Form CMS-10416 Blueprint for Approval of Affordable Healthcare Marketpl

SEG/CCIIO – DRAFT 7/15/2014

Department of Health & Human Services

Centers for Medicare & Medicaid Services

Center for Consumer Information and Insurance Oversight

200 Independence Avenue SW

Washington, DC 20201

BLUEPRINT FOR APPROVAL OF AFFORDABLE HEALTH INSURANCE MARKETPLACES

Blueprint for Approval of
Affordable health Insurance Marketplaces

Introduction

The Affordable Care Act (ACA) establishes Affordable Health Insurance Exchanges, or “Exchanges,” also known as Health Insurance Marketplaces, or “Marketplaces” to provide individuals and small business employees access to affordable health insurance coverage beginning January 1, 2014.¹  A Marketplace is an entity that both facilitates the purchase of qualified health plans (QHP) by qualified individuals and provides for the establishment of a Small Business Health Options Program (SHOP), consistent with Affordable Care Act 1311(b) and 45 CFR 155.20. Marketplaces are competitive and allow individuals and small employers to directly compare and purchase private health insurance options based on price, quality, and other factors. Marketplaces are integral to the Affordable Care Act’s goal of prohibiting discrimination against people with pre-existing conditions and insuring all Americans.

The Affordable Care Act and associated regulations provide states with significant flexibility in the design and operation of their Marketplaces to ensure states are implementing sustainable Marketplaces that best meet the needs of its population. States can choose to establish and operate a State-based Marketplace, or the Secretary of the U.S. Department of Health and Human Services (HHS) will establish and operate a Federally-facilitated Marketplace in any state that does not elect to operate a State-based Marketplace. In a Federally-facilitated Marketplace, the state may establish and operate a State-based SHOP Marketplace, where a state operates the SHOP Marketplace and defers responsibility for the individual Marketplace to the Federally-facilitated Marketplace, or the state may pursue a State Partnership Marketplace, where the state may administer and operate Marketplace activities associated with consumer assistance activities. States that elect to participate in a State Partnership Marketplace will administer these functions in both the individual and the small group markets.

Regulations implementing the Affordable Care Act require HHS to Approve or Conditionally Approve all Marketplaces. States that seek HHS approval to operate a State-based Marketplace, a State-based SHOP Marketplace, or a State Partnership Marketplace for coverage years beginning after January 1, 2014, must complete and submit a Marketplace Blueprint Application that documents how its Marketplace meets, or will meet, all legal and operational requirements associated with the model it chooses to pursue. As part of its Marketplace Blueprint, a state will also demonstrate operational readiness to execute Marketplace activities.²

Flexible Marketplace Options for States

In an effort to provide states with significant flexibility in the development of Marketplaces to meet the needs of their populations, HHS has developed a program that offers multiple Marketplace models as well as a number of design alternatives within each model. A state also has the flexibility to transition between models annually. See Figure 1 for an illustrative representation of the Marketplace models, and flexibility within those models.

Figure 1. Blueprint For Approval Of Affordable Health Insurance Marketplaces: State Model Options

State-based Marketplace	State-based SHOP Marketplace	State Partnership Marketplace	Federally-facilitated Marketplace
State operates all Marketplace activities; however, state may use Federal government services for the following activities: Risk adjustment program3	State operates all activities in the SHOP Marketplace and allows HHS to operate all individual Marketplace activities State may elect to perform or can use Federal government services for the following activities: Medicaid and Children’s Health Insurance Program (CHIP) eligibility: assessment or determination* Risk adjustment program	State operates consumer assistance activities State may elect to perform or can use Federal government services for the following activities: Medicaid and CHIP eligibility: assessment or determination*	HHS operates; however, state may elect to perform or can use Federal government services for the following activities: Medicaid and CHIP eligibility: assessment or determination* Some states are assisting with certain plan management functions on an ad hoc basis
Complete State-based Marketplace Blueprint	Complete SHOP Marketplace Blueprint	Complete State Partnership Marketplace Blueprint	Completion of Blueprint Not Required

* Coordinate with Center for Medicaid and CHIP Services (CMCS) on Decisions and Protocols

HHS will continue to provide Federally-facilitated Marketplaces with as much flexibility as possible; however, HHS will need to ratify inherently governmental decisions made by the State Partnership Marketplaces.

Technical Assistance and Establishment Grant funding under Section 1311(a) of the Affordable Care Act continues to be available to states through 2014 for State-based Marketplaces, State Partnership Marketplaces, State-based SHOP Marketplaces, and states building linkages to the Federally-facilitated Marketplace.⁴ Additionally, states that are interested in requirements as a regional or subsidiary Marketplace under 45 CFR 155.140, or an entity eligible to carry out Exchange functions under 45 CFR 155.110, should contact their State Officer within CCIIO’s State Exchange Group (SEG) or email CCIIO at State.Marketplace.Group@cms.hhs.gov.

Overview of Blueprint and Marketplace Approval Requirements

HHS may approve states that seek to operate a State-based Marketplace, a State-based SHOP Marketplace, or participate in a State Partnership Marketplace based upon review of a state’s Blueprint submission. A Blueprint is made up of two state submission components, which are described in greater detail in the following sections:

• Declaration Letter (Section 1).

• Marketplace Application (Section 2).

States seeking to operate a State-based Marketplace or State-based SHOP Marketplace or to participate in a State Partnership Marketplace must submit a complete Marketplace Blueprint no later than the first business day in June for the following coverage year (e.g., June 1, 2015 for plan year 2016 operations). States are encouraged to submit their Marketplace Declaration Letters early, but a Declaration Letter must be sent to CMS CCIIO 30 business days prior to the required Application submission date, which is the first business day in June for operations that begins in the following plan year.

Marketplace Approval Determinations

HHS will approve a State-based Marketplace, a State-based SHOP Marketplace, or a State Partnership Marketplace once the state has demonstrated the ability to satisfactorily perform all required Marketplace activities specific to the Marketplace model.

HHS recognizes that states depend on HHS, other Federal agencies, contractors, and other State-based Marketplaces for guidance associated with Marketplace establishment. In consideration of this dependency, particularly in the first year of program operations, HHS’ approval of State-based Marketplaces, State-based SHOP Marketplaces, and State Partnership Marketplaces will take into account any additional guidance released related to programmatic transitions (e.g. data conversion requirements). Similarly, HHS expects that states will be in various stages of the Marketplace-development lifecycle when Blueprints are submitted, with many operational enhancement activities likely to occur in subsequent plan years.. HHS will utilize Conditional Approval for State-based Marketplaces, State-based SHOP Marketplaces, and Partnership States whose Marketplace establishment is not fully complete at the time of Blueprint submission.

Conditional Approval and Monitoring of State Progress

Conditional Approval will be granted for a State-based Marketplace, a State-based SHOP Marketplace, or a State Partnership Marketplace that does not meet all Marketplace Approval requirements at the time of the state’s Marketplace Blueprint application submission, but is making significant progress toward these requirements and is anticipated to be operationally ready for the open enrollment period.

A state’s Conditional Approval is based in part upon the Centers for Medicare & Medicaid Services’ (CMS) assessment of state attestations and anticipated dates of completion for activities required as part of the Blueprint Application. Once a state has been Conditionally Approved, CMS will work closely with each Marketplace to monitor state progress, ensure that proposed dates of completion for Blueprint activities and other project milestones are met, and confirm that supporting documentation is submitted and reviewed in accordance with the expected completion dates stated in the state’s Blueprint Application. In addition, CMS and states will continue to utilize Establishment Reviews⁵ and other meeting forums that may be required to monitor and provide guidance to states on their technical Marketplace build and other programmatic requirements as defined in the Marketplace Blueprint.

Conditional Approval will continue as long as a state continues to meet expected progress milestones and until a state successfully demonstrates its ability to perform all required Marketplace activities. Provided that the state is meeting the milestones outlined in its Conditional Approval determination, a state Marketplace will maintain Conditional Approval. In this capacity, a State-based and State-based SHOP Marketplace must be able to:

• Provide consumer support for coverage decisions.

• Facilitate eligibility determinations for individuals (not required for State-based SHOP), employers and employees.

• Provide for enrollment in QHPs.

• Certify health plans as QHPs.

• Operate a SHOP.

• Comply with Federal reporting requirements.

The technical assistance and grant funding available to states prior to Approval or Conditional Approval will continue to be available under the terms and requirements of those programs.

Transitioning from Conditional Approval to Approval

Conditionally-approved states must satisfy any and all conditions identified by CMS and communicated to the state to gain full Marketplace approval. States must demonstrate the ability to perform all required Marketplace activities according to a state’s attestations in the Marketplace Blueprint Application, and continue to comply with Federal guidance and regulations.

HHS will approve a state to operate its Marketplace once it has successfully completed the operational assessment component of the Blueprint. During this assessment, HHS will determine, either on-site or virtually, whether the Blueprint testing and any additional operational readiness evidence sufficiently demonstrates that the state is able to perform all required Marketplace activities. The objective of this assessment is to assure that a Marketplace’s policies, procedures, operations, technology, and other administrative capacities have been implemented and scaled to meet the needs of the state’s Marketplace population.

Questions Regarding the Marketplace Blueprint and Technical Assistance

States should contact their CMS CCIIO State Officer for specific questions regarding Marketplace Blueprint application submissions. Additionally, all states are encouraged to contact CCIIO’s State Marketplace Group for information about technical assistance consultations, available resources, and funding opportunities available to states for Marketplace-build activities. General questions may be directed to State.Marketplace.Group@cms.hhs.gov.

PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid Office of Management and Budget (OMB) control number. The valid OMB control number for this information collection is 0938-1172. The time required to complete this information collection is estimated to average (179.1 hours) or (10,746 minutes) per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

Section I: Declaration Letter

A state seeking to operate a State-based Marketplace, a State-based SHOP Marketplace, or participate in a State Partnership Marketplace will declare the type of Marketplace model it intends to pursue through a Marketplace Declaration Letter as part of its Marketplace Blueprint Application. To facilitate coordination, states seeking to participate in a Federally-facilitated Marketplace without Partnership are also invited, at their option, to complete a Declaration Letter.

A state’s Declaration Letter must be signed by the state’s governor⁶. As described below, the Declaration Letter’s contents should include basic information associated with its designated Marketplace model. The Declaration Letter should include a designation of the individual(s) (i.e., Designee(s)) who will serve as the primary point of contact for HHS regarding the Marketplace. The individual(s) should be authorized to bind the state regarding the state’s Marketplace, as well as to complete and sign the Marketplace Application. In the case of a State-based Marketplace, a State-based SHOP Marketplace or a State Partnership Marketplace, this should be the individual(s) authorized to electronically attest to the facts in the Marketplace Blueprint Application.

States are encouraged to submit their Marketplace Declaration Letters early, but a Declaration Letter must be sent to CMS CCIIO 30 business days prior to the required Blueprint Application submission date of the first business day in June. Declaration Letters may be sent to CMS CCIIO, 200 Independence Avenue SW, Suite 739H, Washington DC, 20201. In addition, please email a copy to the State.Marketplace.Group@cms.hhs.gov. To support HHS’ goal of public transparency, States must post their Marketplace Model Declaration Letter to the state (or other appropriate) website.

Contents of Marketplace Declaration Letters

A state’s Declaration Letter must include the following contents based on the Marketplace Model that the state chooses to pursue.

State-based Marketplace

• Confirmation of the state’s intention to apply to operate a State-based Marketplace

• Designation of the individual(s) (i.e., Designee(s)) authorized to act as primary point(s) of contact and authorized to bind the state with HHS regarding the state’s Marketplace, as well as to complete and sign the Marketplace Application.

• Acknowledgement that HHS and the state may agree to amend their Declaration letter to include additional information necessary to establish their Marketplace.

State-based SHOP Marketplace

• Confirmation of the state’s intention to apply to operate a State-based SHOP Marketplace

• Designation of the individual(s) (i.e., Designee(s)) authorized to act as primary point(s) of contact and authorized to bind the state with HHS regarding the state’s SHOP Marketplace, as well as to complete and sign the Marketplace Application.

• Acknowledgement that HHS and the state may agree to amend their Declaration letter to include additional information necessary to establish their Marketplace.

State Partnership Marketplace

• Confirmation of the state’s intention to participate in a State Partnership Marketplace and operate the following consumer assistance activities:

• Stakeholder engagement.

• Tribal engagement (if applicable).

• Outreach and education.

• Non-Navigator Assistance Personnel Program.

• Agents and brokers.

• Web brokers.

• Designation of the individual(s) (i.e., Designee) authorized to act as primary point of contact and authorized to bind the state with HHS regarding the state’s Partnership Marketplace, as well as to complete and sign the Marketplace Application. The State Medicaid Director will be assumed to be the primary contact on issues related to eligibility determination and coordination, unless otherwise indicated by the state governor or the authorized personnel in the Declaration Letter. In states with a separate CHIP, the state’s CHIP Director will be assumed to serve as the point of contact for CHIP-related eligibility issues, unless otherwise indicated.

• Acknowledgement that HHS and the state may agree to amend their Declaration letter to include additional information necessary to establish their Marketplace.

If a Declaration Letter is not received on or before the first business day in May, HHS will assume the state is maintaining their current operations status.

Section II: Application for Approval of Affordable
Health Insurance Marketplaces

Table of Contents for Blueprint for Approval of Affordable Health Insurance Marketplaces⁷

Blueprint for Approval of Affordable health Insurance Marketplaces i

Introduction i

PRA Disclosure Statement iv

Section I: Declaration Letter vi

Section II: Application for Approval of Affordable Health Insurance Marketplaces viii

Application Instructions 1

Introduction 1

Marketplace Application: Overview of Applicable Marketplace Activities 1

Operational Readiness and Additional Information Requests 8

Attestation 9

State Background Information for Application Submission 10

State-based Marketplace Blueprint Application 11

1.0 Legal Authority and Governance 11

2.0 Consumer and Stakeholder Engagement and Support 14

3.0 Eligibility and Enrollment 31

4.0 Plan Management 50

5.0 Risk Adjustment 57

6.0 SHOP 58

7.0 Organization and Human Resources 63

8.0 Finance and Accounting 64

9.0 Technology 65

10.0 Privacy and Security 72

11.0 Oversight and Monitoring 76

12.0 Contingency Planning 80

13.0 Re-Use 81

14.0 Coordination between the State-based Marketplace and the Federally-Facilitated Marketplace 82

State Partnership Marketplace Blueprint Application 83

1.0 Legal Authority and Governance – Not Applicable 83

2.0 Consumer and Stakeholder Engagement and Support 83

3.0 Eligibility and Enrollment – Not Applicable 92

4.0 Plan Management – Not Applicable 92

5.0 Risk Adjustment – Not Applicable 92

6.0 SHOP – Not Applicable 92

7.0 Organization and Human Resources – Not Applicable 92

8.0 Finance and Accounting – Not Applicable 92

9.0 Technology – If Applicable 92

10.0 Privacy and Security 95

11.0 Oversight and Monitoring 99

12.0 Contingency Planning 102

13.0 Re-Use 103

14.0 Coordination between the Partnership and the Federally-Facilitated Marketplace 104

State-based Small Business Health Options Program (SHOP) Marketplace Blueprint Application 105

1.0 Legal Authority and Governance 105

2.0 Consumer and Stakeholder Engagement and Support 109

3.0 Eligibility and Enrollment 123

4.0 Plan Management 132

5.0 Risk Adjustment 139

6.0 SHOP 140

7.0 Organization and Human Resources 145

8.0 Finance and Accounting 146

9.0 Technology 147

10.0 Privacy and Security 154

11.0 Oversight and Monitoring 158

12.0 Contingency Planning 162

13.0 Re-Use 163

14.0 Coordination between the SHOP and the Federally-facilitated Marketplace 164

Figure 1. Blueprint For Approval Of Affordable Health Insurance Marketplaces: State Model Options ii

Table 1. Roadmap for Completing Blueprint Application 1

The Marketplace Application must be completed online. The Marketplace Application will be available for online completion and submission on CMS’ Center for Consumer Information and Insurance Oversight’s (CCIIO) State Marketplace Resource and Virtual Information System (SERVIS) system https://servis.cms.gov.⁸ The online Marketplace Application has been designed so only the questions relevant to the Marketplace Model the State has selected will be presented to the applicant.

Application Instructions

Introduction

In addition to a Declaration Letter, a complete Marketplace Blueprint requires submission of a Marketplace Application. The Marketplace Application is used to document a state’s completion, or progress towards completion, of all Marketplace requirements either as a State-based Marketplace, a State-based SHOP Marketplace or State Partnership Marketplace.

Marketplace Application: Overview of Applicable Marketplace Activities

The Plan Year 2015 Blueprint contains three separate applications unique to each Marketplace model: 1) State-based Marketplace, 2) State-based SHOP Marketplace; and 3) State Partnership Marketplace. Each Marketplace application comprises a list of activities that a State-based Marketplace, a State-based SHOP Marketplace or a State Partnership Marketplace must perform to comply with the Affordable Care Act and associated regulations. In some instances, a state may use Federal services to perform a Marketplace activity. Table 1 outlines all of the Marketplace activities that each Marketplace model must perform prior to full approval, and should be used to assist states in completing their Marketplace Application. Required activities within a Marketplace model are designated with an “X.” Select activities are also described as “if applicable,” and “optional” meaning that the activity is optional for a particular Marketplace model. States may attest to activities being completed by the Marketplace or a Designee –through contract, agreement, or other arrangement. However, the Marketplace is ultimately responsible for successful performance of the activity. One activity also denotes the availability of leveraging “Federal government services.” HHS encourages states to reach to their State Officer for clarification on any activities that direct states to consult HHS guidance and or regulations that provide more detailed information about the applicability of certain Marketplace functionality requirements.

Table 1. Roadmap for Completing Blueprint Application

Section of Marketplace Blueprint	Required Activities
Marketplace Activity	State-based Marketplace	State Consumer Marketplace Partner	State-based SHOP-only Marketplace
1.0 Legal Authority and Governance
Marketplace Enabling Authority	X		X
Regulatory Authority to Certify Qualified Health Plans (QHPs)	X		X
Risk Adjustment9	X (if applicable)		X (if applicable)
Authority to Generate Revenue	X		X
Board and Governance Structure	X		X
2.0 Consumer and Stakeholder Engagement and Support
Stakeholder Consultation Plan	X	X	X
Tribal Consultation	X (if applicable)	X (if applicable)	X (if applicable)
Outreach and Education	X	X	X
Call Center	X		X
Website	X		X
Navigator Program	X		X
Non-Navigator Personnel Program	X (if applicable)	X	X (if applicable)
Certified Application Counselors	X
Agents and Brokers	X (if applicable)	X (if applicable)	X (if applicable)
Web Brokers	X (if applicable)	X (if applicable)	X (if applicable)
3.0 Eligibility and Enrollment
Single, Streamlined Application/SHOP Application	X		X
Coordination Strategy with SHOP and Insurance Affordability Programs/Federally-facilitated Marketplace	X		X
Infrastructure to Accept and Process Initial Applications and Redeterminations	X		X
Eligibility Verifications	X		X
Infrastructure to Send Notices Electronically	X		X
Infrastructure to Conduct Data Matching	X
Infrastructure to Conduct Eligibility Determinations and Annual Redeterminations	X		X
Enrollment Transactions and APTC/CSR Information Processing	X
Eligibility Appeals	X		X
Electronic Reporting of Eligibility Assessments and Determinations	X		X
4.0 Plan Management
QHP Certification Process	X		X
Collection of QHP Issuer and Plan Data	X		X
QHP Monitoring and Compliance	X		X
Technical Assistance to Issuers	X		X
Recertification, Decertification, and Appeals	X		X
Issuer Accreditation	X		X
Quality Reporting	X		X
5.0 Risk Adjustment
Risk Adjustment	X (can use Federal service)		X (can use Federal service)
6.0 SHOP
SHOP Compliance with 45 CFR 155 Subpart H	X		X
SHOP Premium Aggregation	X		X
Electronically Report Results of Employer Participation, Employer Contribution, and Employee Enrollment Information for the SHOP	X		X
7.0 Organization and Human Resources
Organizational Structure and Staffing Plan	X		X
8.0 Finance and Accounting
Cost, Budget, and Management Plan	X		X
9.0 Technology
Gate Reviews, Consults, and Artifacts	X		X
Essential Functionality	X	X (if applicable)	X
10.0 Privacy and Security
Privacy and Security Standards, Policies and Procedures	X	X (if applicable)	X
Safeguards	X
Connection to the Federal Data Services Hub (FDSH)	X		X (if applicable)
11.0 Oversight and Monitoring
Oversight and Monitoring Policies and Procedures	X	X	X
Mechanisms for Reporting	X		X
Financial Integrity	X	X (if applicable)	X
12.0 Contingency Planning
Contingency/Risk Mitigation Operations	X	X	X
13.0 Re-use
Re-use	X	X	X
14.0 Coordination with the Federally-facilitated Marketplace
Coordination Strategy between the Federally-facilitated Marketplace and the State Partnership Marketplace/SHOP Marketplace	X	X	X

Relationship between Marketplace Application and the Establishment Grant Review Process

HHS has developed an Establishment Review Process to monitor and assist states that have received grant(s) through the Cooperative Agreements for Establishment of Marketplaces under the Affordable Care Act 1311(a). While the Establishment Review Process is intended to support states as they work toward Marketplace Approval, the Establishment Review Process is independent of the Marketplace Approval process. However, to streamline data collection requirements, HHS has aligned requirements so that a state may utilize information submitted during the Establishment Review Process to support a state’s Marketplace Blueprint Application. A state may upload and submit a letter(s) from HHS confirming successful completion of documentation requirements instead of re-submitting documentation.

Marketplace Application: Completion Requirements

To complete the Marketplace Blueprint Application, the state is required to:

• Provide status and expected completion dates.

• Provide supporting documentation.

• Conduct required testing types.

• Report testing results.

• Attest to completing activity.

• Submit required testing documentation.

• Submit Application electronically.

Provide Status and Expected Completion Dates

Sub-activities and any required evidence that must be submitted for approval are listed under each activity. For each requirement within a sub-activity, applicants should designate if the requirement is Complete, In Progress, or Not Started. Once an applicant chooses the status for the requirement, the system prompts the applicant to enter the Completion Date for requirements marked as Complete, Expected Completion Date for activities In Progress, or Expected Start Date and Expected Completion Date for requirements that have not yet been started. For ongoing sub-activities, the applicant should enter a status of “In Progress” with an expected completion date of “Ongoing.”

Submit Supporting Documentation

CMS recognizes that states may not be able to provide final documentation at the time of their initial Blueprint submission. However, for CMS to maintain a clear understanding of state Marketplace development progress, CMS encourages early submission of draft documentation in compliance with Marketplace Blueprint requirements. As a step in completing the Marketplace application, states are requested to provide draft or final documentation wherever feasible. Files should be clearly labeled with the appropriate activity in the file name. If a document encompasses multiple activities, the applicant can cross-reference the document to avoid uploading the same file multiple times.

Uploaded documentation will be reviewed by subject matter experts at CCIIO, the Office of Information Services (OIS), CMCS, and other Federal partners as appropriate, and discussed in more detail during Establishment Reviews and consults. Alternatively, a state may request and receive HHS concurrence to utilize previously submitted documentation as satisfying the requirements of the Establishment Review.

Once an uploaded document is finalized (e.g., final regulation, completed plans etc.) and the sub-activity is complete, the applicant should indicate in their document title that it is “Final.”

Conduct Required Testing Types

CMS uses testing as an element for approving or conditionally approving State-based Marketplaces. States must conduct a number of types of testing prior to open enrollment. The purpose of formal testing is to ensure connectivity, correct data exchange formats and values, correct interpretation of responses from the Federal Data Services Hub (FDSH), and ensure correct information is transmitted and captured. CMS will provide guidance and documentation to assist states with testing the automated functionality of their Marketplaces and reporting results to CMS. In addition, CCIIO has developed Blueprint test scenarios that states must conduct in order to demonstrate their ability to perform certain Eligibility and Enrollment and SHOP functions. The Blueprint application delineates where testing submissions are required.

Submit Testing Results

Federally-required testing for State-based Marketplaces fall under two general categories:

• Blueprint Testing:

1. Blueprint Test Scenario Results: For those activities indicated in the activity table as requiring Blueprint testing, states perform the tests using CMS-provided and state-specific input data for the Blueprint test scenarios. States then record the results of their Blueprint testing in the CMS-provided Blueprint test results template and submit to CMS along with supporting documentation.

2. Independent Verification and Validation (IV&V) Attestation: IV&V attests that the Blueprint test scenarios are performed successfully by the State-based Marketplace.

• Federal Data Services Hub (FDSH) Formal Testing:

1. State Test Summary: States provide a summary of the testing of the interface between their information technology systems and the FDSH, including the dates and results of each CMS required FDSH testing type, any unresolved issues and plans and dates for completion.

