ACA Now

Implementation Status

Extensive implementation efforts are underway in preparation for October 1, 2013, Exchange open enrollment.

CCIIO inventories Exchange-related regulations and guidance, fact sheets and FAQs, letters – including correspondence to States regarding Exchange approval – and other resources – including the final Exchange blueprint – on its website.

The healthcare.gov website also general information about the establishment of Exchanges.

Also see additional information in regarding CCIIO funding opportunities and other resources. Additionally, CCIIO also maintains a page with an interactive map of states and territories receiving Exchange establishment grant funding.

2012

On December 10, 2012, CMS sent an FAQ to all State governors regarding Exchanges, market reforms and Medicaid expansion, including discussion of Federally Facilitated Exchanges’ approach to coordinating state processes with Qualified Health Plan (QHP) certification.

On December 10, 2012, HHS announced conditional approval of State-Based Exchanges (SBEs) in Colorado, Connecticut, Massachusetts, Maryland, Oregon and Washington. HHS also announced additional approval of Minnesota and Rhode Island as SBEs and Delaware and the first, preliminarily-approved State Partnership Exchange (SPE). On January 3, 2013, HHS announced conditional approval of California, Hawaii, Idaho, Nevada, New Mexico, Vermont and Utah as SBEs and Arkansas as a SPE. For a catalogue of these state Exchange approvals and additional information regarding each, please see the CCIIO website devoted to this issue.

2013 – Winter

On January 3, 2013, CCIIO released additional guidance regarding State Partnership Exchanges.

On January 17, 2013, HHS announced $1.5 billion in Exchange Establishment grants to 11 states. A state-by-state breakdown of these awards is available here.

CMS’s proposed rule, issued on February 1, 2013, addresses Exchanges’ role in determining eligibility for exemptions from shared responsibility payments for failure to maintain minimum essential coverage and issuing corresponding certificates certifying exemption from those requirements, if applicable.

On February 14, 2013, CCIIO Director Gary Cohen testified before the Senate Finance Committee regarding the Agency’s and State’s readiness to implement Exchanges under the ACA. Members’ statements and testimony from the hearing are available here.

On February 15, 2013, the final deadline for States to apply for State-Federal partnership Exchanges passed. Twenty-six states will have Federally Facilitated Exchanges, 16 and Washington, D.C., will run State-Based Exchanges, and seven states are planning to operate State-Federal Partnership Exchanges. Utah requested that the Federal government run its individual market Exchange while the state continues its small business Exchange. More information regarding the status of Exchanges is available here.

On February 15, 2013, CMS posted a fact sheet summarizing all Exchange planning grants that had been issued by that date, including an interactive map.

A February 25, 2013, final rule provides for a process whereby additional QHP accrediting entities potentially could be recognized.

On March 11, 2013, CCIIO published a proposed rule regarding the Small Business Health Options Program (SHOP) that would amend existing regulations on triggering events and special enrollment periods for qualified employees and their dependents, as well as implement a transitional policy regarding employees’ choice of qualified health plans (QHPs) in the SHOP. Comments are due on April 1.

HHS’s March 11, 2013, final rule – the Notice of Benefit and Payment Parameters for 2014 – includes provisions that, in part, relate to SHOP implementation.

On March 13, 2013, CMS announced the submission to OMB of a revised information collection request (see #3) regarding recognized accrediting entities’ submission of certain QHP accreditation-related data to HHS and Exchanges.

On March 18, 2013, HHS held a National Health Insurance Marketplace Stakeholder Conference Call in which agency officials provided updates on the operational execution of State Partnership and Federally Facilitated Marketplaces, noting the Federal Data Services Hub – a single access point for verifying determinants of subsidy and other program-related eligibility – is “nearly complete.” The agency said CMS Regional Offices will host quarterly calls beginning in late April in each state with a Federally Facilitated or State Partnership Marketplace; more information is available here.

On March 27, 2013, CCIIO released a letter announcing a non-exhaustive database of available essential community providers (ECPs) – those who serve predominantly low-income, medically underserved individuals – to assist issuers in complying with QHP requirements specified in regulations and in the issuer letter for FFEs and FF-SHOPS. CCIIO also provided a link to ECPs providing dental services and a database of HPSA and low-income ZIP codes for issuers subject to the alternate ECP standard for the purposes of QHP certification, which applies to QHPs in Federally Facilitated and State Partnership Marketplaces, as described in a March 1 draft issuer letter.

On March 28, 2013, CMS released a slide deck under its National Training Program to educate stakeholders about Health Insurance Marketplaces.

On March 29, 2013, CCIIO posted FAQs about reuse of an Exchange for stand-alone vision plans and other ancillary insurance products such as disability or life insurance products.

2013 – Spring

CCIIO opened the application submission window for Qualified Health Plan certification in Federally Facilitated Marketplaces on April 1, 2013, and it was slated to continue through April 30 but was extended until May 3 in an FAQ available on the agency’s Registration for Technical Assistance Portal (registration required), where various other operational guidance also is being posted.

On April 4, 2013, CCIIO posted a chart indicating the systems (HIOS, SERFF and/or State system) that QHP issuers should use to file QHP applications. CCIIO also posted other QHP application resources on its QHP page.

Also on April 4, 2013, CMS requested clearance for 2 surveys (individual and SHOP) to “aid in understanding levels of consumer awareness and customer service needs” involving the Health Insurance Marketplaces.

On April 5, 2013, CMS published a proposed rule outlining standards for Navigators in Health Insurance Marketplaces. The rule proposes standards for Navigators and Non-Navigator Assistance Personnel, including conflict-of-interest and training and certification standards, among other provisions. Comments are due on May 6. Also see a concurrently published Paperwork Reduction Act statement regarding disclosure-related reporting associated with various Navigator standards.

On April 5, 2013, CCIIO released a final letter to issuers providing Qualified Health Plans (QHP) in Federally Facilitated Marketplaces and Federally Facilitated SHOPs, including State Partnership Exchanges, with operational and technical guidance in areas such as QHP certification standards and QHP performance and oversight. This followed a draft letter on March 1.

On April 8, 2013, CCIIO posted an interactive map of Exchange establishment grants.

On April 9, 2013, CMS released a Funding Opportunity Announcement (FOA) under which the agency intends to provide up to $54 million to support the establishment of Navigators in Federally Facilitated and State Partnership Marketplaces. Applications are due by June 7. Also see CCIIO’s FAQs on the Navigator FOA, as well as an overview of the application process and a concurrently released Paperwork Reduction Act Notice regarding reporting requirements under these cooperative agreements.

On April 11, 2013, CMS posted to REGTAP (see above; registration required) a list of insurers that, based on data reported separately for MLR purposes, would be subject to the “tying” provision between participation in the Federally Facilitated individual and SHOP markets for those with small group market share of over 20 percent.

On April 12, 2013, CCIIO posted the companion guide for the enrollment (834) transaction that Federally Facilitated Marketplaces will use, including detailed technical and operational specifications.

On April 18, 2013, CCIIO posted a fact sheet on Marketplace consumer assistance summarizing the roles of Navigators, in-person assistance personnel, certified application counselors and agents/brokers, as well as their availability by Marketplace type (Federally Facilitated, Partnership or State Based), funding mechanisms and training requirements.

On April 22, 2013, CCIIO released a fact sheet detailing progress toward implementing Federally Facilitated Marketplaces. CCIIO also released a Marketplace timeline charting implementation steps culminating in October 1 open enrollment, as well as a narrative description of the timeline.

On April 23, 2013, CCIIO released FAQs regarding the use of funds under 1311(a) for marketing activities in a Federally Facilitated or Plan Management State Partnership Marketplace.

On April 24, 2013, CCIIO Director Gary Cohen testified before the House Energy and Commerce Oversight and Investigations Subcommittee, saying the agency is on track with Marketplace implementation and noting milestones including the on-time opening of the submission window for health insurance issuers to submit QHP applications for Federally Facilitated Marketplaces, as well as a successful test for the Federal Data Hub that will facilitate verification of certain eligibility-related data.

On April 29, 2013, DOL, Treasury and HHS issued FAQs clarifying that waivers from the annual limit requirements will expire on the approved expiration date, notwithstanding any modifications that plans may make to their plan or policy years. The FAQs also clarify that the ACA’s provider non-discrimination and clinical trial coverage provisions are self-implementing and that no regulations are expected “in the near future.” The Departments note that the Qualified Health Plan transparency reporting requirements under section 1311(e)(3) will take effect “only after QHPs have been certified as QHPs for one benefit year,” adding that outside-the-Exchange reporting requirements under PHSA 2715A will not take effect sooner than this.

On May 6, CCIIO posted an April 30 memo containing Model Language for Individual Market Renewal Notices via the Insurance Standards Bulletin Series. The agency notes that if the language is “provided uniformly to all applicable enrollees” it will be considered acceptable under regulatory requirements barring the use or issuer marketing practices that “have the effect of discouraging the enrollment of persons with significant health needs in health insurance coverage.”

On May 14, CCIIO released FAQs on Health Insurance Marketplaces addressing issues involving: (1) CMS oversight of state-operated premium stabilization programs, advance payments of the premium tax credit and cost-sharing reductions; (2) issuer oversight in Federally Facilitated Marketplaces; (3) State-Based Marketplace reporting requirements; (4) privacy and security standards for State-Based Marketplaces and consumer assistance personnel; (5) cost-sharing reductions and health savings accounts; (6) eligibility and enrollment – specifically, CMS’s intent to “propose rulemaking and supplemental guidance on the use of [Health Plan Identifiers] in enrollment and payment transactions between issuers and the Federally Facilitated Marketplace”; and (7) issuer withdrawal from the small group or large group market.

On May 30, in a blog posting, the White House released a memo regarding competition and choices in Health Insurance Marketplaces, referencing “early reports.”

On June 4, CCIIO issued a final rule on the Small Business Health Options Program (SHOP) and, in tandem, finalized SHOP applications for small employers (3 pages) and their employees (2 pages) to use starting on October 1, 2013, in SHOP Marketplaces. In the final rule, CCIIO adopts a transitional approach to employee choice; all SHOPs will allow small businesses to let their employees choose coverage from a number of plans starting in 2015.

On June 14, CMS released a proposed rule addressing a variety of ACA issues related to program integrity and oversight of Health Insurance Marketplaces and premium stabilization programs, including state-operated risk adjustment and reinsurance programs. The rule also includes proposed provisions regarding overseeing issuers of Qualified Health Plans in Federally Facilitated Marketplaces and states’ ability to have Federally Facilitated Individual Marketplaces while running State-Based SHOPs. Also see a CCIIO fact sheet.

On June 19, the GAO released a report assessing CMS’s progress toward implementing Federally Facilitated, as well as a separate report detailing progress toward implementing Small Business Health Options Program (SHOP) Exchanges. Noting some missed deadlines, GAO concluded that while “much progress has been made…much remains to be accomplished within a relatively short amount of time.”

On June 20, Senate Finance Committee (SFC) Ranking Member Orrin Hatch (R-UT), joined by several other SFC Republicans, wrote a letter to HHS expressing concern about the “leniency” of consumer protections in a recent proposed rule regarding Standards for Navigators and Non-Navigator Assistance Personnel.

On June 24, HHS re-launched www.healthcare.gov to feature new information for consumers and small businesses focused on the Health Insurance Marketplaces and opened an around-the-clock consumer call center to provide educational information and – when open enrollment begins on October 1 – assistance with choosing and enrolling in coverage. See an HHS press release. In tandem, CMS announced the availability of new resources on http://marketplace.cms.gov/ for partner organizations conducting consumer outreach and enrollment.

On June 24, CCIIO released a timeline for opening Health Insurance Marketplaces for October 1 open enrollment, underscoring implementation is “on target.”

On June 25, via an announcement on REGTAP (registration required), CMS extended – to July 1 – the QHP application resubmission window for issuers in Federally Facilitated Marketplaces to correct CMS or certain state identified issues with their applications.

On June 26, HHS issued a final rule implementing certain ACA provisions pertaining to the shared responsibility provision, which calls for individuals to maintain “minimum essential coverage.”  The final rule also delineates the process by which an individual may qualify for an exemption to the application of this requirement or how to comply with the associated tax penalty for purposes of federal filing.

