Other Resources
- Consumer Support and Information
- Content Requirements for Healthcare.gov
- Pre-Existing Condition Insurance Plan (PCIP)
- Early Retiree Reinsurance Program (ERRP)
- Affordable Insurance Exchanges
- Consumer Operated and Oriented Plan (CO-OP) Program
- Health Insurance Market Reforms
- Payment Policy and Financial Management
- COBRA
- Reports
Consumer Support and Information
Consumer Assistance Program Grants
Reports:
- June 7, 2012
Summary of First Year Consumer Assistance Program Grant Data (PDF - 442 KB)
External Appeals
Model Notice:
- June 22, 2011
Model Notice of Adverse Benefits Determination (PDF – 256 KB)
Model Notice of Final External Review Decision (PDF – 101 KB)
Model Notice of Final Internal Adverse Benefits Determination (PDF – 265 KB)
Notice of Privacy Act Rights:
- September 7, 2010
Notice of Privacy Act Statement for Issuers in States without External Review Laws (PDF -10 KB)
Federal Register Notice:
- August 23, 2010
Federal Register Notice on External Review
Summary of Benefits and Coverage and Uniform Glossary
Forms:
- Summary of Benefits and Coverage (SBC) Template
- Standard Format (Corrected, May 11, 2012) (DOC - 175 KB)
- Accessible Format (Corrected, May 11, 2012) (PDF - 480 KB)
- Chinese (DOC – 54 KB)
- Chinese (PDF- 565 KB)
- Navajo (DOC – 67 KB)
(Note: In order to use the Navajo SBC template in Word format, it may be necessary to install Times New Roman Navajo fonts. Times New Roman Navajo fonts are available free of charge on a number of sources on the Internet.)
- Uniform Glossary
Instructions/Guidance:
- Sample Completed SBC
- Standard Format (Corrected, May 11, 2012) (DOC - 200 KB)
- Accessible Format (Corrected, May 11, 2012) (PDF - 533 KB)
- Instructions for Completing the SBC – Group Health Plan Coverage (PDF – 89 KB)
- Instructions for Completing the SBC – Individual Health Insurance Coverage (PDF – 81 KB)
- Why This Matters language for SBC "Yes" Answers
- Why This Matters language for SBC "No" Answers
- Guide for Coverage Examples Calculations – Maternity Scenario
- Standard Format (XLSX – 91 KB)
- Accessible Format (PDF – 98 KB)
- Guide for Coverage Examples Calculations – Diabetes Scenario
- Standard Format (Corrected May 11, 2012) (XLSX - 56 KB)
- Accessible Format (Corrected May 11, 2012) (PDF - 343 KB)
- Narrative for Maternity Scenario (PDF – 11 KB)
- Narrative for Diabetes Scenario (PDF – 11 KB)
- Checklist for Coverage Calculator (PDF – 43 KB)
- Coverage Examples Calculator Instructions (PDF – 274 KB)
- Coverage Examples Calculator Logic (PDF – 91 KB)
- Coverage Examples Calculator (XLSM – 442 KB) (updated September 7, 2012)
(Note: This version of the coverage examples calculator corrects an error in a previous version that would result in an error message with regard to coverage of preventive services and maximum out-of-pockets. That programming error did not impact the accuracy of the results in either the manual or automated processes, so plans and issuers that have successfully used the previous versions (June 4, 2012 and Updated July 23, 2012) of the calculator may use the results from the previous version.)
