CMS-10877 EDE Communication Toolkit

Supporting Statement for Direct Enrollment Entities (CMS-10877)

Appendix_I_EDE-Communications-Toolkit_03.10.23_508

DE Entity Operational Readiness Review (ORR)

OMB: 0938-1463

Document [pdf]

Download: pdf | pdf

EDE Communications Toolkit

OMB Control #: 0938-NEW
Expiration Date: XX/XX/20XX

Overview of Communications Toolkit
Purpose of the Communications Toolkit
This document must be used by Enhanced Direct Enrollment (EDE) Entities to develop the EDE user interface (UI). This document
outlines the communications requirements that must be met in order to participate in EDE.
All requirements in the Communications toolkit must be implemented by EDE Entities and audited by an EDE Auditor regardless of
an Entity's selected end-state application phase, unless specifically indicated otherwise (i.e., "Requirement 6: Phase-Specific
Requirements").
Note: The Communications Toolkit requirements represent the minimum communications that EDE Entities must provide. CMS does
not prevent EDE Entities from providing additional communications from those described within the Communications Toolkit;
however, any changes made to an audited or approved EDE Environment must be documented through the EDE Entity-initiated
Change Request Process, as described in the EDE Guidelines, Section XI.
Note on Draft
All requirements are subject to change.
Navigating Updates to the Toolkit
N/A
User Guide - Tabs
This tab displays EDE communications requirements.
This tab displays acceptable documents for each data matching issue (DMI)
type.

Requirements
DMI Document Types
SVI Document Types

This tab displays acceptable documents for each SEP verification issue (SVI)
type.
Tab: Requirements
Columns

Requirement
High-Level Description of EDE Entity Communications
Requirements
Communications Requirement for EDE Entities
Document Submission Requirements and Additional
Notes to EDE Entities and Auditors
Auditor Compliance Conclusion
**
Risk Level**
Risk Mitigation Strategy**
Estimated Resolution Date**
Auditor Comments**

Description
This column assigns a unique number for each requirement.
This column displays high-level descriptions of communication requirements.
This column displays specific communication requirements.
This column displays additional notes to EDE Entities and Auditors for
implementing and reviewing certain requirements, respectively.
This column is for Auditor use only.
This column is for Auditor use only.
This column is for Auditor use only.
This column is for Auditor use only.
This column is for Auditor use only.

Tab: DMI Document Types
Columns
DMI Type
Full Lists of Acceptable Documents
Document Upload Menu Language

Description
This column describes each type of DMI.
This column contains the acceptable documents that the consumer can
submit in response to each type of DMI as described in Requirement 3.
This column contains the required short list of DMI document types for a
document upload menu drop-down list as described in Requirement 2.

PRA DISCLOSURE: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a
valid OMB control number. The valid OMB control number for this information collection is 0938-NEW, expiration date is XX/XX/20XX. The time required
to complete this information collection is estimated to take up to 56,290 hours annually for all direct enrollment entities. 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. ****CMS Disclosure**** Please do not send applications, claims, payments,
medical records or any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not
pertaining to the information collection burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded,
or retained. If you have questions or concerns regarding where to submit your documents, please contact Brittany Cain at Brittany.Cain@cms.hhs.gov.

Tab: SVI Document Types
Columns
SVI Type
Full Lists of Acceptable Documents
Document Upload Menu Language

Description
This column describes each type of SVI.
This column contains the acceptable documents that the consumer can
submit in response to each type of SVI as described in Requirement 3.
This column contains the required short list of SVI document types for a
document upload menu drop-down list, as described in Requirement 2.
Tab: Spanish Translation_Req.17-24

Columns

Description
Requirement
This column assigns a unique number for each requirement.
High-Level Description of EDE Entity Communications This column displays high-level descriptions of communication requirements.
Requirements
Communications Requirement for EDE Entities
This column displays the Spanish-language translation of the content
displayed in the Requirements tab for specific Communications
requirements.
Document Submission Requirements and Additional This column displays additional notes to EDE Entities and Auditors for
Notes to EDE Entities and Auditors
implementing and reviewing certain requirements, respectively.
Auditor Compliance Conclusion
**
This column is for Auditor use only.
Risk Level**
Risk Mitigation Strategy**
Estimated Resolution Date**
Auditor Comments**

This column is for Auditor use only.
This column is for Auditor use only.
This column is for Auditor use only.
This column is for Auditor use only.
Tab: Spanish Translation_Req.25-29

Columns

This column is for Auditor use only.
This column is for Auditor use only.
This column is for Auditor use only.
This column is for Auditor use only.

Auditor User Guide
Communications Toolkit
Purpose of This Toolkit
This document is designed to help Enhanced Direct Enrollment (EDE) Auditors evaluate and document that the EDE Entity is compliant with the communications requirements set forth by
CMS.
The Auditor must verify that the EDE Entity complies with all communication requirements.
Required Documentation:
The Auditor must provide written confirmation in this toolkit, as part of the Operational Readiness Review (ORR), stating that it confirmed the EDE Entity is compliant with the requirements
listed in this toolkit. For some requirements, Auditors must include screenshots/other evidence as explained in column D of the "Requirements" tab. When uploading supporting
documentation to your DE/EDE PME Site, please group files by the Communications toolkit requirement and compress the folders into one zip file. Also review the EDE Business Audit
Instructions and Report Template section, 1.3 How to Submit the Completed Business Report and Toolkits, for further instructions on how to submit required documentation.
All requirements in the Communications toolkit must be implemented by EDE Entities and audited by an EDE Auditor regardless of an Entity's selected end-state application phase, unless
specifically indicated otherwise (i.e., "Requirement 6: Phase -Specific Requirements").
Tip:
The Auditor may be able to review some of the communications requirements while completing the API Functional Integration Toolkit and the Eligibility Results Toolkit(s).
Note:
For Auditors reviewing an EDE Entity’s Spanish-language version of critical communications, the Auditor can add additional columns for the auditor compliance findings fields (yellowshaded columns) to the Communications toolkit ("Requirements" tab) to document compliance of the Spanish-language translation, or complete the Spanish audit in a second copy of the
toolkit as a supplemental submission after the initial ORR submission. On June 20, 2018, CMS released an FAQ on this topic, available here: https://www.cms.gov/CCIIO/Programs-andInitiatives/Health-Insurance-Marketplaces/Downloads/FAQ-EDE-Spanish-Translation-and-Audit-Requirements.PDF
Note:
The Communications Toolkit requirements represent the minimum communications that EDE Entities must provide. CMS does not prevent EDE Entities from providing additional
communications from those described within the Communications Toolkit; however, any changes made to an audited or approved EDE Environment must be documented through the EDE
Entity-initiated Change Request Process, as described in the EDE Guidelines, Section XI.

Note on Draft
All requirements are subject to change.
Tabs for Auditor Review
Tab

Requirements

DMI Document Types

SVI Document Types

Description

How to Review

This tab displays communication requirements.

The Auditor will use this tab to track compliance with each requirement
defined within the tab. The Auditor must carefully examine the requirement
prior to confirming the EDE Entity's compliance with this toolkit.
Tip: The Auditor may be able to review some of the communications
requirements while completing the API Functional Integration Toolkit and the
Eligibility Results Toolkit(s).

This tab contains the acceptable documents that the
consumer can submit in response to each type of data The Auditor must reference this tab when completing the Requirements tab
matching issue (DMI).
This tab contains the acceptable documents that the
consumer can submit in response to each type of SEP The Auditor must reference this tab when completing the Requirements tab
verification issue (SVI).
Audit Requirements by Tab

Tab: Requirements
In this tab, the Auditor must scroll to the right to complete the last five columns whose column headings are shaded in yellow or marked with "**."
Columns
Requirement

Description
This column assigns a unique number for each
requirement.
High-Level Description of EDE Entity Communications High-level description of communication
Requirements
requirements.
Communications Requirement for EDE Entities
Specific communication requirements.

How to Review

Document Submission Requirements and Additional
Notes to EDE Entities and Auditors

The Auditor must use this information to inform the audit, and follow any
instructions listed in this column.

Auditor Compliance Conclusion
**

Additional notes to EDE Entities and auditors for
implementing and reviewing certain requirements,
respectively.
The Auditor must provide a conclusion as to whether
the scenario or requirement defined in each row is
compliant with the CMS requirements.

N/A
This column contains the high-level requirement categories for the Auditors
to review.
The Auditor must determine if EDE Entity is compliant with these
requirements.

The Auditor will verify that EDE Entity is compliant with CMS requirements as
defined in the other columns in the "Requirements" tab. The Auditor must
use the "DMI Document Types" and "SVI Document Types" tabs to verify
compliance with certain requirements. If the EDE Entity is compliant with
each requirement, the Auditor must indicate "Yes" in this column. If the row
is not compliant, the Auditor must indicate the noncompliance with a "No" in
this column.

Columns

Description

How to Review

Risk Level**

Auditors must assign a risk level to each risk it
identifies.

The Auditor must assign a risk level of "high" or "low" to each risk. High-risk
issues may impact a consumer’s eligibility determination, enrollment
disposition or status, or legal attestation. High-risk issues may also greatly
hinder the consumer experience or impact data collection (e.g., skipping a
question that is required for an EDE Entity to ask, but optional for the
consumer to answer).
Low-risk issues are unlikely to affect a consumer’s eligibility determination,
enrollment disposition or status, legal attestation, experience (i.e., in a
negative or confusing way), or data collection. Note: These risk
determinations are applicable for the business audit only and not the privacy
and security audit.

Risk Mitigation Strategy**

Auditors must explain how a risk(s) was mitigated.

As the Auditor identifies compliance risks, the Auditor and EDE Entity will
identify a mitigation strategy that will mitigate or eliminate the compliance
risk. The Auditor must document that mitigation strategy here. This includes
documenting the mitigation strategy for any identified risk that the DE Entity
has resolved.

Estimated Resolution Date**

Auditors must provide a timeframe for risk resolution CMS recommends Auditors work with the EDE Entity to provide a realistic
(required for unresolved high-risk findings).
timeframe of when a risk will be closed or mitigated given other
dependencies and their expertise.
Auditors must use the Auditor comments column for The Auditor can add any comments necessary during the review, but is not
any additional notes or comments pertaining to each required to do so.
item.

Auditor Comments**

Tab: DMI Document Types
Columns
DMI Type

Description
This column describes each type of DMI.

Full Lists of Acceptable Documents

This column contains the acceptable documents that
the consumer can submit in response to each type of
DMI.

How to Review
The Auditor must use this information to inform the audit for how the EDE
Entity messages DMIs to the consumer and what the applicable next steps
are to resolve the DMI.
The Auditor must use this information to inform the audit for how the EDE
Entity messages DMIs to the consumer and what the applicable next steps
are to resolve the DMI, as described in Requirement 3.

Document Upload Menu Language

This column contains the required short list of
document types for a DMI document upload menu
drop-down list, as described in Requirement 2.

The Auditor must use this information to inform the audit for evaluating how
the EDE Entity populates the DMI document upload drop-down menu
consistent with Requirement 2.

Columns
SVI Type

Description
This column describes each type of SVI.

Full Lists of Acceptable Documents

This column contains the acceptable documents that
the consumer can submit in response to each type of
SVI.

Document Upload Menu Language

This column contains the required short list of
The Auditor must use this information to inform the audit for evaluating how
document types for a SVI document upload menu drop- the EDE Entity populates the SVI document upload drop-down menu
consistent with Requirement 2.
down list, as described in Requirement 2.

Tab: SVI Document Types
How to Review
The Auditor must use this information to inform the audit for how the EDE
Entity messages an SVI to the consumer and what the applicable next steps
are to resolve the SVI.
The Auditor must use this information to inform the audit for how the EDE
Entity messages an SVI to the consumer and what the applicable next steps
are to resolve the SVI, as described in Requirement 3.

