The Center for Consumer Information & Insurance Oversight
Regulations and Guidance
- Affordable Care Act
- Consumer Support and Information
- Content Requirements for Plan Finder
- Pre-Existing Condition Insurance Plan (PCIP)
- Early Retiree Reinsurance Program (ERRP)
- Health Insurance Marketplaces
- Minimum Acceptable Risk Standards
- Premium Stabilization Programs
- State Innovations
- Consumer Operated and Oriented Plan (CO-OP) Program
- Other Insurance Protections
- Health Insurance Market Reforms
- Health Insurance Portability and Accountability Act of 1996 (HIPAA)
Affordable Care Act
Guidance
- November 4, 2014
Group Health Plans that Fail to Cover In-Patient Services - April 14, 2015
Key Dates in 2015: QHP Certification in the FFM; Rate Review; Risk Adjustment, Reinsurance, and Risk Corridors - December 23, 2015
Key Dates in 2016: QHP Certification in the FFM; Rate Review; Risk Adjustment, Reinsurance and Risk Corridors - February 29, 2016
Final: Key Dates in 2016: QHP Certification in the FFM; Rate Review; Risk Adjustment, Reinsurance and Risk Corridors - July 21, 2016
[CMS–9931-NC] Coverage for Contraceptive Services ACTION: Request for information - November 10, 2016
Proposed Key Dates in 2017: QHP Certification in the FFM; Rate Review; Risk Adjustment, and Reinsurance - December 16, 2016
Final Key Dates in 2017: QHP Certification in the FFM; Rate Review; Risk Adjustment and Reinsurance
Consumer Support and Information
External Appeals
Regulations
- July 23, 2010
OCIIO-9993-IFC: Interim Final Rules for Group Health Plans and Health Insurance Issuers Relating to Internal Claims and Appeals and External Review Processes Under the Patient Protection and Affordable Care Act - Opens in a new window (PDF – 257 KB) - June 22, 2011
CMS-9993-IFC2: Group Health Plans and Health Insurance Issuers: Rules Relating to Internal Claims and Appeals and External Review Processes - Opens in a new window
- July 26, 2011
CMS-9993-CN: Group Health Plans and Health Insurance Issuers: Rules Relating to Internal Claims and Appeals and External Review Processes; Correction - Opens in a new window (PDF - 184 KB)
Guidance
- August 26, 2010
Notice: Availability of Interim Procedures for Federal External Review and Model Notices Relating to Internal Claims and Appeals and External Review Under the Patient Protection and Affordable Care Act - Opens in a new window - August 26, 2010
Technical Guidance: Interim Procedures for Federal External Review Relating to Internal Claims and Appeals and External Review For Health Insurance Issuers in the Group and Individual Markers and under the Patient Protection and Affordable Care Act (PDF – 51 KB) - September 1, 2010
Technical Guidance: Issuers in the Individual Market to Establish County Level Estimates Pertaining to the Culturally and Linguistically Appropriate Standards Set Forth in the Internal Claims and Appeals and External Review Processes under the Patient Protection and Affordable Care Act (PDF – 26 KB) - September 20, 2010
Guidance: Interim Procedures for Internal Claims and Appeals under the Patient Protection and Affordable Care Act (PDF – 29 KB) - September 23, 2010
Technical Guidance: Interim Procedures for Federal External Review Relating to Internal Claims and Appeals and External Review under the Patient Protection and Affordable Care Act for Self-Insured Non-Federal Government Health Plans (PDF – 17 KB) - March 18, 2011
Technical Guidance: Extension of Non-Enforcement Period Relating to Certain Interim Procedures for Internal Claims and Appeals under the Patient Protection and Affordable Care Act - Opens in a new window - June 22, 2011
Technical Release 2011-02: Guidance on External Review for Group Health Plans and Health Insurance Issuers Offering Group and Individual Health Coverage, and Guidance for States on State External Review Processes (PDF – 381 KB) - June 22, 2011
Technical Guidance- June 22, 2011: Updated Instructions for Calculating County Level Estimates Pertaining to the Culturally and Linguistically Appropriate Standards Set Forth in the Internal Claims and Appeals and External Review Processes under the Affordable Care Act (PDF – 54 KB) - August 17, 2012
Technical Guidance: Content of Notices – Adverse Benefit Determinations and Final Internal Adverse Benefit Determinations for Beneficiaries in Non-Federal Governmental Health Plans (PDF – 64 KB) - March 15, 2013
Technical Guidance: Extension of the Transition Period for the Temporary NAIC-Similar State External Review Process under the Affordable Care Act (PDF – 208 KB) - July 24, 2013
Technical Guidance - July 24, 2013: Updated Instructions for Calculating County Level Estimates Pertaining to the Culturally and Linguistically Appropriate Standards Set Forth in the Internal Claims and Appeals and External Review Processes under the Affordable Care Act (PDF – 298 KB) - June 15, 2015
Technical Guidance – June 15, 2015: Instructions for Self-Insured Non-Federal Governmental Health Plans and Health Insurance Issuers Offering Group and Individual Health Coverage on How to Elect a Federal External Review Process (PDF - 29 KB) - January 11, 2017
Technical Guidance – January 11, 2017: Standards for Self-Insured Non-Federal Governmental Health Plans and Health Insurance Issuers Offering Group and Individual Health Coverage Using the HHS-Administered Federal External Review Process (PDF - 77 KB) - January 12, 2017
Technical Guidance January 12, 2017: Instructions for Self-Insured Non-Federal Governmental Health Plans and Health Insurance Issuers Offering Group and Individual Health Coverage on How to Elect a Federal External Review Process (PDF - 31 KB)
Summary of Benefits and Coverage and Uniform Glossary
Regulations
- August 22, 2011
CMS-9982-P: Summary of Benefits and Coverage and the Uniform Glossary - Opens in a new window - February 14, 2012
CMS-9982-F: Summary of Benefits and Coverage and Uniform Glossary - Opens in a new window - December 22, 2014
CMS-9938-P: Summary of Benefits and Coverage and Uniform Glossary - June 12, 2015
CMS-9938-F: Summary of Benefits and Coverage and Uniform Glossary
Guidance
- August 22, 2011
Notice: Summary of Benefits and Coverage and Uniform Glossary - Templates, Instructions, and Related Materials under the Public Health Service Act - Opens in a new window - February 14, 2012
Summary of Benefits and Coverage and Uniform Glossary - Templates, Instructions, and Related Materials, and Guidance for Compliance - Opens in a new window
February 2016 Proposed Supporting Materials for Public Comment
- Proposed SBC Blank Template
- Proposed Uniform Glossary
- Proposed SBC Sample Completed Template
- Proposed Why This Matters language for SBC "No" Answers
- Proposed Why This Matters language for SBC "Yes" Answers
- Proposed Instructions for Completing the SBC – Individual Health Insurance Coverage
- Proposed Instructions for Completing the SBC – Group Health Plan Coverage
- Proposed Guide for Coverage Examples Calculations – Maternity Scenario, Diabetes Scenario, and Foot Fracture
- Proposed Coverage Examples Narrative – Maternity Scenario
- Proposed Coverage Examples Narrative – Diabetes Scenario
- Proposed Coverage Examples Narrative – Foot Fracture
Language Access Guide for Exchanges, Qualified Health Plan (QHP) Issuers, and Web-Brokers
- March 30, 2016
Technical Guidance – March 30, 2016 Guidance and Population Data for Exchanges, Qualified Health Plan Issuers, and Web-Brokers to Ensure Meaningful Access by Limited-English Proficient Speakers Under 45 CFR §155.205(c) and §156.250 - January 13, 2017
Appendix A: Top 15 Non-English Languages by State* - January 13, 2017
Appendix B: Sample Translated Taglines – Languages Are Listed in Alphabetical Order*
*Updated with minor corrections to the information posted March 30, 2016. Entities that relied on the information in the March 30, 2016 appendices for 2016 or 2017 Plan Year materials will not be penalized.
