Overview of Health Insurance Exchanges

Changes from April 29, 2021 to March 17, 2023

This page shows textual changes in the document between the two versions indicated in the dates above. Textual matter removed in the later version is indicated with ~~red strikethrough~~ and textual matter added in the later version is indicated with blue.

Overview of Health Insurance Exchanges
~~April 29, 2021~~March 17, 2023
The Patient Protection and Affordable Care Act (ACA; The Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended) P.L. 111-148, as amended)
required health insurance exchanges to be established in every state. Exchanges are required health insurance exchanges to be established in every state. Exchanges are
virtual marketplaces Vanessa C. Forsberg
~~virtual marketplaces~~ in which consumers and in which consumers and ~~smal~~ small business owners and employees can business owners and employees can
shop for and purchase private Analyst in Health Care Analyst in Health Care
~~shop for and purchase private~~ health insurance coverage and, where applicable, be health insurance coverage and, where applicable, be
~~Financing~~
connected to public health insurance connected to public health insurance Financing programs (e.g., Medicaid).programs (e.g., Medicaid). In general, states must In general, states must

have two types of exchanges: an have two types of exchanges: an individual exchange and aand a small business ~~health~~

health options program (SHOP) exchange.. Exchanges may be established either by the state Exchanges may be established either by the state
itself as a itself as a state-based exchange (SBE) or by the Secretary of Health and Human Services (HHS) as a or by the Secretary of Health and Human Services (HHS) as a federally
facilitated exchange (FFE). Some states have Some states have SBE-FPs: they have SBEs but use the federal information : they have SBEs but use the federal information
technology platform (FP), including the federal exchange website www.HealthCare.gov. technology platform (FP), including the federal exchange website www.HealthCare.gov.
A primary function of the exchanges is to facilitate enrollment. This A primary function of the exchanges is to facilitate enrollment. This ~~general y~~generally includes operating a web portal that includes operating a web portal that
~~al ows~~allows for the comparison and purchase of coverage; making determinations of eligibility for the comparison and purchase of coverage; making determinations of eligibility for coverage and for coverage and
financial assistance; and offering different forms of enrollment assistance, including Navigators and a financial assistance; and offering different forms of enrollment assistance, including Navigators and a ~~cal~~ call center. center.
Exchanges also are responsible for several administrative functions, including certifying the plans that Exchanges also are responsible for several administrative functions, including certifying the plans that ~~wil be~~
will be offered in their marketplaces. offered in their marketplaces.
The ACA The ACA ~~general y~~ generally requires that the private health insurance plans offered through an exchange are requires that the private health insurance plans offered through an exchange are qualified
health plans (QHPs). To be a certified as a QHP, a plan must be offered by a state-licensed health insurance issuer To be a certified as a QHP, a plan must be offered by a state-licensed health insurance issuer
and must meet specified requirements, including covering the and must meet specified requirements, including covering the essential health benefits (EHB). QHPs sold in the . QHPs sold in the
~~individual~~ individual and SHOP exchanges must comply with the same state and federal requirements that apply to QHPs and SHOP exchanges must comply with the same state and federal requirements that apply to QHPs
and other health plans offered outside of the exchanges in the individualand other health plans offered outside of the exchanges in the individual ~~and smal~~ and small-group markets, respectively. group markets, respectively.
~~Additional~~ Additional requirements apply only to QHPs sold in the exchanges. Exchanges also may offer variations of QHPs, requirements apply only to QHPs sold in the exchanges. Exchanges also may offer variations of QHPs,
such as child-only or catastrophic plans, and non-QHP dental-only plans. such as child-only or catastrophic plans, and non-QHP dental-only plans.
~~Individuals and smal~~ Consumers and small businesses must meet certain eligibilitybusinesses must meet certain eligibility criteria to purchase coverage through the individual criteria to purchase coverage through the individual
and SHOP exchanges, respectively. There is an annual and SHOP exchanges, respectively. There is an annual open enrollment period during which any eligible during which any eligible
consumer may purchase coverage via the individual exchanges; otherwise, consumers may purchase coverage consumer may purchase coverage via the individual exchanges; otherwise, consumers may purchase coverage
only if they qualify for a only if they qualify for a special enrollment period. In general, In general, ~~smal~~ small businesses may enroll at any time during the businesses may enroll at any time during the
year. There are plans availableyear. There are plans available ~~in al individual~~ in all individual exchanges, and about exchanges, and about ~~12 mil ion~~16.3 million people obtained health insurance people obtained health insurance
through the individualthrough the individual exchanges during the exchanges during the ~~2021~~2023 open enrollment period. Nationwide SHOP exchange open enrollment period. Nationwide SHOP exchange
enrollment estimates are not regularly released; in addition, there are no SHOP exchange plans availableenrollment estimates are not regularly released; in addition, there are no SHOP exchange plans available in more in more
than half of states in than half of states in ~~2021~~2023, similar to 2022. .
Plans sold through the exchanges, like private health insurance plans sold off the exchanges, have premiums and Plans sold through the exchanges, like private health insurance plans sold off the exchanges, have premiums and
out-of-pocket (OOP) costs. Consumers who obtain coverage through the individual exchanges may be eligibleout-of-pocket (OOP) costs. Consumers who obtain coverage through the individual exchanges may be eligible for for
federal financial assistance with premiums and OOP costs in the form of federal financial assistance with premiums and OOP costs in the form of premium tax credits and and cost-sharing
reductions. . ~~Smal~~ Small businesses that use the SHOP exchangesbusinesses that use the SHOP exchanges may be eligible for may be eligible for small business health insurance tax
credits that assist with the cost of providing health insurance coverage to employees. that assist with the cost of providing health insurance coverage to employees.
The federal government spent an estimated $ The federal government spent an estimated $~~1.8 bil ion~~2.09 billion on the operation of exchanges in on the operation of exchanges in ~~FY2020, and it projected~~
~~$1.2 bil ion in spending for FY2021~~FY2022, projected $2.38 billion in spending for FY2023, and proposed $2.31 billion for FY2024. Much of the federal spending on the exchanges is funded by . Much of the federal spending on the exchanges is funded by user fees paid paid
by the insurers who participate in FFE and SBE-FP exchanges. States with SBEs finance their own exchange by the insurers who participate in FFE and SBE-FP exchanges. States with SBEs finance their own exchange
administration; states with SBE-FPs also finance certain costs (e.g., administration; states with SBE-FPs also finance certain costs (e.g., ~~consumer outreach and assistance programs,~~
~~including~~their own Navigator programs). Navigator programs).
This report provides an overview of key aspects of the health insurance exchanges, including types and This report provides an overview of key aspects of the health insurance exchanges, including types and
administration of exchanges, eligibilityadministration of exchanges, eligibility and enrollment, plan costs and financial assistance, insurer participation, and enrollment, plan costs and financial assistance, insurer participation,
and exchange financing. and exchange financing. ~~The report~~ It also includes information about policy changes enacted under the American also includes information about policy changes enacted under the American
Rescue Plan Act of 2021 (ARPA; P.L. 117-2)Rescue Plan Act of 2021 (ARPA; P.L. 117-2)~~, as wel as administrative policy changes~~ and the budget reconciliation measure known as the Inflation Reduction Act (), as well as recent administrative policy changes, including those made in response to the made in response to the
Coronavirus Disease 2019 (COVID-19) pandemic and related economic recession. Coronavirus Disease 2019 (COVID-19) pandemic and related economic recession.
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Introduction
The Patient Protection and Affordable Care Act (ACA;The Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended) required P.L. 111-148, as amended) required health
insurance exchanges (also known as (also known as marketplaces) to be established in every state. The ACA ) to be established in every state. The ACA
exchanges are virtual marketplaces in which consumers and exchanges are virtual marketplaces in which consumers and ~~smal~~ small businesses can shop for and businesses can shop for and
purchase private health insurance coverage and, where applicable, be connected to public health purchase private health insurance coverage and, where applicable, be connected to public health
insurance programs (e.g., Medicaid).1 Certain consumers and insurance programs (e.g., Medicaid).1 Certain consumers and ~~smal~~ small employers are eligible for employers are eligible for
financial assistance for private health insurance purchased (only) through the exchanges. financial assistance for private health insurance purchased (only) through the exchanges.
Exchanges are intended to simplify the experience of obtaining health insurance. They are not Exchanges are intended to simplify the experience of obtaining health insurance. They are not
intended to supplant the private market outside of the exchanges but rather to provide an intended to supplant the private market outside of the exchanges but rather to provide an
additional source of private health insurance coverage options. additional source of private health insurance coverage options.
The exchanges may be administered by state governments and/or the federal government. The exchanges may be administered by state governments and/or the federal government.
Regardless, the major functions of the exchanges are (1) to facilitate consumers’ and Regardless, the major functions of the exchanges are (1) to facilitate consumers’ and ~~smal~~
small businesses’ purchase of coverage (by operating a web portal, making determinations of eligibility businesses’ purchase of coverage (by operating a web portal, making determinations of eligibility
for coverage and any financial assistance, and offering different forms of enrollment assistance) for coverage and any financial assistance, and offering different forms of enrollment assistance)
and (2) to certify, recertify, and otherwise monitor the plans that are offered in those and (2) to certify, recertify, and otherwise monitor the plans that are offered in those
marketplaces. marketplaces.
Although a relatively Although a relatively ~~smal~~ small proportion of people in the U.S. obtain their coverage through the proportion of people in the U.S. obtain their coverage through the
exchanges,2 the administration and functioning of these marketplaces are ongoing topics of exchanges,2 the administration and functioning of these marketplaces are ongoing topics of
interest to congressional audiences and other stakeholders. An understanding of the exchanges interest to congressional audiences and other stakeholders. An understanding of the exchanges
can provide context for current health policy discussions and proposals related to health care can provide context for current health policy discussions and proposals related to health care
coverage and costs, the roles of the public and private sectors in the provision of health coverage, coverage and costs, the roles of the public and private sectors in the provision of health coverage,
and more. and more.
This report provides an overview of key aspects of the health insurance exchanges. It begins with This report provides an overview of key aspects of the health insurance exchanges. It begins with
summary information about types and administration of exchanges and the plans sold in them. summary information about types and administration of exchanges and the plans sold in them.
Sections on the individualSections on the individual ~~and smal~~ and small business exchanges discuss eligibilitybusiness exchanges discuss eligibility and enrollment, plan and enrollment, plan
costs and financial assistance available to eligiblecosts and financial assistance available to eligible consumers and consumers and ~~smal~~ small businesses, insurer businesses, insurer
participation, and other topics. The final sections describe types of enrollment assistance available participation, and other topics. The final sections describe types of enrollment assistance available
to exchange consumers and provide information on federal funding for the exchanges. to exchange consumers and provide information on federal funding for the exchanges.
Appendixes offer further details, including exchange types by state.Appendixes offer further details, including exchange types by state. The report includes~~The report has been updated~~
~~to include~~ information about policy changes enacted under the American Rescue Plan Act of 2021 information about policy changes enacted under the American Rescue Plan Act of 2021
(ARPA; P.L. 117-2)(ARPA; P.L. 117-2)~~, as wel as administrative policy changes made in 2021~~ and the budget reconciliation measure known as the Inflation Reduction Act (P.L. 117-169), as well as recent administrative policy changes, including those made in response to the ~~in response to the~~
Coronavirus Disease 2019 (COVID-19) pandemic and related economic Coronavirus Disease 2019 (COVID-19) pandemic and related economic recession. ~~recession.~~

1 In this report, the terms 1 In this report, the terms consumers and and individuals generally are used generally are used interchangeably, interchangeably, ~~as are small businesses and~~
sm all em ployers.
~~2 For example, about 12~~often to refer to consumers purchasing coverage directly from insurers for themselves and/or their families via the individual exchanges. Similarly, small businesses and small employers may be used interchangeably, often in reference to such employers and/or their employees purchasing coverage via the SHOP exchanges. 2 For example, about 16.3 million people obtained health insurance through the individual million people obtained health insurance through the individual exchanges duringexchanges during the the ~~2021~~2023
open enrollment period (open enrollment period (~~for coverage beginning January 2021). T his figure is approximatel y 3.6~~November 1, 2022, through January 15, 2023, in most states). This figure is approximately 4.88% of the U.S. % of the U.S.
population of aboutpopulation of about 331 million people. See Table 2 ~~regarding~~ 334.4 million people as of February 2023. See Table 1 regarding exchange enrollment estimates and sources. exchange enrollment estimates and sources. ~~T he~~The U.S. U.S.
population estimate is population estimate is ~~as of April 2020, per the 2020 Census results: https://www.census.gov/.~~

part of a series of monthly projections made by the U.S. Census Bureau based upon the 2020 Census, at https://www.census.gov/popclock/. Congressional Research Service Congressional Research Service

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Overview
Types and Administration of Exchanges
Individual and SHOP Exchanges
The ACA The ACA required health insurance exchanges to be established in required health insurance exchanges to be established in al all states and the District of states and the District of
Columbia.3 In general, the health insurance exchanges began operating in October 2013 to Columbia.3 In general, the health insurance exchanges began operating in October 2013 to ~~al ow~~
allow consumers to shop for health insurance plans that began as soon as January 1, 2014. consumers to shop for health insurance plans that began as soon as January 1, 2014.
There are two types of exchanges— There are two types of exchanges—individual exchanges and and small business health options
program (SHOP) exchanges.4 These exchanges are part of the .4 These exchanges are part of the ~~individual (also cal ed non-group)~~
~~and smal~~ nongroup and small-group segments of the private health insurance market, respectively.5 In an individual -group segments of the private health insurance market, respectively.5 In an individual
exchange, eligible consumers can compare and purchase exchange, eligible consumers can compare and purchase ~~non-group~~nongroup insurance for themselves and insurance for themselves and
their families and can apply for premium tax credits and cost-sharing reductions (PTCs and their families and can apply for premium tax credits and cost-sharing reductions (PTCs and
~~CSRs;~~ CSRs) that are available only through the exchanges (see see “Premium Tax Credits and Cost-Sharing Reductions””). ). In a SHOP exchange, In a SHOP exchange, ~~smal~~
small businesses can compare and purchase businesses can compare and purchase ~~smal~~ small-group insurance and can apply for -group insurance and can apply for ~~smal~~ small business business
health insurance tax credits (see health insurance tax credits (see “~~Smal~~ Small Business Health Care Tax Credit”); in addition, ); in addition,
employees of employees of ~~smal~~ small businesses can enroll in plans offered by their employers on a SHOP businesses can enroll in plans offered by their employers on a SHOP
exchange. exchange.
Each exchange covers a whole state.6 Within Each exchange covers a whole state.6 Within ~~a given~~an exchange, private insurers may offer plans exchange, private insurers may offer plans
that cover the whole state or only certain areas within the state (e.g., one or more counties). Plans that cover the whole state or only certain areas within the state (e.g., one or more counties). Plans
sold within a given exchange may cover services offered by providers located in more than one sold within a given exchange may cover services offered by providers located in more than one
state. state.
In general, consumers and In general, consumers and ~~smal~~ small businesses may obtain coverage within their state’s individual or businesses may obtain coverage within their state’s individual or
SHOP exchange, respectively, or they may shop in the SHOP exchange, respectively, or they may shop in the ~~individual or smal~~ nongroup or small-group health insurance -group health insurance
markets outside of the exchanges, which existed prior to the ACA and continue to exist.7 Outside markets outside of the exchanges, which existed prior to the ACA and continue to exist.7 Outside
of the ACAof the ACA exchanges, consumers can purchase coverage through agents or brokers, or they can exchanges, consumers can purchase coverage through agents or brokers, or they can
purchase it directly from insurers. In addition, there were and purchase it directly from insurers. In addition, there were and ~~stil~~ still are privately operated websites are privately operated websites
that that ~~al ow~~allow the comparison and purchase of coverage sold by different insurers, broadly similar in the comparison and purchase of coverage sold by different insurers, broadly similar in
concept to the ACA exchanges.8concept to the ACA exchanges.8

~~3 T he~~ 3 The Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended) also gave the territories the option Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended) also gave the territories the option
of establishingof establishing exchanges, but none elected to do so, by the statutory deadline of October 1, 2013. See 42 U.S.C. exchanges, but none elected to do so, by the statutory deadline of October 1, 2013. See 42 U.S.C.
§18043. §18043.
4 The~~4 T he~~ term term individual exchange is used is used for purposes of this report. It is not defined in exchange-related statute or for purposes of this report. It is not defined in exchange-related statute or
regulations. regulations.
5 5 ~~T he~~Broadly, private health insurance private health insurance market includes both the group market ~~(largely made up of~~includes group plans (largely, employer-sponsored employer-sponsored
insurance) and the individual m arket ~~(which includes plans directly purchased from an insurer). T he~~insurance) and nongroup plans (i.e., plans that consumers purchase directly from insurers). The group market is divided ~~group market is~~
~~divided~~ into small- and large-group market segments; a into small- and large-group market segments; a ~~sm all~~small group is typically defined as a group of up to 50 is typically defined as a group of up to 50
~~individuals~~ individuals (e.g., employees), and a (e.g., employees), and a large group is typically defined as one with 51 or more individuals. is typically defined as one with 51 or more individuals.
6 6 ~~T here~~There is an option for states to coordinate in administering regional exchanges or for a single is an option for states to coordinate in administering regional exchanges or for a single state to establish state to establish
subsidiarysubsidiary exchanges that serve geographically distinct areas (see 45 C.F.R.exchanges that serve geographically distinct areas (see 45 C.F.R. §155.410)§155.410) , but none have done so. , but none have done so.
7 However, plans are not available in all small business7 However, plans are not available in all small business health options program (SHOP) exchanges in health options program (SHOP) exchanges in ~~2021~~2023. .
8 An example of a privately owned website8 An example of a privately owned website that allows for comparison and purchase of coverage from different insurers that allows for comparison and purchase of coverage from different insurers
is ehealthinsurance.com. Note that some types of coverage sold outsideis ehealthinsurance.com. Note that some types of coverage sold outside of the federal and state exchanges, potentially of the federal and state exchanges, potentially
includingincluding some types of coverage available on private sites like this one, are not subject to some or all federal health some types of coverage available on private sites like this one, are not subject to some or all federal health
insurance requirements. For more information, see CRSinsurance requirements. For more information, see CRS Report R46003, Report R46003, Applicability of Federal ~~Requirem ents~~Requirements to
Selected Health Coverage ~~Arrangem ents~~Arrangements. .
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State-Based and Federally Facilitated Exchanges
A state can choose to establish its own A state can choose to establish its own state-based exchange (SBE). If a state opts not to (SBE). If a state opts not to
administer its own exchange, or if the Department of Health and Human Services (HHS) administer its own exchange, or if the Department of Health and Human Services (HHS)
determines the state is not in a position to do so, then HHS is required to establish and administer determines the state is not in a position to do so, then HHS is required to establish and administer
the exchange in the state as a the exchange in the state as a federally facilitated exchange (FFE).(FFE).
There is one variation on the SBE approach: a state may have a There is one variation on the SBE approach: a state may have a state-based exchange using a
federal platform (SBE-FP), which means the state oversees the exchange but uses the (SBE-FP), which means the state oversees the exchange but uses the ~~federal y~~
federally facilitated information technology (IT) platform, or facilitated information technology (IT) platform, or federal platform (FP) (i.e., HealthCare.gov). (FP) (i.e., HealthCare.gov).
There is also a variation on the FFE approach: a state may have a There is also a variation on the FFE approach: a state may have a state partnership FFE, which , which
~~al ows~~allows the state to manage certain aspects of its exchange while HHS manages the remaining the state to manage certain aspects of its exchange while HHS manages the remaining
aspects and has authority over the exchange. In early guidance on this option, HHS indicated a aspects and has authority over the exchange. In early guidance on this option, HHS indicated a
state could elect to perform some plan management and/or certain consumer assistance functions, state could elect to perform some plan management and/or certain consumer assistance functions,
and HHS would perform other functions, including facilitating enrollment through the federal and HHS would perform other functions, including facilitating enrollment through the federal
HealthCare.gov platform and funding Navigator entities in the state.9 In federal and private HealthCare.gov platform and funding Navigator entities in the state.9 In federal and private
resources that track exchange data, this variation may not be reported on separatelyresources that track exchange data, this variation may not be reported on separately, but rather but rather
may be included in may be included in ~~overal~~ overall counts of FFEs, which is the model this report counts of FFEs, which is the model this report ~~general y~~generally follows. follows.10
In rulemaking finalized In rulemaking finalized January 19, 2021 (the 2022 Notice of Benefit and Payment Parameters, or January 19, 2021 (the 2022 Notice of Benefit and Payment Parameters, or
“Payment Notice”“Payment Notice”1110), HHS and the Department of the Treasury established new “direct ), HHS and the Department of the Treasury established new “direct
enrollment” variations of the exchange types: FFE-DE, SBE-DE, and SBE-FP-DE.enrollment” variations of the exchange types: FFE-DE, SBE-DE, and SBE-FP-DE.12 States States
electing these options would “adopt a private sector-based enrollment approach as an alternative electing these options would “adopt a private sector-based enrollment approach as an alternative
to the consumer-facing enrollment website operated by the Exchange (for example, to the consumer-facing enrollment website operated by the Exchange (for example,
HealthCare.gov for the FFEs).” In other words, consumers would enroll in exchange plans via HealthCare.gov for the FFEs).” In other words, consumers would enroll in exchange plans via
private agents or brokers, rather than on an exchange website like HealthCare.gov. The exchange private agents or brokers, rather than on an exchange website like HealthCare.gov. The exchange
would would ~~stil~~ still have to “make availablehave to “make available a website listing basic [qualified health plan] QHP a website listing basic [qualified health plan] QHP
information for comparison,” but this website would direct consumers to “approved partner information for comparison,” but this website would direct consumers to “approved partner
websites for consumer shopping, plan selection, and enrollment activities.” Per the final rule, this websites for consumer shopping, plan selection, and enrollment activities.” Per the final rule, this
~~wil be~~would have been an option for SBEs as of plan year (PY) 2022, and for FFEs and SBE-FPs as of PY2023. an option for SBEs as of plan year (PY) 2022, and for FFEs and SBE-FPs as of PY2023.
The final rule was published but did not take effect before the presidential transitionThe final rule was published but did not take effect before the presidential transition~~, and as such,~~
~~may be reconsidered by the Biden Administration.13~~

~~9 See Centers for Medicare & Medicaid Services (CMS) Center for Consumer Information and Insurance Oversight~~
~~(CCIIO), “ General Guidance~~ . The Biden Administration subsequently repealed the establishment of these DE exchange type options.11 “Direct Enrollment” (DE) and the Exchanges Although current regulations do not allow states to adopt a direct enrol ment exchange type (e.g., FFE-DE), there are ongoing uses of DE approaches and systems in the exchanges. In general, DE can be a way for consumers to enrol in an exchange plan directly on an insurer’s or web-broker’s website or otherwise with an agent or broker, rather than enrol ing on an exchange website (e.g., HealthCare.gov). 9 See Centers for Medicare & Medicaid Services (CMS) Center for Consumer Information and Insurance Oversight (CCIIO), “General Guidance on Federally Facilitated Exchanges,” May 16, 2012, at https://www.cms.gov/CCIIO/on Federally Facilitated Exchanges,” May 16, 2012, at https://www.cms.gov/CCIIO/
Resources/Fact-Sheets-and-FAQs/Downloads/ffe-guidance-05-16-2012.pdf. AlsoResources/Fact-Sheets-and-FAQs/Downloads/ffe-guidance-05-16-2012.pdf. Also see CMS,see CMS, CCIIO, “CCIIO, “Guidance ~~Guidance~~ on on
State Partnership Exchange,” January 3, 2013, at https://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/State Partnership Exchange,” January 3, 2013, at https://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/
Downloads/partnership-guidance-01-03-2013.pdf. For more information about Navigators, see Downloads/partnership-guidance-01-03-2013.pdf. For more information about Navigators, see “ Navigators and Other
Exchange-Based Enrollment Assistance” in this report. in this report.
10 10 ~~T his report focuses on the three types of exchanges that are commonly discussed in CMS resources, but other entities~~
~~may also track states with variations of state partnership FFEs. For example, the Kaiser Family Foundation (KFF) notes~~
~~FFEs in which the state conducts plan management activities at “ State Health Insurance Marketplace T ypes, 202 1,” at~~
~~https://www.kff.org/health-reform/state-indicator/state-health-insurance-marketplace-types/.~~
~~11 See 2022 Payment Notice,~~See 2022 Payment Notice, “Part 1,” starting page 6143, regarding information in this starting page 6143, regarding information in this ~~p aragraph. T he~~paragraph. The Notice of Notice of ~~Benefit~~ Benefit and and
Payment Parameters, or Payment Notice, is an annually publishedPayment Parameters, or Payment Notice, is an annually published rule that includes updates and policy changes related rule that includes updates and policy changes related
to the exchanges and private health insurance. to the exchanges and private health insurance. See Table D-1 ~~for~~Because different parts of the Final 2022 Payment Payment Notice were published in January 2021, May 2021, and September 2021, the informal references “Part 1,” Part 2,” and “Part 3” are used to distinguish them in this report. See Table D-1 for Payment Notice citations. 11 2022 Payment Notice, “Part 3,” starting on page 53424. ~~Notice citations.~~
~~12 For additional discussion of direct enrollment, see “ Online Enrollment versus Direct Enrollment” in the SHOP~~
~~section of this report.~~
~~13 See Office of Management and Budget, “Memorandum for the Heads of Executive Departments and Agencies,”~~
~~86 Federal Register 7424, January 28, 2021.~~
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~~For PY2021, 30 states have FFEs, 15 states have SBEs, and 6 states have SBE-FPs.14 A few states~~
~~have changed approaches one or more times (e.g., initial y~~ In the individual exchanges, consumers can enrol on their exchange website and may also have DE options. In FF-SHOP and some SB-SHOP exchanges, DE is the only enrol ment option. See “Enrol ment Processes and Options” in the SHOP section of this report, and “Brokers, Agents, and Other Third-Party Assistance Entities” in the Exchange Enrol ment Assistance section, for more information. For PY2023, 30 states have FFEs, 18 states have SBEs, and three states have SBE-FPs.12 A few states have changed approaches one or more times (e.g., initially worked to create an SBE but then worked to create an SBE but then
switched to an SBE-FP or FFE model). Changes in the first few years varied in terms of whether switched to an SBE-FP or FFE model). Changes in the first few years varied in terms of whether
the state moved toward more or less federal involvement, but in several cases, a state transitioned the state moved toward more or less federal involvement, but in several cases, a state transitioned
from a fully state-based approach to an SBE-FP (i.e., transitioned toward more federal from a fully state-based approach to an SBE-FP (i.e., transitioned toward more federal
involvement). Recent and ongoing transitions are involvement). Recent and ongoing transitions are ~~general y~~generally in the direction of less federal in the direction of less federal
~~involvement. As of the publication of this report, at least five states are transitioning or~~
~~considering transitions for PY2022 or beyond.15~~
~~SHOP exchanges may be federal y facilitated (FF-SHOP) or state-based (SB-SHOP).16 For~~
~~PY2021, there are 32 FF-SHOPs and 18 SB-SHOPs. However, in more than half of these states,~~
and more state involvement. For example, as of PYs 2020-23, the following states have transitioned from FFE to SBE-FP, and/or from SBE-FP to SBE: Nevada, New Jersey, Pennsylvania, Maine, Virginia, Kentucky, and New Mexico.13 After pursuing an alternative approach in recent years, Georgia is now seeking to transition from FFE to SBE.14 SHOP exchanges may be federally facilitated (FF-SHOP) or state-based (SB-SHOP).15 Most states’ individual and SHOP exchanges are administered in the same way (e.g., both state-based or both federally facilitated). However, in about half of the states, no insurers are offering medical plans in the SHOP exchange, meaning there is effectively no no insurers are offering medical plans in the SHOP exchange, meaning there is effectively no
~~SHOP exchange there.17 One state is exempted from operating a SHOP exchange.18 For the 2021~~
~~plan year, most states’ individual and SHOP exchanges are administered in the same way (i.e.,~~
~~both state-based or both federal y facilitated). However, a handful of states have different~~
approaches for their individual and SHOP exchanges. Some resources refer to this as a bifurcated
~~approach.~~
SeeSHOP exchange there.16 For PY2023, there are 8 FF-SHOPs and 15 SB-SHOPs with medical plans, 27 states with no SHOP medical plans, and one state exempted from operating a SHOP exchange.17 See Figure 1 for individual and SHOP exchange types by state in for individual and SHOP exchange types by state in ~~PY2021~~PY2023, and , and see see Table A-1 for for
additional information, including on state transitions to different exchange types. additional information, including on state transitions to different exchange types.