Content Requirements for Healthcare.gov
Q&A:
- November 8, 2011
HCR Plan Finder Data Entry
Instructions/Guidance:
- August 1, 2011
State Data Submission Technical Instructions HIOS (PDF – 2 MB) - September 4, 2012
Issuer Data Submission Technical Instructions HIOS (PDF – 4 MB) - August 21, 2012
Issuer Data Submission User Manual RBIS (PDF - 4 MB)
Forms:
- May 11, 2010
HIOS State Data Submission Form (XLS – 347 KB) - April 21, 2011
CMP Issuer Data Entry Forms (ZIP – 209 KB) - September 26, 2011
RBIS Issuer Data Entry Forms (ZIP - 1 MB) - October 27, 2011
HIOS Issuer Data Entry Form (XLS – 2 MB) - December 12, 2011
RBIS Individual Market Issuer Data Entry Forms (ZIP – 2 MB)
Paperwork Reduction Act Documents:
- July 1, 2010
Paperwork Reduction Act for Web Portal - October 1, 2010
Paperwork Reduction Act for Web Portal
Pre-Existing Condition Insurance Plan (PCIP)
Brochures:
- July 2010
The Affordable Care Act – What it Means for Those with Pre-Existing Conditions (PDF – 354 KB)
Posters:
- July 2010
Do You Need Health Insurance, But Have a Pre-Existing Condition? (PDF – 271 KB)
Solicitation:
- May 10, 2010
Solicitation for State Proposals to Operate Qualified High Risk Pools (PDF – 205 KB)
Model Contract:
- Model Contract to Operate a Qualified High Risk Pool (PDF 141 KB)
Data:
- PCIP Data as of May 31 2011
- Update on Federal PCIP September 29, 2011 (PDF 624 KB)
- Update on Federal PCIP December 31, 2011 (PDF - 174 KB)
- Update on Federal PCIP March 31, 2012 (PDF - 122 KB)
- Update on Federal PCIP June 30, 2012 (PDF - 131 KB)
- Update on Federal PCIP September 30, 2012 (PDF - 464 KB)
Reports
- February 23, 2012
Report on the Implementation and Operation of the Pre-Existing Condition Insurance Plan Program (PDF - 330 KB) - February 1, 2013
Annual Report on the Implementation and Operation of the PCIP Program (PDF -300KB)
Early Retiree Reinsurance Program (ERRP)
Reports:
- March 2, 2011
Report on Implementation and Operation of the Early Retiree Reinsurance Program during Calendar Year 2010 (PDF – 269 KB) - March 31, 2011
Progress Report on the Early Retiree Reinsurance Program (PDF – 138 KB) - May 13, 2011
Early Retiree Reinsurance Program: Reimbursement Update (PDF – 190 KB) - June 17, 2011
Early Retiree Reinsurance Program: Reimbursement Update (PDF – 273 KB) - July 15, 2011
Early Retiree Reinsurance Program: Reimbursement Update (PDF – 281 KB) - August 12, 2011
Early Retiree Reinsurance Program: Reimbursement Update (PDF – 280 KB) - September 16, 2011
Early Retiree Reinsurance Program: Reimbursement Update (PDF – 280 KB) - October 14, 2011
Early Retiree Reinsurance Program: Reimbursement Update (PDF – 310 KB) - November 4, 2011
Early Retiree Reinsurance Program: Reimbursement Update (PDF – 397 KB) - November 18, 2011
Early Retiree Reinsurance Program: Reimbursement Update (PDF – 610 KB) - December 9, 2011
Early Retiree Reinsurance Program: Reimbursement Update (PDF – 671 KB) - February 17, 2012
Early Retiree Reinsurance Program: Reimbursement Update (PDF – 646 KB)
February 17, 2012
Early Retiree Reinsurance Program Status Update February 2012 (PDF – 68 KB)
Affordable Insurance Exchanges
Videos:
- August 30, 2010
Stakeholder Conference on Exchange
Presentations:
- September 2011
State Exchange Grantee Meeting Materials - March 2012
Affordable Insurance Exchanges Final Rule (PDF - 749 KB) - May 2012
System-wide Exchange Conference Materials - November 26, 2012
EHB/AV/Accreditation Notice of Proposed Rulemaking (PDF – 593 KB) - January 3, 2013
State Partnership Exchange (PDF – 267 KB)
Forms:
- May 16, 2012
