Title 45

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 Authority:42 U.S.C. 18021-18024, 18031-18033, 18041-18042, 18051, 18054, 18071, and 18081-18083. Source:77 FR 11718, Feb. 27, 2012, unless otherwise noted.

45:2.0.1.1.13.1SUBPART A
Subpart A - General Provisions.
45:2.0.1.1.13.1.1.1SECTION 155.10
   155.10 Basis and scope.
45:2.0.1.1.13.1.1.2SECTION 155.20
   155.20 Definitions.
45:2.0.1.1.13.2SUBPART B
Subpart B - General Standards Related to the Establishment of an Exchange
45:2.0.1.1.13.2.1.1SECTION 155.100
   155.100 Establishment of a State Exchange.
45:2.0.1.1.13.2.1.2SECTION 155.105
   155.105 Approval of a State Exchange.
45:2.0.1.1.13.2.1.3SECTION 155.106
   155.106 Election to operate an Exchange after 2014.
45:2.0.1.1.13.2.1.4SECTION 155.110
   155.110 Entities eligible to carry out Exchange functions.
45:2.0.1.1.13.2.1.5SECTION 155.120
   155.120 Non-interference with Federal law and non-discrimination standards.
45:2.0.1.1.13.2.1.6SECTION 155.130
   155.130 Stakeholder consultation.
45:2.0.1.1.13.2.1.7SECTION 155.140
   155.140 Establishment of a regional Exchange or subsidiary Exchange.
45:2.0.1.1.13.2.1.8SECTION 155.150
   155.150 Transition process for existing State health insurance exchanges.
45:2.0.1.1.13.2.1.9SECTION 155.160
   155.160 Financial support for continued operations.
45:2.0.1.1.13.2.1.10SECTION 155.170
   155.170 Additional required benefits.
45:2.0.1.1.13.3SUBPART C
Subpart C - General Functions of an Exchange
45:2.0.1.1.13.3.1.1SECTION 155.200
   155.200 Functions of an Exchange.
45:2.0.1.1.13.3.1.2SECTION 155.205
   155.205 Consumer assistance tools and programs of an Exchange.
45:2.0.1.1.13.3.1.3SECTION 155.206
   155.206 Civil money penalties for violations of applicable Exchange standards by consumer assistance entities in Federally-facilitated Exchanges.
45:2.0.1.1.13.3.1.4SECTION 155.210
   155.210 Navigator program standards.
45:2.0.1.1.13.3.1.5SECTION 155.215
   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.
45:2.0.1.1.13.3.1.6SECTION 155.220
   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.
45:2.0.1.1.13.3.1.7SECTION 155.221
   155.221 Standards for direct enrollment entities and for third-parties to perform audits of direct enrollment entities.
45:2.0.1.1.13.3.1.8SECTION 155.222
   155.222 Standards for HHS-approved vendors of Federally-facilitated Exchange training for agents and brokers.
45:2.0.1.1.13.3.1.9SECTION 155.225
   155.225 Certified application counselors.
45:2.0.1.1.13.3.1.10SECTION 155.227
   155.227 Authorized representatives.
45:2.0.1.1.13.3.1.11SECTION 155.230
   155.230 General standards for Exchange notices.
45:2.0.1.1.13.3.1.12SECTION 155.240
   155.240 Payment of premiums.
45:2.0.1.1.13.3.1.13SECTION 155.260
   155.260 Privacy and security of personally identifiable information.
45:2.0.1.1.13.3.1.14SECTION 155.270
   155.270 Use of standards and protocols for electronic transactions.
45:2.0.1.1.13.3.1.15SECTION 155.280
   155.280 Oversight and monitoring of privacy and security requirements.
45:2.0.1.1.13.3.1.16SECTION 155.285
   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.
45:2.0.1.1.13.4SUBPART D
Subpart D - Exchange Functions in the Individual Market: Eligibility Determinations for Exchange Participation and Insurance Affordability Programs
