The Center for Consumer Information & Insurance Oversight
Other Resources
- Affordable Care Act
- Consumer Support and Information
- Content Requirements for Plan Finder
- Pre-Existing Condition Insurance Plan (PCIP)
- Early Retiree Reinsurance Program (ERRP)
- Health Insurance Marketplaces
- Consumer Operated and Oriented Plan (CO-OP) Program
- Health Insurance Market Reforms
- Premium Stabilization Programs
- COBRA
- Reports
- CCIIO Examinations, Audits, and Reviews of Issuers
Affordable Care Act
Innovation in the Marketplace Newsletters
Consumer Support and Information
Consumer Assistance Program Grants
Reports
- June 7, 2012
Summary of First Year Consumer Assistance Program Grant Data (PDF) (PDF - 442 KB)
External Appeals
Model Notice
- June 22, 2011
Model Notice of Adverse Benefits Determination (PDF) (PDF – 256 KB)
Model Notice of Final External Review Decision (PDF) (PDF – 101 KB)
Model Notice of Final Internal Adverse Benefits Determination (PDF) (PDF – 265 KB)
Notice of Privacy Act Rights
- January 11, 2017
Notice of Privacy Act Statement for Issuers in States without External Review Laws (PDF) (PDF – 20 KB)
Federal Register Notice
- August 23, 2010
Federal Register Notice on External Review
Summary of Benefits and Coverage and Uniform Glossary
SBC Materials and Supporting Documents (Authorized for use for plan or policy years that begin on or after January 1, 2021)
Applicability: Plans and issuers will be required to use the 2021 Summary of Benefits and Coverage (SBC), the 2021 SBC Calculator Guide and Narratives, and, should they choose to use the SBC Calculator, the 2021 SBC Calculator beginning on the first day of the first open enrollment period for any plan years (or, in the individual market, policy years) that begin on or after January 1, 2021, with respect to coverage for plan or policy years beginning on or after that date.
NOTE: The Departments of Health and Human Services, Labor, and the Treasury identified minor errors in several of the 2021 SBC materials and supporting documents posted in November 2019, including the 2021 SBC Template. We corrected the errors and released remediated documents on February 3, 2020. These documents are posted below.
Forms
- Summary of Benefits and Coverage (SBC) Template
- Standard Format (DOCX)
- Accessible Format (PDF)
- Chinese Standard Format (DOCX)
- Chinese Accessible Format (PDF)
- Spanish Standard Format (DOCX)
- Spanish Accessible Format (PDF)
- Tagalog Standard Format (DOCX)
- Tagalog Accessible Format (PDF)
- Navajo Standard Format (DOC)
- Navajo Accessible Format (PDF)
- Navajo Oral Translation (MP3)
- Uniform Glossary
- English (PDF)
- List of anchors (XLSX) for SBC Uniform Glossary terms on https://www.HealthCare.gov/sbc-glossary/
- Chinese (PDF) (PDF)
- Spanish(PDF) (PDF)
- Tagalog (PDF) (PDF)
- Navajo (PDF)
- Navajo Oral Translation (MP3)
Instructions/Guidance
- Sample Completed SBC
- Instructions for Completing the SBC – Group Health Plan Coverage (PDF) (for January 1, 2021)
- Instructions for Completing the SBC – Individual Health Insurance Coverage (PDF) (for January 1, 2021)
- Why This Matters language for SBC “Yes” Answers (for January 1, 2021)
- English (PDF)
- Chinese (PDF) (PDF)
- Spanish (PDF) (PDF)
- Tagalog (PDF) (PDF)
- Navajo (PDF)
- Navajo Oral Translation (MP3)
- Why This Matters language for SBC “No” Answers (for January 1, 2021)
- English (PDF)
- Chinese (PDF) (PDF)
- Spanish (PDF) (PDF)
- Tagalog (PDF) (PDF)
- Navajo (PDF)
- Navajo Oral Translation (MP3)
- Guide for Coverage Examples Calculations – Maternity Scenario
- Guide for Coverage Examples Calculations – Diabetes Scenario
- Guide for Coverage Examples Calculations – Simple Foot Fracture Scenario
- Narrative for Maternity Scenario (PDF)
- Narrative for Diabetes Scenario (PDF)
- Narrative for Simple Foot Fracture Scenario (PDF)
- Coverage Examples Calculator Instructions (PDF)
- Coverage Examples Calculator (VND.MS-EXCEL.SHEET.MACROENABLED.12) (updated October 2019 for use on or after January 1, 2021)
- Crosswalk of Changes (PDF) (describes updates made to the October 2019 version of the Coverage Examples Calculator)
SBC Materials and Supporting Documents (Authorized for use prior to January 1, 2021)
Applicability: Health plans and issuers that maintain an annual open enrollment period will be required to use the April, 2017 edition of the SBC template and associated documents beginning on the first day of the first open enrollment period that begins on or after April 1, 2017 with respect to coverage for plan years (or, in the individual market, policy years) beginning on or after that date. For plans and issuers that do not use an annual open enrollment period, this SBC template and associated documents is required beginning on the first day of the first plan year (or, in the individual market, policy year) that begins on or after April 1, 2017 and before January 1, 2021.