14 See Table A-1 ~~for details and citations for this paragraph.~~ 12 In tallies throughout this report, the District of Columbia is In tallies throughout this report, the District of Columbia is
counted ascounted as a state. a state.
~~15 One of these states, Georgia,~~13 For some considerations regarding such transitions, see Sabrina Corlette et al., States Seek Greater Control, Cost-Savings by Converting to State-Based Marketplaces, Robert Wood Johnson Foundation, October 2019, at https://www.rwjf.org/en/library/research/2019/10/states-seek-greater-control-cost-savings-by-converting-to-state-based-marketplaces.html. 14 In 2020, Georgia received approval through the Section 1332 state innovation waiver process received approval through the Section 1332 state innovation waiver process to shift to its own Georgia Access ~~shift to it s~~
~~own Georgia Access~~ Model, essentially a direct enrollment Model, essentially a direct enrollment ~~approach~~exchange type, beginning in PY2023. , beginning in PY2023. ~~T his 1332 process~~However, the Georgia Access Model component of the waiver was suspended for PY2023 in 2022. For more information about the 1332 waiver process, which allows allows
states to waive specified ACAstates to waive specified ACA provisions, includingprovisions, including provisions related to the establishment of health insurance provisions related to the establishment of health insurance
exchanges and related activitiesexchanges and related activities~~. See CRS~~ , see CRS Report R44760, Report R44760, State Innovation Waivers: Frequently Asked Questions ~~for~~
~~more information.~~
~~16 As of June 2018, states can no longer select a state-based SHOP using the federal IT~~ . In February 2023, Georgia indicated its intention to transition to an SBE approach. See State of Georgia Office of Commissioner of Insurance and Safety Fire, Letter to CCIIO, February 14, 2023, at https://oci.georgia.gov/document/document/georgia-sbe-blueprint-letter-cms/download. 15 As of June 2018, states could no longer select a state-based SHOP using the federal IT platform (SB-FP-SHOP) platform (SB-FP-SHOP)
approach, except that the two states with that model at that time (Nevada and Kentucky) could maintain it. According approach, except that the two states with that model at that time (Nevada and Kentucky) could maintain it. According
to CMS,to CMS, those states no longer usethose states no longer use that model. See “Enrollment Processes and Options” ~~that model. For more information, see “ Online Enrollment versus Direct Enrollment~~
in the SHOP section of this in the SHOP section of this ~~report.~~
~~17 See~~ report for more information. 16 See “Insurer Participation”” in the SHOP in the SHOP ~~Exchanges~~ section of this report for more information. section of this report for more information.
1817 Hawaii Hawaii received a Section 1332 waiver exempting it from operating a SHOP exchange.received a Section 1332 waiver exempting it from operating a SHOP exchange.
Initially set to expire after PY2021, the waiver was extended through PY2026 in December 2021. Congressional Research Service Congressional Research Service

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Overview of Health Insurance Exchanges

Figure 1. Individual and SHOP Exchange Types by State, Plan Year ~~2021~~2023

~~Sources:~~ ~~Congressional Research Service (CRS)~~Source: CRS il ustration. il ustration. See data sources iSee data sources in Table A-1.
Notes: SHOP = SHOP = ~~smal~~ small business health options program; IT =business health options program; IT = information technology. Counts of “states” include information technology. Counts of “states” include
the Districtthe District of Columbia. In the individual exchanges, of Columbia. In the individual exchanges, plan year ~~is general y that~~ is generally the calendar year, but group calendar year, but group ~~coverage~~
plan years, including in the SHOP exchanges, may start at any time during a calendar year. See plan years, including in the SHOP exchanges, may start at any time during a calendar year. See ~~“Types and~~
~~Administration of Exchanges”~~ ~~in this report~~ report “Overview” regarding individual and SHOP exchanges, and federal and state regarding individual and SHOP exchanges, and federal and state
administration of exchanges. administration of exchanges.
In In ~~more than~~about half of half of the states, no insurersstates, no insurers are offering medicalare offering medical plans in the SHOP exchange, meaning there is plans in the SHOP exchange, meaning there is
effectively no SHOP exchange there.effectively no SHOP exchange there. ~~These states have a circle symbol in the SHOP Exchange map above.~~ See See
“Insurer Participation” in in the SHOP the SHOP ~~Exchanges~~ section of this report for moresection of this report for more information. information.
~~Hawai received~~ There are medical plans available in all individual exchanges. Hawaii received a Section 1332 waiver exempting it from operating a SHOP exchange. For morea Section 1332 waiver exempting it from operating a SHOP exchange. For more information, information,
see CRS Report R44760, see CRS Report R44760, State Innovation Waivers: ~~Frequently~~ Frequently Asked Questions. .
Exchange Administration
Whether state-based or Whether state-based or ~~federal y~~federally facilitated, exchanges are required by law to facilitated, exchanges are required by law to ~~fulfil~~ fulfill certain certain
minimum functions. ACA provisions related to the establishment and operation of the exchanges minimum functions. ACA provisions related to the establishment and operation of the exchanges
are codified at 42 U.S.C. §§18031 et seq. Other federal provisions also are relevant, for example are codified at 42 U.S.C. §§18031 et seq. Other federal provisions also are relevant, for example
regarding the requirements for plans that may be sold through the exchanges.regarding the requirements for plans that may be sold through the exchanges.19
18 A primary function of the exchanges is to provide a way for consumers and A primary function of the exchanges is to provide a way for consumers and ~~smal~~ small businesses to businesses to
compare and purchase health plan options offered by participating insurers.compare and purchase health plan options offered by participating insurers.2019 This This ~~general y~~generally
includes operating a web portal that includes operating a web portal that ~~al ows~~allows for comparing and purchasing coverage, making for comparing and purchasing coverage, making
determinations of eligibilitydeterminations of eligibility for coverage and financial assistance, and offering different forms of for coverage and financial assistance, and offering different forms of
enrollment assistance. enrollment assistance.
Exchanges also are responsible for several administrative functions, including certifying the plans Exchanges also are responsible for several administrative functions, including certifying the plans
that that ~~wil~~ will be offered in their marketplaces.be offered in their marketplaces.2120 This includes This includes ~~annual y~~annually certifying or recertifying plans certifying or recertifying plans
to be sold in their exchanges as to be sold in their exchanges as qualified health plans (QHPs, discussed below). QHP (QHPs, discussed below). QHP
certification involves a review of various factors, including the plan’s benefits, cost-sharing certification involves a review of various factors, including the plan’s benefits, cost-sharing
~~structure, provider network, premiums, marketing practices, and quality improvement activities,~~

~~19 See~~ 18 See “Qualified Health Plans” in this report. in this report.
2019 42 U.S.C. 42 U.S.C. §18031(b)(1)(A). §18031(b)(1)(A).
2120 42 U.S.C. 42 U.S.C. §18031(d)(4). §18031(d)(4).
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structure, provider network, premiums, marketing practices, and quality improvement activities, to ensure compliance with applicable federal and state standards.to ensure compliance with applicable federal and state standards.2221 The QHP certification process The QHP certification process
is to be completed each year in time for insurers to market their plans and premiums during the is to be completed each year in time for insurers to market their plans and premiums during the
exchanges’ annual open enrollment period (see exchanges’ annual open enrollment period (see “Open and Special Enrollment Periods”). ).
Exchanges’ other administrative activities include collecting enrollment and other data, reporting Exchanges’ other administrative activities include collecting enrollment and other data, reporting
data to and otherwise interacting with the Departments of HHS and the Treasury, and working data to and otherwise interacting with the Departments of HHS and the Treasury, and working
with state insurance departments and federal regulators to conduct ongoing oversight of plans. with state insurance departments and federal regulators to conduct ongoing oversight of plans.
Qualified Health Plans
In general, health insurance plans offered through exchanges must be In general, health insurance plans offered through exchanges must be qualified health plans
(QHPs).(QHPs).2322 A QHP is a plan offered by a state-licensed insurer that is certified to be sold in that A QHP is a plan offered by a state-licensed insurer that is certified to be sold in that
state’s exchange, covers the state’s exchange, covers the essential health benefits (EHB) package, and meets other specified (EHB) package, and meets other specified
requirements.requirements.2423 Covering the EHB package means covering 10 broad categories of benefits Covering the EHB package means covering 10 broad categories of benefits ~~and~~
~~services,~~ , complying with limits on consumer cost sharing on the EHB, and meeting certain complying with limits on consumer cost sharing on the EHB, and meeting certain
generosity requirements (in terms of generosity requirements (in terms of actuarial value) or AV).24 As discussed later in this report, an AV is an estimate of the “percentage of total average costs for covered benefits” to be paid by a plan. Plan AVs are associated with metal levels (90% AV for platinum plans, 80% for gold, 70% for silver, and 60% for bronze), and the higher the AV percentage, the lower the cost sharing, on average.25 .25
QHPs are subject to the same state and federal requirements that apply to health plans offered QHPs are subject to the same state and federal requirements that apply to health plans offered
outside of exchanges.26 Thus, a QHP offered through an individual exchange must comply with outside of exchanges.26 Thus, a QHP offered through an individual exchange must comply with
state and federal requirements applicable to individualstate and federal requirements applicable to individual ~~market~~ market (or nongroup market) plans; a QHP offered through a plans; a QHP offered through a
SHOP exchange must comply with state and federal requirements applicable to SHOP exchange must comply with state and federal requirements applicable to ~~smal~~ small-group -group
market plans. For example, the requirement to cover the EHBmarket plans. For example, the requirement to cover the EHB applies to individualapplies to individual ~~and smal -~~
and small-group plans both in and out of the exchanges.group plans both in and out of the exchanges.
There are additional requirements that apply only to QHPs sold in the exchanges. There are additional requirements that apply only to QHPs sold in the exchanges.27 For example, an For example, an
insurer wanting to insurer wanting to ~~sel~~ sell QHPs in an exchange must offer at least one silver-level and one gold-QHPs in an exchange must offer at least one silver-level and one gold-
level plan in level plan in al all of the areas in which the insurer offers coverage within that exchange. In of the areas in which the insurer offers coverage within that exchange. In
addition, QHPs addition, QHPs that use provider networks must meet network adequacy standards, including maintaining provider networks must meet network adequacy standards, including maintaining provider networks
that are “sufficient in number and types of providers” and include that are “sufficient in number and types of providers” and include “essential community providers (i.e., certain types of providers that serve predominantly low-income and medically underserved individuals). As of PY2023, QHP issuers in FFEs must meet 21 42 U.S.C. §18031(c)(1); 42 U.S.C. §18031(e). For more information, also see CMS, CCIIO, 2023 Final Letter to Issuers in the Federally Facilitated Exchanges, April 28, 2022~~essential community~~
~~providers.”27~~
~~A QHP is the only type of comprehensive health plan an exchange may offer, but QHPs may be~~
~~offered outside of exchanges, as wel . Besides standard QHPs, other types of plans may be~~
~~available in a given exchange, including child-only plans, catastrophic plans, consumer operated~~
~~and oriented plans (CO-OPs), and multi-state plans (MSPs). Technical y, these are also QHPs.~~

~~22 42 U.S.C. §18031(c)(1); 42 U.S.C. §18031(e). For more information, see, for example, CMS, CCIIO, “ Final 2021~~
~~Lett er to Issuers in the Federally Facilitated Exchanges,” May 7, 2020~~, at https://www.cms.gov/CCIIO/Resources/, at https://www.cms.gov/CCIIO/Resources/
Regulations-and-Guidance/Downloads/Final-Regulations-and-Guidance/Downloads/Final-~~2021~~2023-Letter-to-Issuers-Letter-to-Issuers~~-in-the-Federally-facilitated-Marketplaces~~.pdf. .pdf.
Hereinafter referred to as “CMSHereinafter referred to as “CMS ~~2021~~, 2023 Final Letter to Letter to ~~Issuers.”~~
23Issuers.” 22 42 U.S.C. 42 U.S.C. §18031(d)(2)(B). §18031(d)(2)(B).
2423 42 U.S.C. 42 U.S.C. §18021(a)(1). §18021(a)(1).
2524 42 U.S.C. 42 U.S.C. ~~§18022. For brief explanation of actuarial value (AV) and cost -sharing limits, see~~ ~~“ Premiums and Cost~~
~~Sharing”~~ ~~in this report. For more information on the essential health benefits, cost-sharing limits, and AV requirements,~~
see CRS Report R45146, Federal Requirem ents on Private Health Insurance Plans §18022. 25 See “Cost Sharing, Maximum Out-of-Pocket Limits, and Actuarial Value Levels” for more information. .
26 For more information about federal requirements applicable26 For more information about federal requirements applicable to different types of plans, see CRSto different types of plans, see CRS Report R45146, Report R45146,
Federal ~~Requirem ents~~Requirements on Private Health Insurance Plans. . ~~T his~~This report also addresses report also addresses states’ roles as the primary states’ roles as the primary
regulators of health insurance. regulators of health insurance.
27 See, 27 See, for example, 42 U.S.C.for example, 42 U.S.C. §§18021, 18023, and 18031; and 45 C.F.R. §§156.200 et seq. Also see §§18021, 18023, and 18031; and 45 C.F.R. §§156.200 et seq. Also see ~~the CMS 2021~~
~~Letter to Issuers. Network adequacy standards are at 45 C.F.R. §156.200. T he requirement regarding silver and gold~~
~~plans is discussed in “ Premiums and Cost Sharing” in this report.~~
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Stand-alone dental plans (SADPs) are the only non-QHPs offered in the exchanges. See Table B-
CMS, 2023 Final Letter to Issuers. Congressional Research Service 6 link to page 40 link to page 40 link to page 9 Overview of Health Insurance Exchanges “time and distance” standards related to network adequacy requirements.28 Also as of PY2023, QHP issuers in FFEs and SBE-FPs must offer standardized plans, as explained below. A QHP is the only type of comprehensive health plan an exchange may offer, but QHPs may be offered outside of exchanges, as well. Besides standard QHPs, other types of plans may be available in a given exchange, including child-only plans, catastrophic plans, consumer operated and oriented plans (CO-OPs), and multi-state plans (MSPs). Technically, these are also QHPs. Stand-alone dental plans (SADPs) are the only non-QHPs offered in the exchanges. See Table B-1 for more information. for more information.
Under federal law, insurers are not required to offer plans in the exchanges, just as they are not Under federal law, insurers are not required to offer plans in the exchanges, just as they are not
required to offer plans in markets outside the exchanges. If an insurer does want to offer a plan in required to offer plans in markets outside the exchanges. If an insurer does want to offer a plan in
an exchange, it must meet applicable federal and state requirements, as discussed in this section an exchange, it must meet applicable federal and state requirements, as discussed in this section
and the prior one on and the prior one on “Exchange Administration.” Insurer participation in the individual Insurer participation in the individual and and
~~SHOP exchanges is discussed in the sections below.~~
~~Individual Exchanges~~
~~Eligibility and Enrollment~~
~~Consumers may purchase health insurance plans for themselves and their families in their state’s~~
~~individual exchange. Consumers may enroll as long as they (1) meet state residency~~
~~requirements;28 (2) are not incarcerated, except individuals in custody pending the disposition of~~
~~charges; and (3) are U.S. citizens, U.S. nationals, or “lawfully present” residents.29~~
~~Undocumented individuals are prohibited from purchasing coverage through the exchanges, even~~
~~if they were to pay the entire premium without financial assistance.~~
~~Consumers can use their state’s exchange website (HealthCare.gov or a state-run site) to apply for~~
~~coverage and financial assistance and to compare and enroll in plans. The ACA requires~~
~~exchanges to provide a “single, streamlined form” that consumers can use to apply for “al~~
~~applicable State health subsidy programs within the State.”30~~SHOP exchanges is discussed in the sections below. Standardized Plans In the 2023 Payment Notice finalized in May 2022, HHS indicated that insurers offering QHPs in FFEs and SBE-FPs29 are required to offer “standardized plans” starting in PY2023. In general, a non-standardized plan is one that meets the requirements outlined above (i.e., QHP and other applicable federal or state requirements), but otherwise may vary in terms of benefits, cost sharing, and/or other features. A standardized plan also meets those requirements, and meets certain other parameters—particularly in terms of cost-sharing requirements—outlined by HHS in the 2023 Payment Notice. Standardized plans may still vary in other ways. Specifically, HHS designed a standardized plan option for each metal level of plan offered in the exchanges, and specified variations of them. For each of these standardized plans, cost-sharing requirements are set for certain categories of benefits and overall (e.g., the plan’s deductible and annual out-of-pocket limit). QHP issuers must offer a standardized plan “at every product network type ... , at every metal level, and throughout every service area that they offer non-standardized QHP options in the individual market.”30 For example, if an insurer offers a non-standardized gold health maintenance organization (HMO) QHP in a given service area, such insurer must also offer a standardized gold HMO QHP throughout that service area.31 For tables outlining the cost-sharing requirements, and for other details, including on exchanges’ and other entities’ displays of standardized plan options, see the 2023 Payment Notice. Other 28 QHP network adequacy standards, including time and distance requirements, are at 45 C.F.R. §156.230. Essential community provider requirements are at 45 C.F.R. §156.235. 29 2023 Payment Notice, starting on page 27310; codified at 45 C.F.R. §156.201. This policy does not apply in SBEs, although some states with SBEs already do or plan to require QHP issuers to offer standardized plans. This policy also does not apply in FFEs or SBE-FPs where a state has its own requirements for standardized plans as of January 1, 2020 (Oregon), and there are variations of the requirements to accommodate certain states’ cost-sharing laws (Delaware and Louisiana). 30 2023 Payment Notice, page 27312. 31 CMS, HHS Notice of Benefit and Payment Parameters for 2023 Final Rule Fact Sheet, April 28, 2022, at https://www.cms.gov/newsroom/fact-sheets/hhs-notice-benefit-and-payment-parameters-2023-final-rule-fact-sheet. A plan’s service area is the geographic area – generally a whole county or group of counties – in which it is available to consumers. See HealthCare.gov, “Service area,” at https://www.healthcare.gov/glossary/service-area/. Also see 45 C.F.R. §155.1055. Congressional Research Service 7 link to page 20 link to page 20 link to page 30 Overview of Health Insurance Exchanges resources provide further background on this issue, including prior federal rulemaking on standardized plans and certain state approaches.32 Individual Exchanges Eligibility and Enrollment Consumers may purchase health insurance plans for themselves and their families in their state’s individual exchange. Consumers may enroll as long as they (1) meet state residency requirements;33 (2) are not incarcerated, except individuals in custody pending the disposition of charges; and (3) are U.S. citizens, U.S. nationals, or “lawfully present” residents.34 Undocumented individuals are prohibited from purchasing coverage through the exchanges, even if they were to pay the entire premium without financial assistance. Consumers can use their state’s exchange website (HealthCare.gov or a state-run site) to apply for coverage and financial assistance and to compare and enroll in plans. The ACA requires exchanges to provide a “single, streamlined form” that consumers can use to apply for “all applicable State health subsidy programs within the State.”35 This means that through one form, This means that through one form,
consumers can be determined eligible for exchange financial assistance (see consumers can be determined eligible for exchange financial assistance (see “Premium Tax
Credits and Cost-Sharing Reductions”” in this report), as in this report), as ~~wel~~ well as Medicaid and the State as Medicaid and the State
Children’s HealthChildren’s Health Insurance Program (CHIP), as discussed below.Insurance Program (CHIP), as discussed below.3136 The exchange website The exchange website
displays displays al all exchange plans availableexchange plans available to a consumer, with estimates of the consumer’s costs, to a consumer, with estimates of the consumer’s costs,
including monthly premiums that reflect the application of any federal financial assistance for including monthly premiums that reflect the application of any federal financial assistance for
which they are eligible.which they are eligible.
In addition to using their exchange website, consumers can apply and enroll by phone, by mail, In addition to using their exchange website, consumers can apply and enroll by phone, by mail, or
~~in person~~in person, and/or via approved partner websites (i.e., via direct enrollment), as available by state. Enrollment assistance is available for those who want it (e.g., , as available by state. Enrollment assistance is available for those who want it (e.g.,
through exchange Navigators or through agents or brokersthrough exchange Navigators or through agents or brokers~~; see “Exchange Enrollment~~
~~Assistance” in this report).~~

~~28 State residency may be established through a variety of means, including actual or planned residence~~ ).37 32 See, for example, HHS Office of the Assistant Secretary for Planning and Evaluation (ASPE), Facilitating Consumer Choice: Standardized Plans in Health Insurance Marketplaces, December 28, 2021, at https://aspe.hhs.gov/reports/standardized-plans-health-insurance-marketplaces. Also see Katie Keith, “Final 2023 Payment Rule, Part 2: Standard Plans And Other Exchange Provisions,” Health Affairs Forefront, April 30, 2022, at https://www.healthaffairs.org/do/10.1377/forefront.20220430.953129/. 33 State residency may be established through a variety of means, including actual or planned residence in a state, actual in a state, actual
or planned employment in a state, and other circumstances. See 45 C.F.R. §155.305. or planned employment in a state, and other circumstances. See 45 C.F.R. §155.305.
2934 U.S. U.S. citizens and U.S.citizens and U.S. nationals are eligiblenationals are eligible for coverage through the exchanges. for coverage through the exchanges. Lawfully present immigrants are immigrants are
also eligiblealso eligible for coverage through the exchanges. Examples of for coverage through the exchanges. Examples of lawfully present immigrants include immigrants include those who have those who have
qualified non-citizen immigration status without a waiting immigration status without a waiting period, humanitarian statuses or circumstances, valid non-period, humanitarian statuses or circumstances, valid non-
immigrant visas, and legalimmigrant visas, and legal status conferred by other laws. Seestatus conferred by other laws. See 45 C.F.R.45 C.F.R. §155.305 and HealthCare.gov, “§155.305 and HealthCare.gov, “ Coverage for Coverage for
LawfullyLawfully Present Immigrants,” at https://www.healthcare.gov/immigrants/lawfully-present-immigrants/. Present Immigrants,” at https://www.healthcare.gov/immigrants/lawfully-present-immigrants/.
3035 42 U.S.C. 42 U.S.C. §18083, 45 C.F.R. §155.405. §18083, 45 C.F.R. §155.405.
3136 Medicaid Medicaid is a joint federal-state program that finances the delivery of primary and acute medical services, as wellis a joint federal-state program that finances the delivery of primary and acute medical services, as well as as
long-term services and supports, to a diverselong-term services and supports, to a diverse low-income population, including children, pregnant women, adults, low-income population, including children, pregnant women, adults,
individualsindividuals with disabilities,with disabilities, and people agedand people aged 65 and older. CHIP is65 and older. CHIP is a means-tested program that provides health a means-tested program that provides health
coverage to targeted low-income children and pregnant women in families that have annual income above Medicaid coverage to targeted low-income children and pregnant women in families that have annual income above Medicaid
eligibilityeligibility levels but have no health insurance. levels but have no health insurance. ~~T he~~The “applicable State health subsidy “applicable State health subsidy programs” also includeprograms” also include the Basic the Basic
Health Program, which isHealth Program, which is operational in two states: Minnesota and Newoperational in two states: Minnesota and New York. 37 See “Exchange Enrollment Assistance” in this report for information on Navigators, agents and brokers, and approved web brokers and other technology providers. ~~York.~~
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Interaction with Medicaid, CHIP, and Medicare
In conjunction with the streamlined application mentioned above, exchanges must have systems In conjunction with the streamlined application mentioned above, exchanges must have systems
for coordinating with the Medicaid and CHIP programs on eligibilityfor coordinating with the Medicaid and CHIP programs on eligibility determinations and determinations and
enrollment into those programs, for eligible consumers. These systems may vary by state.enrollment into those programs, for eligible consumers. These systems may vary by state.3238
Consumers who are eligible for Medicaid or CHIP may choose to buy exchange coverage instead, Consumers who are eligible for Medicaid or CHIP may choose to buy exchange coverage instead,
but they would not be eligiblebut they would not be eligible for financial assistance for exchange coverage (i.e., PTCs or cost-for financial assistance for exchange coverage (i.e., PTCs or cost-
sharing reductions). sharing reductions).
There are some limitations on the sale of exchange plans to Medicare-eligible There are some limitations on the sale of exchange plans to Medicare-eligible or Medicare-or Medicare-
enrolled individuals.enrolled individuals.3339 In short, it is In short, it is ~~general y il egal to sel~~ generally illegal to sell an individualan individual exchange plan to exchange plan to
someone enrolled in someone enrolled in or entitled to Medicare because it would duplicate coverage. Medicare because it would duplicate coverage.
Open and Special Enrollment Periods
Consumers may enroll in coverage through the exchanges only during specified Consumers may enroll in coverage through the exchanges only during specified ~~enrollment~~
~~periods.~~
~~Anyone eligible~~ “open” and “special” enrollment periods. Open Enrollment Periods Anyone eligible for exchange plan coverage may for exchange plan coverage may newly enroll (or make changes to existing coverage) ~~enroll~~ during an annual during an annual open enrollment period
(OEP).(OEP).3440 The OEP The OEP ~~typical y~~typically takes place in takes place in ~~fal~~ fall of the year preceding the of the year preceding the plan year (PY; the (PY; the
calendar year in the individualcalendar year in the individual exchanges) during which the coverage is effective.exchanges) during which the coverage is effective. ~~The OEP for~~
~~PY2021 coverage was November 1, 2020, to December 15, 2020,~~ The annual federal OEP is November 1 to January 15, for FFE and SBE-FP states.41 This means, for example, that the OEP for PY2023 was November 1, 2022, to January 15, 2023.42 This is also the default OEP for SBEs, but states with SBEs may extend their OEPs, and they may also choose to offer a shorter OEP than is federally offered, as long as the SBE’s OEP is at least November 1-December 15.43 38 45 C.F.R. Part 155, Subpart D, including §155.302. Regarding FFE and SBE-FP states, also see Section 2.1.2 of CMS, Federally-facilitated Exchange (FFE) and Federally-facilitated Small Business Health Options Program (FF-SHOP) Enrollment Manual, July 28, 2022~~for FFE and SBE-FP states.~~
~~States with SBEs may extend their OEPs, and many do. See Table 1, including table notes, for~~
~~details.~~
~~Before and during an OEP, consumers already enrolled in coverage through an exchange should~~
~~receive notification from the exchange and from their insurer about the opportunity to make any~~
~~updates to their application data and/or coverage choices. Insurers must notify consumers of~~
~~changes to their plans such as premiums, benefit coverage, or provider networks (such changes~~
~~general y cannot be made during a plan year, only in preparation for, and as applicable to, a new~~

~~32 45 C.F.R. Part 155, Subpart D, including §155.302. Regarding FFE and SBE-FP states, also see “Medicaid & CHIP~~
~~Eligibility” in Section 2.1 of CMS, FFE and FF-SHOP Enrollment Manual, June 26, 2018, at https://www.cms.gov/~~
~~CCIIO/Programs-and-Initiatives/Health-Insurance-Marketplaces/General-Resources-Items/FFM-and-FF-SHOP-~~
~~Enrollment -Manual. Information for consumers is at Medicare.gov, “ Medicare & the Marketplace,” at~~
~~https://www.medicare.gov/about -us/medicare-the-marketplace~~, at https://www.cms.gov/files/document/ffeffshop-enrollment-manual-2022.pdf. Hereinafter referred to as . Hereinafter referred to as “CMS,CMS, FFE and FF-SHOP
~~Enrollm ent Manual. Regarding SBE~~ Enrollment Manual (2022).” Regarding SBE states, also see Sarastates, also see Sara ~~Rosenbaum et al.,~~ ~~Stream lining Medicaid Enrollm ent~~ Rosenbaum et al., Streamlining Medicaid Enrollment: The
Role of the Health Insurance Marketplaces and the ~~Im pact~~Impact of State Policies, Commonwealth Fund, March 30, 2016, at , Commonwealth Fund, March 30, 2016, at
https://www.commonwealthfund.org/publications/issue-briefs/2016/mar/streamlining-medicaid-enrollmenthttps://www.commonwealthfund.org/publications/issue-briefs/2016/mar/streamlining-medicaid-enrollment -role-health--role-health-
insurance. insurance.
33 39 Social Security Act §1882(d)(3)(A)(i). Medicare is a federal Medicare is a federal ~~health insurance~~ program that pays for covered health care services for most people aged 65 program that pays for covered health care services for most people aged 65
and older and for certain permanently disabled individualsand older and for certain permanently disabled individuals under the age of 65. under the age of 65. ~~T he~~The prohibition on selling an individual prohibition on selling an individual
exchange plan to someone enrolled in exchange plan to someone enrolled in or entitled to Medicare doesMedicare does not apply to employmentnot apply to employment -based coverage, including-based coverage, including coverage coverage
~~sold~~ sold in the SHOP exchanges. Seein the SHOP exchanges. See CMS,CMS, “ “Medicare andMedicare and the Marketplace,” updated December the Marketplace,” updated December ~~2019~~2021, at , at
https://www.cms.gov/Medicare/Eligibility-and-Enrollment/Medicare-and-the-Marketplace/Overview1.html. Also see https://www.cms.gov/Medicare/Eligibility-and-Enrollment/Medicare-and-the-Marketplace/Overview1.html. Also see
Section Section ~~2.6~~3.4.8 of CMS,.8 of CMS, FFE and FF-SHOP Enrollment Manual (2022). ~~FFE and FF-SHOP Enrollm ent Manual,~~ ~~June 26, 2018, at https://www.cms.gov/CCIIO/~~
~~Programs-and-Initiatives/Health-Insurance-Marketplaces/General-Resources-Items/FFM-and-FF-SHOP-Enrollment -~~
~~Manual.~~ Information for consumers is at Medicare.gov, “Information for consumers is at Medicare.gov, “ Medicare & the Marketplace,” at https://www.medicare.gov/Medicare & the Marketplace,” at https://www.medicare.gov/
about-us/medicare-the-about-us/medicare-the-marketplace. 40~~marketplace. CMS, FFE and FF-SHOP Enrollm ent Manual.~~
~~34 45 C.F.R. §155.410.~~
~~Congressional Research Service~~

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~~plan year).35 If an existing exchange plan enrollee does not take any action during the OEP, they~~
~~general y wil be automatical y reenrolled in the same plan for the upcoming plan year.36~~
~~Table 1. Open Enrollment Periods for Individual Exchanges on the Federal Platform,~~
~~by Plan Year~~

~~Plan Year~~

~~2014~~
~~2015~~
~~2016~~
~~2017~~
~~2018~~
~~2019~~
~~2020~~
~~2021~~
~~Oct. 1,~~
~~Nov. 15,~~
~~Nov. 1,~~
~~Nov. 1,~~
~~Nov. 1,~~
~~Nov. 1,~~
~~Nov. 1,~~
~~Nov. 1,~~
~~HealthCare.~~
~~2013-~~
~~2014-~~
~~2015-~~
~~2016-~~
~~2017-~~
~~2018-~~
~~2019-~~
~~2020-~~
~~gov OEP~~
~~Mar. 31,~~
~~Feb. 15,~~
~~Jan. 31,~~
~~Jan. 31,~~
~~Dec. 15,~~
~~Dec. 15,~~
~~Dec. 15,~~
~~Dec. 15,~~
~~2014~~
~~2015~~
~~2016~~
~~2017~~
~~2017~~
~~2018~~
~~2019~~
~~2020~~
Source: CRS analysis of Department of Health and Human Services (HHS) reports on enrol ment during annual
~~open enrol ment periods. See the “Pre-effectuated Enrol ment Data” section of CRS Report R46638,~~ ~~Health~~
~~Insurance Exchanges: Sources for Statistics~~ ~~for reports by year.~~
Notes: FFE = federal y facilitated exchange; OEP = open enrol ment period; PY = plan year; SBE = state-based
~~exchange; SBE-FP = state-based exchange using the federal information technology platform; SEP = special~~
~~enrol ment period. See “State-Based and Federal y Facilitated Exchanges” in this report for more information.~~
~~The HealthCare.gov OEP applies to FFE and SBE-FP states. In some years, there also have been federal OEP~~
~~extensions or SEPs for broadly applicable situations, such as the SEP during PY2021 due to the COVID-19~~
~~pandemic. See “Open and Special Enrol ment Periods” in this report for more information.~~
~~The OEPs of SBEs may be longer in a given year. For PY2021, 13 of 15 SBEs extended their OEPs. See CMS,~~
~~“2021 Marketplace Open Enrol ment Period Public Use Files” at https://www.cms.gov/research-statistics-data-~~
~~systems/marketplace-products/2021-marketplace-open-enrol ment-period-public-use-files.~~
~~Consumers also may be al owed to enroll for coverage in an exchange if they qualify for a~~ ~~special~~
~~enrollment period~~ ~~(SEP). General y, consumers qualify for SEPs due to a change in personal~~
~~circumstances—for example,~~ 45 C.F.R. §155.410. 41 These annual OEP dates were updated via rulemaking, effective as of the PY2022 OEP (in fall 2021). See the 2022 Payment Notice, “Part 3,” starting on page 53429. See prior year OEPs at 45 C.F.R. §155.410(b) and (e). 42 Consumers enrolling by December 15 of a given OEP are to have coverage beginning January 1. Consumers enrolling December 16-January 15 are to have coverage beginning February 1. 43 For PY2023 SBE OEPs, see CMS, “State Exchange OE Chart PY 2023,” at https://www.cms.gov/files/document/state-exchange-open-enrollment-chart.pdf. For PY2022 and prior year SBE OEP information, see the CMS page of Congressional Research Service 9 Overview of Health Insurance Exchanges Before and during an OEP, consumers already enrolled in coverage through an exchange should receive notification from the exchange and from their insurer about the opportunity to make any updates to their application data and/or coverage choices. Insurers must notify consumers of changes to their plans such as premiums, benefit coverage, or provider networks.44 If an existing exchange plan enrollee does not take any action during the OEP, they generally will be automatically reenrolled in the same plan for the upcoming plan year.45 Special Enrollment Periods Outside of an OEP, consumers may only enroll in coverage (or switch plans) via the exchange if they qualify for a special enrollment period (SEP). Generally, consumers qualify for SEPs due to a qualifying life event (QLE), also called a triggering event.46 This includes, for example:  Loss of qualifying coverage, which includes most types of comprehensive coverage (e.g., Medicare, Medicaid, and group and nongroup private insurance).47 This SEP also applies when a dependent turns 26 and is no longer eligible to be covered on a parent’s plan. This SEP does not apply in certain circumstances, such as loss of coverage due to failure to pay premiums, or voluntarily ending coverage during a plan year.48  Change in household size, for example due to a change in marital status or ~~a change in marital status or number of dependents—or loss of~~
~~qualifying coverage.37 HHS also may choose to offer SEPs or extend an OEP for some or al~~

