Other Resources

• Affordable Care Act
• No Surprises Act
  • Federal Independent Dispute Resolution
• Consumer Support and Information
  • Consumer Assistance Program Grants
  • Navigators
  • External Appeals
  • Summary of Benefits and Coverage and Uniform Glossary
• Content Requirements for Plan Finder
• Pre-Existing Condition Insurance Plan (PCIP)
• Early Retiree Reinsurance Program (ERRP)
• Health Insurance Marketplaces
  • Planning and Establishment Grants
• Consumer Operated and Oriented Plan (CO-OP) Program
• Health Insurance Market Reforms
  • Annual Limits
  • Coverage for Young Adults
  • Excepted Benefits
  • Medical Loss Ratio
  • Mental Health Parity
  • Patient’s Bill of Rights
  • Prevention
  • Review of Insurance Rates
  • Self-Funded Non-Federal Governmental Plans
  • Standard Notices
• Premium Stabilization Programs
• COBRA
• Reports
• CCIIO Examinations, Audits, and Reviews of Issuers 

Affordable Care Act

Innovation in the Marketplace Newsletters

• September 2016 (PDF)
• October 2016 (PDF)
• January 2017 (PDF)

No Surprises Act

Federal Independent Dispute Resolution

Reports

• December 23, 2022
  Initial Report on the Independent Dispute Resolution (IDR) Process: April 15 - September 30, 2022 (PDF) (PDF)
• April 27, 2023
  Partial Report on the Independent Dispute Resolution (IDR) Process: October 1 - December 31, 2022 (PDF) (PDF)

Consumer Support and Information

Consumer Assistance Program Grants

Reports

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

Navigators

• January 19, 2021
  Navigator Funding and Enrollment Data, PY 2016-2020 (XLSX)

External Appeals

Model Notice

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

Notice of Privacy Act Rights

• January 11, 2017
  Notice of Privacy Act Statement for Issuers in States without External Review Laws (PDF) (PDF – 20 KB)

Federal Register Notice

• July 23, 2010
  Federal Register Notice on External Review

Summary of Benefits and Coverage and Uniform Glossary

SBC Materials and Supporting Documents (Authorized for use for plan or policy years that begin on or after January 1, 2021)

Applicability: Plans and issuers will be required to use the 2021 Summary of Benefits and Coverage (SBC), the 2021 SBC Calculator Guide and Narratives, and, should they choose to use the SBC Calculator, the 2021 SBC Calculator beginning on the first day of the first open enrollment period for any plan years (or, in the individual market, policy years) that begin on or after January 1, 2021, with respect to coverage for plan or policy years beginning on or after that date.

NOTE: The documents below were updated on 7/26/2023 to reflect the new expiration date of 5/31/2026 under the Paperwork Reduction Act. There are no changes to the content of any of the documents.

Forms

• Summary of Benefits and Coverage (SBC) Template
  • Standard Format (DOCX)
  • Accessible Format (PDF)
  • Chinese Standard Format (DOCX)
  • Chinese Accessible Format (PDF)
  • Spanish Standard Format (DOCX)
  • Spanish Accessible Format (PDF)
  • Tagalog Standard Format  (DOCX)
  • Tagalog Accessible Format (PDF)
  • Navajo Standard Format (DOCX)
  • Navajo Accessible Format (PDF)
  • Navajo Oral Translation
• Uniform Glossary
  • English (PDF)
  • List of anchors (XLSX) for SBC Uniform Glossary terms on https://www.HealthCare.gov/sbc-glossary/
  • Chinese (PDF) (PDF)
  • Spanish(PDF) (PDF)
  • Tagalog (PDF) (PDF)
  • Navajo (PDF)
  • Navajo Oral Translation (MP3)

Instructions/Guidance

• Sample Completed SBC
  • Standard Format (DOCX)
  • Accessible Format (PDF)
  • AI/AN Zero Cost Sharing (PDF)
  • AI/AN Limited Cost Sharing (PDF)
• Instructions for Completing the SBC – Group Health Plan Coverage (PDF) (for January 1, 2021)
• Instructions for Completing the SBC – Individual Health Insurance Coverage (PDF) (for January 1, 2021)
• Why This Matters language for SBC “Yes” Answers (for January 1, 2021)
  • English (PDF)
  • Chinese (PDF) (PDF)
  • Spanish (PDF) (PDF)
  • Tagalog (PDF) (PDF)
  • Navajo (PDF)
  • Navajo Oral Translation (MP3)
• Why This Matters language for SBC “No” Answers (for January 1, 2021)
  • English (PDF)
  • Chinese (PDF) (PDF)
  • Spanish (PDF) (PDF)
  • Tagalog (PDF) (PDF)
  • Navajo (PDF)
  • Navajo Oral Translation (MP3)
• Guide for Coverage Examples Calculations – Maternity Scenario
  • Standard Format (XLSX)
  • Accessible Format (PDF)
• Guide for Coverage Examples Calculations – Diabetes Scenario
  • Standard Format (XLSX)
  • Accessible Format (PDF)
• Guide for Coverage Examples Calculations – Simple Foot Fracture Scenario
  • Standard Format (XLSX)
  • Accessible Format (PDF)
• Narrative for Maternity Scenario (PDF)
• Narrative for Diabetes Scenario (PDF)
• Narrative for Simple Foot Fracture Scenario (PDF)
• Coverage Examples Calculator Instructions (PDF)
• Coverage Examples Calculator (VND.MS-EXCEL.SHEET.MACROENABLED.12) (XLSM) (updated October 2019 for use on or after January 1, 2021)

SBC Materials and Supporting Documents (Authorized for use prior to January 1, 2021)

Applicability: Health plans and issuers that maintain an annual open enrollment period will be required to use the April, 2017 edition of the SBC template and associated documents beginning on the first day of the first open enrollment period that begins on or after April 1, 2017 with respect to coverage for plan years (or, in the individual market, policy years) beginning on or after that date. For plans and issuers that do not use an annual open enrollment period, this SBC template and associated documents is required beginning on the first day of the first plan year (or, in the individual market, policy year) that begins on or after April 1, 2017 and before January 1, 2021.

