Form CMS-10416 Blueprint for Approval of Affordable Healthcare Marketpl

The Patient Protection and Affordable Care Act (P.L. 111-148) and the Health Care and Education Reconciliation Act of 2010 (P.L. 111-152) (together referred to as the ACA) established American Health Benefit Exchanges, beginning January 1, 2014, to provide individuals and small business employees access to health insurance coverage. ACA § 1311(b) and 45 CFR § 155.100 describe an Exchange as an entity that both facilitates the purchase of Qualified Health Plans (QHPs) by qualified individuals and provides for the establishment of a Small Business Health Options Program (SHOP).

The ACA and its implementing regulations provide states with flexibility in the design and operation of Exchanges to ensure states are implementing Exchanges that best meet their consumers’ needs. States can choose to establish and operate a State-based Exchange (SBE) or a State-based Exchange on the Federal Platform (SBE-FP). To operate an SBE, a state must first operate an SBE-FP per § 155.106(c), meeting all requirements established under § 155.200(f), for at least one plan year, including its first Open Enrollment period. States electing to operate as an SBE-FP rely on the federal HealthCare.gov platform to carry out eligibility and enrollment functions but operate other Exchange functions themselves, including consumer assistance and outreach. The Secretary of the U.S. Department of Health and Human Services (HHS) operates a Federally-facilitated Exchange (FFE) in states that do not elect to operate either an SBE-FP or SBE. FFE states can also work with CMS to undertake certain Plan Management functions for their individual and SHOP markets.

Pursuant to 45 CFR §§ 155.105 and 155.106, states that elect to operate an SBE-FP or SBE must complete and submit an Exchange Blueprint Application. The Exchange Blueprint Application documents that an Exchange will meet the legal and operational requirements associated with the Exchange model a state chooses to pursue. As part of its Exchange Blueprint Application submission, a state will also agree to demonstrating operational readiness to implement and execute the required Exchange activities described in the Exchange Blueprint Application.

This document includes the Exchange Blueprint Application for states seeking approval to operate either an SBE-FP or SBE for coverage years beginning on, or after, January 1, 2025, and includes the following application components:

Declaration of Intent Letter (Section II)
Exchange Blueprint Application (Section III)
- Part A: Application Attestation
- Part B: Exchange Declarations
- Parts C and D: SBE and SBE-FP Application

This Exchange Blueprint Application replaces previous versions. All FFE states electing to operate an SBE-FP or SBE must submit a Declaration of Intent Letter and the applicable sections of the Exchange Blueprint Application. States that already have a conditionally-approved Exchange Blueprint Application as an SBE-FP or SBE for a coverage year prior to January 1, 2025 and wish to transition to a new State Exchange model must submit an updated Declaration of Intent Letter and Exchange Blueprint Application for the applicable model.

An SBE transitioning to an SBE-FP should also refer to the Appendix in this document for further information.

A state operating as an SBE-FP or SBE that is electing to transition to the FFE should follow the process described in 45 CFR § 155.106(b).

Figure 1: State Exchange Model Options and Exchange Blueprint Application Requirements and Timelines for Coverage Years Beginning On, or After, January 1, 2025

SBE	SBE-FP	FFE
State performs all Exchange functions, including coordination with state Medicaid and Children’s Health Insurance Program (CHIP). State may rely on CMS for the following functions: Exemptions processing (45 CFR § 155 Subpart G) Risk adjustment (45 CFR § 153 Subpart D) Employer appeal upon notice of employee’s receipt of APTC/CSR (45 CFR § 155.555)	State performs the following Exchange functions: Plan Management Consumer Assistance, including a Navigator program (and marketing and consumer outreach, in coordination with CMS) SHOP State relies on CMS for the following functions: Eligibility and enrollment (Individual Market) Related eligibility support, such as consumer call center, marketing, and consumer casework (Individual Market) State elects whether CMS (through the HealthCare.gov eligibility platform) will perform Medicaid and CHIP assessments or determinations. (Notification is through CMS’s Center for Medicaid and CHIP Services (CMCS)).	CMS performs all Exchange functions through HealthCare.gov. State may elect to perform certain plan management (PM) functions.¹ State elects whether CMS (through the HealthCare.gov eligibility platform) will perform Medicaid and CHIP assessments or determinations. (Notification is through CMS’s CMCS).
State Must Submit: Declaration of Intent at least 21 months prior to the beginning of SBE’s first Open Enrollment SBE Blueprint Application at least 15 months prior to the beginning of an SBE-FP’s first Open Enrollment per 45 CFR § 155.106.(c)(1)	State Must Submit: Declaration of Intent – at least 9 months prior to the beginning of an SBE- FP’s first Open Enrollment SBE-FP Exchange Blueprint Application at least 3 months prior to the beginning of an SBE- FP’s first Open Enrollment per 45 CFR § 155.106(c)(1) Execute the SBE-FP Federal Platform Agreement and Information Disclosure Agreement with CMS prior to the beginning of an SBE-FP’s first Open Enrollment per 45 CFR § 155.106(c)(4)²	Not applicable. SBEs or SBE-FPs that wish to transition to the FFE should notify CMS in accordance with timelines in 45 CFR § 155.106(b)

SBE

SBE-FP

FFE

State performs all Exchange functions, including coordination with state Medicaid and Children’s Health Insurance Program (CHIP).

State may rely on CMS for the following functions:

Exemptions processing (45 CFR § 155 Subpart G)
Risk adjustment (45 CFR § 153 Subpart D)
Employer appeal upon notice of employee’s receipt of APTC/CSR (45 CFR § 155.555)

State performs the following Exchange functions:

Plan Management
Consumer Assistance, including a Navigator program (and marketing and consumer outreach, in coordination with CMS)
SHOP

State relies on CMS for the following functions:

Eligibility and enrollment (Individual Market)
Related eligibility support, such as consumer call center, marketing, and consumer casework (Individual Market)

State elects whether CMS (through the HealthCare.gov eligibility platform) will perform Medicaid and CHIP assessments or determinations. (Notification is through CMS’s Center for Medicaid and CHIP Services (CMCS)).

CMS performs all Exchange functions through HealthCare.gov.

State may elect to perform certain plan management (PM) functions.¹

State elects whether CMS (through the HealthCare.gov eligibility platform) will perform Medicaid and CHIP assessments or determinations. (Notification is through CMS’s CMCS).

State Must Submit:

Declaration of Intent at least 21 months prior to the beginning of SBE’s first Open Enrollment
SBE Blueprint Application at least 15 months prior to the beginning of an
SBE-FP’s first Open Enrollment per 45 CFR § 155.106.(c)(1)

State Must Submit:

Declaration of Intent – at least 9 months prior to the beginning of an SBE- FP’s first Open Enrollment
SBE-FP Exchange Blueprint Application at least 3 months prior to the beginning of an SBE- FP’s first Open Enrollment per 45 CFR § 155.106(c)(1)
Execute the SBE-FP Federal Platform Agreement and Information Disclosure Agreement with CMS prior to the beginning of an SBE-FP’s first Open Enrollment per 45 CFR § 155.106(c)(4)²

Not applicable.

SBEs or SBE-FPs that wish to transition to the FFE should notify CMS in accordance with timelines in 45 CFR § 155.106(b)

Exchange Blueprint Application Submission, Review and Approval Process

Upon a state’s submission of its Declaration of Intent Letter, HHS’s Centers for Medicare & Medicaid Services (CMS) will engage the state and provide technical assistance on the completion of the state’s Exchange Blueprint Application, if not already submitted, and the process toward approval or conditional approval.

HHS recognizes that states depend on HHS/CMS, other federal agencies, and contractors for guidance associated with their Exchange establishment. CMS’s approval of an SBE-FP and SBE will take into account that states will be in various stages of development when states submit an Exchange Blueprint Application to CMS. As a result, CMS will grant conditional approval for an SBE or SBE-FP that does not meet all applicable Exchange requirements at the time of Exchange Blueprint Application submission, but that has:

Attested to meeting all applicable requirements in the Exchange Blueprint Application;
Is making significant progress toward meeting the requirements with projected dates of completion, and;
Is anticipated to be operationally ready for the applicable Open Enrollment Period.

Once a state has been conditionally approved, CMS will work closely with each Exchange to monitor state progress and ensure that proposed dates of completion for Exchange Blueprint Application activities and other project milestones are met in accordance with the state’s projected completion dates.

Public Engagement

As described in 45 CFR § 155.106(a)(2), a State electing to be an SBE or SBE-FP must conduct specific public engagement activities. Upon submission of its Exchange Blueprint application the State must publish, through its website, a public notice indicating that the State is seeking approval from HHS to transition to a State Exchange. The notice should include a copy of the Exchange Blueprint application, a description of the Plan Year for which the State seeks to transition to a State Exchange, and information about when and where the State will conduct public engagements regarding the State's Exchange Blueprint application.

A State must conduct, prior to receiving approval or conditional approval, at least one public engagement regarding the State's Exchange Blueprint application progress. The public engagement is meant to provide interested parties the opportunity to learn about the State's progress in transitioning to a State Exchange and offer input on that transition. A State can determine the timeline and manner, within the parameters of 45 CFR § 155.106(a)(2)(ii), in which to hold this public engagement but must submit the plan to CMS for review and approval. Following this initial public engagement a State must conduct periodic public engagements, either in-person or virtually, in a timeframe and manner considered effective by the State.

Assessment of State Progress, Documentation and Readiness Reviews

CMS will utilize regular calls with the state, state-submitted documentation, and implementation and/or operational readiness reviews to monitor and provide guidance to states on their Exchange information technology (IT) system build and implementation of programmatic requirements as defined in the Exchange Blueprint Application. Operational readiness entails CMS’s and its federal agency partners’ assessment of the capacity of an Exchange to conduct Exchange business. The objective of these assessments is to assure that an Exchange’s policies, procedures, operations, technology, and other administrative capacities have been implemented and scaled to meet the needs of the State Exchange’s population. CMS will use the information in an Exchange’s Blueprint Application to determine the need for, and timing of, in-person or virtual periodic readiness assessments.

CMS will require that the State provide documentation and information technology testing results demonstrating progress towards meeting the Exchange Blueprint Application requirements. Requests for documentation and information technology system testing results may occur as part of the regular monitoring calls, readiness reviews or other consults as requested by CMS.

CMS also requires formal testing between the State’s IT system and the CMS Federal Data Services Hub (FDSH) to ensure connectivity, correct data exchange formats and values, correct interpretation of responses from the FDSH by the State, and ensure correct information is transmitted and captured. CMS will provide guidance and documentation to assist States with testing the automated functionality of their Exchanges and reporting results to CMS.

An Exchange’s conditional approval status will continue as long as a State continues to meet expected progress milestones and until a State successfully demonstrates its ability to perform all required Exchange activities and comply with all applicable Federal guidance and regulations. Provided that the State is continuing to demonstrate progress in meeting the requirements outlined in its conditional approval determination, a State Exchange will maintain conditional approval status. Questions Regarding the Exchange Blueprint Application and Technical Assistance

States can contact CMS/CCIIO’s State Marketplace and Insurance Programs Group (SMIPG) at SBMOversight@cms.hhs.gov for information about technical assistance consultations, and resources available to states on the Exchange Blueprint Application process. SBE-FP and SBE states with an assigned CMS CCIIO State Officer (SO) should contact him or her for specific questions regarding Exchange Blueprint Application submissions.

PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995 (PRA), no persons are required to respond to a collection of information unless it displays a valid Office of Management and Budget (OMB) control number. The valid OMB control number for this information collection is 0938-1172. This information collection is required for States electing to be an SBE or SBE-FP and seeking approval from HHS/CMS as such. Information provided by States collected through the State Exchange Blueprint Application tool will be used by CMS to determine a state’s compliance with federal requirements to establish and operate an SBE or SBE-FP and serves as the basis for HHS/CMS to make its determination of whether a state can be approved to operate an SBE or SBE-FP. The time required to complete this information collection is estimated to average 53.25 hours per response, including the time to review instructions, search existing data resources, gather the data needed, to review and complete the information collection. This information collection is required for States wanting to obtain and establish an SBE or SBE-FP pursuant to 45 CFR §§ 155.105 and 155.106 and is private/confidential to the extent permitted by law. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to:

CMS

7500 Security Boulevard

Attn: PRA Reports Clearance Officer

Mail Stop C4- 26-05

Baltimore, Maryland 21244-1850

SECTION II: DECLARATION OF INTENT LETTER

A State seeking to operate an SBE-FP or SBE for coverage years beginning on, or after, January 1, 2025 will declare the type of Exchange model it intends to pursue through an Exchange Declaration of Intent (DOI) to be submitted to CMS CCIIO in advance of the submission of an Exchange Blueprint Application.

A State’s Declaration of Intent must be signed by the State’s governor. As described below, the Declaration of Intent’s contents must include basic information associated with its designated Exchange model(s). The Declaration of Intent should include a designation of the individual(s) who will serve as the primary point of contact for CMS regarding the Exchange. The individual(s) should be authorized to bind the State regarding the State’s Exchange, as well as to complete and sign the Exchange Blueprint Application.

States are encouraged to submit their Exchange Declaration of Intent as early as possible but no later than the following timelines:

States transitioning to an SBE must submit the DOI no later than 21 months prior to the beginning of an SBE’s first Open Enrollment. This timeframe presumes that the State will operate as an SBE-FP for one year. The State’s Declaration of Intent should include confirmation of the plan year for which the State intends to operate both as an SBE-FP and an SBE. A State planning to transition to an SBE that plans to operate as an SBE-FP for longer than one year or that is already operating as an SBE-FP should contact CMS CCIIO for further guidance.
States transitioning to an SBE-FP only must submit the DOI no later than 9 months prior to the beginning of an SBE-FP’s first Open Enrollment.

These timelines are based on CMS’s experience with the length of time needed for States to implement the business processes and information technology platforms required for each Exchange operational model. States are recommended to consult with CMS CCIIO for further guidance as needed. A State’s Declaration of Intent should be sent to:

CMS CCIIO

200 Independence Avenue SW, Suite 739H

Washington DC, 20201

In addition, please email a copy to SBMOversight@cms.hhs.gov. To support CMS’s goal of public transparency, states must post their Declaration of Intent Letter to the state (or other appropriate) website.

Contents of Declaration of Intent Letter

A state’s Declaration of Intent Letter must include the following:

The Exchange model that the state chooses to pursue (SBE-FP or SBE).
Confirmation of the plan year (PY) for which the State intends to begin operations (i.e., PY 2025 or a subsequent PY). If applying to be an SBE, confirmation of the PY for which the State intends to operate an SBE-FP and an SBE.
Designation of the individual(s) (Designee(s)) authorized to act as primary point(s) of contact and authorized to bind the state with CMS regarding the State’s Exchange, as well as to complete and sign the Exchange Blueprint Application.
Acknowledgement that CMS and the state may agree to amend its Declaration of Intent Letter to include additional information necessary to establish its Exchange.

SECTION III: APPLICATION FOR APPROVAL
OF STATE-BASED HEALTH INSURANCE EXCHANGES

Application Instructions

CMS requires that states seeking approval to operate an SBE-FP or SBE must complete and submit an Exchange Blueprint Application. States that already have a conditionally-approved Exchange Blueprint Application that are seeking to transition to a different Exchange model (either an SBE-FP or SBE) must submit an update to their Exchange Blueprint Application for approval.

The Exchange Blueprint Application documents that a state’s Exchange has met, or will meet, all legal and operational requirements associated with the Exchange model that the state intends to operate. Specifically, a state must attest to the current ability of its Exchange to meet specified requirements or to its intention to complete the specified requirements by a future date. As part of its Exchange Blueprint submission, a state will also agree to demonstrating operational readiness to execute Exchange activities. States may attest to activities being completed by the Exchange or a designee through contract, agreement, or other arrangement. However, the Exchange is ultimately responsible for meeting all applicable federal requirements outlined in the Exchange Blueprint Application and for the successful performance of each activity. CMS considers the Exchange Blueprint Application an agreement that exists solely between the state and CMS. CMS encourages states to reach out to CMS/CCIIO/SMIPG at SBMOversight@cms.hhs.gov for clarification on any activities that direct states to consult CMS guidance and or regulations that provide more detailed information about the applicability of certain Exchange functional requirements to specific Exchange models.

Per regulations at 45 CFR § 155.106, states seeking to operate an SBE must submit their Exchange Blueprint Application (or updated Exchange Blueprint Application) to CMS at least 15 months prior to the beginning of an SBE’s first Open Enrollment. States seeking to operate an SBE-FP must submit their Exchange Blueprint Application (or updated Exchange Blueprint Application) to CMS at least three months prior to the beginning of an SBE-FP’s first Open Enrollment.

The Exchange Blueprint Application is electronically available for states to complete and submit through the CMS/CCIIO State Exchange Resource Virtual Information System (SERVIS) (https://portal.cms.gov). To gain access to SERVIS and be able to complete and submit the Exchange Blueprint Application, a state without an assigned CMS CCIIO SO would need to email a request to SBMOversight@cms.hhs.gov with the subject line Exchange Blueprint Application Notification. States with an assigned CMS CCIIO SO will work closely with their SO to complete and submit an update to their Exchange Blueprint Application.

The Exchange Blueprint Application includes the following components. States seeking approval to operate an SBE-FP or SBE for coverage years beginning on, or after, January 1, 2025 must complete and submit Part A and Part B. States complete Part C or Part D depending on their Exchange model:

Part A. Application Attestation: The individual(s) designated in a state’s Declaration of Intent Letter (the Designee(s)) must attest on the state’s behalf to the accuracy of the information submitted for the entire Exchange Blueprint Application submission.

Part B. Exchange Declarations: The applicant must provide an overview of key Exchange options within the model the state has chosen to operate.

Part C. State-based Exchange Blueprint Application: States seeking to be SBEs must attest to either completion or expected completion of required activities.

Part D. State-based Exchange on the Federal Platform Blueprint Application: States seeking to be SBE-FPs must attest to either completion or expected completion of required activities.

PART A: APPLICATION ATTESTATION

ON THIS DATE, I ATTEST THAT THE STATEMENTS AND INFORMATION CONTAINED IN THIS EXCHANGE BLUEPRINT APPLICATION AND DOCUMENTS SUBMITTED IN CONJUNCTION WITH THIS EXCHANGE BLUEPRINTAPPLICATION ACCURATELY REPRESENT THE STATUS OF MY STATE’S INSURANCE EXCHANGE BEING DEVELOPED UNDER TITLE I OF THE PATIENT PROTECTION AND AFFORDABLE CARE ACT OF 2010 (Pub. L. 111-148), AS AMENDED BY THE HEALTH CARE AND EDUCATION RECONCILIATION ACT OF 2010 (Pub. L. 111-152), AND REFERRED TO COLLECTIVELY AS THE AFFORDABLE CARE ACT; AND REGULATIONS AT 45 CFR §§ 153, 155, AND 156.

Shape5 (Name of State)

Shape7 (Signature of Governor Designee of the State, Date Signed)

FUTURE REVIEWS FOR FUNCTIONALITY OR COMPLIANCE: The Exchange agrees to participate in implementation and operational readiness reviews prior to opening as an Exchange as requested by CMS. As part of these reviews, CMS may request the Exchange to provide testing results or other documentation demonstrating Exchange’s ability to comply with regulations in 45 CFR § 155.

Agree: Do not agree:

DESIGNATED EXCHANGE OFFICIAL(S) CONTACT INFORMATION THAT IS COMPLETING THE EXCHANGE BLUEPRINT APPLICATION & ATTESTATION:

NAME:

TELEPHONE:

EMAIL ADDRESS:

NAME:

TELEPHONE:

EMAIL ADDRESS:

PART B: EXCHANGE DECLARATIONS

STATE(S) NAME:

STATE EXCHANGE MODEL AND PLAN YEAR: (Check which model your state is applying for, as well as indicate the plan year state intends to begin operations of the model)

SBE Plan Year

SBE-FP Plan Year

Regional Exchange Plan Year

(Please note that, in addition to meeting the requirements described in the Exchange Blueprint Application, states seeking approval to operate a Regional Exchange must also meet the requirements under 45 CFR § 155.140)

Shape11

DECLARATION of INTENT LETTER: (Confirm whether your state has submitted its Declaration of Intent Letter or if it is included with the Exchange Blueprint Application)

Declaration of Intent Letter submitted

Shape12 Date submitted to CMS

If you are seeking to implement an SBE, indicate if you will be relying on CMS for any of the following Exchange functions: (check all that apply)

Risk adjustment (45 CFR § 153 Subpart D)

Exemptions (45 CFR § 155 Subpart G)

Employer coverage appeals (45 CFR § 155.555)

GOVERNANCE STRUCTURE: (check one)

State agency

Quasi-governmental entity

Nonprofit

Other

PART C: STATE-BASED EXCHANGE BLUEPRINT APPLICATION

Legal Authority and Governance

Shape16 1.1 Exchange Enabling Authority: The Exchange will have the appropriate authority to operate an SBE compliant with Affordable Care Act § 1321(b) and applicable rulemaking.

Provide citation of Exchange-enabling authority:

Shape17

Provide URL of Exchange-enabling authority:

Shape18

I attest this activity is complete

Shape19

I attest this activity will be complete

Completion/Expected
Completion Date

1.2 Authority to Certify Qualified Health Plans (QHPs): The Exchange will have the appropriate state authority to certify QHPs and oversee QHP issuers consistent with 45 CFR § 155.1010(a), in coordination with the appropriate state insurance oversight entity.

Provide citation of Exchange-enabling authority:

Provide URL of Exchange-enabling authority:

Shape23

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

1.3 Risk Adjustment: If the Exchange opts to perform risk adjustment, the state will have the legal authority to operate the risk adjustment program per 45 CFR § 153 and Affordable Care Act 1343.

Exchange will perform risk adjustment.

Exchange opts not to perform risk adjustment.

