Regulations and Guidance
Regulations and Guidance
- Affordable Care Act
- No Surprises Act
- Consumer Support and Information
- Content Requirements for Plan Finder
- Pre-Existing Condition Insurance Plan (PCIP)
- Early Retiree Reinsurance Program (ERRP)
- Health Insurance Marketplaces
- Minimum Acceptable Risk Standards
- Premium Stabilization Programs
- State Innovations
- Consumer Operated and Oriented Plan (CO-OP) Program
- Other Insurance Protections
- Health Insurance Market Reforms
- Health Insurance Portability and Accountability Act of 1996 (HIPAA)
Affordable Care Act
Guidance
- November 4, 2014
Group Health Plans that Fail to Cover In-Patient Services (PDF) - April 14, 2015
Key Dates in 2015: QHP Certification in the FFM; Rate Review; Risk Adjustment, Reinsurance, and Risk Corridors (PDF) - December 23, 2015
Key Dates in 2016: QHP Certification in the FFM; Rate Review; Risk Adjustment, Reinsurance and Risk Corridors (PDF) - February 29, 2016
Final: Key Dates in 2016: QHP Certification in the FFM; Rate Review; Risk Adjustment, Reinsurance and Risk Corridors (PDF) - July 21, 2016
[CMS–9931-NC] Coverage for Contraceptive Services ACTION: Request for information (PDF) - November 10, 2016
Proposed Key Dates in 2017: QHP Certification in the FFM; Rate Review; Risk Adjustment, and Reinsurance (PDF) - February 17, 2017
Revised Key Dates in 2017: QHP Certification in the FFM; Rate Review; Risk Adjustment and Reinsurance (PDF) - April 13, 2017
Final Revised Key Dates in 2017: QHP Certification in the FFE; Rate Review; Risk Adjustment, Reinsurance and Risk Corridors (PDF) - November 27, 2017
Proposed Key Dates for Calendar Year 2018: QHP Certification in the FFEs; Rate Review; Risk Adjustment (PDF) - April 9, 2018
Final Key Dates for Calendar Year 2018: QHP Certification in the FFEs; Rate Review; Risk Adjustment (PDF) - January 17, 2019
Proposed Key Dates for Calendar Year 2019: QHP Certification in the FFEs; Rate Review; Risk Adjustment (PDF) - April 18, 2019
Final Key Dates for Calendar Year 2019: QHP Certification in the FFEs; Rate Review; Risk Adjustment (PDF) - January 31, 2020
Proposed Key Dates for Calendar Year 2020; QHP Certification in the FFEs; Rate Review; Risk Adjustment (PDF) - May 7, 2020
Final Key Dates for Calendar Year 2020: QHP Certification in the FFEs; Rate Review; Risk Adjustment (PDF) - December 1, 2020
Proposed Key Dates for Calendar Year 2021: Qualified Health Plan (QHP) Data Submission and Certification; Rate Review; and Risk Adjustment (PDF) - February 2, 2021
Final Key Dates for Calendar Year 2021: Qualified Health Plan (QHP) Data Submission and Certification; Rate Review; and Risk Adjustment (PDF) - November 23, 2021
Proposed Key Dates for Calendar Year 2022: Qualified Health Plan (QHP) Data Submission and Certification; Rate Review; and Risk Adjustment (PDF) - December 28, 2021
Premium Adjustment Percentage, Maximum Annual Limitation on Cost Sharing, Reduced Maximum Annual Limitation on Cost Sharing, and Required Contribution Percentage for the 2023 Benefit Year (PDF) - March 25, 2022
Key Dates for Calendar Year 2022: Qualified Health Plan (QHP) Data Submission and Certification; Rate Review; and Risk Adjustment (PDF) - May 18, 2022
Revised: Key Dates for Calendar Year 2022: Qualified Health Plan (QHP) Data Submission and Certification; Rate Review; and Risk Adjustment (PDF) - December 12, 2022
Premium Adjustment Percentage, Maximum Annual Limitation on Cost Sharing, Reduced Maximum Annual Limitation on Cost Sharing, and Required Contribution Percentage for the 2024 Benefit Year (PDF) - December 15, 2022
Proposed Key Dates for Calendar Year 2023: Qualified Health Plan (QHP) Data Submission and Certification; Rate Review; Form Review; and Risk Adjustment (PDF) - March 10, 2023
Final Key Dates for Calendar Year 2023: Qualified Health Plan (QHP) Data Submission and Certification; Rate Review; Form Review and Risk Adjustment (PDF) - November 15, 2023
Premium Adjustment Percentage, Maximum Annual Limitation on Cost Sharing, Reduced Maximum Annual Limitation on Cost Sharing, and Required Contribution Percentage for the 2025 Benefit Year (PDF) - November 16, 2023
Proposed Key Dates for Calendar Year 2024: Qualified Health Plan (QHP) Data Submission and Certification; Rate Review; Form Review and Risk Adjustment (PDF) - May 8, 2024
Revised Final Key Dates for Calendar Year 2024; Qualified Health Plan (QHP) Data Submission and Certification; Rate Review and Risk Adjustment (PDF) - October 8, 2024
Premium Adjustment Percentage, Maximum Annual Limitation on Cost Sharing, Reduced Maximum Annual Limitation on Cost Sharing, and Required Contribution Percentage for the 2026 Benefit Year (PDF)
No Surprises Act
Regulations
- July 13, 2021
CMS-9909-IFC: Requirements Related to Surprise Billing; Part I - September 16, 2021
CMS-9907-P: Requirements Related to Air Ambulance Services, Agent and Broker Disclosures, and Provider Enforcement - October 7, 2021
CMS-9908-IFC: Requirements Related to Surprise Billing; Part II - August 26, 2022
CMS-9909-F and CMS-9908-F: Requirements Related to Surprise Billing: Final Rules - September 20, 2023
CMS-9890-P: Federal Independent Dispute Resolution (IDR) Process Administrative Fee and Certified IDR Entity Fee Ranges (PDF) - November 3, 2023
CMS-9897-P: Federal Independent Disputes Resolution Operations - December 21, 2023
CMS-9890-F: Federal Independent Dispute Resolution (IDR) Process Administrative Fee and Certified IDR Entity Fee Ranges
Good Faith Estimates for Uninsured (or Self-pay) Individuals
Guidance
- December 21, 2021
Guidance on Good Faith Estimates for Providers, Facilities, People without Insurance, and People Who Plan to Pay for the Costs Themselves - Part 1 (PDF)
*This document was updated on December 27, 2022 to include links to other FAQs on this topic. - April 5, 2022
Guidance on Good Faith Estimates for Uninsured (or Self-Pay) Individuals - Part 2 (PDF)
*This document was updated on December 27, 2022 to include links to other FAQs on this topic. - December 2, 2022
Guidance on Good Faith Estimates for Uninsured (or Self-Pay) Individuals – Part 3 (PDF) - December 27, 2022
Guidance on Good Faith Estimates for Uninsured (or Self-Pay) Individuals – Part 4 (PDF)
*This document was updated on February 21, 2023 to correct a typo in A1 and A2. Service "costs" has been replaced with service "codes." - June 5, 2023
Model Notices: Good Faith Estimate for Health Care Items and Services and Abbreviated Good Faith Estimate for No-Cost Health Care Items and Services (PDF)
Patient-Provider Dispute Resolution
Guidance
- December 21, 2021
Guidance on Good Faith Estimates and the Patient-Provider Dispute Resolution (PPDR) Process for People without Insurance or Who Plan to Pay for the Costs Themselves (PDF) - December 21, 2021
Guidance on Good Faith Estimates and the Patient-Provider Dispute Resolution (PPDR) Process for Providers and Facilities as Established in Surprise Billing, Part II; Interim Final Rule with Comment Period (CMS 9908-IFC) (PDF) - December 21, 2021
Calendar Year 2022 Fee Guidance for the Federal Patient-Provider Dispute Resolution (PPDR) Process as Established in Surprise Billing, Part II; Interim Final Rule with Comment Period (CMS 9908-IFC) (PDF) - December 21, 2021
Guidance on Good Faith Estimates and the Patient-Provider Dispute Resolution (PPDR) Process for Selected Dispute Resolution (SDR) Entities as Established in Surprise Billing, Part II, Interim Final Rule with Comment Period (CMS 9908-IFC) (PDF) - October 31, 2022
Calendar Year 2023 Fee Guidance for the Federal Patient-Provider Dispute Resolution (PPDR) Process as Established in Surprise Billing, Part II; Interim Final Rule with Comment Period (CMS 9908-IFC) (PDF)
Federal Independent Dispute Resolution
Guidance
- September 30 2021
Technical Guidance 2021-01: Calendar Year 2022 Fee Guidance for the Federal Independent Dispute Resolution Process Under the No Surprises Act (PDF) - February 28, 2022
Memorandum Regarding Continuing Surprise Billing Protections for Consumers (PDF) - August 19, 2022
Federal Independent Dispute Resolution Process Status Update (PDF) - October 7, 2022 (revised December 15, 2023)
These guidance documents are effective as of July 26, 2022, and applicable to all items and services furnished before October 25, 2022, for plan years (in the individual market, policy years) beginning on or after January 1, 2022, by an out-of-network provider subject to the Requirements Related to Surprise Billing; Part II, Interim Final Rules, 86 FR 55980. - October 31, 2022
As a result of the opinion and order in Texas Medical Association v. Unites States Department of Health and Human Services, Case No. 6:23-cv-59-JDK. as of August 3, 2023, the administrative fee reverts to the amount established in the following October 2022 guidance document: - December 23, 2022
Effective August 3, 2023, this December 2022 guidance document was vacated in part by the United States District Court for the Eastern District of Texas Medical Association v. United States Department of Health and Human Services, Case No. 6:23-cv-59-JDK: Amendment to the Calendar Year 2023 Fee Guidance for the Federal Independent Dispute Resolution Process under the No Surprises Act: Change in Administrative Fee (PDF) - March 17, 2023 (Revised December 15, 2023)
These guidance documents are applicable to all items and services that are furnished on or after October 25, 2022, for plan years (in the individual market, policy years) beginning on or after January 1, 2022, by an out-of-network provider subject to the Requirements Related to Surprise Billing; Part II Interim Final Rules, 86 FR 55980 and Requirements Related to Surprise Billing Final Rules; 87 FR 52618. - April 27, 2023
- August 11, 2023
- October 6, 2023
- November 28, 2023
Advanced Explanation of Benefits (AEOB)
Regulations
- April 23, 2024
Consumer Support and Information
Transparency in Coverage
Regulations
- November 15, 2019
CMS-9915-P: Transparency in Coverage - October 29, 2020
CMS-Transparency in Coverage 9915-F (PDF)
Guidance
- December 27, 2019
Announcement of in Intention to Extend the Transparency in Coverage Comment Period (PDF)
External Appeals
Regulations
- July 23, 2010
OCIIO-9993-IFC: Interim Final Rules for Group Health Plans and Health Insurance Issuers Relating to Internal Claims and Appeals and External Review Processes Under the Patient Protection and Affordable Care Act (PDF) - June 24, 2011
CMS-9993-IFC2: Group Health Plans and Health Insurance Issuers: Rules Relating to Internal Claims and Appeals and External Review Processes - July 26, 2011
CMS-9993-CN: Group Health Plans and Health Insurance Issuers: Rules Relating to Internal Claims and Appeals and External Review Processes; Correction (PDF) - May 3, 2012
2012-10582: Affordable Care Act Internal Claims and Appeals and External Review Procedures for Non-Grandfathered Plans - November 18, 2015
CMS-9993-F: Final Rules for Grandfathered Plans, Preexisting Condition Exclusions, Lifetime and Annual Limits, Rescissions, Dependent Coverage, Appeals, and Patient Protections Under the Affordable Care Act - October 7, 2021
CMS-9908-IFC: Requirements Related to Surprise Billing; Part II: Interim Final Rules for Group Health Plans and Health Insurance Issuers relating to the expanded scope of external review that includes the No Surprises Act (NSA) provisions
Guidance
- June 22, 2011
Technical Release 2011-02: Guidance on External Review for Group Health Plans and Health Insurance Issuers Offering Group and Individual Health Coverage, and Guidance for States on State External Review Processes (PDF) - August 17, 2012
Technical Guidance: Content of Notices – Adverse Benefit Determinations and Final Internal Adverse Benefit Determinations for Beneficiaries in Non-Federal Governmental Health Plans (PDF) - July 24, 2013
Technical Guidance: Updated Instructions for Calculating County Level Estimates Pertaining to the Culturally and Linguistically Appropriate Standards Set Forth in the Internal Claims and Appeals and External Review Processes under the Affordable Care Act (PDF) - January 12, 2017
Technical Guidance: Instructions for Self-Insured Non-Federal Governmental Health Plans and Health Insurance Issuers Offering Group and Individual Health Coverage on How to Elect a Federal External Review Process (PDF) - July 12, 2019
Update to Technical Guidance: Standards for Self-Insured Non-Federal Governmental Health Plans and Health Insurance Issuers Offering Group and Individual Health Coverage Using the HHS-Administered Federal External Review Process (PDF) - December 30, 2021
Technical Guidance: Guidance for States, Plans, and Issuers on State External Review Processes Regarding Requirements in the No Surprises Act (PDF)
*This document was updated on February 1, 2022, to correct an error on page 5 regarding the website address to access instructions for MOVEit registration.