Content Requirements for Plan Finder
Regulations
- May 5, 2010
Health Care Reform Insurance Web Portal Requirements (PDF – 368 KB)
Guidance
- May 3, 2010
Memorandum: User Access and Authorization for the Health Insurance Oversight System
Pre-Existing Condition Insurance Plan (PCIP)
Regulations
- July 30, 2010
OCIIO–9995–IFC: Pre-Existing Condition Insurance Plan Program - Opens in a new window (PDF – 198 KB) - August 30, 2012
CMS–9995–IFC2: Pre-Existing Condition Insurance Plan Program - Opens in a new window - May 22, 2013
CMS–9995–IFC3: Pre-Existing Condition Insurance Plan Program - Opens in a new window
Guidance
- October 6, 2010
The Pre-Existing Condition Insurance Plan Program and Newborn Coverage (PDF – 105 KB) - December 28, 2010
Portability of Coverage, Enrollee Notices, and Third Party Payments (PRD – 57 KM) - February 17, 2011
Eligibility for Children under Age 19 in the Federally-Administered Pre-Existing Condition Insurance Plan (PDF – 166 KB) - March 23, 2011
Pre-Existing Condition Insurance Plan Eligibility and Access to Other Creditable Coverage (PDF – 145 KB) - May 31, 2011
PCIP Premium and Benefit Revisions(PDF – 31 KB) - May 31, 2011
Question and Answer Regarding Anti-Dumping Provisions Related to the Pre-Existing Condition Insurance Plan Program (PDF – 13 KB) - May 25, 2012
Management of PCIP Program in 2012 (PDF - 75 KB) - April 24, 2014
Special Enrollment Period for Individuals Losing Coverage through the Pre-Existing Condition Insurance Program (PCIP) on April 30, 2014
Early Retiree Reinsurance Program (ERRP)
Regulations
- May 5, 2010
Early Retiree Reinsurance Program (PDF – 132 KB)
Guidance
- June 3, 2010
CMS-SORN: Privacy Act of 1974 Report of New System of Records (System No. 09-90-0250) - April 5, 2011
CMS-9996-N ERRP Program Notice to Stop Accepting Applications - December 13, 2011
CMS-9996-N2: Early Retiree Reinsurance Program Notice regarding Incurred Claims Date - March 21, 2012
CMS-9996-N3: Early Retiree Reinsurance Program Notice regarding the Date by which Plan Sponsors Must Use Funds - March 27, 2012
Explanation of the Appeal Process for the Early Retiree Reinsurance Program(PDF – 78 KB) - April 23, 2013
CMS-9996-N4: Early Retiree Reinsurance Program Notice regarding Termination of Several Operational Processes
Health Insurance Marketplaces
Regulations
- July 15, 2011
CMS-9989-P:Establishment of Exchanges and Qualified Health Plans - Opens in a new window (PDF - 425 KB) - August 17, 2011
CMS-9974-P: Exchange Functions in the Individual Market: Eligibility Determinations; Exchange Standards for Employers - Opens in a new window (PDF - 319 KB) - August 17, 2011
CMS-2349-P: Medicaid Program; Eligibility Changes under the Affordable Care Act of 2010 - Opens in a new window (PDF - 394 KB) - August 17, 2011
REG-131491-10: Health Insurance Premium Tax Credits - Opens in a new window (PDF - 247 KB) - September 30, 2011
Patient Protection and Affordable Care Act: Establishment of Exchanges and qualified Health Plans and Standards Related to Reinsurance, Risk Corridors, and Risk Adjustment: Extension of Comment Period - Opens in a new window (PDF - 143 KB) - March 16, 2012
Regulatory Impact Analysis: Establishment of Exchanges and Qualified Health Plans (CMS-9989-FWP) and Standards Related to Reinsurance Risk Corridors and Risk Adjustment (CMS-9975-F) (PDF - 315 KB) - March 27, 2012
CMS-9989-F: Establishment of Exchanges and Qualified Health Plans; Exchange Standards for Employers - Opens in a new window (PDF - 906 KB) - May 29, 2012
CMS-9989-CN: Establishment of Exchanges and Qualified Health Plans; Exchange Standards for Employers; Correction - Opens in a new window - January 14, 2013
CMS-2334-P: Essential Health Benefits in Alternative Benefit Plans, Eligibility Notices, Fair Hearing and Appeal Processes for Medicaid and Exchange Eligibility Appeals - Opens in a new window - January 30, 2013
CMS-9958-P: Eligibility for Exemptions; Miscellaneous Minimum Essential Coverage Provisions - Opens in a new window - March 11, 2013
CMS-9964-P2: Establishment of Exchanges and Qualified Health Plans; Small Business Health Options Program - Opens in a new window - April 3, 2013
CMS-9955-P: Patient Protection and Affordable Care Act; Exchange Functions: Standards for Navigators and Non-Navigator Assistance Personnel - Opens in a new window how do yo - June 4, 2013
CMS-9964-F2: Establishment of Exchanges and Qualified Health Plans; Small Business Health Options Program - Opens in a new window - June 14, 2013
CMS-9957-P: Patient Protection and Affordable Care Act; Program Integrity: Exchange, SHOP, Premium Stabilization Programs, and Market Standards - Opens in a new window - June 26, 2013
CMS-9958-F: Patient Protection and Affordable Care Act; Exchange Functions: Eligibility for Exemptions; Miscellaneous Minimum Essential Coverage Provisions - Opens in a new window - July 5, 2013
CMS-2334-F: Medicaid and Children’s Health Insurance Programs: Essential Health Benefits in Alternative Benefit Plans, Eligibility Notices, Fair Hearing and Appeal Processes, and Premiums and Cost Sharing; Exchanges: Eligibility and Enrollment - Opens in a new window - July 12, 2013
CMS-9955-F: Patient Protection and Affordable Care Act; Exchange Functions: Standards for Navigators and Non-Navigator Assistance Personnel; Consumer Assistance Tools and Programs of an Exchange and Certified Application Counselors - Opens in a new window - August 28, 2013
CMS-9957-F: Patient Protection and Affordable Care Act; Program Integrity: Exchange, SHOP, and Eligibility Appeals - October 24, 2013
CMS-9957-F2: Patient Protection and Affordable Care Act; Program Integrity: Exchange, Premium Stabilization Programs, and Market Standards; Amendments to HHS Notice of Benefit and Payment Parameters for 2014 - December 12, 2013
CMS-9945-IFC: Patient Protection and Affordable Care Act; Maximizing January 1, 2014 Coverage Opportunities - December 31, 2013
CMS-9957-CN: Patient Protection and Affordable Care Act; Program Integrity: Exchange, Premium Stabilization Programs, and Market Standards; Amendments to HHS Notice of Benefit and Payment Parameters for 2014 Correction (PDF- 176 KB) - June 26, 2014
CMS-9941-P: Patient Protection and Affordable Care Act; Annual Eligibility Redeterminations for Exchange Participation and Insurance Affordability Programs; Health Insurance Issuer Standards Under the Affordable Care Act, Including Standards Related to Exchanges (PDF) - September 2, 2014
CMS-9941-F: Patient Protection and Affordable Care Act; Annual Eligibility Redeterminations for Exchange Participation and Insurance Affordability Programs; Health Insurance Issuer Standards Under the Affordable Care Act, Including Standards Related to Exchanges (PDF) - May 6, 2016