Forms
- Summary of Benefits and Coverage (SBC) Template
- Standard Format (DOC) (DOC)
- Accessible Format (PDF) (PDF)
- Chinese Standard Format (DOCX) (DOC)
- Chinese Accessible Format (PDF) (PDF)
- Spanish Standard Format (DOCX) (DOC)
- Spanish Accessible Format (PDF) (PDF)
- Tagalog Standard Format (DOCX) (DOC)
- Tagalog Accessible Format (PDF) (PDF)
- Navajo Standard Format (DOCX) (DOC)
- Navajo Accessible Format (PDF) (PDF)
- Navajo Oral Translation (MP3)
- Uniform Glossary
- English (PDF) (PDF)
- List of anchors (XLSX) for SBC Uniform Glossary terms on https://www.HealthCare.gov/sbc-glossary/
- Chinese (PDF) (PDF)
- Spanish (PDF)(PDF)
- Tagalog (PDF) (PDF)
- Navajo (PDF) (PDF)
- Navajo Oral Translation (MP3)
Instructions/Guidance
- Sample Completed SBC
- Instructions for Completing the SBC – Group Health Plan Coverage (PDF) (PDF) (for April 1, 2017)
- Instructions for Completing the SBC – Individual Health Insurance Coverage (PDF) (PDF) (for April 1, 2017)
- Why This Matters language for SBC “Yes” Answers (for April 1, 2017)
- English (PDF) (PDF)
- Chinese (PDF) (PDF)
- Spanish (PDF) (PDF)
- Tagalog (PDF) (PDF)
- Navajo (PDF) (PDF)
- Navajo Oral Translation (MP3)
- Why This Matters language for SBC “No” Answers (for April 1, 2017)
- English (PDF) (PDF)
- Chinese (PDF) (PDF)
- Spanish (PDF) (PDF)
- Tagalog (PDF) (PDF)
- Navajo (PDF) (PDF)
- Navajo Oral Translation (MP3)
- Guide for Coverage Examples Calculations – Maternity Scenario
- Standard Format (XLSX) (XLSX)
- Accessible Format (PDF) (PDF)
- Guide for Coverage Examples Calculations – Diabetes Scenario
- Standard Format (XLSX) (XLSX)
- Accessible Format (PDF) (PDF)
- Guide for Coverage Examples Calculations – Simple Foot Fracture Scenario
- Standard Format (XLSX) (XLSX)
- Accessible Format (PDF) (PDF)
- Narrative for Maternity Scenario (PDF) (PDF)
- Narrative for Diabetes Scenario (PDF) (PDF)
- Narrative for Simple Foot Fracture Scenario (PDF) (PDF)
- Coverage Examples Calculator Instructions (PDF) (PDF)
- Coverage Examples Calculator (VND.MS-EXCEL.SHEET.MACROENABLED.12) (XLSM) (updated May 2016 to address an error in the calculation of cost sharing after the annual limitation on cost sharing)
SBC Materials and Supporting Documents (Authorized for use prior to April 1, 2017)
Forms
- Summary of Benefits and Coverage (SBC) Template
- Standard Format (DOC) (Authorized for second year of applicability) (DOC – 182 KB)
- Accessible Format (PDF) (Authorized for second year of applicability) (PDF – 366 KB)
- Standard Format (DOC) (Authorized for first year of applicability) (DOC - 175 KB)
- Accessible Format (PDF) (Authorized for first year of applicability) (PDF - 607 KB)
- Chinese (Authorized for second year of applicability) (DOCX)
- Chinese (Authorized for second year of applicability) (PDF)
- Chinese (Authorized for first year of applicability) (DOCX) (DOC – 54 KB)
- Chinese (Authorized for first year of applicability) (PDF) (PDF- 565 KB)
- Navajo (Authorized for second year of applicability) (DOCX)
- Navajo (Authorized for second year of applicability) (PDF)
- Navajo Oral Translation (Authorized for second year of applicability) [MP3, 27MB]
- Navajo (Authorized for first year of applicability) (DOCX) (DOC – 67 KB)