Tab: Spanish Translation_Req.17-24
Columns

Description
This column assigns a unique number for each
requirement.
High-Level Description of EDE Entity Communications This column displays high-level descriptions of
Requirements
communication requirements.
Communications Requirement for EDE Entities
This column displays the Spanish-language translation
of the content displayed in the Requirements tab for
specific Communications requirements.
Requirement

Document Submission Requirements and Additional
Notes to EDE Entities and Auditors
Auditor Compliance Conclusion
**

This column displays additional notes to EDE Entities
and Auditors for implementing and reviewing certain
requirements, respectively.
The Auditor must provide a conclusion as to whether
the scenario or requirement defined in each row is
compliant with the CMS requirements.

How to Review

N/A
This column contains the high-level requirement categories for the Auditors
to review.
The Auditor must determine if EDE Entity is compliant with these
requirements.

The Auditor must use this information to inform the audit, and follow any
instructions listed in this column.
The Auditor will verify that EDE Entity is compliant with CMS requirements as
defined in the other columns in the "Requirements" tab. The Auditor must
use the "DMI Document Types" and "SVI Document Types" tabs to verify
compliance with certain requirements. If the EDE Entity is compliant with
each requirement, the Auditor must indicate "Yes" in this column. If the row
is not compliant, the Auditor must indicate the noncompliance with a "No" in
this column.

Risk Level**

Columns

Description
Auditors must assign a risk level to each risk it
identifies.

How to Review
The Auditor must assign a risk level of "high" or "low" to each risk. High-risk
issues may impact a consumer’s eligibility determination, enrollment
disposition or status, or legal attestation. High-risk issues may also greatly
hinder the consumer experience or impact data collection (e.g., skipping a
question that is required for an EDE Entity to ask, but optional for the
consumer to answer).
Low-risk issues are unlikely to affect a consumer’s eligibility determination,
enrollment disposition or status, legal attestation, experience (i.e., in a
negative or confusing way), or data collection. Note: These risk
determinations are applicable for the business audit only and not the privacy
and security audit.

Risk Mitigation Strategy**

Auditors must explain how a risk(s) was mitigated.

Estimated Resolution Date**

Auditor Comments**

Tab: Spanish Translation_Req.25-29
Columns

Document Submission Requirements and Additional
Notes to EDE Entities and Auditors

How to Review

N/A
This column contains the high-level requirement categories for the Auditors
to review.
The Auditor must determine if EDE Entity is compliant with these
requirements.

The Auditor must use this information to inform the audit, and follow any
instructions listed in this column.

Risk Level**

Auditors must assign a risk level to each risk it
identifies.

Risk Mitigation Strategy**

Auditors must explain how a risk(s) was mitigated.

Estimated Resolution Date**

Auditor Compliance Conclusion
**

Auditor Comments**

Requirements
Requirement

High-Level
Description of EDE
Entity
Communications
Requirements
EDE Entity
Application
Submission & Data
Matching Issue (DMI)
Creation
Communications

Communications Requirement for EDE Entities

Document Submission Requirements and Additional Notes to EDE Entities and Auditors Auditor Compliance Conclusion**

EDE Entities must send emails to the consumer to notify them that their application was submitted and whether they have any DMIs. CMS currently sends two separate emails for the application submission and DMI creation events; however, the wording and format The Auditor must submit sample communications that the EDE Entity is using to
of how the Entity communicates this to the consumer does not need to mirror CMS’s current wording and format. The EDE Entity must reasonably communicate the content of these messages to the consumer such that the consumer is educated about the application communicate application submission and DMI creation to consumers. This must
submission and DMI creation events in a way that is clear and consumer friendly.
include a sample for when an Annual Income DMI is created after async processing
completed. Additionally, partners must provide a screenshot of the stored EBP Annual
CMS has functionality that enables consumers to complete application submission when a trusted data source is not available (i.e. "asynchronous submission" or "async processing"). For applications submitted when the IRS is unavailable and where IRS
Income Event (after async processing completes) from their logs that corresponds to
information is needed for income verification, the Standalone Eligibility Service (SES) will queue the application and complete income verification once the IRS becomes available. These applications will either have annual income verified or an annual income DMI the email communication.
created within 24 hours, and sometimes much sooner. EDE Entities are required to send the consumer an email to notify them if they have an Annual Income DMI after async processing completed.
Note: When an application is submitted during "async processing" and other, non-income DMIs are communicated to the consumer via the Entity's application submission and DMI creation event emails, it's recommended to include content in those
communications that informs the consumer that their annual income information is still being processed and encourage them to check back in 24 hours to see if action is needed.
Entities may improve these communications in contrast to CMS’s approach based on their knowledge of the consumer (examples: Combine the Application Submission & DMI Creation information into a single message; leverage the user interface to reinforce key
items to the consumer, etc.).
For EDE Entities and Auditors to reference, CMS has included example documents for these communications from HealthCare.gov (e.g., see the files "DMI Creation - English.pdf" and "Application Submitted - English.pdf").

Document Upload
Requirement; DMI
and Special
Enrollment Period
(SEP) Verification
Issue (SVI) User
Interface Display

EDE Entities must provide, for each DMI and the loss of qualifying healthcare coverage Special Enrollment Period (SEP) Verification Issue (SVI), information specific to each DMI and SVI type. On the document upload page, for each DMI and SVI action item, EDE
Entities must provide the following information: action item (title/type of DMI/SVI), deadline, person(s) it applies to, description of action required, provide a drop-down menu for the consumer to select and upload documents for that DMI or SVI as detailed below
(the list must be specific to the DMI or SVI type), status of the DMI or SVI (based on API, but converted from the status provided in the API to a consumer-friendly status term), and provide a way for the consumer to download any notices related to the DMI or SVI
(with a date and consumer-friendly title for each notice) (please also review requirements 12 and 13 on this tab of the Toolkit). EDE Entities must also provide introductory educational content that describes at a high level the purpose of uploading documents. At a
minimum, this must describe that the consumer will need to upload documents to the Exchange to provide proof of the consumer's information as provided on the application in order to complete their eligibility application and/or enrollment. As part of this
content, the EDE Entity must also, at a minimum, list out the condensed list of document types a consumer may upload for the respective DMI or SVI; this is required independent of the EDE Entity's chosen approach for displaying the full list of acceptable documents
for a DMI or SVI (as described later in this requirement). These condensed lists of document types are available in column C of the "DMI Document Types" and "SVI Document Types" tabs.

The Auditor must provide screenshots for each DMI and the loss of qualifying
healthcare coverage SVI that includes the following:
- Initial document upload page and educational content,
- An unobstructed and complete view of the full document upload drop down menu,
- A copy of the EDE Entity's hyperlinked webpage hosting the full list of acceptable
documents (if the Entity is using this option and not relying solely on HealthCare.gov),
- A representation of the document upload page with multiple DMIs and/or SVIs (if the
EDE Entity displays multiple DMIs and/or SVIs on the same document upload page),
The EDE Entity must also provide a drop-down menu for the consumer to select a document type to upload specific documents that may be used to resolve each DMI or SVI. The required content for the drop down is in column C of the "DMI Document Types" and "SVI and
Document Types" tabs. If the EDE Entity lists multiple DMIs and/or SVIs on each page, the EDE Entity must provide a unique document upload selection drop down for each DMI and SVI. The EDE Entity must not allow consumers to select document types that are not - Any other screenshots that constitute the DMI or SVI educational content or
applicable for a DMI or SVI as indicated in column C of the "DMI Document Types" or "SVI Document Types" tabs.
document upload functionality.
In addition to the basic DMI and SVI display detailed in Requirement 2, EDE Entities have two options for displaying the full list of acceptable documents for a DMI or SVI, as displayed in column B of the "DMI Document Types" and "SVI Document Types" tabs. In
both cases, EDE Entities must provide all of the information included in the "DMI Document Types" and "SVI Document Types" tabs for each respective DMI and SVI; however, one option allows EDE Entities to display some content on a separate webpage. CMS will
allow flexibility in the display of the full list of acceptable documents as long as the content from column B is accessible to consumers and consistent with the other standards in this requirement. The tow options for displaying the full list of acceptable documents
are as follows:

The Auditor must provide screenshots for each DMI and the loss of qualifying
healthcare coverage SVI that includes the following:
- A copy of the EDE Entity's hyperlinked webpage hosting the full list of acceptable
documents (if the Entity is using this option and not relying solely on HealthCare.gov),
- A screenshot demonstrating the EDE Entity's URL to the DMI- or SVI-specific
1a) For the first option, after the introductory educational content, EDE Entities must provide a link to a separate webpage listing the full list of acceptable documents that a consumer may upload to resolve the respective DMI or SVI, as detailed in column B of the
HealthCare.gov webpage displaying the full list of acceptable documents.
"DMI Document Types" and "SVI Document Types" tabs. If the EDE Entity opts to create its own webpage listing the full list of acceptable documents for each respective DMI or SVI, the Entity must also add the URLs to HealthCare.gov for each respective DMI and SVI
- Any other screenshots that constitute the DMI or SVI educational content or
(as provided on the "DMI Document Types" and "SVI Document Types" tabs of this toolkit) to the webpage. The EDE Entity must provide explanatory text describing the URL as containing the official full list of acceptable documents. As HealthCare.gov may change the document upload functionality.
full list of acceptable documents, EDE Entities must provide this URL to allow users to access the official full list of acceptable documents.
1b) Alternatively, the EDE Entity may provide a link to the specific webpage (or section of a webpage) on HealthCare.gov that provides the full list of acceptable documents for that specific DMI or SVI consistent with the "DMI Document Types" and "SVI Document
Types" tabs. If the EDE Entity uses the alternative approach for displaying the full list of acceptable documents to resolve DMIs and SVIs, the EDE Entity must provide a link to the applicable section of the webpage for the specific DMI or SVI; the EDE Entity may not
only direct the consumer to the beginning of a page that contains a full list of all documents that may be used to resolve all DMIs and SVIs.
2) For the second option, EDE Entities may include all DMI and SVI educational content, including the full list of acceptable documents to resolve DMIs and SVIs, on one webpage. The EDE Entity would provide the full set of educational content specific to the
relevant DMI or SVI from column B of the "DMI Document Types" and "SVI Document Types" tabs on the same page as the document upload functionality. If the EDE Entity opts to create its own content on the document upload page listing the full list of acceptable
documents for each respective DMI or SVI, the Entity must also add the URLs to HealthCare.gov for each respective DMI and SVI (as provided on the "DMI Document Types" and "SVI Document Types" tabs of this toolkit) to the webpage. The EDE Entity must provide
explanatory text describing the URL as containing the official full list of acceptable documents. As HealthCare.gov may change the full list of acceptable documents, EDE Entities must provide this URL to allow users to access the official full list of acceptable
documents.
Disclaimer: CMS has listed the DMI and SVI documents in the "DMI Document Types" and "SVI Document Types" tabs within this toolkit. However, you may also find these documents listed on HealthCare.gov at the following sites:
https://www.healthcare.gov/help/how-do-i-resolve-an-inconsistency/ and https://www.healthcare.gov/help/prove-coverage-loss/. It is possible that HealthCare.gov's full list of documents may be more current than those listed in this toolkit.

EDE Entities must display information related to a consumer's or agent's/broker's ability to resolve certain DMIs (Citizenship, Immigration, Income, and Social Security Number (SSN)) through updates to the consumer's application. EDE Entities must display this
information, at a minimum, on the DMI document upload page in the user interface for each specific, applicable DMI (i.e., Citizenship, Immigration, Income, and SSN).
The messaging must at a minimum include the following information, with dynamic content indicated by brackets: "To resolve this data matching issue [alternative: state the consumer-facing name of the DMI], in addition to uploading documents to the
Marketplace, [Consumers/Agents and Brokers] can resolve the issue by updating the application with more information. For example, entering Social Security Numbers, entering immigration documents, and checking that household income is correctly reported on
the application. To do so, [insert EDE Entity's instructions]."

