[Federal Register Volume 79, Number 172 (Friday, September 5, 2014)]
[Rules and Regulations]
[Pages 52994-53006]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2014-21178]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

45 CFR Parts 146, 147, 148, 155, and 156

[CMS-9941-F]
RIN 0938-AS32


Patient Protection and Affordable Care Act; Annual Eligibility 
Redeterminations for Exchange Participation and Insurance Affordability 
Programs; Health Insurance Issuer Standards Under the Affordable Care 
Act, Including Standards Related to Exchanges

AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.

ACTION: Final rule.

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SUMMARY: This final rule specifies additional options for annual 
eligibility redeterminations and renewal and re-enrollment notice 
requirements for qualified health plans offered through the Exchange, 
beginning with annual redeterminations for coverage for benefit year 
2015. This final rule provides additional flexibility for Exchanges, 
including the ability to propose unique approaches that meet the 
specific needs of their state, while streamlining the consumer 
experience.

DATES: These regulations are effective on October 6, 2014.

FOR FURTHER INFORMATION CONTACT: Jacob Ackerman, (301) 492-4179, for 
questions regarding parts 146 through 148. Christine Hammer, (301) 492-
4431, for questions regarding part 155. Spencer Manasse, (301) 492-
5141, for questions regarding part 156.

SUPPLEMENTARY INFORMATION: This Federal Register document is also 
available from the Federal Register online database through Federal 
Digital System (FDsys), a service of the U.S. Government Printing 
Office. This database can be accessed via the internet at http://www.gpo.gov/fdsys.

Table of Contents

I. Background
    A. Legislative Overview
    B. Stakeholder Consultation and Input
    C. Structure of the Final Rule
II. Provisions of the Proposed Regulations and Analysis and 
Responses to Public Comments
    A. Part 146--Requirements for the Group Health Insurance Market; 
Subpart E--Provisions Applicable to Only Health Insurance Issuers
    B. Part 147--Health Insurance Reform Requirements for the Group 
and Individual Health Insurance Markets
    C. Part 148--Requirements for the Individual Health Insurance 
Market; Subpart B--Requirements Relating to Access and Renewability 
of Coverage
    D. Part 155--Exchange Establishment Standards and Other Related 
Standards Under the Affordable Care Act; Subpart D--Exchange 
Functions in the Individual Market: Eligibility Determinations for 
Exchange Participation and Insurance Affordability Programs
    E. Part 156--Health Insurance Issuer Standards Under the 
Affordable Care Act, Including Standards Related to Exchanges; 
Subpart M--Qualified Health Plan Issuer Responsibilities
III. Collection of Information Requirements
IV. Regulatory Impact Statement

I. Background

A. Legislative Overview

    The Patient Protection and Affordable Care Act (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 Patient Protection and Affordable Care Act, 
was enacted on March 30, 2010. In this final rule, we refer to the two 
statutes collectively as the ``Affordable Care Act.'' Subtitles A and C 
of Title I of the Affordable Care Act reorganized, amended, and added 
to the provisions of part A of Title XXVII of the Public Health Service 
Act (PHS Act) relating to group health plans and health insurance 
issuers in the group and individual markets.
    Starting on October 1, 2013 for coverage starting as soon as 
January 1, 2014, qualified individuals and qualified employers have 
been able to purchase qualified health plans (QHPs)--private health 
insurance that has been certified as meeting certain standards--through 
competitive marketplaces called Exchanges or Health Insurance 
Marketplaces. The word ``Exchanges'' refers to both State Exchanges, 
also called State-based Exchanges, and Federally-facilitated Exchanges 
(FFEs). In this final rule, we use the terms ``State Exchange'' or 
``FFE'' when we are referring to a particular type of Exchange. When we 
refer to ``FFEs,'' we are also referring to State Partnership 
Exchanges, which are a form of FFE.
    Section 1411(f)(1)(B) of the Affordable Care Act directs the 
Secretary of Health and Human Services (the Secretary) to establish 
procedures to redetermine the eligibility of individuals on a periodic 
basis in appropriate circumstances. Section 1321(a) of the Affordable 
Care Act provides authority for the Secretary to establish standards 
and regulations to implement the statutory requirements related to 
Exchanges, QHPs and other components of Title I of the Affordable Care 
Act. Section 2703 of the PHS Act, as added by the Affordable Care Act, 
and sections 2712 and 2741 of the PHS Act, as added by the Health 
Insurance Portability and Accountability Act of 1996, require health 
insurance issuers in the group and individual markets to guarantee the 
renewability of coverage unless an exception applies.

B. Stakeholder Consultation and Input

    The Department of Health and Human Services (HHS) has consulted 
with stakeholders on a number of policies related to the operation of 
Exchanges, including eligibility redetermination. HHS has held a number 
of listening sessions with consumers, providers, employers, health 
plans, and State representatives to gather public input. HHS consulted 
with stakeholders through regular meetings with the National 
Association of Insurance Commissioners (NAIC), regular contact with 
states through the Exchange grant process, meetings with the CMS Tribal 
Technical Advisory Group and an All Tribes Call on July 21, 2014 with 
tribal leaders and representatives, health insurance issuers, trade 
groups, consumer advocates, employers, and

[[Page 52995]]

other interested parties. We considered all of the public input as we 
developed the policies in this final rule.

C. Structure of the Final Rule

    The regulations in this final rule will be codified in 45 CFR parts 
146, 147, 148, 155, and 156. Part 146 specifies standards related to 
the group health insurance market, including guaranteed renewability of 
coverage for employers in the group market. Part 147 specifies 
standards related to health insurance reforms for the group and 
individual health insurance markets, including guaranteed renewability 
of coverage. Part 148 specifies standards for the individual health 
insurance market, including guaranteed renewability of individual 
health insurance coverage. Part 155 specifies standards related to the 
establishment, operation, and minimum functionality of Exchanges, 
including annual eligibility redeterminations. Part 156 specifies 
standards for health insurance issuers with respect to participation in 
an Exchange.

II. Provisions of the Proposed Regulations and Analysis and Responses 
to Comments

    On July 1, 2014, we published a proposed rule in the Federal 
Register (79 FR 37262) entitled, Patient Protection and Affordable Care 
Act; Annual Eligibility Redeterminations for Exchange Participation and 
Insurance Affordability Programs; Health Insurance Issuer Standards 
Under the Affordable Care Act, Including Standards Related to 
Exchanges. The July 1, 2014 proposed rule (hereinafter referred to as 
the July 1, 2014 Annual Eligibility Redeterminations proposed rule) 
proposed additional options for annual eligibility redeterminations and 
renewal and re-enrollment notice requirements for QHPs offered through 
the Exchange, beginning with annual redeterminations for the 2015 
benefit year. In total, we received 36 comments on the July 1, 2014 
Annual Eligibility Redeterminations proposed rule. Comments represented 
a wide variety of stakeholders, including but not limited to states, 
tribal organizations, health plans, healthcare providers, consumer 
groups, and industry experts. We note that we received some public 
comments that were outside the scope of the proposed rule and are not 
addressed in this final rule. We have not provided explicit responses 
to such comments.
    In this final rule, we provide a summary of each proposed 
provision, a summary of and responses to public comments received, and 
the provisions we are finalizing.

A. Part 146--Requirements for the Group Health Insurance Market; 
Subpart E--Provisions Applicable to Only Health Insurance Issuers

    For a discussion of the provisions of this final rule related to 
Part 146, see section II.B of this preamble.

B. Part 147--Health Insurance Reform Requirements for the Group and 
Individual Health Insurance Markets

    In the preamble to the July 1, 2014 Annual Eligibility 
Redeterminations proposed rule, we proposed establishing a notice 
requirement that would apply to all issuers subject to the guaranteed 
renewability requirements that nonrenew coverage based on continued 
coverage not being available in the enrollee's service area as a result 
of changes that do not result in product discontinuances. This proposal 
was intended to ensure that enrollees receive notice when the product 
(as defined in 45 CFR 144.103) that they purchased no longer covers 
their location in its service area and their coverage will be 
nonrenewed consistent with the guaranteed renewability provisions. We 
sought comment on this proposal, including the appropriate timeframe 
for providing the notice. We received no comments on this proposal.
    In this final rule, we amend the guaranteed renewability 
regulations at Sec.  146.152(b)(5), Sec.  147.106(b)(5), and Sec.  
148.122(c)(4) to direct an issuer that nonrenews coverage based on 
enrollees' movement outside the service area to provide notice in 
writing to each plan sponsor or individual, as applicable, (and to all 
participants and beneficiaries covered under the coverage) affected by 
such nonrenewal. This notice must be provided in the form and manner 
specified by the Secretary for notices of product discontinuances. This 
requirement applies to grandfathered and non-grandfathered coverage in 
the individual, small group, and large group markets offered through or 
outside an Exchange.
    Final Rule Action: We are amending the guaranteed renewability 
regulations at Sec.  146.152, Sec.  147.106, and Sec.  148.122 to 
establish a notice requirement for issuers that nonrenew coverage based 
on an enrollee no longer being located within the product's service 
area.

C. Part 148--Requirements for the Individual Health Insurance Market; 
Subpart B--Requirements Relating to Access and Renewability of Coverage

    For a discussion of the provisions of this final rule related to 
Part 148, see section II.B of this preamble.

