Blueprint for Approval of Affordable State-based and State Partnership Insurance Exchanges - Frequently Asked Questions
Below are a number of Frequently Asked Questions (FAQs) regarding the approval process for Affordable Insurance Exchanges as set forth in the Blueprint for Approval of Affordable State-based and State Partnership Insurance Exchanges.
Table of Contents
May 16, 2012
Q1: My State is pursuing a State-based Exchange or a State Partnership Exchange for plan year 2014 (beginning on October 1, 2013). What do we need to do now?
A1: A State that intends to pursue a State-based Exchange or a State Partnership for 2014 should prepare to submit an Exchange Blueprint, which is comprised of two parts:
■ An Exchange Model Declaration Letter from your Governor; and
■ An Application describing readiness to perform Exchange activities and functions.
The Exchange Blueprint is due no later than 30 business days prior to January 1 (i.e., on or before November 16, 2012, for plan year 2014). The Exchange Model Declaration may be submitted with the Application or before submission of the Application. If a State’s model Declaration Letter is received at least 20 business days prior to the Application, a State may request a Blueprint consultation where CMS will provide technical assistance and guidance to the State in completing the Application.
Note: Please see revisions to this answer below under “Blueprint Submission Deadline.”
Q2: My State is considering a Federally-facilitated Exchange. Is there anything we need to do?
A2: A Blueprint Application is not required. However, it is recommended that your Governor submit an Exchange Model Declaration Letter as described in the Exchange Blueprint. This will improve service to your residents by helping to ensure alignment between your existing State markets and the Federally-facilitated Exchange.
Q3: What happens if my State does not submit a Declaration Letter to HHS about its decision to pursue an Exchange Model?
A3: If a State does not choose an Exchange model, HHS will assume that the State is not planning to operate as a State-based Exchange or a State Partnership Exchange. HHS will operate the Federally-facilitated Exchange in the State and will perform the Exchange-related programs of risk adjustment and reinsurance. Your State will work with the Center for Medicaid and CHIP Services within CMS to determine whether the Federally-facilitated Exchange will make eligibility determinations or assessments for these programs.
Q4: Are there any advantages for a State if it submits a Declaration Letter prior to the submission of its Exchange Blueprint?
A4: Yes. A State pursuing a State-based Exchange or a State Partnership Exchange will be offered an opportunity to consult with CMS staff to discuss the Application portion of the Blueprint (“Blueprint Consultation”) when its Model Declaration Letter is received, provided the letter is received at least 20 business days prior to the submission of the application. A Blueprint Consultation is optional; it provides a State with the opportunity to ask questions and receive feedback on the preparation of the remainder of its Exchange Blueprint, prior to submission.
Q5: Where can I find the Blueprint? Must the application be filed electronically?
A5: The Blueprint Declaration Letter must be submitted through an email to State.Exchange.Group@cms.hhs.gov, as well as mailed to CMS Center for Consumer Information and Insurance Oversight (CCIIO), 200 Independence Ave SW, Suite 739H, Washington, DC 20201. The Blueprint Application must be submitted electronically, and will be available on the State Exchange Resource and Virtual Information System (SERVIS), available at: https://servis.cms.gov - Opens in a new window on September 14, 2012. The individual(s) designated by the Governor in the Model Declaration Letter may complete and electronically sign the application.
Q6: When will approval of the Exchanges be granted by HHS?
A6: The Affordable Care Act directs HHS to make initial Exchange approval determinations no later than January 1, 2013, for Exchange operation in plan year 2014. However, States that submit their Blueprints early may receive an earlier determination. States seeking HHS approval to operate an Exchange for coverage years beginning after 2014 (e.g., plan year 2015 beginning on October 1, 2014), will submit a Model Declaration Letter and Blueprint in accordance with the same process and timeframes specified for States seeking to operate an Exchange, beginning January 1, 2014.
Q7: What information is required for the Blueprint?
A7: States are asked to submit a compilation of attestations, descriptions of processes, supporting documentation and reference files. The State may be asked to provide additional information after the Blueprint has been submitted, as determined necessary by CMS. In addition to completing the Exchange Blueprint, HHS may conduct on-site or virtual Exchange assessments, as part of its verification of an Exchange’s operational readiness. HHS will use the results from a State’s Reference File submissions to determine the timing for a State’s operational readiness assessment. HHS will make an approval or conditional approval decision based on the documentation and the completed Exchange Blueprint.
Additionally, the Establishment Review process has been designed to support States as they work toward Exchange approval. States may submit documentation from HHS that confirms successful Establishment Review performance, in place of certain Blueprint required documentation.
Q8: What are reference files?
A8: These are files and documentation that the State will submit to demonstrate its Exchange’s ability to perform a particular Exchange activity. Where noted, the State may attest to having received confirmation from HHS of successfully providing the relevant documentation as part of the Establishment Review. In such cases, the State does not need to upload the files, and HHS will confirm the State’s submitted files and documentation from the Establishment Review conducted during oversight of the § 1311(a) grants to ensure adequate compliance related to the activity. The following provides a description of the types of reference files that may be required:
a. Summary of results of State-developed testing: These summaries document comprehensive State-defined and executed system testing, including details of Exchange activities tested, the scope of testing activities conducted, and metrics detailing the results of that testing as they relate to each designated Exchange Blueprint requirement.
b. Results of State execution of CMS-developed test scenarios: These scenarios will be developed by CMS to confirm implementation of those Exchange activities that require standardization across all State Exchanges. These scenarios will be released to a central Test Library on the Collaborative Application Lifecycle Tool (CALT).
c. Summary of Independent Verification & Validation (IV&V) of applicable system components: These reports by an independent third party provide verification and validation that designated Exchange activities are built and operating as designed and in compliance with documented requirements.