Also on June 26, the IRS released a Notice  providing transition relief from shared responsibility payments for “specified individuals who are eligible to enroll in certain eligible employer-sponsored health plans with a plan year other than a calendar year (non-calendar year plans) if the plan year begins in 2013 and ends in 2014.”

Additionally, CCIIO on June 26 released guidance on hardship exemption criteria and special enrollment periods that Federally Facilitated Marketplaces will use; State-Based Marketplaces may use the criteria or develop their own within regulatory parameters.

On June 28, the IRS released a notice of proposed rulemaking regarding the information that Exchanges are required to report to the IRS regarding health insurance premium tax credits, among other specified details. The proposed rule provides more specific rules on reporting of information – which, the IRS notes, helps enable such functions as the reconciliation of the premium tax credit with advance credit payments. Comments are due on or around August 28, 2013.

On June 28, CMS posted a Paperwork Reduction Act package regarding clearance associated with development and testing of enrollee satisfaction surveys for those using Health Insurance Marketplaces, as well as for Qualified Health Plan enrollees.

2013 – Summer

On July 1, CMS announced an initiative under which it will enlist librarians’ help in educating consumers on Health Insurance Marketplaces as October 1, 2013, open enrollment approaches

On July 8, via the REGTAP portal (registration required), CMS posted a presentation, “Health Insurance Marketplace: Agent Broker Outreach Meetings.”

On July 9, CCIIO posted an Exchange Establishment Grants Awards List.

On July 10, the Health Resources and Services Administration awarded $150M in grants to 1,159 community health centers to facilitate enrollment in Exchange, Medicaid and CHIP coverage, noting, “with these funds, health centers are expected to hire an additional 2,900 outreach and eligibility assistance workers” (see press release and details on funding by state).

On July 12, CMS posted a final rule  (also see a press release) on standards – such as those related to conflict of interest, training and accessibility – for Navigators and Non-Navigator Assistance Personnel in FederallyFacilitated Exchanges, including State Partnership Exchanges. State-based Exchanges are not required to follow HHS Navigator standards – or those for non-Navigator Assistance Programs not funded through Exchange Establishment grants, although CMS says in the preamble that “we believe that State Exchanges may find the federal standards to be useful models.” Also see a July 12 Paperwork Reduction Act package regarding necessary disclosures.

On July 12, CCIIO released guidance on the Certified Application Counselor Program in Federally Facilitated and State Partnership Marketplaces, as well as a sample application for organizations seeking – under a provision of the final rule – to become designated by Marketplaces as being able to certify their staff and volunteers as Certified Application Counselors.

On July 18, HHS’s Assistant Secretary for Planning and Evaluation released a report based on proposed 2014 individual market rates in 10 states (CA, CO, NM, NY, OH, OR, RI, VT, VA and WA) and DC indicating that premiums for the lowest-cost individual silver plan will be, on average, 18% lower than an estimate that ASPE extrapolated from 2016 CBO predictions published in March 2012. HHS also issued a press release.

On July 16, via the REGTAP portal (registration required), CMS posted a presentation, “Affordable Care Act (ACA) HHS-operated Small Business Health Options (SHOP) Enrollment.”

On July 17, CMS posted an update on the REGTAP portal (registration required) noting that, during a Plan Preview period from August 8-23, 2013, issuers applying to offer Qualified Health Plans (QHPs) in Federally Facilitated and State Partnership Marketplaces will be able to “view the data that will be displayed to consumers for QHPs if submitted plans are approved for certification.” The update also noted final dates for making changes to QHP data templates for applicants who seek to offer coverage in Federally Facilitated Marketplaces.

On July 19, CMS – via the REGTAP portal (registration required) – issued revised guidance noting that issuers that have applied to offer QHPs in the Federally Facilitated Marketplace but do not yet have state commercial licensure must obtain it by July 31; details here.

On July 25, CMS submitted to OMB and requested comment on an information collection activities notice, including a new collection on a Cooperative Agreement to Support Navigators in Federally Facilitated and State Partnership Exchanges. The notice (see #9 on p. 3 of the PDF) notes Navigator awardee reporting requirements and indicates that following a 60-day comment period, “several commenters suggested changes to the reporting requirements which were incorporated where appropriate.” Also see the Paperwork Reduction Act package containing CMS’s supporting statement.

On July 26, CMS requested comments on a proposed information collection (see #8 on p. 3) laying out reporting requirements designed to monitor the effectiveness of the Enrollment Assistance Program, operating in population centers within states with Federally Facilitated Marketplaces and seeking to reach “populations not covered or targeted by the Navigator Program.” Comments are due on September 24, 2013.

On July 29, CMS has posted the application (background page, application page) for organizations – including hospitals, community health centers, social service agencies and others – in states with Federally Facilitated or State Partnership Marketplaces that are interested in being designated as a Certified Application Counselor (CAC) organization. No application deadline is noted.

On July 30, CMS announced it is recognizing public and private organizations as “Champions for Coverage” (see an online form with details on official recognition) for taking steps (e.g., sending an e-mail to customers or networks, promoting Heathcare.gov and other official information resources) to raise awareness of Marketplace coverage options and ways to enroll.

On July 29, via REGTAP (registration required), CMS issued an FAQ addressing various issues, including the Plan Preview period for issuers in Federally Facilitated and State Partnership Marketplaces.

On July 30, via REGTAP (registration required), CMS issued an FAQ regarding the Federally Facilitated SHOP.

On July 5, CMS issued a final rule with wide-ranging eligibility provisions, including several regarding Exchanges’ eligibility and enrollment. Specifically, before January 1, 2015, State-based Exchanges may “accept the applicant’s attestation regarding enrollment in an eligible employer-sponsored plan and eligibility for qualifying coverage in an eligible employer sponsored plan for the benefit year for which coverage is requested without further verification.” For income verification, for the first year of operations, rule note that CMS is “providing Exchanges with temporarily expanded discretion to accept an attestation of projected annual household income without further verification” applicable to individuals who are not part of a statistically-significant sampling strategy that is delineated in the rule. Other provisions address, among others, authorized representatives, enrollment-related transactions, special enrollment periods and terminations. Also see a July 8 Paperwork Reduction Act package related to information collection under the Exchange-related provisions of this rule.

On July 2, CMS posted a supporting statement on a dedicated Paperwork Reduction Act pageregarding information collection requirements stemming from a recent final rule specific to Exchanges’ responsibilities for determining eligibility for certificates of exemption from the shared responsibility requirement.

On July 2, IRS published in the Federal Register a notice of proposed rulemaking regarding the information that Exchanges are required to report to the agency regarding health insurance premium tax credits, including specific rules on reporting of information by Exchanges to help enable such functions as the reconciliation of the premium tax credit with advance credit payments. Comments are due on Sept. 3, 2013.

On August 5, HHS formally announced that consumers in states with Federally Facilitated Marketplaces can create a personal account on healthcare.gov, representing the “first step to enroll in new coverage options in the Marketplace.” See a blog posting by Secretary Sebelius – which includes an infographic depicting account creation as a step toward QHP enrollment –  as well as a July 30 step-by-step overview of the process on healthcare.gov.

In August, CMS held a “Plan Preview” period, including a series of Q&A calls, with Qualified Health Plan (QHP) issuers on Federally Facilitated and State Partnership Marketplaces, enabling them to see their data.

In a development related to Marketplaces, on August 7, the USDA posted a modified grant opportunity (applications were due on August 15) for approximately $795,000 in funding for USDA Extension/Land-Grant Entities to participate in Marketplace-related consumer outreach. See the grant notice and accompanying information.

On August 5, HHS’s Office of Inspector General released a report finding that any “additional delays in completing the security assessment and testing” for the Federal Data Services Hub – a facilitator of Exchanges’ access to federal agencies’ data relevant to eligibility verification – could result in CMS having “limited information on [Hub-related] security risks and controls before the Exchanges open.”

On August 9, CCIIO released guidance on states’ option to develop alternatives to the previously released single, model Small Business Health Options Program applications (see model employee and employer applications), which Federally Facilitated SHOPs will exclusively use for purposes of assessing SHOP eligibility and facilitating enrollment in SHOP Qualified Health Plans.

On August 15, HHS announced it is distributing $67M to 105 Navigator grant applicants across 34 states with Federally Facilitated and State Partnership Marketplaces (see a state-by-state listing of organizations receiving Navigator Cooperative Agreements). In tandem, HHS posted a list of 100 national organizations and businesses that it has designated as “Champions for Coverage” that will direct their partners and members to official Marketplace information sources, such as call centers and healthcare.gov; their activities are described here. Also see a CMS press release on these developments.

On August 15, CMS posted training materials for Marketplace consumer assisters as part of the Federally Facilitated Marketplace Training and Certification Program. See the following files: Navigator training (ZIP) – which contains courses 1-14, ranging from a “Training Overview” to “Eligibility & Enrollment,” “Privacy & Security” and “Customer Service Standards” – as well as Content of Certified Application Counselor Training Courses.

On August 16, CMS published an information collection Notice (see #11) – Cooperative Agreement to Support Establishment of State-Operated Health Insurance Exchanges – noting that the “submitted revision adds sets of Outcomes and Operational Metrics to States’ data collection requirements; we will use the resulting data to evaluate Marketplace performance and overall effectiveness of the ACA.”  Comments on the information collection are due to the OMB desk officer by September 16

On August 16, CMS published a proposed information collection Notice (see #4 on p. 3 of the PDF) explaining intended revisions to the Blueprint for Approval of Affordable Health Insurance Marketplaces. The applicable documents are available in a Paperwork Reduction Act package posted concurrently. Comments are due by October 15.

On August 16, CMS published a proposed information collection and comment request (see#3 on p. 2 of the PDF), “Data Submission for the Federally-facilitated Exchange (FFE) User Fee Adjustment.” It relates to accommodations for self-certifying entities relative to otherwise-applicable requirements to provide first-dollar contraceptive services and the insurer and third-party administrator information collections that underlie the “processes and standards to fund the payments for the contraceptive services that are provided for participants and beneficiaries in self-insured plans of eligible organizations under the accommodation…through an adjustment in the Federally-facilitated Exchange (FFE) user fee payable by an issuer participating in an FFE.”  See the applicable documentation in CMS’s Paperwork Reduction Act package. Comments are due on October 15.

On August 19, HHS announced a video content it is co-sponsoring with the Young Invisibles seeking entries that educate young Americans about ACA coverage options. Several parameters the videos can address, among others, include availability of coverage under a parent’s plan to age 26 and Marketplace coverage options. More details are available in an August 22 Federal Register Notice.

On August 21, CMS posted a Paperwork Reduction Act package containing the State Health Insurance Exchange Incident Report, noting that “as part of the privacy and security oversight of State Health Insurance Exchanges, States will be required to report security incidents including breaches of personally identifiable information.”

On August 28, as reported by Reuters, HHS notified QHP issuers on Federally Facilitated Marketplaces (FFMs) that it will not finalize agreements between September 5-9 as planned but will wait until mid-month, while reiterating that FFMs remain “on track” to open on October 1. Via the Registration for Technical Assistance List-Serv, CMS also confirmed “QHP agreement signing will occur in mid-September. CMS will provide more information on this process via a webinar the week of September 3.”

On August 29, CMS released Marketplace-focused outreach materials for providers, “Health Insurance Marketplaces: 10 Things Providers Need to Know” and “Health Insurance Marketplaces: 10 Things to Tell Your Patients.”

In August, CMS posted FAQs regarding designation of Certified Application Counselor Organizations in Federally Facilitated Marketplaces.

Also in August, CMS posted on its marketplace.cms.gov website a ZIP file containing speaker slides, as well as a slide deck with speaker notes, titled “Overview of the SHOP Marketplaces.”

On August 30, CCIIO published a wide-ranging final rule (also see a factsheet) on Marketplace program integrity and other provisions, noting that it “generally is finalizing previously proposed policies without change.” The rule addressed oversight of Qualified Health Plan (QHP) issuers in Federally Facilitated Marketplaces; individual and SHOP eligibility appeals, including details on a “federally-managed appeals process [that] will be available for appellants in the individual market”; HHS privacy and security-related Marketplace compliance monitoring; an option for a state to operate a State-based SHOP, while having a Federally Facilitated Individual Marketplace; standards regarding issuers’ acceptance of various payment methods from Marketplace consumers; provisions addressing agents and brokers; QHP issuer direct enrollment; and a clarification regarding certain outside-the-Marketplaces plans’ participation in the risk corridors program.