35 See Section 2.6 of CMS, FFE and FF-SHOP Enrollment Manual~~; the~~number of dependents, or due to a death in the family.49 Regarding dependents, birth and adoption (and other specified scenarios) are QLEs that trigger SEPs but generally not pregnancy.50 marketplace public use files at https://www.cms.gov/research-statistics-data-systems/marketplace-products/2022-marketplace-open-enrollment-period-public-use-files. 44 See Section 3.2.5 of CMS, FFE and FF-SHOP Enrollment Manual (2022); its “Reenrollment Communications to Enrollees” “Reenrollment Communications to Enrollees”
section cites CMSsection cites CMS ~~guidance:~~ , Updated Federal Standard Renewal and Product Discontinuation Notices in the Individual Market (Required for Notices Provided in Connection with Coverage Beginning in the 2021 Plan Year), July 31, 2020, , ~~September~~
~~2016,~~ at https://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/at https://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/~~Final-~~Updated-Federal-Updated-Federal-
~~Standard-Renewal-and-Product -Discontinuation-Notices-090216.pdf. T here, see “~~ Standard-Notices-for-coverage-beginning-in-the-2021-plan-year.pdf. There, see “Instructions for Attachment 2Instructions for Attachment 2.”
36,” item 20. 45 For more information about plan renewal options and processes, including For more information about plan renewal options and processes, including automatic renewals of enrollees in their automatic renewals of enrollees in their
existing plans or in alternate plans if their existing ones willexisting plans or in alternate plans if their existing ones will no longer be available, seeno longer be available, see Section Section ~~2.6~~3.2 of CMS, of CMS, FFE and
FF-SHOP ~~Enrollm ent Manual~~Enrollment Manual (2022). Although this manual describes. Although this manual describes processes for HealthCare.gov states, SBEsprocesses for HealthCare.gov states, SBEs also have also have
processes for automatic reenrollment. processes for automatic reenrollment.
3746 In addition to the examples and their regulatory citations shown here, see HealthCare.gov information on SEPs at https://www.healthcare.gov/coverage-outside-open-enrollment/special-enrollment-period/ and https://www.healthcare.gov/sep-list/. Also see 45 C.F.R. §147.104 regarding SEPs applicable to the individual and group markets overall. 47 45 C.F.R. §155.420(d)(1), (e)(1). Qualifying coverage generally means the types of generally means the types of minimum essential coverage (MEC) that are identified in the (MEC) that are identified in the
Internal Revenue CodeInternal Revenue Code (IRC) Section 5000A and its implementing regulations.(IRC) Section 5000A and its implementing regulations. ~~Most types of comprehensive coverage~~
~~are considered MEC, including public coverage (e.g., Medicaid, Medicare), as well as private insurance (e.g.,~~
~~employer-sponsored insurance and non-group insurance). For other types of coverage losses t hat can trigger an~~
~~exchange special enrollment period (SEP), see 45 C.F.R. §155.420. Also see 45 C.F.R. §147.104 regarding SEPs~~
~~applicable to the individual and group markets overall.~~
~~Congressional Research Service~~

9

~~Overview of Health Insurance Exchanges~~

48 While exchange plan enrollees may voluntarily terminate their coverage at any time during the plan year, this would not necessarily trigger an SEP through which someone could select a new plan. 49 45 C.F.R. §155.420(d)(2). 50 There is no federal SEP specifically for pregnant individuals, but there are pregnancy-related SEPs in at least eight SBEs: Colorado (as of 2024), Connecticut, Maine, Maryland, New Jersey, New York, Vermont, and Washington, DC. In addition, see 45 C.F.R. §155.420(d)(1)(iii), which specifies that the loss of certain other pregnancy-related coverage (e.g., via Medicaid) would trigger a federal exchange SEP. Congressional Research Service 10 Overview of Health Insurance Exchanges  Becoming newly eligible for exchange coverage (e.g., by becoming a U.S. citizen or leaving incarceration), and/or having a change in income that affects eligibility for federal subsidies for coverage.51  Change in residence, such as moving to a new state (or new ZIP code or county within a state), including moves for school or seasonal work.52  Certain other situations, including errors or misrepresentations made by exchanges and/or plans,53 and other exceptional or complex circumstances.54 HHS also may choose to offer SEPs or extend an OEP for some or all consumers due to broadly applicable circumstancesconsumers due to broadly applicable circumstances~~.38 Subject to statutory requirements, HHS~~
~~may make changes to SEPs.39~~
~~Federal SEPs apply to FFEs, SBE-FPs and general y to SBEs, but SBEs have flexibility regarding~~
~~implementation of some SEPs.~~, or otherwise make SEP changes (subject to statutory requirements).55 For example, due in part to the COVID-19 pandemic, HHS created an SEP to allow all exchange-eligible consumers to newly enroll or update their enrollment in an exchange plan from February 15, 2021, to August 15, 2021.56 In addition, for the duration of the COVID-19 emergency declared by the Federal Emergency Management Agency (FEMA), if someone otherwise qualifies for another SEP, but misses their SEP enrollment deadline (generally a 60 day period) due to the impacts of COVID-19, they might still qualify to enroll.57 Federal SEPs apply to FFEs, SBE-FPs, and generally to SBEs. However, SBEs have flexibility regarding implementation of some SEPs.58 SBEs also may create their own SEPs, subject to applicable SBEs also may create their own SEPs, subject to applicable
federal and state laws. federal and state laws. ~~Federal~~ SEPs for the individual exchanges may or may not apply to the SEPs for the individual exchanges may or may not apply to the
federal SHOP exchanges and/or to the federal SHOP exchanges and/or to the ~~individual~~nongroup market outside the exchanges. market outside the exchanges.4059
Eligibility Eligibility for Medicaid or CHIP may be determined at any point during the calendar year and has for Medicaid or CHIP may be determined at any point during the calendar year and has
~~no connection to an applicant’s state’s exchange OEP.~~
~~Special Enrollment Periods and COVID-19~~
~~COVID-19 pandemic and related economic recession, there have been questions about SEPs to~~
~~al ow consumers to enroll in coverage via the exchanges.~~
~~In response to COVID-19, most SBEs created SEPs to al ow individuals to purchase coverage.~~
~~These SEPs general y were open in spring 2020, with varied timing and durations. Some were~~
~~extended one or more times. In general, these SEPs were available to any uninsured individuals~~
~~eligible for exchange coverage.41~~
~~In 2020, HHS did not announce a COVID-related federal SEP for al uninsured individuals to~~
~~enroll in coverage in FFEs and SBE-FPs. However, an existing SEP al ows individuals to enroll if~~
~~they lose their job-based coverage or other qualifying coverage. A June 2020 Centers for~~
~~Medicare & Medicaid Services (CMS) report on exchange enrollment during the pandemic~~
~~further stated that “any consumers who qualified for a SEP but missed the deadline as a result of~~
~~the COVID-19 pandemic—for example, if they were sick with COVID-19 or were caring for~~
~~someone who was sick with COVID-19—may also be eligible for another SEP.”42 This is similar~~
~~to federal SEPs announced in relation to prior disasters. In addition, at least as of the second half~~
~~of 2020, the federal exchange website HealthCare.gov indicated that losing qualifying coverage~~
~~since the start of 2020 could qualify someone for an SEP, as opposed to the standard eligibility~~
~~criterion of losing qualifying coverage in the prior 60 days.43~~

~~38 For example, in 2014, the Department of Health and Human Services (HHS) established an SEP due to technical~~
~~problems submitting insurance applications through the federal information technology platform (i.e., HealthCare.gov).~~
~~In 2015, HHS established an SEP around tax season for individuals who had not enrolled in 2015 cov erage and were~~
~~subject to the 2014 individual mandate penalty. For 2018 coverage, HHS established an SEP for consumers in states~~
~~that were affected by the 2017 hurricanes or other severe weather events. See, for example, HHS, HealthCare.gov,~~
~~“Special Enrollment Periods for Complex Issues,” at https://www.healthcare.gov/sep-list/.~~
~~39 Statutory requirements for exchange SEPs are at 42 U.S.C. §18031(c)(6). Multiple examples and discussion of~~
~~administrative changes made to SEPs are in the HHS final rule, “ Patient Protection and Affordable Care Act; Market~~
~~Stabilization,” 82 Federal Register 18346, April 18, 2017, at https://www.federalregister.gov/documents/2017/04/18/~~
~~2017-07712/patient-protection-and-affordable-care-act-market-stabilization. T he background of this rule also provides~~
~~information on prior administrative actions related to SEPs.~~
~~40 For more information about SEPs, see Section 5 of CMS, FFE and FF-SHOP Enrollment Manual.~~
~~41 T he National Association of Insurance Commissioners (NAIC) has been tracking various state-level actions related~~
~~to COVID-19 and insurance, including SEPs announced by SBEs. See NAIC, “ Coronavirus Resource Center,” “ Life~~
~~and Health” spreadsheet, at https://content.naic.org/naic_coronavirus_info.htm.~~
~~42 T his report was initially published in June 2020 and then reissued in November 2020 with corrected data. CMS,~~
~~Special Trends Report: Enrollm ent Data and Coverage Options for Consum ers During the COVID-19 Public Health~~
~~Em ergency,~~ ~~November 2020, at https://www.cms.gov/CCIIO/Resources/Forms-Reports-and-Other-Resources/~~
~~Downloads/SEP-Report -Nov-2020.pdf.~~
~~43 HealthCare.gov page on SEPs, at https://www.healthcare.gov/coverage-outside-open-enrollment/special-enrollment-~~
~~Congressional Research Service~~

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~~link to page 16 link to page 29 link to page 29~~ ~~Overview of Health Insurance Exchanges~~

~~On January 28, 2021, HHS (via CMS) announced a new COVID-19-related SEP, in effect~~
~~February 15-May 15, 2021, to al ow al exchange-eligible consumers to newly enroll or update~~
~~their enrollment in an exchange plan.44 This SEP was subsequently extended to August 15,~~
~~2021.45 This SEP is available in al states using the HealthCare.gov enrollment platform (FFEs~~
~~and SBE-FPs); states with SBEs are “strongly encouraged” by CMS to take similar action.~~
~~Per the initial announcement, CMS wil spend $50 mil ion to conduct a consumer outreach~~
~~campaign to promote the SEP. CMS later announced $2.3 mil ion in funding newly available to~~
~~existing Navigator grantees (consumer outreach entities) in FFE states, to assist with SEP~~
~~outreach and enrollment efforts.46~~
~~For information about other coverage options following loss of job-based coverage, see CRS In~~
~~Focus IF11523, Health Insurance Options Following Loss of Employment.~~
~~Enrollment Estimates~~
~~Annual individual exchange enrollment estimates to date are shown in Table 2. Given the~~
~~exchange eligibility determination process, as wel as the different time frames of OEPs and~~
~~SEPs, CMS releases data on exchange enrollment in stages. Pre-effectuated enrollment is the~~
~~number of unique individuals who have been determined eligible to enroll in an exchange plan~~
~~and have selected a plan. These individuals may or may not have submitted the first premium~~
~~payment. In general, cumulative and final pre-effectuated enrollment estimates are released~~
~~during and soon after an annual open enrollment period.~~
~~Subsequently, effectuated enrollment is the number of unique individuals who have been~~
~~determined eligible to enroll in an exchange plan, have selected a plan, and have submitted the~~
~~first premium payment for an exchange plan. Effectuated enrollment estimates general y are~~
~~point-in-time and may change over the coverage year. For example, due to changes in life~~
~~circumstances, an individual may disenroll (e.g., if later offered coverage through an employer),~~
~~or enroll (e.g., given eligibility for an SEP) in an exchange plan, outside of an OEP.~~
~~CMS also releases average effectuated enrollment estimates over specified time periods (e.g.,~~
~~over the first half of an enrollment year or monthly for the previous enrollment year). See the~~
“Enrollment Statistics” section of CRS Report R46638, Health Insurance Exchanges: Sources for
Statistics, for HHS reports and resources detailing different enrollment estimates by year.

~~period/.~~
~~44 CMS, “2021 Special Enrollment Period in response to the COVID-19 Emergency,” January 28, 2021, at~~
~~https://www.cms.gov/newsroom/fact-sheets/2021-special-enrollment -period-response-covid-19-emergency.~~
~~45 CMS, “Extended Access Opportunity to Enroll in More Affordable Coverage T hrough HealthCare.gov,” March 23,~~
~~2021, at https://www.cms.gov/newsroom/fact-sheets/extended-access-opportunity-enroll-more-affordable-coverage-~~
~~through-healthcaregov.~~
~~46 CMS, “ CMS Announces Additional Navigator Funding to Support Marketplace Special Enrollment Period,” March~~
~~1, 2021, at https://www.cms.gov/newsroom/press-releases/cms-announces-additional-navigator-funding-support -~~
~~marketplace-special-enrollment-period. For more information about the Navigators, see~~ ~~“ Navigators and Other~~
~~Exchange-Based Enrollment Assistance”~~ ~~in this report .~~
~~Congressional Research Service~~

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~~link to page 16 link to page 16 link to page 16 link to page 12 link to page 12 link to page 7~~ ~~Overview of Health Insurance Exchanges~~

~~Table 2. Nationwide Individual Exchange Enrollment Estimates, by Plan Year~~

~~Plan Year~~
~~Nationwide~~
~~Enrollment~~
~~Estimate~~
~~Type~~
~~2014~~
~~2015~~
~~2016~~
~~2017~~
~~2018~~
~~2019~~
~~2020~~
~~2021~~
~~Pre-~~
~~effectuated,a~~
~~8.0M~~
~~11.7M~~
~~12.7M~~
~~12.2M~~
~~11.8M~~
~~11.4M~~
~~11.4M~~
~~12.0M~~
~~final for PY~~
~~OEP~~
~~Effectuated,~~
~~early in the~~
~~Early~~
~~2014~~
~~10.2M,~~
~~11.1M,~~
~~10.3M,~~
~~10.6M,~~
~~10.6M,~~
~~10.7M,~~
~~Data~~
~~plan year~~
~~estimate~~
~~Mar.~~
~~Mar.~~
~~Feb.~~
~~Feb.~~
~~Feb.~~
~~Feb.~~
~~expected~~
~~(point-in-time~~
~~not~~
~~2015~~
~~2016~~
~~2017~~
~~2018~~
~~2019~~
~~2020~~
~~summer~~
~~as of date~~
~~found~~
~~2021~~
~~shown)b~~
~~Effectuated,~~
~~late in the plan~~
~~year (point-in-~~
~~6.3M,~~
~~8.8M,~~
~~9.1M,~~
~~8.9M,~~
~~9.2M,~~
~~9.1M,~~
~~Data~~
~~Data~~
~~time or~~
~~Dec.~~
~~Dec.~~
~~Dec.~~
~~Dec.~~
~~Dec.~~
~~Dec.~~
~~expected~~
~~expected~~
~~average for~~
~~2014~~
~~2015~~
~~2016~~
~~2017~~
~~2018~~
~~2019~~
~~summer~~
~~summer~~
~~month~~
~~2021~~
~~2022~~
~~shown)c~~
Source: CRS analysis based on Department of Health and Human Services (HHS) reports of individual exchange
~~enrol ment. Data sources are in CRS Report R46638, Health Insurance Exchanges: Sources for Statistics, in report~~
~~sections specified in table notes below.~~
Notes: FFE = federal y facilitated exchange; OEP = open enrol ment period; PY = plan year; SBE = state-based
~~exchange; SBE-FP = state-based exchange using the federal information technology platform. See~~ ~~“Open and~~
no connection to an applicant’s state’s exchange OEP. 51 45 C.F.R. §155.420(d)(3, 6). 52 45 C.F.R. §155.420(d)(7). Note, per HealthCare.gov, that “moving only for medical treatment or staying somewhere for vacation doesn’t qualify you for a Special Enrollment Period.” 53 45 C.F.R. §155.420(d)(4, 5, 12). 54 45 C.F.R. §155.420(d)(8-15). These include SEPs related to gaining or maintaining status as an Indian, being a victim of domestic abuse or spousal abandonment, having access to an Individual Coverage Health Reimbursement Account (ICHRA) or being enrolled in COBRA continuation coverage, and more. 55 Statutory requirements for exchange SEPs are at 42 U.S.C. §18031(c)(6), and Secretarial authority to establish standards for the exchanges is at 42 U.S.C. §18041(a). Also see 45 C.F.R. §155.420(d)(9) regarding SEPs for “exceptional circumstances.” Examples of certain administrative changes made to SEPs are in the HHS final rule, “Patient Protection and Affordable Care Act; Market Stabilization,” 82 Federal Register 18346, April 18, 2017, at https://www.federalregister.gov/documents/2017/04/18/2017-07712/patient-protection-and-affordable-care-act-market-stabilization. 56 This SEP was initially set to end May 15, 2021, and was later extended to August 15, 2021. See CMS, “2021 Special Enrollment Period in response to the COVID-19 Emergency,” January 28, 2021, at https://www.cms.gov/newsroom/fact-sheets/2021-special-enrollment-period-response-covid-19-emergency, and CMS, “Extended Access Opportunity to Enroll in More Affordable Coverage Through HealthCare.gov,” March 23, 2021, at https://www.cms.gov/newsroom/fact-sheets/extended-access-opportunity-enroll-more-affordable-coverage-through-healthcaregov. 57 Regarding this enrollment flexibility, see HealthCare.gov at https://www.healthcare.gov/coverage-outside-open-enrollment/special-enrollment-period/. Regarding the COVID-19 emergency declared by FEMA (which, as of February 2023 is set to end on May 11, 2023), see CRS Insight IN12088, Effects of Terminating the Coronavirus Disease 2019 (COVID-19) PHE and NEA Declarations. 58 For example, the COVID-19 SEP, described above, was available in all FFEs and SBE-FPs. States with SBEs were “strongly encouraged” by CMS to take similar action, and all SBEs (15 in PY2021) did so. See page 19 of HHS, 2021 FINAL MARKETPLACE SPECIAL ENROLLMENT PERIOD REPORT, September 15, 2021, at https://www.hhs.gov/sites/default/files/2021-sep-final-enrollment-report.pdf. 59 For more information about SEPs, see Section 6 of CMS, FFE and FF-SHOP Enrollment Manual (2022). Congressional Research Service 11 link to page 18 link to page 18 Overview of Health Insurance Exchanges Monthly SEP for Certain Low-Income Populations As discussed later in this report, consumers may be eligible (based on income and other criteria) to receive premium tax credits (PTCs) that reduce the cost of buying certain health plans offered through the exchanges. In 2021, the American Rescue Plan Act (ARPA; P.L. 117-2) temporarily enhanced eligibility for and the amount of these PTCs. In August 2022, P.L. 117-169, which is commonly known as the Inflation Reduction Act of 2022 (IRA), extended these PTC enhancements through tax year 2025. Separately, a new federal SEP was created through rulemaking in September 2021, effective as of PY2022.60 This is a monthly SEP for consumers who are eligible for the PTC and have expected household incomes up to 150% of the federal poverty level (FPL). Specifically, such individuals may newly enroll or switch plans once a month during periods of time when they would qualify for a $0 premium on a benchmark plan due to the PTC. In the preamble of the rule finalizing this SEP, HHS stated that the SEP eligibility criteria are based on the ARPA enhancements to the PTC. Although this SEP was not required by ARPA and is not exclusive to ARPA, it is effective only during times when PTC enhancements are available, such as those in ARPA and now in the IRA. In other words, the IRA’s extension of the PTC enhancements has also effectively extended this SEP. Consumers eligible for this SEP have certain enrollment options depending on their current enrollment status. For example, current exchange plan enrollees who become eligible under this SEP are only able to change to a silver-level plan, but new enrollees may select any metal-level plan. These options may be more limited than the enrollment options related to other SEPs.61 The enrollment options and adverse selection concerns are also summarized in a Health Affairs article on the final rule.62 This SEP is available in all FFE and SBE-FP states. It is optional for SBEs and at least nine SBEs have implemented it. Insurers are not required to offer this SEP outside of the exchanges.63 HHS also clarified in the final rule that this new SEP and its related enrollment options do not change eligibility for, or enrollment options for, any other exchange SEP. SEP Related to the Unwinding of Medicaid Continuous Enrollment In January 2023, CMS announced a new SEP for eligible consumers who lose Medicaid or CHIP coverage due to the end of these programs’ continuous enrollment conditions, which have been in place during the COVID-19 pandemic. For consumers using HealthCare.gov, this SEP is to be available if they apply for coverage or update their applications between March 31, 2023, and July 31, 2024, and attest to an end of Medicaid or CHIP coverage during that period. This SEP is available in all FFE and SBE-FP states. It is optional for SBEs.64 60 45 C.F.R. §155.420(d)(16), as added by the 2022 Payment Notice, “Part 3,” starting at page 53432. The discussion of the effective date starts on page 53438. 61 See 45 C.F.R. §155.420(a)(3-4) for enrollment options (e.g., for enrollees and/or their dependents, and for different metal level plans) for different SEPs. Plan metal levels are explained in “Cost Sharing, Maximum Out-of-Pocket Limits, and Actuarial Value Levels” in this report. 62 Katie Keith, “Biden Administration Finalizes First Marketplace Rule, Including New Low-Income Special Enrollment Period,” Health Affairs Forefront, September 20, 2021, at https://www.healthaffairs.org/do/10.1377/forefront.20210919.154415/. 63 45 C.F.R. §147.104(b)(2)(i)(G), as added by the 2022 Payment Notice, “Part 3.” 64 For further details, including regarding consumers who may be eligible for more than one SEP, see CMS, Temporary Congressional Research Service 12 link to page 17 link to page 18 link to page 18 link to page 18 Overview of Health Insurance Exchanges Enrollment Estimates Annual individual exchange enrollment estimates to date are shown i n Table 1. Given the exchange eligibility determination process, as well as the different time frames of OEPs and SEPs, CMS releases data on exchange enrollment in stages. Pre-effectuated enrollment is the number of unique individuals who have been determined eligible to enroll in an exchange plan and have selected a plan. These individuals may or may not have submitted the first premium payment. In general, cumulative and final pre-effectuated enrollment estimates are released during, and soon after, an annual open enrollment period. As of the date of this report, CMS has released a 2023 OEP “Final National Snapshot,” estimating that 16.3 million consumers signed up for a plan in the individual exchanges nationwide, between November 1, 2022, and January 15, 2023.65 Additional pre-effectuated enrollment data will likely be released in spring 2023. Subsequently, effectuated enrollment is the number of unique individuals who have been determined eligible to enroll in an exchange plan, have selected a plan, and have submitted the first premium payment for an exchange plan. Effectuated enrollment estimates generally are point-in-time and may change over the coverage year. For example, due to changes in life circumstances, an individual may disenroll (e.g., if later offered coverage through an employer), or enroll (e.g., given eligibility for an SEP) in an exchange plan, outside of an OEP. CMS also releases average effectuated enrollment estimates over specified time periods (e.g., over the first half of an enrollment year or monthly for the previous enrollment year). See the “Enrollment Statistics” section of CRS Report R46638, Health Insurance Exchanges: Sources for Statistics, for HHS reports and resources detailing different enrollment estimates by year. Table 1. Nationwide Individual Exchange Enrollment Estimates, by Plan Year (in millions) 2014 2015 2016 2017 2018 2019 2020 2021 2022 Pre-effectuated (final for PY 8.0 11.7 12.7 12.2 11.8 11.4 11.4 12.0 14.5 OEP)a Effectuated, Early early in PY 2014 10.2, 11.1, 10.3, 10.6, 10.6, 10.7, 11.3, 13.8, (point-in-time estimate Mar. Mar. Feb. Feb. Feb. Feb. Feb. Feb. as of date not 2015 2016 2017 2018 2019 2020 2021 2022 shown)b found Dec. Effectuated, 2022 late in PY 6.3, 8.8, 9.1, 8.9, 9.2, 9.1, 9.9, 12.2, data (point-in-time Dec. Dec. Dec. Dec. Dec. Dec. Dec. Dec. expected or average for 2014 2015 2016 2017 2018 2019 2020 2021 summer month shown)c 2023 Source: CRS analysis of Department of Health and Human Services (HHS) reports of individual exchange enrol ment. Data sources are in CRS Report R46638, Health Insurance Exchanges: Sources for Statistics, in report sections specified in table notes below. Special Enrollment Period (SEP) for Consumers Losing Medicaid or the Children’s Health Insurance Program (CHIP) Coverage Due to Unwinding of the Medicaid Continuous Enrollment Condition– Frequently Asked Questions (FAQ), January 27, 2023, at https://www.cms.gov/technical-assistance-resources/temp-sep-unwinding-faq.pdf. 65 CMS, Marketplace 2023 Open Enrollment Period Report: Final National Snapshot, January 25, 2023, at https://www.cms.gov/newsroom/fact-sheets/marketplace-2023-open-enrollment-period-report-final-national-snapshot. Congressional Research Service 13 link to page 13 link to page 22 link to page 9 link to page 20 Overview of Health Insurance Exchanges Notes: OEP = open enrol ment period; PY = plan year. In the individual exchanges, a plan year is generally the calendar year. See “Open and Special Enrol ment Periods” in this report for more information. a. Pre-effectuated enrollment ~~Special Enrol ment Periods”~~ ~~and “State-Based and Federal y Facilitated Exchanges” in this report.~~
a. Pre-effectuated enrol ment is the number of unique individuals who have been determinedis the number of unique individuals who have been determined ~~eligible~~ eligible to enrolto enrol in in
an exchange plan and have selected a plan but may or may not have submitted the first premium an exchange plan and have selected a plan but may or may not have submitted the first premium payment. payment.
Final pre-effectuated enrol mentFinal pre-effectuated enrol ment ~~estimates typical y~~ estimates typically are released are released fol owing an OEP and include any broadly fol owing an OEP and include any broadly
applicable OEP extensions or longer applicable OEP extensions or longer ~~SBE OEPs.~~ state-based exchange (SBE) OEPs. For these data sourcesFor these data sources by year,by year, see the “Pre-effectuated see the “Pre-effectuated
Enrol ment Data” section of the report mentioned above. ForEnrol ment Data” section of the report mentioned above. For example, the 2021 estimate is from CMS, example, the 2021 estimate is from CMS,
Health Insurance Exchanges 2021 Open ~~Enrol ment~~Enrollment Report,, ~~April~~ April 2021. 2021.
b. b. Effectuated ~~enrol ment~~ enrollment is the number of unique individuals who have been determinedis the number of unique individuals who have been determined ~~eligible~~ eligible to enrolto enrol in an in an
exchange plan, have selected exchange plan, have selected a plan, and have submitted the first premiuma plan, and have submitted the first premium payment for an payment for an ~~ex change~~exchange plan. plan.
HHS HHS ~~general y releases~~ generally releases effectuated enrol menteffectuated enrol ment ~~estimates~~ estimates for a point in time earlyfor a point in time early in the plan year and may in the plan year and may
releaserelease additional point-in-time estimatesadditional point-in-time estimates during the year. Data sources by year are in the “Point-in-Time during the year. Data sources by year are in the “Point-in-Time
Effectuated Enrol ment Data” section of the report mentioned above. For example,Effectuated Enrol ment Data” section of the report mentioned above. For example, the 2020 estimate is the 2020 estimate is
from CMS, from CMS, Early 2020 Effectuated ~~Enrol ment~~ Enrollment Snapshot, July 2020.July 2020.
c. See table note (b) regarding effectuated enrol ment c. See table note (b) regarding effectuated enrol ment and point-in-time estimates.and point-in-time estimates. AverageAverage estimatesestimates reflect reflect
an average over a specified an average over a specified time period, in this case one month. For PY2014 and PY2015, quarterly pointtime period, in this case one month. For PY2014 and PY2015, quarterly point -in--in-
time estimatestime estimates ~~were~~ were released,released, including those shown. Averageincluding those shown. Average monthly enrol mentmonthly enrol ment data weredata were not provided not provided
for those years.for those years. For PYs 2016 and on, average monthly enrol mentFor PYs 2016 and on, average monthly enrol ment data are provided. Although point-in-data are provided. Although point-in-
time and average monthly estimatestime and average monthly estimates are not the same,are not the same, they are provided here to show late-year enrol ment they are provided here to show late-year enrol ment
estimatesestimates across across al all plan years. Data sources by year are in the “Point-in-Time Effectuated Enrol ment Data” plan years. Data sources by year are in the “Point-in-Time Effectuated Enrol ment Data”
and “Average Monthly Effectuated Enrolment Data” sectionsand “Average Monthly Effectuated Enrolment Data” sections of the report mentioned aboveof the report mentioned above~~. For example,~~
(e.g., the 2018 estimate is from the end of the report CMS,the 2018 estimate is from the end of the report CMS, Early 2019 Effectuated ~~Enrol ment~~ Enrollment Snapshot, August 2019). Premiums, Cost Sharing, and Subsidies Typically~~August~~
~~2019.~~
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~~Premiums and Cost Sharing~~
~~Typical y~~, enrollees of private health insurance plans (in or out of the exchanges) pay , enrollees of private health insurance plans (in or out of the exchanges) pay ~~monthly~~
~~premiums~~premiums to obtain coverage. They also are . They also are ~~general y~~generally responsible for out-of-pocket (OOP) costs, or cost responsible for out-of-pocket (OOP) costs, or cost ~~sharing~~sharing, as , as
~~they use services. In general, cost sharing includes deductibles, coinsurance, and co-payments, up~~
~~to an annual maximum amount of OOP spending.47~~they use benefits. Premiums
Premiums are set by Premiums are set by ~~health insurance issuers~~insurers and are based on their expected medical claims costs and are based on their expected medical claims costs
(i.e., the payments they expect to make(i.e., the payments they expect to make to health care providers for covered health benefits for a given group of enrollees for covered health benefits for a given group of enrollees,
~~or a given risk pool~~), administrative expenses, taxes, fees, and profit. The premium-setting ), administrative expenses, taxes, fees, and profit. The premium-setting
process is subject to federal and state requirements, as applicable to plans both in and out of the process is subject to federal and state requirements, as applicable to plans both in and out of the
exchanges. For example, insurers cannot vary premiums based on health status.exchanges. For example, insurers cannot vary premiums based on health status.4866 In addition, In addition,
insurers that want to offer plans in the exchanges must submit their proposed premiums for insurers that want to offer plans in the exchanges must submit their proposed premiums for
federal or state approval (depending on exchange type) each year.federal or state approval (depending on exchange type) each year.4967 If consumers do not pay their If consumers do not pay their
premiums, insurers may terminate their coverage, subject to applicable federal and state premiums, insurers may terminate their coverage, subject to applicable federal and state
~~requirements.50~~
~~In addition to setting premiums, insurers set cost-sharing levels, or the share of the costs of~~
~~covered benefits (or medical claims) for which the insurer and enrollee wil be responsible. Most~~
~~health plans sold through the exchanges (and non-grandfathered plans sold in the individual and~~
~~smal -group markets off-exchange51) are subject to~~ ~~minimum~~ requirements.68 Data on exchange premiums are in Table 3 at the end of this section. Cost Sharing, Maximum Out-of-Pocket Limits, and Actuarial Value Levels As enrollees receive benefits covered by the plan, the costs for the benefits are paid by the enrollee and/or the plan, depending on the plan’s terms. In general, enrollee cost sharing includes 66 See CRS Report R45146, Federal Requirements on Private Health Insurance Plans for more information about this and other requirements related to setting premiums. 67 See “Exchange Administration” in this report. 68 See 45 C.F.R. §156.270 regarding insurer termination of enrollee coverage, including for nonpayment of premiums. It also addresses the “grace period” of three consecutive months of premium nonpayment for enrollees who receive a premium tax credit (discussed in the “Premium Tax Credits and Cost-Sharing Reductions” section of this report). Congressional Research Service 14 link to page 20 link to page 40 link to page 11 Overview of Health Insurance Exchanges deductibles, coinsurance, and co-payments, up to an annual limit on consumer out-of-pocket (OOP) spending.69 Federally-set maximum OOP limits apply to all health plans sold in the exchanges and to all non-grandfathered nongroup and group plans sold outside the exchanges.70 The maximum OOP limits are updated each year through HHS rulemaking and/or guidance. See Table 2 for the maximum limits that apply to most plans. QHP issuers must also offer plan variations with reduced OOP limits for consumers who qualify for cost-sharing reductions, as discussed in the next section. And as of PY2023, certain QHP issuers must also offer standardized plans as specified in rulemaking, some of which would also have lower OOP limits than shown in Table 2.71 Plans may set their OOP limits lower than the applicable maximums. Most health plans sold through the exchanges (and non-grandfathered plans sold in the nongroup and small-group markets off-exchange72) must provide coverage in compliance with one of four levels of actuarial value (AV), which correspond to a precious metal designation.73 AV is an estimate of the “percentage of total average costs for covered benefits” to be paid by a plan.74 The four AV levels are 90% for platinum, 80% for gold, 70% for silver, and 60% for bronze.75 Given that plans and enrollees collectively pay total costs, AV is the plan counterpart to enrollee cost-sharing expenses ~~(AV) standards~~ ~~and~~
~~accordingly, are given a precious metal designation (platinum, gold, silver, or bronze).52 AV is a~~
~~summary measure of a plan’s generosity in terms of cost sharing, estimated for a standard~~
~~population.53 Actuarial values by metal level are platinum (AV of 90%), gold (80%), silver (70%),~~
~~and bronze (60%). For example, for a silver plan, the insurer expects to cover approximately 70%~~
~~of cost sharing for the plan’s enrollees overal . The higher the AV percentage, the lower the cost~~
~~sharing, on average, for the plan population. However, plans with higher AV also may have~~
~~higher premiums, on average, to cover their increased share of their enrollees’ medical claims~~

