Other Resources

Consumer Support and Information
Content Requirements for Healthcare.gov
Pre-Existing Condition Insurance Plan (PCIP)
Early Retiree Reinsurance Program (ERRP)
Affordable Insurance Exchanges
- Planning and Establishment Grants
Consumer Operated and Oriented Plan (CO-OP) Program
Health Insurance Market Reforms
Premium Stabilization Programs
COBRA
Reports
- GAO Report: “Private Health Insurance: Data on Application and Coverage Denials”

Consumer Support and Information

Consumer Assistance Program Grants

Reports

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

External Appeals

Summary of Benefits and Coverage and Uniform Glossary

Forms

Summary of Benefits and Coverage (SBC) Template
- Standard Format (Authorized for second year of applicability) (DOC – 182 KB)
- Accessible Format (Authorized for second year of applicability) (PDF – 366 KB)
- Standard Format (Authorized for first year of applicability) (DOC - 175 KB)
- Accessible Format (Authorized for first year of applicability) (PDF - 607 KB)
- Chinese (DOC – 54 KB)
- Chinese (PDF- 565 KB)
- Navajo (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 (PDF – 258 KB)
- Navajo - Oral Translation (MP3 – 21 MB)
- Spanish (DOC – 170KB)
- Spanish (PDF – 458 KB)
- Tagalog (DOC – 71 KB)
- Tagalog (PDF – 446 KB)
Uniform Glossary
- English (PDF – 140 KB )
- Chinese (PDF – 226 KB)
- Navajo (PDF – 400 KB)
- Navajo - Oral Translation (MP3 – 26 MB)
- Spanish (PDF – 349 KB)
- Tagalog (PDF - 145 KB)

Instructions/Guidance

Sample Completed SBC
- Standard Format (Authorized for second year of applicability) (DOC – 206 KB)
- Accessible Format (Authorized for second year of applicability) (PDF – 431 KB)
- Standard Format (Corrected, May 11, 2012) (DOC - 200 KB)
- Accessible Format (Corrected, May 11, 2012) (PDF - 533 KB)
Instructions for Completing the SBC – Group Health Plan Coverage (PDF – 89 KB)
Instructions for Completing the SBC – Individual Health Insurance Coverage (PDF – 81 KB)
Why This Matters language for SBC "Yes" Answers
- English (PDF – 120 KB)
- Chinese (PDF-159 KB)
- Navajo (PDF-641 KB)
- Navajo Oral Translation (MP3 – 7 MB)
- Spanish (PDF – 288 KB)
- Tagalog ( PDF – 111 KB)
Why This Matters language for SBC "No" Answers
- English (PDF – 92 KB)
- Chinese (PDF – 147 KB)
- Navajo (PDF – 446 KB)
- Navajo - Oral Translation (MP3 – 4.4 MB)
- Spanish (PDF – 292 KB)
- Tagalog (PDF- 107 KB)
Guide for Coverage Examples Calculations – Maternity Scenario
- Standard Format (XLSX – 91 KB)
- Accessible Format (PDF – 98 KB)
Guide for Coverage Examples Calculations – Diabetes Scenario
- Standard Format (Corrected May 11, 2012) (XLSX - 56 KB)
- Accessible Format (Corrected May 11, 2012) (PDF - 343 KB)
Narrative for Maternity Scenario (PDF – 11 KB)
Narrative for Diabetes Scenario (PDF – 11 KB)
Checklist for Coverage Calculator (PDF – 43 KB)
Coverage Examples Calculator Instructions (PDF – 274 KB)
Coverage Examples Calculator Logic (PDF – 91 KB)
Coverage Examples Calculator (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 Healthcare.gov

Q&A

March 28, 2013
HCR Plan Finder Data Entry

Instructions/Guidance

March 28, 2013
Plan Finder State User Manual (PDF – 1.4 MB)
Plan Finder Issuer User Manual (PDF - 1.6 MB)
HIOS Portal User Manual (PDF – 2.54 MB)
Rate and Benefits Information System (RBIS) User Manual (PDF – 3.7 MB)