Throughout September, President Obama – in one instance, joined by former President Bill Clinton – and Secretary Sebelius have made numerous public appearances promoting ACA coverage options in the lead-up to October 1 open enrollment, while emphasizing that October 1 marks only the beginning of a six-month enrollment period.

On August 29, House Energy and Commerce (E&C) Republicans sent letters to recipients of Navigator funding querying them on such issues as training, procedures for handling personal information and grant-related documentation. Recipients of the letters are detailed here.

On August 30, HHS released a Paperwork Reduction Act (PRA) Package including details on information collections associated with the August 30 Marketplace Program Integrity final rule, the provisions of which addressed an aspect of the risk corridors program, agents and brokers in Federally Facilitated Marketplaces and various other issues. The PRA package also contains provisions on additional information collections related to Navigators, certified application counselors and habilitative services, among other topics.

On September 4, CMS posted FAQs confirming that Qualified Health Plan and standalone dental issuers in Federally Facilitated Marketplaces would receive an Application Notice on September 9, noting whether their plans are approved for certification. Issuers then had until September 11 to return a signed agreement to CMS. Final confirmation was anticipated in mid- to late-September.

On September 10, at a House Energy and Commerce Health Subcommittee hearing, contractors working with HHS on operational implementation of Marketplaces – including those creating the infrastructure for Federally Facilitated Marketplaces and the Federal Data Hub, as well as assisting with income/employer verification –   affirmed they are tracking project milestones in the lead-up to October 1 open enrollment and said they will be ready. However, a consultant working with states anticipated “rocky” implementation and that few states would have “comprehensively working Exchanges” on day-one. Hearing video and witness testimony is available on the hearing page. E&C Democratic staff also released a supplementary memo addressing several issues, including Marketplace contractors’ security and privacy safeguards.

On September 11, CMS posted a fact sheet, “Security of the Marketplace Data Services Hub,” in which it indicated that the “Hub completed its independent Security Controls Assessment on August 23, 2013 and received an authorization to operate on September 6, 2013.” Also on September 11, the House Committee on Homeland Security’s Subcommittee on Cybersecurity, Infrastructure Protection and Security Technologies held a hearing on the Hub’s security at which HHS’s Assistant Inspector General for Audit Services, among others, testified.
September 13, CMS published details of its analysis of an application by the  Accreditation Association for Ambulatory Health Care (AAAHC) to accredit Qualified Health Plans (QHPs) in Health Insurance Marketplaces, concluding “it is appropriate to recognize AAAHC as an accrediting entity for the purpose of QHP certification.” Comments are due on October 15.

On September 13, CMS released technical FAQs on tobacco rating in Federally Facilitated SHOPs, noting, for example FF-SHOPs “will not impose the tobacco premium rating surcharge at the time of initial enrollment (or re-enrollment) if the employee or dependent, as applicable, agrees at the time of enrollment (or renewal or re-enrollment) to participate in a wellness program meeting the standards of section 2705 of the Public Health Service Act, such as a tobacco cessation program.”

On September 16, HHS published a Notice requesting emergency clearance from OMB for Marketplace data collection activities related to eligibility determination effectiveness, health insurance market impact and other effects, noting usual procedures would not enable timely collection given the October 1 initiation of open enrollment.

On September 16, CMS posted a Paperwork Reduction Act Package, “Cooperative Agreement to Support Establishment of State-Operated Health Insurance Exchanges,” addressing metrics for State-Based Marketplaces in their inaugural year of operations and a “proposed expansion to weekly, monthly and quarterly reporting of some measures [that] will allow [CMS] to gain increased insights into the challenges faced by states during their start-up year.”

On September 17, AHRQ published a proposed information collection regarding the Medical Expenditure Panel Survey—Insurance Component that, in part, would help assess employer-sponsored coverage impacts of SHOP Marketplaces. Comments are due by October 17.

On September 17, HHS released a report (also see an HHS press release) estimating that nearly 10.8M in Marketplaces could pay less than $100 in monthly, post-premium tax credit QHP premiums.

On September 18, CMS, the Department of Justice and the FTC announced an inter-agency initiative to stem fraud and privacy violations in Health Insurance Marketplaces, including the “Establishment of a rapid response mechanism for addressing privacy or cybersecurity threats.” CMS released a fact sheet for consumers on safeguarding themselves against Marketplace fraud.

On September 18, CMS sent a proposed rule to OMB for review relating to “Program Integrity: Exchange, SHOP, Premium Stabilization Programs, and Market Standards,” including wide-ranging provisions, including those relating to the risk adjustment, risk corridors and reinsurance, as well as advance payments of the premium tax credit and cost-sharing reductions, among other issues.

On September 18, CMS posted a handout, “Tips for Assisters to Help Consumers Navigate the Marketplace.”

On September 18, Republicans on the House Oversight and Government Reform Subcommittee released a preliminary staff report raising concerns about the Navigator program, Risks of Fraud and Misinformation with ObamaCare Outreach Campaign: How Navigator and Assister Program Mismanagement Endangers Consumers.

On September 19, CCIIO Director Gary Cohen testified before the House Energy and Commerce Oversight and Investigations Subcommittee, telling Members all Marketplaces in all 50 states would be ready on Oct 1. He also said CMS does not “anticipate a huge amount of [Marketplace] enrollment necessarily” in October given that coverage is effective January 1, 2014, and consumers have until Dec. 15, 2013, to pay premiums. He added that CCIIO is “well mobilized” to address any glitches that may arise during open enrollment. Video and additional information is available here. Subcommittee Republicans expressed concern about the integrity of the Navigator program, citing passages from grant applications.

On September 20, House E&C Republicans sent a letter to CCIIO Director Gary Cohen asking additional questions about the Navigator program (also see a related release).

On September 20, HHS awarded $2.5M in grants to rural organizations, including universities, hospitals and other nonprofit and public organizations, to assist their communities in understanding  Marketplace coverage and eligibility. Through a $1.25M inter-agency agreement, the University of Georgia also is working on outreach in 12 states.

On September 25, HHS released a report (also see an HHS release) on Qualified Health Plan availability and average premiums in Federally Facilitated and State Partnership Marketplaces, finding Marketplaces will have, on average, 53 plan options. HHS also said premiums would be 16% below CBO’s estimates, not taking into account premium subsidies. For the data book, see here. Additionally, the White House presents some of the report’s data in an interactive map. House Energy and Commerce (E&C) Republicans expressed concern that the Administration did not compare Marketplace premiums to rates in the private market today and said some would experience “rate shock”; see an E&C Republican release, as well as a release from House Ways and Means Republicans.

On September 25, in announcing Marketplace-related outreach to Hispanic communities, the White House said the Spanish-language version of www.healthcare.gov, www.cuidadodesalud.gov, “will continue to add functionality such as a new online enrollment tool that will allow consumers to create accounts, complete an online application and shop for health plans” in the lead-up to the October 21-28 National Hispanic Week of Action – and thus signaling such functionality will not be available for October 1.

On September 26, CMS posted a release in which it effectively acknowledged that in Federally Facilitated SHOPs, online enrollment would not be fully available until November. The agency noted that starting October 1, small business would be able to “start the application process and get an overview of available plans and premiums in their area,” while “all functions for SHOP will be available in November.”  The release also laid out CMS’s plans for outreach to small businesses to raise awareness of SHOP Marketplaces.

On September 26, CCIIO posted the final individual short form application – “Application for Health Coverage & Health Paying Costs (Short Form)” (also see instructions) – along with the individual application without financial assistance  (also see instructions). Additionally, CCIIO posted the family application (also see instructions).

On September 30, CMS released a primer on Marketplaces for providers. CMS also is maintaining an inventory of “partner resources” here that include SAMHSA’s Getting Ready for the Health Insurance Marketplace Toolkits.

On September 30, CMS released a fact sheet on exemptions from individual mandate penalties and routes for applying for exemptions, including through Marketplaces.

Also on September 30, HHS added a “find local help” tool to Healthcare.gov so consumers can locate in-person assistance, including Navigators and assisters.

2013 – Fall

On October 1, Health Insurance Marketplaces’ open enrollment period commenced. The Federally Facilitated Marketplace (FFM) website, Healthcare.gov, has experienced technical obstacles, stymieing such functions as account creation and resulting in site downtime and enrollment barriers. FFMs’ rollout has precipitated congressional oversight and an HHS-driven “tech surge,” outlined below, along with other Marketplace developments.

On October 1, CMS posted consumer-oriented videos on Health Insurance Marketplaces and premium tax credits, among other topics. On October 28, HHS released a report finding that 46% of uninsured, single young adults ages 18-34 in 34 Federal Marketplace states could obtain bronze plans for less than $50 in post-subsidy, monthly premiums in 2014. Also see an HHS release.

On October 2, CMS released technical FAQs on Federally Facilitated SHOPs, addressing premium calculations – including composite premiums – and employer and employee contributions.

Also on October 2, HHS released FFM individual plan-level details in electronic spreadsheet form. Data also are available on data.healthcare.gov: Qualified Health Plan (QHP) Individual Medical Landscape, QHP Individual Dental Landscape,  QHP SHOP Medical Landscape and QHP SHOP Dental Landscape.

On October 3, CMS posted its draft Federally Facilitated Marketplace Enrollment Operational Policy and Guidance detailing initial and annual open enrollment periods and coverage effective dates, the process for paying premiums, direct enrollment via the QHP issuer’s website, cancellation logistics, special enrollment periods and other issues. It said the “draft manual will go into effect with minimal changes” as of Oct. 1, 2013, while soliciting comments at EnrollmentGuidance@cms.hhs.gov in anticipation of updated versions.

On October 4, CMS released FAQs  noting it is illegal to “knowingly sell or issue” an individual QHP to a Medicare beneficiary, pointing to “longstanding prohibitions on the sale and issuance of duplicate coverage to Medicare beneficiaries.”

On October 7, White House Press Secretary Jay Carney said  FFM enrollment data will be released in monthly installments, citing the Massachusetts Exchange and Part D as precedents. The Administration subsequently noted such enrollment data releases would commence by mid-November.

On October 8, in a letter to HHS, House Energy and Commerce (E&C) Republicans requested data on first-week FFM enrollments, as well as agency assessments of FFMs’ performance. Also see a release. Also on October 8, Sen. Alexander (R-TN) released a “Guide to Obamacare Glitches” in which he documents reports of consumer challenges completing Marketplace applications, among other issues.

On October 8, HHS issued a release – drawing on a previously released agency analysis – to provide city-level details on post-subsidy premiums in Florida’s Marketplace.

On October 9, CMS released a fact sheet explaining the process for appealing Marketplace eligibility or subsidy determinations and laying out how to initiate an internal appeal and external review of a health plan decision.

On October 10, Healthcare.gov added a feature enabling users in 36 FFM states to preview pre-tax credit premium estimates for plans in their county without creating an account.

On October 10, requesting a briefing by October 16, House E&C Republicans asked HHS to disclose analyses of FFMs’ technical issues, testing and action taken to address consumer enrollment challenges. The Members separately wrote to Marketplace contractors (see those letters here, as well as a press release).

On October 10, writing to Secretary Sebelius (also see a release), Rep. Issa (R-CA) and Sen. Alexander (R-TN) request Marketplace enrollment data, as well as details on system design, implementation and corrective steps.

On October 10, the National Association of Insurance Commissioners released a paper for comment by October 29 on the role of navigators, assisters, application counselors and licensed producers in Marketplaces.

On October 11, CMS released a Q&A including 45 FAQs address small business’ eligibility to participate in Federally Facilitated SHOP Marketplaces, minimum participation requirements and the application process, among other issues.

On October 16, CCIIO released a Word document that lays out the parameters for the Employer Group Service used by Federally Facilitated SHOPs to convey employee enrollment and group changes to issuers via the Federal Data Services Hub.

On October 20, in a blog post, HHS outlined technical issues and steps to address them – including a so-called “tech surge” leveraging public and private sector experts. HHS also said 19M consumers had visited Healthcare.gov to date; 4.7M unique visitors were logged on Oct. 1, the White House said. In subsequent blog posts inventoried here, the agency provided updates on technical progress and, on October 22, announced private sector CEO and government performance expert Jeff Zients had been tapped to help lead the IT response effort. On October 23, HHS said it would provide regular updates on efforts to improve Healthcare.gov via press briefings and blog entries.

