45 CFR Part 155 — Exchange Establishment Standards and Other Related Standards Under the Affordable Care Act

PART 155—EXCHANGE ESTABLISHMENT STANDARDS AND OTHER RELATED STANDARDS UNDER THE AFFORDABLE CARE ACT Authority: 42 U.S.C. 18021-18024, 18031-18033, 18041-18042, 18051, 18054, 18071, and 18081-18083. Source: 77 FR 11718, Feb. 27, 2012, unless otherwise noted. Subpart A—General Provisions. Source: 77 FR 18444, Mar. 27, 2012, unless otherwise noted. § 155.10 Basis and scope. (a) Basis. (1) 1301. Qualified health plan defined (2) 1302. Essential health benefits requirements (3) 1303. Special rules (4) 1304. Related definitions (5) 1311. Affordable choices of health benefit plans. (6) 1312. Consumer choice (7) 1313. Financial integrity. (8) 1321. State flexibility in operation and enforcement of Exchanges and related requirements. (9) 1322. Federal program to assist establishment and operation of nonprofit, member-run health insurance issuers. (10) 1331. State flexibility to establish Basic Health Programs for low-income individuals not eligible for Medicaid. (11) 1334. Multi-State plans. (12) 1402. Reduced cost-sharing for individuals enrolling in QHPs. (13) 1411. Procedures for determining eligibility for Exchange participation, advance premium tax credits and reduced cost sharing, and individual responsibility exemptions. (14) 1412. Advance determination and payment of premium tax credits and cost-sharing reductions. (15) 1413. Streamlining of procedures for enrollment through an exchange and State Medicaid, CHIP, and health subsidy programs. (b) Scope. § 155.20 Definitions. The following definitions apply to this part: Advance payments of the premium tax credit Affordable Care Act Agent or broker Agent or broker direct enrollment technology provider Annual open enrollment period Applicant (1) An individual who is seeking eligibility for him or herself through an application submitted to the Exchange, excluding those individuals seeking eligibility for an exemption from the individual shared responsibility payment pursuant to subpart G of this part, or transmitted to the Exchange by an agency administering an insurance affordability program for at least one of the following: (i) Enrollment in a QHP through the Exchange; or (ii) Medicaid, CHIP, and the BHP, if applicable. (2) For SHOP: (i) An employer seeking eligibility to purchase coverage through the SHOP; or (ii) An employer, employee, or a former employee seeking eligibility for enrollment in a QHP through the SHOP for himself or herself and, if the qualified employer offers dependent coverage through the SHOP, seeking eligibility to enroll his or her dependents in a QHP through the SHOP. Application filer Benefit year Catastrophic plan Code Cost sharing Cost-sharing reductions Direct enrollment entity Direct enrollment entity application assister Educated health care consumer Eligible employer-sponsored plan Eligible noncitizen Employee Employer Employer contributions Enrollee Exchange Exchange Blueprint Exchange service area Federal platform agreement Federally-facilitated Exchange Federally-facilitated SHOP Full-time employee Grandfathered health plan Group health plan Health insurance issuer issuer Health insurance coverage Health plan Individual market Initial open enrollment period Issuer application assister Large employer Lawfully present (1) Is a qualified noncitizen as defined at 42 CFR 435.4; (2) Is in a valid nonimmigrant status, as defined in 8 U.S.C. 1101(a)(15) or otherwise under the immigration laws (as defined in 8 U.S.C. 1101(a)(17)); (3) Is paroled into the United States in accordance with 8 U.S.C. 1182(d)(5) for less than 1 year, except for a noncitizen paroled for prosecution, for deferred inspection or pending removal proceedings; (4) Is granted temporary resident status in accordance with 8 U.S.C. 1160 or 1255a; (5) Is granted Temporary Protected Status (TPS) in accordance with 8 U.S.C. 1254a; (6) Is granted employment authorization under 8 CFR 274a.12(c); (7) Is a Family Unity beneficiary in accordance with section 301 of Pub. L. 101-649 as amended; or section 1504 of the LIFE Act Amendments of 2000, title XV of H.R. 5666, enacted by reference in Pub. L. 106-554 (see section 1504 of App. D to Pub. L. 106-554); (8) Is covered by Deferred Enforced Departure (DED) in accordance with a decision made by the President; (9) Is granted deferred action; (10) Has a pending application for adjustment of status; (11)(i) Has a pending application for asylum under 8 U.S.C. 1158, for withholding of removal under 8 U.S.C. 1231(b)(3)(A), or for protection under the regulations implementing the Convention Against Torture; and (ii) Is under the age of 14; (12) Has been granted withholding of removal under the regulations implementing the Convention Against Torture; or (13) Has a pending or approved petition for Special Immigrant Juvenile classification as described in 8 U.S.C. 1101(a)(27)(J). (14) An individual with deferred action under the Department of Homeland Security's Deferred Action for Childhood Arrivals process, as described at 8 CFR 236.22, shall not be considered to be lawfully present as described in any of the above categories in paragraphs (1) through (13) of this definition. Minimum essential coverage Navigator Plan year Plain language Preponderance of the evidence Qualified employee Qualified employer Qualified health plan QHP Qualified health plan issuer QHP issuer Qualified health plan issuer direct enrollment technology provider Qualified individual SHOP Small employer Small group market Special enrollment period State Web-broker [77 FR 18444, Mar. 27, 2012, as amended at 78 FR 15532, Mar. 11, 2013; 78 FR 39523, July 1, 2013; 78 FR 42313, July 15, 2013; 78 FR 54134, Aug. 30, 2013; 80 FR 10864, Feb. 27, 2015; 81 FR 12336, Mar. 8, 2016; 81 FR 94175, Dec. 22, 2016; 84 FR 17562, Apr. 25, 2019; 86 FR 24288, May 5, 2021; 89 FR 39436, May 8, 2024; 90 FR 27220, June 25, 2025; 91 FR 29864, May 20, 2026] § 155.30 Severability. (a) Any part of the definition of “lawfully present” in § 155.20 held to be invalid or unenforceable, including as applied to any person or circumstance, shall be construed so as to continue to give the maximum effect to the provision as permitted by law, along with other provisions not found invalid or unenforceable, including as applied to persons not similarly situated or to dissimilar circumstances, unless such holding is that the provision of this subpart is invalid and unenforceable in all circumstances, in which event the provision shall be severable from the remainder of this subpart and shall not affect the remainder thereof. (b) The provisions in § 155.20 with respect to the definition of “lawfully present” are intended to be severable from one another. [89 FR 39436, May 8, 2024] Subpart B—General Standards Related to the Establishment of an Exchange § 155.100 Establishment of a State Exchange. (a) General requirements. (1) An Exchange that facilitates the purchase of health insurance coverage in QHPs in the individual market and that provides for the establishment of a SHOP; or (2) An Exchange that provides only for the establishment of a SHOP. (b) Timing. (c) Eligible Exchange entities. [77 FR 18444, Mar. 27, 2012, as amended at 78 FR 54134, Aug. 30, 2013] § 155.105 Approval of a State Exchange. (a) State Exchange approval requirement. (b) State Exchange approval standards. (1) The Exchange is able to carry out the required functions of an Exchange consistent with subparts C, D, E, F, G, H, and K of this part unless the State is approved to operate only a SHOP by HHS pursuant to § 155.100(a)(2), in which case the Exchange must perform the minimum functions described in subpart H and all applicable provisions of other subparts referenced therein; (2) The Exchange is capable of carrying out the information reporting requirements in accordance with section 36B of the Code, unless the State is approved to operate only a SHOP by HHS pursuant to § 155.100(a)(2); (3) The entire geographic area of the State is in the service area of an Exchange, or multiple Exchanges consistent with § 155.140(b); and (c) State Exchange approval process. (1) Elect to establish an Exchange by submitting, in a form and manner specified by HHS, an Exchange Blueprint that sets forth how the Exchange meets the standards outlined in paragraph (b) of this section; and (2) Demonstrate operational readiness to execute its Exchange Blueprint through a readiness assessment conducted by HHS. (d) State Exchange approval. (e) Significant changes to Exchange Blueprint. (f) HHS operation of an Exchange. (2) If an electing State has an approved or conditionally approved Exchange pursuant to § 155.100(a)(2) by January 1, 2013, HHS must (directly or through agreement with a not-for-profit entity) establish and operate an Exchange that facilitates the purchase of health insurance coverage in QHPs in the individual market and operate such Exchange within the State. In this case, the requirements in §§ 155.120(c), 155.130 and subparts C, D, E, F, G, and K of this part will apply to the Exchange operated by HHS. [77 FR 18444, Mar. 27, 2012, as amended at 78 FR 42313, July 15, 2013; 78 FR 54134, Aug. 30, 2013; 89 FR 26419, Apr. 15, 2024; 91 FR 29864, May 20, 2026] § 155.106 Election to operate an Exchange after 2014. (a) Election to operate an Exchange. (1) Comply with the State Exchange approval requirements and process set forth in § 155.105; (2) Submit an Exchange Blueprint application for HHS approval at least 15 months prior to the date on which the Exchange proposes to begin open enrollment as a State Exchange. (i) Public notice. (ii) Public engagements. (3) Have in effect an approved, or conditionally approved, Exchange Blueprint and operational readiness assessment prior to the date on which the Exchange would begin open enrollment as a State Exchange; (4) Develop a plan jointly with HHS to facilitate the transition to a State Exchange; and (5) If the open enrollment period for the year the State intends to begin operating an SBE has not been established, this deadline must be calculated based on the date open enrollment began or will begin in the year in which the State is submitting the Blueprint application. (b) Transition process for State Exchanges that cease operations. (1) Notify HHS that it will no longer operate an Exchange at least 12 months prior to ceasing operations; and (2) Coordinate with HHS on a transition plan to be developed jointly between HHS and the State. (c) Process for State Exchanges that seek to utilize the Federal platform for select functions. (1) If the State Exchange does not have a conditionally approved Exchange Blueprint application, submit one for HHS approval at least 3 months prior to the date on which the Exchange proposes to begin open enrollment as an SBE-FP; (2) If the State Exchange has a conditionally approved Exchange Blueprint application, submit any significant changes to that application for HHS approval, in accordance with § 155.105(e), at least 3 months prior to the date on which the Exchange proposes to begin open enrollment as an SBE-FP; (3) Have in effect an approved, or conditionally approved, Exchange Blueprint and operational readiness assessment prior to the date on which the Exchange proposes to begin open enrollment as a State-based Exchanges on the Federal platform (SBE-FP), in accordance with HHS rules in this chapter, as a State Exchange utilizing the Federal platform; (4) Prior to approval, or conditional approval, of the Exchange Blueprint, execute a Federal platform agreement for utilizing the Federal platform for select functions; and (5) Coordinate with HHS on a transition plan to be developed jointly between HHS and the State. [77 FR 18444, Mar. 27, 2012, as amended at 79 FR 13837, Mar. 11, 2014; 81 FR 12336, Mar. 8, 2016; 83 FR 17060, Apr. 17, 2018; 88 FR 25917, Apr. 27, 2023; 89 FR 26419, Apr. 15, 2024; 91 FR 29864, May 20, 2026] § 155.110 Entities eligible to carry out Exchange functions. (a) Eligible contracting entities. (1) An entity: (i) Incorporated under, and subject to the laws of, one or more States; (ii) That has demonstrated experience on a State or regional basis in the individual and small group health insurance markets and in benefits coverage; and (iii) Is not a health insurance issuer or treated as a health insurance issuer under subsection (a) or (b) of section 52 of the Code of 1986 as a member of the same controlled group of corporations (or under common control with) as a health insurance issuer; or (2) The State Medicaid agency, or any other State agency that meets the qualifications of paragraph (a)(1) of this section. (b) Responsibility. (c) Governing board structure. (1) Is administered under a formal, publicly-adopted operating charter or by-laws; (2) Holds regular public governing board meetings that are announced in advance; (3) Represents consumer interests by ensuring that overall governing board membership: (i) Includes at least one voting member who is a consumer representative; (ii) Is not made up of a majority of voting representatives with a conflict of interest, including representatives of health insurance issuers or agents or brokers, or any other individual licensed to sell health insurance; and (4) Ensures that a majority of the voting members on its governing board have relevant experience in health benefits administration, health care finance, health plan purchasing, health care delivery system administration, public health, or health policy issues related to the small group and individual markets and the uninsured. (d) Governance principles. (2) The Exchange must implement procedures for disclosure of financial interests by members of the Exchange board or governance structure. (e) SHOP independent governance. (2) If a State chooses to operate its Exchange and SHOP under a single governance or administrative structure, it must ensure that the Exchange has adequate resources to assist individuals and small employers in the Exchange. (f) HHS review. § 155.120 Non-interference with Federal law and non-discrimination standards. (a) Non-interference with Federal law. (b) Non-interference with State law. (c) Non-discrimination. (i) Comply with applicable non-discrimination statutes; and (ii) Not discriminate based on race, color, national origin, disability, age, or sex (which includes discrimination on the basis of sex characteristics, including intersex traits; pregnancy or related conditions; sexual orientation; gender identity; and sex stereotypes). (2) Notwithstanding the provisions of paragraph (c)(1)(ii) of this section, an organization that receives Federal funds to provide services to a defined population under the terms of Federal legal authorities that participates in the certified application counselor program under § 155.225 may limit its provision of certified application counselor services to the same defined population, but must comply with paragraph (c)(1)(ii) of this section with respect to the provision of certified application counselor services to that defined population. If the organization limits its provision of certified application counselor services pursuant to this exception, but is approached for certified application counselor services by an individual who is not included in the defined population that the organization serves, the organization must refer the individual to other Exchange-approved resources that can provide assistance. If the organization does not limit its provision of certified application counselor services pursuant to this exception, the organization must comply with paragraph (c)(1)(ii) of this section. [77 FR 18444, Mar. 27, 2012, as amended at 79 FR 30342, May 27, 2014; 85 FR 37247, June 19, 2020; 89 FR 37703, May 6, 2024] § 155.130 Stakeholder consultation. The Exchange must regularly consult on an ongoing basis with the following stakeholders: (a) Educated health care consumers who are enrollees in QHPs; (b) Individuals and entities with experience in facilitating enrollment in health coverage; (c) Advocates for enrolling hard to reach populations, which include individuals with mental health or substance abuse disorders; (d) Small businesses and self-employed individuals; (e) State Medicaid and CHIP agencies; (f) Federally-recognized Tribes, as defined in the Federally Recognized Indian Tribe List Act of 1994, 25 U.S.C. 479a, that are located within such Exchange's geographic area; (g) Public health experts; (h) Health care providers; (i) Large employers; (j) Health insurance issuers; and (k) Agents and brokers. § 155.140 Establishment of a regional Exchange or subsidiary Exchange. (a) Regional Exchange. (1) The Exchange spans two or more States, regardless of whether the States are contiguous; and (2) The regional Exchange submits a single Exchange Blueprint and is approved to operate consistent with § 155.105(c). (b) Subsidiary Exchange. (1) Each such Exchange serves a geographically distinct area; and (2) The area served by each subsidiary Exchange is at least as large as a rating area described in section 2701(a) of the PHS Act. (c) Exchange standards. (1) Otherwise meet the requirements of an Exchange consistent with this part; and (2) Meet the following standards for SHOP: (i) Perform the functions of a SHOP for its service area in accordance with subpart H of this part; and (ii) Encompass the same geographic area for its regional or subsidiary SHOP and its regional or subsidiary Exchange except: (A) In the case of a regional Exchange established pursuant to § 155.100(a)(2), the regional SHOP must encompass a geographic area that matches the combined geographic areas of the individual market Exchanges established to serve the same set of States establishing the regional SHOP; and (B) In the case of a subsidiary Exchange established pursuant to § 155.100(a)(2), the combined geographic area of all subsidiary SHOPs established in the State must encompass the geographic area of the individual market Exchange established to serve the State. [77 FR 18444, Mar. 27, 2012, as amended at 78 FR 54134, Aug. 30, 2013] § 155.150 Transition process for existing State health insurance exchanges. (a) Presumption. (1) The exchange was in operation prior to January 1, 2010; and (2) The State has insured a percentage of its population not less than the percentage of the population projected to be covered nationally after the implementation of the Affordable Care Act, according to the Congressional Budget Office estimates for projected coverage in 2016 that were published on March 30, 2011. (b) Process for determining non-compliance. § 155.160 Financial support for continued operations. (a) Definition. (b) Funding for ongoing operations. (1) States may generate funding, such as through user fees on participating issuers, for Exchange operations; and (2) No Federal grants under section 1311 of the Affordable Care Act will be awarded for State Exchange establishment after January 1, 2015. § 155.170 Additional required benefits. (a) Additional required benefits. (2) For plan years beginning on or after January 1, 2028, a State may require a QHP to cover benefits in addition to the essential health benefits, which are any State-required benefits that are: (i) Required by a State action taking place after December 31, 2011; (ii) Applicable to the small group and/or individual markets; (iii) Specific to required care, treatment, or services; and (iv) Not required by State action for purposes of compliance with Federal requirements. (3) A State must make payments in accordance with paragraph (b) of this section to defray the cost of any State-required benefits in addition to the EHB. (4) The State will identify which State-required benefits are in addition to the EHB. (b) Payments. (1) To an enrollee, as defined in § 155.20 of this subchapter; or (2) Directly to the QHP issuer on behalf of the individual described in paragraph (b)(1) of this section. (c) Cost of additional required benefits. (2) A QHP issuer's calculation shall be: (i) Based on an analysis performed in accordance with generally accepted actuarial principles and methodologies; (ii) Conducted by a member of the American Academy of Actuaries; and (iii) Reported to the State. [78 FR 12865, Feb. 25, 2013, as amended at 81 FR 12337, Mar. 8, 2016; 89 FR 26419, Apr. 15, 2024; 91 FR 29864, May 20, 2026] Subpart C—General Functions of an Exchange § 155.200 Functions of an Exchange. (a) General requirements. (b) Certificates of exemption. (c) Oversight and financial integrity. (d) Quality activities. (e) Clarification. (f) Requirements for State Exchanges on the Federal platform. (2) A State Exchange on the Federal platform must establish and oversee requirements for its issuers that are no less strict than the following requirements that are applied to Federally-facilitated Exchange issuers: (i) Data submission requirements under § 156.122(d)(2) of this subchapter; (ii)—(iv) [Reserved] (v) Changes of ownership of issuers requirements under § 156.330 of this subchapter; (vi) QHP issuer compliance and compliance of delegated or downstream entities requirements under § 156.340(a)(4) of this subchapter; and (vii) Casework requirements under § 156.1010 of this subchapter. (3) If a State is not substantially enforcing any requirement listed under § 155.200(f)(2) with respect to a QHP issuer or plan in a State-based Exchange on the Federal platform, HHS may enforce that requirement directly against the issuer or plan by means of plan suppression under § 156.815 of this subchapter. (4) A State Exchange on the Federal platform that utilizes the Federal platform for SHOP functions, for plan years beginning on or after January 1, 2018, must require its QHP issuers to make any changes to rates in accordance with the timeline applicable in a Federally-facilitated SHOP under § 155.706(b)(6)(i)(A). A State Exchange on the Federal platform that utilizes the Federal platform for SHOP functions, as set forth in paragraphs (f)(4)(i) through (vii) of this section, for plan years beginning prior to January 1, 2018, must— (i) If utilizing the Federal platform for SHOP eligibility, enrollment, or premium aggregation functions, establish standard processes for premium calculation, premium payment, and premium collection that are consistent with the requirements applicable in a Federally-facilitated SHOP under § 155.705(b)(4); (ii) If utilizing the Federal platform for SHOP enrollment or premium aggregation functions, require its QHP issuers to make any changes to rates in accordance with the timeline applicable in a Federally-facilitated SHOP under § 155.705(b)(6)(i)(A); (iii) If utilizing the Federal platform for SHOP enrollment functions, establish minimum participation rate requirements and calculation methodologies that are consistent with those applicable in a Federally-facilitated SHOP under § 155.705(b)(10); (iv) If utilizing the Federal platform for SHOP enrollment or premium aggregation functions, establish employer contribution methodologies that are consistent with the methodologies applicable in a Federally-facilitated SHOP under § 155.705(b)(11)(ii); (v) If utilizing the Federal platform for SHOP enrollment functions, establish annual employee open enrollment period requirements that are consistent with § 155.725(e)(2); (vi) If utilizing the Federal platform for SHOP enrollment functions, establish effective dates of coverage for an initial group enrollment or a group renewal that are consistent with the effective dates of coverage applicable in a Federally-facilitated SHOP under § 155.725(h)(2); and (vii) If utilizing the Federal platform for SHOP eligibility, enrollment, or premium aggregation functions, establish policies for the termination of SHOP coverage or enrollment that are consistent with the requirements applicable in a Federally-facilitated SHOP under § 155.735. [77 FR 18444, Mar. 27, 2012, as amended at 78 FR 39523, July 1, 2013; 78 FR 54134, Aug. 30, 2013; 81 FR 12337, Mar. 8, 2016; 81 FR 94175, Dec. 22, 2016; 83 FR 17060, Apr. 17, 2018; 84 FR 71710, Dec. 27, 2019] § 155.205 Consumer assistance tools and programs of an Exchange. (a) Call center. (b) Internet Web site. (1) Provides standardized comparative information on each available QHP and at a minimum includes: (i) Premium and cost-sharing information; (ii) The summary of benefits and coverage established under section 2715 of the PHS Act; (iii) Identification of whether the QHP is a bronze, silver, gold, or platinum level plan as defined by section 1302(d) of the Affordable Care Act, or a catastrophic plan as defined by section 1302(e) of the Affordable Care Act; (iv) The results of the enrollee satisfaction survey, as described in section 1311(c)(4) of the Affordable Care Act; (v) Quality ratings assigned in accordance with section 1311(c)(3) of the Affordable Care Act; (vi) Medical loss ratio information as reported to HHS in accordance with 45 CFR part 158; (vii) Transparency of coverage measures reported to the Exchange during certification in accordance with § 155.1040; and (viii) The provider directory made available to the Exchange in accordance with § 156.230. (2) Publishes the following financial information: (i) The average costs of licensing required by the Exchange; (ii) Any regulatory fees required by the Exchange; (iii) Any payments required by the Exchange in addition to fees under paragraphs (b)(2)(i) and (ii) of this section; (iv) Administrative costs of such Exchange; and (v) Monies lost to waste, fraud, and abuse. (3) Provides applicants with information about Navigators as described in § 155.210 and other consumer assistance services, including the toll-free telephone number of the Exchange call center required in paragraph (a) of this section. (4) Allows for an individual to submit a single streamlined eligibility application to the Exchange in accordance with § 155.405 and for the Exchange to make all determinations of eligibility for enrollment in a QHP and insurance affordability programs, in accordance with subpart D of this part, through the operation of a centralized eligibility and enrollment platform on the Exchange's website; or, if the Exchange is a State-based Exchange on the Federal platform, through the Federal eligibility and enrollment platform. (5) Allows a qualified individual to select a QHP and allows the Exchange to maintain records of all QHP enrollments, in accordance with subpart E of this part, through the operation of a centralized eligibility and enrollment platform on the Exchange's website; or, if the Exchange is a State-based Exchange on the Federal platform, through the Federal eligibility and enrollment platform. (6) Makes 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. (7) A State-based Exchange on the Federal platform must at a minimum maintain an informational Internet Web site that includes the capability to direct consumers to Federal platform services to apply for, and enroll in, Exchange coverage. (c) Accessibility. (1) Individuals living with disabilities including accessible Web sites and the provision of auxiliary aids and services at no cost to the individual in accordance with the Americans with Disabilities Act and section 504 of the Rehabilitation Act. (2) Individuals who are limited English proficient through the provision of language services at no cost to the individual, including (i) For all entities subject to this standard, oral interpretation. (A) For Exchanges and QHP issuers, this standard also includes telephonic interpreter services in at least 150 languages. (B) For a web-broker, beginning November 1, 2015, or when such entity has been registered with the Exchange for at least 1 year, whichever is later, this standard also includes telephonic interpreter services in at least 150 languages. (ii) Written translations; and (iii) For all entities subject to this standard, taglines in non-English languages indicating the availability of language services. (A) For Exchanges and QHP issuers, this standard also includes taglines on Web site content and any document that is critical for obtaining health insurance coverage or access to health care services through a QHP for qualified individuals, applicants, qualified employers, qualified employees, or enrollees. A document is deemed to be critical for obtaining health insurance coverage or access to health care services through a QHP if it is required to be provided by law or regulation to a qualified individual, applicant, qualified employer, qualified employee, or enrollee. Such taglines must indicate the availability of language services in at least the top 15 languages spoken by the limited English proficient population of the relevant State or States, as determined in guidance published by the Secretary. If an Exchange is operated by an entity that operates multiple Exchanges, or if an Exchange relies on an entity to conduct its eligibility or enrollment functions and that entity conducts such functions for multiple Exchanges, the Exchange may aggregate the limited English proficient populations across all the States served by the entity that operates the Exchange or conducts its eligibility or enrollment functions to determine the top 15 languages required for taglines. A QHP issuer may aggregate the limited English proficient populations across all States served by the health insurance issuers within the issuer's controlled group (defined for purposes of this section as a group of two or more persons that is treated as a single employer under sections 52(a), 52(b), 414(m), or 414(o) of the Internal Revenue Code of 1986, as amended), whether or not those health insurance issuers offer plans through the Exchange in each of those States, to determine the top 15 languages required for taglines. Exchanges and QHP issuers may satisfy tagline requirements with respect to Web site content if they post a Web link prominently on their home page that directs individuals to the full text of the taglines indicating how individuals may obtain language assistance services, and if they also include taglines on any critical stand-alone document linked to or embedded in the Web site. Exchanges, and QHP issuers that are also subject to § 92.8 of this subtitle, will be deemed in compliance with paragraph (c)(2)(iii)(A) of this section if they are in compliance with § 92.8 of this subtitle. (B) For a web-broker, beginning when such entity has been registered with the Exchange for at least 1 year, this standard also includes taglines on website content and any document that is critical for obtaining health insurance coverage or access to health care services through a QHP for qualified individuals, applicants, qualified employers, qualified employees, or enrollees. Website content or documents are deemed to be critical for obtaining health insurance coverage or access to health care services through a QHP if they are required to be provided by law or regulation to a qualified individual, applicant, qualified employer, qualified employee, or enrollee. Such taglines must indicate the availability of language services in at least the top 15 languages spoken by the limited English proficient population of the relevant State or States, as determined in guidance published by the Secretary. A web-broker that is licensed in and serving multiple States may aggregate the limited English populations in the States it serves to determine the top 15 languages required for taglines. A web-broker may satisfy tagline requirements with respect to website content if it posts a Web link prominently on its home page that directs individuals to the full text of the taglines indicating how individuals may obtain language assistance services, and if it also includes taglines on any critical stand-alone document linked to or embedded in the website. (iv) For Exchanges, QHP issuers, and web-brokers, website translations. (A) For an Exchange, beginning no later than the first day of the individual market open enrollment period for the 2017 benefit year, content that is intended for qualified individuals, applicants, qualified employers, qualified employees, or enrollees on a Web site that is maintained by the Exchange must be translated into any non-English language that is spoken by a limited English proficient population that reaches 10 percent or more of the population of the relevant State, as determined in guidance published by the Secretary. (B) For a QHP issuer, beginning no later than the first day of the individual market open enrollment period for the 2017 benefit year, if the content of a Web site maintained by the QHP issuer is critical for obtaining health insurance coverage or access to health care services through a QHP, within the meaning of § 156.250 of this subchapter, it must be translated into any non-English language that is spoken by a limited English proficient population that reaches 10 percent or more of the population of the relevant State, as determined in guidance published by the Secretary. (C) For a web-broker, beginning on the first day of the individual market open enrollment period for the 2017 benefit year, or when such entity has been registered with the Exchange for at least 1 year, whichever is later, content that is intended for qualified individuals, applicants, qualified employers, qualified employees, or enrollees on a website that is maintained by the web-broker must be translated into any non-English language that is spoken by a limited English proficient population that comprises 10 percent or more of the population of the relevant State, as determined in guidance published by the Secretary. (3) Inform individuals of the availability of the services described in paragraphs (c)(1) and (2) of this section and how to access such services. (d) Consumer assistance. (2) The Exchange must provide 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. (e) Outreach and education. [77 FR 18444, Mar. 27, 2012, as amended at 78 FR 42859, July 17, 2013; 80 FR 10864, Feb. 27, 2015; 81 FR 12337, Mar. 8, 2016; 81 FR 94175, Dec. 22, 2016; 84 FR 17563, Apr. 25, 2019; 86 FR 24288, May 5, 2021; 89 FR 26419, Apr. 15, 2024; 91 FR 29864, May 20, 2026] § 155.206 Civil money penalties for violations of applicable Exchange standards by consumer assistance entities in Federally-facilitated Exchanges. (a) Enforcement actions. (1) Civil money penalties (CMPs), subject to the provisions of this section. (2) Corrective action plans. In the notice of assessment of CMPs specified in paragraph (l) of this section, HHS may provide an individual or entity specified in paragraph (b) of this section the opportunity to enter into a corrective action plan to correct the violation instead of paying the CMP, based on evaluation of the factors set forth in paragraph (h) of this section. In the event that the individual or entity does not follow such a corrective action plan, HHS could require payment of the CMP. (b) Consumer assistance entities. (1) Individual Navigators and Navigator entities in a Federally-facilitated Exchange, including grantees, sub-grantees, and all personnel carrying out Navigator duties on behalf of a grantee or sub-grantee; (2) Non-Navigator assistance personnel authorized under § 155.205(d) and (e) and non-Navigator assistance personnel entities in a Federally-facilitated Exchange, including but not limited to individuals and entities under contract with HHS to facilitate consumer enrollment in QHPs in a Federally-facilitated Exchange; and (3) Organizations that a Federally-facilitated Exchange has designated as certified application counselor organizations and individual certified application counselors carrying out certified application counselor duties in a Federally-facilitated Exchange. (c) Grounds for assessing CMPs. (d) Basis for initiating an investigation of a potential violation Information. (i) Complaints from the general public; (ii) Reports from State regulatory agencies, and other Federal and State agencies; or (iii) Any other information that indicates that a consumer assistance entity may have engaged or may be engaging in activity specified in paragraph (c) of this section. (2) Who may file a complaint. (e) Notice of investigation. (1) Description of the activity that is being investigated. (2) Explanation that the consumer assistance entity has 30 days from the date of the notice to respond with additional information or documentation, including information or documentation to refute an alleged violation. (3) State that a CMP might be assessed if the allegations are not, as determined by HHS, refuted within 30 days from the date of the notice. (f) Request for extension. (g) Responses to allegations of noncompliance. (h) Factors in determining noncompliance and amount of CMPs, if any. (1) HHS must take into account the following: (i) The consumer assistance entity's previous or ongoing record of compliance, including but not limited to compliance or noncompliance with any corrective action plan. (ii) The gravity of the violation, which may be determined in part by— (A) The frequency of the violation, taking into consideration whether any violation is an isolated occurrence, represents a pattern, or is widespread; and (B) Whether the violation caused, or could reasonably be expected to cause, financial or other adverse impacts on consumer(s), and the magnitude of those impacts; (2) HHS may take into account the following: (i) The degree of culpability of the consumer assistance entity, including but not limited to— (A) Whether the violation was beyond the direct control of the consumer assistance entity; and (B) The extent to which the consumer assistance entity received compensation—legal or otherwise—for the services associated with the violation; (ii) Aggravating or mitigating circumstances; (iii) Whether other remedies or penalties have been assessed and/or imposed for the same conduct or occurrence; or (iv) Other such factors as justice may require. (i) Maximum per-day penalty. (j) Settlement authority. (k) Limitations on penalties Circumstances under which a CMP is not imposed. (i) Any violation for the period of time during which none of the consumer assistance entities knew, or exercising reasonable diligence would have known, of the violation; or (ii) The period of time after any of the consumer assistance entities knew, or exercising reasonable diligence would have known, of the failure, if the violation was due to reasonable cause and not due to willful neglect and the violation was corrected within 30 days of the first day that any of the consumer assistance entities against whom the penalty would be imposed knew, or exercising reasonable diligence would have known, that the violation existed. (2) Burden of establishing knowledge. (3) Time limit for commencing action. (l) Notice of assessment of CMP. (1) A description of the basis for the determination; (2) The basis for the CMP; (3) The amount of the CMP, if applicable; (4) The date the CMP, if applicable, is due; (5) Whether HHS would permit the consumer assistance entity to enter into a corrective action plan in place of paying the CMP, and the terms of any such corrective action plan; (6) An explanation of the consumer assistance entity's right to a hearing under paragraph (m) of this section; and (7) Information about the process for filing a request for a hearing. (m) Appeal of proposed sanction. (n) Failure to request a hearing. (2) HHS will notify the consumer assistance entity in writing of any CMP that has been assessed and of the means by which the consumer assistance entity may pay the CMP. (3) The consumer assistance entity has no right to appeal a CMP with respect to which it has not requested a hearing in accordance with paragraph (m) of this section unless the consumer assistance entity can show good cause in accordance with § 150.405(b) of this subchapter for failing to timely exercise its right to a hearing. [79 FR 30342, May 27, 2014, as amended at 87 FR 27388, May 6, 2022] § 155.210 Navigator program standards. (a) General requirements. (b) Standards. (1) A set of standards, to be met by all entities and individuals to be awarded Navigator grants, designed to prevent, minimize and mitigate any conflicts of interest, financial or otherwise, that may exist for an entity or individuals to be awarded a Navigator grant and to ensure that all entities and individuals carrying out Navigator functions have appropriate integrity; and (2) A set of training standards, to be met by all entities and individuals carrying out Navigator functions under the terms of a Navigator grant, to ensure the entities and individuals are qualified to engage in Navigator activities, including training standards on the following topics: (i) The needs of underserved and vulnerable populations; (ii) Eligibility and enrollment rules and procedures; (iii) The range of QHP options and insurance affordability programs; and (iv) The privacy and security standards applicable under § 155.260. (c) Entities and individuals eligible to be a Navigator. (i) Be capable of carrying out at least those duties described in paragraph (e) of this section; (ii) Demonstrate to the Exchange that the entity has existing relationships, or could readily establish relationships, with employers and employees, consumers (including uninsured and underinsured consumers), or self-employed individuals likely to be eligible for enrollment in a QHP; (iii) Meet any licensing, certification or other standards prescribed by the State or Exchange, if applicable, so long as such standards do not prevent the application of the provisions of title I of the Affordable Care Act. Standards that would prevent the application of the provisions of title I of the Affordable Care Act include but are not limited to the following: (A) Except as otherwise provided under § 155.705(d), requirements that Navigators refer consumers to other entities not required to provide fair, accurate, and impartial information. (B) Except as otherwise provided under § 155.705(d), requirements that would prevent Navigators from providing services to all persons to whom they are required to provide assistance. (C) Requirements that would prevent Navigators from providing advice regarding substantive benefits or comparative benefits of different health plans. (D) Requiring that a Navigator hold an agent or broker license or imposing any requirement that, in effect, would require all Navigators in the Exchange to be licensed agents or brokers. (E) Imposing standards that would, as applied or as implemented in a State, prevent the application of Federal requirements applicable to Navigator entities or individuals or applicable to the Exchange's implementation of the Navigator program. (iv) Not have a conflict of interest during the term as Navigator; and, (v) Comply with the privacy and security standards adopted by the Exchange as required in accordance with § 155.260. (2) The Exchange must include an entity from at least one of the following categories for receipt of a Navigator grant: (i) Community and consumer-focused nonprofit groups; (ii) Trade, industry, and professional associations; (iii) Commercial fishing industry organizations, ranching and farming organizations; (iv) Chambers of commerce; (v) Unions; (vi) Resource partners of the Small Business Administration; (vii) Licensed agents and brokers; and (viii) Other public or private entities or individuals that meet the requirements of this section. Other entities may include but are not limited to Indian tribes, tribal organizations, urban Indian organizations, and State or local human service agencies. (d) Prohibition on Navigator conduct. (1) Be a health insurance issuer or issuer of stop loss insurance; (2) Be a subsidiary of a health insurance issuer or issuer of stop loss insurance; (3) Be an association that includes members of, or lobbies on behalf of, the insurance industry; (4) Receive any consideration directly or indirectly from any health insurance issuer or issuer of stop loss insurance in connection with the enrollment of any individuals or employees in a QHP or a non-QHP. Notwithstanding the requirements of this paragraph (d)(4), in a Federally-facilitated Exchange, no health care provider shall be ineligible to operate as a Navigator solely because it receives consideration from a health insurance issuer for health care services provided; (5) Charge any applicant or enrollee, or request or receive any form of remuneration from or on behalf of an individual applicant or enrollee, for application or other assistance related to Navigator duties; (6) Provide to an applicant or potential enrollee gifts of any value as an inducement for enrollment. The value of gifts provided to applicants and potential enrollees for purposes other than as an inducement for enrollment must not exceed nominal value, either individually or in the aggregate, when provided to that individual during a single encounter. For purposes of this paragraph (d)(6), the term gifts includes gift items, gift cards, cash cards, cash, and promotional items that market or promote the products or services of a third party, but does not include the reimbursement of legitimate expenses incurred by a consumer in an effort to receive Exchange application assistance, such as travel or postage expenses; (7) Use Exchange funds to purchase gifts or gift cards, or promotional items that market or promote the products or services of a third party, that would be provided to any applicant or potential enrollee; or (8) [Reserved] (9) Initiate any telephone call to a consumer using an automatic telephone dialing system or an artificial or prerecorded voice, except in cases where the individual Navigator or Navigator entity has a relationship with the consumer and so long as other applicable State and Federal laws are otherwise complied with. (e) Duties of a Navigator. (1) Maintain expertise in eligibility, enrollment, and program specifications and conduct public education activities to raise awareness about the Exchange; (2) Provide information and services in a fair, accurate, and impartial manner, which includes: providing information that assists consumers with submitting the eligibility application; clarifying the distinctions among health coverage options, including QHPs; and helping consumers make informed decisions during the health coverage selection process. Such information must acknowledge other health programs; (3) Facilitate selection of a QHP; (4) Provide referrals to any applicable office of health insurance consumer assistance or health insurance ombudsman established under section 2793 of the PHS 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; (5) Provide information in a manner that is culturally and linguistically appropriate to the needs of the population being served by the Exchange, including individuals with limited English proficiency, and ensure accessibility and usability of Navigator tools and functions for individuals with disabilities in accordance with the Americans with Disabilities Act and section 504 of the Rehabilitation Act; (6) Ensure that applicants— (i) Are informed, prior to receiving assistance, of the functions and responsibilities of Navigators, including that Navigators are not acting as tax advisers or attorneys when providing assistance as Navigators and cannot provide tax or legal advice within their capacity as Navigators; (ii) Provide authorization in a form and manner as determined by the Exchange prior to a Navigator's obtaining access to an applicant's personally identifiable information, and that the Navigator maintains a record of the authorization provided in a form and manner as determined by the Exchange. The Exchange must establish a reasonable retention period for maintaining these records. In Federally-facilitated Exchanges, this period is no less than six years, unless a different and longer retention period has already been provided under other applicable Federal law; and (iii) May revoke at any time the authorization provided the Navigator pursuant to paragraph (e)(6)(ii) of this section; and (7) In a Federally-facilitated Exchange, no individual or entity shall be ineligible to operate as a Navigator solely because its principal place of business is outside of the Exchange service area; (8) Provide targeted assistance to serve underserved or vulnerable populations, as identified by the Exchange, within the Exchange service area. (i) In a Federally-facilitated Exchange, this paragraph (e)(8) will apply beginning with the Navigator grant application process for Navigator grants awarded in 2018. The Federally-facilitated Exchange will identify populations as vulnerable or underserved that are disproportionately without access to coverage or care, or that are at a greater risk for poor health outcomes, in the funding opportunity announcement for its Navigator grants, and applicants for those grants will have an opportunity to propose additional vulnerable or underserved populations in their applications for the Federally-facilitated Exchange's approval. (ii) [Reserved] (9) The Exchange may require or authorize Navigators to provide information and assistance with any of the following topics. In federally-facilitated Exchanges, FY 2021 Navigator grantees will be required to perform these duties beginning with the Navigator grant funding awarded in FY 2022 for the second 12-month budget period of the 36-month period of performance. Beginning with Navigator grants awarded in 2022, including non-competing continuation awards, Navigators are required to provide information and assistance with all of the following topics: (i) Understanding the process of filing Exchange eligibility appeals; (ii) Understanding and applying for exemptions from the requirement to maintain minimum essential coverage granted through the Exchange; (iii) The Exchange-related components of the premium tax credit reconciliation process, and understanding the availability of IRS resources on this process; (iv) Understanding basic concepts and rights related to health coverage and how to use it; and (v) Referrals to licensed tax advisers, tax preparers, or other resources for assistance with tax preparation and tax advice related to consumer questions about the Exchange application and enrollment process, and premium tax credit reconciliations. (f) Funding for Navigator grants. [77 FR 18444, Mar. 27, 2012, as amended at 78 FR 42859, July 17, 2013; 79 FR 30344, May 27, 2014; 79 FR 42986, July 24, 2014; 81 FR 12337, Mar. 8, 2016; 83 FR 17061, Apr. 17, 2018; 84 FR 17563, Apr. 25, 2019; 86 FR 53503, Sept. 27, 2021; 88 FR 25917, Apr. 27, 2023] § 155.215 Standards applicable to Navigators and Non-Navigator Assistance Personnel carrying out consumer assistance functions under §§ 155.205(d) and (e) and 155.210 in a Federally-facilitated Exchange and to Non-Navigator Assistance Personnel funded through an Exchange Establishment Grant. (a) Conflict-of-interest standards. (1) Conflict-of-interest standards for Navigators. (A) Is not a health insurance issuer or issuer of stop loss insurance; (B) Is not a subsidiary of a health insurance issuer or issuer of stop loss insurance; (C) Is not an association that includes members of, or lobbies on behalf of, the insurance industry; and (D) Will not receive any consideration directly or indirectly from any health insurance issuer or issuer of stop loss insurance in connection with the enrollment of any individuals or employees in a QHP or non-QHP. (ii) All Navigator entities must submit to the Exchange a written plan to remain free of conflicts of interest during the term as a Navigator. (iii) All Navigator entities, including the Navigator's staff, must provide information to consumers about the full range of QHP options and insurance affordability programs for which they are eligible. (iv) All Navigator entities, including the Navigator's staff, must disclose to the Exchange and, in plain language, to each consumer who receives application assistance from the Navigator: (A) Any lines of insurance business, not covered by the restrictions on participation and prohibitions on conduct in § 155.210(d), which the Navigator intends to sell while carrying out the consumer assistance functions; (B) Any existing employment relationships, or any former employment relationships within the last 5 years, with any health insurance issuers or issuers of stop loss insurance, or subsidiaries of health insurance issuers or issuers of stop loss insurance, including any existing employment relationships between a spouse or domestic partner and any health insurance issuers or issuers of stop loss insurance, or subsidiaries of health insurance issuers or issuers of stop loss insurance; and (C) Any existing or anticipated financial, business, or contractual relationships with one or more health insurance issuers or issuers of stop loss