The Auditor must provide screenshots for this messaging for each applicable DMI with
the following:
- A screenshot demonstrating the EDE Entity's display of the required messaging, with
the EDE Entity's instructions populated for each of the applicable DMIs (Citizenship,
Immigration, Income, and SSN).

CMS strongly recommends that EDE Entities update communications, including the DMI Creation email, for consumers related to resolving DMIs with this information for the applicable DMIs (i.e., Citizenship, Immigration, Income, and SSN).
Note: This messaging does not replace the DMI document upload and status page messaging required by Requirements 2 and 3 above.
5

Explain to
In communications to the consumer and in the user interface, EDE Entities must inform consumers that the consumers will continue to receive additional communications from HealthCare.gov. However, EDE Entities should encourage consumers to return to the EDE The Auditor does not need to submit any screenshots or evidence of this requirement,
Consumers They Will Entity's site rather than HealthCare.gov to address their needs. EDE Entities should embed this information into the initial application submission communication (e.g., “Be aware you may get e-mails from HealthCare.gov but come back to us for all of your needs.”) but must evaluate the EDE Entity's compliance with this requirement.
Continue to Receive and other communications.
HealthCare.gov
Communications

Phase-Specific
Requirements

If an EDE Entity has implemented Phase 1 or Phase 2, the Auditor must confirm that the UI includes a disclaimer stating that the website does not support all use cases and application scenarios, and identifying which scenarios are not supported. The disclaimer
should direct the consumer to alternative pathways, such as the traditional DE double-redirect pathway or direct the consumer to the FFE (HealthCare.gov or the Marketplace Call Center at 1-800-318-2596 (TTY: 1-855-889-4325)). EDE Entities are permitted to
display this disclaimer to only those consumers who require an unsupported use case or scenario for the EDE Entity's applicable phase.

Phase 3 (including prospective phase change EDE Entities): Phase 3 EDE Entities are required to support all use cases and application scenarios The auditor must confirm that the UI does not include this disclaimer
Consumer-Friendly
EDE Entities must use clear, consumer-friendly language in the UI throughout the EDE end-user experience. The following guidelines apply to approved terminology that EDE Entities may use for specific terms. Terminology that falls outside of these guidelines below
Communications and may be impermissible. Auditors must describe any discrepancies with the below guidelines as findings for this requirement.
Marketing
Throughout the EDE - EDE Entities may describe the premium tax credit as a premium tax credit, advance premium tax credit, tax credit, or subsidy. EDE Entities must not describe the premium tax credit as a discount.
End-User Experience - EDE Entities may describe cost-sharing reductions as cost-sharing reductions or reduced cost-sharing.
- EDE Entities may refer to data matching issue (DMIs) tasks as: data matching issues; inconsistencies; confirmation of eligibility results; or document upload action items.
- EDE Entities may refer to SVI tasks as: document upload action items; confirmation of [insert name of special enrollment period]; confirm your eligibility for a special enrollment period.
- EDE Entities may refer to the Federally-facilitated Exchanges as HealthCare.gov or the Marketplace.
- EDE Entities must not use the term Obamacare.
- EDE Entities must not use acronyms in the UI (e.g., APTC, CSR, DMI, SVI, SEP, QHP, EDE, NPN, HC.gov).
- EDE Entities must not display API values in the UI (e.g., displaying status codes pulled directly from the APIs).
- EDE Entities must display the date format consistently across their entire EDE end-user experience. Acceptable date formats are MM/DD/YYYY or YYYY/MM/DD.
Post-Eligibility
EDE Entities must provide account management functions for consumers (e.g., ways for consumers to take action on action items, update application information, report life changes, make updates to an enrollment, etc.). In order to support consumers with these
Application
account management functions, EDE Entities must provide an application or enrollment management experience that includes, but is not limited to, functionality to account for the following: action items the consumer needs to take; the status of and ability to
Communications
upload documents to resolve DMIs and SVIs; the status and action items for SEPs and the Open Enrollment Period (OEP); notices generated by the FFE; and application and enrollment status, including details about the consumer's QHP. Additionally, after enrolling
the consumer, the EDE Entity must provide clear, consumer-friendly instructions to the consumer on how to make any necessary updates to their FFE application, including reporting changes in circumstances (CiCs) or supporting consumers during SEPs outside of
the OEP.
EDE Entities have flexibility in how they implement the account management functions within the UI and integrate the various requirements in this toolkit as long as their implementation is otherwise consistent with the specific standards described in this toolkit
and includes functionality to support the required processes.

The Auditor does not need to submit any screenshots or evidence of this requirement,
but must evaluate the EDE Entity's compliance with this requirement.

The Auditor must submit a screen recording (or several recordings) demonstrating the
EDE Entity's dashboard, including where a consumer would be able to access the
account management functions detailed in the requirement (in column C). Such as,
how to navigate to sections within the UI. The video can include branching off of this
page, navigating to subsections/links within the dashboard.
The file format for video files should be MP4.

When consumers log in to the EDE Entity's pathway, the UI should be refreshed to get the latest status of the application, enrollment, and any action items flagged for the consumer and their household members (DMI, SVI, etc.).
9

In addition to the display of status information (e.g., related to the application, DMIs, SVIs, enrollments, etc.) in the application and enrollment management functionality in the UI, the EDE Entity must communicate ongoing status information and provide
information to assist consumers with the management of their application and coverage. These communications include, but are not limited to, the status of DMIs and SVIs and a link to the document upload page where they may be resolved, the availability of
SEPs, the timing of the OEP, providing access to and communicating the availability of new notices generated by the FFE, and the status of applications and enrollments. This information must be communicated in the EDE Entity's UI, but additionally, the EDE Entity
should communicate this information to consumers through email or text message based on consumer preferences; however, this requirement does not modify the required email communications detailed in Requirement 1.
The EDE Entity may reference the file "My Account Messaging for Notices.pdf" to review HealthCare.gov's messaging for notices. This file is stored in the Business Audit Report Template and Toolkits zip folder.

The Auditor must verify that EDE Entity’s EDE implementation is providing status
information and ongoing communications to consumers according to CMS
requirements as it relates to the status of their application, eligibility, enrollment,
notices, and action items the consumer needs to take and verify that the EDE Entity's
EDE implementation is showing changes to those statuses (new information) over
time.
The Auditor does not need to submit any screenshots or evidence of this requirement,
but must evaluate the EDE Entity's compliance with this requirement.

The UI must display high-level eligibility results, next steps for enrollment, and information about the following for each consumer: program eligibility, DMIs, SEPs, SVIs, and enrollment steps in a clear, comprehensive and consumer-friendly way. At a minimum, EDE The Auditor must submit screenshots of the eligibility results page that demonstrate
Entities must display, per consumer, their eligibility for the following: Marketplace plans, advance payments of the premium tax credit (APTC), cost-sharing reductions (CSRs), Medicaid/Children's Health Insurance Program (CHIP), and SEPs, as well as display
the high-level eligibility results detailed in column C.
whether any SVIs and DMIs exist. The Application UI Toolkit, Eligibility Results tab contains the applicable specific display requirements for the Eligibility Results page of the EDE Environment. EDE Entities may also include information on the next steps that
consumers must take for any applicable DMIs and SVIs, consistent with the descriptions of those next steps in Requirements 25 through 29.
EDE Entities should not focus the high-level overview on the eligibility results page solely or primarily on Marketplace program eligibility and must clearly indicate each consumer's eligibility for Medicaid/CHIP
Any time a consumer submits a change in circumstance (CiC) resulting in QHP and APTC eligibility, EDE Entities are required to notify the consumer of their APTC or CSR eligibility and allow the consumer to modify their QHP selection (if the consumer is also SEPeligible and is not restricted to their current plan by Plan Category Limitations) and APTC allocation, accordingly. This applies whether the amount of APTC the consumer is eligible for changes or not. The EDE Entity must provide clear, consumer-friendly
instructions of the steps necessary to modify the consumer's QHP selection or APTC allocation.

The Auditor does not need to submit any screenshots or evidence of this requirement,
but must evaluate the EDE Entity's compliance with this requirement.

EDE Entities must provide consumers with the most recent CMS-provided Eligibility Determination Notices (EDNs) generated by the FFE any time they submit or update an application pursuant to requirements provided by CMS. EDE Entities must provide the EDN in a
downloadable format in the UI at the time the consumer’s application is submitted or updated.

For all notices, including the EDN, EDE Entities must provide an interactive UI element for the consumer to view/download the PDF (e.g., a link or button) at the time the consumer’s application is submitted or updated and must have a process for providing access to The Auditor must submit screenshots of the EDE Entity's display of notices for
the consumer’s most recent notices via the API. EDE Entities must display a consumer-facing name for each notice, provide a date within the UI when the notice was generated, and provide historical access to previous notices.
consumers, including the display of SVI or DMI notices, an EDN, and historical access
to previous notices (i.e., at least two notices of the same type with a preceding version
EDE Entities should only download the notice(s) (i.e., make a call to the Notice Retrieval API) based on a consumer’s action to view/download the notice. This should trigger a call to retrieve the notice from the Notice Retrieval API (in other words, every time a
of the notice shown as well as the current notice), and an expired DMI notice (i.e., the
consumer or agent/broker seeks to view a notice, there should be a call to retrieve the latest notice); EDE Entities should not store cached versions of notices to display in this scenario, because a cached version of a notice could be outdated.
creation of a particular DMI and an expired notice for the same DMI).

The Auditor must verify that the EDN is accessible to the consumer in the UI. The
Auditor must verify that the EDE Entity has a process for providing consumers with a
downloadable EDN in the UI and for providing access to a current EDN via the API.

In the UI for providing access to notices, the EDE Entity must provide a link to the document upload pages for resolving action items. CMS allows flexibility in how an EDE Entity implements this requirement; however, the consumer must be clearly provided a link to
the location within the UI where the consumer can upload documents to resolve an action item.
14

Refresh Consumer
Information when
They Revisit the EDE
Entity Website
Spanish Translation

The EDE Entity must refresh the information, including the Get App, Get Enrollment, and Meta Data Search APIs, when the consumer or Agent/Broker revisits the EDE Entity's EDE environment to determine if there are new notices and information that should be made
available to the consumer.

The Auditor does not need to submit any screenshots or evidence of this requirement,
but must evaluate the EDE Entity's compliance with this requirement.

The EDE Entity must translate the critical communications content identified in this toolkit (e.g., communications informing consumers of their application status or action items; critical communications that the consumer will no longer receive from the Exchange;
and any other critical communications that the EDE Entity is providing to the consumer in relation to the consumer’s use of its EDE pathway) into any non-English language that is spoken by a limited English proficient (LEP) population that reaches 10 percent or
more of the population of the relevant state, as determined in guidance published by the Secretary of HHS. For example, if the EDE Entity plans to offer the EDE pathway for consumers in Texas, the Auditor must verify that the EDE Entity’s Spanish-language versions of
the critical communications content outlined in this toolkit is compliant with the outlined requirements.

The Auditor must include a screenshot(s) of how the consumer navigates to the
Spanish-language website to satisfy the website display requirement to inform
individuals of the availability of the services to support limited English proficiency
(LEP) (e.g. website translation). For example, this could be a screenshot of the button a
consumer clicks to be able to view their UI in Spanish.

Set Clear
Expectations &
Awareness of
Marketplace
Program

The EDE Educational Content is a list of discrete questions and answers that an EDE Entity must display in the UI. For each education requirement listed below, an EDE Entity must use the exact language provided in its UI. If an EDE Entity wishes to modify the
language provided, it must request approval. Auditors should refer to the Business Report Template and Toolkits WinZip File for additional Spanish content.