(Note: In order to use the Navajo SBC template in Word format, it may be necessary to install Times New Roman Navajo fonts. Times New Roman Navajo fonts are available free of charge on a number of sources on the Internet.) - Navajo (Authorized for first year of applicability) (PDF) (PDF – 258 KB)
- Navajo (Authorized for first year of applicability) - Oral Translation (MP3 – 21 MB)
- Spanish (Authorized for second year of applicability) (DOCX)
- Spanish (Authorized for second year of applicability) (PDF)
- Spanish (Authorized for first year of applicability) (DOCX) (DOC – 170KB)
- Spanish (Authorized for first year of applicability) (PDF) (PDF – 458 KB)
- Tagalog (Authorized for second year of applicability) (DOCX)
- Tagalog (Authorized for second year of applicability) (PDF)
- Tagalog (Authorized for first year of applicability) (DOCX) (DOC – 71 KB)
- Tagalog (Authorized for first year of applicability) (PDF) (PDF – 446 KB)
- Uniform Glossary
- English (PDF) (PDF – 140 KB )
- Chinese (PDF) (PDF – 226 KB)
- Navajo (PDF) (PDF – 400 KB)
- Navajo - Oral Translation (MP3 – 26 MB)
- Spanish (PDF) (PDF – 349 KB)
- Tagalog (PDF) (PDF - 145 KB)
Instructions/Guidance
- Sample Completed SBC
- Standard Format (DOC) (Authorized for second year of applicability) (DOC – 206 KB)
- Accessible Format (PDF) (Authorized for second year of applicability) (PDF – 431 KB)
- Standard Format (DOC) (Corrected, May 11, 2012) (DOC - 200 KB)
- Accessible Format (PDF) (Corrected, May 11, 2012) (PDF - 533 KB)
- Instructions for Completing the SBC – Group Health Plan Coverage (PDF) (PDF – 89 KB)
- Instructions for Completing the SBC – Individual Health Insurance Coverage (PDF) (PDF – 81 KB)
- Why This Matters language for SBC "Yes" Answers
- English (PDF) (PDF – 120 KB)
- Chinese (PDF) (PDF-159 KB)
- Navajo (PDF) (PDF-641 KB)
- Navajo Oral Translation (MP3 – 7 MB)
- Spanish (PDF) (PDF – 288 KB)
- Tagalog (PDF) ( PDF – 111 KB)
- Why This Matters language for SBC "No" Answers
- English (PDF) (PDF – 92 KB)
- Chinese (PDF) (PDF – 147 KB)
- Navajo (PDF) (PDF – 446 KB)
- Navajo - Oral Translation (MP3 – 4.4 MB)
- Spanish (PDF) (PDF – 292 KB)
- Tagalog (PDF) (PDF- 107 KB)
- Guide for Coverage Examples Calculations – Maternity Scenario
- Standard Format (XLSX) (XLSX – 91 KB)
- Accessible Format (PDF) (PDF – 98 KB)
- Guide for Coverage Examples Calculations – Diabetes Scenario
- Standard Format (XLSX) (Corrected May 11, 2012) (XLSX - 56 KB)
- Accessible Format (PDF) (Corrected May 11, 2012) (PDF - 343 KB)
- Narrative for Maternity Scenario (PDF) (PDF – 11 KB)
- Narrative for Diabetes Scenario (PDF) (PDF – 11 KB)
- Checklist for Coverage Calculator (PDF) (PDF – 43 KB)
- Coverage Examples Calculator Instructions (PDF) (PDF – 274 KB)
- Coverage Examples Calculator Logic (PDF) (PDF – 91 KB)
- Coverage Examples Calculator (VND.MS-EXCEL.SHEET.MACROENABLED.12) (XLSM – 442 KB) (updated September 7, 2012)
(Note: This version of the coverage examples calculator corrects an error in a previous version that would result in an error message with regard to coverage of preventive services and maximum out-of-pockets. That programming error did not impact the accuracy of the results in either the manual or automated processes, so plans and issuers that have successfully used the previous versions (June 4, 2012 and Updated July 23, 2012) of the calculator may use the results from the previous version.)