insurance, or subsidiaries of health insurance issuers or issuers of stop loss insurance. (2) Conflict-of-interest standards for Non-Navigator assistance personnel carrying out consumer assistance functions under § 155.205(d) and (e). (i) Comply with the prohibitions on Navigator conduct set forth at § 155.210(d) and the duties of a Navigator set forth at § 155.210(e)(2). (ii) Submit to the Exchange a written attestation that the entity or individual— (A) Is not a health insurance issuer or issuer of stop loss insurance; (B) Is not a subsidiary of a health insurance issuer or issuer of stop loss insurance; (C) Is not an association that includes members of, or lobbies on behalf of, the insurance industry; and (D) Will not receive any consideration directly or indirectly from any health insurance issuer or issuer of stop loss insurance in connection with the enrollment of any individuals or employees in a QHP or non-QHP. (iii) Submit to the Exchange a written plan to remain free of conflicts of interest while carrying out consumer assistance functions under § 155.205(d) and (e). (iv) Provide information to consumers about the full range of QHP options and insurance affordability programs for which they are eligible. (v) Submit to the Exchange, and, in plain language, to each consumer who receives application assistance from the entity or individual: (A) Any lines of insurance business, not covered by the restrictions on participation and prohibitions on conduct in § 155.210(d), which the entity or individual intends to sell while carrying out the consumer assistance functions; (B) Any existing employment relationships, or any former employment relationships within the last five years, with any health insurance issuers or issuers of stop loss insurance, or subsidiaries of health insurance issuers or issuers of stop loss insurance, including any existing employment relationships between a spouse or domestic partner and any health insurance issuers or issuers of stop loss insurance, or subsidiaries of health insurance issuers or issuers of stop loss insurance; and (C) Any existing or anticipated financial, business, or contractual relationships with one or more health insurance issuers or issuers of stop loss insurance, or subsidiaries of health insurance issuers or issuers of stop loss insurance. (b) Training standards for Navigators and Non-Navigator assistance personnel carrying out consumer assistance functions under §§ 155.205(d) and (e) and 155.210. (1) Certification and recertification standards. (i) Obtain certification by the Exchange prior to carrying out any consumer assistance functions or outreach and education activities under § 155.205(d) and (e) or § 155.210; (ii) Register for and complete a HHS-approved training; (iii) Following completion of the HHS-approved training described in paragraph (b)(1)(ii) of this section, complete and achieve a passing score on all approved certification examinations prior to carrying out any consumer assistance functions under § 155.205(d) and (e) or § 155.210; (iv) Obtain continuing education and be certified and/or recertified on at least an annual basis; and (v) Be prepared to serve both the individual Exchange and SHOP. (2) Training module content standards. (c) Providing Culturally and Linguistically Appropriate Services (CLAS Standards). (1) Develop and maintain general knowledge about the racial, ethnic, and cultural groups in their service area, including each group's diverse cultural health beliefs and practices, preferred languages, health literacy, and other needs; (2) Collect and maintain updated information to help understand the composition of the communities in the service area, including the primary languages spoken; (3) Provide consumers with information and assistance in the consumer's preferred language, at no cost to the consumer, including the provision of oral interpretation of non-English languages and the translation of written documents in non-English languages when necessary or when requested by the consumer to ensure effective communication. Use of a consumer's family or friends as oral interpreters can satisfy the requirement to provide linguistically appropriate services only when requested by the consumer as the preferred alternative to an offer of other interpretive services; (4) Provide oral and written notice to consumers with limited English proficiency, in their preferred language, informing them of their right to receive language assistance services and how to obtain them; (5) Receive ongoing education and training in culturally and linguistically appropriate service delivery; and (6) Implement strategies to recruit, support, and promote a staff that is representative of the demographic characteristics, including primary languages spoken, of the communities in their service area. (d) Standards ensuring access by persons with disabilities. (1) Ensure that any consumer education materials, Web sites, or other tools utilized for consumer assistance purposes, are accessible to people with disabilities, including those with sensory impairments, such as visual or hearing impairments, and those with mental illness, addiction, and physical, intellectual, and developmental disabilities; (2) Provide auxiliary aids and services for individuals with disabilities, at no cost, when necessary or when requested by the consumer to ensure effective communication. Use of a consumer's family or friends as interpreters can satisfy the requirement to provide auxiliary aids and services only when requested by the consumer as the preferred alternative to an offer of other auxiliary aids and services; (3) Provide assistance to consumers in a location and in a manner that is physically and otherwise accessible to individuals with disabilities; (4) Ensure that authorized representatives are permitted to assist an individual with a disability to make informed decisions; (5) Acquire sufficient knowledge to refer people with disabilities to local, state, and federal long-term services and supports programs when appropriate; and (6) Be able to work with all individuals regardless of age, disability, or culture, and seek advice or experts when needed. (e) Monitoring. (f) State or Exchange standards. (1) Requirements that non-Navigator entities or individuals refer consumers to other entities not required to provide fair, accurate, and impartial information. (2) Requirements that would prevent non-Navigator entities or individuals from providing services to all persons to whom they are required to provide assistance. (3) Requirements that would prevent non-Navigator entities or individuals from providing advice regarding substantive benefits or comparative benefits of different health plans. (4) Imposing standards that would, as applied or as implemented in a State, prevent the application of Federal requirements applicable to non-Navigator entities or individuals or applicable to the Exchange's implementation of the non-Navigator assistance personnel program. (g) Consumer authorization. (1) Are informed, prior to receiving assistance, of the functions and responsibilities of non-Navigator assistance personnel, including that non-Navigator assistance personnel are not acting as tax advisers or attorneys when providing assistance as non-Navigator assistance personnel and cannot provide tax or legal advice within their capacity as non-Navigator assistance personnel; (2) Provide authorization in a form and manner as determined by the Exchange prior to a non-Navigator assistance personnel's obtaining access to an applicant's personally identifiable information, and that the non-Navigator assistance personnel maintains a record of the authorization provided in a form and manner as determined by the Exchange. The Exchange must establish a reasonable retention period for maintaining these records. In Federally-facilitated Exchanges, this period is no less than six years, unless a different and longer retention period has already been provided under other applicable Federal law; and (3) May revoke at any time the authorization provided the non-Navigator assistance personnel pursuant to paragraph (g)(2) of this section. (h) Physical presence. (i) Prohibition on compensation per enrollment. [78 FR 42859, July 17, 2013, as amended at 79 FR 30344, May 27, 2014; 81 FR 12338, Mar. 8, 2016; 83 FR 17061, Apr. 17, 2018; 84 FR 17563, Apr. 25, 2019] § 155.220 Ability of States to permit agents and brokers and web-brokers to assist qualified individuals, qualified employers, or qualified employees enrolling in QHPs. (a) General rule. (1) Enroll individuals, employers or employees in any QHP in the individual or small group market as soon as the QHP is offered through an Exchange in the State; (2) Subject to paragraphs (c), (d), and (e) of this section, enroll qualified individuals in a QHP in a manner that constitutes enrollment through the Exchange; and (3) Subject to paragraphs (d) and (e) of this section, assist individuals in applying for advance payments of the premium tax credit and cost-sharing reductions for QHPs. (b)(1) Web site disclosure. (2) A Federally-facilitated Exchange or SHOP will limit the information provided on its Web site regarding licensed agents and brokers to information regarding licensed agents and brokers who have completed registration and training. (c) Enrollment through the Exchange. (1) The agent, broker, or web-broker ensures the applicant's completion of an eligibility verification and enrollment application through the Exchange internet website as described in § 155.405, or ensures that the eligibility application information is submitted for an eligibility determination through the Exchange-approved web service subject to meeting the requirements in paragraphs (c)(3)(ii) and (c)(4)(i)(F) of this section; (2) The Exchange transmits enrollment information to the QHP issuer as provided in § 155.400(a) to allow the issuer to effectuate enrollment of qualified individuals in the QHP. (3)(i) When an internet website of a web-broker is used to complete the QHP selection, at a minimum the internet website must: (A) Disclose and display the following QHP information provided by the Exchange or directly by QHP issuers consistent with the requirements of § 155.205(c), and to the extent that enrollment support for a QHP is not available using the web-broker's website, prominently display a standardized disclaimer provided by HHS stating that enrollment support for the QHP is available on the Exchange website, and provide a Web link to the Exchange website: ( 1 ( 2 ( 3 ( 4 ( 5 ( 6 (B) Provide consumers the ability to view all QHPs offered through the Exchange; (C) Not provide financial incentives, such as rebates or giveaways; (D) Display all QHP data provided by the Exchange; (E) Maintain audit trails and records in an electronic format for a minimum of ten years and cooperate with any audit under this section; (F) Provide consumers with the ability to withdraw from the process and use the Exchange Web site described in § 155.205(b) instead at any time; (G) For the Federally-facilitated Exchange, prominently display a standardized disclaimer provided by HHS, and provide a Web link to the Exchange Web site; and (H) Prominently display information provided by HHS pertaining to a consumer's eligibility for advance payments of the premium tax credit or cost-sharing reductions; (I) Allow the consumer to select an amount for advance payments of the premium tax credit, if applicable, and make related attestations in accordance with § 155.310(d)(2); (J) Comply with the applicable requirements in § 155.221; and (K) Not display QHP advertisements or recommendations, or otherwise provide favored or preferred placement in the display of QHPs, based on compensation the agent, broker, or web-broker receives from QHP issuers; and (L) Prominently display a clear explanation of the rationale for QHP recommendations and the methodology for its default display of QHPs. (ii) When an internet website of a web-broker is used to complete the Exchange eligibility application, at a minimum the internet website must: (A) Comply with the requirements in paragraph (c)(3)(i) of this section; (B) Use exactly the same eligibility application language as appears in the FFE Single Streamlined Application required in § 155.405, unless HHS approves a deviation; (C) Ensure that all necessary information for the consumer's applicable eligibility circumstances are submitted through the Exchange-approved web service; and (D) Ensure that the process used for consumers to complete the eligibility application complies with all applicable Exchange standards, including §§ 155.230 and 155.260(b). (4) When an agent or broker, through a contract or other arrangement, uses the internet website of a web-broker to help an applicant or enrollee complete a QHP selection or complete the Exchange eligibility application in the Federally-facilitated Exchange: (i) The web-broker who makes the website available must: (A) Provide HHS with a list of agents and brokers who enter into such a contract or other arrangement to use the web-broker's website, in a form and manner to be specified by HHS; (B) Verify that any agent or broker accessing or using the Web site pursuant to the arrangement is licensed in the State in which the consumer is selecting the QHP; and has completed training and registration and has signed all required agreements with the Federally-facilitated Exchange pursuant to paragraph (d) of this section and § 155.260(b); (C) Ensure that its name and any identifier required by HHS prominently appears on the Internet Web site and on written materials containing QHP information that can be printed from the Web site, even if the agent or broker that is accessing the Internet Web site is able to customize the appearance of the Web site; (D) Terminate the agent or broker's access to its Web site if HHS determines that the agent or broker is in violation of the provisions of this section and/or HHS terminates any required agreement with the agent or broker; (E) Report to HHS and applicable State departments of insurance any potential material breach of the standards in paragraphs (c) and (d) of this section, or the agreement entered into under § 155.260(b), by the agent or broker accessing the internet website, should it become aware of any such potential breach. A web-broker that provides access to its website to complete the QHP selection or the Exchange eligibility application or ability to transact information with HHS to another web-broker website is responsible for ensuring compliance with applicable requirements in paragraph (c)(3) of this section for any web pages of the other web-broker's website that assist consumers, applicants, qualified individuals, and enrollees in applying for APTC and CSRs for QHPs, or in completing enrollment in QHPs, offered in the Exchanges. (F) When an internet website of a web-broker is used to complete the Exchange eligibility application, obtain HHS approval verifying that all requirements in this section are met. (ii) HHS retains the right to temporarily suspend the ability of a web-broker making its website available to transact information with HHS, if HHS discovers a security and privacy incident or breach, for the period in which HHS begins to conduct an investigation and until the incident or breach is remedied to HHS' satisfaction. (iii) Web-brokers operating in State Exchanges that do not use the Federal platform that permit other agents and brokers, through a contract or other arrangement, to use their internet website to help an applicant or enrollee complete a QHP selection or complete the Exchange eligibility application must comply with the standards in paragraphs (c)(4)(i)(A), (B), (D) and (F) of this section, except that all references to “Federally-facilitated Exchange” or “HHS” in paragraphs (c)(4)(i)(A), (B), (D), and (F) will be understood to mean “the applicable State Exchange.” (5) 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. (6) In addition to applicable requirements under § 155.221(b)(4), a web-broker must demonstrate operational readiness and compliance with applicable requirements prior to the web-broker's internet website being used to complete an Exchange eligibility application or a QHP selection, which may include submission or completion, in the form and manner specified by HHS, of the following: (i) Operational data including licensure information, points of contact, and third-party relationships; (ii) Enrollment testing, prior to approval or renewal; (iii) Website reviews performed by HHS; (iv) Security and privacy assessment documentation, including: (A) Penetration testing results; (B) Security and privacy assessment reports; (C) Vulnerability scan results; (D) Plans of action and milestones; and (E) System security and privacy plans. (v) Agreements between the web-broker and HHS. (d) Agreement. (1) Registers with the Exchange in advance of assisting qualified individuals enrolling in QHPs through the Exchange; (2) Receives training in the range of QHP options and insurance affordability programs, except that a licensed agent or broker entity that registers with the Federally-facilitated Exchange in its capacity as a business organized under the laws of a State, and not as an individual person, and direct enrollment technology providers are exempt from this requirement; and (3) Complies with the Exchange's privacy and security standards adopted consistent with § 155.260. (e) Compliance with State law. (f) Termination notice to HHS. (2) The notice must include the intended date of termination, but if it does not specify a date of termination, or the date provided is not acceptable to HHS, HHS may set a different termination date that will be no less than 30 days from the date on the agent's, broker's, or web-broker's notice of termination. (3) Prior to the date of termination, an agent, broker, or web-broker should— (i) Notify applicants, qualified individuals, or enrollees that the agent, broker, or web-broker is assisting, of the agent's, broker's, or web-broker's intended date of termination; (ii) Continue to assist such individuals with Exchange-related eligibility and enrollment services up until the date of termination; and (iii) Provide such individuals with information about alternatives available for obtaining additional assistance, including but not limited to the Federally-facilitated Exchange Web site. (4) When the agreement between the agent, broker, or web-broker and the Exchange under paragraph (d) of this section is terminated under paragraph (f) of this section, the agent, broker, or web-broker will no longer be registered with the Federally-facilitated Exchanges, or be permitted to assist with or facilitate enrollment of qualified individuals, qualified employers or qualified employees in coverage in a manner that constitutes enrollment through a Federally-facilitated Exchange, or be permitted to assist individuals in applying for advance payments of the premium tax credit and cost-sharing reductions for QHPs. The agent's, broker's, or web-broker's agreement with the Exchange under § 155.260(b) will also be terminated through the termination without cause process set forth in that agreement. The agent, broker, or web-broker must continue to protect any personally identifiable information accessed during the term of either of these agreements with the Federally-facilitated Exchanges. (g) Standards for termination for cause from the Federally-facilitated Exchange. (2) An agent, broker, or web-broker may be determined noncompliant under paragraph (g)(1) of this section if HHS finds by a preponderance of the evidence that the agent, broker, or web-broker violated— (i) Any standard specified under this section; (ii) Any term or condition of the agreement with the Federally-facilitated Exchanges required under paragraph (d) of this section, or any term or condition of the agreement with the Federally-facilitated Exchange required under § 155.260(b); (iii) Any State law applicable to agents, brokers, or web-brokers, as required under paragraph (e) of this section, including but not limited to State laws related to confidentiality and conflicts of interest; or (iv) Any Federal law applicable to agents, brokers, or web-brokers. (3)(i) Except as provided in paragraph (g)(3)(ii) of this section, HHS will notify the agent, broker, or web-broker of the specific finding of noncompliance or pattern of noncompliance made under paragraph (g)(1) of this section, and after 30 days from the date of the notice, may terminate the agreement for cause if the matter is not resolved to the satisfaction of HHS. (ii) HHS may immediately terminate the agreement for cause upon notice to the agent or broker without any further opportunity to resolve the matter if an agent or broker fails to maintain the appropriate license under State law as an agent, broker, or insurance producer in every State in which the agent or broker actively assists consumers with applying for advance payments of the premium tax credit or cost-sharing reductions or with enrolling in QHPs through the Federally-facilitated Exchanges. (4) After the applicable period in paragraph (g)(3) of this section has elapsed and the agreement under paragraph (d) of this section is terminated, the agent, broker, or web-broker will no longer be registered with the Federally-facilitated Exchanges, or be permitted to assist with or facilitate enrollment of a qualified individual, qualified employer, or qualified employee in coverage in a manner that constitutes enrollment through a Federally-facilitated Exchange, or be permitted to assist individuals in applying for advance payments of the premium tax credit and cost-sharing reductions for QHPs. The agent's, broker's, or web-broker's agreement with the Exchange under § 155.260(b)(2) will also be terminated through the process set forth in that agreement. The agent, broker, or web-broker must continue to protect any personally identifiable information accessed during the term of either of these agreements with the Federally-facilitated Exchanges. (5) Fraud or abusive conduct— (i)(A) If HHS reasonably suspects that an agent, broker, or web-broker may have may have engaged in fraud, or in abusive conduct that may cause imminent or ongoing consumer harm using personally identifiable information of an Exchange enrollee or applicant or in connection with an Exchange enrollment or application, HHS may temporarily suspend the agent's, broker's, or web-broker's agreements required under paragraph (d) of this section and under § 155.260(b) for up to 90 calendar days. Suspension will be effective on the date of the notice that HHS sends to the agent, broker, or web-broker advising of the suspension of the agreements. (B) The agent, broker, or web-broker may submit evidence in a form and manner to be specified by HHS, to rebut the allegation during this 90-day period. If the agent, broker, or web-broker submits such evidence during the suspension period, HHS will review the evidence and make a determination whether to lift the suspension within 45 calendar days of receipt of such evidence. If the rebuttal evidence does not persuade HHS to lift the suspension, or if the agent, broker, or web-broker fails to submit rebuttal evidence during the suspension period, HHS may terminate the agent's, broker's, or web-broker's agreements required under paragraph (d) of this section and under § 155.260(b) for cause under paragraph (g)(5)(ii) of this section. (ii) If there is a finding or determination by a Federal or State entity that an agent, broker, or web-broker engaged in fraud, or abusive conduct that may result in imminent or ongoing consumer harm, using personally identifiable information of Exchange enrollees or applicants or in connection with an Exchange enrollment or application, HHS will terminate the agent's, broker's, or web-broker's agreements required under paragraph (d) of this section and under § 155.260(b) for cause. The termination will be effective starting on the date of the notice that HHS sends to the agent, broker, or web-broker advising of the termination of the agreements. (iii) During the suspension period under paragraph (g)(5)(i) of this section and following termination of the agreements under paragraph (g)(5)(i)(B) or (g)(5)(ii) of this section, the agent, broker, or web-broker will not be registered with the Federally-facilitated Exchanges, or be permitted to assist with or facilitate enrollment of qualified individuals, qualified employers, or qualified employees in coverage in a manner that constitutes enrollment through a Federally-facilitated Exchange, or be permitted to assist individuals in applying for advance payments of the premium tax credit and cost-sharing reductions for QHPs. The agent, broker, or web-broker must continue to protect any personally identifiable information accessed during the term of either of these agreements with the Federally-facilitated Exchanges. (6) The State department of insurance or equivalent State agent or broker licensing authority will be notified by HHS in cases of suspensions or terminations effectuated under this paragraph (g). (h) Request for reconsideration of termination for cause from the Federally-facilitated Exchange Request for reconsideration. (2) Timeframe for request. (3) Notice of reconsideration decision. (i) Use of agents' and brokers' and web-brokers' internet websites for SHOP. (j) Federally-facilitated Exchange standards of conduct. (i) Have executed the required agreement under paragraph § 155.260(b); (ii) Be registered with the Federally-facilitated Exchanges under paragraph (d)(1) of this section; and (iii) Comply with the standards of conduct in paragraph (j)(2) of this section. (2) Standards of conduct. (i) Provide consumers with correct information, without omission of material fact, regarding the Federally-facilitated Exchanges, QHPs offered through the Federally-facilitated Exchanges, and insurance affordability programs, and refrain from conduct that is misleading (including by having a direct enrollment website that HHS determines could mislead a consumer into believing they are visiting HealthCare.gov (ii) Provide the Federally-facilitated Exchanges with correct information, and document that eligibility application information has been reviewed by and confirmed to be accurate by the consumer, or the consumer's authorized representative designated in compliance with § 155.227, prior to the submission of information, under section 1411(b) of the Affordable Care Act, including but not limited to: (A) Documenting that eligibility application information has been reviewed by and confirmed to be accurate by the consumer or the consumer's authorized representative must require the consumer or their authorized representative to take an action that produces a record that can be maintained by the individual or entity described in paragraph (j)(1) of this section and produced to confirm the consumer or their authorized representative has reviewed and confirmed the accuracy of the eligibility application information. For enrollments for plan years ending prior to January 1, 2028, non-exhaustive examples of acceptable documentation include obtaining the signature of the consumer or their authorized representative (electronically or otherwise), verbal confirmation by the consumer or their authorized representative that is captured in an audio recording, a written response (electronic or otherwise) from the consumer or their authorized representative to a communication sent by the agent, broker, or web-broker, or other similar means or methods specified by HHS in guidance. ( 1 ( 2 ( 3 (B) Entering only an email address on an application for Exchange coverage or an application for advance payments of the premium tax credit and cost-sharing reductions for QHPs that belongs to the consumer or the consumer's authorized representative designated in compliance with § 155.227. A consumer's email address may only be entered with the consent of the consumer or the consumer's authorized representative. Properly entered email addresses must adhere to the following guidelines: ( 1 ( 2 (C) Entering only a telephone number on an application for Exchange coverage or an application for advance payments of the premium tax credit and cost-sharing reductions for QHPs that belongs to the consumer or their authorized representative designated in compliance with § 155.227. Telephone numbers may not be the personal number or business number of the agent, broker, or web-broker assisting the consumer, or their business or agency, unless the telephone number is actually that of the consumer or their authorized representative. (D) Entering only a mailing address on an application for Exchange coverage or an application for advance payments of the premium tax credit and cost-sharing reductions for QHPs that belongs to, or is primarily accessible by, the consumer or their authorized representative designated in compliance with § 155.227, is not for the exclusive or convenient use of the agent, broker, or web-broker, and is an actual residence or a secure location where the consumer or their authorized representative may receive correspondence, such as a P.O. Box or homeless shelter. Mailing addresses may not be that of the agent, broker, or web-broker assisting the consumer, or their business or agency, unless the address is the actual residence of the consumer or their authorized representative. (E) When submitting household income projections used by the Exchange to determine a tax filer's eligibility for advance payments of the premium tax credit in accordance with § 155.305(f) or cost-sharing reductions in accordance with § 155.305(g), entering only a consumer's household income projection that the consumer or the consumer's authorized representative designated in compliance with § 155.227 has knowingly authorized and confirmed as accurate. Household income projections must be calculated and attested to by the consumer. The agent, broker, or web-broker assisting the consumer may answer questions posed by the consumer related to household income projection, such as helping the consumer determine what qualifies as income. (iii) Obtain and document the receipt of consent of the consumer or their authorized representative designated in compliance with § 155.227, employer, or employee prior to assisting with or facilitating enrollment through a Federally-facilitated Exchange or assisting the individual in applying for advance payments of the premium tax credit and cost-sharing reductions for QHPs; (A) Obtaining and documenting the receipt of consent must require the consumer, or the consumer's authorized representative designated in compliance with § 155.227, to take an action that produces a record that can be maintained and produced by an individual or entity described in paragraph (j)(1) of this section to confirm the consumer's or their authorized representative's consent has been provided. For enrollments for plan years ending prior to January 1, 2028, non-exhaustive examples of acceptable documentation of consent include obtaining the signature of the consumer or their authorized representative (electronically or otherwise), verbal confirmation by the consumer or their authorized representative that is captured in an audio recording, a response from the consumer or their authorized representative to an electronic or other communication sent by the agent, broker, or web-broker, or other similar means or methods specified by HHS in guidance. (B) The documentation required under paragraph (j)(2)(iii)(A) of this section must include a description of the scope, purpose, and duration of the consent provided by the consumer or their authorized representative designated in compliance with § 155.227, the date consent was given, name of the consumer or their authorized representative, and the name of the agent, broker, web-broker, or agency being granted consent, as well as a process through which the consumer or their authorized representative may rescind the consent. (C) For enrollments for plan years beginning on or after January 1, 2028, including enrollments under § 155.335(j), all documentation required under paragraph (j)(2)(iii)(A) of this section must be collected by having the consumer or the consumer's authorized representative take an action to execute an HHS-approved and -created consumer consent form. The action the consumer or the consumer's authorized representative took to provide consent must be clear to HHS. This may include hand-written or electronic written signature or initials on the HHS-approved and -created consumer consent form, an email from the consumer or the consumer's representative, or a recorded verbal conversation. A signature that is simply typed on the documentation or a filled-in check box does not properly indicate consent was provided by the consumer or the consumer's authorized representative. (D) An individual or entity described in paragraph (j)(1) of this section must maintain the documentation described in paragraph (j)(2)(iii)(A) of this section for a minimum of 10 years, and produce the documentation upon request in response to monitoring, audit, and enforcement activities conducted consistent with paragraphs (c)(5), (g), (h), and (k) of this section. (iv) Protect consumer personally identifiable information according to § 155.260(b)(3) and the agreement described in § 155.260(b)(2); (v) Comply with all applicable Federal and State laws and regulations. (vi) Not engage in scripting and other automation of interactions with CMS Systems or the Direct Enrollment Pathways, unless approved in advance in writing by CMS. (vii) Only use an identity that belongs to the consumer when identity proofing the consumer's account on HealthCare.gov (viii) When providing information to Federally-facilitated Exchanges that may result in a determination of eligibility for a special enrollment period in accordance with § 155.420, obtain authorization from the consumer to submit the request for a determination of eligibility for a special enrollment period and make the consumer aware of the specific triggering event and special enrollment period for which the agent, broker, or web-broker will be submitting an eligibility determination request on the consumer's behalf. (3) Marketing requirements. (i) Comply with the standards of conduct under paragraph (j)(2) of this section; and (ii) Provide consumers with correct information, without omission of material fact, regarding the Federally-facilitated Exchanges, QHPs offered through the Federally-facilitated Exchanges, and insurance affordability programs, and refrain from marketing that is misleading, materially inaccurate, coercive, or discriminates based on race, color, national origin, disability, age, or sex. (iii) Examples of prohibited misleading marketing practices agents, brokers, and web-brokers may not include in their marketing of FFE plans include, but are not limited to: (A) Providing cash, monetary rebates, gift cards, travel vouchers, or cash equivalents as an inducement for enrollment or otherwise. (B) Offering gifts to consumers, unless the gifts are of nominal value, are offered to similarly situated consumers without regard to whether or not the consumers enroll, and are not in the form of cash or cash equivalents. (C) Falsely asserting or suggesting that consumers will always qualify for zero-dollar insurance/zero-dollar premiums. (D) Falsely using identical or facsimiles of government or other official logos and notations. (E) Miscommunicating enrollment timelines and deadlines. (F) Misconstruing legislation, regulations, or Executive Orders, including listing fake or incorrect references or citations. (G) Utilizing the image or likeness and/or utilize a quote from a notable figure, such as a celebrity or politician, in an advertisement claiming that figure has endorsed you or your agency when that endorsement is not truthful. (iv) An individual or entity described in paragraph (j)(1) of this section must produce any marketing material upon request, within the specified timeframe HHS mandates, in response to monitoring, audit, and enforcement activities conducted consistent with paragraphs (c)(5), (g), (h), and (k) of this section. (v) An individual or entity described in paragraph (j)(1) of this section is responsible to ensure that all marketing-related materials created, written, released, or otherwise produced by the individual or entity or on their behalf adhere to the requirements of paragraphs (j)(3)(ii) and(iii) of this section, and to make all such marketing-related materials available upon request in accordance with paragraph (j)(3)(iv) of this section. (4) If an agent, broker, or web-broker fails to provide correct information, he, she, or it will nonetheless be deemed in compliance with paragraphs (j)(2)(i) and (ii) of this section if HHS determines that there was a reasonable cause for the failure to provide correct information and that the agent, broker, or web-broker acted in good faith. (k) Penalties other than termination of the agreement with the Federally-facilitated Exchanges. (i) May be denied the right to enter into agreements with the Federally-facilitated Exchanges in future years; and (ii) May be subject to civil money penalties as described in § 155.285. (2) HHS will notify the agent, broker, or web-broker of the proposed imposition of penalties under paragraph (k)(1)(i) of this section as part of the termination notice issued under paragraph (g) of this section and, after 30 calendar days from the date of the notice, may impose the penalty if the agent, broker, or web-broker has not requested a reconsideration under paragraph (h) of this section. The proposed imposition of penalties under paragraph (k)(1)(ii) of this section will follow the process outlined under § 155.285. (3) HHS may immediately suspend the agent's or broker's ability to transact information with the Exchange if HHS discovers circumstances that pose unacceptable risk to the accuracy of the Exchange's eligibility determinations, Exchange operations, applicants, or enrollees, or Exchange information technology systems, including but not limited to risk related to noncompliance with the standards of conduct under paragraph (j)(2)(i), (ii), or (iii) of this section and the privacy and security standards under § 155.260, until the circumstances of the incident, breach, or noncompliance are remedied or sufficiently mitigated to HHS' satisfaction. (l) Application to State Exchanges using a Federal platform. (m) Web-broker agreement suspension, termination, and denial and information collection. (2) A web-broker's agreement executed under paragraph (d) of this section may be suspended or terminated under paragraph (g) of this section, and a web-broker may be denied the right to enter into agreements with the Federally-facilitated Exchanges under paragraph (k)(1)(i) of this section, if it is under the common ownership or control or is an affiliated business of another web-broker that had its agreement suspended or terminated under paragraph (g) of this section. (3) The Exchange may collect information from a web-broker during its registration with the Exchange under paragraph (d)(1) of this section, or at another time on an annual basis, in a form and manner to be specified by HHS, sufficient to establish the identities of the individuals who comprise its corporate ownership and leadership and to ascertain any corporate or business relationships it has with other entities that may seek to register with the Federally-facilitated Exchange as web-brokers. (n) Application to State Exchanges that do not use the Federal platform. HealthCare.gov” (1) State Exchanges may add State-specific information to the standardized disclaimers and information under paragraphs (c)(3)(i)(A), (G), and (I) of this section that does not conflict with the HHS-provided language. (2) State Exchanges must establish the form and manner for their web-brokers to demonstrate operational readiness and compliance with applicable requirements in order for the web-broker's internet website being used to complete an Exchange eligibility application or a QHP selection, which may include submission or completion of the following items to the State Exchange, in the form and manner specified by the Exchange: (i) Operational data including licensure information, points of contact and third-party relationships; (ii) Enrollment testing, prior to approval or renewal; (iii) website reviews performed by the State Exchange; (iv) Security and privacy documentation, including: (A) Penetration testing results; (B) Security and privacy assessment reports; (C) Vulnerability scan results; (D) Plans of action and milestones; and (E) System security and privacy plans. (v) Agreements between the web-broker and the State Exchange. [77 FR 18444, Mar. 27, 2012, as amended at 78 FR 15533, Mar. 11, 2013; 78 FR 54134, Aug. 30, 2013; 79 FR 13837, Mar. 11, 2014; 81 FR 12338, Mar. 8, 2016; 81 FR 94176, Dec. 22, 2016; 84 FR 17563, Apr. 25, 2019; 85 FR 37248, June 19, 2020; 86 FR 24288, May 5, 2021; 87 FR 27388, May 6, 2022; 88 FR 25917, Apr. 27, 2023; 89 FR 26420, Apr. 15, 2024; 89 FR 37703, May 6, 2024; 90 FR 4539, Jan. 15, 2025; 90 FR 27220, June 25, 2025; 91 FR 29864, May 20, 2026] § 155.221 Standards for direct enrollment entities and for third-parties to perform audits of direct enrollment entities. (a) Direct enrollment entities. (1) QHP issuers that meet the applicable requirements in this section and § 156.1230 of this subchapter; and (i) For purposes of applying the requirements of § 156.1230(b) of this subchapter to State Exchanges, all references to “Federally-facilitated Exchange” and “HHS”, and “HealthCare.gov” will be understood to mean “the applicable State Exchange”, “the applicable State Exchange”, and “the applicable State Exchange website”, respectively. (ii) [Reserved] (2) Web-brokers that meet the applicable requirements in this section and § 155.220. (b) Direct enrollment entity requirements. (1) Display and market QHPs offered through the Exchange, individual health insurance coverage as defined in § 144.103 of this subchapter offered outside the Exchange (including QHPs and non-QHPs other than excepted benefits), and any other products, such as excepted benefits, on at least three separate website pages on its non-Exchange website, except as permitted under paragraph (c) of this section; (2) Prominently display a standardized disclaimer in the form and manner provided by HHS; (3) Limit marketing of non-QHPs during the Exchange eligibility application and QHP selection process in a manner that minimizes the likelihood that consumers will be confused as to which products and plans are available through the Exchange and which products and plans are not, except as permitted under paragraph (c)(1) of this section; (4) Demonstrate operational readiness and compliance with applicable requirements prior to the direct enrollment entity's internet website being used to complete an Exchange eligibility application or a QHP selection, which may include submission or completion, in the form and manner specified by HHS, of the following: (i) Business audit documentation including: (A) Notices of intent to participate including auditor information; (B) Documentation packages including privacy questionnaires, privacy policy statements, and terms of service; and (C) Business audit reports including testing results. (ii) Security and privacy audit documentation including: (A) Interconnection security agreements; (B) Security and privacy controls assessment test plans; (C) Security and privacy assessment reports; (D) Plans of action and milestones; (E) Privacy impact assessments; (F) System security and privacy plans; (G) Incident response plans; and (H) Vulnerability scan results. (iii) Eligibility application audits performed by HHS; (iv) Online training modules offered by HHS; and (v) Agreements between the direct enrollment entity and HHS. (5) Comply with applicable Federal and State requirements. (6) Implement and prominently display website changes in a manner that is consistent with display changes made to the Federally-facilitated Exchange website by meeting standards communicated and defined by HHS within a time period set by HHS, unless HHS approves a deviation from those standards. Direct enrollment entities may request a deviation by submitting a proposed alternative display and (c) Exceptions to direct enrollment entity display and marketing requirement. (1) Display and market QHPs offered through the Exchange and individual health insurance coverage as defined in § 144.103 of this subchapter offered outside the Exchange (including QHPs and non-QHPs other than excepted benefits) on the same website pages when assisting individuals who have communicated receipt of an offer of an individual coverage health reimbursement arrangement as described in § 146.123(c) of this subchapter, as a standalone benefit, or in addition to an offer of an arrangement under which the individual may pay the portion of the premium for individual health insurance coverage that is not covered by an individual coverage health reimbursement arrangement using a salary reduction arrangement pursuant to a cafeteria plan under section 125 of the Internal Revenue Code, but must clearly distinguish between the QHPs offered through the Exchange and individual health insurance coverage offered outside the Exchange (including QHPs and non-QHPs other than excepted benefits), and prominently communicate that advance payments of the premium tax credit and cost-sharing reductions are available only for QHPs purchased through the Exchange, that advance payments of the premium tax credit are not available to individuals who accept an offer of an individual coverage health reimbursement arrangement or who opt out of an individual coverage health reimbursement arrangement that is considered affordable, and that a salary reduction arrangement under a cafeteria plan may only be used toward the cost of premiums for plans purchased outside the Exchange; and (2) Display and market Exchange-certified stand-alone dental plans offered outside the Exchange and non-certified stand-alone dental plans on the same website pages. (d) Direct enrollment entity application assister requirements. (e) Federally-facilitated Exchange direct enrollment entity suspension. (f) Third parties to perform audits of direct enrollment entities. (g) Third-party auditor standards. (1) Has experience conducting audits or similar services, including experience with relevant privacy and security standards; (2) Adheres to HHS specifications for content, format, privacy, and security in the conduct of an operational readiness review, which includes ensuring that direct enrollment entities are in compliance with the applicable privacy and security standards and other applicable requirements; (3) Collects, stores, and shares with HHS all data related to the third-party entity's audit of direct enrollment entities in a manner, format, and frequency specified by HHS until 10 years from the date of creation, and complies with the privacy and security standards HHS adopts for direct enrollment entities as required in accordance with § 155.260; (4) Discloses to HHS any financial relationships between the entity and individuals who own or are employed by a direct enrollment entity for which it is conducting an operational readiness review; (5) Complies with all applicable Federal and State requirements; (6) Ensures, on an annual basis, that appropriate staff successfully complete operational readiness review training as established by HHS prior to conducting audits under paragraph (f) of this section; (7) Permits access by the Secretary and the Office of the Inspector General or their designees in connection with their right to evaluate through audit, inspection, or other means, to the third-party entity's books, contracts, computers, or other electronic systems, relating to the third-party entity's audits of a direct enrollment entity's obligations in accordance with standards under paragraph (f) of this section until 10 years from the date of creation of a specific audit; and (8) Complies with other minimum business criteria as specified in guidance by HHS. (h) Multiple auditors. (i) Application to State Exchanges using a Federal platform. (j) Application to State that do not use the Federal platform. (1) State Exchanges may add State-specific information to the standardized disclaimer under paragraph (b)(2) of this section that does not conflict with the HHS-provided language. (2) State Exchanges must establish the form and manner for their direct enrollment entities to demonstrate operational readiness and compliance with applicable requirements in order for the direct enrollment entity's internet website being used to complete an Exchange eligibility application or a QHP selection, which may include submission or completion of the following documentation to the State Exchange, in the form and manner specified by the Exchange: (i) Business audit documentation including: (A) Notices of intent to participate including auditor information; (B) Documentation packages including privacy questionnaires, privacy policy statements, and terms of service; and (C) Business audit reports including testing results. (ii) Security and privacy audit documentation including: (A) Interconnection security agreements; (B) Security and privacy controls assessment test plans; (C) Security and privacy assessment reports; (D) Plans of action and milestones; (E) Privacy impact assessments; (F) System security and privacy plans; (G) Incident response plans; and (H) Vulnerability scan results. (3) State Exchanges must require their direct enrollment entities to implement and prominently display website changes in a manner that is consistent with the display changes made by State Exchanges to the State Exchanges' websites, consistent with the process of defining and communicating standards and setting advance notice periods in paragraph (b)(6) of this section, except that all references in paragraph (b)(6) of this section to “Federally-Facilitated Exchange website” would be understood to mean “State Exchange website,” references to “HHS” would be understood to mean “State Exchange,” and the reference to “unless HHS approves a deviation from those standards” would be understood to mean “unless the State Exchange approves a deviation from those standards under the deviation request process it is required to establish should the State Exchange elect to permit deviation requests.” [83 FR 17061, Apr. 17, 2018, as amended at 84 FR 17566, Apr. 25, 2019; 86 FR 6176, Jan. 19, 2021; 86 FR 24289, May 5, 2021; 86 FR 53503, Sept. 27, 2021; 89 FR 26420, Apr. 15, 2024] § 155.225 Certified application counselors. (a) General rule. (b) Exchange designation of organizations. (i) Enters into an agreement with the Exchange to comply with the standards and requirements of this section including the standards specified in paragraphs (d)(3) through (d)(5) of this section; and (ii) Maintains a registration process and method to track the performance of certified application counselors. (iii) Provides data and information to the Exchange regarding the number and performance of its certified application counselors and regarding the consumer assistance provided by its certified application counselors, upon request, in the form and manner specified by the Exchange. Beginning for the third quarter of calendar year 2017, in a Federally-facilitated Exchange, organizations designated by the Exchange must submit quarterly reports that include, at a minimum, data regarding the number of individuals who have been certified by the organization; the total number of consumers who received application and enrollment assistance from the organization; and of that number, the number of consumers who received assistance in applying for and selecting a QHP, enrolling in a QHP, or applying for Medicaid or CHIP. (2) An Exchange may comply with paragraph (a) of this section either by— (i) Designating organizations to certify application counselors in compliance with paragraph (b)(1) of this section; (ii) Directly certifying individual staff members or volunteers of Exchange designated organizations to provide the duties specified in paragraph (c) of this section if the staff member or volunteer enters into an agreement with the Exchange to comply with the standards and requirements for certified application counselors in this section; or (iii) A combination of paragraphs (b)(2)(i) and (b)(2)(ii) of this section. (3) In a Federally-facilitated Exchange, no individual or entity shall be ineligible to operate as a certified application counselor