2. Independent Verification and Validation (IV&V) Report: The state’s IV&V contractor submits a report validating that state-developed software performs according to Federal Data Services Hub connectivity requirements, design requirements and specifications.

Attestations

Attestation: The individual(s) designated in the Declaration Letter (the Designee(s)) must attest, on behalf of the state, to either completion or expected completion of a Marketplace activity. Specifically, the state can attest to the current ability of its Marketplace to meet specified requirements. Alternatively, if the state is unable to meet requirements by the Marketplace Application submission date, the state may attest to expected completion and its ability to meet the specified activity requirements by a future date.

Applicants will attest to either completion or expected completion at the activity level, as well as the accuracy of the information submitted for the entire Blueprint submission.

Activity attestation: Once all of the information required for sub-activities has been entered into the system, the system will prompt the applicant to attest to the information. If all sub-activities are notated as complete, the system will prompt the applicant to attest to the completion of the activity. If any sub-activities are still in progress or not started, the system will prompted the applicant to attest to their understanding that all activities will be complete prior to Marketplace implementation.

Application attestation: All applicants will be required to attest that all information submitted in the Blueprint accurately represents the status of their state’s insurance Marketplace being developed under Title I of the Affordable Care Act.

Submit Application Electronically

The Marketplace Application is be electronically available for States to complete on HHS’ CCIIO State Marketplace Resource and Virtual Information System (SERVIS) system (https://servis.cms.gov).

Operational Readiness and Additional Information Requests

In addition to reviewing the completed Marketplace Application, HHS will conduct on-site or virtual Marketplace Assessments as part of its verification of a Marketplace’s Operational Readiness. Operational Readiness entails HHS’ and its Federal agency partners’ assessment to determine the capacity of a Marketplace to conduct Marketplace business. The objective of the Operational Readiness assessment is to assure that a Marketplace’s policies, procedures, operations, technology, and other administrative capacities have been implemented and scaled to meet the needs of the State’s Marketplace’s population. HHS will use the information in a State’s Marketplace Application, including results from a State’s Testing Files, to determine the need for, and timing of, an on-site or virtual Operational Readiness Assessment. Finally, a state may be asked to provide supplemental information following submission of the Marketplace Application, as determined necessary by HHS and its Federal agency partners.

Attestation

ON THIS DATE, I ATTEST THAT THE STATEMENTS AND INFORMATION CONTAINED IN THIS MARKETPLACE BLUEPRINT AND DOCUMENTS SUBMITTED IN CONJUNCTION WITH THIS MARKETPLACE BLUEPRINT ACCURATELY REPRESENT THE STATUS OF MY STATE’S INSURANCE MARKETPLACE BEING DEVELOPED UNDER TITLE I OF THE PATIENT PROTECTION AND AFFORDABLE CARE ACT OF 2010 (Pub. L. 111-148), AS AMENDED BY THE HEALTH CARE AND EDUCATION RECONCILIATION ACT OF 2010 (Pub. L. 111-152), AND REFERRED TO COLLECTIVELY AS THE AFFORDABLE CARE ACT; AND REGULATIONS AT 45 CFR PARTS 153, 155, AND 156.

State:

_____________________________________________________________________________

(Name of State)

________________________________________________________________________________

(Signature of Governor Designee of the State, Date Signed)

State Background Information
for Application Submission

1. STATE NAME

2. DESIGNATED MARKETPLACE OFFICIAL(S) TO COMPLETE MARKETPLACE BLUEPRINT APPLICATION & CONTACT INFORMATION

NAME:

TELEPHONE:

EMAIL ADDRESS:

NAME:

TELEPHONE:

EMAIL ADDRESS:

3. STATE MARKETPLACE MODEL (Can check more than one. States applying for a State-based Marketplace are encouraged to also select and complete partnership requirements.)

__STATE-BASED MARKETPLACE

__STATE-BASED SHOP MARKETPLACE

__STATE PARTNERSHIP MARKETPLACE

4. If you are pursuing a State-based Marketplace or a State-based SHOP Marketplace, indicate if you will be using the following Federal service:

__5.1 Risk adjustment program

State-based Marketplace Blueprint Application

1.0 Legal Authority and Governance

1.1	Marketplace Enabling Authority: The state has enabling authority to operate a State-based Marketplace (SBM), including a Small Business Health Options Program (SHOP), compliant with Affordable Care Act Section 1321(b) and applicable rulemaking.
1.1a The Marketplace and SHOP have been established by state law, regulation or executive order.			☐ Not Started		Expected Start Date Click here to enter a date. Expected Completion DateClick here to enter a date.
			☐ In Progress		Expected Completion DateClick here to enter a date.
			☐ Complete		Completion DateClick here to enter a date.
Provide citation and URL of Marketplace-enabling authority: If SHOP is authorized separately: Provide citation of enabling authority for SHOP: If authority is not explicitly defined: Upload a statement from the grantee’s legal counsel, the governor’s legal counsel, or the state’s attorney general certifying authorization:
1.1		I attest this activity is complete ☐		I attest this activity will be complete ☐		Completed/Expected Completion Date Click here to enter a date.

1.2	Regulatory Authority to Certify Qualified Health Plans (QHPs): The Marketplace has the appropriate authority to perform the certification of QHPs and to oversee QHP issuers consistent with 45 CFR 155.1010(a).
1.2a The Marketplace has the appropriate statutory and/or regulatory authority(ies) to certify QHPs.			☐ Not Started		Expected Start Date Click here to enter a date. Expected Completion DateClick here to enter a date.
			☐ In Progress		Expected Completion DateClick here to enter a date.
			☐ Complete		Completion DateClick here to enter a date.
Provide citation AND URL of Marketplace authority to certify QHPs:
1.2		I attest this activity is complete ☐		I attest this activity will be complete ☐		Completed/Expected Completion Date Click here to enter a date.

1.3	If applicable: Risk Adjustment: If the state is performing risk adjustment, the state has the legal authority to operate the risk adjustment program per 45 CFR 153 and Affordable Care Act 1343.
1.3a The state has the applicable statutory and/or regulatory authority(ies) to operate risk adjustment for the Marketplace.			☐ Not Started		Expected Start Date Click here to enter a date. Expected Completion DateClick here to enter a date.
			☐ In Progress		Expected Completion DateClick here to enter a date.
			☐ Complete		Completion DateClick here to enter a date.
Provide citation and URL of authority to operate risk adjustment:
1.3b The state has selected the entity operating the risk adjustment program. Note: the risk adjustment entity must meet the requirements outlined in 45 CFR 155.110 and cannot be a health insurance issuer. Options include Department of Insurance (DOI), Medicaid, or “other entity.”			☐ Not Started		Expected Start Date Click here to enter a date. Expected Completion DateClick here to enter a date.
			☐ In Progress		Expected Completion DateClick here to enter a date.
			☐ Complete		Completion DateClick here to enter a date.
Legal name of entity: Provide description of entity and how entity will meet requirements of 45 CFR 155.110:
1.3		I attest this activity is complete ☐		I attest this activity will be complete ☐		Completed/Expected Completion Date Click here to enter a date.

1.4	Authority to Generate Revenue: The Marketplace has the appropriate authority to generate revenue to ensure operational sustainability, and has defined methods for generating revenue (e.g., user fees) pursuant to Affordable Care Act 1311(d)(5)(A).
1.4a The Marketplace has the appropriate statutory and/or regulatory authority(ies) to generate revenue.			☐ Not Started		Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
			☐ In Progress		Expected Completion Date Click here to enter a date.
			☐ Complete		Completion Date Click here to enter a date.
Provide citation: AND URL of Marketplace authority to generate revenue:
1.4		I attest this activity is complete ☐		I attest this activity will be complete ☐		Completed/Expected Completion Date Click here to enter a date.

1.5

Board and Governance Structure: The Marketplace has established a board and governance structure in compliance with Affordable Care Act Section 1311(d) and 45 CFR 155.110.

1.5a The Marketplace has determined its governance structure.

☐ Not Started

Expected Start Date Click here to enter a date.

Expected Completion Date Click here to enter a date.

☐ In Progress

Expected Completion Date Click here to enter a date.

☐ Complete

Completion Date Click here to enter a date.

Planned governance structure (check one):

State agency: ☐ If state agency, please proceed to Section 2.0.

Quasi-governmental entity: ☐ Nonprofit:☐ Other:☐

Upload formal, publically adopted Marketplace charter/by-laws:

1.5b The Marketplace has established governance principles that include conflict of interest standards, accountability and transparency standards, and disclosure of financial interests.

☐ Not Started

Expected Start Date Click here to enter a date.

Expected Completion Date Click here to enter a date.

☐ In Progress

Expected Completion Date Click here to enter a date.

☐ Complete

Completion Date Click here to enter a date.

Upload board member governance principles:

1.5c The Marketplace has established a governing board in compliance with Affordable Care Act 1311(d) and 45 CFR 155.110.

Board Member Name	Affiliation	Health Experience	Consumer Representation

Upload board members’ bios or resumes:

1.5d The Marketplace holds scheduled board meetings no less than quarterly.

Provide link to board meeting schedules and agendas:

1.5

I attest this activity is complete ☐

I attest this activity will be complete ☐

Completed/Expected Completion Date Click here to enter a date.

2.0 Consumer and Stakeholder Engagement and Support

The U.S. Department of Health and Human Services (HHS) recognizes that a state seeking to transition between Marketplace models after plan year 2014 may have system capabilities and/or policies in place that have already been developed and paid for as part of the implementation of their plan year 2014 Marketplace. A state that previously operated a Partnership Marketplace and intends to leverage existing functionalities, personnel, policies, and/or system solutions is not required to resubmit documentation or artifacts that have been previously approved by HHS; however, a state should identify which functionalities it will be leveraging and submit any documentation or artifacts that have been modified to support the build and overall approval of its new Marketplace model. A state may also upload a text document that lists artifacts the state previously submitted to the Centers for Medicare & Medicaid Services (CMS) that are now updated to include Marketplace requirements/functionality (e.g., a listing of CALT IDs in a text document).

2.1	Stakeholder Consultation Plan: The Marketplace has developed and implemented a stakeholder consultation plan that includes seeking input for the duration of Marketplace planning and operation from consumers, small businesses, state Medicaid and Children’s Health Insurance Program (CHIP) agencies, agents/brokers, large employers, and other relevant stakeholders pursuant to 45 CFR 155.130.
2.1a The Marketplace has developed a stakeholder consultation plan that addresses how consultations will occur on an ongoing basis with consumers, small businesses, state Medicaid and CHIP agencies, agents/brokers, large employers, and other relevant stakeholders pursuant to 45 CFR 155.130.			☐ Not Started		Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
			☐ In Progress		Expected Completion Date Click here to enter a date.
			☐ Complete		Completion Date Click here to enter a date.
Upload stakeholder consultation plan:
2.1b The Marketplace has made available stakeholder consultation schedules, agendas, and feedback received (to be updated quarterly).			☐ Not Started		Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
			☐ In Progress		Expected Completion Date Click here to enter a date.
			☐ Complete		Completion Date Click here to enter a date.
Upload stakeholder consultation materials:
2.1		I attest this activity is complete ☐		I attest this activity will be complete ☐		Completed/Expected Completion Date Click here to enter a date.

2.2		If applicable: Tribal Consultation: If a state has Federally-recognized tribes, the Marketplace, in consultation with the Federally-recognized tribes, has developed and submitted to HHS a tribal consultation policy and process pursuant to 45 CFR 155.130(f).
2.2a The Marketplace has a tribal consultation policy that includes culturally appropriate mechanisms for initiating and engaging in consultation sessions with tribal governments.			☐ Not Started		Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
			☐ In Progress		Expected Completion Date Click here to enter a date.
			☐ Complete		Completion Date Click here to enter a date.
Upload tribal consultation materials:
2.2b The Marketplace has made available to the public tribal consultation schedules, agendas, and outcomes and/or next steps resulting from tribal consultation sessions (to be updated quarterly).			☐ Not Started		Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
			☐ In Progress		Expected Completion Date Click here to enter a date.
			☐ Complete		Completion Date Click here to enter a date.
Upload tribal consultation materials:
2.2	I attest this activity is complete ☐			I attest this activity will be complete ☐		Completed/Expected Completion Date Click here to enter a date.

2.3		Outreach and Education: The Marketplace conducts outreach and education activities to educate consumers about and encourage participation in the Marketplace and insurance affordability programs pursuant to 45 CFR 155.205(c)(e). Any outreach and education materials and activities must be timely, accessible, and written in plain language. Materials must also be timely and accessible for individuals living with disabilities and individuals who have limited English proficiency. The Marketplace must provide and inform individuals about the availability of auxiliary aids and services for people with disabilities. Individuals who have limited English proficiency must receive language services at no cost to the individual, including oral interpretation, written translations, and taglines in non-English languages indicating the availability of language services. HHS expects that outreach and education materials will address eligibility and enrollment options, program information, benefits and services available through the Marketplace, SHOP Marketplace, and other insurance affordability programs. In addition, the Marketplace has an outreach plan for the general public and for the stakeholders listed in 45 CFR 155.130, including: individuals and entities with experience in facilitating enrollment such as agents/brokers, small businesses and their employees, large employers, health care providers, Federally-recognized tribes, and advocates for hard-to-reach populations.
2.3a The Marketplace has developed an outreach and education plan that addresses outreach for each type of stakeholder identified in 45 CFR 155.130, and metrics and criteria for assessing the impact of outreach and marketing efforts.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload outreach and education plan:
Upload metrics and criteria for assessing marketing efforts:
2.3b The Marketplace has created outreach materials that could include advertisements, social media, and other digital campaign materials, or has otherwise created a plan for conducting outreach and education consistent with HHS regulations and guidance pursuant to 45 CFR 155.205(e).				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload sample digital campaign materials:
2.3c The Marketplace has a paid media plan including dates, channels, markets, and budget.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload paid media plan:
2.3d The Marketplace has developed media and/or marketing materials in plain language and in a manner that is accessible and timely to all consumers including consumers with disabilities.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload sample marketing materials:
2.3	I attest this activity is complete ☐		I attest this activity will be complete ☐			Completed/Expected Completion Date Click here to enter a date.

2.4		Call Center: The Marketplace provides for the operation of a toll-free telephone hotline (call center) to respond to requests for assistance from the public (including individuals, employers, and employees) pursuant to 45 CFR 155.205(a). The Marketplace call center is capable of providing information to applicants and enrollees in plain language, in a manner that is accessible and timely for individuals living with disabilities and individuals who have limited English proficiency. The Marketplace must provide and inform individuals about the availability of auxiliary aids and services for people with disabilities. Individuals who have limited English proficiency must receive language services at no cost to the individual, including oral interpretation.
2.4a The Marketplace has begun the process of creating or contracting for the call center, such as by hiring call center staff, or by releasing a call center request for proposal (RFP) or contract modification if leveraging existing Medicaid/CHIP call center(s). The RFP for a new call center or existing call center must include provisions for language access services for limited English proficient (LEP) individuals and auxiliary aids and services for people with disabilities, pursuant to 45 CFR 155.205(c).					☐ Not Started		Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
					☐ In Progress		Expected Completion Date Click here to enter a date.
					☐ Complete		Completion Date Click here to enter a date.
The Marketplace will utilize existing call center: ☐ or the Marketplace will create a new call center: ☐
Upload plans for creating a call center, such as RFP (if creating new call center), hiring plans, or contract modifications if using an existing call center:
2.4b The Marketplace has created the call center. For example, if the Marketplace is establishing a call center through contract, the Marketplace has awarded a call center contract.				☐ Not Started		Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress		Expected Completion Date Click here to enter a date.
				☐ Complete		Completion Date Click here to enter a date.
Call Center (check one): Integrated with Medicaid: ☐ Operating as a separate entity: ☐ Other:
If applicable, name of call center vendor:
If applicable, upload call center contract:
2.4c The Marketplace has a call center strategy in place for triaging between insurance affordability programs and other state and Federal agencies pursuant to 45 CFR 155.300 and 42 CFR 434.4. The call center strategy includes projected call volumes and staffing, systems test scenarios, call flows, quality scorecard, quality monitoring methodology, and business continuity contingency scenarios.				☐ Not Started		Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress		Expected Completion Date Click here to enter a date.
				☐ Complete		Completion Date Click here to enter a date.
Upload call center strategy:
2.4d The Marketplace has created training materials for customer service representatives, including training schedules and scripts, and information on providing interpretation services for individuals with limited English proficiency, appropriate auxiliary aids and services for people with disabilities, and other accessibility requirements pursuant to 45 CFR 155.205(c)(1), (c)(2)(i), and (c)(3).				☐ Not Started		Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress		Expected Completion Date Click here to enter a date.
				☐ Complete		Completion Date Click here to enter a date.
Upload sample call center representative training materials:
Start date for call center representative initial training: Click here to enter a date.
2.4e The Marketplace has performed call center functionality and operational readiness testing (e.g., email and web chat functionality, call routing, connection with interpreter services, call handling, call tracking capabilities, Interactive Voice Response, Relay Services, TTY/TDD).				☐ Not Started		Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress		Expected Completion Date Click here to enter a date.
				☐ Complete		Completion Date Click here to enter a date.
2.4f The Marketplace has launched its operational toll-free call center.				☐ Not Started		Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress		Expected Completion Date Click here to enter a date.
				☐ Complete		Completion Date Click here to enter a date.
Marketplace call center phone number:
2.4	I attest this activity is complete ☐		I attest this activity will be complete ☐					Completed/Expected Completion Date Click here to enter a date.

2.5		Website: The Marketplace has established and maintains an up-to-date website that provides information on QHPs available through the Marketplace, the SHOP, and other insurance affordability programs. It also includes requirements as specified in 45 CFR 155.205(b). The website is required to provide information in plain language and in a manner that is timely and accessible to persons with disabilities and persons with limited English proficiency that are set forth at 155.205(c). This also includes auxiliary aids and services, written translations, and taglines in non-English languages indicating the availability of language services.
2.5a The Marketplace has created a website operations plan that includes the strategy for projected volumes, systems test scenarios, customer feedback, performance and QA monitoring, and business continuity contingency scenarios.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload website operations plan:
2.5b The Marketplace website displays all information required under 155.205(b), including premium and cost-sharing information for QHPs, QHP comparison(s), health plan coverage categories (e.g., Bronze, Silver, Gold, Platinum), transparency of coverage measures, and a provider directory.				☐ Not Started		Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress		Expected Completion Date Click here to enter a date.
				☐ Complete		Completion Date Click here to enter a date.
Provide final URL link to Marketplace website:
2.5c The Marketplace has a test plan and has performed testing to ensure 508 compliance and demonstrated website functionality and readiness, including accessibility for people with disabilities.				☐ Not Started		Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress		Expected Completion Date Click here to enter a date.
				☐ Complete		Completion Date Click here to enter a date.
Upload test plan:
Upload testing results:
2.5d The Marketplace has launched its website for consumers to enroll in coverage.				☐ Not Started		Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress		Expected Completion Date Click here to enter a date.
				☐ Complete		Completion Date Click here to enter a date.
2.5	I attest this activity is complete ☐		I attest this activity will be complete ☐				Completed/Expected Completion Date Click here to enter a date.

2.6

Navigator Program: The Marketplace has established or has a process in place to establish and operate a Navigator program that is consistent with the applicable requirements of 45 CFR 155.210, including the development of training and conflict of interest standards, provision of accessible services for limited English proficient individuals and people with disabilities as specified in 45 CFR 155.215, and adherence to privacy and security standards as specified in 45 CFR 155.210 and 45 CFR 155.260.

2.6a The Marketplace has a plan for operating a Navigator program, and has developed training standards, conflict of interest standards, privacy standards, and has entered agreements pursuant to 45 CFR 155.260(b) with Navigators grantees to ensure adherence to privacy and security standards and all other terms and conditions of the grant.

☐ Not Started

Expected Start Date Click here to enter a date.

Expected Completion Date Click here to enter a date.

☐ In Progress

Expected Completion Date Click here to enter a date.

☒ Complete

Completion Date Click here to enter a date.

Upload Navigator operating plan:

If applicable: Name of training contractor:

Upload training standards:

Upload conflict of interest standards:

Upload Marketplace/Navigator agreement, including Terms and Conditions, ensuring adherence to privacy and security standards pursuant to 155.260(b) and stipulating grantee’s responsibilities for assuring that individual Navigators comply with all applicable Federal and state statutes and regulations:

2.6b The Marketplace has a strategy for funding the Navigator program and making the program fully self-sustaining.

☐ Not Started

Expected Start Date Click here to enter a date.

Expected Completion Date Click here to enter a date.

☐ In Progress

Expected Completion Date Click here to enter a date.

☐ Complete

Completion Date Click here to enter a date.

Upload Navigator sustainability plan and timeline for ongoing funding:

2.6c The Marketplace has developed an oversight and monitoring plan for the Navigator program, including ensuring that Navigator grantees are providing appropriate oversight of individual Navigators to assure compliance with Federal and state requirements and the delivery of high quality services to consumers.

☐ Not Started

Expected Start Date Click here to enter a date.

Expected Completion Date Click here to enter a date.

☐ In Progress

Expected Completion Date Click here to enter a date.

☐ Complete

Completion Date Click here to enter a date.

Upload Navigator oversight and monitoring plan:

2.6d The Marketplace has released a Navigator request for applications, including an application template.

☐ Not Started

Expected Start Date Click here to enter a date.

Expected Completion Date Click here to enter a date.

☐ In Progress

Expected Completion Date Click here to enter a date.

☐ Complete

Completion Date Click here to enter a date.

Upload Navigator application:

2.6e The Marketplace has awarded Navigator grants.

☐ Not Started

Expected Start Date Click here to enter a date.

Expected Completion Date Click here to enter a date.

☐ In Progress

Expected Completion Date Click here to enter a date.

☐ Complete

Completion Date Click here to enter a date.

Grantee	Award Amount	Service Area Covered

2.6f The Marketplace has developed training materials for Navigators, including how Navigators must adhere to conflict of interest standards, Culturally and Linguistically Appropriate Services (CLAS) standards, and the privacy and security standards established pursuant to CFR 155.260.

☐ Not Started

Expected Start Date Click here to enter a date.

Expected Completion Date Click here to enter a date.

☐ In Progress

Expected Completion Date Click here to enter a date.

☐ Complete

Completion Date Click here to enter a date.

Upload sample Navigator training materials:

2.6g The Marketplace has deployed a Navigator program for consumers, including having released a funding opportunity announcement or other vehicle to announce the availability of grant awards, awarded such grants to appropriate entities, and ensured that grantees have trained staff that are available to assist consumers as needed.

☐ Not Started

Expected Start Date Click here to enter a date.

Expected Completion Date Click here to enter a date.

☐ In Progress

Expected Completion Date Click here to enter a date.

☐ Complete

Completion Date Click here to enter a date.

2.6

I attest this activity is complete ☐

I attest this activity will be complete ☐

Completed/Expected Completion Date Click here to enter a date.

2.7		If applicable: Non-Navigator Assistance Personnel Program: The Marketplace has established a non-Navigator assistance personnel program as a transitional program to fill in any gaps in its Navigator program during its initial year of operation. This program ensures that the full range of services that its Navigator program will provide in subsequent years are provided during its initial year of operation, and if the Marketplace so chooses, this program can operate as an ongoing program that will complement the Navigator program even after the Marketplace becomes financially self-sustaining. The Marketplace has a process in place to operate the program consistent with the applicable requirements of 45 CFR 155.205(c), (d), and (e), and if the Non-Navigator program is funded with section 1311(a) Exchange Establishment Grant funds, 45 CFR 155.215(a)(2) and 155.215(b) through (e).
2.7a The Marketplace has created a plan for a non-Navigator assistance personnel program that addresses developing and meeting conflict of interest standards, adherence to privacy and security standards and training standards, and if applicable, how the Marketplace will comply with and ensure non-Navigator assistance personnel’s compliance with standards under 155.215(a)(2) and 155.215(b) through (e). The plan should note if the non-Navigator assistance personnel program will be transitional or ongoing and how the non-Navigator assistance personnel program will complement and/or coordinate with the Navigator program.				☐ Not Started		Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress		Expected Completion Date Click here to enter a date.
				☐ Complete		Completion Date Click here to enter a date.
Upload non-Navigator assistance personnel program operating plan:
If applicable: Name of training contractor:
Upload training standards: Upload conflict of interest standards: Upload plan for adherence to Privacy and security standards:
2.7b The Marketplace has developed an oversight and monitoring plan for the non-Navigator assistance personnel program, including ensuring that entities operating under such programs are providing appropriate oversight of personnel to assure compliance with Federal and state requirements and the delivery of high quality services to consumers.					☐ Not Started		Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
					☐ In Progress		Expected Completion Date Click here to enter a date.
					☐ Complete		Completion Date Click here to enter a date.
Upload oversight and monitoring plan:
2.7c The Marketplace has identified and established legal relationships with non-Navigator assistance personnel.					☐ Not Started		Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
					☐ In Progress		Expected Completion Date Click here to enter a date.
					☐ Complete		Completion Date Click here to enter a date.
Upload a list and description of non-Navigator assistance personnel including funding agreements/contracts, and service areas that non-Navigator assistance personnel will cover:
2.7d The Marketplace has developed training materials for the non-Navigator assistance personnel program, including how non-Navigator assistance personnel must adhere to conflict of interest standards, Culturally and Linguistically Appropriate Services (CLAS) standards, accessibility, and privacy and security standards implemented pursuant to CFR 155.260, and if applicable, how non-Navigator assistance personnel must adhere to standards under 155.215(a)(2) and 155.215(b) through (d).					☐ Not Started		Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
					☐ In Progress		Expected Completion Date Click here to enter a date.
					☐ Complete		Completion Date Click here to enter a date.
Upload non-Navigator assistance personnel training materials:
2.7e The Marketplace has deployed the non-Navigator assistance personnel program for consumers, which includes releasing a funding opportunity funding announcement or other vehicle to announce the availability of funding to support such work, and has allocated funding to appropriate entities through a state-approved process.					☐ Not Started		Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
					☐ In Progress		Expected Completion Date Click here to enter a date.
					☐ Complete		Completion Date Click here to enter a date.
2.7	I attest this activity is complete ☐		I attest this activity will be complete ☐					Completed/Expected Completion Date Click here to enter a date.