Summary of Benefits and Coverage and Uniform Glossary
Regulations
- August 22, 2011
CMS-9982-P: Summary of Benefits and Coverage and the Uniform Glossary (PDF) - February 14, 2012
CMS-9982-F: Summary of Benefits and Coverage and Uniform Glossary (PDF) - December 22, 2014
CMS-9938-P: Summary of Benefits and Coverage and Uniform Glossary (PDF) - June 12, 2015
CMS-9938-F: Summary of Benefits and Coverage and Uniform Glossary (PDF)
Guidance
- August 22, 2011
Notice: Summary of Benefits and Coverage and Uniform Glossary - Templates, Instructions, and Related Materials under the Public Health Service Act (PDF) - February 14, 2012
Summary of Benefits and Coverage and Uniform Glossary - Templates, Instructions, and Related Materials, and Guidance for Compliance (PDF)
February 2016 Proposed Supporting Materials for Public Comment
- Proposed SBC Blank Template (PDF)
- Proposed Uniform Glossary (PDF)
- Proposed SBC Sample Completed Template (PDF)
- Proposed Why This Matters language for SBC "No" Answers (PDF)
- Proposed Why This Matters language for SBC "Yes" Answers (PDF)
- Proposed Instructions for Completing the SBC – Individual Health Insurance Coverage (PDF)
- Proposed Instructions for Completing the SBC – Group Health Plan Coverage (PDF)
- Proposed Guide for Coverage Examples Calculations – Maternity Scenario, Diabetes Scenario, and Foot Fracture (PDF)
- Proposed Coverage Examples Narrative – Maternity Scenario (PDF)
- Proposed Coverage Examples Narrative – Diabetes Scenario (PDF)
- Proposed Coverage Examples Narrative – Foot Fracture (PDF)
Language Access Guide for Exchanges, Qualified Health Plan (QHP) Issuers, and Web-Brokers
- March 30, 2016
Technical Guidance – March 30, 2016 Guidance and Population Data for Exchanges, Qualified Health Plan Issuers, and Web-Brokers to Ensure Meaningful Access by Limited-English Proficient Speakers Under 45 CFR §155.205(c) and §156.250 (PDF) - January 13, 2017
Appendix A: Top 15 Non-English Languages by State* (PDF) - December 10, 2018
Appendix B: Sample Translated Taglines – Languages Are Listed in Alphabetical Order* (PDF)
Updated with minor corrections to the information posted January 13, 2017. Entities that relied on the information in previous appendices will not be penalized.
Content Requirements for Plan Finder
Regulations
Guidance
- May 3, 2010
Memorandum: User Access and Authorization for the Health Insurance Oversight System
Pre-Existing Condition Insurance Plan (PCIP)
Regulations
- July 30, 2010
OCIIO–9995–IFC: Pre-Existing Condition Insurance Plan Program (PDF) - August 30, 2012
CMS–9995–IFC2: Pre-Existing Condition Insurance Plan Program (PDF) - May 22, 2013
CMS–9995–IFC3: Pre-Existing Condition Insurance Plan Program (PDF)
Guidance
- October 6, 2010
The Pre-Existing Condition Insurance Plan Program and Newborn Coverage (PDF) - December 28, 2010
Portability of Coverage, Enrollee Notices, and Third Party Payments (PDF) - February 17, 2011
Eligibility for Children under Age 19 in the Federally-Administered Pre-Existing Condition Insurance Plan (PDF) - March 23, 2011
Pre-Existing Condition Insurance Plan Eligibility and Access to Other Creditable Coverage (PDF) - May 31, 2011
PCIP Premium and Benefit Revisions (PDF) - May 31, 2011
Question and Answer Regarding Anti-Dumping Provisions Related to the Pre-Existing Condition Insurance Plan Program (PDF) - May 25, 2012
Management of PCIP Program in 2012 (PDF) - April 24, 2014
Special Enrollment Period for Individuals Losing Coverage through the Pre-Existing Condition Insurance Program (PCIP) on April 30, 2014 (PDF)
Early Retiree Reinsurance Program (ERRP)
Regulations
- May 5, 2010
Early Retiree Reinsurance Program (PDF)
Guidance
- June 3, 2010
CMS-SORN: Privacy Act of 1974 Report of New System of Records (System No. 09-90-0250) (PDF) - April 5, 2011
CMS-9996-N ERRP Program Notice to Stop Accepting Applications (PDF) - December 13, 2011
CMS-9996-N2: Early Retiree Reinsurance Program Notice regarding Incurred Claims Date (PDF) - March 21, 2012
CMS-9996-N3: Early Retiree Reinsurance Program Notice regarding the Date by which Plan Sponsors Must Use Funds(PDF) - March 27, 2012
Explanation of the Appeal Process for the Early Retiree Reinsurance Program (PDF) - April 23, 2013
CMS-9996-N4: Early Retiree Reinsurance Program Notice regarding Termination of Several Operational Processes (PDF)
Health Insurance Marketplaces
Regulations
- July 15, 2011
CMS-9989-P:Establishment of Exchanges and Qualified Health Plans (PDF) - August 17, 2011
CMS-9974-P: Exchange Functions in the Individual Market: Eligibility Determinations; Exchange Standards for Employers (PDF) - August 17, 2011
CMS-2349-P: Medicaid Program; Eligibility Changes under the Affordable Care Act of 2010 (PDF) - August 17, 2011
REG-131491-10: Health Insurance Premium Tax Credits (PDF) - September 30, 2011
Patient Protection and Affordable Care Act: Establishment of Exchanges and qualified Health Plans and Standards Related to Reinsurance, Risk Corridors, and Risk Adjustment: Extension of Comment Period (PDF) - March 16, 2012
Regulatory Impact Analysis: Establishment of Exchanges and Qualified Health Plans (CMS-9989-FWP) and Standards Related to Reinsurance Risk Corridors and Risk Adjustment (CMS-9975-F) (PDF) - March 27, 2012
CMS-9989-F: Establishment of Exchanges and Qualified Health Plans; Exchange Standards for Employers (PDF) - May 29, 2012
CMS-9989-CN: Establishment of Exchanges and Qualified Health Plans; Exchange Standards for Employers; Correction (PDF) - January 14, 2013
CMS-2334-P: Essential Health Benefits in Alternative Benefit Plans, Eligibility Notices, Fair Hearing and Appeal Processes for Medicaid and Exchange Eligibility Appeals (PDF) - January 30, 2013
CMS-9958-P: Eligibility for Exemptions; Miscellaneous Minimum Essential Coverage Provisions (PDF) - March 11, 2013
CMS-9964-P2: Establishment of Exchanges and Qualified Health Plans; Small Business Health Options Program (PDF) - April 3, 2013
CMS-9955-P: Patient Protection and Affordable Care Act; Exchange Functions: Standards for Navigators and Non-Navigator Assistance Personnel (PDF) - June 4, 2013
CMS-9964-F2: Establishment of Exchanges and Qualified Health Plans; Small Business Health Options Program (PDF) - June 14, 2013
CMS-9957-P: Patient Protection and Affordable Care Act; Program Integrity: Exchange, SHOP, Premium Stabilization Programs, and Market Standards (PDF) - June 26, 2013
CMS-9958-F: Patient Protection and Affordable Care Act; Exchange Functions: Eligibility for Exemptions; Miscellaneous Minimum Essential Coverage Provisions (PDF) - July 5, 2013
CMS-2334-F: Medicaid and Children’s Health Insurance Programs: Essential Health Benefits in Alternative Benefit Plans, Eligibility Notices, Fair Hearing and Appeal Processes, and Premiums and Cost Sharing; Exchanges: Eligibility and Enrollment (PDF) - July 12, 2013
CMS-9955-F: Patient Protection and Affordable Care Act; Exchange Functions: Standards for Navigators and Non-Navigator Assistance Personnel; Consumer Assistance Tools and Programs of an Exchange and Certified Application Counselors (PDF) - August 28, 2013
CMS-9957-F: Patient Protection and Affordable Care Act; Program Integrity: Exchange, SHOP, and Eligibility Appeals (PDF) - October 24, 2013
CMS-9957-F2: Patient Protection and Affordable Care Act; Program Integrity: Exchange, Premium Stabilization Programs, and Market Standards; Amendments to HHS Notice of Benefit and Payment Parameters for 2014 (PDF) - December 12, 2013
CMS-9945-IFC: Patient Protection and Affordable Care Act; Maximizing January 1, 2014 Coverage Opportunities (PDF) - December 31, 2013
CMS-9957-CN: Patient Protection and Affordable Care Act; Program Integrity: Exchange, Premium Stabilization Programs, and Market Standards; Amendments to HHS Notice of Benefit and Payment Parameters for 2014 Correction (PDF) - June 26, 2014
CMS-9941-P: Patient Protection and Affordable Care Act; Annual Eligibility Redeterminations for Exchange Participation and Insurance Affordability Programs; Health Insurance Issuer Standards Under the Affordable Care Act, Including Standards Related to Exchanges (PDF) - September 2, 2014
CMS-9941-F: Patient Protection and Affordable Care Act; Annual Eligibility Redeterminations for Exchange Participation and Insurance Affordability Programs; Health Insurance Issuer Standards Under the Affordable Care Act, Including Standards Related to Exchanges (PDF) - May 6, 2016
CMS-9933-IFC: Patient Protection and Affordable Care Act; Amendments to Special Enrollment Periods and the Consumer Operated and Oriented Plan Program (PDF) - December 12, 2016
CMS-3337-IFC: Conditions for Coverage for End-Stage Renal Disease Facilities - February 15, 2017
CMS-9929-P: Patient Protection and Affordable Care Act; Market Stabilization Proposed Rule (PDF) - April 18, 2017
CMS-9929-F: Patient Protection and Affordable Care Act; Market Stabilization Final Rule (PDF) - Opens in a new window - November 7, 2018
CMS-9922-P: Patient Protection and Affordable Care Act; Exchange Program Integrity (PDF)
Guidance
- November 3, 2010
Guidance: Exchange and Medicaid Information Technology (IT) Systems (PDF) - November 18, 2010
Guidance: Initial Guidance to States on Exchanges - May 31, 2011
Guidance: Guidance for Exchange and Medicaid Information Technology (IT) Systems: Version 2.0 (PDF) - November 29, 2011
State Exchange Implementation Questions and Answers (PDF) - April 26, 2012
Verification of Access to Employer-Sponsored Coverage Bulletin (PDF) - May 16, 2012
General Guidance on Federally-facilitated Exchanges (PDF) - December 10, 2012
Exchanges, Market Reforms and Medicaid Frequently Asked Questions (PDF) - January 3, 2013
Guidance on State Partnership Exchange (PDF) - March 1, 2013
Draft 2014 Letter to Issuers on Federally-facilitated and State Partnership Exchanges (PDF) - April 5, 2013
2014 Letter to Issuers on Federally-facilitated and State Partnership Exchanges (PDF) - May 1, 2013
Role of Agents, Brokers, and Web-brokers in Health Insurance Marketplaces (PDF) - May 10, 2013
Small Business Health Options Program (SHOP)-Only Marketplace (PDF) - June 18, 2013
Guidance on State Alternative Applications for Health Coverage (PDF) - June 26, 2013
Guidance on Hardship Exemption Criteria and Special Enrollment Periods (PDF) - July 12, 2013
Guidance on Certified Application Counselor Program for the Federally Facilitated Marketplace including State Partnership Marketplaces (PDF) - July 12, 2013
Sample Application: Apply to be a Certified Application Counselor (CAC) Organization (PDF) - August 9, 2013
Guidance on State Alternative Applications for Health Coverage through the Small Business Health Options Program (SHOP) (PDF) - September 27, 2013
Guidance on Internal Revenue Ruling 2013-17 and Eligibility for Advance Payments of the Premium Tax Credit and Cost-Sharing Reductions (PDF) - October 3, 2013
Federally Facilitated Marketplace Enrollment Operational Policy & Guidance (PDF) - January 10, 2014
The Sale of Individual Market Policies to Medicare Beneficiaries Under 65 Losing Coverage Due to High Risk Pool Closures (PDF) - January 31, 2014
Frequently Asked Questions on the Sale of Individual Market Policies to Medicare Beneficiaries Under 65 Losing Coverage Due to High Risk Pool Closures (PDF) - February 4, 2014
Draft 2015 Letter to Issuers in the Federally-facilitated Marketplaces (PDF) - February 27, 2014
CMS Bulletin to Marketplaces on Availability of Retroactive Advance Payments of the PTC and CSRs in 2014 Due to Exceptional Circumstances (PDF) - March 13, 2014
Casework Guidance for Issuers in Federally-facilitated Marketplaces, including State Partnership Market Places (PDF) - March 14, 2014
2015 Letter to Issuers in the Federally-facilitated Marketplaces (PDF) - March 26, 2014
Guidance for Issues on People "In Line" for the Federally-facilitated Marketplace at the end of the Initial Open Enrollment Period (PDF) - March 26, 2014
Guidance for Issues on Special Enrollment Periods for Complex Cases in the Federally-facilitated Marketplace after the Initial Open Enrollment Period (PDF) - March 31, 2014
Shared Responsibility Provision Question and Answer (PDF) - May 2, 2014
Special Enrollment Periods and Hardship Exemptions for Persons Meeting Certain Criteria (PDF) - June 26, 2014
Guidance on Annual Redeterminations for Coverage for 2015 (PDF) - September 18, 2104
Shared Responsibility Guidance – Filing Threshold Hardship Exemption (PDF) - September 18, 2014
Shared Responsibility Guidance – Exemption for Individuals Eligible for Services through an Indian Health Care Provider (PDF) - October 6, 2014
Guidance on Hardship Exemptions, Age Offs, and Renewal of Catastrophic Coverage (PDF) - October 24, 2014
Guidance for Issuers on the Termination of a Consumer’s Enrollment in the Federally-facilitated Marketplace Due to Death (PDF) - November 21, 2014
Guidance on Hardship Exemptions for Persons Meeting Certain Criteria (PDF) - December 1, 2014
Guidance for Issuers on 2015 Reenrollment in the Federally-facilitated Marketplace (PDF) - December 19, 2014
Draft 2016 Letter to Issuers in the Federally-facilitated Marketplaces (PDF) - February 20, 2015
Final 2016 Letter to Issuers in the Federally-facilitated Marketplaces (PDF) - March 20, 2015
Guidance on Hardship Exemptions for Persons Meeting Certain Criteria (PDF) - March 31, 2015
Guidance for Ending Special Enrollment Periods for Coverage during Calendar Year 2014 (PDF) - April 22, 2015