CMS-9933-IFC: Patient Protection and Affordable Care Act; Amendments to Special Enrollment Periods and the Consumer Operated and Oriented Plan Program - December 12, 2016
CMS-3337-IFC: Conditions for Coverage for End-Stage Renal Disease Facilities
Guidance
- November 3, 2010
Guidance: Exchange and Medicaid Information Technology (IT) Systems (PDF -110 KB) - November 18, 2010
Guidance: Initial Guidance to States on Exchanges - May 31, 2011
Guidance: Guidance for Exchange and Medicaid Information Technology (IT) Systems: Version 2.0 (PDF – 401 KB) - November 29, 2011
State Exchange Implementation Questions and Answers (PDF – 135 KB) - April 26, 2012
Verification of Access to Employer-Sponsored Coverage Bulletin (PDF - 122 KB) - May 16, 2012
General Guidance on Federally-facilitated Exchanges (PDF – 196 KB) - December 10, 2012
Exchanges, Market Reforms and Medicaid Frequently Asked Questions (PDF – 251 KB) - January 3, 2013
Guidance on State Partnership Exchange (PDF – 226 KB) - March 1, 2013
Draft 2014 Letter to Issuers on Federally-facilitated and State Partnership Exchanges (PDF - 450 KB) - April 5, 2013
2014 Letter to Issuers on Federally-facilitated and State Partnership Exchanges (PDF - 430 KB) - May 1, 2013
Role of Agents, Brokers, and Web-brokers in Health Insurance Marketplaces (PDF - 507 KB) - May 10, 2013
Small Business Health Options Program (SHOP)-Only Marketplace (PDF - 34 KB) - June 18, 2013
Guidance on State Alternative Applications for Health Coverage [PDF, 138KB] - June 26, 2013
Guidance on Hardship Exemption Criteria and Special Enrollment Periods (PDF – 203 KB) - July 12, 2013
Guidance on Certified Application Counselor Program for the Federally Facilitated Marketplace including State Partnership Marketplaces (PDF – 79 KB) - July 12, 2013
Sample Application: Apply to be a Certified Application Counselor (CAC) Organization (PDF – 209 KB) - August 9, 2013
Guidance on State Alternative Applications for Health Coverage through the Small Business Health Options Program (SHOP) (PDF – 128 KB) - September 27, 2013
Guidance on Internal Revenue Ruling 2013-17 and Eligibility for Advance Payments of the Premium Tax Credit and Cost-Sharing Reductions [PDF, 205KB] - October 3, 2013
Federally Facilitated Marketplace Enrollment Operational Policy & Guidance [PDF, 680KB] - January 10, 2014
The Sale of Individual Market Policies to Medicare Beneficiaries Under 65 Losing Coverage Due to High Risk Pool Closures - January 31, 2014
Frequently Asked Questions on the Sale of Individual Market Policies to Medicare Beneficiaries Under 65 Losing Coverage Due to High Risk Pool Closures [PDF, 75KB] - February 4, 2014
Draft 2015 Letter to Issuers in the Federally-facilitated Marketplaces - February 27, 2014
CMS Bulletin to Marketplaces on Availability of Retroactive Advance Payments of the PTC and CSRs in 2014 Due to Exceptional Circumstances [PDF, 165KB] - March 13, 2014
Casework Guidance for Issuers in Federally-facilitated Marketplaces, including State Partnership Market Places [PDF, 139KB] - March 14, 2014
2015 Letter to Issuers in the Federally-facilitated Marketplaces [PDF, 344KB] - March 26, 2014
Guidance for Issues on People "In Line" for the Federally-facilitated Marketplace at the end of the Initial Open Enrollment Period [PDF, 66KB] - March 26, 2014
Guidance for Issues on Special Enrollment Periods for Complex Cases in the Federally-facilitated Marketplace after the Initial Open Enrollment Period [PDF, 110KB] - March 31, 2014
Shared Responsibility Provision Question and Answer [PDF, 60KB] - May 2, 2014
Special Enrollment Periods and Hardship Exemptions for Persons Meeting Certain Criteria [PDF, 216KB] - June 26, 2014
Guidance on Annual Redeterminations for Coverage for 2015 (PDF, 154KB) - September 18, 2104
Shared Responsibility Guidance – Filing Threshold Hardship Exemption - September 18, 2014
Shared Responsibility Guidance – Exemption for Individuals Eligible for Services through an Indian Health Care Provider - October 6, 2014
Guidance on Hardship Exemptions, Age Offs, and Renewal of Catastrophic Coverage - October 24, 2014
Guidance for Issuers on the Termination of a Consumer’s Enrollment in the Federally-facilitated Marketplace Due to Death - November 21, 2014
Guidance on Hardship Exemptions for Persons Meeting Certain Criteria - December 1, 2014
Guidance for Issuers on 2015 Reenrollment in the Federally-facilitated Marketplace - December 19, 2014
Draft 2016 Letter to Issuers in the Federally-facilitated Marketplaces - February 20, 2015
Final 2016 Letter to Issuers in the Federally-facilitated Marketplaces - March 20, 2015
- Guidance on Hardship Exemptions for Persons Meeting Certain Criteria
- March 31, 2015
Guidance for Ending Special Enrollment Periods for Coverage during Calendar Year 2014 - April 22, 2015
Guidance on Annual Eligibility Re-determinations and Re-enrollments for Marketplace Coverage for 2016 - May 29, 2015
CMS Bulletin on Proposed Out-Of-Pocket (OOP) Cost Comparison Tool for the Federally-facilitated Marketplaces (FFMs) - June 12, 2015
Distribution of Information Regarding Advance Payments of the Premium Tax Credit (APTC) and Cost-Sharing Reductions (CSR) in Federal Standard Notices for Coverage Offered through the Federally-facilitated Marketplaces - July 27, 2015
Updated Guidance on Victims of Domestic Abuse and Spousal Abandonment - August 25, 2015
Guidance for Issuers on 2016 Reenrollment in the Federally-facilitated Marketplace (FFM) - October 1, 2015
Federally-facilitated Marketplace and Federally-facilitated Small Business Health Options Program Enrollment Manual - October 29, 2015
CMS Final Bulletin on Out-of-Pocket (OOP) Cost Comparison Tool for the Federally-facilitated Marketplaces (FFMs) - December 4, 2015
Issuer Guidance for Handling 2015 Unaffiliated Issuer Enrollments and Clarification to Section V of Bulletin 16: Guidance for Issuers on 2016 Reenrollment in the Federally-Facilitated Marketplaces - December 4, 2015
Policy-Based Payments Bulletin: Approach to 2016 Marketplace Payment Program Integrity, Withholding for Issuers Delayed on Policy-Based Payments Implementation, and Payment Adjustment for Issuers Deemed Policy-Based Payments Ready - December 23, 2015
Draft 2017 Letter to Issuers in the Federally-facilitated Marketplaces - February 29, 2016
Final 2017 Letter to Issuers in the Federally-facilitated Marketplaces - March 22, 2016
Policy-Based Payments: April 2016 Transition of All Issuers to Policy-based Payments and Subsequent Adjustments Only in Cases of Extreme Variation Between Policy-based Payments and the Manual Payment Process - April 1, 2016