Q10: What standard will be used for approval of a State-based Exchange?
A10: HHS will approve a State-based Exchange if the Blueprint and any additional operational readiness testing demonstrate that the State-based Exchange has the ability to perform Exchange activities. HHS recognizes that States will be in various stages of the Exchange development lifecycle and that some systems-development and contracting activities associated with building an operational Exchange will need to occur in 2013. Therefore, HHS will consider approving a State-based Exchange with conditions to operate for plan year 2014.
Q11: If my State cannot demonstrate that it meets all Exchange activity requirements, what will happen?
A11: HHS may Conditionally Approve an Exchange if the State can demonstrate that significant progress is being made on Exchange activities (listed in the Blueprint) at a pace that ensures that the State will have an operational Exchange by the initial open enrollment period (October 1, 2013).
Q12: What does a State need to do if it receives a conditional approval of its Exchange?
A12: A State that receives a Conditional Approval of its Exchange will be expected to sign an agreement that outlines the terms and conditions of its Conditional Approval determination. The agreement will include provision(s) that the Exchange adhere to monitoring reviews by HHS to ensure that the establishment of the Exchange continues to progress at a pace that will allow it to be operational for the initial open enrollment period. The frequency and focus of the monitoring reviews will depend upon the Exchange activities that remain outstanding. Technical assistance and systems testing will also provided in all States that receive Conditional Approval. In addition, HHS will approve a State to operate its Exchange once it has successfully completed an Operational Readiness assessment.
Q13: How long can a State stay conditionally approved?
A13: A State Exchange will remain Conditionally Approved until it meets all Approval requirements.
Q14: Can a State reference documents in its Blueprint that were submitted to CMS during the State’s Establishment Review?
A14: Yes. States that have received notification from CMS of their successful completion of portions of the Establishment Review may be able to reference the information as responses to certain sections of the Blueprint.
Q15: If a State has questions about the Exchange Blueprint, who is the appropriate contact person?
A15: The State’s State Officer at the CCIIO is the point of contact for all questions related to the Exchange Blueprint submission. General questions may be directed to State.Exchange.Group@cms.hhs.gov
November 9, 2012
Q1: When does a state have to tell the Centers for Medicare & Medicaid Services (CMS) that it wants to establish a State-based Exchange for 2014?
A1: In order for CMS to provide a state with technical resources and support necessary to meet the January 1, 2013, approval/conditional approval statutory deadline, a state that intends to establish a State-based Exchange must submit a Declaration Letter by Friday, November 16.
Q2: If a state wants to establish a State-based Exchange, when is the Blueprint Application due? What about the Declaration Letter?
A2: In order to provide states with more time to create a comprehensive Blueprint Application that is fully representative of their work, the Department of Health and Human Services (HHS) extended the deadline for State-based Exchange Blueprint Applications to Friday, December 14, 2012. Declaration Letters for State-based Exchanges remain due on Friday, November 16, 2012. CMS encourages states to begin working with the Center for Consumer Information and Insurance Oversight (CCIIO) on their Blueprint Applications as early as possible in order to identify any issues early and to receive feedback on their Blueprint Applications. A state may also submit its Blueprint Application prior to the deadline.
Q3: My state is ready to declare that it intends to establish a State-based Exchange, but still needs more time to determine whether it will establish and operate Risk Adjustment and Reinsurance programs. What should my state do?
A3: If a state knows what Exchange Model it intends to pursue, and who is the appropriate designee to execute the Declaration Letter, CMS encourages each state to submit a Declaration Letter on or before November 16, 2012. If a state has concerns about whether its decisions will be made by mid-November 2012, please talk to your CCIIO State Officer about your options. An interested state must commit to running either program in their Blueprint Application (Sections 5.1 and 5.2) that is due December 14, 2012. Please keep in mind that only a State that has elected to operate a State-based Exchange (not a State that has elected to participate in a State Partnership Exchange) can operate a risk adjustment program, or the State-based Exchange can defer its operation to the federal government. A state may elect to establish and operate a reinsurance program regardless of the Exchange model selected.
Q4: My state is not sure it wants to establish and operate a State-based Exchange, but we want to be involved in our Exchange. What options do we have?
A4: CMS established the option for states to pursue a State Partnership Exchange, where a state can work with CMS and elect to operate the Plan Management functions, Consumer Assistance functions, or both within the Federally-facilitated Exchange established for your state. States have until Friday, February 15, 2013, to submit a Declaration Letter and Blueprint Application declaring what partnership role they would like to have in operating the Exchange in their states. Ultimately, CMS wants as many states involved in operating Exchange as possible and we encourage states to talk with their CCIIO State Officer to discuss the partnership options.
Q5: If a state is ready to submit its Blueprint Application, does it have to wait until December 14, 2012?
A5: No, a State may submit its Blueprint Application for State-based Exchanges any time before December 14, 2012, and for State-Partnership Exchanges any time before February 15, 2013.
Q6: If a state applies to establish a State-based Exchange and later decides it would rather be a State Partnership Exchange in 2014, can it change its mind?
A6: Yes, if a state applies to establish a State-based Exchange for plan year 2014 and later decides it is more prepared to operate as a State Partner, it can move into a State Partnership model. States should contact their CCIIO State Officer as early as possible to begin the transition.
Q7: If a state has a State Partnership Exchange in 2014, can it move to a State-based Exchange in 2015?
A7: Yes. If a state decides to be a State-based Exchange for plan year 2015, it will have to submit its State-based Exchange Declaration Letter and Blueprint Application, completing all the relevant additional sections. For the 2015 plan year, the Declaration Letter and Blueprint Application are due November 18, 2013, and December 16, 2013, respectively. It can also establish a State-based Exchange in subsequent years.