~~47 A deductible is the amount an insured consumer pays for covered health care services before coverage begins (with~~
~~exceptions). Coinsurance is the share of costs, figured in percentage form, an insured consumer pays for a covered~~
~~health service. A co-paym ent is the fixed dollar amount an insured consumer pays for a covered health service. Once an~~
~~insured consumer’s out-of-pocket spending has met an out-of-pocket limit or maximum in a plan year, the insurer will~~
~~generally pay 100% of covered costs for the remainder of the plan year.~~
~~48 See CRS Report R45146, Federal Requirements on Private Health Insurance Plans, for more information about this~~
~~and other requirements related to setting premiums.~~
~~49 See “Exchange Administration” in this report.~~
~~50 See 45 C.F.R. §156.270 regarding insurer termination of enrollee coverage, including for nonpayment of premiums.~~
~~It also addresses the “grace period” of three consecutive months of premium nonpayment for enrollees who receive a~~
~~premium tax credit (discussed in the “ Premium T ax Credits and Cost -Sharing Reductions” section of this report ).~~
51 Grandfathered plans ~~are individual or group plans in which at least one individual was~~ . The higher the AV percentage, the lower the cost sharing, on average. For example, a silver plan expects to cover approximately 70% of total costs for covered benefits. Because enrollees’ use of such benefits vary, a given silver plan enrollee’s actual cost sharing may be more or less than 30% of costs associated with receipt of covered benefits. AV is not a measure of plan generosity for an enrolled individual or family, nor is it a measure of premiums or benefits packages. With the exception of “catastrophic” plans and stand-alone dental plans (see Table B-1), plans sold in the exchanges must have at least 60% AV. An insurer selling plans in an exchange must offer at least a silver and gold plan throughout each service area in which it offers coverage.76 69 In general, beginning with each plan year, an enrollee pays 100% of the costs of their covered benefits until they meet a threshold amount called a deductible. Exceptions apply. After that, the enrollee pays coinsurance (a percentage amount) or co-payments (a flat amount) for covered benefits, and the plan pays the rest. If an enrollee’s spending meets an annual OOP limit, the plan will generally pay 100% of covered costs for the remainder of the plan year. 70 45 C.F.R. §156.130(a). The annual out-of-pocket limit is generally only required to apply to the plan’s covered EHB that are furnished by an in-network provider, unless otherwise addressed in federal or state law. See CRS Report R45146, Federal Requirements on Private Health Insurance Plans for more information, including about self-only and other-than-self-only coverage, as shown in the table. 71 See the “Standardized Plans” section of this report. 72 Grandfathered plans are individual or group plans in which at least one individual was enrolled as of enactment of enrolled as of enactment of
the ACA (March 23, 2010) and which continue to meet certain criteria. Plans that maintain their grandfathered status the ACA (March 23, 2010) and which continue to meet certain criteria. Plans that maintain their grandfathered status
are exempt from some, but not all, federal requirements. are exempt from some, but not all, federal requirements. ~~T here~~There are no grandfathered plans sold through the exchanges, are no grandfathered plans sold through the exchanges,
but they may be available off the exchanges. For more information, see CRSbut they may be available off the exchanges. For more information, see CRS Report R46003, Report R46003, Applicability of Federal
~~Requirem ents~~Requirements to Selected Health Coverage ~~Arrangem ents~~Arrangements, as well, as well as HHS,as HHS, “ “Grandfathered Health Insurance Grandfathered Health Insurance ~~P lans~~Plans,” at ,” at
https://www.healthcare.gov/health-care-law-protections/grandfathered-plans/. https://www.healthcare.gov/health-care-law-protections/grandfathered-plans/.
52 73 42 U.S.C. 42 U.S.C. ~~§18022(d).~~
~~53 Actuarial value (AV) is expressed as the percentage of medical expenses estimated to be paid by the insurer for a~~
~~standard population and set of allowed charges. It is not a measure of plan generosity for an enrolled individual or~~
~~family, nor is it a measure of premiums or benefits packages. AV calculations are required to apply only to the plan’s~~
~~covered essential health benefits (EHB) that are furnished by an in-network provider, unless otherwise addressed in~~
~~federal or state law.~~
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~~costs (assuming other factors affecting premiums remain the same, such as administrative~~
~~expenses). The AV standards, and the related metal levels, are meant, in part, to help consumers in~~
~~comparing the value of plans.~~
~~With the exception of “catastrophic” plans and stand-alone dental plans (see Table B-1), plans~~
~~must have at least 60% AV to be sold in the exchanges. Insurers sel ing a given plan in an~~
~~exchange must offer at least a silver and gold version of the plan throughout each service area in~~
~~which the insurers offer coverage.54~~
~~Annual OOP limits also apply to al health plans sold in the exchanges (and to al non-~~
~~grandfathered individual and group plans sold outside the exchanges).55 These limits are updated~~
~~each year through HHS rulemaking (see Table 3). Plans may set their OOP limits lower than~~
~~these maximums.~~
~~Additional data on premiums and cost sharing are in Table 4 at the end of the following section.~~
~~Table 3. Annual Out-of-Pocket Limits, by Plan Year~~
~~(Federal y set maximums; insurers may set lower out-of-pocket limits)~~
~~Plan Year~~

~~2014~~
~~2015~~
~~2016~~
~~2017~~
~~2018~~
~~2019~~
~~2020~~
~~2021~~
~~Self-only coverage~~
~~$6,350~~
~~$6,600~~
~~$6,850~~
~~$7,150~~
~~$7,350~~
~~$7,900~~
~~$8,150~~
~~$8,550~~
~~Coverage other~~
~~$12,700~~
~~$13,200~~
~~$13,700~~
~~$14,300~~
~~$14,700~~
~~$15,800~~
~~$16,300~~
~~$17,100~~
~~than self-only~~
~~Percentage increase~~
~~N/A~~
4%
4%
4%
3%
7%
3%
5%
~~over prior year~~
~~Source:~~ ~~CRS analysis of relevant federal rulemaking. These amounts are~~ §18022(d). 74 See the definition of actuarial value in the glossary posted on HealthCare.gov at https://www.healthcare.gov/glossary/actuarial-value/. AV calculations include only costs associated with a plan’s covered EHB that are furnished by in-network providers, unless otherwise addressed in federal or state law. 75 Regulations allow plans to fall within a specified AV range and still comply with one of the four levels; see 45 C.F.R. §156.140(c)(2). 76 45 C.F.R. §156.200(c)(1). Congressional Research Service 15 link to page 20 link to page 20 link to page 45 link to page 11 link to page 20 Overview of Health Insurance Exchanges Table 2. Maximum Annual Limitations on Cost Sharing, by Plan Year (federally set maximums; insurers may set lower out-of-pocket limits) 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 Self-Only $6,350 $6,600 $6,850 $7,150 $7,350 $7,900 $8,150 $8,550 $8,700 $9,100 Coveragea Coverage $12,700 $13,200 $13,700 $14,300 $14,700 $15,800 $16,300 $17,100 $17,400 $18,200 Other Than Self-Onlya Percentage N/A 3.9% 3.8% 4.4% 2.8% 7.5% 3.2% 4.9% 1.8% 4.6% Increase over Prior Year Source: CRS analysis of relevant federal rulemaking regarding 45 C.F.R. §156.130(a)(2). These amounts have generally been updated each year through an HHS rule called ~~updated each year through an HHS rule~~
~~cal ed~~ the Notice of Benefit and Payment Parameters, the Notice of Benefit and Payment Parameters, also known as the Payment Notice. Starting with PY2023, these OOP limits and certain other payment parameters wil be published in guidance instead of future Payment Notices. For PY2023 amounts, see CMS, Premium Adjustment Percentage, Maximum Annual Limitation on Cost Sharing, Reduced Maximum Annual Limitation on Cost Sharing, and Required Contribution Percentage for the 2023 Benefit Year, December 28, 2021, at https://www.cms.gov/files/document/2023-papi-parameters-guidance-v4-final-12-27-21-508.pdf. This is also referenced in the 2023 Payment Notice, page 27305~~also known as the Payment Notice. For example, the~~
~~PY2021 rates were finalized in the 2021 Payment Notice, p. 29229. PY2022 OOP limits are not set, as of the~~
~~date of this report. Unlike in past years, HHS published a partial final Payment Notice for PY2022 in which HHS~~
~~stated its intention to publish the remainder, including the PY2022 OOP limits, at a later date~~. Annual Payment . Annual Payment
Notices are cited inNotices are cited in Table D-1.
Notes: PY = plan year. Out-of-pocket (OOP) limits are related to an insured consumer’s cost sharing, or OOP
~~spending~~ Notes: Once an enrol ee’s cost sharing (including deductibles, coinsurance, and co-payments (including deductibles, coinsurance, and co-payments~~; see “Premiums and Cost Sharing” in this report~~
~~for more information). Once this OOP spending meets~~ ) meet the plan’s OOP limitthe plan’s OOP limit ~~or maximum~~ in a plan year, the in a plan year, the
insurer insurer ~~general y wil~~ generally wil pay 100% of covered costs for the remainderpay 100% of covered costs for the remainder of the plan year. This table shows federally-set OOP limits that apply to most plans, but some plan variations must have lower OOP limits. See “Standardized Plans” and “Premium Tax Credits and Cost-Sharing Reductions” in this report. Plans may also set their OOP limits lower than the applicable maximums. a. If a consumer is solely enrol ed in a plan, the self-only limit applies. If a consumer and one or more dependents are enrol ed in a plan, both the self-only and the other than self-only limits may apply. See “Maximum Annual Limitation on Cost-Sharing” in CRS Report R45146, Federal Requirements on Private Health Insurance Plans for further information~~of the plan year. An individual enrol ed in a~~
~~plan by themselves has self-only coverage. An individual enrol ed in a plan with a spouse and/or dependents has~~
~~coverage other than self-only, or family coverage~~. .
Premium Tax Credits and Cost-Sharing Reductions
Consumers purchasing coverage through the individual exchanges may be eligible Consumers purchasing coverage through the individual exchanges may be eligible to receive to receive
financial assistance that effectively reduces their cost of that coverage. Eligibility for such financial assistance that effectively reduces their cost of that coverage. Eligibility for such
assistance is based primarily on incomeassistance is based primarily on income, and assistance is ~~and~~ provided in the form of premium tax credits (PTCs) provided in the form of premium tax credits (PTCs)
and cost-sharing reductions (CSRs).and cost-sharing reductions (CSRs).56

~~54 45 C.F.R. §156.200(c)(1).~~
~~55 Like AV calculations, the annual out -of-pocket limit is only required to apply to the plan’s covered EHB that are~~
~~furnished by an in-network provider, unless otherwise addressed in federal or state law.~~
~~56 For more information about these forms of consumer financial assistance, including applicable eligibility criteria and~~
~~illustrative examples, see CRS Report R44425, Health Insurance Prem ium Tax Credit and Cost-Sharing Reductions.~~
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~~The PTC general y is available~~ 77 As temporarily enhanced (see text box), the PTC generally is available to consumers with household incomes to consumers with household incomes ~~between 100% and 400%~~
above 100% of the federal poverty level (FPL)of the federal poverty level (FPL)~~, with some exceptions,~~ and who do not have access to public and who do not have access to public
coverage (e.g., Medicaid) or employment-based coverage that meets certain standards. coverage (e.g., Medicaid) or employment-based coverage that meets certain standards. Some exceptions apply. The credit The credit
is designed to reduce an eligibleis designed to reduce an eligible individual’s cost of purchasing health insurance coverage individual’s cost of purchasing health insurance coverage
through the exchange. The amount of the PTC is based on a statutory formula and varies from through the exchange. The amount of the PTC is based on a statutory formula and varies from
person to person. It is designed to provide larger credit amounts to individuals with lower person to person. It is designed to provide larger credit amounts to individuals with lower
incomes compared to those with higher incomes. Although the amount of the PTC is based on the incomes compared to those with higher incomes. Although the amount of the PTC is based on the
second-lowest-cost silver plan second-lowest-cost silver plan (SLCSP) in a consumer’s local area, consumers may apply the credit to any in a consumer’s local area, consumers may apply the credit to any
bronze- or higher-metal level plan availablebronze- or higher-metal level plan available to them on to them on their state’s exchange. 77 For more information about these forms of consumer financial assistance, including applicable eligibility criteria and illustrative examples, see CRS Report R44425, Health Insurance Premium Tax Credit and Cost-Sharing Reductions. Congressional Research Service 16 link to page 16 link to page 16 link to page 22 link to page 22 Overview of Health Insurance Exchanges ~~their state’s exchange.~~
Individuals who receive PTCs also may be eligible Individuals who receive PTCs also may be eligible for subsidies that reduce cost-sharing for subsidies that reduce cost-sharing
expenses.expenses.5778 These cost-sharing reductions (CSRs) are applied in two ways. First, an insurer must These cost-sharing reductions (CSRs) are applied in two ways. First, an insurer must
reduce the annual OOP limit that otherwise would apply to an eligiblereduce the annual OOP limit that otherwise would apply to an eligible individual’s exchange plan. individual’s exchange plan.
Second, the insurer must effectively raise the Second, the insurer must effectively raise the ~~actuarial value~~AV of the eligible of the eligible individual’s plan, for individual’s plan, for
example by reducing other cost-sharing requirements example by reducing other cost-sharing requirements ~~beyond~~in addition to the lowered OOP cap. Among other the lowered OOP cap. Among other
~~eligibility~~ eligibility requirements, CSRs requirements, CSRs ~~general y~~generally are available are available to consumers who are eligible for PTCs and to consumers who are eligible for PTCs and
have incomes between 100% and 250% of the FPL. Although a PTC can be applied to any metal have incomes between 100% and 250% of the FPL. Although a PTC can be applied to any metal
level plan, CSRs are applicablelevel plan, CSRs are applicable only to silver plans. only to silver plans.
Premium Tax Credit and Cost-Sharing Reductions Under the
American Rescue Plan Act of 2021
and the Inflation Reduction Act of 2022 Several ~~Several~~ provisions of the Americanprovisions of the American Rescue Plan Act of 2021 (ARPA; P.L. 117-2) temporarily Rescue Plan Act of 2021 (ARPA; P.L. 117-2) temporarily ~~expand~~expanded eligibility eligibility for for
and the amount of the premiumand the amount of the premium tax credit (PTC) and cost-sharing reductions (CSRs) for certain individuals. For tax credit (PTC) and cost-sharing reductions (CSRs) for certain individuals. For
example,example, ~~ARPA expands eligibility for the PTC in tax years 2021 and 2022 by eliminating the phaseout for~~
~~households with annual incomes above 400% the federal poverty level. For more information about this and other~~
~~temporary changes regarding the PTC and CSRs, see~~ ARPA eliminated the eligibility phase-out for households with annual incomes above 400% of the Federal Poverty Level (FPL) and reduced the percentage of annual income used in the credit formula. The temporary formula change benefitted households with incomes between 100% and 150% of FPL the most; such individuals may have received ful subsidies to cover the premiums of certain plans. Enacted in August 2022, P.L. 117-169 (commonly known as the Inflation Reduction Act of 2022) extends the ARPA PTC enhancements – but not its CSR enhancements – through tax year 2025. For more information about these PTC changes and for discussion of ARPA’s CSR changes, see CRS Report R44425, CRS Report R44425, Health Insurance ~~Premium~~ Premium Tax Credit and
Cost-Sharing Reductions. See “Monthly SEP for Certain Low-Income Populations” in this report for discussion of a special enrol ment period related to the PTC enhancements. Premium, APTC, and CSR Data Table 3~~Reductions~~.
~~For information about another ARPA provision relevant to the exchanges, see~~ ~~“American Rescue Plan Act Grants~~
~~for Exchange Modernization”~~ ~~in this report. For information about other health provisions in ARPA, see CRS~~
~~Report R46777,~~ ~~American Rescue Plan Act of 2021 (P.L. 117-2): Private Health Insurance, Medicaid, CHIP, and Medicare~~
~~Provisions~~.
~~Table 4~~ summarizes nationwide data on premiums, advance premium tax credit (APTC) summarizes nationwide data on premiums, advance premium tax credit (APTC) 5879, and , and
CSRs by year, as availableCSRs by year, as available in relevant HHS reports on effectuated enrollment.in relevant HHS reports on effectuated enrollment.5980 The average The average
premium and APTC amounts shown in the table may obscure wide variations in actual amounts premium and APTC amounts shown in the table may obscure wide variations in actual amounts
per consumer, depending on the plan and metal level an individualper consumer, depending on the plan and metal level an individual chooses and/or the factors by chooses and/or the factors by
which an insurer is able to vary premiumswhich an insurer is able to vary premiums~~, discussed below.60 Premium and cost-sharing data on~~

~~57 T he ACA requires the HHS~~ . In addition, the APTC data in the table are not necessarily final for each year, because when an individual receiving an APTC files his or her tax return for a given year, the total amount of advance payments he or she received in that tax year is reconciled with the amount he or she should have received. Premium and cost-sharing data on all plans offered in the exchanges, as opposed to such data for plans selected, also are available, including for PY2023.81 78 The ACA requires the HHS Secretary to provide full reimbursements to insurers that provide these costSecretary to provide full reimbursements to insurers that provide these cost -sharing -sharing
subsidiessubsidies to their enrollees. However, the ACA didto their enrollees. However, the ACA did not appropriate funds for such payments. In October 2017, thenot appropriate funds for such payments. In October 2017, the
~~T rump~~ Trump Administration halted these payments, effective immediately, until Congress appropriates funds. Administration halted these payments, effective immediately, until Congress appropriates funds. ~~I nsurers~~Insurers still still
must provide the subsidiesmust provide the subsidies to eligibleto eligible consumers, butconsumers, but insurers are not reimbursed. Seeinsurers are not reimbursed. See HHS,HHS, “ “Payments to Issuers for Payments to Issuers for
Cost-Sharing Reductions,” October 12, 2017, at https://www.hhs.gov/sites/default/files/csr-paymentCost-Sharing Reductions,” October 12, 2017, at https://www.hhs.gov/sites/default/files/csr-payment -memo.pdf. -memo.pdf.
58 79 Consumers may choose to receive the credit on a monthly basis, in advance of filing taxes, to coincide with the Consumers may choose to receive the credit on a monthly basis, in advance of filing taxes, to coincide with the
payment of insurance premiums (technically, advance payments go directly to insurers). Advance payments payment of insurance premiums (technically, advance payments go directly to insurers). Advance payments
automatically reduce monthly premiums by the credit amount. automatically reduce monthly premiums by the credit amount. ~~T his~~This option is called the advance premium tax credit, or option is called the advance premium tax credit, or
~~APT C~~APTC. Consumers may instead claim the full credit amount of the . Consumers may instead claim the full credit amount of the ~~PT C~~PTC when filing their taxes, even if they have little when filing their taxes, even if they have little
or no federal income tax liability. or no federal income tax liability.
5980 In the reports cited In the reports cited inin Table 43, certain of these data are also available at the state level. In these HHS reports, and in certain of these data are also available at the state level. In these HHS reports, and in
other HHS reports (e.g., on pre-effectuated enrollment) some data may also beother HHS reports (e.g., on pre-effectuated enrollment) some data may also be available on demographics and/or metal available on demographics and/or metal
levels of plans. For more information, see CRSlevels of plans. For more information, see CRS Report R46638, Report R46638, Health Insurance Exchanges: Sources for Statistics. .
~~60 In addition, the APT C data in the table are not necessarily final, because when an individual receiving an APT C files~~ 81 For example, regarding premiums and cost sharing on plans offered in FFEs and SBE-FPs in PY2023, see CMS, CCIIO, Plan Year 2022 Qualified Health Plan Choice and Premiums in HealthCare.gov Marketplaces, October 2022,
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link to page link to page 2022 link to page link to page 2022 link to page link to page 2022 link to page link to page 2122 link to page link to page 2122 link to page link to page 2123 link to page link to page 2123 link to page link to page 2123 link to page link to page 2123 link to page link to page 2118 link to page link to page ~~21 link to page 17~~18 Overview of Health Insurance Exchanges

~~al plans offered in the exchanges, as opposed to such data for plans selected, also are available,~~
~~including for PY2021.61~~
Table 43. Data on Premiums, Advance Premium Tax Credits, and Cost-Sharing
Reductions Nationwide, by Plan Year
( (~~Data based on ef ectuated enrol ment in al~~ based on effectuated enrollment in all individual exchanges) individual exchanges)
~~Plan Year~~

~~2014a~~
~~2015b~~
~~2016b~~
~~2017c~~
~~2018d~~
~~2019e~~
~~2020f~~
~~Average total~~
~~N/A~~
~~N/A~~
~~N/A~~
~~$470.52~~
~~$597.20~~
~~$594.17~~
~~$576.16~~
~~premium per~~
~~mont~~hg 2014a 2015b 2016b 2017c 2018d 2019 2020 2021 2022 Average total premium per N/A N/A N/A $470.52 $597.20 $594.17 $576.16 $574.59 $586.56 monthe
Average APTC Average APTC
$276 $276
$272 $272
$291 $291
$373.06$373.06
$519.89$519.89
$514.01$514.01
~~$491.53~~ $491.53 $485.67 $508.26
per mont per monthhhf
Percentage of Percentage of
enrol ees 86% 86%
85% 85%
85% 85%
84% 84%
87% 87%
87% 87%
86% 86%
~~enrol ees~~
~~receiving APT~~Ci86% 90% receiving APTCg
Percentage of Percentage of
enrol ees 58% 58%
57% 57%
57% 57%
57% 57%
53% 53%
52% 52%
50% 50%
~~enrol ees~~
~~receiving CS~~Rj48% 49% receiving CSRh
Data as of Data as of
Dec. Dec. ~~2014~~
Mar. Mar. ~~2015~~
Mar. Mar. ~~2016~~
~~PY2017~~ PY
Feb. Feb. ~~2018~~ Feb.
Feb. Feb. ~~2019~~ Feb. Feb. 2014 2015 2016 2017 2018 2019 2020 2021 2022 Source
~~Feb. 2020~~
~~Sources~~: CRS analysis based on CRS analysis based on ~~specified~~ Department of Health and Human ServicesDepartment of Health and Human Services (HHS) reports of (HHS) reports of
individual exchange enrol mentindividual exchange enrol ment in privatein private health insurance planshealth insurance plans~~. Titles and publication dates of sources by year~~
~~are listed below. These sources are ful y cited in~~, as specified in table notes and cited at CRS Report R46638, CRS Report R46638, Health ~~Insurance~~ Insurance Exchanges: Sources for
Statistics, in the “Point-in-Time Effectuated Enrol ment Data” sectionin the “Point-in-Time Effectuated Enrol ment Data” section ~~of the report.~~
~~Notes:~~ ~~APTC = Advance premium tax credit; CSR = Cost-sharing reduction; PY = Plan year. These~~. These PY2022 estimates, for example, were point-in-time as of February 2022, and published in September 2022. Notes: N/A = not available. PY = plan year. APTCs (advance premium tax credits) and CSRs (cost-sharing reductions) are types of are types of
financial assistance that effectively reduce premiumsfinancial assistance that effectively reduce premiums and cost sharing, respectively,and cost sharing, respectively, ~~for eligible~~ for eligible consumers consumers
obtaining coverageobtaining coverage in the individual exchanges.in the individual exchanges.
The average premiumThe average premium and APTC amounts shown above mayand APTC amounts shown above may obscure wide variations in actual amounts per obscure wide variations in actual amounts per
consumer,consumer, depending on the metal leveldepending on the metal level plan an individual chooses and/or the factors by which an insurerplan an individual chooses and/or the factors by which an insurer is able is able
to vary premiumsto vary premiums (see (see “Premiums ~~and~~, Cost Sharing, and Subsidies” in this report). In addition, the APTC data in the table are in this report). In addition, the APTC data in the table are
not necessarilynot necessarily final, because when an individual receiving an APTC filesfinal, because when an individual receiving an APTC files his or her tax return for a given year, his or her tax return for a given year,
the total amount of advance payments he or she receivedthe total amount of advance payments he or she received in that tax year is reconciledin that tax year is reconciled with the amount he or with the amount he or
she should have received.she should have received.
a. Relevant data for PY2014 are available only as of Decembera. Relevant data for PY2014 are available only as of December 2014. These numbers are provided to 2014. These numbers are provided to ~~al ow~~allow for for
approximate comparison within the table. Average premium approximate comparison within the table. Average premium amounts wereamounts were not provided in this or the not provided in this or the
fol owing year’sfol owing year’s report. See report. See March 31, 2015 Effectuated ~~Enrol ment~~ Enrollment Snapshot, June 2015. June 2015.
b. Average premium b. Average premium amounts for PY2015 and PY2016 were not provided in those years’amounts for PY2015 and PY2016 were not provided in those years’ or the fol owing or the fol owing
years’ reports. years’ reports. See See March 31, 2015 Effectuated ~~Enrol ment~~ Enrollment Snapshot, June 2015 and June 2015 and March 31, 2016
Effectuated ~~Enrol ment~~ Enrollment Snapshot,, June 2016, respectively. c. The June 2017 report provided average APTC data but not average premium data for February 2017. However, the July 2018 report provided average monthly premium and APTC data for the 2017 plan year (total amounts for the year, divided by the total number of member months). The data in this column, from the July 2018 report, are provided to allow for approximate comparison, but they are average monthly estimates for the year rather than the average estimates for a given month as shown in this table for other years. See 2017 Effectuated Enrollment Snapshot, June 2017 and Early 2018 Effectuated Enrollment Snapshot, July 2018. d. See Early 2018 Effectuated Enrollment Snapshot, July 2018. Subsequent year data in this table are from similar subsequent year reports. ~~June 2016, respectively.~~

~~his or her tax return for a given year, the total amount of advance payments he or she received in that tax year is~~
~~reconciled with the amount he or she should have received based on the individual’s actual income over the course of~~
~~the tax year.~~
~~61 For example, an October 2020 CMS report discusses premiums and cost sharing on plans offered in HealthCare.gov~~
~~exchanges (FFEs and SBE-FPs) in PY2021: CMS, CCIIO,~~ ~~Plan Year 2021 Qualified Health Plan Choice and~~
~~Prem ium s in HealthCare.gov States,~~ ~~October 2020,~~ at https://www.cms.gov/CCIIO/Resources/Data-Resources/QHP-at https://www.cms.gov/CCIIO/Resources/Data-Resources/QHP-
Choice-Premiums. Choice-Premiums. Hereinafter referred to as “CMS, QHP Choice, PY2023.” Also see KFF, “~~Also see KFF,~~ Average Marketplace Premiums by Metal Average Marketplace Premiums by Metal ~~T ier, 2018 -2021~~Tier, 2018-2023,” not dated, at https://www.kff.org/, at https://www.kff.org/
health-reform/state-indicator/average-marketplace-premiums-by-metal-tier/; and KFF, health-reform/state-indicator/average-marketplace-premiums-by-metal-tier/; and KFF, ~~Cost -~~“Cost-Sharing for Plans Offered Sharing for Plans Offered
in the Federal Marketplace, 2014-in the Federal Marketplace, 2014-~~2021~~2023,” February 2023, at https://www.kff.org/slideshow/cost, at https://www.kff.org/slideshow/cost -sharing-for-plans-offered-in-the-federal--sharing-for-plans-offered-in-the-federal-
marketplace/. marketplace/.
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link to page 10 link to page link to page 10 link to page 2224 Overview of Health Insurance Exchanges e. This definition, or a non-substantive variation of it, appears in one or more reports: “Average total premium per month is the total premium (including APTC and any premium paid by the policyholder) for the month, divided by the number of individuals who had an active policy for the month.” f. This definition, or a non-substantive variation of it, appears in one or more reports: “Average APTC per month is the total amount of APTC for the month for all individuals who received APTC, divided by the number of individuals who received APTC.” g. This definition, or a non-substantive variation of it, appears in one or more reports: “APTC enrol ment is the total number of individuals who had an active policy in February 2017, who paid their premium (thus becoming effectuated), and who received an APTC subsidy.” h. This definition, or a non-substantive variation of it, appears in one or more reports: “CSR enrol ment is the total number of individuals who had an active policy in February 2017, who paid their premium (thus effectuating their coverage), and received CSRs.” Insurer Participation As stated earlier (see “Qualified Health Plans”), insurers are not federally ~~Overview of Health Insurance Exchanges~~

~~c. The June 2017 report provided average APTC data but not average premium data for February 2017.~~
~~However, the July 2018 report provided average monthly premium and APTC data for the 2017 plan year~~
~~(total amounts for the year, divided by the total number of member months). The data in this column, from~~
~~the July 2018 report, are provided to al ow for approximate comparison, but they are average monthly~~
~~estimates for the year rather than the average estimates for a given month as shown in this table for other~~
years. See 2017 Effectuated Enrol ment Snapshot, June 2017 and Early 2018 Effectuated Enrol ment Snapshot,
~~July 2018.~~
~~d. See Early 2018 Effectuated Enrol ment Snapshot, July 2018.~~
~~e. See Early 2019 Effectuated Enrol ment Snapshot, August 2019.~~
f.
~~See Early 2020 Effectuated Enrol ment Snapshot, July 2020.~~
~~g. This definition, or a non-substantive variation of it, appears in one or more reports: “Average total premium~~
~~per month is the total premium (including APTC and any premium paid by the policyholder) for the month,~~
~~divided by the number of individuals who had an active policy for the month.”~~
~~h. This definition, or a non-substantive variation of it, appears in one or more reports: “Average APTC per~~
~~month is the total amount of APTC for the month for al individuals who received APTC, divided by the~~
~~number of individuals who received APTC.”~~
i.
~~This definition, or a non-substantive variation of it, appears in one or more reports: “APTC enrol ment is~~
~~the total number of individuals who had an active policy in February 2017, who paid their premium (thus~~
~~becoming effectuated), and who received an APTC subsidy.”~~
j.
~~This definition, or a non-substantive variation of it, appears in one or more reports: “CSR enrol ment is the~~
~~total number of individuals who had an active policy in February 2017, who paid their premium (thus~~
~~effectuating their coverage), and received CSRs.”~~
~~Insurer Participation~~
~~As stated earlier (see “Qualified Health Plans”), insurers are not~~ required to participate in the required to participate in the
exchanges, but they must meet certain requirements if they do want to offer plans in an exchange.exchanges, but they must meet certain requirements if they do want to offer plans in an exchange.
For each plan year to date, at least one insurer has offered an individual exchange plan in each For each plan year to date, at least one insurer has offered an individual exchange plan in each
county in county in al all states. states. See Figure 2 ~~for projected insurer participation in PY2021.62~~ However, there However, there
have been concerns about “bare counties” in one or more plan years, particularly as insurers were have been concerns about “bare counties” in one or more plan years, particularly as insurers were
making their decisions in 2017 about offering coverage for making their decisions in 2017 about offering coverage for PY2018.82 See Figure 2 for CMS projections of insurer participation in all individual exchanges in PY2023. According to a CMS report on FFE and SBE-FP states only, “out of the 33 PY23 HealthCare.gov states, 11 states have more QHP issuers participating in PY23 than PY22, and 22 states have counties with more QHP issuers in PY23 than PY22 due to new issuers entering and existing issuers expanding service areas.”83 82 See, for example, Erica Teichert~~PY2018.63~~

