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FFE and FF-SHOP EnrollmentFederally-Facilitated Exchange (FFE) andFederally-Facilitated Small BusinessHealth Options Program (FF-SHOP)Enrollment ManualThis manual is effective as of August 18, 2021. All enrollments made on or after August 18,2021, should be processed in accordance with the operational requirements set forth in thisdocument.CMS intends to update this manual regularly and publish clarifying bulletins between updates.All previous versions of bulletins that have been incorporated into this version of the manualshould be considered superseded by this manual. If you have questions related to content postedwithin this manual, please email CMS FEPS@cms.hhs.gov.The contents of this document do not have the force and effect of law and are not meant to bindthe public in any way, unless specifically incorporated into a contract. This document is intendedonly to provide clarity to the public regarding existing requirements under the law.i

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FFE and FF-SHOP EnrollmentTable of ContentsINTRODUCTION AND SCOPE. 1Background. 1Types of Exchanges . 1Purpose of Document . 2Acronyms and Definitions . 2Acronyms . 2Definitions. 4Additional Resources . 8ENROLLMENT IN THE INDIVIDUAL FFEs (APPLICABLE TO QHPs/QDPs). 10Eligibility . 11Requirement to File and Reconcile Past APTC . 11Medicaid & CHIP Eligibility . 12Open Enrollment and Coverage Effective Dates. 12Enrollment Transactions . 13Initial Enrollment Transaction . 16Confirmation of the 834 Transaction in Individual Market FFEs. 16Cancellations in the Individual Market FFEs. 17Fraud Cancels Related to Approved Rescissions and Unauthorized Enrollments . 18Free Look Provisions in the Individual Market FFEs (Applicable to QHPs/QDPs). 19Application and Enrollment Changes . 20Age Rating and Accumulators . 21REDETERMINATIONS AND RENEWALS IN THE INDIVIDUAL MARKET FFEs(ANNUAL OPEN ENROLLMENT) . 23Introduction . 23Reenrollment . 25Active Reenrollment . 25Passive Reenrollment/Batch Auto-Reenrollment . 25BAR Operational Process . 27Alternate Enrollments . 27Reenrollment Communications to Enrollees . 28BAR Failure Report to Issuers . 29Enrollment Transaction Types . 29Identifiers on Enrollment Transactions . 31iii

FFE and FF-SHOP EnrollmentCSR & APTC Calculations on Passive Reenrollments. 36Additional Files and Transactions to Support Issuers with Auto-Renewal . 36Enrollee Switch File . 36Passive Cancel Job . 37Cancel Carry Forward Job . 37BAR Progress Report . 37Effectuation at Reenrollment and CIC . 37Life Changes During the OEP . 38Tobacco Rating at Time of Reenrollment . 38Medicare Enrollment and Non-Renewals . 38ENROLLMENT IN THE FF-SHOP (APPLICABLE TO FF-SHOPs AND UNLESSOTHERWISE NOTED, SBE-FPs FOR SHOPs, QHPs/QDPs) . 41Eligibility and Enrollment . 41Retirees . 42COBRA . 42Minimum Participation Rates in the FF-SHOP . 42Initial Enrollment. 42Special Enrollment Periods . 43FF-SHOP Appeals . 43Plan Compare (See Plans and Prices) . 44FF-SHOP Hotline Functionality . 44Qualified Employers . 44Cases of Suspected Fraud or Ineligibility . 44Cancellations and Terminations in the FF-SHOPs . 44Renewals in the FF-SHOPS. 44Dependent Age-Offs in the FF-SHOPs . 44FF-SHOP Required Notices . 45DIRECT ENROLLMENT (APPLICABLE TOTHE INDIVIDUAL MARKET FFEs,QHPs/QDPs) . 46Guidelines for Specific QI Scenarios . 47Applicant Not Eligible for QHP Enrollment. 47Applicant is Eligible for QHP Enrollment and APTC/CSR . 47Applicant is Eligible for QHP Enrollment but Not for APTC/CSR . 47Applicant is Eligible for Medicaid or CHIP . 48Households that Include QIs Eligible for Different Coverage Programs. 48Enrollment Groups . 49iv