D. Part 155--Exchange Establishment Standards and Other Related 
Standards Under the Affordable Care Act; Subpart D--Exchange Functions 
in the Individual Market: Eligibility Determinations for Exchange 
Participation and Insurance Affordability Programs

    In Sec.  155.330, we proposed to amend paragraph (b)(4), which 
addresses reporting changes in the context of eligibility 
redeterminations during a benefit year. Our proposal provided that the 
Exchange must allow an enrollee, or an application filer on behalf of 
the enrollee, to report changes via the channels available for the 
submission of an application; however, we proposed that the Exchange be 
permitted, but not required, to allow an enrollee, or an application 
filer, on behalf of the enrollee, to report changes via mail. We noted 
that experience has shown that eligibility changes reported by mail are 
often difficult to process because they frequently trigger telephone 
contact to gather additional information needed to process the change. 
We noted that, if finalized, we anticipate that the FFE would not 
accept changes reported via mail for the foreseeable future.
    Comment: We received several comments on the proposed changes to 
Sec.  155.330(b)(4). Some comments requested that HHS retain the 
requirement that Exchanges allow enrollees to use mail to report 
changes during the benefit year. These commenters expressed concern 
that finalizing the provision as proposed would place an undue burden 
on vulnerable populations who may not have ready access to phones, the 
Internet, or transportation to in-person assisters. A few commenters 
recommended creating a paper change report form to elicit the correct 
information to process changes reported by mail. In contrast, a few 
commenters supported the flexibility the proposed provision provided to 
Exchanges and viewed the proposal as administratively efficient.
    Response: We are finalizing the provision as proposed, permitting 
Exchanges flexibility to determine whether to provide a process to 
report changes via mail and note that the FFE will be using this 
flexibility to not provide such a process via mail. We agree that 
vulnerable populations must have ready access to the Exchange to report 
changes. However, as noted in the preamble to the proposed rule, 
experience has shown that changes reported via mail often require 
significant follow-up and can result in delays in processing pertinent 
eligibility

[[Page 52996]]

information, often to the detriment of the consumer. Accordingly, while 
Exchanges may allow for the reporting of changes by mail, they are not 
required to do so. The FFE will elect not to allow changes by mail for 
the foreseeable future.
    Comment: One commenter asked whether the call center would be able 
to inform the individual the result of reporting a change. Another 
commenter questioned whether the Exchange would provide written 
confirmation, including an explanation of any action taken, to the 
enrollee who submits a change.
    Response: In the FFE, we anticipate that the majority of enrollees 
will know the outcome of the changes reported through the call center 
during their call. As with all actions that result in a new eligibility 
determination, the enrollees will receive an eligibility determination 
notice (in the format--hard copy or electronic--that they have chosen).
    Final Rule Action: We are finalizing the provision as proposed in 
Sec.  155.330(b)(4).
    In Sec.  155.335(a), we proposed amendments to the general 
requirement for annual eligibility redetermination. Specifically, we 
proposed in paragraph (a)(1) that, except as specified in paragraphs 
(l) and (m) of this section, the Exchange must redetermine the 
eligibility of a qualified individual on an annual basis. In paragraph 
(a)(2), we proposed the Exchange must conduct annual redeterminations 
using one of three options: (1) The procedures described in Sec.  
155.335(b) through (m); (2) alternative procedures specified by the 
Secretary for the applicable plan year; or (3) alternative procedures 
approved by the Secretary based on a showing by the Exchange that the 
alternative procedures would facilitate continued enrollment in 
coverage for which the enrollee remains eligible, provide clear 
information about the process to the qualified individual or enrollee 
(including regarding any action by the qualified individual or enrollee 
necessary to obtain the most accurate redetermination of eligibility), 
and provide adequate program integrity protections.
    Comment: We received many comments supporting the flexibility 
provided by the three options for Exchanges to implement annual 
redetermination procedures. These commenters believed that the proposal 
would promote uninterrupted coverage for enrollees, as well as enhance 
and streamline the redetermination process.
    Response: We appreciate the support for the three options we 
proposed for Exchanges to conduct annual eligibility redeterminations.
    Comment: A few commenters supported moving Exchanges toward a 
single standard for annual eligibility redeterminations, primarily in 
accordance with Sec.  155.335(b) through (m).
    Response: We anticipate that the flexibility offered to Exchanges 
to select procedures for conducting annual redeterminations will 
encourage innovation and best practices that will benefit both 
Exchanges and stakeholders over time. We caution that no matter which 
option an Exchange implements for annual redeterminations, the Exchange 
will be held to applicable program integrity and oversight standards to 
ensure an effective process.
    Comment: Several commenters asked that a fully-automated 
redetermination process be implemented. Specifically, these commenters 
recommended that enrollees not be required to reapply at their Exchange 
in order to maintain accurate subsidies and program eligibility by the 
2016 benefit year. In contrast, one commenter requested that auto-
redeterminations not be implemented until 2016.
    Response: We recognize the importance of a simple consumer 
experience during the eligibility redetermination and re-enrollment 
process as well as the potential benefits consumers may receive by 
regularly updating their application information, or simply confirming 
its accuracy.
    Comment: We received a few comments from the issuer community 
citing concern that the guidance released alongside the proposed rule, 
specifying the alternative procedures that the FFE would use under 
proposed Sec.  155.225(a)(2)(ii) (the Guidance on Annual 
Redeterminations for 2015 \1\), is limited to the 2015 benefit year
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    \1\ Guidance on Annual Redeterminations for Coverage for 2015, 
available at http://www.coms.gov/cciio/resources/Regulations-and-Guidance/index.html.
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    Response: We indicated in the July 1, 2014 Annual Eligibility 
Redeterminations proposed rule that these are the procedures the FFE 
would use for the 2015 benefit year, if the proposed option to select 
these alternative procedures were finalized. The flexibility provided 
for the Secretary to update the alternative procedures under Sec.  
155.335(a)(2)(ii) is intended to ensure that HHS can learn from the 
Exchanges' experience and improve the alternative procedures over time. 
Although HHS may issue revised alternative procedures annually, we 
intend to work with stakeholders to ensure there is sufficient lead 
time in the event changes are made.
    Comment: Commenters, particularly State-based Exchanges, were 
supportive of the option proposed in Sec.  155.335(a)(2)(iii) allowing 
Exchanges to propose alternative procedures, subject to approval by the 
Secretary, for conducting annual redeterminations. In contrast, one 
commenter encouraged HHS to standardize redetermination procedures 
across all Exchanges to reduce administrative burden on the issuer 
community.
    Response: Although we understand the desire to create uniform 
processes across Exchanges by permitting this flexibility, Exchanges 
will be able to benefit from the experiences of one another and be able 
to apply lessons-learned to improve their consumers' redetermination 
experience.
    Comment: We received a few comments regarding how HHS should 
conduct reviews of alternative procedures proposed by Exchanges. One 
commenter requested that reviews of alternative procedures be conducted 
on an individualized basis, considering state-specific factors, 
including operational structure, 2014 experience, and information 
technology capabilities. Similarly, several commenters recommended 
specifying additional standards that Exchanges' alternative procedures 
must meet as part of the review process. Other commenters recommended 
that alternative procedures must meet minimum federal standards, not be 
burdensome for consumers, and be clear improvements from the process 
implemented by the FFE. Finally, a commenter requested that alternative 
procedures for redeterminations be publicly available.
    Response: We appreciate the many suggestions for standards for 
alternative redetermination procedures under Sec.  155.335(a)(2)(iii), 
as well as recommendations for the approval process for those 
procedures. We note that the alternative procedures we are finalizing 
under Sec.  155.335(a)(2)(iii) must provide consumer and program 
integrity protections to ensure a consistent, effective process that 
safeguards public funds. We will work with Exchanges to develop and 
provide guidance about the process for submitting alternative 
procedures for approval under Sec.  155.335(a)(2)(iii).
    Comment: Several commenters submitted comments regarding the 
substance of the Guidance on Annual Redeterminations for 2015 released 
contemporaneously with the July 1, 2014 Annual Eligibility 
Redeterminations proposed rule.

[[Page 52997]]