Forms

• Summary of Benefits and Coverage (SBC) Template
  • Standard Format (DOC)  (DOC)
  • Accessible Format (PDF) (PDF)
  • Chinese Standard Format (DOCX) (DOC)
  • Chinese Accessible Format (PDF) (PDF)
  • Spanish Standard Format (DOCX) (DOC)
  • Spanish Accessible Format (PDF) (PDF)
  • Tagalog Standard Format (DOCX) (DOC)
  • Tagalog Accessible Format (PDF) (PDF)
  • Navajo Standard Format (DOCX) (DOC)
  • Navajo Accessible Format (PDF) (PDF)
  • Navajo Oral Translation (MP3)
• Uniform Glossary
  • English (PDF) (PDF)
  • List of anchors (XLSX) for SBC Uniform Glossary terms on https://www.HealthCare.gov/sbc-glossary/
  • Chinese (PDF) (PDF)
  • Spanish (PDF)(PDF)
  • Tagalog (PDF) (PDF)
  • Navajo (PDF) (PDF)
  • Navajo Oral Translation (MP3)

Instructions/Guidance

• Sample Completed SBC
  • Standard Format (DOC) (DOC)
  • Accessible Format (PDF) (PDF)
  • AI/AN Zero Cost Sharing (PDF)
  • AI/AN Limited Cost Sharing (PDF)
• Instructions for Completing the SBC – Group Health Plan Coverage (PDF) (PDF) (for April 1, 2017)
• Instructions for Completing the SBC – Individual Health Insurance Coverage (PDF) (PDF) (for April 1, 2017)
• Why This Matters language for SBC “Yes” Answers (for April 1, 2017)
  • English (PDF) (PDF)
  • Chinese (PDF) (PDF)
  • Spanish (PDF) (PDF)
  • Tagalog (PDF) (PDF)
  • Navajo (PDF) (PDF)
  • Navajo Oral Translation (MP3)
• Why This Matters language for SBC “No” Answers (for April 1, 2017)
  • English (PDF) (PDF)
  • Chinese (PDF) (PDF)
  • Spanish (PDF) (PDF)
  • Tagalog (PDF) (PDF)
  • Navajo (PDF) (PDF)
  • Navajo Oral Translation (MP3)
• Guide for Coverage Examples Calculations – Maternity Scenario
  • Standard Format (XLSX)
  • Accessible Format (PDF)
• Guide for Coverage Examples Calculations – Diabetes Scenario
  • Standard Format (XLSX) (XLSX)
  • Accessible Format (PDF) (PDF)
• Guide for Coverage Examples Calculations – Simple Foot Fracture Scenario
  • Standard Format (XLSX) (XLSX)
  • Accessible Format (PDF) (PDF)
• Narrative for Maternity Scenario (PDF) (PDF)
• Narrative for Diabetes Scenario (PDF) (PDF)
• Narrative for Simple Foot Fracture Scenario (PDF) (PDF)
• Coverage Examples Calculator Instructions (PDF) (PDF)
• Coverage Examples Calculator (VND.MS-EXCEL.SHEET.MACROENABLED.12) (XLSM)  (updated May 2016 to address an error in the calculation of cost sharing after the annual limitation on cost sharing)

SBC Materials and Supporting Documents (Authorized for use prior to April 1, 2017)

Forms

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

Instructions/Guidance

• Sample Completed SBC
  • Standard Format (DOC)  (Authorized for second year of applicability) (DOC – 206 KB)
  • Accessible Format (PDF)  (Authorized for second year of applicability) (PDF – 431 KB) 
  • Standard Format (DOC) (Corrected, May 11, 2012) (DOC - 200 KB)
  • Accessible Format (PDF) (Corrected, May 11, 2012) (PDF - 533 KB)
• Instructions for Completing the SBC – Group Health Plan Coverage (PDF) (PDF – 89 KB)
• Instructions for Completing the SBC – Individual Health Insurance Coverage (PDF) (PDF – 81 KB)
•  Why This Matters language for SBC "Yes" Answers
  • English (PDF) (PDF – 120 KB)
  • Chinese (PDF) (PDF-159 KB)
  • Navajo (PDF) (PDF-641 KB)
  • Navajo Oral Translation (MP3 – 7 MB)
  • Spanish (PDF) (PDF – 288 KB)
  • Tagalog (PDF) ( PDF – 111 KB)
• Why This Matters language for SBC "No" Answers
  • English (PDF) (PDF – 92 KB)
  • Chinese (PDF) (PDF – 147 KB)
  • Navajo (PDF) (PDF – 446 KB)
  • Navajo - Oral Translation (MP3 – 4.4 MB)
  • Spanish (PDF) (PDF – 292 KB)
  • Tagalog (PDF) (PDF- 107 KB)
• Guide for Coverage Examples Calculations – Maternity Scenario
  • Standard Format (XLSX) (XLSX – 91 KB)
  • Accessible Format (PDF) (PDF – 98 KB)
• Guide for Coverage Examples Calculations – Diabetes Scenario
  • Standard Format (XLSX) (Corrected May 11, 2012) (XLSX - 56 KB)
  • Accessible Format (PDF) (Corrected May 11, 2012) (PDF - 343 KB)
• Narrative for Maternity Scenario (PDF) (PDF – 11 KB)
• Narrative for Diabetes Scenario (PDF) (PDF – 11 KB)
• Checklist for Coverage Calculator (PDF) (PDF – 43 KB)
• Coverage Examples Calculator Instructions (PDF) (PDF – 274 KB)
• Coverage Examples Calculator Logic (PDF) (PDF – 91 KB)
• Coverage Examples Calculator (VND.MS-EXCEL.SHEET.MACROENABLED.12) (XLSM – 442 KB)  (updated September 7, 2012)
  (Note: This version of the coverage examples calculator corrects an error in a previous version that would result in an error message with regard to coverage of preventive services and maximum out-of-pockets.  That programming error did not impact the accuracy of the results in either the manual or automated processes, so plans and issuers that have successfully used the previous versions (June 4, 2012 and Updated July 23, 2012) of the calculator may use the results from the previous version.)