2.8 Certified Application Counselors (CAC): The Marketplace has established a certified application counselor program or designated an entity to certify counselors pursuant to 45 CFR 155.225.
2.8a The Marketplace has developed a strategy for operating the certified application counselor program including the Marketplace’s decision regarding whether the Marketplace will designate organizations who will, in turn, certify their staff members and volunteers to act as certified application counselors, or whether the Marketplace will directly certify staff members and volunteers of Marketplace-designated organizations to act as certified application counselors. The Marketplace has also identified the types of entities that will be designated as certified application counselor organizations, where they will be located, and the process for designating them and withdrawing designation from them.				☐ Not Started		Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress		Expected Completion Date Click here to enter a date.
				☐ Complete		Completion Date Click here to enter a date.
The Marketplace will use designated certified application counselor entities to certify individual certified application counselors: ☐ OR The Marketplace will certify individual certified application counselors: ☐ Upload certified application counselor program strategy including the process for designating and withdrawing designation of certified application counselors:
2.8b The Marketplace has developed training materials for the certified application counselors, including how certified application counselors must adhere to all applicable provisions of 155.225, including the requirement to adhere to privacy and security standards implemented by the Marketplace, pursuant to CFR 155.260.			☐ Not Started		Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
			☐ In Progress		Expected Completion Date Click here to enter a date.
			☐ Complete		Completion Date Click here to enter a date.
Upload certified application counselor training materials:
2.8	I attest this activity is complete ☐	I attest this activity will be complete ☐					Completed/Expected Completion Date Click here to enter a date.

2.9		If applicable: Agents and Brokers: If the state permits activities by agents and brokers pursuant to 45 CFR 155.220(a), the Marketplace has clearly defined the role of agents and brokers including, as applicable, evidence of licensure, training, and compliance with 45 CFR 155.220(c)-(e). The Marketplace will have agreements with agents/brokers operating in the individual Marketplace, consistent with 45 CFR 155.220(d), which address agent/broker registration with the Marketplace, training on QHP options and insurance affordability program(s), and adherence to privacy and security standards implemented, pursuant to 45 CFR 155.260.
2.9a The Marketplace has developed policies and procedures for agents and brokers (e.g., state licensure, training, and verification of compliance with privacy and security standards), including a process for determining how the Marketplace’s website will interface with agent and broker websites.					☐ Not Started		Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
					☐ In Progress		Expected Completion Date Click here to enter a date.
					☐ Complete		Completion Date Click here to enter a date.
Upload agent and broker policies and procedures:
2.9b The Marketplace has developed templates for agreements between the Marketplace and agents and brokers, including language on addressing agents and brokers’ compliance with applicable requirements under 155.220.				☐ Not Started		Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress		Expected Completion Date Click here to enter a date.
				☐ Complete		Completion Date Click here to enter a date.
Upload template agreements:
2.9	I attest this activity is complete ☐		I attest this activity will be complete ☐					Completed/Expected Completion Date Click here to enter a date.

2.10		If applicable: Web Brokers: If the state permits this activity pursuant to 45 CFR 155.220(c)(3), the Marketplace has ensured that any agent or broker whose website will be used to select QHPs will comply with all applicable provisions of 45 CFR 155.220.
2.10a The Marketplace has developed policies and procedures for web brokers including ensuring compliance with all applicable requirements of 155.220(c)(3), and determining how the Marketplace’s website will interface with web brokers’ websites.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload web broker policies and procedures:
2.10b The Marketplace has developed templates for agreements between the Marketplace and web brokers, including language on addressing web brokers’ compliance with applicable requirements under 45 CFR 155.220.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload template agreements:
2.10	I attest this activity is complete ☐		I attest this activity will be complete ☐			Completed/Expected Completion Date Click here to enter a date.

3.0 Eligibility and Enrollment

3.1	Single, Streamlined Application: The Marketplace uses a single, streamlined application for health insurance in the individual and SHOP Marketplaces. The application collects information that is necessary for eligibility in a QHP for the individual market, SHOP, and for Insurance Affordability Programs as specified in 45 CFR 155.405 and in applicable CMS guidance.
3.1a The Marketplace has chosen whether it will use the HHS-developed application or state-developed alternative application for health insurance in the individual and SHOP Marketplaces.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Individual application (check one) alternative: ☐ HHS-developed: ☐
SHOP application employer (check one) alternative: ☐ HHS-developed: ☐
SHOP application employee (check one) alternative: ☐ HHS developed: ☐
3.1b If using an alternative application for the individual Marketplace: The Marketplace has developed online and paper versions of alternative applications for the individual Marketplace in accordance with CMS guidance issued in June 2013 and thereafter, and has submitted online and paper versions of alternative applications for the individual market for HHS approval and has completed an analysis of the differences between the HHS-developed and alternative application(s).				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
3.1b2 If using an alternative application for employers in the SHOP Marketplace: The Marketplace has developed online and paper versions of alternative employer applications for the SHOP Marketplace in accordance with CMS guidance issued in June 2013 and thereafter, and has submitted online and paper versions of alternative employer applications for the SHOP market for HHS approval and has completed an analysis of the differences between the HHS-developed and alternative application(s).				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
3.1b3 If using an alternative application for employees in the SHOP Marketplace: The Marketplace has developed online and paper versions of alternative employee applications for the SHOP Marketplace in accordance with CMS guidance issued in June 2013 and thereafter, and has submitted online and paper versions of alternative employee applications for the SHOP market for HHS approval and has completed an analysis of the differences between the HHS-developed and alternative application(s).				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload alternative individual application:
Upload alternative SHOP employer application:
Upload alternative SHOP employee application:
Upload gap analysis of differences between HHS and alternative individual Marketplace applications:
Upload gap analysis of differences between HHS and state alternative SHOP employer Marketplace applications:
Upload gap analysis of differences between HHS and state alternative SHOP employee Marketplace applications:
3.1c The Marketplace has demonstrated to HHS its online individual application, using state test data, and has submitted state user testing results for paper and online applications.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
3.1c2 The Marketplace has demonstrated to HHS its online SHOP employer application, using state test data, and has submitted state user testing results for paper and online applications.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
3.1c3 The Marketplace has demonstrated to HHS its online SHOP employee application using state test data, and has submitted state user testing results for paper and online applications.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload Marketplace’s and/or state’s user testing results for paper and online individual application: Upload Marketplace’s and/or state’s user testing results for paper and online SHOP employer application: Upload Marketplace’s and/or state’s user testing resutls for paper and online SHOP employee application:
3.1d The Marketplace has received approval from HHS of its alternative individual application (online and paper) and has finalized its online application and published its paper application on its website.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
3.1d2 The Marketplace has received approval from HHS of its alternative SHOP employer application (online and paper) and has finalized its online application and published its paper application on its website.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
3.1d3 The Marketplace has received approval from HHS of its alternative SHOP employee application (online and paper) and has finalized its online application and published its paper application on its website.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload final paper version of individual market application: Provide link to online individual application:
Upload final paper version of SHOP employer application: Provide link to online SHOP employer application:
Upload final paper version of SHOP employee: Provide link to online SHOP employee application:
3.1		I attest this activity is complete ☐	I attest this activity will be complete ☐			Completed/Expected Completion Date Click here to enter a date.

3.2	Coordination Strategy with Insurance Affordability Programs and SHOP: The Marketplace has developed and documented a coordination strategy with other entities administering insurance affordability programs and the SHOP that enables the Marketplace to carry out eligibility and enrollment activities.
3.2a The state has determined which entity is responsible for making the final modified adjusted gross income (MAGI)-based eligibility determination for Medicaid/CHIP.				☐ Not Started		Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress		Expected Completion Date Click here to enter a date.
				☐ Complete		Completion Date Click here to enter a date.
If applicable: Check appropriate box: The Marketplace will conduct Medicaid assessments: ☐ or determinations: ☐
3.2b The Marketplace has a coordination strategy with appropriate state agencies for eligibility determinations and formalized agreements are in place, consistent with 45 CFR 155.345(a), 155.510(a) and 155.705(c).					☐ Not Started		Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
					☐ In Progress		Expected Completion Date Click here to enter a date.
					☐ Complete		Completion Date Click here to enter a date.
3.2c The Marketplace has the capacity to accept and process applications for individual Marketplace coverage that have been collected by and transferred from other agencies, and as applicable, has completed testing of any automated mechanism for transferring applications for individual Marketplace coverage from other agencies.				☐ Not Started		Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress		Expected Completion Date Click here to enter a date.
				☐ Complete		Completion Date Click here to enter a date.
3.2		I attest this activity is complete ☐	I attest this activity will be complete ☐					Completed/Expected Completion Date Click here to enter a date.

3.3	Infrastructure to Accept and Process Initial Applications and Redeterminations: The Marketplace has the infrastructure in place to accept and process initial applications, application updates, notification of changed circumstances, and annual and mid-year redeterminations for enrollees. This includes applicants and enrollees who have disabilities or limited English proficiency or literacy, as well as applications received through all required channels, including in-person, online, mail, and phone.
3.3a The Marketplace has demonstrated sufficient capacity to accept and process initial individual applications.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
3.3b The Marketplace has demonstrated the capacity to accept and process initial SHOP employer and employee applications.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
3.3c The Marketplace has demonstrated sufficient capacity to accept and process mid-year and annual enrollee updates and redeterminations for the individual market.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
3.3d The Marketplace has demonstrated sufficient capacity to accept and process mid-year and annual enrollee updates and redeterminations for the SHOP market.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
3.3e The Marketplace has demonstrated sufficient capacity to accept and process initial individual applications via phone, online, mail, and in-person.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
3.3f The Marketplace has demonstrated sufficient capacity to accept and process initial SHOP employer and employee applications via phone, online, mail, and in-person.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload results for Blueprint test scenarios:
Upload state test summary:
Upload IV&V report:
3.3		I attest this activity is complete ☐	I attest this activity will be complete ☐			Completed/Expected Completion Date Click here to enter a date.

3.4

Eligibility Verifications: The Marketplace conducts required verifications of applicant data, as part of the eligibility determination process, and relies on electronic data sources available through the Federal Data Services Hub (FDSH), known as the Federal Hub, and/or other HHS-approved data sources, to conduct required verifications, pursuant to 45 CFR 155, Subpart D.

3.4a The Marketplace has identified a comprehensive list of data sources that the state is connecting to or interfacing with to conduct required verifications and has provided a verification plan.

Data Source	Federal/ State	Description of Data	Primary/ Secondary Sources	Business Use for Data	Process for Conducting Verifications and Inconsistency Response

3.4b The Marketplace has a process in place to verify access to employer-sponsored coverage.

☐ Not Started

Expected Start Date Click here to enter a date.

Expected Completion Date Click here to enter a date.

☐ In Progress

Expected Completion Date Click here to enter a date.

☐ Complete

Completion Date Click here to enter a date.

Upload outline of approach to verifying access to qualifying employer-sponsored coverage and , if using a sampling process, a description of how it will be implemented:

3.4c The Marketplace has data-sharing agreements in place, in accordance with applicable Federal regulations and guidance, in order to perform required verifications.

☐ Not Started

Expected Start Date Click here to enter a date.

Expected Completion Date Click here to enter a date.

☐ In Progress

Expected Completion Date Click here to enter a date.

☐ Complete

Completion Date Click here to enter a date.

Upload data sharing agreements:

3.4d The Marketplace demonstrates, through the submission of test files, the automated ability to conduct verifications pursuant to 45 CFR 155 subpart D and is able to connect to electronic data sources, such as the Federal Hub, to perform the required verifications.

☐ Not Started

Expected Start Date Click here to enter a date.

Expected Completion Date Click here to enter a date.

☐ In Progress

Expected Completion Date Click here to enter a date.

☐ Complete

Completion Date Click here to enter a date.

Upload results for Blueprint test scenarios:

Upload state test summary:

Upload IV&V report:

3.4

I attest this activity is complete ☐

I attest this activity will be complete ☐

Completed/Expected Completion Date Click here to enter a date.

3.5	Infrastructure to Send Notices Electronically: The Marketplace has the capacity to send notices electronically, including those in alternative formats and multiple languages.
3.5a The Marketplace has demonstrated sufficient capacity to send notices, including eligibility and appeals notices for the individual market, electronically, including notices in alternative formats and multiple languages.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload sample of electronic eligibility notices pursuant to CMS guidance. For example, notice of eligibility determinations for advance payments of premium tax credit (APTC) and cost-sharing reduction (CSR), notices resulting from a Medicaid eligiblity assessment or determination, notices for a family with multiple types of eligibility or coverage, eligibility redetermination notices, and notices related to changes in circumstances:
Upload results for Blueprint test scenarios:
Upload state test summary:
Upload IV&V report::
3.5		I attest this activity is complete ☐	I attest this activity will be complete ☐			Completed/Expected Completion Date Click here to enter a date.

3.6		Infrastructure to Conduct Data Matching: The Marketplace has the capacity to conduct periodic data matching pursuant to 45 CFR 155 Subpart D.
3.6a The Marketplace has demonstrated sufficient capacity to conduct periodic data matching as specified in 45 CFR 155.330.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload a description of the data sources to be used:
Upload results for Blueprint test scenarios:
Upload state test summary:
Upload IV&V report:
3.6	I attest this activity is complete ☐		I attest this activity will be complete ☐			Completed/Expected Completion Date Click here to enter a date.

3.7		Infrastructure to Conduct Eligibility Determinations and Annual Redeterminations: In accordance with 45 CFR 155, Subpart D, the Marketplace can determine individual eligibility for enrollment in a QHP through the Marketplace. The Marketplace can assess or determine eligibility for Medicaid and CHIP based on MAGI. The Marketplace also has the capacity to determine eligibility for advance payment of the premium tax credits (APTC) and cost-sharing reductions (CSR), as well as exemptions from the shared individual responsibility payment. Additionally, the Marketplace can conduct annual eligibility redeterminations.
3.7a The Marketplace can determine individual eligibility for enrollment in a QHP through the Marketplace.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload results for Blueprint test scenarios:
Upload state test summary:
Upload IV&V report:
3.7b The Marketplace can determine employer and employee participation in the SHOP.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload results for Blueprint test scenarios:
Upload state test summary:
Upload IV&V report:
3.7c The Marketplace can make an assessment or determination of eligibility for Medicaid and CHIP based on MAGI.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload results for Blueprint test scenarios:
Upload state test summary:
Upload IV&V report:
3.7d The Marketplace can determine eligibility for APTC and CSR and can calculate and apply individual APTC amounts to QHP premiums for APTC-eligible individuals based on the maximum APTC level an individual is eligible for, the premium(s) of the QHP(s) selected by the individual, and the APTC level selected by the individual to apply to their QHP premium.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload plan describing how the Marketplace will determine individual eligibility for APTC/CSRs:
Upload plan describing how maximum APTC levels for APTC-eligible individuals will be calculated:
Upload plan describing how actual costs of premiums for APTC-eligible individuals will be determined based on the maximum APTC an individual is eligible for and the premium(s) of QHP(s) selected by an individual:
Upload documentation of approach to determining eligibility for and calculating amounts of APTC/CSR:
Upload results for Blueprint test scenarios:
Upload state test summary:
Upload IV&V report:
3.7e The Marketplace can determine eligibility for exemptions from the shared responsibility payments.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload documentation of the general approach for determining eligibility for exemptions, including processing applications, conducting verifications, providing notices to applicants, and generating reports to the Internal Revenue Service (IRS):
Upload results for Blueprint test scenarios:
Upload state test summary:
Upload IV&V report:
3.7f The individual and SHOP Marketplaces are operationally ready to conduct annual redeterminations and employer and employee annual selection periods and process responses, through all channels pursuant to 45 CFR Part 155 Subparts D and H.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload results for Blueprint test scenarios:
Upload state test summary:
Upload IV&V report:
3.7	I attest this activity is complete ☐		I attest this activity will be complete ☐			Completed/Expected Completion Date Click here to enter a date.

3.8		Enrollment Transactions and APTC/CSR Information Processing: The Marketplace has the capacity in the individual Marketplace and SHOP to process enrollment transactions and report and reconcile those transactions, as well as APTC/CSR information in coordination with issuers and HHS in accordance with 45 CFR 155.400, 155.430, and 155.720. This includes exchanging relevant information with issuers and HHS using Health Insurance Portability and Accountability Act (HIPAA) electronic enrollment transaction standards.
3.8a The Marketplace can report and reconcile enrollment transactions and APTC/CSR information in coordination with issuers and HHS, including reporting and reconciling QHP selection and termination information and APTC/CSR information, on a daily and monthly basis with HHS in accordance with HHS guidance.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload a description of enrollment and processing plans:
3.8b The Marketplace has demonstrated through the submission of test files, the ability to report and reconcile QHP selections, terminations, and APTC/ CSR information in coordination with issuers and HHS.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload results for Blueprint test scenarios:
Upload state test summary:
Upload IV&V report:
3.8	I attest this activity is complete ☐		I attest this activity will be complete ☐			Completed/Expected Completion Date Click here to enter a date.

3.9	Infrastructure for Eligibility Appeals: The Marketplace has established an eligibility appeals process for individuals, employers, and SHOP pursuant to 45 CFR 155 Subpart F and Subpart H’s section 155.740.
3.9a Individual Appeals: The Marketplace has determined whether it will operate an individual eligibility appeals process, which includes individuals in Medicaid and CHIP programs. If the Marketplace has determined to operate an individual eligibility appeals process, appellants must first appeal to the Marketplace appeals’ entity and then may appeal to the HHS process upon exhaustion of the Marketplace process. If the Marketplace elects not to operate an individual eligibility appeals process, appellants will appeal directly to HHS. The Marketplace has also determined whether it will operate an appeals process for exemption determinations, or whether it will delegate authority for the appeals process for exemption determinations to HHS.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
(Check one): The Marketplace will ☐ OR ☐ will not operate an individual eligibility appeals process.
(Check one): The Marketplace will ☐ OR ☐ will not delegate authority from the Medicaid and/or CHIP agency to operate an individual eligibility appeals process for Medicaid and/or CHIP eligibility appeals.
(Check one): The Marketplace will ☐ OR ☐ will not delegate authority for appeals of exemption determinations to HHS.
3.9a1 If applicable: If the Marketplace elects to operate an individual eligibility appeals process, the Marketplace has developed an operational approach, including process flows if available, depicting the eligibility appeals process, including entity/entities which are responsible for processing and adjudicating appeals, by appeals type.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload description of operational approach:
Upload plan for transmitting individual eligibility and appeals records to HHS for second-level appeals:
3.9a2 If applicable: If the Marketplace has elected to operate an individual eligibility appeals process for exemption determination appeals, the Marketplace has developed an operational approach, including process flows if available, depicting the eligibility appeals process, by appeals type.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload description of operational approach:
3.9a3 If applicable: If the Marketplace has delegated authority from Medicaid/CHIP to operate an individual eligibility appeals process for Medicaid and/or CHIP eligibility appeals, the Marketplace has developed an operational approach, including process flows if available, depicting applicable appeals process, by appeals type.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload description of operational approach:
Upload plan for transmitting individual eligibility and appeals records to appropriate entities for second-level appeals and/or Medicaid fair hearings:
3.9a4 If applicable: If the Marketplace does not have the delegated authority from Medicaid and/or CHIP to operate an individual eligibility appeals process for Medicaid/and or CHIP eligibility appeals, the Marketplace has developed an operational approach, including process flows if available, depicting the plan/process for transmitting Medicaid and/or CHIP appeals to the appropriate entity/entities for processing Medicaid and/or CHIP appeals, by appeals type.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload operational approach for transmitting Medicaid and/or CHIP appeals to appropriate entity/entities.
Upload plan for transmitting individual eligibility and appeals records to HHS for second-level appeals, if applicable:
3.9b Employer Appeals: The Marketplace operates an employer appeals process, pursuant to 45 CFR 155.555(a) and (b), through which an employer may, in response to a notice under Section 155.310(h), appeal a determination that the employer does not provide minimum essential coverage through an employer-sponsored plan or that the employer does provide coverage but it is not affordable coverage with respect to an employee.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
3.9b1 The Marketplace has developed an operational approach that includes employer appeals process flows depicting the eligibility appeals process and the entity/entities that are responsible for processing and adjudicating appeals.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload operational approach:
3.9c SHOP Appeals: The Marketplace has established a SHOP eligibility appeals process for employers and employees and has developed an operational approach, including process flows and the entities responsible for processing appeals.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload operational approach::
3.9d The Marketplace has developed form and notice templates for each type of eligibility appeal, including final versions of language/messages informing individuals, employers, and SHOP employers and employees about the appeals process and the option to appeal to HHS upon exhaustion of the individual state-based appeals process.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload sample form and notice templates:
3.9e The Marketplace has developed and executed agreements between the appeals entity and the Marketplace and other entities administering Insurance Affordability Programs regarding the appeals processes for such programs.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload agreements:
3.9f The Marketplace has developed standard operating procedures for the appeals processes pursuant to 45 CFR 155.525.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload appeals standard operating procedures:
3.9g The Marketplace demonstrates through the submission of test files, the ability to implement an eligibility appeals process and to implement eligibility pending an appeal and appeals decisions, as appropriate, for individuals, employers, and employees pursuant to 45 CFR 155 Subpart F and Subpart H’s section 155.740. The Marketplace demonstrates through the submission of test files the ability to implement eligibility pending an appeal, pursuant to 45 CFR 155.525.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload results for Blueprint test scenarios:
Upload state test summary:
Upload IV&V report:
3.9		I attest this activity is complete ☐	I attest this activity will be complete ☐			Completed/Expected Completion Date Click here to enter a date.

3.10	Electronic Reporting of Eligibility Assessments and Determinations: The Marketplace can electronically report results of eligibility determinations, including determinations of eligibility for an exemption from the individual responsibility requirement, and provide associated information to other agencies administering insurance affordability programs (HHS and IRS) as applicable. This includes information necessary to support administration of the APTC and CSR and support the employer responsibility provisions of the Affordable Care Act.
3.10a The Marketplace has a process for submitting monthly and annual eligibility and enrollment records to HHS and IRS, including information necessary to support administration of the APTC and CSR and support the employer responsibility provisions of the Affordable Care Act.		☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
		☐ In Progress	Expected Completion Date Click here to enter a date.
		☐ Complete	Completion Date Click here to enter a date.
Upload description of process approach:
3.10b The Marketplace has demonstrated, through the submission of test files, the ability to electronically report results of eligibility and exemption determinations, and provide associated information to HHS, IRS, and other agencies administering insurance affordability programs, including information necessary to support administration of the APTC and CSR and support the employer responsibility provisions of the Affordable Care Act.		☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
		☐ In Progress	Expected Completion Date Click here to enter a date.
		☐ Complete	Completion Date Click here to enter a date.
Upload results for Blueprint test scenarios:
Upload state test summary:
Upload IV&V report:

4.0 Plan Management

HHS recognizes that states seeking to transition between Marketplace models after plan year 2014 may have system capabilities and/or policies in place that have already been developed and paid for as part of the implementation of their plan year 2014 Marketplace. States that intend to leverage existing functionalities, personnel, policies, and/or system solutions are not required to resubmit documentation or artifacts that have been previously approved by HHS; however, states should submit any documentation or artifacts that have been modified to support the build and overall approval of its new Marketplace model. A state may also upload a text document that lists artifacts the state previously submitted to CMS that are now updated to include Marketplace requirements/functionality (e.g., a listing of CALT IDs in a text document).