On October 21, President Obama addressed the nation (remarks) on ACA implementation, noting “nobody is madder than me about the fact that [Healthcare.gov] isn’t working as well as it should, which means it’s going to get fixed.” He noted call-based and in-person application avenues. See a related blog post.

On October 22, CMS released a “quick start” guide to the Marketplace paper-based application, embedding background information, such as a 1-pager on Marketplace features (also see this document as a standalone version) and details on Healthcare.gov’s premium estimate tool. Also see the agency’s Spanish-language instructions for the Marketplace application, released in October (CMS lists additional Spanish-language Marketplace resources here).

On October 21, in a letter to OMB officials (also see a release), House Committee on Oversight and Government Reform Republicans expressed concern that HHS reportedly asked contractors to require Marketplace shoppers to create accounts before seeing premium prices.

On October 23, Rep. Darrell Issa (R-CA) queried companies such as Google in an attempt to discern who from the private sector was involved in HHS’s “tech surge” for addressing Healthcare.gov performance.

On October 23, CMS posted a form through which health insurance issuers can request changes to QHPs and Standalone Dental Plans offered in FFMs.

On October 23, CCIIO posted an updated interactive map on Health Insurance Marketplace Establishment grants. Arkansas, Idaho, Iowa, Connecticut and the District of Columbia received Level 1 Establishment Grants in this round, while Minnesota and Rhode Island received Level 2 awards.

On October 23, Secretary Sebelius and senior HHS and White House officials met with health insurance executives to discuss technical issues arising with 834 enrollment transactions generated by FFMs, as well as issuer “direct enrollment” of consumers via their websites, noting “alpha teams” of CMS and industry experts had been created to seek solutions.

On October 24, CMS released a final rule (see a CCIIO fact sheet) codifying certain program integrity-related components of the ACA pertaining to Exchanges, premium stabilization programs and market standards that were delineated in a June 2013 proposed rule. The final rule also amends and adopts as final provisions delineated in the Amendments to the HHS Notice of Benefit and Payment Parameters for 2014 interim final rule with comment issued in March 2013 related to risk corridors and reconciliation of cost-sharing.

On October 24, Federal Marketplace contractors – CGI Federal, Optum/QSSI, Equifax and Serco – testified at a House E&C hearing examining pre-implementation planning and post-Oct. 1 efforts to address issues with Healthcare.gov.

On October 24, Secretary Sebelius wrote that FFM call centers had fielded 1.6M calls.

On October 24, Sens. Hatch (R-UT) and Grassley (R-IA), Ranking Members of the Senate Finance and Judiciary Committees, respectively, sent a letter to 47 federal contractors involved with the development of the FFM website requesting copies of all contracts and accompanying memoranda and project schedules by November 8. Republicans on the House Oversight and Government Reform Committee wrote to 11 companies receiving the largest FFM contracts requesting similar implementation details.

On October 25, Sen. Jeanne Shaheen (D-NH) and nine additional Democratic Senators wrote to HHS requesting an extension of the open enrollment period.

On October 25, Sen. Alexander (R-TN) and Rep. Issa (R-CA) wrote a letter (also see a press release) to Secretary Sebelius asking HHS to provide documents and information related to HealthCare.gov by October 28 or face a potential subpoena.

On October 25, CMS released an Notice (see #4 on p. 2) soliciting comments by  November 25 on a new information collection regarding reporting procedures for monitoring the effectiveness of an Enrollment Assistance Program designed to complement Navigators in population centers within FFM states.

On October 25, after assessing FFMs’ status, Jeff Zients said that “by the end of November, Healthcare.gov will work smoothly for the vast majority of users”; he indicated the site is “fixable” and identified performance- and functionality-related problems to be addressed. See an HHS blog post.

On October 26, Secretary Sebelius wrote that by October 25, “nearly 700,000 Americans had completed an application through the Marketplaces – more than half of them through the Federal Marketplace”; enrollment figures were not disclosed.

On October 26, in a blog post, Secretary Sebelius elaborated on the Federal Data Hub’s functions and reported that the IRS has provided 330,000 premium subsidy computations through this conduit. On October 25, U.S. Immigration and Customs Enforcement – within the Department of Homeland Security – clarified that it will not use information provided by individuals to determine eligibility or obtain insurance under the ACA, through the Marketplace, “as the basis for pursuing a civil immigration enforcement action against such individuals or members of their household.” On October 23, CMS proposed a Privacy Act Altered System of Records Notice regarding its Health Insurance Exchange Program record system. Among other changes, it proposes adding a “Routine Use” under which it could use data to “provide for disclosures of employee information to employers when an employee submitting an application for an eligibility determination has been determined eligible for advance payments of the premium tax credit and cost-sharing reductions, or as needed to verify whether an applicant is enrolled in an eligible employer sponsored plan.” Most changes take effect immediately; proposed changes to routine uses take effect in 30 days, pending any changes stemming from comments received in the interim.

On October 29, CMS Administrator Marilyn Tavenner testified at the House Energy and Commerce Committee—the first Administration official to do so since Marketplaces launched on October 1. She apologized for consumers’ challenges with Healthcare.gov and said she expects October enrollment figures to be “small,” consistent with Massachusetts’ early experience. Also see the hearing page; video is archived here.

On October 29, House E&C Republicans released communications provided by FFM contractor CGI, sent to CMS on September 6, describing unresolved issues and risks associated with the timeline for FFMs’ launch.

On October 30, Secretary Sebelius testified before the House E&C Committee and apologized for what she characterized as a “miserably frustrating” roll-out of Healthcare.gov while noting that technical difficulties likely presage “very small” initial enrollment numbers. Also see the hearing page, which includes archived video.

On October 29, CMS Administrator Marilyn Tavenner testified at the House Energy and Commerce Committee—the first Administration official to do so since Marketplaces launched on October 1. She apologized for consumers’ challenges with Healthcare.gov and said she expects October enrollment figures to be “small,” consistent with Massachusetts’ early experience. Also see the hearing page; video is archived here.

On October 29, House E&C Republicans released communications provided by FFM contractor CGI, sent to CMS on September 6, describing unresolved issues and risks associated with the timeline for FFMs’ launch.

On October 30, Secretary Sebelius testified before the House E&C Committee and apologized for what she characterized as a “miserably frustrating” roll-out of Healthcare.gov while noting that technical difficulties likely presage “very small” initial enrollment numbers. Also see the hearing page, which includes archived video.

Throughout November, HHS published a series of 15 blog posts (e.g., Nov. 25 update on site capacity) distilling Healthcare.gov technical updates, as relayed in press briefings. See the HHS.gov/Digital blog archives, as the site experienced continued downtime and widely reported problems with capacity, enrollment, 834 transactions, account creation, plan comparison, and other issues. The Administration repeatedly cited Nov. 30 as the date by which the site would be “working smoothly for the vast majority of users.” Also throughout the month, CMS posted operational guidance to Qualified Health Plan (QHP) issuers via Q&As on the FAQ system of the REGTAP portal (registration required). Search by date here.

On Oct. 31, House Oversight and Government Reform Chairman Darrell Issa (R-CA) subpoenaed Secretary Sebelius for documents related to the launch of Healthcare.gov, including enrollment figures. Also on Oct. 31, House Energy and Commerce (E&C) Republicans wrote a letter to HHS expressing concern about the adequacy of Federal Marketplace security testing.

On Oct. 31, HHS indicated in a letter to Rep. Jim McDermott (D-WA) (see a release; original Aug. 6 letter to HHS from Rep. McDermott) that Marketplaces and QHPs offered there are not considered Federal programs under section 1128B of the Social Security Act (known as the Federal Anti-Kickback Statute), which appeared to lift a key barrier to drug manufacturer co-pay assistance and hospital assistance with patient premiums and out-of-pocket costs. On Nov. 4, contrary to expectations, HHS issued a Q&A calling into question the permissibility of any third party intending to assist QHP enrollees with their premium or cost-sharing liabilities. HHS specifically references recent “suggestions” that hospitals and other commercial entities may provide premium and cost-sharing assistance to patients, but then states it has “significant concerns” with such practices, discourages them and encourages QHPs to reject them. HHS concludes the guidance by saying it will “monitor this practice and take appropriate action, if necessary.” On Nov. 7, Sen. Grassley (R-IA) (see a release) wrote to Secretaries Sebelius and Holder that “Congress’ intent to treat kickbacks under PPACA as False Claims Act violations is clear” and that if HHS’s decision articulated in the McDermott letter stands, the agency “would be removing a vital tool to investigate and prosecute fraud.” On Nov. 20, Sen. McCain (R-AZ) sent a letter to HHS expressing concern that the HHS decision leaves QHPs “outside of the scope of important anti-fraud protections.”

On Oct. 31, in an updated FAQ document, CMS detailed the process for computing premiums in Federally Facilitated SHOPs, including the composite premium method that can be leveraged “at an employer’s request or as may be required by applicable state law.”

On Nov. 1, CMS published a Notice requesting comments by Dec. 31, 2013, on an information collection (see #3 on p. 2) – “Initial Plan Data Collection to Support Qualified Health Plan (QHP) Certification and Other Financial Management and Exchange Operations” – relating to revisions to data elements collected from QHPs to support various regulatory requirements. The agency notes that “based on experience with the first year of data collection, we propose revisions to data elements being collected and the burden estimates for years two and three.” Accompanying documents are available in a Paperwork Reduction Act Package.

On Nov. 1, CMS posted slides from a REGTAP training session depicting the process that agents and brokers – including web brokers – follow in registering to provide consumer assistance in Federal Marketplaces. Beginning on slide 44, CMS outlines direct enrollment and Marketplace pathways for effectuating enrollment, including diagramming both processes on slides 47 and 48, respectively.

On Nov. 5, CMS Administrator Marilyn Tavenner testified at a Senate HELP hearing, noting that the agency is making headway on its efforts to stabilize Healthcare.gov and has developed a “targeted outreach plan” – to begin in December – that includes various media in specific markets based on the number of young people and the uninsured population.

On Nov. 5, the House Oversight and Government Reform Committee released notes (also see a press release) from CCIIO HealthCare.gov “war room” meetings spanning 175 pages and covering meetings held Oct. 1-29 between government officials and contractors. These documents followed an Oct. 31 release of CCIIO war room notes taken on Oct. 2 indicating 6 Federal Marketplace enrollments had occurred on the first day of open enrollment. Notes from Oct. 3 cite 248 enrollments (see here) by the end of Oct. 2.

On Nov. 5, House W&M Committee Chairman Dave Camp wrote to CMS he is issuing a subpoena for Marketplace enrollment reports by Nov. 8 (see an accompanying release).

On Nov. 4, the House Oversight and Government Reform Committee released notes taken during CCIIO “war room” meetings between Oct. 3-Oct. 21 (see here; also see a Committee release) – supplied in response to Committee requests – explaining that while “paper applications allow people to feel like they are moving forward in the process and provide another option, at the end of the day, we are all stuck in the same queue.” The notes regarding paper applications, from Oct. 11, explain that “the same portal is being used to determine eligibility no matter how the application is submitted (paper, online)…and there is coordination to improve that experience.”

On Nov. 6, Secretary Sebelius testified at a Senate Finance hearing on Marketplace implementation.

On Nov. 13, in the first of monthly enrollment releases, HHS reported that between October 1 and November 2, 106,185 individuals selected QHPs in states with Federally Facilitated (FFMs) and State-Based Marketplaces (SBMs). HHS notes “this includes those who have paid a premium and those who have not yet paid a premium.” Of the total, 79,391 of those selecting a plan are in SBMs and 26,794 in FFMs, the latter of which span 36 states. Also see an HHS press release, as well as an infographic depicting selected data points.

On Nov. 13, the House Oversight and Government Reform Committee convened a hearing at which top HHS and White House IT officials testified on efforts to address Healthcare.gov – seeking to manage expectations on end-of-month fixes not representing ideal but rather smoother functionality – as well as to assure the site’s safeguarding of consumers’ personal information and improve government contracting for IT services.

On Nov. 14, CMS released a downloadable ZIP file including updated slides and presenter talking points on Health Insurance Marketplaces.