Guidance on Annual Eligibility Re-determinations and Re-enrollments for Marketplace Coverage for 2016 (PDF) - May 29, 2015
CMS Bulletin on Proposed Out-Of-Pocket (OOP) Cost Comparison Tool for the Federally-facilitated Marketplaces (FFMs) (PDF) - June 12, 2015
Distribution of Information Regarding Advance Payments of the Premium Tax Credit (APTC) and Cost-Sharing Reductions (CSR) in Federal Standard Notices for Coverage Offered through the Federally-facilitated Marketplaces (PDF) - July 27, 2015
Updated Guidance on Victims of Domestic Abuse and Spousal Abandonment (PDF) - August 25, 2015
Guidance for Issuers on 2016 Reenrollment in the Federally-facilitated Marketplace (FFM) (PDF) - October 1, 2015
Federally-facilitated Marketplace and Federally-facilitated Small Business Health Options Program Enrollment Manual (PDF)
(Replaced by August 2024 version) - October 29, 2015
CMS Final Bulletin on Out-of-Pocket (OOP) Cost Comparison Tool for the Federally-facilitated Marketplaces (FFMs) (PDF) - December 4, 2015
Issuer Guidance for Handling 2015 Unaffiliated Issuer Enrollments and Clarification to Section V of Bulletin 16: Guidance for Issuers on 2016 Reenrollment in the Federally-Facilitated Marketplaces (PDF) - December 4, 2015
Policy-Based Payments Bulletin: Approach to 2016 Marketplace Payment Program Integrity, Withholding for Issuers Delayed on Policy-Based Payments Implementation, and Payment Adjustment for Issuers Deemed Policy-Based Payments Ready (PDF) - December 23, 2015
Draft 2017 Letter to Issuers in the Federally-facilitated Marketplaces (PDF) - February 29, 2016
Final 2017 Letter to Issuers in the Federally-facilitated Marketplaces (PDF) - March 22, 2016
Policy-Based Payments: April 2016 Transition of All Issuers to Policy-based Payments and Subsequent Adjustments Only in Cases of Extreme Variation Between Policy-based Payments and the Manual Payment Process (PDF) - April 1, 2016
Guidance for Ending Special Enrollment Periods for Coverage during Calendar Year 2015 (PDF) - April 18, 2016
Extension of State-based SHOP Direct Enrollment Transition (PDF) - May 2, 2016
Policy-Based Payments: Reversal of January 2016 – April 2016 Adjustments in the May and June Payment Cycles (PDF) - May 10, 2016
Guidance on Annual Eligibility Redetermination and Re-enrollment for Marketplace Coverage for 2017 (PDF) - June 1, 2016
Effectuation of 2016 Federally-Facilitated Marketplace Dental Enrollment – INFORMATION (PDF) - June 29, 2016
Guidance for State-based Marketplaces No Cost Extensions in 2017 (PDF) - July 19, 2016
Federally-facilitated Marketplace (FFM) and Federally-facilitated Small Business Health Options Program (FF-SHOP) Enrollment Manual (PDF)
(Replaced by August 2024 version) - August 12, 2016
Guidance on Health Coverage Tax Credit Hardship Exemption (PDF) - August 19, 2016
CMS Bulletin on Network Breadth Information for Qualified Health Plans on Healthcare.gov (PDF) - September 6, 2016
Frequently Asked Questions Regarding Verification of Special Enrollment Periods (PDF) - September 30, 2016
Updated CMS Bulletin on Network Breadth Information for Qualified Health Plans on HealthCare.gov (PDF) - November 10, 2016
Draft 2018 Letter to Issuers in the Federally-facilitated Marketplaces (PDF) - December 12, 2016
Policy-Based Payments Bulletin: Temporary Manual Adjustment - Easing Cash Flow Impact of the 2017 Transition for Issuers on Policy-Based Payments (PDF) - December 16, 2016*
Final 2018 Letter to Issuers in the Federally-facilitated Marketplaces and February 17 Addendum (PDF)
*Updated February 17, 2017 - April 6, 2017
Guidance for Ending Special Enrollment Periods for Coverage during Calendar Year 2016 (PDF) - May 15, 2017
The Future of the SHOP: CMS Intends to Allow Small Businesses in SHOPs Using HealthCare.gov More Flexibility when Enrolling in Healthcare Coverage (PDF) - May 17, 2017
Guidance for the Proxy Direct Enrollment Pathway for 2018 Individual Market Open Enrollment Period (PDF) - June 9, 2017
Updated CMS Bulletin on Network Breadth Information for Qualified Health Plans on HealthCare.gov (PDF) - June 9, 2017
Display of 2017 Quality Rating System (QRS) star ratings and Qualified Health Plan (QHP) Enrollee Experience Survey results for QHPs offered through the Health Insurance Exchanges (PDF) - June 16, 2017
State Based Exchange on the Federal Platform (SBE-FP) User Fee Collection Process – Technical Guidance for States (PDF)
**Document updated below on May 1, 2020 - June 16, 2017
Guidelines for Third-party Auditor Operational Readiness Reviews for the Proxy Direct Enrollment Pathway (PDF) - July 13, 2017
Guidance: Annual Eligibility Redetermination and Re-enrollment for Exchange Coverage for 2018 (PDF) - September 28, 2017
Guidance: 2017 Hurricane Disasters – Special Enrollment Periods (SEPs), Termination of Coverage, and Grace Period Flexibilities (PDF) - October 27, 2017
CMS to Allow Small Businesses and Issuers New Flexibilities in the Small Business Health Options Program (SHOP) For Plan Year 2018 (PDF) - November 27, 2017
Draft 2019 Letter to Issuers in the Federally-facilitated Exchanges (PDF) - January 17, 2018
Availability of Marketplace Special Enrollment Period for Individuals Affected by Hurricanes in Puerto Rico and US Virgin Islands (PDF) - February 22, 2018
Guidelines for Third-party Auditor Operational Readiness Reviews for the Enhanced Direct Enrollment Pathway and Related Oversight Requirements (PDF) - April 9, 2018
Final 2019 Letter to Issuers in the Federally-facilitated Exchanges (PDF) - April 9, 2018
Guidance on Hardship Exemptions from the Individual Shared Responsibility Provision for Persons Experiencing Limited Issuer Options or Other Circumstances (PDF) - April 12, 2018
Guidance for Ending Special Enrollment Periods for Coverage during Calendar Year 2017 (PDF) - July 6, 2018
Guidance on Annual Eligibility Redetermination and Re-enrollment for Exchange Coverage for 2019 and Later Years (PDF) - July 26, 2018*
Federally-facilitated Exchange and Federally-facilitated Small Business Health Options Program Enrollment Manual (PDF)
*This version serves as an updated version to the June 26, 2018 release.
(Replaced by August 2024 version) - August 9, 2018
Emergency and Major Disaster Declarations by the Federal Emergency Management Agency (FEMA) – Special Enrollment Periods (SEPs), Termination of Coverage, and Payment Deadline Flexibilities, Effective August 9, 2018 (PDF)
*The August 09, 2018 version was updated to a new version on August 31, 2023. The August 31, 2023 guidance updates and supersedes the guidance on the same subject that was effective August 9, 2018. - September 12, 2018
Guidance on Claiming a Hardship Exemption through the Internal Revenue Service (IRS) (PDF) - October 2, 2018
Display of 2018 Quality Rating System (QRS) star ratings and Qualified Health Plan (QHP) Enrollee Experience Survey results for QHPs offered through the Health Insurance Exchanges (PDF) - December 21, 2018
Availability of Additional Special Enrollment Period for Certain Individuals Affected by Hurricane Michael in Florida and Georgia (PDF) - January 17, 2019
Draft 2020 Letter to Issuers on Federally-facilitated Exchanges (PDF) - February 19, 2019
Guidelines for Third-party Auditor Operational Readiness Reviews for the Enhanced Direct Enrollment Pathway and Related Oversight Requirements - PY 2019 and PY 2020 (PDF) - April 5, 2019
Submission Deadline for Applicants Seeking Prior Year Coverage through Special Enrollment Periods (PDF) - April 18, 2019
Final 2020 Letter to Issuers on Federally-facilitated Exchanges (PDF) - July 16, 2019
Enrollment Manual for Federally-facilitated Exchange and Federally-facilitated Small Business Health Options Program
(Replaced by August 2024 version) - August 9, 2019
Key Priorities for Federally-Facilitated Exchange (FFE) Web-broker Direct Enrollment (DE) Compliance Reviews for Plan Year 2019 (PDF) - August 15, 2019
Quality Rating Information Bulletin for Plan Year 2020 (PDF) - December 10, 2019
Guidance on Updated Direct Enrollment (DE) Web-broker Program Participation Requirements (PDF) - January 31, 2020
Draft 2021 Letter to Issuers in the Federally-facilitated Exchanges (PDF)
Version updated on February 14, 2020 with technical corrections - March 13, 2020
Guidelines for Third-party Auditor Operational Readiness Reviews for the Enhanced Direct Enrollment Pathway and Related Oversight Requirements - PY 2020 and PY 2021 – Year 3 (PDF) - April 6, 2020
COVID-19 and Suspension of Certain Activities Related to the Health Insurance Exchange Quality Rating System, QHP Enrollee Experience Survey (QHP Enrollee Survey) and Quality Improvement Strategy Programs (PDF)April 11. 2020
FAQs about Families First Coronavirus Response Act and the Coronavirus Aid, Relief, and Economic Security Act Implementation (PDF)
*This document was updated on April 15, 2020, to correct an error in footnote 10 regarding the current end date of the public health emergency related to COVID-19. (PDF) - April 9, 2020
Updated 2020 Third-party Audit Submission Deadline for Prospective Primary EDE Entities Seeking to Implement EDE and Existing Primary EDE Entities Seeking to Change Phases in Calendar Year 2020 (PDF) - May 1, 2020
SBE-FP User Fee Collection Process – Resource for States (PDF) - May 7, 2020
Final 2021 Letter to Issuers in the Federally-facilitated Exchanges (PDF) - May 12, 2020
Quality Rating System (QRS), Qualified Health Plan (QHP) Enrollee Experience Survey, and Quality Improvement Strategy (QIS) FAQs in Response to the Coronavirus (COVID-19) Pandemic (PDF) - May 21, 2020
Updated Web-broker Direct Enrollment Program Participation Minimum Requirements (Updated) (PDF) - May 22, 2020
Direct Enrollment Entity Standards of Conduct Website Display Guidance (PDF) - June 10, 2020
Key Priorities for Federally-Facilitated Exchange (FFE) and State-based Exchange on the Federal Platform (SBE-FP) Direct Enrollment (DE) Compliance Reviews for Plan Year 2020 (PDF) - June 29, 2020
Leveraging Existing Health and Disease Management Programs to Provide Mental Health and Substance Use Disorder Resources During the COVID-19 Public Health Emergency (PHE) (PDF) - August 28, 2020
Enforcement Safe Harbor for Qualified Health Plan Termination Notices During the 2020 Benefit Year (PDF) - September 2, 2020
Enrollment Manual for Federally-facilitated Exchange and Federally-facilitated Small Business Health Options Program (PDF)
(Replaced by August 2024 version) - December 1, 2020
Draft 2022 Letter to Issuers in the Federally-facilitated Marketplaces (PDF) - December 21, 2020
Frequently Asked Question (FAQ) Regarding the 2021 Audit Submission Timeline for Third-party Auditor Operational Readiness Reviews for the Enhanced Direct Enrollment (EDE) Pathway (PDF) - February 25, 2021
[Updated on May 6, 2021, see below] Updated - 2021 Special Enrollment Period (SEP) Current Schedule of Planned Maintenance (PDF) - March 23, 2021
Updated - 2021 Special Enrollment Period for COVID-19 Public Health Emergency Technical Stakeholder Guidance (PDF) - May 6, 2021
Final 2022 Letter to Issuers in the Federally-facilitated Exchanges (PDF) - July 23, 2021
Failure to File and Reconcile (FTR) Operations Flexibilities for Plan Years 2021 and 2022 Frequently Asked Questions (FAQ) (PDF) - August 18, 2021
Enrollment Manual for Federally-facilitated Exchange and Federally-facilitated Small Business Health Options Program (PDF)
(Replaced by August 2024 version) - October 22, 2021
Annual Income Threshold Adjustment FAQ (PDF) - January 7, 2022
Draft 2023 Letter to Issuers in the Federally-facilitated Exchanges (PDF) - January 27, 2022
Draft 2023 Letter to Issuers in the Federally-facilitated Exchanges – Extension of Comment Period (PDF) - March 21, 2022
Marketplace Stakeholder Technical Assistance Tip Sheet on the Monthly Special Enrollment Period for Advance Payments of the Premium Tax Credit – Eligible Consumers with Household Income at or below 150% of the Federal Poverty Level (PDF) - April 28, 2022
Final 2023 Letter to Issuers in the Federally-facilitated Exchanges (PDF) - July 18, 2022
Failure to File and Reconcile (FTR) Operations Flexibilities for Plan Year 2023 - Guidance (PDF)
*This document extends guidance in the above July 23, 2021, Failure to File and Reconcile (FTR) Operations Flexibilities for Plan Years 2021 and 2022 Frequently Asked Questions (FAQ) - July 28, 2022
Enrollment Manual for Federally-facilitated Exchange and Federally-facilitated Small Business Health Options Program (PDF)
(Replaced by August 2024 version) - October 28, 2022
Marketplace Stakeholder Technical Assistance Tip Sheet on the Monthly Special Enrollment Period for Advance Payments of the Premium Tax Credit – Eligible Consumers with Household Income at or below 150% of the Federal Poverty Level (PDF) - December 12, 2022
Draft 2024 Letter to Issuers in the Federally-facilitated Exchanges (PDF) - December 14, 2022
Clarifying Guidance on the Frequently Asked Questions on Agent and Broker Compensation and Guaranteed Availability of Coverage (PDF) - May 1, 2023
Final 2024 Letter to Issuers in the Federally-facilitated Exchanges (PDF) - July 12, 2023
Enrollment Manual for Federally-facilitated Exchange (PDF)
(Replaced by August 2024 version) - August 14, 2023
Guidance on Annual Redetermination and Re-enrollment for Marketplace Coverage for 2024 and Later Years (PDF) *This guidance updates and supersedes the guidance on the same subject that was effective August 9, 2018.
