacity of an Exchange to
conduct Exchange business. The objective of these assessments is to assure that an Exchange’s policies,
procedures, operations, technology, and other administrative capacities have been implemented and scaled to
meet the needs of the state’s Exchange’s population. CMS will use the information in a state’s Exchange
Blueprint Application to determine the need for, and timing of, in-person or virtual periodic readiness
assessments.
Additionally, as part of the implementation or operational reviews, CMS may require that the state provide testing
results or supplemental documentation demonstrating progress towards meeting the Exchange Blueprint
Application requirements leading up to the start of its first Open Enrollment as an Exchange. Requests for
documentation and information system testing results may occur as part of the readiness reviews or other
consults as requested by CMS. Additionally, CMS may require formal testing between the state’s IT system and
the CMS Federal Data Services Hub (FDSH) to ensure connectivity, correct data exchange formats and values,
correct interpretation of responses from the FDSH by the state, and ensure correct information is transmitted and
captured. CMS will provide guidance and documentation to assist states with testing the automated functionality of
their Exchanges and reporting results to CMS.
An Exchange’s conditional approval status will continue as long as a state continues to meet expected progress
milestones and until a state successfully demonstrates its ability to perform all required Exchange activities and
comply with all applicable Federal guidance and regulations. Provided that the state is continuing to demonstrate
progress in meeting the requirements outlined in its conditional approval determination, a state Exchange will
maintain conditional approval status. CMS will approve an SBE or SBE-FP once the state has demonstrated the
ability to satisfactorily perform all required Exchange activities, and comply with all Federal program rules and
requirements applicable to the Exchange model they are conditionally-approved to operate.

DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
Center for Consumer Information and Insurance Oversight
200 Independence Avenue SW
Washington, DC 20201

Questions Regarding the Exchange Blueprint Application and Technical
Assistance
States are encouraged to contact CMS/CCIIO’s State Marketplace and Insurance Programs Group (SMIPG) at
[email protected] for information about technical assistance consultations, and resources available
to states on the Exchange Blueprint Application process. SBE and SBE-FP states with an assigned CMS CCIIO
State Officer (SO) should contact him or her for specific questions regarding Exchange Blueprint Application
submissions.

PRA Disclosure Statement
According to the Paperwork Reduction Act of 1995 (PRA), no persons are required to respond to a collection of
information unless it displays a valid Office of Management and Budget (OMB) control number. The valid OMB
control number for this information collection is 0938-1172. The time required to complete this information
collection is estimated to average (31.5 hours) per response, including the time to review instructions, search
existing data resources, gather the data needed, and complete and review the information collection. If you
have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please
write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4- 26-05, Baltimore,
Maryland 21244-1850.

DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
Center for Consumer Information and Insurance Oversight
200 Independence Avenue SW
Washington, DC 20201

SECTION II: DECLARATION OF INTENT LETTER
A state seeking to operate an SBE or SBE-FP for coverage years beginning on, or after, January 1, 2022 will
declare the type of Exchange model it intends to pursue through an Exchange Declaration of Intent Letter to be
submitted to CMS CCIIO in advance of, or by the time of, the submission of an Exchange Blueprint Application.
As previously noted, states that already have a conditionally-approved Exchange Blueprint Application who wish to
transition to an SBE or SBE-FP should submit an update to their Exchange Declaration Letter in advance of, or by the
time of, the submission of their updated Exchange Blueprint Application.
A state’s Declaration of Intent Letter must be signed by the state’s governor. As described below, the
Declaration of Intent Letter’s contents should include basic information associated with its designated
Exchange model. The Declaration of Intent Letter should include a designation of the individual(s) (i.e.,
Designee(s) who will serve as the primary point of contact for CMS regarding the Exchange). The individual(s)
should be authorized to bind the state regarding the state’s Exchange, as well as to complete and sign the
Exchange Blueprint Application. In the case of an SBE or SBE-FP, this should be the individual(s) authorized
to attest to the state’s intent to meet the requirements in the Exchange Blueprint Application.
States are encouraged to submit their Exchange Declaration of Intent Letter as early as possible. CMS has
generally recommended that states submit this letter no later than 21 months prior to the beginning of an
SBE’s first Open Enrollment and no later than nine months prior to the beginning of an SBE-FP’s first Open
Enrollment. However, these timeframes are meant to be general guidelines based on CMS’s experience with
the length of time needed for states to transition Exchange operational models and information technology
platforms. States are recommended to consult with CMS CCIIO for further guidance as needed. A state’s
Declaration of Intent Letters should be sent to:
CMS CCIIO
200 Independence Avenue SW, Suite 739H
Washington DC, 20201.
In addition, please email a copy to the [email protected]. To support CMS’s goal of public
transparency, states must post their Declaration of Intent Letter to the state (or other appropriate) website.

Contents of Declaration of Intent Letter
A state’s Declaration of Intent Letter must include the following:
•

The Exchange model that the state chooses to pursue (SBE or SBE-FP).

•

Confirmation of the plan year (PY) for which the state intends to begin operating an SBE or SBE-FP
(i.e., PY 2022 or a subsequent PY).
Designation of the individual(s) (i.e., Designee(s)) authorized to act as primary point(s) of contact
and authorized to bind the state with CMS regarding the state’s Exchange, as well as to complete
and sign the Exchange Blueprint Application.
Acknowledgement that CMS and the state may agree to amend their Declaration of Intent Letter
to include additional information necessary to establish their Exchange.

•
•

DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
Center for Consumer Information and Insurance Oversight
200 Independence Avenue SW
Washington, DC 20201

SECTION III: APPLICATION FOR APPROVAL
OF STATE-BASED HEALTH INSURANCE EXCHANGES
Application Instructions
CMS requires that states seeking approval to operate an SBE or SBE-FP for coverage years beginning on, or after,
January 1, 2022 must complete and submit an Exchange Blueprint Application. States that already have a
conditionally-approved Exchange Blueprint Application who are seeking to transition to a different Exchange model
(either an SBE or SBE-FP) must submit an update to their Exchange Blueprint Application for approval.
The Exchange Blueprint Application documents that a state’s Exchange has met, or will meet, all legal and
operational requirements associated with the Exchange model that the state intends to operate. Specifically, a state
must attest to the current ability of its Exchange to meet specified requirements or to its intention for completion of
the specified requirements by a future date. As part of its Exchange Blueprint submission, a state will also agree to
demonstrating operational readiness to execute Exchange activities. States may attest to activities being completed
by the Exchange or a designee through contract, agreement, or other arrangement. However, the Exchange is
ultimately responsible for meeting all applicable Federal requirements outlined in the Exchange Blueprint Application
and for the successful performance of each activity. CMS considers the Exchange Blueprint Application as an
agreement that exists solely between the state and CMS. HHS encourages states to reach to CMS/CCIIO/SMIPG at
[email protected] for clarification on any activities that direct states to consult CMS guidance and or
regulations that provide more detailed information about the applicability of certain Exchange functional
requirements to specific Exchange models.
Per regulations at 45 CFR § 155.106, states seeking to operate an SBE must submit their Exchange Blueprint
Application (or updated Exchange Blueprint Application) to CMS at least 15 months prior to the beginning of an
SBE’s first Open Enrollment. States seeking to operate an SBE-FP must submit their Exchange Blueprint
Application (or updated Exchange Blueprint Application) to CMS at least three months prior to the beginning of an
SBE-FP’s first Open Enrollment.
The Exchange Blueprint Application will be electronically available for states to complete and submit through the
CMS/CCIIO State Exchange Resource Virtual Information System (SERVIS) (https://portal.cms.gov). To gain
access to SERVIS and be able to complete and submit the Exchange Blueprint Application, a state without an
assigned CMS CCIIO SO would need to send an email request to [email protected] with subject
line: Exchange Blueprint Application Notification. States with an assigned CMS CCIIO SO will work closely with
their SO to complete and submit an update to their Exchange Blueprint Application.
The Exchange Blueprint Application includes the following components. States seeking approval to operate an
SBE or SBE-FP for coverage years beginning on, or after, January 1, 2022 must complete and submit Part A and
Part B. States complete Part C or Part D, depending on its Exchange model.
Part A. Application Attestation: The individual(s) designated in a state’s Declaration of Intent Letter (the
Designee(s)) must attest, on behalf of the state, to the accuracy of the information submitted for the
entire Exchange Blueprint Application submission.
Part B. Exchange Declarations: The applicant must provide an overview of key Exchange options within
the model the state has chosen to operate.
vii

DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
Center for Consumer Information and Insurance Oversight
200 Independence Avenue SW
Washington, DC 20201

Part C. State-based Exchange Blueprint Application: States seeking to be SBEs must attest to either
completion or expected completion of required activities.
Part D. State-based Exchange on the Federal Platform Blueprint Application: States seeking to be SBEFPs must attest to either completion or expected completion of required activities.

viii

DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
Center for Consumer Information and Insurance Oversight
200 Independence Avenue SW
Washington, DC 20201

PART A. APPLICATION ATTESTATION
ON THIS DATE, I ATTEST THAT THE STATEMENTS AND INFORMATION CONTAINED IN
THIS EXCHANGE BLUEPRINT APPLICATION AND DOCUMENTS SUBMITTED IN
CONJUNCTION WITH THIS EXCHANGE BLUEPRINTAPPLICATION ACCURATELY
REPRESENT THE STATUS OF MY STATE’S INSURANCE EXCHANGE BEING DEVELOPED
UNDER TITLE I OF THE PATIENT PROTECTION AND AFFORDABLE CARE ACT OF 2010
(Pub. L. 111-148), AS AMENDED BY THE HEALTH CARE AND EDUCATION
RECONCILIATION ACT OF 2010 (Pub. L. 111-152), AND REFERRED TO COLLECTIVELY AS
THE AFFORDABLE CARE ACT; AND REGULATIONS AT 45 CFR §§ 153, 155, AND 156.