~~62 As of April 22, 2021, this map of projected insurer participation for PY2021 is the most current one on the CCIIO~~
~~website. In addition, insurer participation maps for PYs 2018 to 2020 are at https://www.cms.gov/CCIIO/Programs-~~
~~and-Initiatives/Health-Insurance-Marketplaces/Health-Insurance-Exchange-Coverage-Maps.html. A Kaiser Family~~
~~Foundation analysis of insurer participation from 2014 to 2020 is discussed later in this section.~~
~~63 See, for example, T eichert, Erica~~, “Last ‘bare’ county in the U.S. scores ACA exchange coverage,” Modern , “Last ‘bare’ county in the U.S. scores ACA exchange coverage,” Modern
Healthcare, AugustHealthcare, August 24, 2017, at https://www.modernhealthcare.com/article/20170824/NEWS/170829941/last-bare-24, 2017, at https://www.modernhealthcare.com/article/20170824/NEWS/170829941/last-bare-
county-in-the-u-s-scores-aca-exchange-coverage. county-in-the-u-s-scores-aca-exchange-coverage.
83 CMS, QHP Choice, PY2023. Congressional Research Service Congressional Research Service

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link to page 20 Overview of Health Insurance Exchanges

Figure 2. Plan Year ~~2021~~2023 Insurer Participation in the Individual Exchanges, by County
~~(CMS map of projected participation as of October 2, 2020)~~

~~Source:~~ ~~CMS, CCIIO~~ Source: Centers for Medicare & Medicaid Services (CMS), Center for Consumer Information and Insurance Oversight (CCIIO), “County by County Plan Year , “County by County Plan Year ~~2021 Projected~~2023 Insurer Participation in Health Insurance Insurer Participation in Health Insurance
Exchanges,” published October Exchanges,” published October ~~16, 2020~~31, 2022, at https://www.cms.gov/CCIIO/Programs-and-Initiatives/Health- at https://www.cms.gov/CCIIO/Programs-and-Initiatives/Health-
Insurance-Insurance-Marketplaces/Health-Insurance-Exchange-Coverage-Maps. This page also has such maps for prior years. An insurer might choose to begin, continue, or stop offering coverage in a state or locality, on and/or off an exchange, for various reasons. ~~Marketplaces/Health-Insurance-Exchange-Coverage-Maps. This page also has insurer participation~~
~~maps for PYs 2018 to 2020.~~
Notes: CCIIO = Center for Consumer Information and Insurance Oversight; CMS = Centers for Medicare &
~~Medicaid Services; PY = plan year. As of April 22, 2021, this map of projected insurer participation for PY2021 is~~
~~the most current one on the CCIIO website.~~
~~CMS notes on map: “Values may not add to 100% due to rounding. Federal y Facilitated Exchange (FFE) data~~
~~reflected on this map are point in time as of 10/02/2020. State-Based Exchange (SBE) data are preliminary and~~
~~self-reported from the Exchanges to CMS. These data are point in time as of 10/09/2020 for CO, CT, DC, ID,~~
~~MA, MD, MN, NV, RI, VT, and WA, and 08/30/2020 for NJ and PA. County-level information for the fol owing~~
~~SBE states (CA and NY) is representative of PY2020 participation as PY2021 participation has not yet been~~
~~provided by the Exchanges to CMS.”~~
~~An insurer might choose to begin, continue, or stop offering coverage in a state or locality, on~~
~~and/or off an exchange, for various reasons. Fundamental y, insurers make decisions based on~~
~~their assessment of their risk, or likelihood and potential magnitude of loss. Individuals differ in~~
~~their health insurance risk based on their health status, with sicker individuals considered high~~
~~risk and expected to have greater health care costs than healthier individuals (i.e., low-risk~~
~~individuals). Other factors that may affect insurers’ risk assessments and decisionmaking~~
~~regarding market participation include federal and state policies, provider and insurer market~~
~~competition, and consumer behavior, as wel as the potential for uncertainty regarding any of~~
~~these factors (e.g., the potential for unexpected federal or state policy changes affecting insurers).~~
In January 2019, the Government Accountability Office (GAO) released a report on insurer In January 2019, the Government Accountability Office (GAO) released a report on insurer
participation and related issues in the individualparticipation and related issues in the individual exchanges.exchanges.6484 The report provided background on The report provided background on
~~a range of potential contributing factors, including the federal requirements imposed by the ACA~~
~~on plans sold in the individual market, including the exchanges65; the consumer financial~~

~~64 Government Accountability Office (GAO),~~ ~~Health Insurance Exchanges: Claims Costs and Federal and State~~
~~Policies Drove Issuer Participation, Prem ium s, and Plan Design~~ ~~, January 2019, at https://www.gao.gov/products/~~
~~GAO-19-215.~~
~~65 Several provisions of the ACA, such as guaranteed issue of health insurance, generally have increased higher-risk~~
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~~link to page 18 link to page 34~~ ~~Overview of Health Insurance Exchanges~~

~~assistance available only in the exchanges66;~~ a range of policy factors that may have affected insurer participation in various ways, including the following:  the federal requirements imposed by the ACA on plans sold in the nongroup market, including the individual exchanges;85  the consumer financial assistance available only in the exchanges;86  the three ACA programs—risk corridors, the three ACA programs—risk corridors,
reinsurance, and risk adjustment—reinsurance, and risk adjustment— meant to mitigate insurers’ financial risk in the individualmeant to mitigate insurers’ financial risk in the individual ~~and~~
~~smal~~ and small-group -group markets, including in the exchanges;87 84 Government Accountability Office (GAO), Health Insurance Exchanges: Claims Costs and Federal and State Policies Drove Issuer Participation, Premiums, and Plan Design, January 2019, at https://www.gao.gov/products/GAO-19-215. 85 Several provisions of the ACA, such as guaranteed issue of health insurance, generally have increased higher-risk individuals’ ability to purchase insurance and restricted insurers’ ability to deny or limit coverage to such individuals. The ACA created some new requirements and expanded some existing requirements, including by applying requirements on the nongroup market that previously existed in one or more segments of the group market. 86 See “Premium Tax Credits and Cost-Sharing Reductions” in this report. One of the factors cited in the GAO report as affecting insurers’ participation was “federal funding changes,” including the ending of federal payments for cost-sharing reduction subsidies in October 2017. 87 Of the three ACA risk-mitigation programs—risk corridors, reinsurance, and risk adjustment—one was designed to be permanent. The risk corridors and reinsurance programs were in effect from 2014 to 2016; the risk adjustment program also began in 2014 and is still in effect. It assesses charges on applicable private health insurance plans with Congressional Research Service 20 link to page 34 link to page 36 Overview of Health Insurance Exchanges  federal policy changes in the years since the enactment of the ACA;88 and  state-level requirements. These and other factors, such as the health of the populations enrolling in exchange plans, had varying impacts on claims costs (the costs insurers pay for their enrollees’ health benefits), which in turn impacted insurer participation, as well as insurers’ decisions about premium amounts and plan designs (e.g., covered benefits, cost sharing, and provider networks). SHOP Exchanges Eligibility and Enrollment Certain small businesses are eligible to use the SHOP exchanges. For purposes of SHOP eligibility, a small business, or small employer, is generally an employer with not more than 50 employees.89 States also may define small employer as having not more than 100 employees–four states do.90 As of 2017, all states have the option to allow large employers to use SHOP exchanges, as well, but no states have done so.91 SHOP eligibility also depends on an employer having at least at least one common-law employee.92 This means, for example, that a person who is self-employed and who has no employees would not be eligible for the SHOP exchange (although they could purchase coverage in the individual exchange, if they meet the other eligibility requirements). In addition, per the definition of common-law employee, neither the business owner nor their business partner(s) nor their spouse or family members (even if involved in the business) count as an employee for purposes of SHOP eligibility. To participate in a SHOP exchange, a small business must offer coverage to all of its full-time employees, which, for purposes of SHOP eligibility, means those employees working 30 or more hours per week on average.93 The business may, but is not required to, offer coverage to part-time relatively healthier enrollees and uses collected charges to make payments to private health plans in the same state that have relatively sicker enrollees. See “Other Federal Funding Sources” in this report regarding the charges assessed on insurers via the risk adjustment program. The phaseouts of the other two programs are cited among “federal funding changes” affecting insurers’ participation decisions. For descriptions of all three programs and their different approaches, see Table 1 in CRS Report R45334, The Patient Protection and Affordable Care Act’s (ACA’s) Risk Adjustment Program: Frequently Asked Questions. 88 See Figure 1 in the GAO report discussed in this section. 89 For purposes of SHOP eligibility, the number of employees is determined using the “full-time equivalent” (FTE) employees calculation method. See 45 C.F.R. §155.20, “Small employer,” which references 26 U.S.C. §4980H. Also see CRS Report R45455, The Affordable Care Act’s (ACA’s) Employer Shared Responsibility Provisions (ESRP) for discussion of FTE calculations. 90 California, Colorado, New York, and Vermont are the only states that define small businesses as having 100 or fewer~~markets, including in the exchanges67; federal policy changes in the years since the~~
~~enactment of the ACA68; and state-level requirements. These and other factors, such as the health~~
~~of the populations enrolling in exchange plans, had varying impacts on claims costs (the costs~~
~~insurers pay for their enrollees’ health benefits), which in turn impacted insurer participation, as~~
~~wel as insurers’ decisions about premium amounts and plan designs (e.g., covered benefits, cost~~
~~sharing, and provider networks).~~
~~Insurer participation general y increased in PY2021 over PY2020. According to an October 2020~~
~~CMS report (on FFE and SBE-FP states only),~~
~~Out of the 36 PY21 HealthCare.gov states, 16 states have more QHP issuers participating~~
~~in PY21 than PY20, and 27 states have counties with more QHP issuers in PY21 than PY20~~
~~due to new issuers entering and existing issuers expanding service areas. Only one state~~
~~(Delaware) has a single QHP issuer in PY21, compared to two states in PY20.69~~
~~A November 2020 Kaiser Family Foundation analysis of insurer participation in al states’~~
~~individual exchanges from 2014 to 2021 also indicates such participation is rising for the third~~
~~consecutive year and “there wil be an average of 5.0 insurers per state in 2021, up from a low of~~
~~3.5 in 2018 but stil below the peak of 6.0 in 2015.”70~~
~~SHOP Exchanges~~
~~Eligibility and Enrollment~~
~~Certain smal businesses are eligible to use the SHOP exchanges. For purposes of SHOP~~
~~eligibility, a smal business, or small employer, is general y an employer with not more than 50~~

~~individuals’ ability to purchase insurance and restricted insurers’ ability to deny or limit coverage to such individuals.~~
~~T he ACA created some new requirements and expanded some existing requirements, including by applying~~
~~requirements on the individual market that previously existed in one or more segments of the group market. See the~~
~~appendix of CRS Report R45146, Federal Requirem ents on Private Health Insurance Plans.~~
~~66 See “Premium T ax Credits and Cost -Sharing Reductions” in this report. One of the factors cited in the GAO report as~~
~~affecting insurers’ participation was “federal funding changes,” including the ending of federal payments for cost -~~
~~sharing reduction subsidies in October 2017.~~
~~67 Of the three ACA risk-mitigation programs—risk corridors, reinsurance, and risk adjustment —one was designed to~~
~~be permanent. T he risk corridors and reinsurance programs were in effect from 2014 to 2016; the risk adjustment~~
~~program also began in 2014 and is still in effect. It assesses charges on applicable private health insurance plans with~~
~~relatively healthier enrollees and uses collected charges to make payments to private health plans in the same state that~~
~~have relatively sicker enrollees. See “ Other Federal Funding Sources” in this report regarding the charges assessed on~~
~~insurers via the risk adjustment program. T he phaseouts of the other two programs are cited among “ federal funding~~
~~changes” affecting insurers’ participation decisions. For descriptions of all three programs and their different~~
~~approaches, see T able 1 in CRS Report R45334,~~ ~~The Patient Protection and Affordable Care Act’s (ACA’s) Risk~~
~~Adjustm ent Program : Frequently Asked Questions~~.
~~68 See Figure 1 in the GAO report discussed in this section.~~
~~69 CMS, CCIIO, Plan Year 2021 Qualified Health Plan Choice and Premiums in HealthCare.gov States, October 2020,~~
~~at the webpage “Qualified Health Plan Choice and Premiums in HealthCare.gov States,” at https://www.cms.gov/~~
~~CCIIO/Resources/Data-Resources/QHP-Choice-Premiums. T he corresponding CMS report from October 2019, posted~~
~~on the same webpage, also showed increasing in surer participation for PY2020 over PY2019.~~
~~70 Rachel Fehr et al., “Insurer Participation on the ACA Marketplaces, 2014-2021,” Kaiser Family Foundation,~~
~~November 2020, at https://www.kff.org/private-insurance/issue-brief/insurer-participation-on-the-aca-marketplaces-~~
~~2014-2021/.~~
~~Congressional Research Service~~

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~~link to page 36~~ ~~Overview of Health Insurance Exchanges~~

~~employees.71 States also may define small employer as having not more than 100 employees–four~~
~~states do.72 As of 2017, al states have the option to al ow large employers to use SHOP~~
~~exchanges, as wel , but no states have done so.73~~
~~SHOP eligibility also depends on an employer having at least at least one~~ ~~common-law~~
~~employee.74 This means, for example, that a person who is self-employed and who has no~~
~~employees would not be eligible for the SHOP exchange (although they could purchase c overage~~
~~in the individual exchange, if they meet the other eligibility requirements). In addition, per the~~
~~definition of common-law employee, neither the business owner nor their business partner(s) nor~~
~~their spouse or family members (even if involved in the business) count as an employee for~~
~~purposes of SHOP eligibility.~~
To participate in a SHOP exchange, a smal business must offer coverage to al of its full-time
employees, which, for purposes of SHOP eligibility, means those employees working 30 or more
~~hours per week on average.75 The business may, but is not required to, offer coverage to part-time~~
~~or other employees, and/or to the spouses and dependents of any employees offered coverage.76~~
~~Employees and their enrolling family members must meet the same citizenship and other~~
~~eligibility requirements that apply in the individual exchanges.~~
~~Enrollment Periods~~
~~Enrollment in a SHOP exchange is not limited to a specified OEP, except in certain~~
~~circumstances.77 Such circumstances aside, a SHOP exchange must allow employers to enroll any~~
~~time during a year, and the employer’s plan year must consist of the 12-month period beginning~~
~~with the employer’s effective date of coverage.78 Whereas plans sold in the individual exchanges~~
~~general y align with the calendar year, plans sold in the SHOP exchanges need not (thus, statutory~~
~~or regulatory provisions affecting the SHOP exchanges may refer to “plan years beginning in” a~~
~~given year).~~
~~There are SEPs for SHOP exchange coverage. Some of the SEPs for the SHOP exchanges are the~~
~~same as in the individual exchanges.79~~

~~71 For purposes of SHOP eligibility, the number of employees is determined using the “full-time equivalent” (FT E)~~
~~employees calculation method. See 45 C.F.R. §155.20, “ Small employer,” which references 26 U.S.C. §4980H. Also~~
~~see CRS Report R45455, The Affordable Care Act’s (ACA’s) Em ployer Shared Responsibility Provisions (ESRP) for~~
~~discussion of FT E calculations.~~
~~72 California, Colorado, New York, and Vermont are the only states that define small businesses as having 100 or fe wer~~
~~employees for the purpose of participation in the SHOP exchanges. See Table A-1.~~
~~73 42 U.S.C. §18032(f)(2)(B). No states have allowed large employers (as defined by the state) use of their SHOP~~
~~exchanges.~~
~~74 For discussion of the SHOP eligibility requirement to have at least one common -law employee, see HHS, “~~ employees for the purpose of participation in the SHOP exchanges. See CMS/CCIIO, “Market Rating Reforms,” updated December 2021, at https://www.cms.gov/CCIIO/Programs-and-Initiatives/Health-Insurance-Market-Reforms/state-rating. Also see Table A-1. 91 42 U.S.C. §18032(f)(2)(B). 92 For discussion of the SHOP eligibility requirement to have at least one common-law employee, see HHS, “Patient Patient
Protection and Affordable Care Act; Establishment of Exchanges and QualifiedProtection and Affordable Care Act; Establishment of Exchanges and Qualified Health Plans; Exchange StandardsHealth Plans; Exchange Standards for for
Employers,” March 27, 2012, 77 Employers,” March 27, 2012, 77 Federal Register 18309 18309, page 18399.page 18399.
7593 For purposes of SHOP For purposes of SHOP eligibility, the definition of eligibility, the definition of full-time employee is at 45 C.F.R. is at 45 C.F.R. §155.20. Congressional Research Service 21 link to page 7 Overview of Health Insurance Exchanges or other employees, and/or to the spouses and dependents of any employees offered coverage.94 Employees and their enrolling family members must meet the same citizenship and other eligibility requirements that apply in the individual exchanges. Enrollment Periods Enrollment in a SHOP exchange is not limited to a specified OEP, except in certain circumstances.95 Such circumstances aside, a SHOP exchange must allow employers to enroll any time during a year, and the employer’s plan year must consist of the 12-month period beginning with the employer’s effective date of coverage.96 Whereas plans sold in the individual exchanges generally align with the calendar year, plans sold in the SHOP exchanges need not (thus, statutory or regulatory provisions affecting the SHOP exchanges may refer to “plan years beginning in” a given year). There are SEPs for SHOP exchange coverage. Some of the SEPs for the SHOP exchanges are the same as in the individual exchanges.97 Enrollment Processes and Options~~§155.20.~~
~~76 45 C.F.R. §155.710(e).~~
~~77 It is possible for SHOP exchanges to establish minimum participation rates and minimum contribution rates.~~
~~Businesses that do not comply with established rates cannot be prohibited from obtaining coverage through SHOP~~
~~exchanges; rather, health insurance plans may limit the availability of coverage for any employer that does not meet an~~
~~allowed minimum participation or contribution rate to an annual enrollment period—November 15 through December~~
~~15 of each year.~~
~~78 45 C.F.R. §155.726(b).~~
~~79 45 C.F.R. §155.726(c). See also Section 3.4 of the CMS, FFE and FF-SHOP Enrollment Manual, which notes that~~
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~~Online Enrollment versus Direct Enrollment~~
For an employee to obtain coverage through a SHOP exchange, a SHOP-eligible employer must For an employee to obtain coverage through a SHOP exchange, a SHOP-eligible employer must
select one or more plan options on the SHOP exchange for its employees to choose from.select one or more plan options on the SHOP exchange for its employees to choose from.8098 Then, Then,
employees employees ~~compare~~review their employer’s plan their employer’s plan ~~options~~option(s) and enroll if they choose. The process of and enroll if they choose. The process of
comparing and enrolling in coverage depends comparing and enrolling in coverage depends ~~partial y on the type of SHOP exchange a state has:~~
partially on a state’s SHOP exchange type:  In states with FF-SHOPs (i.e., states with SHOP exchanges using the federal  In states with FF-SHOPs (i.e., states with SHOP exchanges using the federal
HealthCare.gov platform), employers and employees are able to browse and HealthCare.gov platform), employers and employees are able to browse and
compare plan options on HealthCare.gov, but they need to work directly with a compare plan options on HealthCare.gov, but they need to work directly with a
SHOP-registered agent, broker, or insurer to purchase coverage.SHOP-registered agent, broker, or insurer to purchase coverage.8199 This is This is ~~cal ed~~called
direct enrollment, and it has been the only option in such states since plan years , and it has been the only option in such states since plan years
beginning in 2018beginning in 2018.82100 Previously, employers and employees could purchase Previously, employers and employees could purchase
coverage on HealthCare.gov or via direct enrollment. coverage on HealthCare.gov or via direct enrollment.
~~ States administering their own SB-SHOP websites initial y were al owed to use a~~
~~direct enrollment approach, due to early difficulties some states had in getting~~
~~their SHOP exchange websites online.83 As of April 2016, HHS indicated SB-~~
~~SHOPs would need to implement online portals in time for plan years beginning~~
~~in 2019.84 However, in the 2019 Payment Notice, when HHS transitioned~~
~~HealthCare.gov SHOP exchanges to direct enrollment (see previous bullet), HHS~~
~~also announced SB-SHOPs had the option of retaining or returning to a direct~~
~~enrollment approach or maintaining enrollment sites if they had created them. As~~
~~of September 2020, 6 of the 15 SB-SHOP states are using a direct enrollment~~
~~approach only.85~~
~~Besides exchange website enrollment versus direct enrollment options, a significant factor~~
~~affecting access to SHOP plans is whether any insurers are offering plans in that state’s SHOP~~

~~SHOP~~ 94 45 C.F.R. §155.710(e). 95 It is possible for SHOP exchanges to establish minimum participation rates and minimum contribution rates. Businesses that do not comply with established rates cannot be prohibited from obtaining coverage through SHOP exchanges; rather, health insurance plans may limit the availability of coverage for any employer that does not meet an allowed minimum participation or contribution rate to an annual enrollment period—November 15 through December 15 of each year. See, for example, the HealthCare.gov page on SHOP eligibility and enrollment: https://www.healthcare.gov/small-businesses/choose-and-enroll/qualify-for-shop-marketplace/. 96 45 C.F.R. §155.726(b). 97 45 C.F.R. §155.726(c). See also Section 4.4 of CMS, FFE and FF-SHOP Enrollment Manual (2022), which notes that SHOP exchange SEPs “cross-referenc[e] most, but not all, of the qualifying events listed at 155.420(d) [which lists exchange SEPs “cross-referenc[e] most, but not all, of the qualifying events listed at 155.420(d) [which lists
SEPsSEPs for the individual exchanges].for the individual exchanges]. ~~Specifically, SEPs described in 45 CFR §155.420(d)(1)(ii), (3), and (6) do not~~
~~apply in SHOPs.”~~
80” 98 A business A business with locations or employees in multiple states has options for offering SHOP coverage to all its eligible with locations or employees in multiple states has options for offering SHOP coverage to all its eligible
employees. Seeemployees. See 45 C.F.R. §155.710 and HealthCare.gov, “45 C.F.R. §155.710 and HealthCare.gov, “ SHOP Coverage for Multiple Locations and Businesses,”SHOP Coverage for Multiple Locations and Businesses,” at at
https://www.healthcare.gov/small-businesses/provide-shop-coverage/business-in-more-than-one-state/. https://www.healthcare.gov/small-businesses/provide-shop-coverage/business-in-more-than-one-state/.
8199 HealthCare.gov, “Overview of SHOP: Health insurance for small businesses,” HealthCare.gov, “Overview of SHOP: Health insurance for small businesses,” at https://www.healthcare.gov/small-at https://www.healthcare.gov/small-
businesses/choose-and-enroll/shop-marketplace-overview/.businesses/choose-and-enroll/shop-marketplace-overview/.
~~82 HHS~~ 100 HHS finalized this change in the 2019 Payment Notice (page 16996), citing generally low employer participation in finalized this change in the 2019 Payment Notice (page 16996), citing generally low employer participation in
the SHOP exchanges and decreasingthe SHOP exchanges and decreasing insurer participation (both discussedinsurer participation (both discussed ~~elsewhere~~ elsewhere in the SHOP section of this in the SHOP section of this
report). HHS also confirmed in the 2019 Payment Notice that because of these reductions in federal SHOPreport). HHS also confirmed in the 2019 Payment Notice that because of these reductions in federal SHOP ~~web~~ web portal portal
functionality, state-based SHOP exchanges wouldfunctionality, state-based SHOP exchanges would no longer be ableno longer be able to use the federal ITto use the federal IT platform. In other words, platform. In other words,
HHSHHS eliminated the SB-FP-SHOPeliminated the SB-FP-SHOP option (discussedoption (discussed in in “ State-Based and Federally Facilitated Exchanges”). ). ~~T he two~~
~~states that used this option at the time, Kentucky and Nevada, were allowed to continue doing so if desired, despite the~~
~~reduced functionality of HealthCare.gov for SHOP. However, they have since transitioned their SHOPs to other types~~
~~(see Table A-1). Citation for this rule is in Table D-1.~~
~~83 For iterations of guidance on this topic issued between 2014 and 2016 , see CMS, CCIIO, “Extension of State-Based~~
~~SHOP Direct Enrollment T ransition,” April 18, 2016, at https://www.cms.gov/CCIIO/Resources/Regulations-and-~~
~~Guidance/Downloads/1332-and-SHOP-Guidance-508-FINAL.PDF.~~
~~84 Ibid. In April 2016, CMS also outlined different options for those states to consider, including transitioning to the~~
~~federal IT platform (becoming an SB-FP-SHOP) or applying for an ACA Section 1332 waiver to obtain an exception to~~
~~the requirement to have a SHOP exchange at all. For more information about ACA Section 1332 waivers, see CRS~~
~~Report R44760, State Innovation Waivers: Frequently Asked Questions.~~
~~85 See Table A-1.~~
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~~exchange. For PY2021, there are no insurers offering medical plans in SHOP exchanges in more~~
~~than half of states.86~~The two Congressional Research Service 22 link to page 36 link to page 36 link to page 45 link to page 36 Overview of Health Insurance Exchanges  States administering their own SB-SHOP websites initially were allowed to use a direct enrollment approach, due to early difficulties some states had in getting their SHOP exchange websites online.101 As of April 2016, HHS indicated SB-SHOPs would need to implement online portals in time for plan years beginning in 2019.102 However, in the 2019 Payment Notice, when HHS transitioned HealthCare.gov SHOP exchanges to direct enrollment (see previous bullet), HHS also announced SB-SHOPs had the option of retaining or returning to a direct enrollment approach or maintaining enrollment sites if they had created them. For PY2023, of the 15 SB-SHOP states with medical plans offered, nine are using DE approaches only.103 Besides exchange website enrollment versus direct enrollment options, a significant factor affecting enrollment processes is whether any insurers are offering plans in that state’s SHOP exchange. For PY2023, there are no insurers offering medical plans in SHOP exchanges in about half of states.104 In such states, the federal or state SHOP webpage instructs users to work In such states, the federal or state SHOP webpage instructs users to work
directly with an agent, broker, or insurer to obtain coverage in the directly with an agent, broker, or insurer to obtain coverage in the ~~smal~~ small-group market off-exchange. See Table A-1 for more information on SHOP exchange plan availability and enrollment methods, by state. Enrollment Estimates Unlike individual ~~-group market off-~~
~~exchange.~~
~~Following is a summary of SHOP exchange plan availability and enrollment methods, by SHOP~~
~~exchange type, for PY2021. See Table A-1 for more information, including by state.~~
~~ FF-SHOP, 32 states: al direct enrollment only, 9 with and 23 without SHOP plans.~~
~~ SB-SHOP, 18 states: 7 states with plans and SHOP website enrollment option, 6 with~~
~~plans and direct enrollment only, and 5 with no SHOP plans.~~
~~ No SHOP, 1 state: state received waiver al owing it not to have a SHOP.87~~
~~Enrollment Estimates~~
~~Unlike individual~~ exchange enrollment data, SHOP exchange enrollment data are not released exchange enrollment data, SHOP exchange enrollment data are not released
~~annual y~~annually. However, CMS estimated that there were approximately 27,000 . However, CMS estimated that there were approximately 27,000 ~~smal~~ small employers and employers and
233,000 employees using the SHOP exchanges across the country in January 2017.233,000 employees using the SHOP exchanges across the country in January 2017.88105 CMS CMS
previously estimated 10,700 active previously estimated 10,700 active ~~smal~~ small employers and 85,000 employees in the SHOP employers and 85,000 employees in the SHOP
~~exchanges as of May 2015.89~~
~~According to a 2019 GAO report that included 2016 SHOP exchange enrollment data for 46~~
~~states,~~
~~As a proportion of the overall small group market, SHOP exchanges in most states had~~
~~little enrollment—that is, typically less than 1 percent of the overall small group market ..~~
~~The District of Columbia, Rhode Island, and Vermont were the only states where the SHOP~~
~~exchange was more than 3 percent of the overall small group market. The District of~~
~~Columbia and Vermont require all small group plans to be purchased through the state’s~~
~~SHOP exchange.90~~
~~In addition, District of Columbia SHOP enrollment includes congressional Members and staff, as~~
~~discussed below.~~