FFE and FF-SHOP EnrollmentQHP Display Guidance . 50QHP Issuer DE Entities. 50Web-Broker DE Entities . 53Mandatory Display Language for Consumers That Attest to a Health ReimbursementArrangement Offer . 58Mandatory Attestations . 58SPECIAL ENROLLMENT PERIODS (APPLICABLE TO INDIVIDUAL MARKET FFEs,QHPs/QDPs) . 60SEP Pre-Enrollment Verification . 60Plan Category Limitations for SEPs . 61PCL Background. 61Availability and Length of SEPs . 62SEP Triggering Events and Coverage Effective Dates . 63Regular Coverage Effective Dates . 63Other Coverage Effective Dates . 63SEPs Accessed Outside of the Application Process . 74Exceptional Circumstances SEPs . 75Plan Display Errors . 77Identifying and Resolving Plan Errors . 78Processing Plan Display Error SEPs . 80PREMIUMS (APPLICABLE TO INDIVIDUAL MARKET FFEs, QHPs/QDPs) . 82Effectuation of Prospective Coverage Under Regular Coverage Effective Dates and SpecialEffective Dates . 82Effectuation of Coverage with a Retroactive Effective Date Associated with an SEP thatis Not Verified. 82Payment for Reenrollments . 84Binder Payment Extensions Directed by the Exchange or State Authority . 84Premium Payment Threshold . 85Terminations for Non-Payment of Premiums . 86Examples . 87Issuer Option to Condition New Enrollment on Payment of Past Due Premium . 88Enrollment Transactions Received for a Subscriber Whose Coverage is BeingTerminated . 89Additional Non-Payment Examples. 92Grace Periods for Enrollees Receiving the Benefit of APTC . 95Claims Pended by an Issuer During a Three-Consecutive-Month Grace Period forEnrollees Receiving the Benefit of APTC . 95v

FFE and FF-SHOP EnrollmentGrace Periods Ending After the End of the Annual Open Enrollment Period . 96Grace Periods Ending on or Before December 31 . 98Termination Occurring During a Grace Period . 98Involuntary Termination Due to a Citizenship/Immigration Status InconsistencyExpiration During a Grace Period . 99Termination of APTC During a Grace Period . 100Processing Fees and Premium Payments . 100Over-Billed Premiums . 100Under-Billed Premiums . 101Examples . 101Collections and Grace Periods for Non-Payment of Under-Billed Premium . 101Voluntary Termination of Coverage During Repayment of Under-Billed Premium . 103Payment Redirect . 104Premium Payment Methods . 105Payment of Premium by a Third-Party . 105Enforcement Discretion Regarding FEMA-Designated Natural Disasters . 106TERMINATIONS (APPLICABLE TO THE INDIVIDUAL MARKET FFEs, SBE-FPs,QHPs/QDPs) . 107Enrollee Requested Terminations . 107Termination of an Enrollee’s Coverage in the FFE Due to Report of Death . 108Aging-Off Terminations . 109Issuer Termination Notice Requirements . 109Examples . 110REINSTATEMENTS (APPLICABLE TO INDIVIDUAL MARKET FFEs, QHPs/QDPs) . 111Reinstatements in the FFEs . 111ENROLLMENT DATA ALIGNMENT (APPLICABLE TO INDIVIDUAL MARKETFFEs, QHPs/QDPs) . 114Inbound 834 (IC834) . 116Enrollment Reconciliation & Pre-Audit Files . 118Resolution of Enrollment and Payment Discrepancies (Disputes) . 120Payment Disputes. 121Enrollment Disputes . 122HICS Direct Dispute Process . 124SEED (System of Exchange Enrollment Data) . 125SEED Resources . 125FORMS 1095-A GENERATION AND CORRECTIONS . 126vi

FFE and FF-SHOP EnrollmentForm 1095-A Initial Generation Process . 126Examples . 127Anatomy of a Form 1095-A . 128Form 1095-A Part 1: Recipient Information . 128Form 1095-A Part II: Covered Individuals . 128Form 1095-A Part III: Coverage Information . 129How Issuers Should Answer Enrollee Questions About Forms 1095-A. 129Basic Form 1095-A Questions Issuers May Answer . 130Enrollee Questions to Be Directed to the IRS or the Tax Filer’s Tax Preparer . 130Enrollee Questions to Be Directed to the Exchange . 130Form 1095-A Basics for Assisting QHP Enrollees . 130Form 1095-A Reprints and Corrections . 131Form 1095-A Corrections Process: Additional Information . 132Impact of Prior Year Appeals . 133Steps to Follow for Prior Year Appeal Adjudications . 134ELIGIBILITY CHANGES FOR THE DUALLY ENROLLED AND DECEASED . 135Periodic Data Matching . 135Medicaid/CHIP Periodic Data Matching . 136Medicare Periodic Data Matching. 136Medicare Anti-Duplication. 137Deceased Enrollee Periodic Data Matching . 138ADDRESSING INDIVIDUAL-REPORTED UNAUTHORIZED ENROLLMENTS &ISSUER-REPORTED FRAUDULENT ENROLLMENTS . 139Individual Complaints Alleging Unauthorized Enrollments . 139Operational Process for Cancelling Unauthorized Enrollments. 139Issuers’ Requests: Examples of Elements Demonstrating an Appropriate Rescission ofQHPs in the Exchanges. 141Reporting Fraudulent Enrollments . 141IMPLEMENTATION OF ELIGIBILITY APPEAL DECISIONS AND RELATEDENROLLMENTS IN THE FFEs . 144Background. 144CMS Role . 145Notify Issuer to Implement an Appeal Decision . 145Notify Issuer to Implement a Request for Eligibility Pending Appeal . 145Notify Issuer to Discontinue Eligibility Pending Appeal and Implement the AppealDecision . 145vii