State:
(Name of State)

(Signature of Governor Designee of the State, Date Signed)

FUTURE REVIEWS FOR FUNCTIONALITY OR COMPLIANCE: The Exchange agrees to
participate in implementation and operational readiness reviews prior to opening as an Exchange
as requested by CMS. As part of these reviews, CMS may request the Exchange to provide testing
results or other documentation demonstrating Exchange’s ability to comply with regulations in 45
CFR § 155.
Agree:

☐

Do not agree:

☐

DESIGNATED EXCHANGE OFFICIAL(S) CONTACT INFORMATION THAT IS
COMPLETING THE EXCHANGE BLUEPRINT APPLICATION & ATTESTATION:
NAME:
TELEPHONE:
EMAIL ADDRESS:
NAME:
TELEPHONE:
EMAIL ADDRESS:

DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
Center for Consumer Information and Insurance Oversight
200 Independence Avenue SW
Washington, DC 20201

PART B. EXCHANGE DECLARATIONS
1. STATE(S) NAME:
2. STATE EXCHANGE MODEL AND PLAN YEAR: (Indicate which model your state is applying
for, as well as the plan year state intends to begin operations of the model)
SBE
SBE-FP
__Regional Exchange

___ Plan Year
___ Plan Year
___ Plan Year

(Please note that in addition to meeting the requirements described in the Exchange Blueprint
Application, states seeking approval to operate a Regional Exchange must also meet the
requirements under 45 CFR § 155.140)
3. DECLARATION of INTENT LETTER: (Confirm whether your state has submitted its Declaration
of Intent Letter or if it is included with the Exchange Blueprint Application)
Declaration of Intent Letter submitted
Declaration of Intent Letter submitted with this Exchange Blueprint Application
4. If you are pursuing an SBE, indicate if you will be relying on CMS for any of the
following Exchange functions: (check all that apply)
Risk adjustment (45 CFR § 153 Subpart D)
__ Exemptions (45 CFR § 155 Subpart G)
__ Employer coverage appeals (45 CFR § 155.555)
5. GOVERNANCE STRUCTURE: (check one)
State agency
Quasi-governmental entity
Nonprofit
Other

x

DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
Center for Consumer Information and Insurance Oversight
200 Independence Avenue SW
Washington, DC 20201

PART C. STATE-BASED EXCHANGE BLUEPRINT APPLICATION
1.0 Legal Authority and Governance
1.1

Exchange Enabling Authority: The Exchange will have the appropriate authority to
operate an SBE, including a Small Business Health Options Program (SHOP), compliant
with Affordable Care Act § 1321(b) and applicable rulemaking.

Provide citation and URL of Exchange-enabling authority:
I attest this activity
is complete ☐
1.2

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click here to
enter a date.

Authority to Certify Qualified Health Plans (QHPs): The Exchange will have the appropriate
state authority to perform the certification of QHPs and to oversee QHP issuers consistent with
45 CFR § 155.1010(a), in coordination with the appropriate state insurance oversight entity.

Provide citation and URL of Exchange authority to certify QHPs:
I attest this activity
is complete ☐
1.3

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click here to
enter a date.

If applicable: Risk Adjustment: If the Exchange opts to perform risk adjustment, the state
will have the legal authority to operate the risk adjustment program per 45 CFR § 153 and
Affordable Care Act 1343.

Provide citation and URL of authority to operate risk adjustment:
I attest this activity is
complete ☐
1.4

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click here
to enter a date.

Authority to Generate Revenue: The Exchange will have the appropriate authority to generate
revenue to ensure operational sustainability, and will have defined methods for generating revenue
(e.g., user fees) pursuant to ACA § 1311(d)(5)(A).

Provide citation and URL of Exchange authority to generate revenue:
I attest this activity is
complete ☐
1.5

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click here
to enter a date.

Board and Governance Structure: The Exchange will establish a board and governance
structure in compliance with ACA § 1311(d) and 45 CFR § 155.110.
I attest this activity is
complete ☐

I attest this activity will be
complete ☐

Completed/Expected
Completion Date
Click here to enter a
date.

DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
Center for Consumer Information and Insurance Oversight
200 Independence Avenue SW
Washington, DC 20201

2.0 Consumer Assistance Tools and Programs
2.1

Stakeholder Consultation: The Exchange will conduct stakeholder consultation to seek input for the
duration of Exchange planning and operation pursuant to 45 CFR § 155.130. This includes consultation
with consumers, small businesses, state Medicaid and CHIP agencies, agents/brokers, large
employers, if applicable, Federally-recognized Tribes, as defined in the Federally Recognized Indian
Tribe List Act of 1994, 25 U.S.C. 479a and other relevant stakeholders.
I attest this activity is
complete ☐

2.2

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click
here to enter a date.

Call Center
a. The Exchange will establish and operate a toll-free call center which will provide eligibility and
enrollment support and will respond to any requests for assistance from consumers pursuant to 45
CFR § 155.205(a).
I attest this activity is
complete ☐

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click here
to enter a date.

b. The Exchange call center will provide information to consumers in a manner that is accessible and
timely for individuals living with disabilities and for individuals who have limited English proficiency,
including providing and informing consumers about the availability of auxiliary aids and services, and
oral interpretation at no cost to the consumer, in accordance to CMS regulations and guidance
pursuant to 45 CFR § 155.205(c)(1), (c)(2)(i), and (c)(3).
I attest this activity is
complete ☐
2.3

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click
here to enter a date.

Website
a. The Exchange will establish and maintain an up-to-date internet website in accordance with 45
CFR § 155.205 (b).
I attest this activity is
complete ☐

I attest this activity will be
complete☐

Completed/Expected
Completion Date Click here
to enter a date.

b. The Exchange website will supply comparative information on available QHPs, which may be
provided through consumer-facing plan comparison and shopping tools, and will include information
on premium and cost sharing, benefits and coverage, metal categories, and all other requirements in
accordance with 45 CFR § 155.205(b)(1).
I attest this activity is
complete ☐

I attest this activity will be
complete☐

Completed/Expected
Completion Date Click here
to enter a date.

DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
Center for Consumer Information and Insurance Oversight
200 Independence Avenue SW
Washington, DC 20201

c. The Exchange website will publish financial information including, the average costs of licensing
required by the Exchange, any regulatory fees required by the Exchange, monies lost to waste, fraud
and abuse, and all other requirements in accordance with 45 CFR § 155.205(b)(2).
Completed/Expected
I attest this activity is
I attest this activity will be
Completion Date Click here
complete ☐
complete☐
to enter a date.
d. The Exchange website will provide consumers with information about Navigators as described in
45 CFR § 155.210 and other consumer assistance services, including the toll-free telephone
number of the Exchange call center in accordance with 45 CFR § 155.205(b)(3).
I attest this activity is
complete ☐

I attest this activity will be
complete☐

Completed/Expected
Completion Date Click
here to enter a date.

e. The Exchange website will allow for eligibility determinations to be made in accordance with 45
CFR § 155 Subpart D pursuant to 45 CFR § 155.205(b)(4).
I attest this activity is
complete ☐

I attest this activity will be
complete☐

Completed/Expected
Completion Date Click
here to enter a date.

f. The Exchange website will allow for qualified individuals to select a QHP in accordance with 45
CFR § 155 Subpart E pursuant to 45 CFR § 155.205(b)(5).
I attest this activity is
complete ☐

I attest this activity will be
complete☐

Completed/Expected
Completion Date Click
here to enter a date.

g. The Exchange website will make available by electronic means, a calculator to facilitate the
comparison of available QHPs after the application of any advance payments of the premium tax
credit and any cost-sharing reductions pursuant to 45 CFR § 155.205(b)(6).
I attest this activity is
complete ☐

I attest this activity will be
complete☐

Completed/Expected
Completion Date Click
here to enter a date.

h. The Exchange website will meet accessibility standards including providing information to
consumers in plain language, and in a manner, that is accessible and timely for individuals living
with disabilities and for individuals who have limited English proficiency, in accordance with CMS
regulations and guidance pursuant to 45 CFR § 155.205(c). The Exchange website will inform
individuals about the availability of auxiliary aids and services for people with disabilities, language
services at no cost to the individual, oral interpretation, written translations, and will provide
taglines in non-English languages indicating the availability of language services.
I attest this activity is
complete ☐

I attest this activity will be
complete☐

Completed/Expected
Completion Date Click
here to enter a date.

DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
Center for Consumer Information and Insurance Oversight
200 Independence Avenue SW
Washington, DC 20201

2.4

Outreach and Education
a. The Exchange will coordinate and conduct outreach and education activities to educate consumers
about the Exchange and insurance affordability programs, and to encourage consumer participation
in the Exchange as specified in 45 CFR § 155.205(e). These activities could include, for example,
informational marketing materials, advertisements, community outreach events, or other outreach and
education activities that the Exchange determines suitable for its consumers.
I attest this activity is
complete ☐

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click here
to enter a date.

b. The Exchange outreach and education information will meet accessibility standards including
providing information to consumers in plain language, and in a manner, that is accessible and timely
for individuals living with disabilities and for individuals who have limited English proficiency, in
accordance with CMS regulations and guidance pursuant to 45 CFR § 155.205(c). The Exchange
outreach and education information will inform individuals about the availability of auxiliary aids and
services for people with disabilities, language services at no cost to the individual, oral interpretation,
written translations, and will provide taglines in non-English languages indicating the availability of
language services.
I attest this activity is
complete ☐
2.5

Completed/Expected
Completion Date Click
here to enter a date.

Consumer Assistance: The Exchange will implement consumer assistance functions in
accordance with 45 CFR § 155.205(d) including providing referrals to any applicable office of
health insurance consumer assistance or health insurance ombudsman established under section
2793 of the Public Health Service Act, or any other appropriate State agency or agencies, for any
enrollee with a grievance, complaint, or question regarding their health plan, coverage, or a
determination under such plan or coverage.
I attest this activity is
complete ☐

2.6

I attest this activity will be
complete ☐

I attest this activity will be
complete☐

Completed/Expected
Completion Date Click
here to enter a date.

Navigator Program
a. The Exchange will establish, fund and operate a Navigator program through which it will award
grants to eligible entities or individuals capable of carrying out Navigator duties as required under 45
CFR § 155.210.
I attest this activity is
complete ☐

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click here
to enter a date.

DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
Center for Consumer Information and Insurance Oversight
200 Independence Avenue SW
Washington, DC 20201

b. The Exchange will develop and publicly disseminate a set of standards to be met by Navigator
grantees designed to prevent or minimize potential conflicts of interest that may exist for entities or
individuals to be awarded grants in accordance with 45 CFR § 155.210(b)(1).
I attest this activity is complete
☐

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click
here to enter a date.

c. The Exchange will develop and publicly disseminate a set of training standards to be met
by Navigator grantees that will ensure expertise concerning topics such as QHP options,
insurance affordability programs, eligibility and enrollment rules and regulations, privacy and
security standards, and all other requirements in accordance with 45 CFR § 155.210(b)(2).
I attest this activity is
complete ☐

I attest this activity
will be complete ☐

Completed/Expect
ed Completion
Date Click here to

d. The Exchange will enter into agreements pursuant to 45 CFR § 155.260(b) with
Navigator grantees to ensure adherence to all terms and conditions of privacy and security
standards.
I attest this activity is
I attest this activity
Completed/Expected
Completion Date Click
complete ☐
will be complete ☐
here to enter a date.
2.7

If applicable: Non-Navigator Assistance Personnel
If the Exchange opts to have a non-Navigator assistance personnel program, the Exchange
will maintain full responsibility for program operations, as well as for selecting and ensuring
the proper training of all non-Navigator assistance personnel in the SBE-FP. Specifically,
the SBE-FP will develop and implement a training program for non-Navigator assistance
personnel and ensure they comply with all applicable regulatory requirements, including 45
CFR §§ 155.205(d)-(e), 45 CFR 155.215, and 45 CFR 155.260(b).
I attest this activity is
complete ☐

2.8

I attest this activity
will be complete ☐

Completed/Expected
Completion Date Click
here to enter a date.

Certified Application Counselors (CACs)
a. The Exchange will establish a CAC program pursuant to 45 CFR § 155.225 and will either,
designate an organization to certify CACs to perform specified duties, will directly certify CACs to
perform specified duties, or will implement a combination of both these approaches in establishing
their CAC program.
I attest this activity is
complete ☐

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click here
to enter a date.

DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
Center for Consumer Information and Insurance Oversight
200 Independence Avenue SW
Washington, DC 20201

b. The Exchange will ensure, either directly, or through designated organizations, that CACs
complete required state-specific training(s) on topics including QHP options, insurance affordability
programs, eligibility and enrollment rules and all other applicable regulatory requirements.
I attest this activity is
complete ☐

I attest this activity will be
complete☐

Completed/Expected
Completion Date Click here
to enter a date.

c. The Exchange will ensure CACs adherence to all terms and conditions of privacy and security
standards pursuant to 45 CFR § 155.260(b).
I attest this activity is
complete ☐
2.9

I attest this activity will be
complete☐

Completed/Expected
Completion Date Click here
to enter a date.

If applicable: Agents and Brokers: A state may permit agents and brokers to assist consumers to
enroll in QHPs pursuant to 45 CFR § 155.220.
a. The Exchange will clearly define the role of agents and brokers including, as applicable, evidence
of licensure, training, and compliance with regulatory requirements under 45 CFR § 155.220.
I attest this activity is
complete ☐

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click here
to enter a date.

b. The Exchange will have an agreement in place with agents and brokers operating in the individual
Exchange consistent with 45 CFR § 155.220(d). The agreement will ensure agent and broker
compliance with regulatory requirements including, advanced registration with the Exchange,
completed training on QHP options and insurance affordability program(s), and adherence to privacy
and security standards pursuant to 45 CFR § 155.260.
I attest this activity is
complete ☐
2.10

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click
here to enter a date.

If applicable: Web Brokers: If the state permits agents and brokers to enroll consumers in
QHPs, and assist consumers in applying for insurance affordability programs pursuant to 45 §
CFR 155.220(c)(3), the Exchange will ensure that any agent or broker whose website will be
used to select QHPs will comply with all applicable provisions of 45 CFR § 155.220.
I attest this activity is
complete ☐

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click
here to enter a date.

DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
Center for Consumer Information and Insurance Oversight
200 Independence Avenue SW
Washington, DC 20201

3.0 Eligibility and Enrollment
3.1

Single, Streamlined Application: The Exchange will use the CMS-developed single, streamlined
application (or state-developed alternative single, streamlined application) for health insurance
coverage. The application collects information that is necessary for eligibility in a QHP for the
individual market, and for Insurance Affordability Programs as specified in 45 CFR § 155.405 and in
applicable CMS guidance. If the Exchange is using an alternative application for the individual
Marketplace, the Exchange agrees to perform state user testing and submit results, upon request, to
CMS.
I attest this activity is
complete ☐

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click here
to enter a date.

Individual application (check one): Alternative ☐ CMS-developed ☐
3.2

Coordination Strategy with Insurance Affordability Programs and SHOP
a. The Marketplace will develop and document a coordination strategy with other entities administering
insurance affordability programs and the SHOP that enables the Marketplace to carry out eligibility
and enrollment activities, consistent with 45 CFR §§ 155.345(a),155.510(a) and 155.706.
I attest this activity is
complete ☐

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click here
to enter a date.

b. The Exchange will have the capability to accept and process applications for individual Exchange
coverage that have been collected by, and transferred from, its respective state Medicaid agency or
state human services agency that processes insurance affordability program applications, and will
also have the capability to collect and transmit information to the applicable state agencies necessary
to provide coverage to an applicant determined or assessed eligible for Medicaid and CHIP without
undue delay, in accordance with 45 CFR § 155.345(a).
I attest this activity is
complete ☐
3.3

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click
here to enter a date.

Accepting and Processing Initial Applications and Redeterminations: The Exchange will have
the capability in place to accept and process initial applications, application updates, notification of
changed circumstances, and annual and mid-year redeterminations for enrollees. This includes
applicants and enrollees who have disabilities or limited English proficiency or literacy, as well as
applications received through all required channels, including in-person, online, mail, and phone.
I attest this activity is
complete ☐

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click here
to enter a date.

DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
Center for Consumer Information and Insurance Oversight
200 Independence Avenue SW
Washington, DC 20201

3.4

Eligibility Verifications
a. The Exchange will have a process to verify applicant data, as part of the eligibility determination
process pursuant to 45 CFR § 155 Subpart D. This includes verification of Social Security Number
(SSN), Household Income and Family Size, Citizenship, Immigration status, Residency, American
Indian/Alaskan Native Status, Incarceration status, Employer Sponsored Minimum Essential
Coverage, Non-Employer Sponsored Minimum Essential Coverage.
I attest this activity is
complete ☐

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click here
to enter a date.

b. To the extent required under 45 CFR § 155 Subpart D, the Exchange will use electronic data
sources available through the Federal Data Services Hub (FDSH), known as the Federal Hub, and/or
other CMS-approved data sources, to verify applicant data. The Exchange will have data matching
agreements in place (such as the Computer Matching Agreement between CMS and State
Administering Entities) and will complete necessary testing to connect to electronic data sources,
including the Federal Hub, to perform the required eligibility verifications.
Completed/Expected
I attest this activity is
I attest this activity will be
Completion
Date Click here
complete ☐
complete ☐
to enter a date.
c. The Exchange will have the capability to process inconsistencies in accordance with 45 CFR § 155
Subpart D, when the Exchange cannot verify information required to determine eligibility for enrollment
in a QHP through the Exchange, advance payments of the premium tax credit and cost-sharing
reductions.
I attest this activity is
complete ☐

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click here
to enter a date.

