Other Resources

• Consumer Support and Information
  • Consumer Assistance Program Grants
  • External Appeals
  • Summary of Benefits and Coverage and Uniform Glossary
• Content Requirements for Plan Finder
• Pre-Existing Condition Insurance Plan (PCIP)
• Early Retiree Reinsurance Program (ERRP)
• Health Insurance Marketplaces
  • Planning and Establishment Grants
• Consumer Operated and Oriented Plan (CO-OP) Program
• Health Insurance Market Reforms
  • Annual Limits
  • Coverage for Young Adults
  • Grandfathered Plans
  • Medical Loss Ratio
  • Patient’s Bill of Rights
  • Prevention
  • Review of Insurance Rates
  • Self-Funded Non-Federal Governmental Plans
• Premium Stabilization Programs
• COBRA
• Reports

 

Consumer Support and Information

Consumer Assistance Program Grants

Reports

• June 7, 2012
  Summary of First Year Consumer Assistance Program Grant Data (PDF - 442 KB)

External Appeals

Model Notice

• June 22, 2011
  Model Notice of Adverse Benefits Determination (PDF – 256 KB)
  Model Notice of Final External Review Decision (PDF – 101 KB)
  Model Notice of Final Internal Adverse Benefits Determination (PDF – 265 KB)

Notice of Privacy Act Rights

• September 7, 2010
  Notice of Privacy Act Statement for Issuers in States without External Review Laws (PDF -10 KB)

Federal Register Notice

• August 23, 2010
  Federal Register Notice on External Review

Summary of Benefits and Coverage and Uniform Glossary

Forms

• Summary of Benefits and Coverage (SBC) Template
  • Standard Format  (Authorized for second year of applicability) (DOC – 182 KB)
  • Accessible Format  (Authorized for second year of applicability)  (PDF – 366 KB) 
  • Standard Format (Authorized for first year of applicability) (DOC - 175 KB)
  • Accessible Format (Authorized for first year of applicability) (PDF - 607 KB)
  • Chinese (Authorized for second year of applicability) [DOCX, 78KB]
  • Chinese (Authorized for second year of applicability) [PDF, 618KB]
  • Chinese (Authorized for first year of applicability) (DOC – 54 KB)
  • Chinese (Authorized for first year of applicability) (PDF- 565 KB)
  • Navajo (Authorized for second year of applicability) [DOCX, 3MB]
  • Navajo (Authorized for second year of applicability) [PDF, 163KB]
  • Navajo Oral Translation (Authorized for second year of applicability) [MP3, 27MB]
  • Navajo (Authorized for first year of applicability) (DOC – 67 KB)
    (Note: In order to use the Navajo SBC template in Word format, it may be necessary to install Times New Roman Navajo fonts.  Times New Roman Navajo fonts are available free of charge on a number of sources on the Internet.)
  • Navajo (Authorized for first year of applicability) (PDF – 258 KB)
  • Navajo (Authorized for first year of applicability)  - Oral Translation (MP3 – 21 MB)
  • Spanish (Authorized for second year of applicability) [DOCX, 83KB]
  • Spanish (Authorized for second year of applicability) [PDF, 534KB]
  • Spanish (Authorized for first year of applicability) (DOC – 170KB)
  • Spanish (Authorized for first year of applicability) (PDF – 458 KB)
  • Tagalog (Authorized for second year of applicability) [DOCX, 81KB]
  • Tagalog (Authorized for second year of applicability) [PDF, 481KB]
  • Tagalog (Authorized for first year of applicability) (DOC – 71 KB)
  • Tagalog (Authorized for first year of applicability) (PDF – 446 KB)
• Uniform Glossary
  • English (PDF – 140 KB )
  • Chinese (PDF – 226 KB)
  • Navajo (PDF – 400 KB)
  • Navajo - Oral Translation (MP3 – 26 MB)
  • Spanish (PDF – 349 KB)
  • Tagalog (PDF  - 145 KB)