4.1		QHP Certification Process: The Marketplace has the capacity and a process in place to certify QHPs pursuant to 45 CFR 155.1000(c), in alignment with market reform rules contained in 45 CFR 144, 147, 150, 154, and 156, and according to QHP certification requirements and standards contained in 45 CFR 156, including, but not limited to, standards relating to licensure, solvency, service area, network adequacy, essential community providers, marketing and discriminatory benefit design, accreditation, and consideration of rate increases.
4.1a The Marketplace has developed the necessary infrastructure to certify QHPs pursuant to 45 CFR155.1000(c) in accordance with minimum QHP certification requirements and has a process in place for ensuring issuers and health plans meet each of the QHP certification standards, including any differences specific to SHOP.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload QHP certification standards:
Upload process for QHP certification:
4.1b The Marketplace has released its QHP application templates and certification timeline and standards to issuers.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload QHP application materials:
4.1c The Marketplace has completed QHP certification.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
4.1d The Marketplace has worked with issuers to validate QHP data and has completed plan preview.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
4.1e The Marketplace has posted certified QHP options online for consumers.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Provide link to certified QHPs on website:
4.1	I attest this activity is complete ☐		I attest this activity will be complete ☐			Completed/Expected Completion Date Click here to enter a date.

4.2

Collection of QHP Issuer and Plan Data: The Marketplace uses plan management system(s) or processes that: support the collection of QHP issuer and plan data; facilitate the QHP certification process; manage QHP issuers and plans; and integrate with other Marketplace business areas, including the Marketplace website, call center, quality, eligibility and enrollment, and premium processing.

4.2a The Marketplace has selected a plan management system and process that supports the collection of QHP issuer and plan data.

☐ Not Started

Expected Start Date Click here to enter a date.

Expected Completion Date Click here to enter a date.

☐ In Progress

Expected Completion Date Click here to enter a date.

☐ Complete

Completion Date Click here to enter a date.

Name of plan management system:

Upload timeline for plan management system implementation:

Upload documentation describing collection methods that will be used to support the business operations of plan management:

For Marketplaces using System for Electronic Rate and Form Filing (SERFF): Upload receipt of National Association of Insurance Commissioners (NAIC) validation of SERFF connection:

For Marketplaces not using SERFF: Submit state test summary/validation of state’s plan management system(s), including justification for how the state will receive the data for certification purposes:

4.2b The Marketplace has conducted market analysis of issuer participation including the anticipated number of health plans expected to participate in the Marketplace.

Marketplace Plan Management	Expected	Final	Comments
State QHP Application Submission Deadline
Number of Issuer Submissions: Individual Market
Number of QHPs Available: Individual Market
Number of Issuer Submissions: SHOP Market
Number of QHPs Available: SHOP Market
Number of Office of Personnel Management (OPM) Multi-State Plans (MSP)
Identify Any Counties with Fewer than One Issuer: Individual Market
Identify Any Counties with Fewer than One Issuer: SHOP Market
Identify Any Counties with One Issuer: Individual Market
Identify Any Counties with One Issuer: SHOP Market
If Applicable, Identify Number of Issuer Submissions: Co-ops
If Applicable, Identify Number of QHPs Available: Co-ops

4.2c The Marketplace has launched a plan management system(s) and process(es) that support the collection of QHP issuer and plan data.

☐ Not Started

Expected Start Date Click here to enter a date.

Expected Completion Date Click here to enter a date.

☐ In Progress

Expected Completion Date Click here to enter a date.

☐ Complete

Completion Date Click here to enter a date.

4.2

I attest this activity is complete ☐

I attest this activity will be complete ☐

Completed/Expected Completion Date Click here to enter a date.

4.3		QHP Monitoring and Compliance: The Marketplace has the capacity to ensure QHPs’ ongoing compliance with QHP certification requirements pursuant to 45 CFR 155.1010(a) (2), including a process for monitoring QHP performance and collecting, analyzing, and resolving enrollee complaints.
4.3a The Marketplace has a plan for processing QHP complaints.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload plan for processing QHP complaints:
4.3b The Marketplace has a plan for ongoing QHP monitoring and compliance.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload plan for monitoring QHP compliance:
4.3c The Marketplace has a system and standard operating procedures in place for tracking complaints.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Name of complaint tracking system: Upload complaint tracking system standard operating procedures:
4.3d The Marketplace has launched its QHP complaint tracking system.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
4.3	I attest this activity is complete ☐		I attest this activity will be complete ☐			Completed/Expected Completion Date Click here to enter a date.

4.4	Technical Assistance to Issuers: The Marketplace supports issuers and provides technical assistance to ensure ongoing compliance with QHP issuer operational standards.
4.4a The Marketplace has a timeline and strategy for providing issuer technical assistance and support activities.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload technical assistance timeline and strategy:
4.4b The Marketplace has created technical assistance materials for issuers.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload sample technical assistance materials:
4.4c The Marketplace has communicated technical assistance strategy and opportunities to issuers.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
4.4		I attest this activity is complete ☐	I attest this activity will be complete ☐			Completed/Expected Completion Date Click here to enter a date.

4.5	Recertification, Decertification, and Appeals: The Marketplace has a process for QHP issuer recertification, decertification, and appeal of decertification determinations pursuant to 45 CFR 155.1075 and 155.1080.
4.5a The Marketplace has a process in place for QHP issuer recertification, decertification, and appeals, including the process for transitioning enrollees to new QHPs in the event of QHP decertification. Note if there are any differences specific to SHOP.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload processes for QHP issuer recertification, decertification, and appeals:
4.5		I attest this activity is complete ☐	I attest this activity will be complete ☐			Completed/Expected Completion Date Click here to enter a date.

4.6	Issuer Accreditation: The Marketplace has a set timeline for QHP issuer accreditation in accordance with 45 CFR 155.1045. The Marketplace also has systems and procedures in place to ensure QHP issuers meet accreditation requirements (per 45 CFR 156.275) as part of QHP certification in accordance with applicable rulemaking and guidance.
4.6a The Marketplace has established a QHP issuer accreditation timeline.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload QHP issuer timeline:
4.6b The Marketplace has systems and procedures in place to ensure QHP issuers meet accreditation requirements (per 45 CFR 156.275) as part of QHP certification in accordance with applicable rulemaking and guidance.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload procedures for ensuring QHP issuers meet accreditation requirements:
Upload a sample notice sent to QHP issuers on accreditation requirements:
4.6		I attest this activity is complete ☐	I attest this activity will be complete ☐			Completed/Expected Completion Date Click here to enter a date.

4.7		Quality Reporting: The Marketplace has systems and procedures in place to ensure that QHP issuers meet the minimum certification requirements pertaining to quality reporting and provide relevant information to the Marketplace and HHS pursuant to Affordable Care Act 1311(c)(1), 1322(e)(3), and as specified in rulemaking.
4.7a The Marketplace has systems and procedures in place to ensure QHP issuers meet minimum certification requirements pertaining to quality reporting.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload procedures for QHP issuers to meet minimum quality reporting requirements:
If applicable: For states that are setting quality reporting requirements for 2015 certification, upload documentation that lists the reporting requirements:
4.7	I attest this activity is complete ☐		I attest this activity will be complete ☐			Completed/Expected Completion Date Click here to enter a date.

5.0 Risk Adjustment

5.1	If applicable: Risk Adjustment: If state is performing risk adjustment, the state has a process in place and has identified the entity that will implement the risk adjustment program. This risk adjustment entity must meet the requirements outlined in 45 CFR 155.110 and can include DOIs.
5.1a The state has published a notice of benefit and payment parameters following the publication of the final HHS notice of benefit and payment parameters for 2015, as required by 45 CFR 153.100(b).				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
5.1b The Marketplace has developed a process and timeline for implementing and operating the risk adjustment program.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload process and timeline for operating risk adjustment program:
5.1		I attest this activity is complete ☐	I attest this activity will be complete ☐			Completed/Expected Completion Date Click here to enter a date.

6.0 SHOP

6.1	SHOP Compliance with 45 CFR 155 Subpart H: The SHOP is compliant with regulatory requirements pursuant to 45 CFR 155 Subpart H.
6.1a The state has determined the size of a small employer, as well as methods for determining whether an employee is a full-time employee.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Select the size of a small employer: 1-50: ☐or 1-100: ☐ Select method state will use to count employees: Federal FTE method: ☐ or state method: ☐
6.1b The Marketplace has established policy decisions that ensure SHOP compliance with 45 CFR 155 Subpart H.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload SHOP policy decisions: :
6.1c The Marketplace has established what employee choice options (and employer choice option, if applicable) will be available to employers.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload documentation describing employee/employer choice options in addition to the required single metal level of choice:
6.1d The Marketplace requires all QHP issuers to make any changes to rates at a uniform time that is no more frequent than quarterly and prohibits all QHP issuers from varying rates for a qualified employer during the employer’s plan year.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
6.1e The Marketplace has established the premium calculator for SHOP in accordance with 45 CFR 155.705(b)(11).				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload premium calculator:
6.1f The Marketplace has developed a uniform enrollment timeline and process that includes information pertaining to grace periods, effective dates of coverage, enrollment periods, and reinstatement policies.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload enrollment timeline and process:
6.1g If applicable: If the Marketplace implements minimum participation requirements in the SHOP, state regulatory authority exists for uniform group participation rules for offering health insurance coverage in the SHOP.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Provide citation of state regulatory authority for SHOP uniform participation rules:
6.1h The Marketplace has demonstrated its website’s ability to make employer and employee eligibility determinations and facilitate comparison(s) of available QHPs in the SHOP.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
6.1		I attest this activity is complete ☐	I attest this activity will be complete ☐			Completed/Expected Completion Date Click here to enter a date.

6.2	SHOP Premium Aggregation: The Marketplace has the capacity for SHOP premium aggregation pursuant to 45 CFR 155.705(b)(4). The Marketplace has systems in place for billing qualified employers, receiving qualified employer contributions toward premiums, and making aggregated premium payments to issuers. The Marketplace has a process for managing non-payment or late premiums, including how and when notices are sent to employers in accordance with 45 CFR 155.735. The Marketplace also has the capacity to maintain books, records, documents, and other evidence of accounting procedures and practices of the premium aggregation program for each benefit year for at least 10 years.
6.2a The Marketplace has developed a SHOP premium aggregation process.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload SHOP premium aggregation process:
6.2b The Marketplace has established SHOP premium aggregation.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
The Marketplace has completed/expects to complete activity by (date): Click here to enter a date.
6.2c The Marketplace has developed sample or model premium aggregation invoices and notices.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload sample of notices and invoices:
6.2d The Marketplace has a formalized agreement in place indicating the SHOP’s ability to receive payments from employers and dispense to issuers.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload agreement:
6.2e The Marketplace has developed termination policies and processes for managing non-payment or late premiums, including how and when notices are sent to employers in accordance with 45 CFR 155.735.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload non-payment policies and procedures:
6.2f The Marketplace demonstrates, through the submission of test files, the automated ability to perform SHOP premium aggregation pursuant to 45 CFR 155.705(b)(4).				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload results for Blueprint test scenarios:
Upload state test summary:
Upload IV&V report:
6.2		I attest this activity is complete ☐	I attest this activity will be complete ☐			Completed/Expected Completion Date Click here to enter a date.

6.3	Electronically Report Results of Employer Participation, Employer Contribution, and Employee Enrollment Information for the SHOP: The SHOP has the capacity to electronically report information to the Internal Revenue Service (IRS) for tax administration purposes as defined in 155.720(i).
6.3a The Marketplace demonstrates through the submission of test files, the automated ability to electronically report employer participation, employer contribution, and employee enrollment information to IRS for tax administration purposes.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload results for Blueprint test scenarios: UPLOAD
Upload state test summary:
Upload IV&V report:
6.3		I attest this activity is complete ☐	I attest this activity will be complete ☐			Completed/Expected Completion Date Click here to enter a date.

7.0 Organization and Human Resources

7.1	Organizational Structure and Staffing Plan: The Marketplace has created a staffing plan that addresses competencies, roles, and responsibilities needed to develop and operate a Marketplace, and provide job descriptions for the following Marketplace personnel: call center, eligibility and enrollment, plan management, SHOP, and premium aggregation activities. The Marketplace has created an organizational chart.
7.1a The Marketplace has created a staffing plan that addresses competencies, roles, and responsibilities for the call center, eligibility and enrollment, plan management, and SHOP. The Marketplace has created an organizational chart.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload current staffing plan:
Upload projected staffing plan:
Upload organizational chart:
7.1b The Marketplace has developed training materials for staff or contractors who will perform key Marketplace activities for the call center, eligibility and enrollment, plan management, and SHOP.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload sample training materials:
7.1		I attest this activity is complete ☐	I attest this activity will be complete ☐			Completed/Expected Completion Date Click here to enter a date.

8.0 Finance and Accounting

8.1	Cost, Budget, and Management Plan: The Marketplace has a long-term cost, budget, and management plan, monitors its finances, and is able to track its costs and revenues.
8.1a The Marketplace has established methods to generate revenue and address any financial deficits.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload plan to generate revenue and monitor finances:
8.1b The Marketplace has developed a long-term operational budget and management plan, and established the capabilities to monitor finances and track costs and revenues. Long-term strategies for financial sustainability and tracking financial trends have been determined. Plan should include the Marketplace’s proposed budget for 2014 and proposed budget for the upcoming five years from initial year of operations, if available.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload proposed long-term operational budget and management plan for the next five consecutive plan years:
Upload operating budget, which includes estimated sources of revenue, enrollment projections, and per member per month (pmpm) costs:
Upload proposed 2015 and future years budget and management plan:
8.1		I attest this activity is complete ☐	I attest this activity will be complete ☐			Completed/Expected Completion Date Click here to enter a date.

9.0 Technology

HHS recognizes that states seeking to transition between Marketplace models after plan year 2014 may have system capabilities and/or policies in place that have already been developed and paid for as part of the implementation of their plan year 2014 Marketplace. States that intend to leverage functionalities, policies, and/or system solutions are not required to resubmit documentation or artifacts that have been previously approved by HHS; however, states should submit any documentation or artifacts that have been modified to support the build and overall approval of its new Marketplace model.

9.1	Gate Reviews, Consults, and Artifacts: The Marketplace has complied with relevant HHS information technology guidance including the IT Enterprise Life Cycle (ELC) methodology. The Marketplace has completed the ELC milestone gate reviews and consults. As agreed upon with CMS, the Marketplace has submitted all applicable artifacts or functionally equivalent requirements.
9.1a The Marketplace has completed the Architecture Review (AR) and Project Baseline Review (PBR) through successful completion of all activities, consults, and artifacts within this ELC phase and/or completion of all iterations or functional equivalents for this phase as agreed to with CMS. The Marketplace must perform pre- and post-review gate activities. The Marketplace must submit preliminary, baseline, updated, and final versions of artifacts as specified in the ELC. The ELC process aligns with the Establishment Review Process.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Please refer to the ELC guidance document to determine the frequency of ELC artifact submissions, as well as the level of completeness expected for each Gate Review. Submission of the initial ELC Architecture and Project Management artifacts are to be updated within six weeks of signing a Systems Integrator and uploaded into CALT as final. The following artifacts are uploaded into CALT at a minimum of every two weeks: Updated Project Schedule Updated Risk Register Updated Performance Metrics Updated Financial Status Report The following artifacts are uploaded on a monthly basis: IV&V Status Reports The following are uploaded when applicable: Updated Staffing Plan Updated Communications Plan CALT ID number for completed documentation associated with the AR and PBR or a functionally equivalent review:
9.1b The Marketplace has completed the Final Detailed Design Review (FDDR) through successful completion of all activities, consults, and artifacts within this ELC phase and/or completion of all iterations or functional equivalents for this phase as agreed to with CMS. A Marketplace must perform pre- and post-review gate activities. This phase has two consults and may include additional consults as determined by HHS. The Marketplace must submit preliminary, baseline, updated, and final versions of artifacts as specified in the ELC.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
CALT ID number for completed documentation associated with the FDDR or a functionally equivalent review: Please refer to the ELC guidance document to determine the frequency of ELC artifact submissions, as well as the level of completeness expected for each Gate Review. Please review the status of the ELC documents for the consults and the expected status of each artifact at each consult and they all must be final for the Final Design Review based on day one functionality.
9.1c The Marketplace has obtained approval to participate in informal Federal integration testing.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
9.1d The Marketplace has obtained approval to participate in formal Federal integration testing.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
9.1e The Marketplace has demonstrated all core functionality of its Marketplace through an online demonstration.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
9.1f The Marketplace has completed formal Marketplace system testing and has submitted all applicable test reports, including Blueprint test scenario results, applicable state testing summaries, and IV&V results.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload test reports:
9.1g The Marketplace has completed user acceptance testing (UAT) with no major defects.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
CALT ID numbers for system performance and user acceptance testing (UAT) test reports: OR
Upload system performance and user acceptance testing (UAT) test reports:
9.1h The Marketplace has completed the Operational Readiness Review (ORR) through submission of and CMS review and validation of required artifacts and activities or functional equivalents as agreed to with CMS. A Marketplace must perform pre- and post-review gate activities. This phase has one consult and may include additional consults as determined by HHS. The Marketplace must submit preliminary, baseline, updated, and final versions of artifacts as specified in the ELC and also conduct a final demonstration of day one functionality.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
CALT ID numbers for completed documentation associated with the ORR or a functionally equivalent review: Please refer to the ELC guidance document to determine the frequency of ELC artifact submissions, as well as the level of completeness expected for each Gate Review. Please review the status of the ELC documents for the ORR and the expected status of each artifact for this review.
9.1i The Marketplace has completed and submitted all outstanding final versions of all artifacts listed under previous ELC gates and reviews.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
CALT ID numbers for final documentation associated with previous ELC gate reviews: OR
Upload final documentation associated with previous ELC gate reviews:
9.1j The Marketplace monitors the performance of the system/application during normal operations against original user requirements and any newly implemented requirements or changes.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date
Upload annual Operations Readiness Report, including any newly implemented requirements or changes:
9.1		I attest this activity is complete ☐	I attest this activity will be complete ☐			Completed/Expected Completion Date Click here to enter a date.

9.2	Essential Functionality: The Marketplace has determined its IT integration approach for implementing essential functionality of its Marketplace, such as assigning internal resources or issuing an RFP for technology services.
9.2a The Marketplace has issued an RFP for a systems integrator (SI).				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
CALT ID number for RFP for an SI vendor: OR
Upload RFP for an SI vendor:
9.2b The Marketplace has issued an RFP for a Marketplace platform.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
CALT ID number for RFP for an Marketplace platform vendor: OR
Upload RFP for an Marketplace platform vendor:
9.2c The Marketplace has issued an RFP for an IV&V vendor.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
CALT ID number for RFP for an IV&V vendor OR
Upload RFP for an IV&V vendor:
9.2d The Marketplace has selected an SI and has signed the contract.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
CALT ID number for SI contract: OR
Upload SI contract:
9.2e The Marketplace has selected a vendor for a Marketplace platform and has signed the contract.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
CALT ID number for Marketplace platform contract: OR
Upload Marketplace platform contract:
9.2f The Marketplace has selected an IV&V vendor and has signed the contract.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
CALT ID number for signed IV&V contract: OR
Upload signed IV&V contract:
9.2g The Marketplace has effectively achieved HHS-defined essential functionality for each required activity via test results, defect tracking reports, and confirmed by IV&V reports.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
9.2		I attest this activity is complete ☐	I attest this activity will be complete ☐			Completed/Expected Completion Date Click here to enter a date.

10.0 Privacy and Security

HHS recognizes that states seeking to transition between Marketplace models after plan year 2014 may have system capabilities and/or policies in place that have already been developed and paid for as part of the implementation of their plan year 2014 Marketplace. States that intend to leverage functionalities, policies, and/or system solutions are not required to resubmit documentation or artifacts that have been previously approved by HHS; however, states should submit any documentation or artifacts that have been modified to support the build and overall approval of its new Marketplace model. A state may also upload a text document that lists artifacts that the state previously submitted to CMS that are now updated to include Marketplace requirements/functionality (e.g., a listing of CALT IDs in a text document). Please work with your State Officer to determine which privacy and security activities are applicable to your Marketplace model.

All State-based Marketplaces (SBMs) will need to establish security and privacy standards consistent with 45 CFR 155.260 and 155.280. As a condition to connect to the Federal Data Services Hub, the U.S. Department of Health and Human Services (HHS requires states to use the Minimum Acceptable Risk Standards for Exchanges (MARS-E) guidance as a minimum standard upon which to base their own security standards. In addition, SBMS should refer to the checklist in the Privacy and Security Timelines and Artifacts For Health Insurance Marketplaces, Medicaid/CHIP Agencies and Partner Organizations April 2013 to determine the privacy and security documents that apply to your Marketplace.

10.1	Privacy and Security Standards, Policies and Procedures: The Marketplace has established and implemented written policies and procedures and has all required privacy and security agreements in place according to the standards set forth in 45 CFR 155.260(a) – (g).
10.1a The Marketplace has completed the ACA Health Insurance Exchange Privacy Impact Assessment (PIA) and submitted to CMS.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
CALT ID number for PIA:
10.1b The Marketplace has submitted its System Security Plan (SSP) document.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
CALT ID number for SSP document:
10.1b1 The Marketplace has submitted its SSP workbook.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
CALT ID number for SSP workbook:
10.1b2 The Marketplace has selected an Independent Assessor to perform a Security Assessment of the Marketplace.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
10.1b3 The Marketplace has submitted its Independent Security Assessment Plan & Results report.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
CALT ID number for Independent Security Test Plan & Results report:
10.1b4 The Marketplace has submitted its Plan of Actions & Milestones (POA&M) based on residual risks identified during the Independent Security Assessment to obtain an initial Authority to Connect, as required by HHS.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
CALT ID number for Plan of Actions & Milestones (POA&M):
10.1c The Marketplace has developed its Information Security Risk Assessment document.				☐ Not Started		Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress		Expected Completion Date Click here to enter a date.
				☐ Complete		Completion Date Click here to enter a date.
CALT ID number for Information Security Risk Assessment:
10.1d The Marketplace has signed and submitted the Computer Matching Agreement (CMA) between CMS and state-based administering entities to CMS.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
CALT ID number for CMA:
10.1e The Marketplace has signed and submitted the Information Exchange Agreement (IEA) to CMS.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
CALT ID number for IEA:
10.1f The Marketplace has executed all required Interconnection Security Agreements (ISA) (i.e., Master and Associate ISAs).				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
CALT ID number for ISA:
10.1		I attest this activity is complete ☐	I attest this activity will be complete ☐				Completed/Expected Completion Date Click here to enter a date.

10.2	Safeguards: The Marketplace has established safeguards to protect the confidentiality of all Federal information received through the FDSH, including but not limited to Federal tax information.
10.2a The Marketplace has developed its Affordable Care Act Safeguard Security Report (SSR) for IRS for approval.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
CALT ID number for SSR:
10.2b The Marketplace has received a letter of acceptance from the IRS on its Safeguard Security Report (SSR).				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
10.2		I attest this activity is complete ☐	I attest this activity will be complete ☐			Completed/Expected Completion Date Click here to enter a date.

10.3	Connection to the FDSH: The Marketplace has implemented and verified the privacy and security safeguards required to connect to the FDSH.
10.3a If applicable: The Marketplace has performed its own Security Assessment and Authorization, and has received an Authority to Operate (ATO) from the Marketplace authorizing official.					☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
					☐ In Progress	Expected Completion Date Click here to enter a date.
					☐ Complete	Completion Date Click here to enter a date.
Upload ATO:
10.3b The Marketplace has obtained HHS approval for an Authority to Connect (ATC) to the FDSH.			☐ Not Started			Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
			☐ In Progress			Expected Completion Date Click here to enter a date.
			☐ Complete			Completion Date Click here to enter a date.
Upload ATC:
10.3		I attest this activity is complete ☐		I attest this activity will be complete ☐			Completed/Expected Completion Date Click here to enter a date.

11.0 Oversight and Monitoring

11.1

Oversight and Monitoring Policies and Procedures: The Marketplace has written policies and procedures and has tools and/or systems to perform routine monitoring and auditing of Marketplace activities, including fraud, waste, and abuse (and will supplement those policies and procedures to implement regulations promulgated under the Affordable Care Act 1313). The Marketplace also has the capacity to maintain books, records, documents, and other evidence of procedures and practices to demonstrate compliance for each benefit year for at least 10 years.

11.1a The Marketplace has policies and procedures in place for performing routine oversight and monitoring of Marketplace activities, as well as for maintaining the necessary documentation to demonstrate compliance with Federal standards.

☐ Not Started

Expected Start Date Click here to enter a date.

Expected Completion Date Click here to enter a date.

☐ In Progress

Expected Completion Date Click here to enter a date.

☐ Complete

Completion Date Click here to enter a date.