- November 15, 2023
Draft 2025 Letter to Issuers in the Federally-facilitated Exchanges (PDF) - April 10, 2024
Final 2025 Letter to Issuers in the Federally-facilitated Exchanges (PDF) - April 19, 2024
Failure to File and Reconcile (FTR) Operations Frequently Asked Questions (FAQ) (PDF)
*This document supersedes guidance in the above July 18, 2022 Failure to File and Reconcile (FTR) Operations Flexibilities for Plan Year 2023. - August 19, 2024
Enrollment Manual for Federally-facilitated Exchange (PDF) - October 4, 2024
Draft 2026 Letter to Issuers in the Federally-facilitated Exchanges (PDF)
Plan Management
Regulations
- June 5, 2012
CMS-9965-P: Data Collection to Support Standards Related to Essential Health Benefits; Recognition of Entities for the Accreditation of Qualified Health Plans (PDF) - July 18, 2012
CMS-9965-F: Data Collection to Support Standards Related to Essential Health Benefits; Recognition of Entities for the Accreditation of Qualified Health Plans (PDF) - November 26, 2012
CMS-9961-N: Recognition of Entities for the Accreditation of Qualified Health Plans (PDF) - November 26, 2012
CMS-9980-P: Standards Related to Essential Health Benefits, Actuarial Value, and Accreditation (PDF) - February 20, 2013
CMS-9980-F: Standards Related to Essential Health Benefits, Actuarial Value, and Accreditation (PDF) - Additional Information on State EHB Benchmark Plans
- 2014 Actuarial Value Calculator (XLSM)
- 2014 Actuarial Value Calculator Methodology (PDF)
*See below under Premium Stabilization/Regulations for 2015 Actuarial Value Calculator and Methodology and 2016, 2017 and 2018 Actuarial Value Calculator and Methodologies are under the Guidance portion of this section. - Minimum Value Calculator (XLSM)
- Minimum Value Calculator Methodology (PDF)
Guidance
- December 16, 2011
Essential Health Benefits Bulletin (PDF) - January 25, 2012
Essential Health Benefits: Illustrative List of the Largest Three Small Group Products by State (PDF) - February 17, 2012
Frequently Asked Questions on the Essential Health Benefits Bulletin (PDF) - February 24, 2012
Actuarial Value and Cost-Sharing Reductions Bulletin (PDF) - July 2, 2012
Essential Health Benefits: List of the Largest Three Small Group Products by State (PDF) - January 28, 2013
Issuers of Stand-alone Dental Plans (PDF) - February 20, 2013
State Evaluation of Plan Management Activities of Health Plans and Issuers (PDF) - November 19, 2013
Notice with Comment: Quality Rating System (QRS), Framework Measures, and Methodology (PDF) - May 6, 2014
Issuers of Stand-alone Dental Plans (PDF) - August 15, 2014
State Technical Assistance on State-Specific Data for Actuarial Value Calculator (PDF)
Actuarial Value Calculator Continuance Tables (XLSM) - January 16, 2015
2016 Actuarial Value Calculator (XLSM)
2016 Actuarial Value Calculator Methodology (PDF) - February 19, 2015
Issuers of Stand-alone Dental Plans (PDF) - April 08, 2015
Essential Health Benefits: List of the Largest Three Small Group Products by State (PDF) - May 19, 2015
Updated Essential Health Benefits: List of the Largest Three Small Group Products by State (PDF) - August 28, 2015
List of Proposed 2017 EHB Benchmark Plans and Related Information - November 9, 2015
List of Final 2017 EHB Benchmark Plans and Related Information (PDF) - January, 21, 2016
2017 Actuarial Value Calculator (XLSM)
2017 Actuarial Value Calculator Methodology (PDF) - March 7, 2016
Issuers of Stand-alone Dental Plans (PDF) - April 29, 2016
CMS Bulletin on display of Quality Rating System (QRS) star ratings and Qualified Health Plan (QHP) Enrollee Survey results for QHPs offered through Marketplaces (PDF) - September 30, 2016
UPDATE: CMS Quality Rating Information Bulletin (PDF) - August 8, 2016
Notice to States Regarding Marketplace Auto Re-Enrollment (PDF) - September 1, 2016
PY2017 QHP Issuer Certification and Privacy and Security Agreement (PDF) - September 2, 2016
Frequently Asked Questions Regarding Crosswalk of Enrollees into Plans Offered by Other Issuers (PDF) - September 16, 2016
FAQ on Compliance Safe Harbor for Issuers Affected by an Increase in Enrollment for the 2017 Plan Year (PDF) - April 13, 2017
2018 Actuarial Value Calculator (VND.MS-EXCEL.SHEET.MACROENABLED.12)
2018 Actuarial Value Calculator Methodology (PDF) - April 13, 2017
Guidance to States on Review of Qualified Health Plan Certification Standards in Federally-facilitated Marketplaces for Plan Years 2018 and Later (PDF) - October 6, 2017
CMS Bulletin Addressing Enforcement of Section 1303 of the Patient Protection and Affordable Care Act (PDF) - December 28, 2017
2019 Actuarial Value Calculator (VND.MS-EXCEL.SHEET.MACROENABLED.12)
2019 Actuarial Value Calculator Methodology (PDF) - March 19, 2019
2020 Actuarial Value Calculator (VND.MS-EXCEL.SHEET.MACROENABLED.12)
2020 Actuarial Value Calculator Methodology (PDF) - January 10, 2020
FAQ on 2020 QHP Enrollee Survey Sample Frame Reporting Requirements (PDF) - November 19, 2020
- Proposed QHP PY2022 Data Submission and Certification Timeline Bulletin (PDF)
- December 3, 2020
Draft 2022 Actuarial Value Calculator (XLSM)
Draft 2022 Actuarial Value Calculator Methodology (PDF) - February 26, 2021
PY2022 QHP Data Submission and Certification Timeline Bulletin (PDF) - May 6, 2021
2022 Actuarial Value Calculator (XLSM)
2022 Actuarial Value Calculator Methodology (PDF) - November 23, 2021
Proposed PY2023 QHP Data Submission and Certification Timeline Bulletin (PDF) - December 30, 2021
Draft 2023 Actuarial Value Calculator (XLSM)
Draft 2023 Actuarial Value Calculator Methodology (PDF) - February 28, 2022
PY2023 QHP Data Submission and Certification Timeline Bulletin (PDF) - April 28, 2022
2023 Actuarial Value Calculator (XLSM)
2023 Actuarial Value Calculator Methodology (PDF) - May 18, 2022
Revised: PY2023 QHP Data Submission and Certification Timeline Bulletin (PDF) - December 12, 2022
Draft 2024 Actuarial Value Calculator (XLSM)
Draft 2024 Actuarial Value Calculator Methodology (PDF) - December 15, 2022
Proposed QHP PY2024 Data Submission and Certification Timeline Bulletin (PDF) - March 10, 2023
PY2024 QHP Data Submission and Certification Timeline Bulletin PY2024 QHP Data Submission and Certification Timeline Bulletin (PDF) - March 31, 2023
FAQs on Coverage of Abortion for which Public Funding is Prohibited by Qualified Health Plan (QHP) Issuers in the Individual Market (PDF) - April 17, 2023
2024 Actuarial Value Calculator (XLSM)
2024 Actuarial Value Calculator Methodology (PDF) - November 15, 2023
Draft 2025 Actuarial Value Calculator (XLSM)
Draft 2025 Actuarial Value Calculator Methodology (PDF) - November 16, 2023
Proposed PY2025 QHP Data Submission and Certification Timeline Bulletin (PDF) - April 2, 2024
2025 Actuarial Value Calculator (XLSM)
2025 Actuarial Value Calculator Methodology (PDF) - April 15, 2024
PY2025 QHP Data Submission and Certification Timeline Bulletin (PDF) - May 8,, 2024
Revised PY2025 QHP Data Submission and Certification Timeline Bulletin (PDF) - October 15, 2024
Final 2026 Actuarial Value Calculator (XLSM)
Final 2026 Actuarial Value Calculator Methodology (PDF)
Eligibility Appeals
Guidance
- October 24, 2014
Paper-Based Appeals Process (PDF) - March 22, 2016
Paper-Based Appeals Process (PDF)
Agents & Brokers
- Frequently Asked Questions: Consumer Consent & Application Review Requirements (PDF)
- Frequently Asked Questions: Social Security Numbers (PDF)
- Frequently Asked Questions: National Producer Number Override (PDF)
Minimum Acceptable Risk Standards
Guidance:
- August 1, 2012
Harmonized Security and Privacy Framework – Exchange Reference Architecture Supplement V1.0 (PDF)
Minimum Acceptable Risk Standards for Exchanges – Exchange Reference Architecture Supplement, V1.0 (PDF)
Catalog of Minimum Acceptable Risk Controls for Exchanges – Exchange Reference Architecture Supplement, V1.0 (PDF) - November 10, 2015
Volume 1: MARS-E v2.0: Harmonized Security and Privacy Framework (PDF)
Volume 2: MARS-E v2.0: Minimum Acceptable Risk Standards for Exchanges (PDF)
Volume 3: MARS-E v2.0: Catalog of Security and Privacy Controls (PDF)
Volume 4: MARS-E v2.0: ACA Administering Entity System Security Plan (PDF) - May 25, 2021
version 2.2, volume 1 (PDF)
version 2.2, volume 2 (PDF)
Premium Stabilization Programs
Regulations
- July 15, 2011
CMS-9975-P: Standards Related to Reinsurance, Risks Corridors and Risk Adjustment (PDF) - July 15, 2011
CMS-9989-P2: Preliminary Regulatory Impact Analysis: Establishment of Exchanges and Qualified Health Plans (CMS-9989-P) and Standards Related to Reinsurance, Risk Corridors and Risk Adjustment (CMS-9975-P) (PDF) - March 16, 2012
Regulatory Impact Analysis: Establishment of Exchanges and Qualified Health Plans (CMS-9989-FWP) and Standards Related to Reinsurance, Risk Corridors and Risk Adjustment (CMS-9975-F) (PDF) - March 23, 2012
CMS-9975-F: Standards Related to Reinsurance, Risks Corridors and Risk Adjustment (PDF) - December 7, 2012
CMS-9964-P: HHS Benefit and Payment Parameters for 2014, and Medical Loss Ratio (PDF) - March 11, 2013
CMS-9964-F: HHS Benefit and Payment Parameters for 2014(PDF) - March 11, 2013
CMS-9964-IFC: Amendments to the HHS Notice of Benefit and Payment Parameters for 2014 (PDF) - November 25, 2013
CMS-9954-P: Proposed HHS Notice of Benefit and Payment Parameters for 2015 (PDF) March 4, 2014
CMS-9954-F: HHS Notice of Benefit and Payment Parameters for 2015 (PDF)- November 21, 2014
CMS-9954-P: Proposed HHS Notice of Benefit and Payment Parameters for 2016 (PDF) - February 20, 2015
CMS-9944-F: Final HHS Notice of Benefit and Payment Parameters for 2016 (PDF) - November 20, 2015
CMS-9937-P: Proposed HHS Notice of Benefit and Payment Parameters for 201 (PDF)7 - February 29, 2016
CMS-9937-F: Final HHS Notice of Benefit and Payment Parameters for 2017 (PDF) - August 29, 2016
CMS-9934-P: Proposed HHS Notice of Benefit and Payment Parameters for 2018 (PDF) - December 16, 2016
CMS-9934-F: Final HHS Notice of Benefit and Payment Parameters for 2018 (PDF) (Updated December 21, 2016) - October 27, 2017
CMS-9930-P: Proposed HHS Notice of Benefit and Payment Parameters for 2019 (PDF) - Opens in a new window - April 9, 2018
CMS-9930-F: Final HHS Notice of Benefit and Payment Parameters for 2019 (PDF) - Opens in a new window - April 9, 2018
Example of an Acceptable Methodology for Comparing Benefits of a State’s EHB-benchmark Plan Selection in Accordance with 45 CFR 156.111(b)(2)(i) and (ii) (PDF) - April 12, 2018
2019 Final HHS Risk Adjustment Model Coefficients (PDF) - July 24, 2018
CMS- 9920-F: Adoption of the Methodology for the HHS-operated Permanent Risk Adjustment Program under the Patient Protection and Affordable Care Act for the 2017 Benefit Year (PDF) - August 8, 2018
CMS- 9919-P: Patient Protection and Affordable Care Act; Methodology for the HHS-operated Permanent Risk Adjustment Program for 2018 Proposed Rule (PDF) - November 30, 2018
CMS-9917-F: Patient Protection and Affordable Care Act; Elimination of Internal Agency Process for Implementation of the Federally-Facilitated User Fee Adjustment Final Rule - December 7, 2018
CMS-9919-F: Patient Protection and Affordable Care Act: Adoption of the Methodology for the HHS-Operated Permanent Risk Adjustment Program for the 2018 Benefit Year, final rule - January 17, 2019
CMS-9926-P: Proposed HHS Notice of Benefit and Payment Parameters for 2020 - April 18, 2019
CMS-9926-F: Final HHS Notice of Benefit and Payment Parameters for 2020 - January 31, 2020