Content Requirements for Plan Finder
Q&A
- September 1, 2016
Plan Finder Data Entry
Instructions/Guidance
- June 1, 2016
CMS.gov Enterprise Portal Quick Reference Guide for Existing Users Adding Multi-Factor Authentication (MFA) to their Health Insurance Oversight System (HIOS) Application Role (PDF) - June 1, 2016
Abbreviated Reference Guide for Existing Users Adding Multi-Factor Authentication (MFA) to their Health Insurance Oversight System (HIOS) Application Role (PDF) - June 1, 2016
EIDM YouTube video for Multi Factor Authentication Registration - August 24, 2018
HIOS Data Change Request Quick Guide (PDF) - April 22, 2019
HIOS Portal Quick Guide (PDF) - April 22, 2019
HIOS Plan Finder User Manual (PDF) - December 16, 2019
Rate and Benefit Information System (RBIS) User Manual (PDF) - December 16, 2109
HIOS Portal User Manual (PDF)
Pre-Existing Condition Insurance Plan (PCIP)
Data
- PCIP Data as of May 31 2011
- Update on Federal PCIP September 29, 2011 (PDF) (PDF 624 KB)
- Update on Federal PCIP December 31, 2011 (PDF) (PDF - 174 KB)
- Update on Federal PCIP March 31, 2012 (PDF) (PDF - 122 KB)
- Update on Federal PCIP June 30, 2012 (PDF) (PDF - 131 KB)
- Update on Federal PCIP September 30, 2012 (PDF) (PDF - 464 KB)
- Update on Federal PCIP December 31, 2012 (PDF) (PDF - 99 KB)
- Update on Federal PCIP March 31, 2013 (PDF) (PDF - 98 KB)
- Update on Federal PCIP June 30, 2013 (PDF) (PDF - 125 KB)
- Update on Federal PCIP September 30, 2013 (PDF) (PDF - 105 KB)
Reports
- February 23, 2012
Report on the Implementation and Operation of the Pre-Existing Condition Insurance Plan Program (PDF) (PDF - 330 KB) - February 1, 2013
Annual Report on the Implementation and Operation of the PCIP Program (PDF) (PDF -300KB)
Early Retiree Reinsurance Program (ERRP)
Reports
Health Insurance Marketplaces
Presentations
- September 2011
State Exchange Grantee Meeting Materials - March 2012
Affordable Insurance Exchanges Final Rule (PDF) (PDF - 749 KB) - May 2012
System-wide Exchange Conference Materials - November 26, 2012
EHB/AV/Accreditation Notice of Proposed Rulemaking (PDF) (PDF – 593 KB) - January 3, 2013
State Partnership Exchange (PDF) (PDF – 267 KB) - February 25, 2013
EHB/AV/Accreditation Final Rule (PDF) (PDF - 549 KB) - January 27, 2016
2014 Plan Year Issuer Compliance Summary Report Presentation (PDF)
Marketplace Year 3: Issuer Insights and Innovation - June 9, 2016
Forum Agenda (PDF)
CMS Acting Administrator Andy Slavitt Remarks"> CMS Acting Administrator Andy Slavitt Remarks - Opens in a new window
HHS Secretary Burwell Remarks"> HHS Secretary Burwell Remarks - Opens in a new window
Marketplace Success Stories Blog by CEO Kevin Counihan"> Marketplace Success Stories Blog by CEO Kevin Counihan - Opens in a new window
Forum Recording:
- Welcome by HHS Secretary Burwell
- The Marketplace Consumer: Understanding the Marketplace Population Through Two Years’ Worth of Data
- Innovation in Provider Contracting
- Keynote by Andy Slavitt
- Care Coordination
- Conversation with the CEO - Looking Ahead
Session Slides:
- The Marketplace Consumer: Understanding the Marketplace Population Through Two Years’ Worth of Data (PDF)
- Innovation in Provider Contracting (PDF)
- Care Coordination (PDF)
Marketplace Year 3: Issuer Insights and Innovation – October 5, 2016
Forum Agenda (PDF)
CMS Acting Administrator Andy Slavitt Remarks"> CMS Acting Administrator Andy Slavitt Remarks - Opens in a new window
HHS Secretary Burwell Remarks"> HHS Secretary Burwell Remarks - Opens in a new window
Forum Recordings (Forthcoming)
- Welcome by HHS Secretary Burwell
- Looking Ahead to the Future of the Marketplace: A Conversation with CEOs
- The Marketplace Consumer – Using Data to Drive Outreach and Engagement
- Innovation in Plan Design and Provider Outreach
- Keynote by Andy Slavitt
- Engaging Consumers in their Care – Perspectives from Care Coordination and Beyond
Session Slides
- The Marketplace Consumer – Using Data to Drive Outreach and Engagement (PDF)
- Innovation in Plan Design and Provider Outreach (PDF)