Guidance for Ending Special Enrollment Periods for Coverage during Calendar Year 2015 - April 18, 2016
Extension of State-based SHOP Direct Enrollment Transition - May 2, 2016
Policy-Based Payments: Reversal of January 2016 – April 2016 Adjustments in the May and June Payment Cycles - May 10, 2016
Guidance on Annual Eligibility Redetermination and Re-enrollment for Marketplace Coverage for 2017 - June 1, 2016
Effectuation of 2016 Federally-Facilitated Marketplace Dental Enrollment – INFORMATION - June 29, 2016
Guidance for State-based Marketplaces No Cost Extensions in 2017 - July 19, 2016
Federally-facilitated Marketplace (FFM) and Federally-facilitated Small Business Health Options Program (FF-SHOP) Enrollment Manual - August 12, 2016
Guidance on Health Coverage Tax Credit Hardship Exemption - August 19, 2016
CMS Bulletin on Network Breadth Information for Qualified Health Plans on Healthcare.gov - September 6, 2016
Frequently Asked Questions Regarding Verification of Special Enrollment Periods - September 30, 2016
Updated CMS Bulletin on Network Breadth Information for Qualified Health Plans on HealthCare.gov - November 10, 2016
Draft 2018 Letter to Issuers in the Federally-facilitated Marketplaces - December 12, 2016
Policy-Based Payments Bulletin: Temporary Manual Adjustment - Easing Cash Flow Impact of the 2017 Transition for Issuers on Policy-Based Payments - December 16, 2016
Final 2018 Letter to Issuers in the Federally-facilitated Marketplaces
Plan Management
Regulations
- June 5, 2012
CMS-9965-P: Data Collection to Support Standards Related to Essential Health Benefits; Recognition of Entities for the Accreditation of Qualified Health Plans - Opens in a new window - July 18, 2012
CMS-9965-F: Data Collection to Support Standards Related to Essential Health Benefits; Recognition of Entities for the Accreditation of Qualified Health Plans - Opens in a new window - November 26, 2012
CMS-9961-N: Recognition of Entities for the Accreditation of Qualified Health Plans - Opens in a new window - November 26, 2012
CMS-9980-P: Standards Related to Essential Health Benefits, Actuarial Value, and Accreditation - Opens in a new window - February 20, 2013
CMS-9980-F: Standards Related to Essential Health Benefits, Actuarial Value, and Accreditation - Opens in a new window
Additional Information on State EHB Benchmark Plans
2014 Actuarial Value Calculator (XLSM – 1.4 MB)
2014 Actuarial Value Calculator Methodology (PDF - 214 KB)
*See below under Premium Stabilization/Regulations for 2015 Actuarial Value Calculator and Methodology and 2016, 2017 and 2018 Actuarial Value Calculator and Methodologies are under the Guidance portion of this section.
Minimum Value Calculator (XLSM – 598 KB)
Minimum Value Calculator Methodology (PDF - 154 KB)
Guidance
- December 16, 2011
Essential Health Benefits Bulletin (PDF - 104 KB) - January 25, 2012
Essential Health Benefits: Illustrative List of the Largest Three Small Group Products by State (PDF – 135 KB) - February 17, 2012
Frequently Asked Questions on the Essential Health Benefits Bulletin (PDF – 88 KB) - February 24, 2012
Actuarial Value and Cost-Sharing Reductions Bulletin (PDF - 123 KB) - July 2, 2012
Essential Health Benefits: List of the Largest Three Small Group Products by State (PDF – 183 KB) - January 28, 2013
Issuers of Stand-alone Dental Plans (PDF - 223 KB) - February 20, 2013
State Evaluation of Plan Management Activities of Health Plans and Issuers (PDF - 35 KB) - November 19, 2013
Notice with Comment: Quality Rating System (QRS), Framework Measures, and Methodology - May 6, 2014
Issuers of Stand-alone Dental Plans - August 15, 2014
State Technical Assistance on State-Specific Data for Actuarial Value Calculator
Actuarial Value Calculator Continuance Tables - January 16, 2015
2016 Actuarial Value Calculator
2016 Actuarial Value Calculator Methodology - February 19, 2015
Issuers of Stand-alone Dental Plans - April 08, 2015
Essential Health Benefits: List of the Largest Three Small Group Products by State (PDF – 243 KB) - May 19, 2015
Updated Essential Health Benefits: List of the Largest Three Small Group Products by State (PDF 181 KB) - August 28, 2015
List of Proposed 2017 EHB Benchmark Plans and Related Information - November 9, 2015
List of Final 2017 EHB Benchmark Plans and Related Information - January, 21, 2016
2017 Actuarial Value Calculator
2017 Actuarial Value Calculator Methodology - March 7, 2016
Issuers of Stand-alone Dental Plans - April 29, 2016
CMS Bulletin on display of Quality Rating System (QRS) star ratings and Qualified Health Plan (QHP) Enrollee Survey results for QHPs offered through Marketplaces- September 30, 2016
UPDATE: CMS Quality Rating Information Bulletin
- September 30, 2016
- August 8, 2016
Notice to States Regarding Marketplace Auto Re-Enrollment - September 1, 2016
PY2017 QHP Issuer Certification and Privacy and Security Agreement - September 2, 2016
Frequently Asked Questions Regarding Crosswalk of Enrollees into Plans Offered by Other Issuers - September 16, 2016
FAQ on Compliance Safe Harbor for Issuers Affected by an Increase in Enrollment for the 2017 Plan Year - December 16, 2016
2018 Actuarial Value Calculator
2018 Actuarial Value Calculator Methodology
Eligibility Appeals
Guidance
- October 24, 2014
Paper-Based Appeals Process - March 22, 2016
Paper-Based Appeals Process
Minimum Acceptable Risk Standards
Guidance:
- August 1, 2012
Harmonized Security and Privacy Framework – Exchange Reference Architecture Supplement V1.0 (PDF – 487 KB)
Minimum Acceptable Risk Standards for Exchanges – Exchange Reference Architecture Supplement, V1.0 (PDF - 185 KB)
Catalog of Minimum Acceptable Risk Controls for Exchanges – Exchange Reference Architecture Supplement, V1.0 (PDF - 1,994 KB) - November 10, 2015
Volume 1: MARS-E v2.0: Harmonized Security and Privacy Framework
Volume 2: MARS-E v2.0: Minimum Acceptable Risk Standards for Exchanges
Volume 3: MARS-E v2.0: Catalog of Security and Privacy Controls
Volume 4: MARS-E v2.0: ACA Administering Entity System Security Plan
Premium Stabilization Programs
Regulations
- July 15, 2011
CMS-9975-P: Standards Related to Reinsurance, Risks Corridors and Risk Adjustment - Opens in a new window (PDF - 281 KB) - July 15, 2011
CMS-9989-P2: Preliminary Regulatory Impact Analysis: Establishment of Exchanges and Qualified Health Plans (CMS-9989-P) and Standards Related to Reinsurance, Risk Corridors and Risk Adjustment (CMS-9975-P) (PDF – 204 KB) - March 16, 2012
Regulatory Impact Analysis: Establishment of Exchanges and Qualified Health Plans (CMS-9989-FWP) and Standards Related to Reinsurance, Risk Corridors and Risk Adjustment (CMS-9975-F) (PDF – 315 KB) - March 23, 2012