45:2.0.1.1.13.4.1.1SECTION 155.300
   155.300 Definitions and general standards for eligibility determinations.
45:2.0.1.1.13.4.1.2SECTION 155.302
   155.302 Options for conducting eligibility determinations.
45:2.0.1.1.13.4.1.3SECTION 155.305
   155.305 Eligibility standards.
45:2.0.1.1.13.4.1.4SECTION 155.310
   155.310 Eligibility process.
45:2.0.1.1.13.4.1.5SECTION 155.315
   155.315 Verification process related to eligibility for enrollment in a QHP through the Exchange.
45:2.0.1.1.13.4.1.6SECTION 155.320
   155.320 Verification process related to eligibility for insurance affordability programs.
45:2.0.1.1.13.4.1.7SECTION 155.330
   155.330 Eligibility redetermination during a benefit year.
45:2.0.1.1.13.4.1.8SECTION 155.335
   155.335 Annual eligibility redetermination.
45:2.0.1.1.13.4.1.9SECTION 155.340
   155.340 Administration of advance payments of the premium tax credit and cost-sharing reductions.
45:2.0.1.1.13.4.1.10SECTION 155.345
   155.345 Coordination with Medicaid, CHIP, the Basic Health Program, and the Pre-existing Condition Insurance Plan.
45:2.0.1.1.13.4.1.11SECTION 155.350
   155.350 Special eligibility standards and process for Indians.
45:2.0.1.1.13.4.1.12SECTION 155.355
   155.355 Right to appeal.
45:2.0.1.1.13.5SUBPART E
Subpart E - Exchange Functions in the Individual Market: Enrollment in Qualified Health Plans
45:2.0.1.1.13.5.1.1SECTION 155.400
   155.400 Enrollment of qualified individuals into QHPs.
45:2.0.1.1.13.5.1.2SECTION 155.405
   155.405 Single streamlined application.
45:2.0.1.1.13.5.1.3SECTION 155.410
   155.410 Initial and annual open enrollment periods.
45:2.0.1.1.13.5.1.4SECTION 155.415
   155.415 Allowing issuer or direct enrollment entity application assisters to assist with eligibility applications.
45:2.0.1.1.13.5.1.5SECTION 155.420
   155.420 Special enrollment periods.
45:2.0.1.1.13.5.1.6SECTION 155.430
   155.430 Termination of Exchange enrollment or coverage.
45:2.0.1.1.13.6SUBPART F
Subpart F - Appeals of Eligibility Determinations for Exchange Participation and Insurance Affordability Programs
45:2.0.1.1.13.6.1.1SECTION 155.500
   155.500 Definitions.
45:2.0.1.1.13.6.1.2SECTION 155.505
   155.505 General eligibility appeals requirements.
45:2.0.1.1.13.6.1.3SECTION 155.510
   155.510 Appeals coordination.
45:2.0.1.1.13.6.1.4SECTION 155.515
   155.515 Notice of appeal procedures.
45:2.0.1.1.13.6.1.5SECTION 155.520
   155.520 Appeal requests.
45:2.0.1.1.13.6.1.6SECTION 155.525
   155.525 Eligibility pending appeal.
45:2.0.1.1.13.6.1.7SECTION 155.530
   155.530 Dismissals.
45:2.0.1.1.13.6.1.8SECTION 155.535
   155.535 Informal resolution and hearing requirements.
45:2.0.1.1.13.6.1.9SECTION 155.540
   155.540 Expedited appeals.
45:2.0.1.1.13.6.1.10SECTION 155.545
   155.545 Appeal decisions.
45:2.0.1.1.13.6.1.11SECTION 155.550
   155.550 Appeal record.
45:2.0.1.1.13.6.1.12SECTION 155.555
   155.555 Employer appeals process.
45:2.0.1.1.13.7SUBPART G
Subpart G - Exchange Functions in the Individual Market: Eligibility Determinations for Exemptions
45:2.0.1.1.13.7.1.1SECTION 155.600
   155.600 Definitions and general requirements.
45:2.0.1.1.13.7.1.2SECTION 155.605
   155.605 Eligibility standards for exemptions.
45:2.0.1.1.13.7.1.3SECTION 155.610
   155.610 Eligibility process for exemptions.
45:2.0.1.1.13.7.1.4SECTION 155.615
   155.615 Verification process related to eligibility for exemptions.
45:2.0.1.1.13.7.1.5SECTION 155.620
   155.620 Eligibility redeterminations for exemptions during a calendar year.
45:2.0.1.1.13.7.1.6SECTION 155.625
   155.625 Options for conducting eligibility determinations for exemptions.
45:2.0.1.1.13.7.1.7SECTION 155.630
   155.630 Reporting.
45:2.0.1.1.13.7.1.8SECTION 155.635
   155.635 Right to appeal.
45:2.0.1.1.13.8SUBPART H
Subpart H - Exchange Functions: Small Business Health Options Program (SHOP)