FFE and FF-SHOP EnrollmentIssuer Role . 146Enrollment Requirements . 146HICS Case Resolution Requirements . 147Appeal Decision Scenarios. 148Impact of Appeals on Reconciliation . 153HEALTH INSURANCE CASEWORK SYSTEM . 155HICS Access. 155HICS Category Use . 155HICS Casework and Expectations . 156HICS Casework Best Practices . 157DATA MATCHING ISSUES MONTHLY PROCESSES . 159Background. 159What Are Data Matching Issues or Inconsistencies? . 159How Does an Enrollee Know if He or She Has an Income DMI? . 159Exchange DMIs Issuer Outreach Files Delivery Processes and Impact to Enrollees . 159DMIs Outreach Schedule and Process . 160Exchange DMI File Delivery Schedule . 161Late Submission of Documentation for DMIs . 161HEALTH REIMBURSEMENT ARRANGEMENTS . 163Individual Coverage HRA and QSEHRA Employer Notice Requirements . 163Individual Coverage HRA/QSEHRA SEP. 164Individual Coverage HRA/QSEHRA Affordability. 165ENROLLMENT COMMUNITY FOR CONTACT MANAGEMENT & INQUIRIES . 167Organizations in the Enrollment Community . 167APPENDIX A – SAMPLE WELCOME LETTER . 169APPENDIX B – SAMPLE NON-PAYMENT NOTICE FOR THE INDIVIDUALMARKET WHERE THE ISSUER HAS ADOPTED THE PAYMENT POLICYATTRIBUTING PREMIUM PAYMENTS TO PAST DUE PREMIUMS BEFORE BINDERPAYMENTS FOR NEW ENROLLMENT . 171APPENDIX C – SAMPLE NON-PAYMENT NOTICE FOR THE INDIVIDUALMARKET WHERE THE ISSUER HAS NOT ADOPTED THE PAYMENT POLICYATTRIBUTING PREMIUM PAYMENTS TO PAST DUE PREMIUMS BEFORE BINDERPAYMENTS FOR NEW ENROLLMENT . 173APPENDIX D – SAMPLE TERMINATION LETTER . 175List of ExhibitsExhibit 1: Commonly Used Acronyms . 2viii

FFE and FF-SHOP EnrollmentExhibit 2: Additional Resources . 8Exhibit 3: FFE Enrollment Process. 10Exhibit 4: Coverage Effective Dates for the FFE OEP. 13Exhibit 5: Retroactive Enrollment Reasons and Dates . 14Exhibit 6: Retroactive Termination Reasons and Dates . 15Exhibit 7: Retroactivity Examples . 15Exhibit 8: Process for Reporting Changes . 20Exhibit 9: Reportable Changes . 21Exhibit 10: Passive Reenrollment Codes . 30Exhibit 11: NPN Rules . 31Exhibit 12: Reenrollment Transaction Illustration. 32Exhibit 13: Multiple Transactions Illustrated for a Single Enrollment . 35Exhibit 14: SEP Triggering Events and Coverage Effective Dates Summary. 65Exhibit 15: SEP Effective Date Examples . 74Exhibit 16: Sample SEP Coverage Effective Dates for FEMA-Emergency Affected Individuals . 76Exhibit 17: Identifying and Correcting Plan Display Errors That May Qualify for SEPs . 79Exhibit 18: Resolving Plan Display Error SEPs . 80Exhibit 19: Premium Payment Threshold Lifecycle . 86Exhibit 20: Example Timeline . 90Exhibit 21: Example Timeline . 91Exhibit 22: Volume of Policy Updates Performed . 116Exhibit 23: PPR-820 Payment Dispute Process. 121Exhibit 24: Enrollment Dispute Process . 122Exhibit 25: HICS Direct Dispute Process . 124Exhibit 26: Form 1095-A Generation Process Overview . 126Exhibit 27: Form 1095-A Elements . 128Exhibit 28: Recipient Information Section . 128Exhibit 29: Covered Individuals Section . 129Exhibit 30: Coverage Information Section . 129Exhibit 31: Appeal Decision Scenarios . 148Exhibit 32: Example Delivery and Transaction Schedule . 161Exhibit 33: User Types . 167Exhibit 34: Enrollment Community for Contact Management & Inquiries . 167ix

FFE and FF-SHOP EnrollmentINTRODUCTION AND SCOPEBackgroundThe Patient Protection and Affordable Care Act (Pub. L. 111–148) was enacted

Enrollment Manual. This manual is effective as of August 18, 2021. All enrollments made on or after August 18, 2021, should be processed in accordance with the operational requirements set forth in this document. CMS intends to update this manual regularly and publish clarifying bulletins between updates.