FFE and FF-SHOP Enrollment
i
Federally-facilitated Exchange (FFE) and
Federally-facilitated Small Business Health
Options Program (FF-SHOP) Enrollment
Manual
This manual is effective as of July 28, 2022. All enrollments made on or after July 28, 2022,
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.
All previous versions of bulletins that have been incorporated into this version of the manual
should be considered superseded by this manual. If you have questions related to content posted
within this manual, please email [email protected].
The contents of this document do not have the force and effect of law and are not meant to bind
the public in any way, unless specifically incorporated into a contract. This
document is intended
only to provide clarity to the public regarding existing requirements under the law.
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TABLE OF CONTENTS
Introduction and Scope ........................................................................................................................ 1
Background................................................................................................................................... 1
Types of Exchanges ...................................................................................................................... 1
Purpose of Document ................................................................................................................... 2
Acronyms and Definitions ........................................................................................................... 2
Acronyms .......................................................................................................................... 2
Definitions ......................................................................................................................... 4
Additional Resources ........................................................................................................ 9
Enrollment in the Individual FFE (Applicable to QHPs/QDPs) ..................................................... 10
Eligibility ..................................................................................................................................... 11
Requirement to File and Reconcile Past APTC .............................................................. 11
Medicaid and CHIP Eligibility........................................................................................ 12
Open Enrollment and Coverage Effective Dates ..................................................................... 12
Enrollment Transactions ........................................................................................................... 13
Initial Enrollment Transaction ........................................................................................ 16
Confirmation of the 834 Transaction in Individual Market FFE .................................... 16
Cancellations in the Individual Market FFE ................................................................... 17
Fraud Cancels Related to Approved Rescissions and Unauthorized Enrollments .......... 18
Free Look Provisions in the Individual Market FFE (Applicable to QHPs/QDPs) ........ 19
Application and Enrollment Changes ...................................................................................... 20
Age Rating and Accumulators ........................................................................................ 22
Electronic Notice Requirements ............................................................................................... 23
Redeterminations and Renewals in the Individual Market FFE (Annual Open Enrollment) ..... 24
Introduction ................................................................................................................................ 24
Reenrollment .............................................................................................................................. 26
Active Reenrollment ....................................................................................................... 26
Passive Reenrollment/BAR ............................................................................................. 26
BAR Operational Process ............................................................................................... 28
Alternate Enrollments ..................................................................................................... 28
R
eenrollment Communications to Enrollees .................................................................. 29
BAR Failure Report to Issuers ........................................................................................ 29
Enrollment Transaction Types ................................................................................................. 30
Identifiers on Enrollment Transactions ........................................................................... 32
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CSR and APTC Calculations on Passive Reenrollments ................................................ 38
Additional Files and Transactions to Support Issuers with Auto-Renewal .......................... 38
Enrollee Switch File ........................................................................................................ 38
Passive Cancel Job .......................................................................................................... 39
Cancel Carry Forward Job .............................................................................................. 39
BAR Progress Report ...................................................................................................... 40
Effectuation at Reenrollment and CIC ............................................................................ 40
Life Changes During the OEP ........................................................................................ 40
Tobacco Rating at Time of Reenrollment ....................................................................... 40
Medicare Enrollment and Non-Renewals ....................................................................... 41
Enrollment in the FF-SHOP (Applicable to FF-SHOPs and Unless Otherwise Noted, SBE-FPs
for SHOPs, QHPs/QDPs) ................................................................................................................... 43
Eligibility and Enrollment ......................................................................................................... 43
Retirees ........................................................................................................................... 44
COBRA ........................................................................................................................... 44
Minimum Participation Rates in the FF-SHOP ...................................................................... 44
Initial Enrollment ....................................................................................................................... 44
Special Enrollment Periods ....................................................................................................... 45
FF-SHOP Appeals ...................................................................................................................... 45
Plan Compare (See Plans and Prices) ...................................................................................... 46
FF-SHOP Hotline Functionality ............................................................................................... 46
Qualified Employers ....................................................................................................... 46
Cases of Suspected Fraud or Ineligibility ....................................................................... 46
Cancellations and Terminations in the FF-SHOPs ................................................................. 46
Renewals in the FF-SHOPs ....................................................................................................... 46
Dependent Age-offs in the FF-SHOPs ...................................................................................... 46
FF-SHOP Required Notices ...................................................................................................... 47
Direct Enrollment (Applicable to the Individual Market FFE, QHPs/QDPs) ............................... 48
Guidelines for Specific QI Scenarios ........................................................................................ 49
Applicant Not Eligible for QHP Enrollment ................................................................... 49
Applicant is Eligible for QHP Enrollment and APTC/CSR ........................................... 49
Applicant is Eligible for QHP Enrollment but Not for APTC/CSR ............................... 49
Applicant is Eligible for Medicaid or CHIP ................................................................... 50
Households that Include QIs Eligible for Different Coverage Programs ........................ 50
Enrollment Groups .................................................................................................................... 51
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QHP Display Guidance .............................................................................................................. 52
QHP Issuer DE Entities ................................................................................................... 52
Web-Broker DE Entities ................................................................................................. 55
Mandatory Display Language for Consumers that Attest to a Health Reimbursement
Arrangement Offer .................................................................................................................... 60
Mandatory Attestations ............................................................................................................. 60
Special Enrollment Periods (Applicable to the Individual Market FFE, QHPs/QDPs) ............... 62
SEP Pre-enrollment Verification .............................................................................................. 62
Plan Category Limitations for SEPs ........................................................................................ 63
PCL Background ........................................................................................................................ 63
Availability and Length of SEPs ............................................................................................... 64
SEP Triggering Events and Coverage Effective Dates ........................................................... 65
Coverage Effective Dates ................................................................................................ 66
SEPs Accessed Outside of the Application Process ................................................................. 78
Exceptional Circumstances SEPs ............................................................................................. 78
Plan Display Errors ................................................................................................................... 81
Identifying and Resolving Plan Errors ............................................................................ 82
Processing Plan Display Error SEPs ............................................................................... 83
Premiums (Applicable to the Individual Market FFE, QHPs/QDPs) ............................................ 85
Effectuation of Prospective Coverage Under Regular Coverage Effective Dates and Special
Effective Dates ............................................................................................................................ 85
Effectuation of Coverage with a Retroactive Effective Date Associated with an SEP that
Is Not Verified ...................................................................................................................... 85
Payment for Reenrollments ............................................................................................. 87
Binder Payment Extensions Directed by the Exchange or State Authority .................... 88
Premium Payment Threshold ................................................................................................... 88
Terminations for Non-Payment of Premiums ......................................................................... 90
Examples ......................................................................................................................... 91
Prohibition of Option to Condition New Enrollment on Payment of Past Due Premium
92
Enrollment Transactions Received for a Subscriber Whose Coverage Is Being
Terminated ............................................................................................................................ 92
Grace Periods for Enrollees Receiving the Benefit of APTC ................................................. 96
Claims Pended by an Issuer During a Three-Consecutive-Month Grace Period for
Enrollees Receiving the Benefit of APTC ............................................................................ 97
Grace Periods Ending After the End of the Annual Open Enrollment Period ................ 97
Grace Periods Ending on or Before December 31 ........................................................ 100
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Termination Occurring During a Grace Period ............................................................. 100
Involuntary Termination Due to a Citizenship/Immigration Status Inconsistency
Expiration During a Grace Period ....................................................................................... 101
Removal of APTC During a Grace Period .................................................................... 101
Processing Fees and Premium Payments ...................................................................... 102
Over-Billed Premiums ............................................................................................................. 103
Under-Billed Premiums ........................................................................................................... 103
Examples ....................................................................................................................... 103
Collections and Grace Periods for Non-Payment of Under-Billed Premium ............... 104
Voluntary Termination of Coverage During Repayment of Under-Billed Premium .... 106
Payment Redirect ..................................................................................................................... 107
Premium Payment Methods .................................................................................................... 108
Payment of Premium by a Third Party .................................................................................. 108
Enforcement Discretion Regarding FEMA-Designated Natural Disasters ........................ 109
Terminations (Applicable to the Individual Market FFE, SBE-FPs, QHPs/QDPs) ................... 110
Enrollee Requested Terminations .......................................................................................... 110
Termination of an Enrollee’s Coverage in the FFE Due to Report of Death ..................... 111
Aging-off Terminations ........................................................................................................... 112
Issuer Termination Notice Requirements .............................................................................. 113
Examples ....................................................................................................................... 113
Reinstatements (Applicable to Individual Market FFE, QHPs/QDPs) ........................................ 115
Reinstatements in the FFE ...................................................................................................... 115
Enrollment Data Alignment (Applicable to Individual Market FFE, QHPs/QDPs) ......... 118
IC834 ......................................................................................................................................... 120
Enrollment Reconciliation and Pre-Audit Files .................................................................... 122
Resolution of Enrollment and Payment Discrepancies (Disputes) ...................................... 124
Disputes Timeline ..................................................................................................... 125
90-Day Requirements ............................................................................................... 125
Disputes Over 90 Calendar Days; 15-Day Requirement .......................................... 125
Post-Deadline Inaccuracies (PDIs) ........................................................................... 125
Audits and Disputes .................................................................................................. 125
Payment Dispute Process .......................................................................................... 126
Enrollment Dispute Process ...................................................................................... 127
HICS Direct Dispute Process .................................................................................... 129
Unmatched “I” Record ............................................................................................................ 130
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SEE
D ......................................................................................................................................... 130
SEED Resources ....................................................................................................... 131
Forms 1095-A Generation and Corrections........................................................................... 132
Form 1095-A Initial Generation Process ............................................................................... 132
Examples ................................................................................................................................... 133
Anatomy of a Form 1095-A ..................................................................................................... 134
Form 1095-A Part 1: Recipient Information ............................................................. 134
Form 1095-A Part II: Covered Individuals ............................................................... 135
Form 1095-A Part III: Coverage Information ........................................................... 135
How Issuers Should Answer Enrollee Questions About Forms 1095-A .............................. 136
Basic Form 1095-A Questions Issuers May Answer ................................................ 136
Enrollee Questions to Be Directed to the IRS or the Tax Filer’s Tax Preparer ........ 136
Enrollee Questions to Be Directed to the Exchange ................................................. 137
Form 1095-A Basics for Assisting QHP Enrollees ................................................................ 137
Form 1095-A Reprints and Corrections .................................................................... 138
Form 1095-A Corrections Process: Additional Information ..................................... 139
Impact of Prior Year Appeals ................................................................................................. 141
Steps to Follow for Prior Year Appeal Adjudications .............................................. 141
Eligibility Changes for the Dually Enrolled or Deceased ..................................................... 142
Periodic Data Matching ........................................................................................................... 142
Medicaid/CHIP Periodic Data Matching ............................................................................... 143
Medicare Periodic Data Matching .......................................................................................... 144
Medicare Anti-Duplication ...................................................................................................... 144
Deceased Enrollee Periodic Data Matching ........................................................................... 145
Addressing Individual-Reported Unauthorized Enrollments and Issuer-Reported
Fraudulent Enrollments ................................................................................................................... 146
Individual Complaints Alleging Unauthorized Enrollments ............................................... 146
Operational Process for Cancelling Unauthorized Enrollments ............................... 146
Issuers’ Requests: Examples of Elements Demonstrating an Appropriate Rescission of
QHPs in the Exchanges ............................................................................................................ 148
Reporting Fraudulent Enrollments ............................................................................ 148
Implementation of Eligibility Appeal Decisions and Related Enrollments in the FFE ..... 152
Background............................................................................................................................... 152
CMS Role .................................................................................................................................. 153
Notify Issuer to Implement an Appeal Decision ....................................................... 153
Notify Issuer to Implement a Request for Eligibility Pending Appeal ..................... 153
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Notify Issuer to Discontinue Eligibility Pending Appeal and Implement the Appeal
Decision .............................................................................................................................. 153
Issuer Role ................................................................................................................................ 154
Enrollment Requirements ......................................................................................... 154
HICS Case Resolution Requirements ....................................................................... 155
Appeal Decision Scenarios ....................................................................................................... 156
Impact of Appeals on Reconciliation ...................................................................................... 162
Health Insurance Casework System ....................................................................................... 163
HICS Access .............................................................................................................................. 163
HICS Category Use .................................................................................................................. 163
HICS Casework and Expectations ......................................................................................... 164
HICS Casework Best Practices ............................................................................................... 165
Data Matching Issues Monthly Processes .............................................................................. 168
Background............................................................................................................................... 168
What Are Data Matching Issues or Inconsistencies? ................................................ 168
How Does an Enrollee Know if They Have an Income DMI? ................................. 168
Exchange DMIs Issuer Outreach Files Delivery Processes and Impact to Enrollees ........ 168
DMIs Outreach Schedule and Process ...................................................................... 169
Exchange DMI File Delivery Schedule .................................................................... 170
Late Submission of Documentation for DMIs ....................................................................... 170
Health Reimbursement Arrangements .................................................................................. 172
Individual Coverage HRA and QSEHRA Employer Notice Requirements ....................... 172
Individual Coverage HRA/QSEHRA SEP ............................................................................. 174
Individual Coverage HRA/QSEHRA Affordability.............................................................. 174
Enrollment Community for Contact Management and Inquiries ....................................... 176
Organizations in the Enrollment Community ....................................................................... 176
Appendix A – Sample Welcome Letter .................................................................................. 178
Appendix B – Sample Non-Payment Notice for the Individual Market ............................. 180
Appendix C – Sample Termination Letter ............................................................................ 182
Appendix D – Sample Plan Display Error Notice with No Special Enrollment Period ..... 184
Appendix E – Sample Plan Display Error Notice with A Special Enrollment Period ....... 185
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LIST OF EXHIBITS
Exhibit 1: Commonly Used Acronyms ....................................................................................................... 2
Exhibit 2: Additional Resources ................................................................................................................. 9
Exhibit 3: FFE Enrollment Process ........................................................................................................... 10
Exhibit 4: Coverage Effective Dates for the FFE OEP ............................................................................. 13
Exhibit 5: Retroactive Enrollment Reasons and Dates ............................................................................. 14
Exhibit 6: Retroactive Termination Reasons and Dates ........................................................................... 15
Exhibit 7: Retroactivity Examples ............................................................................................................ 15
Exhibit 8: Process for Reporting Changes ................................................................................................ 20
Exhibit 9: Reportable Changes ................................................................................................................. 21
Exhibit 10: Passive Reenrollment Codes .................................................................................................. 31
Exhibit 11: NPN Rules ............................................................................................................................. 32
Exhibit 12: Reenrollment Transaction Illustration .................................................................................... 33
Exhibit 13: Multiple Transactions Illustrated for a Single Enrollment ..................................................... 37
Exhibit 14: SEP Triggering Events and Coverage Effective Dates Summary .......................................... 68
Exhibit 15: SEP Effective Date Examples ................................................................................................ 77
Exhibit 16: Sample SEP Coverage Effective Dates for FEMA-Emergency Affected Individuals ........... 80
Exhibit 17: Identifying and Correcting Plan Display Errors That May Qualify for SEPs ........................ 83
Exhibit 18: Resolving Plan Display Error SEPs ....................................................................................... 84
Exhibit 19: Premium Payment Threshold Lifecycle ................................................................................. 89
Exhibit 20: Example Timeline .................................................................................................................. 93
Exhibit 21: Example Timeline .................................................................................................................. 94
Exhibit 22: Volume of Policy Updates Performed ................................................................................. 120
Exhibit 23: PPR-820 Payment Dispute Process ...................................................................................... 126
Exhibit 24: Enrollment Dispute Process ................................................................................................. 127
Exhibit 25: HICS Direct Dispute Process ............................................................................................... 129
Exhibit 26: Form 1095-A Generation Process Overview ....................................................................... 133
Exhibit 27: Form 1095-A Elements ........................................................................................................ 134
Exhibit 28: Recipient Information Section ............................................................................................. 135
Exhibit 29: Covered Individuals Section ................................................................................................ 135
Exhibit 30: Coverage Information Section ............................................................................................. 135
Exhibit 31: Appeal Decision Scenarios .................................................................................................. 156
Exhibit 32: Example Delivery and Transaction Schedule ...................................................................... 170
Exhibit 33: User Types ........................................................................................................................... 176
Exhibit 34: Enrollment Community for Contact Management and Inquiries ......................................... 176
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INTRODUCTION AND SCOPE
Background
The Patient Protection and Affordable Care Act (ACA) (Pub. L. 111–148) was enacted on March 23,
2010. The Health Care and Education Reconciliation Act of 2010 (Pub. L. 111–152), which amended
and revised several provisions of the ACA, was enacted on March 30, 2010. The statute has been
updated periodically since, including provisions changed by the American Rescue Plan Act of 2021
(Pub. L. 117-2). In this manual, the law is referred to collectively as the ACA. The ACA created
competitive private Health Insurance Exchanges (also referred to as Marketplaces) that enable
qualified individuals (QIs) to shop for, select, and enroll in quality, affordable private health plans. The
Exchanges also allow QIs to obtain eligibility determinations or eligibility assessments for coverage
under Medicaid, the Children’s Health Insurance Program (CHIP), and the Basic Health Program
(BHP), where applicable. In addition, the ACA created Small Business Health Options Program
(SHOP) Exchanges that enable qualified employers to provide health plans to their employees. QIs and
qualified employers have been able to obtain coverage from private health insurance companies
through the Exchanges since October 1, 2013, for coverage beginning January 1, 2014.