    Response: The substance of the Guidance on Annual Redeterminations 
for 2015 is beyond the scope of the proposed rule and these comments 
are not addressed in this final rule.
    Final Rule Action: We are finalizing Sec.  155.335(a) with a minor 
modification changing ``plan year'' to ``benefit year'' in Sec.  
155.335(a)(2)(ii).
    In Sec.  155.335(e), we proposed to revise the language regarding 
change reporting to generally align with the standards in Sec.  
155.330(b), so that Sec.  155.335(e) would specify that, except as 
specified in proposed paragraph (e)(1), the Exchange must require a 
qualified individual to report any change with respect to the 
eligibility standards specified in Sec.  155.305 within 30 days of any 
such change. In paragraph (e)(1), we proposed that the Exchange must 
not require a qualified individual who did not request an eligibility 
determination for insurance affordability programs to report changes 
that affect eligibility for insurance affordability programs. Finally, 
in paragraph (e)(2), we proposed to amend the existing provision 
requiring that the Exchange must allow a qualified individual, or an 
application filer, on behalf of the qualified individual, to report 
changes via the channels available for submission of an application, as 
described in Sec.  155.405(c)(2). We proposed that this requirement 
would continue to apply, except that the Exchange would be permitted 
but not required to allow a qualified individual, or an application 
filer, on behalf of the qualified individual, to report changes via 
mail.
    Comment: We received some comments regarding the proposed 
provisions in paragraph (e). A few commenters recommended not revising 
the provisions in paragraph (e) at all. Other commenters sought 
clarification as to whether the changes reported at annual 
redetermination should be based on current circumstances or could be 
based on expected changes in the coming benefit year. Another commenter 
supported the proposed provision in paragraph (e)(1), which would not 
permit Exchanges to require a qualified individual who did not request 
an eligibility determination for insurance affordability programs to 
report changes that affect eligibility for insurance affordability 
programs. One commenter recommended that Exchanges be required to 
inform people about the availability of financial assistance through 
the Exchange even if they are not currently receiving it. Finally, one 
commenter requested that Exchanges be required to include a summary of 
the individual's application on file in the annual redetermination 
notice and to ensure that this information is in plain language so it 
is easily accessible for all consumers.
    Response: We believe the amendments made to this paragraph are 
necessary to generally align with the standards in Sec.  155.330, 
including proposed Sec.  155.330(b)(4), which governs the corresponding 
requirements for eligibility redeterminations during the benefit year. 
We note that non-income related eligibility criteria, such as residency 
changes must be reported within 30 days following the change in 
accordance with Sec.  155.330(b)(1). However, we further clarify, in 
response to comment, that eligibility for advance payments of the 
premium tax credit and cost-sharing reductions is based on projected 
annual household income and consumers may update that information at 
any time throughout the year. We also note that Exchanges may, but are 
not required, to remind consumers who do not currently receive advance 
payments of the premium tax credit or cost-sharing reductions through 
the Exchange that they may be eligible for this financial assistance. 
Consistent with all applicable requirements, Exchanges can provide 
additional information at their discretion.
    Comment: Several commenters requested that paragraph (e) provide a 
minimum threshold below which income changes would not be required to 
be reported for annual redetermination. We also received a comment 
asking that Exchanges use consistent messaging about reporting changes 
in income to reduce consumer confusion.
    Response: We note that the provision for reporting changes during 
the benefit year at Sec.  155.330 does permit Exchanges to establish a 
reasonable threshold for reporting changes in income. However, we have 
declined to establish a threshold in this instance, in order to promote 
the greatest possible accuracy of annual eligibility redeterminations. 
Because all consumers will be subject to annual redeterminations, we 
consider the accuracy of annual redeterminations to be a priority and a 
significant way in which Exchanges can help reduce the risk that 
consumers may have to pay back any amount of their advance payments of 
the premium tax credit at tax filing time if, through the 
reconciliation process, the IRS determines the advance payment of the 
premium tax credit to be in excess of the premium tax credit for which 
the consumer was actually eligible. We note that consumers who do not 
have steady or predictable income have the same change reporting 
options as all other consumers and are able to project income-related 
changes for the year as part of their annual eligibility 
redetermination, reducing the frequency with which they must report an 
income-related change. Finally, Exchanges must adhere to the standards 
in Sec.  155.330(b) requiring consumers to report changes during the 
benefit year; however, Exchanges have flexibility to establish 
reasonable thresholds below which changes in income do not have to be 
reported for purposes of a mid-year redetermination. Given this 
flexibility, we do not believe it is necessary to impose specific 
requirements regarding change reporting messages across Exchanges.
    Comment: We received several comments about the requirement in 
proposed Sec.  155.335(e) that qualified individuals report any change 
with respect to eligibility standards within 30 days of such a change. 
One commenter questioned what the consequences were if an individual 
fails to report a change within 30 days or reports the change more than 
30 days after the change. Another commenter suggested clarifying that 
individuals who report changes more than 30 days after they occur can 
still receive an updated eligibility determination.
    Response: The requirement to report changes within 30 days is 
intended to ensure that eligibility determinations remain accurate in 
view of qualified individuals' most current eligibility information, 
and reduce the risk that consumers may have to repay advance payments 
of the premium tax credit in excess of what they are eligible for, 
through the reconciliation process. Individuals who report changes more 
than 30 days after the change will still receive an updated eligibility 
determination.
    Comment: We received comments both supporting and opposing the 
proposed change in paragraph (e)(2) to eliminate the requirement for 
Exchanges to accept changes reported by mail, with many commenters 
focusing on the potential lack of access vulnerable populations may 
have to the methods Exchanges are required to provide for reporting 
changes. We also received a few general recommendations related to this 
provision. For example, one commenter recommended Exchanges establish 
tiered support through the call center. Another comment emphasized the 
need for a streamlined process for consumers to update their income and 
eligibility information without having to go through the entire 
application process.
    Response: As noted in responses to the comments regarding the 
proposed

[[Page 52998]]

changes to Sec.  155.330(b)(4), we agree that vulnerable populations 
must have access to the Exchange to report changes. However, changes 
reported by mail often require significant follow-up in order to obtain 
enough information to process the change, which creates a burden on 
both the Exchange and the consumer to complete the change reporting 
process. The required methods for accepting reported changes should 
only require a one-time interaction with the Exchange and we do not 
believe they inappropriately limit the ability of consumers to 
efficiently report changes. Therefore, we are finalizing the provision 
as proposed, permitting Exchanges flexibility to determine whether to 
accept reports of changes via mail.
    Final Rule Action: We are finalizing Sec.  155.335(e) as proposed.
    In Sec.  155.335(j), we proposed to modify the standards for re-
enrollment in coverage. First, in paragraph (j)(1), we proposed that if 
an enrollee remains eligible for enrollment in a QHP through the 
Exchange upon annual redetermination, and the product under which the 
QHP in which he or she was enrolled remains available for renewal, 
consistent with 45 CFR 147.106, such enrollee will have his or her 
enrollment in a QHP under the product renewed unless he or she 
terminates coverage, including termination of coverage in connection 
with voluntarily selecting a different QHP, in accordance with Sec.  
155.430. In this situation, we proposed that the QHP in which the 
enrollee will be renewed will be selected according to the following 
order of priority: (1) In the same plan as the enrollee's current QHP; 
(2) if the enrollee's current QHP is not available, the enrollee's 
coverage will be renewed in a plan at the same metal level as the 
enrollee's current QHP; (3) if the enrollee's current QHP is not 
available and the enrollee's product no longer includes a plan at the 
same metal level as the enrollee's current QHP, the enrollee's coverage 
will be renewed in a plan that is one metal level higher or lower than 
the enrollee's current QHP; and (4) if the enrollee's current QHP is 
not available and the enrollee's product no longer includes a plan that 
is at the same metal level as, or one metal level higher or lower than 
the enrollee's current QHP, the enrollee's coverage will be renewed in 
any other plan offered under the product in which the enrollee's 
current QHP is offered in which the enrollee is eligible to enroll.
    Second, in paragraph (j)(2), we proposed standards to address re-
enrollment in situations in which the product under which an enrollee's 
QHP is offered is not available through the Exchange for renewal, 
consistent with Sec.  147.106. In this situation, we proposed the 
issuer may still re-enroll the enrollee in a different product offered 
by the same issuer, to the extent permitted by applicable state law, 
unless the enrollee terminates coverage. To the extent that an issuer 
is re-enrolling such an enrollee, we proposed that the plan in which 
the enrollee will be renewed will be selected according to the 
following order of priority: (1) In a plan through the Exchange at the 
same metal level as the enrollee's current QHP in the product offered 
by the issuer that is the most similar to the enrollee's current 
product; (2) if the issuer does not offer another plan through the 
Exchange at the same metal level as the enrollee's current QHP, the 
enrollee will be re-enrolled in a plan through the Exchange that is one 
metal level higher or lower than the enrollee's current QHP in the 
product offered by the issuer through the Exchange that is the most 
similar to the enrollee's current product; (3) if the issuer does not 
offer another plan through the Exchange at the same metal level as, or 
one metal level higher or lower than the enrollee's current QHP, the 
enrollee will be re-enrolled in any other plan offered through the 
Exchange by the QHP issuer in which the enrollee is eligible to enroll; 
and (4) if the issuer does not offer any plan through the Exchange in 
which the enrollee is eligible to enroll, the enrollee may be re-
enrolled in a plan offered outside the Exchange by the QHP issuer under 
the product that is the most similar to the enrollee's current product, 
in which the enrollee is eligible to enroll. We also solicited comment 
regarding whether paragraphs (j)(1)(iii) and (j)(2)(ii) should only 
prioritize a plan with a lower metal level, and whether in general, 
priority should be placed on plans that have a premium that is closest 
to the plan in which an enrollee is currently enrolled.
    Comment: One commenter noted the importance of continuity of 
coverage without gaps and suggested that consumers have full 
transparency into the process and be informed why they are being 
enrolled in a product and notified that some issuers who did not 
participate in the Exchange in the 2014 benefit year may be offering 
plans in the 2015 benefit year that consumers may want to consider. 
Similarly, a commenter did not support the re-enrollment provisions, 
believing they would steer members away from the shopping experience 
and discourage incumbent issuers from creating new and innovative 
products. A few commenters noted their general support for the 
provisions in paragraph (j) and noted that they would cause the least 
amount of disruption to the enrollee.
    Response: We believe that the rule, as finalized, best furthers the 
goal of creating continuity of coverage for consumers at annual 
redetermination and enrollment. We agree that consumers should 
understand why they are being enrolled into a new plan, if applicable, 
and be reminded that, in all cases, after being redetermined to be 
eligible for coverage through the Exchange, they can return to the 
Exchange to shop for another plan, if they wish.
    Comment: Some commenters suggested delaying the implementation of 
the proposed auto-enrollment policy until the 2016 benefit year due to 
concerns about operational readiness. A commenter asked that, if HHS 
did proceed with 2015 implementation, the enrollment policy be 
permitted only at the end of open enrollment after all enrollee 
outreach has been conducted.
    Response: We understand that QHP issuers, Exchanges, consumers, and 
other stakeholders are concerned that they have time to prepare for the 
redetermination and enrollment period for benefit year 2015 coverage. 
We agree that encouraging aggressive outreach and enrollee engagement 
are important. However, it is important for stakeholders to have 
sufficient guidance to conduct redetermination and re-enrollment in 
accordance with federal standards during the entire open enrollment 
period for the 2015 benefit year. Postponing the implementation of 
enrollment procedures until the end of the open enrollment period could 
result in some consumers experiencing gaps in coverage. We believe that 
the Exchange should complete the redetermination and re-enrollment 
process early enough so that consumers have coverage (and financial 
assistance, if applicable) effective January 1, 2015.
    Comment: A few commenters provided general comments on and 
alternatives to the proposed hierarchies in paragraphs (j)(1) and (2). 
For instance, one commenter disagreed with the use of the hierarchy 
because of the substantial differences in plans that a consumer may be 
renewed or re-enrolled into at different metal levels and in different 
product lines. Another commenter thought enrolling a consumer in a 
product or plan other than the consumer's identical QHP would cause 
confusion and interrupt established provider-patient care, and inflate 
premiums. Similarly, a few commenters requested flexibility in applying 
the hierarchy in cases where its application could harm consumers or 
where the enrollee is in a unique