Instructions/Guidance

• Sample Completed SBC
  • Standard Format  (Authorized for second year of applicability) (DOC – 206 KB)
  • Accessible Format  (Authorized for second year of applicability) (PDF – 431 KB) 
  • Standard Format (Corrected, May 11, 2012) (DOC - 200 KB)
  • Accessible Format (Corrected, May 11, 2012) (PDF - 533 KB)
• Instructions for Completing the SBC – Group Health Plan Coverage (PDF – 89 KB)
• Instructions for Completing the SBC – Individual Health Insurance Coverage (PDF – 81 KB)
•  Why This Matters language for SBC "Yes" Answers
  • English (PDF – 120 KB)
  • Chinese (PDF-159 KB)
  • Navajo (PDF-641 KB)
  • Navajo Oral Translation (MP3 – 7 MB)
  • Spanish (PDF – 288 KB)
  • Tagalog ( PDF – 111 KB)
• Why This Matters language for SBC "No" Answers
  • English (PDF – 92 KB)
  • Chinese (PDF – 147 KB)
  • Navajo (PDF – 446 KB)
  • Navajo - Oral Translation (MP3 – 4.4 MB)
  • Spanish (PDF – 292 KB)
  • Tagalog (PDF- 107 KB)
• Guide for Coverage Examples Calculations – Maternity Scenario
  • Standard Format (XLSX – 91 KB)
  • Accessible Format (PDF – 98 KB)
• Guide for Coverage Examples Calculations – Diabetes Scenario
  • Standard Format (Corrected May 11, 2012) (XLSX - 56 KB)
  • Accessible Format (Corrected May 11, 2012) (PDF - 343 KB)
• Narrative for Maternity Scenario (PDF – 11 KB)
• Narrative for Diabetes Scenario (PDF – 11 KB)
• Checklist for Coverage Calculator (PDF – 43 KB)
• Coverage Examples Calculator Instructions (PDF – 274 KB)
• Coverage Examples Calculator Logic (PDF – 91 KB)
• Coverage Examples Calculator (XLSM – 442 KB)  (updated September 7, 2012)
  (Note: This version of the coverage examples calculator corrects an error in a previous version that would result in an error message with regard to coverage of preventive services and maximum out-of-pockets.  That programming error did not impact the accuracy of the results in either the manual or automated processes, so plans and issuers that have successfully used the previous versions (June 4, 2012 and Updated July 23, 2012) of the calculator may use the results from the previous version.)

Content Requirements for Plan Finder

Q&A

• May 28, 2013
  Plan Finder Data Entry

Instructions/Guidance

• March 28, 2013
  Plan Finder State User Manual (PDF – 1.4 MB)
  HIOS Portal User Manual (PDF – 3.66 MB)
  Rate and Benefits Information System (RBIS) User Manual  (PDF – 3.7 MB)
• August 18,2014
  Plan Finder Issuer User Manual (PDF - 1.5 MB)

Forms

• September 26, 2011
  RBIS Issuer Data Entry Forms (ZIP - 1 MB)
• October 27, 2011
  HIOS Issuer Data Entry Form (XLS – 2 MB)
• December 12, 2011
  RBIS Individual Market Issuer Data Entry Forms (ZIP – 26 MB)

Selected 2014 QHP Templates

• Plan and Benefits Template
• Plan and Benefits Add-In File
• Rates Template
• Business Rules Template
• Service Area Template

Pre-Existing Condition Insurance Plan (PCIP)

Data

• PCIP Data as of May 31 2011
• Update on Federal PCIP September 29, 2011 (PDF 624 KB)
• Update on Federal PCIP December 31, 2011 (PDF - 174 KB)
• Update on Federal PCIP March 31, 2012 (PDF - 122 KB)
• Update on Federal PCIP June 30, 2012 (PDF - 131 KB)
• Update on Federal PCIP September 30, 2012 (PDF - 464 KB)
• Update on Federal PCIP December 31, 2012  (PDF - 99 KB)  
• Update on Federal PCIP March 31, 2013  (PDF - 98 KB)  
• Update on Federal PCIP June 30, 2013  (PDF - 125 KB)  
• Update on Federal PCIP September 30, 2013 (PDF - 105 KB)  

Reports

• February 23, 2012
  Report on the Implementation and Operation of the Pre-Existing Condition Insurance Plan Program (PDF - 330 KB)
• February 1, 2013
  Annual Report on the Implementation and Operation of the PCIP Program (PDF -300KB)

Early Retiree Reinsurance Program (ERRP)

Reports

• June 25, 2014
  Early Retiree Reinsurance Program: Reimbursement Update [PDF, 1MB]

Health Insurance Marketplaces

Presentations

• September 2011
  State Exchange Grantee Meeting Materials
• March 2012
  Affordable Insurance Exchanges Final Rule (PDF - 749 KB)
• May 2012
  System-wide Exchange Conference Materials
• November 26, 2012
  EHB/AV/Accreditation Notice of Proposed Rulemaking (PDF – 593 KB)
• January 3, 2013
  State Partnership Exchange (PDF – 267 KB)
• February 25, 2013
  EHB/AV/Accreditation Final Rule (PDF - 549 KB)