Content Requirements for Plan Finder

Q&A

• September 1, 2016
  Plan Finder Data Entry

Instructions/Guidance

• June 1, 2016
  CMS.gov Enterprise Portal Quick Reference Guide for Existing Users Adding Multi-Factor Authentication (MFA) to their Health Insurance Oversight System (HIOS) Application Role (PDF)
• June 1, 2016
  Abbreviated Reference Guide for Existing Users Adding Multi-Factor Authentication (MFA) to their Health Insurance Oversight System (HIOS) Application Role (PDF)
• June 1, 2016
  EIDM YouTube video for Multi Factor Authentication Registration
• April 22, 2019
  HIOS Plan Finder User Manual (PDF)  
• August 29, 2022
  HIOS Portal User Manual (PDF)
• August 29, 2022
  HIOS Data Change Request Quick Guide (PDF)
• August 29, 2022
  Rate and Benefit Information System (RBIS) User Manual (PDF)   
• August 29, 2022
  HIOS Manage Relationships Functionality Quick Reference Guide (PDF)
• March 3, 2023
  HIOS Portal Quick Guide (PDF)
• March 3, 2023
  Plan Management QHP Module Quick Guide (PDF)

Pre-Existing Condition Insurance Plan (PCIP)

Data

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

Reports

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

Early Retiree Reinsurance Program (ERRP)

Reports

• June 25, 2014
  Early Retiree Reinsurance Program: Reimbursement Update (PDF)

Health Insurance Marketplaces

Qualified Health Plan (QHP) Directory Pilot (September 17, 2024)

As part of its ongoing work to improve access to care, reduce clinician burden, and support interoperability throughout the health sector, the Centers for Medicare & Medicaid Services (CMS) is partnering with the state of Oklahoma on a first-of-its-kind directory pilot that will help inform the design and feasibility of any future efforts toward a National Directory of Healthcare (NDH). One goal of this pilot is to develop an automated, single, statewide centralized directory for Qualified Health Plans (QHPs) and providers in Oklahoma to improve data accuracy, lessen burden on providers and payers, lower administrative costs, support interoperable data exchange, and ultimately improve patient and provider experiences. CMS believes that this pilot will serve as a proof-of-concept and help inform any future development of an NDH that can serve as a centralized database for provider information.

Presentations

• September 2011
  State Exchange Grantee Meeting Materials
• March 2012
  Affordable Insurance Exchanges Final Rule (PDF) (PDF - 749 KB)
• May 2012
  System-wide Exchange Conference Materials
• November 26, 2012
  EHB/AV/Accreditation Notice of Proposed Rulemaking (PDF) (PDF – 593 KB)
• January 3, 2013
  State Partnership Exchange (PDF) (PDF – 267 KB)
• February 25, 2013
  EHB/AV/Accreditation Final Rule (PDF) (PDF - 549 KB)
• January 27, 2016
  2014 Plan Year Issuer Compliance Summary Report Presentation (PDF)

Marketplace Year 3: Issuer Insights and Innovation - June 9, 2016

Forum Agenda (PDF)
CMS Acting Administrator Andy Slavitt Remarks"> CMS Acting Administrator Andy Slavitt Remarks - Opens in a new window  
HHS Secretary Burwell Remarks"> HHS Secretary Burwell Remarks - Opens in a new window  
Marketplace Success Stories Blog by CEO Kevin Counihan"> Marketplace Success Stories Blog by CEO Kevin Counihan - Opens in a new window  

Forum Recording:

• Welcome by HHS Secretary Burwell
• The Marketplace Consumer: Understanding the Marketplace Population Through Two Years’ Worth of Data
• Innovation in Provider Contracting
• Keynote by Andy Slavitt
• Care Coordination
• Conversation with the CEO - Looking Ahead

Session Slides:

• The Marketplace Consumer: Understanding the Marketplace Population Through Two Years’ Worth of Data (PDF)
• Innovation in Provider Contracting (PDF)
• Care Coordination (PDF)

