Part 155 — Exchange Establishment Standards and Other Related Standards Under the Affordable Care Act
Subpart A — General Provisions.
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.
- § 155.222— Standards for HHS-approved vendors of Federally-facilitated Exchange training for agents and brokers.
- § 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.
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 network adequacy standards.
- § 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 M — Oversight and Program Integrity Standards for State Exchanges
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.