~~86 T he number of states with no insurers offering plans in SHOP exchanges in 2021 is based on CRS analysis of the~~
~~2021 “Business Rules” public use file at CMS, “ Health Insurance Exchange Public Use Files (Exchange PUFs),” at~~
~~https://www.cms.gov/CCIIO/Resources/Data-Resources/marketplace-puf, as well as information available on~~
~~HealthCare.gov and state exchange websites.~~ exchanges as of May 2015.106 states that used this option at the time, Kentucky and Nevada, were allowed to continue doing so if desired, despite the reduced functionality of HealthCare.gov for SHOP. However, they have since transitioned their SHOPs to other types (see Table A-1). Citation for the 2019 Payment Notice is in Table D-1. 101 For iterations of guidance on this topic issued between 2014 and 2016, see CMS, CCIIO, “Extension of State-Based SHOP Direct Enrollment Transition,” April 18, 2016, at https://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/1332-and-SHOP-Guidance-508-FINAL.PDF. 102 Ibid. In April 2016, CMS also outlined different options for those states to consider, including transitioning to the federal IT platform (becoming an SB-FP-SHOP) or applying for an ACA Section 1332 waiver to obtain an exception to the requirement to have a SHOP exchange at all. For more information about ACA Section 1332 waivers, see CRS Report R44760, State Innovation Waivers: Frequently Asked Questions. 103 See Table A-1. 104 The number of states with no insurers offering plans in SHOP exchanges in 2023 is based on CRS analysis of the 2023 “Business Rules” public use file at CMS, “Health Insurance Exchange Public Use Files (Exchange PUFs),” at https://www.cms.gov/CCIIO/Resources/Data-Resources/marketplace-puf, as well as information available on HealthCare.gov and state exchange websites. Comparable information about insurer participation in SHOP exchanges Comparable information about insurer participation in SHOP exchanges
in prior years may not be consistently available. However, a 2019 GAOin prior years may not be consistently available. However, a 2019 GAO report indicates that in 2015-2017, there was at report indicates that in 2015-2017, there was at
least one insurerleast one insurer participating in each of the 46 participating in each of the 46 ~~o f~~of 51 states for which it had such 51 states for which it had such data for all three of those years. See data for all three of those years. See
~~T able~~Table 7 in GAO, 7 in GAO, Private Health Insurance: ~~Enrollm ent Rem ains Concentrated Am ong~~Enrollment Remains Concentrated Among Few Issuers, Including in
Exchanges, March 21, 2019, at https://www.gao.gov/products/GAO-19-306. Hereinafter referred to as “March 21, 2019, at https://www.gao.gov/products/GAO-19-306. Hereinafter referred to as “ GAO GAO
Enrollment Report, March 2019.” Enrollment Report, March 2019.”
~~87 See footnote 18. See Table A-1 for details and citations.~~
~~88 T his~~105 This estimate excludes Hawaii, estimate excludes Hawaii, as Hawaii’sas Hawaii’s SHOP exchange wasSHOP exchange was no longer operational in 2017 due to the state’s no longer operational in 2017 due to the state’s
receipt of a 1332 waiver. Seereceipt of a 1332 waiver. See CMS,CMS, CCIIO,CCIIO, “ “SHOP Marketplace Enrollment as of January 2017,” May 15, 2017, at SHOP Marketplace Enrollment as of January 2017,” May 15, 2017, at
https://www.cms.gov/CCIIO/Resources/Data-Resources/Downloads/https://www.cms.gov/CCIIO/Resources/Data-Resources/Downloads/ ~~SHOP~~ SHOP-Marketplace-Enrollment-Marketplace-Enrollment -Data.pdf. -Data.pdf.
~~89 T his~~106 This estimate excludes Vermont and Idaho; these states had not reported 2015 enrollment data to CMS. See estimate excludes Vermont and Idaho; these states had not reported 2015 enrollment data to CMS. See CMS, CMS,
“Update on SHOP Marketplaces for Small Businesses,”“Update on SHOP Marketplaces for Small Businesses,” ~~July~~ July 2, 2015, archived at http://wayback.archive-it.org/2744/2, 2015, archived at http://wayback.archive-it.org/2744/
~~20170118124128/https:/blog.cms.gov/2015/07/.~~
~~90 See page 24 and Appendix III of the GAO Enrollment Report, March 2019 .~~
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Congressional Research Service 23 link to page 20 link to page 20 Overview of Health Insurance Exchanges According to a 2019 GAO report that included 2016 SHOP exchange enrollment data for 46 states, As a proportion of the overall small-group market, SHOP exchanges in most states had little enrollment—that is, typically less than 1 percent of the overall small-group market ... The District of Columbia, Rhode Island, and Vermont were the only states where the SHOP exchange was more than 3 percent of the overall small-group market. The District of Columbia and Vermont require all small-group plans to be purchased through the state’s SHOP exchange.107 In addition, District of Columbia SHOP enrollment includes congressional Members and staff, as discussed below.
Congressional Member and Staff Enrollment via the D.C. SHOP Exchange
Per the ACA, Members of Congress and their staff Per the ACA, Members of Congress and their staff ~~general y~~generally are required to obtain their health are required to obtain their health
insurance through the exchanges in order to receive a government contribution (i.e., their insurance through the exchanges in order to receive a government contribution (i.e., their
employer’s contribution) for their coverage.employer’s contribution) for their coverage.91108 As implemented, they purchase coverage through As implemented, they purchase coverage through
the District of Columbia’s SHOP exchange. Congressional offices are not eligible for the the District of Columbia’s SHOP exchange. Congressional offices are not eligible for the ~~smal~~
small business tax credit (discussed below), and congressional Members and staff obtaining coverage business tax credit (discussed below), and congressional Members and staff obtaining coverage
through the SHOP are not eligiblethrough the SHOP are not eligible for the PTC and CSRs that are availablefor the PTC and CSRs that are available to individualsto individuals who who
enroll in coverage offered on the individual exchanges (see enroll in coverage offered on the individual exchanges (see “Premium Tax Credits and Cost-
Sharing Reductions”)). .
Premiums and Cost Sharing
The The ~~section~~information earlier in this report on earlier in this report on ~~“Premiums and Cost Sharing”~~premiums and cost sharing in the individual in the individual exchanges, exchanges,
including certain federal requirements that apply to premiums and cost sharingincluding certain federal requirements that apply to premiums and cost sharing~~, general y~~ (e.g., AV levels), generally applies ~~applies~~
in the SHOP exchanges, as in the SHOP exchanges, as ~~wel~~ well. See CRS Report R45146, . See CRS Report R45146, Federal Requirements on Private
Health Insurance Plans for other requirements applicable to the for other requirements applicable to the ~~individual and smal~~ nongroup and small-group ~~-group~~
markets, on and off the exchanges. markets, on and off the exchanges.
Employers who offer coverage through the SHOP exchange, like employers who offer coverage Employers who offer coverage through the SHOP exchange, like employers who offer coverage
otherwise, may choose to subsidize their employees’ premiums. This means the employer pays otherwise, may choose to subsidize their employees’ premiums. This means the employer pays
for part of their employees’ premiums. for part of their employees’ premiums.
CRS is not aware of HHS or other CRS is not aware of HHS or other organizations’ reports on premium or cost-sharing data specific to the SHOP reports on premium or cost-sharing data specific to the SHOP
exchanges.exchanges.
Small Business Health Care Tax Credit
Certain Certain ~~smal~~ small businesses are eligiblebusinesses are eligible for the for the ~~smal~~ small business health care tax credit (SBTC).business health care tax credit (SBTC).92109 In In
general, this credit is availablegeneral, this credit is available only to only to ~~smal~~ small employers with 25 or fewer full-time-equivalent 20170118124128/https:/blog.cms.gov/2015/07/. 107 See page 24 and Appendix III of the GAO Enrollment Report, March 2019. 108~~employers with 25 or fewer full-time-equivalent~~
~~(FTE) employees that purchase coverage through SHOP exchanges and contribute at least 50% of~~
~~premium costs for their full-time employees.93 (For the purpose of this tax credit,~~ ~~full-time~~
~~employees~~ ~~are those who work an average of 40 hours per week, whereas for the purpose of~~
~~SHOP eligibility, full-time employees are those who work an average of 30 hours per week.94) The~~
~~intent of the credit is to assist smal employers with the cost of providing health insurance~~
~~coverage to employees. The credit is available to eligible smal businesses for two consecutive~~
~~tax years (beginning with the first year the smal employer purchases coverage through a SHOP~~
~~exchange).~~

91 Other federal employees may obtain coverage through the Federal Employees Health Benefits Program (FEHB). Other federal employees may obtain coverage through the Federal Employees Health Benefits Program (FEHB).
Like many other employers, the federal government contributes to the cost of its employees’ premiums. Like many other employers, the federal government contributes to the cost of its employees’ premiums. ~~T his~~This is also is also
true for the Congressional Members and staff who obtain coverage through the SHOP. Certain congressional staff may true for the Congressional Members and staff who obtain coverage through the SHOP. Certain congressional staff may
not be requirednot be required to obtain their coverage through the SHOP, and may beto obtain their coverage through the SHOP, and may be able to otherwise obtain coverage through able to otherwise obtain coverage through
FEHB. SeeFEHB. See Office of Personnel Management, “Office of Personnel Management, “ Members of Congress and Designated Staff – General,”Members of Congress and Designated Staff – General,” at at
https://www.opm.gov/healthcare-insurance/changes-in-health-coverage/changes-in-health-coverage-faqs/.https://www.opm.gov/healthcare-insurance/changes-in-health-coverage/changes-in-health-coverage-faqs/.
~~92 See~~ 109 See 26 U.S.C.26 U.S.C. §45R for eligibility§45R for eligibility for the Small Businessfor the Small Business Health Care Health Care ~~T ax~~Tax Credit ( Credit (~~SBT C)~~ SBTC) and credit amount details Congressional Research Service 24 link to page 20 link to page 23 link to page 25 Overview of Health Insurance Exchanges (FTE) employees that purchase coverage through SHOP exchanges and contribute at least 50% of premium costs for their full-time employees.110 (For the purpose of this tax credit, full-time employees are those who work an average of 40 hours per week, whereas for the purpose of SHOP eligibility, full-time employees are those who work an average of 30 hours per week.111) The intent of the credit is to assist small employers with the cost of providing health insurance coverage to employees. The credit is available to eligible small businesses for two consecutive tax years (beginning with the first year the small employer purchases coverage through a SHOP exchange).~~and credit amount details~~
~~described in this section.~~
~~93 See the SHOP “ Eligibility and Enrollment ” section of this report for discussion of full-time equivalent employees.~~
~~94 Regarding SHOP eligibility, see 26 U.S.C. §4980H, 26 CFR §54.4980H-1(a)(21), and 45 CFR §155.20. Regarding~~
~~the SBT C, see 26 U.S.C. §45R.~~
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In states with no insurers offering plans through the SHOP exchange In states with no insurers offering plans through the SHOP exchange ~~(see discussion above),~~
, certain eligiblecertain eligible employers employers ~~stil~~ still may be able to receive the credit. If they received their first year’s may be able to receive the credit. If they received their first year’s
credit by offering coverage through the SHOP exchange and there were no SHOP plans available credit by offering coverage through the SHOP exchange and there were no SHOP plans available
the next year, they may receive their second consecutive year’s credit with a plan purchased off-the next year, they may receive their second consecutive year’s credit with a plan purchased off-
exchange.exchange.95112
The maximum credit is 50% of an employer’s contribution toward premiums for for-profit The maximum credit is 50% of an employer’s contribution toward premiums for for-profit
employers and 35% of employer contributions for nonprofit organizations. The full credit is employers and 35% of employer contributions for nonprofit organizations. The full credit is
availableavailable to employers that have 10 or fewer FTE employees who have average taxable wages of to employers that have 10 or fewer FTE employees who have average taxable wages of
~~$27,800~~$30,700 or less (in or less (in ~~2021).96~~2023).113 In general, the credit is phased out as the number of FTE employees In general, the credit is phased out as the number of FTE employees
increases from 10 to 25 and as average employee compensation increases to a maximum of two increases from 10 to 25 and as average employee compensation increases to a maximum of two
times the limittimes the limit for the full credit.for the full credit.97114
Employees who enroll in a SHOP plan do not receive this tax credit, nor are they eligible Employees who enroll in a SHOP plan do not receive this tax credit, nor are they eligible for the for the
financial assistance available to certain consumers who purchase coverage on the individual financial assistance available to certain consumers who purchase coverage on the individual
~~market~~exchanges (see (see “Premium Tax Credits and Cost-Sharing Reductions”~~” above~~). ).
The IRS has published information on the number of SBTCs filed in tax years 2010-2016. The IRS has published information on the number of SBTCs filed in tax years 2010-2016.98115 For For
2016, the IRS indicates that 6,952 employers claimed the SBTC.2016, the IRS indicates that 6,952 employers claimed the SBTC.99
116 Insurer Participation
As stated above, as of As stated above, as of ~~PY2020~~PY2023, there are no insurers offering SHOP , there are no insurers offering SHOP medical plans in plans in ~~more than~~about half half of states. of
~~states.100~~
Some of the factors affecting insurer participation in the individualSome of the factors affecting insurer participation in the individual exchanges (see exchanges (see “Insurer
Participation” in the Individual Exchanges section above) also may affect insurer participation in in the Individual Exchanges section above) also may affect insurer participation in
the SHOP exchanges. For example, just as in the the SHOP exchanges. For example, just as in the ~~individual~~ nongroup market, there were new federal market, there were new federal
requirements imposed by the ACArequirements imposed by the ACA on plans sold in the on plans sold in the ~~smal~~ small-group market (including described in this section. 110 See the SHOP “Eligibility and Enrollment” section of this report for discussion of full-time equivalent employees. 111 Regarding SHOP eligibility, see 26 U.S.C. §4980H, 26 CFR §54.4980H-1(a)(21), and 45 CFR §155.20. Regarding the SBTC, see 26 U.S.C. §45R. 112 Internal Revenue Service (IRS), Small Business Health Care Tax Credit Questions and Answers: Who Gets the Tax Credit, Question 6D, updated September 2022, at https://www.irs.gov/newsroom/small-business-health-care-tax-credit-questions-and-answers-who-gets-the-tax-credit. 113 IRS, Rev. Proc. 2022-38, Section 3.10, at https://www.irs.gov/pub/irs-drop/rp-22-38.pdf, referring to 26 U.S.C. §45R(d)(3)(B). 114 26 U.S.C. §45R(d)(1)(B). 115 IRS, SOI Tax Stats - Affordable Care Act (ACA) Statistics: Credit for Small Employer Health Insurance, “Premiums,” page updated Sept. 2022, at~~-group market (including the SHOP~~
~~exchanges), and insurers in the smal -group market were or are participating in risk-mitigation~~
~~programs.~~
~~There are also factors unique to the SHOP exchanges that may have affected insurer participation.~~
~~For example, in December 2016, effective January 2018, HHS removed a requirement that in~~
~~order to participate in a federal y facilitated individual exchange, an insurer with more than 20%~~
~~of the smal -group market in that state also would have to participate in that SHOP exchange. In~~
~~the rule, HHS acknowledged the elimination of this requirement likely would reduce insurer~~
~~participation, and thus employer and employee participation, in affected SHOP exchanges.101~~

~~95 Internal Revenue Service (IRS),~~ ~~Small Business Health Care Tax Credit Questions and Answers: Who Gets the Tax~~
~~Credit,~~ ~~Question 6D, updated September 2020, at https://www.irs.gov/newsroom/small-business-health-care-tax-credit -~~
~~questions-and-answers-who-gets-the-tax-credit~~.
~~96 IRS, Rev. Proc. 2020-45, Section 3.11, at https://www.irs.gov/pub/irs-drop/rp-20-45.pdf, referring to 26 U.S.C.~~
~~§45R(d)(3)(B).~~
~~97 26 U.S.C. §45R(d)(1)(B).~~
~~98 IRS,~~ ~~SOI Tax Stats - Affordable Care Act (ACA) Statistics: Credit for Small Employer Health Insurance,~~
“~~Premiums,” page updated Sept. 2020, at~~ https://www.irs.gov/statistics/soi-tax-stats-affordable-care-act-aca-statistics-https://www.irs.gov/statistics/soi-tax-stats-affordable-care-act-aca-statistics-
credit-for-small-employer-health-insurance-premiums. credit-for-small-employer-health-insurance-premiums.
99 116 Ibid. Ibid. ~~See~~ See excel file, “excel file, “ Small BusinessSmall Business Health Care Health Care ~~T ax~~Tax Credits Filed Credits Filed ~~in T ax~~ in Tax Years 2010–2016,” linked on this Years 2010–2016,” linked on this
webpage. webpage.
~~100 See “Online Enrollment versus Direct Enrollment” in this report.~~
~~101 2018 Payment Notice, page 94144. Citation for this rule is at Table D-1.~~
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Congressional Research Service 25 link to page 45 Overview of Health Insurance Exchanges the SHOP exchanges), and insurers in the small-group market were or are participating in risk-mitigation programs. There are also factors unique to the SHOP exchanges that may have affected insurer participation. For example, in December 2016, effective January 2018, HHS removed a requirement that in order to participate in a federally facilitated individual exchange, an insurer with more than 20% of the small-group market in that state also would have to participate in that SHOP exchange. In the rule, HHS acknowledged the elimination of this requirement likely would reduce insurer participation, and thus employer and employee participation, in affected SHOP exchanges.117 Other issues also have been discussed as affecting employer and/or insurer participation in the Other issues also have been discussed as affecting employer and/or insurer participation in the
SHOP exchanges, such as delays in setting up online enrollment capabilities when the SHOPs SHOP exchanges, such as delays in setting up online enrollment capabilities when the SHOPs
were being established and the limitedwere being established and the limited duration and administrative complexity of the duration and administrative complexity of the ~~smal~~
small business tax credit.business tax credit.~~102~~
118 Exchange Enrollment Assistance
Navigators and Other Exchange-Based Enrollment Assistance
Federal statute and regulations require exchanges to carry out certain consumer outreach and Federal statute and regulations require exchanges to carry out certain consumer outreach and
assistance functions. These functions assistance functions. These functions ~~general y~~generally include in-person and other forms of outreach and include in-person and other forms of outreach and
assistance.assistance.~~103~~119
Each exchange must have a Each exchange must have a Navigator program.program.~~104~~120 Navigators are entities whose employees Navigators are entities whose employees
and/or volunteersand/or volunteers  conduct public outreach and education activities about the exchanges and conduct public outreach and education activities about the exchanges and
QHPs;QHPs;  provide impartial information to consumers (including provide impartial information to consumers (including ~~smal~~ small employers and their employers and their
employees) about their insurance options;employees) about their insurance options;  help consumers access individual and SHOP exchange help consumers access individual and SHOP exchange
coverage, exchange coverage, exchange financial assistance, and/or public program coverage (e.g., Medicaid or financial assistance, and/or public program coverage (e.g., Medicaid or
CHIP) if they qualify;CHIP) if they qualify; ~~and~~  refer consumers to any applicable consumer assistance programs as refer consumers to any applicable consumer assistance programs as
needed, such needed, such as state agencies that assist consumers with questions or complaints about their as state agencies that assist consumers with questions or complaints about their
plansplans~~. Navigators also may, but are not federal y required to, provide other assistance, such as~~
~~information or referrals regarding reconciliation of consumers’ PTCs via their annual income tax~~
~~filing.105~~ ; and  comply with other Navigator requirements, as specified. States may impose additional Navigator requirements, as long as “such standards do not States may impose additional Navigator requirements, as long as “such standards do not
prevent the application of the provisions of Title I of the Affordable Care Act.”prevent the application of the provisions of Title I of the Affordable Care Act.”~~106~~
~~Navigators are funded by the exchanges, via grants (federal or state, depending on exchange type)~~
~~provided to qualifying organizations. Information on current and prior-year Navigator grantees in~~
~~FFE states is available on the CMS website.107 For FFE states, certain eligibility requirements~~
~~changed in 2018 and 2019. For example, Navigator entities are no longer required to maintain a~~
~~physical presence in their exchange service area.108 Also for FFE states, additional funding was~~

~~102 See GAO,~~ 121 117 2018 Payment Notice, page 94144. Citation for this rule is at Table D-1. 118 See GAO, Small Business Health Insurance Exchanges: Low Initial Enrollment Likely due to Multiple, Evolving
Factors, November 2014, at https://www.gao.gov/products/GAO-15-58, November 2014, at https://www.gao.gov/products/GAO-15-58~~. Also see Jost, T imothy, “~~ ; and GAO, Enrollment Remains Concentrated among Few Issuers, including in Exchanges, March 2019, at https://www.gao.gov/assets/gao-19-306.pdf. Also see Timothy Jost, “CMS Announces CMS Announces
Plans Plans ~~T o~~To Effectively End Effectively End ~~T he~~The SHOP Exchange,” Health Affairs Blog, May 15, 2017, at https://www.healthaffairs.org/ SHOP Exchange,” Health Affairs Blog, May 15, 2017, at https://www.healthaffairs.org/
do/10.1377/hblog20170515.060112/full/. do/10.1377/hblog20170515.060112/full/.
~~103~~119 For example, see 42 U.S.C. For example, see 42 U.S.C. §18031(i), 45 C.F.R. §155.205, 45 C.F.R. §155.210, and 45 C.F.R.§18031(i), 45 C.F.R. §155.205, 45 C.F.R. §155.210, and 45 C.F.R. §155.225. §155.225.
~~104~~120 Ibid. Ibid. Specifically, for the requirement to implement Navigator programs, see 45 C.F.R. §155.210. Specifically, for the requirement to implement Navigator programs, see 45 C.F.R. §155.210.
~~105 Some functions that were previously required are now optional for federally funded Navigator grantees. See 45~~
~~C.F.R. §155.210(e)(9).~~
~~106 45 C.F.R. §155.210(c)(1)(iii).~~
~~107 For information on FFE Navigator grants, see CMS, “ In-Person Assistance in the Health Insurance Marketplaces,”~~
~~at https://www.cms.gov/CCIIO/Programs-and-Initiatives/Health-Insurance-Marketplaces/assistance. Per the list of~~
~~2020 grantees, there were no eligible applicants in FFE states South Carolina and Utah. CRS is not aware of a~~
~~compilation of information about Navigator grants in states that administer these programs (those with SBEs and SBE-~~
~~FPs).~~
~~108 T he eligibility requirement changes were made via~~121 45 C.F.R. §155.210(c)(1)(iii). Congressional Research Service 26 link to page 45 Overview of Health Insurance Exchanges Navigators are funded by the exchanges, via grants (federal or state, depending on exchange type) provided to qualifying organizations. Information on current and prior-year Navigator grants in FFE states is available on the CMS website.122 Also for FFE states, additional funding was made available for Navigator grantees in March 2021, for purposes of outreach and enrollment efforts regarding the COVID-19 SEP (discussed earlier in this report).123 For FFE states, certain Navigator eligibility requirements were changed in the 2019 and 2020 the 2019 and 2020 Payment Notices. For example, Navigator entities were no longer required to maintain a physical presence in their exchange service area, and it became optional rather than mandatory for Navigators to provide assistance on certain post-enrollment topics (e.g., eligibility appeals, PTC reconciliation, and how to use health coverage).124 In the 2022 Payment Notice “Part 3,” HHS again required that FFE Navigators provide assistance on the post-enrollment topics but did not reverse the other changes.~~Payment Notices (cited in Table D-1). T he~~
~~changes, and existing eligibility requirements, are summarized in the 2019 Navigator funding opportunity~~
~~announcement, Cooperative Agreem ent to Support Navigators in Federally Facilitated Exchanges, at~~
~~https://www.grants.gov/web/grants/search-grants.html?keywords=CA-NAV-19-001 (select “ archived” option under~~
~~“opportunity status”).~~
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~~made available for Navigator grantees in March 2021, for purposes of outreach and enrollment~~
~~efforts regarding the COVID-19 SEP.109~~
Exchanges also must have a Exchanges also must have a Certified Application Counselor (CAC) program. (CAC) program.~~110~~125 CAC staff CAC staff
and/or volunteers also provide impartial information to consumers about their insurance options and/or volunteers also provide impartial information to consumers about their insurance options
and can assist them in applying for individual and SHOP exchange coverage, exchange financial and can assist them in applying for individual and SHOP exchange coverage, exchange financial
assistance, and/or public program coverage (e.g., Medicaid or CHIP) if they qualify. They do not assistance, and/or public program coverage (e.g., Medicaid or CHIP) if they qualify. They do not
necessarily provide public outreach and education or perform many of the other functions that necessarily provide public outreach and education or perform many of the other functions that
Navigators do. CACs are not exchange-funded in FFE states and are not required to be exchange-Navigators do. CACs are not exchange-funded in FFE states and are not required to be exchange-
funded in other states. funded in other states.
Although Navigator and CAC assisters can help consumers understand their options, they may Although Navigator and CAC assisters can help consumers understand their options, they may
not advise them on which plan to select. Once a consumer chooses a plan, the assisters may help not advise them on which plan to select. Once a consumer chooses a plan, the assisters may help
them enroll in coverage. Neither Navigators nor CACs may be health insurers or take them enroll in coverage. Neither Navigators nor CACs may be health insurers or take
compensation for compensation for ~~sel ing~~selling health policies from insurers or consumers. health policies from insurers or consumers.~~111~~
126 Besides facilitating the above assistance programs, exchanges must provide for the operation of a Besides facilitating the above assistance programs, exchanges must provide for the operation of a
~~cal~~ call center and maintain a website (e.g., HealthCare.gov) that meets certain informational center and maintain a website (e.g., HealthCare.gov) that meets certain informational
requirements.requirements.~~112~~127 Exchanges also provide consumer information and outreach via mail, radio or Exchanges also provide consumer information and outreach via mail, radio or
television ads, and/or other methods.television ads, and/or other methods.
~~Overal~~ Overall, exchanges’ consumer outreach efforts and materials must meet certain standards , exchanges’ consumer outreach efforts and materials must meet certain standards
regarding accessibility for individuals with disabilities or with regarding accessibility for individuals with disabilities or with ~~limited~~ limited English proficiency.English proficiency.~~113~~
~~Brokers, Agents, and Other Third-Party Assistance Entities~~
~~Pursuant to state law, exchanges also may certify insurance agents, brokers, and/or web-brokers~~
~~to help consumers obtain coverage through exchanges.114~~
~~ An agent or broker is “a person or entity licensed by the State as an agent, broker~~
~~or insurance producer.”115 They may be individuals or entities that sel plans for~~
~~different insurance companies, general y receiving a commission from those~~
~~companies for doing so; or they may be employees of an insurance company who~~
~~help people enroll in that company’s plans.~~
~~ A web-broker is an exchange-certified individual or group of agent(s) or~~
~~broker(s), or other business entity (including a “direct enrollment technology~~
~~provider”), “that develops and hosts a non-Exchange website that interfaces with~~
~~an Exchange to assist consumers with direct enrollment in qualified health plans~~
~~offered through the Exchange.”116 In other words, they offer privately owned and~~
~~operated websites that may be similar in concept to the ACA exchange websites,~~
~~in that they al ow for comparison of purchase of different plans.~~

~~109 See “Special Enrollment Periods and COVID-19” in this report.~~
~~110~~128 122 For information on FFE Navigator grants, see CMS, “In-Person Assistance in the Health Insurance Marketplaces,” at https://www.cms.gov/CCIIO/Programs-and-Initiatives/Health-Insurance-Marketplaces/assistance. This includes the 2022 Navigator grants announced in August 2022. CRS is not aware of a compilation of information about Navigator grants in states that administer these programs (those with SBEs and SBE-FPs). 123 CMS, “CMS Announces Additional Navigator Funding to Support Marketplace Special Enrollment Period,” March 1, 2021, at https://www.cms.gov/newsroom/press-releases/cms-announces-additional-navigator-funding-support-marketplace-special-enrollment-period. 124 Payment Notice citations are in Table D-1. 125 For the requirement to implement certified application counselor programs, see 45 C.F.R. §155.225. For the requirement to implement certified application counselor programs, see 45 C.F.R. §155.225.
~~111~~126 45 C.F.R. §155.215. 45 C.F.R. §155.215.
~~112~~127 45 C.F.R. §155.205. 45 C.F.R. §155.205.
~~113 45 C.F.R. §155.205.~~
~~114 45 C.F.R. §155.220. Definitions of terms discussed in this section, and of other related terms such as~~ ~~direct~~
~~enrollm ent entity, are at 45 C.F.R. §155.20.~~
~~115 Ibid.~~
~~116 Ibid. See 45 C.F.R. §155.20 for full definition of this term.~~
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~~If certified to sel~~ 128 45 C.F.R. §155.205. Congressional Research Service 27 link to page 43 link to page 26 Overview of Health Insurance Exchanges Brokers, Agents, and Other Third-Party Assistance Entities Pursuant to state law, exchanges also may certify insurance agents, brokers, and/or web-brokers to help consumers obtain coverage through exchanges.129 In general, agents or brokers may be individuals or entities that sell plans for different insurance companies, usually receiving a commission from those companies for doing so. There are also insurance company agents who help people enroll in that company’s plans. Different types of “web-brokers” and “direct enrollment technology providers” can also be approved to operate non-exchange websites that interface with exchange websites, to allow consumers to enroll in exchange plans without visiting the exchange website.130 If certified to sell exchange plans, any of these “third party” entities must follow rules about exchange plans, any of these “third party” entities must follow rules about
providing information and access to providing information and access to al all plans that would be availableplans that would be available to a consumer to a consumer ~~on the actual~~
via the exchange website.exchange website.~~117~~131 Unlike the exchange websites and exchange Unlike the exchange websites and exchange Navigators and other assistors, however, assistors, however, ~~they~~these entities may ~~may~~
also assist consumers with enrolling in plans that are not availablealso assist consumers with enrolling in plans that are not available on the exchanges. on the exchanges.
In states where SHOP exchanges only offer direct enrollment (i.e., consumers cannot purchase In states where SHOP exchanges only offer direct enrollment (i.e., consumers cannot purchase
SHOP plans via the exchange website), or in states where there are no insurers offering SHOP SHOP plans via the exchange website), or in states where there are no insurers offering SHOP
plans, the SHOP exchange websites direct consumers to these third party assisters, who can help plans, the SHOP exchange websites direct consumers to these third party assisters, who can help
them enroll in SHOP plans and/or them enroll in SHOP plans and/or ~~smal~~ small-group plans available-group plans available off-exchange.off-exchange.~~118~~132
Exchange Spending and Funding
Initial Grants for Exchange Planning and Establishment
The ACAThe ACA provided an indefiniteprovided an indefinite (i.e., unspecified) appropriation for HHS grants to states to (i.e., unspecified) appropriation for HHS grants to states to
support the planning and establishment of exchanges.support the planning and establishment of exchanges.~~119~~133 For each fiscal year (FY) between For each fiscal year (FY) between
FY2011 and FY2014, the HHS Secretary determined the total amount that was made available to FY2011 and FY2014, the HHS Secretary determined the total amount that was made available to
each state for exchange grants. However, none of these exchange grants could be awarded after each state for exchange grants. However, none of these exchange grants could be awarded after
January 1, 2015, and exchanges were expected to be self-sustaining beginning in 2015.January 1, 2015, and exchanges were expected to be self-sustaining beginning in 2015.~~120~~134
Ongoing Federal Spending on Exchange Operation
The federal government spent an estimated $The federal government spent an estimated $~~1.8 bil ion on operating the exchanges in FY2020,~~
~~and it projected $1.2 bil ion in spending for FY2021.121 Se~~e ~~Figure~~2.09 billion on the operation of exchanges in FY2022, projected $2.38 billion in spending for FY2023, and proposed $2.31 billion for FY2024.135 See Table C-1, which includes these , which includes these
numbers as numbers as ~~wel~~ well as estimated and prior year 129 45 C.F.R. §155.220. Definitions of terms discussed in this section, and other related terms, are at 45 C.F.R. §155.20. 130 For more information, see CMS, “Direct Enrollment and Enhanced Direct Enrollment,” updated May 2022, at https://www.cms.gov/programs-and-initiatives/health-insurance-marketplaces/direct-enrollment-and-enhanced-direct-enrollment. 131 45 C.F.R. §155.220. 132 See “Enrollment Processes and Options” in the SHOP section of this report for more information. 133 42 U.S.C. §18031(a). 134 42 U.S.C. §18031(a)(4)(B) specifies that no grant shall be awarded under this subsection after January 1, 2015. See CRS ~~as estimated and prior year federal spending on the exchanges by activity (e.g.,~~
~~information technology, Navigator grants), in a table that is included by CMS in its annual budget~~
~~justification to Congress.~~
~~In general, this federal spending is specific to FFEs. For example, the federal government funds~~
~~the Navigator program only in states with FFEs. Some of the federal spending, particularly in~~
~~terms of information technology and the cal center, also is applicable to SBE-FPs, because these~~
~~state-based exchanges use the federal HealthCare.gov platform. CMS performs and funds some~~
~~functions for al exchanges, including SBEs, such as “verifying consumers’ eligibility data for~~
~~financial assistance through the Exchange or other health insurance programs, including Medicaid~~
~~and the Children’s Health Insurance Program (CHIP).”122~~