[[Page 52999]]

situation. For example, if the enrollee lives outside of the plan's 
service area, is enrolled in a catastrophic plan, or has aged off a 
parent's policy, the consumer may not have eligibility to re-enroll in 
the same plan.
    Response: We understand the complexities that may result when 
consumers are placed in a different plan or product as the result of 
renewal or re-enrollment. However, we note that placement into another 
plan or product is not intended to be the usual result of the open 
enrollment period. The hierarchy proposed in Sec.  155.335(j)(1) and 
(2) is only intended for use when a consumer's plan is no longer 
available or the product is discontinued, which we do not expect to be 
the typical scenario. The hierarchy then provides a structured process 
for renewal and re-enrollment which are intended to limit the 
differences between the consumer's current plan and new plan. We are 
finalizing the renewal and re-enrollment provisions with the 
hierarchical structure to guide the renewal and re-enrollment process 
while protecting the interests of the enrollee. Finally, we note that 
we are reviewing the unique situations noted by commenters and intend 
to issue guidance as to how to handle re-enrollment in these situations 
in the future.
    Comment: We received several comments regarding the issuer's role 
in the re-enrollment process, particularly around the determination of 
when a product is ``most similar'' to an enrollee's current product, as 
stated in Sec.  155.335(j)(2)(i), (ii), and (iv). For example, a few 
commenters suggested that the Exchange, not the QHP issuer, should 
determine comparability of plans to ensure that these determinations 
are objective and in a consumer's best interest. Commenters requested 
that HHS define the criteria used in determining plan comparability and 
to define how a product will be determined ``similar.'' Finally, one 
commenter indicated support for allowing the issuer to determine which 
product is most similar
    Response: QHP issuers are in a unique position to understand both 
the characteristics of enrollees' current products and the issuers' 
other product offerings. As part of the QHP certification process QHP 
issuers in the FFE will submit crosswalks, mapping similar plans and 
products. Mapping enrollees in a given product to a similar product is 
a common industry practice.
    As noted earlier, a key priority during the open enrollment period 
is to ensure that current enrollees have continuity of coverage and do 
not experience a gap in that coverage or their financial assistance. 
QHP issuers, coordinating with Exchanges to implement the re-enrollment 
and renewals, can streamline the re-enrollment and renewal process 
because they can easily determine whether a product will be available 
and, if not, what product, in accordance with the hierarchy established 
in this rule, would cause the least amount of disruption to the 
enrollee for re-enrollment.
    Finally, we note that a product (as defined in Sec.  144.103) means 
a unique set of health insurance coverage benefits that an issuer 
offers using a particular product network type (for example, HMO, PPO, 
POS, EPO, or indemnity) within a service area. Accordingly, when 
mapping individuals to a new product, we expect that QHP issuers will 
select a product that most closely resembles the benefits, network 
type, and service area of the enrollee's current product. Nonetheless, 
we are not establishing a ``most similar'' standard in this final rule. 
States, Exchanges, and QHP issuers may use a reasonable, good faith 
interpretation to determine what constitutes the most similar product 
for this purpose. Finally, we note that State-based Exchanges that opt 
to implement an alternative approach to annual redeterminations, in 
accordance with Sec.  155.335(a)(2)(ii) or (iii), may also choose to 
establish a standard in this regard for renewal or re-enrollment.
    Comment: A few commenters representing the issuer community 
submitted questions regarding the link between stand-alone dental plans 
and the renewal of medical coverage. For example, a commenter 
questioned whether there is an impact on enrollment in a stand-alone 
dental plan if an individual re-enrolls into a different medical plan. 
We received one suggestion that re-enrollment for stand-alone dental 
plans should emphasize maintaining the same plan type, such as high or 
low coverage, and design, such as family or child-only coverage.
    Response: As excepted benefits, dental plans are not subject to the 
guaranteed renewability standards in Sec.  147.106 and, therefore, the 
hierarchies in Sec.  155.335(j) do not need to apply to them in the 
same way.
    Nonetheless, to minimize disruptions in coverage for enrollees, in 
the FFE, re-enrollment for stand-alone dental plan (SADP) enrollees 
will follow the hierarchy in Sec.  155.335(j) if the enrollee does not 
make any new SADP selections. We also note that SADPs are identified as 
either high or low plans, rather than using metal levels like medical 
plans. Therefore, the application of the hierarchy in the FFE for 
renewal or re-enrollment will account for this difference. For example, 
where a medical plan renewal will require, in accordance with Sec.  
155.335(j)(1)(ii), renewal in a plan at the same metal level as the 
enrollee's current QHP for medical coverage, application of this 
standard to SADP will result in renewal in a plan at the same plan 
level, either high or low, as the enrollee's current SADP QHP. 
Similarly, where the hierarchy states at Sec.  155.335(j)(1)(iii) that 
if a plan at the same metal level as the enrollee's current plan is no 
longer available within the enrollee's current product, the enrollee 
will be renewed in a plan that is one metal level higher or lower than 
the enrollee's current QHP, in the SADP context, the FFE will renew or 
re-enroll the enrollee into the plan within the product that is offered 
at the permissible level other than the one of the enrollee's current 
SAPD (e.g., if the enrollee is currently in a high SAPD, he or she will 
be renewed into the low SADP).
    We clarify that if an enrollee visits the FFE during the 2015 open 
enrollment period to change his or her QHP enrollment, he or she will 
need to re-select his or her SADP at the same time, because the FFE 
requires that QHPs and SADPs be selected at the same time. If an 
enrollee doesn't return to the FFE to affirmatively select plans by 
December 15, 2014, the FFE will process the renewal or re-enrollment 
plan indicated by SADP and QHP issuers on the 2015 Plan ID Crosswalk 
Template in accordance with the hierarchies set forth in this rule. We 
note that changes in medical QHP coverage during Open Enrollment are 
independent of changes to SADP, and vice versa.
    Comment: A few commenters requested that HHS clarify the meaning of 
``a plan at the same metal level'' proposed at paragraph (j)(1)(ii). 
One commenter suggested that this meant a plan with the same QHP 
issuer.
    Response: We clarify that the hierarchy in Sec.  155.335(j)(1) and 
(2) only refer to plans and products offered by the enrollee's current 
issuer. The hierarchy does not permit auto-enrollment into a product 
offered by a different issuer; however, the enrollee always has the 
option to shop for coverage with another issuer during the open 
enrollment period. We have added the word ``same'' before the word 
``issuer'' in Sec.  155.335(j)(2)(i), (ii), and (iii) to help clarify 
the intent. We also note one technical addition to Sec.  
155.335(j)(2)(ii) where we have added the word ``or'' at the end of the 
paragraph.
    Comment: We received a few comments regarding the proposed

[[Page 53000]]

