45 CFR Part 155
PART 155—EXCHANGE ESTABLISHMENT STANDARDS AND OTHER RELATED STANDARDS UNDER THE AFFORDABLE CARE ACT
- PART 155—EXCHANGE ESTABLISHMENT STANDARDS AND OTHER RELATED STANDARDS UNDER THE AFFORDABLE CARE ACT
- Subtitle A—Department of Health and Human Services › Subchapter B—Requirements Relating to Health Care Access
- Subpart A—General Provisions.
- § 155.10 Basis and scope.
- § 155.20 Definitions.
- § 155.30 Severability.
- Subpart B—General Standards Related to the Establishment of an Exchange
- § 155.100 Establishment of a State Exchange.
- § 155.105 Approval of a State Exchange.
- § 155.106 Election to operate an Exchange after 2014.
- § 155.110 Entities eligible to carry out Exchange functions.
- § 155.120 Non-interference with Federal law and non-discrimination standards.
- § 155.130 Stakeholder consultation.
- § 155.140 Establishment of a regional Exchange or subsidiary Exchange.
- § 155.150 Transition process for existing State health insurance exchanges.
- § 155.160 Financial support for continued operations.
- § 155.170 Additional required benefits.
- Subpart C—General Functions of an Exchange
- § 155.200 Functions of an Exchange.
- § 155.205 Consumer assistance tools and programs of an Exchange.
- § 155.206 Civil money penalties for violations of applicable Exchange standards by consumer assistance entities in Federally-facilitated Exchanges.
- § 155.210 Navigator program standards.
- § 155.215 Standards applicable to Navigators and Non-Navigator Assistance Personnel carrying out consumer assistance functions under §§ 155.205(d) and (e) and 155.210 in a Federally-facilitated Exchange and to Non-Navigator Assistance Personnel funded through an Exchange Establishment Grant.
- § 155.220 Ability of States to permit agents and brokers and web-brokers to assist qualified individuals, qualified employers, or qualified employees enrolling in QHPs.
- § 155.221 Standards for direct enrollment entities and for third-parties to perform audits of direct enrollment entities.
- § 155.225 Certified application counselors.
- § 155.227 Authorized representatives.
- § 155.230 General standards for Exchange notices.
- § 155.240 Payment of premiums.
- § 155.260 Privacy and security of personally identifiable information.
- § 155.270 Use of standards and protocols for electronic transactions.
- § 155.280 Oversight and monitoring of privacy and security requirements.
- § 155.285 Bases and process for imposing civil penalties for provision of false or fraudulent information to an Exchange or improper use or disclosure of information.
- Subpart D—Exchange Functions in the Individual Market: Eligibility Determinations for Exchange Participation and Insurance Affordability Programs
- § 155.300 Definitions and general standards for eligibility determinations.
- § 155.302 Options for conducting eligibility determinations.
- § 155.305 Eligibility standards.
- § 155.310 Eligibility process.
- § 155.315 Verification process related to eligibility for enrollment in a QHP through the Exchange.
- § 155.320 Verification process related to eligibility for insurance affordability programs.
- § 155.330 Eligibility redetermination during a benefit year.
- § 155.335 Annual eligibility redetermination.
- § 155.340 Administration of advance payments of the premium tax credit and cost-sharing reductions.
- § 155.345 Coordination with Medicaid, CHIP, the Basic Health Program, and the Pre-existing Condition Insurance Plan.
- § 155.350 Special eligibility standards and process for Indians.
- § 155.355 Right to appeal.
- Subpart E—Exchange Functions in the Individual Market: Enrollment in Qualified Health Plans
- § 155.400 Enrollment of qualified individuals into QHPs.
- § 155.405 Single streamlined application.
- § 155.410 Initial and annual open enrollment periods.
- § 155.415 Allowing issuer or direct enrollment entity application assisters to assist with eligibility applications.
- § 155.420 Special enrollment periods.
- § 155.430 Termination of Exchange enrollment or coverage.
- Subpart F—Appeals of Eligibility Determinations for Exchange Participation and Insurance Affordability Programs
- § 155.500 Definitions.
- § 155.505 General eligibility appeals requirements.
- § 155.510 Appeals coordination.
- § 155.515 Notice of appeal procedures.
- § 155.520 Appeal requests.
- § 155.525 Eligibility pending appeal.
- § 155.530 Dismissals.
- § 155.535 Informal resolution and hearing requirements.
- § 155.540 Expedited appeals.
- § 155.545 Appeal decisions.
- § 155.550 Appeal record.
- § 155.555 Employer appeals process.
- Subpart G—Exchange Functions in the Individual Market: Eligibility Determinations for Exemptions
- § 155.600 Definitions and general requirements.