1
Types of Exchanges
The Exchanges established by the ACA are established in one of several different ways, including as a:
• State-based Exchange (SBE): A state that elected to establish its own Exchange operates an
SBE.
• Federally-facilitated Exchange (FFE): Pursuant to Section 1321(c)(1) of the ACA, the
Federal government established an FFE in any state that did not elect to establish a State-based
Exchange or in a state that the Secretary of the Department of Health & Human Services (the
Secretary) determined would not have an operable Exchange.
• State-based Exchange on the Federal Platform (SBE-FP): An SBE-FP uses the Federal
eligibility and enrollment platform operated by the FFE to perform its eligibility and
enrollment functions. As such, the information in this manual is applicable to SBE-FPs and
issuers participating in SBE-FPs in accordance with 45 CFR 155 Subpart E. SBE-FPs are
directly responsible for performing certain Exchange functions, including the certification of
Qualified Health Plans (QHPs) and consumer assistance such as Medicaid consumer support in
coordination with their respective State Medicaid agency (by phone, website, and the
Marketplace Call Center).
• State-based Small Business Health Options Program (SB-SHOP): An SB-SHOP is a type
of SBE designed to assist qualified employers in facilitating the enrollment of their employees
in QHPs offered in the small group market.
• Federally-facilitated Small Business Health Options Program (FF-SHOP): An FF-SHOP is
a type of FFE designed to assist qualified employers in facilitating the enrollment of their
employees in QHPs offered in the small group market.
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For background information, see section 1311(b)(1) of the ACA and 45 CFR 155.410(c)(1)(i).
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Purpose of Document
This manual provides operational policy and guidance on key topics related to eligibility and
enrollment within the FFE and FF-SHOPs, as well as within the SBE-FPs, which use the Federal
platform to perform their eligibility and enrollment functions. For ease of reference, this document will
use the terms “FFE” and “FF-SHOP” to refer to all individual market Exchanges and SHOPs,
respectively, that rely on the Federal eligibility and enrollment platforms.
Where necessary, CMS will indicate whether the guidance described pertains to the FFE and FF-
SHOP, only the FFE, or only the FF-SHOP. Additionally, we have indicated, where applicable, the
guidance pertains to both QHPs and Exchange-certified stand-alone dental plans, which this manual
refers to as Qualified Dental Plans (QDPs).
The information provided in this document applies to organizations and entities that may be involved
in or assist with enrolling a QI into a QHP or QDP using the FFE’s eligibility and enrollment
functions. These entities include:
• SBE-FPs and issuers participating in the SBE-FPs;
• QHP and QDP issuers;
• Agents or brokers (A/Bs), including web-brokers, who are registered with the FFE;
• Navigators, Certified Application Counselors (CACs), and caseworkers;
• Third-party administrators (TPAs) of QHPs, QDPs, or employer-sponsored coverage; and
• Trading partners of QHP and QDP issuers, such as healthcare clearinghouses.
Acronyms and Definitions
Acronyms
Exhibit 1 and the subsection that follows describe the commonly used acronyms and terms that appear
throughout this document.
Exhibit 1: Commonly Used Acronyms
Acronyms
Descriptions
A/B
Agent or Broker
ACA
Affordable Care Act
AMRC
Additional Maintenance Reason Code
API
Application Programming Interface
APTC
Advance Payments of the Premium Tax Credit
ARP
American Rescue Plan Act of 2021
BAR
Batch Auto-Reenrollment
BHP
Basic Health Program
BUU
Batch Update Utility
CAC
Certified Application Counselor
CCIIO
Center for Consumer Information & Insurance Oversight
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Acronyms
Descriptions
CHIP
Children’s Health Insurance Program
CMS
Centers for Medicare & Medicaid Services
CIC
Change in Circumstance
CSR
Cost-Sharing Reduction
DE
Direct Enrollment
DMI
Data Matching Issue/Inconsistency
DSH
Data Services Hub
EDA
Enrollment Data Alignment
EDE
Enhanced Direct Enrollment
EDI
Electronic Data Interchange
EDN
Eligibility Determination Notice
EDS
External Data Source
EFT
Electronic Fund/File Transfer
EHB
Essential Health Benefits
EIN
Employer Identification Number
ER&R
Enrollment Resolution and Reconciliation
ET
Eastern Time
FEMA
Federal Emergency Management Agency
FFE
Federally-facilitated Exchange
FF-SHOP
Federally-facilitated Small Business Health Options Program
FPL
Federal Poverty Level
HHS
Department of Health & Human Services
HICS
Health Insurance Casework System
HIOS
Health Insurance Oversight System
HIPAA
Health Insurance Portability and Accountability Act of 1996
HRA
Health Reimbursement Arrangement
ICHRA
Individual Coverage Health Reimbursement Arrangement
IRS
Internal Revenue Service
LC
Life Change
MAGI
Modified Adjusted Gross Income
MCR
Marketplace Consumer Record
MEC
Minimum Essential Coverage
MLR
Medical Loss Ratio
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Acronyms
Descriptions
MOEN
Marketplace Open Enrollment Notice
OEP
Open Enrollment Period
PBP
Plan Benefit Package
PCL
Plan Category Limitations
PDI
Post-Deadline Inaccuracy
PMP/PP
Partial Month Premium/Premium Proration
PTC
Premium Tax Credit
QDP
Qualified Dental Plan
QHP
Qualified Health Plan
QI
Qualified Individual
QSEHRA
Qualified Small Employer Health Reimbursement Arrangement
RA
Risk Adjustment
RCNI
Reconciliation Inbound
SBE
State-based Exchange (operating its own platform)
SBE-FP
State-based Exchange on the Federal Platform
SEED
System of Exchange Enrollment Data
SEP
Special Enrollment Period
SOAP
Simple Object Access Protocol
TPA
Third-Party Administrator
UEFF
Unauthorized Enrollment Finder File
UIR
Unmatched “I” Record
Definitions
Form 1095-A: A tax form (like a W-2) that the Exchange furnishes to individuals who are enrolled in
QHPs through the Exchange. The Form 1095-A provides enrollees with information about their health
coverage so they can file their taxes, reconcile APTC, and claim the PTC.
Accumulators: Metrics such as a deductible or maximum out-of-pocket limit that determine how
much of the medical costs an enrollee must pay before the plan pays or the plan payment amount
changes.
Advance Payments of the Premium Tax Credit (APTC): APTC can be used by eligible taxpayers
who are enrolled in QHPs through an individual market Exchange to lower their monthly premium
costs. Eligible taxpayers may choose how much APTC to apply to their premiums each month, up to a
maximum amount, which is then paid directly to the insurer. The APTC must be reconciled with the
PTC on an individual’s Federal income tax return. If the APTC amount received for the year is less
than the PTC, the individual will receive the difference as a higher refund or lower tax due. If the
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APTC amount received for the year is more than the PTC, the excess advance payments may have to
be repaid with the individual’s tax return.
Agent or Broker (A/B): A/B has the meaning set forth in 45 CFR 155.20.
Applicant: Applicant has the meaning set forth in 45 CFR 155.20.
Application Filer: Application filer has the meaning set forth in 45 CFR 155.20.
Auto-Reenrollment (Passive): Auto-reenrollment is an enrollment transaction that continues
coverage in the individual market FFE for the new plan year for an enrollee who does not actively
select a plan for the new plan year during the OEP automatically, without a lapse in coverage, if timely
premium payment is made.
Batch Auto-Reenrollment (BAR): BAR is the process the individual market FFE uses to implement
auto-reenrollment.
Consolidated Omnibus Budget Reconciliation Act (COBRA): COBRA is Federal legislation that
amended the Employee Retirement Income Security Act of 1974, the Internal Revenue Code of 1986
(Code), and the Public Health Service Act to provide for continuation of group health coverage that
otherwise might be terminated. COBRA contains provisions giving certain former employees, retirees,
spouses, former spouses, and dependent children the right to temporary continuation of group health
plan coverage at group rates. COBRA coverage, however, is available only when coverage under the
group health plan is lost due to specific events.
Cost-Sharing Reduction (CSR): CSR has the meaning set forth in 45 CFR 155.20.
Data Matching Issue/Inconsistency (DMI): When an application filer provides information to the
Marketplace as a part of the application process and the information the application filer provided does
not match the information received by the Exchange from its trusted data sources, such as the Office of
Personnel Management, Department of Homeland Security, or Social Security Administration, a DMI
results. The application filer needs to resolve DMIs related to citizenship or immigration within 95
days and all other DMIs within 90 days. Otherwise, the enrollee’s enrollment through the Marketplace
may be terminated and/or the enrollee’s APTC and CSR may be terminated or adjusted, if applicable.
Deductible: The amount an enrollee must pay for covered health care services before the plan starts to
pay. Once the deductible is met, enrollees generally must pay only a copayment or coinsurance for
covered services.
Electronic Data Interchange (EDI): EDI is an automated transfer of data in a specific format
following specific data content rules between a Marketplace and a QHP or QDP issuer. EDI
transactions are transferred electronically through HealthCare.gov or an SBE.
Enrollee: Enrollee has the meaning set forth in 45 CFR 155.20.
Enrollment Group (in the individual market FFE): All QIs enrolled and linked by the Marketplace-
assigned policy identifier. Additional QIs may be linked by the policy Marketplace identifier, such as a
custodial parent, but may not be considered part of the enrollment group.
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Enrollment Data Alignment (EDA): The ongoing processes used to ensure consistency of enrollment
and financial data between issuers and the FFE. Since CMS makes payment of APTC to QHP issuers
based on the enrollment files, all entities’ enrollment data must be reconciled. In addition, the
enrollment data stored in the FFE is used as the basis for annual generation of Form 1095-A tax data
for QIs. Discrepancies can arise when an issuer accepts a change from an enrollee based on HICS
instructions (i.e., a change that has not been reflected in the FFE, but one that the reconciliation
process identifies) and enters it directly into its system. By regulation, issuers are required to reconcile
enrollment information with the FFE at least monthly.
Full-Time Employee: For SHOP eligibility purposes, an employee who is employed, on average, at
least 30 hours of service per week (26 U.S.C. §4980H, 26 CFR 54.4980H-1(a)(21), and 45 CFR
155.20). For purposes of the Small Business Health Care Tax Credit, a full-time employee is an
employee who is employed, on average, at least 40 hours of service per week (26 U.S.C. §45R).
Health Insurance Casework System (HICS): The authorized and secure electronic system
recognized and used by the FFE to input, track, and monitor QIs’ and enrollees’ concerns, unresolved
issues, complaints, and cases that are not able to be resolved by CMS. The FFE uses HICS to
appropriately assign unresolved cases and communicate effective date changes to issuers for
resolution, when appropriate.
Health Reimbursement Arrangement (HRA): An HRA is an account-based group health plan
funded solely by employer contributions that reimburses an employee’s medical care expenses up to a
maximum dollar amount for a coverage period (for example, a calendar or non-calendar year). Medical
care expenses means expenses for medical care as defined under section 213(d) of the Code. An
employer may allow unused amounts to be rolled over to be used in subsequent years. In addition to
the employee’s medical care expenses, an HRA may also reimburse medical care expenses incurred by
the employee’s spouse, dependents, and children who, as of the end of the taxable year, have not
attained age 27 (dependents).
Insurance Affordability Programs: APTC and CSR, as well as Medicaid, CHIP, and, where
applicable, BHP coverage.
Individual Coverage Health Reimbursement Arrangement (ICHRA): A type of HRA that requires
eligible employees and dependents to have individual health insurance coverage or Medicare Parts A
(Hospital Insurance) and B (Medical Insurance) or Part C (Medicare Advantage). Reimbursements by
the ICHRA may include premiums and cost sharing for individual health insurance coverage and for
Medicare; employers could begin offering ICHRAs as of January 1, 2020.