requirement to re-enroll an enrollee in a plan that is one metal level 
higher or lower than the enrollee's current QHP at Sec.  
155.335(j)(1)(iii) and (j)(2)(ii). For example, one commenter noted 
that the proposed rule did not specify whether the consumer or the QHP 
issuer decides whether to enroll into a higher or lower plan if the QHP 
issuer no longer offers the same level plan, and recommended that the 
Exchange, not the QHP issuer, make the enrollment decision. Another 
commenter recommended that QHP issuers must clearly inform the consumer 
what metal level the new plan will be and whether it is a higher or 
lower metal level than the consumer's existing plan.
    A few commenters also addressed the request for comment regarding 
whether the hierarchy should only prioritize a plan with a lower metal 
level, or whether, in general, priority should be placed on plans that 
have a premium that is closest to the premium of the plan in which an 
enrollee is currently enrolled.
    Response: We note that there was no consensus in favor of one 
approach over the other. As noted before, these provisions are not 
expected to be used frequently and are positioned in the hierarchy to 
promote less-disruptive re-enrollment scenarios first. These provisions 
are being finalized without substantive changes.
    We also clarify, in response to the comments, that these provisions 
impose requirements on the Exchange because, although the QHP issuers 
will facilitate the enrollment by submitting plan crosswalks, the 
Exchange is ultimately responsible for ensuring that enrollment is 
effectuated according to the hierarchy. To reflect this, we are not 
finalizing proposed Sec.  155.335(j)(2)(iv), because this provision 
addresses enrollment outside the Exchange. In cases where an enrollee 
cannot be re-enrolled in a plan within the Exchange in accordance with 
Sec.  155.335(j)(2)(i)-(iii), the issuer will follow applicable 
guaranteed renewability requirements and applicable state law to 
complete re-enrollment outside the Exchange.
    Comment: We also received comments from tribes regarding the 
effects of proposed renewal and re-enrollment regulations on American 
Indians and Alaska Natives (AI/ANs), noting that the zero and limited 
cost-sharing plan variations available to AI/ANs cross the four metal 
levels. The commenters recommended that the regulations be revised to 
give QHP issuers the flexibility to keep AI/ANs in their current plan 
or another bronze level plan. Finally, the commenters highlighted the 
importance of addressing this special circumstance for AI/ANs because 
they should always have an alternate zero or limited cost-sharing plan 
at any level available to them and should never be moved to a higher 
level plan if their zero or limited cost-sharing plan variation is 
eliminated.
    Response: All QHPs must offer zero and limited cost-sharing plan 
variations at every metal level and, thus, if a particular QHP is no 
longer offered, the AI/AN should be able to enroll in another zero or 
limited cost-sharing plan variation at the same metal level, if a QHP 
is offered at that metal level. However, if a QHP is not available at a 
specific metal level, such as the bronze metal level, then no plan 
variations will be available at that level. If a qualified individual 
who is an Indian, as defined by section 4 of the Indian Health Care 
Improvement Act is auto-enrolled in a higher level metal plan than 
desired, pursuant to Sec.  155.420(d)(8), he or she can change his or 
her enrollment once per month, mitigating any undesired outcome of 
automatic enrollment.
    Comment: One commenter urged HHS to adopt a mechanism to 
accommodate auto-enrollment within an insurance holding company system.
    Response: We disagree that a QHP issuer should be permitted to 
auto-enroll individuals into a product of another licensed issuer. 
Section 2703(c) of the Public Health Service (PHS) Act and Sec.  
147.106(c) provide that, in any case in which a QHP issuer decides to 
discontinue offering a particular product offered in the individual 
market, that product may be discontinued by the issuer in accordance 
with applicable state law in the applicable market only if certain 
requirements are met. Among the requirements for product 
discontinuation is that the issuer must offer to each individual 
provided that particular product the option to purchase, on a 
guaranteed availability basis, any other health insurance coverage 
offered by the issuer in that market. An issuer does not satisfy the 
requirement to offer other health insurance coverage currently being 
offered ``by the issuer'' if it auto-enrolls qualified individuals into 
a product of another issuer that is separately licensed to engage in 
the business of insurance in a State. Nothing in the PHS Act or the 
regulations under the PHS Act prevents an issuer that elects to 
discontinue offering all health insurance coverage in a market (market 
withdrawal under Sec.  147.106(d)) from auto-enrolling affected 
individuals into a product of another licensed issuer, to the extent 
permitted by applicable state law.
    Comment: We received many comments concerning the possibility for 
enrollees to be re-enrolled in a plan that prevents them from 
continuing to receive financial assistance through the Exchange. Two 
specific scenarios created concern for commenters. First, commenters 
were concerned that enrollees might lose access to cost-sharing 
reductions if they are re-enrolled into a non-silver level plan. 
Second, commenters noted that enrollees who are re-enrolled into a 
product outside the Exchange would lose eligibility for both advance 
payments of the premium tax credit and cost-sharing reductions. We 
received many recommendations regarding how to address these two 
scenarios. Several commenters urged HHS to simply prevent issuers from 
auto-enrolling qualified individuals into plans outside the Exchange if 
the qualified individual is eligible for advance payments of the 
premium tax credit, or into a non-silver level plan if the qualified 
individual is eligible for cost-sharing reductions. Similarly, a few 
commenters suggested that we add consideration of a plan's cost-sharing 
structure as a factor in any auto-enrollment schema. Another commenter 
suggested that if an individual is re-enrolled in a plan that results 
in a negative impact on his or her financial assistance that the 
Exchange should permit the individual to change plans during open 
enrollment and for a 90-day period following open enrollment.
    Response: We agree with commenters that losing access to advance 
payments of the premium tax credit and/or cost-sharing reductions in 
order to maintain coverage under a product that is no longer available 
through an Exchange is not the preferable outcome for renewal and re-
enrollment. The hierarchy of renewal and re-enrollment options set out 
in Sec.  155.335(j) was created in order to minimize such disruptions. 
We contend that instances where an enrollee will be re-enrolled into 
coverage that prevents the enrollee from taking advantage of advance 
payments of the premium tax credit and/or cost-sharing reductions will 
be rare. We note that Sec.  156.200(c)(1) requires all issuers offering 
a QHP through the Exchange to offer at least one plan at the silver 
level. Issuers generally have found that plans offered at this level 
are their most popular plans, and they understand the role of advance 
payments of the premium tax credit and/or cost-sharing reductions in 
making coverage affordable to their enrollees. We also note that the 
hierarchy is designed to prioritize options that generally do not

[[Page 53001]]

eliminate eligibility for advance payments of the premium tax credit 
(or the premium tax credit) and/or cost-sharing reductions.
    Section 155.335(j)(2) of this final rule specifically addresses re-
enrollment in Exchange coverage when an enrollee's current product is 
not available for renewal ``through the Exchange.'' Nonetheless, the 
product may continue to be available for renewal outside the Exchange. 
We interpret the guaranteed renewability provisions of Sec.  147.106 to 
mean that, if the product remains available for renewal, including 
outside the Exchange, the issuer must renew the coverage within the 
product in which the enrollee is currently enrolled at the option of 
the enrollee, unless an exception to the guaranteed renewability 
requirements applies. However, for the reasons stated above, to the 
extent that the issuer is subject to 45 CFR 155.335(j) with regard to 
an enrollee's coverage through the Exchange, the issuer must, subject 
to applicable state law regarding automatic enrollments, automatically 
enroll the enrollee in accordance with the re-enrollment hierarchy, 
even where that results in re-enrollment in a plan under a different 
product offered by the same QHP issuer through the Exchange. 
Enrollments completed pursuant to Sec.  155.335(j) will be considered 
to be a renewal of the enrollee's coverage, provided the enrollee also 
is given the option to renew coverage within his or her current product 
outside the Exchange. We intend to evaluate this policy and may provide 
future guidance on how an issuer continuing to offer an enrollee's 
product outside the Exchange can comply with the guaranteed 
renewability provisions. We reiterate that enrollees have the 
opportunity to shop for a new plan during the open enrollment period 
regardless of whether they are automatically re-enrolled into plan that 
does not meet their needs. We encourage Exchanges and QHP issuers to 
remind enrollees of that option.
    Final Rule Action: We are finalizing Sec.  155.335(j) with a few 
modifications. First, we have added the word ``same'' before the word 
``issuer'' in Sec.  155.335(j)(2)(i), (ii), and (iii). Second, we have 
added the word ``or'' at the end of Sec.  155.335(j)(2)(ii). We are not 
finalizing Sec.  155.335(j)(2)(iv).

B. Part 156--Health Insurance Issuer Standards Under the Affordable 
Care Act, Including Standards Related to Exchanges; Subpart M--
Qualified Health Plan Issuer Responsibilities

    In 45 CFR 147.106(f)(1) of the final rule entitled, ``Patient 
Protection and Affordable Care Act; Exchange and Insurance Market 
Standards for 2015 and Beyond,'' published on May 27, 2014 (79 FR 
30240) (Market Standards Rule), we specified that health insurance 
issuers of non-grandfathered plans in the individual market will 
provide written notice of renewals before the first day of the next 
annual open enrollment period in a form and manner specified by the 
Secretary. Under Sec.  147.106(c)(1), health insurance issuers of non-
grandfathered plans in the individual market also will provide written 
notices of product discontinuances.
    We proposed adding a new Sec.  156.1255, which would require a 
health insurance issuer in the individual market that is renewing an 
enrollment group's coverage in a QHP offered through the Exchange 
(including a renewal with modifications), or that is discontinuing a 
product that includes plans offered through the Exchange and 
automatically enrolling an enrollee in a QHP under a different product 
offered by the same QHP issuer through the Exchange, to include certain 
information in the renewal or discontinuation notices, as applicable. 
We proposed that the additional information include premium and advance 
payment of premium tax credit information, an explanation of the 
requirement to report changes to the Exchange, a description of the 
reconciliation process for advance payments of the premium tax credit, 
and an explanation that if the enrollment group's coverage is being 
renewed in a QHP at a different (non-silver) metal level, cost-sharing 
reductions will not be provided for the upcoming year unless the 
enrollment group changes its enrollment to select a new silver-level 
plan.
    Finally, we proposed establishing a notice requirement that would 
apply to all plans subject to the guaranteed renewability requirements 
that nonrenew coverage based on continued coverage not being available 
in the enrollee's service area as a result of changes that do not 
result in product discontinuances. We sought comment on this proposal, 
including the appropriate timeframe for providing the notice.
    Comment: Commenters were generally supportive of the additional 
required content proposed for the renewal and re-enrollment notices. 
For example, commenters approved of the inclusion of information about 
changes to the advance payment of the premium tax credit and the 
reminders of the requirement to report changes, the reconciliation 
process, and the availability of cost-sharing reductions. Two 
commenters were concerned that the issuer notice content would not 
encourage enrollees to take any action. A few commenters urged issuers 
to ensure notices are provided in plain language and include 
appropriate accessibility features. Finally, one commenter recommended 
including language reminding enrollees to consider how changes in their 
enrollment might affect their access to financial assistance for health 
coverage and that they have the option to shop for other coverage.
    Response: We appreciate the support received for the proposed 
additional required content for the renewal and re-enrollment notices. 
We note that, pursuant to Sec.  156.250, issuer notices must comply 
with the standards for notices found at Sec.  155.230(b) (which also 
cross-references Sec.  155.205(c)), which includes accessibility and 
readability requirements.
    We also note that issuers are required to provide enrollees a 
Summary of Benefits and Coverage (SBC), a document that summarizes 
benefits and cost-sharing under a plan. Issuers must provide the SBC at 
various specific points in time, including annually upon renewal. At 
renewal, the SBC must reflect any modified policy or plan terms that 
will be effective on the first day of the new policy or benefit year. 
If a written application is required for renewal or reissuance, the SBC 
must be provided no later than the date written application materials 
are distributed. If renewal or reissuance is automatic, the SBC 
generally must be provided no later than 30 days prior to the first day 
of the new policy or benefit year. 45 CFR 147.200(a)(1)(ii)(E)(2) and 
(a)(1)(iv)(C)(2). This requirement also applies in the situation in 
which an issuer nonrenews or discontinues coverage under an existing 
health insurance product and, consistent with applicable Federal and 
State law, automatically enrolls an individual or plan sponsor (and 
participants and beneficiaries covered under such coverage) in a plan 
under a different product offered by such issuer in which the 
individuals are eligible to enroll. As such, the requirements to 
provide an SBC in connection with an automatic renewal or reissuance of 
coverage apply and the SBC generally is required to be provided no 
later than 30 days prior to the first day of the new policy or benefit 
year. An issuer is not prohibited from providing the SBC earlier than 
30 days prior to the new policy or benefit year, and when possible 
issuers are encouraged to provide SBCs by the first day of the open 
enrollment period to allow individuals enough time to