Marketplace Year 3: Issuer Insights and Innovation – October 5, 2016

Forum Agenda (PDF)
CMS Acting Administrator Andy Slavitt Remarks"> CMS Acting Administrator Andy Slavitt Remarks - Opens in a new window 
HHS Secretary Burwell Remarks"> HHS Secretary Burwell Remarks - Opens in a new window

Forum Recordings (Forthcoming)

• Welcome by HHS Secretary Burwell
• Looking Ahead to the Future of the Marketplace: A Conversation with CEOs
• The Marketplace Consumer – Using Data to Drive Outreach and Engagement
• Innovation in Plan Design and Provider Outreach
• Keynote by Andy Slavitt
• Engaging Consumers in their Care – Perspectives from Care Coordination and Beyond

Session Slides

• The Marketplace Consumer – Using Data to Drive Outreach and Engagement (PDF)
• Innovation in Plan Design and Provider Outreach (PDF)
• Engaging Consumers in their Care – Perspectives from Care Coordination and Beyond (PDF)

Forms

• May 16, 2012
  Paperwork Reduction Act (PRA) display of Draft Blueprint for Approval of Affordable State-based and State Partnership Insurance Exchanges (click on CMS – 10416).
• August 9, 2022
  Final Blueprint for Exchanges (PDF)
• November 9, 2012
  Frequently Asked Questions on the Blueprint for Exchanges (PDF)
• October 9, 2013
  Marketplace Consumer Application
  • Individual Short Form"> Individual Short Form - Opens in a new window (PDF)  
  • Individual Short Form Instructions - Opens in a new window (PDF)
  • Family - Opens in a new window (PDF)
  • Family Instructions - Opens in a new window (PDF)
  • Individual without Financial Assistance - Opens in a new window (PDF)
  • Individual without Financial Assistance Instructions - Opens in a new window (PDF)
• April 7, 2014
  Compliance Reviews in the Federally-Facilitated Marketplace
  • Key Priorities for FFM Compliance Reviews for the 2014 Benefit Year (PDF)
• April 2, 2015
• Compliance Reviews in the Federally-Facilitated
  • Marketplace Key Priorities for FFM Compliance Reviews for the 2015 Benefit Year (PDF)
• February 23, 2016
  Compliance Reviews in the Federally-Facilitated
  • Marketplace Key Priorities for FFM Compliance Reviews for the 2016 Benefit Year (PDF)

Reports

• August 23, 2013
  Impact of Changing the Maximum Out-of-Pocket Amounts for Qualified Health Plans and Stand Alone Dental Plans (PDF)
• December 16, 2015
  2014 Plan Year Issuer Compliance Summary Report (PDF)
• August 11, 2016
  Changes in ACA Individual Market Costs from 2014-2015: Near-Zero Growth Suggests an Improving Risk Pool (PDF)
• March 15, 2017
  Health Insurance Exchanges 2017 Open Enrollment Report
• April 3, 2018
  Health Insurance Exchanges 2018 Open Enrollment Report
• March 25, 2019
  Health Insurance Exchanges 2019 Open Enrollment Report
• August 12, 2019
  Trends in Subsidized and Unsubsidized Enrollment – Benefit Years 2017 to 2018 (PDF)  
• April 1, 2020
  Health Insurance Exchanges 2020 Open Enrollment Report (PDF)
• June 25, 2020
  Special Trends Report:  Enrollment Data and Coverage Options for Consumers During the COVID-19 Public Health Emergency (PDF) (note this report was updated on November 23, 2020)
• July 22, 2020
  Early 2020 Effectuated Enrollment Snapshot (PDF)
• October 9, 2020
  Trends in Subsidized and Unsubsidized Enrollment (PDF)
• October 30, 2020
  Increasing Competition on the Exchanges to Improve Consumer Choice and Affordability (PDF)
• October 30, 2020
  Agents and Brokers in the Marketplace  (PDF)
• November 23, 2020
  Special Trends Report:  Enrollment Data and Coverage Options for Consumers During the COVID-19 Public Health Emergency (PDF)
• December 16, 2020
  Effectuated Enrollment for the First Half of 2020 (PDF) (PDF)
• December 16, 2020
  2016 2020 Effectuated Enrollment Tables (XLSX)
• January 15, 2021
  Impact of Enhanced Direct Enrollment During the Open Enrollment Period for 2021 Coverage (PDF)
• January 19, 2021
  The Unsubsidized Uninsured: The Impact of Premium Affordability on Insurance Coverage (PDF)
• April 21, 2021
  Health Insurance Exchanges 2021 Open Enrollment Report (PDF)
• June 5, 2021
  Effectuated Enrollment: Early 2021 Snapshot and Full Year 2020 Average (PDF)
• June 5, 2021
  2016 2020 Full Year Effectuated Enrollment Tables (XLSX)
• June 5, 2021
  2016 2021 Feb Effectuated Enrollment Tables (XLSX)
• September 15, 2021
  2021 Aug 15 Effectuated Enrollment Table (XLSX)
• December 3, 2021
  2016 2021 First Half Effectuated Enrollment Tables (XLSX)
• March 23, 2022
  Health Insurance Exchanges 2022 Open Enrollment Report (PDF)
• June 17, 2022
  2022 HealthCare.gov Consumer Savings Under the American Rescue Plan
  • Data by State and Congressional District (XLSX)
  • Methodology (PDF)
  • Marketplace Enrollment and Savings Infographic (PDF)
  • Marketplace Enrollment and Savings Factoids (PDF)
  • FFM Marketplace Enrollment and Savings Premium Table (PDF)
• September 16, 2022
  • Effectuated Enrollment: Early 2022 Snapshot and Full Year 2021 Average (PDF)
• September 16, 2022
  • 2020-2021 Full Year Effectuated Enrollment Tables (XLSX)
• September 16, 2022
  • 2021-2022 Feb Effectuated Enrollment Tables (XLSX)
• November 29, 2022
  • 2021-2022 Effectuated Enrollment Tables, First Six Months (XLSX)
• March 23, 2023
  • Health Insurance Marketplaces 2023 Open Enrollment Report (PDF)
• July 25, 2023
  • 2020-2022 Plan Selections with DMIs Created (XLSX)​​​
• August 11, 2023
  • Effectuated Enrollment: Early 2023 Snapshot and Full Year 2022 Average (PDF)
• December 14, 2023
  • Effectuated Enrollment: Early Snapshot 2023 and Full Year 2022 Average  (XLSX)
• December 14, 2023
  • 2017 2023 First Half Effectuated Enrollment Tables (XLSX)
• March 22, 2024
  • Health Insurance Marketplaces 2024 Open Enrollment Report (PDF)
• July 02, 2024
  • Effectuated Enrollment: Early Snapshot 2024 and Full Year 2023 Average (PDF)
• July 02, 2024
  • February Effectuated Enrollment Tables (XLSX)
• July 02, 2024
  • Full Year Effectuated Enrollment Tables (XLSX)