Provide citation of authority to operate risk adjustment:

Provide URL of authority to operate risk adjustment:

Shape29

I attest this activity is complete

Shape30

I attest this activity will be complete

Completion/Expected
Completion Date

1.4 Authority to Generate Revenue: The Exchange will have the appropriate authority to generate revenue to ensure operational sustainability and will have defined methods for generating revenue (e.g., user fees) pursuant to ACA § 1311(d)(5)(A).

Provide citation of Exchange-enabling authority:

Provide URL of Exchange-enabling authority:

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape35 1.5 If applicable: Board and Governance Structure: If the Exchange is an independent State agency or a non-profit entity established by the State, the Exchange will establish a board and governance structure in compliance with ACA § 1311(d) and 45 CFR § 155.110.

Exchange will establish a board and governance structure.

Exchange opts not to establish a board and governance structure.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape39 1.6 Public Notice and Engagement

a. The Exchange will issue a public notice of its Exchange Blueprint application submission through its website in compliance with 45 CFR § 155.106(a)(2)(i).

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

URL for public notice:

Shape45 b. The Exchange will conduct at least one public engagement (such as a townhall meeting or public hearing) either in-person or virtually, regarding the Exchange Blueprint application progress in compliance with 45 CFR § 155.106(a)(2)(ii). The Exchange will submit a plan to CMS for approval. Following the initial public engagement, the Exchange will conduct periodic public engagements, either in-person or virtually, in a timeframe and manner considered effective by the State.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Date(s) and format of public engagement(s):

Shape49 1.7 Stakeholder Consultation: The Exchange will conduct stakeholder consultation to seek input for the duration of Exchange planning and operation pursuant to 45 CFR § 155.130. This includes consultation with consumers, small businesses, State Medicaid and CHIP agencies, agents/brokers, large employers, if applicable, Federally-recognized Tribes, as defined in the Federally Recognized Indian Tribe List Act of 1994, 25 U.S.C. 479a and other relevant stakeholders.

I attest this activity is complete

Shape53

I attest this activity will be complete

Completion/Expected
Completion Date

1.8 Open Enrollment: The Exchange will provide an initial Open Enrollment period and annual open enrollment periods in accordance with 45 CFR § 155.410.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

2.0 Consumer Assistance Tools and Programs

Shape57 2.1 Call Center

a. The Exchange will establish and operate a toll-free call center that will provide eligibility and enrollment support and will respond to any requests for assistance from consumers pursuant to 45 CFR § 155.205(a).

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape62 b. The Exchange call center will provide information to consumers in a manner that is accessible and timely for individuals living with disabilities and for individuals who have limited English proficiency, including providing about and informing consumers of the availability of auxiliary aids and services, and oral interpretation at no cost to the consumer, in accordance with CMS regulations and guidance pursuant to 45 CFR § 155.205(c)(1), (c)(2)(i), and (c)(3).

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape64 c. The Exchange call center will provide consumers with access to a live call center representative during the Exchange's published hours of operation, who can assist consumers with filing their Exchange application, including providing consumers with information on their eligibility for Advance Premium Tax Credits (APTCs) and Cost-Sharing Reductions (CSRs), facilitating a consumer's comparison of QHPs, and helping consumers complete their Exchange applications for submission to the Exchange, pursuant to 45 CFR § 155.205(a).

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape67 2.2 Website

a. The Exchange will establish and maintain an up-to-date internet website in accordance with 45 CFR § 155.205(b).

I attest this activity is complete

Shape72

I attest this activity will be complete

Completion/Expected
Completion Date

b. The Exchange will engage with and solicit feedback from experts, stakeholders, consumers, and CMS in the website design process to ensure website ease of use for consumers and functionality. This includes ease of access to information on health coverage programs and assisters, as well as ease of navigation to the online eligibility application and enrollment process without assister support (i.e., applicant self-service in applying for, and enrolling in, coverage through the Exchange). The Exchange will submit a plan to CMS for approval.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape75 c. The Exchange website will supply comparative information on available QHPs, which may be provided through consumer-facing plan comparison and shopping tools, and will include information on premiums and cost sharing, benefits and coverage, metal categories, and all other requirements in accordance with 45 CFR § 155.205(b)(1).

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape77 d. The Exchange website will provide consumers with information about Navigators as described in 45 CFR § 155.210 and other consumer-assistance services, including the toll-free telephone number of the Exchange call center in accordance with 45 CFR § 155.205(b)(3). The website must clearly define and explain the roles of Navigators and other assisters in the QHP selection and enrollment process.

I attest this activity is complete

Shape80

I attest this activity will be complete

Completion/Expected
Completion Date

e. The Exchange website will allow for eligibility determinations to be made in accordance with 45 CFR § 155 Subpart D pursuant to 45 CFR § 155.205(b)(4).

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape85 f. The Exchange website will allow for qualified individuals to select a QHP in accordance with 45 CFR § 155 Subpart E pursuant to 45 CFR § 155.205(b)(5).

I attest this activity is complete

Shape86

I attest this activity will be complete

Completion/Expected
Completion Date

g. The Exchange website will make 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 CSRs pursuant to 45 CFR § 155.205(b)(6).

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape90 h. The Exchange website will meet accessibility standards including providing information to consumers in plain language, and in a manner that is accessible and timely for individuals living with disabilities and for individuals who have limited English proficiency, in accordance with CMS regulations and guidance pursuant to 45 CFR § 155.205(c). The Exchange website will inform individuals about the availability of auxiliary aids and services for people with disabilities, language services at no cost to the individual, oral interpretation, and written translations. It will provide taglines in non-English languages indicating the availability of language services.

I attest this activity is complete

Shape92

I attest this activity will be complete

Completion/Expected
Completion Date

2.3 Outreach and Education

a. The Exchange will coordinate and conduct outreach and education activities to educate consumers about the Exchange and insurance affordability programs, and to encourage consumer participation in the Exchange as specified in 45 CFR § 155.205(e). These activities could include, for example, informational marketing materials, advertisements, community outreach events, or other outreach and education activities that the Exchange determines suitable for its consumers.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape97 b. The Exchange will fund its outreach and education activities in an amount that is sufficient, based upon the State’s assessment, to reach and educate potential consumers, including currently uninsured residents in the State. The Exchange will provide its outreach and education plan to CMS.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape99 c. The Exchange outreach and education information will meet accessibility standards including providing information to consumers in plain language, and in a manner that is accessible and timely for individuals living with disabilities and for individuals who have limited English proficiency, in accordance with CMS regulations and guidance pursuant to 45 CFR § 155.205(c). The Exchange outreach and education information will inform individuals about the availability of auxiliary aids and services for people with disabilities, language services at no cost to the individual, oral interpretation, and written translations. It will provide taglines in non-English languages indicating the availability of language services.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape102 2.4 Consumer Assistance: The Exchange will implement consumer assistance functions in accordance with 45 CFR § 155.205(d) including providing 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.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape105 2.5 Navigator Program

a. The Exchange will establish, fund, and operate a Navigator program through which it will award grants to eligible entities or individuals capable of carrying out Navigator duties as required under 45 CFR § 155.210.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Upload document that outlines how State is implementing Navigator program according to regulatory requirements 45 CFR § 155.210.

Shape111 b. Total funding available to Navigator applicants and the final amount of Navigator grantees in the state should consider that Navigators will provide targeted assistance to uninsured individuals, consumers currently enrolled in QHP coverage, and underserved or vulnerable populations, as identified by the Exchange, within the Exchange’s service area.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape114 c. The Exchange will develop and publicly disseminate a set of standards for Navigator grantees to meet that prevent or minimize potential conflicts of interest that may exist for entities or individuals to be awarded grants in accordance with 45 CFR § 155.210(b)(1).

I attest this activity is complete

Shape116

I attest this activity will be complete

Completion/Expected
Completion Date

d. The Exchange will develop and publicly disseminate a set of training standards for Navigator grantees to meet that ensure expertise concerning topics such as QHP options, insurance affordability programs, eligibility and enrollment rules and regulations, privacy and security standards, and all other requirements in accordance with 45 CFR § 155.210(b)(2).

I attest this activity is complete

Shape120

I attest this activity will be complete

Completion/Expected
Completion Date

e. The Exchange will enter into agreements pursuant to 45 CFR § 155.260(b) with Navigator grantees to ensure adherence to all terms and conditions of privacy and security standards.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape122 2.6 Non-Navigator Assistance Personnel

If the Exchange opts to have a non-Navigator assistance personnel program, the Exchange will maintain full responsibility for program operations, as well as for selecting and ensuring the proper training of all non-Navigator assistance personnel in the Exchange. Specifically, the Exchange will develop and implement a training program for non-Navigator assistance personnel and ensure they comply with all applicable regulatory requirements, including 45 CFR §§ 155.205(d)-(e), 45 CFR 155.215, and 45 CFR 155.260(b).

The Exchange will use non-Navigator assistance personnel.

The Exchange does not opt to use non-Navigator assistance personnel.

I attest this activity is complete

Shape127

I attest this activity will be complete

Completion/Expected
Completion Date

2.7 Certified Application Counselors (CACs)

a. The Exchange will establish a CAC program pursuant to 45 CFR § 155.225 and will either designate an organization to certify CACs to perform specified duties, directly certify CACs to perform specified duties, or implement a combination of both these approaches in establishing its CAC program.

I attest this activity is complete

Shape131

I attest this activity will be complete

Completion/Expected
Completion Date

b. If the Exchange designates an organization to certify CACs (i.e., a CAC designated organization [CDO]), the Exchange will establish a formal agreement with the CDO pursuant to § 155.225(b)(i), and ensure that the CDO meets the standards and requirements for CACs pursuant to § 155.225(b).

The Exchange will designate an organization to certify CACs.

The Exchange does not opt to designate an organization to certify CACs.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape135 c. The Exchange will ensure, either directly or through a CDO, that CACs meet certification standards established by the Exchange including completion of approved required Exchange training pursuant to 45 CFR § 155.225(d) and that CACs comply with all applicable regulatory requirements, including 45 CFR § 155.225(e), 45 CFR § 155.225(f), and 45 CFR § 155.225(g).

I attest this activity is complete

Shape138

I attest this activity will be complete

Completion/Expected
Completion Date

d. The Exchange will ensure CACs adherence to all terms and conditions of privacy and security standards pursuant to 45 CFR § 155.260(b).

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape141 2.8 Agents and Brokers: If the Exchange permits agents and brokers to assist consumers with enrolling in QHPs pursuant to 45 CFR § 155.220, the Exchange will clearly define the role of agents and brokers including, as applicable, evidence of licensure, training, and compliance with regulatory requirements under 45 CFR § 155.220.

The Exchange will use agents and brokers to assist consumers with enrolling in QHPs.

The Exchange does not opt to use agents and brokers to assist consumers with enrolling in QHPs.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape145 a. The Exchange will ensure that an agent or broker receives consent from an applicant to access the applicant’s personally-identifiable information prior to assisting applicants in applying for and enrolling in coverage through the Exchange, in accordance with 45 CFR § 155.220(c). The Exchange will ensure that an agent or broker confirms an applicant’s completion of an eligibility application through the Exchange internet website in order for the applicant to receive and eligibility determination.