On Nov. 14, CMS issued a CMS issued a notice with comment describing the Quality Rating System (QRS) framework and methodology – which includes a list of proposed quality measures – to rate QHPs offered on the Exchange based on the relative quality and price, as well as enrollee satisfaction/consumer experience. Comments are due on Jan. 21, 2014. Also see a Nov. 1 Paperwork Reduction Act Package on Marketplace consumer experience surveys (including enrollee satisfaction survey and Marketplace survey-related data collection); the corresponding Federal Register Notice is here (see #2 on p. 1).

On Nov. 15, CMS published in the Federal Register, as part of a new information collection (see #2 on p. 2), a request for OMB approval and public comment – due by Jan. 14, 2013 – on an annual accounting-related report to be filed by State-Based Marketplaces on receipts and expenditures.

On Nov. 19, CMS posted a downloadable ZIP file containing materials in Spanish used to train certified application counselors, who assist applicants with enrolling in coverage through Marketplaces.

On Nov. 19, the House E&C Committee released a McKinsey report  pointing to risks posed to the implementation of the Marketplaces months prior to the Healthcare.gov’s launch. Also see July 2013 e-mails (press release) released by the E&C Committee Republicans indicating CMS officials were concerned that federal contractors were not able to meet the Oct. 1 Federal Marketplace opening deadline.

On Nov. 19, the House Committee on Science, Space and Technology held a hearing on Healthcare.gov security, as did the House E&C Oversight and Investigations Subcommittee (testimony and video here), the latter of which included Marketplace contractors. At the E&C hearing, a CMS official indicated that 30-40% of “back-end” (e.g., those related to payment and reconciliation, among other functions) Marketplace IT systems remain to be built.

On Nov. 20, noting they do not believe HHS currently can certify Marketplaces’ income verification procedures –required by Jan. 1, 2014 – House Ways and Means Committee Republicans wrote a letter to the agency seeking data on current verification error rates and contingency plans, among other issues.

On Nov. 20, the Senate Small Business and Entrepreneurship Committee held a hearing on SHOP Marketplaces, including testimony by CCIIO Director Gary Cohen; Assistant Secretary of the DOL’s Employee Benefits Security Administration Phyllis Borzi; representatives of the KY, DC and NM Marketplaces and others.

On Nov. 20, in a blog post, CMS noted the agency has trained 19,000 assisters – including Navigators, in-person assisters and certified application counselors – and estimates they have helped more than 450,000 individuals with Marketplace coverage.

On Nov. 21, according to news reports (e.g., Bloomberg), HHS intends for 2015 open enrollment to begin on Nov. 15, 2014, a month later than anticipated, giving insurers more time to factor experience into rates.

On Nov. 21, House Energy and Commerce Republicans released e-mails (also see a press release) among Administration officials and Federal Marketplace contractors in which CMS Deputy CIO Henry Chao, for example, discusses “getting [Healthcare.gov] performance to at least 10k or greater concurrent users without defects,” while noting the potential for greater surges, as other e-mails document issues with tests involving less user capacity.

On Nov. 22, HHS announced that it intends to extend for 1 week, to Dec. 23, 2013, the deadline by which consumers must enroll in and make the first premium payment for coverage through Marketplaces in order to secure coverage effective dates of January 1, 2014.

On Nov. 25, HHS issued a proposed rule establishing the CY 2015 benefit and payment parameters for the cost-sharing reductions (including the annual limitation on cost-sharing for stand-alone dental plans), advance premium tax credit, reinsurance, and risk adjustment programs as required by the ACA.  In addition, the proposed rule establishes the user fees for the Federally-facilitated Exchanges (FFEs), the annual open enrollment period for 2015, the actuarial value (AV) calculator, and other key provisions as required by the law.  Note that the rule allows for adjustments to the risk corridors and other premium stabilization programs in 2014 to account for the “transitional policy” (see the Nov. 14 CCIIO letter to Insurance Commissioners) that addressed plan cancellations, which could equate to broader risk corridors and thus higher stabilization payments to plans. Comments are due by Dec. 26, 2013.

In a Nov. 27 blog post, HHS announced that, instead of launching online Federally Facilitated SHOP enrollment in November 2013 as anticipated, this will be delayed until November 2014. Small business in Federal Marketplace can, meanwhile, enroll via “direct enrollment” mechanisms through agents, brokers and insurers, the agency said.

On Nov. 30, Healthcare.gov interim site-work lead Jeff Zients issued a report (CMS release; HHS blog post) indicating that the Administration had met its goal of securing site functionality for a “substantial majority” of users and enabling 50,000 concurrent users.

On Nov. 30, HHS released “QHP landscape files” with refreshed and amplified data on QHPs available through Marketplaces. See: Individual Medical Plan Landscape (enhanced data); SHOP Medical Plan Landscape (enhanced data); and SHOP Dental Plan Landscape. Also see Background Information. The augmented Marketplace plan data, including more refined age-based premium calculations, underpin an updated Premium Estimation Tool available at Healthcare.gov.

On Dec. 19, in an interim final rule (press release; fact sheet), HHS codified the requirement for insurers to take payment for premiums through Dec. 31, 2013, for coverage on Jan. 1, and urged insurers to further extend that payment deadline (some provided until Jan. 10 or later). HHS also urged insurers to treat out-of-network providers as in-network for acute episodes and to refill prescriptions covered under previous plans. For states using the challenged Healthcare.gov, the Pre-Existing Condition Insurance Plan will have coverage extended through the end of January 2014 (see below for a subsequent extension).

In December 2013 and January 2014, CMS posted approximately 100 operational FAQs for Qualified Health Plan (QHP) issuers on the REGTAP portal (registration/account required). Search by date here.

On December 1, 2013, CCIIO posted “Tips for Agents and Brokers” on assisting consumers beginning Dec. 1, via a health plan issuer or the Marketplace website, to enroll in Marketplace coverage.

On December 3, 2013 CMS released a fact sheet on Healthcare.gov’s site performance. The agency also noted “more robust window shopping” (see a related blog post) and a “customer call-back service” and describes the availability of direct enrollment via issuers, as well as in-person application assistance. Also see a blog post on enrollment avenues.

On December 4, 2013 HHS posted “Tips for In-Person Enrollment Assisters: Helping Consumers Who Have Attempted but Not Completed Applications” (here). Additionally, on December 4, CMS released a statement to the media, jointly with America’s Health Insurance Plans and the Blue Cross and Blue Shield Association, indicating “we are working together closely to resolve back-end issues between health plans and healthcare.gov,” adding “we will report on our progress.” Also on December 4, the House Oversight and Government Reform Committee held a hearing on Marketplaces’ rollout.

On December 6, 2013 CCIIO released FAQs providing assistance to states in use of funding for Exchange operations under section 1311 of the ACA for IT vendor change requests and responses to congressional inquiries. Also on December 6, HHS announced that Healthcare.gov received 3.7M visits between midnight Dec. 1 through noon Dec. 6, following the agency’s announcement that it had met its goal of having the site functioning smoothly for most users by late November. The agency said the “site remained stable and experienced no unscheduled downtimes,” with a 0.77% average error rate. The queuing system was activated twice.

On December 11, 2013 ASPE released a monthly enrollment report indicating that 258,497 people selected Marketplace plans in November, placing cumulative, Oct. 1 through Nov. 30 enrollments at 364,682. This included 227,478 via State-Based Marketplaces and 137,204 through Healthcare.gov, including those who have and have not yet paid premiums. Additionally, on December 11, HHS announced that more than 1,150 health centers are receiving $58M in grants to amplify efforts to reach out to the uninsured and enroll them in Marketplace coverage options. Also on December 11, CCIIO Director Gary Cohen testified at a House Small Business Committee hearing (materials) on implementation of SHOP Marketplaces. Finally, On December 11, ahead of formal testimony to the House Energy & Commerce Health Subcommittee, (details here), Secretary Sebelius in a blog post delineates three steps to “bette[r] understan[d] the structural and managerial policies that led to the flawed launch of HealthCare.gov,” namely: (1) request the OIG to review the development of HealthCare.gov (letter here); (2) request CMS Administrator Tavenner to create a new full-time, permanent position and appoint a CMS Chief Risk Officer to focus on mitigating risk across CMS’ programs; and (3) update and expand CMS employee training on best practices for contractor and procurement management, rules and procedures.

On December 11, 2013 House Oversight and Government Reform Committee Chairman sent a letter to HHS critiquing what he contends is HHS’s recent instruction (letter) to Healthcare.gov contractors that, he asserts, effectively precludes their cooperation with Congressional investigators. On Dec. 13, HHS contractor MITRE (letter; press release) provided Security Control Assessments in response to a congressional subpoena.

On December 16, 2013 CMS posted a series of documents (Excel File: Verifying QHP, Federally Facilitated Marketplace Data) as part of a process to verify QHP issuer enrollment data against Federal Marketplace extracts. Also see an Issuer Metrics Template v3 (Excel), as well as additional documents in the REGTAP library (registration/account required).

On December 16, 2013 at a House Oversight and Government Reform field hearing in Texas on  Exchange Navigators and assisters, Committee majority staff released a report calling into question HHS’s contingency planning with respect to the implementation of these two programs following the Healthcare.gov rollout.

On December 17, 2013 Secretary Sebelius announced that Kurt DelBene, a former Microsoft Office president, would start that week, overseeing Healthcare.gov. He replaced interim manager Jeff Zients, who was detailed to the project as the rollout stalled. Also on Decemeber 17, CMS posted (on the REGTAP portal) slides detailing SHOP Marketplaces.

On December 19, 2013 CMS posted (on the REGTAP portal) slides on the Health Insurance Casework System for Qualified Health Plan issuers, involving timely resolution of issues.

On December 23, 2013 the deadline (extended from Dec. 15) for enrolling in coverage effective Jan. 1, HHS extended the deadline to Dec. 24 at midnight. A blog post on Healthcare.gov notes that latitude; in another blog post, HHS added it was spending Dec. 24 completing Dec. 23 applications that were in a queue.

On December 30, 2013 CCIIO issued FAQs regarding the State-based Marketplace Annual Reporting Tool.

On December 31, 2013 in a blog post, CMS Administrator Marilyn Tavenner announced that 2.1 million people had signed up for QHPs via Federal and State Exchanges between Oct. 1 and Dec. 31, with consumers in December signing up at a rate six times that of October and November. Additionally, CMS posted earlier (Nov. 13) slides providing details and a scenario-based discussion of the audit files it will provide to QHP issuers as part of the process of reconciling plan and Federal Marketplace enrollment records. Also on December 31, CMS issued a correction to its October 2013 final program integrity rule clarifying (via a cross-reference) that certain oversight and program integrity aspects also apply to the SHOP.

2014 – Winter

On January 1, 2014 HHS posted a series of primers on Healthcare.gov describing how consumers can use new Marketplace coverage, while offering topic-specific Q&As addressing getting prescription medications regular medical care, among other topics. Fact sheets released as standalone handouts include:

• Using Your Health Insurance Marketplace Coverage on Jan. 1, 2014
• What to Know About Getting Your Prescription Medications
• What You Should Know About Provider Networks
• Appealing Your Insurer’s Decision Not to Pay
• What You Should Know About Seeing Your Doctor
• Getting Emergency Care
• I Signed Up, But I Don’t Have Coverage. What Should I Do?

On January 2, 2014 CMS released a primer for Navigators and in-person assisters, “Helping Consumers with Eligibility and the Application Process” that includes FAQs on whether “dreamers” qualify for Marketplace coverage, as well as green card holders’ qualification for premium subsidies, among other issues. Also on January 2, noting the discontinuation of the its Office of Public Engagement, CMS indicated in the Federal Register that it has created a new Office of Hearings and Inquiries and has a new structure for conducting Marketplace eligibility appeals, among other functions.

On January 7, 2014 citing the lack of an automated process to effectuate eligibility updates through Marketplace websites, CMS released guidance indicating that Federal Marketplaces are “establishing an interim short-term policy to allow enrollees to make certain specific changes to their enrollment data directly with issuers.” Also on January 7, CMS (on REGTAP) an Excel file for QHPs’ and others’ use in reporting February 2014 enrollment and payment-related data to the agency. Also see Jan. 13 slides on this process and, as released on Jan. 17, a chart that “illustrates which Issuers or State Based Marketplaces on behalf of Issuers must submit Enrollment and Payment Data Templates as part of the Interim Marketplace Payment Process.” Jan. 17 slides provide an update on preparing February enrollment and payment data.