- Engaging Consumers in their Care – Perspectives from Care Coordination and Beyond (PDF)
Forms
- May 16, 2012
Paperwork Reduction Act (PRA) display of Draft Blueprint for Approval of Affordable State-based and State Partnership Insurance Exchanges (click on CMS – 10416). - August 14, 2012 (Revised November 16, 2012)
Final Blueprint for Exchanges (PDF) (PDF - 731 KB) - November 9, 2012
Frequently Asked Questions on the Blueprint for Exchanges - October 9, 2013
Marketplace Consumer Application- Individual Short Form"> Individual Short Form - Opens in a new window
- Individual Short Form Instructions - Opens in a new window
- Family - Opens in a new window
- Family Instructions - Opens in a new window
- Individual without Financial Assistance - Opens in a new window
- Individual without Financial Assistance Instructions - Opens in a new window
- April 7, 2014
Compliance Reviews in the Federally-Facilitated Marketplace - April 2, 2015
- Compliance Reviews in the Federally-Facilitated
- February 23, 2016
Compliance Reviews in the Federally-Facilitated
Reports
- August 23, 2013
Impact of Changing the Maximum Out-of-Pocket Amounts for Qualified Health Plans and Stand Alone Dental Plans (PDF) - December 16, 2015
2014 Plan Year Issuer Compliance Summary Report (PDF) - August 11, 2016
Changes in ACA Individual Market Costs from 2014-2015: Near-Zero Growth Suggests an Improving Risk Pool (PDF) - March 15, 2017
Health Insurance Exchanges 2017 Open Enrollment Report - April 3, 2018
Health Insurance Exchanges 2018 Open Enrollment Report - March 25, 2019
Health Insurance Exchanges 2019 Open Enrollment Report - August 12, 2019
Trends in Subsidized and Unsubsidized Enrollment – Benefit Years 2017 to 2018 (PDF) - April 1, 2020
Health Insurance Exchanges 2020 Open Enrollment Report (PDF) - June 25, 2020
Special Trends Report: Enrollment Data and Coverage Options for Consumers During the COVID-19 Public Health Emergency (PDF)
Planning and Establishment Grants
Pre-Application Conference Calls (Upcoming)
- June 29, 2012
Dates and Times of Pre-Application Conference Calls for Exchange Establishment FOA:- July 19, 2012 – 1:30-3:00pm EST
- October 4, 2012 - 2:00-3:30pm EST
- January 10, 2013 - 2:00-3:30pm EST
- April 10, 2013 - 1 -2:30 PM EST
Call in: 1 877 267 1577; Meeting ID: 0360
Consumer Operated and Oriented Plan (CO-OP) Program
Presentations
- April 2012
Consumer Operated and Oriented Plan (CO-OP) Program (PDF) (PDF – 347 KB)
Health Insurance Market Reforms
Annual Limits
Application Information
- June 17, 2011
Annual Limit Waiver Application Forms and Instructions- Annual Limit Waiver Application—New Application Form (XLS) (XLS – 49 MB)
- Annual Limit Waiver Application—Waiver Extension Form (XLS) (XLS – 50 MB)
- Annual Limit Waiver Application Instructions (PDF) (PDF – 89 KB)
- Annual Limit Waiver Data Dictionary (XLS) (XLS – 20 KB)
- January 6, 2012
Coverage for Young Adults
Data
- January 12, 2010
Estimated number of uninsured individuals ages 19-25, by county (XLS) (XLS – 2 MB)
Excepted Benefits
Medical Loss Ratio
Forms
- May 19, 2011
Medical Loss Ratio (MLR) 2011 Quarterly Reporting Forms for “Mini-med” and Expatriate Plans- MLR Quarterly Reporting Form for “Mini-med” Plans (XLS) (XLS – 50 KB)
- MLR Quarterly Reporting Form for Expatriate Plans (XLS) (XLS – 52 KB)
- MLR Quarterly Reporting Form Instructions (PDF) (PDF – 68 KB)
- June 17, 2011 (corrected)
MLR Quarterly Reporting Form Instructions (PDF) (PDF – 70 KB) - May 11, 2012
Medical Loss Ratio (MLR) 2011 Annual Reporting Form (OMB 0938-1164)- MLR Annual Reporting Form (XLSX) (XLSX - 119 KB)
- MLR Annual Reporting Form Instructions (PDF) (PDF - 204 KB)
Medical Loss Ratio (MLR) Rebate Notices to Policyholders and Subscribers (OMB 0938-1164)
- Notice to Subscribers in the Individual Market (Notice #1) (PDF) (PDF – 38 KB)
- Notice to Group Policyholders and Their Subscribers, Rebate Sent to the Policyholder (Notice #2) (PDF) (PDF - 54 KB)
- Notice to Subscribers of Group Policyholders, Rebate Sent to the Subscribers (Notice #3) (PDF) (PDF - 41 KB)