[[Page 53002]]

consider their coverage options available with respect to the upcoming 
policy or benefit year. If an issuer does provide the SBC earlier than 
30 days prior to the new plan or policy year, and there are no changes 
to the information reflected in the SBC prior to the first day of the 
new plan or policy year, the issuer will have satisfied the requirement 
to provide the renewal SBC.
    Comment: Some commenters were concerned that the implementation of 
Sec.  156.1255(a), which requires the inclusion of premium and advance 
payments of the premium tax credit information, would not provide 
useful information to the enrollee. Specifically, commenters noted that 
the advance payments of the premium tax credit information could 
reflect the enrollee's 2014 advance payment of the premium tax credit 
while the premium information could reflect 2015 benefit year costs. 
The commenters also suggested that if updated information regarding the 
household size and income was not available, the Exchange should either 
perform outreach encouraging the enrollee to obtain an updated 
eligibility determination or the Exchange should provide advance 
payment of the premium tax credit information reflecting the second 
lowest-cost silver plan for that Exchange and enrollee-type.
    Response: We agree that it is important to provide enrollees with 
information that will help them make informed decisions about their 
coverage for the upcoming benefit year. As part of that process, and as 
discussed in the guidance issued alongside the July 1, 2014 Annual 
Eligibility Redeterminations proposed rule, the FFE will encourage 
enrollees to return to the Exchange to update their application 
information and obtain an eligibility determination that will account 
for updated FPL thresholds, household size, and income, as all 
Exchanges must require enrollees to report changes with respect to 
eligibility standards.
    In the proposed rule, Sec.  156.1255(a) would have required QHP 
issuers to provide the premium and premium tax credit information for 
the enrollee's 2015 plan. In the final rule, we retain this requirement 
but clarify that issuers must provide advance payment of the premium 
tax credit information by adding the phrase ``advance payment of the'' 
before ``premium tax credit information[.]''
    Comment: We received comments regarding providing specific notice 
messages for re-enrollment options for American Indians and Alaskan 
Natives (AI/ANs). For example, cost-sharing reductions for these 
enrollees is implemented differently from how it is implemented for 
other enrollees, and the information described in Sec.  156.1255(d) may 
not be applicable for these enrollees, who may need a more targeted 
explanation.
    Response: We understand the concern that AI/ANs receive the 
appropriate messaging regarding requirements specific to their 
coverage. We have revised Sec.  156.1255(d) by adding a clarification 
that in accordance with Sec.  155.305(g)(1)(ii), cost-sharing 
reductions are only available to an individual who is not an Indian if 
he or she is enrolled in a silver-level QHP. This reflects that AI/ANs 
can continue to enroll or renew in a zero or limited cost-sharing plan 
at any metal level and still qualify for cost-sharing reductions. The 
FFE will continue to provide education and outreach to AI/ANs regarding 
the cost-sharing reductions that may be available to them at any metal 
level. We also are making a technical edit to remove the word ``with'' 
from Sec.  156.1255(d) and replace it with ``being provided[.]''
    Final Rule Action: We are finalizing the provisions proposed in 
Sec.  156.1255 with minor modifications. We are replacing the phrase 
``discontinuing a product'' with ``nonrenewing coverage'' to clarify 
that the additional notice content required by Sec.  156.1255 will be 
included in notices required to be provided not only when issuers 
discontinue a product, but also when issuers nonrenew coverage based on 
enrollees' movement outside the service area, as set forth in Sec.  
147.106(b)(5) of this final rule and discussed in more detail in 
section II.B of this preamble. We are also adding a cross-reference to 
Sec.  147.106(b)(5), accordingly. We are adding the phrase ``advance 
payment of the'' before ``premium tax credit information'' in Sec.  
156.1255(a). We clarified the reference to Sec.  155.305(g)(1)(ii) by 
adding ``of this subchapter'' after the citation. Finally, we are 
removing the word ``with'' from Sec.  156.1255(d) and replacing it with 
``being provided[.]''

III. Collection of Information Requirements

Emergency Clearance: Public Information Collection Requirements 
Submitted to the Office of Management and Budget (OMB)

    In compliance with section 3506(c)(2)(A) of the Paperwork Reduction 
Act of 1995 (PRA), we have also submitted to the Office of Management 
and Budget (OMB) the final information collection request for emergency 
approval review for a 180-day period. While the collection is necessary 
to ensure compliance with an initiative of the Administration, we are 
requesting emergency review under 5 CFR 1320.13(a)(2)(i) because public 
harm is reasonably likely to result if the regular clearance procedures 
are followed.
    In the July 1, 2014 Annual Eligibility Redeterminations proposed 
rule (79 FR 37262), we solicited public comments on each of the 
sections identified as containing information collection requirements 
(ICRs), as required by section 3506(c)(2)(A) of the PRA. We received 
several comments on the notice requirements, which have been addressed 
earlier in the preamble. We generally used data from the Bureau of 
Labor Statistics to derive average labor costs (including fringe 
benefits) for estimating the burden associated with the ICRs.
    The approval of this data collection process is essential to 
ensuring that renewal and discontinuance notices associated with the 
2015 benefit year are provided to consumers in a timely manner prior to 
the open enrollment period for the 2015 benefit year. Consumers will 
need the information in these notices in order to make decisions 
regarding their coverage for the 2015 benefit year.

ICRs Regarding Renewal and Re-enrollment Notice Requirements (Sec.  
156.1255)

    As specified in Sec.  156.1255, a health insurance issuer that is 
renewing an enrollment group's coverage in the individual market in a 
QHP offered through the Exchange (including a renewal with 
modifications), in accordance with Sec.  147.106, or that is 
discontinuing a product and automatically enrolling an enrollee in a 
QHP under a different product offered by the same QHP issuer through 
the Exchange, in accordance with Sec.  155.335, must include certain 
information in the written notice required by Sec.  147.106(b)(5), 
(c)(1), or (f)(1), as applicable. Contemporaneously with the issuance 
of this final rule, we are issuing a bulletin specifying the form and 
manner of the notices by providing standard notices that issuers 
generally will use when discontinuing or renewing coverage in the 
individual market.
    Since there are existing requirements for issuers to send renewal 
and discontinuance notices, we only estimate the burden for QHP issuers 
to revise current notices to comply with the provisions of this final 
rule. We

[[Page 53003]]

estimate that there are 575 QHP issuers and assume that they would all 
revise their existing notices to comply with the requirements in this 
final rule.
    For renewal notices, we estimate that, for each issuer, it will 
require three hours of clerical labor (at a cost of $33.67 per hour) to 
prepare the notice and one hour for a senior manager (at a cost of 
$75.34 per hour) to review it. We also estimate that it will take a 
computer programmer 20 hours (at a cost of $52.53 per hour) to write 
and test a program to automate the notices. The total burden for each 
issuer to prepare the notice will be 24 hours with an equivalent cost 
of approximately $1,277. For all 575 QHP issuers, the total burden will 
be 13,800 hours with an equivalent cost of approximately $705,479.
    For re-enrollment (or nonrenewal) notices, we estimate that, for 
each issuer, it will require two hours of clerical labor (at a cost of 
$33.67 per hour) to prepare the notice and one hour for a senior 
manager (at a cost of $75.34 per hour) to review the notice. We also 
estimate that it will take a computer programmer six hours (at a cost 
of $52.53 per hour) to write and test a program to automate the 
notices. The total annual burden for each issuer to prepare the notice 
will be nine hours with an equivalent cost of approximately $492. For 
all 575 QHP issuers, the total annual burden will be 5,175 hours with 
an equivalent cost of approximately $263,265. These burden estimates 
are lower than those in the proposed rule, because we assume that 
simplifications made to the form of the nonrenewal notices to reduce 
variable text will reduce clerical and computer programming hours by 
approximately one third.
    The accompanying bulletin ``Form and Manner of Notices When 
Discontinuing or Renewing a Product in the Group or Individual Market'' 
provides that states that are enforcing the Affordable Care Act may 
develop their own standard notices, provided the State-developed 
notices are at least as protective as the Federal standard notices. 
However, we anticipate that fewer than 10 states would opt for this 
alternative. Under 5 CFR 1320.3(c)(4), this requirement is not subject 
to the PRA as it would affect fewer than 10 entities in a 12-month 
period.
    We have submitted an information collection request to OMB for 
review and approval of the ICRs contained in this final rule. The 
requirements are not effective until approved by OMB and assigned a 
valid OMB control number.