I attest this activity is complete

Shape148

I attest this activity will be complete

Completion/Expected
Completion Date

b. The Exchange will have an agreement in place with agents and brokers operating in the individual Exchange consistent with 45 CFR § 155.220(d). The agreement will ensure agent and broker compliance with regulatory requirements including advanced registration with the Exchange, completed training on QHP options and insurance affordability program(s), and adherence to privacy and security standards pursuant to 45 CFR § 155.260.

I attest this activity is complete

Shape151

I attest this activity will be complete

Completion/Expected
Completion Date

2.9 Web Brokers:

Shape154 If the State permits web-brokers to enroll consumers in QHPs, and assist consumers in applying for insurance affordability programs, the Exchange will ensure that any web-broker whose non-Exchange website will be used to select QHPs will comply with all applicable provisions of 45 CFR § 155.220.

The Exchange will use Web Brokers.

The Exchange does not opt to use Web Brokers.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape156 a. The Exchange, in accordance with 45 CFR § 155.220, will ensure a web broker non-Exchange website discloses and displays the standardized, comparative QHP information provided by the Exchange or directly by QHP issuers, along with standardized disclaimers, and provides a web link to the Exchange’s website.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape159 b. In accordance with 45 CFR § 155.220(n), the Exchange will ensure a web broker non-Exchange website prominently displays information provided by the Exchange pertaining to a consumer’s eligibility for APTCs or CSRs.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape162 c. In accordance with 45 CFR § 155.220(n), the Exchange will ensure that a web broker non-Exchange website provides consumers with correct information, without omission of material fact, regarding the Exchange, QHPs offered through the Exchange, and insurance affordability programs.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape165 d. In accordance with 45 CFR § 155.220(n), the Exchange will establish the form and manner for its web-brokers to demonstrate operational readiness and compliance with applicable requirements to the Exchange, prior to the web-broker’s website being used to complete an Exchange eligibility application or a QHP selection.

Upload document that outlines operational readiness criteria and assessment process.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

3.0 Eligibility and Enrollment

Shape169 Shape171 3.1 Single, Streamlined Application: The Exchange will use either the CMS-developed single, streamlined application or a State-developed alternative single, streamlined application for health insurance coverage as provided under 45 CFR § 155.405. The Exchange will perform State user testing and submit results, upon request, to CMS.

Individual application (check one):

State-developed alternative

Shape172 CMS-developed

a. The Exchange will ensure that the single, streamlined application only requires information that is necessary for determining eligibility in a QHP for the individual market, and for insurance affordability programs as specified in 45 CFR § 155.405 and in applicable CMS guidance and that it minimizes consumer burden including through only requiring applicants to enter information once and clearly marking optional fields.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape175 b. The Exchange will ensure that the single, streamlined application provides a separate question flow for applicants who are not requesting an eligibility determination or assessment for insurance affordability programs from the question flow for applicants who are requesting an eligibility determination or assessment for insurance affordability programs.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape178 c. The Exchange will ensure that the single, streamlined application contains the appropriate screening questions for non-MAGI Medicaid programs, so that the Exchange is able to refer potentially eligibility applicants to the appropriate State Medicaid Agency (SMA) or State human services agency for a full determination of eligibility for non-MAGI Medicaid.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape181 d. As a designated voter registration entity under the National Voter Registration Act (NVRA), the Exchange will ensure the single, streamlined application contains an opportunity for all applicants to obtain voter registration information and be directed to the State’s pathway to voter registration.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape184 e. The Exchange will ensure that the single, streamlined application collects consent from the application filer to use the information provided to verify applicant information through electronic data sources, as required by privacy agreements between the Social Security Administration, Internal Revenue Service, and Department of Homeland Security.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape187 f. The Exchange will ensure that the single, streamlined application collects consent from the application filer to use the information provided to verify applicant information through electronic data sources, as required by privacy agreements between the Social Security Administration, Internal Revenue Service, and Department of Homeland Security.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape190 g. An Exchange will ensure that the single, streamlined application provides an applicant with eligibility results that clearly detail each applicant’s program eligibility and any data inconsistencies, if applicable. The eligibility results must also detail next steps and provide the opportunity for the application filer to view and print their Eligibility Determination Notice (EDN). Under 45 CFR § 155.302(b)(4), the Exchange must also give all applicants who are found ineligible for Medicaid the opportunity to request a full Medicaid determination.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape194 3.2 Coordination Strategy with Insurance Affordability Programs and SHOP

a. The Exchange will develop and document a coordination strategy with other entities administering insurance affordability programs and the Small Business Health Options Program (SHOP) that enables the Exchange to carry out eligibility and enrollment activities, consistent with 45 CFR §§ 155.345(a),155.510(a) and 155.706.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape197 b. If electing to make final eligibility determinations for MAGI based Medicaid, the Exchange will ensure that all processes for determining MAGI based Medicaid eligibility are consistent with the processes in place at the SMA. This includes all processes for verifying applicant data, notifying applicants of their eligibility results, and for resolving any data inconsistencies. The Exchange will document their agreement with the SMA on these processes.

I attest this activity is complete

Shape201

I attest this activity will be complete

Completion/Expected
Completion Date

c. The Exchange will have the capability to accept and process applications for individual Exchange coverage that have been collected by, and transferred from, its respective SMA or state human services agency that processes insurance affordability program applications without undue delay in accordance with 45 CFR § 155.345(a). The Exchange must accept all eligibility information and verification from its respective State Medical Agency (SMA) and must not duplicate any verifications or collect information from an applicant/consumer that was previously collected by the SMA. The Exchange must also provide notice of receipt of information, and final eligibility determination to the SMA. The Exchange agrees to test this process between the Exchange and the SMA, or other participating agency, and submit those results to CMS upon request.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape203 d. The Exchange will also have the capability to collect and transmit verified applicant information to the applicable state agencies necessary to provide coverage to an applicant determined or assessed eligible for Medicaid and CHIP without undue delay, in accordance with 45 CFR § 155.345(a). The Exchange agrees to test this process between the Exchange and the SMA, or other participating agency, and submit those results to CMS upon request.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape206 3.3 Accepting and Processing Applications and Application Updates Year.

a. The Exchange will have the capability in place to accept and process initial applications for eligibility per the requirement at 45 CFR § 155.310(a).

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape210 b. The Exchange will have the capability in place to accept and process application updates or consumer changes in circumstances in accordance with the requirement at 45 CFR § 155.330.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape214 c. The Exchange will have the capability in place to accept applications from enrollees who have disabilities or limited English proficiency or literacy, as well as applications received through all required channels, including in person, online, mail, and phone as required per 45 CFR § 155.205.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape216 3.4 Eligibility Verifications. The Exchange will have a process to verify applicant data, as part of the eligibility determination process pursuant to 45 CFR § 155 Subpart D.

a. In accordance with 45 CFR § 155 Subpart D, the Exchange will and maintain an Eligibility Verification plan, available for CMS review upon request, that describes the Exchange’s data sources and processes used for conducting required eligibility verifications for eligibility in a QHP and eligibility for insurance affordability programs in accordance with 45 CFR §155 Subpart D.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape220 b. The Exchange will have the capability to process inconsistencies in accordance with 45 CFR § 155 Subpart D, when the Exchange cannot verify information required to determine eligibility for enrollment in a QHP through the Exchange, or advance payments of the premium tax credit and cost-sharing reductions. The Exchange will send notices to the applicant regarding the inconsistency without delay and will provide a minimum of 90 days resolution period for the applicant, with the option to extend the resolution period for income inconsistencies at the discretion of the Exchange.

I attest this activity is complete

Shape223

I attest this activity will be complete

Completion/Expected
Completion Date

c. The Exchange will take action on the consumer pursuant to the requirements at 45 CFR § 155.305(f)(4) when the Exchange finds that a tax-payer has failed to file an income tax return reconciling advanced payments of premium tax credit with their actual allotted premium tax credit.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape226 3.5 Conducting Periodic Data Matching: The Exchange will have the capability to conduct periodic data matching (PDM) pursuant to 45 CFR § 155 Subpart D. The Exchange must be able to periodically (at least twice per year) examine available data sources to identify enrollee death, or, for an enrollee who is receiving APTC/CSR, to identify eligibility determinations/enrollment in Medicare, Medicaid, CHIP, or a Basic Health Program (BHP) if applicable. An Exchange operating an integrated eligibility system with a single eligibility rules engine is deemed in compliance with this requirement.

I attest the Exchange operates an integrated eligibility system.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape232 3.6 Conducting Eligibility Determinations and Annual Redeterminations: The Exchange will have the capability to conduct eligibility determinations for the individual market and SHOP, along with individual annual redeterminations, in accordance with 45 CFR § 155 Subpart D.

a. The Exchange will determine individual eligibility for QHP coverage.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape234 b. The Exchange will determine employer eligibility for the Small Business Health Care Tax Credit (SBHCTC) for participation in the SHOP.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape238 c. The Exchange will assess or determine eligibility for Medicaid and CHIP based on modified adjusted gross income (MAGI) and notify the applicant of the opportunity to request a full determination of eligibility from the Medicaid agency.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape240 d. The Exchange will determine eligibility for APTC and CSR and will be able to calculate and apply individual APTC amounts to QHP premiums for APTC-eligible individuals based on the maximum APTC level an individual is eligible for, the premium(s) of the QHP(s) the individual selected, and the APTC level the individual selected to apply to their QHP premium.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape243 e. The Exchange must have the capability to provide special enrollment periods (SEPs) to qualified individuals who have experienced a triggering event as specified in 45 CFR § 155.420, such that they may receive a determination of eligibility and enroll in a QHP, or in the case of current enrollees, that they may make changes to their QHP. The Exchange will conduct pre-enrollment verification of this triggering event, pursuant to 155.420(g).

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape246 f. The Exchange will determine eligibility for exemptions from the shared responsibility payments or has elected to use the CMS service for this function.

Check here if the Exchange plans to use the CMS service for this function.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape251 If State does not elect to use CMS service, upload plan for determining eligibility for exemptions.

g. The Exchange will have the capability to conduct annual eligibility redeterminations and re-enrollments and will submit its procedures for doing so to CMS for approval on an annual basis pursuant to §155.335 (a)(2)(iii).

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape254 3.7 Enrollment Transactions and APTC/CSR Information Processing: The Exchange will have the capability to process individual market QHP enrollment transactions and report eligibility and enrollment information in accordance with 45 CFR §§ 155.400, 155.430, and 155.720 and relevant CMS guidance.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape257 a. The Exchange will have the capability to collect premiums in the processing of individual market QHP enrollment transactions or ensure that the Exchange’s issuers have the capability to collect premiums in the processing of individual market QHP enrollment transactions.

