ACA Exchange Participation Applications Available For Review

Even while awaiting the Supreme Court decision on the constitutionality of the health reform law (the ACA), the federal agencies in charge of implementing the law continued their tasks in that regard. Then, on July 2, just a few days after the High Court’s decision, the Centers for Medicare and Medicaid Services (CMS) published on its website four items regarding data collection to implement ACA provisions to extend health insurance coverage under the new Affordable Insurance Exchanges and Small Business Health Options Program (SHOP) Exchanges.


You may recall that the ACA requires states to establish by 2014 state-based American Health Benefit Exchanges and SHOP Exchanges to be administered by a governmental agency or nonprofit organization. Through these Exchanges, individuals and small businesses with 100 or fewer employees can purchase qualified health insurance coverage. The Exchanges will become operational by Jan. 1, 2014. The open enrollment period for Exchanges begins on Oct. 1, 2013, and ends on March 31, 2014, but individuals may apply outside of the open enrollment period if they qualify for a special enrollment period.

CMS anticipates that 90 percent of Exchange applications from individuals and small employers will be submitted online. For small employers, this figure reflects CMS’ expectation that 85 percent of applications will be facilitated by a broker who will be required to submit information electronically. In all instances, as required, the individual and SHOP enrollment applications will be a single, streamlined form that will be used to determine Exhange eligibility and to collect the information necessary for a qualified individual, employer, or employee, to purchase coverage through an Exchange. Application may be made online, using a paper application, over the phone through a call center operated by an Exchange, or in person through an agent, broker, or Navigator. CMS has developed these applcations.

The four items are the following:

1. Initial Plan Data Collection to Support Qualified Health Plan (QHP) Issuer and Plan Qualifications. Data necessary for QHP certification, ongoing oversight, financial management, eligibility, and enrollment functions, including information to be displayed on the Exchange website and to support other Exchange business functions such as determinations of the second-lowest-cost-(silver) plan, payments for cost-sharing reductions. The data collection requirements also apply for stand-alone dental plans. Among the data elements to be collected for QHPs are accreditation, service area, benefits and associated cost-sharing and limits, summary of benefits and coverage, prescription drug formulary information, and reinsurance and risk adjustment.

2. Certification and Other Financial Management and Exchange Operations Data Collection to Support Eligibility Determinations and Enrollment for Employees in the SHOP. If an employee does not enroll in coverage through the SHOP, the information will be erased after a specified period of time. If an employee enrolls in coverage through the SHOP, the information will be retained to document the enrollment, to allow reconciliation with issuer records, and to provide information for future coverage renewals or changes in coverage. The applicant must sign the application to the SHOP, and a process to use an electronic signature is being developed. The online application process will be available by Oct. 1, 2013. Generally, qualified employees will provide or confirm this information annually, but also when the employee experiences changes in enrollment or eligibility. Information must be submitted to ensure that employees and their dependents are enrolled or disenrolled in a timely manner and that employers receive the correct monthly bill in order to make accurate payroll deductions.

3. Data Collection to Support Eligibility Determinations and Enrollment for Small Businesses in the SHOP. Through the SHOP, the new Exchanges will assist qualified small employers in enrolling their employees in QHPs offered in the small group market. If an employer does not complete the application, the information will be erased after a specified period of time. If an employer completes the application and offers coverage to qualified employees through the SHOP, the information will be retained to document the offer of coverage, to allow reconciliation with issuer records, and to provide information for future coverage renewals or changes in coverage. The single employer application will be available both as a paper form and an online process. The online version will be part of an interactive website that further simplifies the application process by determining which questions to ask based on answers given to previous questions. This process ensures that applicants answer as few questions as necessary in order to receive an eligibility determination. The application is not yet available for completion electronically.

4. Data Collection to Support Eligibility Determinations for Insurance Affordability Programs and Enrollment through Exchanges, Medicaid and Children’s Health Insurance Program Agencies. For eligible individuals who enroll in a QHP through an Exchange, the ACA provides for a premium tax credit that is available on an advanced basis (“Advance Payments of the Premium Tax Credit”, or APTC) to reduce the monthly insurance costs and cost-sharing obligations, including co-pays and deductibles. CMS is working to develop and provide to each state a single, streamlined form that may be used to apply for coverage through the Exchange and Insurance Affordability Programs, including APTC/CSR, Medicaid, CHIP, and the Basic Health Program, if applicable.

Appendix B provided with the CMS item contains the list of data elements needed to determine eligibility for an individual applying to directly enroll in a QHP through the Exchange (not applying for Insurance Affordability Programs), while Appendix A contains the list of data elements needed to determine eligibility for APTC/CSR through the Exchange.

In preparing the applications, the CMS consulted extensively with major stakeholders and says it intends to further consult with states, consumer groups, brokers, community-based organizations, health providers and tribal leaders, and to conduct consumer focus groups and “engage experts in simplifying language and promoting a positive user experience.”

The Congressional Budget Office (CBO) estimated in March 2012 that approximately 20 million people will apply for coverage through the Exchanges and Insurance Affordability Programs in 2014 with an additional six and ten million in 2015 and 2016, respectively.