Other Resources

• Consumer Support and Information
  • External Appeals
  • Summary of Benefits and Coverage and Uniform Glossary
• Content Requirements for Healthcare.gov
• Pre-Existing Condition Insurance Plan (PCIP)
• Early Retiree Reinsurance Program (ERRP)
• Affordable Insurance Exchanges
  • Planning and Establishment Grants
  • Territory Cooperative Agreements
  • Information Technology Systems
• Health Insurance Market Reforms
  • Annual Limits
  • Coverage for Young Adults
  • Grandfathered Plans
  • Medical Loss Ratio
  • Patient’s Bill of Rights
  • Review of Insurance Rates
  • Self-Funded Non-Federal Governmental Plans
• COBRA
• Reports
  • GAO Report: “Private Health Insurance: Data on Application and Coverage Denials”

Consumer Support and Information 

External Appeals 

Model Notice:

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

Notice of Privacy Act Rights:

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

Federal Register Notice:

• August 23, 2010
  Federal Register Notice on External Review

Summary of Benefits and Coverage and Uniform Glossary

Forms:

• Summary of Benefits and Coverage (SBC) Template
  • Standard Format (DOC – 173 KB )
  • Accessible Format (PDF – 174 KB)
• Uniform Glossary (PDF – 140 KB )

Instructions/Guidance:

• Sample Completed SBC
  • Standard Format (DOC – 199 KB)
  • Accessible Format (PDF – 247 KB)
• Instructions for Completing the SBC – Group Health Plan Coverage (PDF – 89 KB)
• Instructions for Completing the SBC – Individual Health Insurance Coverage (PDF – 81 KB)
• Why This Matters language for SBC "Yes" Answers (PDF – 120 KB)
• Why This Matters language for SBC "No" Answers  (PDF – 92 KB)
• Guide for Coverage Examples Calculations – Maternity Scenario
  • Standard Format (XLSX – 91 KB)
  • Accessible Format (PDF – 98 KB)
• Guide for Coverage Examples Calculations – Diabetes Scenario
  • Standard Format (XLSX – 57 KB)
  • Accessible Format (PDF – 119 KB)
• Narrative for Maternity Scenario (PDF – 11 KB)
• Narrative for Diabetes Scenario (PDF – 11 KB)
• RBIS IFP Benefits Template Addition
  • Standard Format (XLS – 20 MB)
  • Accessible Format (PDF – 39 KB)

Content Requirements for Healthcare.gov 

Q&A:

• November 8, 2011
  HCR Plan Finder Data Entry

Instructions/Guidance:

• August 1, 2011
  State Data Submission Technical Instructions HIOS (PDF – 2 MB)
• October 27, 2011
  Issuer Data Submission Technical Instructions HIOS (PDF – 2 MB)
• December 12, 2011
  Issuer Data Submission User Manual RBIS (PDF - 4 MB)

Forms:

• May 11, 2010
  HIOS State Data Submission Form (XLS – 347 KB)
• April 21, 2011
  CMP Issuer Data Entry Forms (ZIP – 209 KB)
• September 26, 2011
  RBIS Issuer Data Entry Forms (ZIP - 1 MB)
• October 27, 2011
  HIOS Issuer Data Entry Form (XLS – 2 MB)
• December 12, 2011
  RBIS Individual Market Issuer Data Entry Forms (ZIP – 2 MB)

Paperwork Reduction Act Documents:

• July 1, 2010
  Paperwork Reduction Act for Web Portal
• October 1, 2010
  Paperwork Reduction Act for Web Portal

Pre-Existing Condition Insurance Plan (PCIP) 

Brochures:

• July 2010
  The Affordable Care Act – What it Means for Those with Pre-Existing Conditions (PDF – 354 KB)

Posters:

• July 2010
  Do You Need Health Insurance, But Have a Pre-Existing Condition? (PDF – 271 KB)

Solicitation:

• May 10, 2010
  Solicitation for State Proposals to Operate Qualified High Risk Pools (PDF – 205 KB)

Model Contract:

• Model Contract to Operate a Qualified High Risk Pool (PDF 141 KB)

Data:

• PCIP Data as of May 31 2011
• Update on Federal PCIP September 29, 2011 (PDF 624 KB)
• Update on Federal PCIP December 31, 2011 (PDF - 174 KB)