On January 8, 2014, as part of an ongoing probe of Healthcare.gov security, House Oversight and Government Reform Committee Chairman Darrell Issa calls (letter; press release) Secretary Sebelius; statements about Healthcare.gov security “false and misleading,” citing contractor and other officials’ statements, and asks for clarification of her testimony, if needed. Also see a separate release by the Committee documenting Healthcare.gov security concerns.

On January 9, 2014 CMS released “Tips for In-Person Enrollment Assisters: Helping Consumers with Casework” (see here).

On January 10, 2014 HRSA released a guide, “How Health Centers Can Help Newly Insured Individuals Address Potential Issues” (see here); it focuses on Federal Marketplace states. Also on January 10, in guidance, HHS noted it will not enforce certain anti-duplication provisions when plans sell individual policies to under-65 Medicare beneficiaries who are losing state high-risk pool coverage they had used as supplemental insurance.

On January 13, 2014 HHS released the first official demographic data on individuals enrolling in State and Federal Marketplaces and their product selections. Data show: one-quarter of Exchange enrollees are between the ages of 18 and 34. More than half are aged 45-64; 30% are under age 30. 60% selected silver plans. The report also conveyed that 2.2 million selected QHPs through December; 1,196,000 came through Healthcare.gov, with 1,059,000 of those selections being recorded in December. In addition, on or around January 13, federal officials posted a document (downloadable PDF) laying out the rationale for a “one-year [$91.1 million] contract action,” saying it is “an interim, transitory solution to meet the Agency’s immediate and urgent need for specific FFM functions and modules” formerly performed by CGI Federal and to be assumed by Accenture. The agency indicated that if specified Healthcare.gov functionality “is not complete by mid-March 2014, the Government could make erroneous payments to providers and insurers.”

On January 16, 2014 at an Oversight and Investigations Subcommittee hearing, CCIIO Director Gary Cohen (testimony) said the agency is continuing to see “very good” Healthcare.gov enrollment numbers into early January and plans enhanced outreach to young people. He indicated the agency is heavily focused on back-end financial systems enabling advance premium subsidy and cost-sharing reduction payments to insurers, saying those were expected to be made the following week via an interim process, and that data were not yet fully available on who has paid premiums, necessitating later reconciliation for those receiving advance financial assistance.

Also on January 16, 2014 CMS posted slides on Federally Facilitated Small Business Health Options Program-related FAQs, including on the “direct enrollment” approach being used in the absence of online enrollment capability.

On January 17, 2014 President Obama signed the omnibus appropriations bill for 2014, which includes a specification that HHS publish, in the FY 2015 President’s budget, information describing the “uses of all funds used by [CMS] specifically for Health Insurance Marketplaces for each fiscal year” since ACA enactment, as well as proposed uses for such funds in 2015, among other provisions. Also on January 17, CMS posted an overview of training, including “Affordable Care Act and Marketplace Basics,” “Individual Marketplace” and “SHOP Marketplace,” for agents and brokers participating in Federal Marketplaces. Also see: Quick Reference Guide for Agent and Broker Registration in FFMs

On January 22, 2014 through an updated interactive map, CCIIO conveys details of the latest round of Marketplace Establishment Grants awarded to states.

On January 24, 2014 QHP sign ups reached approximately 3 million, CMS Administrator Marilyn Tavenner wrote in a blog post. Also on January 24, CMS posted slides from a technical support call explaining a Federal Marketplace issue with 834 enrollment transactions related to cost-sharing reduction amounts. Among other issues, the agency also notes that February enrollment data showed a “dramatic drop” among some plans and indicated that the “February tab should reflect the entire enrollment profile for February, not just any new enrollments for the month.”

On January 27, 2014, with respect to Marketplace enrollee demographics, White House Press Secretary Jay Carney said, “We are seeing, and we saw in December, a significant surge in the percentage of young Americans under 35 enrolling, and that those numbers are consistent with what we saw in Massachusetts.”

On January 28, 2014, the House Oversight and Government Reform Committee held a hearing, “A Roadmap for Hackers? – Documents Detailing HealthCare.gov Security Vulnerabilities,” materials for which are posted here. The Committee had also held a Jan. 16 hearing on Healthcare.gov security (details are available here); the House Committee on Science, Space and Technology also held a related hearing (materials) that day, “Healthcare.gov: Consequences of Stolen Identity.”

On January 30, 2014, CMS submitted for OMB review and requested comments in 30 days on the State-based Marketplace Annual Reporting Tool (see #2), used to assess compliance with Marketplace regulations and to “provide a mechanism to collect innovative approaches to meeting challenges encountered by the SBMs during the preceding year as well as providing information to us regarding potential changes in priorities and approaches for the upcoming year.”

On Feb. 4, CBO released updated projections for changes in insurance coverage under the ACA and now estimates that 6 million will gain coverage through Exchanges in 2014, down from 7 million in the May 2013 baseline; 2015 projections for Exchange enrollment remain unchanged at 13 million.

On Feb. 4, CCIIO released a draft letter to Qualified Health Plan (QHP) issuers in Federally Facilitated Marketplaces (FFMs) that lays out 2015 policy parameters and timelines for QHP certification and accompanying requirements in FFMs. States performing plan management functions in FFMs have some latitude to customize the guidance. These policies – if adopted in the final letter and, in some cases, pursued in envisioned rulemaking – generally would apply only in the “2015 certification year and beyond,” complementing previously finalized regulations on market-wide QHP certification. Comments on the draft letter were due by Feb. 25, 2014. Also see slides released on Feb. 13, in which CMS outlines elements of the draft 2015 issuer letter pertaining to Federally Facilitated SHOP Marketplaces, including employee choice models and corresponding premium aggregation services.

On Feb. 4, CMS released a fact sheet with advice for small employers on the potential to offer employees coverage through SHOP Marketplaces.

On Feb. 4, HRSA posted a grant opportunity, a component of which aims to “train Ryan White core medical providers to both initiate contracts with qualified health plans and facilitate client enrollment into those health plans.”

On Feb. 6, in a package of policy bulletins, CMS provides Federally Facilitated and State Partnership Marketplaces with operational guidance on newly available functionality for consumers to report life changes via Healthcare.gov. Special enrollment periods are yet to be automated; interim processes are discussed in the guidance. Specific bulletins (see above link) include:

• Bulletin #2: Functionality for Consumer-Initiated Application and Enrollment Changes
• Bulletin #3: Special Enrollment Periods: Effective Dates and Processes
• Bulletin #4: Enrollee-Initiated Termination Instructions through the FFM
• Bulletin #5: Flexibility during the Initial Open Enrollment Period to Change Plans Offered by the Same Issuer at the Same Metal Level
• Bulletin #6: Clarifications of the Instructions Presented in the December 17, 2013, Interim Final Rule and Bulletin #001; the clarifications address premium due dates in cases in which retroactive coverage is granted.

On Feb. 6, Sens. Hatch, Alexander, Enzi and Grassley asked (release) CMS Administrator Marilyn Tavenner about the agency’s plans to address consumer appeals to correct Marketplace application errors.

On Feb. 7, CCIIO posted FAQs on third-party payments of premiums and cost-sharing for QHPs in Marketplaces clarifying that earlier, Nov. 4, 2013, FAQs (available here), in which the agency expressed “significant concerns with this practice” by commercial entities, discouraged such approaches and encouraged “issuers to reject such third-party payments,”  do not apply to premium and cost-sharing payments made on behalf of QHP enrollees by the Ryan White HIV/AIDS program or by Indian tribes, tribal organizations, urban Indian organizations, and state and federal government programs or grantees. CCIIO indicates that in these cases, “QHP issuers and Marketplaces are encouraged to accept such payments.” CCIIO also clarifies that such payments made by private, not-for-profit foundations would not be implicated in the Nov. 4 FAQ under certain circumstances, including if they are encompassed in the aforementioned types of programs or grantees or if “they are made on behalf of QHP enrollees who satisfy defined criteria that are based on financial status and do not consider enrollees’ health status,” although in the latter instance, CCIIO would “expect that premium and any cost sharing payments cover the entire policy year.” Also see a blog post.

On Feb. 10, CMS published an information collection notice regarding “Initial Plan Data Collection to Support Qualifies Health Plan Certification and Other Financial Management and Exchange Operations,” noting “based on experience with the first year of data collection, we propose revisions to data elements being collected and the burden estimates for years two and three.” Comments are due by March 12, 2014.

On Feb. 11, HHS sent a proposed rule, “Marketplace and Insurance Market Standards for 2015-2016,” to OMB for regulatory review, noting that the regulation “would update policy based on experience with initial open enrollment” (details).

On Feb. 11, HHS released a report (press release) finding 8 in 10 Uninsured Latinos may qualify for assistance via Marketplaces.

On Feb. 12, HHS announced (press release; enrollment report; infographic) that as of Feb. 1, nearly 3.3M had enrolled in Qualified Health Plans (QHPs) via State-based (about 1.36M) and Federally Facilitated (about 1.94M) Marketplaces (FFMs), 1.1M of which occurred in January 2014. Young adults (ages 18-34) accounted for 27% of January plan selections via FFMs, reflecting, for that month, a 3 percentage-point increase versus the proportion of young adults enrolling in the October through the end of December period. For the first time, HHS reported on metallic tier selections by demographics.

On Feb. 12, House E&C Chairman Fred Upton (R-MI) and subcommittee chairs, citing ongoing technological barriers to enrollment, requested that GAO review the Cover Oregon Marketplace, including the use of $304 million in federal grants. Also see a press release.

On Feb. 14, CMS posted a fact sheet that outlines immigration- and citizenship-related information, including documentation options, for use in completing the Healthcare.gov application.

On Feb. 14, White House Press Secretary Jay Carney said Qualified Health Plan issuers “have the most up-to-date, comprehensive, and reliable information on the number of people who have paid their premiums” and that there’s an automated payment system that will be coming online fully in the next several months, which will include in the flow of information more specific, timely data relating to the payment of premiums by enrollees provided by the insurance company, which is just a way of saying we will — CMS will have concrete and timely data on those who have paid.” He pointed to media accounts indicating that, he said, a “very high percentage have been meeting their premium deadlines.”

On Feb. 18, CMS posted webinar slides regarding technical assistance for the Marketplace payment process of advanced premium tax credits and cost sharing reduction payments, specific to the March reporting, as well as restatement submissions. (Also: Feb. 12 slides).

On Feb. 20, House Energy and Commerce Committee Chairman Fred Upton and colleagues sent a letter to Federal Marketplace contractor Accenture requesting a briefing and documents relating to its work.

On Feb. 21, CCIIO posted guidance, addressing Medicaid managed care organizations’ (MCO) and health insurance issuers’ outreach to former enrollees regarding coverage options.

On Feb. 25, in a blog post by Administrator Marilyn Tavenner, the Centers for Medicare and Medicaid Services reports that approximately 4M have selected Qualified Health Plans via State-Based and Federally Facilitated Marketplaces since Oct. 1, 2013. (President Obama had said close to 4M on Feb. 20.) The 4M mark is approximately a 700,000 increase since the last enrollment report (which tabulated data as of Feb. 1, as released on Feb. 12; see above).

On Feb. 27, CCIIO issued a notice explaining data collection procedures, comments on which are due on or around March 27, for State Health Insurance Exchange Incident Report through which state-based Administering Entities would report “suspected or confirmed incidents affecting loss or suspected loss of PII within one hour of discovery,” among other protocols.

On March 4, the President’s fiscal year 2015 budget request included $25M over a 2-year period to “monitor and prevent fraud, waste, and abuse in the Health Insurance Marketplace.”

On March 4, CMS posted updated slides, “Overview of the Health Insurance Marketplace” (ZIP file) and “Health Insurance Marketplace 101” (ZIP); both contain slide decks, as well as speakers’ notes.

On March 5, CCIIO issued the 2015 Notice of Benefits and Payment Parameters final rule (fact sheet). Among other provisions, it includes a “state-level adjustment in the risk corridors formula to account for the transitional policy’s [on canceled plans] effect on the expected 2014 risk pool in a way such that the program is projected to be budget neutral, with payments in equaling payments out, while helping to ensure that prices remain affordable in 2015 and beyond,” according to the agency. The rule also finalizes the 2015 benefit year open enrollment as Nov. 15, 2014, through Feb. 15, 2015 (versus the proposed January 15, 2015 end date).

