CMS-10507 SMART SBE Annual Alternative Redeterminations Template

FINAL AS OF 11/05/2021
CMS OPTIONAL TEMPLATE

OMB CONTROL NUMBER: 0938-1244
EXPIRATION DATE: XX/XX/XXXX

State Exchange Annual Eligibility Redeterminations
Alternative Procedures Template
Background
Regulations under 45 CFR §155.335 require that Exchanges re-determine the eligibility of a qualified individual on an annual basis.
The Exchange must conduct annual redeterminations using one of the following methods:
•
•
•

Option 1 -The procedures described in §155.335(a)(2)(i).
Option 2- Alternative procedures specified by the Secretary for the applicable benefit year §155.335(a)(2)(ii); or
Option 3- Alternative procedures to be approved by the Secretary under §155.335 (a)(2)(iii).
Under this section, Exchanges have the flexibility to submit alternative procedures to be approved by the Secretary. The
alternative procedures must:
• Demonstrate that Exchange would facilitate continued enrollment in coverage for which the enrollee remains eligible.
• Provide clear information about the process to the qualified individual or enrollee (including regarding any action by
the qualified individual or enrollee necessary to obtain the most accurate redetermination of eligibility).
• Provide adequate program integrity protections.

Review and Approval for SBE Redetermination and Re-Enrollment Plans
All states newly electing to be State-based Exchanges (SBE) must submit their redetermination and re-enrollment plans to CMS for
review as part of the Blueprint Application approval process. Subsequently SBEs must submit their re-determination and reenrollment plans for the upcoming Open Enrollment through the annual SMART submission, and identify any changes from their
previous reviewed plan. States have the option to submit the plans on the following template. CMS reviews each SBE redetermination plan in accordance with 155.335 and conducts any necessary follow up during the SBE’s Open Enrollment Readiness
Review. Any identified non-compliance issues are identified and addressed through the SMART.

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INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for
internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full
extent of the law.

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OMB CONTROL NUMBER: 0938-1244
EXPIRATION DATE: XX/XX/XXXX

SBE Redeterminations and Reenrollment Procedures for Plan Year [XXXX]
Procedures

SBE Response

1. Have there been any updates or operational changes to this
year’s alternative redeterminations plan from the year
prior? Please describe any major programmatic, policy, or
operational changes that impact the eligibility redetermination
process that will be implemented for you Exchange for this plan year.

Eligibility Redeterminations

SBE Response

1. Provide a description of the SBE’s process for conducting eligibility
redeterminations, including:
a. Dates for conducting the redeterminations (specific date or date
range).
b. Type of consumers who receive a redetermination (e.g., only
existing enrolled consumers or all consumers who were
previously determined eligible).
c. Steps for handling consumers without an active authorization to
obtain tax information for use in annual re-determination.
2. Provide an overview of how consumer eligibility is determined,
including:
a. Eligibility verifications that will be conducted via the Federal
Data Services Hub (FDSH).
b. Eligibility verifications that are conducted using data sources
other than through the FDSH.
i. If there are non-FDSH data sources used, what
are they and for what type of eligibility
verification?
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INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for
internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full
extent of the law.

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Procedures

OMB CONTROL NUMBER: 0938-1244
EXPIRATION DATE: XX/XX/XXXX

SBE Response

c. Confirmation that eligibility will be redetermined using updated
eligibility data (i.e., the updated federal poverty level tables, the
applicable benchmark plan, and premium and affordability
percentage adjustments).
d. Whether income verifications will be conducted using the FDSH
Renewal and Redetermination Verification (RRV) service, or the
FDSH IFSV synchronous service for eligibility redeterminations.
e. What kinds of income values returned from the FDSH (e.g.
AGI, MAGI, or both) is the SBE able to use in eligibility
redeterminations? How are these income values used in
eligibility redeterminations?

3. Any anticipated changes in FDSH utilization, particularly any anticipated
increased usage of FDSH, from previous years

Re-Enrollment Process
1. Describe the populations or groups who will be eligible for automatic reenrollment, including:
a. Type of groups who will not be eligible for automatic reenrollment and any income thresholds applied.
b. Percentage of consumers you expect to be eligible for autorenewals.
2. Describe the procedures for mapping consumers to another plan, if their
plan is no longer offered.
a. If using a plan crosswalk, please provide details.
3. Provide a timeline for sending re-enrollment transactions to carriers,
including:

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INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for
internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full
extent of the law.

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Procedures

OMB CONTROL NUMBER: 0938-1244
EXPIRATION DATE: XX/XX/XXXX

SBE Response

a. Date/date range when auto-renewals will be reflected in plan
selections.
4. Describe any major policy or operational changes to this year’s annual
redetermination process that will be implemented for this plan year.

Program Integrity Updates

SBE Response

1. Confirm the SBEs processes and procedures regarding the “Failure to
Reconcile” (FTR) tax filing requirements in compliance with
155.305(f)(4) for the coming plan year, include:
a. FTR codes that will be applied (i.e. 007, 009, 010)
b. Timing to apply FTR codes (i.e. at redetermination, or later in the
benefit year)
c. Confirmation of whether consumers will be allowed to self-attest
to meeting their tax filing and reconciliation requirement to
override the FTR data flag from the IRS.
i. If so, confirm whether consumer attestations will be
rechecked against IRS data at a later date; and
ii. Confirm the date/timeframe when consumer attestations
will be rechecked against IRS data.
2. Describe the actions that will be taken (i.e. removal of APTC) as a result
of FTR flags indicating consumers have not met their tax filing and
reconciliation requirements, include:
a. Noticing approach and timelines.

Consumer Outreach and Education Approach

SBE Response

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INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for
internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full
extent of the law.

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Procedures

OMB CONTROL NUMBER: 0938-1244
EXPIRATION DATE: XX/XX/XXXX

SBE Response

1. Describe the SBEs consumer outreach and education procedures
regarding redeterminations and renewals during open enrollment,
including:
a. Number and type of notices, and content for each
population/group of consumers.
b. Whether actual or projected premium rates are included in the
notice(s).
c. Whether actual or projected APTC amounts included in
consumer notice(s).
2. Describe your QHP issuers’ consumer outreach and noticing approach
regarding open enrollment and renewals, include:
a. Description of the content that will be included in consumer
notices from QHP issuers.
b. Description of the timeline issuers utilize to notice consumers
regarding open enrollment and renewal activities.

Paperwork Reduction Act Statement

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INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for
internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full
extent of the law.

FINAL AS OF 11/05/2021
CMS OPTIONAL TEMPLATE

OMB CONTROL NUMBER: 0938-1244
EXPIRATION DATE: XX/XX/XXXX

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INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for
internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full
extent of the law.