Life Change (LC): A circumstance that could affect an applicant’s or enrollee’s eligibility for
enrollment through the Marketplace or for insurance affordability programs (e.g., birth, adoption,
foster care, change in household income). LCs that are not reported to the applicable Marketplace
(“Change in Circumstance”) could potentially lead to an enrollee or applicable tax filer repaying all or
some of the APTC the enrollee received during the year.
Marketplace Account: The Marketplace account provides an individual with a username and
password to create an individual application and perform other functions related to obtaining health
coverage through a Marketplace. A Marketplace account user does not need to be the policyholder for
FFE and FF-SHOP Enrollment
7
coverage purchased from applications submitted by the Marketplace account user.
Minimum Essential Coverage (MEC): MEC is the type of coverage an individual must have to meet
the individual shared responsibility requirement under the ACA. The MEC requirement can be
fulfilled by a number of different types of coverage outlined in section 5000A(f) of the Code and in 45
CFR 156.602, such as individual health insurance coverage, job-based coverage, Medicare, Medicaid,
CHIP, TRICARE, and certain other types of coverage.
Modified Adjusted Gross Income (MAGI): MAGI is the figure used to determine eligibility for
insurance affordability programs in the Marketplaces, and for Medicaid and CHIP. Generally, MAGI
is an individual’s adjusted gross income plus certain other income, including tax-exempt Social
Security, interest, or foreign income, and without certain deductions allowed for adjusted gross income
(26 CFR 1.36B-1(e)(2) and 42 CFR 435.603).
Open Enrollment Period (OEP): The period each year during which a QI may enroll or change
coverage in an individual market QHP through the Marketplace (45 CFR 155.20).
Out-of-Pocket Maximum: The maximum amount that an enrollee is required to pay for covered
services provided by in-network providers during a given plan year. Once this limit is reached, the plan
will cover 100% of coverage costs.
Partial Month Premium/Premium Proration (PMP/PP): Occurs in the Exchange when an enrollee
has periods of coverage that last less than a full month. In the FFE and FF-SHOP, the prorated monthly
premium for partial coverage months is calculated based on the actual number of days that the
applicable enrollee or enrollees has/have coverage. Specifically, the premium is prorated as follows:
the full month premium for one month of the coverage is divided by the number of days in the month.
The result of the calculation is multiplied by the number of days in which the enrollee had coverage
during the partial coverage month.
Plan Year: Plan year has the meaning set forth in 45 CFR 155.20.
Plan Category Limitations (PCL): Established in the 2017 Market Stabilization Rule, enrollees and
their dependents, including newly added household members, who qualify for common SEPs, like a
loss of health insurance, moving, or a change in household size, are generally only able to enroll in a
plan from their current plan category. See 45 CFR 155.420(a)(4).
Product: Product has the meaning set forth in 45 CFR 144.103.
Qualified Health Plan (QHP): A health insurance plan that meets certain requirements and, on the
basis of meeting those requirements, is certified to be sold through an Exchange. A QHP must be
certified by each Exchange through which it is sold. QHP has the meaning set forth in 45 CFR 155.20.
QHP Issuer: QHP issuer has the meaning set forth in 45 CFR 155.20.
Qualified Individual (QI): QI has the meaning set forth in 45 CFR 155.20.
Qualified Employee: Qualified employee has the meaning set forth in 45 CFR 155.20.
Qualified Employer: Qualified employer has the meaning set forth in 45 CFR 155.20.
FFE and FF-SHOP Enrollment
8
Qualified Small Employer Health Reimbursement Arrangement (QSEHRA): A type of HRA
created in the 21st Century Cures Act, which permits small employers who don't offer group health
plan coverage to any of their employees to provide a QSEHRA to their eligible employees. An eligible
employee can use a QSEHRA to reimburse medical care expenses, as that term is defined under
section 213(d) of the Code, for him or herself, as well as any covered dependents (if permitted by the
employer). To receive reimbursements from a QSEHRA, an employee and any covered dependents
must be enrolled in MEC. Small employers could provide QSEHRAs for plan years beginning on or
after January 1, 2017.
Reinstatement: Reinstatement is the correction of an erroneous termination or cancellation action that
results in the restoration of an enrollment with no break in coverage (45 CFR 155.430(e)(3)).
Reenrollment (Active): An 834 enrollment transaction that continues enrollment in coverage through
the individual market Exchange for an enrollee who actively returns to the Exchange, generally during
the OEP, to make a plan selection for the new plan year.
System of Exchange Enrollment Data (SEED): A web application that provides issuers and third-
party administrators (TPAs) with a secure way to access real-time FFE data. SEED supports the FFE
EDA and casework processes.
SHOP Application Filer: SHOP application filer has the meaning set forth at 45 CFR 155.700(b).
Small Employer: Small employer has the meaning set forth in 45 CFR 155.20.
Special Enrollment Period (SEP): SEP has the meaning set forth in 45 CFR 155.20.
Subscriber: A subscriber is the individual enrolling in coverage who has elected benefits for an
enrollment group or the person for whom benefits have been elected by the application filer in the
event that the application filer is not the person enrolling in coverage. There is always only one
subscriber per enrollment group and each member of the enrollment group will be associated with the
subscriber. The subscriber may also be referred to as the anchor for the group.
Tax Filer: A tax filer is an individual who will file taxes for the coverage year on behalf of a tax
household.
Web-broker: An individual A/B, group of A/Bs, or business entity registered with an Exchange under
45 CFR 155.220(d)(1) that develops and hosts a non-Exchange website that interfaces with an
Exchange to assist consumers with direct enrollment (DE) in QHPs offered through the Exchange as
described in 45 CFR 155.220(c)(3) or 155.221. The term also includes an A/B DE technology
provider.
FFE and FF-SHOP Enrollment
9
Additional Resources
Exhibit 2 lists contact information for additional resources referenced throughout this manual.
Exhibit 2: Additional Resources
Resources
Contact Information
CCIIO
www.cms.gov/cciio
Marketplace Call Center
1-800-318-2596
1-855-889-4325 (TTY)
HealthCare.gov
www.healthcare.gov
Medicaid
www.medicaid.gov
Medicare
www.medicare.gov
Registration for Technical Assistance Portal
(REGTAP)
http://www.regtap.info/
FF-SHOP Hotline
1-800-706-7893
1-888-201-6445 (TTY)
CMSzONE
https://zone.cms.gov
Marketplace Service Desk (MSD)
[email protected]
1-855-CMS-1515
HICS
[email protected]s.gov
1-888-205-0684
Agent/Broker Help Desk
FFMProducer-AssisterHel[email protected]s.gov
For instructions on registering for CMSzONE, visit https://www.regtap.info/reg_librarye.php?i=2466.
FFE and FF-SHOP Enrollment
10
ENROLLMENT IN THE INDIVIDUAL FFE (APPLICABLE TO
QHPS/QDPS)
For qualified individuals (QIs) to purchase coverage in a Qualified Health Plan/Qualified Dental Plan
(QHP/QDP) through the Federally-facilitated Exchange (FFE), QIs must enroll in coverage through
the FFE during an Open Enrollment Period (OEP) or qualify for a special enrollment period (SEP) (see
Section 6, Special Enrollment Periods (Applicable to the Individual Market FFE, QHPs/QDPs)).
Exhibit 3 depicts a high-level, end-to-end system flow of the process for a QI to enroll in a QHP/QDP
through the FFE. Please refer to Exhibit 3 when reviewing the enrollment instructions in the
succeeding sections. Exhibit 3 does not pertain to Direct Enrollment (DE). Please refer to Section 5,
Direct Enrollment (Applicable to the Individual Market FFE, QHPs/QDPs), for the DE process.
Exhibit 3: FFE Enrollment Process
FFE and FF-SHOP Enrollment
11
Eligibility
Pursuant to 45 CFR 155.405, an individual completes a single streamlined application for enrollment
in coverage through the Exchange. The Exchange uses this single streamlined application to determine
both the QI’s eligibility to purchase coverage through the Exchange and, if the applicant chooses to
apply for insurance affordability programs, the QI’s eligibility for advance payments of the premium
tax credit (APTC), cost-sharing reduction (CSR), and in some states, Medicaid and the Children’s
Health Insurance Program (CHIP).
2
Requirement to File and Reconcile Past APTC
CMS regulations require that Exchanges determine that QIs are not eligible for APTC if they had
APTC paid on their behalf for a prior year but their tax filer did not file a Federal income tax return
and reconcile APTC for that year (45 CFR 155.305(f)(4)). When a tax filer does not comply with this
requirement, it is known as “Failure to File and Reconcile” or “FTR.”
Special note for FTR in plan years 2021 and 2022: CMS is providing additional flexibilities for
enrollees and Exchanges by adjusting FTR operations for plan years 2021 and 2022. These
additional flexibilities are due to the continued impact of the 2019 novel coronavirus disease
(COVID-19) pandemic on the processing of 2019 and 2020 Federal income tax returns, as well
as a recent change passed by Congress regarding reconciliation of APTC with PTC for tax year
2020 under the American Rescue Plan Act of 2021, and the IRS’ implementation of that change.
Specifically, for plan years 2021 and 2022, CMS will not be taking certain actions in the FFE to
remove the financial help enrollees receive to help pay for their health coverage because of their
FTR status.
In April 2021, the IRS announced that taxpayers whose 2020 APTC is more than their PTC
allowed for 2020 (excess APTC) are not required to reconcile their APTC with their PTC by
attaching Form 8962, Premium Tax Credit, to their 2020 tax return. See the IRS News Release
3
about suspending the requirement to repay excess APTC, the Instructions for Form 8962,
Premium Tax Credit,
4
and IRS Fact Sheet
5
for more details about the changes related to the PTC
for tax year 2020.
Because taxpayers with excess APTC for 2020 are not required to file Form 8962 to reconcile
APTC for tax year 2020, CMS will not take any FTR actions based on 2020 tax returns for plan
year 2022 for enrollees in the FFE. As such, CMS will not warn enrollees via the Marketplace
Open Enrollment Notice (MOEN) or FTR Direct Warning Notices when they have an FTR status
or take action to terminate APTC for plan year 2022 based on having an FTR status. Finally,
CMS will not run FTR Recheck in 2022. This flexibility does not change the general requirement
for taxpayers for whom APTC was paid in years before 2020 to file their taxes and reconcile the
APTC with the PTC allowed for the year. Consumers can find the latest information on filing
2
Currently, no FFE or State-based Exchange on the Federal Platform (SBE-FP) states make eligibility determinations for a
Basic Health Program (BHP).
3
https://www.irs.gov/newsroom/irs-suspends-requirement-to-repay-excess-advance-payments-of-the-2020-premium-tax-
credit-those-claiming-net-premium-tax-credit-must-file-form-8962
4
https://www.irs.gov/forms-pubs/about-form-8962
5
https://www.irs.gov/newsroom/more-details-about-changes-for-taxpayers-who-received-advance-payments-of-the-2020-
premium-tax-credit
FFE and FF-SHOP Enrollment
12
and reconciling for 2020 Federal income tax returns at https://www.irs.gov/newsroom/irs-
suspends-requirement-to-repay-excess-advance-payments-of-the-2020-premium-tax-credit-
those-claiming-net-premium-tax-credit-must-file-form-8962.
Medicaid and CHIP Eligibility
Depending on a state’s election, the FFE either makes final eligibility determinations for Medicaid and
CHIP based on the applicant’s Modified Adjusted Gross Income (MAGI) or assesses the applicant’s
potential eligibility for Medicaid and CHIP based on their MAGI. In all states, the FFE screens
applicants for potential eligibility for Medicaid based on criteria other than MAGI and transfers
applications screened as potentially eligible on a basis other than MAGI to the state Medicaid agency
for full eligibility determinations. Applicants who believe they may be eligible for Medicaid on a basis
other than MAGI may also request that their applications be transferred to the state Medicaid agency
for a full eligibility determination. Medicaid and CHIP applicants always have the option to apply for
Medicaid and CHIP through their state Medicaid/CHIP agency directly. In an assessment state, the
state Medicaid/CHIP agencies make the final eligibility determinations for applicants assessed as
potentially eligible by the FFE via application transfers.
Open Enrollment and Coverage Effective Dates
During the OEP, a QI may enroll in a QHP. The QI can make multiple elections during the OEP, and
may change plans, even if the original selection’s coverage (active or passive) has been effectuated.
However, the last election made by the end of the OEP that is effectuated will be the coverage in
which the QI is enrolled through the FFE.
6
If the QI enrolled in a QHP and paid for the first month’s
premium payment (i.e., binder payment), as required by 45 CFR 155.400(e), but then selected another
QHP during the OEP and that enrollment is effectuated for the same coverage effective date, the initial
issuer of the QHP in which coverage was previously effectuated will need to cancel the coverage and
refund premiums. The initial issuer of that QHP will receive notification of the plan selection change
from the Marketplace. Outstanding enrollments will also be identified during enrollment
reconciliation.
The coverage effective date for plan selections made during the OEP generally is the following
January 1 (if the plan selection is made between November 1 and December 15), or the following
February 1 (if the plan selection is made between December 16 and January 15). However, QIs who
qualify for an SEP during the OEP may receive a coverage effective date as indicated in Section 6,
Special Enrollment Periods (Applicable to the Individual Market FFE, QHPs/QDPs). Effective
dates for enrollee changes to plan selection post-effectuation align with normal effective dates as
established in 45 CFR 155.410(f) (although for some SEPs, accelerated or retroactive effective dates
may apply). An enrollee can change plans by contacting the Marketplace Call Center or by logging
into their HealthCare.gov account, accessing “My Plans and Programs,” and selecting “Change Plan.”
Enrollees may change plans during a valid enrollment period without reporting life changes on their
applications.
Note that, under 45 CFR 155.310(c), the FFE must accept an application and make an eligibility
6
The last plan selection made by December 15 that is effectuated will be the coverage in which the QI is enrolled for a
January 1 effective date, while the last plan selection made by January 15 that is effectuated will be the coverage in which the
QI is enrolled for a February 1 effective date.
FFE and FF-SHOP Enrollment
13
determination at any point in time during the year. Eligibility determinations made outside the OEP
can enable individuals to learn whether they are QIs, whether they are eligible for an SEP for FFE
coverage, whether they are eligible for APTC/CSR, or whether they are eligible for Medicaid or CHIP.
There are generally no restrictions on when a QI can enroll for Medicaid or CHIP.
Exhibit 4 illustrates OEP plan selection and coverage effective dates for upcoming plan years.
Exhibit 4: Coverage Effective Dates for the FFE OEP
Enrollment Transactions
45 CFR 155.270 requires each Exchange to use standards, implementation specifications, operating
rules, and code sets adopted by the Department of Health & Human Services (HHS) under Health
Insurance Portability and Accountability Act of 1996 (HIPAA) and the ACA when conducting certain
electronic transactions with a covered entity, such as a QHP or QDP issuer.