Upload oversight and monitoring policies and procedures:

Upload a timeline for continual monitoring of operationalized Marketplace oversight activities:

11.1b The Marketplace has defined roles and responsibilities for individuals and organizations responsible for oversight and monitoring.

☐ Not Started

Expected Start Date Click here to enter a date.

Expected Completion Date Click here to enter a date.

☐ In Progress

Expected Completion Date Click here to enter a date.

☐ Complete

Completion Date Click here to enter a date.

Responsible Marketplace Staff or Organization (Name, title, and contact information)	Defined Role and Responsibility for Oversight	Defined Role and Responsibility for Monitoring

11.1c The Marketplace has developed a comprehensive training program for Marketplace personnel on common oversight and monitoring concepts, regulations, and processes.

☐ Not Started

Expected Start Date Click here to enter a date.

Expected Completion Date Click here to enter a date.

☐ In Progress

Expected Completion Date Click here to enter a date.

☐ Complete

Completion Date Click here to enter a date.

Upload oversight and monitoring training program:

11.1d The Marketplace has established quality controls as part of oversight and monitoring of Marketplace activities.

☐ Not Started

Expected Start Date Click here to enter a date.

Expected Completion Date Click here to enter a date.

☐ In Progress

Expected Completion Date Click here to enter a date.

☐ Complete

Completion Date Click here to enter a date.

Upload documentation of quality controls to be used for oversight and monitoring activities:

Upload documentation of systems to be used to assist with oversight and monitoring activities:

11.1e The Marketplace has established an IT governance board and has developed policies and procedures for management controls and risk management systems.

☐ Not Started

Expected Start Date Click here to enter a date.

Expected Completion Date Click here to enter a date.

☐ In Progress

Expected Completion Date Click here to enter a date.

☐ Complete

Completion Date Click here to enter a date.

Upload management controls policies and procedures:

Upload risk management system policies and procedures:

Upload documentation of systems to be used for IT oversight and monitoring activities:

11.1

I attest this activity is complete ☐

I attest this activity will be complete ☐

Completed/Expected Completion Date Click here to enter a date.

11.2	Mechanisms for Reporting: The Marketplace has the capacity to collect and report performance and outcome metrics related to Marketplace activities, including metrics related to fraud, waste, and abuse, in a format and manner specified by HHS necessary for, but not limited to, annual reports required by Affordable Care Act 1313(a).
11.2a The Marketplace has developed policies, procedures, and a timeline for the collection and reporting of performance and outcome metrics, including HHS’ performance metrics.			☐ Not Started		Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
			☐ In Progress		Expected Completion Date Click here to enter a date.
			☐ Complete		Completion Date Click here to enter a date.
Upload policies and procedures for collecting performance and outcome metrics:
Upload timeline for collecting and reporting performance and outcome metrics:
11.2b If applicable: The Marketplace has performance and outcome metrics that are in addition to HHS’ Marketplace performance metrics.			☐ Not Started		Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
			☐ In Progress		Expected Completion Date Click here to enter a date.
			☐ Complete		Completion Date Click here to enter a date.
Upload state-specific list of metrics:
11.2c The Marketplace has developed policies, procedures, and a timeline for reporting instances of suspected fraud, waste, and abuse, including mechanisms for reporting the results of fraud, waste, and abuse investigations.			☐ Not Started		Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
			☐ In Progress		Expected Completion Date Click here to enter a date.
			☐ Complete		Completion Date Click here to enter a date.
Upload policies and procedures for reporting instances of fraud, waste, and abuse, including mechanisms for reporting the results of investigations regarding fraud, waste, and abuse:
11.2d The Marketplace has defined enforcement standards for fraud, waste, and abuse that are clearly and consistently communicated to employees, business partners, and consumers.			☐ Not Started		Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
			☐ In Progress		Expected Completion Date Click here to enter a date.
			☐ Complete		Completion Date Click here to enter a date.
Upload enforcement standards for fraud, waste, and abuse:
11.2		I attest this activity is complete ☐		I attest this activity will be complete ☐		Completed/Expected Completion Date Click here to enter a date.

11.3	Financial Integrity: The Marketplace has instituted policies and procedures that promote compliance with the financial integrity provisions of Affordable Care Act 1313 (and will supplement those policies and procedures to implement regulations promulgated under the Affordable Care Act 1313), including the requirements related to accounting, reporting, auditing, cooperation with investigations, and application of the False Claims Act.
11.3a The Marketplace has adopted financial or accounting standards in accordance with generally accepted accounting principles (GAAP).			☐ Not Started		Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
			☐ In Progress		Expected Completion Date Click here to enter a date.
			☐ Complete		Completion Date Click here to enter a date.
Upload policies and procedures for adherence to GAAP:
11.3b The Marketplace has developed policies and procedures that promote compliance with financial integrity requirements, including accounting, reporting, auditing, cooperation with investigations, and application of False Claims Act.			☐ Not Started		Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
			☐ In Progress		Expected Completion Date Click here to enter a date.
			☐ Complete		Completion Date Click here to enter a date.
Upload financial integrity policies and procedures:
11.3		I attest this activity is complete ☐		I attest this activity will be complete ☐		Completed/Expected Completion Date Click here to enter a date.

12.0 Contingency Planning

12.1	Contingency/Risk Mitigation Operations: The Marketplace has developed and submitted to HHS its contingency plans. Please refer to CMS guidance for current guidance on contingency plan submissions for SBMs.
12.1a The Marketplace has submitted a contingency plan for any functionality that may not be available for the initial “go-live” date of the Marketplace, which includes any interim plans for a work-around, as well a plan to move from the work-around to a final solution at a later date.			☐ Not Started		Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
			☐ In Progress		Expected Completion Date Click here to enter a date.
			☐ Complete		Completion Date Click here to enter a date.
CALT ID number for contingency plan documentation: OR
Upload contingency plan documentation:
12.1b The Marketplace has submitted both an operational contingency and a recovery operations plan for CMS review and validation.			☐ Not Started		Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
			☐ In Progress		Expected Completion Date Click here to enter a date.
			☐ Complete		Completion Date Click here to enter a date.
CALT ID number for operational contingency and recovery operations plan documentation: OR
Upload operational contingency and recovery operations plan documentation:
12.1		I attest this activity is complete ☐		I attest this activity will be complete ☐		Completed/Expected Completion Date Click here to enter a date.

13.0 Re-Use

HHS recognizes that states seeking to transition between Marketplace models after plan year 2014 may have system capabilities and/or policies in place that have already been developed and paid for as part of the implementation of their plan year 2014 Marketplace. States that intend to leverage functionalities, policies, and/or system solutions are not required to resubmit documentation or artifacts that have been previously approved by HHS; however, states should submit any documentation or artifacts that have been modified to support the build and overall approval of its new Marketplace model. Please work with your State Officer to identify any re-use opportunities for your state.

13.1	Re-Use: The Marketplace has participated in discussions between states and/or solutions being developed cooperatively between states.
13.1a The Marketplace has submitted re-use documentation, which identifies aspects of its system that it is willing to provide to other states for re-use.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
CALT ID number for re-use documentation: OR
Upload re-use documentation:
13.1		I attest this activity is complete ☐	I attest this activity will be complete ☐			Completed/Expected Completion Date Click here to enter a date.

14.0 Coordination between the State-based Marketplace and the Federally-Facilitated Marketplace

14.1	Coordination Strategy between the Federally-facilitated Marketplace and the State-based Marketplace: The Marketplace has developed and documented a coordination strategy between the Federally-facilitated Marketplace and the state’s Marketplace.

14.1a The Marketplace has a coordination strategy with the Federally-facilitated Marketplace and formalized agreements are in place.		☐ Not Started		Expected Start Date  Expected Completion Date
		☐ In Progress		Expected Completion Date
		☐ Complete		Completion Date
Upload documentation:
14.1	I attest this activity is complete ☐		I attest this activity will be complete ☐		Completed/Expected Completion Date

State Partnership Marketplace Blueprint Application

1. Legal Authority and Governance – Not Applicable

2.0 Consumer and Stakeholder Engagement and Support

The U.S. Department of Health and Human Services (HHS) recognizes that states seeking to transition between Marketplace models after plan year 2014 may have system capabilities and or policies in place that have already been developed and paid for as part of the implementation of their plan year 2014 Marketplace. States that intend to leverage existing functionalities, personnel, policies, and/or system solutions are not required to resubmit documentation or artifacts that have been previously approved by HHS; however, states should submit any documentation or artifacts that have been modified to support the build and overall approval of its new Marketplace model. A state may also upload a text document that lists artifacts that the state previously submitted to the Centers for Medicare & Medicaid Services (CMS) that are now updated to include Marketplace requirements/functionality (e.g., a listing of CALT IDs in a text document).

2.1	If electing to conduct Outreach and Education activities: Stakeholder Consultation Plan: The State Partnership Marketplace (SPM) has developed and implemented a supplemental stakeholder consultation plan for SPM activities.
2.1a The State Partnership Marketplace has developed a supplemental stakeholder consultation plan that addresses how consultations will occur on an ongoing basis with consumers, small businesses, state Medicaid and Children’s Health Insurance Program (CHIP) agencies, agents/brokers, employer organizations, and other relevant stakeholders as required under 45 CFR 155.130.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload stakeholder consultation plan:
2.1b The State Partnership Marketplace has made available stakeholder consultation schedules, agendas, and feedback received (to be updated quarterly).				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload stakeholder consultation materials:
2.1		I attest this activity is complete ☐	I attest this activity will be complete ☐			Completed/Expected Completion Date Click here to enter a date.

2.2	If applicable: Tribal Consultation: If a state has Federally-recognized tribes, and is electing to conduct outreach and education activities, the State Partnership Marketplace, in consultation with the Federally-recognized tribes, has developed and submitted to HHS a tribal consultation policy and process pursuant to 45 CFR 155.130(f). If not electing to conduct outreach and education activities, the State Partnership Marketplace participates in the Federally-facilitated Marketplace (FFM) tribal consultation process related to applicable and relevant activities and functions of the State Partnership Marketplace pursuant to 45 CFR 155.130(f).
2.2a If electing to conduct outreach and education activities: The State Partnership Marketplace has a tribal consultation policy that includes culturally appropriate mechanisms for initiating and engaging in consultation sessions with tribal governments.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload tribal consultation policy:
2.2b If electing to conduct outreach and education activities: The State Partnership Marketplace has made available to the public tribal consultation schedules, agendas, outcomes, and/or next steps resulting from tribal consultation sessions (to be updated quarterly).				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload tribal consultation materials:
2.2c If not electing to conduct outreach and education activities: The State Partnership Marketplace has conducted engagement and follow-up activities with tribes resulting from feedback and recommendations provided during the Federally-facilitated Marketplace’s tribal consultation sessions.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload materials from follow-up tribal activities:
2.2		I attest this activity is complete ☐	I attest this activity will be complete ☐			Completed/Expected Completion Date Click here to enter a date.

2.3	If electing to conduct Outreach and Education activities: Outreach and Education: The State Partnership Marketplace conducts outreach and education activities to educate consumers about and encourage participation in the State Partnership Marketplace and insurance affordability programs pursuant to 45 CFR 155.205(c)(e). Any outreach and education materials and activities must be timely and accessible, and written in plain language. Materials must also be timely and accessible for individuals living with disabilities and individuals who have limited English proficiency. The State Partnership Marketplace must provide and inform individuals about the availability of auxiliary aids and services for people with disabilities. Individuals who have limited English proficiency must receive language services at no cost to the individual, including oral interpretation, written translations, and taglines in non-English languages indicating the availability of language services. HHS expects that outreach and education materials will address eligibility and enrollment options, program information, benefits and services available through the Marketplace, Small Business Health Options Program (SHOP), and other insurance affordability programs. In addition, the State Partnership Marketplace has an outreach plan for the general public and for the stakeholders listed in 45 CFR 155.130, including: individuals and entities with experience in facilitating enrollment such as agents/brokers, small businesses and their employees, large employers, health care providers, Federally-recognized tribes, and advocates for hard-to-reach populations.
2.3a The State Partnership Marketplace has developed an outreach and education plan that addresses outreach for each type of stakeholder identified in 45 CFR 155.130, and metrics and criteria for assessing the impact of outreach and marketing efforts.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload outreach and education plan:
Upload metrics and criteria from assessing marketing efforts:
2.3b The State Partnership Marketplace has created outreach materials which could include advertisements, social media, and other digital campaign materials, or has otherwise created a plan for conducting outreach and education consistent with HHS regulations and guidance, pursuant to 45 CFR 155.205 (e).				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload sample digital campaign materials:
2.3c The State Partnership Marketplace has a paid media plan including dates, channels, markets, and budget.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload paid media plan:
2.3d The State Partnership Marketplace has developed media and/or marketing materials in plain language and in a manner that is accessible and timely to all consumers, including consumers with a disability.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload sample marketing materials:
2.3		I attest this activity is complete ☐	I attest this activity will be complete ☐			Completed/Expected Completion Date Click here to enter a date.

2.4	Navigator Program: The State Partnership Marketplace has established a process to conduct ongoing coordination with HHS for monitoring of Navigator entities and providing technical assistance to Navigators.
2.4a The State Partnership Marketplace has developed an oversight and monitoring plan for the Navigator program (e.g., any state-specific certification or licensure requirements), including how the State Partnership Marketplace will provide technical assistance to Navigators.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload Navigator oversight and monitoring plan:
2.4b If applicable: The State Partnership Marketplace has developed state-specific training content and materials for Navigators.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload sample Navigator training materials:
2.4		I attest this activity is complete ☐	I attest this activity will be complete ☐			Completed/Expected Completion Date Click here to enter a date.

2.5	If electing to conduct Consumer Assistance activities: Non-Navigator Assistance Personnel Program: The State Partnership Marketplace has established a non-Navigator assistance personnel program distinct from the Navigator program. The State Partnership Marketplace has a process in place to operate the program consistent with the applicable requirements of 45 CFR 155.205(c), (d), and (e), and if the Non-Navigator program is funded with section 1311(a) Exchange Establishment Grant funds, 45 CFR 155.215(a)(2) and 155.215(b) through (e).
2.5a The State Partnership Marketplace has created a plan for a non-Navigator assistance personnel program that addresses developing and meeting training standards, Culturally and Linguistically Appropriate Services (CLAS) standards, conflict of interest standards, adherence to privacy and security standards, and if applicable, how the Marketplace will comply with and ensure non-Navigator assistance personnel’s compliance with standards under 155.215(a)(2) and 155.215(b) through (e). The plan should note how the non-Navigator assistance personnel program will compliment and/or coordinate with the Navigator program.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload non-Navigator assistance personnel program operating plan:
If applicable: Name of training contractor:
Upload training standards:
Upload conflict of interest standards:
Upload plan for adherence to privacy and security standards:
2.5b The State Partnership Marketplace has created a timeline and strategy for funding the non-Navigator assistance personnel program, including a sustainability plan.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload timeline and strategy for funding non-Navigator assistance personnel program:
2.5c The State Partnership Marketplace has developed an oversight and monitoring plan for the non-Navigator assistance personnel program (e.g., any state-specific certification or licensure requirements).				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload oversight and monitoring plan:
2.5d The State Partnership Marketplace has identified and established legal relationships with non-Navigator assistance personnel.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload a list and description of non-Navigator assistance personnel including funding agreements/contracts, and service areas that non-Navigator assistance personnel will cover:
2.5e If applicable: The State Partnership Marketplace has developed state-specific training materials for the non-Navigator assistance personnel program, including how non-Navigator assistance personnel must adhere to conflict of interest standards, Culturally and Linguistically Appropriate Services (CLAS) standards, accessibility, and privacy and security standards implemented pursuant to CFR 155.260, and if applicable, how non-Navigator assistance personnel must adhere to standards under 155.215(a)(2) and 155.215(b) through (d).				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload non-Navigator assistance personnel training materials:
2.5f The State Partnership Marketplace has deployed the non-Navigator assistance personnel program for consumers, which includes releasing a funding opportunity funding announcement or other vehicle to announce the availability of funding to support such work, and has allocated funding to appropriate entities through a state-approved process.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
2.5		I attest this activity is complete ☐	I attest this activity will be complete ☐			Completed/Expected Completion Date Click here to enter a date.

2.6	If electing to conduct Consumer Assistance activities: Agents and Brokers: If the state permits activities by agents and brokers pursuant to 45 CFR 155.220(a), the State Partnership Marketplace has clearly defined the role of agents and brokers including, as applicable, evidence of licensure, training, and compliance with 45 CFR 155.220(c)-(e). The State Partnership Marketplace will have agreements with agents/brokers operating in the individual Marketplace, consistent with 45 CFR 155.220(d), which address agent/broker registration with the State Partnership Marketplace, training on qualified health plan (QHP) options and insurance affordability program(s), and adherence to privacy and security standards implemented, pursuant to 45 CFR 155.260.
2.6a The State Partnership Marketplace has developed policies and procedures for agents and brokers (e.g., state licensure, training, verification of compliance with privacy/security standards), including a process for determining how the Marketplace’s website will interface with agent/broker websites (if applicable).				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload agent and broker policies and procedures:
2.6b The State Partnership Marketplace has developed templates for agreements between the Marketplace and agents and brokers, including language on addressing agents and brokers’ compliance with applicable requirements under 155.220.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload template agreements:
2.6		I attest this activity is complete ☐	I attest this activity will be complete ☐			Completed/Expected Completion Date Click here to enter a date.

2.7	If electing to conduct Consumer Assistance activities: Web Brokers: If the state permits this activity pursuant to 45 CFR 155.220(c)(3), the State Partnership Marketplace has ensured that any agent or broker whose website will be used to select QHPs will comply with all applicable provisions of 45 CFR 155.220.
2.7a The State Partnership Marketplace has developed policies and procedures for web brokers, including ensuring compliance with all applicable requirements of 155.220(c)(3), and determining how the Marketplace’s website will interface with web brokers’ websites.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload web broker policies and procedures:
2.7b The State Partnership Marketplace has developed templates for agreements between the Marketplace and web brokers, including language on addressing web brokers’ compliance with applicable requirements under 45 CFR 155.220.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload template agreements:
2.7		I attest this activity is complete ☐	I attest this activity will be complete ☐			Completed/Expected Completion Date Click here to enter a date.

3. Eligibility and Enrollment – Not Applicable

3. Plan Management – Not Applicable

3. Risk Adjustment – Not Applicable

3. SHOP – Not Applicable

3. Organization and Human Resources – Not Applicable

3. Finance and Accounting – Not Applicable

9.0 Technology – If Applicable

HHS recognizes that states seeking to transition between Marketplace models after plan year 2014 may have system capabilities and or policies in place that have already been developed and paid for as part of the implementation of their plan year 2014 Marketplace. States that intend to leverage functionalities, policies, and/or system solutions are not required to resubmit documentation or artifacts that have been previously approved by HHS; however, states should submit any documentation or artifacts that have been modified to support the build and overall approval of any technology functions operated by the of the State Partnership Marketplace for plan year 2015. A state may also upload a text document that lists artifacts that the state previously submitted to CMS that are now updated to include Marketplace requirements/functionality (e.g., a listing of CALT IDs in a text document). Please work with your State Officer to determine which technology activities are applicable to your Marketplace model.

9.1	If applicable: Essential Functionality: The State Partnership Marketplace has provided risk management artifacts, completed testing, and effectively achieved HHS-defined essential functionality for each required activity via test results and defect tracking reports.
9.1a The State Partnership Marketplace has completed the project schedule and risk registers. Project schedules and risk registers are uploaded into CALT at a minimum of every two weeks.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
9.1b The State Partnership Marketplace has obtained approval to participate in formal Federal integration testing.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
9.1c The State Partnership Marketplace has completed formal Marketplace system testing and submits all applicable test reports, including Blueprint test scenario results and applicable state testing summaries.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload system and performance test reports:
9.1d The State Partnership Marketplace has demonstrated the core functionality of its Marketplace through an online demonstration of the following: Transfer of applications. Appeals process.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
9.1e The State Partnership Marketplace has demonstrated the core functionality to provide consumer assistance through the call center including transferring calls from the FFM or Medicaid call center.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
9.1f The State Partnership Marketplace has completed user acceptance testing (UAT) with no major defects.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload documentation:
9.1		I attest this activity is complete ☐	I attest this activity will be complete ☐			Completed/Expected Completion Date Click here to enter a date.

10.0 Privacy and Security

HHS recognizes that states seeking to transition between Marketplace models after plan year 2014 may have system capabilities and or policies in place that have already been developed and paid for as part of the implementation of their plan year 2014 Marketplace. A state that intends to leverage functionalities, policies, and/or system solutions is not required to resubmit documentation or artifacts that have been previously approved by HHS; however, states should submit any documentation or artifacts that have been modified to support the build and overall approval of any privacy and security functionality operated by the State Partnership Marketplace as part of its plan year 2015 operations. A state may also upload a text document that lists artifacts that the state previously submitted to CMS that are now updated to include Marketplace requirements/functionality (e.g., a listing of CALT IDs in a text document). Please work with your State Officer to determine which privacy and security activities are applicable to your Marketplace model.

The U.S. Department of Health and Human Services (HHS recommends that states use the Minimum Acceptable Risk Standards for Exchanges (MARS-E) guidance as a minimum standard upon which to base their own security standards, but they are not required to do so. Please refer to the checklist in the Privacy and Security Timelines and Artifacts For Health Insurance Marketplaces, Medicaid/CHIP Agencies and Partner Organizations April 2013 to determine the privacy and security documents that apply to your Marketplace.

10.1	If applicable: Privacy and Security Standards, Policies and Procedures: The State Partnership Marketplace has established and implemented written policies and procedures and has all required privacy and security agreements in place according to the standards set forth in 45 CFR 155.260(a)–(g).
10.1a The State Partnership Marketplace has completed the ACA Health Insurance Exchange Privacy Impact Assessment (PIA) and submitted to CMS.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
CALT ID number for PIA:
10.1b The State Partnership Marketplace has submitted its System Security Plan (SSP) document.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
CALT ID number for SSP:
10.1b1 The State Partnership Marketplace has submitted its SSP workbook.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
CALT ID number for SSP workbook:
10.1b2 The State Partnership Marketplace has selected an Independent Assessor to perform a Security Assessment of the State Partnership Marketplace.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
10.1b3 The State Partnership Marketplace has submitted its Independent Security Assessment Plan and Results Report.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
CALT ID number for Independent Security Assessment Plan and Results Report:
10.1b4 The State Partnership Marketplace has submitted its Plan of Actions & Milestones (POA&M) based on residual risks identified during the Independent Security Assessment to obtain an initial Authority to Connect, as required by HHS.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
CALT ID number for POA&M:
10.1c The State Partnership Marketplace has developed its Information Security Risk Assessment document.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
CALT ID number for Information Security Risk Assessment document:
10.1d The State Partnership Marketplace has signed and submitted the Computer Matching Agreement (CMA) between CMS and State-based administering entities to CMS.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
CALT ID number for CMA:
10.1e The State Partnership Marketplace has signed and submitted the Information Exchange Agreement (IEA) to CMS.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
CALT ID number for IEA:
10.1f The State Partnership Marketplace has developed its Interconnection Security Agreement (ISA).				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
CALT ID number for ISA:
10.1		I attest this activity is complete ☐	I attest this activity will be complete ☐			Completed/Expected Completion Date Click here to enter a date.

11.0 Oversight and Monitoring

11.1

Oversight and Monitoring Policies and Procedures: The State Partnership Marketplace has written policies and procedures and has tools and/or systems to perform routine monitoring and auditing of State Partnership Marketplace activities, including fraud, waste, and abuse (and will supplement those policies and procedures to implement regulations promulgated under the Affordable Care Act 1313). The State Partnership Marketplace also has the capacity to maintain books, records, documents, and other evidence of procedures and practices to demonstrate compliance for each benefit year for at least 10 years.

11.1a The State Partnership Marketplace has policies and procedures in place for performing routine oversight and monitoring of Marketplace activities, as well as for maintaining the necessary documentation to demonstrate compliance with Federal standards.

☐ Not Started

Expected Start Date Click here to enter a date.

Expected Completion Date Click here to enter a date.

☐ In Progress

Expected Completion Date Click here to enter a date.

☐ Complete

Completion Date Click here to enter a date.

Upload oversight and monitoring policies and procedures:

Upload a timeline for continual monitoring of operationalized State Partnership Marketplace oversight activities:

11.1b The State Partnership Marketplace has defined roles and responsibilities for individuals and organizations responsible for oversight and monitoring.

Responsible State Partnership Marketplace Staff or Organization (Name, title, and contact information)	Defined Role and Responsibility for Oversight	Defined Role and Responsibility for Monitoring

11.1c The State Partnership Marketplace has developed a comprehensive training program for State Partnership Marketplace personnel on common oversight and monitoring concepts, regulations, and processes.

☐ Not Started

Expected Start Date Click here to enter a date.

Expected Completion Date Click here to enter a date.

☐ In Progress

Expected Completion Date Click here to enter a date.