Check here if the Exchange plans to have its issuers perform this function on behalf of the Exchange.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape261 b. The Exchange will have the capability to perform reconciliation of enrollment transactions and APTC/CSR information in coordination with the Exchange’s issuers in a timely manner.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape264 c. The Exchange will have the capability to report and reconcile eligibility and enrollment information in coordination with CMS.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape268 3.8 Eligibility Appeals for Individuals, Employers, and SHOP

a. The Exchange will operate an eligibility appeals process for individual consumers pursuant to 45 CFR 155 Subpart F, which includes:

Operating a first-tier appeals process that should be exhausted prior to utilizing the HHS appeals process option under 45 CFR 155.505(c)(2); and

Appeals from applicants who receive, from the Exchange, an assessment or determination of eligibility for the Medicaid and CHIP programs.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Check one:

The Exchange will delegate authority to the Medicaid and/or CHIP agency to operate an individual eligibility appeals process for applicants who receive, from the Exchange, an assessment or determination of eligibility for the Medicaid and/or CHIP programs.

Shape272 The Exchange will not delegate authority to the Medicaid and/or CHIP agency to operate an individual eligibility appeals process for applicants who receive, from the Exchange, an assessment or determination of eligibility for the Medicaid and/or CHIP programs.

b. The Exchange will determine whether it will operate an employer appeals process, pursuant to 45 CFR §§ 155.555(a) and (b), through which an employer may, in response to a notice under 45 CFR § 155.310(h), appeal a determination that the employer does not provide MEC through an employer-sponsored plan or that the employer does provide coverage but that it is not affordable coverage with respect to an employee. If the Exchange elects not to operate an employer appeals process, appellants will appeal directly to CMS.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Check one:

The Exchange will operate an employer appeals process.

The Exchange will not operate an employer appeals process and use CMS’s employer appeals process instead.

Shape276 If applicable: If the Exchange has elected to operate an employer eligibility appeals process, the Exchange will develop an operational approach that includes employer appeals process flows depicting the eligibility appeals process and the entity/entities that are responsible for processing and adjudicating appeals.

I attest this activity is complete

Shape278

I attest this activity will be complete

Completion/Expected
Completion Date

c. The Exchange will establish a SHOP eligibility appeals process for employers pursuant to 45 CFR § 155.740, including identifying and/or designating the entities responsible for processing SHOP eligibility appeals.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape281 3.9 Electronic Reporting of Eligibility Assessments and Determinations: The Exchange will have the capability to electronically report results of eligibility determinations, including determinations of eligibility for an exemption from the individual responsibility requirement (if applicable), and provide associated information to the federal agencies administering insurance affordability programs including CMS and IRS in accordance with federal guidance. This includes information necessary to support the administration of the APTC and CSR and support the employer responsibility provisions of the ACA.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape284 3.10 Standards for Applications, Forms, and Notices: The Exchange will provide applications, forms, and notices to individuals and SHOP employers that adhere to standards in 45 CFR § 155.230 and 155.310.

a. The Exchange will generate applications, forms, and notices for individuals and SHOP employers that meet accessibility and readability requirements in 45 CFR § 155.205(c). This includes the single, streamlined application, along with notices of eligibility determination and annual redetermination.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape288 b. The Exchange will provide notices that meet the content and format requirements in 45 CFR § 155.230 and will provide individuals with timely noticing of eligibility determinations in accordance with 45 CFR § 155.310.

I attest this activity is complete

Shape291

I attest this activity will be complete

Completion/Expected
Completion Date

c. The Exchange will have the ability to send notices to applicants or enrollees under the circumstances required and specified in 45 CFR § 155 Subpart D, this includes: a notice of initial eligibility determination, a notice of any changes to eligibility identified either through PDM or redeterminations, notice of failure to reconcile (FTR) status, notice of the right to appeal, notice of an incomplete eligibility application, and notice of data that is invalid or inconsistent with electronic verification.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape294 3.11 Centralized Eligibility and Enrollment Platform

a. The Exchange will operate a centralized eligibility and enrollment platform on the Exchange’s website such that the Exchange allows for the submission of the single, streamlined application for enrollment in a QHP and insurance affordability programs by consumers through the Exchange's website, and performs eligibility determinations for all consumers based on submissions of the single, streamlined application, in accordance with 45 CFR § 155.205(b)(4).

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape298 b. Through the centralized eligibility and enrollment platform operated on its website, the Exchange will make all determinations regarding consumer eligibility for QHP coverage and insurance affordability programs, regardless of whether an individual files an application for enrollment in a QHP on the Exchange's website, or on a non-Exchange website operated by an entity described under 45 CFR § 155.220, such as a web broker defined at 45 CFR § 155.20, or a direct enrollment entity or QHP issuer described under 45 CFR § 155.221.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape301 c. As the eligibility determination function is inherently a function that only the Exchange should perform, the Exchange will operate its own centralized eligibility and enrollment platform, or contract with a private vendor or state entity to operate its centralized eligibility and enrollment platform to perform this function on behalf of the Exchange, in accordance with 45 CFR § 155.302(a). The Exchange will not rely on non-Exchange entities, including a web broker defined at 45 CFR § 155.20 or other entity under 45 CFR § 155.220 or § 155.221, to make eligibility determinations on behalf of the Exchange.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape304 d. Through the centralized eligibility and enrollment platform operated on its website, the Exchange will maintain records of all effectuated enrollments in QHPs, including changes in effectuated QHP enrollments, in accordance with 45 CFR § 155.205(b)(5).

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape307 3.12 Direct Enrollment Entities: If the Exchange opts to establish a Direct Enrollment program, the Exchange will permit QHP issuers and web brokers that meet applicable provisions in 45 CFR § 155.221 and other applicable regulatory requirements to assist consumers with direct enrollment in QHPs offered through the Exchange in a manner that is considered to be through the Exchange, to the extent permitted by applicable state law.

The Exchange will use Direct Enrollment Entities.

The Exchange will not use Direct Enrollment Entities.

a. The Exchange, in accordance with 45 CFR § 155.221(j), will ensure a direct enrollment entity displays and markets QHPs offered through the Exchange, individual health insurance coverage as defined in 45 CFR § 144.103 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, excepted as permitted under 45 CFR § 155.221(c).

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape311

b. The Exchange, in accordance with 45 CFR § 155.221(j), will ensure a direct enrollment entity limits 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 45 CFR § 155.221(c)(1).

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape314 c. The Exchange, in accordance with 45 CFR § 155.221(j), may permit direct enrollment entity application assisters, to the extent permitted by state law, to assist individuals in the individual market with applying for a determination or redetermination of eligibility for coverage through the Exchange and for insurance affordability programs, provided that the direct enrollment entity ensures that each of its direct enrollment application assisters meets the requirements in 45 CFR § 155.415(b).

I attest this activity is complete

Shape317

I attest this activity will be complete

Completion/Expected
Completion Date

d. The Exchange, in accordance with 45 CFR § 155.221(j), will establish the form and manner for its direct enrollment entities to 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. The direct enrollment entity’s demonstration of operational readiness may include submission and/or completion of business audit documentation and security and privacy audit documentation as listed in 45 CFR § 155.221(j)(2), in the form and manner specified by the Exchange.

Upload document that outlines operational readiness criteria and assessment process.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

4.0 Plan Management

Shape320 4.1 Certification of Qualified Health Plans for the Individual Market and SHOP

a. The Exchange will develop the necessary infrastructure to certify QHPs pursuant to 45 CFR § 155.1010(a), including plan management system(s) or processes that support the collection of QHP issuer and plan data; facilitate the QHP certification process; and manage QHP issuers and plans. This includes the Exchange working in coordination with the appropriate state regulatory entity (e.g., the state’s department of insurance) to ensure the necessary organizational capacity will be in place.

I attest this activity is complete

Shape324

I attest this activity will be complete

Completion/Expected
Completion Date

b. The Exchange will have a review process in place for ensuring issuers and health plans meet the minimum QHP certification standards pursuant to CFR § 155.1000(c) and 45 CFR § 156. This includes the Exchange coordinating with the appropriate state regulatory entity (e.g., the state’s department of insurance) to ensure the necessary review processes will be in place to ensure the applicable QHP certification standards are met.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape327 4.2 QHP Monitoring and Compliance: The Exchange will have the capacity to ensure QHPs’ ongoing compliance with QHP certification requirements pursuant to 45 CFR § 155.1010(a)(2).

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape330 4.3 Recertification: The Exchange will have a process in place for QHP issuer recertification that will, at a minimum, include a review of initial certification criteria, pursuant to 45 CFR § 155.1075.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape333 4.4 Decertification and Appeals: The Exchange will have a process in place for QHP decertification, including appeal of decertification determinations, and notice of decertification to appropriate parties, pursuant to 45 CFR § 155.1080.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape336 4.5 Issuer Accreditation and Enforcement: The Exchange will set a timeline for QHP issuer accreditation in accordance with 45 CFR § 155.1045. The Exchange will also have systems and procedures in place to ensure QHP issuers meet accreditation requirements (per 45 CFR § 156.275) as part of QHP certification in accordance with applicable rulemaking and guidance.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape340 4.6 Quality Reporting: The Exchange will have systems and procedures in place to ensure that QHP issuers meet the minimum certification requirements pertaining to quality reporting and provide relevant information to the Exchange and CMS pursuant to ACA §§ 1311(c)(1), 1322(e)(3), and as specified in rulemaking.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape344 4.7 Network Adequacy: The Exchange will enforce network adequacy standards that ensure that the provider network of each QHP on the Exchange meets the standards specified in 45 CFR § 155.1050.

a. Network Adequacy: The Exchange will establish and impose network adequacy time and distance standards for QHPs that are at least as stringent as standards for QHPs participating on the Federally-facilitated Exchanges, approved by HHS under 155.1050(a)(2)(i), for plan years beginning on or after January 1, 2026, as specified in 45 CFR § 155.1050.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape346 b. Network Adequacy: The Exchange will conduct, prior to QHP certification, quantitative network adequacy reviews to evaluate compliance, and require that all issuers seeking certification of a plan as a QHP submit information to the Exchange reporting whether or not network providers offer telehealth services.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape349 c. Network Adequacy: The Exchange will apply and enforce alternate quantitative network adequacy standards, approved by HHS under 155.1050(a)(2)(ii), for plan years beginning on or after January 1, 2026, that are reasonably calculated to ensure a level of access to providers that is as great as that ensure by the Federal network adequacy standards and the Exchange will evaluate whether plans comply with applicable network adequacy standards prior to certifying any plan as a QHP.

Exchange will apply, enforce, and evaluate HHS-approved alternative quantitative network adequacy standards.

Exchange will apply federal standards.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Upload approved alternative network adequacy strategy plan.

5.0 SHOP

Shape355 5.1 Employer Size: The state will determine the size of a small employer, as well as methods for determining whether an employee is a full-time employee (FTE).

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Select the size of a small employer:

1–50

1–100

Select method state will use to count employees:

Federal FTE method

State method

Shape359 5.2 Enrollment: The Exchange will determine whether to perform enrollment functions, or to permit enrollment directly through QHP issuers and/or registered agents/brokers, or both serve as the enrollment platform and permit enrollment directly through QHP issuers and/or registered agents/brokers in accordance with 45 CFR 155 Subpart H.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Select the Exchange’s enrollment method:

The Exchange will provide an enrollment platform without permitting enrollment directly through QHP issuers and/or registered agents/brokers.