Additionally, HHS oversees and monitors FFE issuers and non-Exchange entities to verify compliance
with security and privacy standards, as required by 45 CFR 155.280.
The Exchange, QHP, and QDP issuers transmit enrollment transactions in files using the Accredited
Standards Committee (ASC) X12 834 Benefit Enrollment and Maintenance Version 5010 (834
enrollment transaction), adopted by the Secretary on January 23, 2009.
CMS released an ASC X12 834 Standard Companion Guide to be used in conjunction with the ASC
X12 Version 005010 834 TR3, which outlines transactional information. Additionally, a Maintenance
834 Operations Manual was published by CMS to explain how certain new data elements, such as
APTC and CSR data in the FFE, and employer and qualified employee premium contributions in the
Federally-facilitated Small Business Health Options Program (FF-SHOP), will be included in the
existing version of the 834 enrollment transaction. Issuers offering QHPs or QDPs through the FFE
must use the ASC X12 834 enrollment transaction in combination with the updated Companion Guide
and Operations Manual for purposes of enrollment transactions. Both documents can be found on
CMSzONE at their respective links below:
Federally-facilitated Marketplace Maintenance 834 Operations Manual:
https://zone.cms.gov/document/federally-facilitated-marketplace-maintenance-834-operations-manual
ASC X12 005010 834 Companion Guide:
https://zone.cms.gov/document/asc-x12-005010-834-companion-guide
For purposes of transmitting enrollment information to QHP and QDP issuers, the FFE transmits daily
electronic files to the issuers, or their trading partners, in the adopted 834 enrollment transaction.
Errors will be reported using the ASC X12 acknowledgement transactions, including the TA1 and the
999, for syntax and content. This information is explained in greater detail in the Companion Guide.
Retroactive transactions can have either an enrollment or a termination outcome, which could result in
impacts to payments including adjustments to APTC and CSR, as well as other enrollee information,
FFE and FF-SHOP Enrollment
14
since they are based on plan benefit start and end dates. Retroactive effective dates can result from
unforeseen life events, such as death; from FFE or issuer error, such as incorrect data being manually
entered from a paper application; or from an administrative process, such as an eligibility appeal
decision. Many of the events and circumstances that result in retroactivity are addressed by regulations
on terminations (45 CFR 155.430(d)), SEPs (45 CFR 155.420(b)), redeterminations (45 CFR
155.330(f)), and appeals of eligibility determinations for Exchange participation and insurance
affordability programs (45 CFR 155.545(c)). For more information on these topics please refer to
Section 3, Redeterminations and Renewals in the Individual Market FFE (Annual Open
Enrollment); Section 8, Terminations (Applicable to the Individual Market FFE, SBE-FPs,
QHPs/QDPs); Section 12, Eligibility Changes for the Dually Enrolled or Deceased; and Section
14, Implementation of Eligibility Appeal Decisions and Related Enrollments in the FFE.
The retroactive enrollment or termination effective dates for these triggering events and circumstances
are outlined in the respective sections of the regulations. Examples of unique circumstances that may
involve retroactive enrollment include those where, if a QI fulfilled all enrollment requirements, but,
for some reason, the FFE or QHP/QDP issuer was unable to process the enrollment for the required
effective date, the FFE may process a retroactive enrollment effective date. If an enrollment was never
processed, or if a valid termination request was properly made, but not processed or acted on by the
FFE or the QHP/QDP, the FFE may grant retroactive terminations. Those circumstances will be
addressed on an individual basis, and determinations of outcomes will be decided by the FFE in
collaboration with issuers, when needed.
In most cases, issuers will receive an 834 transaction from the Exchange, which communicates the
correct retroactive enrollment or termination effective dates. However, in some cases (e.g., an eligible
enrollee opts for retroactive effect of an appeal decision), CMS notifies the issuer(s) using the Health
Insurance Casework System (HICS), which specifies the effective date for the retroactive enrollment
or termination and/or application of APTC/CSR amounts.
Unlike a reinstatement, which is a correction of records with the practical effect of “erasing” a prior
disenrollment, a retroactive enrollment is an action to enroll a QI into a QHP or QDP for a new time
period. Reasons and effective dates for retroactive enrollments and terminations are outlined in
Exhibit 5 and Exhibit 6. In some limited cases, CMS may determine that a QI is eligible for an SEP
due to an extraordinary circumstance beyond the QI’s control and may also permit retroactive
enrollment and termination, as necessary.
Exhibit 5: Retroactive Enrollment Reasons and Dates
Reason
Effective Date
Birth, Adoption, Placement for Adoption, or
Placement in Foster Care
Date of Event
FFE or QHP/QDP Issuer Error
Date to Be Determined (TBD) by CMS
Exceptional Circumstances
Date to Be Determined (TBD) by CMS
Eligibility Appeals Outcome
Date TBD by Appeal Outcome
FFE and FF-SHOP Enrollment
15
Exhibit 6: Retroactive Termination Reasons and Dates
7
Reason
Effective Date
Death
Date of Event
Rescission
Policy Start Date
Exhausted Three-Consecutive-Month Grace Period
Last Day of First Month of Grace Period
Exceptional Circumstances
Date to Be Determined (TBD) by CMS
FFE Termination Error or FFE Systems Limitations
Date to Be Determined (TBD) by CMS
Eligibility Appeals Outcome
Date to Be Determined (TBD) by Appeal Outcome
Exhibit 7 provides examples related to retroactivity.
Exhibit 7: Retroactivity Examples
Family Composition
Action
Outcome
Subscriber, Spouse, and
Two Dependent Children
Twin dependent children born on
August 1. Newborn dependents
are enrolled retroactively into the
family’s current QHP.
The FFE sends enrollment information for the
enrollment group to the issuer. The issuer
receives the transactions and confirms receipt
of the transactions by sending an
acknowledgement to the FFE. The issuer
makes updates to its system. Coverage is
effective August 1.
Subscriber and Spouse
Subscriber contacts FFE to
inform FFE of spouse’s sudden
death three weeks prior.
The FFE terminates the deceased enrollee’s
coverage with a prospective termination date
and redetermine eligibility for the remaining
subscriber. The FFE then assigns a Category
Two HICS case to the issuer specifying a
retroactive termination date to be the date of
death. The issuer may require additional steps
to process the premium refund in accordance
with applicable state law, and the FFE
recoups any APTC and adjusts issuer user
fees.
Subscriber Only
Issuer sends termination
transaction to FFE on November
2 with a termination effective
date of August 31 for non-
payment of premium for a
subscriber who is receiving
APTC (grace period exhausted
October 31).
The issuer sends termination information for
the subscriber to the FFE. The issuer makes
updates to its system. The issuer then sends a
notice to the subscriber regarding the
termination of coverage.
The retroactive termination date is August 31,
the last day of the first month of the three-
month grace period.
7
This is not an exhaustive list.
FFE and FF-SHOP Enrollment
16
Initial Enrollment Transaction
Once a QI selects a QHP, and QDP if desired, the FFE sends an 834 enrollment transaction to the
issuer. The FFE accumulates transactions and sends them once daily (seven days a week, except
during scheduled maintenance windows). Starting in July 2022, the FFE will accumulate transactions
and send them two times a day (6:00 a.m. and 6:00 p.m. ET).
If a QI makes a plan selection and subsequently makes a change later in the same day before daily
transactions are submitted, the plan selection and the change each generate separate 834 transactions,
and issuers must process each transaction in sequence based on the timestamp and Electronic Data
Interchange (EDI) file. However, to obtain the highest level of accuracy in determining order of
transactions, issuers should pay specific attention to the date time stamp on the actual 834 enrollment
transaction, and not just the date and time on the EDI file.
Confirmation of the 834 Transaction in Individual Market FFE
In the FFE, once an issuer receives either full payment or payment within its established premium
payment threshold in accordance with Section 7.2, Premium Payment Threshold, for any applicable
initial premium due from the enrollee, and the issuer has received the initial 834 enrollment
transaction, the issuer will send the FFE a full 834 effectuation/confirmation transaction (Additional
Maintenance Reason Code [AMRC] of CONFIRM). The confirmation transaction provides the FFE
verification that the issuer has effectuated enrollment.
Issuers should not wait to confirm enrollment of a QI until after the APTC is paid. For purposes of
generating the confirmation transaction, full payment occurs when the issuer receives full payment (or
payment within the premium payment threshold if the issuer utilizes such) of the portion of the
premium for which the QI is responsible.
When a QI pays their portion of the binder payment before the coverage effective date, CMS expects
QHP and QDP issuers to send the confirmation transaction to the FFE no later than the fifth calendar
day of the effective month of coverage. In the case where the binder payment is made after the
effective date of coverage, but coverage is effectuated retroactively by the issuer from the date the
premium payment is made, CMS expects QHP and QDP issuers to send the confirmation transaction to
the FFE without undue delay (up to 48 hours from activation of policy in issuer’s system).
Issuers should be aware that Inbound 834 (IC834) transactions for prior years will not be accepted
after the annual cut-off which typically occurs in late March.
Examples
Example 2A: A QI selects a QHP on November 20 during the OEP and is therefore assigned a
coverage effective date of January 1. The monthly premium is $200, and the issuer does not make use
of a premium payment threshold. The QI is eligible for a maximum APTC of $75 per month. The QI
selects the maximum APTC and, therefore, is responsible for a monthly premium payment of $125.
The issuer has established a premium payment deadline of the coverage effective date. The QI is,
therefore, required to make payment of initial month’s premium of $125 to the QHP issuer no later
than January 1. The QHP issuer receives payment of $125 from the QI on December 31. The QHP
issuer then sends the FFE the 834 confirmation transaction on January 2. The QHP issuer has met the
FFE’s expectation for timely transmission of the confirmation transaction.
FFE and FF-SHOP Enrollment
17
Example 2B: Same circumstances as Example 2A, except the QI mails a payment of $100 on
December 16. The issuer receives the payment on December 18. The enrollee makes an additional
payment towards the initial month’s premium of $25 on December 21, and the issuer receives the
payment on December 28. The QHP issuer then sends the FFE the 834 confirmation transaction on
December 30. The QHP issuer has met the FFE’s expectation for timely transmission of the
confirmation transaction.
Additional information on 834 effectuation transactions to the individual FFE can be found at the ASC
X12 005010 834 Companion Guide linked earlier in this section.
Cancellations in the Individual Market FFE
Pursuant to 45 CFR 155.430(e)(2), a cancellation transaction is a specific type of termination that ends
a QI’s enrollment on the date coverage became effective resulting in coverage never having been
effective, (noting that the termination transaction may include a termination or end date of the day
before [11:59 p.m. ET] the effective date of coverage). Cancellations can be initiated by the issuer or
the QI, however, if an effectuation has been sent by the issuer to the FFE a cancellation cannot be
submitted under certain circumstances, including when the enrollee resides in an area that is outside
the plan's coverage area, or in response to anti-duplication transactions.
A QI may choose to cancel coverage prior to the coverage effective date for any reason (and in certain
states, during a free look period). For instance, the QI may no longer want or need health insurance
coverage through the FFE because they have gained other coverage. Or, the QI may have changed
their mind within an enrollment period about the QHP or QDP they selected, and therefore, wish to
select a different available QHP or QDP.
Cancellation transactions initiated by the QI are voluntary and the associated request must generally be
made on HealthCare.gov, with an Enhanced DE (EDE) partner, or at the Marketplace Call Center.
Because the FFE cannot automatically cancel a passive reenrollment initiated through the annual Batch
Auto-Reenrollment (BAR) process (as explained in Section 3.2.2, Passive Reenrollment/), if the
enrollee actively reenrolls via a disconnected application (either directly or through an assister),
enrollee cancellation requests to issuers for passive reenrollments (policy origin = 11) that are still in
passive status (no active plan selection has been completed) are the exception. Issuers are therefore
expected to process cancellation requests received directly from the QI for passive reenrollments.
Issuers should report the cancellation via IC834 or monthly reconciliation.
A QI must complete submission of their cancellation request to the FFE by 11:59 p.m. ET on the date
prior to the coverage effective date. A QI who enrolled through the FFE cannot request a cancellation
after their coverage effective date (unless the enrollee is in a free look period), or another basis under
45 CFR 155.430(b)(1)(iv)(B) or (C) applies. The QI may elect to cancel enrollment in a QHP or QDP
and select a different available QHP or QDP, as many times as they choose, within an enrollment
period, as long as the QI completes submission of the cancellation request prior to the coverage
effective date.
QHP and QDP issuers in the FFE may initiate a cancellation transaction due to non-payment of the
binder payment by the QI. CMS expects QHP and QDP issuers to transmit cancellation transactions to
the FFE without undue delay (no more than 48 hours after updating the policy to a cancelled status in
the issuer’s system). As previously mentioned, issuers may not send a cancellation if an effectuation
has been sent to the FFE under certain circumstances, including if the enrollee resides in an area that is
FFE and FF-SHOP Enrollment
18
outside the plan's coverage area or in response to anti-duplication transactions.
NOTE: Issuers that receive a HICS case to cancel a passive reenrollment (policy origin = 11) should
cancel the passive auto-reenrollment.
Active policies must be cancelled or terminated by the enrollee through the Exchange unless there is a
HICS case noting an enrollment blocker. However, if an enrollee makes a change to a passive
enrollment that results in an M834 transaction (policy origin other than 11), the enrollment is
considered an active selection.
Examples
Example 2C: A QI selects a QHP on December 12 during the OEP and therefore is assigned a
coverage effective date of January 1. The full monthly premium for the selected plan is $300 and the
issuer does not make use of a premium payment threshold. The enrollee is qualified for a maximum
APTC of $125 per month. The enrollee elects to receive the full APTC amount of $125. Therefore, the
834 enrollment transaction indicates the full monthly premium of $300, which includes the monthly
APTC amount of $125 and the $175 enrollee-responsible portion of the monthly premium. The issuer
established a premium payment deadline of 30 days from the coverage effective date.
The enrollee mails the $175 payment on January 30. The issuer does not receive the payment until
February 3. The issuer should send the FFE an IC834 cancellation transaction without undue delay and
refund the QI $175 since the payment was not received prior to the effective coverage date.
Furthermore, the issuer must set the cancellation end date on the IC834 to January 1 as any date after
January 1 would indicate a period of active coverage for the policy.
Additionally, CMS will recoup any APTC paid to the QHP or QDP issuer and adjust user fees for that
enrollee. The issuer should report the cancellation to the FFE during the monthly enrollment data
reconciliation.
