This proposed tool allows users to measure the actuarial value of health plans and compliance with actuarial value standards established under Section 1302(d) by the Affordable Care Act.

Actuarial Value Calculator Methodology (PDF – 176 KB)

Guidance:

December 16, 2011
Essential Health Benefits Bulletin (PDF - 104 KB)
January 25, 2012
Essential Health Benefits: Illustrative List of the Largest Three Small Group Products by State (PDF – 135 KB)
February 17, 2012
Frequently Asked Questions on the Essential Health Benefits Bulletin (PDF – 88 KB)
February 24, 2012
Actuarial Value and Cost-Sharing Reductions Bulletin (PDF - 123 KB)
July 2, 2012
Essential Health Benefits: List of the Largest Three Small Group Products by State (PDF – 183 KB)
January 28, 2013
Issuers of Stand-alone Dental Plans (PDF - 223 KB)
January 31, 2013
Companion Guide for the Enrollment Transaction Information (PDF - 587 KB)

Payment Policy and Financial Management

Regulations:

July 15, 2011
CMS-9975-P: Standards Related to Reinsurance, Risks Corridors and Risk Adjustment (PDF - 281 KB)
July 15, 2011
CMS-9989-P2: Preliminary Regulatory Impact Analysis: Establishment of Exchanges and Qualified Health Plans (CMS-9989-P) and Standards Related to Reinsurance, Risk Corridors and Risk Adjustment (CMS-9975-P) (PDF – 204 KB)
March 16, 2012
Regulatory Impact Analysis: Establishment of Exchanges and Qualified Health Plans (CMS-9989-FWP) and Standards Related to Reinsurance, Risk Corridors and Risk Adjustment (CMS-9975-F) (PDF – 315 KB )
March 23, 2012
CMS-9975-F: Standards Related to Reinsurance, Risks Corridors and Risk Adjustment (PDF - 336 KB)
December 7, 2012
CMS-9964-P: HHS Benefit and Payment Parameters for 2014, and Medical Loss Ratio

Guidance

May 1, 2012
Bulletin on the Risk Adjustment Program: Proposed Operations by the Department of Health and Human Services (PDF – 207 KB)
May 31, 2012
Bulletin on the Transitional Reinsurance Program: Proposed Payment Operations by the Department of Health and Human Services (PDF – 187 KB)
January 15, 2013
Instructions for the Proposed HHS Risk Adjustment Model (PDF - 210 KB)
Technical Details on the Proposed HHS Risk Adjustment Model (XLSX - 795 KB)

State Innovations

Regulations:

March 10, 2011
Application, Review, and Reporting Process for Waivers for State Innovation
February 22, 2012
CMS-9987-F: Application, Review, and Reporting Process for Waivers for State Innovation

Consumer Operated and Oriented Plans Program

Regulations:

June 23, 2010
Establishment of the Consumer Operated and Oriented Plan (CO-OP) Advisory Board
July 20, 2011
Establishment of the Consumer Operated and Oriented Plan (CO-OP) Program
December 13, 2011
CMS-9983-F: Patient Protection and Affordable Care Act, Establishment of Consumer Operated and Oriented Plan (CO-OP) Program (PDF - 244 KB)
February 10, 2012
IRS Revenue Procedures Published in the Federal Register For Tax-Exempt 501(c)(29) Qualified Nonprofit Health Insurance Issuers

Health Market Reforms

Regulations

November 26, 2012
CMS-9979-P: Incentives for Wellness Programs in Group Health Plans
November 26, 2012
CMS-9972-P:Patient Protection and Affordable Care Act: Health Insurance Market Rules; Rate Review
January 30, 2013
CMS-9958-P: Eligibility for Exemptions; Miscellaneous Minimum Essential Coverage Provisions

Guidance

January 25, 2013
Employer Prescription Drug Coverage that Supplements Medicare Part D Coverage provided through an Employer Group Waiver Plan

Annual Limits

Regulations:

June 28, 2010
OCIIO–9994–IFC: Patient Protection and Affordable Care Act: Preexisting Condition Exclusions, Lifetime and Annual Limits, Rescissions, and Patient Protections

Guidance:

September 3, 2010
OCIIO Sub-Regulatory Guidance: Process for Obtaining Waivers of the Annual Limits Requirements of PHS Act Section 271 1 (PDF – 48 KB)
November 5, 2010
OCIIO Supplemental Guidance: Waivers of the Annual Limits Requirements (PDF – 61 KB)
December 9, 2010
OCIIO Supplemental Guidance: Consumer Notices on Waivers of the Annual Limits Requirements (PDF – 53 KB)
December 9, 2010
OCIIO Supplemental Guidance: Sale of New Business by Issuers Receiving Waivers (PDF – 55 KB)
June 17, 2011
CCIIO Supplemental Guidance (CCIIO 2011 – 1D): Concluding the Annual Limit Waiver Application Process (PDF – 76 KB)
August 19, 2011
CCIIO Supplemental Guidance (CCIIO 2011 - 1E): Exemption for Health Reimbursement Arrangements that are Subject to PHS Act Section 2711 (PDF - 44 KB)

Association Coverage

Guidance:

September 1, 2011
CCIIO Technical Guidance: Application of Individual and Group Market Requirements under Title XXVII of the Public Health Service Act when Insurance Coverage Is Sold to, or through, Associations (PDF – 56 KB)

Coverage for Young Adults

Regulations:

May 13, 2010
OCIIO – 4150 – IFC: Group Health Plans and Health Insurance Issuers Relating to Dependent Coverage of Children to Age 26 Under the Patient Protection and Affordable Care Act (PDF – 178 KB)

Guidance:

October 13, 2010
Q&A: Enrollment of Children Under 19 Under the New Policy That Prohibits Pre-Existing Condition Exclusions

Employer Responsibility

Guidance:

October 13, 2010
Frequently Asked Questions from Employers Regarding Automatic Enrollment, Employer Shared Responsibility, and Waiting Periods (PDF - 93 KB)
August 31, 2012
Waiting Period Guidance Under Public Health Service Act Section 2708 (PDF – 87 KB)

Grandfathered Plans

Regulations:

Medical Loss Ratio

Regulations:

December 1, 2010
OCIIO–9998–IFC: Health Insurance Issuers Implementing Medical Loss Ratio (MLR) Requirements Under the Patient Protection and Affordable Care Act (PDF – 2 MB)
Technical Appendix
Interim Final Rule for Health Insurance Issuers Implementing Medical Loss Ratio (MLR) Requirements under the Patient Protection and Affordable Care Act (PDF – 300 KB)
Technical Correction (December 30, 2010)
Technical Correction to the Medical Loss Ratio Interim Final Rule (PDF – 59 KB)
December 7, 2011
CMS-9998-FC: Medical Loss Ratio Requirements under the Patient Protection and Affordable Care Act
CMS-9998-IFC2: Medical Loss Ratio Rebate Requirements for Non-Federal Governmental Plans
May 16, 2012
CMS-9998-F: Medical Loss Ratio Requirements under the Patient Protection and Affordable Care Act
May 16, 2012
CMS-9998-IFC3: Medical Loss Ratio Requirements under the Patient Protection and Affordable Care Act; Correcting Amendment
November 30, 2012
CMS-9964-P: HHS Benefit and Payment Parameters for 2014, and Medical Loss Ratio

Guidance:

December 17, 2010
OCIIO Technical Guidance: Process for a State to Submit a Request for Adjustment to the Medical Loss Ratio Standard of PHS Act Section 2718 (PDF – 35 KB)
April 26, 2011
CCIIO Technical Guidance: Submission of 2011 Quarterly Reports of MLR Data by Issuers of “Mini-med” and Expatriate Plans (PDF – 26 KB)
May 13, 2011
CCIIO Technical Guidance: Questions and Answers Regarding the Medical Loss Ratio Interim Final Rule (PDF – 75 KB)
May 19, 2011
CCIIO Technical Guidance: Deadline for Submission of 2011 First Quarter MLR Data by Issuers of “Mini-med” and Expatriate Plans (PDF – 26 KB)
July 18, 2011
CCIIO Technical Guidance: Questions and Answers Regarding the Medical Loss Ratio Interim Final Rule (PDF – 66 KB)
February 10, 2012
CCIIO Technical Guidance: Questions and Answers Regarding the Medical Loss Ratio Interim Final Rule (PDF - 94 KB)
March 30, 2012
Memo to Insurance Companies: Medical Loss Ratio Annual Reporting Procedures (PDF - 96 KB)
April 20, 2012
CCIIO Technical Guidance: Questions and Answers Regarding the Medical Loss Ratio
Regulation (PDF –101 KB)
May 15, 2012
Memo to Insurance Companies: Guidance for Medical Loss Ratio Annual Reporting Form (PDF – 66 KB)
Memo to Insurance Companies: Guidance for Medical Loss Ratio Notices of Rebates (PDF – 67 KB)
May 24, 2012
CCIIO Technical Guidance: Questions and Answers Regarding the Medical Loss Ratio
Reporting Form (PDF - 91 KB)
May 30, 2012
CCIIO Technical Guidance: Questions and Answers Regarding the Medical Loss Ratio
Reporting Requirements (PDF - 83 KB)
July 17, 2012
CCIIO Technical Guidance: Questions and Answers Regarding the Medical Loss Ratio
Reporting and Rebate Requirements (PDF - 69 KB)

Patient’s Bill of Rights

Regulations:

June 28, 2010
OCIIO–9994–IFC: Patient Protection and Affordable Care Act: Preexisting Condition Exclusions, Lifetime and Annual Limits, Rescissions, and Patient Protections

Guidance:

September 3, 2010
OCIIO Sub-Regulatory Guidance: Process for Obtaining Waivers of the Annual Limits Requirements of PHS Act Section 2711

Prevention

Regulations:

July 19, 2010
OCIIO–9992–IFC: Interim Final Rules for Group Health Plans and Health Insurance Issuers Relating to Coverage of Preventive Services under the Patient Protection and Affordable Care Act
August 3, 2011
CMS-9992-IFC2: Group Health Plans and Health Insurance Issuers Relating to Coverage of Preventive Services under the Patient Protection and Affordable Care Act (PDF - 201 KB)
February 10, 2012
CMS-9992-F: Group Health Plans and Health Insurance Issuers Relating to Coverage of Preventive Services Under the Patient Protection and Affordable Care Act (PDF – 164 KB)
March 21, 2012
CMS 9968-ANPRM: Preventive Services Under the Affordable Care Act (PDF - 263 KB)
February 6, 2013
CMS-9968-P: Coverage of Certain Preventive Services Under the Affordable Care Act

Guidance:

Review of Insurance Rates

Regulations:

December 23, 2010
OCIIO–9998–IFC: Rate Increase Disclosure and Review; Proposed Rule (PDF – 215 KB)
May 19, 2011
CMS-9999-FC: Rate Increase Disclosure and Review; Final Rule (PDF - 282 KB)
September 6, 2011
CMS-9999-F: Rate Increase Disclosure and Review: Definitions of Individual Market and Small Group Market (PDF - 526 KB)
November 26, 2012
CMS-9972-P:Patient Protection and Affordable Care Act: Health Insurance Market Rules; Rate Review

Guidance:

March 30, 2012
State-Specific Threshold Proposals Guidance for States (PDF - 200 KB)

Student Health Plans

Regulations:

February 11, 2011
CMS–9981–P: Student Health Insurance Coverage (PDF – 250 KB)
March 21, 2012
CMS-9981-F: Student Health Insurance Coverage (PDF – 288 KB)

Health Insurance Portability and Accountability Act of 1996 (HIPAA)

Guidance:

March 1998
Program Memorandum: Agent Commissions and Application Processing Delays (PDF - 87 KB)
June 1999
Program Memorandum: Applicability of the Health Insurance Portability and Accountability Act of 1996 to Secondary Coverage and Continuing Coverage (PDF - 157 KB)
June 1999
Program Memorandum: Issues Related to Eligible Individual Status Under the Health Insurance Portability and Accountability Act of 1996 (PDF 130 KB)
September 1999
Program Memorandum: Group Size Issues Under Title XXVII of the Public Health Service Act (PDF - 136 KB)
March 2000
Program Memorandum: Imposing Nonconfinement Clause on Eligible Individuals (PDF -68 KB)
June 2000
Program Memorandum: Issue Related to Eligible Individual Status Under Section 2741(b) of the Public Health Service Act (PDF -122 KB)
June 2000
Program Memorandum: The Relationship of Certain Types of State Laws to the Application of the Guaranteed Availability Requirements of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) in the Small Group Market
August 2000
Program Memorandum: State “succeeding carrier” or “extension of benefits” laws and an issuer’s obligation under HIPAA to enroll an eligible individual who is disabled.
November 2000
Program Memorandum: Guaranteed Availability Under Title XXVII of the Public Health Service Act – Applicability of Group Participation Rules
November 2000
Program Memorandum: Circumstances Under which Health Insurance Regulated as “Individual” Coverage Under State Law is Subject to the Group Market Requirements of The Health Insurance Portability and Accountability Act of 1996 (HIPAA)
March 2001
Program Memorandum: Guaranteed Renewability of Conversion Policies
August 2001
Program Memorandum: Identifying Federally Eligible Individuals in states Electing to Use Alternative mechanisms to Comply with Guaranteed Availability Requirements under Title XXVII of the PHS Act
March 2002
Program Memorandum: How to Apply the “Product Withdrawal” and “Market Exit” Exceptions of the Guaranteed Renewability Requirements of Title XXVII of the PHS Act
August 2002
Program Memorandum: Application of Group and Individual Market Requirements Under Title XXVII of the Public Health Service (PHS) Act When Insurance Coverage is Sold To, or Through Associations
August 2002
Program Memorandum: The Obligation Health Insurance Issuers Have to Association Members and Associations Under Title XXVII of the PHS Act With Respect to Guaranteed Renewability of Coverage
September 2002
Program Memorandum: Characteristics of Bona Fide Associations, and How Selling Coverage Exclusively Through Them Affects an Issuer’s Guaranteed Availability Obligations Under Title XXVII of the PHS Act
September 2002
Program Memorandum: How Selling Coverage Exclusively Through Bona Fide Associations Affects and Issuer’s Guaranteed Renewability Obligations Under Title XXVII of the PHS Act
March 2004
Program Memorandum: HIPAA Enforcement Is Not Preempted by COBRA; Non-HIPAA-Related State Insurance Law is Not Preempted by Public Sector COBRA
June 2004
Program Memorandum: Federal Eligibility Under HIPAA After Group Health Plan Termination
March 2005
Program Memorandum: Coverage through a Foreign Government, the U.S. Government, and a State Children’s Health Insurance Program, is Creditable Coverage for Purposes of Identifying Eligible Individuals under HIPAA
June 2005
Program Memorandum: Benefit Exclusions that Cannot be Applied to Eligible Individuals Under HIPAA Individual Market Provisions
May 2008
Program Memorandum: Circumstances Under Which Supplemental Health Insurance Coverage Satisfies the Requirements for Excepted Benefits Under Section 2791(c) of the Public Health Service Act