or organization designated by the Exchange under paragraph (b) of this section solely because its principal place of business is outside of the Exchange service area. (c) Duties. (1) Provide information to individuals and employees about the full range of QHP options and insurance affordability programs for which they are eligible, which includes: providing fair, impartial, and accurate information that assists consumers with submitting the eligibility application; clarifying the distinctions among health coverage options, including QHPs; and helping consumers make informed decisions during the health coverage selection process; (2) Assist individuals and employees to apply for coverage in a QHP through the Exchange and for insurance affordability programs; and (3) Help to facilitate enrollment of eligible individuals in QHPs and insurance affordability programs. (d) Standards of certification. (1) Completes Exchange approved training regarding QHP options, insurance affordability programs, eligibility, and benefits rules and regulations governing all insurance affordability programs operated in the state, as implemented in the state, and completes and achieves a passing score on all Exchange approved certification examinations, prior to functioning as a certified application counselor; (2) Discloses to the organization, or to the Exchange if directly certified by an Exchange, and potential applicants any relationships the certified application counselor or sponsoring agency has with QHPs or insurance affordability programs, or other potential conflicts of interest; (3) Complies with the Exchange's privacy and security standards adopted consistent with § 155.260, and applicable authentication and data security standards; (4) Agrees to act in the best interest of the applicants assisted; (5) Either directly or through an appropriate referral to a Navigator or non-Navigator assistance personnel authorized under § 155.205(d) and (e) or § 155.210, or to the Exchange call center authorized under § 155.205(a), provides information in a manner that is accessible to individuals with disabilities, as defined by the Americans with Disabilities Act, as amended, 42 U.S.C. 12101 et seq. and section 504 of the Rehabilitation Act, as amended, 29 U.S.C. 794; (6) Enters into an agreement with the organization regarding compliance with the standards specified in paragraphs (d), (f), and (g) of this section; (7) Is recertified on at least an annual basis after successfully completing recertification training as required by the Exchange; and (8) Meets any licensing, certification, or other standards prescribed by the State or Exchange, if applicable, so long as such standards do not prevent the application of the provisions of title I of the Affordable Care Act. Standards that would prevent the application of the provisions of title I of the Affordable Care Act include but are not limited to the following: (i) Requirements that certified application counselors refer consumers to other entities not required to provide fair, accurate, and impartial information. (ii) Requirements that would prevent certified application counselors from providing services to all persons to whom they are required to provide assistance. (iii) Requirements that would prevent certified application counselors from providing advice regarding substantive benefits or comparative benefits of different health plans. (iv) Imposing standards that would, as applied or as implemented in a State, prevent the application of Federal requirements applicable to certified application counselors, to an organization designated by the Exchange under paragraph (b) of this section, or to the Exchange's implementation of the certified application counselor program. (e) Withdrawal of designation and certification. (2) If an Exchange directly certifies organizations' individual certified application counselors, it must establish procedures to withdraw certification from individual certified application counselors when it finds noncompliance with the requirements of this section. (3) An organization designated by the Exchange under paragraph (b) of this section must establish procedures to withdraw certification from individual certified application counselors when it finds noncompliance with the requirements of this section. (f) Availability of information; authorization. (1) Are informed, prior to receiving assistance, of the functions and responsibilities of certified application counselors, including that certified application counselors are not acting as tax advisers or attorneys when providing assistance as certified application counselors and cannot provide tax or legal advice within their capacity as certified application counselors; (2) Provide authorization in a form and manner as determined by the Exchange prior to a certified application counselor obtaining access to an applicant's personally identifiable information, and that the organization or certified application counselor maintains a record of the authorization in a form and manner as determined by the Exchange. The Exchange must establish a reasonable retention period for maintaining these records. In Federally-facilitated Exchanges, this period is no less than six years, unless a different and longer retention period has already been provided under other applicable Federal law; and (3) May revoke at any time the authorization provided the certified application counselor, pursuant to paragraph (f)(2) of this section. (g) Fees, consideration, solicitation, and marketing. (1) Impose any charge on applicants or enrollees for application or other assistance related to the Exchange; (2) Receive any consideration directly or indirectly from any health insurance issuer or issuer of stop-loss insurance in connection with the enrollment of any individuals in a QHP or a non-QHP. In a Federally-facilitated Exchange, no health care provider shall be ineligible to operate as a certified application counselor or organization designated by the Exchange under paragraph (b) of this section solely because it receives consideration from a health insurance issuer for health care services provided; (3) Beginning November 15, 2014, if operating in a Federally-facilitated Exchange, provide compensation to individual certified application counselors on a per-application, per-individual-assisted, or per-enrollment basis; (4) Provide to an applicant or potential enrollee gifts of any value as an inducement for enrollment. The value of gifts provided to applicants and potential enrollees for purposes other than as an inducement for enrollment must not exceed nominal value, either individually or in the aggregate, when provided to that individual during a single encounter. For purposes of this paragraph (g)(4), the term gifts includes gift items, gift cards, cash cards, cash, and promotional items that market or promote the products or services of a third party, but does not include the reimbursement of legitimate expenses incurred by a consumer in an effort to receive Exchange application assistance, such as travel or postage expenses; or (5) [Reserved] (6) Initiate any telephone call to a consumer using an automatic telephone dialing system or an artificial or prerecorded voice, except in cases where the individual certified application counselor or designated organization has a relationship with the consumer and so long as other applicable State and Federal laws are otherwise complied with. [78 FR 42861, July 17, 2013, as amended at 79 FR 30345, May 27, 2014; 79 FR 42986, July 24, 2014; 81 FR 12341, Mar. 8, 2016; 88 FR 25918, Apr. 27, 2023] § 155.227 Authorized representatives. (a) General rule. (2) Designation of an authorized representative must be in a written document signed by the applicant or enrollee, or through another legally binding format subject to applicable authentication and data security standards. If submitted, legal documentation of authority to act on behalf of an applicant or enrollee under State law, such as a court order establishing legal guardianship or a power of attorney, shall serve in the place of the applicant's or enrollee's signature. (3) The Exchange must ensure that the authorized representative agrees to maintain, or be legally bound to maintain, the confidentiality of any information regarding the applicant or enrollee provided by the Exchange. (4) The Exchange must ensure that the authorized representative is responsible for fulfilling all responsibilities encompassed within the scope of the authorized representation, as described in this section, to the same extent as the applicant or enrollee he or she represents. (5) The Exchange must provide information both to the applicant or enrollee, and to the authorized representative, regarding the powers and duties of authorized representatives. (b) Timing of designation. (1) At the time of application; and (2) At other times and through methods as described in § 155.405(c)(2). (c) Duties. (i) Sign an application on the applicant or enrollee's behalf; (ii) Submit an update or respond to a redetermination for the applicant or enrollee in accordance with § 155.330 or § 155.335; (iii) Receive copies of the applicant's or enrollee's notices and other communications from the Exchange; and (iv) Act on behalf of the applicant or enrollee in all other matters with the Exchange. (2) The Exchange may permit an applicant or enrollee to authorize a representative to perform fewer than all of the activities described in paragraph (c)(1) of this section, provided that the Exchange tracks the specific permissions for each authorized representative. (d) Duration. (1) The applicant or enrollee notifies the Exchange that the representative is no longer authorized to act on his or her behalf using one of the methods available for the submission of an application, as described in § 155.405(c). The Exchange must notify the authorized representative of such change; or (2) The authorized representative informs the Exchange and the applicant or enrollee that he or she no longer is acting in such capacity. An authorized representative must notify the Exchange and the applicant or enrollee on whose behalf he or she is acting when the authorized representative no longer has legal authority to act on behalf of the applicant or enrollee. (e) Compliance with State and Federal law. (f) Signature. [78 FR 42313, July 15, 2013] § 155.230 General standards for Exchange notices. (a) General requirement. (1) An explanation of the action reflected in the notice, including the effective date of the action. (2) Any factual findings relevant to the action. (3) Citations to, or identification of, the relevant regulations supporting the action. (4) Contact information for available customer service resources. (5) An explanation of appeal rights, if applicable. (b) Accessibility and readability requirements. (c) Re-evaluation of appropriateness and usability. (d) Electronic notices. (2) Unless otherwise required by Federal or State law, the SHOP must provide required notices electronically or, if an employer or employee elects, through standard mail. If notices are provided electronically, the SHOP must comply with the requirements for electronic notices in 42 CFR 435.918(b)(2) through (5) for the employer or employee. (3) In the event that an individual market Exchange or SHOP is unable to send select required notices electronically due to technical limitations, it may instead send these notices through standard mail, even if an election has been made to receive such notices electronically. [77 FR 11718, Feb. 27, 2012, as amended at 78 FR 42314, July 15, 2013; 81 FR 94177, Dec. 22, 2016] § 155.240 Payment of premiums. (a) Payment by individuals. (b) Payment by tribes, tribal organizations, and urban Indian organizations. (c) Payment facilitation. (d) Required standards. (e) Premium calculation. (1) For a Federally-facilitated Exchange, the premium for coverage lasting less than one month must equal the product of— (i) The premium for one month of coverage divided by the number of days in the month; and (ii) The number of days for which coverage is being provided in the month described in paragraph (e)(1)(i) of this section. (2) [Reserved] [77 FR 18444, Mar. 27, 2012, as amended at 79 FR 30346, May 27, 2014] § 155.260 Privacy and security of personally identifiable information. (a) Creation, collection, use and disclosure. (i) For the Exchange to carry out the functions described in § 155.200; (ii) For the Exchange to carry out other functions not described in paragraph (a)(1)(i) of this section, which the Secretary determines to be in compliance with section 1411(g)(2)(A) of the Affordable Care Act and for which an individual provides consent for his or her information to be used or disclosed; or (iii) For the Exchange to carry out other functions not described in paragraphs (a)(1)(i) and (ii) of this section, for which an individual provides consent for his or her information to be used or disclosed, and which the Secretary determines are in compliance with section 1411(g)(2)(A) of the Affordable Care Act under the following substantive and procedural requirements: (A) Substantive requirements. (B) Procedural requirements for approval of a use or disclosure of personally identifiable information. ( 1 ( 2 ( 3 ( 4 (2) The Exchange may not create, collect, use, or disclose personally identifiable information unless the creation, collection, use, or disclosure is consistent with this section. (3) The Exchange must establish and implement privacy and security standards that are consistent with the following principles: (i) Individual access. (ii) Correction. (iii) Openness and transparency. (iv) Individual choice. (v) Collection, use, and disclosure limitations. (vi) Data quality and integrity. (vii) Safeguards. (viii) Accountability. (4) For the purposes of implementing the principle described in paragraph (a)(3)(vii) of this section, the Exchange must establish and implement operational, technical, administrative and physical safeguards that are consistent with any applicable laws (including this section) to ensure— (i) The confidentiality, integrity, and availability of personally identifiable information created, collected, used, and/or disclosed by the Exchange; (ii) Personally identifiable information is only used by or disclosed to those authorized to receive or view it; (iii) Return information, as such term is defined by section 6103(b)(2) of the Code, is kept confidential under section 6103 of the Code; (iv) Personally identifiable information is protected against any reasonably anticipated threats or hazards to the confidentiality, integrity, and availability of such information; (v) Personally identifiable information is protected against any reasonably anticipated uses or disclosures of such information that are not permitted or required by law; and (vi) Personally identifiable information is securely destroyed or disposed of in an appropriate and reasonable manner and in accordance with retention schedules; (5) The Exchange must monitor, periodically assess, and update the security controls and related system risks to ensure the continued effectiveness of those controls. (6) The Exchange must develop and utilize secure electronic interfaces when sharing personally identifiable information electronically. (b) Application to non-Exchange entities Non-Exchange entities. (i) Gains access to personally identifiable information submitted to an Exchange; or (ii) Collects, uses, or discloses personally identifiable information gathered directly from applicants, qualified individuals, or enrollees while that individual or entity is performing functions agreed to with the Exchange. (2) Prior to any person or entity becoming a non-Exchange entity, Exchanges must execute with the person or entity a contract or agreement that includes: (i) A description of the functions to be performed by the non-Exchange entity; (ii) A provision(s) binding the non-Exchange entity to comply with the privacy and security standards and obligations adopted in accordance with paragraph (b)(3) of this section, and specifically listing or incorporating those privacy and security standards and obligations; (iii) A provision requiring the non-Exchange entity to monitor, periodically assess, and update its security controls and related system risks to ensure the continued effectiveness of those controls in accordance with paragraph (a)(5) of this section; (iv) A provision requiring the non-Exchange entity to inform the Exchange of any change in its administrative, technical, or operational environments defined as material within the contract; and (v) A provision that requires the non-Exchange entity to bind any downstream entities to the same privacy and security standards and obligations to which the non-Exchange entity has agreed in its contract or agreement with the Exchange. (3) When collection, use or disclosure is not otherwise required by law, the privacy and security standards to which an Exchange binds non-Exchange entities must: (i) Be consistent with the principles and requirements listed in paragraphs (a)(1) through (6) of this section, including being at least as protective as the standards the Exchange has established and implemented for itself in compliance with paragraph (a)(3) of this section; (ii) Comply with the requirements of paragraphs (c), (d), (f), and (g) of this section; and (iii) Take into specific consideration: (A) The environment in which the non-Exchange entity is operating; (B) Whether the standards are relevant and applicable to the non-Exchange entity's duties and activities in connection with the Exchange; and (C) Any existing legal requirements to which the non-Exchange entity is bound in relation to its administrative, technical, and operational controls and practices, including but not limited to, its existing data handling and information technology processes and protocols. (c) Workforce compliance. (d) Written policies and procedures. (1) Be in writing, and available to the Secretary of HHS upon request; and (2) Identify applicable law governing collection, use, and disclosure of personally identifiable information. (e) Data sharing. (1) Meet any applicable requirements described in this section; (2) Meet any applicable requirements described in section 1413(c)(1) and (c)(2) of the Affordable Care Act; (3) Be equal to or more stringent than the requirements for Medicaid programs under section 1942 of the Act; and (4) For those matching agreements that meet the definition of “matching program” under 5 U.S.C. 552a(a)(8), comply with 5 U.S.C. 552a(o). (f) Compliance with the Code. (g) Improper use and disclosure of information. [77 FR 18444, Mar. 27, 2012, as amended at 77 FR 31515, May 29, 2012; 79 FR 13837, Mar. 11, 2014; 79 FR 30346, May 27, 2014; 81 FR 12341, Mar. 8, 2016; 81 FR 61581, Sept. 6, 2016] § 155.270 Use of standards and protocols for electronic transactions. (a) HIPAA administrative simplification. (b) HIT enrollment standards and protocols. [77 FR 18444, Mar. 27, 2012, as amended at 78 FR 54135, Aug. 30, 2013] § 155.280 Oversight and monitoring of privacy and security requirements. (a) General. (b) Audits and investigations. [78 FR 54135, Aug. 30, 2013, as amended at 81 FR 12341, Mar. 8, 2016] § 155.285 Bases and process for imposing civil penalties for provision of false or fraudulent information to an Exchange or improper use or disclosure of information. (a) Grounds for imposing civil money penalties. (i) Failure to provide correct information under section 1411(b) of the Affordable Care Act where such failure is attributable to negligence or disregard of any rules or regulations of the Secretary with negligence and disregard defined as they are in section 6662 of the Internal Revenue Code of 1986: (A) “Negligence” includes any failure to make a reasonable attempt to provide accurate, complete, and comprehensive information; and (B) “Disregard” includes any careless, reckless, or intentional disregard for any rules or regulations of the Secretary. (ii) Knowing and willful provision of false or fraudulent information required under section 1411(b) of the Affordable Care Act, where knowing and willful means the intentional provision of information that the person knows to be false or fraudulent; or (iii) Knowing and willful use or disclosure of information in violation of section 1411(g) of the Affordable Care Act, where knowing and willful means the intentional use or disclosure of information in violation of section 1411(g). Such violations would include, but not be limited to, the following: (A) Any use or disclosure performed which violates relevant privacy and security standards established by the Exchange pursuant to § 155.260; (B) Any other use or disclosure which has not been determined by the Secretary to be in compliance with section 1411(g)(2)(A) of the Affordable Care Act pursuant to § 155.260(a); and (C) Any other use or disclosure which is not necessary to carry out a function described in a contract with a non-Exchange entity executed pursuant to § 155.260(b)(2). (2) For purposes of this section, the term “person” is defined to include, but is not limited to, all individuals; corporations; Exchanges; Medicaid and CHIP agencies; other entities gaining access to personally identifiable information submitted to an Exchange to carry out additional functions which the Secretary has determined ensure the efficient operation of the Exchange pursuant to § 155.260(a)(1); and non-Exchange entities as defined in § 155.260(b) which includes agents, brokers, Web-brokers, QHP issuers, Navigators, non-Navigator assistance personnel, certified application counselors, in-person assistors, and other third party contractors. (b) Factors in determining the amount of civil money penalties imposed. (1) The nature and circumstances of the conduct including, but not limited to: (i) The number of violations; (ii) The severity of the violations; (iii) The person's history with the Exchange including any prior violations that would indicate whether the violation is an isolated occurrence or represents a pattern of behavior; (iv) The length of time of the violation; (v) The number of individuals affected or potentially affected; (vi) The extent to which the person received compensation or other consideration associated with the violation; (vii) Any documentation provided in any complaint or other information, as well as any additional information provided by the individual to refute performing the violation; and (viii) Whether other remedies or penalties have been imposed for the same conduct or occurrence. (2) The nature of the harm resulting from, or reasonably expected to result from, the violation, including but not limited to: (i) Whether the violation resulted in actual or potential financial harm; (ii) Whether there was actual or potential harm to an individual's reputation; (iii) Whether the violation hindered or could have hindered an individual's ability to obtain health insurance coverage; (iv) [Reserved] (v) The actual or potential impact of the provision of false or fraudulent information or of the improper use or disclosure of the information; and (vi) Whether any person received a more favorable eligibility determination for enrollment in a QHP or insurance affordability program, such as greater advance payment of the premium tax credits or cost-sharing reductions than he or she would be eligible for if the correct information had been provided. (3) No penalty will be imposed under paragraph (a)(1)(i) of this section if HHS determines that there was a reasonable cause for the failure to provide correct information required under section 1411(b) of the Affordable Care Act and that the person acted in good faith. (c) Maximum penalty. (1) The following provisions provide maximum penalties for a single “plan year,” where “plan year” has the same meaning as at § 155.20: (i) Any person who fails to provide correct information as specified in paragraph (a)(1)(i) of this section may be subject to a maximum civil money penalty of $25,000 as adjusted annually under 45 CFR part 102 for each application, as defined at paragraph (c)(1)(iii) of this section, pursuant to which a person fails to provide correct information. (ii) Any person who knowingly and willfully provides false information as specified in paragraph (a)(1)(ii) of this section may be subject to a maximum civil money penalty of $250,000 as adjusted annually under 45 CFR part 102 for each application, as defined at paragraph (c)(1)(iii) of this section, on which a person knowingly and willfully provides false information. (iii) For the purposes of this subsection, “application” is defined as a submission of information, whether through an online portal, over the telephone through a call center, or through a paper submission process, in which the information is provided in relation to an eligibility determination; an eligibility redetermination based on a change in an individual's circumstances; or an annual eligibility redetermination for any of the following: (A) Enrollment in a qualified health plan; (B) Premium tax credits or cost sharing reductions; or (C) An exemption from the individual shared responsibility payment. (2) Any person who knowingly or willfully uses or discloses information as specified in paragraph (a)(1)(iii) of this section may be subject to the following civil money penalty: (i) A civil money penalty for each use or disclosure described in paragraph (a)(1)(iii) of this section of not more than $25,000 as adjusted annually under 45 CFR part 102 per use or disclosure. (ii) For purposes of paragraph (c) of this section, a use or disclosure includes one separate use or disclosure of a single individual's personally identifiable information where the person against whom a civil money penalty may be imposed has made the use or disclosure. (3) These penalties may be imposed in addition to any other penalties that may be prescribed by law. (d) Notice of intent to issue civil money penalty. (1) This written notice will be either hand delivered, sent by certified mail, return receipt requested, or sent by overnight delivery service with signature upon delivery required. The written notice must include the following elements: (i) A description of the findings of fact regarding the violations with respect to which the civil money penalty is proposed; (ii) The basis and reasons why the findings of fact subject the person to a penalty; (iii) Any circumstances described in paragraph (b) of this section that were considered in determining the amount of the proposed penalty; (iv) The amount of the proposed penalty; (v) An explanation of the person's right to a hearing under any applicable administrative hearing process; (vi) A statement that failure to request a hearing within 60 calendar days after the date of issuance printed on the notice permits the assessment of the proposed penalty; and (vii) Information explaining how to file a request for a hearing and the address to which the hearing request must be sent. (2) The person may request a hearing before an ALJ on the proposed penalty by filing a request in accordance with the procedure to file an appeal specified in paragraph (f) of this section. (e) Failure to request a hearing. (1) HHS will notify the person in writing of any penalty that has been imposed, the means by which the person may satisfy the penalty, and the date on which the penalty is due. (2) A person has no right to appeal a penalty with respect to which the person has not timely requested a hearing in accordance with paragraph (d) of this section. (f) Appeal of proposed penalty. (g) Enforcement authority HHS. (2) OIG. (h) Settlement authority. (i) Limitations. [79 FR 30346, May 27, 2014, as amended at 81 FR 61581, Sept. 6, 2016] Subpart D—Exchange Functions in the Individual Market: Eligibility Determinations for Exchange Participation and Insurance Affordability Programs § 155.300 Definitions and general standards for eligibility determinations. (a) Definitions. Applicable Children's Health Insurance Program (CHIP) MAGI-based income standard Applicable Medicaid modified adjusted gross income (MAGI)-based income standard Federal poverty level FPL Federal Register Indian Insurance affordability program MAGI-based income Minimum value Modified Adjusted Gross Income (MAGI) Non-citizen Qualifying coverage in an eligible employer-sponsored plan State CHIP Agency State Medicaid Agency Tax dependent Tax filer (1) To file an income tax return for the benefit year, in accordance with 26 U.S.C. 6011, 6012, and implementing regulations; (2) If married (within the meaning of 26 CFR 1.7703-1), to file a joint tax return for the benefit year; (3) That no other taxpayer will be able to claim him, her or them as a tax dependent for the benefit year; and (4) That he, she, or they expects to claim a personal exemption deduction under section 151 of the Code on his or her tax return for one or more applicants, who may or may not include himself or herself and his or her spouse. (b) Medicaid and CHIP. (c) Attestation. (2) The attestations specified in §§ 155.310(d)(2)(ii) and 155.315(f)(4)(ii) must be provided by the tax filer. (d) Reasonably compatible. [77 FR 18444, Mar. 27, 2012, as amended at 78 FR 42314, July 15, 2013] § 155.302 Options for conducting eligibility determinations. (a) Options for conducting eligibility determinations. (1) Directly, through contracting arrangements in accordance with § 155.110(a) under which the Exchange carries out all eligibility determinations for QHP coverage and related insurance affordability programs; or, as a State-based Exchange on the Federal platform, through a Federal platform agreement under which HHS carries out eligibility determinations and other requirements contained within this subpart; or (2) Through a combination of the approach described in paragraph (a)(1) of this section and one or both of the options described in paragraph (b) or (c) of this section, subject to the standards in paragraph (d) of this section. (b) Medicaid and CHIP. (1) The Exchange makes such an assessment based on the applicable Medicaid and CHIP MAGI-based income standards and citizenship and immigration status, using verification rules and procedures consistent with 42 CFR parts 435 and 457, without regard to how such standards are implemented by the State Medicaid and CHIP agencies. (2) Notices and other activities required in connection with an eligibility determination for Medicaid or CHIP are performed by the Exchange consistent with the standards identified in this subpart or the State Medicaid or CHIP agency consistent with applicable law. (3) Applicants found potentially eligible for Medicaid or CHIP. (4) Applicants not found potentially eligible for Medicaid and CHIP. (A) Withdraw his or her application for Medicaid and CHIP, unless the Exchange has assessed the applicant as potentially eligible for Medicaid based on factors not otherwise considered in this subpart, in accordance with § 155.345(b), and provided that the application will not be considered withdrawn if he or she appeals his or her eligibility determination for advance payments of the premium tax credit or cost-sharing reductions and the appeals entity described in § 155.500(a) finds that the individual is potentially eligible for Medicaid or CHIP; or (B) Request a full determination of eligibility for Medicaid and CHIP by the applicable State Medicaid and CHIP agencies. (ii) To the extent that an applicant described in paragraph (b)(4)(i) of this section requests a full determination of eligibility for Medicaid and CHIP, the Exchange must— (A) Transmit all information provided as a part of the application, update, or renewal that initiated the assessment, and any information obtained or verified by the Exchange to the State Medicaid agency and CHIP agency via secure electronic interface, promptly and without undue delay; and (B) Consider such an applicant as ineligible for Medicaid and CHIP for purposes of determining eligibility for advance payments of the premium tax credit and cost-sharing reductions until the State Medicaid or CHIP agency notifies the Exchange that the applicant is eligible for Medicaid or CHIP. (5) The Exchange and the Exchange appeals entity adheres to the eligibility determination or appeals decision for Medicaid or CHIP made by the State Medicaid or CHIP agency, or the appeals entity for such agency. (6) The Exchange and the State Medicaid and CHIP agencies enter into an agreement specifying their respective responsibilities in connection with eligibility determinations for Medicaid and CHIP, and provide a copy of such agreement to HHS upon request. (c) Advance payments of the premium tax credit and cost-sharing reductions. (1) Verifications, notices, and other activities required in connection with an eligibility determination for advance payments of the premium tax credit and cost-sharing reductions are performed by the Exchange in accordance with the standards identified in this subpart or by HHS in accordance with the agreement described in paragraph (c)(4) of this section; (2) The Exchange transmits all information provided as a part of the application, update, or renewal that initiated the eligibility determination, and any information obtained or verified by the Exchange, to HHS via secure electronic interface, promptly and without undue delay; (3) The Exchange adheres to the eligibility determination for advance payments of the premium tax credit and cost-sharing reductions made by HHS; and (4) The Exchange and HHS enter into an agreement specifying their respective responsibilities in connection with eligibility determinations for advance payments of the premium tax credit and cost-sharing reductions. (d) Standards. (1) Eligibility processes for all insurance affordability programs are streamlined and coordinated across HHS, the Exchange, the State Medicaid agency, and the State CHIP agency, as applicable; (2) Such arrangement does not increase administrative costs and burdens on applicants, enrollees, beneficiaries, or application filers, or increase delay; and (3) Applicable requirements under 45 CFR 155.260, 155.270, and 155.315(i), and section 6103 of the Code for the confidentiality, disclosure, maintenance, and use of information are met. [77 FR 18444, Mar. 27, 2012, as amended at 78 FR 42314, July 15, 2013; 81 FR 12341, Mar. 8, 2016; 89 FR 26421, Apr. 15, 2024] § 155.305 Eligibility standards. (a) Eligibility for enrollment in a QHP through the Exchange. (1) Citizenship, status as a national, or lawful presence. (2) Incarceration. (3) Residency. (i) For an individual who is age 21 and over, is not living in an institution as defined in 42 CFR 435.403(b), is capable of indicating intent, and is not receiving an optional State supplementary payment as addressed in 42 CFR 435.403(f), the service area of the Exchange of the individual is the service areas of the Exchange in which he or she is living and— (A) Intends to reside, including without a fixed address; or (B) Has entered with a job commitment or is seeking employment (whether or not currently employed). (ii) For an individual who is under the age of 21, is not living in an institution as defined in 42 CFR 435.403(b), is not eligible for Medicaid based on receipt of assistance under title IV-E of the Social Security Act as addressed in 42 CFR 435.403(g), is not emancipated, is not receiving an optional State supplementary payment as addressed in 42 CFR 435.403(f), the Exchange service area of the individual— (A) Is the service area of the Exchange in which he or she resides, including without a fixed address; or (B) Is the service area of the Exchange of a parent or caretaker, established in accordance with paragraph (a)(3)(i) of this section, with whom the individual resides. (iii) Other special circumstances. (iv) Special rule for tax households with members in multiple Exchange service areas. (B) If both spouses in a tax household enroll in a QHP through the same Exchange, a tax dependent may only enroll in a QHP through that Exchange, or through the Exchange that services the area in which the dependent meets a residency standard described in paragraphs (a)(3)(i), (ii), or (iii) of this section. (v) Temporary absence. (b) Eligibility for QHP enrollment periods. (c) Eligibility for Medicaid. (1) Is a pregnant woman, as defined in the Medicaid State Plan in accordance with 42 CFR 435.4; (2) Is under age 19; (3) Is a parent or caretaker relative of a dependent child, as defined in the Medicaid State plan in accordance with 42 CFR 435.4; or (4) Is not described in paragraph (c)(1), (2), or (3) of this section, is under age 65 and is not entitled to or enrolled for benefits under part A of title XVIII of the Social Security Act, or enrolled for benefits under part B of title XVIII of the Social Security Act. (d) Eligibility for CHIP. (e) Eligibility for BHP. (f) Eligibility for advance payments of the premium tax credit In general. (i) He or she is expected to have a household income that will qualify the tax filer as an applicable taxpayer according to 26 CFR 1.36B-2(b) for the benefit year for which coverage is requested; and (ii) One or more applicants who is expected to be a member of the tax filer's family within the meaning of 26 CFR 1.36B-1(d) for the benefit year— (A) Meets the requirements for eligibility for enrollment in a QHP through the Exchange, as specified in paragraph (a) of this section; and (B) Is not eligible for minimum essential coverage for the full calendar month for which advance payments of the premium tax credit would be paid, with the exception of coverage in the individual market, in accordance with 26 CFR 1.36B-2(a)(2) and (c). (C) He or she is a U.S. citizen, U.S. national, or an eligible noncitizen as defined in § 155.20. (2) [Reserved] (3) Enrollment required. (4) Compliance with tax filing requirement APTC eligibility. (B) For plan year 2028 and beyond, an Exchange must implement a 1-tax year FTR policy described in paragraph (f)(4)(ii)(A) of this section. (ii) Failure to file and reconcile. (A) A tax filer and their spouse, if the tax filer is married, is considered to have failed to file and reconcile for 1 tax year if HHS notifies the Exchange as part of the process described in § 155.320(c)(3) that APTC payments were made on behalf of either the tax filer or the tax filer's spouse, if the tax filer is a married couple, for the most recent year for which tax data would be utilized for verification of household income and family size in accordance with § 155.320(c)(1)(i), and the tax filer or the tax filer's spouse did not comply with the requirement to file an income tax return for that year as required by 26 U.S.C. 6011, 6012, and in 26 CFR chapter I, and reconcile APTC for that period. (B) A tax filer and their spouse, if the tax filer is married, is considered to have failed to file and reconcile for 2 tax years if HHS notifies the Exchange as part of the process described in § 155.320(c)(3) that APTC payments were made on behalf of either the tax filer or the tax filer's spouse, if the tax filer is a married couple, for the 2 most recent consecutive tax years for which tax data would be utilized for verification of household income and family size in accordance with § 155.320(c)(1)(i), and the tax filer or the tax filer's spouse did not comply with the requirement to file an income tax return for those years as required by 26 U.S.C. 6011, 6012, and in 26 CFR chapter I, and reconcile APTC for that period. (iii) Notice Requirements. For purposes of paragraph (f)(4)(ii) of this section, the following notice requirements apply. (A) An Exchange that implements a 2-tax year FTR policy as described in paragraph (f)(4)(ii)(B) of this section must: ( 1 ( i ( ii ( 2 ( i ( ii (B) An Exchange that implements 1-tax year FTR policy as described in paragraph (f)(4)(ii)(A) of this section must: (1) Send a notification to the tax filer, consistent with the standards applicable to the protection of Federal Tax Information, that informs the tax filer that the Exchange has determined that the tax filer or the tax filer's spouse, if the tax filer is married, has failed to file and reconcile of the need to file and reconcile, and of the risk of being determined ineligible for APTC if they fail to file and reconcile immediately; or (2) Send a notification to either the tax filer or their enrollee, that informs the tax filer or enrollee that they may be at risk of being determined ineligible for APTC in the future. These notices must educate tax filers or their enrollees on the requirement to file and reconcile, while not directly stating that the IRS indicates the tax filer or the tax filer's spouse, if the tax filer is married, has failed to file and reconcile. (5) Calculation of advance payments of the premium tax credit. (6) Collection of Social Security numbers. (g) Eligibility for cost-sharing reductions Eligibility criteria. (A) Meets the requirements for eligibility for enrollment in a QHP through the Exchange, as specified in paragraph (a) of this section; (B) Meets the requirements for advance payments of the premium tax credit, as specified in paragraph (f) of this section; and (C) Is expected to have a household income that does not exceed 250 percent of the FPL, for the benefit year for which coverage is requested. (ii) The Exchange may only provide cost-sharing reductions to an enrollee who is not an Indian if he or she is enrolled through the Exchange in a silver-level QHP, as defined by section 1302(d)(1)(B) of the Affordable Care Act. (2) Eligibility categories. (i) An individual who is expected to have a household income greater than or equal to 100 percent of the FPL and less than or equal to 150 percent of the FPL for the benefit year for which coverage is requested, or for an individual who is eligible for advance payments of the premium tax credit under paragraph (f)(2) of this section, a household income less than 100 percent of the FPL for the benefit year for which coverage is requested; (ii) An individual is expected to have a household income greater than 150 percent of the FPL and less than or equal to 200 percent of the FPL for the benefit year for which coverage is requested; and (iii) An individual who is expected to have a household income greater than 200 percent of the FPL and less than or equal to 250 percent of the FPL for the benefit year for which coverage is requested. (3) Special rule for family policies. (i) Individuals not eligible for changes to cost sharing; (ii) Individuals described in § 155.350(b) (the special cost-sharing rule for Indians regardless of income); (iii) Individuals described in paragraph (g)(2)(iii) of this section; (iv) Individuals described in paragraph (g)(2)(ii) of this section; (v) Individuals described in paragraph (g)(2)(i) of this section; and (vi) Individuals described in § 155.350(a) (the cost-sharing rule for Indians with household incomes under 300 percent of the FPL). (4) For the purposes of paragraph (g) of this section, “household income” means household income as defined in section 36B(d)(2) of the Code. (h) Eligibility for enrollment through the Exchange in a QHP that is a catastrophic plan. (1) Has not attained the age of 30 before the beginning of the plan year; or (2) Has a certification in effect for any plan year that he or she is exempt from the requirement to maintain minimum essential coverage under section 5000A of the Code by reason of— (i) Section 5000A(e)(1) of the Code (relating to individuals without affordable coverage); or (ii) Section 5000A(e)(5) of the Code (relating to individuals with hardships). [77 FR 18444, Mar. 27, 2012, as amended at 78 FR 15533, Mar. 11, 2013; 78 FR 42315, July 15, 2013; 87 FR 27388, May 6, 2022; 88 FR 25918, Apr. 27, 2023; 89 FR 26421, Apr. 15, 2024; 90 FR 4540, Jan. 15, 2025; 90 FR 27221, June 25, 2025; 91 FR 29866, May 20, 2026] § 155.310 Eligibility process. (a) Application Accepting applications. (2) Information collection from non-applicants. (3) Collection of Social Security numbers. (ii) The Exchange may not require an individual who is not seeking coverage for himself or herself to provide a Social Security number, except as specified in § 155.305(f)(6). (b) Applicant choice for Exchange to determine eligibility for insurance affordability programs. (c) Timing. (d) Determination of eligibility. (2) Special rules relating to advance payments of the premium tax credit. (ii) The Exchange may authorize advance payments of the premium tax credit on behalf of a tax filer only if the Exchange first obtains necessary attestations from the tax filer regarding advance payments of the premium tax credit, including, but not limited to attestations that— (A) He or she will file an income tax return for the benefit year, in accordance with 26 U.S.C. 6011, 6012, and implementing regulations; (B) If married (within the meaning of 26 CFR 1.7703-1), he or she will file a joint tax return for the benefit year; (C) No other taxpayer will be able to claim him or her as a tax dependent for the benefit year; and (D) He or she will claim a personal exemption deduction on his or her tax return for the applicants identified as members of his or her family, including the tax filer and his or her spouse, in accordance with § 155.320(c)(3)(i). (3) Special rule relating to Medicaid and CHIP. (e) Timeliness standards. (2) The Exchange must assess the timeliness of eligibility determinations based on the period from the date of application or transfer from an agency administering an insurance affordability program to the date the Exchange notifies the applicant of its decision or the date the Exchange transfers the application to another agency administering an insurance affordability program, when applicable. (f) Effective dates for eligibility. (1) For an initial eligibility determination, in accordance with the dates specified in §§ 155.410(c) and (f) and 155.420(b), as applicable, (2) For a redetermination, in accordance with the dates specified in §§ 155.330(f) and 155.335(i), as applicable. (g) Notification of eligibility determination. (h) Notice of an employee's receipt of advance payments of the premium tax credit and cost-sharing reductions to an employer. (1) Identify the employee; (2) Indicate that the employee has been determined eligible advance payments of the premium tax credit and cost-sharing reductions and has enrolled in a qualified health plan through the Exchange; (3) Indicate that, if the employer has 50 or more full-time employees, the employer may be liable for the payment assessed under section 4980H of the Code; and (4) Notify the employer of the right to appeal the determination. (i) Certification program for employers. (j) Duration of eligibility determinations without enrollment. (k) Incomplete application. (1) Provide notice to the applicant indicating that information necessary to complete an eligibility determination is missing, specifying the missing information, and providing instructions on how to provide the missing information; and (2) Provide the applicant with a period of no less than 10 days and no more than 90 days from the date on which the notice described in paragraph (k)(1) of this section is sent to the applicant to provide the information needed to complete the application to the Exchange. (3) During the period described in paragraph (k)(2) of this section, the Exchange must not proceed with an applicant's eligibility determination or provide advance payments of the premium tax credit or cost-sharing reductions, unless an application filer has provided sufficient information to determine his or her eligibility for enrollment in a QHP through the Exchange, in which case the Exchange must make such a determination for enrollment in a QHP. [77 FR 18444, Mar. 27, 2012, as amended at 78 FR 42314, July 15, 2013; 78 FR 54136, Aug. 30, 2013; 81 FR 12341, Mar. 8, 2016] § 155.315 Verification process related to eligibility for enrollment in a QHP through the Exchange. (a) General requirement. (b) Validation of Social Security number. (2) To the extent that the Exchange is unable to validate an individual's Social Security number through the Social Security Administration, or the Social Security Administration indicates that the individual is deceased, the Exchange must follow the procedures specified in paragraph (f) of this section, except that the Exchange must provide the individual with a period of 90 days from the date on which the notice described in paragraph (f)(2)(i) of this section is received for the applicant to provide satisfactory documentary evidence or resolve the inconsistency with the Social Security Administration. The date on which the notice is received means 5 days after the date on the notice, unless the individual demonstrates that he or she did not receive the notice within the 5 day period. (c) Verification of citizenship, status as a national, or lawful presence Verification with records from the Social Security Administration. (2) Verification with the records of the Department of Homeland Security. (3) Inconsistencies and inability to verify information. (d) Verification of residency. (1) Except as provided in paragraphs (d)(3) and (4) of this section, accept his or her attestation without further verification; or (2) Examine electronic data sources that are available to the Exchange and which have been approved by HHS for this purpose, based on evidence showing that such data sources are sufficiently current and accurate, and minimize administrative costs and burdens. (3) If information provided by an applicant regarding residency is not reasonably compatible with other information provided by the individual or in the records of the Exchange the Exchange must examine information in data sources that are available to the Exchange and which have been approved by HHS for this purpose, based on evidence showing that such data sources are sufficiently current and accurate. (4) If the information in such data sources is not reasonably compatible with the information provided by the applicant, the Exchange must follow the procedures specified in paragraph (f) of this section. Evidence of immigration status may not be used to determine that an applicant is not a resident of the Exchange service area. (e) Verification of incarceration status. (1) Accepting an applicant's attestation that they are not currently incarcerated; or (2) Verifying an applicant's attestation of incarceration status using any electronic data source that is available to the Exchange and which has been approved by HHS for this purpose. HHS will approve an electronic data source for incarceration verification if it provides data that are current and accurate, and if its use minimizes administrative costs and burdens. (3) If an Exchange verifies an applicant's attestation of incarceration status using an approved data source under paragraph (e)(2) of this section, to the extent that an applicant's attestation is not reasonably compatible with information from the approved data source or other information provided by the applicant or in the records of the Exchange, the Exchange must follow the procedures specified in § 155.315(f). (f) Inconsistencies. (1) Must make a reasonable effort to identify and address the causes of such inconsistency, including through typographical or other clerical errors, by contacting the application filer to confirm the accuracy of the information submitted by the application filer; (2) If unable to resolve the inconsistency through the process described in paragraph (f)(1) of this section, must— (i) Provide notice to the applicant regarding the inconsistency; and (ii) Provide the applicant with a period of 90 days from the date on which the notice described in paragraph (f)(2)(i) of this section is sent to the applicant to either present satisfactory documentary evidence via the channels available for the submission of an application, as described in § 155.405(c), except for by telephone through a call center, or otherwise resolve the inconsistency. (3) May extend the period described in paragraph (f)(2)(ii) of this section for an applicant if the applicant demonstrates that a good faith effort has been made to obtain the required documentation during the period. (4) During the periods described in paragraphs (f)(1) and (f)(2)(ii) of this section, must: (i) Proceed with all other elements of eligibility determination using the applicant's attestation, and provide eligibility for enrollment in a QHP to the extent that an applicant is otherwise qualified; and (ii) Ensure that advance payments of the premium tax credit and cost-sharing reductions are provided on behalf of an applicant within this period who is otherwise qualified for such payments and