The Exchange will provide an enrollment platform and permit enrollment directly through QHP issuers and/or registered agents/brokers

The Exchange will both provide the enrollment platform, and permit enrollment directly through QHP issuers and/or registered agents/brokers.

Other

If “other,” please describe the enrollment method:

Shape364 5.3 Employer and Employee Choice: The Exchange will establish whether SHOP will offer employer and/or employee choice, in accordance with 45 CFR §§ 155.706(b)(2)-(3).

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Select the Exchange’s employee choice method:

Horizontal Choice

Vertical Choice

Shape369 Both

5.4 Rates: The Exchange will require all QHP issuers to make any changes to rates at uniform time that is quarterly, monthly, or annually, and prohibits all QHP issuers from varying rates for a qualified employer during the employer’s plan year, in accordance with 45 CFR § 155.706(b)(6).

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape371 5.5 Premium Calculator: The Exchange will establish the premium calculator for SHOP in accordance with 45 CFR § 155.706(b)(11).

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Provide website link to premium calculator:

Shape376 5.6 Uniform Enrollment Timeline: The Exchange will develop a uniform enrollment timeline and process that includes information pertaining to grace periods, effective dates of coverage, enrollment periods, and reinstatement policies, in accordance with 45 CFR § 156.286(b).

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape378 5.7 Minimum Participation: If the Exchange implements minimum participation requirements in the SHOP, state regulatory authority exists for uniform group participation rules for offering health insurance coverage in the SHOP.

The Exchange will implement minimum participation requirements and designate or establish a state regulatory authority to monitor them.

The Exchange will not implement minimum participation requirements.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Provide citation of state regulatory authority for SHOP uniform participation rules:

Shape383 5.8 Eligibility Determinations: The Exchange will develop and maintain a website that is capable of providing employer eligibility determinations for the Small Business Healthcare Tax Credit (SBHCTC).

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

6.0 Finance and Organization

Shape386 6.1 Cost, Budget, and Management Plan: The Exchange will have a long-term budget (i.e., with costs and revenues) and management plan, and will have long-term strategies for financial sustainability as required by ACA § 1311(d)(5)(A) and 45 CFR § 155.160(b).

a. The Exchange will establish methods to generate revenue and address any financial deficits.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape391 b. The Exchange will have the ability to annually submit a multi-year operational budget and management plan as required by CMS pursuant to 45 CFR § 155.1200(a)(3).

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape394 6.2 Financial Accounting Procedures and Financial Statement: The Exchange will keep accurate financial accounting procedures in accordance with generally accepted accounting principles (GAAP) pursuant to 45 CFR § 155.1200(a)(1). The Exchange will provide a financial statement in accordance with GAAP principles pursuant to 45 CFR § 155.1200(b)(1).

I attest this activity is complete

Shape396

I attest this activity will be complete

Completion/Expected
Completion Date

6.3 Oversight of Entities Eligible to Carry Out Exchange Functions: The Exchange will establish agreements and oversee entities who carry out one or more responsibilities of the Exchange in accordance with 45 CFR § 155.110(a) and (b).

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape399 6.4 Exchange Organizational Structure and Staffing Plan: The Exchange will implement an organizational structure and staffing plan that enables the Exchange to support its ongoing business operations and perform all functions of an Exchange described in 45 CFR §155.200.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape402 6.5 Publish Financial Information: The Exchange will publish financial information including the average costs of licensing required by the Exchange, any regulatory fees required by the Exchange, monies lost to waste, fraud and abuse, and all other requirements in accordance with 45 CFR § 155.205(b)(2).

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

7.0 Technology

Shape406 7.1 Information Technology (IT) Operational Readiness Reviews, Consults, and Artifacts: The Exchange will comply with relevant CMS IT guidance and will complete IT operational readiness reviews and consults with CMS.

a. The Exchange will complete IT operational readiness reviews with CMS through successful completion of all activities, consults, and submission of artifacts and/or completion of all iterations or functional equivalents for each project phase as agreed to with CMS.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape410 b. The Exchange will follow necessary CMS guidelines to participate in formal federal integration testing.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape412 c. The Exchange will demonstrate all core functionality of its Exchange through an online demonstration.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape415 d. The Exchange will participate in IT operational readiness reviews (ORRs), as appropriate, conducted by the Centers for Medicaid & CHIP Services (CMCS) as part of its requirements and oversight of IT projects receiving enhanced federal financial participation under Title XIX of the Social Security Act. The Exchange will submit required artifacts and activities, or functional equivalents as agreed to with CMS.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape419 7.2 Essential Functionality: The Exchange will determine its IT integration approach for implementing essential functionality of its Exchange, such as assigning internal resources and/or contracting for a systems integrator or for technology services.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

8.0 Privacy and Security

Shape421 All SBEs will need to meet security and privacy standards under 45 CFR §§ 155.260 and 155.280. As a condition to connect to the FDSH, CMS requires states to use the Minimum Acceptable Risk Standards for Exchanges (MARS-E) guidance as a minimum standard upon which to base their own security standards. In addition, SBEs should refer to the checklist in the Privacy and Security Timelines and Artifacts For Health Insurance Marketplaces, Medicaid/CHIP Agencies and Partner Organizations to determine the privacy and security documents that apply to them.

8.1 Privacy Standards, Policies, and Procedures: The Exchange will establish and implement written policies and procedures and will execute required privacy agreements with CMS according to the standards set forth in 45 CFR § 155.260.

a. The Exchange will complete the ACA Health Insurance Exchange Privacy Impact Assessment (PIA) and submit it to CMS.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape427 b. The Exchange will sign and submit the Computer Matching Agreement (CMA) between CMS and state-based administering entities to CMS.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape430 c. The Exchange will sign and submit the Information Exchange Agreement (IEA) to CMS.

I attest this activity is complete

Shape433

I attest this activity will be complete

Completion/Expected
Completion Date

8.2 Security Standards, Policies, and Procedures: The Exchange will establish and implement written policies and procedures and will execute required security agreements with CMS according to the standards set forth in 45 CFR § 155.260.

a. The Exchange will submit its System Security Plan (SSP) workbook to CMS.

I attest this activity is complete

Shape437

I attest this activity will be complete

Completion/Expected
Completion Date

b. The Exchange will submit its Independent Security Assessment Report (SAR) to CMS.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape440 c. The Exchange will submit its Plan of Actions & Milestones (POAM) based on residual risks identified during the Independent Assessment to obtain an initial Authority to Connect to the FDSH.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape444 d. The Exchange will execute all required Interconnection Security Agreements (ISA) (i.e., Master and Associate ISAs).

I attest this activity is complete

Shape446

I attest this activity will be complete

Completion/Expected
Completion Date

8.3 IRS FTI Safeguards: The Exchange will establish safeguards to protect the confidentiality of all federal information received through the FDSH, including but not limited to federal tax information.

a. The Exchange will develop its ACA Safeguards Security Report (SSR) for IRS for approval.

I attest this activity is complete

Shape450

I attest this activity will be complete

Completion/Expected
Completion Date

b. The Exchange will receive a letter of acceptance from the IRS on its SSR.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape453 8.4 Connection to the FDSH Production Environment: The Exchange will implement, and verify with CMS that it has met, the privacy and security safeguards required to connect to the FDSH production environment.

a. The Exchange will perform its own System Authorization and will receive an Authority to Operate (ATO) from the Exchange authorizing official.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape458 b. The Exchange will obtain CMS approval for an Authority to Connect (ATC) to the FDSH production environment.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

9.0 Program Integrity and Oversight

Shape460 9.1 Maintenance of Records: The Exchange will have the capacity to maintain books, records, documents, and other evidence of procedures and practices to demonstrate compliance with federal requirements for each benefit year for at least 10 years pursuant to 45 CFR § 155.1210.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape463 9.2 Oversight and Monitoring: The Exchange will establish and implement a comprehensive oversight and monitoring plan that includes policies and procedures to identify incidents of fraud, waste, and abuse.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape466 9.3 Program Integrity Reporting: The Exchange will conduct program integrity and oversight activities in accordance with 45 CFR § 155.1200. This includes completion of the State-based Marketplace Annual Reporting Tool (SMART); independent external programmatic and financial audits; and participation in oversight activities and readiness reviews as determined necessary by CMS.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape469 9.4 Enrollment Metrics: The Exchange will develop policies, procedures, and a timeline for collecting and reporting enrollment metrics. The Exchange will submit individual and, if applicable, SHOP enrollment indicator metric reports in accordance with CMS timelines and templates.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

10.0 Contingency Planning

Shape472 10.1 Contingency/Risk Mitigation Operations

a. The Exchange will establish a contingency plan for any functionality that may not be available or ready to begin Open Enrollment operations as an SBE, which includes any interim work-around or risk mitigation plans, as well a plan to move from the work around to a final solution at a later date.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape478 b. The Exchange will establish both an operational contingency and a recovery operations plan.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

PART D: STATE-BASED EXCHANGE ON THE FEDERAL PLATFORM BLUEPRINT APPLICATION

1.0 Legal Authority and Governance

Shape479 1.1 SBE-FP Federal Platform Agreement: The Exchange will execute a Federal Platform Agreement with CMS prior to the beginning of Open Enrollment for any coverage year in which the Exchange elects to operate on the federal platform (45 CFR § 155.106(c)(4)).

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape482 1.2 Exchange Enabling Authority: The Exchange will have the appropriate authority to operate an SBE-FP compliant with Affordable Care Act § 1321(b) and applicable rulemaking.

Provide citation of Exchange-enabling authority:

Provide URL of Exchange-enabling authority:

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape487 1.3 Authority to Certify Qualified Health Plans (QHPs): The Exchange will have the appropriate state authority to certify QHPs consistent with 45 CFR § 155.1010(a), in coordination with the appropriate state insurance oversight entity.

Provide citation of Exchange-enabling authority:

Provide URL of Exchange-enabling authority:

I attest this activity
is complete

I attest this activity
will be complete

Completion/Expected
Completion Date

Shape492 1.4 Authority to Generate Revenue: The Exchange will have the appropriate authority to generate revenue to ensure operational sustainability and will have defined methods for generating revenue (e.g., user fees) pursuant to ACA § 1311(d)(5)(A). If the Exchange collects the required Federal Platform User Fee from issuers and remit to CMS, the Exchange will have the capability to pay this User Fee to CMS.

Indicate whether the Exchange will collect the required Federal Platform User Fee from issuers and remit to CMS.

Indicate whether the Exchange elects to additionally collect state-level user fees.

Provide citation of Exchange-enabling authority

Provide URL of Exchange-enabling authority

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape498 1.5 If applicable: Board and Governance Structure: If the Exchange is an independent State agency or a non-profit entity established by the State, the Exchange will establish a board and governance structure in compliance with ACA § 1311(d), 45 CFR § 155.110(c).