Paperwork Reduction Act (PRA) display of Draft Blueprint for Approval of Affordable State-based and State Partnership Insurance Exchanges (click on CMS – 10416). - August 14, 2012 (Revised November 16, 2012)
Final Blueprint for Exchanges (PDF - 731 KB) - November 9, 2012
Frequently Asked Questions on the Blueprint for Exchanges
Planning and Establishment Grants
Pre-Application Conference Calls (Upcoming)
June 29, 2012
Dates and Times of Pre-Application Conference Calls for Exchange Establishment FOA:- July 19, 2012 – 1:30-3:00pm EST
- October 4, 2012 - 2:00-3:30pm EST
- January 10, 2013 - 2:00-3:30pm EST
- April 4, 2013 - 2:00-3:30pm EST
Call in: 1-877-267-1577; Meeting ID: 2766
Pre-Application Conference Calls (Archive)
- August 5, 2010
Transcript and Audio (MP3 9 MB) - August 25, 2010
Transcript and Audio (MP3 7 MB) - February 3, 2011
Transcript (PDF – 182 KB) and call replay number: 800-947-6840 (valid until 6/29/2012) - March 3, 2011
Transcript (PDF – 118 KB) and call replay number: 800-274-8005 (valid until June 29, 2012) - March 24, 2011
Transcript (PDF – 83 KB) and call replay number: 800-846-1910 (valid until June 29, 2012)
Webinars:
- February 23, 2011
Exchange IT Gap Analysis Webinar Transcript (PDF – 189 KB)
Territory Cooperative Agreement
Pre-Application Conference Calls:
- January 26, 2011
Transcript (PDF – 149 KB) and call replay number: 800-759-6899 (valid until 2/272011)
Information Technology Systems
Transcripts:
- November 8, 2010
Technical Assistance Call on Cooperative Agreements to Support Innovative Exchange Information Technology Systems - November 18, 2010
Technical Assistance Call on Cooperative Agreements to Support Innovative Exchange Information Technology Systems - December 14, 2010
Technical Assistance Call on Cooperative Agreements to Support Innovative Exchange Information Technology Systems
Cover Memo:
- November 3, 2010
To States from OCIIO and CMS on IT for Exchanges and Medicaid (PDF – 103 KB)
Consumer Operated and Oriented Plan (CO-OP) Program
Presentations:
- April 2012
Consumer Operated and Oriented Plan (CO-OP) Program (PDF – 347 KB)
Health Insurance Market Reforms
Annual Limits
Application Information:
- June 17, 2011
Annual Limit Waiver Application Forms and Instructions- Annual Limit Waiver Application—New Application Form (XLS – 49 MB)
- Annual Limit Waiver Application—Waiver Extension Form (XLS – 50 MB)
- Annual Limit Waiver Application Instructions (PDF – 89 KB)
- Annual Limit Waiver Data Dictionary (XLS – 20 KB)
- January 6, 2012
Coverage for Young Adults
Data:
- January 12, 2010
Estimated number of uninsured individuals ages 19-25, by county (XLS – 2 MB)
Grandfathered Plans
Amendment to Regulation:
Medical Loss Ratio
Forms:
- May 19, 2011
Medical Loss Ratio (MLR) 2011 Quarterly Reporting Forms for “Mini-med” and Expatriate Plans- MLR Quarterly Reporting Form for “Mini-med” Plans (XLS – 50 KB)
- MLR Quarterly Reporting Form for Expatriate Plans (XLS – 52 KB)
- MLR Quarterly Reporting Form Instructions (PDF – 68 KB)
- June 17, 2011
Medical Loss Ratio (MLR) 2011 Quarterly Reporting Form Instructions
Please note that these instructions replace an earlier version that had several minor inconsistencies. In addition, these instructions clarify that an issuer who submits reports for more than one State may choose either to submit Excel worksheets for each State report in separate Excel files or to combine the worksheets into a single Excel file.- MLR Quarterly Reporting Form Instructions (PDF – 70 KB)
- May 11, 2012
Medical Loss Ratio (MLR) 2011 Annual Reporting Form (OMB 0938-1164)- MLR Annual Reporting Form (XLSX - 119 KB)
- MLR Annual Reporting Form Instructions (PDF - 204 KB)
- Notice to Subscribers in the Individual Market (Notice #1) (PDF – 38 KB)