reductions, as described in § 155.305, if the tax filer attests to the Exchange that he or she understands that any advance payments of the premium tax credit paid on his or her behalf are subject to reconciliation. (5) If, after the period described in paragraph (f)(2)(ii) of this section, the Exchange remains unable to verify the attestation, the Exchange must determine the applicant's eligibility based on the information available from the data sources specified in this subpart, unless such applicant qualifies for the exception provided under paragraph (g) of this section, and notify the applicant of such determination in accordance with the notice requirements specified in § 155.310(g), including notice that the Exchange is unable to verify the attestation. (6) When electronic data to support the verifications specified in § 155.315(d) or § 155.320(b) is required but it is not reasonably expected that data sources will be available within 1 day of the initial request to the data source, the Exchange must accept the applicant's attestation regarding the factor of eligibility for which the unavailable data source is relevant. (g) Exception for special circumstances. (h) Flexibility in information collection and verification. (i) Applicant information. (j) Verification related to eligibility for enrollment through the Exchange in a QHP that is a catastrophic plan. (1) Verifying the applicant's attestation of age as follows— (i) Except as provided in paragraph (j)(1)(iii) of this section, accepting his or her attestation without further verification; or (ii) Examining electronic data sources that are available to the Exchange and which have been approved by HHS for this purpose, based on evidence showing that such data sources are sufficiently current and accurate, and minimize administrative costs and burdens. (iii) If information regarding age is not reasonably compatible with other information provided by the individual or in the records of the Exchange, the Exchange must examine information in data sources that are available to the Exchange and which have been approved by HHS for this purpose based on evidence showing that such data sources are sufficiently current and accurate. (2) Verifying that an applicant has a certification of exemption in effect as described in § 155.305(h)(2). (3) To the extent that the Exchange is unable to verify the information required to determine eligibility for enrollment through the Exchange in a QHP that is a catastrophic plan as described in paragraphs (j)(1) and (2) of this section, the Exchange must follow the procedures specified in § 155.315(f), except for § 155.315(f)(4). [77 FR 18444, Mar. 27, 2012, as amended at 77 FR 31515, May 29, 2012; 78 FR 42316, July 15, 2013; 88 FR 25918, Apr. 27, 2023; 89 FR 26421, Apr. 15, 2024; 90 FR 27221, June 25, 2025] § 155.320 Verification process related to eligibility for insurance affordability programs. (a) General requirements. (2) Unless a request for modification is granted in accordance with § 155.315(h), the Exchange must verify or obtain information in accordance with this section before making an eligibility determination for insurance affordability programs, and must use such information in such determination. (b) Verification of eligibility for minimum essential coverage other than through an eligible employer-sponsored plan. (ii) The Exchange must verify whether an applicant has already been determined eligible for coverage through Medicaid, CHIP, or the BHP, if a BHP is operating in the service area of the Exchange, within the State or States in which the Exchange operates using information obtained from the agencies administering such programs. (2) Consistent with § 164.512(k)(6)(i) of this subchapter, the disclosure to HHS of information regarding eligibility for and enrollment in a health plan, which may be considered protected health information, as that term is defined in § 160.103 of this subchapter, is expressly authorized, for the purposes of verification of applicant eligibility for minimum essential coverage as part of the eligibility determination process for advance payments of the premium tax credit or cost-sharing reductions. (c) Verification of household income and family/household size Data Data regarding annual household income. (B) If the identifying information for one or more individuals does not match a tax record on file with the Secretary of the Treasury that may be disclosed in accordance with section 6103(l)(21) of the Code and its accompanying regulations, the Exchange must proceed in accordance with § 155.315(f)(1). (ii) Data regarding MAGI-based income. (iii) Payment to use income data through the Verify Current Income Hub service. (2) Verification process for Medicaid and CHIP Household size. (B) The Exchange must verify the information in paragraph (c)(2)(i)(A) of this section by accepting an applicant's attestation without further verification, unless the Exchange finds that an applicant's attestation to the individuals that comprise his or her household for Medicaid and CHIP is not reasonably compatible with other information provided by the application filer for the applicant or in the records of the Exchange, in which case the Exchange must utilize data obtained through electronic data sources to verify the attestation. If such data sources are unavailable or information in such data sources is not reasonably compatible with the applicant's attestation, the Exchange must request additional documentation to support the attestation within the procedures specified in 42 CFR 435.952. (ii) Verification process for MAGI-based household income. (3) Verification process for advance payments of the premium tax credit and cost-sharing reductions Family size. (B) To the extent that the applicant attests that the information described in paragraph (c)(1)(i) of this section represents an accurate projection of a tax filer's family size for the benefit year for which coverage is requested, the Exchange must determine the tax filer's eligibility for advance payments of the premium tax credit and cost-sharing reductions based on the family size data in paragraph (c)(1)(i) of this section. (C) To the extent that the data described in paragraph (c)(1)(i) of this section is unavailable, or an applicant attests that a change in circumstances has occurred or is reasonably expected to occur, and so it does not represent an accurate projection of a tax filer's family size for the benefit year for which coverage is requested, the Exchange must verify the tax filer's family size for advance payments of the premium tax credit and cost-sharing reductions by accepting an applicant's attestation without further verification, except as specified in paragraph (c)(3)(i)(D) of this section. (D) If the Exchange finds that an applicant's attestation of a tax filer's family size is not reasonably compatible with other information provided by the application filer for the family or in the records of the Exchange, with the exception of the data described in paragraph (c)(1)(i) of this section, the Exchange must utilize data obtained through other electronic data sources to verify the attestation. If such data sources are unavailable or information in such data sources is not reasonably compatible with the applicant's attestation, the Exchange must request additional documentation to support the attestation within the procedures specified in § 155.315(f). (E) The Exchange must verify that neither advance payments of the premium tax credit nor cost-sharing reductions are being provided on behalf of an individual using information obtained by transmitting identifying information specified by HHS to HHS. (ii) Basic verification process for annual household income. (B) The Exchange must require the applicant to attest regarding a tax filer's projected annual household income; (C) To the extent that the applicant's attestation indicates that the information described in paragraph (c)(3)(ii)(A) of this section represents an accurate projection of the tax filer's household income for the benefit year for which coverage is requested, the Exchange must determine the tax filer's eligibility for advance payments of the premium tax credit and cost-sharing reductions based on the household income data in paragraph (c)(3)(ii)(A) of this section. (D) To the extent that the data described in paragraph (c)(1)(i) of this section is unavailable, or an applicant attests that a change in circumstances has occurred or is reasonably expected to occur, and so it does not represent an accurate projection of the tax filer's household income for the benefit year for which coverage is requested, the Exchange must require the applicant to attest to the tax filer's projected household income for the benefit year for which coverage is requested. (iii) Verification process for changes in household income. (A) Except as specified in paragraphs (c)(3)(iii)(B), (C), and (D) of this section, if an applicant's attestation to projected annual household income, as described in paragraph (c)(3)(ii)(B) of this section, would qualify the tax payer as an applicable taxpayer under 26 CFR 1.36B-2(b) for the plan year for which coverage is requested and is more than a reasonable threshold above the annual household income computed in accordance with paragraph (c)(3)(ii)(A) of this section, the data described in paragraph (c)(3)(ii)(A) of this section indicates that projected annual household income is under 100 percent of the FPL, and the Exchange has not verified the applicant's MAGI-based income through the process specified in paragraph (c)(2)(ii) of this section to be within the applicable Medicaid or CHIP MAGI-based income standard, the Exchange must proceed in accordance with § 155.315(f)(1) through (4). For the purposes of this paragraph, a reasonable threshold is established by the Exchange in guidance and approved by HHS, but must not be less than 10 percent, and can also include a threshold dollar amount. (B) If data available to the Exchange in accordance with paragraph (c)(1)(ii) of this section indicate that a tax filer's projected annual household income is in excess of his or her attestation by a significant amount, the Exchange must proceed in accordance with § 155.315(f)(1) through (4). (C) If other information provided by the application filer indicates that a tax filer's projected annual household income is in excess of his or her attestation by a significant amount, the Exchange must utilize data available to the Exchange in accordance with paragraph (c)(1)(ii) of this section to verify the attestation. If such data is unavailable or are not reasonably compatible with the applicant's attestation, the Exchange must proceed in accordance with § 155.315(f)(1) through (4). (D) [Reserved] (E) If, at the conclusion of the period specified in § 155.315(f)(2)(ii), the Exchange remains unable to verify the applicant's attestation, the Exchange must determine the applicant's eligibility based on the information described in paragraph (c)(3)(ii)(A) of this section, notify the applicant of such determination in accordance with the notice requirements specified in § 155.310(g), and implement such determination in accordance with the effective dates specified in § 155.330(f). (F) If, at the conclusion of the period specified in § 155.315(f)(2)(ii), the Exchange remains unable to verify the applicant's attestation and the information described in paragraph (c)(3)(ii)(A) of this section is unavailable, the Exchange must determine the tax filer ineligible for advance payments of the premium tax credit and cost-sharing reductions, notify the applicant of such determination in accordance with the notice requirements specified in § 155.310(g), and discontinue any advance payments of the premium tax credit and cost-sharing reductions in accordance with the effective dates specified in § 155.330(f). (iv) Eligibility for alternate verification process for decreases in annual household income and situations in which tax return data is unavailable. (A) The Secretary of the Treasury does not have tax return data that may be disclosed under section 6103(l)(21) of the Code for the tax filer that is at least as recent as the calendar year two years prior to the calendar year for which advance payments of the premium tax credit or cost-sharing reductions would be effective; (B) The applicant attests that the tax filer's applicable family size has changed or is reasonably expected to change for the benefit year for which the applicants in his or her family are requesting coverage, or the members of the tax filer's family have changed or are reasonably expected to change for the benefit year for which the applicants in his or her family are requesting coverage; (C) The applicant attests that a change in circumstances has occurred or is reasonably expected to occur, and so the tax filer's annual household income has decreased or is reasonably expected to decrease from the data described in paragraph (c)(1)(i) of this section for the benefit year for which the applicants in his or her family are requesting coverage; (D) The applicant attests that the tax filer's filing status has changed or is reasonably expected to change for the benefit year for which the applicants in his or her family are requesting coverage; or (E) An applicant in the tax filer's family has filed an application for unemployment benefits. (v) Alternate verification process. (vi) Alternate verification process for decreases in annual household income estimates and for situations in which tax return data is unavailable. (A) Data. (B) Eligibility. (C) Increases in annual household income. ( 1 ( 2 (D) Decreases in annual household income and situations in which electronic data is unavailable. (E) If, following the 90-day period described in paragraph (c)(3)(vi)(D) of this section, an applicant has not responded to a request for additional information from the Exchange and the data sources specified in paragraph (c)(1) of this section indicate that an applicant in the tax filer's family is eligible for Medicaid or CHIP, the Exchange must not provide the applicant with eligibility for advance payments of the premium tax credit, cost-sharing reductions, Medicaid, CHIP or the BHP, if a BHP is operating in the service area of the Exchange. (F) If, at the conclusion of the period specified in § 155.315(f)(2)(ii), the Exchange remains unable to verify the applicant's attestation, the Exchange must determine the applicant's eligibility based on the information described in paragraph (c)(3)(ii)(A) of this section, notify the applicant of such determination in accordance with the notice requirements specified in § 155.310(g), and implement such determination in accordance with the effective dates specified in § 155.330(f). (G) If, at the conclusion of the period specified in § 155.315(f)(2)(ii), the Exchange remains unable to verify the applicant's attestation for the tax filer and the information described in paragraph (c)(3)(ii)(A) of this section is unavailable, the Exchange must determine the tax filer ineligible for advance payments of the premium tax credit and cost-sharing reductions, notify the applicant of such determination in accordance with the notice requirement specified in § 155.310(g), and discontinue any advance payments of the premium tax credit and cost-sharing reductions in accordance with the effective dates specified in § 155.330(f). (vii) Definition of household income. (viii) Definition of family size. (ix) Verification of eligible noncitizen status. (B) Inconsistencies and inability to verify information. For an applicant who attests to having an eligible noncitizen status as defined at § 155.20, and for whom the Exchange cannot verify such attestation through the Department of Homeland Security, the Exchange must follow the procedures specified in § 155.315(f)(1) through (4). The date on which the notice is received means 5 days after the date on the notice, unless the applicant demonstrates that he or she did not receive the notice within the 5 day period as described in § 155.315(b)(2). (C) If, at the conclusion of the period specified in paragraph (c)(3)(ix)(B) of this section, the Exchange remains unable to verify the applicant's attestation, the Exchange must determine the applicant ineligible for advance payments of the premium tax credit and cost-sharing reductions, notify the applicant of such determination in accordance with the notice requirements specified in § 155.310(g), and discontinue any advance payments of the premium tax credit and cost-sharing reductions in accordance with the effective dates specified in § 155.330(f). (4) The Exchange must provide education and assistance to an applicant regarding the process specified in this paragraph. (d) Verification related to enrollment in an eligible employer-sponsored plan and eligibility for qualifying coverage in an eligible employer-sponsored plan General requirement. (2) Data. (i) Obtain data about enrollment in and eligibility for an eligible employer-sponsored plan from any electronic data sources that are available to the Exchange and which have been approved by HHS, based on evidence showing that such data sources are sufficiently current, accurate, and minimize administrative burden. (ii) Obtain any available data regarding enrollment in employer-sponsored coverage or eligibility for qualifying coverage in an eligible employer-sponsored plan based on federal employment by transmitting identifying information specified by HHS to HHS for HHS to provide the necessary verification using data obtained by HHS. (iii) Obtain any available data from the SHOP that corresponds to the State in which the Exchange is operating. (3) Verification procedures. (ii) Except as specified in paragraph (d)(3)(i) or (d)(4)(i) of this section, the Exchange must accept an applicant's attestation regarding the verification specified in paragraph (d) of this section without further verification. (4) Alternate procedures. (i) Based on the Exchange's assessment of risk for inappropriate payment of advance payments of the premium tax credit or cost-sharing reductions, implement a verification process that is reasonably designed to ensure the accuracy of the data and is based on the activities or methods used by an Exchange such as studies, research, and analysis of an Exchange's own enrollment data, for enrollment in or eligibility for qualifying coverage in an eligible employer sponsored plan, as appropriate. (A) The Exchange must provide notice to the applicant if, as part of the verification process described under paragraph (d)(4)(i) of this section, the Exchange will be contacting any employer identified on the application for the applicant and the members of his or her family, as defined in 26 CFR 1.36B-1(d), to verify whether the applicant is enrolled in an eligible employer sponsored plan or is eligible for qualifying coverage in an eligible employer sponsored plan for the benefit year for which coverage is requested; (B) Proceed with all other elements of the eligibility determination using the applicant's attestation, and provide eligibility for enrollment in a QHP to the extent that an applicant is otherwise qualified; (C) Ensure that advance payments of the premium tax credit and cost-sharing reductions are provided on behalf of an applicant who is otherwise qualified for such payments and reductions, as described in § 155.305, if the tax filer attests to the Exchange that he or she understands that any advance payments of the premium tax credit paid on his or her behalf are subject to reconciliation; (D) If the Exchange receives any information from an employer relevant to the applicant's enrollment in an eligible employer-sponsored plan or eligibility for qualifying coverage in an eligible employer-sponsored plan, the Exchange must determine the applicant's eligibility based on such information and in accordance with the effective dates specified in § 155.330(f), and if such information changes his or her eligibility determination, notify the applicant and his or her employer or employers of such determination in accordance with the notice requirements specified in § 155.310(g) and (h); (E) To carry out the process described in paragraph (d)(4)(iii) of this section, the Exchange must only disclose an individual's information to an employer to the extent necessary for the employer to identify the employee. (ii) [Reserved] (e) Additional verification related to immigration status for Medicaid and CHIP. (2) For purposes of determining eligibility for CHIP, the Exchange must verify whether an applicant who does not attest to being a citizen or a national has satisfactory immigration status to be eligible for CHIP, in accordance with 42 CFR 457.320(b) and if applicable under the State Child Health Plan, section 2107(e)(1)(J) of the Act. [77 FR 18444, Mar. 27, 2012, as amended at 78 FR 42316, July 15, 2013; 78 FR 54136, Aug. 30, 2013; 79 FR 30347, May 27, 2014; 81 FR 12341, Mar. 8, 2016; 83 FR 17061, Apr. 17, 2018; 86 FR 24289, May 5, 2021; 87 FR 27389, May 6, 2022; 88 FR 25918, Apr. 27, 2023; 89 FR 26421, Apr. 15, 2024; 90 FR 27221, June 25, 2025; 91 FR 29866, May 20, 2026] § 155.330 Eligibility redetermination during a benefit year. (a) General requirement. (b) Requirement for individuals to report changes. (2) The Exchange must not require an enrollee who did not request an eligibility determination for insurance affordability programs to report changes that affect eligibility for insurance affordability programs. (3) The Exchange may establish a reasonable threshold for changes in income, such that an enrollee who experiences a change in income that is below the threshold is not required to report such change. (4) The Exchange must allow an enrollee, or an application filer on behalf of the enrollee, to report changes via the channels available for the submission of an application, as described in § 155.405(c)(2), except that the Exchange is permitted but not required to allow an enrollee, or an application filer, on behalf of the enrollee, to report changes via mail. (c) Verification of reported changes. (1) Verify any information reported by an enrollee in accordance with the processes specified in §§ 155.315 and 155.320 prior to using such information in an eligibility redetermination; and (2) Provide periodic electronic notifications regarding the requirements for reporting changes and an enrollee's opportunity to report any changes as described in paragraph (b)(3) of this section, to an enrollee who has elected to receive electronic notifications, unless he or she has declined to receive notifications under this paragraph (c)(2). (d) Periodic examination of data sources General requirement. (i) Death; and (ii) For an enrollee on whose behalf advance payments of the premium tax credit or cost-sharing reductions are being provided, eligibility determinations for or enrollment in Medicare, Medicaid, CHIP, or the Basic Health Program, if a Basic Health Program is operating in the service area of the Exchange. (2) Flexibility. (i) Would reduce the administrative costs and burdens on individuals while maintaining accuracy and minimizing delay, that it would not undermine coordination with Medicaid and CHIP, and that applicable requirements under §§ 155.260, 155.270, 155.315(i), and section 6103 of the Code with respect to the confidentiality, disclosure, maintenance, or use of such information will be met; and (ii) Comply with the standards specified in paragraph (e)(2) of this section. (3) Definition of periodically. (ii) Beginning with the 2025 calendar year, the Exchange must perform the periodic examination of data sources described in paragraph (d)(1)(i) of this section at least twice in a calendar year. (iii) Notwithstanding the requirements of paragraphs (d)(3)(i) and (ii) of this section, the Secretary has authority to temporarily suspend the requirement that Exchanges conduct the PDM processes described at paragraph (d)(3)(i) or (ii) of this section during certain situations or circumstances that leads to the limited availability of data needed to conduct PDM or of documentation needed for an enrollee to notify the Exchange that the result of PDM is inaccurate as described in paragraph (e)(2)(i)(C) of this section. (e) Redetermination and notification of eligibility Enrollee-reported data. (i) Redetermine the enrollee's eligibility in accordance with the standards specified in § 155.305; (ii) Notify the enrollee regarding the determination in accordance with the requirements specified in § 155.310(g); and (iii) Notify the enrollee's employer, as applicable, in accordance with the requirements specified in § 155.310(h). (2) Data matching. (A) Notify the enrollee regarding the updated information, as well as the enrollee's projected eligibility determination after considering such information. (B) Allow an enrollee 30 days from the date of the notice to notify the Exchange that such information is inaccurate. (C) If the enrollee responds contesting the updated information, proceed in accordance with § 155.315(f) of this part. (D) If the enrollee does not respond contesting the updated information within the 30-day period specified in paragraph (e)(2)(i)(B) of this section, proceed in accordance with paragraphs (e)(1)(i) and (ii) of this section, provided the enrollee has not directed the Exchange to terminate his or her coverage under such circumstances, in which case the Exchange will terminate the enrollee's coverage in accordance with § 155.430(b)(1)(ii), and provided the enrollee has not been determined to be deceased, in which case the Exchange will terminate the enrollee's coverage in accordance with § 155.430(d)(7). (ii) If the Exchange identifies updated information regarding income, family size, or family composition, with the exception of information regarding death, the Exchange must— (A) Follow procedures described in paragraph (e)(2)(i)(A) and (B) of this section; and (B) If the enrollee responds confirming the updated information, proceed in accordance with paragraphs (e)(1)(i) and (ii) of this section. (C) If the enrollee does not respond within the 30-day period specified in paragraph (e)(2)(i)(B) of this section, maintain the enrollee's existing eligibility determination without considering the updated information. (D) If the enrollee provides more up-to-date information, proceed in accordance with paragraph (c)(1) of this section. (iii) If the Exchange identifies updated information that the tax filer for the enrollee's household or the tax filer's spouse did not comply with the requirements described in § 155.305(f)(4), the Exchange when redetermining and providing notification of eligibility for advance payments of the premium tax credit must: (A) Follow the procedures specified in paragraph (e)(2)(i) of this section; (B) Follow the procedures in guidance published by the Secretary; or (C) Follow alternative procedures approved by the Secretary based on a showing by the Exchange that the alternative procedures facilitate continued enrollment in coverage with financial assistance for which the enrollee remains eligible, provide appropriate information about the process to the enrollee (including regarding any action by the enrollee necessary to obtain the most accurate redetermination of eligibility), and provide adequate program integrity protections and safeguards for Federal tax information under section 6103 of the Internal Revenue Code with respect to the confidentiality, disclosure, maintenance, or use of such information. (f) Effective dates. (i) Resulting from a redetermination under this section on the first day of the month following the date of the notice described in paragraph (e)(1)(ii) of this section; or (ii) Resulting from an appeal decision, on the date specified in the appeal decision; or (iii) Affecting enrollment or premiums only, on the first day of the month following the date on which the Exchange is notified of the change; (2) Except as specified in paragraphs (f)(3) through (5) of this section, the Exchange may determine a reasonable point in a month after which a change described in paragraph (f)(1) of this section will not be effective until the first day of the month after the month specified in paragraph (f)(1) of this section. Such reasonable point in a month must be no earlier than the 15th of the month. (3) Except as specified in paragraphs (f)(4) and (5) of this section, the Exchange must implement a change described in paragraph (f)(1) of this section that results in a decreased amount of advance payments of the premium tax credit, or a change in the level of cost-sharing reductions, and for which the date of the notices described in paragraphs (f)(1)(i) and (ii) of this section, or the date on which the Exchange is notified in accordance with paragraph (f)(1)(iii) of this section is after the 15th of the month, on the first day of the month after the month specified in paragraph (f)(1) of this section. (4) The Exchange must implement a change associated with the events described in § 155.420(b)(2)(i) and (ii) on the coverage effective dates described in § 155.420(b)(2)(i) and (ii), respectively. (5) Notwithstanding paragraphs (f)(1) through (f)(4) of this section, the Exchange may provide the effective date of a change associated with the events described in § 155.420(d)(4), (d)(5), and (d)(9) based on the specific circumstances of each situation. (g) Recalculation of advance payments of the premium tax credit and cost-sharing reductions. (i) Recalculate the amount of advance payments of the premium tax credit in such a manner as to account for any advance payments already made on behalf of the tax filer for the benefit year for which information is available to the Exchange, such that the recalculated advance payment amount is projected to result in total advance payments for the benefit year that correspond to the tax filer's total projected premium tax credit for the benefit year, calculated in accordance with 26 CFR 1.36B-3 (or, if less than zero, be set at zero); or (ii) Recalculate advance payments of the premium tax credit using an alternate method that has been approved by the Secretary. (2) When an eligibility redetermination in accordance with this section results in a change in cost-sharing reductions, the Exchange must determine an individual eligible for the category of cost-sharing reductions that corresponds to his or her expected annual household income for the benefit year (subject to the special rule for family policies set forth in § 155.305(g)(3)). [77 FR 18444, Mar. 27, 2012, as amended at 78 FR 15533, Mar. 11, 2013; 78 FR 42318, July 15, 2013; 79 FR 30347, May 27, 2014; 79 FR 53005, Sept. 5, 2014; 81 FR 94177, Dec. 22, 2016; 84 FR 71710, Dec. 27, 2019; 85 FR 29259, May 14, 2020; 89 FR 26422, Apr. 15, 2024] § 155.335 Annual eligibility redetermination. (a) General requirement. (2) The Exchange must conduct annual redeterminations required under paragraph (a)(1) of this section using one of the following: (i) The procedures described in paragraphs (b) through (m) of this section; (ii) Alternative procedures specified by the Secretary for the applicable benefit year; or (iii) Alternative procedures approved by the Secretary based on a showing by the Exchange that the alternative procedures 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), and provide adequate program integrity protections. (3) The annual redeterminations described in paragraph (a)(2)(ii) of this section are subject to the requirements in paragraph (n) of this section. (b) Updated income and family size information. (c) Notice to qualified individual. (1)-(2) [Reserved] (3) The qualified individual's projected eligibility determination for the following year, after considering any updated information described in paragraph (b) of this section, including, if applicable, the amount of any advance payments of the premium tax credit and the level of any cost-sharing reductions or eligibility for Medicaid, CHIP or BHP. (d) Timing. (2) For redeterminations under this section for coverage effective on or after January 1, 2017, the Exchange may send the notice specified in paragraph (c) of this section separately from the notice of annual open enrollment specified in § 155.410(d), provided that— (i) The Exchange sends the notice specified in paragraph (c) of this section no earlier than the date of the notice of annual open enrollment specified in § 155.410(d); and (ii) The timing of the notice specified in paragraph (c) of this section allows a reasonable amount of time for the enrollee to review the notice, provide a timely response, and for the Exchange to implement any changes in coverage elected during the annual open enrollment period. (e) Changes reported by qualified individuals. (1) The Exchange must not require a qualified individual who did not request an eligibility determination for insurance affordability programs to report changes that affect eligibility for insurance affordability programs. (2) The Exchange must allow a qualified individual, or an application filer, on behalf of the qualified individual, to report changes via the channels available for the submission of an application, as described in § 155.405(c)(2), except that the Exchange is permitted but not required to allow a qualified individual, or an application filer, on behalf of the qualified individual, to report changes via mail. (f) Verification of reported changes. (g) Response to redetermination notice. (2) To the extent that a qualified individual does not sign and return the notice described in paragraph (c) of this section within the 30-day period specified in paragraph (e) of this section, the Exchange must proceed in accordance with the procedures specified in paragraph (h)(1) of this section. (h) Redetermination and notification of eligibility. (i) Redetermine the qualified individual's eligibility in accordance with the standards specified in § 155.305 using the information provided to the qualified individual in the notice specified in paragraph (c) of this section, as supplemented with any information reported by the qualified individual and verified by the Exchange in accordance with paragraphs (e) and (f) of this section. (ii) Notify the qualified individual in accordance with the requirements specified in § 155.310(g). (iii) If applicable, notify the qualified individual employer, in accordance with the requirements specified in § 155.310(h). (2) If a qualified individual reports a change for the information provided in the notice specified in paragraph (c) of this section that the Exchange has not verified as of the end of the 30-day period specified in paragraph (e) of this section, the Exchange must redetermine the qualified individual's eligibility after completing verification, as specified in paragraph (f) of this section. (i) Effective date of annual redetermination. (j) Re-enrollment. (1) The product under which the QHP in which the enrollee is enrolled remains available through the Exchange for renewal, consistent with § 147.106 of this subchapter, the Exchange will renew the enrollee in a QHP under that product, unless the enrollee terminates coverage, including termination of coverage in connection with voluntarily selecting a different QHP, in accordance with § 155.430, or unless otherwise provided in paragraph (j)(1)(iii)(A) of this section, as follows: (i) The Exchange will re-enroll the enrollee in the same plan as the enrollee's current QHP, unless the current QHP is not available through the Exchange; (ii) If the enrollee's current QHP is not available through the Exchange, the Exchange will re-enroll the enrollee in a QHP within the same product at the same coverage level as described in sections 1302(d) or (e) of the ACA as the enrollee's current QHP that has the most similar network compared to the enrollee's current QHP; (iii) If the enrollee's current QHP is not available through the Exchange and the enrollee's product no longer includes a QHP at the same coverage level as described in sections 1302(d) or (e) of the ACA as the enrollee's current QHP and— (A) The enrollee's current QHP is a silver level plan, the Exchange will re-enroll the enrollee in a silver level QHP under a different product offered by the same QHP issuer that is most similar to the enrollee's current product and that has the most similar network compared to the enrollee's current QHP. If no such silver level QHP is available for enrollment through the Exchange, the Exchange will re-enroll the enrollee in a QHP under the same product that is coverage level higher or lower than the enrollee's current QHP and that has the most similar network compared to the enrollee's current QHP; or (B) The enrollee's current QHP is not a silver level plan, the Exchange will re-enroll the enrollee in a QHP under the same product that is one coverage level higher or lower than the enrollee's current QHP and that has the most similar network compared to the enrollee's current QHP; (iv) If the enrollee's current QHP is not available through the Exchange and the enrollee's product no longer includes a QHP that is at the same coverage level as described in sections 1302(d) or (e) of the ACA as, or one coverage level higher or lower than, the enrollee's current QHP, the Exchange will re-enroll the enrollee in any other QHP offered under the product in which the enrollee's current QHP is offered in which the enrollee is eligible to enroll and that has the most similar network compared to the enrollee's current QHP; or (v) Notwithstanding the other provisions in this paragraph (j)(1), to the extent permitted by applicable State law, if the enrollee's current QHP is a catastrophic plan as described in section 1302(e) of the ACA, and the enrollee will no longer meet the criteria for enrollment in a catastrophic plan as described in section 1302(e)(2) of the ACA: (A) The Exchange will re-enroll the enrollee in a bronze metal level QHP within the same product as the enrollee's current QHP that has the most similar network compared to the enrollee's current QHP; or (B) If no bronze plan is available through this product, the Exchange will re-enroll the enrollee in the QHP with the lowest coverage level offered under the product in which the enrollee's current QHP is offered in which the enrollee is eligible to enroll and that has the most similar network compared to the enrollee's current QHP. (2) No plans under the product under which the QHP in which the enrollee is enrolled are available through the Exchange for renewal, consistent with § 147.106 of this subchapter, the Exchange will enroll the enrollee in a QHP under a different product offered by the same QHP issuer, to the extent permitted by applicable State law, unless the enrollee terminates coverage, including termination of coverage in connection with voluntarily selecting a different QHP, in accordance with § 155.430, as follows: (i) The Exchange will re-enroll the enrollee in a QHP at the same coverage level as the enrollee's current QHP in the product offered by the same issuer that is the most similar to the enrollee's current product and that has the most similar network compared to the enrollee's current QHP; (ii) If the issuer does not offer another QHP at the same coverage level as the enrollee's current QHP, the Exchange will re-enroll the enrollee in a QHP that is one coverage level higher or lower than the enrollee's current QHP and that has the most similar network compared to the enrollee's current QHP in the product offered by the same issuer through the Exchange that is the most similar to the enrollee's current product; (iii) If the issuer does not offer another QHP through the Exchange at the same coverage level as, or one metal level higher or lower than the enrollee's current QHP, the Exchange will re-enroll the enrollee in any other QHP offered by the same issuer in which the enrollee is eligible to enroll and that has the most similar network compared to the enrollee's current QHP in the product that is most similar to the enrollee's current product; or (iv) Notwithstanding the other provisions in this paragraph (j)(2), to the extent permitted by applicable State law, if the enrollee's current QHP is a catastrophic plan as described in section 1302(e) of the ACA, and the enrollee will no longer meet the criteria for enrollment in a catastrophic plan as described in section 1302(e)(2) of the ACA: (A) The Exchange will re-enroll the enrollee in a bronze metal level QHP offered by the same issuer in which the enrollee is eligible to enroll and that has the most similar network compared to the enrollee's current QHP in the product that is most similar to the enrollee's current product; or (B) If no bronze plan is available through this product, the Exchange will re-enroll the enrollee in the QHP with the lowest coverage level offered under the product in which the enrollee's current QHP is offered in which the enrollee is eligible to enroll and that has the most similar network compared to the enrollee's current QHP. (3) No QHPs from the same issuer are available through the Exchange, the Exchange may enroll the enrollee in a QHP issued by a different issuer, to the extent permitted by applicable State law, unless the enrollee terminates coverage, including termination of coverage in connection with voluntarily selecting a different QHP, in accordance with § 155.430, as follows: (i) As directed by the applicable State regulatory authority; or (ii) If the applicable State regulatory authority declines to provide direction, in a similar QHP from a different issuer, as determined by the Exchange. (4) For purposes of this section, catastrophic coverage is not a coverage level that is considered higher or lower than metal level coverage when re-enrolling an enrollee to a plan that is a metal level higher or lower than their current plan, and an Exchange may not re-enroll an enrollee that has coverage under section 1302(d) into catastrophic coverage. (k) Authorization of the release of tax data to support annual redetermination. (2) The Exchange is authorized to obtain the updated tax return information described in paragraph (b) of this section for a period of no more than five years based on a single authorization, provided that— (i) An individual may decline to authorize the Exchange to obtain updated tax return information; or (ii) An individual may authorize the Exchange to obtain updated tax return information for fewer than five years; and (iii) The Exchange must allow an individual to discontinue, change, or renew his or her authorization at any time. (l) Limitation on redetermination. (m) Special rule. (n) Additional consumer protections. [77 FR 18444, Mar. 27, 2012, as amended at 78 FR 42319, July 15, 2013; 79 FR 53005, Sept. 5, 2014; 81 FR 12342, Mar. 8, 2016; 88 FR 25918, Apr. 27, 2023; 89 FR 26422, Apr. 15, 2024; 90 FR 27221, June 25, 2025] § 155.340 Administration of advance payments of the premium tax credit and cost-sharing reductions. (a) Requirement to provide information to enable advance payments of the premium tax credit and cost-sharing reductions. (1) Transmit eligibility and enrollment information to HHS necessary to enable HHS to begin, end, or change advance payments of the premium tax credit or cost-sharing reductions; and (2) Notify and transmit information necessary to enable the issuer of the QHP to implement, discontinue the implementation, or modify the level of advance payments of the premium tax credit or cost-sharing reductions, as applicable, including: (i) The dollar amount of the advance payment; and (ii) The cost-sharing reductions eligibility category. (b) Requirement to provide information related to employer responsibility. (2) If an enrollee for whom advance payments of the premium tax credit are made or who is receiving cost-sharing reductions notifies the Exchange that he or she has changed employers, the Exchange must transmit the enrollee's name and taxpayer identification number to HHS. (3) In the event that an individual for whom advance payments of the premium tax credit are made or who is receiving cost-sharing reductions terminates coverage from a QHP through the Exchange during a benefit year, the Exchange must— (i) Transmit the individual's name and taxpayer identification number, and the effective date of coverage termination, to HHS, which will transmit it to the Secretary of the Treasury; and, (ii) Transmit the individual's name and the effective date of the termination of coverage to his or her employer. (c) Requirement to provide information related to reconciliation of advance payments of the premium tax credit. (d) Timeliness standard. (e) Allocation of advance payments of the premium tax credit among policies. (1) That portion of the advance payment of the premium tax credit that is less than or equal to the aggregate adjusted monthly premiums, as defined in 26 CFR 1.36B-3(e), for the QHP policies properly allocated to EHB must be allocated among the QHP policies in a reasonable and consistent manner specified by the Exchange; and (2) Any remaining advance payment of the premium tax credit must be allocated among the stand-alone dental policies in a reasonable and consistent manner specified by the Exchange. (f) Allocation of advance payments of the premium tax credit among policies offered through a Federally-facilitated Exchange. (1) That portion of the advance payment(s) of the premium tax credit to be allocated among QHP policies will be allocated based on the number of enrollees covered under the QHP, weighted by the age of the enrollees, using the default uniform age rating curve established by the Secretary of HHS under 45 CFR 147.102(e), with the portion allocated to any single QHP policy not to exceed the portion of the QHP's adjusted monthly premium properly allocated to EHB. If the portion of the advance payment(s) of the premium tax credit allocated to a QHP under this subparagraph exceeds the portion of the same QHP's adjusted monthly premium properly allocated to EHB, the remainder will be allocated evenly among all other QHPs in which individuals in the tax filers' tax households are enrolled. (2) That portion of the advance payment(s) of the premium tax credit to be allocated among stand-alone dental policies will be allocated based on the number of enrollees covered under the stand-alone dental policy, weighted by the age of the enrollees, using the default uniform age rating curve established by the Secretary of HHS under 45 CFR 147.102(e), with the portion allocated to any single stand-alone dental policy not to exceed the portion of the stand-alone dental policy premium properly allocated to EHB. If the portion of the advance payment(s) of the premium tax credit allocated to a stand-alone dental policy under this subparagraph exceeds the portion of the same policy's premium properly allocated to EHB, the remainder will be allocated evenly among all other stand-alone dental policies in which individuals in the tax filers' tax households are enrolled. (g) Reduction of enrollee's portion of premium to account for advance payments of the premium tax credit. (1) Reduce the portion of the premium for the policy collected from the individual for the applicable month(s) by the amount of the advance payment of the premium tax credit; and (2) Include with each billing statement, as applicable, to or for the individual the amount of the advance payment of the premium tax credit for the applicable month(s) and the remaining premium owed for the policy. (h) Failure to reduce enrollee's premiums to account for advance payments of the premium tax credit. (1) Unless a refund is requested by or for the enrollee, the Exchange must, within 45 calendar days of discovery of the error, apply the excess premium paid by or for the enrollee to the enrollee's portion of the premium (or refund the amount directly). If any excess premium remains, the Exchange must then apply the excess premium to the enrollee's portion of the premium for each subsequent month for the remainder of the period of enrollment or benefit year until the excess premium is fully refunded (or refund the remaining amount directly). If any excess premium remains at the end of the period of enrollment or benefit year, the Exchange must refund any excess premium within 45 calendar days of the end of the period of enrollment or benefit year, whichever comes first. (2) If a refund is requested by or for the enrollee, the refund must be provided within 45 calendar days of the date of the request. (i) Calculation of advance payments of the premium tax credit when policy coverage lasts less than the full coverage month. (i) In an Exchange using the Federal eligibility and enrollment platform, the amount of the advance payment of the premium tax credit paid to the issuer of the policy must equal the product of— (A) The advance payments of the premium tax credit applied to the policy for one month of coverage divided by the number of days in the month; and (B) The number of days for which coverage is being provided in the month under the policy described in paragraph (i)(1)(i) of this section. (ii) [Reserved] (2) For plan years beginning with 2024 and beyond, a State Exchange operating its own platform will be required to calculate advance payments of the premium tax credit in accordance with a methodology that does not cause the amount of advance payments of the premium tax credit applied to an enrollee's monthly premium to exceed their expected monthly premium assistance credit amount when the enrollee is enrolled in a policy for less than the full coverage month, including when the enrollee is enrolled in multiple policies within a month, each lasting less than the full coverage month, and to prospectively report the methodology it intends to implement in the subsequent plan year to HHS under § 155.1200(b)(2). [77 FR 18444, Mar. 27, 2012, as amended at 78 FR 15533, Mar. 11, 2013; 78 FR 42320, July 15, 2013; 78 FR 65095, Oct. 30, 2013; 87 FR 27389, May 6, 2022] § 155.345 Coordination with Medicaid, CHIP, the Basic Health Program, and the Pre-existing Condition Insurance Plan. (a) Agreements. (1) Minimize burden on individuals; (2) Ensure prompt determinations of eligibility and enrollment in the appropriate program without undue delay, based on the date the application is submitted to or redetermination is initiated by the Exchange or the agency administering Medicaid, CHIP, or the BHP; (3) [Reserved] (4) Ensure compliance with paragraphs (c), (d), (e), and (g) of this section. (b) Responsibilities related to individuals potentially eligible for Medicaid based on other information or through other coverage groups. (c) Individuals requesting additional screening. (d) Notification of applicant and State Medicaid agency. (1) Transmit all information provided on the application and any information obtained or verified by, the Exchange to the State Medicaid agency, promptly and without undue delay; and (2) Notify the applicant of such transmittal. (e) Treatment of referrals to Medicaid on eligibility for advance payments of the premium tax credit and cost-sharing reductions. (f) Special rule. (1) Provide the applicant with any information regarding income used in the Medicaid and CHIP eligibility determination; and (2) Follow the procedures specified in § 155.320(c)(3). (g) Determination of eligibility for individuals submitting applications directly to an agency administering Medicaid, CHIP, or the BHP. (1) Accept, via secure electronic interface, all information provided on the application and any information obtained or verified by, the agency administering Medicaid, CHIP, or the BHP, if a BHP is operating in the service area of the Exchange, for the individual, and not require submission of another application; (2) Notify such agency of the receipt of the information described in paragraph (g)(1) of this section and final eligibility determination for enrollment in a QHP, advance payments of the premium tax credit, and cost-sharing reductions. (3) Not duplicate any eligibility and verification findings already made by the transmitting agency, to the extent such findings are made in accordance with this part. (4) Not request information or documentation from the individual already provided to another agency administering an insurance affordability program and included in the transmission of information provided on the application or other information transmitted from the other agency. (5) Determine the individual's eligibility for enrollment in a QHP, advance payments of the premium tax credit, and cost-sharing reductions, promptly and without undue delay, and in accordance with this subpart. (6) Follow a streamlined process for eligibility determinations regardless of the agency