☐ Complete

Completion Date Click here to enter a date.

Upload oversight and monitoring training program:

11.1d The State Partnership Marketplace has established quality controls as part of oversight and monitoring of State Partnership Marketplace activities.

☐ Not Started

Expected Start Date Click here to enter a date.

Expected Completion Date Click here to enter a date.

☐ In Progress

Expected Completion Date Click here to enter a date.

☐ Complete

Completion Date Click here to enter a date.

Upload documentation of quality controls to be used for oversight and monitoring activities:

Upload documentation of systems to be used to assist with oversight and monitoring activities:

11.1

I attest this activity is complete ☐

I attest this activity will be complete ☐

Completed/Expected Completion Date Click here to enter a date.

11.2	If applicable Financial Integrity: The State Partnership Marketplace has instituted policies and procedures that promote compliance with the financial integrity provisions of Affordable Care Act 1313 (and will supplement those policies and procedures to implement regulations promulgated under the Affordable Care Act 1313), including the requirements related to accounting, reporting, auditing, cooperation with investigations, and application of the False Claims Act.
11.2a If applicable: The State Partnership Marketplace has adopted financial or accounting standards in accordance with generally accepted accounting principles (GAAP).			☐ Not Started		Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
			☐ In Progress		Expected Completion Date Click here to enter a date.
			☐ Complete		Completion Date Click here to enter a date.
Upload policies and procedures for adherence to GAAP:
11.2b If applicable: The State Partnership Marketplace has developed policies and procedures that promote compliance with financial integrity requirements, including accounting, reporting, auditing, cooperation with investigations, and application of False Claims Act.			☐ Not Started		Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
			☐ In Progress		Expected Completion Date Click here to enter a date.
			☐ Complete		Completion Date Click here to enter a date.
Upload financial integrity policies and procedures:
11.2		I attest this activity is complete ☐		I attest this activity will be complete ☐		Completed/Expected Completion Date Click here to enter a date.

12.0 Contingency Planning

12.1	Contingency/Risk Mitigation Operations: The State Partnership Marketplace has developed and submitted to HHS contingency plans. Please refer to CMS guidance for current guidance on contingency plan submissions for State Partnership Marketplaces.
12.1a The State Partnership Marketplace has submitted a contingency plan for any functionality that may not be available for the initial “go-live” date of the State Partnership Marketplace, which includes any interim plans for a work-around, as well a plan to move from the work-around to a final solution at a later date.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
CALT ID number for contingency plan documentation: OR
Upload contingency plan documentation:
12.1b The State Partnership Marketplace has submitted an operational contingency and recovery operations plan for CMS review and validation.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
CALT ID number for operational contingency and recovery operations plan documentation: OR
Upload operational contingency and recovery operations plan documentation:
12.1		I attest this activity is complete ☐	I attest this activity will be complete ☐			Completed/Expected Completion Date Click here to enter a date.

13.0 Re-Use

HHS recognizes that a state seeking to transition between Marketplace models after plan year 2014 may have system capabilities and or policies in place that have already been developed and paid for as part of the implementation of their plan year 2014 Marketplace. A state that intends to leverage functionalities, policies, and/or system solutions are not required to resubmit documentation or artifacts that have been previously approved by HHS; however, a state should submit any documentation or artifacts that have been modified to support the build and overall approval of its new Marketplace model. A state may also upload a text document that lists artifacts that the state previously submitted to CMS that are now updated to include Marketplace requirements/functionality (e.g., a listing of CALT IDs in a text document). Please work with your State Officer to identify re-use opportunities for your state.

13.1	Re-Use: The State Partnership Marketplace has participated in discussions between states and/or solutions being developed cooperatively between states.
13.1a The State Partnership Marketplace has submitted re-use documentation, which identifies aspects of its system that it is willing to provide to other states for re-use.			☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
			☐ In Progress	Expected Completion Date Click here to enter a date.
			☐ Complete	Completion Date Click here to enter a date.
CALT ID number for re-use documentation: OR
Upload re-use documentation:
13.1		I attest this activity is complete ☐		I attest this activity will be complete ☐	Completed/Expected Completion Date Click here to enter a date.

14.0 Coordination between the Partnership and the Federally-Facilitated Marketplace

14.1	Coordination Strategy between the Federally-facilitated Marketplace and the State Partnership Marketplace: The State Partnership Marketplace has developed and documented a coordination strategy with the Federally-facilitated Marketplace.
14.1a The State Partnership Marketplace has a coordination strategy with the Federally-facilitated Marketplace and formalized agreements are in place.				☐ Not Started	Expected Start Date  Expected Completion Date
				☐ In Progress	Expected Completion Date
				☐ Complete	Completion Date
Upload documentation:
14.1		I attest this activity is complete ☐	I attest this activity will be complete ☐			Completed/Expected Completion Date

State-based Small Business Health Options Program (SHOP) Marketplace Blueprint Application

1.0 Legal Authority and Governance

1.1	SHOP Marketplace Enabling Authority: The state has enabling authority to operate only a Small Business Health Options Program (SHOP) Marketplace, consistent with Affordable Care Act Sections 1311 and 1321 and 45 CFR 155.110(a)(2).
1.1a The SHOP Marketplace has been established by state law, regulation, or executive order.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Provide citation: AND Provide URL of SHOP Marketplace enabling authority: If authority is not explicitly defined: Upload a statement from the grantee’s legal counsel, the governor’s legal counsel, or the state’s attorney general certifying authorization:
1.1		I attest this activity is complete ☐	I attest this activity will be complete ☐			Completed/Expected Completion Date Click here to enter a date.

1.2	Regulatory Authority to Certify Qualified Health Plans (QHPs): The SHOP Marketplace has the appropriate authority to perform the certification of QHPs offered through the SHOP and to oversee QHP issuers consistent with 45 CFR 155.1010(a).
1.2a The SHOP Marketplace has the appropriate statutory and/or regulatory authority(ies) to certify QHPs.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Provide citation: AND Provide URL of SHOP Marketplace authority to certify QHPs:
1.2		I attest this activity is complete ☐	I attest this activity will be complete ☐			Completed/Expected Completion Date Click here to enter a date.

1.3	If applicable: Risk Adjustment: If the state is performing risk adjustment, the state has the legal authority to operate the risk adjustment program per 45 CFR 153 and Affordable Care Act 1343.
1.3a The state has the applicable statutory and/or regulatory authority(ies) to operate risk adjustment for the Marketplace.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Provide citation: AND Provide URL of authority to operate risk adjustment:
1.3b The state has selected the entity operating the risk adjustment program. Note: The risk adjustment entity must meet the requirements outlined in 45 CFR 155.110 and cannot be a health insurance issuer. Options include Department of Insurance (DOI), Medicaid, or “other entity.”				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Legal name of entity: Provide description of entity and how entity will meet requirements of 45 CFR 155.110:
1.3		I attest this activity is complete ☐	I attest this activity will be complete ☐			Completed/Expected Completion Date Click here to enter a date.

1.4	Authority to Generate Revenue: The SHOP Marketplace has the appropriate authority to generate revenue to ensure operational sustainability, and has defined methods for generating revenue (e.g., user fees) pursuant to Affordable Care Act 1311(d)(5)(A).
1.4a The SHOP Marketplace has the appropriate statutory and/or regulatory authority(ies) to generate revenue.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Provide citation: AND Provide URL of SHOP Marketplace authority to generate revenue:
1.4		I attest this activity is complete ☐	I attest this activity will be complete ☐			Completed/Expected Completion Date Click here to enter a date.

1.5

Board and Governance Structure: The SHOP Marketplace has established a board and governance structure in compliance with Affordable Care Act 1311(d) and 45 CFR 155.110.

1.5a The SHOP Marketplace has determined its governance structure.

☐ Not Started

Expected Start Date Click here to enter a date.

Expected Completion Date Click here to enter a date.

☐ In Progress

Expected Completion Date Click here to enter a date.

☐ Complete

Completion Date Click here to enter a date.

Planned governance structure (check one):

State agency: ☐ If state agency, please proceed to Section 2.0.

Quasi-governmental entity ☐ Nonprofit ☐ Other ☐

Upload formal, publically adopted SHOP Marketplace charter/by-laws:

1.5b The SHOP Marketplace has established governance principles that include conflict of interest standards, accountability and transparency standards, and disclosure of financial interests.

☐ Not Started

Expected Start Date Click here to enter a date.

Expected Completion Date Click here to enter a date.

☐ In Progress

Expected Completion Date Click here to enter a date.

☐ Complete

Completion Date Click here to enter a date.

Upload board member governance principles:

1.5c The SHOP Marketplace has established a governing board in compliance with Affordable Care Act 1311(d) and 45 CFR 155.110.

☐ Not Started

Expected Start Date Click here to enter a date.

Expected Completion Date Click here to enter a date.

☐ In Progress

Expected Completion Date Click here to enter a date.

☐ Complete

Completion Date Click here to enter a date.

Board Member Name	Affiliation	Health Experience	Consumer Representation

Upload board members bios or resumes:

1.5d The SHOP Marketplace holds scheduled board meetings no less than quarterly.

☐ Not Started

Expected Start Date Click here to enter a date.

Expected Completion Date Click here to enter a date.

☐ In Progress

Expected Completion Date Click here to enter a date.

☐ Complete

Completion Date Click here to enter a date.

Provide link to board meeting schedules and agendas:

1.5

I attest this activity is complete ☐

I attest this activity will be complete ☐

Completed/Expected Completion Date Click here to enter a date.

2.0 Consumer and Stakeholder Engagement and Support

The U.S. Department of Health and Human Services (HHS) recognizes that a state seeking to transition between Marketplace models after plan year 2014 may have system capabilities and/or policies in place that have already been developed and paid for as part of the implementation of their plan year 2014 Marketplace. A state that intend to leverage existing functionalities, personnel, policies, and/or system solutions are not required to resubmit documentation or artifacts that have been previously approved by HHS; however, a state should submit any documentation or artifacts that have been modified to support the build and overall approval of its new Marketplace model. A state may also upload a text document that lists artifacts that the state previously submitted to the Centers for Medicare & Medicaid Services (CMS) that are now updated to include Marketplace requirements/functionality (e.g., a listing of CALT IDs in a text document).

2.1	Stakeholder Consultation Plan: The SHOP Marketplace has developed and implemented a stakeholder consultation plan that includes seeking input for the duration of Marketplace planning and operation from employees, small businesses, agents/brokers, employer organizations, and other relevant stakeholders as required under 45 CFR 155.130.
2.1a The SHOP Marketplace has developed a stakeholder consultation plan that addresses how consultations will occur on an ongoing basis with employees, small businesses, agents/brokers, employer organizations, and other relevant stakeholders as required under 45 CFR 155.130.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload stakeholder consultation plan:
2.1b The SHOP Marketplace has made available stakeholder consultation schedules, agendas, and feedback received (to be updated quarterly).				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload stakeholder consultation materials:
2.1		I attest this activity is complete ☐	I attest this activity will be complete ☐			Completed/Expected Completion Date Click here to enter a date.

2.2	If applicable: Tribal Consultation: If a state has Federally-recognized tribes, the SHOP Marketplace, in consultation with the Federally-recognized tribes, has developed and submitted to HHS a tribal consultation policy and process pursuant to 45 CFR 155.130(f).
2.2a The SHOP Marketplace has a tribal consultation policy that includes culturally appropriate mechanisms for initiating and engaging in consultation sessions with tribal governments.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload tribal consultation policy:
2.2b The SHOP Marketplace has made available to the public tribal consultation schedules, agendas, outcomes, and/or next steps resulting from tribal consultation sessions (to be updated quarterly).				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload tribal consultation materials:
2.2		I attest this activity is complete ☐	I attest this activity will be complete ☐			Completed/Expected Completion Date Click here to enter a date.

2.3	Outreach and Education: The SHOP Marketplace conducts outreach and education activities to educate consumers about and encourage participation in the SHOP Marketplace pursuant to 45 CFR 155.205(c)(e). Any outreach and education materials and activities must be timely, accessible, and written in plain language. Materials must also be timely and accessible for individuals living with disabilities and individuals who have limited English proficiency. The SHOP Marketplace must provide and inform individuals about the availability of auxiliary aids and services for people with disabilities. Individuals who have limited English proficiency must receive language services at no cost to the individual, including oral interpretation, written translations, and taglines in non-English languages indicating the availability of language services. HHS expects that outreach and education materials will address eligibility and enrollment options, program information, benefits and services available through the Marketplace, and other insurance affordability programs. In addition, the SHOP Marketplace has an outreach plan for the stakeholders listed in 45 CFR 155.130, including: individuals and entities with experience in facilitating enrollment such as agents/brokers, small businesses and their employees, large employers, health care providers, Federally-recognized tribes, and advocates for hard-to-reach populations.
2.3a The SHOP Marketplace has developed an outreach and education plan that addresses outreach for each type of stakeholder identified in 45 CFR 155.130, and metrics and criteria for assessing the impact of outreach and marketing efforts.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload outreach and education plan:
Upload metrics and criteria for assessing marketing efforts:
2.3b The SHOP Marketplace has created outreach materials that could include advertisements, social media, and other digital campaign materials, or has otherwise created a plan for conducting outreach and education consistent with HHS regulations and guidance pursuant to 45 CFR 155.205(e).				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload sample digital campaign materials:
2.3c The SHOP Marketplace has a paid media plan including dates, channels, markets, and budget.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload paid media plan:
2.3d The SHOP Marketplace has developed media and/or marketing materials in plain language and in a manner that is accessible and timely to all consumers, including consumers with disabilities.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload sample marketing materials:
2.3		I attest this activity is complete ☐	I attest this activity will be complete ☐			Completed/Expected Completion Date Click here to enter a date.

2.4	Call Center: The SHOP Marketplace provides for the operation of a toll-free telephone hotline (call center) to respond to requests for assistance from the public (including individuals, employers, and employees) pursuant to 45 CFR 155.205(a). The SHOP Marketplace call center is capable of providing information to applicants and enrollees in plain language, in a manner that is accessible and timely for individuals living with disabilities and individuals who have limited English proficiency. The SHOP Marketplace must provide and inform individuals about the availability of auxiliary aids and services for people with disabilities. Individuals who have limited English proficiency must receive language services at no cost to the individual, including oral interpretation.
2.4a The SHOP Marketplace has begun the process of creating or contracting for the call center, such as by hiring call center staff, or by releasing a call center request for proposal (RFP) or contract modification if leveraging existing Medicaid/Children’s Health Insurance Program (CHIP) call center(s). The RFP for a new call center or existing call center must include provisions for language access services for limited English proficient (LEP) individuals and auxiliary aids and services for people with disabilities, pursuant to 45 CFR 155.205(c).				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
The SHOP Marketplace will utilize existing call center: ☐ or the SHOP Marketplace will create a new call center: ☐ Upload plans for creating a call center, such as RFP (if creating new call center), hiring plans, or contract modifications if using an existing call center:
2.4b The SHOP Marketplace has created the call center. For example, if the SHOP Marketplace is establishing a call center through contract, the SHOP Marketplace has awarded a call center contract.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Provide name of call center vendor:
Call center (check one): Integrated with Medicaid: ☐ Operating as a separate entity: ☐ Other:
If applicable: Upload call center contract:
2.4c The SHOP Marketplace has a call center strategy in place for coordinating with the Federally-facilitated Marketplace regarding handling calls between insurance affordability programs and other state and Federal agencies. The call center strategy includes projected call volumes and staffing, systems test scenarios, call flows, referral processes for the individual market, quality scorecard, quality monitoring methodology, and business continuity contingency scenarios.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload call center strategy:
2.4d The SHOP Marketplace has created training materials for customer service representatives, including training schedules and scripts, and information on providing interpretation services for individuals with limited English proficiency, appropriate auxiliary aids and services for people with disabilities, and other accessibility requirements pursuant to 45 CFR 155.205(c)(1), (c)(2)(i), and (c)(3).				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload sample call center training materials:
Start date for SHOP Marketplace call center representative training: Click here to enter a date.
2.4e The Marketplace has performed call center functionality and operational readiness testing (e.g., email and web chat functionality, call routing, connection with interpreter services, call handling, call tracking capabilities, Interactive Voice Response, and Relay Services, TTY/TDD).				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
2.4f The SHOP Marketplace has launched its operational toll-free call center.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
SHOP Marketplace call center phone number:
2.4		I attest this activity is complete ☐	I attest this activity will be complete ☐			Completed/Expected Completion Date Click here to enter a date.

2.5	Website: The SHOP Marketplace has established and maintains an up-to-date website that provides information on QHPs available through the Marketplace, the SHOP, and other insurance affordability programs. It also includes requirements as specified in 45 CFR 155.205(b).The website is required to provide information in plain language and in a manner that is timely and accessible to persons with disabilities and persons with limited English proficiency that are set forth at 155.205(c). This also includes auxiliary aids and services, written translations, and taglines in non-English languages indicating the availability of language services.
2.5a The SHOP Marketplace has created a website operations plan that includes the strategy for projected volumes, systems test scenarios, customer feedback, performance and QA monitoring, and business continuity contingency scenarios.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload website operations plan:
2.5b The SHOP Marketplace website displays a link to the Federal Health Insurance Marketplace website, as well as SHOP-specific premium and cost-sharing amounts, QHP comparison(s), health plan coverage categories (e.g. Bronze, Silver, Gold, Platinum), transparency of coverage measures, and a provider directory.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Provide final URL link to SHOP Marketplace website:
2.5c The SHOP Marketplace has a test plan and has performed testing to ensure 508 compliance and has demonstrated website functionality and readiness, including accessibility for people with disabilities.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload test plan:
Upload testing results:
2.5d The SHOP Marketplace has launched its website for consumers to enroll in coverage.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
2.5		I attest this activity is complete ☐	I attest this activity will be complete ☐			Completed/Expected Completion Date Click here to enter a date.

2.6

Navigator Program: The SHOP Marketplace has established or has a process in place to establish and operate a SHOP-only Navigator program that is consistent with the applicable requirements of 45 CFR 155.210, including the development of training and conflict of interest standards, provision of accessible services for limited English proficient individuals and people with disabilities as specified in 45 CFR 155.215, and adherence to privacy and security standards specified in 45 CFR 155.210 and 45 CFR 155.260.

In addition, states operating a SHOP-only Marketplace are required to comply with 45 CFR 155.210(e)3-4 through referrals to agents and brokers pursuant to 45 CFR 155.705(d)

2.6a The SHOP Marketplace has a plan for operating a Navigator program, and has developed training standards, conflict of interest standards, privacy standards, and has entered into agreements pursuant to 45 CFR 155.260(b) with Navigators to ensure adherence to privacy and security standards.

☐ Not Started

Expected Start Date Click here to enter a date.

Expected Completion Date Click here to enter a date.

☐ In Progress

Expected Completion Date Click here to enter a date.

☐ Complete

Completion Date Click here to enter a date.

Upload Navigator operating plan:

If applicable: Name of training contractor:

Upload training standards:

Upload conflict of interest standards:

Upload SHOP Marketplace/Navigator agreement, including Terms and Conditions, ensuring adherence to privacy and security standards pursuant to 155.260(b) and stipulating grantee’s responsibilities for assuring that individual Navigators comply with all applicable Federal and state statutes and regulations:

2.6b The SHOP Marketplace has a strategy for funding the Navigator program and making the program fully self-sustaining.

☐ Not Started

Expected Start Date Click here to enter a date.

Expected Completion Date Click here to enter a date.

☐ In Progress

Expected Completion Date Click here to enter a date.

☐ Complete

Completion Date Click here to enter a date.

Upload Navigator sustainability plan and timeline for ongoing funding:

2.6c The SHOP Marketplace has developed an oversight and monitoring plan for the Navigator program, including ensuring that Navigator grantee(s) are providing appropriate oversight of individual Navigators to assure compliance with Federal and state requirements and the delivery of high quality services to consumers.

☐ Not Started

Expected Start Date Click here to enter a date.

Expected Completion Date Click here to enter a date.

☐ In Progress

Expected Completion Date Click here to enter a date.

☐ Complete

Completion Date Click here to enter a date.

Upload Navigator oversight and monitoring plan:

2.6d The SHOP Marketplace has released a Navigator request for applications, including an application template.

☐ Not Started

Expected Start Date Click here to enter a date.

Expected Completion Date Click here to enter a date.

☐ In Progress

Expected Completion Date Click here to enter a date.

☐ Complete

Completion Date Click here to enter a date.

Upload Navigator application:

2.6e The SHOP Marketplace has awarded Navigator grants.

☐ Not Started

Expected Start Date Click here to enter a date.

Expected Completion Date Click here to enter a date.

☐ In Progress

Expected Completion Date Click here to enter a date.

☐ Complete

Completion Date Click here to enter a date.

Grantee	Award Amount	Service Area Covered

2.6f The SHOP Marketplace has developed state-specific training materials on outreach and education for SHOP-only Navigators.

☐ Not Started

Expected Start Date Click here to enter a date.

Expected Completion Date Click here to enter a date.

☐ In Progress

Expected Completion Date Click here to enter a date.

☐ Complete

Completion Date Click here to enter a date.

Upload sample Navigator training materials:

2.6g The Marketplace has deployed a Navigator program for consumers, including having released a funding opportunity announcement or other vehicle to announce the availability of grant awards, awarded such grants to appropriate entities, and ensured that grantees have trained staff that are available to assist consumers as needed.

☐ Not Started

Expected Start Date Click here to enter a date.

Expected Completion Date Click here to enter a date.

☐ In Progress

Expected Completion Date Click here to enter a date.

☐ Complete

Completion Date Click here to enter a date.

2.6

I attest this activity is complete ☐

I attest this activity will be complete ☐

Completed/Expected Completion Date Click here to enter a date.

2.7	If applicable: Non-Navigator Assistance Personnel Program: The SHOP Marketplace has established a non-Navigator assistance personnel program that is complimented by and coordinated with the Navigator program, or serves as a transition program until the Navigator program is fully operational. The SHOP Marketplace has a process in place to operate the program consistent with the applicable requirements of 45 CFR 155.205(c), (d), and (e), and if the Non-Navigator program is funded with section 1311(a) Exchange Establishment Grant funds, 45 CFR 155.215(a)(2) and 155.215(b) through (e).
2.7a The SHOP Marketplace has created a plan for a non-Navigator assistance personnel program that addresses developing and meeting training standards, Culturally and Linguistically Appropriate Services (CLAS) standards, conflict of interest standards, and adherence to privacy and security standards, and if applicable, how the Marketplace will comply with and ensure non-Navigator assistance personnel’s compliance with standards under 155.215(a)(2) and 155.215(b) through (e). The plan should note if the non-Navigator assistance personnel program will be transitional or ongoing and how the non-Navigator assistance personnel program will compliment and/or coordinate with the Navigator program.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload non-Navigator assistance personnel program operating plan:
If applicable: Name of training contractor:
Upload training standards:
Upload conflict of interest standards:
Upload plan for adherence to privacy and security standards:
2.7b The SHOP Marketplace has developed an oversight and monitoring plan for the non-Navigator assistance personnel program, including ensuring that entities operating under such programs are providing appropriate oversight of personnel to assure compliance with Federal and state requirements and the delivery of high quality services to consumers.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload oversight and monitoring plan:
2.7c The SHOP Marketplace has identified and established legal relationships with non-Navigator assistance personnel.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload a list and description of non-Navigator assistance personnel including funding agreements/contracts, and service areas that non-Navigator assistance personnel will cover:
2.7d The SHOP Marketplace has developed training materials for the non-Navigator assistance personnel program, including how non-Navigator assistance personnel must adhere to conflict of interest standards, CLAS standards, accessibility, and privacy and security standards implemented pursuant to CFR 155.260, and if applicable, how non-Navigator assistance personnel must adhere to standards under 155.215(a)(2) and 155.215(b) through (d).				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload non-Navigator assistance personnel training materials:
2.7e The SHOP Marketplace has deployed the non-Navigator assistance personnel program for consumers, which includes releasing a funding opportunity funding announcement or other vehicle to announce the availability of funding to support such work, and has allocated funding to appropriate entities through a state-approved process.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
2.7		I attest this activity is complete ☐	I attest this activity will be complete ☐			Completed/Expected Completion Date Click here to enter a date.

2.8	If applicable: Agents and Brokers: If the state permits activities by agents and brokers pursuant to 45 CFR 155.220(a), the Marketplace has clearly defined the role of agents and brokers including, as applicable, evidence of licensure, training, and compliance with 45 CFR 155.220(c)-(e). The Marketplace will have agreements with agents/brokers operating in the individual Marketplace, consistent with 45 CFR 155.220(d), which address agent/broker registration with the Marketplace, training on QHP options and insurance affordability program(s), and adherence to privacy and security standards implemented, pursuant to 45 CFR 155.260.
2.8a The SHOP Marketplace has developed policies and procedures for agents and brokers (e.g., state licensure, training, and verification of compliance with privacy and security standards), including a process for determining how the SHOP Marketplace’s website will interface with agent/broker websites.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload agent and broker policies and procedures:
2.8b The SHOP Marketplace has developed templates for agreements between the SHOP Marketplace and agents and brokers including language on addressing agents’ and brokers’ compliance with applicable requirements under 45 CFR 155.220.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload template agreements:
2.8		I attest this activity is complete ☐	I attest this activity will be complete ☐			Completed/Expected Completion Date Click here to enter a date.