- Notice to Group Policyholders and Their Subscribers, Rebate Sent to the Policyholder (Notice #2) (PDF - 54 KB)
- Notice to Subscribers of Group Policyholders, Rebate Sent to the Subscribers (Notice #3) (PDF - 41 KB)
- Instructions for Notices 1, 2 and 3 (PDF - 87 KB)
- May 16, 2012
Notice to Policyholders and Subscribers when MLR Standard is Met (PDF - 15 KB) - December 4, 2012
Paperwork Reduction Act (PRA) display of Medical Loss Ratio (MLR) 2012 Annual Reporting Form (click on “CMS-10418”)- MLR 2012 Annual Reporting Form (XLSX – 116 KB)
- MLR 2012 Annual Reporting Form Instructions (PDF – 639 KB)
Reports:
Patient’s Bill of Rights
Q&A:
- October 13, 2010
Enrollment of Children Under 19 Under the New Policy That Prohibits Pre-Existing Condition Exclusions
Data:
- January 19, 2011
Data Files – First Estimate (XLS – 151 KB)
Data Files – Second Estimate (XLS – 151 KB)
Data Files – First and Second Estimates by State (XLS – 35.5 KB)
Methodology:
- January 12, 2011
Methodology for Children and Adults with Pre-Existing Conditions, by Congressional District
Review of Insurance Rates
- May 27, 2011
Paperwork Reduction Act (PRA) display of Rate Increase Disclosure and Review Reporting Requirements (click on “CMS-10379”) - July 29, 2011 (Update October 11, 2011: rate review training manuals, instructions, and other materials are now located under Training Resources. Please click on the link below.)
Rate Review Training Resources - September 20, 2011
Report: Early Achievements of Health Insurance Rate Review Grants (PDF - 268 KB)
Note: The Cycle II proposal summary for the California Department of Managed Health Care was corrected on September 22, 2011. - September 11, 2012
Annual Rate Review Report - November 20, 2012
Paperwork Reduction Act (PRA) display of Rate Increase Disclosure and Review Requirements (click on “CMS-10379”)- Proposed Unified Rate Review Data Template (XLSX – 66 KB)
Self-Funded Non-Federal Governmental Plans
HIPAA Opt-Out Materials:
- September 21, 2010
Memo on Amendments to the HIPAA Opt-Out Provision made by the Affordable Care Act (PDF – 44 KB) - April 1, 2011
Procedures and Requirements for HIPAA Exemption Election
Model HIPAA Exemption Election Document (PDF – 78 KB)
Model Notice to Enrollees of HIPAA Exemption (PDF – 7 KB) - May 23, 2012
List of HIPAA Opt-Out Elections for Self-Funded, Non-Federal Government Plans (PDF– 336 KB)
Payment Policy and Financial Management
White Papers:
- September 12, 2011
Risk Adjustment Implementation Issues – White Paper (PDF – 2 MB)
Questions and Answers on Risk Adjustment White Paper
Risk Adjustment Spring Meeting (May 7-8, 2012):
- CMS-9966-N: Notice of Meeting (PDF - 194 KB)
- Registration: Register by April 30, 2012, 5 pm est.
To register, please visit the Registration Website. - Conference Materials
- Risk Adjustment Overview (PDF – 268 KB)
- Reinsurance, Risk Corridors, and Risk Adjustment Final Rule: Risk Adjustment (PDF – 252 KB)
- HHS Risk Adjustment Model (PDF – 340 KB)
- Risk Adjustment Payment Transfer Methodology (PDF – 763 KB)
- State Flexibility and Alternate Methodologies (PDF – 336 KB)
- Risk Adjustment Program: HHS Operations (PDF – 608 KB)
- Proposed Technical Concept: Distributed Data Processing (PDF – 290 KB)
- State Flexibility and Risk Adjustment Implementation (PDF – 410 KB)
Presentations:
- March 23, 2012
Reinsurance, Risk Corridors, and Risk Adjustment Final Rule (PDF – 361 KB)
COBRA
Forms:
- October 17, 2012
CMS Request for Review of Premium Assistance Denial (PDF - 992 KB)
Reports
GAO
- March 16, 2011
"Private Health Insurance: Data on Application and Coverage Denials" (PDF – 1.13 MB)