CMS-9975-F: Standards Related to Reinsurance, Risks Corridors and Risk Adjustment - Opens in a new window (PDF - 336 KB) - December 7, 2012
CMS-9964-P: HHS Benefit and Payment Parameters for 2014, and Medical Loss Ratio - Opens in a new window - March 11, 2013
CMS-9964-F: HHS Benefit and Payment Parameters for 2014 - Opens in a new window - March 11, 2013
CMS-9964-IFC: Amendments to the HHS Notice of Benefit and Payment Parameters for 2014 - Opens in a new window - November 25, 2013
CMS-9954-P: Proposed HHS Notice of Benefit and Payment Parameters for 2015 - March 4, 2014
CMS-9954-F: HHS Notice of Benefit and Payment Parameters for 2015 - November 21, 2014
CMS-9954-P: Proposed HHS Notice of Benefit and Payment Parameters for 2016 - February 20, 2015
CMS-9944-F: Final HHS Notice of Benefit and Payment Parameters for 2016 - November 20, 2015
CMS-9937-P: Proposed HHS Notice of Benefit and Payment Parameters for 2017 - February 29, 2016
CMS-9937-F: Final HHS Notice of Benefit and Payment Parameters for 2017 - August 29, 2016
CMS-9934-P: Proposed HHS Notice of Benefit and Payment Parameters for 2018 - December 16, 2016
CMS-9934-F: Final HHS Notice of Benefit and Payment Parameters for 2018
Guidance
- May 1, 2012
Bulletin on the Risk Adjustment Program: Proposed Operations by the Department of Health and Human Services (PDF – 207 KB) - May 31, 2012
Bulletin on the Transitional Reinsurance Program: Proposed Payment Operations by the Department of Health and Human Services (PDF – 187 KB) - June 2, 2014
2014 Benefit Year Risk Adjustment HHS-Developed Risk Adjustment Model Algorithm Software - 2014 Benefit Year Risk Adjustment SAS Version of HHS-Developed Risk Adjustment Model Algorithm Software (SASsoftware.zip)
- Sample Datasets
- October 20, 2014
The Transitional Reinsurance Program: Availability of the ACA Transitional Reinsurance Program Annual Enrollment and Contributions Submission Form on Pay.gov - April 14, 2015
Transitional Reinsurance Program’s Contribution Collections for the 2014 Benefit Year - April 14, 2015
Transitional Reinsurance Program – Timing of Contributions Refund Requests - April 17, 2015
Transitional Adjustment for 2014 Risk Corridors Program - April 24, 2015
Evaluation of EDGE Data Submissions Bulletin for the 2014 Benefit Year - April 27, 2015
EDGE Data Submission Grace Period Bulletin for the 2014 Benefit Year - August 7, 2015
Preliminary Risk Corridors Program Results for the 2014 Benefit Year - August 13, 2015
Overview of Draft Fiscal Year 2016 ICD-10 Crosswalk for HHS-HCC Risk Adjustment Model
Draft Fiscal Year 2016 ICD-10 Crosswalk for HHS-HCC Risk Adjustment Model - September 2, 2015
Adjustment of Risk Adjustment Transfers Due to Submission of Incorrect Data - October 9, 2015
Early Reinsurance Payments for the 2015 Benefit Year - October 19, 2015
2015 Benefit Year Risk Adjustment: HHS-Developed Risk Adjustment Model Algorithm “Do It Yourself (DIY)” Software - November 19, 2015
Risk Corridors Payments for the 2014 Benefit Year Guidance - January 20, 2016
- February 12, 2016
- March 16, 2016
Cost-Sharing Reduction Reconciliation Guidance for Benefit Years 2014 and 2015 Final - March 18, 2016
Evaluation of EDGE Data Submissions Bulletin for the 2015 Benefit Year - March 18, 2016
Cost-Sharing Reduction Reconciliation Error Codes - March 28, 2016
Cost-Sharing Reduction Reconciliation Attestation Error Codes - April 15, 2016
Extension of Data Submission Deadline for Cost-sharing Reduction Reconciliation - April 28, 2016
Cost-Sharing Reduction Reconciliation Error Codes - June 17, 2016
Alternative Schedule for Payment of Charges for Reconciliation of the Cost-sharing Reduction Portion of Advance Payments for the 2014 and 2015 Benefit Years - June 23, 2016
Cost-Sharing Reduction Discrepancy Reporting Inbound Specification - June 27, 2016
Alternative Schedule for Payment of Charges for Reconciliation of the Cost-sharing Reduction Portion of Advance Payments for the 2014 and 2015 Benefit Years - July 1, 2016
Alternative Schedule for Payment of Charges for Reconciliation of the Cost-sharing Reduction Portion of Advance Payments for the 2014 and 2015 Benefit Years Issuer Agreement - July 6, 2016
Alternative Schedule for Payment of Charges for Reconciliation of the Cost-sharing Reduction Portion of Advance Payments for the 2014 and 2015 Benefit Years Extension - July 15, 2016
Netting of Payments and Charges under 45 CFR 156.1215 - August 5, 2016
Reporting Cost-sharing Reduction Amounts for 2015 MLR and Risk Corridors - November 2, 2016
Cost-Sharing Reduction Reconciliation Guidance for Benefit Year 2016 DRAFT - November 18, 2016
Risk Corridors Payments and Charge Amounts for the 2015 Benefit Year - December 19, 2016
2016 Benefit Year Risk Adjustment: HHS-Developed Risk Adjustment Model Algorithm “Do It Yourself (DIY)” Software
Instructions (PDF)
Technical Details (Excel)
2016 Benefit Year Risk Adjustment: SAS Version of HHS-Developed Risk Adjustment Model Algorithm Software (SASsoftware.zip) - December 23, 2016
Evaluation of EDGE Data Submissions for 2016 Benefit Year - December 27, 2016
Final Cost-Sharing Reduction Reconciliation Guidance for Benefit Year 2016 - January 5, 2017
Final Cost-Sharing Reduction Reconciliation Issuer to MIDAS Inbound Specification for the 2016 Benefit Year and Prior Year Restatements
Final Cost-Sharing Reduction Reconciliation Issuer to MIDAS Attestation Inbound Specification for the 2016 Benefit Year and Prior Year Restatements
Final Cost-Sharing Reduction Reconciliation Data File Error Code List for the 2016 Benefit Year and Prior Year Restatements
Final Cost-Sharing Reduction Reconciliation Attestation File Error Code List for the 2016 Benefit Year and Prior Year Restatements
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State Innovations
Regulations
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Consumer Operated and Oriented Plan (CO-OP) Program
Regulations
- June 23, 2010
Establishment of the Consumer Operated and Oriented Plan (CO-OP) Advisory Board - Opens in a new window
- July 20, 2011
Establishment of the Consumer Operated and Oriented Plan (CO-OP) Program - Opens in a new window - December 13, 2011
CMS-9983-F: Patient Protection and Affordable Care Act, Establishment of Consumer Operated and Oriented Plan (CO-OP) Program - Opens in a new window (PDF - 244 KB) - February 10, 2012
IRS Revenue Procedures Published in the Federal Register For Tax-Exempt 501(c)(29) Qualified Nonprofit Health Insurance Issuers - April 4, 2013
Questions and Answers on Consumer Operated and Oriented Plan Program Contingency Fund (PDF - 168 KB)
Guidance
- July 29, 2015
CO-OP Program Guidance Manual
- June 23, 2010