3.5

Conducting Periodic Data Matching: The Exchange will have the capability to conduct periodic
data matching pursuant to 45 CFR § 155 Subpart D.
I attest this activity will be
Completed/Expected
I attest this activity is complete
complete
☐
Completion Date Click
☐
here to enter a date.

3.6

Conducting Eligibility Determinations and Annual Redeterminations: The Exchange will have
the capability to conduct eligibility determinations for the individual market and SHOP, along with
individual annual redeterminations, in accordance with 45 CFR § 155 Subpart D.
a. The Exchange will determine individual eligibility for QHP coverage.
I attest this activity is
complete ☐

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click here
to enter a date.

b. The Exchange will determine employer and employee eligibility for participation in the SHOP.
I attest this activity is
complete ☐

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click here
to enter a date.

DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
Center for Consumer Information and Insurance Oversight
200 Independence Avenue SW
Washington, DC 20201

c. The Exchange will assess or determine eligibility for Medicaid and CHIP based on Modified
Adjusted Gross Income (MAGI) and notify the applicant of the opportunity to request a full
determination of eligibility from the Medicaid agency.
Completed/Expected
I attest this activity will be
I attest this activity is
Completion Date Click here
complete ☐
complete ☐
to enter a date.
d. The Exchange will determine eligibility for APTC and CSR and will be able to calculate and apply
individual APTC amounts to QHP premiums for APTC-eligible individuals based on the maximum
APTC level an individual is eligible for, the premium(s) of the QHP(s) selected by the individual, and
the APTC level selected by the individual to apply to their QHP premium.
Completed/Expected
I attest this activity will be
I attest this activity is
Completion Date Click here
complete ☐
complete ☐
to enter a date.
e. The Exchange will determine eligibility for exemptions from the shared responsibility payments or
has elected to use the CMS service for this function.
Check here if the Exchange plans to use the CMS service for this function: ☐
I attest this activity is
complete ☐

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click here
to enter a date.

f. The individual Exchange will have the capability to conduct annual redeterminations through all
channels pursuant to 45 CFR §155 Subpart D.
I attest this activity is
complete ☐
3.7

Completed/Expected
Completion Date Click here
to enter a date.

Enrollment Transactions and APTC/CSR Information Processing: The Exchange will have the
capability to process individual market QHP enrollment transactions and report and reconcile those
transactions, as well as APTC/CSR information in coordination with issuers and CMS in accordance
with 45 CFR §§ 155.400, 155.430, and 155.720 and relevant CMS guidance.
I attest this activity is
complete ☐

3.8

I attest this activity will be
complete ☐

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click
here to enter a date.

Eligibility Appeals for Individuals, Employers, and SHOP
a. The Exchange will operate an eligibility appeals process for individual consumers pursuant to 45
CFR 155 Subpart F, which includes applicants for the Medicaid and CHIP programs.
I attest this activity is
complete ☐

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click here
to enter a date.

(Check one): The Exchange will ☐ OR ☐ will not delegate authority to the Medicaid and/or CHIP agency to
operate an individual eligibility appeals process for Medicaid and/or CHIP eligibility appeals.

DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
Center for Consumer Information and Insurance Oversight
200 Independence Avenue SW
Washington, DC 20201

b. The Exchange will determine whether it will operate an employer appeals process, pursuant to 45
CFR §§ 155.555(a) and (b), through which an employer may, in response to a notice under 45 CFR
§ 155.310(h), appeal a determination that the employer does not provide minimum essential
coverage through an employer-sponsored plan or that the employer does provide coverage but that
it is not affordable coverage with respect to an employee. If the Exchange elects not to operate an
employer appeals process, appellants will appeal directly to CMS.
I attest this activity is
complete ☐

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click here
to enter a date.

(Check one): The Exchange will ☐ OR ☐ will not operate an employer appeals process.
If applicable: If the Exchange has elected to operate an employer eligibility appeals process, the
Exchange will develop an operational approach that includes employer appeals process flows
depicting the eligibility appeals process and the entity/entities that are responsible for processing and
adjudicating appeals.
I attest this activity is
complete ☐

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click here
to enter a date.

c. The Exchange will establish a SHOP eligibility appeals process for employers and employees
pursuant to 45 CFR § 155.740, including identifying and/or designating the entities responsible for
processing SHOP eligibility appeals.
I attest this activity is
complete ☐
3.9

Completed/Expected
Completion Date Click here
to enter a date.

Electronic Reporting of Eligibility Assessments and Determinations: The Exchange will have
the capability to electronically report results of eligibility determinations, including determinations
of eligibility for an exemption from the individual responsibility requirement (if applicable), and
provide associated information to the agencies administering insurance affordability programs
(i.e., CMS and IRS) as applicable. This includes information necessary to support administration
of the APTC and CSR and support the employer responsibility provisions of the ACA.
I attest this activity is complete
☐

3.10

I attest this activity will be
complete ☐

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click
here to enter a date.

Standards for Applications, Forms, and Notices: The Exchange will provide applications, forms,
and notices to individuals and SHOP employers that adhere to standards in 45 CFR § 155.230 and
155.310.
a. The Exchange will generate applications, forms, and notices for individuals and SHOP employers
that meet accessibility and readability requirements in 45 CFR § 155.205(c). This includes the single,
streamlined application, along with notices of eligibility determination and annual redetermination.
I attest this activity is
complete ☐

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click here
to enter a date.

DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
Center for Consumer Information and Insurance Oversight
200 Independence Avenue SW
Washington, DC 20201

b. The Exchange will provide notices that meet the content and format requirements in 45 CFR §
155.230 and will provide individuals with timely noticing of eligibility determinations in accordance with
45 CFR § 155.310.
I attest this activity is
complete ☐

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click here
to enter a date.

4.0 Plan Management
4.1

Certification of Qualified Health Plans for the Individual Market and SHOP
a. The Exchange will develop the necessary infrastructure to certify QHPs pursuant to 45 CFR §
155.1010(a), including plan management system(s) or processes that support the collection of QHP
issuer and plan data; facilitate the QHP certification process; manage QHP issuers and plans. This
includes the Exchange working in coordination with the appropriate State regulatory entity (e.g.,
State Department of Insurance) to ensure the necessary organizational capacity will be in place.
I attest this activity is
complete ☐

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click here
to enter a date.

b. The Exchange will have a review process in place for ensuring issuers and health plans meet the
minimum QHP certification standards pursuant to CFR § 155.1000(c) and 45 CFR § 156. This
includes the Exchange working in coordination with the appropriate State regulatory entity (e.g., State
Department of Insurance) to ensure the necessary review processes will be in place to ensure the
applicable QHP certification standards are met.
I attest this activity is
complete ☐
4.2

Completed/Expected
Completion Date Click here
to enter a date.

QHP Monitoring and Compliance: The Exchange will have the capacity to ensure QHPs’
ongoing compliance with QHP certification requirements pursuant to 45 CFR § 155.1010(a)(2).
I attest this activity is
complete ☐

4.3

I attest this activity will be
complete ☐

I attest this activity will
be complete ☐

Completed/Expect
ed Completion
Date Click here to
enter a date.

Recertification: The Exchange will have a process in place for QHP issuer recertification which will
at a minimum include a review of initial certification criteria, pursuant to 45 CFR § 155.1075.
I attest this activity is
complete ☐

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click
here to enter a date.

DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
Center for Consumer Information and Insurance Oversight
200 Independence Avenue SW
Washington, DC 20201

4.4

Decertification, and Appeals: The Exchange will have a process in place for QHP
decertification, including appeal of decertification determinations, and notice of
decertification to appropriate parties, pursuant to 45 CFR § 155.1080.
I attest this activity is
complete ☐

4.5

Completed/Expected
Completion Date Click
here to enter a date.

Issuer Accreditation and Enforcement: The Exchange will set a timeline for QHP issuer
accreditation in accordance with 45 CFR § 155.1045. The Exchange will also have 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.
I attest this activity is
complete ☐

4.6

I attest this activity will be
complete ☐

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click
here to enter a date.

Quality Reporting: The Exchange will have 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 CMS pursuant to ACA §§ 1311(c)(1), 1322(e)(3), and
as specified in rulemaking.
I attest this activity is
complete ☐

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click
here to enter a date.

5.0 SHOP
5.1

Employer Size: The state will determine the size of a small employer, as well as methods for
determining whether an employee is a full-time employee (FTE).
I attest this activity is
complete ☐

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click here
to enter a date.

Select the size of a small employer: 1-50: ☐or 1-100: ☐
Select method state will use to count employees: Federal FTE method: ☐ or state method: ☐
5.2

Enrollment: The Exchange will determine whether to perform enrollment functions, or to permit
enrollment directly through QHP issuers and/or registered agents/brokers, or both serve as the
enrollment platform and permit enrollment directly through QHP issuers and/or registered
agents/brokers, in accordance with 45 CFR §155 Subpart H.
I attest this activity is
complete ☐

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click here
to enter a date.

DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
Center for Consumer Information and Insurance Oversight
200 Independence Avenue SW
Washington, DC 20201

Select the Exchange’s enrollment method:
Exchange will provide an enrollment platform: ☐
Exchange will permit enrollment directly through QHP issuers and/or registered agents/brokers: ☐
Exchange will both provide the enrollment platform, as well as permit enrollment directly through QHP issuers
and/or registered agents/brokers: ☐
5.3

Employer and Employee Choice: The Exchange will establish whether or not SHOP will offer
employer and/or employee choice, in accordance with 45 CFR §§ 155.706(b)(2)-(3).
I attest this activity is
complete ☐

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click here
to enter a date.

Select the Exchange’s employee choice method:
Horizontal Choice: ☐
Vertical Choice: ☐
Both: ☐
5.4

Rates: The Exchange will require all QHP issuers to make any changes to rates at uniform time that is
quarterly, monthly, or annually, and prohibits all QHP issuers from varying rates for a qualified
employer during the employer’s plan year, in accordance with 45 CFR § 155.706(b)(6).
I attest this activity is
complete ☐

5.5

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click here
to enter a date.

Premium Calculator: The Exchange will establish the premium calculator for SHOP in accordance
with 45 CFR § 155.706(b) (11).
I attest this activity is
complete ☐

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click here
to enter a date.

Provide website link to premium calculator:
5.6

Uniform Enrollment Timeline: The Exchange will develop a uniform enrollment timeline and process
that includes information pertaining to grace periods, effective dates of coverage, enrollment periods,
and reinstatement policies, in accordance with 45 CFR § 156.286(b).
I attest this activity is
complete ☐

5.7

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complete ☐

Completed/Expected
Completion Date Click here
to enter a date.

Minimum Participation (If applicable): If the Exchange implements minimum participation
requirements in the SHOP, state regulatory authority exists for uniform group participation rules for
offering health insurance coverage in the SHOP.
I attest this activity is
complete ☐

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click here
to enter a date.

DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
Center for Consumer Information and Insurance Oversight
200 Independence Avenue SW
Washington, DC 20201

Provide citation of state regulatory authority for SHOP uniform participation rules:
5.8

Eligibility Determinations: The Exchange will develop and maintain a website that is capable of
providing employer eligibility determinations and facilitating comparison(s) of available QHPs in the
SHOP.
I attest this activity is complete
☐

5.9

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click
here to enter a date.

Electronically Report Results of Employer Eligibility Information for the SHOP: The SHOP will
have the capacity to electronically report information to IRS for tax administration purposes, in
accordance with 45 CFR § 155.721.
I attest this activity is complete
☐

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click
here to enter a date.

6.0 Finance and Accounting
6.1

Cost, Budget, and Management Plan: The Exchange will have a long-term budget (i.e.,
with costs and revenues) and management plan, and will have long-term strategies for
financial sustainability, as required by ACA § 1311(d)(5)(A).
a. The Exchange will establish methods to generate revenue and address any financial deficits.
I attest this activity is
complete ☐

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click here
to enter a date.

b. The Exchange will have the ability to submit, on an annual basis, a multi-year operational budget
and management plan as required by CMS.
I attest this activity is
complete ☐
6.2

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click here
to enter a date.

Financial Accounting Procedures and Financial Statement: The Exchange will keep accurate
financial accounting procedures in accordance with generally accepted accounting principles (GAAP)
pursuant to 45 CFR § 155.1200(a)(1). The Exchange will provide a financial statement in accordance
with GAAP principles by April 1 pursuant to 45 CFR § 155.1200(b)(1).
I attest this activity is
complete ☐

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click
here to enter a date.

DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
Center for Consumer Information and Insurance Oversight
200 Independence Avenue SW
Washington, DC 20201

7.0 Technology
7.1

Information Technology (IT) Operational Readiness Reviews, Consults, and Artifacts: The
Exchange will comply with relevant CMS information technology guidance and will complete IT
operational readiness reviews and consults with CMS.
a. The Exchange will complete IT operational readiness reviews with CMS through successful
completion of all activities, consults, and submission of artifacts and/or completion of all iterations or
functional equivalents for each project phase as agreed to with CMS.
I attest this activity is
complete ☐

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click here
to enter a date.

b. The Exchange will follow necessary CMS guidelines in order to participate in formal Federal
integration testing.
I attest this activity is
complete ☐

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click here
to enter a date.

c. The Exchange will demonstrate all core functionality of its Exchange through an online
demonstration.
I attest this activity is
complete ☐

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click here
to enter a date.

d. The Exchange will participate in IT operational readiness reviews, as appropriate, conducted by the
Centers for Medicaid & CHIP Services (CMCS) as part of its requirements and oversight of IT projects
receiving enhanced Federal financial participation under Title XIX of the Social Security Act. The
Exchange will submit required artifacts and activities or functional equivalents as agreed to with CMS.
I attest this activity is
complete ☐
7.2

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click here
to enter a date.

Essential Functionality: The Exchange will determine its IT integration approach for implementing
essential functionality of its Exchange, such as assigning internal resources and/or contracting for a
systems integrator or for technology services.
I attest this activity is
complete ☐

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click here
to enter a date.

DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
Center for Consumer Information and Insurance Oversight
200 Independence Avenue SW
Washington, DC 20201

8.0 Privacy and Security
All SBEs will need to meet security and privacy standards under 45 CFR §§ 155.260 and 155.280. As a
condition to connect to the FDSH, CMS requires states to use the Minimum Acceptable Risk Standards for
Exchanges (MARS-E) guidance as a minimum standard upon which to base their own security standards.
In addition, SBEs should refer to the checklist in the Privacy and Security Timelines and Artifacts For
Health Insurance Marketplaces, Medicaid/CHIP Agencies and Partner Organizations to determine the
privacy and security documents that apply to them.
8.1

Privacy Standards, Policies and Procedures: The Exchange will establish and implement written
policies and procedures, and will execute required privacy agreements with CMS according to the
standards set forth in 45 CFR § 155.260.
a. The Exchange will complete the ACA Health Insurance Exchange Privacy Impact Assessment
(PIA) and submit to CMS.
I attest this activity is
I attest this activity will be
Completed/Expected
Completion Date Click here
complete ☐
complete ☐
to enter a date.
b. The Exchange will sign and submit the Computer Matching Agreement (CMA) between CMS and
state-based administering entities to CMS.
Completed/Expected
Completion Date Click here
to enter a date.
c. The Exchange will sign and submit the Information Exchange Agreement (IEA) to CMS.

8.2

I attest this activity is
complete ☐

I attest this activity will be
complete ☐

I attest this activity is
complete ☐

I attest this activity will be
complete ☐

I attest this activity is
complete ☐

I attest this activity will be
complete ☐

I attest this activity is
complete ☐

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click here
to enter a date.
Security Standards, Policies and Procedures: The Exchange will establish and implement written
policies and procedures, and will execute required security agreements with CMS according to the
standards set forth in 45 CFR § 155.260.
a. The Exchange will submit its System Security Plan (SSP) workbook to CMS.
Completed/Expected
Completion Date Click here
to enter a date.
b. The Exchange will submit its Independent Security Assessment Report (SAR) to CMS.
Completed/Expected
Completion Date Click here
to enter a date.
c. The Exchange will submit its Plan of Actions & Milestones (POA&M) based on residual risks
identified during the Independent Assessment to obtain an initial Authority to Connect to the FDSH.

DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
Center for Consumer Information and Insurance Oversight
200 Independence Avenue SW
Washington, DC 20201

I attest this activity is
complete ☐

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click here
to enter a date.

d. The Exchange will execute all required Interconnection Security Agreements (ISA) (i.e., Master and
Associate ISAs).
I attest this activity is
complete ☐
8.3

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click here
to enter a date.

IRS FTI Safeguards: The Exchange will establish safeguards to protect the confidentiality of all
Federal information received through the FDSH, including but not limited to Federal tax
information.
a. The Exchange will develop its ACA Safeguards Security Report (SSR) for IRS for approval.
I attest this activity is
complete ☐

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click here
to enter a date.

b. The Exchange will receive a letter of acceptance from the IRS on its Safeguards Security Report
(SSR).
I attest this activity is
complete ☐
8.4

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click here
to enter a date.

Connection to the FDSH Production Environment: The Exchange will implement, and verify
with CMS that it has met, the privacy and security safeguards required to connect to the FDSH
production environment.
a. The Exchange will perform its own System Authorization, and will receive an Authority to Operate
(ATO) from the Exchange authorizing official.
I attest this activity is
complete ☐

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click here
to enter a date.

b. The Exchange will obtain CMS approval for an Authority to Connect (ATC) to the FDSH production
environment.
I attest this activity is
complete ☐

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click here
to enter a date.

DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
Center for Consumer Information and Insurance Oversight
200 Independence Avenue SW
Washington, DC 20201

9.0 Program Integrity and Oversight
9.1

Maintenance of Records: The Exchange will have the capacity to maintain books, records,
documents, and other evidence of procedures and practices to demonstrate compliance with
Federal requirements for each benefit year for at least 10 years pursuant to 45 CFR § 155.1210.
I attest this activity is complete
☐

9.2

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click
here to enter a date.

Program Integrity Reporting: The Exchange will conduct program integrity and oversight activities in
accordance with 45 CFR § 155.1200. This includes completion of the State-based Marketplace
Annual Reporting Tool (SMART); independent external programmatic and financial audits; and
participation in oversight activities and readiness reviews as determined necessary by CMS.
I attest this activity is
complete ☐

9.4

Completed/Expected
Completion Date Click
here to enter a date.