- § 155.605 Eligibility standards for exemptions.
- § 155.610 Eligibility process for exemptions.
- § 155.615 Verification process related to eligibility for exemptions.
- § 155.620 Eligibility redeterminations for exemptions during a calendar year.
- § 155.625 Options for conducting eligibility determinations for exemptions.
- § 155.630 Reporting.
- § 155.635 Right to appeal.
- Subpart H—Exchange Functions: Small Business Health Options Program (SHOP)
- § 155.700 Standards for the establishment of a SHOP.
- § 155.705 Functions of a SHOP for plan years beginning prior to January 1, 2018.
- § 155.706 Functions of a SHOP for plan years beginning on or after January 1, 2018.
- § 155.710 Eligibility standards for SHOP.
- § 155.715 Eligibility determination process for SHOP for plan years beginning prior to January 1, 2018.
- § 155.716 Eligibility determination process for SHOP for plan years beginning on or after January 1, 2018.
- § 155.720 Enrollment of employees into QHPs under SHOP for plan years beginning prior to January 1, 2018.
- § 155.721 Record retention and IRS Reporting for plan years beginning on or after January 1, 2018.
- § 155.725 Enrollment periods under SHOP for plan years beginning prior to January 1, 2018.
- § 155.726 Enrollment periods under SHOP for plan years beginning on or after January 1, 2018.
- § 155.730 Application standards for SHOP for plan year beginning prior to January 1, 2018.
- § 155.731 Application standards for SHOP for plan years beginning on or after January 1, 2018.
- § 155.735 Termination of SHOP enrollment or coverage for plan years beginning prior to January 1, 2018.
- § 155.740 SHOP employer and employee eligibility appeals requirements for plan years beginning prior to January 1, 2018.
- § 155.741 SHOP employer and employee eligibility appeals requirements for plan year beginning on or after January 1, 2018.
- Subparts I-J [Reserved]
- Subpart K—Exchange Functions: Certification of Qualified Health Plans
- § 155.1000 Certification standards for QHPs.
- § 155.1010 Certification process for QHPs.
- § 155.1020 QHP issuer rate and benefit information.
- § 155.1030 QHP certification standards related to advance payments of the premium tax credit and cost-sharing reductions.
- § 155.1040 Transparency in coverage.
- § 155.1045 Accreditation timeline.
- § 155.1050 Establishment of Exchange provider access standards.
- § 155.1051 Effective Essential Community Provider Review Program.
- § 155.1055 Service area of a QHP.
- § 155.1065 Stand-alone dental plans.
- § 155.1075 Recertification of QHPs.
- § 155.1080 Decertification of QHPs.
- § 155.1090 Request for the reconsideration of a denial of certification.
- Subpart L [Reserved]
- Subpart M—Oversight and Program Integrity Standards for State Exchanges
- § 155.1200 General program integrity and oversight requirements.
- § 155.1210 Maintenance of records.
- Subpart N—State Flexibility
- § 155.1300 Basis and purpose.
- § 155.1302 Coordinated waiver process.
- § 155.1304 Definitions.
- § 155.1308 Application procedures.
- § 155.1312 State public notice requirements.
- § 155.1316 Federal public notice and approval process.
- § 155.1318 Modification from the normal public notice requirements during an emergent situation.
- § 155.1320 Monitoring and compliance.
- § 155.1322 Pass-through funding for approved waivers.
- § 155.1324 State reporting requirements.
- § 155.1328 Periodic evaluation requirements.
- § 155.1330 Waiver amendment.
- § 155.1332 Waiver extension.
- Subpart O—Quality Reporting Standards for Exchanges
- § 155.1400 Quality rating system.
- § 155.1405 Enrollee satisfaction survey system.
- Subpart P—Improper Payment Pre-Testing and Assessment (IPPTA) for State-based Exchanges
- § 155.1500 Purpose and scope.
- § 155.1505 Definitions.
- § 155.1510 Data submission.
- § 155.1515 Pre-testing and assessment procedures.
- Subpart Q—State Exchange Improper Payment Measurement (SEIPM)
- § 155.1600 Purpose and scope.
- § 155.1605 Applicability date and implementation.
- § 155.1610 Definitions.
- § 155.1615 Information submission.
- § 155.1620 Sampling procedures.
- § 155.1625 Determining payment errors.
- § 155.1630 Difference Resolution and appeal process.
- § 155.1635 Corrective action plan (CAP).
- § 155.1640 SEIPM preparation phase.
- § 155.1645 Minimizing potential duplicate audit requirements.
- § 155.1650 Failure to comply.
Feedback