~~117 45 C.F.R. §155.220.~~
~~118 See “Eligibility and Enrollment ” in the SHOP section of this report for more information about SHOP exchange~~
~~enrollment options and plan availability.~~
~~119 42 U.S.C. §18031(a).~~
~~120 42 U.S.C. §18031(a)(4)(B) specifies that no grant shall be awarded under this subsection after January 1, 2015. See~~
~~CRS~~ Report R43066, Report R43066, Federal Funding for Health Insurance Exchanges (last updated in October 2014) for more (last updated in October 2014) for more
information about these planning and establishment grants. information about these planning and establishment grants.
~~121 Department of Health and Human Services, Centers for Medicare & Medicaid Services,~~ 135 CMS, Justification of Estimates
for Appropriations ~~Com m ittees~~Committees, Fiscal Year ~~2021~~2024, March , March ~~3, 2020~~13, 2023, at , at https://www.cms.gov/files/document/cms-fy-2024-congressional-justification-estimates-appropriations- Congressional Research Service 28 link to page 34 link to page 44 link to page 45 Overview of Health Insurance Exchanges federal spending on the exchanges by activity (e.g., information technology, Navigator grants), as provided by CMS in its annual budget justification to Congress. In general, this federal spending is specific to FFEs. For example, the federal government funds the Navigator program only in states with FFEs. Some of the federal spending, particularly in terms of information technology and the call center, also is applicable to SBE-FPs because these state-based exchanges use the federal HealthCare.gov platform. CMS performs and funds some functions for all exchanges, including SBEs, such as “verifying eligibility data for financial assistance through the Marketplace or other health insurance programs, including Medicaid and the Children’s Health Insurance Program (CHIP).”136 ~~https://www.cms.gov/About -CMS/Agency-~~
~~Information/PerformanceBudget/FY2021-CJ-Final.pdf. See “ Federal Exchanges” table and narrative, page 195 -200,~~
~~and “Health Insurance Exchange T ransparency Table,” page 241. T he HHS FY2020 spending estimate was as of~~
~~January 2020. Hereinafter referred to as “ CMS Budget Justification, FY 2021.”~~
~~122 Page 196 of the CMS Budget Justification, FY2021.~~
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The costs of the plans themselves are covered by enrollees’ premiums and in some cases are The costs of the plans themselves are covered by enrollees’ premiums and in some cases are
subsidized by the federal government (i.e., via PTCs). The costs of the PTCs are financed through subsidized by the federal government (i.e., via PTCs). The costs of the PTCs are financed through
a permanent appropriation through the tax code.a permanent appropriation through the tax code.~~123~~137 These tax credit costs are beyond the scope of These tax credit costs are beyond the scope of
this report and are not included in the funding totals discussed in this section. this report and are not included in the funding totals discussed in this section.
Funding Sources for Federal Exchange Spending
User Fees Collected from Participating Insurers
Exchanges may generate funding to sustain their operations, including by assessing fees on Exchanges may generate funding to sustain their operations, including by assessing fees on
participating health insurance plans.participating health insurance plans.~~124~~ 138 To raise funds for the exchanges it administers and/or To raise funds for the exchanges it administers and/or ~~for~~
~~which it~~ provides a web platform, HHS assesses a monthly fee on each health insurance issuer provides a web platform, HHS assesses a monthly fee on each health insurance issuer
that offers plans through an FFE or SBE-FP. Thethat offers plans through an FFE or SBE-FP. The fee is a percentage of the value of the monthly premiums the insurer collects on exchange plans in a given state, and HHS updates the percentage each year through rulemaking. See Figure 3. These user fee amounts are allowed ~~user fee amounts are al owed~~ to fund only to fund only
federal activities or functions specific to federal activities or functions specific to ~~these~~the FFE and SBE-FP exchanges; the user fees cannot fund federal exchanges; the user fees cannot fund federal
activities that serve activities that serve al all exchanges (including SBEs).exchanges (including SBEs).~~125~~139 The fees are lower for insurers in SBE-FP The fees are lower for insurers in SBE-FP
states because the federal government performs fewer functions for those exchanges than for states because the federal government performs fewer functions for those exchanges than for
FFEs, but those insurers also may be subject to exchange participation fees levied by the states.FFEs, but those insurers also may be subject to exchange participation fees levied by the states.
~~The fee is a percentage of the value of the monthly premiums the insurer collects on exchange~~
plans in a given state, and HHS updates the percentage each year through rulemaking. See Figure
3.
~~User fees also have been~~ Most of the total federal spending on exchange operations is funded by these user fees, as shown in Table C-2. Other funding sources, including for federal activities applicable also to SBEs, are discussed in the next section. In prior years, user fees were also assessed on insurers participating in SHOP exchanges. However, HHS assessed on insurers participating in SHOP exchanges. However, HHS
announced in the 2019 Payment Notice that as of plan years beginning on or after January 1, announced in the 2019 Payment Notice that as of plan years beginning on or after January 1,
2018, the fees would no longer be assessed on insurers participating in FF-SHOPs and 2018, the fees would no longer be assessed on insurers participating in FF-SHOPs and ~~SB-FP-~~
~~SHOPs, due to the reduced functionality of the federal SHOP website also announced in that~~
~~rule.126~~

~~123 31 U.S.C. §1324(b).~~
~~124 42 U.S.C. §18031(d)(5)(A).~~
~~125 For further discussion, see 2020 Payment Notice (cited i~~n committees.pdf. See “Federal Marketplace Programs” table and narrative, pages 199-204, and “Health Insurance Marketplaces Transparency Table,” pages 237-238. Hereinafter referred to as “CMS Budget Justification, FY 2024.” 136 Page 200 of the CMS Budget Justification, FY2024. 137 31 U.S.C. §1324(b). 138 42 U.S.C. §18031(d)(5)(A). 139 For further discussion, see 2020 Payment Notice (cited in Table D-1), Section E.2., page 29216. Also see discussion ), Section E.2., page 29216. Also see discussion
of CMSof CMS activities conducted on behalf of certain versus all exchangesactivities conducted on behalf of certain versus all exchanges at CMSat CMS ~~Budget~~ Budget Justification, Justification, ~~FY2021, p. 196.~~
~~126 2019 Payment Notice (cited in Table D-1), page 17007. See “ Online Enrollment versus Direct Enrollment”~~
~~regarding t he reduced functionality of federal SHOP websites.~~
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~~Figure 3. Federal User Fee~~ SB-FP-SHOPs, due to the reduced functionality of the federal SHOP website also announced in that rule.140 Figure 3. Federal User Fees for Insurers Participating in Specified Types of Individual
Exchanges, by Plan Year
( (~~Fee~~fee is the stated percentage of the value of monthly premiums is the stated percentage of the value of monthly premiums ~~col ected~~collected by insurer on exchange plans) by insurer on exchange plans)

Source: CRS analysis of annual “Payment Notice” federal CRS analysis of annual “Payment Notice” federal rules cited inrules cited in Table D-1, ~~as wel~~ , as well as Internal Revenue as Internal Revenue
Service,Service, “Rev. Proc. 2013-25,” May 2, 2013, at http://www.irs.gov/pub/irs-drop/rp-13-25.pdf. “Rev. Proc. 2013-25,” May 2, 2013, at http://www.irs.gov/pub/irs-drop/rp-13-25.pdf.
Notes: FFE = FFE = ~~federal y facilitated exchange. SBE = state-based exchange.~~federally facilitated exchange; SBE-FP = state-based exchange using SBE-FP = state-based exchange using
the federal information technology (IT) platform.the federal information technology (IT) platform. See See “Types and Administration of Exchanges~~” for~~” for discussion discussion of of
~~exchange types.~~
~~Although some SBE-FPs existed prior to plan year 2017, HHS did not begin assessing a user fee on insurers in~~
~~those states until then.~~
~~SBEs’ assessment of user fees, if any, varies, as discussed in this section of the report.~~

~~Most of the total federal spending on exchange operations is funded by these user fees. In~~
~~FY2018-FY2020, user fees funded between 65.3% and 78.8% of this federal spending.127 As~~
~~stated above, the user fees only fund activities specific to FFEs and certain activities for SBE-~~
~~FPs. Funding sources for federal activities applicable also to SBEs are discussed in the next~~
~~section.~~
~~For FY2021, CMS proposed that $1.12 bil ion, or 93.6%, of its overal estimated FY2021~~
~~exchange spending would come from anticipated user-fee collections.128 However, this higher~~
~~percentage of spending sourced from user fees likely would depend on enactment of a legislative~~
~~proposal included by CMS in its FY2021 budget. The proposal would “al ow user fees collected~~
~~for FFE operations to be available for any federal administrative Exchange-related operating~~
~~activity.”129 This means CMS could use the user fees to fund its activities performed for al~~
~~exchanges, not just for its activities that are specific to FFE and SBE-FP exchanges. If this~~
~~proposal is not enacted, CMS must continue to use other funding sources for the activities it~~
~~performs on behalf of al exchanges. See “Ongoing Federal Spending on Exchange Operation”~~
~~for examples of these different types of activities.~~

~~127 Based on CRS analysis of data provided in CMS Budget Justifications for FY2021 and FY2020 (see Table C-1).~~
~~Comparable data not found in prior years’ budget justifications.~~
~~128 Ibid.~~
~~129 CMS Budget Justification, FY2021, page 199.~~
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~~Other Federal Funding Sources~~
~~Besides the user fees collected from participating insurers, federal funding for the exchanges~~
~~(including for federal activities related to al exchanges, including SBEs) largely comes from~~
~~discretionary appropriations for program management and program integrity. There is also a risk-~~
~~adjustment user fee, related to the risk-mitigation program briefly mentioned earlier in this~~
~~report.130 There is currently no mandatory HHS appropriation for exchange activities.131 An~~
~~overview of recent and currently proposed funding sources is in Table C-1.~~
~~State Financing of the Exchanges~~
~~States with SBEs finance their own exchange administration. States with SBE-FPs also finance~~
~~the costs associated with the exchange functions they administer (whereas the federal user fee is~~
~~assessed on insurers in such states to finance federal y run functions such as the IT platform, as~~
~~discussed above).~~ exchange types. State-based exchanges’ (SBEs’) assessment of user fees, if any, varies, as discussed below in this report. Other Federal Funding Sources Besides the user fees collected from participating insurers, federal funding for the exchanges (including for federal activities related to all exchanges, including SBEs) largely comes from discretionary appropriations for program management and program integrity. There is also a risk-adjustment user fee, related to the risk-mitigation program briefly mentioned earlier in this report.141 There is currently no mandatory HHS appropriation for exchange activities.142 An overview of recent and currently proposed funding sources is in Table C-2. State Financing of the Exchanges States with SBEs finance their own exchange administration. States with SBE-FPs also finance the costs associated with the exchange functions they administer (whereas the federal user fee is assessed on insurers in such states to finance federally run functions such as the IT platform, as discussed above). 140 2019 Payment Notice (cited in Table D-1), page 17007. See “Enrollment Processes and Options” regarding the reduced functionality of the federal SHOP website. 141 See “Insurer Participation” in the Individual Exchanges section of the report. 142 According to the “Federal Exchanges” table in the FY2020 CMS CJ, a portion of the mandatory Health Care Fraud and Abuse Control (HCFAC) appropriation went to the exchanges in FY2018 and FY2019. However, that table in the FY2021 CJ does not show this for FY2019, and it is also not shown in subsequent CJs. See Table C-2 for citations. Congressional Research Service 30 Overview of Health Insurance Exchanges States may finance their exchanges by collecting user fees from participating ~~States may finance their exchanges by collecting user fees from participating~~
insurers, as the federal government does. In addition, states may use other state funding to support insurers, as the federal government does. In addition, states may use other state funding to support
their exchanges. CRS is not aware of an estimate of total or state-level spending on, or financing their exchanges. CRS is not aware of an estimate of total or state-level spending on, or financing
sources for, SBE and SBE-FP exchanges. sources for, SBE and SBE-FP exchanges.
American Rescue Plan Act Grants for Exchange Modernization
Section 2801 of the ARPA Section 2801 of the ARPA ~~provides~~provided for new grants to be awarded to health insurance exchanges for new grants to be awarded to health insurance exchanges
“for purposes of enabling such Exchange to modernize or update any system, program, or “for purposes of enabling such Exchange to modernize or update any system, program, or
technology utilized by such Exchange to ensure such Exchange is compliant with technology utilized by such Exchange to ensure such Exchange is compliant with al all applicable applicable
requirements.” The HHS Secretary requirements.” The HHS Secretary iswas authorized to determine specified aspects of the grant authorized to determine specified aspects of the grant
funding application process. Eligibilityfunding application process. Eligibility for these grants for these grants iswas limited to SBEs and SBE-FPs. The limited to SBEs and SBE-FPs. The
legislationlegislation ~~specifies~~ specified that FFEs that FFEs ~~are~~were not eligible not eligible through its reference to exchanges established through its reference to exchanges established
under 42 U.S.C. Section 18041(c). under 42 U.S.C. Section 18041(c).
For this grant program, $20 For this grant program, $20 ~~mil ion is~~million was appropriated for FY2021, out of Treasury funds not appropriated for FY2021, out of Treasury funds not
otherwise appropriated. The funding otherwise appropriated. The funding iswas to remain available until the end of FY2022. to remain available until the end of FY2022.
In September 2021, CMS awarded $20 million in grants to 21 SBEs and SBE-FPs that applied for them.143 See See “Premium Tax Credits and Cost-Sharing Reductions” regarding other ARPA provisions ” regarding other ARPA provisions
relevant to the exchanges and the plans sold in them.relevant to the exchanges and the plans sold in them.~~132~~

~~130 See “Insurer Participation” in the Individual Exchanges section of the report.~~
~~131 According to the “Federal Exchanges” table in the FY2020 CMS CJ, a portion of the mandatory Health Care Fraud~~
~~and Abuse Control (HCFAC) appropriation went to the exchanges in FY2018 and FY2019. However, that table in the~~
~~FY2021 CJ does not show this for FY2019. See Table C -1 for citations.~~
~~132~~144 143 See CMS, 2021 State Marketplace Modernization Grant Awards, September 10, 2021, at https://www.cms.gov/files/document/state-based-marketplace-modernization-grant-awardee-list-2021.pdf. 144 For information about other health provisions in ARPA, see CRS For information about other health provisions in ARPA, see CRS Report R46777, Report R46777, American Rescue Plan Act of
2021 (P.L. 117-2): Private Health Insurance, Medicaid, CHIP, and Medicare ~~Provision s~~Provisions. .
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Appendix A. Exchange Information by State
As discussed in this report, the major types of exchanges in terms of state versus federal As discussed in this report, the major types of exchanges in terms of state versus federal
administration are state-based exchanges (SBEs), administration are state-based exchanges (SBEs), ~~federal y~~federally facilitated exchanges (FFEs), and facilitated exchanges (FFEs), and
state-based exchanges using a federal platform (SBE-FPs). For plan year (PY) state-based exchanges using a federal platform (SBE-FPs). For plan year (PY) ~~2021~~2023, there are 30 , there are 30
FFEs, FFEs, 1518 SBEs, and SBEs, and 63 SBE-FPs. SBE-FPs.
A few states have changed approaches one or more times (e.g., A few states have changed approaches one or more times (e.g., ~~initial y~~initially worked to create an SBE worked to create an SBE
but then switched to an SBE-FP or FFE model). Changes in the first few years varied in terms of but then switched to an SBE-FP or FFE model). Changes in the first few years varied in terms of
whether the state moved toward more or less federal involvement, but in several cases, a state whether the state moved toward more or less federal involvement, but in several cases, a state
transitioned from a fully state-based approach to an SBE-FP (i.e., transitioned toward more transitioned from a fully state-based approach to an SBE-FP (i.e., transitioned toward more
federal involvement). Recent and ongoing transitions federal involvement). Recent and ongoing transitions ~~general y~~ generally are in the direction of less federal are in the direction of less federal
involvement.involvement. ~~There were three changes for PY2015, one for PY2016, three for PY2017, none for~~
~~PY2018 or PY2019, three for PY2020, and four for PY2021. As of the publication of this report,~~
~~at least five states are known to be transitioning or considering transitions for PY2022 or beyond.~~
~~SHOP exchanges may be federal y~~ SHOP exchanges may be federally facilitated (FF-SHOP) or state-based (SB-SHOP). facilitated (FF-SHOP) or state-based (SB-SHOP).~~133~~145 For For
~~PY2021~~PY2023, there are , there are 3230 FF-SHOPs and FF-SHOPs and ~~18 SB-SHOPs. However, in more than half of~~ 20 SB-SHOPs. One state (Hawaii) is exempted from operating a SHOP exchange. However, in about half of all states, no states, no
insurers are offering medical plans in the SHOP exchange, meaning there is effectively no SHOP insurers are offering medical plans in the SHOP exchange, meaning there is effectively no SHOP
~~exchange there. See “Insurer Participation” in the SHOP Exchanges section of this report for~~
~~more information. One state is exempted from operating a SHOP exchange.~~
~~For PY2021 plan~~exchange there. For PY2023, most states’ individual and SHOP exchanges are administered in the same way , most states’ individual and SHOP exchanges are administered in the same way
(i.e., both state-based or both (i.e., both state-based or both ~~federal y~~federally facilitated). However, a facilitated). However, a ~~handful of~~few states have different states have different
approaches for their individual and SHOP exchanges. Some resources refer to this as a approaches for their individual and SHOP exchanges. Some resources refer to this as a bifurcated
approach. approach.
Table A-1 shows individual exchange types by state, with information on past changes in shows individual exchange types by state, with information on past changes in
individualindividual exchange types and changes underwayexchange types and changes underway ~~or planned~~. It also shows SHOP exchange types . It also shows SHOP exchange types
by state and provides details on SHOP plan availabilityby state and provides details on SHOP plan availability and enrollment method. and enrollment method.

~~133 As of June 2018, states can no longer select the state-based using the federal IT~~ Table A-1. Exchange Types and Key Details by State, Plan Year 2023 Individual Exchange Typea SHOP Exchange Typeb (with notes on exchange type (with notes on plan availability State Exchange Website transitions, if applicable) and enrollment options) U.S. Totals FFE: 30 FF-SHOP: 8 states with plans (al SBE: 18 DE only); 22 without plans SBE-FP: 3 SB-SHOP: 15 states with plans (9 are DE only); 5 without plans (plans and online enrol ment available in all counties, all states) No SHOP: 1 Alabama HealthCare.gov FFE FF-SHOP, DE onlyc Alaska HealthCare.gov FFE FF-SHOP, but no medical plansd Arizona HealthCare.gov FFE FF-SHOP, but no medical plansd Arkansas My Arkansas Insurance; SBE-FP as of PY17 (initially FFE)e SB-SHOP, but no medical plansf HealthCare.gov California Covered California SBE SB-SHOP (up to 100 employees)g Colorado Connect for Health SBE SB-SHOP, DE onlyh Colorado (up to 100 employees)g Connecticut Access Health CT SBE SB-SHOP 145 As of June 2018, states can no longer select the state-based using the federal IT platform (SB-FP-SHOP) approach, platform (SB-FP-SHOP) approach,
except that the two states with that model at that time (Nevada and Kentucky) could maintain itexcept that the two states with that model at that time (Nevada and Kentucky) could maintain it . According to CMS, . According to CMS,
those states no longer usethose states no longer use that model. ~~that model. For more information, see “ Online Enrollment versus Direct Enrollment” in the~~
~~“SHOP Exchanges” section of this report.~~
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~~Table A-1. Exchange Types and Key Details by State, Plan Year 2021~~
~~Individual Exchange Typea~~
~~SHOP Exchange Typeb~~
~~(and~~39 link to page 38 link to page 38 link to page 39 link to page 38 Overview of Health Insurance Exchanges Individual Exchange Typea SHOP Exchange Typeb (with notes on exchange type notes on exchange type
(with notes on plan availability (with notes on plan availability ~~and~~
State
Exchange Website
transitions, if applicabletransitions, if applicable)
~~enrol ment~~ ) and enrollment options)options)
~~U.S. Totals~~

~~FFE: 30~~
FF-SHOP: 32 (23 have no plans;
~~SBE: 15~~
~~al are direct enrol ment only)~~
~~SBE-FP: 6~~
SB-SHOP: 18 (5 have no plans; 6
~~are direct enrol ment only)~~
~~(plans and online enrol ment available~~
~~in al counties, al states)~~
~~No SHOP: 1~~
~~Alabama~~ Delaware HealthCare.gov FFEi FF-SHOP, but no medical plansd District of DC Health Link SBE SB-SHOP Columbia Florida
HealthCare.gov HealthCare.gov
FFE FFE
FF-SHOP, FF-SHOP, ~~via direct enrol mentc~~
~~Alaska~~but no medical plansd Georgia
HealthCare.gov HealthCare.gov
FFE FFE j
FF-SHOP, FF-SHOP, ~~but no medical plansd~~
~~Arizona~~DE onlyc Hawaii
HealthCare.gov HealthCare.gov
FFE FFE
~~FF-SHOP, but no medical plansd~~
~~Arkansas~~
~~Myarinsurance.com;~~
~~SBE-FP as of PY17~~
~~SB-SHOP, but no medical plansf~~
~~HealthCare.gov~~
~~(initial y FFE)e~~
~~California~~
~~Coveredca.com~~
~~SBE~~
~~SB-SHOP (up to 100 employees) g~~
~~Colorado~~
~~Connectforhealthco.com~~
~~SBE~~
~~SB-SHOP, via direct enrol menth~~
~~(up to 100 employees)g~~
~~Connecticut~~
~~Accesshealthct.com~~
~~SBE~~
~~SB-SHOP~~
~~Delaware~~
~~HealthCare.gov~~
~~FFEi~~
~~FF-SHOP, but no medical plansd~~
~~District of~~
~~DChealthlink.com~~
~~SBE~~
~~SB-SHOP~~
~~Columbia~~
~~Florida~~
~~HealthCare.gov~~
~~FFE~~
~~FF-SHOP, but no medical plansd~~
~~Georgia~~
~~HealthCare.gov~~
~~FFE (planning to replace exchange~~
~~FF-SHOP, via direct enrol mentc~~
~~with alternate approach as of PY23) j~~
~~Hawai~~
~~HealthCare.gov~~
~~FFE as of PY17 i (initial y SBE, then~~
~~No SHOP exchangek~~
~~SBE-FP for PY16)e~~
~~Idaho~~
~~Yourhealthidaho.org~~
~~SBE as of PY15~~
~~SB-SHOP, via direct enrol menth~~
~~(initial y SBE-FP)e~~
~~Il inois~~as of PY17i (initially SBE, then No SHOP exchange per waiverk SBE-FP for PY16)e Idaho Your Health Idaho SBE as of PY15 (initially SBE-FP)e SB-SHOP, DE onlyh Il inois HealthCare.gov FFEi FF-SHOP, but no medical plansd Indiana HealthCare.gov FFE FF-SHOP, but no medical plansd Iowa HealthCare.gov FFEi FF-SHOP, but no medical plansd Kansas HealthCare.gov FFEi FF-SHOP, but no medical plansd Kentucky kynect SBE as of PY22 (initially SBE, then SB-SHOP, DE onlyh SBE-FP as of PY17)e Louisiana HealthCare.gov FFE FF-SHOP, but no medical plansd Maine CoverME.gov SBE as of PY22 (initially FFE, then SB-SHOP, DE onlyh SBE-FP as of PY21)e Maryland Maryland Health Connection SBE SB-SHOP, DE onlyh Massachusetts Massachusetts Health SBE SB-SHOP Connector Michigan HealthCare.gov FFEi FF-SHOP, but no medical plansd Minnesota MNsure SBE SB-SHOP, but no medical plansf Mississippi HealthCare.gov FFE
~~HealthCare.gov~~
~~FFEi~~
FF-SHOP, but no medical FF-SHOP, but no medical planplansd
~~Indiana~~Missouri
HealthCare.gov HealthCare.gov
FFE FFE
FF-SHOP, but no medical FF-SHOP, but no medical planplansd
~~Iowa~~Montana
HealthCare.gov HealthCare.gov
FFEi
FF-SHOP, FF-SHOP, ~~but no medical plansd~~
~~Kansas~~DE onlyc Nebraska
HealthCare.gov HealthCare.gov
FFEi
FF-SHOP, but no medical FF-SHOP, but no medical planplansd
~~Kentucky~~
~~Healthbenefitexchange.ky.~~
~~SBE-FP as of PY17 (initial y SBE)~~
FFNevada Nevada Health Link SBE as of PY20 (initially SBE, then SB-SHOP, but no medical-SHOP, but no medical planplansd
~~gov; HealthCare.gov~~
~~Planning for SBE as of PY22e~~
~~Louisiana~~sf SBE-FP as of PY15)e New
HealthCare.gov HealthCare.gov
~~FFE~~FFEi FF-SHOP, DE onlyc Hampshire New Jersey Get Covered NJ SBE as of PY21 (initially FFE, then SB-SHOP, DE onlyh SBE-FP as of PY20)e New Mexico beWellnm
~~FF-SHOP, but no medical plansd~~
~~Maine~~
~~Enrol 207.com;~~
~~SBE-FP as of PY21 (initial y FFE)i~~
~~FF-SHOP, via direct enrol mentc~~
~~HealthCare.gov~~
~~Considering SBEe~~
~~Maryland~~
~~Marylandhealthconnection.~~
~~SBE~~
~~SB-SHOP, via direct enrol menth~~
~~gov~~
~~Massachusetts~~
~~Mahealthconnector.org~~
~~SBE~~
~~SB-SHOP~~
~~Michigan~~ SBE as of PY22 (initially SBE-FP)e SB-SHOP New York New York State of Health SBE SB-SHOP, DE onlyh (up to 100 employees)g North HealthCare.gov FFE
~~HealthCare.gov~~
~~FFEi~~
FF-SHOP, but no medical FF-SHOP, but no medical planplansd
~~Minnesota~~
~~Mnsure.org~~
~~SBE~~
SBCarolina North Dakota HealthCare.gov FFE FF-SHOP, but no medical-SHOP, but no medical ~~plansf~~
~~Mississippi~~
plansd Ohio HealthCare.gov HealthCare.gov
~~FFE~~FFEi
FF-SHOP, FF-SHOP, ~~but no medical plan~~sdDE onlyc
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Individual Exchange Typea
SHOP Exchange Typeb
~~(and~~ (with notes on exchange type notes on exchange type
(with notes on plan availability (with notes on plan availability ~~and~~
State
Exchange Website
transitions, if applicabletransitions, if applicable)
~~enrol ment~~ ) and enrollment options)options)
~~Missouri~~ Oklahoma HealthCare.gov FFE FF-SHOP, but no medical plansd Oregon Oregon Health Insurance SBE-FP as of PY15 (initially SBE)e SB-SHOP, DE onlyh Marketplace; HealthCare.gov Pennsylvania Pennie SBE as of PY21 (initially FFE, then SB-SHOP, but no medical plansf SBE-FP as of PY20)e Rhode Island Health Source RI SBE SB-SHOP South HealthCare.gov FFE FF-SHOP, but no medical plansd Carolina South Dakota HealthCare.gov FFEi FF-SHOP, but no medical plansd Tennessee HealthCare.gov FFE FF-SHOP, but no medical plansd Texas HealthCare.gov FFE FF-SHOP, but no medical plansd Utah HealthCare.gov FFEi FF-SHOP, but no medical plansd Vermont Vermont Health Connect SBE SB-SHOP, DE onlyh (up to 100 employees)g Virginia Cover Virginia; SBE-FP as of PY21 (initially FFE)e FF-SHOP, DE onlyc HealthCare.gov Transitioning to SBE for future PYl Washington Washington Healthplanfinder SBE SB-SHOP, but no medical plansf West Virginia HealthCare.gov FFEi FF-SHOP, but no medical plansd Wisconsin HealthCare.gov FFE FF-SHOP, DE onlyc Wyoming HealthCare.gov FFE FF-SHOP, DE onlyc Sources: CRS analysis of data at the sources indicated in notes section below. Notes: SHOP = Small business health options program. FFE = Federally-facilitated individual exchange; FF-SHOP = Federally-facilitated SHOP exchange. SBE = State-based individual exchange; SB-SHOP = State-based SHOP exchange. SBE-FP = State-based individual exchange using the federal information technology (IT) platform. Counts of “states” include the District of Columbia. In the individual exchanges, “plan year” is generally that calendar year, but group coverage plan years, including in the SHOP exchanges, may start at any time during a calendar year. See report “Overview” for discussion of exchange types; see Figure 1 for the 2023 exchange types by state in map form. a. 2023 individual exchange types: See footnotes 1-4
~~HealthCare.gov~~
~~FFE~~
~~FF-SHOP, but no medical plansd~~
~~Montana~~
~~HealthCare.gov~~
~~FFEi~~
~~FF-SHOP, via direct enrol mentc~~
~~Nebraska~~
~~HealthCare.gov~~
~~FFEi~~
~~FF-SHOP, but no medical plansd~~
~~Nevada~~
~~Nevadahealthlink.com~~
~~SBE as of PY20 (initial y SBE, then~~
~~SB-SHOP, but no medical plansf~~
~~SBE-FP as of PY15)e~~
~~New~~
~~HealthCare.gov~~
~~FFEi~~
~~FF-SHOP, via direct enrol mentc~~
~~Hampshire~~

~~New Jersey~~
~~Nj.gov/getcoverednj/~~
~~SBE as of PY21 (initial y FFE, then~~
~~SB-SHOP~~
~~SBE-FP as of PY20)e~~
~~New Mexico~~
~~Bewel nm.com;~~
~~SBE-FP~~
~~SB-SHOP~~
~~HealthCare.gov~~
~~Planning for SBE as of PY22e~~

~~New York~~
~~Nystateofhealth.ny.gov~~
~~SBE~~
~~SB-SHOP, via direct enrol menth~~
~~(up to 100 employees)g~~
~~North~~
~~HealthCare.gov~~
~~FFE~~
~~FF-SHOP, but no medical plansd~~
~~Carolina~~

~~North Dakota~~
~~HealthCare.gov~~
~~FFE~~
~~FF-SHOP, but no medical plansd~~
~~Ohio~~
~~HealthCare.gov~~
~~FFEi~~
~~FF-SHOP, via direct enrol mentc~~
~~Oklahoma~~
~~HealthCare.gov~~
~~FFE~~
~~FF-SHOP, but no medical plansd~~
~~Oregon~~
~~Healthcare.oregon.gov/~~
~~SBE-FP as of PY15 (initial y SBE)~~
~~SB-SHOP, via direct enrol menth~~
~~marketplace; HealthCare.gov~~
~~Considering SB e~~

~~Pennsylvania~~
~~Pennie.com~~
~~SBE as of PY21 (initial y FFE, then~~
~~SB-SHOP, but no medical plansf~~
~~SBE-FP as of PY20)e~~
~~Rhode Island~~
~~Healthsourceri.com~~
~~SBE~~
~~SB-SHOP~~
~~South~~
~~HealthCare.gov~~
~~FFE~~
~~FF-SHOP, but no medical plansd~~
~~Carolina~~
~~South Dakota~~
~~HealthCare.gov~~
~~FFEi~~
~~FF-SHOP, but no medical plansd~~
~~Tennessee~~
~~HealthCare.gov~~
~~FFE~~
~~FF-SHOP, but no medical plansd~~
~~Texas~~
~~HealthCare.gov~~
~~FFE~~
~~FF-SHOP, but no medical plansd~~
~~Utah~~
~~HealthCare.gov~~
~~FFEi~~
~~FF-SHOP, but no medical plansd~~
~~Vermont~~
~~Healthconnect.vermont.~~
~~SBE~~
~~SB-SHOP, via direct enrol menth~~
~~gov~~
~~(up to 100 employees)g~~
~~Virginia~~
~~Coverva.org/marketplace;~~
~~SBE-FP as of PY21 (initial y FFE i)~~
~~FF-SHOP, via direct enrol mentc~~
~~HealthCare.gov~~
~~Planning for SBE as of PY23e~~
~~Washington~~
~~Wahealthplanfinder.org~~
~~SBE~~
~~SB-SHOP, but no medical plansf~~
~~West Virginia~~
~~HealthCare.gov~~
~~FFEi~~
~~FF-SHOP, but no medical plansd~~
~~Wisconsin~~
~~HealthCare.gov~~
~~FFE~~
~~FF-SHOP, via direct enrol mentc~~
~~Wyoming~~
~~HealthCare.gov~~
~~FFE~~
~~FF-SHOP, via direct enrol mentc~~
Sources: Congressional Research Service (CRS) analysis of data at the sources indicated in notes section below.
~~Notes:~~
~~SHOP = Smal business health options program.~~
~~FFE and FF-SHOP = Federal y facilitated individual exchange; federal y facilitated SHOP exchange.~~
~~Congressional Research Service~~

33

~~link to page 6 link to page 9 link to page 25~~ ~~Overview of Health Insurance Exchanges~~