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Other Insurance Protections
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Mental Health Parity
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Regulations
Guidance
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Health Insurance Market Reforms
- November 26, 2012
CMS-9979-P: Incentives for Wellness Programs in Group Health Plans - Opens in a new window - November 26, 2012
CMS-9972-P:Patient Protection and Affordable Care Act: Health Insurance Market Rules; Rate Review - Opens in a new window - January 30, 2013
CMS-9958-P: Eligibility for Exemptions; Miscellaneous Minimum Essential Coverage Provisions - Opens in a new window - February 27, 2013
CMS-9972-F:Patient Protection and Affordable Care Act: Health Insurance Market Rules; Rate Review - Opens in a new window - June 3, 2013
CMS-9979-F: Incentives for Nondiscriminatory Wellness Programs in Group Health Plans - Opens in a new window - March 14, 2014
- May 16, 2014
CMS-9949-F: Patient Protection and Affordable Care Act; Exchange and Insurance Market Standards for 2015 and Beyond - October 28, 2016
CMS-9932-F: Excepted Benefits; Lifetime and Annual Limits; and Short-Term, Limited-Duration Insurance
Guidance
- January 25, 2013
Employer Prescription Drug Coverage that Supplements Medicare Part D Coverage provided through an Employer Group Waiver Plan (PDF - 216 KB) - February 25, 2013
Guidance Regarding Age Curves, Geographical Rating Areas and State Reporting (PDF - 175 KB)
State Rating Requirements Disclosure Form (DOC - 33 KB) - May 6, 2013
Model Language for Individual Market Renewal Notices (PDF - 56 KB) - October 31, 2013
Minimum Essential Coverage Guidance (PDF - 181 KB)
Minimum Essential Coverage Resources - November 20, 2013
Procedural Guidance Regarding State Reporting for Plan or Policy Years Beginning in 2015 [PDF, 108KB] - November 21, 2013
Standard Notices for Transition to ACA Compliant Policies (PDF – 153 KB)
Questions on Transition to ACA Compliant Policies [PDF, 113KB] - December 19, 2013
Options Available for Consumers with Cancelled Policies (PDF – 79 KB) - January 3, 2014
Questions and Answers on Options Available for Consumers with Cancelled Policies [PDF, 125KB] - March 3, 2014
Extended Transition to Affordable Care Act-Compliant Policies [PDF, 147KB] - March 14, 2014
Frequently Asked Question on Coverage of Same-Sex Spouses [PDF, 131KB] - March 14, 2014
Draft Notices When Discontinuing or Renewing a Product in the Group or Individual Market (PDF – 227 KB) - June 26, 2014
Draft Standard Notices When Discontinuing or Renewing a Product in the Small Group or Individual Market [PDF, 528KB] - June 26, 2014
Instructions for Draft Standard Notices for Product Discontinuation and Renewal [PDF, 153KB] - September 2, 2014
Form and Manner of Notices When Discontinuing or Renewing a Product in the Group or Individual Market (Final Notices) - February 13, 2015
Minimum Essential Coverage Application Review Process - July 7, 2015
Guidance on Federal Standard Notices of Product Discontinuation and Renewal in Connection with the Open Enrollment Period for the 2016 Coverage Year - February 29, 2016
Extension of Transitional Policy through Calendar Year 2017 - April 21, 2016
Draft Updated Federal Standard Renewal and Product Discontinuation Notices - September 2, 2016
Final Updated Federal Standard Renewal and Product Discontinuation Notices
Annual Limits
Regulations
Guidance
- September 3, 2010
OCIIO Sub-Regulatory Guidance: Process for Obtaining Waivers of the Annual Limits Requirements of PHS Act Section 2711(PDF – 48 KB) - November 5, 2010
OCIIO Supplemental Guidance: Waivers of the Annual Limits Requirements (PDF – 61 KB) - December 9, 2010
OCIIO Supplemental Guidance: Consumer Notices on Waivers of the Annual Limits Requirements (PDF – 53 KB) - December 9, 2010
OCIIO Supplemental Guidance: Sale of New Business by Issuers Receiving Waivers (PDF-55 KB) - June 17, 2011
CCIIO Supplemental Guidance (CCIIO 2011 – 1D): Concluding the Annual Limit Waiver Application Process (PDF – 76 KB) - August 19, 2011
CCIIO Supplemental Guidance (CCIIO 2011 - 1E): Exemption for Health Reimbursement Arrangements that are Subject to PHS Act Section 2711 (PDF - 44 KB)
Association Coverage
Guidance
- September 1, 2011
CCIIO Technical Guidance: Application of Individual and Group Market Requirements under Title XXVII of the Public Health Service Act when Insurance Coverage Is Sold to, or through, Associations (PDF – 56 KB)
Coverage for Young Adults
Regulations
- May 13, 2010
OCIIO – 4150 – IFC: Group Health Plans and Health Insurance Issuers Relating to Dependent Coverage of Children to Age 26 Under the Patient Protection and Affordable Care Act - Opens in a new window
(PDF – 178 KB)
Guidance
- October 13, 2010
Q&A: Enrollment of Children Under 19 Under the New Policy That Prohibits Pre-Existing Condition Exclusions
Employer Responsibility
Guidance
- October 13, 2010
Frequently Asked Questions from Employers Regarding Automatic Enrollment, Employer Shared Responsibility, and Waiting Periods (PDF - 93 KB) - August 31, 2012
Waiting Period Guidance Under Public Health Service Act Section 2708 (PDF – 87 KB) - March 21, 2013
CMS-9952-P: Ninety-Day Waiting Period Limitation and Technical Amendments to Certain Health Coverage Requirements Under the Affordable Care Act - Opens in a new window - September 16, 2013
Application of Affordable Care Act Provisions to Certain Healthcare Arrangements (PDF – 135 KB)
Grandfathered Plans
Regulations
- June 17, 2010
OCIIO–9991–IFC: OCIIO–9991–IFC: Interim Final Rules for Group Health Plans and Health Insurance Coverage Relating to Status as a Grandfathered Health Plan Under the Patient Protection and Affordable Care Act - Opens in a new window
(PDF – 258) - November 15, 2010
OCIIO–9991–IFC2: OCIIO–9991–IFC2: Amendment to the Interim Final Rules for Group Health Plans and Health Insurance Coverage Relating to Status as a Grandfathered Health Plan Under the Patient Protection and Affordable Care Act - Opens in a new window
Medical Loss Ratio
Regulations
- December 1, 2010
OCIIO–9998–IFC: Health Insurance Issuers Implementing Medical Loss Ratio (MLR) Requirements Under the Patient Protection and Affordable Care Act - Opens in a new window (PDF – 2 MB) - Technical Appendix
Interim Final Rule for Health Insurance Issuers Implementing Medical Loss Ratio (MLR) Requirements under the Patient Protection and Affordable Care Act (PDF – 300 KB) - Technical Correction (December 30, 2010)
Technical Correction to the Medical Loss Ratio Interim Final Rule - Opens in a new window (PDF – 59 KB) - December 7, 2011