Forms

• May 16, 2012
  Paperwork Reduction Act (PRA) display of Draft Blueprint for Approval of Affordable State-based and State Partnership Insurance Exchanges (click on CMS – 10416).
• August 14, 2012 (Revised November 16, 2012)
  Final Blueprint for Exchanges (PDF - 731 KB)
• November 9, 2012
  Frequently Asked Questions on the Blueprint for Exchanges
• October 9, 2013
  Marketplace Consumer Application
  • Individual Short Form
  • Individual Short Form Instructions
  • Family
  • Family Instructions
  • Individual without Financial Assistance
  • Individual without Financial Assistance Instructions
• April 7, 2014
  Compliance Reviews in the Federally-Facilitated Marketplace
  • Key Priorities for FFM Compliance Reviews for the 2014 Benefit Year [PDF, 111KB]

Reports

• August 23, 2013
  Impact of Changing the Maximum Out-of-Pocket Amounts for Qualified Health Plans and Stand Alone Dental Plans

Planning and Establishment Grants

Pre-Application Conference Calls (Upcoming)

• June 29, 2012
  Dates and Times of Pre-Application Conference Calls for Exchange Establishment FOA:
  • July 19, 2012 – 1:30-3:00pm EST
  • October 4, 2012 - 2:00-3:30pm EST
  • January 10, 2013 - 2:00-3:30pm EST
  • April 10, 2013 - 1 -2:30 PM EST
    Call in: 1 877 267 1577; Meeting ID: 0360

Consumer Operated and Oriented Plan (CO-OP) Program

Presentations

• April 2012
  Consumer Operated and Oriented Plan (CO-OP) Program (PDF – 347 KB)

Health Insurance Market Reforms

Annual Limits

Application Information

• June 17, 2011
  Annual Limit Waiver Application Forms and Instructions
  • Annual Limit Waiver Application—New Application Form (XLS – 49 MB)
  • Annual Limit Waiver Application—Waiver Extension Form (XLS – 50 MB)
  • Annual Limit Waiver Application Instructions (PDF – 89 KB)
  • Annual Limit Waiver Data Dictionary (XLS – 20 KB)
• January 6, 2012
  • Approved Applications for Waiver of the Annual Limits Requirements of the PHS Act Section 2711

Coverage for Young Adults

Data

• January 12, 2010
  Estimated number of uninsured individuals ages 19-25, by county (XLS – 2 MB)

Medical Loss Ratio

Forms

• May 19, 2011
  Medical Loss Ratio (MLR) 2011 Quarterly Reporting Forms for “Mini-med” and Expatriate Plans
  • MLR Quarterly Reporting Form for “Mini-med” Plans (XLS – 50 KB)
  • MLR Quarterly Reporting Form for Expatriate Plans (XLS – 52 KB)
  • MLR Quarterly Reporting Form Instructions (PDF – 68 KB)
• June 17, 2011 (corrected)
  MLR Quarterly Reporting Form Instructions (PDF – 70 KB)
• May 11, 2012
  Medical Loss Ratio (MLR) 2011 Annual Reporting Form (OMB 0938-1164)
  • MLR Annual Reporting Form (XLSX - 119 KB)
  • MLR Annual Reporting Form Instructions (PDF - 204 KB)
  Medical Loss Ratio (MLR) Rebate Notices to Policyholders and Subscribers (OMB 0938-1164)
  • Notice to Subscribers in the Individual Market (Notice #1) (PDF – 38 KB)
  • Notice to Group Policyholders and Their Subscribers, Rebate Sent to the Policyholder (Notice #2) (PDF - 54 KB)
  • Notice to Subscribers of Group Policyholders, Rebate Sent to the Subscribers (Notice #3) (PDF - 41 KB)
  • Instructions for Notices 1, 2 and 3 (PDF - 87 KB)
• May 16, 2012
  Notice to Policyholders and Subscribers when MLR Standard is Met (PDF - 15 KB)
• March 29, 2013
  
  • MLR 2012 Annual Reporting Form  (XLSX – 116 KB)
  • MLR 2012 Annual Reporting Form Instructions (PDF – 639 KB)
  • MLR 2012 Annual Reporting Form Calculator and Formula Tool (XLSM - 102 KB)    
• March 25, 2014
  
  • MLR 2013 Annual Reporting Form [XLSX, 125KB]
  • MLR 2013 Annual Reporting Form Instructions [PDF, 483KB]
  • MLR 2013 System Validations [PDF, 175KB]

 

• May 14, 2014
  • MLR 2013 Calculator and Formula Tool [XLSM, 111KB]

 

Reports:

• June 21, 2012
  The 80/20 Rule: Providing Value and Rebates to Millions of Consumers
• February 15, 2013
  The 80/20 Rule: How Insurers Spend Your Health Insurance Premiums
• June 20, 2013
  80/20 Rule Delivers More Value to Consumers in 2012 [PDF, 245KB]
• July 24, 2014
  Consumers Benefit from 80/20 Rule in 2013 [PDF, 149KB]

Patient’s Bill of Rights

Q&A

• October 13, 2010
  Enrollment of Children Under 19 Under the New Policy That Prohibits Pre-Existing Condition Exclusions

Data

• January 19, 2011
  Data Files – First Estimate (XLS – 151 KB)
  Data Files – Second Estimate (XLS – 151 KB)
  Data Files – First and Second Estimates by State (XLS – 35.5 KB)

Methodology

• January 12, 2011
  Methodology for Children and Adults with Pre-Existing Conditions, by Congressional District

Reports

• September 23, 2011
  Patient’s Bill of Rights (PDF – 238 KB)

Prevention

Forms

• June 28, 2013
  Self-certification Form (To be used for plan years beginning on or after January 1, 2014)
  
  • Standard Format (DOC – 28 KB)
  • Accessible Format (PDF – 22 KB)
  Model Notice of Availability of Separate Payments for Contraceptive Services (PDF – 39 KB)

Review of Insurance Rates

• May 27, 2011
  Paperwork Reduction Act (PRA) display of Rate Increase Disclosure and Review Reporting Requirements - Opens in a new window (click on “CMS-10379”)
• July 29, 2011 (Update October 11, 2011: rate review training manuals, instructions, and other materials are now located under Training Resources. Please click on the link below.)
  Rate Review Training Resources
• September 20, 2011
  Report: Early Achievements of Health Insurance Rate Review Grants (PDF - 268 KB)
  Note: The Cycle II proposal summary for the California Department of Managed Health Care was corrected on September 22, 2011.
• September 11, 2012
  Annual Rate Review Report
• February 22, 2013
  Paperwork Reduction Act (PRA) display of Rate Increase Disclosure and Review Reporting Requirements (click on “CMS-10379”)
  This template, used to meet Part I reporting requirements, will be available for download and use via HIOS.
• September 12, 2013
  Rate Review Annual Report - Opens in a new window

Self-Funded Non-Federal Governmental Plans

HIPAA Opt-Out Materials

• September 21, 2010
  Memo on Amendments to the HIPAA Opt-Out Provision made by the Affordable Care Act (PDF – 44 KB)
• April 1, 2011
  Procedures and Requirements for HIPAA Exemption Election
  Model HIPAA Exemption Election Document (PDF – 78 KB)
  Model Notice to Enrollees of HIPAA Exemption (PDF – 7 KB)
• May 6, 2014
  List of HIPAA Opt-Out Elections for Self-Funded, Non-Federal Government Plans (PDF– 573KB)
• July 18, 2014
  HIOS Non-Fed Module User Manual [PDF, 6MB]
• July 21, 2014    
  Updated Procedures and Requirements for HIPAA Exemption Election through the Health Insurance Oversight System (HIOS) [PDF, 151KB]

Premium Stabilization Programs

White Papers

• September 12, 2011
  Risk Adjustment Implementation Issues – White Paper (PDF – 2 MB)
  Questions and Answers on Risk Adjustment White Paper

Risk Adjustment Spring Meeting (May 7-8, 2012)

• CMS-9966-N: Notice of Meeting - Opens in a new window (PDF - 194 KB)
• Registration: Register by April 30, 2012, 5 pm est.
  To register, please visit the Registration Website.
• Conference Materials
  • Risk Adjustment Overview (PDF – 268 KB)
  • Reinsurance, Risk Corridors, and Risk Adjustment Final Rule: Risk Adjustment (PDF – 252 KB)
  • HHS Risk Adjustment Model (PDF – 340 KB)
  • Risk Adjustment Payment Transfer Methodology (PDF – 763 KB)
  • State Flexibility and Alternate Methodologies (PDF – 336 KB)
  • Risk Adjustment Program: HHS Operations (PDF – 608 KB)
  • Proposed Technical Concept: Distributed Data Processing (PDF – 290 KB)
  • State Flexibility and Risk Adjustment Implementation (PDF – 410 KB)

COBRA

Forms

• October 17, 2012
  CMS Request for Review of Premium Assistance Denial (PDF - 992 KB)

Reports

GAO

• March 16, 2011
  "Private Health Insurance: Data on Application and Coverage Denials" (PDF – 1.13 MB)

State High Risk Pool Grant Program

• Report to Congress on the High Risk Pool Grant Program for Fiscal Years 2006 and 2007  (PDF - 298 KB)