Oversight and Monitoring: The Exchange will establish and implement a comprehensive
oversight and monitoring plan that includes policies and procedures to identify incidents of fraud,
waste, and abuse.
I attest this activity is
complete ☐

9.3

I attest this activity will be
complete ☐

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click
here to enter a date.

Enrollment Metrics: The Exchange will develop policies, procedures, and a timeline for the collection
and reporting of enrollment metrics. The Exchange will submit individual, and if applicable, SHOP
enrollment indicator metric reports in accordance with CMS timelines and templates.
I attest this activity is
complete ☐

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click
here to enter a date.

DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
Center for Consumer Information and Insurance Oversight
200 Independence Avenue SW
Washington, DC 20201

10.0 Contingency Planning
10.1

Contingency/Risk Mitigation Operations
a. The Exchange will establish a contingency plan for any functionality that may not be available or
ready to begin Open Enrollment operations as an SBE, which includes any interim work-around or risk
mitigation plans, as well a plan to move from the work around to a final solution at a later date.
I attest this activity is
complete ☐

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click here to
enter a date.

b. The Exchange will establish both an operational contingency and a recovery operations plan.
I attest this activity is
complete ☐

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click here to
enter a date.

DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
Center for Consumer Information and Insurance Oversight
200 Independence Avenue SW
Washington, DC 20201

PART D: STATE-BASED EXCHANGE ON THE FEDERAL
PLATFORM BLUEPRINT APPLICATION
1.0 Legal Authority & Governance
1.1

SBE-FP Federal Platform Agreement: The Exchange will execute a Federal Platform Agreement
with CMS prior to the beginning of Open Enrollment for any coverage year in which the Exchange
elects to operate on the Federal platform (45 CFR § 155.106(c)(4)).
I attest this activity is
complete ☐

1.2

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click here to
enter a date.
Exchange Enabling Authority: The Exchange will have the appropriate authority to operate an
SBE, including a Small Business Health Options Program (SHOP), compliant with Affordable Care
Act § 1321(b) and applicable rulemaking.

Provide citation and URL of Exchange-enabling authority:
I attest this activity is
complete ☐

1.3

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click here to
enter a date.
Authority to Certify Qualified Health Plans (QHPs): The Exchange will have the appropriate state
authority to perform the certification of QHPs and to oversee QHP issuers consistent with 45 CFR §
155.1010(a), in coordination with the appropriate state insurance oversight entity.

Provide citation and URL of Exchange authority to certify QHPs:

1.4

1.5

I attest this activity is
complete ☐

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click here to
enter a date.
Authority to Generate Revenue: The Exchange will have the appropriate authority to generate
revenue to pay the Federal Platform User Fee and to conduct the activities required as an SBE-FP
and has defined methods for generating revenue (e.g., user fees) (ACA § 1311(d)(5)(A)).
I attest this activity is
complete ☐

I attest this activity will be
complete ☐

I attest this activity is
complete ☐

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click here to
enter a date.
Board and Governance Structure: If the Exchange is an independent state agency or a non-profit
entity established by the state, the Exchange will establish a board and governance structure (ACA
§ 1311(d), 45 CFR § 155.110(c)).
Completed/Expected
Completion Date Click here to
enter a date.

1|Page

DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
Center for Consumer Information and Insurance Oversight
200 Independence Avenue SW
Washington, DC 20201

2.0 Consumer Assistance Tools and Programs
2.1

Stakeholder Consultation: The Exchange will conduct stakeholder consultation to seek input for
the duration of Exchange planning and operation pursuant to 45 CFR § 155.130. This includes
consultation with consumers, small businesses, state Medicaid and CHIP agencies, agents/brokers,
large employers, if applicable, Federally-recognized Tribes, as defined in the Federally Recognized
Indian Tribe List Act of 1994, 25 U.S.C. 479a, and other relevant stakeholders to the extent CMS is
unable to, or in coordination with CMS.
I attest this activity is
complete ☐

2.2

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click here to
enter a date.

Toll-Free Hotline
a. The Exchange will establish and operate a toll-free telephone hotline to respond to requests for
assistance to consumers in the SBE-FP, including the capability to provide information to consumer
and appropriately direct them to the Federal call center or HealthCare.gov to apply for, and enroll in,
QHP coverage pursuant to 45 CFR § 155.205(a).
I attest this activity is
complete ☐

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click here to
enter a date.

b. The Exchange toll-free telephone hotline will provide information to consumers in a manner that
is accessible and timely for individuals living with disabilities and for individuals who have limited
English proficiency, including providing and informing consumers about the availability of auxiliary
aids and services, and oral interpretation at no cost to the consumer, in accordance to CMS
regulations and guidance pursuant to 45 CFR §§ 155.205(c)(1), (c)(2)(i), and (c)(3).
I attest this activity is
complete ☐

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click here to
enter a date.

c. The Exchange outreach and education information will meet accessibility standards including
providing information to consumers in plain language, and in a manner, that is accessible and timely
for individuals living with disabilities and for individuals who have limited English proficiency, in
accordance with CMS regulations and guidance pursuant to 45 CFR § 155.205(c). The Exchange
outreach and education information will inform individuals about the availability of auxiliary aids and
services for people with disabilities, language services at no cost to the individual, oral interpretation,
written translations, and will provide taglines in non-English languages indicating the availability of
language services.
I attest this activity is
complete ☐

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click here to
enter a date.

2|Page

DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
Center for Consumer Information and Insurance Oversight
200 Independence Avenue SW
Washington, DC 20201

2.3

Website
a. The Exchange will establish and maintain an up-to-date website in accordance with 45 CFR §
155.205(b).
I attest this activity is
complete ☐

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click here to
enter a date.

b. The Exchange will operate a website with the capability to provide information to consumers and
direct them to HealthCare.gov to apply for, and enroll in, QHP coverage pursuant to 45 CFR §
155.205(b)(7).
I attest this activity is
complete ☐

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click here to
enter a date.

c. The Exchange will develop, operate, and maintain a tool on its internet website for consumers to
use to find local assisters for help with applying for and enrolling in coverage. HealthCare.gov’s Find
Local Help tool will direct consumers to the SBE-FP’s tool.
I attest this activity is
complete ☐

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click here to
enter a date.

d. The Exchange website will meet accessibility standards including providing information to
consumers in plain language, and in a manner, that is accessible and timely for individuals living
with disabilities and for individuals who have limited English proficiency, in accordance with CMS
regulations and guidance pursuant to 45 CFR § 155.205(c). The Exchange website will inform
individuals about the availability of auxiliary aids and services for people with disabilities, language
services at no cost to the individual, oral interpretation, written translations, and will provide taglines
in non-English languages indicating the availability of language services.
I attest this activity is
complete ☐
2.4

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click here to
enter a date.

Outreach and Education
a. The Exchange will coordinate with CMS to conduct outreach and education activities to educate
consumers about the Exchange and insurance affordability programs, and to encourage consumer
participation in the Exchange as specified in 45 CFR § 155.205(e). These activities could include, for
example, informational marketing materials, advertisements, community outreach events, or other
outreach and education activities that the Exchange determines suitable for its consumers.
I attest this activity is
complete ☐

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click here to
enter a date.

3|Page

DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
Center for Consumer Information and Insurance Oversight
200 Independence Avenue SW
Washington, DC 20201

2.5

Consumer Assistance: The Exchange will implement consumer assistance functions in
accordance with 45 CFR § 155.205(d) including providing referrals to any applicable office of health
insurance consumer assistance or health insurance ombudsman established under section 2793 of
the Public Health Service Act, or any other appropriate State agency or agencies, for any enrollee
with a grievance, complaint, or question regarding their health plan, coverage, or a determination
under such plan or coverage.
I attest this activity is
complete ☐

2.6

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click here to
enter a date.

Navigator Program
a. The Exchange will establish, fund and operate a Navigator program through which it will award
grants to eligible entities or individuals capable of carrying out Navigator duties as required under 45
CFR § 155.210.
I attest this activity is
complete ☐

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click here
to enter a date.

b. The Exchange will develop and publicly disseminate a set of standards to be met by Navigator
grantees designed to prevent or minimize potential conflicts of interest that may exist for entities
or individuals to be awarded grants in accordance with 45 CFR § 155.210(b)(1).
I attest this activity is
complete ☐

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click here to
enter a date.

c. The Exchange will develop and publicly disseminate a set of training standards to be met by
Navigator grantees that will ensure expertise concerning topics such as QHP options, insurance
affordability programs, eligibility and enrollment rules and regulations, privacy and security
standards, and all other requirements in accordance with 45 CFR § 155.210(b)(2).
I attest this activity is
complete ☐

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click here to
enter a date.

d. The Exchange will enter into agreements pursuant to 45 CFR § 155.260(b) with Navigator
grantees to ensure adherence to all terms and conditions of privacy and security standards.
I attest this activity is
complete ☐

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click here to
enter a date.