On March 7, CMS released a primer, “Report Life Changes to the Marketplace After You Enroll in Coverage,” that addresses factors ranging from marriage and divorce to income-related fluctuations, noting that while some changes can affect eligibility for Special Enrollment Periods, others may affect premium tax credit amounts, among other impacts.

On March 10, the White House posted its customary supplementary compendium of analytical and historical FY 2015 budgetary documents (Analytical Perspectives and Historical Tables), including a special topics section that includes, on p. 27, a table of state Exchange grants.

On March 10, CMS released its congressional budget justification for fiscal year 2015 noting $629.2M in appropriated funding for the Marketplaces, along with $1.2B in projected user fee collections to fund the Marketplaces at a Program Management program level totaling $1.8 billion;

On March 11, HHS’s Assistant Secretary for Planning and Evaluation posted the fifth in a series of monthly enrollment reports (infographic) finding that between Oct. 1, 2013, and March 1, 2014, more than 4.2M individuals selected a QHPs through State-Based (SBMs) (1.6M) and Federally Facilitated Marketplaces (FFMs) (2.6M). This includes those who have and have not paid premiums. For the cumulative first five months, those ages 18-34 represent 25% of those enrolling through FFMs and SBMs, while those 0-17 represent 6% and those age 35 and over represent 69%, HHS said.

On March 13, at a House Ways and Means Committee hearing on the HHS budget, Secretary Sebelius said there would be no further delays to significant provisions of the ACA, specifically with respect to the individual mandate and the March 31 end-date to the program’s inaugural 6-month enrollment period.

On March 14, CCIIO posted the final call letter to issuers offering Qualified Health Plans (QHPs) in Federally Facilitated Marketplaces (FFMs). The letter finalizes a timeline for FFM QHP certification and addresses QHP network adequacy (p. 18), including finalizing the use of a “reasonable access” standard and noting “CMS will focus most closely on those areas which have historically raised network adequacy concerns” (it indicates these may include hospital systems, mental health providers, oncology providers and primary care providers).

On March 14, CCIIO issued an interim final rule with comment period requiring Qualified Health Plans (QHPs) to “accept premium and cost-sharing payments made on behalf of enrollees by the Ryan White HIV/AIDS Program, other Federal and State government programs that provide premium and cost sharing support for specific individuals, and Indian tribes, tribal organizations, and urban Indian organizations.” This also applies to standalone dental plans (SADPs). In its regulatory impact analysis, CMS says the “vast majority of issuers already accept such payments.”

On March 14, CCIIO issued FAQs on the use of 1311 Exchange grant funds and no-cost extensions.

On March 14, President Obama conducted an interview with WebMD addressing, among other topics, Marketplaces (see a White House blog post).

On March 14, CCIIO posted a proposed rule on Marketplace and broader insurance market standards for “2015 and beyond.” Among other changes, CCIIO proposes “changing the limit on allowable administrative costs to 22 percent [from 20 percent] and the limit on profits to 5 percent [a 2 percentage point increase] in the risk corridors calculation, in recognition of the ongoing uncertainty and changes in the market in 2015,” adding that the agency “expect[s] to implement this change in a budget neutral way” and that the adjustment would be “applied uniformly in all States for 2015 to help additional transition costs and uncertainty.” Comments on the proposed rule are due on April 21.

On March 17, HHS announced in a blog post that Marketplace sign-ups had reached 5M.

On March 26, CCIIO created special enrollment periods (SEPs) enabling those “in line” in Federally Facilitated and State Partnership Marketplaces (FFMs) upon the March 31, 2014 end of open enrollment to have “limited” – but not precisely specified – additional time to complete the application and enrollment process (see here). State-Based Marketplaces “may elect to offer similar SEPs,” the agency notes. Additionally, accompanying guidance also creates FFM SEPs enabling those with certain “complex cases,” outlined in more detail below, to enroll outside the open enrollment period.

On March 27, HHS said in a blog post that more than 6M consumers have signed up for QHPs via Marketplaces since open enrollment began on Oct. 1, 2013.

2014 – Spring

On April 1, 2014 President Obama said more than 7 million had enrolled via Marketplaces. A Healthcare.gov blog post reiterated that Federally Facilitated Marketplaces continued to accept those “in line” as of March 31.

On April 1, CCIIO posted slides for agents and brokers regarding the Federally Facilitated Marketplace changes-in-circumstances functionality.

On April 3, testifying before two House Oversight and Government Reform subcommittees, representatives of State-Based Marketplaces in HI, MA, MD, MN and OR discussed efforts to address roll-out challenges. Covered California shared its “early lessons in implementation.”

On April 4, CMS released slides outlining the timeline for Qualified Health Plan (QHP) certification in Federally Facilitated and State Partnership Marketplaces (see slides 10-11). The slides draw on the final issuer letter released in March.

On April 7, Sens. Hatch (R-UT) and Grassley (R-IA) wrote to HHS seeking details on agency grants to State-Based Marketplaces, as well as HHS’s oversight and technical assistance.

On April 10, testifying on the President’s proposed FY15 HHS budget, Secretary Sebelius reported that 400,000 additional individuals had signed up for QHPs through Marketplaces since the latest report, bringing total sign-ups to 7.5 million. Responding to a question from Sen. Charles Grassley (R-IA), she also said QHPs are “not immune” to Federal; anti-fraud statute with respect to third-party payment of QHP premiums and cost-sharing.

On April 11, CMS published on information collection notice (see #1 on p. 2) regarding progress report requirements under Federally Facilitated and State Partnership Marketplace Navigator Cooperative Agreements. Comments are due by June 10, 2014.

April 15 was the final day for those “in line” for Federally Facilitated Marketplaces as of March 31 to enroll.

On April 17, President Obama announced that 8 million people had signed up for QHPs through Marketplaces. The White House also said that in Federally Facilitated Marketplaces, 35% are under age 35, and 28% are ages 18-34, “virtually the same youth percentage that signed up in Massachusetts in their first year of health reform,” according to the release. Additionally, the Administration pointed to CBO estimates that 5 million people are enrolled in plans that meet ACA standards outside of Marketplaces. Also see a Healthcare.gov blog post on special enrollment periods and corresponding “qualifying life events.”

On April 17, HHS posted a “sources sought” notice (details) that will be “used to obtain information regarding the availability and capability of qualified small businesses (e.g.: 8(a), service-disabled veteran owned, HUBZone and women-owned small businesses) to provide development and maintenance of the Federally Facilitated Marketplace system,” a contract currently held by Accenture (ending January 2015). Responses are due by May 2, 2014.

On April 21, the GAO issued a report on HHS’s efforts to seek support from private entities for Enroll America’s Marketplace outreach and enrollment campaign.

On April 21, CMS released FAQs on addressing enrollment-related casework for QHP issuers in Federally Facilitated Marketplaces.

On April 22-23, CMS hosted an onsite QHP Certification Technical Assistance Session at its Baltimore headquarters, the slides for which are available here (see p. 85 for an overview of key changes for 2015 FFM certification, for example) and here (addressing health insurance issuer casework, among other topics).

On April 23, CMS posted slides discussing Federally Facilitated SHOP (FF-SHOP) eligibility and enrollment notices. Also see CMS slides on FF-SHOP enrollment and payment timelines.

On April 23, CMS posted a chart presenting possible Federally Facilitated Marketplace coverage options after receiving notice of a Medicaid or CHIP coverage denial.

On April 25, CMS released an issue brief providing an overview of ACA-authorized surveys gauging consumer experience with Marketplaces and QHPs, including a chart that summarizes the surveys’ purpose, anticipated uses and timing.

On April 25, CMS released downloadable, Spanish-language slides (ZIP file) on health insurance literacy, focusing on key aspects of Marketplaces, among other dimensions of the ACA.

On April 30, House Energy and Commerce Committee Republicans said that Federally Facilitated Marketplace plans had reported, in response to a query from the Committee, that two-thirds of enrollees paid the first month’s premium by April 15.

On April 21, CMS posted an overview of its Registration for Technical Assistance Portal, where FAQs and other information on Marketplace operations and ACA premium stabilization programs are available.

On May 16, 2014 CCIIO posted 12 FAQs on a range of ACA-related market reforms and Marketplace issues. Among other points, CCIIO says “we are concerned that waiting periods for specific benefits discourage enrollment of or discriminate against individuals with significant health needs or present or predicted disability.”

On May 1, HHS announced that 8 million Qualified Health Plan (QHP) sign-ups (data; infographic) include those who were “in line” as of March 31, as well as others obtaining special enrollment periods through April 19. According to the Marketplace plan selection data, 85% qualified for premium subsidies, and 28% percent were young adults aged 18-34.

On May 2, CCIIO released guidance creating special enrollment periods (SEPs) in Federally Facilitated Marketplaces (FFMs) for those eligible for or enrolled in COBRA continuation coverage, among other categories. The agency says State-Based Marketplaces (SBMs) are encouraged to adopt similar SEPs.

On May 2, CCIIO posted a form that Federally Facilitated QHP issuers use to report how they will comply with the so-called Federally Facilitated SHOP “tying provision,” specifying that issuers with a 20% or greater small group market share participate in SHOPs in order to offer individual market QHPs.

On May 6, CCIIO published a table of issuers that say they will offer standalone dental plans (SADPs) in Federally Facilitated and State Partnership Marketplaces, noting the list is up to date as of April 15, 2014. The table is intended to signal SADPs’ offering pediatric dental essential health benefits, thereby enabling QHPs to omit those benefits if they chose, as permitted by the statute.

On May 6, CMS posted the May 2014 version of slides that provide an overview of SHOP Marketplaces (ZIP file).

On May 7, among other discussion at a Senate Appropriations Committee hearing, CMS Chief Operating Officer Tim Love (testimony) emphasized the agency’s ongoing ACA implementation efforts, the early results of which are evidenced by the most recent Marketplace enrollment figures, he said. Mr. Love also noted agency’s role in improving users’ experience with Healthcare.gov, particularly in advance of the next open enrollment period.

At a May 7 House Energy and Commerce Oversight and Investigations Subcommittee hearing, several insurers confirmed that 80-90% of Marketplace enrollees are paying first-month premiums. Some noted up to 30% had not, at that point, reached their first-month premium due date.

On May 13, CCIIO posted an Excel document that will allow for interim, template-based reporting by SHOP QHPs to the Federally Facilitated Marketplace on specified enrollment data, including enrollees since Jan. 1, 2014.

On May 14, Sens. Hatch (R-UT) and Barrasso (R-WY) introduced legislation that would require states that turn control of Exchanges over to the federal government to reimburse the government for Exchange grants over 10 years.

On May 20, in a technical presentation on Federally Facilitated SHOP enrollment for 2015, CCIIO provides an update on group XML and 834 enrollment transactions that issuers will process and notes that final documents will be available in June 2014.

On May 21, Secretary Sebelius responded to the American Hospital Association reaffirming that private, charitable foundations can pay QHP premiums and cost-sharing if consistent with February 2014 FAQs.

On May 21, CCIIO posted an application for Insurance Commissioners in states with Federally Facilitated SHOPs. It offers the opportunity to explain why an additional one-year transition to SHOP employee choice, beyond 2015 implementation, is in “the best interest of small employers and their employees and dependents, given the likelihood that implementing employee choice would cause issuers to price their products and plans higher than they would otherwise price them.”

On May 27, CCIIO posted slides indicating that says direct enrollment with Federally Facilitated SHOP (FF-SHOP) issuers will no longer be used in 2015, adding that it will use three State-Based SHOPs’ experience to inform the FF-SHOP’s 2015 online functionality.

Also on May 27, CCIIO also posted draft business rules and data elements for HIX 820 standards, through which it will explain SHOP payments to QHP issuers on Federally Facilitated SHOP Marketplaces, and said it would post a final version in June 2014.

On May 3, 2014 the IRS released a final rule identifying the technical elements of Exchange responsibilities to collect and report enrollment and insurance premium tax credit information for those in the individual market, information that is needed to compute premium tax credits and reconcile the amount of the credit with the amount advanced at the beginning of the coverage year.