Upon completion of CMS's review of the EDE Entity's communication requirements in
English, CMS will request screenshots of the final English version of these
requirements and of the associated Spanish-language version of the UI.
The Auditor must review the EDE Educational Content listed below (requirements 1824) and confirm the EDE Entity correctly displays all required content, if applicable.
The Auditor will confirm the EDE Entity uses language identical to the requirements.
The Auditor must provide screenshots documenting the presence of each educational
content requirement.

Risk Level**

Risk Mitigation Strategy**

Estimated Resolution Date**

Auditor Comments**

Requirement

High-Level
Description of EDE
Entity
Communications
Requirements
g

Communications Requirement for EDE Entities

Document Submission Requirements and Additional Notes to EDE Entities and Auditors Auditor Compliance Conclusion**

Instructions for EDE Entities: EDE Entities must display the following educational content (requirements 18 through 24) prior to an individual initiating an FFE application through the EDE pathway. These must be visible to the consumer prior to completing the preeligibility application data collection attestations.

The Auditor must provide a screenshot depicting the screen with this educational
content that clearly shows where this content exists and how a consumer can access it
in the EDE end-user experience. For example, if this educational content is accessed
via a hyperlink, provide a screenshot of the page where the hyperlink can be accessed
by the consumer in the EDE end-user experience.

EDE Entities may provide these FAQs via a hyperlink. If an EDE Entity chooses to do so, the hyperlink should be prominent, clear, and consumer friendly, such as stating: "Additional Information about the Marketplace and [EDE Entity]."
18

Introduction:
Here at [insert EDE Entity's Name], we work with the Health Insurance Marketplace to help you get health coverage.
What’s the Health Insurance Marketplace?
The Marketplace is a health coverage service that helps you shop for and enroll in coverage that fits your needs and budget. The Marketplace can tell you if you qualify for an individual insurance plan with savings or whether you’re eligible for free or low-cost
coverage through Medicaid or the Children’s Health Insurance Program (CHIP). The official Marketplace website is www.HealthCare.gov.

Are there benefits to getting health insurance through the Marketplace?
"Learn more about what Marketplace plans must cover." must hyperlink to more
Marketplace coverage is the only way to get premium tax credits to help lower your monthly premiums and savings on out-of-pocket costs with lower deductibles and copayments. All Marketplace plans must cover the same set of essential health benefits, including information that describes Marketplace plan requirements. This can either be a direct
preventive care, doctor’s visits, prescriptions, hospital, and emergency services. No Marketplace plan can reject you, charge you more, or refuse to pay for essential health benefits for any condition you had before your coverage started. Learn more about what
hyperlink to HealthCare.gov (https://www.healthcare.gov/coverage/what-marketplaceMarketplace plans must cover.
plans-cover/) or the EDE Entity can provide this same type of information on their own
site
How do I apply for and enroll in coverage?
You can apply and enroll with us. We’ll send your information to the Marketplace through HealthCare.gov and let you know the programs and savings you’re eligible for. If any of your information changes, you can also update your application through us.

21
22

What if I’m eligible for Medicaid or CHIP?
If you fill out an application and learn that you’re eligible for coverage through Medicaid or CHIP, the Marketplace will automatically send your information to the state agency that runs these programs. We’ll give you an eligibility notice with more information.

How will I get notices?
Even if you enroll in coverage through [insert EDE Entity's name], you’ll still get some information directly from the Marketplace. Look for notices in the mail from the Health Insurance Marketplace and emails from HealthCare.gov. It’s important to read these notices
and emails because they contain important information that you’ll only get from the Marketplace. We can help you with any follow-up actions you may need to take, including requests from HealthCare.gov.
What if I’m redirected to HealthCare.gov?
We can help most people with their application and enrollment directly on our site. If we need to redirect you to HealthCare.gov to complete your application, we’ll walk you through what to do and help you start to finish.

24
25

Post-Enrollment UI
Communication for
Consumers

Instructions for EDE Entities: EDE Entities must display the following educational content (requirements 26-29) in the UI after a consumer selects a plan through the EDE pathway. For each UI communication requirement listed below, an EDE Entity must use the exact For any requirement that requires an EDE Entity to insert its own instructions for
language provided in its UI. If an EDE Entity wishes to modify the language provided, it must request approval.
completing an action or for any UI elements used to complement those instructions
(e.g., error messages), the EDE Entity must provide specific, consumer-friendly
If a primary EDE Entity is integrating its EDE platform with an upstream EDE Entity's QHP shopping platform, the post-enrollment confirmation communication in the UI must still be implemented consistent with the following requirements (requirements 26-29). This directions. For example, if the EDE Entity is directing the consumer to a location in an
information may be displayed on the upstream EDE Entity's website or the primary EDE Entity's website as a post-enrollment confirmation page, but any data connection or transfer necessary to facilitate the display of this information on an upstream EDE Entity's
account dashboard to upload documents, the EDE Entity must provide either a direct
website must be disclosed in an EDE Entity-initiated Change Request and a copy of the primary EDE Entity's ISA Appendix B. Please refer to the EDE Guidelines for Year 6 for more information. If an upstream EDE Entity wishes to implement the language in these
hyperlink or clear navigation instructions to the specific webpage or location in an
requirements--and more generally, any language or functionality described in this toolkit or in the EDE Guidelines--the EDE Entity must detail and provide evidence of the proposed implementation to CMS via an EDE Entity-initiated Change Request.
account dashboard where the consumer can complete a specific action. The EDE Entity
must not simply direct the consumer to log in to their account.
Note: If at least one member of the household attested to receiving an Individual Coverage HRA (ICHRA) or Qualified Small Employer HRA (QSEHRA) on their eligibility application, after the consumer has completed enrollment, the Entity must display reminder
language (on the eligibility results page and/or as part of the enrollment confirmation communication language described in these requirements) that the consumer will need to notify their employer that the consumer has enrolled in Marketplace coverage. Please
refer to the DE API Specifications for more information and required language to display.
[Post-Enrollment Confirmation page content for a consumer who has an SVI]
After the consumer has confirmed their plan selection, if the FFE has generated an SVI,
but no DMIs, for the consumer, EDE Entities must display this text.
You’ve chosen a plan. You can start using your health coverage after you submit documents and the Marketplace confirms you’re eligible to enroll through a Special Enrollment Period. The sooner you submit documents, the sooner your coverage can become active.
See below for more information about next steps.
When the EDE Entity provides a list of SVIs, the EDE Entity may deviate from the format
provided here; for example, the EDE Entity may use a bulleted list or a table.
What should I do now?
1. You must submit documents to the Marketplace for [insert person(s) and SVI types] by [insert deadlines]. To do this, [insert EDE Entity's instructions].
The deadline for each SVI must be a full date (i.e., month, day, and year).
2. Watch for a notice with the results of the Marketplace’s review of your documents. You may access your Marketplace notices by [insert EDE Entity's instructions].
The Auditor must provide screenshots of this page for a test consumer for whom the
3. Pay your premium after your eligibility is confirmed. You'll receive another notice when it’s time to take this step. You may pay your premium by [insert EDE Entity's instructions].
FFE has generated at least one SVI.
Note: Remember that you can’t start using your coverage until the Marketplace reviews your documents and confirms your information, and you pay your premium.
Expect communications from us and from the Marketplace. When you hear from HealthCare.gov:
- Read your notices and emails.
- HealthCare.gov may send you notices and communications about your coverage. Log in to your account with us to view your Marketplace notices, make updates to your application or coverage, and manage your information.
- Upload documents through [insert EDE Entity's name]. We can help you submit documents if the Marketplace needs to confirm your information.
- Download forms you’ll need when you file your federal income tax return.

After the consumer has confirmed their plan selection, if the FFE has generated an SVI
and a DMI for the consumer, EDE Entities must display this text.
You’ve chosen a plan. You can start using your health coverage after you submit documents and the Marketplace confirms you’re eligible to enroll through a Special Enrollment Period. The sooner you submit documents, the sooner your coverage can become active.
See below for more information about next steps.
When the EDE Entity provides a list of SVIs and DMIs, the EDE Entity may deviate from
the format provided here; for example, the EDE Entity may use a bulleted list or a table.
What should I do now?
1. You must submit documents to the Marketplace for [insert person(s) and SVI types] by [insert deadlines]. To do this, [insert EDE Entity's instructions].
The deadline for each SVI and DMI must be a full date (i.e., month, day, and year).
2. Watch for a notice with the results of the Marketplace’s review of your documents. You may access your Marketplace notices by [insert EDE Entity's instructions].
The Auditor must provide screenshots of this page for a test consumer for whom the
3. Pay your premium after your eligibility is confirmed. You'll receive another notice when it’s time to take this step. You may pay your premium by [insert EDE Entity's instructions].
FFE has generated an SVI and a DMI.
Note: Remember that you can’t start using your coverage until the Marketplace reviews your documents and confirms your information, and you pay your premium.
Is there anything else I should do now?
- Submit required documents to the Marketplace for: [insert person(s) and DMI types] by [insert deadlines]. To do this, [insert EDE Entity's instructions].
- If you confirmed your Special Enrollment Period eligibility and your coverage has begun, but you don’t submit these additional documents by the deadlines listed above, you may lose your Marketplace health coverage, and/or may have a decrease of or lose any
financial help you may be getting.
Expect communications from us and from the Marketplace. When you hear from HealthCare.gov:
- Read your notices and emails.
- HealthCare.gov may send you notices and communications about your coverage. Log in to your account with us to view your Marketplace notices, make updates to your application or coverage, and manage your information.
- Upload documents through [insert EDE Entity's name]. We can help you submit documents if the Marketplace needs to confirm your information.
- Download forms you’ll need when you file your federal income tax return.

What if I need to update my information later?
If you have a life change, like you move, have a change in income, or get married, please let us know right away. To do this, [insert EDE Entity's instructions].
[Post-Enrollment Confirmation page content for a consumer who has a DMI]
Congratulations! You’ve enrolled in Marketplace coverage through [insert EDE Entity's name].
What should I do now?
1. Pay your premiums. To do this, [insert EDE Entity's instructions].
2. Submit required documents to the Marketplace for [insert person(s) and DMI types] by [insert deadlines]. To do this, [insert EDE Entity's instructions]. If you don't submit these documents by the deadlines listed above, you may lose your Marketplace health
coverage and/or may have a decrease of or lose any financial help you may be getting.
3. Watch for a notice with the results of the Marketplace’s review of your documents. You may access your Marketplace notices by [insert EDE Entity's instructions].
Expect communications from us and from the Marketplace. When you hear from HealthCare.gov:
- Read your notices and emails.
- HealthCare.gov may send you notices and communications about your coverage. Log in to your account with us to view your Marketplace notices, make updates to your application or coverage, and manage your information.
- Upload documents through [insert EDE Entity's name]. We can help you submit documents if the Marketplace needs to confirm your information.
- Download forms you’ll need when you file your federal income tax return.

What if I need to update my information later?
If you have a life change, like you move, have a change in income, or get married, please let us know right away. To do this, [insert EDE Entity's instructions].
[Post-Enrollment Confirmation page content for a consumer who has no SVIs or DMIs]
Congratulations! You’ve enrolled in Marketplace coverage through [insert EDE Entity's name].
What should I do now?
- Pay your premiums. To do this, [insert EDE Entity's instructions].
Expect communications from us and from the Marketplace. When you hear from HealthCare.gov:
- Read your notices and emails.
- HealthCare.gov may send you notices and communications about your coverage. Log in to your account with us to view your Marketplace notices, make updates to your application or coverage, and manage your information.
- Download forms you’ll need when you file your federal income tax return.
What if I need to update my information later?
If you have a life change, like you move, have a change in income, or get married, please let us know right away. To do this, [insert EDE Entity's instructions].

After the consumer has confirmed their plan, if the consumer has DMIs, but no SVIs,
the EDE Entity must display this text.
When the EDE Entity provides a list of DMIs, the EDE Entity may deviate from the format
provided here; for example, the EDE Entity may use a bulleted list or a table.
The deadline for each DMI must be a full date (i.e., month, day, and year).
The Auditor must provide screenshots of this page for a test consumer for whom the
FFE has generated at least one DMI.