IV. Regulatory Impact Statement

A. Summary

    We are publishing this final rule to implement the protections 
intended by the Congress in the most economically efficient manner 
possible. We have examined the effects of this rule as required by 
Executive Order 13563 (76 FR 3821, January 21, 2011), Executive Order 
12866 (58 FR 51735, September 1993, Regulatory Planning and Review), 
the Regulatory Flexibility Act (RFA) (September 19, 1980, Pub. L. 96-
354), the Unfunded Mandates Reform Act of 1995 (Pub. L. 104-4), 
Executive Order 13132 on Federalism, and the Congressional Review Act 
(5 U.S.C. 804(2)).

B. Executive Orders 12866 and 13563

    Executive Order 12866 (58 FR 51735) directs agencies to assess all 
costs and benefits of available regulatory alternatives and, if 
regulation is necessary, to select regulatory approaches that maximize 
net benefits (including potential economic, environmental, public 
health and safety effects; distributive impacts; and equity). Executive 
Order 13563 (76 FR 3821, January 21, 2011) is supplemental to and 
reaffirms the principles, structures, and definitions governing 
regulatory review as established in Executive Order 12866.
    Section 3(f) of Executive Order 12866 defines a ``significant 
regulatory action'' as an action that is likely to result in a rule--
(1) having an annual effect on the economy of $100 million or more in 
any one year, or adversely and materially affecting a sector of the 
economy, productivity, competition, jobs, the environment, public 
health or safety, or State, local or tribal governments or communities 
(also referred to as ``economically significant''); (2) creating a 
serious inconsistency or otherwise interfering with an action taken or 
planned by another agency; (3) materially altering the budgetary 
impacts of entitlement grants, user fees, or loan programs or the 
rights and obligations of recipients thereof; or (4) raising novel 
legal or policy issues arising out of legal mandates, the President's 
priorities, or the principles set forth in the Executive Order.
    A regulatory impact analysis (RIA) must be prepared for rules with 
economically significant effects (for example, $100 million or more in 
any 1 year), and a ``significant'' regulatory action is subject to 
review by the OMB. We have concluded that this final rule is not likely 
to have economic impacts of $100 million or more in any one year, and 
therefore does not meet the definition of ``economically significant 
rule'' under Executive Order 12866.
1. Need for Regulatory Action
    This final rule specifies additional options for annual eligibility 
redeterminations, and renewal and re-enrollment notice requirements for 
QHPs in the Exchange beginning with annual redeterminations for 
coverage for benefit year 2015.
2. Summary of Impacts
    We do not expect that there will be additional costs related to the 
additional options provided in this final rule for annual eligibility 
redeterminations, because we believe Exchanges will implement an 
alternative method only if doing so is less costly than the current 
method.
    QHP issuers will incur costs to prepare and send renewal notices to 
comply with the final provisions, as detailed in section III of this 
final rule. States that choose to develop their own notices will incur 
costs to do so. Providing consumers with information such as benefit 
changes and premium amounts will enable them to make decisions 
regarding their coverage for the next benefit year.

C. Regulatory Flexibility Act

    The Regulatory Flexibility Act (RFA) requires agencies that issue a 
regulation to analyze options for regulatory relief of small businesses 
if a rule has a significant impact on a substantial number of small 
entities. The RFA generally defines a ``small entity'' as: (1) a 
proprietary firm meeting the size standards of the Small Business 
Administration (SBA); (2) a nonprofit organization that is not dominant 
in its field; or (3) a small government jurisdiction with a population 
of less than 50,000 (states and individuals are not included in the 
definition of ``small entity''). HHS uses as its measure of significant 
economic impact on a substantial number of small entities a change in 
revenues of more than 3 to 5 percent. We do not believe that this 
threshold will be reached by the provisions of this final rule.

D. Unfunded Mandates Reform Act

    Section 202 of the Unfunded Mandates Reform Act of 1995 (UMRA) 
requires that agencies assess anticipated costs and benefits before 
issuing any rule that includes a federal mandate that could result in 
expenditure in any one year by State, local or tribal governments, in 
the aggregate, or by the private sector, of $100 million in 1995 
dollars, updated annually for inflation.

[[Page 53004]]

In 2014, that threshold level is approximately $141 million.
    UMRA does not address the total cost of a rule. Rather, it focuses 
on certain categories of cost, mainly those ``Federal mandate'' costs 
resulting from: (1) Imposing enforceable duties on State, local, or 
tribal governments, or on the private sector; or (2) increasing the 
stringency of conditions in, or decreasing the funding of, State, 
local, or tribal governments under entitlement programs.
    This final rule will allow Exchanges to choose one of three methods 
for conducting annual eligibility redeterminations. We assume that 
Exchanges will choose an alternative method only if it is less costly 
than the current method. It will also require QHP issuers to include 
specific information in renewal and nonrenewal notices sent to 
enrollees and issuers will incur costs to comply with this requirement. 
States that choose to develop their own notices will incur costs to do 
so. Consistent with policy embodied in UMRA, this final rule has been 
designed to be the least burdensome alternative for State, local and 
tribal governments, and the private sector while achieving the 
objectives of the Affordable Care Act.

E. Federalism

    Executive Order 13132 establishes certain requirements that an 
agency must meet when it promulgates a rule that imposes substantial 
direct requirement costs on State and local governments, preempts State 
law, or otherwise has Federalism implications.
    States are the primary regulators of health insurance coverage, and 
State laws will continue to apply to health insurance coverage and the 
business of insurance. However, if any State law or requirement 
prevents the application of a Federal standard, then that particular 
State law or requirement will be preempted. State requirements that are 
more stringent than the Federal requirements will not be preempted by 
this final rule. Accordingly, states have significant latitude to 
impose requirements with respect to health insurance coverage that are 
more restrictive than the Federal law.

F. Congressional Review Act

    This final rule is subject to the Congressional Review Act 
provisions of the Small Business Regulatory Enforcement Fairness Act of 
1996 (5 U.S.C. 801, et seq.), which specifies that before a rule can 
take effect, the federal agency promulgating the rule shall submit to 
each House of the Congress and to the Comptroller General a report 
containing a copy of the rule along with other specified information. 
This final rule will be transmitted to Congress and the Comptroller 
General in accordance with such provisions.

List of Subjects

45 CFR Part 146

    Health care, Health insurance, Reporting and recordkeeping 
requirements.

45 CFR Part 147

    Health care, Health insurance, Reporting and recordkeeping 
requirements, State regulation of health insurance.

45 CFR Part 148

    Administrative practice and procedure, Health care, Health 
insurance, Penalties, Reporting and recordkeeping requirements.

45 CFR Part 155

    Administration and calculation of advance payments of the premium 
tax credit, Administrative practice and procedure, Advance payments of 
premium tax credit, Cost-sharing reductions, Health care access, Health 
insurance, Reporting and recordkeeping requirements, State and local 
governments.

45 CFR Part 156

    Administrative practice and procedure, Health care, Health 
insurance, Reporting and recordkeeping requirements.
    For the reasons set forth in the preamble, the Department of Health 
and Human Services amends 45 CFR parts 146, 147, 148, 155, and 156 as 
set forth below:

PART 146--REQUIREMENTS FOR THE GROUP HEALTH INSURANCE MARKET

0
1. The authority citation for part 146 continues to read as follows:

    Authority:  Secs. 2702 through 2705, 2711 through 2723, 2791, 
and 2792 of the PHS Act (42 U.S.C. 300gg-1 through 300gg-5, 300gg-11 
through 300gg-23, 300gg-91, and 300gg-92).
0
2. Section 146.152 is amended by revising paragraph (b)(5) to read as 
follows:


Sec.  146.152  Guaranteed renewability of coverage for employers in the 
group market.

* * * * *
    (b) * * *
    (5) Enrollees' movement outside service area. For network plans, 
there is no longer any enrollee under the group health plan who lives, 
resides, or works in the service area of the issuer (or in the area for 
which the issuer is authorized to do business); and in the case of the 
small group market, the issuer applies the same criteria it would apply 
in denying enrollment in the plan under Sec.  146.150(c); provided the 
issuer provides notice in accordance with the requirements of paragraph 
(c)(1) of this section.
* * * * *

PART 147--HEALTH INSURANCE REFORM REQUIREMENTS FOR THE GROUP AND 
INDIVIDUAL HEALTH INSURANCE MARKETS

0
3. The authority citation for part 147 continues to read as follows:

    Authority: Secs. 2701 through 2763, 2791, and 2792 of the Public 
Health Service Act (42 U.S.C. 300gg through 300gg-63, 300gg-91, and 
300gg-92), as amended.


0
4. Section 147.106 is amended by revising paragraph (b)(5) to read as 
follows:


Sec.  147.106  Guaranteed renewability of coverage.

