Form CMS-10840 Agent Broker Consent Form

Appendix A - Agent Broker Consent Form

The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless specifically incorporated into a contract. This document is intended only to provide clarity to the public regarding existing requirements under the law. This model consent form will not supersede any State Agent of Record, Broker of Record, or other form required by a QHP issuer for purposes of paying compensation to the proper agent, broker or web-broker for assisting a particular consumer.

Purpose Statement:

Agents, brokers, and web-brokers (agents and brokers) helping consumers enroll in coverage through Federally- facilitated Marketplaces (FFMs) and State-based Marketplaces on the Federal Platform (SBM-FPs) (collectively, Marketplace), or helping a consumer apply for advance payments of the premium tax credit (APTC) or cost- sharing reductions (CSRs) for qualified health plans (QHPs) offered through Exchanges, must document receipt of consent from a consumer or the consumer’s authorized representative before they provide assistance. Agents and brokers must also document that the consumer (or authorized representative) reviewed eligibility application information and confirmed that it was accurate before the application is submitted.

CMS regulations prescribe the content that must be included as part of this documentation, but they don’t prescribe how agents and brokers must document consumer consent or how the consumer must review and confirm eligibility application information accuracy. Agents and brokers can use different documentation formats for these purposes, such as a recorded phone call, text message, email, electronic document with digital signatures, or physical document with wet signatures. This model consent form serves as an example for how agents and brokers may document consumer consent and consumer review/confirmation of eligibility application information accuracy via a physical document with wet signatures.

This model consent form is a best practice for documenting the receipt of consumer consent and consumer review and confirmation of the accuracy of eligibility application information. You may tailor the form to address the needs of your specific business model. For example, if an agency is involved, you may specify who else within the agency (other than the writing agent) is able to view and use the consumer’s personally identifiable information (PII) to help the writing agent enroll the consumer in Marketplace coverage for compliance, commissions, or other relevant purposes as you see fit.

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 0938-1438. This information collection specifically details what information will be required to be collected and maintained by agents, brokers, and web- brokers were they to receive a request from HHS for consent records. This information collection will provide HHS with documentation that may be used for monitoring, audit, and enforcement activities. The time required to complete this information collection is estimated to take up to 10 minutes per applicant per year, which includes the time to review instructions, search existing data resources, gather the data needed, to review and complete the information collection. This information collection is pursuant to 45 C.F.R. §155.220(c)(5), which states that HHS or its designee may periodically monitor and audit an agent, broker, or web-broker under this subpart to assess its compliance with the applicable requirements of this section. 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, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850, Attention: Information Collections Clearance Officer or email Brian Gubin at [email protected].

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CMS Model Consent Form for Marketplace Agents, Brokers, Web-brokers, and Agencies

I, [insert name of consumer or consumer’s authorized representative], give my permission for [insert name of the person or entity who has the consumer’s consent] to serve as the health insurance agent or broker for myself or my household for purposes of enrolling in a Qualified Health Plan.

I authorize the (pick applicable and delete the rest: agent/broker/web-broker/agency) named above to use the confidential information I provide in writing, electronically, or by phone ONLY for these purposes:

• Searching for an existing Marketplace application.

• Completing an application to enroll in a Marketplace Qualified Health Plan, apply for Medicaid or the Children’s Health Insurance Program (CHIP), or apply for premium tax credits to lower my monthly insurance payment.

• Keeping my Marketplace account up to date and helping with enrollment tasks.

• Responding to inquiries from the Marketplace about my Marketplace application.

By signing this form, I understand that the (pick applicable and delete the rest: agent/broker/web- broker/agency):

• Won’t use or share my confidential information for any other purposes.

• Will protect my confidential information when they collect, share, use or store it.

• Won’t ask for additional confidential or protected health information other than what’s required on the Marketplace application.

I understand that my consent will stay in effect until [insert duration of consent], and I can revoke or change my consent at any time by [insert method to revoke consent].

Name of household contact and/or

Authorized Representative: Phone: Email:

Signature: Date:

Name of primary writing

agent/broker/web-broker: Agent National Producer Number:

Phone:

Email:

Name of agency (if applicable): Agency National Producer Number: Owner of agency:

Phone:

Email:

CMS Model Eligibility Application Review Form for Marketplace Agents, Brokers, Web-brokers, and Agencies

I, [insert name of consumer or consumer’s authorized representative], reviewed the Marketplace eligibility application information and confirmed that it was accurate before the application was submitted.

• The (pick one and delete the rest: agent/broker/web-broker) explained the attestations at the end of the application to me before the application was submitted and I had the chance to ask questions about them.

By signing this form, I understand that the (pick applicable and delete the rest: agent/broker/web- broker/agency):

• Won’t use or share my confidential information for any other purposes.

• Will protect my confidential information when they collect, share, use or store it.

• Won’t ask for additional confidential or protected health information other than what’s required on the Marketplace application.

Name of primary writing agent/broker/web-broker: Agent National Producer Number:

Phone:

Email:

Name of agency (if applicable): Agency National Producer Number: Owner of agency:

Phone: Email:

Name of household contact and/or Authorized Representative: Phone:

Email:

Signature: Date:

Model Consent Verbal Script

This script can be used to meet consent documentation requirements when helping a Marketplace consumer over the phone. This script is intended to be used when consent is being granted to a single agent, broker, or web-broker but may be updated to reflect consent granted to multiple people, if/when appropriate. The conversation should be recorded (where permitted under state law) and producible to CMS on request. This script must be read at the beginning of the conversation with the consumer because you must get consent before you help a consumer apply for or enroll in Marketplace coverage.

Agent: “Hello, my name is [say your name]. Today is [say today’s date, including month and year] Who am I speaking with today?”

Agent: “Do I have your permission to collect, share, use and store your personal information to help you apply for and enroll in a Qualified Health Plan? Your permission would allow me to:

• Search for an existing Marketplace application

• Complete an application to enroll in a Marketplace Qualified Health Plan, apply for Medicaid or Children’s Health Insurance Program (CHIP), or apply for premium tax credits to lower your monthly insurance payment

• Keep your Marketplace account up to date and help with enrollment tasks

• Respond to inquiries from the Marketplace about your Marketplace application

Agent: “Thank you. The consent you just granted will stay in effect until [insert duration of consent]. You can revoke your consent at any time by [state how the consumer may revoke their consent].”

Model Eligibility Application Review Verbal Script

This script can be used to meet requirements related to the review and accuracy confirmation of eligibility application information when enrolling a consumer over the phone. The conversation should be recorded (when allowed under state law) and producible to CMS on request. This script must be read before submitting the consumer’s Marketplace application or enrollment.

Agent: “Hello, my name is [say your name]. Today is [say today’s date, including month and year] Who am I speaking with today?”

Agent: “Let me explain the attestations at the end of the eligibility application. [Explain the attestations to the consumer]. Do you have any questions about the attestations I just explained?”

Agent: “Before I submit your eligibility application, let's review the information you gave during this conversation to confirm it’s accurate and complete. [Review the information on the eligibility application with the consumer]. Have you reviewed the information on the eligibility application and confirmed it’s accurate?”