that initially received an application. (h) Adherence to state decision regarding Medicaid and CHIP. (i) Standards for sharing information between the Exchange and the agencies administering Medicaid, CHIP, and the BHP. (2) Model agreements. (j) Transition from the Pre-existing Condition Insurance Plan (PCIP). [77 FR 18444, Mar. 27, 2012, as amended at 77 FR 31515, May 29, 2012; 78 FR 42320, July 15, 2013; 78 FR 54136, Aug. 30, 2013] § 155.350 Special eligibility standards and process for Indians. (a) Eligibility for cost-sharing reductions. (i) Meets the requirements specified in § 155.305(a) and § 155.305(f); (ii) Is expected to have a household income, as defined in 26 CFR 1.36B-1(e) that does not exceed 300 percent of the FPL for the benefit year for which coverage is requested. (2) The Exchange may only provide cost-sharing reductions to an individual who is an Indian if he or she is enrolled in a QHP through the Exchange. (b) Special cost-sharing rule for Indians regardless of income. (c) Verification related to Indian status. (1) Utilizing any relevant documentation verified in accordance with § 155.315(f); (2) Relying on any electronic data sources that are available to the Exchange and which have been approved by HHS for this purpose, based on evidence showing that such data sources are sufficiently accurate and offer less administrative complexity than paper verification; or (3) To the extent that approved data sources are unavailable, an individual is not represented in available data sources, or data sources are not reasonably compatible with an applicant's attestation, the Exchange must follow the procedures specified in § 155.315(f) and verify documentation provided by the applicant in accordance with the standards for acceptable documentation provided in section 1903(x)(3)(B)(v) of the Social Security Act. [77 FR 18444, Mar. 27, 2012, as amended at 78 FR 42321, July 15, 2013] § 155.355 Right to appeal. Individual appeals. Subpart E—Exchange Functions in the Individual Market: Enrollment in Qualified Health Plans § 155.400 Enrollment of qualified individuals into QHPs. (a) General requirements. (1) Notify the issuer of the applicant's selected QHP; and (2) Transmit information necessary to enable the QHP issuer to enroll the applicant. (b) Timing of data exchange. (1) Send eligibility and enrollment information to QHP issuers and HHS promptly and without undue delay; and (2) Establish a process by which a QHP issuer acknowledges the receipt of such information. (3) Send updated eligibility and enrollment information to HHS promptly and without undue delay, in a manner and timeframe as specified by HHS. (c) Records. (d) Reconcile files. (1) Timeliness standard for State Exchanges to review, resolve, and report data inaccuracies submitted by a State Exchange issuer. (2) [Reserved] (e) Premium payment. (1) In a Federally-facilitated Exchange or State-Based Exchange on the Federal Platform: (i) For prospective coverage to be effectuated under regular coverage effective dates, as provided for in § 155.410(f), the binder payment must consist of the first month's premium, and the deadline for making the binder payment must be no earlier than the coverage effective date, and no later than 30 calendar days from the coverage effective date. (ii) For prospective coverage to be effectuated under special effective dates, as provided for in § 155.420(b)(2) and (3), the binder payment must consist of the first month's premium, and the deadline for making the binder payment must be no earlier than the coverage effective date and no later than 30 calendar days from the date the issuer receives the enrollment transaction or the coverage effective date, whichever is later. (iii) For coverage to be effectuated under retroactive effective dates, as provided for in § 155.420(b)(2), including when retroactive effective dates are due to a delay until after special enrollment period verification, the binder payment must consist of the premium due for all months of retroactive coverage through the first prospective month of coverage, and the deadline for making the binder payment must be no earlier than 30 calendar days from the date the issuer receives the enrollment transaction. If only the premium for 1 month of coverage is paid, only prospective coverage should be effectuated, in accordance with § 155.420(b)(3). (2) Premium payment deadline extension. (f) Processing enrollment transactions. (g) Premium payment threshold. (1) Effectuate an enrollment based on payment of the binder payment under paragraph (e) of this section. (2) Avoid triggering a grace period for non-payment of premium, as described by § 156.270(d) of this subchapter or a grace period governed by State rules. (3) Avoid terminating the enrollment for non-payment of premium as, described by §§ 156.270(g) of this subchapter and 155.430(b)(2)(ii)(A) and (B). (h) Requirements. [77 FR 18444, Mar. 27, 2012, as amended at 78 FR 42321, July 15, 2013; 79 FR 30348, May 27, 2014; 80 FR 10866, Feb. 27, 2015; 81 FR 12343, Mar. 8, 2016; 81 FR 94177, Dec. 22, 2016; 82 FR 18381, Apr. 18, 2017; 85 FR 29260, May 14, 2020; 89 FR 26423, Apr. 15, 2024; 90 FR 4540, Jan. 15, 2025; 90 FR 27222, June 25, 2025; 91 FR 29867, May 20, 2026] § 155.405 Single streamlined application. (a) The application. (1) Enrollment in a QHP; (2) Advance payments of the premium tax credit; (3) Cost-sharing reductions; and (4) Medicaid, CHIP, or the BHP, where applicable. (b) Alternative application. (c) Filing the single streamlined application. (1) Accept the single streamlined application from an application filer; (2) Provide the tools to file an application— (i) Via an Internet Web site; (ii) By telephone through a call center; (iii) By mail; and (iv) In person, with reasonable accommodations for those with disabilities, as defined by the Americans with Disabilities Act. § 155.410 Initial and annual open enrollment periods. (a) General requirements. (2) The Exchange may only permit a qualified individual to enroll in a QHP or an enrollee to change QHPs during the initial open enrollment period specified in paragraph (b) of this section, the annual open enrollment period specified in paragraph (e) of this section, or a special enrollment period described in § 155.420 of this subpart for which the qualified individual has been determined eligible. (b) Initial open enrollment period. (c) Effective coverage dates for initial open enrollment period Regular effective dates. (i) On or before December 23, 2013, the Exchange must ensure a coverage effective date of January 1, 2014. (ii) Between the first and fifteenth day of any subsequent month during the initial open enrollment period, the Exchange must ensure a coverage effective date of the first day of the following month. (iii) Between the sixteenth and last day of the month for any month between January 2014 and March 31, 2014 or between the twenty-fourth and the thirty-first of the month of December 2013, the Exchange must ensure a coverage effective date of the first day of the second following month. (iv) Notwithstanding the requirement of paragraph (c)(1)(i) of this section, an Exchange or SHOP operated by a State may require a January 1, 2014 effective date for plan selection dates later than December 23, 2013; a SHOP may also establish plan selection dates as early as December 15, 2013 for enrollment in SHOP QHPs for a January 1, 2014 coverage effective date. (v) Notwithstanding the regular effective dates set forth in this section, an Exchange may allow issuers to provide for a coverage effective date of January 1, 2014 for plan selections received after December 23, 2013 and on or before January 31, 2014, if a QHP issuer is willing to accept such enrollments. (2) Option for earlier effective dates. (i) For a QHP selection received by the Exchange from a qualified individual in accordance with the dates specified in paragraph (c)(1)(ii) or (iii) of this section, the Exchange may provide a coverage effective date for a qualified individual earlier than specified in such paragraphs, provided that either— (A) The qualified individual has not been determined eligible for advance payments of the premium tax credit or cost-sharing reductions; or (B) The qualified individual pays the entire premium for the first partial month of coverage as well as all cost sharing, thereby waiving the benefit of advance payments of the premium tax credit and cost-sharing reduction payments until the first of the next month. (ii) For a QHP selection received by the Exchange from a qualified individual on a date set by the Exchange after the fifteenth of the month for any month between December 2013 and March 31, 2014, the Exchange may provide a coverage effective date of the first of the following month. (d) Notice of annual open enrollment period. (e) Annual open enrollment period. (2) For the benefit years beginning on January 1, 2016 and January 1, 2017, the annual open enrollment period begins on November 1 of the calendar year preceding the benefit year, and extends through January 31 of the benefit year. (3) For the benefit years beginning on January 1, 2018 through January 1, 2021, the annual open enrollment period begins on November 1 and extends through December 15 of the calendar year preceding the benefit year. (4) For benefit years beginning on January 1, 2022, through January 1, 2026— (i) Subject to paragraphs (e)(4)(ii) and (iii) of this section, the annual open enrollment period begins on November 1 of the calendar year preceding the benefit year and extends through January 15 of the benefit year. (ii) For State Exchanges, for the benefit years beginning on or after January 1, 2025, a later annual open enrollment period end date may be adopted, such that the open enrollment period begins on November 1 of the calendar year preceding the benefit year and ends after January 15 of the benefit year. (iii) For any State Exchange with an annual open enrollment period that began before November 1, 2023, and ended before January 15, 2024, for the 2024 benefit year, that State Exchange may continue to begin open enrollment before November 1 for consecutive future benefit years, so long as the open enrollment period continues uninterrupted for at least 11 weeks. If such State Exchange changes the date(s) of their annual open enrollment period, it must comply with paragraphs (e)(4)(i) and (ii) for all future annual open enrollment periods. (5) For benefit years beginning on or after January 1, 2027— (i) The annual open enrollment period for all Exchanges must begin no later than November 1 and must end no later than December 31 of the calendar year preceding the benefit year. (ii) The annual open enrollment period must not exceed 9 weeks in duration. (f) Effective date. (i) January 1, 2015, for QHP selections received by the Exchange on or before December 15, 2014. (ii) February 1, 2015, for QHP selections received by the Exchange from December 16, 2014 through January 15, 2015. (iii) March 1, 2015, for QHP selections received by the Exchange from January 16, 2015 through February 15, 2015. (2) For the benefit years beginning on January 1, 2016 through January 1, 2021, the Exchange must ensure coverage is effective— (i) January 1, for QHP selections received by the Exchange on or before December 15 of the calendar year preceding the benefit year. (ii) February 1, for QHP selections received by the Exchange from December 16 of the calendar year preceding the benefit year through January 15 of the benefit year. (iii) March 1, for QHP selections received by the Exchange from January 16 through January 31 of the benefit year. (3) For benefit years beginning on January 1, 2022, through January 1, 2026, the Exchange must ensure that coverage is effective— (i) Subject to paragraph (f)(3)(ii) of this section— (A) January 1, for QHP selections received by the Exchange on or before December 15 of the calendar year preceding the benefit year. (B) February 1, for QHP selections received by the Exchange from December 16 of the calendar year preceding the benefit year through January 15 of the benefit year. (C) The first of the following month, for QHP selections received by the 15 of a month after January, if applicable under paragraph (e)(4)(ii) of this section. (D) The first of the second following month, for plan selections received between the 16th and the end of a month, beginning January 16 of the benefit year, if applicable under paragraph (e)(4)(ii) of this section. (ii) For State Exchanges not utilizing the Federal platform, for a QHP selection received by the Exchange during the open enrollment period for which effective dates specified in paragraph (f)(3)(i) of this section would apply, the Exchange may provide a coverage effective date that is earlier than specified in such paragraph. (4) For benefit years beginning on or after January 1, 2027, the Exchange must ensure that coverage is effective January 1, for QHP selections received by the Exchange on or before December 31 of the calendar year preceding the benefit year. (g) Automatic enrollment. [77 FR 18444, Mar. 27, 2012, as amended at 78 FR 76218, Dec. 17, 2013; 79 FR 13838, Mar. 11, 2014; 79 FR 30348, May 27, 2014; 80 FR 10866, Feb. 27, 2015; 81 FR 12343, Mar. 8, 2016; 82 FR 18381, Apr. 18, 2017; 86 FR 53503, Sept. 27, 2021; 89 FR 26423, Apr. 15, 2024; 90 FR 27222, June 25, 2025] § 155.415 Allowing issuer or direct enrollment entity application assisters to assist with eligibility applications. (a) Exchange option. (b) Application assister requirements. (1) Receives training on QHP options and insurance affordability programs, eligibility, and benefits rules and regulations, and for application assisters providing assistance in the Federally-facilitated Exchanges or a State Exchange using the Federal platform, the assisters must fulfill this requirement by completing registration and training in a form and manner to be specified by HHS; (2) Complies with the Exchange's privacy and security standards adopted consistent with § 155.260; and (3) Complies with applicable State law related to the sale, solicitation, and negotiation of health insurance products, including any State licensure laws applicable to the functions to be performed by the issuer application assister or direct enrollment entity application assister, as well as State law related to confidentiality and conflicts of interest. [84 FR 17567, Apr. 25, 2019] § 155.420 Special enrollment periods. (a) General requirements General parameters. (2) Definition of dependent. (3) Use of special enrollment periods. (4) Use of special enrollment periods by enrollees. (ii)(A) If an enrollee or their dependents become newly eligible for cost-sharing reductions in accordance with paragraph (d)(6)(i) or (ii) of this section and the enrollee or their dependents are not enrolled in a silver-level QHP, the Exchange must allow the enrollee and their dependents to change to a silver-level QHP if they elect to change their QHP enrollment; or (B) Beginning January 2022, if an enrollee or their dependents become newly ineligible for cost-sharing reductions in accordance with paragraph (d)(6)(i) or (ii) of this section and the enrollee or his or her dependents are enrolled in a silver-level QHP, the Exchange must allow the enrollee and their dependents to change to a QHP one metal level higher or lower if they elect to change their QHP enrollment; (C) No later than January 1, 2024, if an enrollee or his or her dependents become newly ineligible for advance payments of the premium tax credit in accordance with paragraph (d)(6)(i) or (ii) of this section, the Exchange must allow the enrollee and his or her dependents to change to a QHP of any metal level, if they elect to change their QHP enrollment; or (iii) For the other triggering events specified in paragraph (d) of this section, except for paragraphs (d)(2)(i), (d)(4), and (d)(6)(i) and (ii) of this section for becoming newly eligible or ineligible for CSRs, and paragraphs (d)(8), (9), (10), (12), and (14) of this section: (A) If an enrollee qualifies for a special enrollment period, the Exchange must allow the enrollee and his or her dependents, if applicable, to change to another QHP within the same level of coverage (or one metal level higher or lower, if no such QHP is available), as outlined in § 156.140(b) of this subchapter; (B) If a dependent qualifies for a special enrollment period, and an enrollee who does not also qualify for a special enrollment period is adding the dependent to his or her QHP, the Exchange must allow the enrollee to add the dependent to his or her current QHP; or, if the QHP's business rules do not allow the dependent to enroll, the Exchange must allow the enrollee and his or her dependents to change to another QHP within the same level of coverage (or one metal level higher or lower, if no such QHP is available), as outlined in § 156.140(b) of this subchapter, or enroll the new qualified individual in a separate QHP; or (C) If a qualified individual who is not an enrollee qualifies for a special enrollment period and has one or more dependents who are enrollees who do not also qualify for a special enrollment period, the Exchange must allow the newly enrolling qualified individual to add himself or herself to a dependent's current QHP; or, if the QHP's business rules do not allow the qualified individual to enroll in the dependent's current QHP, to enroll with his or her dependent(s) in another QHP within the same level of coverage (or one metal level higher or lower, if no such QHP is available), as outlined in § 156.140(b) of this subchapter, or enroll himself or herself in a separate QHP. (5) Prior coverage requirement. (b) Effective dates Regular effective dates. (2) Special effective dates. (ii) In the case of marriage as described in paragraph (d)(2) of this section the Exchange must ensure that coverage is effective for a qualified individual or enrollee on the first day of the month following plan selection. (iii) In the case of a qualified individual or enrollee eligible for a special enrollment period as described in paragraph (d)(4), (5), (9), (11), (12), or (13) of this section, the Exchange must ensure that coverage is effective on an appropriate date based on the circumstances of the special enrollment period. (iv) If a qualified individual, enrollee, or dependent, as applicable, loses coverage as described in paragraph (d)(1) or (d)(6)(iii) of this section, or is enrolled in COBRA continuation coverage for which an employer is paying all or part of the premiums, or for which a government entity is providing subsidies, and the employer contributions or government subsidies completely cease as described in paragraph (d)(15) of this section, gains access to a new QHP as described in paragraph (d)(7) of this section, becomes newly eligible for enrollment in a QHP through the Exchange in accordance with § 155.305(a)(2) as described in paragraph (d)(3) of this section, becomes newly eligible for advance payments of the premium tax credit in conjunction with a permanent move as described in paragraph (d)(6)(iv) of this section, and if the plan selection is made on or before the day of the triggering event, the Exchange must ensure that the coverage effective date is the first day of the month following the date of the triggering event. If the plan selection is made after the date of the triggering event, the Exchange must ensure that coverage is effective in accordance with paragraph (b)(1) of this section or on the first day of the following month, at the option of the Exchange. Notwithstanding the requirements of this paragraph (b)(2)(iv) with respect to losses of coverage as described at paragraphs (d)(1), (d)(6)(iii), and (d)(15) of this section, at the option of the Exchange, if the plan selection is made on or before the last day of the month preceding the triggering event, the Exchange must ensure that the coverage effective date is the first day of the month in which the triggering event occurs. (v) If an enrollee or his or her dependent dies as described in paragraph (d)(2)(ii) of this section, the Exchange must ensure that coverage is effective on the first day of the month following the plan selection, or it may permit the enrollee or his or her dependent to elect a coverage effective date in accordance with paragraph (b)(1) of this section. If the Exchange permits the enrollee or his or her dependent to elect a coverage effective date in accordance with paragraph (b)(1) of this section, the Exchange must ensure coverage is effective on the date duly selected by the enrollee or his or her dependent. (vi) If a qualified individual, enrollee, or dependent newly gains access to an individual coverage HRA or is newly provided a QSEHRA, each as described in paragraph (d)(14) of this section, and if the plan selection is made before the day of the triggering event, the Exchange must ensure that coverage is effective on the first day of the month following the date of the triggering event or, if the triggering event is on the first day of a month, on the date of the triggering event. If the plan selection is made on or after the day of the triggering event, the Exchange must ensure that coverage is effective on the first day of the month following plan selection. (3) Option for earlier effective dates. (ii) For a QHP selection received by the Exchange under a special enrollment period for which special effective dates specified in paragraph (b)(2)(ii) of this section would apply, the Exchange may provide a coverage effective date that is earlier than specified in such paragraph. (4) Advance payments of the premium tax credit and cost-sharing reductions. (5) Option for earlier effective dates due to untimely notice of triggering event. (c) Availability and length of special enrollment periods General rule. (2) Advanced availability. (3) Advanced availability for individuals with an individual coverage HRA or QSEHRA. (4) Special rule. (5) Availability for individuals who did not receive timely notice of triggering events. (6) Special rule for individuals losing Medicaid or CHIP. (d) Triggering events. (1) The qualified individual or his or her dependent either: (i) Loses minimum essential coverage. The date of the loss of coverage is the last day the consumer would have coverage under his or her previous plan or coverage; (ii) Is enrolled in any non-calendar year group health plan, individual health insurance coverage, or qualified small employer health reimbursement arrangement (as defined in section 9831(d)(2) of the Internal Revenue Code); even if the qualified individual or his or her dependent has the option to renew or re-enroll in such coverage. The date of the loss of coverage is the last day of the plan year; (iii) Loses pregnancy-related coverage described under section 1902(a)(10)(A)(i)(IV) and (a)(10)(A)(ii)(IX) of the Act (42 U.S.C. 1396a(a)(10)(A)(i)(IV), (a)(10)(A)(ii)(IX)) or loses access to health care services through coverage provided to a pregnant woman's unborn child, based on the definition of a child in 42 CFR 457.10. The date of the loss of coverage is the last day the qualified individual would have pregnancy-related coverage or access to health care services through the unborn child coverage; or (iv) Loses medically needy coverage as described under section 1902(a)(10)(C) of the Social Security Act only once per calendar year. The date of the loss of coverage is the last day the consumer would have medically needy coverage. (2)(i) The qualified individual gains a dependent or becomes a dependent through marriage, birth, adoption, placement for adoption, or placement in foster care, or through a child support order or other court order. (A) In the case of marriage, at least one spouse must demonstrate having minimum essential coverage as described in 26 CFR 1.5000A-1(b) for 1 or more days during the 60 days preceding the date of marriage. (B) [Reserved] (ii) At the option of the Exchange, the enrollee loses a dependent or is no longer considered a dependent through divorce or legal separation as defined by State law in the State in which the divorce or legal separation occurs, or if the enrollee, or his or her dependent, dies. (3) The qualified individual, or his or her dependent, becomes newly eligible for enrollment in a QHP through the Exchange because he or she newly satisfies the requirements under § 155.305(a)(1) or (2); (4) The qualified individual's or his or her dependent's, enrollment or non-enrollment in a QHP is unintentional, inadvertent, or erroneous and is the result of the error, misrepresentation, misconduct, or inaction of an officer, employee, or agent of the Exchange or HHS, its instrumentalities, or a non-Exchange entity providing enrollment assistance or conducting enrollment activities. For purposes of this provision, misconduct includes the failure to comply with applicable standards under this part, part 156 of this subchapter, or other applicable Federal or State laws as determined by the Exchange. (5) The enrollee or, his or her dependent adequately demonstrates to the Exchange that the QHP in which he or she is enrolled substantially violated a material provision of its contract in relation to the enrollee; (6)(i) The enrollee is determined newly eligible or newly ineligible for advance payments of the premium tax credit or has a change in eligibility for cost-sharing reductions; (ii) The enrollee's dependent enrolled in the same QHP is determined newly eligible or newly ineligible for advance payments of the premium tax credit or has a change in eligibility for cost-sharing reductions; (iii) A qualified individual or his or her dependent who is enrolled in an eligible employer-sponsored plan is determined newly eligible for advance payments of the premium tax credit based in part on a finding that such individual is ineligible for qualifying coverage in an eligible-employer sponsored plan in accordance with 26 CFR 1.36B-2(c)(3), including as a result of his or her employer discontinuing or changing available coverage within the next 60 days, provided that such individual is allowed to terminate existing coverage; (iv) A qualified individual who was previously ineligible for advance payments of the premium tax credit solely because of a household income below 100 percent of the FPL and who, during the same timeframe, was ineligible for Medicaid because he or she was living in a non-Medicaid expansion State, who either experiences a change in household income or moves to a different State resulting in the qualified individual becoming newly eligible for advance payments of the premium tax credit; or (v) At the option of the Exchange, the qualified individual, or his or her dependent— (A) Experiences a decrease in household income; (B) Is newly determined eligible by the Exchange for advance payments of the premium tax credit; and (C) Had minimum essential coverage as described in 26 CFR 1.5000A-1(b) for one or more days during the 60 days preceding the date of the financial change. (7) The qualified individual or enrollee, or his or her dependent, gains access to new QHPs as a result of a permanent move and— (i) Had minimum essential coverage as described in 26 CFR 1.5000A-1(b) for one or more days during the 60 days preceding the date of the permanent move. (ii) [Reserved] (8) The qualified individual— (i) Who gains or maintains status as an Indian, as defined by section 4 of the Indian Health Care Improvement Act, may enroll in a QHP or change from one QHP to another one time per month; or (ii) Who is or becomes a dependent of an Indian, as defined by section 4 of the Indian Health Care Improvement Act and is enrolled or is enrolling in a QHP through an Exchange on the same application as the Indian, may change from one QHP to another one time per month, at the same time as the Indian; (9) The qualified individual or enrollee, or his or her dependent, demonstrates to the Exchange, in accordance with guidelines issued by HHS, that the individual meets other exceptional circumstances as the Exchange may provide; (10) A qualified individual or enrollee— (i) Is a victim of domestic abuse or spousal abandonment as defined by 26 CFR 1.36B-2 or a dependent or unmarried victim within a household, is enrolled in minimum essential coverage, and sought to enroll in coverage separate from the perpetrator of the abuse or abandonment; or (ii) Is a dependent of a victim of domestic abuse or spousal abandonment, on the same application as the victim, may enroll in coverage at the same time as the victim; (11) A qualified individual or dependent— (i) Applies for coverage on the Exchange during the annual open enrollment period or due to a qualifying event, is assessed by the Exchange as potentially eligible for Medicaid or the Children's Health Insurance Program (CHIP), and is determined ineligible for Medicaid or CHIP by the State Medicaid or CHIP agency either after open enrollment has ended or more than 60 days after the qualifying event; or (ii) Applies for coverage at the State Medicaid or CHIP agency during the annual open enrollment period, and is determined ineligible for Medicaid or CHIP after open enrollment has ended; (12) The enrollment in a QHP through the Exchange was influenced by a material error related to plan benefits, service area, cost-sharing, or premium. A material error is one that is likely to have influenced a qualified individual's, enrollee's, or their dependent's enrollment in a QHP. (13) At the option of the Exchange, the qualified individual provides satisfactory documentary evidence to verify his or her eligibility for an insurance affordability program or enrollment in a QHP through the Exchange following termination of Exchange enrollment due to a failure to verify such status within the time period specified in § 155.315. (14) The qualified individual, enrollee, or dependent newly gains access to an individual coverage HRA (as defined in 45 CFR 146.123(b)) or is newly provided a qualified small employer health reimbursement arrangement (QSEHRA) (as defined in section 9831(d)(2) of the Internal Revenue Code). The triggering event is the first day on which coverage for the qualified individual, enrollee, or dependent under the individual coverage HRA can take effect, or the first day on which coverage under the QSEHRA takes effect. An individual, enrollee, or dependent will qualify for this special enrollment period regardless of whether they were previously offered or enrolled in an individual coverage HRA or previously provided a QSEHRA, so long as the individual, enrollee, or dependent is not enrolled in the individual coverage HRA or covered by the QSEHRA on the day immediately prior to the triggering event. (15) The qualified individual or his or her dependent is enrolled in COBRA continuation coverage for which an employer is paying all or part of the premiums, or for which a government entity is providing subsidies, and the employer completely ceases its contributions to the qualified individual's or dependent's COBRA continuation coverage or government subsidies completely cease. The triggering event is the last day of the period for which COBRA continuation coverage is paid for or subsidized, in whole or in part, by an employer or government entity. For purposes of this paragraph, “COBRA continuation coverage” has the meaning provided for in § 144.103 of this subchapter and includes coverage under a similar State program. (e) Loss of coverage. (1) Failure to pay premiums on a timely basis, including COBRA continuation coverage premiums prior to expiration of COBRA continuation coverage, except for circumstances in which an employer completely ceases its contributions to COBRA continuation coverage, or government subsidies of COBRA continuation coverage completely cease as described in paragraph (d)(15) of this section, or (2) Situations allowing for a rescission as specified in 45 CFR 147.128. (f) For purposes of this section, references to eligibility for advance payments of the premium tax credit refer to being eligible for such advance payments in an amount greater than zero dollars per month. References to ineligibility for advance payments of the premium tax credit refer to being ineligible for such payments or being eligible for such payments but being eligible for a maximum of zero dollars per month of such payments. (g) Special enrollment period verification. [77 FR 18444, Mar. 27, 2012] Editorial Note: For Federal Register § 155.430 Termination of Exchange enrollment or coverage. (a) General requirements. (b) Termination events Enrollee-initiated terminations. (ii) The Exchange must provide an opportunity at the time of plan selection for an enrollee to choose to remain enrolled in a QHP if he or she becomes eligible for other minimum essential coverage and the enrollee does not request termination in accordance with paragraph (b)(1)(i) of this section. If an enrollee does not choose to remain enrolled in a QHP in such situation, the Exchange must initiate termination of his or her enrollment in the QHP upon completion of the process specified in § 155.330(e)(2). (iii) The Exchange must establish a process to permit individuals, including enrollees' authorized representatives, to report the death of an enrollee for purposes of initiating termination of the enrollee's Exchange enrollment. The Exchange may require the reporting party to submit documentation of the death. Any applicable premium refund, or premium due, must be processed by the deceased enrollee's QHP in accordance with State law. (iv) The Exchange must permit an enrollee to retroactively terminate or cancel the enrollee's coverage or enrollment in a QHP in the following circumstances: (A) The enrollee demonstrates to the Exchange that he or she attempted to terminate his or her coverage or enrollment in a QHP and experienced a technical error that did not allow the enrollee to terminate his or her coverage or enrollment through the Exchange, and requests retroactive termination within 60 days after he or she discovered the technical error. (B) The enrollee demonstrates to the Exchange that his or her enrollment in a QHP through the Exchange was unintentional, inadvertent, or erroneous and was the result of the error or misconduct of an officer, employee, or agent of the Exchange or HHS, its instrumentalities, or a non-Exchange entity providing enrollment assistance or conducting enrollment activities. Such enrollee must request cancellation within 60 days of discovering the unintentional, inadvertent, or erroneous enrollment. For purposes of this paragraph (b)(1)(iv)(B), misconduct includes the failure to comply with applicable standards under this part, part 156 of this subchapter, or other applicable Federal or State requirements as determined by the Exchange. (C) The enrollee demonstrates to the Exchange that he or she was enrolled in a QHP without his or her knowledge or consent by any third party, including third parties who have no connection with the Exchange, and requests cancellation within 60 days of discovering of the enrollment. (D) In a Federally-facilitated Exchange or a State-based Exchange on the Federal platform, if HHS elects to permit such terminations, and in a State Exchange that elects to permit such terminations, the enrollee demonstrates to the Exchange that the enrollee enrolled in Medicare Part A or B coverage with a retroactive effective date, and requests retroactive termination of QHP coverage within 60 days of the enrollment. The effective date of the retroactive termination must be no earlier than the later of the day before the first day of coverage under Medicare Part A or B, and the day that is six months before the retroactive termination in QHP coverage is requested. A retroactive termination date as described in this paragraph is not available for enrollments in stand-alone dental plans. (2) Exchange-initiated terminations. (i) The enrollee is no longer eligible for coverage in a QHP through the Exchange; (ii) Non-payment of premiums for coverage of the enrollee, and (A) The exhaustion of the 3-month grace period, as described in § 156.270(d) and (g) of this subchapter, required for enrollees, who when first failing to timely pay premiums, are receiving advance payments of the premium tax credit. (B) Any other grace period not described in paragraph (b)(2)(ii)(A) of this section has been exhausted; (iii) The enrollee's coverage is rescinded in accordance with § 147.128 of this subchapter, after a QHP issuer demonstrates, to the reasonable satisfaction of the Exchange, if required by the Exchange, that the rescission is appropriate; (iv) The QHP terminates or is decertified as described in § 155.1080; or (v) The enrollee changes from one QHP to another during an annual open enrollment period or special enrollment period in accordance with § 155.410 or § 155.420. (vi) The enrollee was enrolled in a QHP without his or her knowledge or consent by a third party, including by a third party with no connection with the Exchange. (vii) Any other reason for termination of coverage described in § 147.106 of this subchapter. (3) Prohibition of issuer-initiated terminations due to aging-off. (c) Termination of coverage or enrollment tracking and approval. (1) Establish mandatory procedures for QHP issuers to maintain records of termination of enrollment in a QHP through the Exchange; (2) Send termination information to the QHP issuer and HHS, promptly and without undue delay in accordance with § 155.400(b). (3) Require QHP issuers to make reasonable accommodations for all individuals with disabilities (as defined by the Americans with Disabilities Act) before terminating enrollment of such individuals through the Exchange; and (4) Retain records in order to facilitate audit functions. (d) Effective dates for termination of coverage or enrollment. (i) Reasonable notice is defined as at least fourteen days before the requested effective date of termination; and (ii) Changes in eligibility for advance payments of the premium tax credit and cost sharing reductions, including terminations, must adhere to the effective dates specified in § 155.330(f). (2) In the case of a termination in accordance with paragraph (b)(1) of this section, the last day of enrollment through the Exchange is— (i) The termination date specified by the enrollee, if the enrollee provides reasonable notice; (ii) If the enrollee does not provide reasonable notice, fourteen days after the termination is requested by the enrollee; or (iii) At the option of the Exchange, on the date on which the termination is requested by the enrollee, or on another prospective date selected by the enrollee; or (iv) If an Exchange does not require an earlier termination date in accordance with paragraph (d)(2)(iii) of this section, at the option of the QHP issuer, on a date on or after the termination is requested by the enrollee that is less than 14 days after the termination is requested by the enrollee, if the enrollee requests an earlier termination date; or (v) At the option of the Exchange, for an individual who is newly determined eligible for Medicaid, CHIP, or the Basic Health Program, if a Basic Health Program is operating in the service area of the Exchange, the day before the enrollee's date of eligibility for Medicaid, CHIP, or the Basic Health Program. (vi) The retroactive termination date requested by the enrollee, if specified by applicable State laws. (3) In the case of a termination in accordance with paragraph (b)(2)(i) of this section, the last day of enrollment in a QHP through the Exchange is the last day of eligibility, as described in § 155.330(f), unless the individual requests an earlier termination effective date per paragraph (b)(1) of this section. (4) In the case of a termination in accordance with paragraph (b)(2)(ii)(A) of this section, the last day of enrollment in a QHP through the Exchange will be the last day of the first month of the 3-month grace period. (5) In the case of a termination in accordance with paragraph (b)(2)(ii)(B) of this section, the last day of enrollment in a QHP through the Exchange should be consistent with existing State laws regarding grace periods. (6) In the case of a termination in accordance with paragraph (b)(2)(v) of this section, the last day of coverage in an enrollee's prior QHP is the day before the effective date of coverage in his or her new QHP, including any retroactive enrollments effectuated under § 155.420(b)(2)(iii). (7) In the case of a termination due to death, the last day of enrollment in a QHP through the Exchange is the date of death. (8) In cases of retroactive termination dates, the Exchange will ensure that appropriate actions are taken to make necessary adjustments to advance payments of the premium tax credit, cost-sharing reductions, premiums, claims, and user fees. (9) In case of a retroactive termination in accordance with paragraph (b)(1)(iv)(A) of this section, the termination date will be no sooner than the date that would have applied under paragraph (d)(2) of this section, based on the date that the enrollee can demonstrate he or she contacted the Exchange to terminate his or her coverage or enrollment through the Exchange, had the technical error not occurred. (10) In case of a retroactive cancellation or termination in accordance with paragraph (b)(1)(iv)(B) or (C) of this section, the cancellation date or termination date will be the original coverage effective date or a later date, as determined appropriate by the Exchange, based on the circumstances of the cancellation or termination. (11) In the case of cancellation in accordance with paragraph (b)(2)(vi) of this section, the Exchange may cancel the enrollee's enrollment upon its determination that the enrollment was performed without the enrollee's knowledge or consent and following reasonable notice to the enrollee (where possible). The termination date will be the original coverage effective date. (12) In the case of retroactive cancellations or terminations in accordance with paragraphs (b)(1)(iv)(A), (B) and (C) of this section, such terminations or cancellations for the preceding coverage year must be initiated within a timeframe established by the Exchange based on a balance of operational needs and consumer protection. This timeframe will not apply to cases adjudicated through the appeals process. (e) Termination, cancellation, and reinstatement. (1) Termination. (2) Cancellation. (3) Reinstatement. [77 FR 18444, Mar. 27, 2012, as amended at 77 FR 31515, May 29, 2012; 78 FR 42322, July 15, 2013; 79 FR 30348, May 27, 2014; 80 FR 10867, Feb. 27, 2015; 81 FR 12343, Mar. 8, 2016; 81 FR 94179, Dec. 22, 2016; 83 FR 17063, Apr. 17, 2018; 85 FR 29260, May 14, 2020; 88 FR 25920, Apr. 27, 2023; 89 FR 26423, Apr. 15, 2024] Subpart F—Appeals of Eligibility Determinations for Exchange Participation and Insurance Affordability Programs Source: 78 FR 54136, Aug. 30, 2013, unless otherwise noted. § 155.500 Definitions. In addition to those definitions in §§ 155.20 and 155.300, for purposes of this subpart and § 155.740 of subpart H, the following terms have the following meanings: Appeal record Appeal request Appeals entity Appellant De novo review Evidentiary hearing Vacate [78 FR 54136, Aug. 30, 2013, as amended at 83 FR 17063, Apr. 17, 2018] § 155.505 General eligibility appeals requirements. (a) General requirements. (b) Right to appeal. (1) An eligibility determination made in accordance with subpart D, including— (i) An initial determination of eligibility, including the amount of advance payments of the premium tax credit and level of cost-sharing reductions, made in accordance with the standards specified in § 155.305(a) through (h); and (ii) A redetermination of eligibility, including the amount of advance payments of the premium tax credit and level of cost-sharing reductions, made in accordance with §§ 155.330 and 155.335; (iii) A determination of eligibility for an enrollment period, made in accordance with § 155.305(b); (2) An eligibility determination for an exemption made in accordance § 155.605; (3) A failure by the Exchange to provide timely notice of an eligibility determination in accordance with § 155.310(g), § 155.330(e)(1)(ii), § 155.335(h)(1)(ii), or § 155.610(i); and (4) A denial of a request to vacate dismissal made by a State Exchange appeals entity in accordance with § 155.530(d)(2), made under paragraph (c)(2)(i) of this section; and (5) An appeal decision issued by a State Exchange appeals entity in accordance with § 155.545(b), consistent with § 155.520(c). (c) Options for Exchange appeals. (1) A State Exchange appeals entity, or an eligible entity described in paragraph (d) of this section that is designated by the Exchange, if the Exchange establishes an appeals process in accordance with the requirements of this subpart; or (2) The HHS appeals entity— (i) Upon exhaustion of the State Exchange appeals process; (ii) If the Exchange has not established an appeals process in accordance with the requirements of this subpart; or (iii) If the Exchange has delegated appeals of exemption determinations made by HHS pursuant to § 155.625(b) to the HHS appeals entity, and the appeal is limited to a determination of eligibility for an exemption. (d) Eligible entities. (e) Representatives. (f) Accessibility requirements. (g) Review of Exchange eligibility appeal decisions. (1) Administrative review. (i) Request by a party to the appeal. 