Planning and Establishment Grants

Pre-Application Conference Calls (Upcoming)

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

Consumer Operated and Oriented Plan (CO-OP) Program

Presentations

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

Health Insurance Market Reforms

Annual Limits

Application Information

• June 17, 2011
  Annual Limit Waiver Application Forms and Instructions
  • Annual Limit Waiver Application—New Application Form (XLS) (XLS – 49 MB)
  • Annual Limit Waiver Application—Waiver Extension Form (XLS) (XLS – 50 MB)
  • Annual Limit Waiver Application Instructions (PDF) (PDF – 89 KB)
  • Annual Limit Waiver Data Dictionary (XLS) (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) (XLS – 2 MB)

Excepted Benefits

• June 25, 2018
  • Limited Wrap Around Coverage Questions and Instructions (PDF)  

Medical Loss Ratio

Forms

• May 19, 2011
  Medical Loss Ratio (MLR) 2011 Quarterly Reporting Forms for “Mini-med” and Expatriate Plans
  • MLR Quarterly Reporting Form for “Mini-med” Plans (XLS) (XLS – 50 KB)
  • MLR Quarterly Reporting Form for Expatriate Plans (XLS) (XLS – 52 KB)
  • MLR Quarterly Reporting Form Instructions (PDF) (PDF – 68 KB)
• June 17, 2011 (corrected)
  MLR Quarterly Reporting Form Instructions (PDF) (PDF – 70 KB)

• May 11, 2012
  Medical Loss Ratio (MLR) 2011 Annual Reporting Form (OMB 0938-1164)

  Medical Loss Ratio (MLR) Rebate Notices to Policyholders and Subscribers (OMB 0938-1164)