2.9		If applicable: Web Brokers: If the state permits this activity pursuant to 45 CFR 155.220(c)(3), the SHOP Marketplace has ensured that any agent or broker whose website will be used to select QHPs will comply with all applicable provisions of 45 CFR 155.220.
2.9a The SHOP Marketplace has developed policies and procedures for web brokers including ensuring compliance with all applicable requirements of 155.220(c)(3), and determining how the Marketplace’s website will interface with web brokers’ websites.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload web broker policies and procedures:
2.9b The SHOP Marketplace has developed templates for agreements between the Marketplace and web brokers, including language on addressing web brokers’ compliance with applicable requirements under 45 CFR 155.220.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload template agreements:
2.9	I attest this activity is complete ☐		I attest this activity will be complete ☐			Completed/Expected Completion Date Click here to enter a date.

3.0 Eligibility and Enrollment

HHS recognizes that a State seeking to transition between Marketplace models after plan year 2014 may have system capabilities and/or policies in place that have already been developed and paid for as part of the implementation of their plan year 2014 Marketplace. A State that intends to leverage existing Eligibility and Enrollment functionalities, policies, and/ or system solutions are not required to resubmit documentation or artifacts that have been previously approved by HHS; however, a state should submit any documentation or artifacts that have been modified to support the build and overall approval of its new Marketplace model. A State may also upload a text document that lists artifacts that the state previously submitted to CMS that are now updated to include Marketplace requirements/functionality (e.g., a listing of CALT IDs in a text document).

3.1	SHOP Application: The SHOP Marketplace uses employer-specific and employee-specific applications for health insurance in the small business market. The applications collect information that is necessary for eligibility in a QHP for the SHOP Marketplace as specified in 45 CFR 155.730.
3.1a The SHOP Marketplace has chosen whether it will use the HHS-developed SHOP employer and employee applications or state-developed alternatives for health insurance in the SHOP Marketplace.				☐ Not Started		Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress		Expected Completion Date Click here to enter a date.
				☐ Complete		Completion Date Click here to enter a date.
SHOP application employer (check one) alternative: ☐ HHS-developed: ☐ SHOP application employee (check one) alternative: ☐ HHS developed: ☐
3.1b If using an alternative application for employers in the SHOP Marketplace: The SHOP Marketplace has developed online and paper versions of alternative employer applications for the SHOP Marketplace in accordance with CMS guidance issued in June 2013 and thereafter, and has submitted online and paper versions of alternative employer applications for the SHOP market for HHS approval and has completed an analysis of the differences between the HHS-developed and alternative application(s).					☐ Not Started		Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
					☐ In Progress		Expected Completion Date Click here to enter a date.
					☐ Complete		Completion Date Click here to enter a date.
3.1b2 If using an alternative application for employees in the SHOP Marketplace: The Marketplace has developed online and paper versions of alternative employee applications for the SHOP Marketplace in accordance with CMS guidance issued in June 2013 and thereafter, and has submitted online and paper versions of alternative employee applications for the SHOP market for HHS approval and has completed an analysis of the differences between the HHS-developed and alternative application(s).					☐ Not Started		Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
					☐ In Progress		Expected Completion Date Click here to enter a date.
					☐ Complete		Completion Date Click here to enter a date.
Upload alternative SHOP employer application:
Upload alternative SHOP employee application:
Upload gap analysis of differences between HHS and state alternative SHOP employer application:
Upload gap analysis of differences between HHS and state alternative SHOP employee application:
3.1c The SHOP Marketplace has demonstrated to HHS its online SHOP employer application, using state test data, and has submitted state user testing results for paper and online applications.					☐ Not Started		Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
					☐ In Progress		Expected Completion Date Click here to enter a date.
					☐ Complete		Completion Date Click here to enter a date.
3.1c2 The SHOP Marketplace has demonstrated to HHS its online SHOP employee application using state test data, and has submitted state user testing results for paper and online applications.					☐ Not Started		Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
					☐ In Progress		Expected Completion Date Click here to enter a date.
					☐ Complete		Completion Date Click here to enter a date.
Upload SHOP Marketplace’s and/or state’s user testing results for paper and online SHOP employer applications:
Upload SHOP Marketplace’s and/or state’s user testing results for paper and online SHOP employee applications:
3.1d The SHOP Marketplace has received approval from HHS of its alternative SHOP employer application (online and paper) and has finalized its online application and published its paper application on its website.					☐ Not Started		Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
					☐ In Progress		Expected Completion Date Click here to enter a date.
					☐ Complete		Completion Date Click here to enter a date.
3.1d2 The SHOP Marketplace has received approval from HHS of its alternative SHOP employee application (online and paper) and has finalized its online application and published its paper application on its website.					☐ Not Started		Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
					☐ In Progress		Expected Completion Date Click here to enter a date.
					☐ Complete		Completion Date Click here to enter a date.
Upload final paper version of SHOP employer application: Provide link to online SHOP employer application:
Upload final paper version of SHOP employee application: Provide link to online SHOP employee application:
3.1		I attest this activity is complete ☐	I attest this activity will be complete ☐					Completed/Expected Completion Date Click here to enter a date.

3.2	Coordination Strategy between the Federally-facilitated Marketplace and SHOP: The SHOP Marketplace has developed and documented a coordination strategy with the Federally-facilitated Marketplace for individual eligibility and enrollment activities.
3.2a The SHOP Marketplace has a coordination strategy with the Federally-facilitated Marketplace and formalized agreements are in place.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload documentation:
3.2		I attest this activity is complete ☐	I attest this activity will be complete ☐			Completed/Expected Completion Date Click here to enter a date.

3.3	Infrastructure to Accept and Process Initial Applications and Redeterminations: The SHOP Marketplace has the infrastructure in place to accept and process initial applications, application updates, and redeterminations for employers and employees. This includes employers and employees who have disabilities or limited English proficiency or literacy, as well as applications received through all required channels, including in-person, online, mail, and phone.
3.3a The SHOP Marketplace has developed a process for determining employer eligibility in the SHOP.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload the SHOP Marketplace’s process for determining employer eligibility in the SHOP:
Upload uniform enrollment timeline that includes information pertaining to initial payment requirements and effective dates:
3.3b The SHOP Marketplace has the capacity to accept and process initial SHOP Marketplace employer and employee applications and midyear updates and redeterminations via phone, online, mail, and in-person.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload results for Blueprint test scenarios:
Upload state test summary:
Upload IV&V report:
3.3		I attest this activity is complete ☐	I attest this activity will be complete ☐			Completed/Expected Completion Date Click here to enter a date.

3.4	Infrastructure to Support Verifications: The SHOP Marketplace is able to conduct verifications.
3.4a The SHOP Marketplace plans to use the optional verification process as outlined in 45 CFR 155.715(c)(2).				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
The SHOP Marketplace will use: ☐ or will NOT use: ☐ the optional verification process.
3.4		I attest this activity is complete ☐	I attest this activity will be complete ☐			Completed/Expected Completion Date Click here to enter a date.

3.5	Infrastructure to Send Notices Electronically: The SHOP Marketplace has the capacity to send notices electronically, including those in alternative formats and multiple languages pursuant to 45 CFR 155 Subpart H and 155.230.
3.5a The SHOP Marketplace has demonstrated sufficient capacity to send notices electronically, including notices in alternative formats and multiple languages.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload sample of electronic eligibility notices pursusant to CMS guidance for employers and employees:
3.5b The SHOP Marketplace is operationally ready to generate responses to annual redeterminations.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload results for Blueprint test scenarios:
Upload state test summary:
Upload IV&V report:
3.5		I attest this activity is complete ☐	I attest this activity will be complete ☐			Completed/Expected Completion Date Click here to enter a date.

3.6	Infrastructure to Conduct Eligibility Determinations: The SHOP Marketplace can determine employer and employee eligibility for enrollment in a QHP through the SHOP Marketplace.
3.6a The SHOP Marketplace can determine employer and employee eligibility for SHOP participation and enrollment in a QHP through the SHOP Marketplace.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload results for Blueprint test scenarios:
Upload state test summary:
Upload IV&V report:
3.6		I attest this activity is complete ☐	I attest this activity will be complete ☐			Completed/Expected Completion Date Click here to enter a date.

3.7	Infrastructure for Eligibility Appeals: The SHOP Marketplace has established an eligibility appeals process for the SHOP Marketplace pursuant to 45 CFR 155.740.
3.7a Employer Appeals: The SHOP Marketplace operates an employer appeals process, pursuant to 45 CFR 155.555(a) and (b), through which an employer may, in response to a notice under Section 155.310(h), appeal a determination that the employer does not provide minimum essential coverage through an employer-sponsored plan or that the employer does provide coverage but it is not affordable coverage with respect to an employee.			☐ Not Started			Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
			☐ In Progress			Expected Completion Date Click here to enter a date.
			☐ Complete			Completion Date Click here to enter a date.
3.7b The SHOP Marketplace has developed an operational approach that includes employer appeals process flows depicting the eligibility appeals process and the entity/entities that are responsible for processing and adjudicating appeals.					☐ Not Started		Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
					☐ In Progress		Expected Completion Date Click here to enter a date.
					☐ Complete		Completion Date Click here to enter a date.
Upload operational approach:
3.7c The SHOP Marketplace has developed form and notice templates for each type of eligibility appeal, including final versions of language/messages informing SHOP Marketplace employers and employees of the appeals process.			☐ Not Started			Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
			☐ In Progress			Expected Completion Date Click here to enter a date.
			☐ Complete			Completion Date Click here to enter a date.
Upload sample form and notice templates:
3.7d The SHOP Marketplace has developed standard operating procedures for the appeals process.			☐ Not Started			Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
			☐ In Progress			Expected Completion Date Click here to enter a date.
			☐ Complete			Completion Date Click here to enter a date.
Upload appeals standard operating procedures:
3.7e The SHOP Marketplace demonstrates through the submission of test files, the ability to implement an eligibility appeals process, and to implement appeals decisions, as appropriate, for employers and employees pursuant to 45 CFR 155.740.			☐ Not Started			Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
			☐ In Progress			Expected Completion Date Click here to enter a date.
			☐ Complete			Completion Date Click here to enter a date.
Upload results for Blueprint test scenarios:
Upload state test summary:
Upload IV&V report:
3.7		I attest this activity is complete ☐		I attest this activity will be complete ☐				Completed/Expected Completion Date Click here to enter a date.

3.8	Electronic Reporting of Eligibility Assessments and Determinations: The SHOP Marketplace can electronically report results of eligibility determinations. This includes information necessary to support the employer responsibility provisions of the Affordable Care Act.

3.8a    The SHOP Marketplace has a process for submitting monthly and annual eligibility and enrollment records to HHS and IRS, including information necessary to support the employer responsibility provisions of the Affordable Care Act.	☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
	☐ In Progress	Expected Completion Date Click here to enter a date.
	☐ Complete	Completion Date Click here to enter a date.
Upload description of process approach:
3.8b    The SHOP Marketplace has demonstrated, through the submission of test files, the ability to electronically report results of eligibility determinations and support the employer responsibility provisions of the Affordable Care Act.	☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
	☐ In Progress	Expected Completion Date Click here to enter a date.
	☐ Complete	Completion Date Click here to enter a date.
Upload results for Blueprint test scenarios:
Upload state test summary:
Upload IV&V report:

4.0 Plan Management

HHS recognizes that a state seeking to transition between Marketplace models after plan year 2014 may have system capabilities and/or policies in place that have already been developed and paid for as part of the implementation of their plan year 2014 Marketplace. A state that intends to leverage existing functionalities, personnel, policies, and/or system solutions are not required to resubmit documentation or artifacts that have been previously approved by HHS; however, a state should submit any documentation or artifacts that have been modified to support the build and overall approval of its new Marketplace model. A state may also upload a text document that lists artifacts that the state previously submitted to CMS that are now updated to include Marketplace requirements/functionality (e.g., a listing of CALT IDs in a text document).

4.1	QHP Certification Process: The SHOP Marketplace has the capacity and a process in place to certify QHPs pursuant to 45 CFR 155.1000(c), in alignment with market reform rules contained in 45 CFR 144, 147, 150, 154, and 156, and according to QHP certification requirements and standards contained in 45 CFR 156, including, but not limited to, standards relating to licensure, solvency, service area, network adequacy, essential community providers, marketing and discriminatory benefit design, accreditation, and consideration of rate increases.
4.1a The SHOP Marketplace has developed the necessary infrastructure to certify QHPs pursuant to 45 CFR155.1000(c) in accordance with minimum QHP certification requirements and has a process in place for ensuring issues and health plans meet each of the QHP certification standards, including any differences specific to SHOP.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload standard operating procedures for certifying QHPs pursuant to 45 CFR 155.1000(c) in accordance with minimum QHP certification requirements:
Upload documentation describing how the SHOP Marketplace will ensure that issuers and health plans meet each of the QHP certification standards, including the process that the SHOP Marketplace will use to evaluate issuers and health plans against each of the QHP certification standards:
Upload documentation identifying entities responsible for QHP certification, including an explanation of roles and responsibilities of each entity and integration points, as they relate to each of the QHP certification standards:
Upload staffing strategy for entities performing QHP certification reviews:
4.1b The SHOP Marketplace has released its QHP application templates, certification timeline, and standards to issuers.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload QHP application materials:
4.1c The SHOP Marketplace has completed QHP certification.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
4.1d The SHOP Marketplace has worked with issuers to validate QHP data and has completed plan preview.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
4.1e The SHOP Marketplace has posted certified QHP options online for consumers.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Provide link to certified QHPs on website:
4.1		I attest this activity is complete ☐	I attest this activity will be complete ☐			Completed/Expected Completion Date Click here to enter a date.

4.2

Collection of QHP Issuer and Plan Data: The SHOP Marketplace uses a plan management system(s) or processes that: support the collection of QHP issuer and plan data; facilitate the QHP certification process; manage QHP issuers and plans; and integrate with other SHOP Marketplace business areas, including the SHOP Marketplace website, call center, quality, eligibility and enrollment, and premium processing.

4.2a The SHOP Marketplace has selected a plan management system and process that supports the collection of QHP issuer and plan data.

☐ Not Started

Expected Start Date Click here to enter a date.

Expected Completion Date Click here to enter a date.

☐ In Progress

Expected Completion Date Click here to enter a date.

☐ Complete

Completion Date Click here to enter a date.

Name of plan management system:

Upload timeline for plan management system implementation:

Upload documentation describing collection methods that will be used to support the business operations of plan management:

For SHOP Marketplaces using System for Electronic Rate and Form Filing (SERFF): Receipt of National Association of Insurance Commissioners (NAIC) validation of SERFF connection by (date):

For SHOP Marketplaces not using SERFF: Submit state test summary/validation of state’s plan management system(s), including justification for how the state will receive the data for certification purposes:

4.2b The SHOP Marketplace has conducted market analysis of issuer participation including the anticipated number of health plans expected to participate in the SHOP Marketplace.

☐ Not Started

Expected Start Date Click here to enter a date.

Expected Completion Date Click here to enter a date.

☐ In Progress

Expected Completion Date Click here to enter a date.

☐ Complete

Completion Date Click here to enter a date.

SHOP Marketplace Plan Management	Expected	Final	Comments
State QHP Application Submission Deadline
Number of Issuer Submissions: SHOP Market
Number of QHPs Available: SHOP Market
Number of Office of Personnel Management (OPM) Multi-State Plans (MSP)
Identify Any Counties with Fewer Than One Issuer
Identify Any Counties with One Issuer
If Applicable, Identify Number of Issuer Submissions: Co-ops
If Applicable, Identify Number of QHPs Available: Co-ops

4.2c The SHOP Marketplace has launched a plan management system(s) and process(es) that support the collection of QHP issuer and plan data.

☐ Not Started

Expected Start Date Click here to enter a date.

Expected Completion Date Click here to enter a date.

☐ In Progress

Expected Completion Date Click here to enter a date.

☐ Complete

Completion Date Click here to enter a date.

4.2

I attest this activity is complete ☐

I attest this activity will be complete ☐

Completed/Expected Completion Date Click here to enter a date.

4.3	QHP Monitoring and Compliance: The SHOP Marketplace has the capacity to ensure QHP’s ongoing compliance with QHP certification requirements pursuant to 45 CFR 155.1010(a)(2), including a process for monitoring QHP performance and collecting, analyzing, and resolving enrollee complaints.
4.3a The SHOP Marketplace has a plan for processing QHP complaints.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload plan for processing QHP complaints:
4.3b The SHOP Marketplace has a plan for ongoing QHP monitoring and compliance.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload plan for monitoring QHP compliance:
4.3c The SHOP Marketplace has a system and standard operating procedures in place for tracking complaints.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Name of complaint tracking system: Upload complaint tracking system standard operating procedures:
4.3d The SHOP Marketplace has launched its QHP complaint tracking system.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
4.3		I attest this activity is complete ☐	I attest this activity will be complete ☐			Completed/Expected Completion Date Click here to enter a date.

4.4	Technical Assistance to Issuers: The Marketplace supports issuers and provides technical assistance to ensure ongoing compliance with QHP issuer operational standards.
4.4a The SHOP Marketplace has a timeline and strategy for providing issuer technical assistance and support activities.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload technical assistance timeline and strategy:
4.4b The SHOP Marketplace has created technical assistance materials for issuers.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload sample technical assistance materials:
4.4c The SHOP Marketplace has communicated technical assistance strategy and opportunities to issuers.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
4.4		I attest this activity is complete ☐	I attest this activity will be complete ☐			Completed/Expected Completion Date Click here to enter a date.

4.5		Recertification, Decertification, and Appeals: The SHOP Marketplace has a process for QHP issuer recertification, decertification, and appeal of decertification determinations pursuant to 45 CFR 155.1075 and 155.1080.
4.5a The SHOP Marketplace has a process in place for QHP issuer recertification, decertification, and appeals, including the process for transitioning enrollees to new QHPs in the event of QHP decertification.			☐ Not Started		Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
			☐ In Progress		Expected Completion Date Click here to enter a date.
			☐ Complete		Completion Date Click here to enter a date.
Upload processes for QHP issuer recertification, decertification, and appeals:
4.5	I attest this activity is complete ☐			I attest this activity will be complete ☐		Completed/Expected Completion Date Click here to enter a date.

4.6	Issuer Accreditation: The SHOP Marketplace has a set timeline for QHP issuer accreditation in accordance with 45 CFR 155.1045. The SHOP Marketplace also has systems and procedures in place to ensure QHP issuers meet accreditation requirements (per 45 CFR 156.275) as part of QHP certification in accordance with applicable rulemaking and guidance.
4.6a The SHOP Marketplace has established a QHP issuer accreditation timeline.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload QHP issuer timeline:
4.6b The SHOP Marketplace has systems and procedures in place to ensure QHP issuers meet accreditation requirements (per 45 CFR 156.275) as part of QHP certification in accordance with applicable rulemaking and guidance.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload procedures for ensuring QHP issuers meet accreditation requirements:
Upload a sample notice sent to QHP issuers on accreditation requirements:
4.6		I attest this activity is complete ☐	I attest this activity will be complete ☐			Completed/Expected Completion Date Click here to enter a date.

4.7	Quality Reporting: The SHOP Marketplace has systems and procedures in place to ensure that QHP issuers meet the minimum certification requirements pertaining to quality reporting and provide relevant information to the Marketplace and HHS pursuant to Affordable Care Act 1311(c)(1), 1322(e)(3), and as specified in rulemaking.
4.7a The SHOP Marketplace has systems and procedures in place to ensure QHP issuers meet minimum certification requirements pertaining to quality reporting.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload procedures for QHP issuers to meet minimum quality reporting requirements:
If applicable: For states that are setting quality reporting requirements for 2015 certification, upload documentation that lists the reporting requirements:
4.7		I attest this activity is complete ☐	I attest this activity will be complete ☐			Completed/Expected Completion Date Click here to enter a date.

5.0 Risk Adjustment

5.1	If applicable: Risk Adjustment: If the state is performing risk adjustment, the state has a process in place and has identified the entity that will implement the risk adjustment program. This risk adjustment entity must meet the requirements outlined in 45 CFR 155.110 and can include DOIs.

5.1a The state has published a notice of benefit and payment parameters following the publication of the final HHS notice of benefit and payment parameters for 2015, as required by 45 CFR 153.100(b).			☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
			☐ In Progress	Expected Completion Date Click here to enter a date.
			☐ Complete	Completion Date Click here to enter a date.
5.1b The SHOP Marketplace has developed a process and timeline for implementing and operating the risk adjustment program.			☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
			☐ In Progress	Expected Completion Date Click here to enter a date.
			☐ Complete	Completion Date Click here to enter a date.
Upload process and timeline for operating risk adjustment program:
5.1	I attest this activity is complete ☐	I attest this activity will be complete ☐			Completed/Expected Completion Date Click here to enter a date.

6.0 SHOP

HHS recognizes that a State seeking to transition between Marketplace models after plan year 2014 may have system capabilities and/or policies in place that have already been developed and paid for as part of the implementation of their plan year 2014 Marketplace. A State that intends to leverage existing functionalities, personnel, policies, and/or system solutions are not required to resubmit documentation or artifacts that have been previously approved by HHS; however, a State should submit any documentation or artifacts that have been modified to support the build and overall approval of its new Marketplace model. A State may also upload a text document that lists artifacts that the State previously submitted to CMS that are now updated to include SHOP Marketplace requirements/functionality (e.g., a listing of CALT IDs in a text document).

6.1	SHOP Marketplace Compliance with 45 CFR 155 Subpart H: The SHOP Marketplace is compliant with regulatory requirements pursuant to 45 CFR 155 Subpart H including: standards for the establishment of a SHOP Marketplace, functions of a SHOP Marketplace, eligibility standards for the SHOP Marketplace, eligibility determination process for the SHOP Marketplace, enrollment of employees into QHPs under the SHOP Marketplace, enrollment periods under the SHOP Marketplace, and application standards for the SHOP Marketplace.
6.1a The State has determined the size of a small employer, as well as methods for determining whether an employee is a full-time employee.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Select the size of a small employer: 1-50: ☐ or 1-100: ☐ Select method state will use to count employees: Federal FTE method: ☐ or state method: ☐ UPLOAD
6.1b The SHOP Marketplace has established policy decisions that ensure SHOP compliance with 45 CFR 155 Subpart H.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload SHOP policy decisions:
6.1c The SHOP Marketplace has established what employee choice options (and employer choice option, if applicable) will be available to employers.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload documentation describing employee/employer choice options in addition to the required single metal level of choice:
6.1d The SHOP Marketplace requires all QHP issuers to make any changes to rates at uniform time that is no more frequent than quarterly and prohibits all QHP issuers from varying rates for a qualified employer during the employer’s plan year.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
6.1e The SHOP Marketplace has established the premium calculator for SHOP in accordance with 45 CFR 155.705(b)(11).				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload premium calculator:
6.1f The SHOP Marketplace has developed a uniform enrollment timeline and process that includes information pertaining to grace periods, effective dates of coverage, enrollment periods, and reinstatement policies.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload enrollment timeline and process:
6.1g If applicable: If the SHOP Marketplace implements minimum participation requirements in the SHOP, state regulatory authority exists for uniform group participation rules for offering health insurance coverage in the SHOP.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Provide citation of state regulatory authority for SHOP uniform participation rules:
6.1h The SHOP Marketplace has demonstrated its website’s ability to make employer and employee eligibility determinations and facilitate comparison(s) of available QHPs in the SHOP.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
6.1		I attest this activity is complete ☐	I attest this activity will be complete ☐			Completed/Expected Completion Date Click here to enter a date.

6.2	SHOP Premium Aggregation: The SHOP Marketplace has the capacity for SHOP premium aggregation pursuant to 45 CFR 155.705(b) (4). The SHOP Marketplace has systems in place for billing qualified employers, receiving qualified employer contributions toward premiums, and making aggregated premium payments to issuers. The SHOP Marketplace has a process for managing non-payment or late premiums; including how and when notices are sent to employers in accordance with 45 CFR 155.735. The SHOP Marketplace also has the capacity to maintain books, records, documents, and other evidence of accounting procedures and practices of the premium aggregation program for each benefit year for at least 10 years.
6.2a The SHOP Marketplace has developed a SHOP premium aggregation process.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload SHOP premium aggregation process:
6.2b The SHOP Marketplace has established SHOP premium aggregation.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
6.2c The SHOP Marketplace has developed sample or model premium aggregation invoices and notices.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload sample of notices and invoices:
6.2d The SHOP Marketplace has a formalized agreement in place indicating the SHOP’s ability to receive payments from employers and dispense to issuers.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload agreement:
6.2e The SHOP Marketplace has developed termination policies and processes for managing non-payment or late premiums; including how and when notices are sent to employers in accordance with 45 CFR 155.735.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload non-payment policies and procedures:
6.2f The SHOP Marketplace demonstrates through the submission of test files, the automated ability to perform SHOP premium aggregation pursuant to 45 CFR 155.705(b)(4).				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload results for Blueprint test scenarios:
Upload state test summary:
Upload IV&V report:
6.2		I attest this activity is complete ☐	I attest this activity will be complete ☐			Completed/Expected Completion Date Click here to enter a date.