After the consumer has confirmed their plan selection, if they have no DMIs or SVIs,
EDE Entities must display this text.
The Auditor must provide screenshots of this page for a test consumer with no DMIs or
SVIs.

Risk Level**

Risk Mitigation Strategy**

Estimated Resolution Date**

Auditor Comments**

DMI Document Types
For reference, CMS is providing the HealthCare.gov hyperlinks in English and Spanish of the full lists for the documents in cells C1 and D1.

https://www.healthcare.gov/help/how-do-i-resolve-an-inconsistency/ https://www.cuidadodesalud.gov/es/help/how-do-i-resolve-aninconsistency/
Document Upload Menu Language

DMI Type

Note : HealthCare.gov, collapses the selectable document types for file upload menus, so not all documents are shown in the menus
(columns C and D). Examples of document types are provided on the UI on screen with a link to a full list of documents. Please refer
to Requirements 2 and 3 on the Requirements Tab for more information.

Full Lists of Acceptable Documents

·
·
·
·

U.S. passport
Certificate of Naturalization (N-550/N-570)
Certificate of Citizenship (N-560/N-561)
State-issued enhanced driver's license (available in Michigan, New York, Vermont, and Washington)

·
Document from federally recognized Indian tribe that includes your name and the name of the federally recognized Indian
tribe that issued the document, and shows your membership, enrollment, or affiliation with the tribe. Documents you can provide
include:
o
o
o
o

A tribal enrollment card
A Certificate of Degree of Indian Blood
A tribal census document
Documents on tribal letterhead signed by a tribal official

English Document Type Menu List:
·
U.S. passport
·
Certificate of Naturalization (N-550/N-570)
·
Certificate of Citizenship (N-560/N-561)
·
State-issued enhanced Driver’s License

Spanish Document Type Menu List:
·
Pasaporte de los EE.UU.
·
Certificado de Naturalización (N-550/N-570)
·
Certificado de Ciudadanía (N-560/N-561)
·
Licencia de manejar emitida por el estado

·
·

Document from a federally recognized Indian tribe
Other

Documento de tribu reconocida federalmente
Otro

If you don’t have any of the documents above, you can submit 2 documents — one from each list below.
You can submit one of these documents:

Citizenship

·
·
·
·
·
·
·
·
·
·
·
·
·
·
·

U.S. public birth certificate
Consular Report of Birth Abroad (FS-240, CRBA)
Certification of Report of Birth (DS-1350)
Certification of Birth Abroad (FS-545)
U.S. Citizen Identification Card (I-197 or the prior version I-179)
Northern Mariana Card (I-873)
Final adoption decree showing the person’s name and U.S. place of birth
U.S. Civil Service Employment Record showing employment before June 1, 1976
Military record showing a U.S. place of birth
U.S. medical record from a clinic, hospital, physician, midwife, or institution showing a U.S. place of birth
U.S. life, health, or other insurance record showing U.S. place of birth
Religious record showing U.S. place of birth recorded in the U.S.
School record showing the child’s name and U.S. place of birth
Federal or state census record showing U.S. citizenship or U.S. place of birth
Documentation of a foreign-born adopted child who received automatic U.S. citizenship (IR3 or IH3)

AND one of these documents (that has a photograph or other information, like your name, age, race, height, weight, eye color, or address):
·
Driver's license issued by a state or territory or ID card issued by the federal, state, or local government
·
School identification card
·
U.S. military card or draft record or military dependent’s identification card
·
U.S. Coast Guard Merchant Mariner card
·
Voter Registration Card
·
A clinic, doctor, hospital, or school record, including preschool or day care records (for children under 19 years old)
·
2 documents containing consistent information that proves your identity, like employer IDs, high school and college
diplomas, marriage certificates, divorce decrees, property deeds, or titles
·
Permanent Resident Card, "Green Card" (I-551)

Immigration status

Reentry Permit (I-327)

·
·
·

Refugee Travel Document (I-571)
Employment Authorization Card (I-766)
Machine Readable Immigrant Visa (with temporary I-551 language)

Temporary I-551 Stamp (on Passport or I-94/I-94A)

·
·

Foreign passport
Arrival/Departure Record (I-94/I-94A)

Arrival/Departure Record in foreign passport (I-94)

·
·
·
·
·
·
·

Certificate of Eligibility for Nonimmigrant Student Status (I-20)
Certificate of Eligibility for Exchange Visitor Status (DS-2019)
Notice of Action (I-797)
Document indicating a member of a federally recognized Indian tribe or American Indian born in Canada
Certification from U.S. Department of Health and Human Services (HHS) Office of Refugee Resettlement (ORR)
Document indicating withholding of removal (or withholding of deportation)
Office of Refugee Resettlement (ORR) eligibility letter (if under 18)

English Document Type Menu List:

Spanish Document Type Menu List:

·
Permanent Resident/Green Card (I-551)
·
Reentry Permit (I-327)
·
Refugee Travel Document (I-571)
·
Employment Authorization Card (I-766)
·
Machine Readable Immigrant Visa (with temporary I-551
language)
·
Temporary I-551 Stamp (on Passport or I-94/I-94A)
·
Arrival/Departure Record (I-94/I-94A)

·
Tarjeta de Residente Permanente, “Tarjeta Verde” (I-551)
·
Permiso de Readmisión (I-327)
·
Documento de Viaje de Refugiado (I-571)
·
Tarjeta de Autorización de Empleo (I-766)
·
Visa de Inmigrante Legible por Máquina (con temporal I551 lenguaje)
·
Sello de I-551 temporal (on Passport or I-94/I-94A)
·
Registro de Llegada/Salida (I-94/I-94A)

·
·

Arrival/Departure Record in foreign passport (I-94)
Other

Registro de Llegada/Salida en pasaporte extranjero (I-94)
Otro

Document Upload Menu Language
DMI Type

Full Lists of Acceptable Documents

Resident of American Samoa Card

The documents you submit to the Marketplace to confirm your income must show a yearly income amount that closely matches the yearly
English Document Type Menu List:
income amount you entered on your application. For example, if you have a different job than you had last year, send the Marketplace recent
pay stubs from your new job, instead of last year's tax return or W2.
·
1040 tax return
·
W2 and/or 1099s
·
Pay stub documentation
· 1040 federal or state tax return. Must contain your first and last name, income amount, and tax year. If you file Schedule 1, you

Spanish Document Type Menu List:

·
·
·

Declaración de impuestos 1040
W-2 y/o 1099s
Talón de pago

must submit it with your 1040.

· Wages and tax statement (W-2 and/or 1099, including 1099 MISC, 1099G, 1099R, 1099SSA, 1099DIV, 1099SS, 1099INT). Must
contain your first and last name, income amount, tax year, and employer name (if applicable).
· Pay stub. Must contain your first and last name, income amount, pay period or frequency of pay with the date of payment. If a
pay stub includes overtime, tell us the average overtime amount per paycheck.
· Self-employment ledger documentation (can be a Schedule C, the most recent quarterly or year-to-date profit and loss
statement, or a self-employment ledger). Must contain your first and last name, company name, and income amount. If you’re
submitting a self-employment ledger, include the dates covered by the ledger, and the net income from profit/loss.
· Social Security Administration Statements (Social Security Benefits Letter). Must contain first and last name, benefit amount,
and frequency of pay.
· Unemployment Benefits Letter. Must contain your first and last name, source/agency, benefits amount, and duration (start and
end date, if applicable).
· Or, complete a written explanation form. To submit this form, select "Other" from the drop down menu when you're on the
upload screen in the application. [hyperlink for underlined content for Entity reference:
https://www.healthcare.gov/downloads/annual-income-letter-explanation.pdf]
Has your household income changed since you submitted your application? If so, it’s important to report this change to the
Marketplace right away. Learn how to report a life change. [Insert: EDE Entity's hyperlink or instructions to the individual on
how to report a life change through the EDE environment.]

Household income

Documents to confirm self-employment income:
·
1040 SE with Schedule C, F, or SE (for self-employment income)
·
1065 Schedule K1 with Schedule E
·
Tax return
·
Bookkeeping records
·
Receipts for all allowable expenses
·
Signed time sheets and receipt of payroll, if you have employees
·
Most recent quarterly or year-to-date profit and loss statement
· Or, complete a written explanation form. To submit this form, select "Other" from the drop down menu when you're on the upload
screen in the application. [hyperlink for underlined content for Entity reference: https://www.healthcare.gov/downloads/annual-income-letterexplanation.pdf]
Documents to confirm unearned income:
·
Annuity statement
·
Statement of pension distribution from any government or private source
·
Worker’s compensation letter
·
Prizes, settlements, and awards, including court-ordered awards letter
·
Proof of gifts and contributions
·
Proof of inheritances in cash or property
·
Proof of strike pay and other benefits from unions
·

Sales receipts or other proof of money received from the sale, exchange, or replacement of things you own

·
·
·
·
·
·
·
·
·
·

Interests and dividends income statement
Loan statement showing loan proceeds
Royalty income statement or 1099-MISC
Proof of bonus/incentive payments
Proof of severance pay
Pay stub indicating sick pay
Letter, deposit, or other proof of deferred compensation payments
Pay stub indicating substitute/assistant pay
Pay stub indicating vacation pay
Proof of residuals

Self-employment documentation

Documentación de empleo por cuenta propia

Social Security statements

Documento o carta de la Administración del Seguro Social

Unemployment benefits letter

Carta de beneficios de desempleo

Other

Otro

Document Upload Menu Language
DMI Type

Full Lists of Acceptable Documents

·
Letter, deposit, or other proof of travel/business reimbursement pay
· Or, complete a written explanation form. To submit this form, select "Other" from the drop down menu when you're on the
upload screen in the application. [hyperlink for underlined content for Entity reference:
https://www.healthcare.gov/downloads/annual-income-letter-explanation.pdf]
Get more details for other income situations. [hyperlink for underlined content for Entity reference:
https://www.healthcare.gov/downloads/consumer_guide_for_household_income_booklet.pdf]

Incarceration status

·
·
·

Official release papers from the institution or Department of Corrections
Parole papers
Unexpired state ID, driver’s license, work ID, or passport

Pay stubs

·
Federal, state, or local benefit letter
·
·
Clinic, doctor, or hospital records for services provided
·
·
Medical claim explanation of benefits provided
·
School record/schedule showing enrollment (like for college students)
·
Bank or credit card statement showing transaction history (showing only your name, but not a joint account)
·
Military records
·
Cell phone bill (showing only your name)
·
Lease (must be an active lease where you’re currently residing)
·
Signed notarized statement from the individual with alleged false incarceration inconsistency showing that you’re living in the
community and includes your name, date of birth, and address
·
Written statement from someone within the community which shows your name, date of birth, address, phone number, your
relationship with the person with alleged false incarceration inconsistency (if it’s not you), and that you’re present and
participating within the community
·
Rent receipts (showing only your name)
What if I don't have any of those documents?
You can submit a letter providing the reason you can't provide the requested documents. The Marketplace will take your
letter into consideration. You can use this template. [hyperlink for underlined content for Entity reference:
https://www.healthcare.gov/downloads/letter-of-explanation-application-info.pdf] To submit this letter, select "Other" from
the drop-down menu when you're on the upload screen in the application.
·
Tribal Enrollment/Membership card from a federally recognized tribe
·
Document issued by Bureau of Indian Affairs (BIA) recognizing you as American Indian/Alaska Native

American Indian or
Alaska Native status

Authentic document from a federally recognized tribe declaring your membership

Certificate of Degree of Indian Blood

·
Certificate of Indian status card
·
I-872 American Indian Card (Texas and Oklahoma Kickapoo American and Mexican members)
·
Document issued by Indian Health Service (IHS) showing that you were/are eligible for IHS services as an American
Indian/Alaska Native
·