Reports

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

Early Retiree Reinsurance Program (ERRP) 

Reports: 

• March 2, 2011
  Report on Implementation and Operation of the Early Retiree Reinsurance Program during Calendar Year 2010 (PDF – 269 KB)
• March 31, 2011
  Progress Report on the Early Retiree Reinsurance Program (PDF – 138 KB)
• May 13, 2011
  Early Retiree Reinsurance Program: Reimbursement Update (PDF – 190 KB)
• June 17, 2011
  Early Retiree Reinsurance Program: Reimbursement Update (PDF – 273 KB)
• July 15, 2011
  Early Retiree Reinsurance Program: Reimbursement Update (PDF – 281 KB)
• August 12, 2011
  Early Retiree Reinsurance Program:  Reimbursement Update (PDF – 280 KB)
• September 16, 2011
  Early Retiree Reinsurance Program: Reimbursement Update (PDF – 280 KB)  
• October 14, 2011
  Early Retiree Reinsurance Program: Reimbursement Update (PDF – 310 KB)
• November 4, 2011
  Early Retiree Reinsurance Program: Reimbursement Update (PDF – 397 KB)
• November 18, 2011
  Early Retiree Reinsurance Program: Reimbursement Update (PDF – 610 KB)
• December 9, 2011
  Early Retiree Reinsurance Program: Reimbursement Update (PDF – 671 KB)
• February 17, 2012
  Early Retiree Reinsurance Program: Reimbursement Update (PDF – 646 KB)
  February 17, 2012
  Early Retiree Reinsurance Program Status Update February 2012 (PDF –  68 KB)  
  

Affordable Insurance Exchanges 

Videos:

• August 30, 2010
  Stakeholder Conference on Exchange

White Papers: 

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

Materials for State Exchange Grantee Meeting:

• September 19, 2011
  Overview of Exchange Models and Options for States (PDF - 407 KB)
  Developing the Federally-Facilitated Exchange (PDF – 230 KB)
  Introduction to the Exchange Approval Process (PDF – 336 KB)
  Financial Management 101 (PDF – 399 KB)
  Notice of Proposed Rulemaking: Affordable Insurance Exchanges (PDF - 444 KB)
  Three Notices of Proposed Rulemaking: A Simple Seamless Path to Affordable Coverage (PDF - 533 KB)
  Operational Alternatives for State Based Exchanges (PDF - 380 KB)
  Premium Stabilization in the Affordable Care Act: Risk Adjustment (PDF - 344 KB)
  Quality (PDF - 386 KB)
  Financial Management – Preparing for Exchange Certification (PDF - 442 KB)
  The Small Business Health Options Program (SHOP) (PDF – 376 KB)
  Market Research: Critical Input to Exchange Success (PDF - 516 KB)
  Market Research: Critical Input to Exchange Success – Handout (PDF – 98 KB)
  Tribal Consultation (PDF – 322 KB) *updated 10/20/2011
  Exchange Security (PDF – 417 KB)
  Plan Management: Preparing for State-Based Exchange Certification  (PDF – 358 KB)

Planning and Establishment Grants 

Pre-Application Conference Calls:

• August 5, 2010
  Transcript and Audio (MP3 9 MB)
• August 25, 2010
  Transcript and Audio (MP3 7 MB)
• February 3, 2011
  Transcript (PDF – 182 KB) and call replay number: 800-947-6840 (valid until 6/29/2012)
• March 3, 2011
  Transcript (PDF – 118 KB) and call replay number: 800-274-8005 (valid until June 29, 2012)
• March 24, 2011
  Transcript (PDF – 83 KB) and call replay number: 800-846-1910 (valid until June 29, 2012)

Webinars:

• February 23, 2011
  Exchange IT Gap Analysis Webinar Transcript (PDF – 189 KB)

Territory Cooperative Agreement 

Pre-Application Conference Calls:

• January 26, 2011
  Transcript (PDF – 149 KB) and call replay number: 800-759-6899 (valid until 2/272011)

Information Technology Systems 

Transcripts:

• November 8, 2010
  Technical Assistance Call on Cooperative Agreements to Support Innovative Exchange Information Technology Systems
• November 18, 2010
  Technical Assistance Call on Cooperative Agreements to Support Innovative Exchange Information Technology Systems
• December 14, 2010
  Technical Assistance Call on Cooperative Agreements to Support Innovative Exchange Information Technology Systems