6.3	Electronically Report Results of Employer Participation, Employer Contribution, and Employee Enrollment Information for the SHOP: The SHOP Marketplace has the capacity to electronically report information to the Internal Revenue Service (IRS) for tax administration purposes as defined in 155.720(i).
6.3a The SHOP Marketplace demonstrates through the submission of test files, the automated ability to electronically report employer participation, employer contribution, and employee enrollment information to IRS for tax administration purposes.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload results for Blueprint test scenarios:
Upload state test summary:
Upload IV&V report:
6.3		I attest this activity is complete ☐	I attest this activity will be complete ☐			Completed/Expected Completion Date Click here to enter a date.

7.0 Organization and Human Resources

7.1	Organizational Structure and Staffing Plan: The SHOP Marketplace has an appropriate organizational structure and staffing resources to perform SHOP Marketplace activities.
7.1a The SHOP Marketplace has created a staffing plan that addresses competencies, roles, and responsibilities needed to develop and operate a SHOP Marketplace, and provide job descriptions for the following SHOP Marketplace personnel: call center, eligibility and enrollment, plan management, and premium aggregation activities. The SHOP Marketplace has created an organizational chart.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload current staffing plan:
Upload projected staffing plan:
Upload organizational chart:
7.1b The SHOP Marketplace has developed training materials for staff or contractors who will perform key SHOP Marketplace activities for the call center, eligibility and enrollment, plan management, and premium aggregation services.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload sample training materials:
7.1		I attest this activity is complete ☐	I attest this activity will be complete ☐			Completed/Expected Completion Date Click here to enter a date.

8.0 Finance and Accounting

8.1	Cost, Budget, and Management Plan: The SHOP Marketplace has a long-term cost, budget, and management plan, monitors its finances, and is able to track its costs and revenues.
8.1a The SHOP Marketplace has established methods to generate revenue and address any financial deficits.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload plan to generate revenue and monitor finances:
8.1b The SHOP Marketplace has developed a long-term operational budget and management plan, and established the capabilities to monitor finances and track costs and revenues. Long-term strategies for financial sustainability and tracking financial trends have been determined. Plan should include the SHOP Marketplace’s proposed budget for 2014 and proposed budget for the upcoming five years from initial year of operations, if available.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload proposed long-term operational budget and management plan for the next five consecutive plan years:
Upload operating budget, which includes estimated sources of revenue, enrollment projections, and per member per month (pmpm) costs:
Upload proposed 2015 and future years budget and management plan:
8.1		I attest this activity is complete ☐	I attest this activity will be complete ☐			Completed/Expected Completion Date Click here to enter a date.

9.0 Technology

HHS recognizes that states seeking to transition between Marketplace models after plan year 2014 may have system capabilities and/or policies in place that have already been developed and paid for as part of the implementation of their plan year 2014 Marketplace. States that intend to leverage functionalities, policies, and/or system solutions are not required to resubmit documentation or artifacts that have been previously approved by HHS; however, states should submit any documentation or artifacts that have been modified to support the build and overall approval of its new Marketplace model. A state may also upload a text document that lists artifacts that the state previously submitted to CMS that are now updated to include Marketplace requirements/functionality (e.g., a listing of CALT IDs in a text document).

9.1	Gate Reviews, Consults, and Artifacts: The SHOP Marketplace has complied with relevant HHS information technology guidance including the IT Enterprise Life Cycle (ELC) methodology. The SHOP Marketplace has completed the ELC milestone gate reviews and consults. As agreed upon with CMS, the Marketplace has submitted all applicable artifacts or functional equivalent requirements.
9.1a The SHOP Marketplace has completed the Architecture Review (AR) and Project Baseline Review (PBR) through successful completion of all activities, consults, and artifacts within this ELC phase and/or completion of all iterations or functional equivalents for this phase as agreed to with CMS. The SHOP Marketplace must perform pre- and post-review gate activities. The SHOP Marketplace must submit preliminary, baseline, updated, and final versions of artifacts as specified in the ELC. The ELC process lines up with the Establishment Review Process				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Please refer to the ELC guidance document to determine the frequency of ELC artifact submissions, as well as the level of completeness expected for each Gate Review. Submission of the initial ELC Architecture and Project Management artifacts are to be updated within six weeks of signing a Systems Integrator and uploaded into CALT as final. The following artifacts are uploaded into CALT at a minimum of every two weeks: Updated Project Schedule. Updated Risk Register. Updated Performance Metrics. Updated Financial Status Report. The following artifacts are uploaded on a monthly basis: IV&V Status Reports. The following artifacts are uploaded when applicable: Updated Staffing Plan. Updated Communications Plan. CALT ID number for completed documentation associated with the AR and PBR or a functionally equivalent review: ­­­­­­
9.1b The SHOP Marketplace has completed the Final Detailed Design Review (FDDR) through successful completion of all activities, consults, and artifacts within this ELC phase and/or completion of all iterations or functional equivalents for this phase as agreed to with CMS. A SHOP Marketplace must perform pre- and post-review gate activities. This phase has two consults and may include additional consults as determined by HHS. The SHOP Marketplace must submit preliminary, baseline, updated, and final versions of artifacts as specified in the ELC.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
CALT ID number for completed documentation associated with the FDDR or a functionally equivalent review: ­­­­­­ Please refer to the ELC guidance document to determine the frequency of ELC artifact submissions, as well as the level of completeness expected for each Gate Review. Please review the status of the ELC documents for the consults and the expected status of each artifact at each consult and they all must be final for the Final Design Review based on day one functionality.
9.1c The SHOP Marketplace has obtained approval to participate in informal Federal integration testing.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
9.1d The SHOP Marketplace has obtained approval to participate in formal Federal integration testing.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
9.1e The SHOP Marketplace has demonstrated the core functionality of its Marketplace through an online demonstration.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
9.1f The SHOP Marketplace has completed formal Marketplace system testing and submitted all applicable test reports including Blueprint test scenario results, applicable state testing summaries, and IV&V results.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload test reports:
9.1g The SHOP Marketplace has completed user acceptance testing (UAT) with no major defects.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
CALT ID numbers for system performance and user acceptance testing (UAT) test reports: OR
Upload system performance and user acceptance testing (UAT) test reports:
9.1h The SHOP Marketplace has completed the Operational Readiness Review (ORR) through submission of and CMS review and validation of required artifacts and activities or functional equivalents as agreed to with CMS. A Marketplace must perform pre- and post-review gate activities. This phase has one consult and may include additional consults as determined by HHS. The Marketplace must submit preliminary, baseline, updated, and final versions of artifacts as specified in the ELC and conduct a demonstration of day one functionality.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
CALT ID number for completed documentation associated with the ORR or a functionally equivalent review: ­­­­­­ Please refer to the ELC guidance document to determine the frequency of ELC artifact submissions, as well as the level of completeness expected for each Gate Review. Please review the status of the ELC documents for the ORR and the expected status of each artifact for this review.
Upload system performance and user acceptance testing (UAT) test reports:
9.1i The SHOP Marketplace has completed and submitted all outstanding final versions of all artifacts listed under previous ELC gates and reviews.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
CALT ID numbers for final documentation associated with previous ELC gate reviews: OR
Upload final documentation associated with previous ELC gate reviews:
9.1j The SHOP Marketplace monitors the performance of the system/application during normal operations against original user requirements and any newly implemented requirements or changes.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload annual Operations Readiness Report, including any newly implemented requirements or changes:
9.1		I attest this activity is complete ☐	I attest this activity will be complete ☐			Completed/Expected Completion Date Click here to enter a date.

9.2	Essential Functionality: The SHOP Marketplace has determined its IT integration approach for implementing essential functionality of its SHOP Marketplace, such as assigning internal resources or issuing an RFP for technology services.
9.2a The SHOP Marketplace has issued an RFP for a systems integrator (SI).				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
CALT ID number for RFP for an SI vendor: OR
Upload RFP for an SI vendor:
9.2b The SHOP Marketplace has issued an RFP for a SHOP Marketplace platform.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
CALT ID number for RFP for a SHOP Marketplace platform vendor: OR
Upload RFP for a SHOP Marketplace platform vendor:
9.2c The SHOP Marketplace has issued an RFP for an IV&V vendor.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
CALT ID number for RFP for an IV&V vendor OR
Upload RFP for an IV&V vendor:
9.2d The SHOP Marketplace has selected a SI and has signed a contract.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
CALT ID number for SI contract OR
Upload SI contract:
9.2e The SHOP Marketplace has selected a vendor for a SHOP Marketplace platform and has signed a contract.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
CALT ID number for Marketplace platform contract OR
Upload Marketplace platform contract:
9.2f The SHOP Marketplace has selected an IV&V vendor and has signed a contract.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
CALT ID number for signed IV&V contract OR
Upload signed IV&V contract:
9.2g The SHOP Marketplace has effectively achieved HHS-defined essential functionality for each required activity via test results, defect tracking reports, and confirmed by IV&V reports.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
9.2		I attest this activity is complete ☐	I attest this activity will be complete ☐			Completed/Expected Completion Date Click here to enter a date.

10.0 Privacy and Security

HHS recognizes that a state seeking to transition between Marketplace models after plan year 2014 may have system capabilities and/or policies in place that have already been developed and paid for as part of the implementation of their plan year 2014 Marketplace. A state that intends to leverage functionalities, policies, and/or system solutions are not required to resubmit documentation or artifacts that have been previously approved by HHS; however, a state should submit any documentation or artifacts that have been modified to support the build and overall approval of its new Marketplace model. Please work with your State Officer to determine which privacy and security activities are applicable to your Marketplace model. A state may also upload a text document that lists artifacts that the state previously submitted to CMS that are now updated to include Marketplace requirements/functionality (e.g., a listing of CALT IDs in a text document).

As with all State-based Marketplaces (SBMs), State-based SHOP Marketplaces will need to establish security and privacy standards consistent with 45 CFR 155.260 and 155.280. HHS recommends that states use the Minimum Acceptable Risk Standards for Exchanges (MARS-E) guidance as a minimum standard upon which to base their own security standards, but they are not required to do so. CMS, however, recognizes that several documents in the MARS-E suite are linked to an approval process that is necessary to obtain the authority to connect to the Federal Data Services Hub (FDSH), and that State-based SHOP Marketplaces may have no cause to connect to the FDSH at this time. CMS therefore recognizes that states establishing and operating

State-based SHOP Marketplaces might need to modify the MARS-E guidance, such as the guidance used to develop a Privacy Impact Assessment (PIA), in order to tailor that guidance to their plans for operating the Marketplace. In addition to MARS-E guidance, please refer to the checklist in the Privacy and Security Timelines and Artifacts For Health Insurance Marketplaces, Medicaid/CHIP Agencies and Partner Organizations April 2013 to determine the privacy and security documents that apply to your State-based SHOP Marketplace.

10.1	Privacy and Security Standards, Policies, and Procedures: The SHOP Marketplace has established and implemented written policies and procedures and has all required privacy and security agreements in place according to the standards set forth in 45 CFR 155.260(a)–(g).
10.1a The SHOP Marketplace has completed the ACA Health Insurance Exchange Privacy Impact Assessment (PIA) and submitted to CMS.				☐ Not Started		Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress		Expected Completion Date Click here to enter a date.
				☐ Complete		Completion Date Click here to enter a date.
CALT ID number for PIA:
10.1b The SHOP Marketplace has submitted its System Security Plan (SSP) document.			☐ Not Started		Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
			☐ In Progress		Expected Completion Date Click here to enter a date.
			☐ Complete		Completion Date Click here to enter a date.
CALT ID number for SSP document:
10.1b1 The SHOP Marketplace has submitted its SSP workbook.			☐ Not Started		Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
			☐ In Progress		Expected Completion Date Click here to enter a date.
			☐ Complete		Completion Date Click here to enter a date.
CALT ID number for SSP workbook:
10.1b2 The SHOP Marketplace has selected an Independent Assessor to perform a Security Assessment of the SHOP Marketplace.			☐ Not Started		Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
			☐ In Progress		Expected Completion Date Click here to enter a date.
			☐ Complete		Completion Date Click here to enter a date.
10.1b3 The SHOP Marketplace has submitted its Independent Security Assessment Plan & Results report.			☐ Not Started		Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
			☐ In Progress		Expected Completion Date Click here to enter a date.
			☐ Complete		Completion Date Click here to enter a date.
CALT ID number for Independent Security Test Plan & Results report:
10.1b4 The Marketplace has submitted its Plan of Actions & Milestones (POA&M) based on residual risks identified during the Independent Security Assessment to obtain an initial Authority to Connect, as required by HHS.			☐ Not Started		Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
			☐ In Progress		Expected Completion Date Click here to enter a date.
			☐ Complete		Completion Date Click here to enter a date.
CALT ID number for POA&M:
10.1c The SHOP Marketplace has developed its Information Security Risk Assessment document or functional equivalent.			☐ Not Started		Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
			☐ In Progress		Expected Completion Date Click here to enter a date.
			☐ Complete		Completion Date Click here to enter a date.
CALT ID number for Information Security Risk Assessment document:
10.1d The SHOP Marketplace has signed and submitted the Computer Matching Agreement (CMA) between CMS and state-based administering entities to CMS only if connecting to the FDSH.			☐ Not Started		Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
			☐ In Progress		Expected Completion Date Click here to enter a date.
			☐ Complete		Completion Date Click here to enter a date.
CALT ID number for CMA:
10.1e The SHOP Marketplace has signed and submitted the Information Exchange Agreement (IEA) to CMS only if connecting to the FDSH.			☐ Not Started		Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
			☐ In Progress		Expected Completion Date Click here to enter a date.
			☐ Complete		Completion Date Click here to enter a date.
CALT ID number for IEA:
10.1f The SHOP Marketplace has developed its Interconnection Security Agreement (ISA) only if connecting to the FDSH.			☐ Not Started		Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
			☐ In Progress		Expected Completion Date Click here to enter a date.
			☐ Complete		Completion Date Click here to enter a date.
CALT ID number for ISA:
10.1		I attest this activity is complete ☐	I attest this activity will be complete ☐				Completed/Expected Completion Date Click here to enter a date.

10.2		If applicable: Connection to the FDSH: The SHOP Marketplace has implemented and verified the privacy and security safeguards required to connect to the Federal Data Services Hub (FDSH).
10.2a If applicable: The SHOP Marketplace has performed its own Security Assessment and Authorization and has received the Authority to Operate (ATO), from the SHOP Marketplace authorizing official.			☐ Not Started			Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
			☐ In Progress			Expected Completion Date Click here to enter a date.
			☐ Complete			Completion Date Click here to enter a date.
Upload ATO:
10.2b The SHOP Marketplace has obtained HHS approval for an Authority to Connect (ATC) to the FDSH, only if connecting to the FDSH.				☐ Not Started		Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress		Expected Completion Date Click here to enter a date.
				☐ Complete		Completion Date Click here to enter a date.
Upload ATC:
10.2	I attest this activity is complete ☐				I attest this activity will be complete ☐		Completed/Expected Completion Date Click here to enter a date.

11.0 Oversight and Monitoring

11.1

Oversight and Monitoring Policies and Procedures: The SHOP Marketplace has written policies and procedures and has tools and/or systems to perform routine monitoring and auditing of SHOP Marketplace activities, including fraud, waste, and abuse (and will supplement those policies and procedures to implement regulations promulgated under the Affordable Care Act 1313). The SHOP Marketplace also has the capacity to maintain books, records, documents, and other evidence of procedures and practices to demonstrate compliance for each benefit year for at least 10 years.

11.1a The SHOP Marketplace has policies and procedures in place for performing routine oversight and monitoring of SHOP Marketplace activities, as well as maintaining the necessary documentation to demonstrate compliance with Federal standards.

☐ Not Started

Expected Start Date Click here to enter a date.

Expected Completion Date Click here to enter a date.

☐ In Progress

Expected Completion Date Click here to enter a date.

☐ Complete

Completion Date Click here to enter a date.

Upload oversight and monitoring policies and procedures:

Upload a timeline for continual monitoring of operationalized SHOP Marketplace oversight activities:

11.1b The SHOP Marketplace has defined roles and responsibilities for individuals and organizations responsible for oversight and monitoring.

☐ Not Started

Expected Start Date Click here to enter a date.

Expected Completion Date Click here to enter a date.

☐ In Progress

Expected Completion Date Click here to enter a date.

☐ Complete

Completion Date Click here to enter a date.

Responsible SHOP Marketplace Staff or Organization (Name, title, and contact information)	Defined Role and Responsibility for Oversight	Defined Role and Responsibility for Monitoring

11.1c The SHOP Marketplace has developed a comprehensive training program for SHOP Marketplace personnel on common oversight and monitoring concepts, regulations, and processes.

☐ Not Started

Expected Start Date Click here to enter a date.

Expected Completion Date Click here to enter a date.

☐ In Progress

Expected Completion Date Click here to enter a date.

☐ Complete

Completion Date Click here to enter a date.

Upload oversight and monitoring training program:

11.1d The SHOP Marketplace has established quality controls as part of oversight and monitoring of SHOP Marketplace activities.

☐ Not Started

Expected Start Date Click here to enter a date.

Expected Completion Date Click here to enter a date.

☐ In Progress

Expected Completion Date Click here to enter a date.

☐ Complete

Completion Date Click here to enter a date.

Upload documentation of quality controls to be used for oversight and monitoring activities:

Upload documentation of systems to be used to assist with oversight and monitoring activities:

11.1e The SHOP Marketplace has established an IT governance board and has developed policies and procedures for management controls and risk management systems.

☐ Not Started

Expected Start Date Click here to enter a date.

Expected Completion Date Click here to enter a date.

☐ In Progress

Expected Completion Date Click here to enter a date.

☐ Complete

Completion Date Click here to enter a date.

Upload management controls policies and procedures:

Upload risk management system policies and procedures:

Upload documentation of systems to be used for IT oversight and monitoring activities:

11.1

I attest this activity is complete ☐

I attest this activity will be complete ☐

Completed/Expected Completion Date Click here to enter a date.

11.2	Mechanisms for Reporting: The SHOP Marketplace has the capacity to collect and report performance and outcome metrics related to SHOP Marketplace activities, including metrics related to fraud, waste, and abuse, in a format and manner specified by HHS necessary for, but not limited to, annual reports required by Affordable Care Act 1313(a).
11.2a The SHOP Marketplace has developed policies, procedures, and a timeline for the collection and reporting of performance and outcome metrics, including HHS’ performance metrics.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload policies and procedures for collecting performance and outcome metrics:
Upload timeline for collecting and reporting performance and outcome metrics:
11.2b If applicable: The SHOP Marketplace has performance and outcome metrics that are in addition to HHS’ SHOP Marketplace performance metrics.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload state-specific list of metrics:
11.2c The SHOP Marketplace has developed policies, procedures, and a timeline for reporting instances of suspected fraud, waste, and abuse, including mechanisms for reporting the results of fraud, waste, and abuse investigations.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload policies and procedures for reporting instances of fraud, waste, and abuse, including mechanisms for reporting the results of investigations regarding fraud, waste, and abuse:
11.2d The SHOP Marketplace has defined enforcement standards for fraud, waste, and abuse that are clearly and consistently communicated to employees, business partners, and consumers.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload enforcement standards for fraud, waste, and abuse:
11.2		I attest this activity is complete ☐	I attest this activity will be complete ☐			Completed/Expected Completion Date Click here to enter a date.

11.3	Financial Integrity: The SHOP Marketplace has instituted policies and procedures that promote compliance with the financial integrity provisions of Affordable Care Act 1313 (and will supplement those policies and procedures to implement regulations promulgated under the Affordable Care Act 1313), including the requirements related to accounting, reporting, auditing, cooperation with investigations, and application of the False Claims Act.
11.3a The SHOP Marketplace has adopted financial or accounting standards in accordance with generally accepted accounting principles (GAAP).				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload policies and procedures for adherence to GAAP:
11.3b The SHOP Marketplace has developed policies and procedures that promote compliance with financial integrity requirements, including accounting, reporting, auditing, cooperation with investigations, and application of False Claims Act.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
Upload financial integrity policies and procedures:
11.3		I attest this activity is complete ☐	I attest this activity will be complete ☐			Completed/Expected Completion Date Click here to enter a date.

12.0 Contingency Planning

12.1	Contingency/Risk Mitigation Operations: The SHOP Marketplace has developed and submitted to HHS contingency plans. Please refer to CMS guidance for current guidance on contingency plan submissions for State-based SHOP Marketplaces.
12.1a The SHOP Marketplace has submitted a contingency plan for any functionality that may not be available for the initial “go-live” date of the SHOP Marketplace, which includes any interim plans for a work-around, as well a plan to move from the work-around to a final solution at a later date.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
CALT ID number for contingency plan documentation: OR
Upload documentation:
12.1b The SHOP Marketplace has submitted an operational contingency and recovery operations plan for CMS review and validation.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
CALT ID number for operational contingency and recovery operations plan documentation: OR
Upload operational contingency and recovery operations plan documentation:
12.1		I attest this activity is complete ☐	I attest this activity will be complete ☐			Completed/Expected Completion Date Click here to enter a date.

13.0 Re-Use

HHS recognizes that a state seeking to transition between Marketplace models after plan year 2014 may have system capabilities and or policies in place that have already been developed and paid for as part of the implementation of their plan year 2014 Marketplace. A state that intends to leverage functionalities, policies, and/or system solutions are not required to resubmit documentation or artifacts that have been previously approved by HHS; however, a state should submit any documentation or artifacts that have been modified to support the build and overall approval of its new Marketplace model. Please work with your State Officer to identify re-use opportunities for your state.

13.1	Re-Use: The SHOP Marketplace has participated in discussions between states and/or solutions being developed cooperatively between states.
13.1a The SHOP Marketplace has submitted re-use documentation, which identifies aspects of its system that it is willing to provide to other states for re-use.				☐ Not Started	Expected Start Date Click here to enter a date. Expected Completion Date Click here to enter a date.
				☐ In Progress	Expected Completion Date Click here to enter a date.
				☐ Complete	Completion Date Click here to enter a date.
CALT ID number for re-use documentation: OR
Upload re-use documentation:
13.1		I attest this activity is complete ☐	I attest this activity will be complete ☐			Completed/Expected Completion Date Click here to enter a date.

14.0 Coordination between the SHOP and the Federally-facilitated Marketplace

14.1	Coordination Strategy Between the Federally-facilitated Marketplace and SHOP: The SHOP Marketplace has developed and documented a coordination strategy with the Federally-facilitated Marketplace.
14.1a The SHOP Marketplace has a coordination strategy with the Federally-facilitated Marketplace and formalized agreements are in place.				☐ Not Started	Expected Start Date  Expected Completion Date
				☐ In Progress	Expected Completion Date
				☐ Complete	Completion Date
Upload documentation:
14.1		I attest this activity is complete ☐	I attest this activity will be complete ☐			Completed/Expected Completion Date

1 Affordable Care Act 1311(b)(1)

2 45 CFR 155.105, Establishment of Marketplaces and Qualified Health Plans; Marketplace Standards for Employers, 77 Fed. Reg. 18310, 18446 (Mar. 27, 2012)

3 45 CFR 153 and Affordable Care Act 1343

4 http://www.grants.gov/search/search.do;jsessionid=0VqkQpTV3Z1fR74Z7rvnwjqf42vlsyw15Qp1FWKbqrQlJ8CQ7zJj!-1406353995?oppId=180734&mode=VIEW.

5 States that receive grants through the Cooperative Agreements for Establishment of Exchanges under the Affordable Care Act 1311(a) are required to participate in Establishment Reviews to monitor the build and draw down of funding of their Marketplace.

6 CMS has been advised that in some states, the governor does not have the authority to enter into a State Partnership Marketplace. Please contact your CCIIO State Officer if the governor of your state believes that another entity is the appropriate authority to sign the state’s Model Declaration Letter so that CMS can work with your state to identify an appropriate arrangement.

7

8 SERVIS and the Collaborative Application Lifecycle Tool (CALT) are password protected. To receive a CALT/SERVIS user ID and password please contact CALT_support@cms.hhs.gov or SERVIS_Support@cms.hhs.gov.

9 45 CFR 153 and Affordable Care Act 1343