U.S. American Indian/Alaska Native tribal enrollment or shareholder documentation

Letter from the Marketplace granting a tribal exemption based on tribal membership or Alaska Native shareholder status

Submit one of the documents below if you need to confirm that your job-based coverage isn’t qualifying health coverage:

No Minimum Essential
Job-Based Coverage

English Document Type Menu List:
·
Official release papers
·
Parole papers
·
Document showing employment/proof of residence
Signed/notarized affidavit
Other

English Document Type Menu List:
·
Tribal Enrollment / Membership Card
·
Document issued by BIA
·

Authentic document from a tribe declaring membership

·
·
·

Certificate of Degree of Indian Blood
Certificate of Indian status card
I-872 American Indian Card

Spanish Document Type Menu List:
·
Documentos de liberación
·
Documentos de Libertad Condicional
·
Documento que muestra el empleo/prueba de residencia
·
·

Declaración notariada/firmada
Otro

Spanish Document Type Menu List:
·
Tarjeta de Membresía o Inscripción Tribal
·
Documentación de accionista o membresía emitida por la
Oficina de Asuntos de Nativos Americanos (BIA).
·
Un documento auténtico emitido por una tribu
reconociendo su membresía.
·
Certificado del grado de sangre indígena
·
Un documento que pruebe el estatus de Indio
·
Tarjeta de Indio Americano I-872

·
U.S. American Indian/Alaska Native tribal enrollment or
shareholder documentation
·
Letter from the Marketplace granting a tribal exemption

·
Documentación de accionista o membresía tribal de Indio
Americano o Nativo de Alaska
·
Carta del Mercado concediendo una exención tribal

·
Otro
Spanish Document Type Menu List:
·
Carta del asegurador médico
·
Comprobante de beneficios médicos
·
Otro

Other

English Document Type Menu List:
·
Letter from employer
·
Statement of health benefits
·
Other

·
Completed Employer Coverage Tool and a cover letter signed by the employer [hyperlink for underlined content for Entity
reference: https://www.healthcare.gov/downloads/employer-coverage-tool.pdf
·
Letter or other documentation from an employer or other documentation with this information:
o Statement that the employer doesn’t currently offer you (or your family member) coverage
o Statement that the employer doesn’t provide coverage that isn’t qualifying health coverage
o Statement showing the cost of your share of the premium for the lowest-cost self-only plan that meets the
minimum value standard (factoring in wellness incentives), if offered [pop-up definition for underlined content for
Entity reference: "A standard of minimum coverage that applies to job-based health plans. If your employer’s
plan meets this standard and is considered “affordable,” you won’t qualify for a premium tax credit if you buy a
Marketplace insurance plan instead "]
·
Health insurance letter that contains confirmation of health coverage and expiration dates for coverage received outside of
the Marketplace
Submit one of the documents below if you need to confirm that you don’t have coverage through Medicaid or CHIP:
English Document Type Menu List:

Spanish Document Type Menu List:

Document Upload Menu Language
DMI Type

Note: Some Medicaid and CHIP programs are known by names specific to that state. Find the name of Medicaid & CHIP programs in your state.
[hyperlink for underlined content for Entity reference: https://www.healthcare.gov/help/medicaid-and-chip-names/]
·
Letter or statement from a Medicaid or CHIP agency that shows that you or your family members aren’t enrolled in or eligible
for Medicaid or CHIP
·
Letter or statement from a Medicaid agency showing that you or a family member are enrolled in a Medicaid program that’s
not considered qualifying health coverage
No coverage through:
Medicaid or the
Children's Health
Insurance Program
(CHIP)

Full Lists of Acceptable Documents

·
·

Letter from Medicaid
Letter from CHIP

·
·

Carta de Medicaid
Carta de CHIP

Other

Otro

·
You can find more detailed information about Medicaid programs that don't provide qualifying coverage. [hyperlink for
underlined content for Entity reference: https://www.healthcare.gov/medicaid-limited-benefits/] If you send document(s)
verifying enrollment in one of these programs, you may be able to continue your financial help for your Marketplace coverage:
o Medicaid coverage only for pregnancy-related services
o Medicaid coverage only for family planning services
o Medicaid coverage only for tuberculosis coverage
o Medicaid coverage only for emergency treatment

o Medicaid Demonstration Projects that cover a limited range of benefits
o Medicaid coverage for “medically needy” individuals whose income is too high for traditional Medicaid and
cover a limited range of benefits. These programs are sometimes known as “Share of Cost” or “Spend Down”
programs.
A letter describing your recent health coverage including:
o The name of the Medicaid/CHIP program you were enrolled in and when your coverage ended, or
o That you were never enrolled in Medicaid/CHIP coverage, or

o The name of the Medicaid/CHIP program with limited benefits that you’re enrolled in that would still allow you
to enroll in the Marketplace with help paying for coverage
Submit one of the documents below if you need to confirm that you don’t have coverage through TRICARE:
English Document Type Menu List:
·
Letter from TRICARE
·
Other
·
Letter or statement from TRICARE that shows the expiration or un-enrollment date of previous health coverage
·

Spanish Document Type Menu List:
·
Carta de TRICARE
·
Otro

Letter or statement from TRICARE that confirms ineligibility for health coverage

·
Letter, statement, or other document indicating a life change event (like divorce) that would make you or a family member
ineligible for TRICARE coverage
·
Letter or statement from TRICARE or other government agency showing that you or a family member are enrolled in a
TRICARE program that’s not considered qualifying health coverage. If you send document(s) verifying enrollment in one of these
programs, you may be able to continue your Marketplace coverage with help paying for coverage:
o TRICARE Plus
No Coverage Through:
TRICARE

o Direct care
o Line-of-duty care
o Transitional care for service-related conditions
o TRICARE coverage limited to space-available care in a facility of the uniformed services for individuals excluded
from TRICARE coverage for care from private sector providers.

What if I don’t have any of those documents?
You can submit a letter describing when your enrollment in TRICARE coverage ended or that you were never
enrolled in TRICARE. The Marketplace will take your letter into consideration. You can use this template.
[hyperlink for underlined content for Entity reference: https://www.healthcare.gov/downloads/letter-ofexplanation-application-info.pdf] To submit this letter, select “Other” from the drop-down menu when you’re
on the upload screen in the application.
Submit this document if you need to confirm that you don’t have coverage through the VA:

No Coverage Through:
Veterans Health Care

Letter from the VA that shows the expiration date of previous health coverage

English Document Type Menu List:

Spanish Document Type Menu List:

Letter from VA

Carta del VA

Other

Otro

Document Upload Menu Language
DMI Type

Program

Full Lists of Acceptable Documents

If you don't have this document, you can submit a letter describing that you're not enrolled in health coverage through the VA.
The Marketplace will take your letter into consideration. You can use this template. [hyperlink for underlined content for Entity
reference: https://www.healthcare.gov/downloads/letter-of-explanation-application-info.pdf] To submit this letter, select
"Other" from the drop-down menu when you're on the upload screen in the application.
Submit this document if you need to confirm that you don’t have coverage through Medicare:

English Document Type Menu List:

Spanish Document Type Menu List:

Letter from Medicare

Carta de Medicare

Other

Otro

· Letter or statement from Medicare or the Social Security Administration stating that you or your family members are:
· Not eligible for or enrolled in premium-free Medicare Part A.
No Coverage Through:
Medicare

· Eligible for (but not enrolled in) Part A coverage that requires premium payments. Important: A Social Security document
that shows you don't pay a premium for "Medical Insurance" refers to Part B. It's not acceptable for verifying eligibility for Part A.
· No longer eligible for Social Security Disability Insurance (SSDI) benefits, and your coverage has ended or will end in the next
90 days.
If you don't have this document, you can submit a letter describing why you're not eligible for premium-free Medicare Part A.
The Marketplace will take your letter into consideration. You can use this template. [hyperlink for underlined content for Entity
reference: https://www.healthcare.gov/downloads/letter-of-explanation-application-info.pdf] To submit this letter, select
"Other" from the drop-down menu when you're on the upload screen in the application.

Submit this document if you need to confirm that you don’t have coverage through the Peace Corps:

No Coverage Through:
Peace Corps

Spanish Document Type Menu List:

·
·

Letter from Peace Corps
Other

Carta del Cuerpo de Paz
Otro

·
Letter from the Peace Corps with the expiration date for any previous health coverage or a letter showing that you never had
this type of coverage
If you don't have this document, you can submit a letter describing that you're no longer eligible for or enrolled in health
coverage through the Peace Corps, or that you were never eligible for or enrolled in health coverage through the Peace Corps.
The Marketplace will take your letter into consideration. You can use this template. [hyperlink for underlined content for Entity
reference: https://www.healthcare.gov/downloads/letter-of-explanation-application-info.pdf] To submit this letter, select
"Other" from the drop-down menu when you're on the upload screen in the application.
Documents must include your first name, last name, and SSN:

Social Security Number

English Document Type Menu List:

·
·
·
·
·
·
·
·
·
·
·

Social Security card
1040 Tax Return (federal or state versions acceptable)
W2 and/or 1099s (includes 1099 MISC, 1099G, 1099R, 1099SSA, 1099DIV, 1099S, 1099INT)
W4 Withholding Allowance Certificate (federal or state versions acceptable)
1095 (includes 1095A, 1095B, 1095C)
Pay stub documentation
Social Security Administration documentation (includes 4029)
Military record
U.S. Military ID card
Military dependent’s ID card
Unemployment Benefits (Unemployment Benefits Letter)

Court Order Granting a Name Change, that must have your original first and last name, new first and last name, and SSN

Divorce decree

English Document Type Menu List:
·
Social Security card
·
Tax form(s)
·
Benefit or income statement
·
Other

Spanish Document Type Menu List:
·
Tarjeta de seguro Social
·
Formularios de impuesto(s)
·
Declaración de beneficios o ingresos
·
Otro

SVI Document Types
For reference, CMS is providing the HealthCare.gov hyperlinks in English and Spanish of the full lists for the
documents in cells C1 and D1.

https://www.healthcare.gov/help/prove-coverage-loss/

https://www.cuidadodesalud.gov/es/help/prove-coverage-loss/

Document Upload Menu Language
SVI Type

Full Lists of Acceptable Documents
If you get a notice from the Marketplace saying you need to submit documents to confirm your loss of
coverage, you can upload or mail documents.

If your notice says that you also need to submit documents to confirm a recent move, in addition to
confirming that you had health coverage for at least 1 day in the past 60 days, be sure to send both types of
documents. [hyperlink for underlined content for Entity reference: https://www.healthcare.gov/help/provemove/]
IMPORTANT: Upload or mail documents as soon as possible. If you don’t submit documents by the deadline,
you won’t have Marketplace coverage.
- Find out how to upload: [hyperlink for underlined content for Entity reference:
https://www.healthcare.gov/help/how-to-upload-documents/]
- Get the mailing address: [hyperlink for underlined content for Entity reference:
https://www.healthcare.gov/help/prove-coverage-loss/]
What documents can I submit?
Documents must show that you lost qualifying health coverage in the past 60 days or will lose coverage in
the next 60 days. These documents must include your name and the date of coverage loss. Documents you
can submit:
A letter from an insurance company, on official letterhead or stationery, including:
A letter or premium bill from your former insurance company that shows you or your dependent’s
cancellation/termination from health coverage.
A decertification letter from your insurance company stating when coverage will no longer be offered.
A letter from an employer, on official letterhead or stationery, that confirms one of these about you or
your spouse or dependent family member:
That your employer dropped or will drop your coverage or benefits.
That your employer stopped or will stop contributing to your cost of coverage.