CMS-9998-FC: Medical Loss Ratio Requirements under the Patient Protection and Affordable Care Act - Opens in a new window
CMS-9998-IFC2: Medical Loss Ratio Rebate Requirements for Non-Federal Governmental Plans - Opens in a new window - May 16, 2012
CMS-9998-F: Medical Loss Ratio Requirements under the Patient Protection and Affordable Care Act - Opens in a new window - May 16, 2012
CMS-9998-IFC3: Medical Loss Ratio Requirements under the Patient Protection and Affordable Care Act; Correcting Amendment - Opens in a new window - November 30, 2012
CMS-9964-P: HHS Benefit and Payment Parameters for 2014, and Medical Loss Ratio - Opens in a new window - March 11, 2013
CMS-9964-F: HHS Benefit and Payment Parameters for 2014 - Opens in a new window
Guidance
- December 17, 2010
OCIIO Technical Guidance: Process for a State to Submit a Request for Adjustment to the Medical Loss Ratio Standard of PHS Act Section 2718 (PDF – 35 KB) - April 26, 2011
CCIIO Technical Guidance: Submission of 2011 Quarterly Reports of MLR Data by Issuers of “Mini-med” and Expatriate Plans (PDF – 26 KB) - May 13, 2011
CCIIO Technical Guidance: Questions and Answers Regarding the Medical Loss Ratio Interim Final Rule (PDF – 75 KB) - May 19, 2011
CCIIO Technical Guidance: Deadline for Submission of 2011 First Quarter MLR Data by Issuers of “Mini-med” and Expatriate Plans (PDF – 26 KB) - July 18, 2011
CCIIO Technical Guidance: Questions and Answers Regarding the Medical Loss Ratio Interim Final Rule (PDF – 66 KB) - February 10, 2012
CCIIO Technical Guidance: Questions and Answers Regarding the Medical Loss Ratio Interim Final Rule (PDF – 94 KB) - March 30, 2012
Memo to Insurance Companies: Medical Loss Ratio Annual Reporting Procedures (PDF – 96 KB) - April 20, 2012
CCIIO Technical Guidance: Questions and Answers Regarding the Medical Loss Ratio Regulation (PDF – 101 KB) - May 15, 2012
Memo to Insurance Companies: Guidance for Medical Loss Ratio Annual Reporting Form (PDF – 66 KB)
Memo to Insurance Companies: Guidance for Medical Loss Ratio Notices of Rebates (PDF – 67 KB) - May 24, 2012
CCIIO Technical Guidance: Questions and Answers Regarding the Medical Loss Ratio Reporting Form (PDF – 91 KB) - May 30, 2012
CCIIO Technical Guidance: Questions and Answers Regarding the Medical Loss Ratio Reporting Requirements (PDF – 83 KB) - July 17, 2012
CCIIO Technical Guidance: Questions and Answers Regarding the Medical Loss Ratio Reporting and Rebate Requirements (PDF – 69 KB) - March 29, 2013
Memo to Insurance Companies: Guidance for 2012 Medical Loss Ratio Annual Reporting Form (PDF –119 KB)
Memo to Insurance Companies: Announcement Regarding Training for 2012 Medical Loss Ratio Reporting Period (PDF – 125 KB) - April 5, 2013
CCIIO Technical Guidance: Questions and Answers Regarding the MLR Reporting and Rebate Requirements (PDF – 139 KB) - May 30, 2013
CCIIO Technical Guidance: Question and Answer Regarding the Requirement that Issuers of Certain Health Insurance Coverage Sold as Fixed Indemnity Insurance Submit an Annual Medical Loss Ratio (MLR) Report to the Secretary (PDF – 89 KB) - July 2, 2013
CCIIO Technical Guidance Questions and Answers Regarding the Medical Loss Ratio Reporting and Rebate Requirements [PDF, 109KB] - December 30, 2013
CCIIO Technical Guidance (CCIIO 2013—0004): Question and Answer Regarding the Medical Loss Ratio Reporting and Rebate Requirements [PDF, 120KB] - May 27, 2015
CCIIO Technical Guidance (CCIIO 2015—0001): Question and Answer Regarding the Medical Loss Ratio Reporting and Rebate Requirements [PDF, 107 KB] - June 19, 2015
Reporting of Cost-Sharing Reduction Amounts in Risk Corridors and Medical Loss Ratio Reporting[PDF, 167 KB] - September 18, 2015
CCIIO Technical Guidance (CCIIO 2015-0002): Question and Answer Regarding the Medical Loss Ratio (MLR) Reporting and Rebate Requirements for the 2014 MLR Reporting Year [PDF, 156 KB]
Patient's Bill of Rights
Regulations
Guidance
- September 3, 2010
OCIIO Sub-Regulatory Guidance: Process for Obtaining Waivers of the Annual Limits Requirements of PHS Act Section 2711
Prevention
Regulations
- July 19, 2010
OCIIO–9992–IFC: Interim Final Rules for Group Health Plans and Health Insurance Issuers Relating to Coverage of Preventive Services under the Patient Protection and Affordable Care Act - August 3, 2011
CMS-9992-IFC2: Group Health Plans and Health Insurance Issuers Relating to Coverage of Preventive Services under the Patient Protection and Affordable Care Act - Opens in a new window (PDF - 201 KB) - February 10, 2012
CMS-9992-F: Group Health Plans and Health Insurance Issuers Relating to Coverage of Preventive Services Under the Patient Protection and Affordable Care Act - Opens in a new window (PDF – 164 KB) - March 21, 2012
CMS 9968-ANPRM: Preventive Services Under the Affordable Care Act - Opens in a new window (PDF - 263 KB) - February 6, 2013
CMS-9968-P: Coverage of Certain Preventive Services Under the Affordable Care Act - Opens in a new window - June 28, 2013
CMS-9968-F: Coverage of Certain Preventive Services Under the Affordable Care Act - Opens in a new window - August 22, 2014
CMS 9940-P Coverage of Certain Preventive Services Under the Affordable Care Act - August 22, 2014
CMS 9939-IFC Coverage of Certain Preventive Services Under the Affordable Care Act - July 10, 2015
CMS 9940-F: Coverage of Certain Preventive Services Under the Affordable Care Act
Guidance
- July 19, 2010
Recommendation: Recommendations of the U.S. Preventive Service Task Force - Opens in a new window - June 28, 2013
Guidelines: HRSA's Women's Preventive Services: Required Health Plan Coverage Guidelines - Opens in a new window
- June, 28, 2013
CCIIO Technical Guidance: Guidance on the Temporary Enforcement Safe Harbor for Certain Employers, Group Health Plans and Group Health Insurance Issuers with Respect to the Requirement to Cover Contraceptive Services Without Cost Sharing Under Section 2713 of the Public Health Service Act, Section 715(a)(1) of the Employee Retirement Income Security Act, and Section 9815(a)(1) of the Internal Revenue Code (PDF - 177 KB) - August 22, 2014
Model Notice to Secretary of HHS
Review of Insurance Rates
Regulations
- December 23, 2010
OCIIO–9998–IFC: Rate Increase Disclosure and Review; Proposed Rule - Opens in a new window (PDF – 215 KB) - May 19, 2011
CMS-9999-FC: Rate Increase Disclosure and Review; Final Rule (PDF - 282 KB) - September 6, 2011
CMS-9999-F: Rate Increase Disclosure and Review: Definitions of Individual Market and Small Group Market - Opens in a new window (PDF - 526 KB) - November 26, 2012
CMS-9972-P:Patient Protection and Affordable Care Act: Health Insurance Market Rules; Rate Review - Opens in a new window - February 22, 2013