CMS 9916-P: Proposed HHS Notice of Benefit and Payment Parameters for 2021 - May 7, 2020
CMS 9916-F: Final HHS Notice of Benefit and Payment Parameters for 2021 - May 29, 2020
CMS-9913-P: Proposed Amendments to HHS-RADV - November 24, 2020
CMS-9913-F: Final Amendments to HHS-RADV (PDF) - December 04, 2020
CMS 9914-P: Proposed HHS Notice of Benefit and Payment Parameters for 2022 (PDF) - January 19, 2021
CMS 9914-F: Final HHS Notice of Benefit and Payment Parameters for 2022 (Part I) - March 5, 2021
CMS 9914-F: Final HHS Notice of Benefit and Payment Parameters for 2022 (Part 2) - July 1, 2021
CMS-9906-P: Patient Protection and Affordable Care Act: Updating Payment Parameters, Section 1332 Waiver Implementing Regulations, and Improving Health Insurance Markets for 2022 and Beyond Proposed Rule - September 27, 2021
CMS-9906-F: Patient Protection and Affordable Care Act; Updating Payment Parameters, Section 1332 Waiver Implementing Regulations, and Improving Health Insurance Markets for 2022 and Beyond Final Rule - April 28, 2022
CMS-9911-F: Patient Protection and Affordable Care Act; HHS Notice of Benefit and Payment Parameters for 2023 (PDF) - December 12, 2022
CMS-9899-P: Patient Protection and Affordable Care Act, HHS Notice of Benefit and Payment Parameters for 2024 (PDF)
Notice: This HHS-approved document has been submitted to the Office of the Federal Register (OFR) for publication and has not yet been placed on public display or published in the Federal Register. The document may vary slightly from the published document if minor editorial changes have been made during the OFR review process. The document published in the Federal Register is the official HHS-approved document. - April 17, 2023
CMS-9899-F: Patient Protection and Affordable Care Act, HHS Notice of Benefit and Payment Parameters for 2024 (PDF)
Notice: This HHS-approved document has been submitted to the Office of the Federal Register (OFR) for publication and has not yet been placed on public display or published in the Federal Register. The document may vary slightly from the published document if minor editorial changes have been made during the OFR review process. The document published in the Federal Register is the official HHS-approved document. - November 15, 2023
CMS-9895-P: Patient Protection and Affordable Care Act, HHS Notice of Benefit and Payment Parameters for 2025 (PDF)
Notice: This HHS-approved document has been submitted to the Office of the Federal Register (OFR) for publication and has not yet been placed on public display or published in the Federal Register. The document may vary slightly from the published document if minor editorial changes have been made during the OFR review process. The document published in the Federal Register is the official HHS-approved document. - April 2, 2024
CMS-9895-P: Patient Protection and Affordable Care Act; HHS Notice of Benefit and Payment Parameters for 2025 (PDF)
Notice: This HHS-approved document has been submitted to the Office of the Federal Register (OFR) for publication and has not yet been placed on public display or published in the Federal Register. The document may vary slightly from the published document if minor editorial changes have been made during the OFR review process. The document published in the Federal Register is the official HHS-approved document.
Guidance
- May 1, 2012
Bulletin on the Risk Adjustment Program: Proposed Operations by the Department of Health and Human Services (PDF) - May 31, 2012
Bulletin on the Transitional Reinsurance Program: Proposed Payment Operations by the Department of Health and Human Services (PDF) - June 2, 2014
2014 Benefit Year Risk Adjustment HHS-Developed Risk Adjustment Model Algorithm Software - 2014 Benefit Year Risk Adjustment SAS Version of HHS-Developed Risk Adjustment Model Algorithm Software (ZIP)
- Sample Datasets
- October 20, 2014
The Transitional Reinsurance Program: Availability of the ACA Transitional Reinsurance Program Annual Enrollment and Contributions Submission Form on Pay.gov (PDF) - April 14, 2015
Transitional Reinsurance Program’s Contribution Collections for the 2014 Benefit Year (PDF) - April 14, 2015
Transitional Reinsurance Program – Timing of Contributions Refund Requests (PDF) - April 17, 2015
Transitional Adjustment for 2014 Risk Corridors Program (PDF) - April 24, 2015
Evaluation of EDGE Data Submissions Bulletin (PDF) for the 2014 Benefit Year - April 27, 2015
EDGE Data Submission Grace Period Bulletin (PDF) for the 2014 Benefit Year - August 7, 2015
Preliminary Risk Corridors Program Results (PDF) for the 2014 Benefit Year - August 13, 2015
Overview of Draft Fiscal Year 2016 ICD-10 Crosswalk for HHS-HCC Risk Adjustment Model (PDF)
Draft Fiscal Year 2016 ICD-10 Crosswalk for HHS-HCC Risk Adjustment Model (XLSX) - September 2, 2015
Adjustment of Risk Adjustment Transfers Due to Submission of Incorrect Data (PDF) - October 9, 2015
Early Reinsurance Payments for the 2015 Benefit Year (PDF) - October 19, 2015
2015 Benefit Year Risk Adjustment: HHS-Developed Risk Adjustment Model Algorithm “Do It Yourself (DIY)” Software
2015 Benefit Year Risk Adjustment: SAS Version of HHS-Developed Risk Adjustment Model Algorithm Software (ZIP) - November 19, 2015
Risk Corridors Payments for the 2014 Benefit Year Guidance (PDF) - January 20, 2016
- Evaluation of EDGE Data Submissions for 2015 Benefit Year for Interim Reinsurance Payments and Interim Risk Adjustment Summary Report (PDF)
- Evaluation of EDGE Data Submissions for 2015 Benefit Year for Interim Reinsurance Payments and Interim Risk Adjustment Summary Report (PDF) – Revised March 16, 2016
- February 12, 2016
- March 16, 2016
Cost-Sharing Reduction Reconciliation Guidance for Benefit Years 2014 and 2015 Final (PDF) - March 18, 2016
Evaluation of EDGE Data Submissions Bulletin for the 2015 Benefit Year (PDF) - April 15, 2016
Extension of Data Submission Deadline for Cost-sharing Reduction Reconciliation (PDF) - June 17, 2016
Alternative Schedule for Payment of Charges for Reconciliation of the Cost-sharing Reduction Portion of Advance Payments for the 2014 and 2015 Benefit Years (PDF) - June 27, 2016
Alternative Schedule for Payment of Charges for Reconciliation of the Cost-sharing Reduction Portion of Advance Payments for the 2014 and 2015 Benefit Years (PDF) - July 1, 2016
Alternative Schedule for Payment of Charges for Reconciliation of the Cost-sharing Reduction Portion of Advance Payments for the 2014 and 2015 Benefit Years Issuer Agreement (PDF) - July 6, 2016
Alternative Schedule for Payment of Charges for Reconciliation of the Cost-sharing Reduction Portion of Advance Payments for the 2014 and 2015 Benefit Years Extension (PDF) - July 15, 2016
Netting of Payments and Charges under 45 CFR 156.1215 (PDF) - August 5, 2016
Reporting Cost-sharing Reduction Amounts for 2015 MLR and Risk Corridors (PDF) - November 2, 2016
Cost-Sharing Reduction Reconciliation Guidance for Benefit Year 2016 DRAFT (PDF) - November 18, 2016
Risk Corridors Payments and Charge Amounts for the 2015 Benefit Year (PDF) - December 19, 2016
2016 Benefit Year Risk Adjustment: HHS-Developed Risk Adjustment Model Algorithm “Do It Yourself (DIY)” Software
Instructions (PDF)
Technical Details (Excel)
2016 Benefit Year Risk Adjustment: SAS Version of HHS-Developed Risk Adjustment Model Algorithm Software (ZIP) - December 23, 2016
Evaluation of EDGE Data Submissions for 2016 Benefit Year (PDF) - December 27, 2016
Final Cost-Sharing Reduction Reconciliation Guidance for Benefit Year 2016 (PDF) - April 28, 2017
Transitional Reinsurance Program – CMS to Begin Operating on behalf of the State of Connecticut (effective April 7, 2017) (PDF) - May 3, 2017
HHS-Operated Risk Adjustment Data Validation (HHS-RADV) – 2016 Benefit Year Implementation and Enforcement (PDF) - June 28, 2017
CSR Reconciliation Discrepancy Inbound Specification for the 2016 Benefit Year and Prior Year Restatements (PDF) - July 21, 2017
2017 Benefit Year Risk Adjustment: HHS-Developed Risk Adjustment Model Algorithm “Do It Yourself (DIY)” Software - September 18, 2017
- November 3, 2017
- December 1, 2017
2017 Benefit Year Risk Adjustment: HHS-Developed Risk Adjustment Model Algorithm “Do it Yourself (DIY)” Software - March 29, 2018
- Final Cost-Sharing Reduction Reconciliation Guidance for Benefit Year 2017 (PDF)
- Final Cost-Sharing Reduction Reconciliation Issuer to MIDAS Inbound Specification for the 2017 Benefit Year and 2016 Restatements (PDF)
- Final Cost-Sharing Reduction Reconciliation Issuer to MIDAS Attestation Inbound Specification for the 2017 Benefit Year and 2016 Restatements (PDF)
- Final Cost-Sharing Reduction Reconciliation Data File Error Code List for the 2017 Benefit Year and 2016 Restatements (PDF)
- Final Cost-Sharing Reduction Reconciliation Attestation File Error Code List for the 2017 Benefit Year and 2016 Restatements (PDF)
- April 6, 2018
2018 Benefit Year Risk Adjustment: HHS-Developed Risk Adjustment Model Algorithm “Do it Yourself (DIY)” Software - April 9, 2018
Exemption from HHS-Operated Risk Adjustment Data Validation (HHS-RADV) for Issuers in Liquidation or Entering Liquidation (PDF) - May 18, 2018
Guidance on Enrollee-level EDGE Dataset for Research Requests (PDF) - June 18, 2018
CSR Reconciliation Discrepancy Inbound Specification for the 2017 Benefit Year and 2016 Prior Year Restatement (PDF) - July 12, 2018
Implications of the Decision by United States District Court of the District of New Mexico on the Risk Adjustment and Related Programs (PDF) - July 27, 2018
CSR Reconciliation Discrepancy FAQ Submitting New Claims for Benefit Year 2017 (PDF) - July 27, 2018
Update on the HHS-operated Risk Adjustment Program for the 2017 Benefit Year (PDF)
Updated 2019 Benefit Year Final HHS Risk Adjustment Model Coefficients (PDF)
Updated 2019 Benefit Year Final HHS Risk Adjustment Model Coefficients (XLSX) - November 15, 2018
Evaluation of EDGE Data Submissions for the 2018 Benefit Year (PDF) - December 4, 2018
2018 Benefit Year Risk Adjustment: Updated HHS-Developed Risk Adjustment Model Algorithm “Do It Yourself (DIY)” Software - April 3, 2019
- Final Cost-sharing Reduction Reconciliation Issuer to MIDAS Inbound Specification for the 2018 Benefit Year and 2017 Restatements (PDF)
- Final Cost-Sharing Reduction Reconciliation Issuer to MIDAS Attestation Inbound Specification for the 2018 Benefit Year and 2017 Restatements (PDF)
- Final Cost-sharing Reduction Reconciliation Data File Error Code List for the 2018 Benefit Year and 2017 Restatements (PDF)
- Final Cost-Sharing Reduction Reconciliation Attestation File Error Code List for the 2018 Benefit Year and 2017 Restatements (PDF)
- April 4, 2019
2018 Benefit Year Risk Adjustment Updated HHS-Developed Risk Adjustment Model Algorithm "Do It Yourself (DIY)" Software - April 4, 2019
- April 25, 2019
Proposed Updates to the 2018 Benefit Year HHS-Risk Adjustment Data Validation (HHS-RADV) Timeline (PDF) - May 28, 2019
- May 31, 2019
- June 17, 2019
- July 16, 2019
2019 Benefit Year Risk Adjustment Updated HHS-Developed Risk Adjustment Model Algorithm "Do It Yourself (DIY)" Software - November 7, 2019
- December 6, 2019
- January 17, 2020
2019 Benefit Year Risk Adjustment Updated HHS-Development Risk Adjustment Model Algorithm "Do It Yourself (DIY)" Software - January 31, 2020
*Document now links to revised version published on May 12, 2020
(see posting below)
- April 13, 2020
- April 15, 2020