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape501 1.6 Stakeholder Consultation: The Exchange will conduct stakeholder consultation to seek input for the duration of Exchange planning and operation pursuant to 45 CFR § 155.130. This includes consultation with consumers, small businesses, State Medicaid and CHIP agencies, agents/brokers, large employers, if applicable, Federally-recognized Tribes, as defined in the Federally Recognized Indian Tribe List Act of 1994, 25 U.S.C. 479a, and other relevant stakeholders to the extent CMS is unable to, or in coordination with CMS.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

2.0 Consumer Assistance Tools and Programs

Shape504 2.1 Toll-Free Hotline

a. The Exchange will establish and operate a toll-free telephone hotline to respond to requests for assistance to consumers in the SBE-FP, including the capability to provide information to consumer and appropriately direct them to the federal call center or HealthCare.gov to apply for, and enroll in, QHP coverage pursuant to 45 CFR § 155.205(a).

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape508 b. The Exchange’s toll-free telephone hotline will provide information to consumers in a manner that is accessible and timely for individuals living with disabilities and for individuals who have limited English proficiency, including providing and informing consumers about the availability of auxiliary aids and services, and oral interpretation at no cost to the consumer, in accordance to CMS regulations and guidance pursuant to 45 CFR §§ 155.205(c)(1), (c)(2)(i), and (c)(3).

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape511 2.2 Website

a. The Exchange will establish and maintain an up-to-date internet website in accordance with 45 CFR § 155.205(b).

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape516 b. The Exchange will engage with and solicit feedback from experts, stakeholders, consumers, and CMS in the website design process to ensure website ease of use for consumers and functionality as envisioned under the ACA. This includes ease of access to information on health coverage programs and assisters, as well as ease of navigation to the HealthCare.gov online eligibility application and enrollment process without assister support (i.e., applicant self-service in applying for, and enrolling in, coverage through HealthCare.gov). The Exchange will submit a plan to CMS for approval.

I attest this activity is complete

Shape518

I attest this activity will be complete

Completion/Expected
Completion Date

c. The Exchange will develop, operate, and maintain a tool on its internet website for consumers to use to find local assisters for help with applying for and enrolling in coverage. HealthCare.gov’s Find Local Help tool will direct consumers to the SBE-FP’s tool. The Exchange website must clearly define and explain the roles of Navigators and other assisters in the QHP selection and enrollment process pursuant to 45 CFR § 155.210(e).

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape521 d. The Exchange website will meet accessibility standards including providing information to consumers in plain language and in a manner that is accessible and timely for individuals living with disabilities and for individuals who have limited English proficiency, in accordance with CMS regulations and guidance pursuant to 45 CFR § 155.205(c). The Exchange website will inform individuals about the availability of auxiliary aids and services for people with disabilities, language services at no cost to the individual, oral interpretation, and written translations. It will provide taglines in non-English languages indicating the availability of language services.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape524 2.3 Outreach and Education

a. The Exchange will coordinate with CMS to conduct outreach and education activities to educate consumers about the Exchange and insurance affordability programs, and to encourage consumer participation in the Exchange as specified in 45 CFR § 155.205(e). These activities could include, for example, informational marketing materials, advertisements, community outreach events, or other outreach and education activities that the Exchange determines suitable for its consumers. CMS will provide data to facilitate and support the state’s efforts.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape528 b. The Exchange outreach and education information will meet accessibility standards including providing information to consumers in plain language, and in a manner that is accessible and timely for individuals living with disabilities and for individuals who have limited English proficiency, in accordance with CMS regulations and guidance pursuant to 45 CFR § 155.205(c). The Exchange outreach and education information will inform individuals about the availability of auxiliary aids and services for people with disabilities, language services at no cost to the individual, oral interpretation, and written translations. It will provide taglines in non-English languages indicating the availability of language services.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape531 2.4 Consumer Assistance: The Exchange will implement consumer assistance functions in accordance with 45 CFR § 155.205(d) including providing 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.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape534 2.5 Navigator Program

Upload document that outlines how State is implementing Navigator program according to regulatory requirements 45 CFR § 155.210.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape540 b. Total funding available to Navigator applicants and the final amount of Navigator grantees in the state should consider that Navigators will provide targeted assistance to uninsured individuals, consumers currently enrolled in QHP coverage, and underserved or vulnerable populations, as identified by the Exchange, within the Exchange’s service area.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape543 c. The Exchange will coordinate with the FFE on the timing and communication of the state’s grant application process. The Exchange will also notify existing grantees on the FFE of the need to apply for state funding.

I attest this activity is complete

Shape545

I attest this activity will be complete

Completion/Expected
Completion Date

d. The Exchange will develop and publicly disseminate a set of standards for Navigator grantees to meet that prevent or minimize potential conflicts of interest that may exist for entities or individuals to be awarded grants in accordance with 45 CFR § 155.210(b)(1).

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape549 e. The Exchange will develop and publicly disseminate a set of training standards for Navigator grantees to meet that will ensure expertise concerning topics such as QHP options, insurance affordability programs, eligibility and enrollment rules and regulations, privacy and security standards, and all other requirements in accordance with 45 CFR § 155.210(b)(2).

I attest this activity is complete

Shape551

I attest this activity will be complete

Completion/Expected
Completion Date

f. The Exchange will enter into agreements pursuant to 45 CFR § 155.260(b) with Navigator grantees to ensure adherence to all terms and conditions of privacy and security standards.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape555 2.6 Non-Navigator Assistance Personnel

If the Exchange opts to have a non-Navigator assistance personnel program, the Exchange will maintain full responsibility for program operations, as well as for selecting and ensuring the proper training of all non-Navigator assistance personnel in the SBE-FP. Specifically, the SBE-FP will ensure that non-Navigator assistance personnel complete any required FFE and state-specific training(s) and comply with all applicable regulatory requirements, including 45 CFR §§ 155.205(d)-(e), 45 CFR 155.215, and 45 CFR 155.260(b) .

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape558 2.7 Certified Application Counselors (CACs)

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape562 b. The Exchange will ensure, either directly, or through designated organizations, that CACs complete required State-specific training(s) on topics including QHP options, insurance affordability programs, eligibility and enrollment rules and all other applicable regulatory requirements.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape566 c. The Exchange will ensure CACs adherence to all terms and conditions of privacy and security standards pursuant to 45 CFR § 155.260(b).

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape568 2.8 Agents and Brokers: A state will communicate requirements to licensed agents and brokers to register with the FFE and complete FFE training for agents and brokers to assist consumers with enrolling in QHPs pursuant to 45 CFR § 155.220.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

3.0 Eligibility and Enrollment

Shape571 3.1 Use of the Federal Platform for the Individual Market Eligibility and Enrollment Functions and Associated Eligibility Support Functions: As an SBE-FP, the Exchange will use the federal platform for eligibility and enrollment functions as a bundled package. These include using the FFE’s business rules and operational processes related to processing consumer applications for health insurance coverage, eligibility determinations, enrollment processing, exemptions determinations, annual renewals and redeterminations, special enrollment periods (SEPs), Form 1095-A, Medicaid assessments or determinations, employer notifications, eligibility appeals, consumer call center, and consumer casework.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape574 3.2 Small Business Health Options Program (SHOP) Eligibility Determination: The Exchange will have the ability to make employer eligibility determinations for the Small Business Health Care Tax Credit (SBHCTC).

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape578 3.3 Eligibility Appeals for SHOP: The Exchange will establish a SHOP eligibility appeals process for employers pursuant to 45 CFR § 155.740, including identifying and/or designating the entities responsible for processing SHOP eligibility appeals.

I attest this activity
is complete

I attest this activity
will be complete

Completed/Expected
Completion Date

4.0 Plan Management

Shape580 4.1 Certification of Qualified Health Plans for the Individual Market and SHOP

a. The Exchange will develop the necessary infrastructure to certify QHPs pursuant to 45 CFR § 155.1010(a), including plan management systems or processes that support the collection of QHP issuer and plan data; facilitate the QHP certification process; manage QHP issuers and plans; and review and transmit data to CMS for display of certified QHPs on the federal platform in accordance with applicable CMS timelines and requirements, as detailed in the current final Letter to Issuers in the Federally-facilitated Exchanges. This includes the Exchange coordinating with the appropriate state regulatory entity (e.g., the state’s department of insurance) to ensure the necessary organizational capacity will be in place to perform these functions. CMS will provide data to facilitate and support the state’s efforts.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape584 b. The Exchange will have a review process in place for ensuring issuers and health plans meet the minimum QHP certification standards pursuant to CFR § 155.1000(c) and 45 CFR § 156. This includes the Exchange working in coordination with the appropriate state regulatory entity (e.g., the state’s department of insurance) to ensure the necessary review processes will be in place to ensure the applicable QHP certification standards are met.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape587 c. The Exchange must meet CMS deadlines for transfers of QHP application data to CMS, including deadline for final transfer of certified QHP data to CMS, as described in the Annual CMS Letter to Issuers.

Prior to the first transfer of plan data from the SBE-FP to CMS, the SBE-FP should notify issuers of the change in communications regarding review of QHP applications from CMS to the SBE-FP exclusively (e.g., issuers will no longer receive correction notices from CMS).

Note: FFE states that do not perform plan management functions must first transition system platform and their issuers from the Health Insurance Oversight System (HIOS) to the System for Electronic Rates & Forms Filing (SERFF) to provide CMS with plan data.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape590 4.2 QHP Monitoring and Compliance: The Exchange will have the capacity to ensure QHPs’ ongoing compliance with QHP certification requirements pursuant to 45 CFR § 155.1010(a)(2).

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape593 4.3 Recertification: The Exchange will have a process in place for QHP issuer recertification that will, at a minimum, include a review of initial certification criteria, pursuant to 45 CFR § 155.1075.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape596 4.4 Decertification and Appeals: The Exchange will have a process in place for QHP decertification, including appeal of decertification determinations, and notice of decertification to appropriate parties, pursuant to 45 CFR § 155.1080.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape599 4.5 Issuer Accreditation and Enforcement:

a. The Exchange will set a timeline for QHP issuer accreditation in accordance with 45 CFR § 155.1045. The Exchange will also have systems and procedures in place to ensure QHP issuers meet accreditation requirements (per 45 CFR § 156.275) as part of QHP certification in accordance with applicable rulemaking and guidance.

I attest this activity is complete

Shape603

I attest this activity will be complete

Completion/Expected
Completion Date

b. The Exchange will enforce the federal casework standards in 45 CFR § 156.1010 with respect to issuers participating in the SBE-FP.

I attest this activity is complete

Shape606

I attest this activity will be complete

Completion/Expected
Completion Date

4.6 Network Adequacy: The Exchange will enforce network adequacy standards that ensure that the provider network of each QHP on the Exchange meets the standards specified in 45 CFR § 155.1050.

a. Network Adequacy: The Exchange will establish and impose network adequacy time and distance standards for QHPs that are at least as stringent as standards for QHPs participating on the Federally-facilitated Exchanges, approved by HHS under § 155.1050(a)(2)(i), for plan years beginning on or after January 1, 2026, as specified in 45 CFR § 155.1050.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape611 b. Network Adequacy: The Exchange will conduct, prior to QHP certification, quantitative network adequacy reviews to evaluate compliance, and require that all issuers seeking certification of a plan as a QHP submit information to the Exchange reporting whether or not network providers offer telehealth services.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape614 c. Network Adequacy: The Exchange will apply and enforce alternate quantitative network adequacy standards, approved by HHS under 155.1050(a)(2)(ii), for plan years beginning on or after January 1, 2026, that are reasonably calculated to ensure a level of access to providers that is as great as that ensure by the Federal network adequacy standards and the Exchange will evaluate whether plans comply with applicable network adequacy standards prior to certifying any plan as a QHP.