CMS-9972-F:Patient Protection and Affordable Care Act: Health Insurance Market Rules; Rate Review - Opens in a new window
Guidance
- March 30, 2012
State-Specific Threshold Proposals Guidance for States (PDF - 200 KB) - March 31, 2015
Rounding Premiums to the Nearest Dollar (PDF – 235 KB) - April 14, 2015
Guidance on Unified Rate Review Timeline: Timing of Submission and Posting of Rate Filing Justifications for the 2015 Filing Year for Single Risk Pool Compliant Coverage Effective on or after January 1, 2016 - May 13, 2015
Guidance on Uniform Timeline in States Operating State-based Marketplaces - August 12, 2015
Timing for Submission of the Preliminary Justification for Student Health Plans with Rate Increases Effective in 2015 - December 23, 2015
Guidance on Unified Rate Review Timeline: Timing of Submission and Posting of Rate Filing Justifications for the 2016 Filing Year for Single Risk Pool Coverage Effective on or after January 1, 2017 - February 29, 2016
Final Guidance on Unified Rate Review Timeline: Timing of Submission and Posting of Rate Filing Justifications for the 2016 Filing Year for Single Risk Pool Coverage Effective on or after January 1, 2017 - September 26, 2016
Guidance on Issuer Posting of Rate Filing Information - November 10, 2016
Guidance on Unified Rate Review Timeline: Proposed Timing of Submission and Posting of Rate Filing Justifications for the 2017 Filing Year for Single Risk Pool Coverage Effective on or after January 1, 2018 - December 16, 2016
Final Guidance on Unified Rate Review Timeline: Timing of Submission and Posting of Rate Filing Justifications for the 2017 Filing Year for Single Risk Pool Coverage - December 16, 2016
Guidance Regarding Age Curves and State Reporting
Student Health Plans
Regulations
- February 11, 2011
CMS–9981–P: Student Health Insurance Coverage - Opens in a new window (PDF – 250 KB) - March 21, 2012
CMS-9981-F: Student Health Insurance Coverage - Opens in a new window (PDF – 288 KB)
- November 26, 2012
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Guidance
- February 5, 2016
Insurance Standards Bulletin Series: Application of the Market Reforms and Other Provisions of the Affordable Care Act to Student Health Coverage (PDF - 173 KB)
Health Insurance Portability and Accountability Act of 1996 (HIPAA)
Guidance
- March 1998
Program Memorandum:Agent Commissions and Application and Process Delays (PDF - 87 KB) - June 1999
Program Memorandum: Applicability of the Health Insurance Portability and Accountability Act of 1996 to Secondary Coverage and Continuing Coverage(PDF - 157 KB) - June 1999
Program Memorandum: Issues Related to Eligible Individual Status Under the Health Insurance Portability and Accountability Act of 1996(PDF 130 KB) - September 1999
Program Memorandum: Group Size Issues Under Title XXVII of the Public Health Service Act (PDF - 136 KB) - March 2000
Program Memorandum: Imposing Nonconfinement Clause on Eligible Individuals(PDF -68 KB) - June 2000
Program Memorandum: Issue Related to Eligible Individual Status Under Section 2741(b) of the Public Health Service Act (PDF - 122 KB) - June 2000
Program Memorandum: The Relationship of Certain Types of State Laws to the Application of the Guaranteed Availability Requirements of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) in the Small Group Market - August 2000
Program Memorandum: State “succeeding carrier” or “extension of benefits” laws and an issuer’s obligation under HIPAA to enroll an eligible individual who is disabled. - November 2000
Program Memorandum: Guaranteed Availability Under Title XXVII of the Public Health Service Act – Applicability of Group Participation Rules - November 2000
Program Memorandum: Circumstances Under which Health Insurance Regulated as “Individual” Coverage Under State Law is Subject to the Group Market Requirements of The Health Insurance Portability and Accountability Act of 1996 (HIPAA) - March 2001
Program Memorandum: Guaranteed Renewability of Conversion Policies - August 2001
Program Memorandum: Identifying Federally Eligible Individuals in states Electing to Use Alternative mechanisms to Comply with Guaranteed Availability Requirements under Title XXVII of the PHS Act - March 2002
Program Memorandum: How to Apply the “Product Withdrawal” and “Market Exit” Exceptions of the Guaranteed Renewability Requirements of Title XXVII of the PHS Act - August 2002
Program Memorandum: Application of Group and Individual Market Requirements Under Title XXVII of the Public Health Service (PHS) Act When Insurance Coverage is Sold To, or Through Associations - August 2002
Program Memorandum: The Obligation Health Insurance Issuers Have to Association Members and Associations Under Title XXVII of the PHS Act With Respect to Guaranteed Renewability of Coverage - September 2002
Program Memorandum: Characteristics of Bona Fide Associations, and How Selling Coverage Exclusively Through Them Affects an Issuer’s Guaranteed Availability Obligations Under Title XXVII of the PHS Act - September 2002
Program Memorandum: How Selling Coverage Exclusively Through Bona Fide Associations Affects and Issuer’s Guaranteed Renewability Obligations Under Title XXVII of the PHS Act - March 2004
Program Memorandum: HIPAA Enforcement Is Not Preempted by COBRA; Non-HIPAA-Related State Insurance Law is Not Preempted by Public Sector COBRA - June 2004
Program Memorandum: Federal Eligibility Under HIPAA After Group Health Plan Termination - March 2005
Program Memorandum: Coverage through a Foreign Government, the U.S. Government, and a State Children’s Health Insurance Program, is Creditable Coverage for Purposes of Identifying Eligible Individuals under HIPAA - June 2005
Program Memorandum: Benefit Exclusions that Cannot be Applied to Eligible Individuals Under HIPAA Individual Market Provisions - May 2008
Program Memorandum: Circumstances Under Which Supplemental Health Insurance Coverage Satisfies the Requirements for Excepted Benefits Under Section 2791(c) of the Public Health Service Act
- February 5, 2016
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Updates
- December 16, 2016
- December 16, 2016
Final 2018 Letter to Issuers in the FFM
- December 16, 2016
Final Key Dates Calendar for 2017
- December 16, 2016
Final 2018 Actuarial Value Calculator
- December 16, 2016
Final Guidance on Unified Rate Review Timeline
- December 12, 2016
IFC-Conditions for Coverage for End-Stage Renal Disease Facilities
- December 6, 2016
- November 10, 2016
- July 19, 2016
FFM and FF-SHOP Enrollment Manual
- June 30, 2016
Summary Report on Transitional Reinsurance and Risk Adjustment Transfers for the 2015 Benefit Year
- June 17, 2016
- May 6, 2016