  • MLR Annual Reporting Form (XLSX) (XLSX - 119 KB)
  • MLR Annual Reporting Form Instructions (PDF) (PDF - 204 KB)
  • Notice to Subscribers in the Individual Market (Notice #1) (PDF) (PDF – 38 KB)
  • Notice to Group Policyholders and Their Subscribers, Rebate Sent to the Policyholder (Notice #2) (PDF) (PDF - 54 KB)
  • Notice to Subscribers of Group Policyholders, Rebate Sent to the Subscribers (Notice #3) (PDF) (PDF - 41 KB)
  • Instructions for Notices 1, 2 and 3 (PDF) (PDF - 87 KB)
• May 16, 2012
  Notice to Policyholders and Subscribers when MLR Standard is Met (PDF) (PDF - 15 KB)
• March 29, 2013
  • MLR 2012 Annual Reporting Form (XLSX)  (XLSX – 116 KB)
  • MLR 2012 Annual Reporting Form Instructions (PDF) (PDF – 639 KB)
  • MLR 2012 Annual Reporting Form Calculator and Formula Tool (VND.MS-EXCEL.SHEET.MACROENABLED.12) (XLSM - 102 KB)    
• March 25, 2014
  • MLR 2013 Annual Reporting Form (XLSX)
  • MLR 2013 Annual Reporting Form Instructions (PDF)
  • MLR 2013 System Validations (PDF)
• May 14, 2014
  • MLR 2013 Calculator and Formula Tool (VND.MS-EXCEL.SHEET.MACROENABLED.12)
• May 29, 2015 Medical Loss Ratio (MLR) Rebate Notices to Policyholders and Subscribers (OMB 0938-1164)
  • Risk Corridors 2014 Plan Level Data Form (XLSX) (XLSX - 98 KB)
  • Risk Corridors 2014 Plan-Level Instructions (PDF) (PDF - 262 KB)
  • Notice to Subscribers in the Individual Market (Notice #1) (PDF) (PDF - 56 KB)
  • Notice to Group Policyholders and Their Subscribers, Rebate Sent to the Policyholder (Notice #2) (PDF) (PDF - 65 KB)
  • Notice to Subscribers of Group Policyholders, Rebate Sent to the Subscribers (Notice #3) (PDF) (PDF - 44 KB)
  • Instructions for Notices 1, 2 and 3 (PDF) (PDF - 66 KB)
• June 4, 2015
  • MLR 2014 Annual Reporting Form (XLSX) (XLSX – 115 KB)
  • MLR 2014 Annual Reporting Form Instructions (PDF) (PDF – 427 KB)
  • MLR 2014 Calculator and Formula Tool (VND.MS-EXCEL.SHEET.MACROENABLED.12) (XLSM – 147 KB)
• June 19, 2015
  • MLR and Risk Corridors 2014 System Validations (PDF) (PDF – 258 KB)
• May 9, 2016
  • MLR 2015 Annual Reporting Form (XLSX)  (XLSX – 121 KB)
  • MLR 2015 Annual Reporting Form Instructions (PDF)  (PDF – 359 KB)
  • MLR 2015 Calculator and Formula Tool (VND.MS-EXCEL.SHEET.MACROENABLED.12)  (XLSM – 139 KB)
  • Risk Corridors 2015 Plan-Level Data Form (XLSX)  (XLSX – 95 KB)
  • Risk Corridors 2015 Plan-Level Instructions (PDF)  (PDF – 228 KB)
  • MLR and Risk Corridors 2015 System Validations (PDF)  (PDF – 202 KB)
• June 5, 2017
  • MLR 2016 Annual Reporting Form (XLSX)   
  • Risk Corridors 2016 Plan-Level Data Form (XLSX)  
  • Risk Corridors 2016 Plan-Level Instructions (PDF)
• July 12, 2017
  • MLR 2016 Annual Reporting Form Instructions - Revised (PDF)  
  • MLR 2016 Calculator and Formula Tool - Revised (VND.MS-EXCEL.SHEET.MACROENABLED.12)  
• June 5, 2018
  • MLR 2017 Annual Reporting Form (XLSX)
  • MLR 2017 System Validations (PDF)  
• July 16, 2018
  • MLR 2017 Annual Reporting Form Instructions - Revised (PDF)  
  • MLR 2017 Calculator and Formula Tool - Revised (VND.MS-EXCEL.SHEET.MACROENABLED.12)  
• June 25, 2019
  • MLR 2018 Annual Reporting Form Instructions (PDF)  
  • MLR 2018 Annual Reporting Form (XLSX)  
  • 2018-MLR-Calculator (VND.MS-EXCEL.SHEET.MACROENABLED.12)  
  • MLR 2018 System Validations (PDF)  
• July 30, 2020
  • MLR 2019 Annual Reporting Form Instructions (PDF)
  • MLR 2019 Annual Reporting Form  (XLSX) 
  • MLR 2019 Calculator and Formula Tool (XLSM)
• February 16, 2022
  • MLR 2020 Annual Reporting Form Instructions (PDF)
  • MLR 2020 Annual Reporting Form  (XLSX) 
  • MLR 2020 Calculator and Formula Tool (XLSM)
• June 27, 2022
  • MLR 2021 Annual Reporting Form Instructions (PDF)
  • MLR 2021 Annual Reporting Form (XLSX)
  • MLR 2021 Calculator and Formula Tool (XLSM)
• June 23, 2023
  • MLR 2022 Annual Reporting Form Instructions (PDF)
  • MLR 2022 Annual Reporting Form (XLSX)
  • MLR 2022 Calculator and Formula Tool (XLSM)
• June 23, 2023 Medical Loss Ratio (MLR) Rebate Notices to Policyholders and Subscribers
  • Notice to Subscribers in the individual Market (Notice #1) (PDF)
  • Notice to Group Policyholders and their Subscribers, Rebate Sent to the Policyholder (Notice #2) (PDF)
  • Notice to Subscribers of Group Policyholders, Rebate Sent to the Subscribers (Notice #3) (PDF)
  • Instructions for Notices 1, 2 and 3 (PDF)
• May 13, 2024
  • MLR 2023 Annual Reporting Form Instructions (PDF)
  • MLR 2023 Annual Reporting Form (XLSX)
  • MLR 2023 Calculator and Formula Tool (XLSM)

Reports:

•  
  • June 21, 2012
    The 80/20 Rule: Providing Value and Rebates to Millions of Consumers
  • February 15, 2013
    The 80/20 Rule: How Insurers Spend Your Health Insurance Premiums (PDF)
  • June 20, 2013
    80/20 Rule Delivers More Value to Consumers in 2012 (PDF)
  • July 24, 2014
    Consumers Benefit from 80/20 Rule in 2013 (PDF)
  • November 19, 2015
    Consumers Get Rebates, More Premium Value and Stability Protection in 2014 (PDF) (PDF – 778KB)
  • November 18, 2016
    Medical Loss Ratio Report: The 80/20 Rule Increases Value for Consumers for Fifth Year in a Row (PDF) (PDF – 774KB)
  • December 28, 2017
    Summary of 2016 Medical Loss Ratio Results (PDF-326KB) (PDF)

Mental Health Parity

Forms

• April 23, 2018
  Form to Request Documentation from an Employer-Sponsored Health Plan or and Issuer Concerning Treatment Limitations - Opens in a new window  