1 (B) Within 30 days of the date of the party's request for administrative review, the CMS Administrator must: ( 1 ( 2 ( 3 (C) The Exchange eligibility appeal decision of the impartial official as described in § 155.535(c)(4) is final as of the date of the impartial official's decision if the CMS Administrator declines the party's request for review or if the CMS Administrator does not take any action on the party's request for review by the end of the 30-day period described in paragraphs (g)(1)(i)(B)( 1 3 (ii) Review at the discretion of the CMS Administrator. (B) Within 30 days of the date the CMS Administrator initiates a review, the CMS Administrator may: ( 1 ( 2 ( 3 (C) The eligibility Exchange appeal decision of the impartial official as described in § 155.535(c)(4) is final as of the date of the Exchange eligibility appeal decision if the CMS Administrator declines to review the eligibility appeal decision or chooses to take no action by the end of the 30-day period described in paragraphs (g)(1)(i)(B)( 1 3 (iii) Effective dates. (A) If an Exchange eligibility appeal decision is final pursuant to paragraphs (g)(1)(i)(C) and (g)(1)(ii)(C) in this section, the Exchange eligibility appeal decision of the impartial official as described in § 155.535(c)(4) is effective as of the date of the impartial official's decision. (B) If the CMS Administrator renders a final decision after reviewing an Exchange eligibility appeal decision as described in paragraphs (g)(1)(i)(B)( 2 2 (iv) Informal resolution decision. (2) Judicial review. (3) Implementation date. (h) Electronic requirements. [78 FR 54136, Aug. 30, 2013, as amended at 79 FR 30349, May 27, 2014; 81 FR 12344, Mar. 8, 2016; 81 FR 94179, Dec. 22, 2016; 88 FR 25920, Apr. 27, 2023; 90 FR 4540, Jan. 15, 2025] § 155.510 Appeals coordination. (a) Agreements. (1) Minimize burden on appellants, including not asking the appellant to provide duplicative information or documentation that he or she already provided to an agency administering an insurance affordability program or eligibility appeals process, unless the appeals entity, Exchange, or agency does not have access to the information or documentation and cannot reasonably obtain it, and such information is necessary to properly adjudicate an appeal; (2) Ensure prompt issuance of appeal decisions consistent with timeliness standards established under this subpart; and (3) Comply with the requirements set forth in— (i) 42 CFR 431.10(d), if the state Medicaid agency delegates authority to hear fair hearings under 42 CFR 431.10(c)(ii) to the Exchange appeals entity; or (ii) 42 CFR 457.348(b), if the state CHIP agency delegates authority to review appeals under § 457.1120 to the Exchange appeals entity. (b) Coordination for Medicaid and CHIP appeals. (i) The Exchange appeals entity will conduct the appeal in accordance with— (A) Medicaid and CHIP MAGI-based income standards and standards for citizenship and immigration status, in accordance with the eligibility and verification rules and procedures, consistent with 42 CFR parts 435 and 457. (B) Notice standards identified in this subpart, subpart D, and by the State Medicaid or CHIP agency, consistent with applicable law. (ii) Consistent with 42 CFR 431.10(c)(1)(ii), an appellant who has been determined ineligible for Medicaid must be informed of the option to opt into pursuing his or her appeal of the adverse Medicaid eligibility determination with the Medicaid agency, and if the appellant elects to do so, the appeals entity transmits the eligibility determination and all information provided via secure electronic interface, promptly and without undue delay, to the Medicaid agency. (2) Where the Medicaid or CHIP agency has not delegated appeals authority to the appeals entity and the appellant seeks review of a denial of Medicaid or CHIP eligibility, the appeals entity must transmit the eligibility determination and all relevant information provided as part of the initial application or appeal, if applicable, via secure electronic interface, promptly and without undue delay, to the Medicaid or CHIP agency, as applicable. (3) The Exchange must consider an appellant determined or assessed by the appeals entity as not potentially eligible for Medicaid or CHIP as ineligible for Medicaid and CHIP based on the applicable Medicaid and CHIP MAGI-based income standards for purposes of determining eligibility for advance payments of the premium tax credit and cost-sharing reductions. (c) Data exchange. (1) Ensure that all data exchanges that are part of the appeals process, comply with the data exchange requirements in §§ 155.260, 155.270, and 155.345(i); and (2) Comply with all data sharing requests made by HHS. [78 FR 54136, Aug. 30, 2013, as amended at 81 FR 12344, Mar. 8, 2016] § 155.515 Notice of appeal procedures. (a) Requirement to provide notice of appeal procedures. (1) Applicant submits an application; and (2) Notice of eligibility determination is sent under §§ 155.310(g), 155.330(e)(1)(ii), 155.335(h)(1)(ii), and 155.610(i). (b) General content on right to appeal and appeal procedures. (1) An explanation of the applicant or enrollee's appeal rights under this subpart; (2) A description of the procedures by which the applicant or enrollee may request an appeal; (3) Information on the applicant or enrollee's right to represent himself or herself, or to be represented by legal counsel or another representative; (4) An explanation of the circumstances under which the appellant's eligibility may be maintained or reinstated pending an appeal decision, as described in § 155.525; and (5) An explanation that an appeal decision for one household member may result in a change in eligibility for other household members and that such a change will be handled as a redetermination of eligibility for all household members in accordance with the standards specified in § 155.305. § 155.520 Appeal requests. (a) General standards for appeal requests. (1) Must accept appeal requests submitted— (i) By telephone; (ii) By mail; (iii) In person, if the Exchange or the appeals entity, as applicable, is capable of receiving in-person appeal requests; and (iv) Via the Internet. (2) Must assist the applicant or enrollee in making the appeal request, if requested; (3) Must not limit or interfere with the applicant or enrollee's right to make an appeal request; and (4) Must consider an appeal request to be valid for the purpose of this subpart, if it is submitted in accordance with the requirements of paragraphs (b) and (c) of this section and § 155.505(b). (b) Appeal request. (1) 90 days of the date of the notice of eligibility determination; or (2) A timeframe consistent with the state Medicaid agency's requirement for submitting fair hearing requests, provided that timeframe is no less than 30 days, measured from the date of the notice of eligibility determination. (c) Appeal of a State Exchange appeals entity decision to HHS. (d) Acknowledgement of appeal request. (i) Send timely acknowledgment to the appellant of the receipt of his or her valid appeal request, including— (A) Information regarding the appellant's eligibility pending appeal pursuant to § 155.525; and (B) An explanation that any advance payments of the premium tax credit paid on behalf of the tax filer pending appeal are subject to reconciliation under 26 CFR 1.36B-4. (ii) Send timely notice via secure electronic interface of the appeal request and, if applicable, instructions to provide eligibility pending appeal pursuant to § 155.525, to the Exchange and to the agencies administering Medicaid or CHIP, where applicable. (iii) If the appeal request is made pursuant to paragraph (c) of this section, send timely notice via secure electronic interface of the appeal request to the State Exchange appeals entity. (iv) Promptly confirm receipt of the records transferred pursuant to paragraph (d)(3) or (4) of this section to the Exchange or the State Exchange appeals entity, as applicable. (2) Upon receipt of an appeal request that is not valid because it fails to meet the requirements of this section or § 155.505(b), the appeals entity must— (i) Promptly and without undue delay, send written notice to the applicant or enrollee informing the appellant: (A) That the appeal request has not been accepted; (B) About the nature of the defect in the appeal request; and (C) That the applicant or enrollee may cure the defect and resubmit the appeal request by the date determined under paragraph (b) or (c) of this section, as applicable, or within a reasonable timeframe established by the appeals entity. (D) That, in the event the appeal request is not valid due to failure to submit by the date determined under paragraph (b) or (c) of this section, as applicable, the appeal request may be considered valid if the applicant or enrollee sufficiently demonstrates within a reasonable timeframe determined by the appeals entity that failure to timely submit was due to exceptional circumstances and should not preclude the appeal. (ii) Treat as valid an amended appeal request that meets the requirements of this section and § 155.505(b). (3) Upon receipt of a valid appeal request pursuant to paragraph (b) of this section, or upon receipt of the notice under paragraph (d)(1)(ii) of this section, the Exchange must transmit via secure electronic interface to the appeals entity— (i) The appeal request, if the appeal request was initially made to the Exchange; and (ii) The appellant's eligibility record. (4) Upon receipt of the notice pursuant to paragraph (d)(1)(iii) of this section, the State Exchange appeals entity must transmit via secure electronic interface the appellant's appeal record, including the appellant's eligibility record as received from the Exchange, to the HHS appeals entity. [78 FR 54136, Aug. 30, 2013, as amended at 81 FR 12344, Mar. 8, 2016] § 155.525 Eligibility pending appeal. (a) General standards. (b) Implementation. § 155.530 Dismissals. (a) Dismissal of appeal. (1) Withdraws the appeal request in writing or by telephone, if the appeals entity is capable of accepting telephonic withdrawals. (i) Accepting telephonic withdrawals means the appeals entity— (A) Records in full the appellant's statement and telephonic signature made under penalty of perjury; and (B) Provides a written confirmation to the appellant documenting the telephonic interaction. (ii) [Reserved] (2) Fails to appear at a scheduled hearing without good cause; (3) Fails to submit a valid appeal request as specified in § 155.520(a)(4); or (4) Dies while the appeal is pending, except if the executor, administrator, or other duly authorized representative of the estate requests to continue the appeal. (b) Notice of dismissal to the appellant. (1) The reason for dismissal; (2) An explanation of the dismissal's effect on the appellant's eligibility; and (3) An explanation of how the appellant may show good cause why the dismissal should be vacated in accordance with paragraph (d) of this section. (c) Notice of the dismissal to the Exchange, Medicaid, and CHIP. (1) The eligibility determination to implement; and (2) Discontinuing eligibility provided under § 155.525, if applicable. (d) Vacating a dismissal. (1) Vacate a dismissal and proceed with the appeal if the appellant makes a written request within 30 days of the date of the notice of dismissal showing good cause why the dismissal should be vacated; and (2) Provide timely written notice of the denial of a request to vacate a dismissal to the appellant, if the request is denied. [78 FR 54136, Aug. 30, 2013, as amended at 79 FR 30349, May 27, 2014; 81 FR 12344, Mar. 8, 2016] § 155.535 Informal resolution and hearing requirements. (a) Informal resolution. (1) The process complies with the scope of review specified in paragraph (e) of this section; (2) The appellant's right to a hearing is preserved in any case in which the appellant remains dissatisfied with the outcome of the informal resolution process; (3) If the appeal advances to hearing, the appellant is not asked to provide duplicative information or documentation that he or she previously provided during the application or informal resolution process; and (4) If the appeal does not advance to hearing, the informal resolution decision is final and binding. (b) Notice of hearing. (1) The appellant requests an earlier hearing date; or (2) A hearing date sooner than 15 days is necessary to process an expedited appeal, as described in § 155.540(a), and the appeals entity has contacted the appellant to schedule a hearing on a mutually agreed upon date, time, and location or format. (c) Conducting the hearing. (1) At a reasonable date, time, and location or format; (2) After notice of the hearing, pursuant to paragraph (b) of this section; (3) As an evidentiary hearing, consistent with paragraph (e) of this section; and (4) By one or more impartial officials who have not been directly involved in the eligibility determination or any prior Exchange appeal decisions in the same matter. (d) Procedural rights of an appellant. (1) Review his or her appeal record, including all documents and records to be used by the appeals entity at the hearing, at a reasonable time before the date of the hearing as well as during the hearing; (2) Bring witnesses to testify; (3) Establish all relevant facts and circumstances; (4) Present an argument without undue interference; and (5) Question or refute any testimony or evidence, including the opportunity to confront and cross-examine adverse witnesses. (e) Information and evidence to be considered. (f) Standard of review. de novo [78 FR 54136, Aug. 30, 2013, as amended at 81 FR 12344, Mar. 8, 2016] § 155.540 Expedited appeals. (a) Expedited appeals. (b) Denial of a request for expedited appeal. (1) Handle the appeal request under the standard process and issue the appeal decision in accordance with § 155.545(b)(1); and (2) Inform the appellant, promptly and without undue delay, through electronic or oral notification, if possible, of the denial and, if notification is oral, follow up with the appellant by written notice, within the timeframe established by the Secretary. Written notice of the denial must include— (i) The reason for the denial; (ii) An explanation that the appeal request will be transferred to the standard process; and (iii) An explanation of the appellant's rights under the standard process. § 155.545 Appeal decisions. (a) Appeal decisions. (1) Be based exclusively on the information and evidence specified in § 155.535(e) and the eligibility requirements under subpart D or G of this part, as applicable, and if the Medicaid or CHIP agencies delegate authority to conduct the Medicaid fair hearing or CHIP review to the appeals entity in accordance with 42 CFR 431.10(c)(1)(ii) or 457.1120, the eligibility requirements under 42 CFR parts 435 and 457, as applicable; (2) State the decision, including a plain language description of the effect of the decision on the appellant's eligibility; (3) Summarize the facts relevant to the appeal; (4) Identify the legal basis, including the regulations that support the decision; (5) State the effective date of the decision; and (6) If the appeals entity is a State Exchange appeals entity— (i) Provide an explanation of the appellant's right to pursue the appeal before the HHS appeals entity, including the applicable timeframe, if the appellant remains dissatisfied with the eligibility determination; and (ii) Indicate that the decision of the State Exchange appeals entity is final, unless the appellant pursues the appeal before the HHS appeals entity. (b) Notice of appeal decision. (1) Must issue written notice of the appeal decision to the appellant within 90 days of the date an appeal request under § 155.520(b) or (c) is received, as administratively feasible. (2) In the case of an appeal request submitted under § 155.540 that the appeals entity determines meets the criteria for an expedited appeal, must issue the notice as expeditiously as reasonably possible, consistent with the timeframe established by the Secretary. (3) Must provide notice of the appeal decision and instructions to cease pended eligibility to the appellant, if applicable, via secure electronic interface, to the Exchange or the Medicaid or CHIP agency, as applicable. (c) Implementation of appeal decisions. (1) Implement the appeal decision effective— (i) Prospectively, on the first day of the month following the date of the notice of appeal decision, or consistent with § 155.330(f)(2), (3), (4), or (5), if applicable; or (ii) Retroactively, to the coverage effective date the appellant did receive or would have received if the appellant had enrolled in coverage under the incorrect eligibility determination that is the subject of the appeal, at the option of the appellant. (2) Redetermine the eligibility of household members who have not appealed their own eligibility determinations but whose eligibility may be affected by the appeal decision, in accordance with the standards specified in § 155.305. [78 FR 54136, Aug. 30, 2013, as amended at 81 FR 12345, Mar. 8, 2016] § 155.550 Appeal record. (a) Appellant access to the appeal record. (b) Public access to the appeal decision. § 155.555 Employer appeals process. (a) General requirements. (b) Exchange employer appeals process. (c) Appeal request. (1) Allow an employer to request an appeal within 90 days from the date the notice described under § 155.310(h) is sent; (2) Allow an employer to submit relevant evidence to support the appeal; (3) Allow an employer to submit an appeal request to— (i) The Exchange or the Exchange appeals entity, if the Exchange establishes an employer appeals process; or (ii) The HHS appeals entity, if the Exchange has not established an employer appeals process; (4) Comply with the requirements of § 155.520(a)(1) through (3); and (5) Consider an appeal request valid if it is submitted in accordance with paragraph (c)(1) of this section and with the purpose of appealing the determination identified in the notice specified in § 155.310(h). (d) Notice of appeal request. (i) Send timely acknowledgement of the receipt of the appeal request to the employer, including an explanation of the appeals process; (ii) Send timely notice to the employee of the receipt of the appeal request, including— (A) An explanation of the appeals process; (B) Instructions for submitting additional evidence for consideration by the appeals entity; and (C) An explanation of the potential effect of the employer's appeal on the employee's eligibility. (iii) Promptly notify the Exchange of the appeal, if the employer did not initially make the appeal request to the Exchange. (2) Upon receipt of an invalid appeal request, the appeals entity must promptly and without undue delay send written notice to the employer that the appeal request is not valid because it fails to meet the requirements of this section. The written notice must inform the employer— (i) That the appeal request has not been accepted; (ii) About the nature of the defect in the appeal request; and (iii) That the employer may cure the defect and resubmit the appeal request by the date determined under paragraph (c) of this section, or within a reasonable timeframe established by the appeals entity. (iv) Treat as valid an amended appeal request that meets the requirements of this section, including standards for timeliness. (e) Transmittal and receipt of records. (i) The appeal request, if the appeal request was initially made to the Exchange; and (ii) The employee's eligibility record. (2) The appeals entity must promptly confirm receipt of records transmitted pursuant to paragraph (e)(1) of this section to the entity that transmitted the records. (f) Dismissal of appeal. (1) Must dismiss an appeal under the circumstances specified in § 155.530(a)(1) or if the request fails to comply with the standards in paragraph (c)(4) of this section. (2) Must provide timely notice of the dismissal to the employer, employee, and Exchange including the reason for dismissal; and (3) May vacate a dismissal if the employer makes a written request within 30 days of the date of the notice of dismissal showing good cause as to why the dismissal should be vacated. (g) Procedural rights of the employer. (1) Provide relevant evidence for review of the determination of an employee's eligibility for advance payments of the premium tax credit or cost-sharing reductions; (2) Review— (i) The information described in § 155.310(h)(1); (ii) Information regarding whether the employee's income is above or below the threshold by which the affordability of employer-sponsored minimum essential coverage is measured, as set forth by standards described in 26 CFR 1.36B; and (iii) Other data used to make the determination described in § 155.305(f) or (g), to the extent allowable by law, except the information described in paragraph (h) of this section. (h) Confidentiality of employee information. (i) Adjudication of employer appeals. (1) Be reviewed by one or more impartial officials who have not been directly involved in the employee eligibility determination implicated in the appeal; (2) Consider the information used to determine the employee's eligibility as well as any additional relevant evidence provided by the employer or the employee during the course of the appeal; and (3) Be reviewed de novo. (j) Appeal decisions. (1) Be based exclusively on the information and evidence described in paragraph (i)(2) of this section and the eligibility standards in 45 CFR part 155, subpart D; (2) State the decision, including a plain language description of the effect of the decision on the employee's eligibility; and (3) Comply with the requirements set forth in § 155.545(a)(3) through (5). (k) Notice of appeal decision. (1) The employer. Such notice must include— (i) The appeal decision; and (ii) An explanation that the appeal decision does not foreclose any appeal rights the employer may have under subtitle F of the Code. (2) The employee. Such notice must include— (i) The appeal decision; and (ii) An explanation that the employee and his or her household members, if applicable, may appeal a redetermination of eligibility that occurs as a result of the appeal decision. (3) The Exchange. (l) Implementation of the appeal decision. (1) Redetermine the employee's eligibility and the eligibility of the employee's household members, if applicable, in accordance with the standards specified in § 155.305; or (2) Notify the employee of the requirement to report changes in eligibility as described in § 155.330(b)(1). (m) Appeal record. [78 FR 54136, Aug. 30, 2013, as amended at 79 FR 30349, May 27, 2014; 81 FR 12345, Mar. 8, 2016; 81 FR 94179, Dec. 22, 2016] Subpart G—Exchange Functions in the Individual Market: Eligibility Determinations for Exemptions Source: 78 FR 39523, July 1, 2013, unless otherwise noted. § 155.600 Definitions and general requirements. (a) Definitions. Applicant Application filer Exemption Health care sharing ministry Indian tribe Required contribution Required contribution percentage Shared responsibility payment Tax filer (b) Attestation. (c) Reasonably compatible. (d) Accessibility. (e) Notices. [78 FR 39523, July 1, 2013, as amended at 79 FR 30349, May 27, 2014] § 155.605 Eligibility standards for exemptions. (a) Eligibility for an exemption through the Exchange. (b) Duration of single exemption. (c) Religious conscience. (2) Duration of exemption for religious conscience. (ii) If the Exchange granted a certificate of exemption in this category to an applicant prior to his or her reaching the age of 21, the Exchange must send the applicant a notice upon reaching the age of 21 informing the applicant that he or she must submit a new exemption application to maintain the certificate of exemption. (3) The Exchange must make an exemption in this category available prospectively or retrospectively. (d) Hardship General. (i) He or she experienced financial or domestic circumstances, including an unexpected natural or human-caused event, such that he or she had a significant, unexpected increase in essential expenses that prevented him or her from obtaining coverage under a qualified health plan; (ii) The expense of purchasing a qualified health plan would have caused him or her to experience serious deprivation of food, shelter, clothing or other necessities; (iii) He or she has experienced other circumstances that prevented him or her from obtaining coverage under a qualified health plan; or (iv) The applicant, or if the applicant is a tax dependent, the tax filer claiming the applicant as a dependent, has a projected household income that does not qualify them as an applicable taxpayer according to 26 CFR 1.36B-2(b) or does not qualify them for cost-sharing reductions according to 45 CFR 155.305(g)(1)(i)(C). (2) Lack of affordable coverage based on projected income. (i) Eligibility for this exemption is based on projected annual household income; (ii) An eligible employer-sponsored plan is only considered under paragraphs (d)(4)(iii) and (iv) of this section if it meets the minimum value standard described in § 156.145 of this subchapter. (iii) For an individual who is eligible to purchase coverage under an eligible employer-sponsored plan, the Exchange determines the required contribution for coverage such that— (A) An individual who uses tobacco is treated as not earning any premium incentive related to participation in a wellness program designed to prevent or reduce tobacco use that is offered by an eligible employer-sponsored plan; (B) Wellness incentives offered by an eligible employer-sponsored plan that do not relate to tobacco use are treated as not earned; (C) In the case of an employee who is eligible to purchase coverage under an eligible employer-sponsored plan sponsored by the employee's employer, the required contribution is the portion of the annual premium that the employee would pay (whether through salary reduction or otherwise) for the lowest cost self-only coverage. (D) In the case of an individual who is eligible to purchase coverage under an eligible employer-sponsored plan as a member of the employee's family, as defined in 26 CFR 1.36B-1(d), the required contribution is the portion of the annual premium that the employee would pay (whether through salary reduction or otherwise) for the lowest cost family coverage that would cover the employee and all other individuals who are included in the employee's family who have not otherwise been granted an exemption through the Exchange. (iv) For an individual who is ineligible to purchase coverage under an eligible employer-sponsored plan, the Exchange determines the required contribution for coverage in accordance with section 5000A(e)(1)(B)(ii) of the Code, inclusive of all members of the family, as defined in 26 CFR 1.36B-1(d), who have not otherwise been granted an exemption through the Exchange and who are not treated as eligible to purchase coverage under an eligible employer-sponsored plan, in accordance with paragraph (d)(4)(ii) of this section. If there is not a bronze level plan offered through the Exchange in the individual's county, the Exchange must use the annual premium for the lowest cost Exchange metal level plan, excluding catastrophic coverage, available in the individual market through the Exchange in the State in the county in which the individual resides to determine whether coverage exceeds the affordability threshold specified in section 5000A(e)(1) of the Code; and (v) The applicant applies for this exemption prior to the last date on which he or she could enroll in a QHP through the Exchange for the month or months of a calendar year for which the exemption is requested. (vi) The Exchange must make an exemption in this category available prospectively, and provide it for all remaining months in a coverage year, notwithstanding any change in an individual's circumstances. (3) Ineligible for Medicaid based on a State's decision not to expand. (e) Eligibility for an exemption through the IRS. (1) Filing threshold. https://www.cms.gov/cciio/ (2) Self-only coverage in an eligible employer-sponsored plan. https://www.cms.gov/cciio/ (3) Eligible for services through an Indian health care provider. https://www.cms.gov/cciio/ (4) Ineligible for Medicaid based on a State's decision not to expand. https://www.cms.gov/cciio/ (5) General hardship. https://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/Authority-to-Grant-HS-Exemptions-2018-Final-91218.pdf https://www.irs.gov/pub/irs-drop/n-19-05.pdf [78 FR 39523, July 1, 2013, as amended at 79 FR 30349, May 27, 2014; 80 FR 10868, Feb. 27, 2015; 81 FR 12345, Mar. 8, 2016; 83 FR 17063, Apr. 17, 2018; 84 FR 17567, Apr. 25, 2019; 91 FR 29868, May 20, 2026] § 155.610 Eligibility process for exemptions. (a) Application. (b) Alternative application. (c) Exemptions through the eligibility process for coverage. (d) Filing the exemption application. (1) Accept the application from an application filer; and (2) Provide the tools to file an application. (3) For applications submitted before October 15, 2014, the Exchange must, at a minimum, accept the application by mail. (e) Collection of Social Security numbers. (2) The Exchange may not require an individual who is not seeking an exemption for himself or herself to provide a Social Security number, except as specified in paragraph (e)(3) of this section. (3) The Exchange must require an application filer to provide the Social Security number of a tax filer who is not an applicant only if an applicant attests that the tax filer has a Social Security number and filed a tax return for the year for which tax data would be utilized for verification of household income and family size for an exemption under § 155.605(g)(2) that requires such verification. (f) Determination of eligibility; granting of certificates. (g) Timeliness standards. (2) The Exchange must assess the timeliness of eligibility determinations made under this subpart based on the period from the date of application to the date the Exchange notifies the applicant of its decision. (h) Exemptions for previous tax years. (2) The Exchange will only accept an application for an exemption described in § 155.605(d)(1) during one of the 3 calendar years after the month or months during which the applicant attests that the hardship occurred. (i) Notification of eligibility determination for exemptions. (j) Retention of records for tax compliance. (2) In the case of any factor of eligibility that is verified through use of the special circumstances exception described in § 155.615(h), the records that demonstrate qualification for the underlying exemption are the information submitted to the Exchange regarding the circumstances that warranted the use of the exception, as well as records of the Exchange decision to allow such exception. (k) Incomplete application. (i) Provide notice to the applicant indicating that information necessary to complete an eligibility determination is missing, specifying the missing information, and providing instructions on how to provide the missing information; and (ii) Provide the applicant with a period of no less than 30 and no more than 90 days, in the reasonable discretion of the Exchange, from the date on which the notice described in paragraph (k)(1) of this section is sent to the applicant to provide the information needed to complete the application to the Exchange; and (iii) Not proceed with the applicant's eligibility determination during the period described in paragraph (k)(2) of this section. (2) If the Exchange does not receive the requested information within the time allotted in paragraph (k)(1)(ii) of this section, the Exchange must notify the applicant in writing that the Exchange cannot process the application and provide appeal rights to the applicant. [78 FR 39523, July 1, 2013, as amended at 81 FR 12346, Mar. 8, 2016; 83 FR 17064, Apr. 17, 2018] § 155.615 Verification process related to eligibility for exemptions. (a) General rule. (b) Verification related to exemption for religious conscience. (1) Except as specified in paragraph (b)(2) of this section, accepting a form that reflects that he or she is exempt from Social Security and Medicare taxes under section 1402(g)(1) of the Code; (2) Except as specified in paragraphs (b)(3) and (4) of this section, accepting his or her attestation of membership in a religious sect or division, and verifying that the religious sect or division to which the applicant attests membership is recognized by the Social Security Administration as an approved religious sect or division under section 1402(g)(1) of the Code. (3) If information provided by an applicant regarding his or her membership in a religious sect or division is not reasonably compatible with other information provided by the individual or in the records of the Exchange, the Exchange must follow the procedures specified in paragraph (g) of this section. (4) If an applicant attests to membership in a religious sect or division that is not recognized by the Social Security Administration as an approved religious sect or division under section 1402(g)(1) of the Code, the Exchange must provide the applicant with information regarding how his or her religious sect or division can pursue recognition under section 1402(g)(1) of the Code, and determine the applicant ineligible for this exemption until such time as the Exchange obtains information indicating that the religious sect or division has been approved. (c) Verification related to exemption for hardship In general. (2) Lack of affordable coverage based on projected income. (ii) The Exchange must accept an application filer's attestation for an applicant regarding eligibility for minimum essential coverage other than through an eligible employer-sponsored plan, instead of following the procedures specified in § 155.320(b). (3) [Reserved] (4) To the extent that the Exchange is unable to verify any of the information needed to determine an applicant's eligibility for an exemption based on hardship, the Exchange must follow the procedures specified in paragraph (g) of this section. (d) Inability to verify necessary information. (1) Must make a reasonable effort to identify and address the causes of such inconsistency, including typographical or other clerical errors, by contacting the application filer to confirm the accuracy of the information submitted by the application filer; (2) If unable to resolve the inconsistency through the process described in paragraph (g)(1) of this section, must— (i) Provide notice to the applicant regarding the inconsistency; and (ii) Provide the applicant with a period of 90 days from the date on which the notice described in paragraph (g)(2)(i) of this section is sent to the applicant to either present satisfactory documentary evidence via the channels available for the submission of an application, as described in § 155.610(d), except for by telephone, or otherwise to resolve the inconsistency. (3) May extend the period described in paragraph (g)(2)(ii) of this section for an applicant if the applicant demonstrates that a good faith effort has been made to obtain the required documentation during the period. (4) During the period described in paragraph (g)(1) and (g)(2)(ii) of this section, must not grant a certificate of exemption based on the information subject to this paragraph. (5) If, after the period described in paragraph (g)(2)(ii) of this section, the Exchange remains unable to verify the attestation, the Exchange must determine the applicant's eligibility for an exemption based on any information available from the data sources used in accordance with this subpart, if applicable, unless such applicant qualifies for the exception provided under paragraph (h) of this section, and notify the applicant of such determination in accordance with the notice requirements specified in § 155.610(i), including notice that the Exchange is unable to verify the attestation. (e) Exception for special circumstances. (f) Flexibility in information collection and verification. (g) Applicant information. (h) Validation of Social Security number. (2) To the extent that the Exchange is unable to validate an individual's Social Security number through the Social Security Administration, or the Social Security Administration indicates that the individual is deceased, the Exchange must follow the procedures specified in paragraph (g) of this section, except that the Exchange must provide the individual with a period of 90 days from the date on which the notice described in paragraph (g)(2)(i) of this section is received for the applicant to provide satisfactory documentary evidence or resolve the inconsistency with the Social Security Administration. The date on which the notice is received means 5 days after the date on the notice, unless the individual demonstrates that he or she did not receive the notice within the 5 day period. [78 FR 39523, July 1, 2013, as amended at 78 FR 42322, July 15, 2013; 81 FR 12346, Mar. 8, 2016] § 155.620 Eligibility redeterminations for exemptions during a calendar year. (a) General requirement. (b) Requirement for individuals to report changes. (2) The Exchange must allow an individual with a certificate of exemption to report changes via the channels available for the submission of an application, as described in § 155.610(d). (c) Verification of reported changes. (1) Verify any information reported by an individual with a certificate of exemption in accordance with the processes specified in § 155.615 prior to using such information in an eligibility redetermination. (2) Notify an individual in accordance with § 155.610(i) after redetermining his or her eligibility based on a reported change. (3) Provide periodic electronic notifications regarding the requirements for reporting changes and an individual's opportunity to report any changes, to an individual who has a certificate of exemption for which changes must be reported in accordance with § 155.620(b) and who has elected to receive electronic notifications, unless he or she has declined to receive such notifications. (d) Effective date of changes. § 155.625 Options for conducting eligibility determinations for exemptions. (a) Options for conducting eligibility determinations. (1) Directly or through contracting arrangements in accordance with § 155.110(a); or (2) By use of the HHS service under paragraph (b) of this section. (b) Use of HHS service. (c) Administration of hardship exemption based on affordability. [79 FR 30349, May 27, 2014, as amended at 81 FR 12346, Mar. 8, 2016] § 155.630 Reporting. Requirement to provide information related to tax administration. (a) The individual's name, Social Security number, and exemption certificate number; (b) Any other information required in guidance published by the Secretary of the Treasury in accordance with 26 CFR 601.601(d)(2). § 155.635 Right to appeal. (a) For an application submitted before October 15, 2014, the Exchange must include the notice of the right to appeal and instructions regarding how to file an appeal in any notification issued in accordance with § 155.610(i). (b) For an application submitted on or after October 15, 2014, the Exchange must include the notice of the right to appeal and instructions regarding how to file an appeal in any notification issued in accordance with §§ 155.610(i) and 155.625(b)(2)(i). Subpart H—Exchange Functions: Small Business Health Options Program (SHOP) Source: 77 FR 18464, Mar. 27, 2012, unless otherwise noted. § 155.700 Standards for the establishment of a SHOP. (a) General requirement. (2) For plan years beginning on or after January 1, 2018, an Exchange must provide for the establishment of a SHOP that meets the requirements of this subpart and is designed to assist qualified employers in facilitating the enrollment of their employees in qualified health plans. (b) Definition. Group participation rate SHOP application filer [77 FR 18464, Mar. 27, 2012, as amended at 78 FR 54141, Aug. 30, 2013; 80 FR 10868, Feb. 27, 2015; 83 FR 17064, Apr. 17, 2018] § 155.705 Functions of a SHOP for plan years beginning prior to January 1, 2018. (a) Exchange functions that apply to SHOP. (1) Requirements related to individual eligibility determinations in subpart D of this part; (2) Requirements related to enrollment of qualified individuals described in subpart E of this part; (3) The requirement to issue certificates of exemption in accordance with § 155.200(b); and (4) Requirements related to the payment of premiums by individuals, Indian tribes, tribal organizations and urban Indian organizations under § 155.240. (b) Unique functions of a SHOP. (1) Enrollment and eligibility functions. The SHOP must adhere to the requirements outlined in subpart H. (2) Employer choice requirements. (3) SHOP options with respect to employer choice requirements. (A) By the method described in paragraph (b)(2) of this section, or (B) By a method other than the method described in paragraph (b)(2) of this section. (ii) Unless the SHOP makes an election pursuant to paragraph (b)(3)(vi) of this section, for plan years beginning on or after January 1, 2015, a SHOP: (A) Must allow an employer to make available to qualified employees all QHPs at the level of coverage selected by the employer as described in paragraph (b)(2) of this section, and (B) May allow an employer to make one or more QHPs available to qualified employees by a method other than the method described in paragraph (b)(2) of this section. (iii) For plan years beginning before January 1, 2015, a Federally-facilitated SHOP will provide a qualified employer the choice to make available to qualified employees a single QHP. (iv) Unless the Secretary makes an election pursuant to paragraph (b)(3)(vi) of this section, for plan years beginning on or after January 1, 2015, a Federally-facilitated SHOP will provide a qualified employer a choice of two methods to make QHPs available to qualified employees: (A) The employer may choose a level of coverage as described in paragraph (b)(2) of this section, or (B) The employer may choose a single QHP. (v) For plan years beginning on or after January 1, 2015, a Federally-facilitated SHOP will provide a qualified employer a choice of two methods to make stand-alone dental plans available to qualified employees and their dependents: (A) The employer may choose to make available a single stand-alone dental plan. (B) The employer may choose to make available all stand-alone dental plans offered through a Federally-facilitated SHOP at a level of coverage as described in § 156.150(b)(2) of this subchapter. (vi) For plan years beginning in 2015 only, the SHOP may elect to provide employers only with the option set forth at paragraph (b)(3)(ii)(B) of this section, or in the case of a Federally-facilitated SHOP, only with the option set forth at paragraph (b)(3)(iv)(B) of this section, only if the State Insurance Commissioner submits a written recommendation to the SHOP adequately explaining that it is the State Insurance Commissioner's expert judgment, based on a documented assessment of the full landscape of the small group market in his or her State, that not implementing employee choice would be in the best interests of small employers and their employees and dependents, given the likelihood that implementing employee choice would cause issuers to price products and plans higher in 2015 due to the issuers' beliefs about adverse selection. A State Insurance Commissioner's recommendation must be based on concrete evidence, including but not limited to discussions with those issuers expected to participate in the SHOP in 2015. (vii) For plan years beginning in 2015 only, a State Insurance Commissioner should submit the recommendation specified in paragraph (b)(3)(vi) of this section, and the SHOP should make a decision based on that recommendation sufficiently in advance of the end of the QHP certification application window such that issuers can make informed decisions about whether to participate in the SHOP. In a Federally-facilitated-SHOP, State Insurance Commissioners must submit to HHS the recommendation specified in paragraph (b)(3)(vi) of this section on or before June 2, 2014, and HHS will make a decision based on any recommendations submitted by that deadline before the close of the QHP certification application window. (viii) For plan years beginning on or after January 1, 2017, a Federally-facilitated SHOP will provide a qualified employer a choice of at least the two methods to make QHPs available to qualified employees and their dependents described in paragraphs (b)(3)(viii)(A) and (B) of this section, and may also provide a qualified employer with a choice of a third method to make QHPs available to qualified employees and their dependents as described in paragraph (b)(3)(viii)(C) of this section. (A) The employer may choose a level of coverage as described in paragraph (b)(2) of this section; (B) The employer may choose a single QHP; or (C) The employer may offer its qualified employees a choice of all QHPs offered through a Federally-facilitated SHOP by a single issuer across all available levels of coverage, as described in section 1302(d)(1) of the Affordable Care Act and implemented in § 156.140(b) of this subchapter. A State with a Federally-facilitated SHOP may recommend that the Federally-facilitated SHOP not make this additional option available in that State, by submitting a letter to HHS in advance of the annual QHP certification application deadline, by a date to be established by HHS. The State's letter must describe and justify the State's recommendation, based on the anticipated impact this additional option would have on the small group market and consumers. (ix) For plan years beginning on or after January 1, 2017, a Federally-facilitated SHOP will provide a qualified employer a choice of at least the two methods to make stand-alone dental plans available to qualified employees and their dependents described in paragraphs (b)(3)(ix)(A) and (B) of this section, and may also provide a qualified employer with a choice of a third method to make stand-alone dental plans available to qualified employees and their dependents as described in paragraph (b)(3)(ix)(C) of this section. (A) The employer may choose to make available a single stand-alone dental plan; (B) The employer may choose to make available all stand-alone dental plans offered through a Federally-facilitated SHOP at a level of coverage as described in § 156.150(b)(2) of this subchapter; or (C) The employer may offer its qualified employees a choice of all stand-alone dental plans offered through a Federally-facilitated SHOP by a single issuer across all available levels of coverage, as described in § 156.150(b)(2) of this subchapter. A State with a Federally-facilitated SHOP may recommend that the Federally-facilitated SHOP not make this additional option available in that State, by submitting a letter to HHS in advance of the annual QHP certification application deadline, by a date to be established by HHS. The State's letter must describe and justify the State's recommendation, based on the anticipated impact this additional option would have on the small group market and consumers. (x) States operating a State-based Exchange utilizing the Federal platform for SHOP enrollment functions will have the same employer choice models available as States with a Federally-facilitated SHOP, except that a State with a State-based Exchange utilizing the Federal platform for SHOP enrollment functions may decide against offering the employer choice models specified in paragraphs (b)(3)(viii)(C) and (b)(3)(ix)(C) of this section in that State, provided that the State notifies HHS of that decision in advance of the annual QHP certification application deadline, by a date to be established by HHS. (4)(i) Premium aggregation. (A) Provide each qualified employer with a bill on a monthly basis that identifies the employer contribution, the employee contribution, and the total amount that is due to the QHP issuers from the qualified employer; (B) Collect from each employer the total amount due and make payments to QHP issuers in the SHOP for all enrollees except as provided for in paragraph (b)(4)(ii)(A) of this section; and (C) Maintain books, records, documents, and other evidence of accounting procedures and practices of the premium aggregation program for each benefit year for at least 10 years. (ii) The SHOP may establish one or more standard processes for premium calculation, premium payment, and premium collection. (A) The SHOP may, upon an election by a qualified employer, enter into an agreement with a qualified employer to facilitate the administration of continuation coverage by collecting premiums for continuation coverage enrolled in through the SHOP directly from a person enrolled in continuation coverage through the SHOP consistent with applicable law and the terms of the group health plan, and remitting premium payments for this coverage to QHP issuers. A Federally-facilitated SHOP may elect to limit this service to the collection of premiums related to continuation coverage required under 29 U.S.C. 1161, et seq. (B) Qualified employers in a Federally-facilitated SHOP must make premium payments according to a timeline and process established by HHS: ( 1 ( 2 (C) For a Federally-facilitated SHOP, the premium for coverage lasting less than 1 month must equal the product of: ( 1 ( 2 1 (iii) Effective dates. (B) A Federally-facilitated SHOP will perform these functions only in plan years beginning on or after January 1, 2015. (5) QHP Certification. (6) Rates and rate changes. (i) Require all QHP issuers to make any change to rates at a uniform time that is no more frequently than quarterly. (A) In a Federally-facilitated SHOP, rates may be updated quarterly with effective dates of January 1, April 1, July 1, or October 1 of each calendar year, beginning with rates effective no sooner than July 1, 2014. The updated rates must be submitted to HHS at least 60 days in advance of the effective date of the rates. (B) [Reserved] (ii) Prohibit all QHP issuers from varying rates for a qualified employer during the employer's plan year. (7) QHP availability in merged markets. (8) QHP availability in unmerged markets. (9) SHOP expansion to large group market. (10) Participation rules. (i) For plan years beginning before January 1, 2016, subject to § 147.104 of this subchapter, a Federally-facilitated SHOP must use a minimum participation rate of 70 percent, calculated as the number of qualified employees accepting coverage under the employer's group health plan, divided by the number of qualified employees offered coverage, excluding from the calculation any employee who, at the time the employer submits the SHOP application, is enrolled in coverage through another employer's group health plan or through a governmental plan such as Medicare, Medicaid, or TRICARE. For purposes of this calculation, qualified employees who are former employees will not be counted. (ii) For plan years beginning on or after January 1, 2016, subject to § 147.104 of this subchapter, a Federally-facilitated SHOP must use a minimum participation rate of 70 percent, calculated as the number of full-time employees accepting coverage offered by a qualified employer plus the number of full-time employees who, at the time the employer submits the SHOP group enrollment, are enrolled in coverage through another group health plan, governmental coverage (such as Medicare, Medicaid, or TRICARE), coverage sold through the individual market, or in other minimum essential coverage, divided by the number of full-time employees offered coverage. (iii) Notwithstanding paragraphs (b)(10)(i) and (ii) of this section, a Federally-facilitated SHOP may utilize a different minimum participation rate in a State if there is evidence that a State law sets a minimum participation rate or that a higher or lower minimum participation rate is customarily used by the majority of QHP issuers in that State for products in the State's small group market outside the SHOP. (11) Premium calculator. (i) To determine the employer and employee contributions, a SHOP may establish one or more standard methods that employers may use to define their contributions toward employee and dependent coverage. (ii) A Federally-facilitated SHOP must use the following method for employer contributions: (A) When the employer offers a single plan to qualified employees, the employer must use a fixed contribution methodology under which the employer contributes a fixed percentage of the plan's premium for each qualified employee and, if applicable, for each dependent of a qualified employee. The employer's contribution is calculated based on an enrollee's premium before any applicable tobacco surcharge, based on the total premium owed for the enrollee, is applied. (B) When the employer offers a choice of plans to qualified employees, the employer may use a fixed contribution methodology or a reference plan contribution methodology. Under the fixed contribution methodology, the employer contributes a fixed percentage of the premiums for each qualified employee and, if applicable, for each dependent of a qualified employee, across all plans in which any qualified employee, and, if applicable, any dependent of a qualified employee, is enrolled. Under the reference plan contribution methodology, the employer will select a plan from among the plans offered by the employer as described in paragraphs (b)(2) and (3) of this section to serve as a reference plan on which contributions will be based, and then will define a percentage contribution toward premiums under the reference plan; the resulting contribution amounts under the reference plan will be applied toward any plan in which a qualified employee or, if applicable, any dependent of a qualified employee, is enrolled, up to the lesser of the contribution amount or the total amount of any premium for the selected plan before application of a tobacco surcharge, if applicable. The employer's contribution is calculated based on an enrollee's premium before any applicable tobacco surcharge, based on the total premium owed for the enrollee, is applied. (C) The employer will define a percentage contribution toward premiums for employee-only coverage and, if dependent coverage is offered, a percentage contribution toward premiums for dependent coverage. To the extent permitted by other applicable law, for plan years beginning on or after January 1, 2015, a Federally-facilitated SHOP may permit an employer to define a different percentage contribution for full-time employees from the percentage contribution it defines for non-full-time employees, and it may permit an employer to define a different percentage contribution for dependent coverage for full-time employees from the percentage contribution it defines for dependent coverage for non-full-time employees. (D) A Federally-facilitated SHOP may permit employers to base contributions on a calculated composite premium for employees, for adult dependents, and for dependents below age 21. (c) Coordination with individual market Exchange for eligibility determinations. (d) Duties of Navigators in the SHOP. (e) Applicability date. [77 FR 18464, Mar. 27, 2012, as amended at 78 FR 15533, Mar. 11, 2013; 78 FR 33239, June 4, 2013; 78 FR 54141, Aug. 30, 2013; 78 FR 79620, Dec. 31, 2013; 79 FR 13838, Mar. 11, 2014; 79 FR 30349, May 27, 2014; 79 FR 59138, Oct. 1, 2014; 80 FR 10868, Feb. 27, 2015; 81 FR 12346, Mar. 8, 2016; 83 FR 17064, Apr. 17, 2018] § 155.706 Functions of a SHOP for plan years beginning on or after January 1, 2018. (a) Exchange functions that apply to SHOP. (1) Requirements related to individual eligibility determinations in subpart D of this part; (2) Requirements related to enrollment of qualified individuals described in subpart E of this part; (3) The requirement to issue certificates of exemption in accordance with § 155.200(b); and (4) Requirements related to the payment of premiums by individuals, Indian tribes, tribal organizations and urban Indian organizations under § 155.240. (b) Unique functions of a SHOP. (1) Enrollment and eligibility functions. (2) Employer choice requirements. (3) SHOP options with respect to employer choice requirements. (A) Must allow an employer to make available to qualified employees all QHPs at the level of coverage selected by the employer as described in paragraph (b)(2) of this section, and (B) May allow an employer to make one or more QHPs available to qualified employees by a method other than the method described in paragraph (b)(2) of this section. (ii) A Federally-facilitated SHOP will provide a qualified employer a choice of two methods to make QHPs available to qualified employees: (A) The employer may choose a level of coverage as described in paragraph (b)(2) of this section, or (B) The employer may choose a single QHP. (iii) A SHOP may, and a Federally-facilitated SHOP will provide a qualified employer a choice of two methods to make stand-alone dental plans available to qualified employees: (A) The employer may choose to make available a single stand-alone dental plan. (B) The employer may choose to make available all stand-alone dental plans offered through a SHOP. (iv) A SHOP may also provide a qualified employer with a choice of a third method to make QHPs available to qualified employees by offering its qualified employees a choice of all QHPs offered through the SHOP by a single issuer across all available levels of coverage, as described in section 1302(d)(1) of the Affordable Care Act and implemented in § 156.140(b) of this subchapter. A State with a Federally-facilitated SHOP may recommend that the Federally-facilitated SHOP not make this additional option available in that State, by submitting a letter to HHS in advance of the annual QHP certification application deadline, by a date to be established by HHS. The State's letter must describe and justify the State's recommendation, based on the anticipated impact this additional option would have on the small group market and consumers. (v) A SHOP may also provide a qualified employer with a choice of a third method to make stand-alone dental plans available to qualified employees by offering its qualified employees a choice of all stand-alone dental plans offered through the SHOP by a single issuer. A State with a Federally-facilitated SHOP may recommend that the Federally-facilitated SHOP not make this additional option available in that State, by submitting a letter to HHS in advance of the annual QHP certification application deadline, by a date to be established by HHS. The State's letter must describe and justify the State's recommendation, based on the anticipated impact this additional option would have on the small group market and consumers. (vi) States operating a State Exchange utilizing the Federal platform for SHOP enrollment functions will have the same employer choice models available as States with a Federally-facilitated SHOP, except that a State with a State Exchange utilizing the Federal platform for SHOP enrollment functions may decide against offering the employer choice models specified in paragraphs (b)(3)(iv) and (v) of this section in that State, provided that the State notifies HHS of that decision in advance of the annual QHP certification application deadline, by a date to be established by HHS. (4) Continuation of Coverage. (5) QHP Certification. (6) Rates and rate changes. (i) Require all QHP issuers to make any change to rates at a uniform time that is no more frequently than quarterly. (A) In a Federally-facilitated SHOP, rates may be updated quarterly with effective dates of January 1, April 1, July 1, or October 1 of each calendar year. The updated rates must be submitted to HHS at least 60 days in advance of the effective date of the rates. (B) [Reserved] (ii) Prohibit all QHP issuers from varying rates for a qualified employer during the employer's plan year. (7) QHP availability in merged markets. (8) QHP availability in unmerged markets. (9) SHOP expansion to large group market. (10) Participation