Cover Memo:

• November 3, 2010
  To States from OCIIO and CMS on IT for Exchanges and Medicaid (PDF – 103 KB)

Health Market Reforms 

Annual Limits 

Application Information:

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

Coverage for Young Adults 

Data:

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

Grandfathered Plans 

Amendment to Regulation:

• November 11, 2010
  Amendment to the Interim Final Rules for Group Health Plans and Health Insurance Coverage Relating to Status as a Grandfathered Health Plan Under the Patient Protection and Affordable Care Act

Medical Loss Ratio 

Forms:

• May 19, 2011
  Medical Loss Ratio Quarterly Reporting Forms for “Mini-med” and Expatriate Plans
  • MLR Quarterly Reporting Form for “Mini-med” Plans (XLS – 50 KB)
  • MLR Quarterly Reporting Form for Expatriate Plans (XLS – 52 KB)
  • MLR Quarterly Reporting Form Instructions (PDF – 68 KB)
• June 17, 2011
  Medical Loss Ratio Quarterly Reporting Form Instructions
  Please note that these instructions replace an earlier version that had several minor inconsistencies.  In addition, these instructions clarify that an issuer who submits reports for more than one State may choose either to submit Excel worksheets for each State report in separate Excel files or to combine the worksheets into a single Excel file.
  • MLR Quarterly Reporting Form Instructions (PDF – 70 KB)
• December 16, 2011
  Paperwork Reduction Act (PRA) display of Medical Loss Ratio Annual Reporting Form (click on “CMS-10418”) The materials on PRA display can also be found here:

Persons using assistive technology may not be able to fully access information in the following two files. For assistance, please email MLRQuestions@cms.hhs.gov.

• • MLR Annual Reporting Form  (XLSX - 223 KB)
  • MLR Annual Reporting Form Instructions (PDF - 346 KB)
• February 16, 2012
  Paperwork Reduction Act (PRA) display of Medical Loss Ratio Notices to Policy Holders and Subscribers  (click on “CMS-10418”). The materials on PRA display can also be found here:
  
  • Notice to Subscribers in the Individual Market  (Notice #1) (PDF – 44 KB)
  • Notice to Group Policyholders and Their Subscribers, Rebate Sent to the Policyholder  (Notice #2) (PDF - 54 KB)
  • Notice to Subscribers of Group Policyholders, Rebate Sent to the Subscribers  (Notice #3) (PDF - 41 KB)
  • Instructions for Notices 1, 2 and 3 (PDF - 63 KB)
  • Sample Notice to Policyholders and Subscribers When MLR Standard is Met  (Notice #4) (PDF - 30 KB)
  • Sample Instructions for Notice to Policyholders and Subscribers When MLR Standard is Met  (Notice #4) (PDF - 50 KB)

Patient’s Bill of Rights 

Q&A:

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

Data:

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

Methodology:

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

Review of Insurance Rates 

• May 27, 2011
  Paperwork Reduction Act (PRA) display of Rate Increase Disclosure and Review Reporting Requirements (click on “CMS-10379”)
• July 29, 2011  (Update October 11, 2011: rate review training manuals, instructions, and other materials are now located under Training Resources. Please click on the link below.)
  Rate Review Training Resources 
• September 20, 2011 
  Report: Early Achievements of Health Insurance Rate Review Grants (PDF - 268 KB)
  Note: The Cycle II proposal summary for the California Department of Managed Health Care was corrected on September 22, 2011.

Self-Funded Non-Federal Governmental Plans 

HIPAA Opt-Out Materials:

• September 21, 2010
  Memo on Amendments to the HIPAA Opt-Out Provision made by the Affordable Care Act (PDF – 44 KB)
• April 1, 2011
  Procedures and Requirements for HIPAA Exemption Election
  Model HIPAA Exemption Election Document (PDF – 78 KB)
  Model Notice to Enrollees of HIPAA Exemption (PDF – 7 KB)
• July 29, 2011
  List of HIPAA Opt-Out Elections for Self-Funded, Non-Federal Government Plans (PDF– 193 KB)
  

COBRA

Forms:

October 19, 2011
CMS Request for Review of Premium Assistance Denial (PDF - 355 KB)

Reports 

GAO 

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