4|Page

DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
Center for Consumer Information and Insurance Oversight
200 Independence Avenue SW
Washington, DC 20201

2.7

If applicable: Non-Navigator Assistance Personnel
If the Exchange opts to have a non-Navigator assistance personnel program, the
Exchange will maintain full responsibility for program operations, as well as for selecting
and ensuring the proper training of all non-Navigator assistance personnel in the SBE-FP.
Specifically, the SBE-FP will ensure that non-Navigator assistance personnel complete any
required FFE and state-specific training(s) and comply with all applicable regulatory
requirements, including 45 CFR §§ 155.205(d)-(e), 45 CFR 155.215, and 45 CFR
155.260(b).
I attest this activity is
complete ☐

2.8

I attest this activity
will be complete ☐

Completed/Expected
Completion Date
Click here to enter a
date.

Certified Application Counselors (CACs)
a. The Exchange will establish a CAC program pursuant to 45 CFR § 155.225 and will either,
designate an organization to certify CACs to perform specified duties, will directly certify CACs to
perform specified duties, or will implement a combination of both these approaches in establishing
their CAC program.
I attest this activity is
complete ☐

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click here to
enter a date.

b. The Exchange will ensure, either directly, or through designated organizations, that CACs
complete required state-specific training(s) on topics including QHP options, insurance affordability
programs, eligibility and enrollment rules and all other applicable regulatory requirements.
I attest this activity is
complete ☐

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click here to
enter a date.

c. The Exchange will ensure CACs adherence to all terms and conditions of privacy and security
standards pursuant to 45 CFR § 155.260(b).
I attest this activity is
complete ☐
2.9

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click here to
enter a date.

If applicable: Agents and Brokers: A state may permit agents and brokers to assist consumers to
enroll in QHPs pursuant to 45 CFR § 155.220.
a. The Exchange will clearly define the role of agents and brokers including, as applicable, evidence
of licensure, training, and compliance with regulatory requirements under 45 CFR § 155.220.
I attest this activity is
complete ☐

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click here to
enter a date.

5|Page

DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
Center for Consumer Information and Insurance Oversight
200 Independence Avenue SW
Washington, DC 20201

2.10

If applicable: Web Brokers: If the state permits agents and brokers to enroll consumers in QHPs,
and assist consumers in applying for insurance affordability programs pursuant to 45 CFR §
155.220(c)(3), the Exchange will ensure that any agent or broker whose website will be used to
select QHPs will comply with all applicable provisions of 45 CFR § 155.220.
I attest this activity is
complete ☐

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click here to
enter a date.

3.0 Eligibility and Enrollment
3.1

Use of the Federal Platform for the Individual Market Eligibility and Enrollment Functions and
Associated Eligibility Support Functions: As an SBE-FP, the Exchange will use the Federal
platform for eligibility and enrollment functions as a bundled package. These include using the FFE’s
business rules and operational processes related to the processing of consumer applications for
health insurance coverage, eligibility determinations, enrollment processing, exemptions
determinations, annual renewals and redeterminations, special enrollment periods, Form 1095-As,
Medicaid assessments or determinations, employer notifications, eligibility appeals, consumer call
center, and consumer casework.
I attest this activity is
complete ☐

3.2

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click here to
enter a date.

Report Results of Employer SHOP Eligibility Information to IRS for Tax Administration
Purposes:
The Exchange will have the ability to electronically report employer eligibility information to the
Internal Revenue Service (IRS) for tax administration purposes per 45 CFR § 155.720(i). If needed,
the Exchange will ensure it establishes and maintains connectivity to the Federal Data Services Hub
(FDSH) in order to submit SHOP eligibility reporting to IRS.
I attest this activity is
complete ☐

3.4

Completed/Expected
Completion Date Click here to
enter a date.

SHOP Eligibility Determination: The Exchange will have the ability to make employer eligibility
determinations and facilitate comparison(s) of available QHPs in the SHOP.
I attest this activity is
complete ☐

3.3

I attest this activity will be
complete ☐

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click here to
enter a date.

Eligibility Appeals for SHOP: The Exchange will establish a SHOP eligibility appeals process for
employers and employees pursuant to 45 CFR § 155.740, including identifying and/or designating
the entities responsible for processing SHOP eligibility appeals.

6|Page

DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
Center for Consumer Information and Insurance Oversight
200 Independence Avenue SW
Washington, DC 20201

I attest this activity is
complete ☐

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click here to
enter a date.

4.0 Plan Management
4.1

Certification of Qualified Health Plans for the Individual Market and SHOP
a. The Exchange will develop the necessary infrastructure to certify QHPs pursuant to 45 CFR §
155.1010(a), including plan management systems or processes that support the collection of
QHP issuer and plan data; facilitate the QHP certification process; manage QHP issuers and
plans; and review and transmit data to CMS for display of certified QHPs on the Federal platform
in accordance with applicable CMS timelines and requirements. This includes the Exchange
working in coordination with the appropriate State regulatory entity (e.g., State Department of
Insurance) to ensure the necessary organizational capacity will be in place to perform these
functions.
I attest this activity is
complete ☐

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click here to
enter a date.

b. The Exchange will have a review process in place for ensuring issuers and health plans meet
the minimum QHP certification standards pursuant to CFR § 155.1000(c) and 45 CFR § 156. This
includes the Exchange working in coordination with the appropriate State regulatory entity (e.g.,
State Department of Insurance) to ensure the necessary review processes will be in place to
ensure the applicable QHP certification standards are met.
I attest this activity is
complete ☐
4.2

Completed/Expected
Completion Date Click here to
enter a date.

QHP Monitoring and Compliance: The Exchange will have the capacity to ensure QHPs’
ongoing compliance with QHP certification requirements pursuant to 45 CFR § 155.1010(a)(2).
I attest this activity is
complete ☐

4.3

I attest this activity will be
complete ☐

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click here
to enter a date.

Recertification: The Exchange will have a process in place for QHP issuer recertification
which will at a minimum include a review of initial certification criteria, pursuant to 45 CFR §
155.1075.
I attest this activity
is complete ☐

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click here to
enter a date.

7|Page

DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
Center for Consumer Information and Insurance Oversight
200 Independence Avenue SW
Washington, DC 20201

4.4

Decertification, and Appeals: The Exchange will have a process in place for QHP
decertification, including appeal of decertification determinations, and notice of decertification to
appropriate parties, pursuant to 45 CFR § 155.1080.
I attest this activity is
I attest this activity will be
Completed/Expected
complete ☐
Completion Date Click here to
complete ☐
enter a date.

4.5

Issuer Accreditation and Enforcement
a. The Exchange will set a timeline for QHP issuer accreditation in accordance with 45 CFR §
155.1045. The Exchange will also have 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.
I attest this activity is
I attest this activity will be
Completed/Expected
complete ☐
Completion Date Click here to
complete ☐
enter a date.
b. The Exchange will enforce the Federal casework standards in 45 CFR § 156.1010 with respect to
issuers participating in the SBE-FP.
I attest this activity is
complete ☐

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click here to
enter a date.

8|Page

DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
Center for Consumer Information and Insurance Oversight
200 Independence Avenue SW
Washington, DC 20201

5.0 SHOP
5.1

Employer Size: The state will determine the size of a small employer, as well as methods for
determining whether an employee is a full-time employee (FTE).
I attest this activity is
complete ☐

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click here to
enter a date.

Select the size of a small employer: 1-50: ☐or 1-100: ☐
Select method state will use to count employees: Federal FTE method: ☐ or state method: ☐
5.2
Enrollment: The Exchange will determine whether to perform enrollment functions, or to permit
enrollment directly through QHP issuers and/or registered agents/brokers, or both serve as the
enrollment platform and permit enrollment directly through QHP issuers and/or registered
agents/brokers, in accordance with 45 CFR 155 Subpart H.
I attest this activity is
complete ☐

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click here to
enter a date.

Select the Exchange’s enrollment method:
Exchange will provide an enrollment platform: ☐
Exchange will permit enrollment directly through QHP issuers and/or registered agents/brokers: ☐
Exchange will both provide the enrollment platform, as well as permit enrollment directly through QHP issuers
and/or registered agents/brokers: ☐
5.3

Employer and Employee Choice: The Exchange will establish whether or not SHOP will offer
employer and/or employee choice, in accordance with 45 CFR § 155.706(b)(2)-(3).
I attest this activity is
complete ☐

I attest this activity will be
complete ☐

Select the Exchange’s employee choice method:
Horizontal Choice: ☐
Vertical Choice: ☐
5.4

Completed/Expected
Completion Date Click here to
enter a date.

Both: ☐

Rates: The Exchange will require all QHP issuers to make any changes to rates at uniform time that
is quarterly, monthly, or annually, and prohibits all QHP issuers from varying rates for a qualified
employer during the employer’s plan year, in accordance with 45 CFR § 155.706(b)(6).
I attest this activity is
complete ☐

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click here to
enter a date.

9|Page

DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
Center for Consumer Information and Insurance Oversight
200 Independence Avenue SW
Washington, DC 20201

5.5

Premium Calculator: The Exchange will establish the premium calculator for SHOP in accordance
with 45 CFR § 155.706(b)(11).
I attest this activity is
complete ☐

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click here to
enter a date.