Reports

• December 12, 2017
  Department of Health and Human Services (HHS) Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) Enforcement Report (PDF)  
• April 23, 2018
  21st Century Cures Act: Section 13002 Action Plan for Enhanced Enforcement of Mental Health and Substance Use Disorder Coverage - Opens in a new window  
• March 29, 2019
  Department of Health and Human Services (HHS) Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) Enforcement Report for the 2018 Federal Fiscal Year (PDF)  
• March 16, 2020
  FY2019  MHPAEA Enforcement Fact Sheet (PDF) 
  Appendix (PDF)
• January 15, 2021
  FY2020 MHPAEA Enforcement Fact Sheet (PDF)
  Appendix (PDF)
• January 25, 2022
  2022 MHPAEA Report to Congress (PDF)
• July 25, 2023
  2023 MHPAEA Report to Congress (PDF) (PDF)
  FY2022 MHPAEA Enforcement Fact Sheet (PDF)
  Appendix (PDF)

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) (XLS – 151 KB)
  Data Files – Second Estimate (XLS) (XLS – 151 KB)
  Data Files – First and Second Estimates by State (XLS) (XLS – 35.5 KB)

Methodology

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

Reports

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

Prevention

Forms

• June 28, 2013
  Self-certification Form (To be used for plan years beginning on or after January 1, 2014)

  • Standard Format (DOCX) (DOC – 28 KB)
  • Accessible Format (PDF) (PDF – 22 KB)

  Model Notice of Availability of Separate Payments for Contraceptive Services (PDF) (PDF – 39 KB)

Review of Insurance Rates

Forms

• February 2, 2015
  Effective Rate Review (ERR) Annual Survey (OMB 0938-1121)
  o 2015 ERR Annual Determination and Status Questions (PDF)
  o 2015 ERR Instructions (PDF)
• February 25, 2015
  Unified Rate Review (URR) Reporting Requirements for Single Risk Pool Plans (OMB 0938-1141)
  o 2016 URR Instructions (Parts I, II, & III) (PDF)
  o 2016 URR Template (URRT) (VND.MS-EXCEL.SHEET.MACROENABLED.12) (Updated on April 15, 2015)
• o 2016 Instructions for Submitting a Redacted Actuarial Memorandum (PDF) (Posted April 16, 2015)
• April 03, 2015
  Rate Review Justification (RRJ) Reporting Requirements for Transitional Plans and Student Health Plans (OMB 0938-1141)
  o RRJ Instructions (PDF)
  o RRJ Template (XLS)
• February 22, 2016
  Unified Rate Review (URR) Reporting Requirements for Single Risk Pool Plans (OMB 0938-1141)
  o Draft 2017 URR Instructions (Parts I, II, & III) (PDF)
  o Federal Register Notice
• o PRA Supporting Statement (PDF)
• o2017 URR Template v3.3 (URRT) (VND.MS-EXCEL.SHEET.MACROENABLED.12) (Updated March 18, 2016)
• August 18, 2016
  Unified Rate Review (URR) Reporting Requirements for Single Risk Pool Plans (OMB 0938-1141) (PDF)
  Final 2017 URR Instructions (Parts I, II, & III) (Updated August 10, 2016) (PDF)
• February 23, 2017
  2018 URR Template v4.1 (VND.MS-EXCEL.SHEET.MACROENABLED.12)
• April 7, 2017
  Unified Rate Review (URR) Reporting Requirements for Single Risk Pool Plans (OMB 0938-1141) Final 2018 URR Instructions (Parts I, II, & III) (PDF)  
• April 9, 2018
  Unified Rate Review (URR) Reporting Requirements for Single Risk Pool Plans (OMB 0938-1141)
  o Final 2019 URR Instructions (Parts I, II, & III) (PDF)  
  o 2019 URR (VND.MS-EXCEL.SHEET.MACROENABLED.12)  
• April 9, 2018
  Rate Review Justification (RRJ) Reporting Requirements for Transitional Plans (OMB 0938-1141)  
  o RRJ Instructions (PDF)  
  o RRJ Template (XLS)  
• May 8, 2019
  • Draft 2020 URR Instructions (Parts I, II, & III) (PDF)  
  • Draft 2020 URR Template v5.0 (VND.MS-EXCEL.SHEET.MACROENABLED.12)  
• December 20, 2019 
  Unified Rate Review (URR) Reporting Requirements for Single Risk Pool Plans (OMB 0938-1141)  
  o Final 2020 URR Instructions (PDF)(Parts I, II, & III) (PDF)  
  o 2020 URR Template v5.0 (XLSM)
• April 7, 2020 
  Unified Rate Review (URR) Reporting Requirements for Single Risk Pool Plans (OMB 0938-1141)  
  o Final PY2021 URR Instructions (PDF)(Parts I, II, & III) (PDF)
  o URR Template v5.2 (XLSM) (XLSM)
• March 16, 2021
  Unified Rate Review (URR) Reporting Requirements for Single Risk Pool Plans (OMB 0938-1141) 
  o Final PY2022 URR Instructions (Parts I, II & III) (PDF)
  o URR Template v5.3 (XLSM) 
• April 9, 2021
  Health Insurance Oversight System (HIOS) Rate Review System Technical Instructions for States and Health Insurance Issuers (PDF) (RRJ Module for Transitional Plans)
• April 4, 2022
  Unified Rate Review (URR) Reporting Requirements for Single Risk Pool Plans (OMB 0938-1141)  
  o Final PY2023 URR Instructions (Parts I, II, & III) (PDF)
  o URR Template v5.4 (XLSM)
• March 2, 2023
  o URR Template v6.0 (XLSM)

Reports (XLSM)

• September 20, 2011 (XLSM)
  Report: Early Achievements of Health Insurance Rate Review Grants (PDF) (PDF - 268 KB)
  Note: The Cycle II proposal summary for the California Department of Managed Health Care was corrected on September 22, 2011.
• September 11, 2012
  Annual Rate Review Report
• September 12, 2013
  Rate Review Annual Report - Opens in a new window
• December 30, 2015
  Rate Review Annual Report (PDF)