* * * * *
    (b) * * *
    (5) Enrollees' movement outside service area. For network plans, 
there is no longer any enrollee under the plan who lives, resides, or 
works in the service area of the issuer (or in the area for which the 
issuer is authorized to do business); and in the case of the small 
group market, the issuer applies the same criteria it would apply in 
denying enrollment in the plan under Sec.  147.104(c)(1)(i); provided 
the issuer provides notice in accordance with the requirements of 
paragraph (c)(1) of this section.
* * * * *

PART 148--REQUIREMENTS FOR THE INDIVIDUAL HEALTH INSURANCE MARKET

0
5. The authority citation for part 148 continues to reads as follows:

    Authority: Secs. 2701 through 2763, 2791, and 2792 of the Public 
Health Service Act (42 U.S.C. 300gg through 300gg-63, 300gg-91, and 
300gg-92), as amended.


0
6. Section 148.122 is amended by revising paragraph (c)(4) to read as 
follows:


Sec.  148.122  Guaranteed renewability of individual health insurance 
coverage.

* * * * *
    (c) * * *
    (4) Movement outside the service area. For network plans, the 
individual no longer resides, lives, or works in the service area of 
the issuer, or area for which the issuer is authorized to do

[[Page 53005]]

business, but only if coverage is terminated uniformly without regard 
to any health status-related factor of covered individuals; provided 
the issuer provides notice in accordance with the requirements of 
paragraph (d)(1) of this section.
* * * * *

PART 155--EXCHANGE ESTABLISHMENT STANDARDS AND OTHER RELATED 
STANDARDS UNDER THE AFFORDABLE CARE ACT

0
7. The authority citation for part 155 continues to read as follows:

    Authority:  Title I of the Affordable Care Act, sections 1301, 
1302, 1303, 1304, 1311, 1312, 1313, 1321, 1322, 1331, 1332, 1334, 
1402, 1411, 1412, 1413, Pub. L. 111-148, 124 Stat. 119 (42 U.S.C. 
18021-18024, 18031-18033, 18041-18042, 18051, 18054, 18071, and 
18081-18083).


0
8. Section 155.330 is amended by revising paragraph (b)(4) to read as 
follows:


Sec.  155.330  Eligibility redetermination during a benefit year.

* * * * *
    (b) * * *
    (4) The Exchange must allow an enrollee, or an application filer on 
behalf of the enrollee, to report changes via the channels available 
for the submission of an application, as described in Sec.  
155.405(c)(2), except that the Exchange is permitted but not required 
to allow an enrollee, or an application filer, on behalf of the 
enrollee, to report changes via mail.
* * * * *

0
9. Section 155.335 is amended by revising paragraphs (a), (e), and (j) 
to read as follows:


Sec.  155.335  Annual eligibility redetermination.

    (a) General requirement. (1) Except as specified in paragraphs (l) 
and (m) of this section, the Exchange must redetermine the eligibility 
of a qualified individual on an annual basis.
    (2) The Exchange must conduct annual redeterminations required 
under paragraph (a)(1) of this section using one of the following:
    (i) The procedures described in paragraphs (b) through (m) of this 
section;
    (ii) Alternative procedures specified by the Secretary for the 
applicable benefit year; or
    (iii) Alternative procedures approved by the Secretary based on a 
showing by the Exchange that the alternative procedures would 
facilitate continued enrollment in coverage for which the enrollee 
remains eligible, provide clear information about the process to the 
qualified individual or enrollee (including regarding any action by the 
qualified individual or enrollee necessary to obtain the most accurate 
redetermination of eligibility), and provide adequate program integrity 
protections.
* * * * *
    (e) Changes reported by qualified individuals. Except as specified 
in paragraph (e)(1) of this section, the Exchange must require a 
qualified individual to report any change with respect to the 
eligibility standards specified in Sec.  155.305 within 30 days of such 
change.
    (1) The Exchange must not require a qualified individual who did 
not request an eligibility determination for insurance affordability 
programs to report changes that affect eligibility for insurance 
affordability programs.
    (2) The Exchange must allow a qualified individual, or an 
application filer, on behalf of the qualified individual, to report 
changes via the channels available for the submission of an 
application, as described in Sec.  155.405(c)(2), except that the 
Exchange is permitted but not required to allow a qualified individual, 
or an application filer, on behalf of the qualified individual, to 
report changes via mail.
* * * * *
    (j) Re-enrollment. If an enrollee remains eligible for enrollment 
in a QHP through the Exchange upon annual redetermination--
    (1) And the product under which the QHP in which he or she is 
enrolled remains available through the Exchange for renewal, consistent 
with Sec.  147.106 of this subchapter, such enrollee will have his or 
her enrollment through the Exchange in a QHP under that product 
renewed, unless he or she terminates coverage, including termination of 
coverage in connection with voluntarily selecting a different QHP, in 
accordance with Sec.  155.430. The Exchange will ensure that re-
enrollment in coverage under this paragraph (j)(1) occurs under the 
same product in which the enrollee was enrolled, as follows:
    (i) The enrollee's coverage will be renewed in the same plan as the 
enrollee's current QHP, unless the current QHP is not available.
    (ii) If the enrollee's current QHP is not available, the enrollee's 
coverage will be renewed in a plan at the same metal level as the 
enrollee's current QHP.
    (iii) If the enrollee's current QHP is not available and the 
enrollee's product no longer includes a plan at the same metal level as 
the enrollee's current QHP, the enrollee's coverage will be renewed in 
a plan that is one metal level higher or lower than the enrollee's 
current QHP; or
    (iv) If the enrollee's current QHP is not available and the 
enrollee's product no longer includes a plan that is at the same metal 
level as, or one metal level higher or lower than the enrollee's 
current QHP, the enrollee's coverage will be renewed in any other plan 
offered under the product in which the enrollee's current QHP is 
offered in which the enrollee is eligible to enroll.
    (2) And the product under which the QHP in which he or she is 
enrolled is not available through the Exchange for renewal, consistent 
with Sec.  147.106 of this subchapter, such enrollee may be enrolled in 
a plan under a different product offered by the same QHP issuer, to the 
extent permitted by applicable State law, unless he or she terminates 
coverage, including termination of coverage in connection with 
voluntarily selecting a different QHP, in accordance with Sec.  
155.430. The Exchange will ensure that re-enrollment in coverage under 
this paragraph (j)(2) occurs as follows:
    (i) The enrollee will be re-enrolled in a plan through the Exchange 
at the same metal level as the enrollee's current QHP in the product 
offered by the same issuer that is the most similar to the enrollee's 
current product;
    (ii) If the issuer does not offer another plan through the Exchange 
at the same metal level as the enrollee's current QHP, the enrollee 
will be re-enrolled in a plan through the Exchange that is one metal 
level higher or lower than the enrollee's current QHP in the product 
offered by the same issuer through the Exchange that is the most 
similar to the enrollee's current product; or
    (iii) If the issuer does not offer another plan through the 
Exchange at the same metal level as, or one metal level higher or lower 
than the enrollee's current QHP, the enrollee will be re-enrolled in 
any other plan offered through the Exchange by the same issuer in which 
the enrollee is eligible to enroll.
* * * * *

PART 156--HEALTH INSURANCE ISSUER STANDARDS UNDER THE AFFORDABLE 
CARE ACT, INCLUDING STANDARDS RELATED TO EXCHANGES

0
10. The authority citation for part 156 continues to read as follows:

    Authority: Title I of the Affordable Care Act, sections 1301-
1304, 1311-1313, 1321-1322, 1324, 1334, 1342-1343, 1401-1402, Pub. 
L. 111-148, 124 Stat. 119 (42 U.S.C. 18021-18024, 18031-18032, 
18041-18042,

[[Page 53006]]

18044, 18054, 18061, 18063, 18071, 18082, 26 U.S.C. 36B, and 31 
U.S.C. 9701).


0
11. Add Sec.  156.1255 to read as follows:


Sec.  156.1255  Renewal and re-enrollment notices.

    A health insurance issuer that is renewing an enrollment group's 
coverage in an individual market QHP offered through the Exchange 
(including a renewal with modifications) in accordance with Sec.  
147.106 of this subchapter, or that is nonrenewing coverage offered 
through the Exchange and automatically enrolling an enrollee in a QHP 
under a different product offered by the same QHP issuer through the 
Exchange in accordance with Sec.  155.335 of this subchapter, must 
include the following information in the applicable notice described in 
Sec.  147.106(b)(5), (c)(1), or (f)(1) of this subchapter:
    (a) Premium and advance payment of the premium tax credit 
information sufficient to notify the enrollment group of its expected 
monthly premium payment under the renewed coverage, in a form and 
manner specified by the Exchange, provided that if the Exchange does 
not provide this information to enrollees and does not require issuers 
to provide this information to enrollees, consistent with this section, 
such information must be provided in a form and manner specified by 
HHS;
    (b) An explanation of the requirement to report changes to the 
Exchange, as specified in Sec.  155.335(e) of this subchapter, the 
timeframe and channels through which changes can be reported, and the 
implications of not reporting changes;
    (c) For an enrollment group that includes an enrollee on whose 
behalf advance payments of the premium tax credit are being provided, 
an explanation of the reconciliation process for advance payments of 
the premium tax credit established in accordance with 26 CFR 1.36B-4; 
and
    (d) For an enrollment group that includes an enrollee being 
provided cost-sharing reductions, but for whom no QHP under the product 
remains available for renewal at the silver level, an explanation that 
in accordance with Sec.  155.305(g)(1)(ii) of this subchapter, cost-
sharing reductions are only available to an individual who is not an 
Indian if he or she is enrolled in a silver-level QHP.

    Dated: August 15, 2014.
Marilyn Tavenner,
Administrator, Centers for Medicare & Medicaid Services.

    Approved: August 27, 2014.
Sylvia M. Burwell,
Secretary.
[FR Doc. 2014-21178 Filed 9-2-14; 4:15 pm]
BILLING CODE 4120-01-P