Letter from an insurance company
Letter from an employer
Letter about COBRA coverage

Carta de una compañía de seguros
Carta de un empleador
Carta sobre la cobertura COBRA

Health care program document
Pay stubs

Documento del programa de cuidado de salud
Talones de pago si ha perdido la cobertura médica basada en el
empleo
Carta que indique que ha perdido la cobertura médica estudiantil
Documento de pérdida su cobertura debido a divorcio, separación
legal
Documento de pérdida de cobertura por muerte

Letter for loss of student coverage
Document for coverage loss due to divorce/separation

That your employer changed or will change coverage or benefits, and your coverage will no longer be
Document for coverage loss due to death
considered qualifying health coverage.
A letter about COBRA coverage, like a letter from an employer or health insurance company that confirms Letter of explanation
these:
Your employer’s offer of COBRA coverage along with the date this coverage would start.
Other
Your COBRA coverage ended or will end, or your employer stopped or will stop contributing to the cost
of coverage and when.
A health care program document, on official letterhead or stationery, including:
A letter from a government health program, like TRICARE, Veterans Affairs (VA), Peace Corps, or
Medicare, showing when coverage ended or will end.
A letter from your state Medicaid or CHIP agency showing that your eligibility for Medicaid or CHIP was
denied and when it was denied or that your Medicaid or CHIP coverage ended or will end.
A dated copy of your military discharge document (DD214).
A letter if you lost student health coverage, which shows when the coverage ended or will end. This
should be on official letterhead or stationery.
You can also submit any of the documents in the list below. However, these documents may include only
some of the information we need to confirm, so you’ll most likely need to submit more than one of these
(https://www.healthcare.gov documents:
/help/prove-coverage-loss/)
Losing qualifying health
coverage

Pay stubs, if you lost employer-sponsored coverage. You can submit:
2 pay stubs from the past 1-3 months, one that shows a deduction for health coverage and another
which shows that the deduction ended in the past 60 days.

Carta de explicación
Otro

Document Upload Menu Language
SVI Type

Full Lists of Acceptable Documents

If a reduction in work hours caused you to lose coverage, you can submit one previous pay stub that
shows that you worked 30 or more hours and a deduction for health coverage, and a pay stub from the
past 60 days that shows that you worked less than 30 hours and no deduction for health coverage.
Document showing you lost coverage because of divorce, legal separation, custody agreements, or
annulment within 60 days of submitting your application, including:
Divorce or annulment papers that show the date responsibility ends for providing health
coverage or proof that you stopped getting health coverage because of your relationship to your former
spouse.
Legal separation papers that show the date responsibility ends for providing health coverage.
Other confirmation that you lost or will lose coverage because of divorce, legal separation, or
annulment that shows the date that health coverage ends.
Document showing you lost coverage due to death of a family member, including:
A death certificate or public notice of death and proof that you were getting health coverage because of
your relationship to the deceased person, like a letter from an insurance company or employer that
shows the names of the people on the health plan.
Other confirmation that shows you lost or will lose coverage because of the death of a spouse or other
family member.
You can upload more than one document if you have multiple documents to confirm coverage loss. Select the
"UPLOAD DOCUMENTS" button on the upload screen in your application to submit each document.
What if I'm in a plan that ended before the end of the calendar year?
If you’re losing or lost coverage from a non-calendar year plan, you can submit a dated and signed copy of
written verification from an insurance agent, or a dated letter from your insurance company stating when
the coverage year ends. To submit this, select "Other" from the drop-down menu.
What if I don't have any of these documents?
You can submit a letter explaining the coverage you had, why and when you lost it or will lose it, and the
reason you can't provide documents. Use this form and fill out the “Loss of Coverage” section. When you
complete the form, select “Letter of explanation” from the drop-down menu when you’re on the upload
documents screen in the application. [hyperlink for underlined content for Entity reference:
https://www.healthcare.gov/downloads/letter-of-explanation.pdf]
How do I upload or mail the documents?
Find out how to upload documents [hyperlink for underlined content for Entity reference:
https://www.healthcare.gov/help/how-to-upload-documents/]
Mailing address:
Health Insurance Marketplace
Attn: Coverage Processing
465 Industrial Blvd
London, KY 40750-0001

Spanish Translation_Req.17-24
Requirement
17

High-Level Description of EDE Entity
Communications Requirements

Communications Requirement for EDE Entities
Instructions for EDE Entities: EDE Entities must display the following educational content (requirements 17 through 24) prior to an individual initiating an FFE application through the EDE
pathway. These must be visible to the consumer prior to completing the pre-eligibility application data collection attestations.
EDE Entities may provide these FAQs via a hyperlink. If an EDE Entity chooses to do so, the hyperlink should be prominent, clear, and consumer friendly, such as stating: "Additional
Information about the Marketplace and [EDE Entity]."

18
19

21
22
23

Set Clear Expectations & Awareness of Introducción:
Marketplace Program
Aquí, en [inserte el nombre de la entidad EDE], trabajamos con el Mercado de Seguros Médicos para ayudarle a obtener cobertura de salud.
¿Qué es el Mercado de Seguros Médicos?
El Mercado es un servicio de cobertura de salud que le ayuda a buscar e inscribirse en una cobertura que se adapte a sus necesidades y presupuesto. El Mercado puede decirle si usted
califica para un plan de salud individual con ahorros o si usted es elegible para una cobertura gratuita o de bajo costo a través de Medicaid o el Programa de Seguro Médico para Niños
(CHIP, por sus siglas en inglés). El sitio web oficial del Mercado es CuidadoDeSalud.gov.
¿Existen beneficios al obtener un seguro médico a través del Mercado?
La cobertura del Mercado es la única manera de obtener créditos fiscales para las primas para ayudarle a reducir sus primas mensuales y ahorrar en gastos de bolsillo con deducibles y
copagos más bajos. Todos los planes del Mercado deben cubrir el mismo conjunto de beneficios esenciales, incluida la atención preventiva, las visitas al médico, las recetas y los servicios
hospitalarios y de emergencia. Ningún plan del Mercado puede rechazarle, cobrarle más o negarse a pagar los beneficios esenciales por cualquier condición que usted tuviera antes de
que comenzara su cobertura. Obtenga más información sobre lo que deben cubrir los planes del Mercado.

¿Cómo solicito y me inscribo en una cobertura?
Usted puede solicitar e inscribirse con nosotros. Nosotros enviaremos su información al Mercado a través de CuidadoDeSalud.gov y le informaremos sobre los programas y ahorros para
los que usted es elegible. Si alguna de su información cambia, usted también puede actualizar su solicitud a través de nosotros.
¿Qué pasa si soy elegible para Medicaid o CHIP?
Si usted presenta una solicitud y se determina que es elegible para cobertura a través de Medicaid o CHIP, el Mercado enviará automáticamente su información a la agencia estatal que
administra estos programas. Nosotros le daremos un aviso de elegibilidad con más información.
¿Cómo recibiré avisos?
Incluso si usted se inscribe en una cobertura a través de [inserte el nombre de la entidad EDE], usted aún recibirá información directamente del Mercado. Espere recibir avisos del
Mercado de Seguros Médicos por correo postal y correos electrónicos de CuidadoDeSalud.gov. Es importante leer estos avisos y correos electrónicos porque contienen información
importante que solo obtendrá del Mercado de Seguros Médicos. Nosotros podemos ayudarle con cualquier acción de seguimiento que deba tomar, incluidas las peticiones de
CuidadoDeSalud.gov.
¿Qué pasa si me redirigen a CuidadoDeSalud.gov?
Nosotros podemos ayudarle a la mayoría de las personas con las solicitudes e inscripciones directamente en nuestro sitio. Si necesitamos redirigirlo a CuidadoDeSalud.gov para
completar su solicitud, le guiaremos con todo lo que debe hacer y le ayudaremos de principio a fin.

Document Submission Requirements and Additional Notes to EDE
Auditor Compliance Conclusion**
Entities and Auditors
The Auditor must provide a screenshot depicting the screen with this
educational content that clearly shows where this content exists and how
a consumer can access it in the EDE end-user experience. For example, if
this educational content is accessed via a hyperlink, provide a screenshot
of the page where the hyperlink can be accessed by the consumer in the
EDE end-user experience.

"Obtenga más información sobre lo que deben cubrir los planes del
Mercado." must hyperlink to more information that describes
Marketplace plan requirements. This can either be a direct hyperlink to
HealthCare.gov (https://www.cuidadodesalud.gov/es/coverage/whatmarketplace-plans-cover/) or the EDE Entity can provide this same type of
information on their own site.

Risk Level**

Risk Mitigation Strategy**

Estimated Resolution Date**

Auditor Comments**

Spanish Translation_Req.25-29
Requirement
25

High-Level Description of EDE Entity
Communications Requirements

Communications Requirement for EDE Entities
Instructions for EDE Entities: EDE Entities must display the following educational content (requirements 26-29) in the UI after a consumer selects a plan through the EDE pathway. For each UI communication requirement listed below, an EDE Entity must use the exact language provided in its UI. If an EDE Entity
wishes to modify the language provided, it must request approval.
If a primary EDE Entity is integrating its EDE platform with an upstream EDE Entity's QHP shopping platform, the post-enrollment confirmation communication in the UI must still be implemented consistent with the following requirements (requirements 26-29). This information may be displayed on the
upstream EDE Entity's website or the primary EDE Entity's website as a post-enrollment confirmation page, but any data connection or transfer necessary to facilitate the display of this information on an upstream EDE Entity's website must be disclosed in an EDE Entity-initiated Change Request and a copy of
the primary EDE Entity's ISA Appendix B. Please refer to the EDE Guidelines for Year 6 for more information. If an upstream EDE Entity wishes to implement the language in these requirements--and more generally, any language or functionality described in this toolkit or in the EDE Guidelines--the EDE Entity
must detail and provide evidence of the proposed implementation to CMS via an EDE Entity-initiated Change Request.

26 (SVI only)

Note: If at least one member of the household attested to receiving an Individual Coverage HRA (ICHRA) or Qualified Small Employer HRA (QSEHRA) on their eligibility application, after the consumer has completed enrollment, the Entity must display reminder language (on the eligibility results page and/or as
part of the enrollment confirmation communication language described in these requirements) that the consumer will need to notify their employer that the consumer has enrolled in Marketplace coverage. Please refer to the DE API Specifications, Appendix F for more information and required language to
display
Pos t-Enrol l ment UI Communi ca ti on Us ted ha el egi do un pl a n. Us ted puede empeza r a us a r s u cobertura de s a l ud des pués de que envíe l os documentos y el Merca do confi rme que us ted es el egi bl e pa ra i ns cri bi rs e a tra vés de un Período de Es peci a l de Ins cri pci ón. Cua nto a ntes us ted envíe l os documentos , l o má s
pronto que s e a cti va rá s u cobertura . Vea a conti nua ci ón pa ra má s i nforma ci ón s obre l os próxi mos pa s os .
for Cons umers
¿Qué debo hacer ahora?
1. Us ted debe envi a r documentos a l Merca do pa ra [i ns erta r pers ona (s ) y ti po(s ) de SVI] pa ra el [i ns erta r fecha s l ími te]. Pa ra ha cer es to, [i ns erte l a s i ns trucci ones de l a enti da d EDE].
2. Es té a tento a un a vi s o con l os res ul ta dos de l a revi s i ón de s us documentos por pa rte del Merca do. Us ted puede a cceder a s us a vi s os del Merca do medi a nte [i ns erte l a s i ns trucci ones de l a enti da d EDE].
3. Pa gue s u pri ma des pués de que s e confi rme s u el egi bi l i da d. Us ted reci bi rá otro a vi s o cua ndo s ea el momento de ha cer es to. Us ted puede pa ga r s u pri ma medi a nte [i ns erte l a s i ns trucci ones de l a enti da d EDE].
Nota: Recuerde que us ted no puede comenza r a us a r s u cobertura ha s ta que el Merca do revi s e s us documentos y confi rme s u i nforma ci ón, y ha s ta que us ted pa gue s u pri ma .
Espere mensajes de nuestra parte y del Mercado. Cuando usted escuche de CuidadoDeSalud.gov:
- Lea s us a vi s os y correos el ectróni cos .
- Cui da doDeSa l ud.gov puede envi a rl e a vi s os y mens a jes s obre s u cobertura . Ingres e en s u cuenta con nos otros pa ra ver l os a vi s os del Merca do, a ctua l i za r s u s ol i ci tud o cobertura y a dmi ni s tra r s u i nforma ci ón.
- Suba documentos a tra vés de [i ns erte el nombre de l a enti da d EDE]. Podemos a yuda rl e a envi a r documentos s i el Merca do neces i ta confi rma r s u i nforma ci ón.
- Des ca rgue l os formul a ri os que neces i ta rá cua ndo pres ente s u decl a ra ci ón de i mpues tos federa l es s obre l os i ngres os .