- Instructions for Notices 1, 2 and 3 (PDF) (PDF - 87 KB)
- May 16, 2012
Notice to Policyholders and Subscribers when MLR Standard is Met (PDF) (PDF - 15 KB) - March 29, 2013
- MLR 2012 Annual Reporting Form (XLSX) (XLSX – 116 KB)
- MLR 2012 Annual Reporting Form Instructions (PDF) (PDF – 639 KB)
- MLR 2012 Annual Reporting Form Calculator and Formula Tool (VND.MS-EXCEL.SHEET.MACROENABLED.12) (XLSM - 102 KB)
- March 25, 2014
- May 14, 2014
- May 29, 2015
- Risk Corridors 2014 Plan Level Data Form (XLSX) (XLSX - 98 KB)
- Risk Corridors 2014 Plan-Level Instructions (PDF) (PDF - 262 KB)
- Notice to Subscribers in the Individual Market (Notice #1) (PDF) (PDF - 56 KB)
- Notice to Group Policyholders and Their Subscribers, Rebate Sent to the Policyholder (Notice #2) (PDF) (PDF - 65 KB)
- Notice to Subscribers of Group Policyholders, Rebate Sent to the Subscribers (Notice #3) (PDF) (PDF - 44 KB)
- Instructions for Notices 1, 2 and 3 (PDF) (PDF - 66 KB)
- June 4, 2015
- MLR 2014 Annual Reporting Form (XLSX) (XLSX – 115 KB)
- MLR 2014 Annual Reporting Form Instructions (PDF) (PDF – 427 KB)
- MLR 2014 Calculator and Formula Tool (VND.MS-EXCEL.SHEET.MACROENABLED.12) (XLSM – 147 KB)
- June 19, 2015
- MLR and Risk Corridors 2014 System Validations (PDF) (PDF – 258 KB)
- May 9, 2016
- MLR 2015 Annual Reporting Form (XLSX) (XLSX – 121 KB)
- MLR 2015 Annual Reporting Form Instructions (PDF) (PDF – 359 KB)
- MLR 2015 Calculator and Formula Tool (VND.MS-EXCEL.SHEET.MACROENABLED.12) (XLSM – 139 KB)
- Risk Corridors 2015 Plan-Level Data Form (XLSX) (XLSX – 95 KB)
- Risk Corridors 2015 Plan-Level Instructions (PDF) (PDF – 228 KB)
- MLR and Risk Corridors 2015 System Validations (PDF) (PDF – 202 KB)
- June 5, 2017
- July 12, 2017
- June 5, 2018
- July 16, 2018
- June 25, 2019
Reports:
- June 21, 2012
The 80/20 Rule: Providing Value and Rebates to Millions of Consumers - February 15, 2013
The 80/20 Rule: How Insurers Spend Your Health Insurance Premiums (PDF) - June 20, 2013
80/20 Rule Delivers More Value to Consumers in 2012 (PDF) - July 24, 2014
Consumers Benefit from 80/20 Rule in 2013 (PDF) - November 19, 2015
Consumers Get Rebates, More Premium Value and Stability Protection in 2014 (PDF) (PDF – 778KB) - November 18, 2016
Medical Loss Ratio Report: The 80/20 Rule Increases Value for Consumers for Fifth Year in a Row (PDF) (PDF – 774KB) - December 28, 2017
Summary of 2016 Medical Loss Ratio Results (PDF-326KB) (PDF)
- June 21, 2012
Mental Health Parity
Forms
Reports
- December 12, 2017
Department of Health and Human Services (HHS) Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) Enforcement Report (PDF) - April 23, 2018
21st Century Cures Act: Section 13002 Action Plan for Enhanced Enforcement of Mental Health and Substance Use Disorder Coverage - Opens in a new window - March 29, 2019
Department of Health and Human Services (HHS) Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) Enforcement Report for the 2018 Federal Fiscal Year (PDF) - March 16, 2020
FY2019 MHPAEA Enforcement Fact Sheet (PDF)
Appendix (PDF)
Patient’s Bill of Rights
Q&A
- October 13, 2010
Enrollment of Children Under 19 Under the New Policy That Prohibits Pre-Existing Condition Exclusions
Data
- January 19, 2011
Data Files – First Estimate (XLS) (XLS – 151 KB)
Data Files – Second Estimate (XLS) (XLS – 151 KB)
Data Files – First and Second Estimates by State (XLS) (XLS – 35.5 KB)
Methodology
- January 12, 2011
Methodology for Children and Adults with Pre-Existing Conditions, by Congressional District
Reports
- September 23, 2011
Patient’s Bill of Rights (PDF) (PDF – 238 KB)
Prevention
Forms
- June 28, 2013
Self-certification Form (To be used for plan years beginning on or after January 1, 2014)- Standard Format (DOCX) (DOC – 28 KB)
- Accessible Format (PDF) (PDF – 22 KB)
Review of Insurance Rates
Forms
- February 2, 2015
Effective Rate Review (ERR) Annual Survey (OMB 0938-1121)
o 2015 ERR Annual Determination and Status Questions (PDF)
o 2015 ERR Instructions (PDF) - February 25, 2015
Unified Rate Review (URR) Reporting Requirements for Single Risk Pool Plans (OMB 0938-1141)