Self-Funded Non-Federal Governmental Plans

Compliance Checklists

• July 12, 2016 
  Market Reforms (ACA & HIPAA) Non-Grandfathered Plan Provisions Self-Funded Non-Federal Governmental Group Health Plans Compliance Checklist (PDF)
  
  Market Reforms (ACA & HIPAA) Grandfathered Plan Provisions Self-Funded Non-Federal Governmental Group Health Plans Compliance Checklist (PDF)

Presentations

• April 15, 2019
  Non-Federal Governmental Plans: An Introduction (PDF)  
• July 8, 2019
  Non-Federal Governmental Plans and MHPAEA (PDF)
• September 3, 2021
  Non-Federal Governmental Plans and NQTL Comparative Analysis Reviews for MHPAEA Compliance (PDF)
• March 29, 2023
  Non-Federal Governmental Plans and the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) (PDF)

HIPAA Opt-Out Materials

• September 21, 2010
  Memo on Amendments to the HIPAA Opt-Out Provision made by the Affordable Care Act (PDF) (PDF – 44 KB)
• July 21, 2014    
  Updated Procedures and Requirements for HIPAA Exemption Election through the Health Insurance Oversight System (HIOS) (PDF)
• December 31, 2014
  Procedures and Requirements for HIPAA Exemption Election
• August 18, 2016
  HIOS Non-Federal Governmental Health Plan Module Training (PDF)
• September 11, 2018
  HIOS-Non-Fed-User Manual (PDF)
• July 31, 2023
  List of HIPAA Opt-Out Elections for Self-Funded, Non-Federal Governmental Plans (PDF)
• October 11, 2024
  List of HIPAA Opt-Out Elections for Self-Funded, Non-Federal Governmental Plans (PDF)

Standard Notices

• August 12, 2020
  Enforcement Safe Harbor for Individual Market Product Discontinuation Notices in Connection with the Open Enrollment Period for Coverage in the 2021 Benefit Year (PDF)

Premium Stabilization Programs

White Papers

• September 12, 2011
  Risk Adjustment Implementation Issues – White Paper (PDF) (PDF – 2 MB)
  Questions and Answers on Risk Adjustment White Paper
• March 24, 2016
  March 31, 2016, HHS-Operated Risk Adjustment Methodology Meeting Discussion Paper (PDF)

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

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

Instructions

• August 27, 2015
  Instructions for 2014 Risk Corridors Discrepancy Worksheet (PDF)

• October 13, 2015
  FAQs for User Fee Adjustment Data Submission  (PDF 125 KB) (PDF)

  Job Aid: TPA user fee adjustment data submission  (PDF 366 KB) (PDF)
  Job Aid:  Issuer user fee adjustment data submission form  (PDF 193 KB) (PDF)
• March 23, 2018
  FAQ for Federally-facilitated Exchange (FFE) User Fee Adjustment Obligation Reduction (PDF)  
• May 16, 2018
  Federally-facilitated Exchange (FFE) User Fee Adjustment Web Form Quick Start Guide (PDF)  

Forms

• January 29, 2015
  2014 Transitional Reporting Form (Excel) (XLSX)
• August 22, 2016
  Federally-facilitated Marketplace (FFM) User Fee Adjustment Web Form Quick Start Guide (PDF)
• March 23, 2018
  Federally-facilitated Exchange (FFE) User Fee Adjustment Obligation Reduction Attestation Form (XLSX)  
• March 29, 2018
  Cost-Sharing Reduction Reconciliation Attestation Form A – Benefit Year 2017 (XLSX) 
  Cost-Sharing Reduction Reconciliation Attestation Form B – Benefit Year 2017 (XLSX) 
  Cost-Sharing Reduction Reconciliation Attestation Form C – Benefit Year 2016 (XLSX)  
• April 3, 2019
  Cost-sharing Reduction Reconciliation Attestation Form A – Benefit Year 2018 (XLSX)  
  Cost-sharing Reduction Reconciliation Attestation Form B – Benefit Year 2018 (XLSX)  
• May 29, 2019
  CSR Reconciliation Attestation Form A Benefit Year 2018 or 2017 (XLSX)  
  CSR Reconciliation Attestation Form B Benefit Year 2018 or 2017 (XLSX)  
• April 24, 2020
  Cost-sharing Reduction Reconciliation Attestation Form A Benefit Year 2019 (PDF) or 2018 (PDF)  
  Cost-sharing Reduction Reconciliation Attestation Form B Benefit Year 2019 or 2018 (PDF)
• April 13, 2021
  Cost-sharing Reduction Reconciliation Attestation Form A Benefit Year 2020 or 2019 (XLSX)
  Cost-sharing Reduction Reconciliation Attestation Form B Benefit Year 2020 or 2019 (XLSX)
• April 4, 2022
  Cost-sharing Reduction Reconciliation Attestation Form A Benefit Year 2021 or 2020 (XLSX)
  Cost-sharing Reduction Reconciliation Attestation Form B Benefit Year 2021 or 2020 (XLSX)

COBRA

Forms

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

Reports

GAO

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

State High Risk Pool Grant Program

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

CCIIO 

•    September 13, 2023
  "CCIIO-led Behavioral Health & Telehealth Collaborative in Seven States" (PDF) (PDF – 5MB)