Forms

September 26, 2011
RBIS Issuer Data Entry Forms (ZIP - 1 MB)
October 27, 2011
HIOS Issuer Data Entry Form (XLS – 2 MB)
December 12, 2011
RBIS Individual Market Issuer Data Entry Forms (ZIP – 26 MB)

Pre-Existing Condition Insurance Plan (PCIP)

Data

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

Reports

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

Early Retiree Reinsurance Program (ERRP)

Reports

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

Affordable Insurance Exchanges

Presentations

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

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 - 731 KB)
November 9, 2012
Frequently Asked Questions on the Blueprint for Exchanges
April 30, 2013
Marketplace Consumer Application
- Individual Short Form (PDF - 668 KB)
- Family (PDF - 820 KB)
- Individual without Financial Assistance (PDF - 419 KB)

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

Coverage for Young Adults

Data

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

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 – 50 KB)
- MLR Quarterly Reporting Form for Expatriate Plans (XLS – 52 KB)
- MLR Quarterly Reporting Form Instructions (PDF – 68 KB)
June 17, 2011
Medical Loss Ratio (MLR) 2011 Quarterly Reporting Form Instructions
Please note that these instructions replace an earlier version that had several minor inconsistencies. In addition, these instructions clarify that an issuer who submits reports for more than one State may choose either to submit Excel worksheets for each State report in separate Excel files or to combine the worksheets into a single Excel file.
MLR Quarterly Reporting Form Instructions (PDF – 70 KB)
May 11, 2012
Medical Loss Ratio (MLR) 2011 Annual Reporting Form (OMB 0938-1164)
- MLR Annual Reporting Form (XLSX - 119 KB)
- MLR Annual Reporting Form Instructions (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 – 38 KB)
- Notice to Group Policyholders and Their Subscribers, Rebate Sent to the Policyholder (Notice #2) (PDF - 54 KB)
- Notice to Subscribers of Group Policyholders, Rebate Sent to the Subscribers (Notice #3) (PDF - 41 KB)
- Instructions for Notices 1, 2 and 3 (PDF - 87 KB)
May 16, 2012
Notice to Policyholders and Subscribers when MLR Standard is Met (PDF - 15 KB)
February 22, 2013
Paperwork Reduction Act (PRA) display of Medical Loss Ratio (MLR) 2012 Annual Reporting Form (click on “CMS-10418”)
March 29, 2013
- MLR 2012 Annual Reporting Form (XLSX – 116 KB)
- MLR 2012 Annual Reporting Form Instructions (PDF – 639 KB)
- MLR 2012 Annual Reporting Form Calculator and Formula Tool (XLSM - 102 KB)

Reports:

June 21, 2012
The 80/20 Rule: Providing Value and Rebates to Millions of Consumers - Opens in a new window
February 15, 2013
The 80/20 Rule: How Insurers Spend Your Health Insurance Premiums

Patient’s Bill of Rights

Q&A

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

Data

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

Methodology

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

Review of Insurance Rates

May 27, 2011
Paperwork Reduction Act (PRA) display of Rate Increase Disclosure and Review Reporting Requirements - Opens in a new window (click on “CMS-10379”)
July 29, 2011 (Update October 11, 2011: rate review training manuals, instructions, and other materials are now located under Training Resources. Please click on the link below.)
Rate Review Training Resources
September 20, 2011
Report: Early Achievements of Health Insurance Rate Review Grants (PDF - 268 KB)
Note: The Cycle II proposal summary for the California Department of Managed Health Care was corrected on September 22, 2011.
September 11, 2012
Annual Rate Review Report
February 22, 2013
Paperwork Reduction Act (PRA) display of Rate Increase Disclosure and Review Reporting Requirements (click on “CMS-10379”)
This template, used to meet Part I reporting requirements, will be available for download and use via HIOS.