o 2016 URR Instructions (Parts I, II, & III) (PDF)
o 2016 URR Template (URRT) (VND.MS-EXCEL.SHEET.MACROENABLED.12) (Updated on April 15, 2015) - o 2016 Instructions for Submitting a Redacted Actuarial Memorandum (PDF) (Posted April 16, 2015)
- April 03, 2015
Rate Review Justification (RRJ) Reporting Requirements for Transitional Plans and Student Health Plans (OMB 0938-1141)
o RRJ Instructions (PDF)
o RRJ Template (XLS) - February 22, 2016
Unified Rate Review (URR) Reporting Requirements for Single Risk Pool Plans (OMB 0938-1141)
o Draft 2017 URR Instructions (Parts I, II, & III) (PDF)
o Federal Register Notice - o PRA Supporting Statement (PDF)
- o2017 URR Template v3.3 (URRT) (VND.MS-EXCEL.SHEET.MACROENABLED.12) (Updated March 18, 2016)
- August 18, 2016
Unified Rate Review (URR) Reporting Requirements for Single Risk Pool Plans (OMB 0938-1141)
Final 2017 URR Instructions (Parts I, II, & III) (Updated August 10, 2016) (PDF) - February 23, 2017
2018 URR Template v4.1 (VND.MS-EXCEL.SHEET.MACROENABLED.12) - April 7, 2017
Unified Rate Review (URR) Reporting Requirements for Single Risk Pool Plans (OMB 0938-1141) Final 2018 URR Instructions (Parts I, II, & III) (PDF) - April 9, 2018
Unified Rate Review (URR) Reporting Requirements for Single Risk Pool Plans (OMB 0938-1141)
o Final 2019 URR Instructions (Parts I, II, & III) (PDF)
o 2019 URR (VND.MS-EXCEL.SHEET.MACROENABLED.12) - April 9, 2018
Rate Review Justification (RRJ) Reporting Requirements for Transitional Plans (OMB 0938-1141)
o RRJ Instructions (PDF)
o RRJ Template (XLS) - May 8, 2019
- December 20, 2019
Unified Rate Review (URR) Reporting Requirements for Single Risk Pool Plans (OMB 0938-1141)
o Final 2020 URR Instructions (PDF)(Parts I, II, & III) (PDF)
o 2020 URR Template v5.0 (XLSM) - April 7, 2020
Unified Rate Review (URR) Reporting Requirements for Single Risk Pool Plans (OMB 0938-1141)
o Final PY2021 URR Instructions (PDF)(Parts I, II, & III) (PDF)
o URR Template v5.2 (XLSM) (XLSM)
Reports
- September 20, 2011
Report: Early Achievements of Health Insurance Rate Review Grants (PDF) (PDF - 268 KB)
Note: The Cycle II proposal summary for the California Department of Managed Health Care was corrected on September 22, 2011. - September 11, 2012
Annual Rate Review Report - September 12, 2013
Rate Review Annual Report - Opens in a new window - December 30, 2015
Rate Review Annual Report (PDF)
Self-Funded Non-Federal Governmental Plans
Compliance Checklists
- July 12, 2016
Market Reforms (ACA & HIPAA) Non-Grandfathered Plan Provisions Self-Funded Non-Federal Governmental Group Health Plans Compliance Checklist (PDF)
Market Reforms (ACA & HIPAA) Grandfathered Plan Provisions Self-Funded Non-Federal Governmental Group Health Plans Compliance Checklist (PDF)
Presentations
- April 15, 2019
Non-Federal Governmental Plans: An Introduction (PDF) - July 8, 2019
Non-Federal Governmental Plans and MHPAEA (PDF)
HIPAA Opt-Out Materials
- September 21, 2010
Memo on Amendments to the HIPAA Opt-Out Provision made by the Affordable Care Act (PDF) (PDF – 44 KB) - July 21, 2014
Updated Procedures and Requirements for HIPAA Exemption Election through the Health Insurance Oversight System (HIOS) (PDF) - December 31, 2014
Procedures and Requirements for HIPAA Exemption Election - August 18, 2016
HIOS Non-Federal Governmental Health Plan Module Training (PDF) - September 11, 2018
HIOS-Non-Fed-User Manual (PDF) - January 10, 2020
List of HIPAA Opt-Out Elections for Self-Funded, Non-Federal Governmental Plans (PDF) - January 22, 2020
Model Notice to Enrollees of HIPAA Exemption (PDF)
Premium Stabilization Programs
White Papers
- September 12, 2011
Risk Adjustment Implementation Issues – White Paper (PDF) (PDF – 2 MB)
Questions and Answers on Risk Adjustment White Paper - March 24, 2016
March 31, 2016, HHS-Operated Risk Adjustment Methodology Meeting Discussion Paper (PDF)
Risk Adjustment Spring Meeting (May 7-8, 2012)
- CMS-9966-N: Notice of Meeting - Opens in a new window (PDF - 194 KB)
- Registration: Register by April 30, 2012, 5 pm est.