2019 Benefit Year Risk Adjustment Updated HHS-Developed Risk Adjustment Model Algorithm "Do It Yourself (DIY)" Software - April 24, 2020
- Final Cost-sharing Reduction Reconciliation Issuer to MIDAS Inbound Specification for the 2019 Benefit Year and 2018 Restatements (PDF)
- Final Cost-sharing Reduction Reconciliation Issuer to MIDAS Attestation Inbound Specification for the 2019 and Benefit Year and 2018 Restatements (PDF)
- Final Cost-sharing Reduction Reconciliation Data File Error Code List for the 2019 Benefit Year and 2018 Restatements (PDF)
- Final Cost-sharing Reduction Reconciliation Attestation File Error Code List for the 2019 Benefit Year and 2018 Restatements (PDF)
- April 27, 2020
The guidance document was updated by the below April 11, 2023, Risk Adjustment Telehealth and Telephone Services During COVID-19 FAQs. - May 12, 2020
- August 3, 2020
This guidance document was updated by the below April 11, 2023, Risk Adjustment Telehealth and Telephone Services During COVID-19 FAQs. - August 3, 2020
2020 Benefit Year Risk Adjustment Updated HHS-Developed Risk Adjustment Model Algorithm "Do It Yourself (DIY)" Software
* Instructions (PDF)
* Technical Details (XLSX)
* 2019 Benefit Year Risk Adjustment: SAS Version of HHS-Developed Risk Adjustment Model Algorithm Software (ZIP) - November 25, 2020
- January 25, 2021
2020 Benefit Year Risk Adjustment Updated HHS-Developed Risk Adjustment Model Algorithm "Do It Yourself (DIY)" Software - April 13, 2021
- Final Cost-sharing Reduction Reconciliation Issuer to MIDAS Inbound Specification for the 2020 Benefit Year and 2019 Restatements (PDF)
- Final Cost-sharing Reduction Reconciliation Issuer to MIDAS Attestation Inbound Specification for the 2020 and Benefit Year and 2019 Restatements (PDF)
- Final Cost-sharing Reduction Reconciliation Data File Error Code List for the 2020 Benefit Year and 2019 Restatements (PDF)
- Final Cost-sharing Reduction Reconciliation Attestation File Error Code List for the 2020 Benefit Year and 2019 Restatements (PDF)
- April 16, 2021
2020 Benefit Year Risk Adjustment Updated HHS-Developed Risk Adjustment Model Algorithm "Do It Yourself (DIY)" Software - May 6, 2021
This guidance document was updated by the below April 11, 2023, Risk Adjustment Telehealth and Telephone Services During COVID-19 FAQs. - July 16, 2021
- August 3, 2021
2021 Benefit Year Risk Adjustment Updated HHS-Developed Risk Adjustment Model Algorithm "Do It Yourself (DIY)" Software - September 22, 2021
- October 26, 2021
- December 28, 2021
- January 7, 2022
2021 Benefit Year Risk Adjustment Updated HHS-Developed Risk Adjustment Model Algorithm "Do It Yourself (DIY)" Software - April 4, 2022
- Final Cost-sharing Reduction Reconciliation Issuer to MIDAS Inbound Specification for the 2021 Benefit Year and 2020 Restatements (PDF)
- Final Cost-sharing Reduction Reconciliation Issuer to MIDAS Attestation Inbound Specification for the 2021 and Benefit Year and 2020 Restatements (PDF)
- Final Cost-sharing Reduction Reconciliation Data File Error Code List for the 2021 Benefit Year and 2020 Restatements (PDF)
- Final Cost-sharing Reduction Reconciliation Attestation File Error Code List for the 2021 Benefit Year and 2020 Restatements (PDF)
- April 13, 2022
Final 2021 Benefit Year Risk Adjustment Updated HHS-Developed Risk Adjustment Model Algorithm "Do It Yourself (DIY)" Software - April 29, 2022
This guidance document was updated by the below April 11, 2023, Risk Adjustment Telehealth and Telephone Services During COVID-19 FAQs. - May 6, 2022
- July 12, 2022
2022 Benefit Year Risk Adjustment Updated HHS-Developed Risk Adjustment Model Algorithm "Do It Yourself (DIY)" Software - October 25, 2022
Evaluation of EDGE Data Submissions for the 2022 Benefit Year (PDF) - December 29, 2022
2022 Benefit Year Risk Adjustment Updated HHS-Developed Risk Adjustment Model Algorithm "Do It Yourself (DIY)" Software - April 11, 2023
Final 2022 Benefit Year Risk Adjustment: SAS Version of HHS-Developed Risk Adjustment Model Algorithm "Do It Yourself (DIY)" Software - April 11, 2023
This guidance document replaces previous Risk Adjustment Telehealth and Telephone Services During COVID-19 FAQs listed above. - August 22, 2023
2023 Benefit Year Risk Adjustment HHS-Developed Risk Adjustment Model Algorithm "Do It Yourself (DIY)" Software - October 11, 2023
- October 27, 2023
- January 9, 2024
2023 Benefit Year Risk Adjustment HHS-Developed Risk Adjustment Model Algorithm "Do It Yourself (DIY)" Software - March 22, 2024
- April 10, 2024
Final 2023 Benefit Year Risk Adjustment HHS-Developed Risk Adjustment Model Algorithm "Do It Yourself (DIY)" Software - July 17, 2024
2024 Benefit Year Risk Adjustment Updated HHS-Developed Risk Adjustment Model Algorithm "Do It Yourself (DIY)" Software - September 6, 2024
2024 Benefit Year Risk Adjustment Updated HHS-Developed Risk Adjustment Model Algorithm "Do It Yourself (DIY)" Software - October 18, 2024
Risk Adjustment State Flexibility Requests
- October 28, 2017 - Requests for the 2020 Benefit Year
- Alabama: Small Group Market Request - State Flexibility Requests Relating to Risk Adjustment Transfer Reductions for the 2020 Benefit Year (Document 1) (PDF)
- January 17, 2019 Requests for the 2020 Benefit Year
- January 31, 2020
- November 25, 2020
- December 27, 2021
- Alabama: Individual Market Request – State Flexibility Requests Relating to Risk Adjustment Transfer Reductions for the 2023 Benefit Year (Document 1) (PDF)
- Alabama: Small Group Market Request – (Document 2) (PDF)
- December 12, 2022
State Innovations
Regulations
- March 10, 2011
Application, Review, and Reporting Process for Waivers for State Innovation - February 22, 2012
CMS-9987-F: Application, Review, and Reporting Process for Waivers for State Innovation (PDF)
Consumer Operated and Oriented Plan (CO-OP) Program
Regulations
- June 23, 2010
Establishment of the Consumer Operated and Oriented Plan (CO-OP) Advisory Board - July 20, 2011
Establishment of the Consumer Operated and Oriented Plan (CO-OP) Program - December 13, 2011
CMS-9983-F: Patient Protection and Affordable Care Act, Establishment of Consumer Operated and Oriented Plan (CO-OP) Program - February 10, 2012
IRS Revenue Procedures Published in the Federal Register For Tax-Exempt 501(c)(29) Qualified Nonprofit Health Insurance Issuers - April 4, 2013
Questions and Answers on Consumer Operated and Oriented Plan Program Contingency Fund (PDF)
Guidance
- July 29, 2015
CO-OP Program Guidance Manual (PDF)
Other Insurance Protections
Mental Health Parity
Regulations
- November 8, 2013
CMS-4140-F: Final Rules under the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (PDF) - August 3, 2023
CMS-9902-P: Requirements Related to the Mental Health Parity and Addiction Equity Act Proposed Rule (PDF) - September 20, 2023
CMS-9902-P: Requirements Related to the Mental Health Parity and Addiction Equity Act; Extension of Comment Period (PDF) - September 9, 2024
CMS-9902-F: Requirements Related to the Mental Health Parity and Addiction Equity Act (PDF)
Guidance
- June 1, 2016
Warning Signs- Plan or Policy Non-Quantitative Treatment Limitations (NQTLs) that Require Additional Analysis to Determine Mental Health Parity Compliance (PDF) - April 23, 2018
Self-Compliance Tool for the Mental Health Parity and Addiction Equity Act (MHPAEA) (PDF) - April 23, 2018
Form to Request Documentation from an Employer-Sponsored Health Plan or and Issuer Concerning Treatment Limitations (PDF) - October 23, 2020
Self-Compliance Tool for the Mental Health Parity and Addiction Equity Act (MHPAEA) (PDF) - July 24, 2023
DOL Technical Release 2023-01P: Request for Comment on Proposed Required Data Submissions for Nonquantitative Treatment Limitations (NQTLs) Related to Network Composition and Enforcement Safe Harbor for Group Health Plans and Health Insurance Issuers Subject to the Mental Health Parity and Addiction Equity Act. (PDF)
Health Insurance Market Reforms
- November 26, 2012
CMS-9979-P: Incentives for Wellness Programs in Group Health Plans (PDF) - November 26, 2012
CMS-9972-P:Patient Protection and Affordable Care Act: Health Insurance Market Rules; Rate Review (PDF) - January 30, 2013
CMS-9958-P: Eligibility for Exemptions; Miscellaneous Minimum Essential Coverage Provisions (PDF) - February 27, 2013
CMS-9972-F:Patient Protection and Affordable Care Act: Health Insurance Market Rules; Rate Review (PDF) - June 3, 2013
CMS-9979-F: Incentives for Nondiscriminatory Wellness Programs in Group Health Plans (PDF) - March 14, 2014
- May 16, 2014
CMS-9949-F: Patient Protection and Affordable Care Act; Exchange and Insurance Market Standards for 2015 and Beyond (PDF) - October 28, 2016
CMS-9932-F: Excepted Benefits; Lifetime and Annual Limits; and Short-Term, Limited-Duration Insurance (PDF) - February 2, 2018
CMS-9924-P: Short-Term, Limited-Duration Insurance (PDF) - Opens in a new window - August 1, 2018
CMS-9924-F: Short-Term, Limited Duration Insurance - March 6, 2019
CMS-9921-NC: Request for Information Regarding the Sale of Individual Health Insurance Coverage Across State Lines Through Health Care Choice Compacts
Guidance
- January 25, 2013
Employer Prescription Drug Coverage that Supplements Medicare Part D Coverage provided through an Employer Group Waiver Plan (PDF) - February 25, 2013
Guidance Regarding Age Curves, Geographical Rating Areas and State Reporting (PDF)
State Rating Requirements Disclosure Form (PDF) - May 6, 2013
Model Language for Individual Market Renewal Notices (PDF) - October 31, 2013
Minimum Essential Coverage Guidance (PDF)
Minimum Essential Coverage Resources - November 20, 2013
Procedural Guidance Regarding State Reporting for Plan or Policy Years Beginning in 2015 (PDF) - November 21, 2013
Standard Notices for Transition to ACA Compliant Policies (PDF)
Questions on Transition to ACA Compliant Policies (PDF) - December 19, 2013
Options Available for Consumers with Cancelled Policies (PDF) - January 3, 2014
Questions and Answers on Options Available for Consumers with Cancelled Policies (PDF) - March 3, 2014
Extended Transition to Affordable Care Act-Compliant Policies (PDF) - March 14, 2014
Frequently Asked Question on Coverage of Same-Sex Spouses (PDF) - March 14, 2014
Draft Notices When Discontinuing or Renewing a Product in the Group or Individual Market (PDF) - June 26, 2014
Draft Standard Notices When Discontinuing or Renewing a Product in the Small Group or Individual Market (PDF) - June 26, 2014
Instructions for Draft Standard Notices for Product Discontinuation and Renewal (PDF) - September 2, 2014
Form and Manner of Notices When Discontinuing or Renewing a Product in the Group or Individual Market (PDF) (Final Notices) - February 13, 2015
Minimum Essential Coverage Application Review Process (PDF) - July 7, 2015
Guidance on Federal Standard Notices of Product Discontinuation and Renewal in Connection with the Open Enrollment Period for the 2016 Coverage Year (PDF) - February 29, 2016
Extension of Transitional Policy through Calendar Year 2017 (PDF) - April 21, 2016
Draft Updated Federal Standard Renewal and Product Discontinuation Notices (PDF) - September 2, 2016
Final Updated Federal Standard Renewal and Product Discontinuation Notices (PDF) - February 23, 2017
Extension of Transitional Policy through Calendar Year 2018 (PDF) (PDF) - June 1, 2017
(PDF) (PDF) Enforcement Safe Harbor for Product Discontinuation Notices in Connection with the Open Enrollment Period for Coverage in the 2018 Benefit Year Individual Market (PDF) - September 26, 2017