45:2.0.1.1.13.8.1.1SECTION 155.700
   155.700 Standards for the establishment of a SHOP.
45:2.0.1.1.13.8.1.2SECTION 155.705
   155.705 Functions of a SHOP for plan years beginning prior to January 1, 2018.
45:2.0.1.1.13.8.1.3SECTION 155.706
   155.706 Functions of a SHOP for plan years beginning on or after January 1, 2018.
45:2.0.1.1.13.8.1.4SECTION 155.710
   155.710 Eligibility standards for SHOP.
45:2.0.1.1.13.8.1.5SECTION 155.715
   155.715 Eligibility determination process for SHOP for plan years beginning prior to January 1, 2018.
45:2.0.1.1.13.8.1.6SECTION 155.716
   155.716 Eligibility determination process for SHOP for plan years beginning on or after January 1, 2018.
45:2.0.1.1.13.8.1.7SECTION 155.720
   155.720 Enrollment of employees into QHPs under SHOP for plan years beginning prior to January 1, 2018.
45:2.0.1.1.13.8.1.8SECTION 155.721
   155.721 Record retention and IRS Reporting for plan years beginning on or after January 1, 2018.
45:2.0.1.1.13.8.1.9SECTION 155.725
   155.725 Enrollment periods under SHOP for plan years beginning prior to January 1, 2018.
45:2.0.1.1.13.8.1.10SECTION 155.726
   155.726 Enrollment periods under SHOP for plan years beginning on or after January 1, 2018.
45:2.0.1.1.13.8.1.11SECTION 155.730
   155.730 Application standards for SHOP for plan year beginning prior to January 1, 2018.
45:2.0.1.1.13.8.1.12SECTION 155.731
   155.731 Application standards for SHOP for plan years beginning on or after January 1, 2018.
45:2.0.1.1.13.8.1.13SECTION 155.735
   155.735 Termination of SHOP enrollment or coverage for plan years beginning prior to January 1, 2018.
45:2.0.1.1.13.8.1.14SECTION 155.740
   155.740 SHOP employer and employee eligibility appeals requirements for plan years beginning prior to January 1, 2018.
45:2.0.1.1.13.8.1.15SECTION 155.741
   155.741 SHOP employer and employee eligibility appeals requirements for plan year beginning on or after January 1, 2018.
45:2.0.1.1.13.9SUBPART I
Subparts I-J [Reserved]
45:2.0.1.1.13.10SUBPART K
Subpart K - Exchange Functions: Certification of Qualified Health Plans
45:2.0.1.1.13.10.1.1SECTION 155.1000
   155.1000 Certification standards for QHPs.
45:2.0.1.1.13.10.1.2SECTION 155.1010
   155.1010 Certification process for QHPs.
45:2.0.1.1.13.10.1.3SECTION 155.1020
   155.1020 QHP issuer rate and benefit information.
45:2.0.1.1.13.10.1.4SECTION 155.1030
   155.1030 QHP certification standards related to advance payments of the premium tax credit and cost-sharing reductions.
45:2.0.1.1.13.10.1.5SECTION 155.1040
   155.1040 Transparency in coverage.
45:2.0.1.1.13.10.1.6SECTION 155.1045
   155.1045 Accreditation timeline.
45:2.0.1.1.13.10.1.7SECTION 155.1050
   155.1050 Establishment of Exchange network adequacy standards.
45:2.0.1.1.13.10.1.8SECTION 155.1055
   155.1055 Service area of a QHP.
45:2.0.1.1.13.10.1.9SECTION 155.1065
   155.1065 Stand-alone dental plans.
45:2.0.1.1.13.10.1.10SECTION 155.1075
   155.1075 Recertification of QHPs.
45:2.0.1.1.13.10.1.11SECTION 155.1080
   155.1080 Decertification of QHPs.
45:2.0.1.1.13.10.1.12SECTION 155.1090
   155.1090 Request for reconsideration.
45:2.0.1.1.13.11SUBPART L
Subpart L [Reserved]
45:2.0.1.1.13.12SUBPART M
Subpart M - Oversight and Program Integrity Standards for State Exchanges
45:2.0.1.1.13.12.1.1SECTION 155.1200
   155.1200 General program integrity and oversight requirements.
45:2.0.1.1.13.12.1.2SECTION 155.1210
   155.1210 Maintenance of records.
45:2.0.1.1.13.13SUBPART N
Subpart N - State Flexibility
45:2.0.1.1.13.13.1.1SECTION 155.1300
   155.1300 Basis and purpose.
45:2.0.1.1.13.13.1.2SECTION 155.1302
   155.1302 Coordinated waiver process.
45:2.0.1.1.13.13.1.3SECTION 155.1304
   155.1304 Definitions.
45:2.0.1.1.13.13.1.4SECTION 155.1308
   155.1308 Application procedures.
45:2.0.1.1.13.13.1.5SECTION 155.1312
   155.1312 State public notice requirements.
45:2.0.1.1.13.13.1.6SECTION 155.1316
   155.1316 Federal public notice and approval process.
45:2.0.1.1.13.13.1.7SECTION 155.1318
   155.1318 Modification from the normal public notice requirements during the public health emergency.
45:2.0.1.1.13.13.1.8SECTION 155.1320
   155.1320 Monitoring and compliance.
45:2.0.1.1.13.13.1.9SECTION 155.1324
   155.1324 State reporting requirements.
45:2.0.1.1.13.13.1.10SECTION 155.1328
   155.1328 Periodic evaluation requirements.
45:2.0.1.1.13.14SUBPART O
Subpart O - Quality Reporting Standards for Exchanges
45:2.0.1.1.13.14.1.1SECTION 155.1400
   155.1400 Quality rating system.
45:2.0.1.1.13.14.1.2SECTION 155.1405
   155.1405 Enrollee satisfaction survey system.