rules. (i) Subject to § 147.104 of this subchapter, a Federally-facilitated SHOP must use a minimum participation rate of 70 percent, calculated as the number of full-time employees accepting coverage offered by a qualified employer plus the number of full-time employees who, at the time the employer submits the SHOP group enrollment, are enrolled in coverage through another group health plan, governmental coverage (such as Medicare, Medicaid, or TRICARE), coverage sold through the individual market, or in other minimum essential coverage, divided by the number of full-time employees offered coverage. (ii) Notwithstanding paragraphs (b)(10)(i) of this section, a Federally-facilitated SHOP may utilize a different minimum participation rate in a State if there is evidence that a State law sets a minimum participation rate or that a higher or lower minimum participation rate is customarily used by the majority of QHP issuers in that State for products in the State's small group market outside the SHOP. (11) Premium calculator. (c) Coordination with individual market Exchange for eligibility determinations. (d) Duties of Navigators in the SHOP. (e) Applicability date. [83 FR 17064, Apr. 17, 2018] § 155.710 Eligibility standards for SHOP. (a) General requirement. (b) Employer eligibility requirements. (1) Is a small employer; (2) Elects to offer, at a minimum, all full-time employees coverage in a QHP through a SHOP; and (3) Either— (i) Has its principal business address in the Exchange service area and offers coverage to all its full-time employees through that SHOP; or (ii) Offers coverage to each eligible employee through the SHOP serving that employee's primary worksite. (c) Participating in multiple SHOPs. (d) Continuing eligibility. (e) Employee eligibility requirements. [77 FR 18464, Mar. 27, 2012, as amended at 80 FR 10869, Feb. 27, 2015] § 155.715 Eligibility determination process for SHOP for plan years beginning prior to January 1, 2018. (a) General requirement. (b) Applications. (c) Verification of eligibility. (1) Must verify that an individual applicant is identified by the employer as an employee to whom the qualified employer has offered coverage and must otherwise accept the information attested to within the application unless the information is inconsistent with the employer-provided information; (2) May establish, in addition to or in lieu of reliance on the application, additional methods to verify the information provided by the applicant on the applicable application; (3) Must collect only the minimum information necessary for verification of eligibility in accordance with the eligibility standards described in § 155.710; and (4) May not perform individual market Exchange eligibility determinations or verifications described in subpart D of this part. (d) Eligibility adjustment period. (i) Make a reasonable effort to identify and address the causes of such inconsistency, including through typographical or other clerical errors; (ii) Notify the employer of the inconsistency; (iii) Provide the employer with a period of 30 days from the date on which the notice described in paragraph (d)(1)(ii) of this section is sent to the employer to either present satisfactory documentary evidence to support the employer's application, or resolve the inconsistency; and (iv) If, after the 30-day period described in paragraph (d)(1)(iii) of this section, the SHOP has not received satisfactory documentary evidence, the SHOP must— (A) Notify the employer of its denial of eligibility in accordance with paragraph (e) of this section and of the employer's right to appeal such determination; and (B) If the employer was enrolled pending the confirmation or verification of eligibility information, discontinue the employer's participation in the SHOP at the end of the month following the month in which the notice is sent. (2) When the information submitted on the SHOP single employee application is inconsistent with information collected from third-party data sources through the verification process described in § 155.715(c)(2), the SHOP must- (i) Make a reasonable effort to identify and address the causes of such inconsistency, including through typographical or other clerical errors; (ii) Notify the individual of the inability to substantiate his or her employee status; (iii) Provide the employee with a period of 30 days from the date on which the notice described in paragraph (d)(2)(ii) of this section is sent to the employee to either present satisfactory documentary evidence to support the employee's application, or resolve the inconsistency; and (iv) If, after the 30-day period described in paragraph (d)(2)(iii) of this section, the SHOP has not received satisfactory documentary evidence, the SHOP must notify the employee of its denial of eligibility in accordance with paragraph (f) of this section. (e) Notification of employer eligibility. (f) Notification of employee eligibility. (g) Notification of employer withdrawal from SHOP. (1) Each QHP terminates the enrollment through the SHOP of the employer's enrollees enrolled in a QHP through the SHOP; and (2) Each of the employer's qualified employees enrolled in a QHP through the SHOP is notified of the termination of coverage prior to such termination. Such notification must also provide information about other potential sources of coverage, including access to individual market coverage through the Exchange. (h) Applicability date. [77 FR 18464, Mar. 27, 2012, as amended at 79 FR 13839, Mar. 11, 2014; 81 FR 12347, Mar. 8, 2016; 83 FR 17065, Apr. 17, 2018] § 155.716 Eligibility determination process for SHOP for plan years beginning on or after January 1, 2018. (a) General requirement. (b) Applications. (c) Verification of eligibility. (1) May establish, in addition to or in lieu of reliance on the application, additional methods to verify the information provided by the applicant on the applicable application; (2) Must collect only the minimum information necessary for verification of eligibility in accordance with the eligibility standards described in § 155.710; and (3) May not perform individual market Exchange eligibility determinations or verifications described in subpart D of this part. (d) Eligibility adjustment period. (1) Make a reasonable effort to identify and address the causes of such inconsistency, including through typographical or other clerical errors; (2) Notify the employer of the inconsistency; (3) Provide the employer with a period of 30 days from the date on which the notice described in paragraph (d)(2) of this section is sent to the employer to either present satisfactory documentary evidence to support the employer's application, or resolve the inconsistency; and (4) If, after the 30-day period described in paragraph (d)(2) of this section, the SHOP has not received satisfactory documentary evidence, the SHOP must— (i) Notify the employer of its denial or termination of eligibility in accordance with paragraph (e) of this section and of the employer's right to appeal such determination; and (ii) If the employer was enrolled pending the confirmation or verification of eligibility information, discontinue the employer's participation in the SHOP at the end of the month following the month in which the notice is sent. (e) Notification of employer eligibility. (f) Validity of Eligibility Determination. (g) Applicability date. [83 FR 17065, Apr. 17, 2018] § 155.720 Enrollment of employees into QHPs under SHOP for plan years beginning prior to January 1, 2018. (a) General requirements. (b) Enrollment timeline and process. (1) Determination of employer eligibility for purchase of coverage in the SHOP as described in § 155.715; (2) Qualified employer selection of QHPs offered through the SHOP to qualified employees, consistent with § 155.705(b)(2) and (3); (3) Provision of a specific timeframe during which the qualified employer can select the level of coverage or QHP offering, as appropriate; (4) Provision of a specific timeframe for qualified employees to provide relevant information to complete the application process; (5) Determination and verification of employee eligibility for enrollment through the SHOP; and (6) Processing enrollment of qualified employees into selected QHPs. (c) Transfer of enrollment information. (1) Transmit enrollment information on behalf of qualified employees to QHP issuers in accordance with the timeline and process described in paragraph (b) of this section; and (2) Follow requirements set forth in § 155.400(c) of this part. (d) Payment. (1) Follow requirements set forth in § 155.705(b)(4) of this part; and (2) Terminate participation of qualified employers that do not comply with the process established in § 155.705(b)(4). (e) Notification of effective date. (2) For plan years beginning on or after January 1, 2017, the SHOP must ensure that a QHP issuer notifies an enrollee enrolled in a QHP through the SHOP of the effective date of his or her coverage. (3) When a primary subscriber and his or her dependents live at the same address, a separate notice of the effective date of coverage need not be sent to each dependent at that address, provided that the notice sent to each primary subscriber at that address contains all required information about the coverage effective date for the primary subscriber and his or her dependents at that address. (f) Records. (1) Qualified employers participating in the SHOP; and (2) Qualified employees enrolled in QHPs. (g) Reconcile files. (h) Employee termination of coverage from a QHP. (i) Reporting requirement for tax administration purposes. (j) Applicability date. [77 FR 18464, Mar. 27, 2012, as amended at 80 FR 10869, Feb. 27, 2015; 83 FR 17066, Apr. 17, 2018] § 155.721 Record retention and IRS Reporting for plan years beginning on or after January 1, 2018. (a) Records. (b) Reporting requirement for tax administration purposes. (c) Applicability date. [83 FR 17066, Apr. 17, 2018] § 155.725 Enrollment periods under SHOP for plan years beginning prior to January 1, 2018. (a) General requirements. (b) Rolling enrollment in the SHOP. (c) Annual employer election period. (1) The method by which the qualified employer makes QHPs available to qualified employees pursuant to § 155.705(b)(2) and (3); (2) The employer contribution towards the premium cost of coverage; (3) The level of coverage offered to qualified employees as described in § 155.705(b)(2) and (3); and (4) The QHP or QHPs offered to qualified employees in accordance with § 155.705. (d) Annual employer election period notice. (e) Annual employee open enrollment period. (2) Qualified employers in a Federally-facilitated SHOP must provide qualified employees with an annual open enrollment period of at least one week. (f) Annual employee open enrollment period notice. (g) Newly qualified employees. (i) The SHOP must provide an employee who becomes a qualified employee outside of the initial or annual open enrollment period an enrollment period beginning on the first day of becoming a qualified employee. A newly qualified employee must have at least 30 days from the beginning of his or her enrollment period to select a QHP. The enrollment period must end no sooner than 15 days prior to the date that any applicable employee waiting period longer than 45 days would end if the employee made a plan selection on the first day of becoming eligible. (ii) The effective date of coverage for a QHP selection received by the SHOP from a newly qualified employee must always be the first day of a month, and must generally be determined in accordance with paragraph (h) of this section, unless the employee is subject to a waiting period consistent with § 147.116 of this subchapter, in which case the effective date may be on the first day of a later month, but in no case may the effective date fail to comply with § 147.116 of this subchapter. (iii) Waiting periods in the SHOP are calculated beginning on the date the employee becomes a qualified employee who is otherwise eligible for coverage, regardless of when a qualified employer notifies the SHOP about a newly qualified employee. (2) In a Federally-facilitated SHOP or in a State Exchange that uses the Federal platform for SHOP functions, the following rules apply with respect to enrollment and coverage effective dates for newly qualified employees. (i) The SHOP must provide an employee who becomes a qualified employee outside of the initial or annual open enrollment period with a 30-day enrollment period beginning on the date the qualified employer notifies the SHOP about the newly qualified employee. Qualified employers must notify the SHOP about a newly qualified employee on or before the thirtieth day after the day that the employee becomes a newly qualified employee. (ii) The effective date of coverage for a QHP selection received by the SHOP from a newly qualified employee is the first day of the month following plan selection, unless the employee is subject to a waiting period consistent with § 147.116 of this subchapter and paragraph (g)(2)(iii) of this section, in which case the effective date will be on the first day of the month following the end of the waiting period, but in no case may the effective date fail to comply with § 147.116 of this subchapter. If a newly qualified employee's waiting period ends on the first day of a month and the employee has already made a plan selection by that date, coverage must take effect on that date. If a newly qualified employee makes a plan selection on the first day of a month and any applicable waiting period has ended by that date, coverage must be effective on the first day of the following month. If a qualified employer with variable hour employees makes regularly having a specified number of hours of service per period, or working full-time, a condition of employee eligibility for coverage offered through the SHOP, any measurement period that the qualified employer elects to use under § 147.116(c)(3)(i) to determine whether an employee meets the applicable eligibility conditions with respect to coverage offered through the SHOP must not exceed 10 months, beginning on any date between the employee's start date and the first day of the first calendar month following the employee's start date. (iii) Waiting periods in the SHOP are calculated beginning on the date the employee becomes a qualified employee who is otherwise eligible for coverage, regardless of when a qualified employer notifies the SHOP about a newly qualified employee, and must not exceed 60 days in length. Waiting periods must be 0, 15, 30, 45 or 60 days in length. (h) Initial and annual open enrollment effective dates. (2) For a group enrollment received by the Federally-facilitated SHOP from a qualified employer at the time of an initial group enrollment or renewal: (i) Between the first and fifteenth day of any month, the Federally-facilitated SHOP must ensure a coverage effective date of the first day of the following month unless the employer opts for a later effective date within a quarter for which small group market rates are available. (ii) Between the 16th and last day of any month, the Federally-facilitated SHOP must ensure a coverage effective date of the first day of the second following month unless the employer opts for a later effective date within a quarter for which small group market rates are available. (i) Renewal of coverage. (i) The qualified employee terminates coverage from such QHP in accordance with standards identified in § 155.430; (ii) The qualified employee enrolls in another QHP if such option exists; or (iii) The QHP is no longer available to the qualified employee. (2) The SHOP may treat a qualified employer offering coverage through the SHOP as offering the same coverage under § 155.705(b)(3) at the same level of contribution under § 155.705(b)(11) unless: (i) The qualified employer is no longer eligible to offer such coverage through the SHOP; (ii) The qualified employer elects to offer different coverage or a different contribution through the SHOP; (iii) The qualified employer withdraws from the SHOP; or (iv) In the case of a qualified employer offering a single QHP, the single QHP is no longer available through the SHOP. (j)(1) Special enrollment periods. (2) The SHOP must provide a special enrollment period for a qualified employee or dependent of a qualified employee who: (i) Experiences an event described in § 155.420(d)(1) (other than paragraph (d)(1)(ii)), or experiences an event described in § 155.420(d)(2), (4), (5), (7), (8), (9), (10), (11), or (12); (ii) Loses eligibility for coverage under a Medicaid plan under title XIX of the Social Security Act or a State child health plan under title XXI of the Social Security Act; or (iii) Becomes eligible for assistance, with respect to coverage under a SHOP, under such Medicaid plan or a State child health plan (including any waiver or demonstration project conducted under or in relation to such a plan). (3) A qualified employee or dependent of a qualified employee who experiences a qualifying event described in paragraph (j)(2) of this section has: (i) Thirty (30) days from the date of a triggering event described in paragraph (j)(2)(i) of this section to select a QHP through the SHOP; and (ii) Sixty (60) days from the date of a triggering event described in paragraph (j)(2)(ii) or (iii) of this section to select a QHP through the SHOP; (4) A dependent of a qualified employee is not eligible for a special election period if the employer does not extend the offer of coverage to dependents. (5) The effective dates of coverage for special enrollment periods are determined using the provisions of § 155.420(b). (6) Loss of minimum essential coverage is determined using the provisions of § 155.420(e). (7) Notwithstanding anything to the contrary in § 155.420(d), § 155.420(a)(4) and (d)(2)(i)(A) do not apply to special enrollment periods in the SHOP. (k) Limitation. (l) Applicability date. [77 FR 18464, Mar. 27, 2012, as amended at 78 FR 33239, June 4, 2013; 78 FR 65095, Oct. 30, 2013; 79 FR 30350, May 27, 2014; 79 FR 42986, July 24, 2014; 80 FR 10869, Feb. 27, 2015; 81 FR 12347, Mar. 8, 2016; 81 FR 94179, Dec. 22, 2016; 82 FR 18382, Apr. 18, 2017; 83 FR 17066, Apr. 17, 2018] § 155.726 Enrollment periods under SHOP for plan years beginning on or after January 1, 2018. (a) General requirements. (b) Rolling enrollment in the SHOP. (c) Special enrollment periods. (2) The SHOP must ensure that issuers offering QHPs through a SHOP provide a special enrollment period for a qualified employee or a dependent of a qualified employee who; (i) Experiences an event described in § 155.420(d)(1) (other than paragraph (d)(1)(ii)), or experiences an event described in § 155.420(d)(2), (4), (5), (7), (8), (9), (10), (11), or (12); (ii) Loses eligibility for coverage under a Medicaid plan under title XIX of the Social Security Act or a State child health plan under title XXI of the Social Security Act; or (iii) Becomes eligible for assistance, with respect to coverage under a SHOP, under such Medicaid plan or a State child health plan (including any waiver or demonstration project conducted under or in relation to such a plan). (3) A qualified employee or dependent of a qualified employee who experiences a qualifying event described in paragraph (j)(2) of this section has: (i) Thirty (30) days from the date of a triggering event described in paragraph (c)(2)(i) of this section to select a QHP through the SHOP; and (ii) Sixty (60) days from the date of a triggering event described in paragraph (c)(2)(ii) or (iii) of this section to select a QHP through the SHOP; (4) A dependent of a qualified employee is not eligible for a special enrollment period if the employer does not extend the offer of coverage to dependents. (5) The effective dates of coverage for special enrollment periods are determined using the provisions of § 155.420(b). (6) Loss of minimum essential coverage is determined using the provisions of § 155.420(e). (d) Limitation. (e) Applicability date. [83 FR 17066, Apr. 17, 2018] § 155.730 Application standards for SHOP for plan year beginning prior to January 1, 2018. (a) General requirements. (b) Single employer application. (1) Employer name and address of employer's locations; (2) Number of employees; (3) Employer Identification Number (EIN); and (4) A list of qualified employees and their taxpayer identification numbers. (c) Single employee application. (d) Model application. (e) Alternative employer and employee application. (1) In the case of the employer application, the information in described in paragraph (b); and (2) In the case of the employee application, the information necessary to establish eligibility of the employee as a qualified employee and to complete the enrollment of the qualified employee and any dependents to be enrolled. (f) Filing. (1) Accept applications from SHOP application filers; and (2) Provide the tools to file an application via an Internet Web site. (g) Additional safeguards. (2) The SHOP is not permitted to collect information on the single employer or single employee application unless that information is necessary to determine SHOP eligibility or effectuate enrollment through the SHOP. (h) Applicability date. [77 FR 18464, Mar. 27, 2012, as amended at 78 FR 54141, Aug. 30, 2013; 79 FR 13839, Mar. 11, 2014; 83 FR 17066, Apr. 17, 2018] § 155.731 Application standards for SHOP for plan years beginning on or after January 1, 2018. (a) General requirements. (b) Single employer application. (1) Employer name and address of employer's locations; (2) Information sufficient to confirm the employer is a small employer; (3) Employer Identification Number (EIN); and (4) Information sufficient to confirm that the employer is offering, at a minimum, all full-time employees coverage in a QHP through a SHOP. (c) Model application. (d) Alternative employer application. (e) Filing. (1) Accept applications from SHOP application filers; and (2) Provide the tools to file an employer eligibility application via an internet website. (f) Additional safeguards. (2) The SHOP is not permitted to collect information on the single employer or on an employee application unless that information is necessary to determine SHOP eligibility or effectuate enrollment through the SHOP. (g) Applicability date. [83 FR 17066, Apr. 17, 2018] § 155.735 Termination of SHOP enrollment or coverage for plan years beginning prior to January 1, 2018. (a) General requirements. (b) Termination of employer group health coverage or enrollment at the request of the employer. (2) In the Federally-facilitated SHOP, an employer may terminate coverage or enrollment for all enrollees covered by the employer group health plan effective on the last day of any month, provided that the employer has given notice to the Federally-facilitated SHOP on or before the 15th day of any month. If notice is given after the 15th of the month, the Federally-facilitated SHOP may terminate the coverage or enrollment on the last day of the following month. (c) Termination of employer group health coverage for non-payment of premiums. (2) In an FF-SHOP, for premium payments other than payments for the first month of coverage— (i) For a given month of coverage, premium payment is due by the first day of the coverage month. (ii) If premium payment is not received 31 days from the first of the coverage month, the Federally-facilitated SHOP may terminate the qualified employer for lack of payment. The termination would take effect on the last day of the month for which the Federally-facilitated SHOP received full payment. (iii) If a qualified employer is terminated due to lack of premium payment, but within 30 days following its termination the qualified employer requests reinstatement, pays all premiums owed including any prior premiums owed for coverage during the grace period, and pays the premium for the next month's coverage, the Federally-facilitated SHOP must reinstate the qualified employer in its previous coverage. A qualified employer may be reinstated in the Federally-facilitated SHOP only once per calendar year. (iv) Enrollees enrolled in continuation coverage required under 29 U.S.C. 1161, et seq. (3) Payment for COBRA Continuation Coverage. et seq., (d) Termination of employee or dependent coverage or enrollment. (i) The employee or dependent is no longer eligible for coverage under the employer's group health plan; (ii) The employee requests that the SHOP terminate the coverage of the employee or a dependent of the employee under the employer's group health plan; (iii) The QHP in which the enrollee is enrolled terminates, is decertified as described in § 155.1080, or its certification as a QHP is not renewed; (iv) The enrollee changes from one QHP to another during the employer's annual open enrollment period or during a special enrollment period in accordance with § 155.725(j); or (v) The enrollee's coverage is rescinded in accordance with § 147.128 of this subtitle. (2) In the FF-SHOP, termination is effective: (i) In the case of a termination in accordance with paragraphs (d)(1)(i), (ii), (iii), and (v) of this section, termination is effective on the last day of the month in which the Federally-facilitated SHOP receives notice of the event described in paragraph (d)(1)(i), (ii), (iii), or (v) of this section. (ii) In the case of a termination in accordance with paragraph (d)(1)(iv) of this section, the last day of coverage in an enrollee's prior QHP is the day before the effective date of coverage in his or her new QHP, including for any retroactive enrollments effectuated under § 155.725(j)(5). (iii) The FF-SHOP will send qualified employees a notice notifying them in advance of a child dependent's loss of eligibility for dependent child coverage under their plan because of age. The notice will be sent 90 days in advance of the date when the dependent enrollee would lose eligibility for dependent child coverage. The enrollee will also receive a separate termination notice when coverage is terminated, under § 155.735(g). (e) Termination of enrollment or coverage tracking and approval. (f) Applicability date. (1) Beginning on or after January 1, 2015; and (2) In any SHOP providing qualified employers with the option described in § 155.705(b)(2) or the option described in § 155.705(b)(4) before January 1, 2015, beginning with the date that option is offered. (g) Notice of termination. (1) Except as provided in paragraph (g)(3) of this section, if any enrollee's coverage or enrollment through the SHOP is terminated due to non-payment of premiums or due to a loss of the enrollee's eligibility to participate in the SHOP, including where an enrollee loses his or her eligibility because a qualified employer has lost its eligibility, the SHOP must notify the enrollee of the termination. Such notice must include the termination effective date and reason for termination, and must be sent within 3 business days if an electronic notice is sent, and within 5 business days if a mailed hard copy notice is sent. (2) Except as provided in paragraph (g)(3) of this section, if an employer group's coverage or enrollment through the SHOP is terminated due to non-payment of premiums or, where applicable, due to a loss of the qualified employer's eligibility to offer coverage through the SHOP, the SHOP must notify the employer of the termination. Such notice must include the termination effective date and reason for termination, and must be sent within 3 business days if an electronic notice is sent, and within 5 business days if a mailed hard copy notice is sent. (3) Where State law requires a QHP issuer to send the notices described in paragraphs (g)(1) and (2) of this section, a SHOP is not required to send such notices. (4) When a primary subscriber and his or her dependents live at the same address, a separate termination notice need not be sent to each dependent at that address, provided that the notice sent to each primary subscriber at that address contains all required information about the termination for the primary subscriber and his or her dependents at that address. (h) Applicability date. [78 FR 54141, Aug. 30, 2013, as amended at 80 FR 10870, Feb. 27, 2015; 81 FR 12348, Mar. 8, 2016; 83 FR 17067, Apr. 17, 2018] § 155.740 SHOP employer and employee eligibility appeals requirements for plan years beginning prior to January 1, 2018. (a) Definitions. (b) General requirements. (2) The appeals entity must conduct appeals in accordance with the requirements established in this section and §§ 155.505(e) through (h) and 155.510(a)(1) and (2) and (c). (c) Employer right to appeal. (1) A notice of denial of eligibility under § 155.715(e); or (2) A failure by the SHOP to provide a timely eligibility determination or a timely notice of an eligibility determination in accordance with § 155.715(e). (d) Employee right to appeal. (1) A notice of denial of eligibility under § 155.715(f); or (2) A failure by the SHOP to provide a timely eligibility determination or a timely notice of an eligibility determination in accordance with § 155.715(f). (e) Appeals notice requirement. (1) The reason for the denial of eligibility, including a citation to the applicable regulations; and (2) The procedure by which the employer or employee may request an appeal of the denial of eligibility. (f) Appeal request. (1) Allow an employer or employee to request an appeal within 90 days from the date of the notice of denial of eligibility to— (i) The SHOP or the appeals entity; or (ii) HHS, if no State Exchange that provides for establishment of a SHOP has been established; (2) Accept appeal requests submitted through any of the methods described in § 155.520(a)(1); (3) Comply with the requirements of § 155.520(a)(2) and (3); and (4) Consider an appeal request valid if it is submitted in accordance with paragraph (f)(1) of this section. (g) Notice of appeal request. (i) Send timely acknowledgement to the employer, or employer and employee if an employee is appealing, of the receipt of the appeal request, including— (A) An explanation of the appeals process; and (B) Instructions for submitting additional evidence for consideration by the appeals entity. (ii) Promptly notify the SHOP of the appeal, if the appeal request was not initially made to the SHOP. (2) Upon receipt of an appeal request that is not valid because it fails to meet the requirements of this section, the appeals entity must— (i) Promptly and without undue delay, send written notice to the employer or employee that is appealing that— (A) The appeal request has not been accepted, (B) The nature of the defect in the appeal request; and (C) An explanation that the employer or employee may cure the defect and resubmit the appeal request if it meets the timeliness requirements of paragraph (f) of this section, or within a reasonable timeframe established by the appeals entity. (ii) Treat as valid an amended appeal request that meets the requirements of this section. (h) Transmittal and receipt of records. (i) The appeal request, if the appeal request was initially made to the SHOP; and (ii) The eligibility record of the employer or employee that is appealing. (2) The appeals entity must promptly confirm receipt of records transmitted pursuant to paragraph (h)(1) of this section to the SHOP that transmitted the records. (i) Dismissal of appeal. (1) Must dismiss an appeal if the employer or employee that is appealing— (i) Withdraws the request in accordance with the standards set forth in § 155.530(a)(1); or (ii) Fails to submit an appeal request meeting the standards specified in paragraph (f) of this section. (2) Must provide timely notice to the employer or employee that is appealing of the dismissal of the appeal request, including the reason for dismissal, and must notify the SHOP of the dismissal. (3) May vacate a dismissal if the employer or employee makes a written request within 30 days of the date of the notice of dismissal showing good cause why the dismissal should be vacated. (j) Procedural rights of the employer or employee. (k) Adjudication of SHOP appeals. (1) Comply with the standards set forth in § 155.555(i)(1) and (3); and (2) Consider the information used to determine the employer or employee's eligibility as well as any additional relevant evidence submitted during the course of the appeal by the employer or employee. (l) Appeal decisions. (1) Be based solely on— (i) The evidence referenced in paragraph (k)(2) of this section; (ii) The eligibility requirements for the SHOP under § 155.710(b) or (e), as applicable. (2) Comply with the standards set forth in § 155.545(a)(2) through (5); and (3) Be effective as follows: (i) If an employer is found eligible under the decision, then at the employer's option, the effective date of coverage or enrollment through the SHOP under the decision can either be made retroactive to the effective date of coverage or enrollment through the SHOP that the employer would have had if the employer had been correctly determined eligible, or prospective to the first day of the month following the date of the notice of the appeal decision. (ii) For employee appeal decisions only, if an employee is found eligible under the decision, then at the employee's option, the effective date of coverage or enrollment through the SHOP under the decision can either be made effective retroactive to the effective date of coverage or enrollment through the SHOP that the employee would have had if the employee had been correctly determined eligible, or prospective to the first day of the month following the date of the notice of the appeal decision. (iii) If the employer or employee is found ineligible under the decision, then the appeal decision is effective as of the date of the notice of the appeal decision. (m) Notice of appeal decision. (n) Implementation of SHOP appeal decisions. (o) Appeal record. (p) Applicability date. [78 FR 54141, Aug. 30, 2013, as amended at 79 FR 30350, May 27, 2014; 81 FR 12348, Mar. 8, 2016; 81 FR 94180, Dec. 22, 2016; 83 FR 17067, Apr. 17, 2018] § 155.741 SHOP employer and employee eligibility appeals requirements for plan year beginning on or after January 1, 2018. (a) Definitions. (b) General requirements. (2) The appeals entity must conduct appeals in accordance with the requirements established in this section and §§ 155.505(e) through (h) and 155.510(a)(1) and (2) and (c). (c) Employer right to appeal. (1) A notice of denial or termination of eligibility under § 155.716(e); or (2) A failure by the SHOP to provide a timely eligibility determination or a timely notice of an eligibility determination in accordance with § 155.716(e). (d) Appeals notice requirement. (1) The reason for the denial or termination of eligibility, including a citation to the applicable regulations; and (2) The procedure by which the employer may request an appeal of the denial or termination of eligibility. (e) Appeal request. (1) Allow an employer to request an appeal within 90 days from the date of the notice of denial or termination of eligibility to— (i) The SHOP or the appeals entity; or (ii) HHS, if no State Exchange that provides for establishment of a SHOP has been established; (2) Accept appeal requests submitted through any of the methods described in § 155.520(a)(1); (3) Comply with the requirements of § 155.520(a)(2) and (3); and (4) Consider an appeal request valid if it is submitted in accordance with paragraph (e)(1) of this section. (f) Notice of appeal request. (i) Send timely acknowledgement to the employer of the receipt of the appeal request, including— (A) An explanation of the appeals process; and (B) Instructions for submitting additional evidence for consideration by the appeals entity. (ii) Promptly notify the SHOP of the appeal, if the appeal request was not initially made to the SHOP. (2) Upon receipt of an appeal request that is not valid because it fails to meet the requirements of this section, the appeals entity must— (i) Promptly and without undue delay, send written notice to the employer that is appealing that— (A) The appeal request has not been accepted, (B) The nature of the defect in the appeal request; and (C) An explanation that the employer may cure the defect and resubmit the appeal request if it meets the timeliness requirements of paragraph (e) of this section, or within a reasonable timeframe established by the appeals entity. (ii) Treat as valid an amended appeal request that meets the requirements of this section. (g) Transmittal and receipt of records. (i) The appeal request, if the appeal request was initially made to the SHOP; and (ii) The eligibility record of the employer that is appealing. (2) The appeals entity must promptly confirm receipt of records transmitted pursuant to paragraph (g)(1) of this section to the SHOP that transmitted the records. (h) Dismissal of appeal. (1) Must dismiss an appeal if the employer that is appealing— (i) Withdraws the request in accordance with the standards set forth in § 155.530(a)(1); or (ii) Fails to submit an appeal request meeting the standards specified in paragraph (e) of this section. (2) Must provide timely notice to the employer that is appealing of the dismissal of the appeal request, including the reason for dismissal, and must notify the SHOP of the dismissal. (3) May vacate a dismissal if the employer makes a written request within 30 days of the date of the notice of dismissal showing good cause why the dismissal should be vacated. (i) Procedural rights of the employer. (j) Adjudication of SHOP appeals. (1) Comply with the standards set forth in § 155.555(i)(1) and (3); and (2) Consider the information used to determine the employer's eligibility as well as any additional relevant evidence submitted during the course of the appeal by the employer or employee. (k) Appeal decisions. (1) Be based solely on— (i) The evidence referenced in paragraph (j)(2) of this section; (ii) The eligibility requirements for the SHOP under § 155.710(b), as applicable. (2) Comply with the standards set forth in § 155.545(a)(2) through (5) (3) Be effective as follows: (i) If an employer is found eligible under the decision, then at the employer's option, the effective date of coverage or enrollment through the SHOP under the decision can either be made retroactive to the effective date of coverage or enrollment through the SHOP that the employer would have had if the employer had been correctly determined eligible, or prospective to the first day of the month following the date of the notice of the appeal decision. (ii) If the employer is found ineligible under the decision, then the appeal decision is effective as of the date of the notice of the appeal decision. (l) Notice of appeal decision. (m) Implementation of SHOP appeal decisions. (n) Appeal record. (o) Applicability date. [83 FR 17067, Apr. 17, 2018] Subparts I-J [Reserved] Subpart K—Exchange Functions: Certification of Qualified Health Plans Source: 77 FR 18467, Mar. 27, 2012, unless otherwise noted. § 155.1000 Certification standards for QHPs. (a) Definition. Multi-State plan (b) General requirement. (c) General certification criteria. (1) The health insurance issuer provides evidence during the certification process in § 155.1010 that it complies with the minimum certification requirements outlined in subpart C of part 156, as applicable; and (2) The Exchange determines that making the health plan available is in the interest of the qualified individuals and qualified employers, except that the Exchange must not exclude a health plan— (i) On the basis that such plan is a fee-for-service plan; (ii) Through the imposition of premium price controls; or (iii) On the basis that the health plan provides treatments necessary to prevent patients' deaths in circumstances the Exchange determines are inappropriate or too costly. (d) Special rule for SHOP. (e) Denial of certification. [77 FR 18467, Mar. 27, 2012, as amended at 80 FR 10870, Feb. 27, 2015; 90 FR 4541, Jan. 15, 2025] § 155.1010 Certification process for QHPs. (a) Certification procedures. (1) Completion date. (2) Ongoing compliance. (b) Exchange recognition of plans deemed certified for participation in an Exchange. (1) A multi-State plan certified by and under contract with the U.S. Office of Personnel Management. (2) A CO-OP QHP as described in subpart F of part 156 and deemed as certified under § 156.520(e). § 155.1020 QHP issuer rate and benefit information. (a) Receipt and posting of rate increase justification. (b) Rate increase consideration. (i) A justification for a rate increase prior to the implementation of the increase; (ii) Recommendations provided to the Exchange by the State in accordance with section 2794(b)(1)(B) of the PHS Act; and (iii) Any excess of rate growth outside the Exchange as compared to the rate of such growth inside the Exchange. (2) This paragraph does not apply to multi-State plans for which the U.S. Office of Personnel Management will provide a process for rate increase consideration. (c) Benefit and rate information. (1) Rates; (2) Covered benefits; and (3) Cost-sharing requirements. [77 FR 18467, Mar. 27, 2012, as amended at 77 FR 31515, May 29, 2012] § 155.1030 QHP certification standards related to advance payments of the premium tax credit and cost-sharing reductions. (a) Review of plan variations for cost-sharing reductions. (2) The Exchange must provide to HHS the actuarial values of each QHP and silver plan variation, calculated under § 156.135 of this subchapter, in the manner and timeframe established by HHS. (b) Information for administering advance payments of the premium tax credit and advance payments of cost-sharing reductions. (2) The Exchange must submit, in the manner and timeframe established by HHS, to HHS the approved allocations and actuarial memorandum underlying the approved allocations for each health plan at any level of coverage or stand-alone dental plan offered, or intended to be offered in the individual market on the Exchange. (3) The Exchange must use the methodology specified in the annual HHS notice of benefit and payment parameters to calculate advance payment amounts for cost-sharing reductions, and must transmit the advance payment amounts to HHS, in accordance with § 156.340(a) of this subchapter. (4) HHS may use the information provided to HHS by the Exchange under this section for oversight of advance payments of cost-sharing reductions and premium tax credits. (c) Multi-State plans. [78 FR 15534, Mar. 11, 2013, as amended at 79 FR 13839, Mar. 11, 2014] § 155.1040 Transparency in coverage. (a) General requirement. (b) Use of plain language. (c) Transparency of cost-sharing information. § 155.1045 Accreditation timeline. (a) Timeline. (b) Federally-facilitated Exchange. (1) During certification for an issuer's initial year of QHP certification (for example, in 2013 for the 2014 coverage year), a QHP issuer without existing commercial, Medicaid, or Exchange health plan accreditation granted by a recognized accrediting entity for the same State in which the issuer is applying to offer coverage must have scheduled or plan to schedule a review of QHP policies and procedures of the applying QHP issuer with a recognized accrediting entity. (2) Prior to a QHP issuer's second year and third year of QHP certification (for example, in 2014 for the 2015 coverage year and 2015 for the 2016 coverage year), a QHP issuer must be accredited by a recognized accrediting entity on the policies and procedures that are applicable to their Exchange products, or a QHP issuer must have commercial or Medicaid health plan accreditation granted by a recognized accrediting entity for the same State in which the issuer is offering Exchange coverage and the administrative policies and procedures underlying that accreditation must be the same or similar to the administrative policies and procedures used in connection with the QHP. (3) Prior to the QHP issuer's fourth year of QHP certification and in every subsequent year of certification (for example, in 2016 for the 2017 coverage year and forward), a QHP issuer must be accredited in accordance with § 156.275 of this subchapter. [78 FR 12865, Feb. 25, 2013] § 155.1050 Establishment of Exchange provider access standards. (a) Except with regard to multi-State plans: (1) A Federally-facilitated Exchange State without an Effective Provider Access Review Program (as defined in paragraph (d) of this section) must ensure that each QHP provides sufficient access to providers in a manner that meets the standards specified in § 156.230 for network plans, or, for plan years beginning on or after January 1, 2028, § 156.236 for non-network plans if such plans are allowed to be offered through the Exchange, as applicable. A State on the Federally-facilitated Exchanges with an Effective Provider Access Review Program (as defined in paragraph (d) of this section) must ensure that each QHP provides sufficient access to providers in a manner that meets the standards specified in § 156.230(a)(1) for network plans, or, for plan years beginning on or after January 1, 2028, § 156.236(a) for non-network plans if such plans are allowed to be offered through the Exchange, as applicable. (2) State Exchanges and State-based Exchanges on the Federal Platform must ensure that each QHP provides sufficient access to providers in a manner that meets standards under § 156.230(a)(1)(ii) and (iii) for network plans, or, for plan years beginning on or after January 1, 2027, § 156.236(a) for non-network plans if such plans are allowed to be offered through the Exchange, as applicable. (b) The U.S. Office of Personnel Management will ensure compliance with the standards specified in § 156.230 of this subtitle for multi-State plans. (c) A QHP issuer in an Exchange may not be prohibited from contracting with any essential community provider designated under § 156.235(c) of this subtitle. (d)(1) FFE States may elect to conduct their own provider access certification reviews of issuers' plans, with or without a provider network, applying for certification as a QHP to be offered through a Federally-facilitated Exchange provided that the State has demonstrated sufficient authority and the technical capacity to conduct these reviews by satisfying the applicable criteria to be considered to have an Effective Provider Access Review Program under paragraphs (d)(2) through (d)(4) of this section. This option applies to Federally-facilitated Exchange States, including States performing plan management. If States do not satisfy the criteria established under paragraphs (d)(2) through (d)(4) of this section, or do not elect to conduct such reviews, CMS will continue to conduct reviews of QHP issuer provider access in those States consistent with requirements listed under § 156.230 for network plans and under § 156.236 for non-network plans. Applicable requirements for non-network plans under this section are effective for plan years beginning on or after January 1, 2028. (2) Federally-facilitated Exchange States with an Effective Provider Access Review Program must ensure that a QHP issuer that uses a network of providers ensures that the in-network providers, as available to all enrollees, include essential community providers (ECPs) in accordance with § 156.235, and maintains a network that is sufficient in number and types of providers, including providers that specialize in mental health and substance use disorder services, to ensure that all services will be accessible without unreasonable delay. The QHP issuer's provider network consisting of in-network providers, as available to all enrollees, must be consistent with the rules for network plans of section 2702(c) of the PHS Act. (3) Federally-facilitated Exchange States with an Effective Provider Access Review Program must ensure that a QHP issuer that does not use a network of providers (a non-network plan) provides access to a sufficient choice of providers that accept the non-network plan's benefit amount as payment in full, including ECPs and providers that specialize in mental health and substance use disorder services, to ensure that all services will be accessible without unreasonable delay. (4) A Federally-facilitated Exchange State that elects to conduct provider access reviews has an Effective Provider Access Review Program if it meets the following requirements: (i) The State has established provider access standards that are set forth in State statute or regulation, which are consistent with provider access standards as set forth in § 156.230(a)(1)(ii) and (iii), and reports to CMS whether the State has delegated authority to some entity other than the State Department of Insurance to perform any or all provider access review activities. (ii) The State's provider access review process includes reporting systems for State required provider access metrics and documentation of methodology and the State provides descriptions of all data collection systems, resources, templates, and methodologies used by the State, or the State's delegated entity to collect and review provider access data; and the State receives from issuers data and documentation in connection with provider access standards that are sufficient to conduct the examination. (iii) The State's provider access review process includes procedures to ensure full and ongoing compliance with State provider access standards and enforcement frameworks applicable to issuers that fail to meet provider access standards so that those issuers come into compliance with State provider access standards, including standardized processes to assess efforts the issuer is pursuing to come into compliance with State provider access standards and implementing any justification and exception processes for issuers that have not yet or cannot meet provider access requirements. (iv) The State establishes and maintains clear procedures and timeline requirements for regular provider access reviews, including processes that ensure reviews occur prior to completion of each plan year's QHP certification cycle. (v) The State has a process for monitoring and addressing consumer-related provider access complaints to ensure sufficient access to providers consistent with section 1311(c)(1)(B) of the Affordable Care Act and as set forth in State statute. (vi) The State has a process to collect and review information described under § 156.236(b)(4) through (b)(9) from non-network plans, which non-network plans must submit to the FFE for a determination that it provides access to a sufficient choice of providers that accept the non-network plan's benefit amount as payment in full. (5) CMS will determine whether a State has an Effective Provider Access Review Program based on information available to CMS that demonstrates whether the program meets the criteria described under paragraphs (d)(2) through (d)(4) of this section. (6) CMS may grant an exception to the requirements in paragraph (d) of this section if it determines that making such an exception is in the interests of qualified individuals in the State or States in which such Exchange operates. (7) CMS will notify the FFE State electing to conduct provider access certification reviews of its decision in writing whether the State is determined to have an Effective Provider Access Review Program and can therefore conduct its own provider access certification reviews. CMS reserves the right to evaluate at any time whether, and to what extent, an FFE State's circumstances have changed such that it has begun to or has ceased to satisfy the criteria established by CMS under this section. Such evaluations may result in CMS assuming provider access review responsibilities or transitioning such responsibilities back to the State. [77 FR 18467, Mar. 27, 2012, as amended at 89 FR 26423, Apr. 15, 2024; 91 FR 29868, May 20, 2026] § 155.1051 Effective Essential Community Provider Review Program. (a) FFE States may elect to conduct their own ECP certification reviews of issuers' plans with or without a provider network applying for certification as a QHP to be offered through a Federally-facilitated Exchange provided that the State demonstrates it has sufficient authority and the technical capacity to conduct these reviews by satisfying the applicable criteria to be considered to have an Effective Essential Community Provider Review Program under this section. This option applies to all FFE States, including States performing plan management. An FFE State must demonstrate it meets applicable criteria established under paragraphs (b) through (c) of this section for both network plans and non-network plans, and the sufficient authority and technical capacity to conduct reviews of such plans (as assessed by CMS under § 155.1051(e)), to be considered to have an Effective Essential Community Provider Review