On May 16, 2014 CCIIO released a final rule on Marketplace and insurance market standards for “2015 and beyond,” (fact sheet; blog post) addressing prescription drug exception standards; risk corridor and medical loss ratio adjustments; SHOP Marketplaces’ implementation of employee choice; the use of standardized notices for coverage renewal or product discontinuation; and other issues.

Throughout the month of June, CMS posted FAQs to its Registration for Technical Assistance Portal (REGTAP; registration/account required), addressing Qualified Health Plan issues (e.g., “dependents are unable to enroll in Federally Facilitated Small Business Health Options Program coverage without an employee also enrolling”; see here).

On June 2, CCIIO updated its page for agents and brokers; resources include FAQs addressing certain compensation and oversight logistics, among other topics; a reference guide on the training and registration process; and FAQs, a chart and  “operational tips” specific to the registration process. CCIIO also highlights key dates for annual Federal Marketplace agent and broker registration requirements.

On June 4, amid reports that 2 million Federal Marketplace enrollees have data “inconsistencies” associated with their enrollment, HHS said it is asking consumers to submit additional documentation to substantiate income, citizenship and other aspects underlying Marketplace and subsidy eligibility if reported data did not match existing sources. The agency indicated that it is offering some flexibility beyond the standard 90-day window to provide the information.

On June 3, House Energy and Commerce Republicans asked HHS to disclose personnel and offices responsible for awarding grants to State-Based Exchanges that have required the most rework or switched to Healthcare.gov.

On June 3, House Small Business Committee Chairman Sam Graves (R-MO) requested that CMS release state-level data on SHOP enrollment, including the number of small businesses and their employees covered, as well as the number of employers that have paid “at least their first premium.”
On June 6, CMS released slides describing how it will use the HIX 820 transaction to convey Federally Facilitated SHOP payment information to insurers.

On June 10, CMS announced a $60 million grant opportunity for ACA Navigators in states with Federally Facilitated and State Partnership Marketplaces to assist consumers in learning about QHPs, as well as Medicaid and CHIP coverage. The application deadline is July 10, 2014, with letters of intent due on June 30. Also see a  press release and an updated fact sheet on Marketplace consumer assistance. On June 17, CCIIO posted slides reviewing pre-application details for the grants.

On June 10, CCIIO said 18 states with Federally Facilitated SHOPs will opt out of employee choice in 2015 based on a finalized pathway enabling state Insurance Commissioners to recommend an additional 1-year delay in the model’s adoption.

On June 11, CMS posted a form that QHPs and Standalone Dental Plans in Federal Marketplaces can submit if they are requesting changes or corrections to their service areas. Also see a June 5 FAQ on petitioning for post-application changes in service areas in Federal Marketplaces.
On June 12, House Energy and Commerce Health Subcommittee Chairman Joe Pitts (R-PA) convened a hearing to discuss how the ACA affects access to healthcare services and prescription drugs, including narrow networks and medication cost-sharing.

On June 16, CMS announced a Coverage to Care national outreach initiative designed to assist consumers in using health coverage they have newly obtained through Marketplaces. Also see the Roadmap to Better Care and a Healthier You guide, inventory of campaign materials (including a consumer-oriented video series) and an HHS blog post.

On June 17, CCIIO released FAQs for QHP issuers on addressing casework issues, such as those stemming from enrollment-related issues.

On June 19, a Senate Finance Committee Minority Report by Sens. Hatch (R-UT) and Grassley (R-IA) released a report asserted that the “Department of Health and Human Services (HHS) failed to responsibly oversee the IT development of HealthCare.gov and wasted millions of dollars,” adding that “political pressure from the White House to go live on October 1, 2013, trumped operational realities, resulting in the release of an incomplete and insecure website.”

On June 20, HHS Secretary Burwell announced plans to recruit for a newly created, permanent role of Marketplace CEO reporting to CMS Administrator Tavenner that will lead Federal Marketplaces; coordinate State-Based Marketplace relationships; and run CCIIO. The agency also is recruiting for a Marketplace Chief Technology Officer. HHS also appointed Andy Slavitt as an operations-focused Principal Deputy Administrator of CMS. Slavitt most recently was Group Executive Vice President for UnitedHealth’s Optum Unit, a lead Federal Marketplace contractor.

On June 23, while noting a good faith compliance policy for CY14, CMS presented slides on the content of QHP issuer compliance reviews in Federal Marketplaces. See slides 11-12 for the reviews’ scope, including assessing compliance with operational and certification standards, among other elements.

On June 26, CCIIO released a proposed rule and guidance specifying the avenue for Federally Facilitated Marketplace (FFM) enrollees to remain auto-enrolled in the same plan for the 2015 open enrollment period, with Marketplace notices enabling them to, among other things, “update their information to get a tailored and updated tax credit that keeps up with any income changes.”  State-Based Marketplaces (SBMs) would have the ability to use the approach that FFMs intend to use (elaborated in further in the procedural guidance); existing regulatory procedures for annual redeterminations; or “alternative procedures approved by [HHS]” under specified criteria on which comment is sought. Comments are due by July 28, 2014. In tandem, CCIIO issued draft standard notices for health insurance issuers to use when discontinuing or renewing a product in the small group or individual market (see here) and instructions for using the draft notices (see here).

On June 27, CMS posted Paperwork Reduction Act packages (here and here) on Marketplace recertification of certified application counselor organizations and related recordkeeping.

Throughout the month of July, CCIIO posted operational FAQs (including those pertaining to the implementation of the Federally Facilitated SHOP (FF-SHOP) on the REGTAP FAQ page (registration/account required).

2014 – Summer

On July 1, HHS’s OIG published 2 complementary reports recommending improvement in the Marketplace application verification process (here and here).

On July 8, as part of its outreach to QHP issuers in Federally Facilitated Marketplaces (FFMs), CCIIO posted FAQs on the network adequacy template; plan and benefits template; prescription drug template; Data Integrity Tool for checking template data; and Standalone Dental Plan policy issues.

On July 8, CCIIO released a 19-page agent and broker training outlinethat covers four overarching areas for participating in FFMs. Also see updated slides on agent and broker registration to participate in FFMs for the 2015 plan year.

On July 8, CCIIO posted slides discussing the process of conducting Federally Facilitated SHOP (FF-SHOP) testing with Qualified Health Plan (QHP) issuers.

On July 11, CCIIO posted the Word-based certification form for QHPs’Excel submissions of payment and enrollment data for August 2014. Also see accompanying slides.

On July 11, CMS posted slides that provide an overview of a recent proposed rule and guidance on Marketplace annual eligibility redeterminations.

On July 14, HHS announced a Healthcare.gov interface evaluating applicants’ eligibility for a special enrollment period, which would enable them to access Marketplace coverage outside of the open enrollment period based on such factors as job loss (see a related blog post) or change in family status.

On July 15, CCIIO posted slides that include a “walk through of registration steps” for agents and brokers seeking to participate in FFMs for the 2015 plan year. Also see slides for QHP issuers providing an overview of agent and broker participation in the Marketplace.

On July 16, CCIIO released a bulletin conveying guidance that applies to individual QHPs in FFMs and State Partnership Marketplaces. The agency discusses grace period scenarios with selected examples: 1) new enrollment after prior termination for non-payment; 2) grace periods spanning benefit years; and 3) grace periods ending on Dec. 31.

On July 16, CMS released a solicitation for a FFM contractor; Accenture holds the current contract.

On July 16, CCIIO released “Instructions for the Plan ID Crosswalk Template” for FFM QHPs, noting that the template “crosswalks 2014 QHP plan ID and service area combinations (e.g., Plan ID and County combinations) to a 2015 QHP plan ID” and that “this data will facilitate 834 enrollment transactions from CMS to the issuer in December 2014 for those enrollees who have not actively selected a different QHP during open enrollment at that time.”

On July 16, the House Energy and Commerce Committee held a hearing to discuss uncertainties behind the ACA’s eligibility system, including application discrepancies.

On July 22, CMS posted slides describing immigrant families’ eligibility for QHPs, including lawful presence, eligible immigrant status and documentation types (see slides 10-12).

On July 22, two U.S. Court of Appeals panels issued conflicting rulings regarding the legality of offering ACA premium subsidies in Federally Facilitated Marketplaces (FFMs). In King v. Burwell, the Fourth Circuit Court of Appeals in Virginia unanimously ruled that the IRS is valid in allowing premium tax credits in both State-Based and FFMs. Judges noted that “the applicable statutory language is ambiguous and subject to multiple interpretations” but found the IRS’ interpretation is “a permissible exercise of the agency’s discretion.” Just hours earlier, in Halbig v. Burwell, the D.C. Circuit Court of Appeals ruled 2-1 that subsidies are not legal – vacating the IRS’s rule – since the statutory language of the ACA does not explicitly allow enrollees on FFMs to receive them. The White House will ask the full D.C. Court of Appeals to hear the case.

On July 23, HHS issued a release saying 10.3 million had obtained health coverage via Marketplaces’ inaugural open enrollment period, with estimates varying with confidence internals and gains being concentrated in Medicaid expansion states.

On July 24, CMS published a notice delineating targeted corrections to its Exchange and Insurance Market Standards for 2015 and Beyond final rule from May 2014.

On July 24, CMS posted a schedule of upcoming Marketplace-related webinars and a link to training videos.

On July 25, CMS published a notice (see #2 on p. 2) requesting comments by Aug. 25, 2014, on proposed revisions to a currently OMB-approved information collection pertaining to Navigator cooperative agreements in Federally Facilitated and State Partnership Marketplace states.

On July 28, CCIIO posted slides on FF-SHOP functionality for employers, employees and agents and brokers.

On July 29, CCIIO released a guide for QHPs and Standalone Dental Plans in FFMs on responding to benefit correction notices, such as those addressing meaningful difference or other issues.

On July 30, in a Paperwork Reduction Act package, CMS posted finalized QHP templates, saying some of them will be used for 2015 plan certification in FFMs and that the agency “intend[s] to use the templates in this information collection for the 2016 certification process and believe[s] that providing these templates now will give issuers and other stakeholders more opportunity to familiarize themselves with the templates before the 2016 application.”

On July 31, coinciding with a House Energy and Commerce Oversight and Investigations Subcommittee hearing on the topic, the GAO released a report detailing management and contracting errors that led to “cost increases, schedule slips and delayed system functionality” of Healthcare.gov in its early implementation.

In a Dec. 4 report, HHS found that premiums for the reference second-lowest cost silver plans, on which premium subsidies are based, will increase by 2% on average in 2015.

On Dec. 10, before auto-reenrollment began, HHS said that Healthcare.gov plan selections reached 1.38 million (through Dec. 5; 48% new customers vs. 52% returning customers).

On Dec. 11, HHS announced a partnership with the electronic cash transactions company PayNearME to encourage – via messaging on 7-11 store receipts – consumers to visit Healthcare.gov.

Dec. 15 generally was the deadline to sign up for Marketplace coverage with a Jan. 1, 2015, effective date, although issuers in some states voluntarily extended that deadline. The Federal Marketplace auto-reenrollment process also began on Dec. 15. Also see FAQs on the Federal Marketplace reenrollment process. CMS released a notice specifying that consumers who could not be successfully reenrolled (e.g., because of technical errors or an issuer’s departure from the service area) would be afforded a special enrollment period.

On Dec. 16, HHS announced that 2.5 million had selected Healthcare.gov plans through Dec. 12, not yet incorporating the immediate pre-Dec. 15 selections or auto-reenrollments.
On Dec. 16, CCIIO posted FAQs on QHP quality reporting (here, here and here; Registration for Technical Assistance (REGTAP) account required).

On Dec. 17, CCIIO announced Marketplace grants: NY ($63.8M in Level 1 funding); AR ($99.9M in Level 2 funding to support its transition to a State-Based Marketplace); CT ($2.3M in Level 1 funding); NH ($3.4M in Level 1 funding); RI ($2.9M in Level 1 funding); and MA ($9.7M in Level 1 funding). An updated map reflecting the most recent round of grant-making is available here.

On Dec. 17, HHS announced a partnership with technology companies – Monster.com, peers.org and higi – to encourage Marketplace enrollment.

On Dec. 18, for plan year 2016, CCIIO posted a non-exhaustive draft list (Excel File; explanatory background) of essential community providers to assist QHPs in complying with relevant requirements. Comments on the list were accepted through Jan. 2, 2015.