Example 2D: Circumstances are the same as Example 2C except the enrollee mails a payment of $100
but does so on December 16, and the issuer has established a premium payment deadline of the
effective date of coverage. The issuer receives the payment on December 18. The enrollee makes no
further payment towards the initial month’s premium. Although payment was received by the issuer
prior to the coverage effective date because the enrollee did not make payment in full, the issuer
cannot effectuate enrollment by sending the confirmation file. No coverage is effectuated on January 1,
and the issuer should send the FFE the IC834 cancellation transaction without undue delay and refund
the QI $100. Once again, the issuer must set the cancellation end date on the IC834 to January 1, as
any later date would indicate a period of active coverage for the policy. Any APTC paid on the behalf
of the QI must be returned to the FFE.
Fraud Cancels Related to Approved Rescissions and Unauthorized Enrollments
FFE policies may be cancelled when CMS has approved the issuer’s request to rescind the enrollment
because it is satisfied that the issuer has demonstrated that the rescission is appropriate. For example, if
an enrollment was made without the subscriber’s authorization, and the issuer has found no evidence
that the subscriber was aware of the enrollment (“unauthorized enrollments”), the issuer may be able to
demonstrate that a cancelation is appropriate. To cancel an unauthorized enrollment, issuers should
send the FFE an IC834 cancel transaction with a reason code of fraud using the CANCEL-FRD
AMRC, using the equivalent cancel reasons if other Enrollment Data Alignment (EDA) channels are
FFE and FF-SHOP Enrollment
19
utilized.
Additionally, if the issuer is able to demonstrate to the satisfaction of the Exchange that the enrollee, or
person acting on their behalf, made an intentional misrepresentation of material fact, as prohibited by
the terms of the plan or coverage, the issuer may also be able to rescind the enrollment.
For intentional misrepresentation of material fact, as prohibited by the terms of the plan, issuers should
use the CANCEL-RESCIND AMRC if notified that CMS has approved their rescission request (in
both instances, issuers should always use a CANCEL and not a TERMINATION transaction). Issuers
should be aware that policies for prior plan years will still be accepted through IC834 until the annual
cut-off is implemented (typically late March but is subject to change each plan year). After the
deadline, prior year policies cannot be cancelled via IC834, so an issuer will need to submit an
Enrollment Resolution and Reconciliation (ER&R) dispute, setting “Prior Year – End Date” to equal
the start date of the policy and using the appropriate cancel reason of rescission).
For additional information on rescissions and unauthorized enrollments see Section 13, Addressing
Individual-Reported Unauthorized Enrollments and Issuer-Reported Fraudulent Enrollments.
Free Look Provisions in the Individual Market FFE (Applicable to QHPs/QDPs)
Certain states have laws that provide a QI in health insurance coverage a free look period. These
provisions allow an enrollee to retroactively cancel coverage in a QHP or QDP in the FFE, within a
certain period of time.
In states with laws providing for a free look period, an enrollee in an FFE may request cancellation of
coverage in their QHP and QDP after their coverage effective date after first terminating their
coverage through the FFE. Since rules can vary by state, QHP and QDP issuers may initiate free look
cancellations as long as the requests from enrollees are consistent with applicable state laws. Issuers
are encouraged to use the AMRC for “free look” cancels pursuant to the 834 Companion Guide
described earlier in this section.
Premium refund policy in the case of free look cancellations follows existing state-specific guidelines.
Generally, if an enrollee’s request to cancel coverage under a free look provision meets all required
criteria, the QHP or QDP issuer must return any premium paid by the enrollee.
Additionally, CMS will recoup any APTC paid to the QHP or QDP issuer and adjust user fees for that
enrollee. The issuer should report the cancellation to the FFE during the monthly enrollment data
reconciliation. CMS will not initiate an enrollment cancellation through an 834 or through HICS as the
result of a QI seeking a cancellation under free look provisions.
If a QI cancels their QHP or QDP coverage during OEP, the QI may select a new QHP or QDP.
Cancellation under a free look period does not qualify the enrollee for an SEP for loss of minimum
essential coverage (MEC).
Examples
Example 2E: In the FFE, a QI residing in a state with a free look period selects a QHP on December 5
with a coverage effective date of January 1. The enrollee takes the necessary actions that would qualify
them for a free look cancellation within 30 days of coverage from the start of coverage under state law.
On January 30, the enrollee requests cancellation under the free look law from the enrollee’s QHP
issuer. The QHP issuer processes the request with a cancellation date of January 1.
FFE and FF-SHOP Enrollment
20
The QI may return to the FFE to select new coverage as long as they qualify for an SEP. The QI is not
eligible for an SEP as a result of the cancellation of their Exchange coverage.
Example 2F: In the FFE, a QI who is eligible for an SEP and who is residing in a state with a free
look period selects a QHP on January 5 with a coverage effective date of February 1. The enrollee
takes the necessary actions that would qualify them for a free look cancellation within 30 days of
coverage from the start of coverage under state law. On February 28, the enrollee requests cancellation
under the free look provision from the enrollee’s QHP issuer. The QHP issuer processes the request
with a cancellation date of February 1. The QI is not eligible for another SEP as a result of the
cancellation of their Exchange coverage.
To enroll in coverage through the FFE, the QI must wait until the next OEP or must qualify for an
SEP, as provided in 45 CFR 155.420.
Application and Enrollment Changes
In accordance with 45 CFR 155.330(b), and as specified in 45 CFR 155.305, enrollees and tax filers
are required to report changes to information on their applications no later than 30 days after the
changes happen. These changes can be reported to the FFE via internet or by calling the Marketplace
Call Center.
Some updates reported by the enrollee may result in changes to an enrollee’s eligibility for coverage or
financial assistance through the FFE or may qualify the enrollee for an SEP. If changes are not
reported, the tax filer may be liable to repay some or all of the APTC received during the year.
Issuers should instruct enrollees to follow the process for reporting changes through the FFE provided
in Exhibit 8.
Exhibit 8: Process for Reporting Changes
Step
Process
1
The QI logs in to their account and selects the “Report a Life Change”
button. (This button is enabled only for QIs who have a current year application.)
2
The QI lands on a page with information about the types of changes that must be reported to the
Marketplace. The next screen allows the QI to change household eligibility information, make changes
to notification preferences, or report a move to a new state.
3
If the QI reports changes that may affect eligibility, an updated copy of their application is created, pre-
populating some information and attestations from their earlier application.
4
The QI updates the application and answers questions that determine whether the (new) applicants are
or (existing QI) are still eligible for QHP or QDP enrollment through the FFE (and financial assistance
if requested), and if so, whether the new information triggers an SEP.
5
If a QI is eligible for an SEP, the QI’s Eligibility Determination Notice (EDN) contains SEP eligibility
language.
6
If any applicants for whom new information is being provided are eligible to enroll in a QHP/QDP
through a Marketplace (i.e., they are QIs), the QI proceeds to the enrollment to-do list page to finish
QHP and/or QDP enrollment(s) for all QIs on the application.
6a
If new information is being provided for an applicant based on an event that triggers an SEP, all QIs on
the application have the ability to compare and select from QHPs and QDPs available in their service
area under the plan category restrictions for the corresponding SEP(s).
FFE and FF-SHOP Enrollment
21
Step
Process
6b
If the new information provided does not trigger an SEP, the QI will be limited to selecting the QHP or
QDP in which they are currently enrolled. This non-SEP selection will provide the QHP/QDP with the
updated enrollment information.
7
The QI eligible for an SEP sets the amount of APTC the tax household will use and selects a new plan
(or the existing plan, depending on the situation).
8
Once the QI eligible for an SEP selects a plan, the system will generate enrollment transactions to the
issuer as appropriate based on the plan selected.
• Updates that maintain the same subscriber and the same FFE Policy ID will be sent as a
Maintenance (M834) transaction
• Updates that change the subscriber or QHP/QDP ID will change the FFE Policy ID and thus be
sent as a Change in Circumstance (CIC) transaction
In some limited cases, in addition to reporting the change on an application, the enrollee may need to
submit a new application to enroll in coverage. The enrollee should create a new application when the
enrollee has moved to a new state or when the enrollee will no longer be on the same Federal income
tax return as the other enrollees on the current application (such as due to a divorce or when a young
adult will no longer be claimed as a tax dependent by their parents). When this occurs outside the OEP,
the enrollee could qualify for an SEP based on the loss of their previous Marketplace coverage or
based on gaining access to new QHPs as a result of a permanent move. However, in general, QIs do
not need to create a new application or user account in order to report a change.
Exhibit 9 provides a list of reportable changes. Enrollees can also report changes during the annual
eligibility redetermination. For more information on the redetermination process, see Section 3,
Redeterminations and Renewals in the Individual Market FFE (Annual Open Enrollment).
Exhibit 9: Reportable Changes
Change Type*
Where to Report
Increase or decrease in projected annual household income for the coverage year or
change to current month’s household income
FFE
Add or remove applicant or non-applicant household member listed on application
(such as whenever there is a birth, death, or marriage)
FFE
Relocation/change of address to a new ZIP Code or county
FFE
Gain or loss of other health coverage
FFE
Pregnancy (may affect Medicaid eligibility under applicable state rules)
FFE
Change in full-time student status for 18-22-year-olds (could affect Medicaid eligibility
under applicable state rules)
FFE
Becoming the primary caretaker for a child living with you (could affect Medicaid
eligibility under applicable state rules)
FFE
Change in tax filing status (e.g., will or will not file, joint or separate filer) or change in
tax dependents that will be claimed
FFE
Newly incarcerated or released from incarceration
FFE
Change in immigration status or citizenship
FFE
FFE and FF-SHOP Enrollment
22
Change Type*
Where to Report
Change in status as member of federally recognized tribe
FFE
Became disabled or in need of long-term care (or is no longer in need of long-term care)
FFE
Change to available employer coverage
FFE
Change in enrollment in other health coverage
FFE
Correct/update the relationships between family members
FFE
*For information on whether reported changes are classified as financial or demographic, please refer
to Section 2.2 of the M834 Operations Manual, which can be found at
https://zone.cms.gov/document/federally-facilitated-marketplace-maintenance-834-operations-manual.
Age Rating and Accumulators
In accordance with 45 CFR 147.102(a)(1)(iii), QHP issuers must use an enrollee’s age as of the date of
policy issuance or renewal to conduct age rating. Issuers are not permitted to re-rate an enrollee based
on age during the plan year if the enrollee remains on the original policy. New enrollees who enroll
during the middle of the plan year will be age-rated by the FFE as of the start date they enroll in
coverage. If a dependent is added in the middle of the plan year, the FFE will age-rate the dependent as
of the date of their enrollment, while the subscriber will retain the age-rating they received when the
coverage began. If an existing subscriber selects a new plan during the middle of the plan year
(involving a change in the 14-character Plan ID), then all the enrollees on the policy will be age-rated
as of the start date of their policy in the new plan. Finally, if the original subscriber on a policy is
removed during the plan year, a new subscriber is assigned to the policy from the remaining enrollees,
and all the remaining QIs are age-rated as of the effective date of the new policy start date. If the FFE
does not assign the rate as described here, an issuer may generally use EDA to correct it. If the FFE re-
rates after a CIC because a new FFE Policy ID was assigned, but the issuer is required by state law or
business rule to continue the original premium, the issuer may use EDA to change the FFE policy
premium so that age rating reflects the original start date. Issuers must use the annual renewal date on
January 1 to age rate when coverage continues into the next plan year.
The same principle applies to accumulators, such as deductibles and maximum out-of-pocket limits.
Accumulators may not be reset for an enrollee or family remaining in the same policy, as indicated by
the FFE Policy ID remaining unchanged after the CIC. Accumulators may be reset at the beginning of
the plan year or when a new policy is issued (typically indicated by the FFE assigning a new FFE
Policy ID) as occurs when a new plan is selected or a new subscriber is identified. Issuers should also
refer to the laws in their state, which may be more consumer protective regarding when accumulators
may be reset. Changes in eligibility for Cost Sharing Reductions, known as “CSR variants” and
indicated on the 834 by the two-digit suffix to the Plan ID, are not new policy issuances and thus
accumulators must not be reset, consistent with 45 CFR 156.425(b).
Child Rating Limitations
In accordance with 45 CFR 147.102(c)(1), the FFE takes into account no more than the three oldest
covered children when calculating the total family premium. Multiple enrollment scenarios involving
FFE and FF-SHOP Enrollment
23
QIs under the age of 21 can exist and the determination of who is included or excluded in the
calculation of total family premium are outlined below.
• When a Subscriber is 21 years or older, only the three oldest dependents (any relation other
than spouse), aged 20 or younger, will be included as the three oldest covered children in the
total family premium calculation.
• When a Subscriber is aged 20 or younger, and the Subscriber is not the parent of any of the
included dependents and is not a spouse of any of the included dependents, the Subscriber will
be considered to be one of the three oldest covered children when calculating the total family
premium.
• When a Subscriber is aged 20 or younger, and the policy includes an individual aged 20 or
younger who is the spouse of the Subscriber, neither the Subscriber nor the spouse will be
considered as covered children when calculating the total family premium.
• When a Subscriber is aged 20 or younger, and the Subscriber is the parent of any included
dependent aged 20 or younger, the Subscriber will be excluded from the count of the three
oldest children when calculating the total family premium.
Electronic Notice Requirements
Issuers have asked CMS whether it is permissible to send notices to enrollees electronically, rather
than standard mail. In general, CMS regulations do not prohibit issuers from providing notices
electronically. When sending notices electronically, issuers should ensure that the following conditions
are met:
• Enrollees have been given a choice of either standard mail or electronic communication.
• The enrollee has affirmatively consented to electronic communication.
• The issuer satisfies the requirements for electronic notices under other applicable federal or
state law.
In addition, if an issuer cannot send all other supporting materials in electronic format, the notice must
be provided through standard mail. Issuers are encouraged to contact their state’s Department of
Insurance to ensure that any electronic communications are compliant with state regulations.
FFE and FF-SHOP Enrollment
24
REDETERMINATIONS AND RENEWALS IN THE INDIVIDUAL MARKET
FFE (ANNUAL OPEN ENROLLMENT)
Introduction
Pursuant to 45 CFR 155.335, an Exchange has the flexibility to conduct annual redeterminations using
either the procedures described in 45 CFR 155.335(b) through (m), alternative procedures specified by
the Secretary for the applicable plan year, or alternative procedures approved by the Secretary based
on a showing by the Exchange that such procedures meet specified criteria. The alternative procedures
utilized by the Federally-facilitated Exchange (FFE) are published as written guidance on
redetermination and reenrollment on the Center for Consumer Information & Insurance Oversight
(CCIIO) website.
8
We intend to update Batch Auto-Redetermination and Reenrollment operations to
reflect changes made to Marketplace coverage by the American Rescue Plan Act of 2021 (ARP).