Enforcement Safe Harbor for Renewal Notices in Connection with the Open Enrollment Period for Non-Grandfathered Coverage in the 2018 Individual Market Benefit Year (PDF) - April 9, 2018
Extension of Transitional Policy through Calendar Year 2019 (PDF) - July 19, 2018
Updated Federal Standard Renewal and Product Discontinuation Notices (PDF) - July 19, 2018
Enforcement Safe Harbor for Product Discontinuation Notices in Connection with the Open Enrollment Period for Coverage in the 2019 Benefit Year Individual Market (PDF) - August 3, 2018
Guidance Regarding Offering of Plans that are not QHPs without CSR “Loading” (PDF) - March 25, 2019
Extension of Limited Non-Enforcement Policy through Calendar Year 2020 (PDF) - July 30,2019
Updated Federal Standard Renewal and Product Discontinuation Notices, and Enforcement Safe Harbor for Product Discontinuation Notices in Connection with the Open Enrollment Period for Coverage in the Individual Market in the 2020 Benefit Year (PDF)
*This document was updated on July 31st, 2020, to add a footnote regarding the revised notices to be used for policy years beginning on or after January 1, 2021. - July 31, 2020
Updated Federal Standard Renewal and Product Discontinuation Notices in the Individual Market (Required for Notices Provided in Connection with Coverage Beginning in the 2021 Plan Year) (PDF) - September 30, 2019
Opportunity for States to Participate in a Wellness Program Demonstration Project to Implement Health-Contingent Wellness Programs in the Individual Market (PDF) - January 31, 2020
Extension of Limited-Non-Enforcement Policy through Calendar Year 2021 (PDF) - February 7, 2020
Procedural Guidance for States to Recommend Restricting Certain Excepted Benefit Health Reimbursement Arrangements from Reimbursing Premiums for Short-term, Limited-duration Insurance (PDF) - August 10, 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) - January 19, 2021
Extension of Limited Non-Enforcement Policy through Calendar Year 2022 (PDF) - September 1, 2021
Enforcement Safe Harbor for individual Market Product Discontinuation Notices in Connection with the Open Enrollment Period for Coverage in the 2022 Benefit Year (PDF) - March 23, 2022
Extension of Limited Non-Enforcement Policy through Calendar Year 2023 and Later Benefit Years (PDF) - June 22, 2022
Enforcement Safe Harbors related to Federal Standard Renewal and Product Discontinuation Notices; 90-Day Product Discontinuation Notice Requirement in the Individual Market (PDF) - June 20, 2023
Updated Federal Standard Renewal and Product Discontinuation Notices, and Enforcement Safe Harbor for Product Discontinuation Notices in Connection with the Open Enrollment Period for Coverage in the Individual Market in the 2024 Benefit Year. (PDF) - July 17, 2024
Enforcement Safe Harbor for Individual Market Product Discontinuation Notices in Connection with the Open Enrollment Period for Coverage in the 2025 Benefit Year. (PDF) - November 14, 2024
Guidance and Relief under the Public Health Service Act for Non-Federal Governmental Plans and Health Insurance Issuers Offering Health Insurance Coverage Impacted by Hurricane Helene, Tropical Storm Helene, and Hurricane Milton. (PDF)
Annual Limits
Regulations
Guidance
- September 3, 2010
OCIIO Sub-Regulatory Guidance: Process for Obtaining Waivers of the Annual Limits Requirements of PHS Act Section 2711 (PDF) - November 5, 2010
OCIIO Supplemental Guidance: Waivers of the Annual Limits Requirements (PDF) - December 9, 2010
OCIIO Supplemental Guidance: Consumer Notices on Waivers of the Annual Limits Requirements (PDF) - December 9, 2010
OCIIO Supplemental Guidance: Sale of New Business by Issuers Receiving Waivers (PDF) - June 17, 2011
CCIIO Supplemental Guidance (CCIIO 2011 – 1D): Concluding the Annual Limit Waiver Application Process (PDF) - August 19, 2011
CCIIO Supplemental Guidance (CCIIO 2011 - 1E): Exemption for Health Reimbursement Arrangements that are Subject to PHS Act Section 2711 (PDF)
Association Coverage
Guidance
Coverage for Young Adults
Regulations
Guidance
- October 13, 2010
Q&A: Enrollment of Children Under 19 Under the New Policy That Prohibits Pre-Existing Condition Exclusions
Employer Responsibility
Guidance
- October 13, 2010
Frequently Asked Questions from Employers Regarding Automatic Enrollment, Employer Shared Responsibility, and Waiting Periods (PDF) - August 31, 2012
Waiting Period Guidance Under Public Health Service Act Section 2708 (PDF) - March 21, 2013
CMS-9952-P: Ninety-Day Waiting Period Limitation and Technical Amendments to Certain Health Coverage Requirements Under the Affordable Care Act - September 16, 2013
Application of Affordable Care Act Provisions to Certain Healthcare Arrangements (PDF)
Grandfathered Plans
Regulations
- June 17, 2010
OCIIO–9991–IFC: OCIIO–9991–IFC: 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 - November 15, 2010
OCIIO–9991–IFC2: OCIIO–9991–IFC2: 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 - February 21, 2019
CMS-9923-NC: Request for Information Regarding Grandfathered Group Health Plans and Grandfathered Group Health Insurance Coverage
Medical Loss Ratio
Regulations
- December 1, 2010
OCIIO–9998–IFC: Health Insurance Issuers Implementing Medical Loss Ratio (MLR) Requirements Under the Patient Protection and Affordable Care Act (PDF) - Technical Appendix
Interim Final Rule for Health Insurance Issuers Implementing Medical Loss Ratio (MLR) Requirements under the Patient Protection and Affordable Care Act (PDF) - Technical Correction (December 30, 2010)
Technical Correction to the Medical Loss Ratio Interim Final Rule (PDF) - December 7, 2011
CMS-9998-FC: Medical Loss Ratio Requirements under the Patient Protection and Affordable Care Act (PDF)
CMS-9998-IFC2: Medical Loss Ratio Rebate Requirements for Non-Federal Governmental Plans (PDF) - May 16, 2012
CMS-9998-F: Medical Loss Ratio Requirements under the Patient Protection and Affordable Care Act (PDF) - May 16, 2012
CMS-9998-IFC3: Medical Loss Ratio Requirements under the Patient Protection and Affordable Care Act; Correcting Amendment (PDF) - November 30, 2012
CMS-9964-P: HHS Benefit and Payment Parameters for 2014, and Medical Loss Ratio (PDF) - March 11, 2013
CMS-9964-F: HHS Benefit and Payment Parameters for 2014 (PDF)
Guidance
- December 17, 2010
OCIIO Technical Guidance: Process for a State to Submit a Request for Adjustment to the Medical Loss Ratio Standard of PHS Act Section 2718 (PDF) - April 26, 2011
CCIIO Technical Guidance: Submission of 2011 Quarterly Reports of MLR Data by Issuers of “Mini-med” and Expatriate Plans (PDF) - May 13, 2011
CCIIO Technical Guidance: Questions and Answers Regarding the Medical Loss Ratio Interim Final Rule (PDF) - May 19, 2011
CCIIO Technical Guidance: Deadline for Submission of 2011 First Quarter MLR Data by Issuers of “Mini-med” and Expatriate Plans (PDF) - July 18, 2011
CCIIO Technical Guidance: Questions and Answers Regarding the Medical Loss Ratio Interim Final Rule (PDF) - February 10, 2012
CCIIO Technical Guidance: Questions and Answers Regarding the Medical Loss Ratio Interim Final Rule (PDF) - March 30, 2012
Memo to Insurance Companies: Medical Loss Ratio Annual Reporting Procedures (PDF) - April 20, 2012
CCIIO Technical Guidance: Questions and Answers Regarding the Medical Loss Ratio Regulation (PDF) - May 15, 2012
Memo to Insurance Companies: Guidance for Medical Loss Ratio Annual Reporting Form (PDF)
Memo to Insurance Companies: Guidance for Medical Loss Ratio Notices of Rebates (PDF) - May 24, 2012
CCIIO Technical Guidance: Questions and Answers Regarding the Medical Loss Ratio Reporting Form (PDF) - May 30, 2012
CCIIO Technical Guidance: Questions and Answers Regarding the Medical Loss Ratio Reporting Requirements (PDF) - July 17, 2012
CCIIO Technical Guidance: Questions and Answers Regarding the Medical Loss Ratio Reporting and Rebate Requirements (PDF) - March 29, 2013
Memo to Insurance Companies: Guidance for 2012 Medical Loss Ratio Annual Reporting Form (PDF)
Memo to Insurance Companies: Announcement Regarding Training for 2012 Medical Loss Ratio Reporting Period (PDF) - April 5, 2013
CCIIO Technical Guidance: Questions and Answers Regarding the MLR Reporting and Rebate Requirements (PDF) - May 30, 2013
CCIIO Technical Guidance: Question and Answer Regarding the Requirement that Issuers of Certain Health Insurance Coverage Sold as Fixed Indemnity Insurance Submit an Annual Medical Loss Ratio (MLR) Report to the Secretary (PDF) - July 2, 2013
CCIIO Technical Guidance Questions and Answers Regarding the Medical Loss Ratio Reporting and Rebate Requirements (PDF) - December 30, 2013
CCIIO Technical Guidance (CCIIO 2013—0004): Question and Answer Regarding the Medical Loss Ratio Reporting and Rebate Requirements (PDF) - May 27, 2015
CCIIO Technical Guidance (CCIIO 2015—0001): Question and Answer Regarding the Medical Loss Ratio Reporting and Rebate Requirements (PDF) - June 19, 2015
Reporting of Cost-Sharing Reduction Amounts in Risk Corridors and Medical Loss Ratio Reporting (PDF) - September 18, 2015
CCIIO Technical Guidance (CCIIO 2015-0002): Question and Answer Regarding the Medical Loss Ratio (MLR) Reporting and Rebate Requirements for the 2014 MLR Reporting Year (PDF) - April 9, 2018
CCIIO Technical Guidance: Question and Answer Regarding the Medical Loss Ratio (MLR) Reporting and Rebate Requirements (PDF) - April 9, 2018
CCIIO Technical Guidance: Process for a State to Submit a Request for Adjustment to the Individual Market Medical Loss Ratio Standard of PHS Act Section 2718 (PDF) - June 12, 2020
Temporary Period of Relaxed Enforcement for Submitting the 2019 MLR Annual Reporting Form and Issuing MLR Rebates in Response to the Coronavirus Disease 2019 (COVID-19) Public Health Emergency (PDF) - September 30, 2020
Treatment of Risk Corridors Recovery Payments in the Medical Loss Ratio (MLR) and Rebate Calculations (PDF) - December 30, 2020
Treatment of Risk Corridors Recovery Payments in the Medical Loss Ratio (MLR) and Rebate Calculations - Final (PDF) - March 17, 2022
Treatment of Recovered Cost-Sharing Reduction Amounts in the Medical Loss Ratio and Rebate Calculations (PDF)
Patient's Bill of Rights
Regulations
Guidance
- September 3, 2010
OCIIO Sub-Regulatory Guidance: Process for Obtaining Waivers of the Annual Limits Requirements of PHS Act Section 2711 (PDF)
Prevention
Regulations
- July 19, 2010
OCIIO–9992–IFC: Interim Final Rules for Group Health Plans and Health Insurance Issuers Relating to Coverage of Preventive Services under the Patient Protection and Affordable Care Act (PDF) - August 3, 2011
CMS-9992-IFC2: Group Health Plans and Health Insurance Issuers Relating to Coverage of Preventive Services under the Patient Protection and Affordable Care Act (PDF) - February 10, 2012
CMS-9992-F: Group Health Plans and Health Insurance Issuers Relating to Coverage of Preventive Services Under the Patient Protection and Affordable Care Act (PDF) - March 21, 2012
CMS 9968-ANPRM: Preventive Services Under the Affordable Care Act (PDF) - February 6, 2013
CMS-9968-P: Coverage of Certain Preventive Services Under the Affordable Care Act (PDF) - June 28, 2013
CMS-9968-F: Coverage of Certain Preventive Services Under the Affordable Care Act (PDF) - August 22, 2014
CMS 9940-P Coverage of Certain Preventive Services Under the Affordable Care Act - August 22, 2014
CMS 9939-IFC Coverage of Certain Preventive Services Under the Affordable Care Act - July 10, 2015