Program, if they decide to certify such plans. If FFE States do not satisfy the criteria established by CMS under paragraphs (b) through (e) of this section or do not elect to conduct such reviews, then CMS will continue to perform ECP certification reviews consistent with § 156.235 for network plans and § 156.236 for non-network plans. Applicable requirements for non-network plans under this section are effective for plan years beginning on or after January 1, 2028. (b) FFE States with an Effective ECP Review Program must ensure that a QHP issuer with a provider network includes in their provider network a sufficient number and geographic distribution of ECPs, where available, to ensure reasonable and timely access to a broad range of such providers for low-income individuals or individuals residing in Health Professional Shortage Areas within the QHP's service area, in accordance with the Exchange's network adequacy standards. FFE States with an Effective ECP Review Program must also ensure that a non-network plan applying for certification to be offered as a QHP through a Federally-facilitated Exchange demonstrates that it provides reasonable and timely access to ECPs that accept the plan's benefit amount as payment in full to ensure that services will be accessible without unreasonable delay. (c) FFE States with an Effective ECP Review Program must have established ECP requirements that are set forth in State statute or regulation. FFE States must demonstrate that these established ECP requirements ensure that plans meet all the following requirements that promote a sufficient number and geographic distribution of ECPs: (1) The minimum percentage requirements under § 156.235(a)(2)(i) for network plans, and under § 156.236(b)(1) for non-network plans. (2) The Indian health care provider requirement under § 156.235(a)(2)(ii)(A) for network plans and under § 156.236(b)(3) for non-network plans. (3) The category per county requirements, including for each of the eight ECP category types under § 156.235(a)(2)(ii)(B) for network plans and under § 156.236(b)(2) for non-network plans. (d) FFE States with an Effective ECP Review Program that have alternative ECP requirements compared to those described under paragraph (c)(1) through (3) of this section must demonstrate how their requirements would continue to promote a sufficient number and geographic distribution of ECPs to ensure reasonable and timely access to ECPs, and an adequate level of service for low-income enrollees or individuals residing in Health Professional Shortage Areas. (e) CMS will consider all the following factors in its review to determine if an FFE State has an Effective ECP Review Program: (1) The State's legal authority to review whether plans applying for QHP certification meet ECP requirements, including relevant State regulations and statutes. (2) Evidence that the State's requirements are consistent with ECP requirements under paragraph (c)(1) through (3) of this section that promote a sufficient number and geographic distribution of ECPs, or the State provides a rationale to describe how its alternative requirements promote a sufficient number and geographic distribution of ECPs to ensure reasonable and timely access to ECPs. (3) A description of the State's definition of an ECP, if different from the definition under § 156.235(c), including relevant categories and eligibility criteria that the State uses to determine whether a facility qualifies as an ECP. (4) Whether the State utilizes the Federal ECP List or has a process it uses to identify qualified ECPs that may be included within a network plan's provider network. (5) Whether the State utilizes the Federal ECP List or has a process it uses to identify qualified ECPs that may accept a non-network plan's benefit amount as payment in full. (6) A description of data collection systems, resources, templates, or methodologies used by the State to collect and review ECP data. (7) Whether the State generally collects information from QHP issuers regarding the status of contract offers for network plans or offers of benefit amounts as payment in full to an ECP for non-network plans. (8) Whether the State has delegated authority to some other entity other than the State Department of Insurance to perform any or all ECP review activities. (9) Whether the State has compliance reviews, follow-up procedures, and enforcement frameworks applicable to issuers that demonstrate inadequate networks of ECPs or inadequate access to ECPs that accept benefit amounts as payment in full, so that those issuers come into compliance with State ECP requirements, including standardized processes to assess efforts the issuer is pursuing to come into compliance with State ECP requirements and any justification and exception processes for issuers that have not yet or cannot meet ECP requirements. (10) Whether the State has a process for monitoring and addressing consumer-related complaints regarding access to ECPs to ensure sufficient access to ECPs consistent with section 1311(c)(1)(C) of the Affordable Care Act and set forth in State statute. (11) Whether the State collects the information described under § 156.236(b)(4) through (b)(9) from issuers of non-network plans, which issuers of non-network plans must submit to the FFE for a determination that the plan provides reasonable and timely access to ECPs that accept the plan's benefit amount as payment in full. (f) CMS will notify the FFE State electing to conduct ECP certification reviews of its decision in writing whether the State is determined to have an Effective ECP Review Program and can therefore conduct its own ECP certification reviews. CMS reserves the right to evaluate at any time whether, and to what extent, an FFE State's circumstances have changed such that it has begun to or has ceased to satisfy the criteria established by CMS under this section, and consequently no longer has an Effective ECP Review Program. [91 FR 29869, May 20, 2026] § 155.1055 Service area of a QHP. The Exchange must have a process to establish or evaluate the service areas of QHPs to ensure such service areas meet the following minimum criteria: (a) The service area of a QHP covers a minimum geographical area that is at least the entire geographic area of a county, or a group of counties defined by the Exchange, unless the Exchange determines that serving a smaller geographic area is necessary, nondiscriminatory, and in the best interest of the qualified individuals and employers. (b) The service area of a QHP has been established without regard to racial, ethnic, language, health status-related factors specified under section 2705(a) of the PHS Act, or other factors that exclude specific high utilizing, high cost or medically-underserved populations. § 155.1065 Stand-alone dental plans. (a) General requirements. (1) The plan meets the requirements of section 9832(c)(2)(A) of the Code and 2791(c)(2)(A) of the PHS Act; and (2) The plan covers at least the pediatric dental essential health benefit as defined in section 1302(b)(1)(J) of the Affordable Care Act, provided that, with respect to this benefit, the plan satisfies the requirements of section 2711 of the PHS Act; and (3) The plan and issuer of such plan meets QHP certification standards, including § 155.1020(c), except for any certification requirement that cannot be met because the plan covers only the benefits described in paragraph (a)(2) of this section. (b) Offering options. (1) As a stand-alone dental plan; or (2) In conjunction with a QHP. (c) Sufficient capacity. (d) QHP Certification standards. § 155.1075 Recertification of QHPs. (a) Recertification process. (b) Timing. [77 FR 18467, Mar. 27, 2012, as amended at 80 FR 10870, Feb. 27, 2015] § 155.1080 Decertification of QHPs. (a) Definition. Decertification (b) Decertification process. (c) Decertification by the Exchange. (d) Appeal of decertification. (e) Notice of decertification. (1) The QHP issuer; (2) Exchange enrollees in the QHP who must receive information about a special enrollment period, as described in § 155.420; (3) HHS; and (4) The State department of insurance. [77 FR 18467, Mar. 27, 2012, as amended at 77 FR 31515, May 29, 2012] § 155.1090 Request for the reconsideration of a denial of certification. (a) Request for the reconsideration of a denial of certification specific to a Federally-facilitated Exchange Request for reconsideration. (2) Form and manner of request. (3) HHS reconsideration decision. (b) [Reserved] [81 FR 94180, Dec. 22, 2016, as amended at 90 FR 4541, Jan. 15, 2025] Subpart L [Reserved] Subpart M—Oversight and Program Integrity Standards for State Exchanges Source: 78 FR 65095, Oct. 30, 2013, unless otherwise noted. § 155.1200 General program integrity and oversight requirements. (a) General requirement. (1) Keep an accurate accounting of Exchange receipts and expenditures in accordance with generally accepted accounting principles (GAAP). (2) Monitor and report to HHS on Exchange related activities. (3) Collect and report to HHS performance monitoring data. (b) Reporting. (1) A financial statement presented in accordance with GAAP, (2) Information showing compliance with Exchange requirements under this part 155 through submission of annual reports, (3) Performance monitoring data, and (4) If the Exchange is collecting premiums under § 155.240, a report on instances in which it did not reduce an enrollee's premium by the amount of the advance payment of the premium tax credit in accordance with § 155.340(g)(1) and (2). (c) External audits. (1) Provide to HHS the results of the annual external audit; and (2) Inform HHS of any material weakness or significant deficiency identified in the audit and must develop and inform HHS of a corrective action plan for such material weakness or significant deficiency; (3) Make public a summary of the results of the external audit. (d) External audit standard. (1) Compliance with paragraph (a)(1) of this section; (2) Compliance with subparts D and E of this part 155, or other requirements under this part 155 as specified by HHS; (3) Processes and procedures designed to prevent improper eligibility determinations and enrollment transactions, as applicable; (4) Compliance with eligibility and enrollment standards through sampling, testing, or other equivalent auditing procedures that demonstrate the accuracy of eligibility determinations and enrollment transactions; and (5) Identification of errors that have resulted in incorrect eligibility determinations, as applicable. (e) State Exchange Improper Payment Measurement (SEIPM) program. [78 FR 65095, Oct. 30, 2013, as amended at 84 FR 71710, Dec. 27, 2019; 91 FR 29870, May 20, 2026] § 155.1210 Maintenance of records. (a) General. (1) Accommodate periodic auditing of the State Exchange's financial records; and (2) Enable HHS or its designee(s) to inspect facilities, or otherwise evaluate the State- Exchange's compliance with Federal standards. (b) Records. (1) Information concerning management and operation of the State Exchange's financial and other record keeping systems; (2) Financial statements, including cash flow statements, and accounts receivable and matters pertaining to the costs of operations; (3) Any financial reports filed with other Federal programs or State authorities; (4) Data and records relating to the State Exchange's eligibility verifications and determinations, enrollment transactions, appeals, and plan variation certifications; and (5) Qualified health plan contracting (including benefit review) data and consumer outreach and Navigator grant oversight information. (c) Availability. Subpart N—State Flexibility § 155.1300 Basis and purpose. (a) Statutory basis. (1) A process for public notice and comment at the State level, including public hearings, sufficient to ensure a meaningful level of public input. (2) A process for the submission of an application that ensures the disclosure of all of the following: (i) The provisions of law that the State involved seeks to waive. (ii) The specific plans of the State to ensure that the waiver will meet all requirements specified in section 1332. (3) A process for the provision of public notice and comment after a waiver application is received by the Secretary, that is sufficient to ensure a meaningful level of public input and that does not impose requirements that are in addition to, or duplicative of, requirements imposed under the Administrative Procedures Act, or requirements that are unreasonable or unnecessarily burdensome with respect to State compliance. (4) A process for the submission of reports to the Secretary by a State relating to the implementation of a waiver. (5) A process for the periodic evaluation by the Secretary of programs under waivers. (b) Purpose. § 155.1302 Coordinated waiver process. (a) Coordination with applications for waivers under other Federal laws. (b) Coordinated process for section 1332 waivers. § 155.1304 Definitions. For the purposes of this subpart: Complete application Public notice Section 1332 waiver § 155.1308 Application procedures. (a) Acceptable formats for applications. (b) Application timing. (c) Preliminary review. (1) The Secretary and the Secretary of the Treasury, as applicable, will complete the preliminary review of the application within 45 days after it is submitted. (2) If the Secretary and the Secretary of the Treasury, as applicable, determine that the application is not complete, the Secretary will send the State a written notice of the elements missing from the application. (3) The preliminary determination that an application is complete does not preclude a finding during the 180-day Federal decision-making period that a necessary element of the application is missing or insufficient. (d) Notification of preliminary determination. (e) Public notice of completed application. (1) Make available to the public the application, and all related State submissions, including all supplemental information received from the State following the receipt of a complete application for a section 1332 waiver. (2) Indicate the status of the application. (f) Criteria for a complete application. (1) Complies with paragraphs (a) through (f) of this section. (2) Provides written evidence of the State's compliance with the public notice requirements set forth in § 155.1312, including a description of the key issues raised during the State public notice and comment period. (3) Provides all of the following: (i) A comprehensive description of the State legislation and program to implement a plan meeting the requirements for a waiver under section 1332 of PPACA. In analyzing whether the State has satisfied the requirement under section 1332(b)(2)(A) of PPACA that the State enact a law authorizing a waiver under section 1332 of PPACA, the Secretary and the Secretary of the Treasury, as applicable, may consider existing State legislation combined with duly-enacted State regulation or an executive order so long as the State legislation provides statutory authority to enforce PPACA provisions or the State plan; (ii) A copy of the enacted State legislation that provides the State with authority to implement the proposed waiver, as required under section 1332(a)(1)(C) of the Affordable Care Act; (iii) A list of the provisions of law that the State seeks to waive including a description of the reason for the specific requests; and (iv) The analyses, actuarial certifications, data, assumptions, targets, and other information set forth in paragraph (f)(4) of this section sufficient to provide the Secretary and the Secretary of the Treasury, as applicable, with the necessary data to determine that the State's proposed waiver satisfies the general requirements for approval under section 1332(b)(1) of the Affordable Care Act consistent with the provisions of this paragraph; (A) As required under section 1332(b)(1)(A) of the Affordable Care Act (the comprehensive coverage requirement), will provide coverage that is at least as comprehensive as the coverage defined in section 1302(b) of the Affordable Care Act and offered through Exchanges established under the Affordable Care Act as certified by the Office of the Actuary of the Centers for Medicare & Medicaid Services based on sufficient data from the State and from comparable States about their experience with programs created by the Affordable Care Act and the provisions of the Affordable Care Act that the State seeks to waive. To satisfy the comprehensive coverage requirement, the Secretary and the Secretary of the Treasury, as applicable, must determine that the coverage under the State plan is forecasted to be at least as comprehensive overall for residents of the State as coverage absent the waiver; (B) As required under section 1332(b)(1)(B) of the Affordable Care Act (the affordability requirement), will provide coverage and cost sharing protections against excessive out-of-pocket spending that are at least as affordable as the provisions of Title I of the Affordable Care Act would provide. To satisfy the affordability requirement, the Secretary and the Secretary of the Treasury, as applicable, must determine that the coverage under the State plan is forecasted to be at least as affordable overall for State residents as coverage absent the waiver; (C) As required under section 1332(b)(1)(C) of the Affordable Care Act (the scope of coverage requirement), will provide coverage to at least a comparable number of its residents as the provisions of Title I of the Affordable Care Act would provide. To satisfy the scope of coverage requirement, the Secretary and the Secretary of the Treasury, as applicable, must determine that the State plan will provide coverage to a comparable number of State residents under the waiver as would have coverage absent the waiver; and (D) As prohibited under section 1332(b)(1)(D) of the Affordable Care Act (the Federal deficit requirement), will not increase the Federal deficit. (4) Contains the following supporting information: (i) Actuarial analyses and actuarial certifications. (ii) Economic analyses. (A) A detailed 10-year budget plan that is deficit neutral to the Federal government, as prescribed by section 1332(a)(1)(B)(ii) of the Affordable Care Act, and includes all costs under the waiver, including administrative costs and other costs to the Federal government, if applicable; and (B) A detailed analysis regarding the estimated impact of the waiver on health insurance coverage in the State. (iii) Data and assumptions. (A) Information on the age, income, health expenses and current health insurance status of the relevant State population; the number of employers by number of employees and whether the employer offers insurance; cross-tabulations of these variables; and an explanation of data sources and quality; and (B) An explanation of the key assumptions used to develop the estimates of the effect of the waiver on coverage and the Federal budget, such as individual and employer participation rates, behavioral changes, premium and price effects, and other relevant factors. (iv) Implementation timeline. (v) Additional information. (A) An explanation as to whether the waiver increases or decreases the administrative burden on individuals, insurers, and employers, and if so, how and why; (B) An explanation of how the waiver will affect the implementation of the provisions of the Affordable Care Act which the State is not requesting to waive in the State and at the Federal level; (C) An explanation of how the waiver will affect residents who need to obtain health care services out-of-State, as well as the States in which such residents may seek such services; (D) If applicable, an explanation as to how the State will provide the Federal government with all information necessary to administer the waiver at the Federal level; and (E) An explanation of how the State's proposal will address potential individual, employer, insurer, or provider compliance, waste, fraud and abuse within the State or in other States. (vi) Reporting targets. (vii) Other information. (g) Additional supporting information. (2) Requests for additional information, and responses to such requests, will be made available to the public in the same manner as information described in § 155.1316(b). [77 FR 11718, Feb. 27, 2012, as amended at 86 FR 6177, Jan. 19, 2021; 86 FR 53504, Sept. 27, 2021] § 155.1312 State public notice requirements. (a) General. (2) Such public notice and comment period shall include, for a State with one or more Federally-recognized Indian tribes within its borders, a separate process for meaningful consultation with such tribes. (b) Public notice and comment period. (1) A comprehensive description of the application for a section 1332 waiver to be submitted to the Secretary including information and assurances related to all statutory requirements and other information consistent with guidance provided by the Secretary and the Secretary of the Treasury, as applicable. (2) Information relating to where copies of the application for a section 1332 waiver are available for public review and comment. (3) Information relating to how and where written comments may be submitted and reviewed by the public, and the timeframe during which comments will be accepted. (4) The location, date, and time of public hearings that will be convened by the State to seek public input on the application for a section 1332 waiver. (c) Public hearings. (2) Such public hearings shall provide an interested party the opportunity to learn about and comment on the contents of the application for a section 1332 waiver. (3) Such public hearings shall be conducted in an in-person, virtual (that is, one that uses telephonic, digital, and/or web-based platforms), or hybrid (that is, one that provides for both in-person and virtual attendance) format. (d) Submission of initial application. [77 FR 11718, Feb. 27, 2012, as amended at 89 FR 26424, Apr. 15, 2024] § 155.1316 Federal public notice and approval process. (a) General. (b) Public notice and comment period. (2) At the beginning of the Federal notice and comment period, the Secretary will make available through its Web site and otherwise, and shall update as appropriate, public notice that includes all of the following: (i) The complete application for a section 1332 waiver, updates for the status of the State's application, and any supplemental materials received from the State prior to and during the Federal public notice and comment period. (ii) Information relating to where copies of the application for a section 1332 waiver are available for public review and comment. (iii) Information relating to how and where written comments may be submitted and reviewed by the public, and the timeframe during which comments will be accepted. (iv) Any public comments received during the Federal public notice and comment period. (c) Approval of a section 1332 waiver application. § 155.1318 Modification from the normal public notice requirements during an emergent situation. (a) The Secretary and the Secretary of the Treasury may modify, in part, the State public notice requirements under § 155.1312(a)(1), (b), (c), and (d) and the Federal public notice procedures under § 155.1316(b) to expedite a decision on a proposed section 1332 waiver request during an emergent situation, when a delay would undermine or compromise the purpose of the proposed waiver request and be contrary to the interests of consumers. These flexibilities are limited to emergent situations, including natural disasters; public health emergencies; or other emergent situations that threaten consumers' access to comprehensive coverage, consumers' access to health care, or human life. (b) A State must meet all of the following criteria to request a modification under paragraph (a) of this section: (1) The State must request a modification under paragraph (a) of this section, in the form and manner specified by the Secretaries. (2) The State must have acted in good faith, and in a diligent, timely, and prudent manner in the preparation of the request for a modification under paragraph (a) of this section, and the waiver application request, as applicable. (3) The State must, as applicable, detail in its request for a modification from State-level notice procedures under paragraph (a) of this section the justification for the request as it relates to the emergent situation and the alternative public notice procedures it proposes to implement at the State level, including public hearings, that are designed to provide the greatest opportunity and level of meaningful public input from impacted stakeholders that is practicable given the emergency circumstances underlying the State's request for a modification. (4) The State must, as applicable, detail in its request for a modification from Federal-level notice procedures under paragraph (a) of this section the justification for the request and the alternative public notice procedures it requests to be implemented at the Federal level. (5) The State must explain in its request for a modification from State-level notice procedures under paragraph (a) of this section how the emergent circumstances underlying its request result from a natural disaster; public health emergency; or other emergent situations that threaten consumers' access to comprehensive coverage, consumers' access to health care, or human life could not reasonably have been foreseen and how a delay would undermine or compromise the purpose of the waiver and be contrary to the interests of consumers. (c) The Secretary and the Secretary of the Treasury will evaluate a State's request for a modification under paragraph (a) of this section and issue their modification determination within approximately 15 calendar days after the request is received. (d) The Secretary will publish on the CMS website any modification determinations within 15 calendar days of the Secretary and the Secretary of the Treasury making such a determination, as well as the approved revised timeline for public comment under the approved alternative State or Federal public notice procedures, as applicable. (e) The State must publish on its website any modification requests and determinations within 15 calendar days of receipt of the determination, as well as the approved revised timeline for public comment under the alternative State or Federal public notice procedures, as applicable. (f) The State must, as applicable, implement the alternative public notice procedures at the State level if the State's modification request is approved and, if required, amend the waiver application request. (g) The Secretary and the Secretary of the Treasury will consider circumstances to be emergent when they could not have been reasonably foreseen. The Secretary and the Secretary of the Treasury will assess “reasonable foreseeability” based on the specific issues that a section 1332 waiver proposes to address and other relevant factors, and will not make this assessment based solely on the number of days a State may have been aware of such issues. [85 FR 71202, Nov. 6, 2020, as amended at 86 FR 53504, Sept. 27, 2021] § 155.1320 Monitoring and compliance. (a) General. (2) The Secretary and the Secretary of the Treasury will examine compliance with Federal and regulatory requirements consistent with § 155.1308(f)(3)(iv) when conducting implementation reviews under paragraph (b) of this section. (b) Implementation reviews. (2) The Secretary and the Secretary of the Treasury, as applicable, will review documented complaints that a State is failing to comply with requirements specified in the terms and conditions of any approved section 1332 waiver. (3) The Secretary and the Secretary of the Treasury, as applicable, will promptly share with a State any complaint that the Secretary and the Secretary of the Treasury has received and will also provide notification of any applicable monitoring and compliance issues. (c) Post award. (1) Notification requirements for public forum. (2) Modification from the normal post award requirements during an emergent situation. (ii) A State must meet all of the following criteria to request a modification under paragraph (c) of this section: (A) The State must request a modification under paragraph (c)(2) of this section, in the form and manner specified by the Secretaries. (B) The State must have acted in good faith, and in a diligent, timely, and prudent manner to comply with the monitoring and compliance requirement under the waiver and the terms and conditions of the agreement between the Secretary and the Secretary of the Treasury, as applicable, and the State to implement a section 1332 waiver and to submit and prepare the request for a modification under paragraph (c)(2) of this section. (C) The State must detail in its request for a modification under paragraph (c)(2) of this section the alternative post award public notice procedures it proposes to implement at the State level, including public hearings, that are designed to provide the greatest opportunity and level of meaningful public input from impacted stakeholders that is practicable given the emergency circumstances underlying the State's request for a modification. (D) The Secretary and the Secretary of the Treasury will evaluate a State's request for a modification under paragraph (c)(2) of this section and issue their modification determination within approximately 15 calendar days after the request is received. (E) The State must publish on its website any modification requests and determinations within 15 calendar days of receipt of the determination, as well as information on the approved revised timeline for the State's post award public notice procedures, as applicable. (F) The State must explain in its request for a modification under paragraph (c)(2) of this section how the emergent circumstances underlying its request results from a natural disaster; public health emergency; or other emergent situations that threaten consumers' access to comprehensive coverage, consumers' access to health care, or human life and could not reasonably have been foreseen and how the application of the post award public notice requirements would be contrary to the interests of consumers. (iii) The Secretary and the Secretary of the Treasury will consider circumstances to be emergent when they could not have been reasonably foreseen. The Secretary and the Secretary of the Treasury will assess “reasonable foreseeability” based on the specific issues that a section 1332 waiver proposes to address and other relevant factors, and will not make this assessment based solely on the number of days a State may have been aware of such issues. (d) Terminations and suspensions. (e) Closeout costs. (f) Federal evaluators. (2) As part of this required cooperation, a State must submit all requested data and information to the Secretary, the Secretary of the Treasury, as applicable, or the independent evaluator. [77 FR 11718, Feb. 27, 2012, as amended at 85 FR 71203, Nov. 6, 2020; 86 FR 6178, Jan. 19, 2021; 86 FR 53505, Sept. 27, 2021; 89 FR 26424, Apr. 15, 2024] § 155.1322 Pass-through funding for approved waivers. (a) Pass-through funding. (b) [Reserved] [86 FR 53505, Sept. 27, 2021] § 155.1324 State reporting requirements. (a) Quarterly reports. (b) Annual reports. (1) The progress of the section 1332 waiver. (2) Data on compliance with section 1332(b)(1)(A) through (D) of the Affordable Care Act. (3) A summary of the annual post-award public forum, held in accordance with § 155.1320(c), including all public comments received at such forum regarding the progress of the section 1332 waiver and action taken in response to such concerns or comments. (4) Other information consistent with the State's approved terms and conditions. (c) Submitting and publishing annual reports. (1) Within 60 days of receipt of comments from the Secretary, a State must submit to the Secretary the final annual report for the waiver year. (2) The draft and final annual reports are to be published on a State's public web site within 30 days of submission to and approval by the Secretary, respectively. § 155.1328 Periodic evaluation requirements. (a) The Secretary and the Secretary of the Treasury, as applicable, shall periodically evaluate the implementation of a program under a section 1332 waiver consistent with § 155.1308(f)(3)(iv) and any terms and conditions governing the section 1332 waiver. (b) Each periodic evaluation must include a review of the annual report or reports submitted by the State in accordance with § 155.1324 that relate to the period of time covered by the evaluation. [77 FR 11718, Feb. 27, 2012, as amended at 86 FR 53505, Sept. 27, 2021] § 155.1330 Waiver amendment. (a) Amendment to an approved section 1332 waiver. (b) [Reserved] [86 FR 53505, Sept. 27, 2021] § 155.1332 Waiver extension. (a) Extension. (b) [Reserved] [86 FR 53505, Sept. 27, 2021] Subpart O—Quality Reporting Standards for Exchanges Source: 79 FR 30350, May 27, 2014, unless otherwise noted. § 155.1400 Quality rating system. The Exchange must prominently display quality rating information for each QHP on its website, in accordance with § 155.205(b)(1)(v), in a form and manner specified by HHS. [85 FR 29261, May 14, 2020] § 155.1405 Enrollee satisfaction survey system. The Exchange must prominently display results from the Enrollee Satisfaction Survey for each QHP on its website, in accordance with § 155.205(b)(1)(iv), in a form and manner specified by HHS. [85 FR 29261, May 14, 2020] Subpart P—Improper Payment Pre-Testing and Assessment (IPPTA) for State-based Exchanges Source: 88 FR 25920, Apr. 27, 2023, unless otherwise noted. § 155.1500 Purpose and scope. (a) This subpart sets forth the requirements of the IPPTA. The IPPTA is an initiative between HHS and the State-based Exchanges. These requirements are intended to: (1) Prepare State-based Exchanges for the planned measurement of improper payments. (2) Test processes and procedures that support HHS's review of determinations of advance payments of the premium tax credit (APTC) made by State-based Exchanges. (3) Provide a mechanism for HHS and State-based Exchanges to share information that will aid in developing an efficient measurement process. (b) [Reserved] § 155.1505 Definitions. As used in this subpart- Business rules Entity relationship diagram Pre-testing and assessment Pre-testing and assessment checklist Pre-testing and assessment data request form Pre-testing and assessment period Pre-testing and assessment plan Pre-testing and assessment report § 155.1510 Data submission. (a) Requirements. (1) Data documentation. (i) The State-based Exchange's data dictionary including attribute name, data type, allowable values, and description; (ii) An entity relationship diagram, which shall include the structure of the data tables and the residing data elements that identify the relationships between the data tables; and (iii) Business rules and related calculations. (2) Data for processing and testing. (b) Timing. § 155.1515 Pre-testing and assessment procedures. (a) General requirement. (b) Orientation and planning processes. (2) As a part of the planning process, HHS, in collaboration with each State-based Exchange, will develop a pre-testing and assessment plan that takes into consideration relevant activities, if any, that were completed during a prior, voluntary State engagement. The pre-testing and assessment plan will include the pre-testing and assessment checklist. (3) At the conclusion of the pre-testing and assessment planning process, HHS will issue the pre-testing and assessment plan specific to that State-based Exchange. The pre-testing and assessment plan will be for HHS and State-based Exchange internal use only and will not be made available to the public by HHS unless otherwise required by law. (c) Notifications and updates Notification (2) Updates regarding changes. (d) Submission of required data and data documentation. (e) Data processing. (2) HHS will coordinate with each State-based Exchange to provide assistance in aligning the data specified in § 155.1510(a)(2) from the State-based Exchange's existing data structure to the standardized set of data elements. (3) HHS will coordinate with each State-based Exchange to interpret and validate the data specified in § 155.1510(a)(2). (4) HHS will use the data and data documentation submitted by the State-based Exchange to execute the pre-testing and assessment procedures. (f) Pre-testing and assessment checklist. (1) A State-based Exchange's submission of the data documentation as specified in § 155.1510(a)(1). (2) A State-based Exchange's submission of the data for processing and testing as specified in § 155.1510(a)(2); and (3) A State-based Exchange's completion of the pre-testing and assessment processes and procedures related to the IPPTA program. (g) Pre-testing and assessment report. Subpart Q—State Exchange Improper Payment Measurement (SEIPM) Source: 91 FR 29870, May 20, 2026, unless otherwise noted. § 155.1600 Purpose and scope. (a) This subpart sets forth the requirements of the State Exchange Improper Payment Measurement (SEIPM) program. SEIPM is an initiative through which HHS will measure improper payments of advance payment of the premium tax credit (APTC) that are administered by State Exchanges, as described in more detail in § 155.1610. HHS will use the SEIPM program results to produce an estimate of improper payments of APTC aggregated across State Exchanges. (b) Unless otherwise specified by HHS, all State Exchanges must submit information on an annual basis that is necessary to support the SEIPM processes. (c) HHS will publish in the Agency Financial Report an estimate of improper payments that is aggregated across all State Exchanges. § 155.1605 Applicability date and implementation. (a) Applicability date. (b) [Reserved] § 155.1610 Definitions. As used in this subpart— Annual Program Schedule Administrative Appeal Administrative Appeal Decision Corrective Action Plan CAP Difference Resolution Difference Resolution Decision Error (1) Eligibility for and enrollment in a Qualified Health Plan (QHP); (2) Eligibility for APTC, and calculated amount of APTC; (3) Redeterminations of eligibility during a plan year; (4) Eligibility redeterminations for purposes of re-enrollment. Measurement Year Reporting Year Sampled Unit Assessment Package State Exchange Improper Payment Measurement or SEIPM (1) Eligibility for and enrollment in a QHP; (2) Eligibility for APTC, and calculated amount of APTC; (3) Redeterminations of eligibility during a Plan Year; (4) Annual eligibility redeterminations. SEIPM Cycle Tax Household § 155.1615 Information submission. (a) HHS will issue an Annual Program Schedule to each State Exchange no later than January 5th of the Measurement Year. The Annual Program Schedule will specify the deadlines for all information submissions required under this section. (b) On an annual basis, each State Exchange must submit or make available to HHS the following information: (1) Program documentation. (2) Universe. (i) Exchange assigned policy identifier; (ii) Tax household grouping identifier; (iii) SSN inconsistency indicator; (iv) Citizenship inconsistency indicator; (v) Lawful presence inconsistency indicator; (vi) Annual income inconsistency indicator; (vii) Non-employer sponsored minimum essential coverage inconsistency indicator; (viii) Employer sponsored minimum essential coverage inconsistency indicator; (ix) Incarceration inconsistency indicator; (x) Residency inconsistency indicator; (xi) Number of tax household members; and (xii) APTC amount paid over the duration of the benefit year. (3) Tax household Data. (i) Information pertaining to the calculation of the APTC benefits paid that includes monthly enrollment premium amounts, monthly APTC payment amounts, monthly Second Lowest Cost Silver Plan Premium amounts, and the amount of each monthly premium that is attributable to essential health benefits. (ii) Information relevant to enrollment that includes dates and amounts of effectuation payments, premium payment amount, and policy start and end dates. (iii) Information relevant to the determination of eligibility for a special enrollment period (where applicable), which would include (where applicable) information collected by the State Exchange about consumer attestations and representations regarding special enrollment period eligibility criteria, copies of documentary evidence submitted by applicants, electronic verification information, and timing information. (iv) Information about the timing of QHP certification or approval, the coverage area of the associated QHP, and the timing of any QHP decertification or suppression. (v) To the extent applicable, for each person who is included in the APTC payment calculation: (A) Information collected by the State Exchange about consumer attestations regarding QHP and APTC eligibility factors and demographic information relevant to initial QHP enrollment and eligibility. (B) APTC eligibility and payment determinations which includes evidence of required data verifications, the electronic sources consulted, the timing of required verifications, and the results of the verification. (C) Information relevant to QHP and APTC manual eligibility verifications and the resolution of electronic verification inconsistencies, which would include copies of documentary evidence submitted by QHP enrollees, the timing of submissions, the timing of adjudication, and information about good faith extensions. (D) Information relevant to QHP and APTC eligibility redeterminations such as information about automatic annual redeterminations, the timing and results of periodic examinations of data sources, and policy or application changes initiated by the consumer and resultant electronic or manual eligibility verifications. (vi) Any consumer submitted documents that were used to establish new or continued eligibility for enrollment in a QHP and APTC. § 155.1620 Sampling procedures. (a) Sample size. (1) Statistical methodology. (2) State-specific sample sizes. (i) Overall APTC expenditures associated with the State Exchange. (ii) State-level precision goals for the current SEIPM cycle. (iii) The improper payment rate from the State Exchange's previous SEIPM cycle. (3) Sample size parameters. (b) Sample selection procedures. (c) State Exchange coordination and notification Sampled records notification. (i) The total number of sampled tax households selected for the State Exchange. (ii) A unique identifier for each sampled tax household. (iii) Any specific instructions or requirements that HHS determines are needed to facilitate HHS' review of the sampled records. (2) Timing of sampled records notification. (3) Extension of sampling notification timeline. (A) Technical issues prevent completion of the sampling process within the standard timeframe; (B) Data quality issues require additional coordination with State Exchanges before sampling can be completed; or (C) Other circumstances beyond HHS's control necessitate additional time to ensure accurate sampling methodology. (ii) If HHS determines an extension is necessary, HHS will: (A) Notify all affected State Exchanges in writing of the extension and the revised notification date; (B) Provide the reason for the extension; and (C) Confirm the impact, if any, on subsequent SEIPM cycle timelines. § 155.1625 Determining payment errors. (a) Review of records and error identification Systematic review process. (2) Data sources. (3) Error identification. (i) Enrolling or re-enrolling a consumer into a QHP for which APTC was paid. (ii) Consumer eligibility for APTC being paid on the consumer's behalf. (iii) Calculating the APTC amount that was paid on the consumer's behalf. (iv) Taking required actions upon changes to a consumer's status that would affect their APTC-related eligibility or payment amount. (4) Review standards and criteria. (b) Error evaluation. (1) Calculate the correct APTC amount based on the requirements of section 36B of the Internal Revenue Code and applicable implementing regulations. (2) Determine an improper payment amount. (3) Document the error and improper payment amount within a Sampled Unit Assessment Package and provide the Sampled Unit Assessment Package to the State Exchange. (4) Extrapolate the identified improper payments from the sample to estimate the total improper payment amount for the State Exchange's entire universe of APTC payments, using statistically valid methodologies that comply with OMB guidance on improper payment estimation. (c) Reporting. (1) The estimated aggregate improper payment rate for Federal and State Exchanges combined. (2) The estimated aggregate improper payment rate for State Exchanges, and; (3) HHS will provide to each State Exchange a report that documents the State-specific improper payment rate and error analysis. § 155.1630 Difference Resolution and appeal process. (a) Difference Resolution. (2) Upon receipt of a Difference Resolution request, HHS will do the following: (i) Engage with the State Exchange in a collaborative process to examine the disputed findings and any additional documentation provided by the State Exchange. (ii) Evaluate the disputed findings by applying the same protocol used in the original review while considering whether the State Exchange's position is supported by the existing or newly provided evidence. (iii) Prepare the Difference Resolution Decision. (3) The Difference Resolution Decision will be communicated to the State Exchange within 90 days of receipt of the written request for a Difference Resolution. The Difference Resolution Decision will include a summary of the analysis and rationale that informed the decision. (b) Administrative appeal. (i) The State Exchange may not submit new evidence; it may use evidence that was previously submitted during Difference Resolution. (ii) The State Exchange may provide additional context regarding information that was submitted during Difference Resolution. (2) Upon receipt of an appeal request, HHS will do the following: (i) Assign the appeal request to one or more administrative appeal reviewers who were not involved in the original review; (ii) Conduct a comprehensive review of the disputed findings using the administrative record established during the Difference Resolution process; (iii) Independently evaluate the disputed findings by applying the same protocol used in the original review while considering whether the State Exchange's position is supported by the evidence; and (iv) Prepare an appeal decision for the completed review based on a preponderance of the evidence. (3) HHS will issue the appeal decision within 90 days of receipt of the written request for appeal. The appeal decision will include a summary of the analysis and rationale that informed the decision. (c) Difference Resolution and administrative appeal submission requirements. (1) A clear statement of the specific finding(s) being challenged. (2) All factual and legal bases for filing the request. (3) Evidence directly related to the finding(s), which may include: (i) Clarifying information regarding data interpretation. (ii) Legal citations supporting the State Exchange's position. (d) Timing of Difference Resolution and Administrative Appeal decisions. (i) HHS will adjust the affected improper payment rate calculations for the SEIPM cycle. (ii) Updated aggregate rates will be reflected in current cycle reporting. (2) For Difference Resolution Requests or administrative appeals resolved in favor of the State Exchange after completion of the SEIPM cycle: (i) If Difference Resolution or administrative appeal decisions result in material changes to aggregate rates, HHS will publish amended aggregate improper payment rates in subsequent Agency Financial Reports or other appropriate public reporting mechanisms as well as notify affected State Exchanges of any amendments to previously published rates. (ii) If HHS determines, at its discretion, that the Difference Resolution or administrative appeal decisions do not result in material changes to aggregate rates, no action will be taken to publish amended aggregated improper payment rates or notify affected State Exchanges. (e) Good cause exception. § 155.1635 Corrective action plan (CAP). (a) CAP. (b) Development of proposed CAP. (1) In developing a proposed CAP, the State Exchange must conduct an error analysis such as reviewing causes, characteristics, and frequency of errors that are associated with improper payments. The State Exchange must review the findings of the analysis to determine the causes of the errors included in the State Exchange improper payment rate, if any, and to identify the root causes of the resulting improper payments. (i) If a State Exchange has a pending Difference Resolution request or administrative appeal and HHS requests a CAP, HHS may provide a new timeline for CAP submission after the Difference Resolution or Administrative Appeal Decision and calculation of the final improper payment rate. (ii) [Reserved] (2) The State Exchange must determine the corrective actions to be implemented to correct causes of the errors included in the State Exchange improper payment rate and to prevent them from occurring again. (3) The proposed CAP must include measurable milestones, accountability mechanisms, regular monitoring and validation of progress, documentation of implemented corrective actions, and regular status updates. The CAP must include all the following for each identified error: (i) The specific corrective action. (ii) Status of the corrective action. (iii) Scheduled or actual implementation date of the corrective action. (iv) Key personnel responsible for implementing each corrective action. (v) A plan for monitoring the effectiveness of the corrective action. (c) Implementation and evaluation of a CAP. (d) Failures in the CAP process. § 155.1640 SEIPM preparation phase. (a) Any State Exchange in its first year of operation must participate in a 1-year SEIPM preparation phase prior to participating in SEIPM in the subsequent year. (b) To satisfy the requirements of the SEIPM preparation phase, a State Exchange must: (1) Complete the information submission requirements in § 155.1615(b)(1) and (3) using information from the most current Plan Year for a sample size not to exceed 10 unique tax households that address scenarios specified by HHS. (2) Undergo the review procedures in § 155.1625(a) and (b). (3) Participate in technical assistance activities provided by HHS, which may include: (i) Training on SEIPM requirements and procedures; (ii) System readiness assessments; (iii) Data quality validation exercises; and (iv) Process improvement recommendations. (c) At the beginning of each calendar year, HHS will provide any State Exchange that meets the conditions in paragraph (a) of this section with a schedule that spans a 12-month period that specifies when the requirements of this section must be completed. § 155.1645 Minimizing potential duplicate audit requirements. HHS will minimize potential duplicate requirements of the annual independent external programmatic audit described at § 155.1200(c) and (d) and SEIPM, such that, as determined by HHS, a State Exchange may be deemed to satisfy certain requirements of § 155.1200(c) and (d), particularly the review of compliance with subparts D and E, as identified in HHS sub-regulatory guidance, for a particular plan year by successfully completing the SEIPM process. § 155.1650 Failure to comply. (a) General principle. (b) Determination of substantial noncompliance. (1) Fails to submit required data or documentation within the timelines specified in the Annual Program Schedule. (2) Submits data or documentation that is incomplete, inaccurate, or in a format that would reasonably prevent effective review. (3) Fails to implement the CAP process as set out in § 155.1635(d). (4) Demonstrates a pattern of more than five instances during a SEIPM cycle in which the State Exchange fails to respond within 30 calendar days, or provides a non-responsive answer, to HHS requests for clarification or additional information. (c) Notice and opportunity to cure. (1) Provide written notice to the State Exchange specifying the nature of the noncompliance and the potential consequences. (2) Allow the State Exchange a reasonable opportunity, not less than 30 days, to cure the noncompliance or demonstrate that compliance has been achieved. (d) Remedial measures. (1) Enhanced monitoring and reporting. (2) Mandatory implementation of specific operational procedures or controls. (3) On-site visits to State Exchange facilities to assess operational procedures, data systems, and compliance with program requirements. (e) Escalation procedures.

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