Additional guidance may be released separately, for example, with regards to FTR.
For each plan year, the FFE will provide a Marketplace Open Enrollment Notice (MOEN) to all
qualified individuals (QIs) currently enrolled in Qualified Health Plans/Qualified Dental Plans
(QHPs/QDPs) through the FFE in advance of the Open Enrollment Period (OEP) for future plan year
coverage. This notice is focused on announcing the OEP, and contains other basic information,
including a description of the annual redetermination and renewal process, the requirement to report
changes affecting eligibility and the channels for reporting such changes, and the last day plan
selections may be made for coverage starting on January 1 or February 1 of the upcoming plan year.
Information specific to the enrollment, such as the future year premium, and any financial assistance
(possibly initially estimated), will come from the issuer’s renewal or discontinuation notice,
supplementary notice, and/or January or February invoice.
MOENs will contain special messaging for QIs who are at risk for having their advance payments of
the premium tax credit (APTC) discontinued in the new coverage year. These groups include, but are
not limited to, the following:
1. Opt-Out Group: Consists of QIs enrolled in a QHP with APTC or income-based cost-sharing
reduction (CSR) who did not authorize the FFE to request updated tax return information for
the purpose of annual redetermination, or the QI’s authorization has expired.
2. Repeat Passive Re-enrollees (RPR): Consists of QIs who were automatically re-enrolled with
APTC or income-based CSR for the past two consecutive coverage years and have no tax data
(meaning, no income or FTR indicator) available from the Internal Revenue Service (IRS) for
the previous two relevant tax years.
Notices for these groups will state the same information as the standard notice, along with an
explanation that the FFE strongly encourages enrollees receiving APTC or CSR to contact the FFE to
obtain an updated eligibility determination from the FFE and make a plan selection by the last day of
plan selection for a January 1 coverage effective date, as specified in 45 CFR 155.410(f).
8
For example, for the 2019 plan year, the annual redetermination/reenrollment guidance was published July 6, 2018, at;
https://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/2019-Enrollment-ARR-Guidance.pdf
FFE and FF-SHOP Enrollment
25
For a QI who is at risk of losing financial assistance and does not contact the FFE to obtain an updated
eligibility determination and select a QHP by December 15, the FFE will establish future year
eligibility based on a hierarchy of the most recent income data available and reenroll the QI in QHP
coverage without APTC or CSR. The FFE may use either IRS data or verified QI-provided application
data, which is verified either through external data sources (EDSs) or a manual documentation
submission process, whichever is most recent. This income data, together with updated Federal
Poverty Level (FPL) tables and benchmark plan premium information, is used to update eligibility for
APTC and CSR.
Special note for FTR in plan years 2021 and 2022: CMS is providing additional flexibilities for
enrollees and Exchanges by adjusting FTR operations for plan years 2021 and 2022. These
additional flexibilities are due to the continued impact of the 2019 novel coronavirus disease
(COVID-19) pandemic on the processing of 2019 and 2020 Federal income tax returns, as well
as a recent change passed by Congress regarding reconciliation of APTC with PTC for tax year
2020 under the American Rescue Plan Act of 2021, and the IRS’ implementation of that change.
Specifically, for plan years 2021 and 2022, CMS will not be taking certain actions in the FFE to
remove the financial help enrollees receive to help pay for their health coverage because of their
FTR status.
In April 2021, the IRS announced that taxpayers whose 2020 APTC is more than their PTC
allowed for 2020 (excess APTC) are not required to reconcile their APTC with their PTC by
attaching Form 8962, Premium Tax Credit, to their 2020 tax return. See the IRS News Release
9
about suspending the requirement to repay excess APTC, the Instructions for Form 8962,
Premium Tax Credit,
10
and IRS Fact Sheet
11
for more details about the changes related to the
PTC for tax year 2020.
Because taxpayers with excess APTC for 2020 are not required to file Form 8962 to reconcile
APTC for tax year 2020, CMS will not take any FTR actions based on 2020 tax returns for plan
year 2022 for enrollees in the FFE. As such, CMS will not warn enrollees via the Marketplace
Open Enrollment Notice (MOEN) or FTR Direct Warning Notices when they have an FTR status
or take action to terminate APTC for plan year 2022 based on having an FTR status. Finally,
CMS will not run FTR Recheck in 2022. This flexibility does not change the general requirement
for taxpayers for whom APTC was paid in years before 2020 to file their taxes and reconcile the
APTC with the PTC allowed for the year. Consumers can find the latest information on filing
and reconciling for 2020 Federal income tax returns at https://www.irs.gov/newsroom/irs-
suspends-requirement-to-repay-excess-advance-payments-of-the-2020-premium-tax-credit-
those-claiming-net-premium-tax-credit-must-file-form-8962.
9
https://www.irs.gov/newsroom/irs-suspends-requirement-to-repay-excess-advance-payments-of-the-2020-premium-tax-
credit-those-claiming-net-premium-tax-credit-must-file-form-8962
10
https://www.irs.gov/forms-pubs/about-form-8962
11
https://www.irs.gov/newsroom/more-details-about-changes-for-taxpayers-who-received-advance-payments-of-the-2020-
premium-tax-credit
For examples of MOENs, see Marketplace Open Enrollment and Annual Redetermination
Notices at https://marketplace.cms.gov/applications-and-forms/notices.html
FFE and FF-SHOP Enrollment
26
Reenrollment
Reenrollment is the general term used to describe coverage continued into a new plan year, whether
the next plan year’s coverage is under the same or different “product” (as defined in 45 CFR 144.103),
or with a different issuer. Reenrollment for the next plan year can be either “active” or “passive.”
Active Reenrollment
An active reenrollment is initiated by an enrollee returning to the FFE during the OEP to submit an
application and select a plan for the next plan year. It is important that current FFE enrollees who are
seeking to actively reenroll work from future-year applications that are tied to their current-year
applications, rather than creating brand new applications (e.g. through a new HealthCare.gov account)
that are not pre-populated from their current year application. This approach means that enrollees will
get the benefit of pre-populated applications and also helps the FFE and issuers maintain continuity in
enrollments. Tips for enrollees who have trouble logging into their HealthCare.gov account are
available at https://www.healthcare.gov/help/i-am-having-trouble-logging-in-to-my-marketplace-
account/.
Note that it is very important for enrollees or their Agents or Brokers (A/Bs) to access their respective
existing Exchange accounts, so they can receive a pre-populated eligibility application for the future
plan year. This allows the Exchange to accurately connect the future year enrollment with the current
year enrollment. Failure to use a pre-populated application to enroll in future year coverage may lead
to duplicate enrollments and QI confusion.
Prior to assisting a QI, the A/B should determine whether the QI has an existing application to avoid
creating more than one application for the same QI. Failure to follow these steps can create confusion
for the enrollee as well as the issuer, as duplicate enrollments may be created if an existing enrollee’s
pre-populated future year application is not accessed.
To prevent unnecessary creation of a new application, the A/B application search returns both the
current and future year application when the A/B searches for the current year application, prevents an
A/B from pre-populating a future year application using a current year application when a future year
application already exists, and only displays an application with an active policy for a given year,
when one is available.
Passive Reenrollment/BAR
Passive reenrollment, also called Batch Auto-Reenrollment (BAR), is the process that the FFE uses to
reenroll current enrollees who do not return to the FFE to submit an application and select a plan by
December 15 to help ensure that they can have coverage on January 1 of the following year.
Issuers indicate next year’s auto-reenrollment plan as determined under 45 CFR 155.335(j) to the FFE
on the Plan ID Crosswalk Template in current year Plan ID/service area combinations. The Plan ID
Crosswalk is submitted by the issuer with other plan materials during the QHP certification process.
The FFE uses the Plan ID Crosswalk Template to conduct the passive reenrollments.
Auto-reenrollment will run as follows:
• October Wave (approximate start in mid-Oct): All Enrollees eligible for renewal who are
being reenrolled into a plan offered by the same issuer or matched to an alternate plan from a
different issuer by CMS or a State Insurance Department, as applicable. Goal is to complete by
FFE and FF-SHOP Enrollment
27
November 1.
• Incremental Wave (approximate start in late Nov/early Dec): New current year enrollees who
enrolled after earlier October BAR; enrollees whose auto-reenrollment is being updated
because the enrollee or an Exchange reported new eligibility information for the current year
after October BAR.
• December Wave (approximate start in mid-Dec): New current year enrollees who enrolled
after November BAR; enrollees whose auto-reenrollment is being updated because the enrollee
or an Exchange reported new eligibility information for the current year after November BAR.
Most passive reenrollment transactions are sent to issuers before the start of the OEP to provide issuers
time to process and track renewals as well as provide an opportunity to prepare issuer-provided
reenrollment notices that identify the reenrollment plan and financial information if the QI is auto-
reenrolled. Enrollees who visit HealthCare.gov and check their Marketplace accounts during the OEP
will not see their passive reenrollment until December 16, though once they are determined eligible to
enroll in a QHP through the Exchange and proceed to plan selection, they will see the reenrollment
plan pre-selected for their convenience.
Issuers may communicate with QIs regarding these reenrollment transactions but should not send an
invoice for future year coverage until after the OEP starts. An enrollee has until December 31 to
indicate to the Exchange that they do not want to be auto-reenrolled by opting out of passive
reenrollment through BAR on HealthCare.gov. Confirming “stop coverage for (future year)” will send
a current year policy termination that day, effective December 31, and simultaneously cancel the future
year BAR policy (if already sent; if not yet sent the policy will not be auto-renewed).
For passive reenrollments, issuers must reenroll an enrollee in a QHP in accordance with the BAR
reenrollment transactions sent, which follow the hierarchy described at 45 CFR 155.335(j). This
generally requires that an enrollee be renewed in the same QHP, if available, or a plan in the same
product, if available through the Exchange. If no plan in the same product is available through the
Exchange, the issuer may reenroll the enrollee into a different product available through the Exchange.
With regard to enrollees in Silver level QHPs, if an enrollee’s current Silver level QHP is not available
and the enrollee's current product no longer includes a Silver level QHP available to the enrollee
through the Exchange, the enrollee's would be reenrolled in a Silver level QHP in the product offered
by the same issuer that is the most similar to the enrollee's current product, rather than in a plan one
Metal Level higher or lower than their current Silver level QHP, but within the same product.
If an enrollee has not yet been passively reenrolled and makes an active plan selection for the
upcoming year, they will not be passively reenrolled through BAR. Additionally, active plan selections
through December 15 automatically cancel or update any auto-reenrollment already sent for the
enrollee. If an enrollee updates their current plan year coverage after they were passively reenrolled for
the next plan year, those changes generally will be carried forward to the next plan year policy through
the December BAR process. However, if an enrollee makes an active update to their next plan year’s
policy, subsequent updates to current plan year coverage will not be automatically carried forward to
the next plan year’s policy through the December BAR process. Absent a special enrollment period
(SEP) (such as Loss of Coverage due to current year issuer discontinuing coverage), a QI must make
an active plan selection by December 15 for an effective date of January 1, and plan selections
between December 16 to January 15 will have an effective date of February 1. If the enrollee makes an
active plan selection before December 15, any passive reenrollment transaction previously sent by the
FFE and FF-SHOP Enrollment
28
FFE should be disregarded, even if received out of sequence. A QI can make an election at any time
during the OEP or during an SEP, even if a previous passive or active reenrollment has been
effectuated. The new coverage starts in accordance with normal effective dates, unless an enrollee has
an SEP that allows for accelerated effective dates.
BAR Operational Process
• CMS selects application with a current, active enrollment.
• CMS pre-populates a future plan year application; this application is not visible to the enrollee
until the returning enrollee logs into their Marketplace account on or after the first day of OEP.
• CMS creates a future plan year enrollment using the Plan ID Crosswalk Template provided by
the issuer, or in an alternate plan from a different issuer (see Section 3.2.4, Alternate
Enrollments). This enrollment will not be visible to the QI until December 16, and only if the
QI does not actively select a plan for the upcoming plan year.
• CMS sends the enrollment transaction to the issuer.
• CMS repeats steps 1–4 for Incremental Wave and December Wave.
• CMS generates an Eligibility Determination Notice (EDN) and enrollment confirmation
message for enrollees who did not make an active plan selection by the last day of OEP.
Alternate Enrollments
Where no QHP from the same issuer is available to enrollees through the Exchange, then to the extent
permitted by applicable State law, the Exchange directs alternate enrollments for such enrollees into a
QHP from a different issuer. This process does not apply to QDPs or plans in the Small Business
Health Options Program Exchanges (SHOPs).
In such cases, reenrollments are conducted as directed by the applicable State regulatory authority. If
the applicable State’s regulatory authority declines to act, to the extent permitted by applicable State
law, the Exchange may reenroll the affected enrollee in a similar QHP from a different issuer with a
service area that covers the enrollee’s location, taking into account the issuer’s ability to absorb new
enrollment and the lowest premium plan, according to the following hierarchy, which prioritizes
finding a policy offered by a different issuer that is similar to the enrollee’s current coverage.
• The enrollee’s coverage will be auto re-enrolled in a QHP at the same Metal Level under the
same product network type.
• If there is no QHP available at the same Metal Level under the same product network type in
the same service area, the enrollee will be auto re-enrolled in a QHP at the same Metal Level
under a different, if possible similar, product network type.
• If no QHP is available from the same Metal Level under a different product network type in the
same service area, the enrollee will be auto re-enrolled in a QHP that is one Metal Level lower
than the enrollee’s current QHP under the same product network type.
• If no QHP is available that is one Metal Level lower than the enrollee’s current QHP under the
same product network type in the same service area, the enrollee will be auto re-enrolled in a
QHP that is one Metal Level lower under a different, if possible similar, product network type.
• If no QHP is available that is one Metal Level lower under a different product network type in
the same service area, the enrollee will be auto re-enrolled in a QHP that is one Metal Level
higher than the enrollee’s current QHP under the same product network type.
• If no QHP is available that is one Metal Level higher than the enrollee’s current QHP under the
FFE and FF-SHOP Enrollment
29
same product network type in the same service area, the enrollee will be auto re-enrolled in a
QHP that is one Metal Level higher under a different if possible similar, product network type.
• If no QHP is available that is one Metal Level higher under a different product network type in
the same service area, the enrollee will be auto re-enrolled in a QHP at any Metal Level under
the same product network type.
• If no QHP is available for enrollment at any Metal Level under the same product network type
in the same service area, the enrollee will be auto re-enrolled in a QHP at any Metal Level
under a different, if possible similar, product network type.