CMS 9940-F: Coverage of Certain Preventive Services Under the Affordable Care Act (PDF) - September 29, 2023
CMS-9891-NC: Request for Information (RFI); Coverage of Over-the-Counter Preventive Services (PDF) - October 21, 2024
CMS-9887-P: Enhancing Coverage of Preventive Services Under the Affordable Care Act
Guidance
- July 19, 2010
Recommendation: Recommendations of the U.S. Preventive Service Task Force - June 28, 2013
Guidelines: HRSA's Women's Preventive Services: Required Health Plan Coverage Guidelines - June, 28, 2013
CCIIO Technical Guidance: Guidance on the Temporary Enforcement Safe Harbor for Certain Employers, Group Health Plans and Group Health Insurance Issuers with Respect to the Requirement to Cover Contraceptive Services Without Cost Sharing Under Section 2713 of the Public Health Service Act, Section 715(a)(1) of the Employee Retirement Income Security Act, and Section 9815(a)(1) of the Internal Revenue Code (PDF) - August 22, 2014
Model Notice to Secretary of HHS (PDF) - November 30, 2017
Notice by Issuer or Third Party Administrator for Employer/Plan Sponsor of Revocation of the Accommodation for Certain Preventive Services (PDF)
Review of Insurance Rates
Regulations
- December 23, 2010
OCIIO–9998–IFC: Rate Increase Disclosure and Review; Proposed Rule (PDF) - May 19, 2011
CMS-9999-FC: Rate Increase Disclosure and Review; Final Rule (PDF) - September 6, 2011
CMS-9999-F: Rate Increase Disclosure and Review: Definitions of Individual Market and Small Group Market (PDF) - November 26, 2012
CMS-9972-P:Patient Protection and Affordable Care Act: Health Insurance Market Rules; Rate Review (PDF) - February 22, 2013
CMS-9972-F:Patient Protection and Affordable Care Act: Health Insurance Market Rules; Rate Review (PDF)
Guidance
- March 30, 2012
State-Specific Threshold Proposals Guidance for States (PDF) - March 31, 2015
Rounding Premiums to the Nearest Dollar (PDF) - April 14, 2015
Guidance on Unified Rate Review Timeline: Timing of Submission and Posting of Rate Filing Justifications for the 2015 Filing Year for Single Risk Pool Compliant Coverage Effective on or after January 1, 2016 (PDF) - May 13, 2015
Guidance on Uniform Timeline in States Operating State-based Marketplaces (PDF) - August 12, 2015
Timing for Submission of the Preliminary Justification for Student Health Plans with Rate Increases Effective in 2015 (PDF) - December 23, 2015
Guidance on Unified Rate Review Timeline: Timing of Submission and Posting of Rate Filing Justifications for the 2016 Filing Year for Single Risk Pool Coverage Effective on or after January 1, 2017 (PDF) - February 29, 2016
Final Guidance on Unified Rate Review Timeline: Timing of Submission and Posting of Rate Filing Justifications for the 2016 Filing Year for Single Risk Pool Coverage Effective on or after January 1, 2017 (PDF) - September 26, 2016
Guidance on Issuer Posting of Rate Filing Information (PDF) - November 10, 2016
Guidance on Unified Rate Review Timeline: Proposed Timing of Submission and Posting of Rate Filing Justifications for the 2017 Filing Year for Single Risk Pool Coverage Effective on or after January 1, 2018 (PDF) - December 16, 2016
Final Guidance on Unified Rate Review Timeline: Timing of Submission and Posting of Rate Filing Justifications for the 2017 Filing Year for Single Risk Pool Coverage (PDF) - December 16, 2016
Guidance Regarding Age Curves and State Reporting (PDF) - February 17, 2017
Revised Guidance on Unified Rate Review Timeline: Timing of Submission and Posting of Rate Filing Justifications for the 2017 Filing Year for Single Risk Pool Coverage; Revised Timing of Submission for Qualified Health Plan Certification Application (PDF) - April 13, 2017
Final Revised Guidance on Unified Rate Review Timeline: Revised Timing of Submission and Posting of Rate Filing Justifications for the 2017 Filing Year for Single Risk Pool Coverage; Revised Timing of Submission for Qualified Health Plan Certification Application (PDF) - November 27, 2017
Guidance on Unified Rate Review Timeline: Proposed Timing of Submission of Rate Filing Justifications for the 2018 Filing Year for Single Risk Pool Coverage Effective on or after January 1, 2019 (PDF) - April 9, 2018
Guidance on Unified Rate Review Timeline: Timing of Submission of Rate Filing Justifications for the 2018 Filing Year for Single Risk Pool Coverage Effective on or after January 1, 2019 (PDF) - April 9, 2018
2019 State-Specific Threshold Proposals Guidance for States (PDF) - January 17, 2019
Guidance on Unified Rate Review Timeline: Proposed Timing of Submission of Rate Filing Justifications for the 2019 Filing Year for Single Risk Pool Coverage Effective on or after January 1, 2020 (PDF) - April 4, 2019
Guidance on Unified Rate Review Timeline: Timing of Submission of Rate Filing Justifications for the 2019 Filing Year for Single Risk Pool Coverage Effective on or after January 1, 2020 (PDF) - December 20, 2019
Guidance on Unified Rate Review Timeline: Proposed Timing of Submission of Rate Filing Justifications for the 2020 Filing Year for Single Risk Pool Coverage Effective on or after January 1, 2021 (PDF) - March 27, 2020
Guidance on Unified Rate Review Timeline: Timing of Submission of Rate Filing Justifications for the 2020 Filing Year for Single Risk Pool Coverage Effective on or after January 1, 2021 (PDF) - May 7, 2020
Revised Guidance on Unified Rate Review Timeline: Timing of Submission of Rate Filing Justifications for the 2020 Filing Year for Single Risk Pool Coverage Effective on or after January 1, 2021 (PDF) - December 1, 2020
Guidance on Unified Rate Review Timeline: Proposed Timing of Submission of Rate Filing Justifications for the 2021 Filing Year for Single Risk Pool Coverage Effective on or after January 1, 2022 (PDF) - February 2, 2021
Guidance on Unified Rate Review Timeline: Timing of Submission of Rate Filing Justifications for the 2021 Filing Year for Single Risk Pool Coverage Effective on or after January 1, 2022 (PDF) - November 23, 2021
Guidance on Unified Rate Review Timeline: Proposed Timing of Submission of Rate Filing Justifications for the 2022 Filing Year for Single Risk Pool Coverage Effective on or after January 1, 2023 (PDF) - March 24, 2022
Guidance on Unified Rate Review Timeline: Timing of Submission of Rate Filing Justifications for the 2022 Filing Year for Single Risk Pool Coverage Effective on or after January 1, 2023 (PDF) - December 15, 2022
Guidance on Unified Rate Review Timeline: Proposed Timing of Submission of Rate Filing Justifications for the 2023 Filing Year for Single Risk Pool Coverage Effective on or after January 1, 2024 (PDF) - March 15, 2023
Guidance on Unified Rate Review Timeline: Timing of Submission of Rate Filing Justifications for the 2023 Filing Year for Single Risk Pool Coverage Effective on or after January 1, 2024 (PDF) - November 16, 2023
Guidance on Unified Rate Review Timeline: Proposed Timing of Submission of Rate Filing justifications for the 2024 Filing Year for Single Risk Pool Coverage Effective on or after January 1, 2025 (PDF) - April 15, 2024
Guidance on Unified Rate Review Timeline: Timing of Submission of Rate Filing justifications for the 2024 Filing Year for Single Risk Pool Coverage Effective on or after January 1, 2025 (PDF)
Student Health Plans
Regulations
- February 11, 2011
CMS–9981–P: Student Health Insurance Coverage (PDF) - March 21, 2012
CMS-9981-F: Student Health Insurance Coverage (PDF)
Guidance
Self-Funded Non-Federal Governmental Plans
Guidance
Health Insurance Portability and Accountability Act of 1996 (HIPAA)
Guidance
- March 1998
Program Memorandum: Agent Commissions and Application and Process Delays (PDF) - June 1999
Program Memorandum: Applicability of the Health Insurance Portability and Accountability Act of 1996 to Secondary Coverage and Continuing Coverage (PDF) - June 1999
Program Memorandum: Issues Related to Eligible Individual Status Under the Health Insurance Portability and Accountability Act of 1996 (PDF) - September 1999
Program Memorandum: Group Size Issues Under Title XXVII of the Public Health Service Act (PDF) - March 2000
Program Memorandum: Imposing Nonconfinement Clause on Eligible Individuals (PDF) - June 2000
Program Memorandum: Issue Related to Eligible Individual Status Under Section 2741(b) of the Public Health Service Act (PDF) - June 2000
Program Memorandum: The Relationship of Certain Types of State Laws to the Application of the Guaranteed Availability Requirements of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) in the Small Group Market (PDF) - August 2000
Program Memorandum: State “succeeding carrier” or “extension of benefits” laws and an issuer’s obligation under HIPAA to enroll an eligible individual who is disabled (PDF) - November 2000
Program Memorandum: Guaranteed Availability Under Title XXVII of the Public Health Service Act – Applicability of Group Participation Rules (PDF) - November 2000
Program Memorandum: Circumstances Under which Health Insurance Regulated as “Individual” Coverage Under State Law is Subject to the Group Market Requirements of The Health Insurance Portability and Accountability Act of 1996 (HIPAA) (PDF) - March 2001
Program Memorandum: Guaranteed Renewability of Conversion Policies (PDF) - August 2001
Program Memorandum: Identifying Federally Eligible Individuals in states Electing to Use Alternative mechanisms to Comply with Guaranteed Availability Requirements under Title XXVII of the PHS Act (PDF) - March 2002
Program Memorandum: How to Apply the “Product Withdrawal” and “Market Exit” Exceptions of the Guaranteed Renewability Requirements of Title XXVII of the PHS Act (PDF) - August 2002
Program Memorandum: Application of Group and Individual Market Requirements Under Title XXVII of the Public Health Service (PHS) Act When Insurance Coverage is Sold To, or Through Associations (PDF) - August 2002
Program Memorandum: The Obligation Health Insurance Issuers Have to Association Members and Associations Under Title XXVII of the PHS Act With Respect to Guaranteed Renewability of Coverage (PDF) - September 2002
Program Memorandum: Characteristics of Bona Fide Associations, and How Selling Coverage Exclusively Through Them Affects an Issuer’s Guaranteed Availability Obligations Under Title XXVII of the PHS Act (PDF) - September 2002
Program Memorandum: How Selling Coverage Exclusively Through Bona Fide Associations Affects and Issuer’s Guaranteed Renewability Obligations Under Title XXVII of the PHS Act (PDF) - March 2004
Program Memorandum: HIPAA Enforcement Is Not Preempted by COBRA; Non-HIPAA-Related State Insurance Law is Not Preempted by Public Sector COBRA (PDF) - June 2004
Program Memorandum: Federal Eligibility Under HIPAA After Group Health Plan Termination (PDF) - March 2005
Program Memorandum: Coverage through a Foreign Government, the U.S. Government, and a State Children’s Health Insurance Program, is Creditable Coverage for Purposes of Identifying Eligible Individuals under HIPAA (PDF) - June 2005
Program Memorandum: Benefit Exclusions that Cannot be Applied to Eligible Individuals Under HIPAA Individual Market Provisions (PDF) - May 2008
Program Memorandum: Circumstances Under Which Supplemental Health Insurance Coverage Satisfies the Requirements for Excepted Benefits Under Section 2791(c) of the Public Health Service Act (PDF)
Downloads
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Edge 2022 QQ Guidance (PDF)
Page Last Modified:
11/15/2024 08:14 AM