27 (SVI and DMI)

¿Qué pasa si necesito actualizar mi información más tarde?
Si us ted ti ene un ca mbi o de vi da , como s i s e muda , ca mbi a n s us i ngres os o s e ca s a , por fa vor déjenos s a ber de i nmedi a to. Pa ra ha cer es to, [i ns erte l a s i ns trucci ones de l a enti da d EDE].
Us ted ha el egi do un pl a n. Us ted puede empeza r a us a r s u cobertura de s a l ud des pués de que envíe l os documentos y el Merca do confi rme que us ted es el egi bl e pa ra i ns cri bi rs e a tra vés de un Período de Es peci a l de Ins cri pci ón. Cua nto a ntes us ted envíe l os documentos , l o má s
pronto que s e a cti va rá s u cobertura . Vea a conti nua ci ón pa ra má s i nforma ci ón s obre l os próxi mos pa s os .
¿Qué debo hacer ahora?
1. Us ted debe envi a r documentos a l Merca do pa ra [i ns erta r pers ona (s ) y ti po(s ) de SVI] pa ra el [i ns erta r fecha s l ími te]. Pa ra ha cer es to, [i ns erte l a s i ns trucci ones de l a enti da d EDE].
2. Es té a tento a un a vi s o con l os res ul ta dos de l a revi s i ón de s us documentos por pa rte del Merca do. Us ted puede a cceder a s us a vi s os del Merca do medi a nte [i ns erte l a s i ns trucci ones de l a enti da d EDE].
3. Pa gue s u pri ma des pués de que s e confi rme s u el egi bi l i da d. Us ted reci bi rá otro a vi s o cua ndo s ea el momento de ha cer es to. Us ted puede pa ga r s u pri ma medi a nte [i ns erte l a s i ns trucci ones de l a enti da d EDE].
Nota: Recuerde que us ted no puede comenza r a us a r s u cobertura ha s ta que el Merca do revi s e s us documentos y confi rme s u i nforma ci ón, y ha s ta que us ted pa gue s u pri ma .
¿Hay algo más que debo hacer ahora?
- Envíe l os documentos requeri dos a l Merca do pa ra : [i ns erta r pers ona (s ) y ti po(s ) de DMI] pa ra el [i ns erta r fecha s l ími te]. Pa ra ha cer es to, [i ns erte l a s i ns trucci ones de l a enti da d EDE].
- Si us ted confi rmó s u el egi bi l i da d pa ra el Período Es peci a l de Ins cri pci ón y s u cobertura ha comenza do, pero us ted no envía es tos documentos a di ci ona l es a ntes de l a s fecha s l ími te enumera da s a nteri ormente, us ted puede perder s u cobertura de s a l ud del Merca do y/o puede
perder l a a yuda fi na nci era que es tá reci bi endo o es ta puede di s mi nui r.

Document Submission Requirements and Additional Notes to EDE Entities Auditor Compliance Conclusion**
and Auditors
For a ny requi rement tha t requi res a n EDE Enti ty to i ns ert i ts own
i ns tructi ons for compl eti ng a n a cti on or for a ny UI el ements us ed to
compl ement thos e i ns tructi ons (e.g., error mes s a ges ), the EDE
Enti ty mus t provi de s peci fi c, cons umer-fri endl y di recti ons . For
exa mpl e, i f the EDE Enti ty i s di recti ng the cons umer to a l oca ti on i n
a n a ccount da s hboa rd to upl oa d documents , the EDE Enti ty mus t
provi de ei ther a di rect hyperl i nk or cl ea r na vi ga ti on i ns tructi ons to
the s peci fi c webpa ge or l oca ti on i n a n a ccount da s hboa rd where
the cons umer ca n compl ete a s peci fi c a cti on. The EDE Enti ty mus t
not s i mpl y di rect the cons umer to l og i n to thei r a ccount.
After the cons umer ha s confi rmed thei r pl a n s el ecti on, i f the FFE
ha s genera ted a n SVI, but no DMIs , for the cons umer, EDE Enti ti es
mus t di s pl a y thi s text.
When the EDE Enti ty provi des a l i s t of SVIs , the EDE Enti ty ma y
devi a te from the forma t provi ded here; for exa mpl e, the EDE Enti ty
ma y us e a bul l eted l i s t or a ta bl e.
The dea dl i ne for ea ch SVI mus t be a ful l da te (i .e., month, da y, a nd
yea r).
The Audi tor mus t provi de s creens hots of thi s pa ge for a tes t
cons umer for whom the FFE ha s genera ted a t l ea s t one SVI.

After the cons umer ha s confi rmed thei r pl a n s el ecti on, i f the FFE
ha s genera ted a n SVI a nd a DMI for the cons umer, EDE Enti ti es
mus t di s pl a y thi s text.
When the EDE Enti ty provi des a l i s t of SVIs a nd DMIs , the EDE Enti ty
ma y devi a te from the forma t provi ded here; for exa mpl e, the EDE
Enti ty ma y us e a bul l eted l i s t or a ta bl e.
The dea dl i ne for ea ch SVI a nd DMI mus t be a ful l da te (i .e., month,
da y, a nd yea r).
The Audi tor mus t provi de s creens hots of thi s pa ge for a tes t
cons umer for whom the FFE ha s genera ted a n SVI a nd a DMI.

Espere mensajes de nuestra parte y del Mercado. Cuando usted escuche de CuidadoDeSalud.gov:
- Lea s us a vi s os y correos el ectróni cos .
- Cui da doDeSa l ud.gov puede envi a rl e a vi s os y mens a jes s obre s u cobertura . Ingres e en s u cuenta con nos otros pa ra ver l os a vi s os del Merca do, a ctua l i za r s u s ol i ci tud o cobertura y a dmi ni s tra r s u i nforma ci ón.
- Suba documentos a tra vés de [i ns erte el nombre de l a enti da d EDE]. Podemos a yuda rl e a envi a r documentos s i el Merca do neces i ta confi rma r s u i nforma ci ón.
- Des ca rgue l os formul a ri os que neces i ta rá cua ndo pres ente s u decl a ra ci ón de i mpues tos federa l es s obre l os i ngres os .

28 (DMI only)

¿Qué pasa si necesito actualizar mi información más tarde?
Si us ted ti ene un ca mbi o de vi da como s i s e muda ca mbi a n s us i ngres os o s e ca s a por fa vor déjenos s a ber de i nmedi a to Pa ra ha cer es to [i ns erte l a s i ns trucci ones de l a enti da d EDE]
¡Felicidades! Usted se ha inscrito en una cobertura del Mercado a través de [inserte el nombre de la entidad EDE].
¿Qué debo hacer ahora?
1. Pa gue s us pri ma s . Pa ra ha cer es to, [i ns erte l a s i ns trucci ones de l a enti da d EDE].
2. Envíe l os documentos requeri dos a l Merca do pa ra : [i ns erta r pers ona (s ) y ti po(s ) de DMI] pa ra el [i ns erta r fecha s l ími te]. Pa ra ha cer es to, [i ns erte l a s i ns trucci ones de l a enti da d EDE]. Si us ted no envía es tos documentos a ntes de l a s fecha s l ími te enumera da s a nteri ormente,
us ted puede perder s u cobertura de s a l ud del Merca do y/o puede perder l a a yuda fi na nci era que es tá reci bi endo o es ta puede di s mi nui r.
3. Es té a tento a un a vi s o con l os res ul ta dos de l a revi s i ón de s us documentos por pa rte del Merca do. Us ted puede a cceder a s us a vi s os del Merca do medi a nte [i ns erte l a s i ns trucci ones de l a enti da d EDE].
Espere mensajes de nuestra parte y del Mercado. Cuando usted escuche de CuidadoDeSalud.gov:
- Lea s us a vi s os y correos el ectróni cos .
- Cui da doDeSa l ud.gov puede envi a rl e a vi s os y mens a jes s obre s u cobertura . Ingres e en s u cuenta con nos otros pa ra ver l os a vi s os del Merca do, a ctua l i za r s u s ol i ci tud o cobertura y a dmi ni s tra r s u i nforma ci ón.
- Suba documentos a tra vés de [i ns erte el nombre de l a enti da d EDE]. Podemos a yuda rl e a envi a r documentos s i el Merca do neces i ta confi rma r s u i nforma ci ón.
- Des ca rgue l os formul a ri os que neces i ta rá cua ndo pres ente s u decl a ra ci ón de i mpues tos federa l es s obre l os i ngres os .

After the cons umer ha s confi rmed thei r pl a n, i f the cons umer ha s
DMIs , but no SVIs , the EDE Enti ty mus t di s pl a y thi s text.
When the EDE Enti ty provi des a l i s t of DMIs , the EDE Enti ty ma y
devi a te from the forma t provi ded here; for exa mpl e, the EDE Enti ty
ma y us e a bul l eted l i s t or a ta bl e.
The dea dl i ne for ea ch DMI mus t be a ful l da te (i .e., month, da y, a nd
yea r).
The Audi tor mus t provi de s creens hots of thi s pa ge for a tes t
cons umer for whom the FFE ha s genera ted a t l ea s t one DMI.

¡Felicidades! Usted se ha inscrito en una cobertura del Mercado a través de [inserte el nombre de la entidad EDE].
¿Qué debo hacer ahora?
- Pa gue s us pri ma s . Pa ra ha cer es to, [i ns erte l a s i ns trucci ones de l a enti da d EDE].
Espere mensajes de nuestra parte y del Mercado. Cuando usted escuche de CuidadoDeSalud.gov:
- Lea s us a vi s os y correos el ectróni cos .
- Cui da doDeSa l ud.gov puede envi a rl e a vi s os y mens a jes s obre s u cobertura . Ingres e en s u cuenta con nos otros pa ra ver l os a vi s os del Merca do, a ctua l i za r s u s ol i ci tud o cobertura y a dmi ni s tra r s u i nforma ci ón.
- Des ca rgue l os formul a ri os que neces i ta rá cua ndo pres ente s u decl a ra ci ón de i mpues tos federa l es s obre l os i ngres os .
¿Qué pasa si necesito actualizar mi información más tarde?
Si us ted ti ene un ca mbi o de vi da como s i s e muda ca mbi a n s us i ngres os o s e ca s a por fa vor déjenos s a ber de i nmedi a to Pa ra ha cer es to [i ns erte l a s i ns trucci ones de l a enti da d EDE]

After the cons umer ha s confi rmed thei r pl a n s el ecti on, i f they ha ve
no DMIs or SVIs , EDE Enti ti es mus t di s pl a y thi s text.
The Audi tor mus t provi de s creens hots of thi s pa ge for a tes t
cons umer wi th no DMIs or SVIs .

Risk Level**

Risk Mitigation Strategy**

Estimated Resolution Date**

Auditor Comments**

File Type	application/pdf
File Title	EDE Communications Toolkit
Subject	CMS, Communications Toolkit, Auditor User Guide, Requirements, DMI Document Types, SVI Document Types, Spanish Translation, OMB
Author	Centers for Medicare & Medicaid Services (CMS)
File Modified	2024-03-19
File Created	2023-10-11