Exchange will apply, enforce, and evaluate HHS-approved alternate quantitative network adequacy standards.

Exchange will apply federal standards (not alternate standards).

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Upload approved alternative network adequacy strategy plan.

5.0 SHOP

Shape618 5.1 Employer Size: The state will determine the size of a small employer, as well as methods for determining whether an employee is a full-time employee (FTE).

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Select the size of a small employer:

1–50

1–100

Select method state will use to count employees:

Federal FTE method

State method

Shape623 5.2 Enrollment: The Exchange will determine whether to perform enrollment functions, or to permit enrollment directly through QHP issuers and/or registered agents/brokers, or both serve as the enrollment platform and permit enrollment directly through QHP issuers and/or registered agents/brokers, in accordance with 45 CFR 155 Subpart H.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Select the Exchange’s enrollment method:

The Exchange will provide an enrollment platform without permitting enrollment directly through QHP issuers and/or registered agents/brokers.

The Exchange will provide an enrollment platform and permit enrollment directly through QHP issuers and/or registered agents/brokers

The Exchange will both provide the enrollment platform, and permit enrollment directly through QHP issuers and/or registered agents/brokers.

Other

If “other,” please describe the enrollment method:

Shape629 5.3 Employer and Employee Choice: The Exchange will establish whether SHOP will offer employer and/or employee choice, in accordance with 45 CFR § 155.706(b)(2)-(3).

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Select the Exchange’s employee choice method:

Horizontal Choice

Vertical Choice

Both

Shape633 5.4 Rates: The Exchange will require all QHP issuers to make any changes to rates at uniform time that is quarterly, monthly, or annually, and prohibits all QHP issuers from varying rates for a qualified employer during the employer’s plan year, in accordance with 45 CFR § 155.706(b)(6).

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape636 5.5 Premium Calculator: The Exchange will establish the premium calculator for SHOP in accordance with 45 CFR § 155.706(b)(11).

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Provide website link to premium calculator:

Shape640 5.6 Uniform Enrollment Timeline: The Exchange will develop a uniform enrollment timeline and process that includes information pertaining to grace periods, effective dates of coverage, enrollment periods, and reinstatement policies, in accordance with 45 CFR § 156.286(b).

I attest this activity is complete

Shape643

I attest this activity will be complete

Completion/Expected
Completion Date

5.7 Minimum Participation: If the Exchange implements minimum participation requirements in the SHOP, state regulatory authority exists for uniform group participation rules for offering health insurance coverage in the SHOP.

The Exchange will implement the minimum participation requirements and designate or establish a state regulatory authority to monitor them.

The Exchange will not implement minimum participation requirements.

Provide citation of state regulatory authority for SHOP uniform participation rules:

I attest this activity is complete

Shape648

I attest this activity will be complete

Completion/Expected
Completion Date

5.8 Eligibility Determinations: The Exchange will develop and maintain a website that is capable of providing employer eligibility determinations for the SBHCTC.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

6.0 Finance and Organization

Shape651 6.1 Cost, Budget, and Management Plan: The Exchange will have a long-term budget (i.e., with costs and revenues) and management plan, and will have long-term strategies for financial sustainability as required by ACA § 1311(d)(5)(A) and 45 CFR § 155.160(b).

a. The Exchange will establish methods to generate revenue and address any financial deficits.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape655 b. The Exchange will have the ability to annually submit a multi-year operational budget and management plan as required by CMS, pursuant to 45 CFR § 155.1200(a)(3).

I attest this activity is complete

Shape659

I attest this activity will be complete

Completion/Expected
Completion Date

6.2 Financial Accounting Procedures and Financial Statement: The Exchange will keep accurate financial accounting procedures in accordance with generally accepted accounting principles (GAAP) pursuant to 45 CFR § 155.1200(a)(1). The Exchange will provide a financial statement in accordance with GAAP principles pursuant to 45 CFR § 155.1200(b)(1).

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape663 6.3 Oversight of Entities Eligible to Carry Out Exchange Functions: The Exchange will establish agreements and oversee entities who carry out one or more responsibilities of the Exchange in accordance with 45 CFR § 155.110(a) and (b).

I attest this activity is complete

Shape664

I attest this activity will be complete

Completion/Expected
Completion Date

6.4 Exchange Organizational Structure and Staffing Plan: The Exchange will implement an organizational structure and staffing plan that enables the Exchange to support its ongoing business operations and perform all functions of an Exchange described in 45 CFR §155.200.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

7.0 Technology

Shape667 7.1 Essential Functionality: The Exchange will determine its IT approach for performing the essential business functions of the Exchange (e.g., website, plan management, SHOP) by assigning internal resources or, if needed, contracting for technology services.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

8.0 Privacy and Security

Shape670 8.1 Information Disclosure Agreement: In accordance with the Minimum Acceptable Risk Standards for Exchanges (MARS-E), the Exchange will execute an Information Disclosure Agreement (IDA) with CMS, or an updated Information Disclosure Agreement, as applicable, to support authorized sharing of data between CMS and the SBE-FP.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

9.0 Program Integrity and Oversight

Shape673 9.1 Maintenance of Records: The Exchange will have the capacity to maintain books, records, documents, and other evidence of procedures and practices to demonstrate compliance with federal requirements for each benefit year for at least 10 years pursuant to 45 CFR § 155.1210.

I attest this activity is complete

Shape676

I attest this activity will be complete

Completion/Expected
Completion Date

9.2 Oversight and Monitoring: The Exchange will establish and implement a comprehensive oversight and monitoring plan that includes policies and procedures to identify incidents of fraud, waste, and abuse.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape679 9.3 Program Integrity Reporting: The Exchange will conduct program integrity and oversight activities in accordance with 45 CFR § 155.1200. This includes completion of the State-based Marketplace Annual Reporting Tool (SMART); independent external programmatic and financial audits; and participation in oversight activities and readiness reviews as determined necessary by CMS.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

Shape682 9.4 Enrollment Metrics: The Exchange will develop policies, procedures, and a timeline for the collection and reporting of enrollment metrics. The Exchange will submit individual and, if applicable, SHOP enrollment indicator metric reports in accordance with CMS timelines and templates.

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

10.0 User Fee

Shape685 10.1 Assessment of Federal Platform User Fee: In accordance with 45 CFR § 156.50(c)(2), CMS charges all issuers offering QHPs through SBE-FPs a Federal Platform User Fee for the portion of federal platform services and benefits provided to the issuer and is based upon effectuated enrollments at the issuer payee level.

The Exchange will agree to payment of the Federal Platform User Fee established through the CMS Annual Notice of Benefit and Payment Parameters (known as the “Payment Notice”) for each benefit year. The Exchange will inform CMS of its election regarding how the fee is assessed by October 1 prior to the beginning of Open Enrollment of a given benefit year (CMS can either collect user fees from the Exchange or directly from SBE-FP issuer payees).

I attest this activity is complete

I attest this activity will be complete

Completion/Expected
Completion Date

APPENDIX: EXCHANGE BLUEPRINT APPLICATION UPDATE REFERENCE FOR TRANSITION OF A STATE-BASED EXCHANGE TO A STATE-BASED EXCHANGE ON THE FEDERAL PLATFORM

Eligibility and Enrollment

Issuer Transition: The Exchange will ensure that issuers offering plans through the SBE-FP are prepared to transition to the federal platform for the coverage year in which the SBE-FP will begin operations as an SBE-FP. The Exchange will communicate to issuers the requirements for exchanging enrollment data with CMS as part of onboarding to the federal platform.
Completion of Eligibility and Enrollment actions for Prior Plan Years: If transitioning from an SBE, the Exchange will continue processing any outstanding eligibility and enrollment actions applicable to any prior coverage years for which it operated as an SBE. This includes, but is not limited to, changes in circumstances, processing of consumer applications for health insurance coverage, eligibility determinations, enrollment processing, special enrollment periods, Form 1095-As, employer notifications, eligibility appeals, and consumer casework.
FDSH Connectivity: If transitioning from an SBE, the Exchange will ensure it maintains connectivity to the FDSH to complete its various reporting obligations, as applicable, for any prior plan year for which it operated as an SBE and to meet all privacy and other related contractual agreements.
IRS Reporting: If transitioning from an SBE, the Exchange will ensure proper reporting to the IRS for all coverage years prior to the transition, which may include retrospective monthly or annual reporting to the IRS.
CMS Monthly Enrollment and Payment Data Workbook Reporting: If transitioning from an SBE, the Exchange will ensure that it (or its issuers) submit any outstanding CMS monthly enrollment and payment data workbook reporting to CMS for all coverage years prior to the transition, to support CMS payments of advance premium tax credits (APTCs) to the issuers that provided coverage to APTC-eligible consumers. The Exchange may either submit the reporting itself or designate its QHP issuers to submit this reporting.
CMS Policy-Level Enrollment Reporting: If transitioning from an SBE, the Exchange will ensure proper and timely reporting to CMS for all coverage years prior to the transition.

Technology

Information Technology (IT) Decommission Plan: If the Exchange has not already decommissioned an existing eligibility and enrollment system and IT infrastructure, it will develop and execute an Exchange IT Decommission Plan, an IT Systems and Data Migration Strategy, and any other necessary plans for decommissioning.

Privacy and Security

Updated Computer Matching Agreement: In accordance with the Minimum Acceptable Risk Standards for Exchanges (MARS-E), the Exchange must maintain its Computer Matching Agreement (CMA) to complete any eligibility and enrollment functions applicable for any prior plan years for which it operated as an SBE.
Updated Information Exchange Agreement: In accordance with MARS-E, the Exchange must maintain its Information Exchange Agreement (IEA) with CMS to complete any federal reporting obligations applicable for any prior plan years for which it operated as an SBE. The IEA must be current in order to maintain connection to the FDSH, through which such reporting is submitted.
Updated Interconnection Security Agreement: In accordance with MARS-E, the Exchange must maintain its Interconnection Security Agreement (ISA) with CMS to complete any Federal reporting obligations applicable for any prior plan years for which it operated as an SBE. The ISA must be current in order to maintain connection to the FDSH, through which such reporting is submitted.

Program Integrity and Oversight

Retroactive submission of SMART: If transitioning from an SBE, the Exchange will submit any outstanding SMART, and complete conducting any applicable audits, for any coverage years during which it operated as an SBE.

1 A state electing to perform certain PM functions does not have to complete an Exchange Blueprint Application. For additional information, contact the Center for Consumer Information and Insurance Oversight (CCIIO) via the FFE Plan Management State Coordination (PMSC) mailbox at PlanManagementStateCoordination@cms.hhs.gov .

2 45 CFR § 155.106(c)(2)

PRA Disclosure Statement: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1172.

File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
File Modified	0000-00-00
File Created	0000-00-00