The Exchange sends this type of auto-reenrollments to the new future plan year issuer as initial
enrollments, with an Electronic File Transfer (EFT) code of I834, and Additional Maintenance Reason
Code (AMRC) of PASSIVE – NEW TO ISSUER, in contrast to other passive reenrollments, which are
sent with an EFT code of I834AR. For a smoother enrollment experience, we encourage alternate
enrollees who wish to change plans to select a plan by December 15 to have an effective date of
January 1, though they are generally eligible for an accelerated SEP permitting plan changes for
January 1 coverage until December 31.
Reenrollment Communications to Enrollees
In addition to the MOEN sent by the Exchange, issuers are also required to send notices of product
renewal and discontinuation to current enrollees as specified in 45 CFR 147.106 and 156.1255. An
issuer must provide to each individual market policyholder written notice of renewal before the first
day of the next annual OEP. For more information on Federal standard notices of product
discontinuation and renewal in connection with the OEP, see the latest CMS guidance (as of this
document’s publication date, see https://www.cms.gov/CCIIO/Resources/Regulations-and-
Guidance/Downloads/Updated-Federal-Standard-Notices-for-coverage-beginning-in-the-2021-plan-
year.pdf). Issuers should note that as indicated in the standard notice, if future year eligibility from the
FFE is not available when the issuer sends the notice, the issuer may use current year APTC as an
express estimate and communicate to consumers that it will change for the upcoming year. Issuers may
indicate that plan change descriptions in their communications presume current year CSR.
Finally, if the enrollee has not returned to the Exchange to make an active selection for the next plan
year by December 15 for an effective date of January 1, the Marketplace will send both an updated
EDN and an Enrollment Confirmation Message to the enrollee. These notices inform the enrollee of
their eligibility determination for the upcoming plan year and of their passive reenrollment status. The
Enrollment Confirmation Message notes whether the enrollees on the relevant application were
successfully reenrolled. If the enrollees were reenrolled, the confirmation message indicates the plan
name(s), Plan ID(s), and information about any financial assistance that was applied. If the QIs were
not reenrolled (because the coverage was discontinued by the issuer, or the enrollees on the application
are not eligible for passive reenrollment), QIs will not receive an EDN, but are notified in the
Enrollment Confirmation Message of their failure to auto-renew and are encouraged to actively
complete applications and plan selections through the FFE. If the BAR fails, the Exchange does not
generate EDNs because the EDN is dependent on all QIs on the application enrolling in coverage.
BAR Failure Report to Issuers
As in previous years, there are some BAR transactions that cannot be processed due to technical
FFE and FF-SHOP Enrollment
30
issues. This is a very small portion of all applications. For those BAR transactions that are
unsuccessful due to technical issues, a BAR Failure report is sent to the affected issuers. Therefore, not
all issuers will receive this file. The BAR Failure report generally is sent in late December or early
January of the coverage year.
The BAR Failure report is delivered to impacted issuers in the EFT IOUTRC format. Issuers are
encouraged to use this file for voluntary outreach to enrollees; the goal is for the enrollee to actively
re-enroll through the FFE. This file contains enrollee contact information. Enrollees contained in the
BAR Failure report sent to issuers are eligible for a 60-day SEP. The Marketplace Call Center flags
these enrollments for optional January 1 effective dates if the enrollee actively returns to the FFE and
makes a plan selection by March 1. The Exchange will also conduct outreach to these flagged
enrollees. When these flagged enrollees contact the Marketplace Call Center, they may enroll in future
year coverage with either a prospective date or a retroactive effective date of January 1. In both of
these scenarios, the 834 will have a prospective date. If the consumer elected a retroactive effective
date to January 1, a Health Insurance Casework System (HICS) case will be opened by the
Marketplace Call Center.
Enrollment Transaction Types
Since the FFE auto-reenrolls members before OE begins, most active reenrollments are sent as
Maintenance (M834) transactions. Active reenrollments for the future plan year’s coverage are sent in
daily batches as 834 initial enrollments to issuers according to current FFE procedures. Active
reenrollment 834 transactions sent to issuers also include plan selection changes made within the new
plan year, such as when an enrollee replaces future year Plan A with future year Plan B during the
OEP. Plan selection changes are sent as a cancel/term transaction to the first plan, and an initial
enrollment transaction to the gaining plan (plan selection changes are not sent as a Maintenance/M834
transaction).
Regular Change in Circumstance (CIC) transactions where enrollees report a change to their
application information for either current or next year’s coverage during the OEP, such as updating
income, reporting a new phone number, or adding a new family member, are sent according to existing
procedures.
12
The FFE sends passive reenrollment transactions as part of the BAR process described in Section
3.2.2, Passive Reenrollment/BAR. There are two populations for which an issuer may receive
updates made after the initial auto-reenrollment. The updates will be sent to issuers via maintenance
834 transactions in the second wave of BAR in December.
1. The first population is comprised of enrollments that report a current year CIC after being auto-
reenrolled for the future year. The maintenance 834 transaction updates the future year plan to
include the eligibility update made in the current year CIC.
2. The second population is made up of auto-reenrollments that later submitted an active future
year application but did not complete an active future year plan selection. The maintenance 834
transaction updates the future year enrollment with the eligibility information reported in the
12
For specific transactional information about CICs performed on current year policies, please refer to Section 2.2 of the FFE
Maintenance 834 Operations Manual: https://zone.cms.gov/document/federally-f
acilitated-marketplace-maintenance-834-
operations-manual
FFE and FF-SHOP Enrollment
31
active future year enrollment.
Passive reenrollments other than alternate enrollments with new issuers are initial enrollment
transactions with a Maintenance Type Code (INS03) of 021 “Addition,” and a Maintenance Reason
Code (INS04) of 41, with an AMRC that signals that it is an auto-reenrollment in either effectuated or
initial status. All passive reenrollments have an effective date of January 1, and most are sent with EFT
Functional Code of I834AR, though alternate enrollments are sent EFT I834. Exhibit 10 provides a
table of passive reenrollments and their associated Maintenance Type Code, Maintenance Reason
Code, Origin Type, and AMRC.
Exhibit 10: Passive Reenrollment Codes
Grouping
MTC
MRC
Sent/Rec’d
Origin
Type
AMRC
Binder
Required/Issuer
Confirms
Effectuation
EFT
Functional
Code
BAR Effectuated
021
41/NA
11
PASSIVE
N
I834AR
BAR Initial
021
41/28
11
PASSIVE -
INITIAL
N
I834AR
BAR New
Subscribers (e.g.,
young adults who
have aged-out as
dependents by year
end and are being
reenrolled as a
subscriber)
021
41/28
11
PASSIVE -
NEW
SUBSCRIBER
Y
I834AR
BAR New Issuer,
(i.e., enrollee who is
auto-reenrolled by
CMS because no
plans are available to
enrollee from current
year issuer)
021
EC/28
11
PASSIVE
REENROLL -
NEW TO
ISSUER
Y
I834
Issuers should not continue enrollments through the Exchange into the future plan year unless the
issuer receives an 834 enrollment transaction from the FFE or finds the enrollment listed on a future
year Pre-Audit File or in the Get Enrollment real time Application Programming Interface (API). The
vast majority of active reenrollments for QIs who keep their reenrollment plan are sent as 834
maintenance transactions since the FFE sends BAR transactions before the OEP. If re-enrollees update
their future year application and keep the same 14-character Plan ID, removing or changing the
subscriber would mean the update was sent as a CANCELCIC cancellation.
The FFE sends CANCELCIC cancellations for any passive reenrollments for enrollees who
subsequently change Plan IDs during active plan selections before December 15. An initial enrollment
is sent to the issuer of the new plan selected by the QI through an active plan selection, which includes
eligibility updates, if applicable. An issuer that receives a cancellation of the passive reenrollment
should not renew the enrollment unless the enrollee has actively renewed coverage with the issuer,
causing an active reenrollment transaction to be sent. For most enrollments for enrollees who have
FFE and FF-SHOP Enrollment
32
been passively reenrolled, but then make a plan selection change with an effective date after January 1,
the FFE will terminate their passive reenrollment effective the day before the actively selected plan
becomes effective. For example, an enrollee eligible for a Loss of MEC (minimum essential coverage)
SEP because the current year product is no longer available to them may make a plan selection change
(SEP ending March 1) on January 2; the issuer of the auto-reenrolled policy would receive a
termination effective January 31, and the issuer of the newly selected plan would receive a February 1
enrollment. In no case does a plan selection for the future plan year send a termination to the current
year issuer for current year coverage.
For enrollees who actively reenroll for the next plan year before the FFE sends auto-reenrollment
transactions for them, the FFE will not send a passive reenrollment transaction. If the enrollee who has
not been batch auto-reenrolled actively enrolls with a different issuer for the next plan year, the
Exchange will list the subscriber on electronic “Switch Files” sent daily from the beginning of OEP to
mid-December to the enrollee’s current issuers. This list of current year subscribers who have actively
“switched” issuers for the next plan year is provided so current year issuers know to non-renew the
listed subscribers’ enrollments (see Section 3.4.1, Enrollee Switch File, for additional information).
Identifiers on Enrollment Transactions
• FFE-assigned Subscriber ID and Member ID, also known as Exchange Assigned Subscriber ID
and Exchange Assigned Member ID, remain the same for enrollees choosing the same issuer
(i.e., five-digit Health Insurance Oversight System [HIOS] ID) for the next plan year.
• FFE Application IDs and FFE policy numbers are new for all next year plan selections,
whether active or passive.
• The FFE aims to send issuer-assigned identifiers on reenrollments.
• An A/B National Producer Number (NPN), if recorded on the current plan year application,
will be sent on passive reenrollments. For an active reenrollment, the NPN from the current
year will be pre-populated on the next year application (if the NPN is already associated with
the current year application) but may be removed or edited by the applicant. Exhibit 11
illustrates the rules governing how to send NPNs.
• Information for assisters who are not A/Bs is not sent on passive reenrollments.
• Assister information for all types (e.g., Navigators, Certified Application Counselors [CACs])
will be sent on active reenrollments according to existing procedures.
Exhibit 11: NPN Rules
NPN Scenarios
NPN on Current
Year Enrollment
NPN Sent on 1000c Loop on Next
Year 834 Enrollment Transaction
Auto-reenrolled (passive) QI with FFE Policy
associated with NPN before mid-October
123
123
Auto-reenrolled (passive) QI with FFE Policy
updated with NPN after the enrollee has been
auto-reenrolled
123
N/A (At the time BAR auto-renewed
the member, there was no NPN to
carry forward)*
FFE and FF-SHOP Enrollment
33
NPN Scenarios
NPN on Current
Year Enrollment
NPN Sent on 1000c Loop on Next
Year 834 Enrollment Transaction
Active reenrollment by returning QI who
updates the next year application, and is able
to view and edit the current year A/B, but
does not change or remove the A/B associated
with their application
456
456 (The A/B info from the current
year application will be pre-populated
on the next year application)**
Active reenrollment by returning QI who
removes the A/B information on their next
year application
789
N/A. A QI can remove the A/B info on
the future year application.
* NOTE: NPNs received post BAR Wave 1 via Recon will be relayed to issuers in BAR Wave 2.
** NOTE: If the most recent version of the QI’s current year application includes the NPN, the NPN will pre-populate on
the future year application; the NPN will not pre-populate if it is not included on the most recent version of the current year
application. This is particularly important for Direct Enrollment (DE) Entities using the DE QI Flow, who only submit the
NPN via the Submit Enrollment Request but do not include it on the application itself. NPNs submitted via the Submit
Enrollment Request are only written to the QI’s policy, but not the application. This highlights the importance of DE
Entities assisting their clients with the reenrollment process.
Exhibit 12 illustrates reenrollment transaction scenarios and their associated 834 maintenance reason
code, FFE Subscriber IDs, and whether effectuation is sent to the FFE.
Exhibit 12: Reenrollment Transaction Illustration
Scenario
834
Maintenance
Reason Code
FFE
Subscriber ID
(Next Year vs.
Current Year)
New Policy
ID/App ID
Assigned? (Next
Year vs. Current
Year)
Send
Effectuation
to FFE?
Collect
Binder
from
Enrollee?
Auto-reenrollment
(passive) – A current
enrollee does not
return to the FFE to
update eligibility
and plan selection.
Their coverage is
renewed by the
issuer as indicated
on the Plan ID
Crosswalk
Template.
INSO4: 41
Same
Yes/Yes
No
No
FFE and FF-SHOP Enrollment
34
Scenario
834
Maintenance
Reason Code
FFE
Subscriber ID
(Next Year vs.
Current Year)
New Policy
ID/App ID
Assigned? (Next
Year vs. Current
Year)
Send
Effectuation
to FFE?
Collect
Binder
from
Enrollee?
Active reenrollment
– A current enrollee
returns to the FFE
by December 15 to
actively apply and
enroll in next year
coverage. The
enrollee’s next year
selection is the same
product as the
current year’s
product. The
enrollee’s passive
reenrollment is
cancelled by the
FFE
when it sends the
initial enrollment.
INSO4: EC
Same
Yes/Yes
No
No
Active switch after
auto-enrollment – A
current enrollee
actively applies at
the FFE and enrolls
with a different
issuer by December
15. The enrollee’s
passive reenrollment
is cancelled by the
FFE. Since the
enrollee switched to
a different issuer,
the enrollee will also
appear on Switch
File,
13
so the current
year issuer will non-
renew the enrollee’s
coverage.
INSO4: EC
New
Yes/Yes
Yes
Yes
13
The Switch File is an electronic file delivered separately for each issuer offering plans through the FFE to identify the
issuer’s current subscribers who have actively reenrolled in next year coverage offered by a different issuer.
FFE and FF-SHOP Enrollment
35
Scenario
834
Maintenance
Reason Code
FFE
Subscriber ID
(Next Year vs.
Current Year)
New Policy
ID/App ID
Assigned? (Next
Year vs. Current
Year)
Send
Effectuation
to FFE?
Collect
Binder
from
Enrollee?
Active switch before
auto-reenrollment –
A current enrollee
actively enrolls with
a different issuer on
November 1, before
the enrollee was
passively reenrolled.
The FFE will not
send a passive
reenrollment
because the enrollee
is already actively
enrolled, thus there
is no passive
reenrollment for the
FFE to cancel.
However, the
enrollee will appear
on the Switch File,
so the current year
issuer will non-
renew their
coverage.
INSO4: EC
New
Yes/Yes
Yes
Yes
FFE and FF-SHOP Enrollment
36
Scenario
834
Maintenance
Reason Code
FFE
Subscriber ID
(Next Year vs.
Current Year)
New Policy
ID/App ID
Assigned? (Next
Year vs. Current
Year)
Send
Effectuation
to FFE?
Collect
Binder
from
Enrollee?