To register, please visit the Registration Website. - Conference Materials
- Risk Adjustment Overview (PDF) (PDF – 268 KB)
- Reinsurance, Risk Corridors, and Risk Adjustment Final Rule: Risk Adjustment (PDF) (PDF – 252 KB)
- HHS Risk Adjustment Model (PDF) (PDF – 340 KB)
- Risk Adjustment Payment Transfer Methodology (PDF) (PDF – 763 KB)
- State Flexibility and Alternate Methodologies (PDF) (PDF – 336 KB)
- Risk Adjustment Program: HHS Operations (PDF) (PDF – 608 KB)
- Proposed Technical Concept: Distributed Data Processing (PDF) (PDF – 290 KB)
- State Flexibility and Risk Adjustment Implementation (PDF) (PDF – 410 KB)
Instructions
- August 27, 2015
Instructions for 2014 Risk Corridors Discrepancy Worksheet (PDF) - October 13, 2015
FAQs for User Fee Adjustment Data Submission (PDF 125 KB) (PDF) - March 23, 2018
FAQ for Federally-facilitated Exchange (FFE) User Fee Adjustment Obligation Reduction (PDF) - May 16, 2018
Federally-facilitated Exchange (FFE) User Fee Adjustment Web Form Quick Start Guide (PDF)
Forms
- January 29, 2015
2014 Transitional Reporting Form (Excel) (XLSX) - August 22, 2016
Federally-facilitated Marketplace (FFM) User Fee Adjustment Web Form Quick Start Guide (PDF) - March 23, 2018
Federally-facilitated Exchange (FFE) User Fee Adjustment Obligation Reduction Attestation Form (XLSX) - March 29, 2018
Cost-Sharing Reduction Reconciliation Attestation Form A – Benefit Year 2017 (XLSX)
Cost-Sharing Reduction Reconciliation Attestation Form B – Benefit Year 2017 (XLSX)
Cost-Sharing Reduction Reconciliation Attestation Form C – Benefit Year 2016 (XLSX) - April 3, 2019
Cost-sharing Reduction Reconciliation Attestation Form A – Benefit Year 2018 (XLSX)
Cost-sharing Reduction Reconciliation Attestation Form B – Benefit Year 2018 (XLSX) - May 29, 2019
CSR Reconciliation Attestation Form A Benefit Year 2018 or 2017 (XLSX)
CSR Reconciliation Attestation Form B Benefit Year 2018 or 2017 (XLSX) - April 24, 2020
Cost-sharing Reduction Reconciliation Attestation Form A Benefit Year 2019 (PDF) or 2018 (PDF)
Cost-sharing Reduction Reconciliation Attestation Form B Benefit Year 2019 or 2018 (PDF)
COBRA
Forms
- October 17, 2012
CMS Request for Review of Premium Assistance Denial (PDF) (PDF - 992 KB)
Reports
GAO
- March 16, 2011
"Private Health Insurance: Data on Application and Coverage Denials" (PDF – 1.13 MB)
State High Risk Pool Grant Program
Updates
- March 5, 2020 Information Related to COVID–19 Individual and Small Group Market Insurance Coverage
- March 12, 2020 FAQs on Essential Health Benefits Coverage and the Coronavirus (COVID-19)
- March 18, 2020 FAQs on Catastrophic Plan Coverage and the Coronavirus Disease 2019 (COVID-19)
- March 24, 2020 FAQs on Availability and Usage of Telehealth Services through Private Health Insurance Coverage in Response to Coronavirus Disease 2019 (COVID-19)
- March 24, 2020 Payment and Grace Period Flexibilities Associated with the COVID-19 National Emergency
- March 24, 2020 FAQs on Prescription Drugs and the Coronavirus Disease 2019 (COVID-19) for Issuers Offering Health Insurance Coverage in the Individual and Small Group Markets
- April 11, 2020 FAQs about Families First Coronavirus Response Act and the Coronavirus Aid, Relief, and Economic Security Act Implementation
*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. - April 13, 2020 Postponement of 2019 Benefit Year HHS-operated Risk Adjustment Data Validation (HHS-RADV)