Provide website link to premium calculator:
5.6

Uniform Enrollment Timeline: The Exchange will develop a uniform enrollment timeline and
process that includes information pertaining to grace periods, effective dates of coverage, enrollment
periods, and reinstatement policies, in accordance with 45 CFR § 156.286(b).
I attest this activity is
complete ☐

5.7

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click here to
enter a date.

Minimum Participation (If applicable): If the Exchange implements minimum participation
requirements in the SHOP, state regulatory authority exists for uniform group participation rules for
offering health insurance coverage in the SHOP.
I attest this activity is
complete ☐

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click here to
enter a date.

Provide citation of state regulatory authority for SHOP uniform participation rules:
5.8

Eligibility Determinations: The Exchange will develop and maintain a website that is capable of
providing employer eligibility determinations and facilitating comparison(s) of available QHPs in the
SHOP.
I attest this activity is complete
☐

5.9

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click here to
enter a date.

Electronically Report Results of Employer Eligibility Information for the SHOP: The SHOP will
have the capacity to electronically report information to IRS for tax administration, in accordance with
45 CFR § 155.721.
I attest this activity is complete
☐

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click here to
enter a date.

10 | P a g e

DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
Center for Consumer Information and Insurance Oversight
200 Independence Avenue SW
Washington, DC 20201

6.0 Finance and Accounting
6.1

Cost, Budget, and Management Plan: The Exchange will have a long-term budget
(i.e., with costs and revenues) and management plan, and will have long-term strategies
for financial sustainability, as required by ACA § 1311(d)(5)(A).
a. The Exchange will establish methods to generate revenue and address any financial deficits.
I attest this activity is
complete ☐

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click here to
enter a date.

b. The Exchange will have the ability to submit, on an annual basis, a multi-year operational budget
and management plan as required by CMS.
I attest this activity is
complete ☐
6.2

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click here to
enter a date.

Financial Accounting Procedures and Financial Statement: The Exchange will keep accurate
financial accounting procedures in accordance with generally accepted accounting principles (GAAP)
pursuant to 45 CFR § 155.1200(a)(1). The Exchange will provide a financial statement in accordance
with GAAP principles by April 1 pursuant to 45 CFR § 155.1200(b)(1).
I attest this activity is
complete ☐

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click here to
enter a date.

7.0 Technology
7.1

Essential Functionality: The Exchange will determine its IT approach for performing the essential
business functions of the Exchange (e.g., website, plan management, SHOP) by assigning internal
resources or, if needed, contracting for technology services.
I attest this activity is
complete ☐

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click here to
enter a date.

11 | P a g e

DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
Center for Consumer Information and Insurance Oversight
200 Independence Avenue SW
Washington, DC 20201

8.0 Privacy and Security
8.1

Information Disclosure Agreement: In accordance with the Minimum Acceptable Risk Standards
for Exchanges (MARS-E), the Exchange will execute an Information Disclosure Agreement (IDA)
with CMS, or an updated Information Disclosure Agreement, as applicable, to support authorized
sharing of data between CMS and the SBE-FP.
I attest this activity is
I attest this activity will be
Completed/Expected
Completion Date Click here to
complete ☐
complete ☐
enter a date.

9.0 Program Integrity and Oversight
9.1

Maintenance of Records: The Exchange will have the capacity to maintain books, records,
documents, and other evidence of procedures and practices to demonstrate compliance with
Federal requirements for each benefit year for at least 10 years pursuant to 45 CFR § 155.1210.
I attest this activity is
complete ☐

9.2

Completed/Expected
Completion Date Click here to
enter a date.

Oversight and Monitoring: The Exchange will establish and implement a comprehensive oversight
and monitoring plan that includes policies and procedures to identify incidents of fraud, waste, and
abuse.
I attest this activity is
complete ☐

9.3

I attest this activity will be
complete ☐

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click here to
enter a date.

Program Integrity Reporting Procedures: The Exchange will conduct program integrity and
oversight activities in accordance with 45 CFR § 155.1200. This includes completion of the Statebased Marketplace Annual Reporting Tool (SMART); independent external programmatic and
financial audits; and participation in oversight activities and readiness reviews as determined
necessary by CMS.

12 | P a g e

DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
Center for Consumer Information and Insurance Oversight
200 Independence Avenue SW
Washington, DC 20201

I attest this activity is
complete ☐
9.4

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click here to
enter a date.

Enrollment Metrics: The Exchange will develop policies, procedures, and a timeline for the
collection and reporting of enrollment metrics. The Exchange will submit individual, and if applicable,
SHOP enrollment indicator metric reports in accordance with CMS timelines and templates.
I attest this activity is
complete ☐

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click here to
enter a date.

10.0 User Fee
10.1

Assessment of Federal Platform User Fee: In accordance with 45 CFR § 156.50(c)(2), CMS
charges all issuers offering QHPs through SBE-FPs a Federal Platform User Fee for the portion of
Federal platform services and benefits provided to the issuer, and is based upon effectuated
enrollments at the issuer payee level.
The Exchange will agree to payment of the Federal Platform User Fee established through the CMS
Annual Notice of Benefit and Payment Parameters (known as the “Payment Notice”) for each benefit
year. The Exchange will inform CMS of its election regarding how the fee is assessed by October 1
prior to the beginning of Open Enrollment of a given benefit year (e.g., CMS can either collect user
fees from the Exchange or directly from SBE-FP issuer payees).
I attest this activity is
complete ☐

I attest this activity will be
complete ☐

Completed/Expected
Completion Date Click here to
enter a date.

13 | P a g e

DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
Center for Consumer Information and Insurance Oversight
200 Independence Avenue SW
Washington, DC 20201

APPENDIX: EXCHANGE BLUEPRINT APPLICATION UPDATE
REFERENCE FOR TRANSITION OF A STATE-BASED EXCHANGE
TO A STATE-BASED EXCHANGE ON THE FEDERAL PLATFORM
Eligibility and Enrollment
1

Issuer Transition
The Exchange will ensure that issuers offering plans through the SBE-FP are prepared to transition to
the Federal platform for the coverage year in which the SBE-FP will begin operations as an SBE-FP.
The Exchange will communicate to issuers the requirements for exchanging enrollment data with CMS
as part of onboarding to the Federal platform.

2

Completion of Eligibility and Enrollment actions for Prior Plan Years
If transitioning from an SBE, the Exchange will continue processing any outstanding eligibility and
enrollment actions applicable to any prior coverage years for which it operated as an SBE. This
includes, but is not limited to, changes in circumstances, processing of consumer applications for
health insurance coverage, eligibility determinations, enrollment processing, special enrollment
periods, Form 1095-As, employer notifications, eligibility appeals, and consumer casework.

3

FDSH Connectivity
If transitioning from an SBE, the Exchange will ensure it maintains connectivity to the FDSH to
complete its various reporting obligations, as applicable, for any prior plan year for which it operated
as an SBE and to meet all privacy and other related contractual agreements.

4

IRS Reporting
If transitioning from an SBE, the Exchange will ensure proper reporting to the IRS for all coverage
years prior to the transition, which may include retrospective monthly or annual reporting to the IRS.

5

CMS Monthly Enrollment & Payment Data Workbook Reporting
If transitioning from an SBE, the Exchange will ensure that it (or its issuers) submit any outstanding
CMS monthly enrollment and payment data workbook reporting to CMS for all coverage years prior to
the transition, to support CMS payments of advance premium tax credits (APTCs) to the issuers that
provided coverage to APTC-eligible consumers. The Exchange may either submit the reporting itself
or designate its QHP issuers to submit this reporting.

6

CMS Policy Level Enrollment Reporting
If transitioning from an SBE, the Exchange will ensure proper and timely reporting to CMS for all
coverage years prior to the transition.

DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
Center for Consumer Information and Insurance Oversight
200 Independence Avenue SW
Washington, DC 20201

Technology
1

Information Technology (IT) Decommission Plan
If the Exchange has not already decommissioned an existing eligibility and enrollment system and IT
infrastructure, it will develop and execute an Exchange IT Decommission Plan, an IT Systems and
Data Migration Strategy, and any other necessary plans for decommissioning.

Privacy and Security
1

Updated Computer Matching Agreement
In accordance with the Minimum Acceptable Risk Standards for Exchanges (MARS-E), the Exchange
must maintain its Computer Matching Agreement (CMA) in order to complete any eligibility and
enrollment functions applicable for any prior plan years for which it operated as an SBE.

2

Updated Information Exchange Agreement
In accordance with the Minimum Acceptable Risk Standards for Exchanges (MARS-E), the Exchange
must maintain its Information Exchange Agreement (IEA) with CMS in order to complete any Federal
reporting obligations applicable for any prior plan years for which it operated as an SBE. The IEA must
be current in order to maintain connection to the FDSH, through which such reporting is submitted.

3

Updated Interconnection Security Agreement
In accordance with the Minimum Acceptable Risk Standards for Exchanges (MARS-E), the Exchange
must maintain its Interconnection Security Agreement (ISA) with CMS in order to complete any Federal
reporting obligations applicable for any prior plan years for which it operated as a SBE. The ISA must
be current in order to maintain connection to the FDSH, through which such reporting is submitted.

Program Integrity and Oversight
1

Retroactive submission of SMART
If transitioning from an SBE, the Exchange will submit any outstanding SMART, and complete
conducting any applicable audits, for any coverage years during which it operated as an SBE.