Blended (passive,
then active CIC
during OEP) – A
current enrollee is
passively reenrolled
effective January 1
during BAR Wave
1. Because the
enrollee was in the
special notice group
and failed to update
their eligibility
information, the QI
is enrolled with zero
APTC. On
December 14, the
enrollee actively
returns to report
updated eligibility
information via a
CIC and is
determined eligible
for APTC,
reselecting the same
plan, with the
updated information
taking effect January
1. The FFE sends a
cancellation of the
passive
reenrollment, then a
January 1 initial 834
reflecting the
update.
• January 1
initial (no
APTC):
INSO4: 14
(Cancel)
• January 1
during
BAR
January
1initial
(with
APTC):
INSO4: EC
Same
Same
Yes/Yes
Yes/Yes
No
No
No
No
FFE and FF-SHOP Enrollment
37
Scenario
834
Maintenance
Reason Code
FFE
Subscriber ID
(Next Year vs.
Current Year)
New Policy
ID/App ID
Assigned? (Next
Year vs. Current
Year)
Send
Effectuation
to FFE?
Collect
Binder
from
Enrollee?
Blended (passive,
then active CIC after
OEP) – A current
enrollee is passively
enrolled effective
January 1 during
BAR Wave 1.
Because the enrollee
was in the special
notice group and
failed to update their
eligibility
information, the QI
is enrolled with zero
APTC. On
December 18, the
enrollee actively
returns to report
updated eligibility
information via a
CIC and is
determined eligible
for APTC,
reselecting the same
plan, with the
updated information
taking effect
February 1. The FFE
sends the passive
reenrollment
effective January 1,
then a January 31
term/February 1
initial CIC reflecting
the update.
• January 1
initial (no
APTC):
INSO4: 41
• February 1
CIC initial
(with
APTC):
M834
Same
Same
Yes/Yes
No/No
No
No
No
No
Exhibit 13 illustrates multiple transactions for a single enrollment where the same enrollee visits
HealthCare.gov on three separate occasions.
Exhibit 13: Multiple Transactions Illustrated for a Single Enrollment
Transaction Date
December 16
December 18
January 2
Description
Passive reenrollment sent
QI changes plan
QI reports a life change
FFE and FF-SHOP Enrollment
38
Transaction Date
December 16
December 18
January 2
Key 834 Codes
Origin Type on 834 = 11
(auto-reenroll) MRC =
41
Origin Type on 834 = 1
(FFE Online) MRC =
EC Straight term/initial
(not CIC)
Origin Type on 834 = 1
(FFE Online) MTC = 001
(Subscriber) Maintenance
Enrollment Transaction
Electronic Data Interchange
(EDI) Functional Code
I834AR
I834
M834
For detailed transaction requirements, issuers should continue to consult the Companion Guide
instructions related to the ASC X12 Benefit Enrollment and Maintenance 834 Transaction, based on
the 005010X220 Implementation Guide and its associated 005010X220A1 addenda for the FFE. The
Companion Guide can be accessed at https://zone.cms.gov/document/asc-x12-005010-834-companion-
guide.
CSR and APTC Calculations on Passive Reenrollments
For enrollees who do not contact the Exchange to obtain an updated eligibility determination and
select QHPs by December 15, the Exchange will establish future plan year eligibility as follows:
• First, where an enrollee was in the opt-out group, or repeat passive reenrollment group, the
Exchange will discontinue APTC and income-based CSR.
• Second, where an enrollee with APTC or income-based CSR does not fall into the opt-out
group, or repeat passive reenrollment group, of any other category precluding eligibility for
financial assistance, the Exchange will use the current year family size and the most recent
household income and other eligibility information available, updated FPL tables, and updated
benchmark plan premium information to calculate APTC and determine eligibility for income-
based CSR for the next plan year.
Enrollees who actively return to the Exchange to submit updated eligibility information for next year
coverage will have their eligibility re-determined according to standard processes, with updated
eligibility taking effect according to the effective dates described in 45 CFR 155.410(f).
Additional Files and Transactions to Support Issuers with Auto-Renewal
The FFE communicates the vast majority of renewals (both active and passive) and new enrollment to
issuers via 834 enrollment transactions. Because of the unique data architecture of the Exchange,
additional files and transactions are also sent to issuers to inform the issuer of the FFE enrollment. For
example, the Switch File (3.4.1) tells the current year issuer to end coverage December 31, letting the
issuer know that no auto-reenrollment should be expected, while the Passive Cancel File (3.4.2)
eliminates duplicate coverage created in error. The Cancel Carry Forward (3.4.3) job cancels auto-
renewals where eligibility for auto-renewal ended when the associated current year policy terminated
after BAR.
Enrollee Switch File
When an enrollee whose policy is in current (not cancelled or terminated) status completes an active
reenrollment for next year coverage in a plan offered by a different issuer from the current year issuer,
the FFE does not send the current year issuer an 834 termination transaction. Rather, for enrollees for
whom the FFE has already sent passive reenrollments, the current year issuer will receive a
FFE and FF-SHOP Enrollment
39
cancellation for the next year passive enrollment, which is the signal to non-renew coverage unless
another enrollment transaction is received. However, for enrollees who actively switch issuers for the
new plan year and for whom no passive enrollment has been sent, there is no passive reenrollment to
cancel.
To address this, the FFE produces an electronic file for each issuer offering plans through the FFE that
identifies the issuer’s current subscribers who have actively reenrolled in next year coverage offered
by a different issuer. The file is generated daily beginning shortly after the start of OEP until around
the cut-off for January coverage. Each Enrollee Switch File (sent EFT SWTFL) will be cumulative,
identifying current enrollees who have switched issuers as of their most recent plan selection on the
day before the file is generated. Only subscribers who have not been auto-reenrolled and actively
switch issuers for the future plan year are candidates for the Switch File.
If an enrollee who has switched issuers for next year subsequently switches back to a plan offered by
the enrollee’s current year issuer, that enrollee will be removed from the next daily Switch File. A
QDP subscriber will appear on the Switch File if the current subscriber either actively enrolled in a
QHP while declining QDP coverage for the next plan year, or if the QDP subscriber actively switched
to a different QDP issuer.
Passive Cancel Job
When enrollees or their assisters fail to access their existing pre-populated future year application and
create a new application for future year coverage, a duplicate policy is created. The FFE will cancel
passive reenrollments that duplicate active enrollments for future year coverage via the Passive Cancel
Job. This job is scheduled to run periodically in November and December. Issuers will receive these
files in IPA layout via EFT BARCNX. These enrollments have already been cancelled by the FFE and
the issuer should similarly cancel the policy in its records. From January until the next OEP, de-
duplication is performed by the Overlap Clean-up job visible on the Pre-Audit File.
For more information on these files including recommended issuer actions, please refer to the latest
version of the Standard Issuer Enrollment Data Files document, available on CMSzONE at
https://zone.cms.gov/document/enrollment-data-reconciliation.
Cancel Carry Forward Job
During the OEP, an enrollee or issuer may terminate (or even cancel) the current year coverage after
the FFE has sent the passive reenrollment for future year coverage, such as terminations for non-
payment. The Cancel Carry Forward job cancels auto-reenrollments (policy origin of 11) that are
linked to a prior year enrollment that has been cancelled or terminated after auto-renewal. Since the
passive reenrollments were created based upon the prior year coverage that has subsequently ended,
the Cancel Carry Forward job “carries forward” the termination (or cancel) to cancel the future year's
enrollment.
The FFE will send I834 cancels with AMRC of CANCEL-CARRYFORWARD on a periodic basis
from November through March to cancel future year auto-renewals associated with prior year policies
that later terminated or cancelled after BAR. Issuers will review the cancellations documented in the
file and ensure the cancellations are applied to the appropriate passive reenrollments in their system,
taking care to cancel using the FFE Policy ID (not Subscriber ID). Issuers will also see these
cancellations reflected in the Enrollment Pre-Audit (AUD) Files.
FFE and FF-SHOP Enrollment
40
BAR Progress Report
In the run up to and throughout the OEP, the FFE will send QHP and QDP issuers that are expecting
renewals (i.e., continue to offer QHPs through the Exchange) a daily report that totals the auto-
renewals sent to them as of midnight the night before the report’s generation EFT BARPGx. The
report compares the count of “BAR-eligible” policies (current year policies in good standing as of that
incremental run of BAR, updated periodically throughout the OEP) with the actual BAR enrollments
sent by the FFE. Issuers can use the report to track progress and report problems. For example, the
issuer may realize from a lower-than-expected BAR eligible count that the issuer has accidentally
terminated enrollments and seek reinstatements.
Effectuation at Reenrollment and CIC
Issuers do not need to send the FFE an effectuation transaction for any previously effectuated
enrollment passively, or actively reenrolling in coverage (with the same issuer as identified by the five-
digit HIOS ID), as long as the enrollment has the same FFE-assigned Subscriber ID for both plan
years. Similarly, issuers need not send effectuations when an enrollee selects a plan in the same
product in an enrollment update reported through a CIC.
However, effectuation confirmation transactions and binder payments are required for enrollments
with a new subscriber, such as a young adult child being reenrolled as a new subscriber in a passive
reenrollment age-off scenario. Issuers must also send effectuation confirmation transactions and collect
binder payments for active enrollments for new enrollees and for returning enrollees who did not have
continuous coverage with the issuer.
Life Changes During the OEP
An enrollee is able to report life changes triggering CIC transactions to issuers for both current year
and next year coverage during the OEP. Changes to current year coverage, such as the addition of a
baby or spouse, will be reflected on the passive reenrollment for next year coverage if reported to the
FFE by December 15. After December 15, changes to current year coverage cannot be initiated by the
enrollee in self-service mode on HealthCare.gov but must instead be made through the Marketplace
Call Center, which can also assist enrollees in updating their applications and coverage for both the
current and next year, if necessary.
Enrollees who have actively selected next year coverage by December 15, and subsequently want to
update their current year coverage based on a CIC should contact the Marketplace Call Center, which
will also update their next year coverage as well.
Tobacco Rating at Time of Reenrollment
For passive reenrollments, the FFE uses the same tobacco status as the current year. In rare cases of
technical error during passive enrollment, a policy may have an incorrect rating for tobacco status,
issuers may restore the tobacco status inadvertently changed in a passive reenrollment through
reconciliation (see Section 3.2.2, Passive Reenrollment/BAR).
During the OEP or an SEP, enrollees can actively update their enrollment to change their last date of
tobacco use such that an enrollee would be eligible to go from tobacco-rated to non-tobacco rated and
vice versa, with the change taking effect with a prospective effective date basis. Issuers should honor
FFE and FF-SHOP Enrollment
41
tobacco status changes made during an active update during an OEP or SEP.
Medicare Enrollment and Non-Renewals
Section 1882(d)(3)(A)(i)(I) of the Social Security Act (the Medicare anti-duplication provision)
prohibits issuers, A/Bs, and web-brokers who know a QI is enrolled or entitled to Medicare, from
selling or issuing individual health insurance coverage that duplicates
14
QI’s Medicare or Medicaid
benefits. The Medicare anti-duplication provision applies even if the beneficiary has only Medicare
Part A or only Medicare Part B and is intended to protect Medicare beneficiaries from fraudulent or
abusive practices leading to the purchase of excessive or unnecessary coverage. Employer sponsored
coverage, such as plans sold in the Federally-facilitated Small Business Health Options Program (FF-
SHOP), are explicitly exempt from the Medicare anti-duplication provision.
15
Sections 2703 and 2742 of the Public Health Service Act, and promulgated regulations at 45 CFR
147.106 and 148.122, generally require guaranteed renewability of coverage for employers and
individuals in the group and individual health insurance markets. Until 2017, the guaranteed
renewability regulations did not offer Medicare eligibility or entitlement as a basis for nonrenewal or
termination of an individual’s health insurance coverage in the individual market. However, the
Department of Health & Human Services (HHS) Notice of Benefit and Payment Parameters for 2018
proposed and finalized a regulatory interpretation of the Medicare anti-duplication and guaranteed
renewability provisions, which prohibits issuers that have knowledge that an enrollee in individual
health insurance coverage is entitled to Medicare Part A or enrolled in Medicare Part B from renewing
the individual health insurance coverage if it would duplicate Medicare or Medicaid benefits to which
the enrollee is entitled, unless the renewal is effectuated under the same policy or contract of
insurance. State insurance rules determine when a change in policy or contract of insurance has
occurred.
Since January 17, 2017,
16
QHP issuers that have knowledge that an enrollment covers a QHP enrollee
who is entitled to Medicare Part A or enrolled in Medicare Part B must non-renew the entire policy if
the QHP reenrollment plan is a different policy or contract of insurance and the new coverage
duplicates Medicare or Medicaid benefits to which the enrollee is entitled. The issuer should send a
termination transaction to the FFE ending coverage December 31 with an AMRC of TERM-
ANTIDUPLICATION near the end of the plan year (CANCEL-ANTIDUPLICATION on the future
year policy is also acceptable).
A QHP issuer should not presume that all individuals aged 65 or older are entitled to or enrolled in
Medicare. QHP issuers must send a termination or cancellation notice, pursuant to 45 CFR
155.430(b)(2)(i) and 156.270(b)(1), to any enrollees whose coverage has been non-renewed due to an
enrollee in the enrollment group being a Medicare beneficiary. The termination notice should advise
the non-Medicare enrollees on the non-renewed policy that they will be eligible for an SEP and to
actively reenroll in another policy for continued coverage, making the Medicare enrollee a non-
applicant. The Marketplace Call Center will have lists of enrollees eligible for the SEP and enrollees
will not be required to submit documentation as the circumstances are already verified. Please refer to
Section 6, Special Enrollment Periods (Applicable to the Individual Market FFE, QHPs/QDPs),
14
See section 1882(d)(3)(A)(iv) of the Social Security Act (SSA) for the definition of “duplicate.”
15
See section 1882(d)(3)(C) of the SSA.
16
January 17, 2017 was the effective date of the Final HHS Notice of Benefit and Payment Parameters for 2018.
FFE and FF-SHOP Enrollment
42
for information on SEPs.
For enrollees that become eligible for or enrolled in benefits under Medicare after enrolling in
coverage through Exchanges, the enrollee may maintain coverage until coverage is lawfully terminated
in accordance with the Medicare anti-duplication provision, as described above, or otherwise.
However, the QI loses eligibility for APTC and CSR when the enrollee becomes eligible for or
enrolled in Medicare Part A or Medicare Part C (otherwise known as Medicare Advantage), as
determined by IRS regulations. QHPs are encouraged to ask an enrollee who is newly eligible for or
enrolled in benefits under Medicare whether the enrollee wishes to maintain coverage in a QHP and to
provide instructions about how such an enrollee can report a change to the Marketplace to terminate