~~SBE and SB-SHOP = State-based individual exchange; state-based SHOP exchange.~~
~~SBE-FP = State-based individual exchange using the federal information technology (IT) platform; state-based~~
~~SHOP exchange using the federal IT platform.~~
~~Counts of “states” include the District of Columbia. In the individual exchanges, “plan year” is general y that~~
~~calendar year, but group coverage plan years, including in the SHOP exchanges, may start at any time during a~~
~~calendar year. See report “Overview” for discussion of exchange types; see Figure 1 in this report for the 2021~~
~~exchange types by state in map form.~~
~~a. 2021 individual exchange types: SBEs and SBE-FPs are listed at Centers for Medicare & Medicaid~~
~~Services~~ at Centers for Medicare & Medicaid Services (CMS), ~~(CMS),~~ Center for ConsumerCenter for Consumer Information and Insurance Oversight (CCIIO), “Health Insurance Exchange Public Use Files (Exchange PUFs) General Information” (PY 2023), at https://www.cms.gov/CCIIO/Resources/Data-Resources/marketplace-puf. b. 2023 SHOP exchange types: See footnotes cited in the CMS/CCIIO resource at table note (a). Also see HealthCare.gov, “Select your state,” at https://www.healthcare.gov/small-businesses/employers/~~Information and Insurance Oversight (CCIIO), “State-based~~
~~Exchanges,” updated November 1, 2019, at https://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/~~
~~state-marketplaces. Remaining states have FFEs. Cross-referenced at Kaiser Family Foundation, “State~~
~~Health Insurance Marketplace Types, 2021,” at https://www.kff.org/health-reform/state-indicator/state-~~
~~health-insurance-marketplace-types/, and at state exchange websites as needed.~~
~~b. 2021 SHOP exchange types: HealthCare.gov, “Select your state,” at https://www.healthcare.gov/smal -~~
~~businesses/employers/, cross-referenced at state exchange websites or otherwise as needed. Kentucky and~~
~~Nevada both had SB-FP-SHOPs, but according to communication with CMS, their SHOP types are now as~~
~~shown in the table~~. States with no medical. States with no medical plans available in their SHOP exchanges are indicated. In states plans available in their SHOP exchanges are indicated. In states
that do have plans available in their SHOP exchanges, there may or may not be plans available in that do have plans available in their SHOP exchanges, there may or may not be plans available in al all areas. areas.
c. c. All FF-SHOPs ~~are now using a direct~~ (that offer plans) use a direct enrollment approach ~~only.~~ ~~They do~~ only, meaning HealthCare.gov does not offer online not offer online
SHOP plan enrol mentenrol ment but instead but instead ~~instruct~~instructs users to connect with users to connect with agents or brokersagents or brokers ~~offering~~ to enrol in plans through the state’s plans through the state’s
SHOP exchange. See SHOP exchange. See ~~“Online Enrol ment versus Direct Enrol ment” in this report for more information.~~
~~d. No insurers are currently offering medical plans in these FF-SHOPs. (Some may be offering dental~~
~~plans, however.) See CMS, Health Insurance Exchange Public Use Files, 2021: Business Rules PUF, at~~
~~https://www.cms.gov/CCIIO/Resources/Data-Resources/ma rketplace-puf. Contact report author for further~~
~~information.~~
~~e. While most states have maintained the same type of individual exchange they initial y opted for, some have~~
~~transitioned to different exchange types, or are planning to do so.~~
~~For transitions to date~~
~~2014 exchange types:~~ ~~https://aspe.hhs.gov/pdf-report/addendum-health-insurance-marketplace-summary-~~
~~enrol ment-report~~
~~2015 exchange types:~~ ~~FN 3 of https://www.cms.gov/newsroom/fact-sheets/march-31-2015-effectuated-~~
~~enrol ment-snapshot~~
~~2016 exchange types:~~ ~~FN 3 of https://www.cms.gov/newsroom/fact-sheets/march-31-2016-effectuated-~~
~~enrol ment-snapshot~~
2017-2020 exchange types: State level public use files for each year, https://www.cms.gov/Research-
~~Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Marketplace-Products.~~
2021 and future transitions: See table note (a) regarding 2021 exchange types. Two CMS resources also
~~note PY2020 and PY2021 transitions, as referenced where relevant by state below:~~ ~~“CMS PY2021 QHP~~
~~report”~~ ~~(CMS, CCIIO,~~ ~~Plan Year 2021 Qualified Health Plan Choice and Premiums in HealthCare.gov States,~~
~~October 2020, at https://www.cms.gov/CCIIO/Resources/Data-Resources/QHP-Choice-Premiums); and~~
“2020 CMS Navigator Recipients” (CMS, 2020 CMS Navigator Cooperative Agreement Recipients,
~~August 30, 2020, at https://www.cms.gov/CCIIO/Programs-and-Initiatives/Health-Insurance-Marketplaces/~~
~~assistance).~~
~~Kentucky:~~ ~~https://kentucky.gov/Pages/Activity-stream.aspx?n=GovernorBeshear&prId=218~~
~~Maine:~~ ~~https://www.maine.gov/dhhs/blog/maine-progresses-toward-state-based-health-insurance-~~
~~marketplace-2020-08-06. Also see 2020 CMS Navigator Recipients.~~
New Jersey: https://nj.gov/governor/news/news/562019/approved/20190322a.shtml. Also see CMS PY2021
~~QHP report.~~
New Mexico: https://www.bewel nm.com/Special-Enrol ment-(1)/partner-resources/State-Based-Exchange-
~~Transition.~~
~~Oregon:~~ ~~https://healthcare.oregon.gov/marketplace/gov/Pages/tech-consumer-assistance.aspx.~~
~~Pennsylvania:~~ ~~https://www.insurance.pa.gov/Coverage/Pages/State-Based-Exchange.aspx. Also see CMS~~
~~PY2021 QHP report.~~
Virginia: https://www.governor.virginia.gov/newsroom/all-releases/2020/august/headline-860017-en.html.
~~Also see 2020 CMS Navigator Recipients.~~
~~Also see~~ ~~Sabrina Corlette et al.,~~ ~~States Seek Greater Control, Cost-Savings by Converting to State-Based~~
~~Marketplaces, Robert Wood Johnson Foundation, October 2019, at https://www.rwjf.org/en/library/~~
~~research/2019/10/states-seek-greater-control-cost-savings-by-converting-to-state-based-marketplaces.html.~~
~~Congressional Research Service~~

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~~link to page 23 link to page 23~~ ~~Overview of Health Insurance Exchanges~~

f.
~~No insurers are currently offering medical plans in these SB-SHOPs. (Some may be offering~~HealthCare.gov, “How to offer SHOP health insurance to your employees,” at https://www.healthcare.gov/small-businesses/choose-and-enrol /enrol -in-shop/. See “Enrol ment Processes and Options” in the SHOP section of this report for more information. d. No insurers are currently offering SHOP medical plans in these FF-SHOP states. (Some may be offering SHOP dental plans, however.) See CMS/CCIIO Exchange PUFs (PY 2023): “Business Rules PUF (updated October 17, 2022), at the webpage cited in table note (a). For areas where there are no SHOP plans, HealthCare.gov suggests that small businesses contact agents, brokers, and/or insurers directly to learn about other coverage options. Congressional Research Service 34 link to page 25 Overview of Health Insurance Exchanges e. While most states have maintained the same type of individual exchange they initially opted for, some have transitioned to different exchange types. Citations for prior year exchange types: PY2014: ASPE, Addendum to the Health Insurance Marketplace Summary Enrollment Report, April 2014, at https://aspe.hhs.gov/pdf-report/addendum-health-insurance-marketplace-summary-enrol ment-report. PY2015-2016: Footnote 3 of CMS March 2015 and March 2016 Effectuated Enrollment Snapshots at https://www.cms.gov/newsroom/fact-sheets/march-31-2015-effectuated-enrol ment-snapshot and https://www.cms.gov/newsroom/fact-sheets/march-31-2016-effectuated-enrol ment-snapshot, respectively. PY2017-2022: CMS, “Open Enrol ment Period Public Use Files” (PUFs) and/or PUF FAQs for each year, at https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Marketplace-Products. f. No insurers are currently offering SHOP medical plans in these SB-SHOP states. (Some may be offering SHOP dental plans, dental plans,
~~however.) The SHOP website suggests that smal businesses~~ however.) Some state exchange websites suggest that small businesses contact agents, brokers,contact agents, brokers, and/or insurers and/or insurers
directly to learn about directly to learn about other coverage options. See links in table. ~~coverage options outside of the SHOP. See Arkansas: https://myarinsurance.com/~~
~~pages/manage-shop/~~
Minnesota: https://www.mnsure.org/employer-employees/index.jsp
Nevada: https://www.nevadahealthlink.com/overview/
Pennsylvania: Confirmed via state officials
Washington: Confirmed via state officials
g. For the purposes of SHOP exchange participation, states may define g. For the purposes of SHOP exchange participation, states may define ~~smal~~ small employers (or (or ~~smal~~ small businesses) as businesses) as
employers employers that have not morethat have not more than 50 or not morethan 50 or not more than 100 employees.than 100 employees. ~~See SHOP~~ ~~“Eligibility and~~
~~Enrol ment”~~ ~~in this report.~~ Only four states use the threshold Only four states use the threshold of 100; see links in table. See SHOP “Eligibility and Enrol ment” in this report for more information. h. These SB-SHOPs are using a direct ~~of 100. See~~
California: https://www.coveredca.com/forsmal business/eligible/
Colorado: https://connectforhealthco.com/get-started/options-for-smal -business-owners/, “Employer
~~application”~~
New York: https://nystateofhealth.ny.gov/employer
Vermont: https://info.healthconnect.vermont.gov/smal business_faq
h. ~~These SB-SHOPs are using a direct~~ enrollment approach only:: They do not offer online They do not offer online
enrol ment enrol ment but instead instruct users to connect with agentsbut instead instruct users to connect with agents ~~or brokers offering~~, brokers, insurers, or assistors – or to submit a paper application to the exchange—to enrol in plans through the state’s plans through the state’s
~~SHOP exchange. See~~
Colorado: https://connectforhealthco.com/get-started/options-for-smal -business-owners/
Idaho: https://www.yourhealthidaho.org/smal -business-insurance/
Maryland: https://mhcsmal biz.marylandhealthconnection.gov/anonymous-web/#/quote-engine/enrol
New York: https://nystateofhealth.ny.gov/employer
Oregon: https://healthcare.oregon.gov/marketplace/employers/Pages/employers.aspx
Vermont: https://info.healthconnect.vermont.gov/SB
SHOP exchange. See links in table. i. i.
In some FFE states, the federal In some FFE states, the federal government performsgovernment performs ~~al functions. But~~ all exchange administration functions, but in these FFE states, the state in these FFE states, the state
partners with the federalpartners with the federal government to perform some plan management functions. See footnotes cited in the resource at table note (a). j. Georgia initially ~~government to perform some functions. CMS data do not general y identify these~~
~~“partnership” variations, but the Kaiser Family Foundation tracks them at the site linked in table note (a).~~
j.
~~Georgia~~ received approval through the Section 1332 state innovation waiver process to shift to its own received approval through the Section 1332 state innovation waiver process to shift to its own
“Georgia Access“Georgia Access Model,” Model,” ~~essential y~~ essentially a direct enrol menta direct enrol ment approach, beginning in PY2023. approach, beginning in PY2023. ~~This~~However, this component of the waiver was later suspended for PY2023. The 1332 process allows ~~1332 process~~
~~al ows~~ states to waive specified ACA provisions, states to waive specified ACA provisions, including provisionsincluding provisions related to the establishment of health related to the establishment of health
insurance exchanges and related activities.insurance exchanges and related activities. See CRS Report R44760, See CRS Report R44760, State Innovation Waivers: Frequently
Asked Questions,, for background on 1332 waivers and for morefor background on 1332 waivers and for more information about Georgia’sinformation about Georgia’s waiver.waiver.
~~k. Hawai received~~ In February 2023, Georgia indicated its intention to transition to an SBE approach. See State of Georgia Office of Commissioner of Insurance and Safety Fire, Letter to CCIIO, February 14, 2023, at https://oci.georgia.gov/document/document/georgia-sbe-blueprint-letter-cms/download. k. Hawaii received a Section 1332 waiver exempting it from having SHOP exchangea Section 1332 waiver exempting it from having SHOP exchange, initially for ~~for~~ PYs 2017-2021PYs 2017-2021 then extended through PY2026. This is~~. This~~
~~was~~ related to the state’s pre-existing program and requirements related to the state’s pre-existing program and requirements related to employment-based coverage. related to employment-based coverage.
See the report cited in table note (j) for moreSee the report cited in table note (j) for more ~~information about Hawai ’s waiver.~~
information. l. Regarding Virginia’s ongoing transition to a state-based exchange, see https://scc.virginia.gov/pages/Health-Benefit-Exchange-(6). Congressional Research Service Congressional Research Service

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Appendix B. Types of Plans Offered Through the
Exchanges
In general, health insurance plans offered through exchanges must be qualified health plans In general, health insurance plans offered through exchanges must be qualified health plans
(QHPs).(QHPs).~~134~~146 See See “Qualified Health Plans”” in this report regarding QHP certification requirements ~~in this report for requirements QHPs must meet to be~~
~~sold in the exchanges~~. .
A QHP is the only type of comprehensive health plan an exchange may offer, but QHPs may be A QHP is the only type of comprehensive health plan an exchange may offer, but QHPs may be
offered outside of exchanges, as offered outside of exchanges, as ~~wel~~ well. Besides standard QHPs, there may be other types of plans . Besides standard QHPs, there may be other types of plans
availableavailable in a given exchange, including child-only plans, catastrophic plans, consumer operated in a given exchange, including child-only plans, catastrophic plans, consumer operated
and oriented plans (CO-OPs), and multi-state plans (MSPs). and oriented plans (CO-OPs), and multi-state plans (MSPs). ~~Technical y~~Technically, these are , these are al all also QHPs. also QHPs.
Stand-alone dental plans (SADPs) are the only non-QHPs offered in the exchanges. Stand-alone dental plans (SADPs) are the only non-QHPs offered in the exchanges.
Table B-1. Types of Plans Offered Through the Exchanges
~~Can Be~~
~~PTC and~~
PTC and Can Be Offered
CSR
Outside

Summary
Eligible?
Exchanges?
Qualified
A plan that is offered by a state-licensed insurer that A plan that is offered by a state-licensed insurer that ~~meets~~
Health Plan
meets specified requirements,specified requirements, is certified by an is certified by an ~~exchange, and covers~~
~~Yes~~
~~Yes~~
~~(QHP)~~
~~the essential health benefits~~ (QHP) exchange, and covers the essential health benefits Yes Yes (EHB) package. (EHB) package.
QHP Variations
Child-Only Child-Only
A plan in which only individuals under the age of 21 A plan in which only individuals under the age of 21 Health Insurance may enrol . may enrol .
~~Health~~
If an insurerIf an insurer offers an offers an al all-ages QHP in an -ages QHP in an ~~exchange, it also must~~
Yes Yes
Yes Yes
~~Insurance Plan~~
Plan exchange, it also must offer a child-only plan at the same actuarial level.offer a child-only plan at the same actuarial level.
Catastrophic Catastrophic
Plan A plan that providesA plan that provides the EHB and coverage for at least the EHB and coverage for at least ~~three~~
No No
Yes Yes
~~Plan~~
~~primary~~ three primary care visits; however,care visits; however, it does not meet the minimum it does not meet the minimum
~~requirements~~ requirements related to coveragerelated to coverage generosity (i.e.,generosity (i.e., actuarial actuarial
value). Offered in individual but not value). Offered in individual but not ~~smal~~ small business health business health
options program (SHOP) exchanges. Consumeroptions program (SHOP) exchanges. Consumer eligibility eligibility
~~requirements apply~~. requirements apply.a
Consumer Consumer
~~Yes~~
~~Yes~~
~~Operated and~~
A plan sold by a nonprofit, member-runA plan sold by a nonprofit, member-run health Yes Yes Operated and insurance ~~health insurance~~
~~Oriented Plan~~
company created via a Patient Protection and company created via a Patient Protection and ~~Affordable Care~~
~~(CO-OP)~~
Oriented Plan Affordable Care Act (ACA; P.L. 111-148, as amended) Act (ACA; P.L. 111-148, as amended) ~~program.~~ (CO-OP) program.b
Multi-state Multi-state
Plan A plan sold in the exchanges under contract with the A plan sold in the exchanges under contract with the ~~federal~~
Yes Yes
No No
~~Plan~~ (MSP) (MSP)
federal Office of Personnel Management (OPMOffice of Personnel Management (OPM).c
Non-QHPs
~~Dental-Only~~Stand-alone
Coverage for dental care. May be offered either Coverage for dental care. May be offered either ~~as a stand-alone~~
~~Plan~~
as a dental plan stand-alone plan or in conjunction with a QHP, as longplan or in conjunction with a QHP, as long ~~as it covers pediatric~~
Yes, in certain Yes, in certain
~~Yes~~
(SADP) as it covers pediatric dental benefits that meetdental benefits that meet relevant circumstances. Yes EHB requirements~~relevant EHB requirements.~~
~~circumstances~~. .
Sources: CRS analysis of statute and regulation.CRS analysis of statute and regulation. QHP definition: 42 U.S.C. §18021. Child-only and catastrophic QHP definition: 42 U.S.C. §18021. Child-only and catastrophic
plans: 42 U.S.C. §18022. CO-OPs: 42 U.S.C. §18021 and 42 U.S.C.plans: 42 U.S.C. §18022. CO-OPs: 42 U.S.C. §18021 and 42 U.S.C. §18042. MSPs: 42 U.S.C. §18021 and 42 U.S.C. §18042. MSPs: 42 U.S.C. §18021 and 42 U.S.C.
§18054. §18054. ~~Dental-only~~Stand-alone dental plans: 42 U.S.C. §18031(d)(2)(B)(i ), 45 C.F.R. §155.1065, plans: 42 U.S.C. §18031(d)(2)(B)(i ), 45 C.F.R. §155.1065, and 45 C.F.R. §155.705. Premium and 45 C.F.R. §155.705. Premium
tax credits and cost-sharing reductions: 26 U.S.C.tax credits and cost-sharing reductions: 26 U.S.C. §36B(c)(3)(A) and 42 U.S.C. §18071(f)(1). §36B(c)(3)(A) and 42 U.S.C. §18071(f)(1).

~~134 42 U.S.C.~~ 146 42 U.S.C. §18031(d)(2)(B). §18031(d)(2)(B).
Congressional Research Service Congressional Research Service

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Overview of Health Insurance Exchanges

Notes: ~~PTC = premium tax credit. CSR = cost-sharing reduction~~CSR = cost-sharing reduction; PTC = premium tax credit. .
a. Catastrophic plans are available only to individuals under the age of 30 and individuals who obtain hardship a. Catastrophic plans are available only to individuals under the age of 30 and individuals who obtain hardship
or affordability exemptions or affordability exemptions ~~from the ACA’s individual mandate to maintain minimum essential coverage or~~
~~pay a penalty~~through the exchange. See CRS Report R44438, . See CRS Report R44438, The Individual Mandate for Health Insurance Coverage: In Brief. .
b. The HHS Secretary is required to use funds appropriated to the CO-OP program to finance start-up and b. The HHS Secretary is required to use funds appropriated to the CO-OP program to finance start-up and
solvency loans for eligible solvency loans for eligible nonprofit organizations applying to become a CO-OP. The majoritynonprofit organizations applying to become a CO-OP. The majority of products of products
offered by a CO-OP must be QHPs sold in the offered by a CO-OP must be QHPs sold in the ~~non-group and smal~~ nongroup and small-group markets,-group markets, including through including through
exchanges. CMS exchanges. CMS ~~initial y~~ initially awarded loans to 24 CO-OPs, but one of those 24 was dropped fromawarded loans to 24 CO-OPs, but one of those 24 was dropped from the program the program
prior to offering health plans. See CRS Report R44414, prior to offering health plans. See CRS Report R44414, Consumer Operated and Oriented Plan (CO-OP)
Program: Frequently Asked Questions. Among the remaining. Among the remaining 23 CO-OPs, it 23 CO-OPs, it ~~appears that 3 remain~~
~~operational—meaning they are currently offering health plans and there is no indication that they wil stop~~
~~doing so in the future~~appeared that three were stil offering plans as of April 2021. The other 20 CO-OPs offered health plans at one time but have shut down . The other 20 CO-OPs offered health plans at one time but have shut down or were~~or are~~ in in
various stages of shutting down. various stages of shutting down. As of November 2022, the three CO-OPs are offering plans for 2023 enrol ment; CRS has not reconfirmed the status of the other 20 CO-OPs. See See
Maine: Community Health Options: https://www.healthoptions.org/ Community Health Options: https://www.healthoptions.org/
Idaho, Montana, and Wyoming: Mountain Health CO-OP: https://www.mountainhealth.coop/ Mountain Health CO-OP: https://www.mountainhealth.coop/
and Wisconsin: CommonCommon Ground Healthcare Cooperative:Ground Healthcare Cooperative: https://www.commongroundhealthcare.orghttps://www.commongroundhealthcare.org.
c. The ACA directs c. The ACA directs ~~OPM~~ACA directs the federal Office of Personnel Management (OPM) to contract with private to contract with private ~~insurers~~ insurers in each state to offer at least two QHPs under the in each state to offer at least two QHPs under the
MSP program. The termMSP program. The term multi-state plan is meant to indicate that this program is meant to indicate that this program extends across the states, not extends across the states, not
that the plans themselvesthat the plans themselves are necessarilyare necessarily interstate.interstate. There are not currently any multi-state plans available. There are not currently any multi-state plans available.

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link to page 43 link to page 44 link to page 44 link to page link to page 43 link to page 44 link to page 44 link to page 3132 Overview of Health Insurance Exchanges

Appendix C. Exchange Spending and Funding
Details from CMS Budget Justifications
The Centers for Medicare & Medicaid Services (CMS) in the U.S. Department of Health and The Centers for Medicare & Medicaid Services (CMS) in the U.S. Department of Health and
Human Services (HHS) is the federal agency responsible for administering the health insurance Human Services (HHS) is the federal agency responsible for administering the health insurance
exchanges. In support of the President’s annual proposed budget, CMS, like other agencies, exchanges. In support of the President’s annual proposed budget, CMS, like other agencies,
produces a performance budget, also produces a performance budget, also ~~cal ed~~called a budget justification. Actual spending for the a budget justification. Actual spending for the
proposed budget year depends on the availabilityproposed budget year depends on the availability of appropriations, among other factors. of appropriations, among other factors.
However, the narratives and tables in each year’s budget document are also useful in However, the narratives and tables in each year’s budget document are also useful in
understanding prior-year spending. understanding prior-year spending.
Provisions in annual appropriations acts require CMS to provide, in its budget justification for Provisions in annual appropriations acts require CMS to provide, in its budget justification for
each fiscal year, “cost information” that “details the uses of each fiscal year, “cost information” that “details the uses of al all funds used by the Centers for funds used by the Centers for
Medicare & Medicaid Services Medicare & Medicaid Services ~~specifical y~~specifically for Health Insurance Exchanges for each fiscal year for Health Insurance Exchanges for each fiscal year
since the enactment of the ACA and the proposed uses for such funds [for the upcoming fiscal since the enactment of the ACA and the proposed uses for such funds [for the upcoming fiscal
year]” for the categories shown year]” for the categories shown in Figure C-1~~.135~~in Table C-1.147 Each budget justification also includes narrative Each budget justification also includes narrative
information about federal spending in each of the categories listed in the table. information about federal spending in each of the categories listed in the table.
The exchanges are largely funded by user fees assessed on the insurers who offer plans in FFE The exchanges are largely funded by user fees assessed on the insurers who offer plans in FFE
and SBE-FP exchanges. In addition to these user fees, funding comes from discretionary and SBE-FP exchanges. In addition to these user fees, funding comes from discretionary
appropriations to the CMS Program Management account, risk-adjustment user fees, and appropriations to the CMS Program Management account, risk-adjustment user fees, and
appropriations to the Health Care Fraud and Abuse Control account, among other sourcesappropriations to the Health Care Fraud and Abuse Control account, among other sources. Table
~~C-1~~C-2 displays federal exchange spending according to these funding sources. displays federal exchange spending according to these funding sources.
See See “Exchange Spending and Funding” in this report for more information. Find current and in this report for more information. Find current and
prior-year CMS budget justifications at CMS, “Performance and Budget,” at prior-year CMS budget justifications at CMS, “Performance and Budget,” at
https://www.cms.gov/About-CMS/Agency-Information/PerformanceBudget. https://www.cms.gov/About-CMS/Agency-Information/PerformanceBudget.

~~135 See, for example, the Further~~ 147 See, for example, the Consolidated Appropriations Act, Consolidated Appropriations Act, ~~2020 (P.L. 116-94~~2023 (), Division ), Division ~~A, T itle~~H, Title II, Sec. 220 II, Sec. 220. Congressional Research Service 38 Overview of Health Insurance Exchanges Table C-1. CMS “Health Insurance Marketplaces Transparency Table,” Recent Years ($ in thousands) FY2018 FY2019 FY2020 FY2021 FY2022 FY2023 FY2024 Activity Actual Actual Actual Actual Actual Enacted PB Health Plan Bid Review, $37,910 $45,797 $45,480 $38,841 $54,255 $56,219 $53,319 Management and Oversight Payment and Financial $45,141 $50,220 $39,178 $49,821 $47,780 $57,600 $57,600 Management Eligibility and Enrol ment $392,660 $348,488 $371,802 $350,482 $391,341 $391,627 $417,907 Consumer Information $591,948 $579,088 $503,271 $843,729 $903,220 $1,090,299 $975,981 and Outreach Call Center (non-add) $525,326 $499,053 $440,000 $477,247 $535,219 $504,500 $489,500 Navigators Grants & $12,720 $19,499 $19,689 $91,233 $133,293 $141,747 $141,200 Enrollment Assisters (non-add) Consumer Education and $10,744 $11,231 $14,082 $245,749 $211,592 $382,250 $280,750 Outreach (non-add) Information Technology $767,413 $504,283 $549,369 $515,388 $511,706 $552,830 $561,713 Quality $7,240 $7,334 $7,063 $6,391 $6,706 $7,777 $8,282 SHOP and Employer $4,418 $2,117 $200 $197 $195 $195 $195 Activities Other Marketplace $31,196 $40,290 $63,579 $38,827 $35,400 $62,267 $63,644 Federal Payrol and Other $70,892 $77,750 $85,833 $120,071 $134,741 $164,170 $168,924 Administrative Activities Total $1,948,818 $1,655,367 $1,665,775 $1,963,746 $2,085,344 $2,382,984 $2,307,565
~~and the Consolidated Appropriations Act, 2021 (P.L. 116-260), Division H, T itle II, Sec. 220.~~
~~Congressional Research Service~~

38

~~Figure C-1. Centers for Medicare & Medicaid Services “Health Insurance Exchanges Transparency Table,” FY2021~~
~~($ in thousands)~~

Source: Department of Health and Human ServicesDepartment of Health and Human Services, (HHS), Centers for Medicare & Medicaid ServicesCenters for Medicare & Medicaid Services, (CMS), Justification of Estimates for Appropriations Committees, Fiscal Year ~~2021~~2024, ,
March March ~~3, 2020~~13, 2022, at https://www.cms.gov/, at https://www.cms.gov/~~About-CMS/Agency-Information/PerformanceBudget/FY2021-CJ-Final~~files/document/cms-fy-2024-congressional-justification-estimates-appropriations-committees.pdf. See “Health Insurance .pdf. See “Health Insurance ~~Exchanges~~Marketplaces Transparency Table,” Transparency Table,”
~~page 241. Discussion of spending categories is at “Federal Exchanges~~pages 237-238, including for these data for FYs 2010-2017 and for CMS notes on these data. Discussion of spending categories is at “Federal Marketplace Programs” table and narrative, ” table and narrative, ~~page 195-200~~pages 199-204. .
Notes: FY = fiscal yearFY = fiscal year.

~~CRS-39~~

~~link to page 44 link to page 44 link to page 44~~ ; CR = continuing resolution; PB = President’s Budget (proposed). Note that actual spending for the proposed budget year depends on the availability of appropriations, among other factors. Congressional Research Service 39 link to page 44 link to page 44 link to page 44 link to page 44 link to page 44 link to page 44 link to page 44 link to page 44 Overview of Health Insurance Exchanges

Table C-12. CMS Federal Exchange Funding Sources ~~for Specified Fiscal~~, Recent Years
($ in thousands) ($ in thousands)
~~FY2021~~
~~President’s~~
~~FY2021~~
~~Budget +/-~~
~~FY2018~~
~~FY2019~~
~~FY2020~~
~~President’s~~
~~FY 2020~~FY2018 FY2019 FY2020 FY2021 FY2022 FY2023 FY2024
Treasury Accounta
Actual
~~Finalb~~
~~Enactedb~~
~~Budgetc~~
~~Enacted~~Final Final Final Final Enacted PB
Program Management
$1,944,190 $1,944,190
$1,636,111 $1,618,091 $1,939,603 $2,066,898 $2,343,586 $2,263,744~~$1,636,111~~
~~$1,720,937~~
~~$1,171,728~~
~~($549,209)~~
Discretionary Discretionary Appropriation Appropriation
$618,164 $618,164
$263,895 $263,895
$ $~~296,533~~
$0
~~($296,533)~~
~~Program Operations (non-~~261,226 $142,455 $143,977 $147,729 $165,122 Program Operations (non-add)
$580,886
$229,384
$~~268,937~~226,035
$0
~~($286,937)~~119,520 $119,685 $121,000 $137,003
Federal Administration (non-add)
$37,278
$34,511
$~~27,596~~35,191 $22,936 $24,292 $26,729 $28,119
$0
~~($27,596)~~
Offsetting Col ections Offsetting Col ections
$1,304,280 $1,304,280
$1,351,893 $1,335,768 $1,776,028 $1,899,955 $2,163,585 $2,060,800 [FFE] User Fee (non-add)b $1,272,168 $1,304,458 $1,310,948 $1,729,249 $1,853,605 $2,106,081 $2,001,736 Risk Adjustment ~~$1,351,893~~
~~$1,399,404~~
~~$1,171,728~~
~~($227,676)~~
~~Federal y facilitated Exchange User~~
~~$1,272,168~~
~~$1,304,458~~
~~$1,341,039~~
~~$1,120,199~~
~~($220,840)~~
~~Fee (non-add)d~~
~~Risk Adjustment~~ User Fee (non-
add)
$32,112
$47,435
$~~58,365~~
~~$51,530~~
~~($6,836)~~24,820 $46,778 $46,350 $57,504 $59,064
Other Other
$21,746 $21,746
$20,323 $20,323
$ $~~25,000~~
$0
~~($25,000)~~
~~Health~~ 21,097 $21,120 $22,966 $32,272 $37,822 Health Care Fraud and Abuse
Control
$4,629 $4,629
$19,256 $19,256
$ $~~63,918~~
~~$25,384~~
~~($38,534)~~47,684 $24,143 $18,446 $39,398 $43,821
Discretionary Discretionary Appropriation Appropriation
$0 $0
$19,256 $19,256
$ $~~63,918~~
~~$25,384~~
~~($38,534)~~47,684 $24,143 $18,446 $39,398 $43,821
Mandatory Appropriatio Mandatory Appropriationenc
$4,629 $4,629
~~n/a~~
~~n/a~~
~~n/a~~
~~n/a~~N/A N/A N/A N/A N/A N/A
Total, Program Level
$1,948,818
$1,655,367 $1,665,775 $1,963,746 $2,085,344 $2,382,984 $2,307,565 FFE~~$1,655,367~~
~~$1,784,855~~
~~$1,197,112~~
~~($587,743)~~

~~Exchange~~ User Fee Amounts as
a Percentage ~~of Program Level~~ of
65.3%
~~78.8%~~
~~75.1%~~
~~93.6%~~
~~n/a~~
~~Funding Source~~sf78.8% 78.7% 88.1% 88.9% 88.4% 86.7% Program Level Funding Sourcesd
Sources: Unless otherwiseUnless otherwise specified,specified, ~~data are~~ compiled by CRS from compiled by CRS from ~~the fol owing sources.~~ Centers for Medicare & Medicaid Services (CMS) annual budget justifications as indicated below, available at https://www.cms.gov/About-CMS/Agency-Information/PerformanceBudget. Comparable data Comparable data
were not found in prior years’not found in prior years’ budget justifications. budget justifications.
FY2019-FY2021 columns in table: Department of Health and Human Services, Centers for Medicare &
~~Medicaid Services,~~ ~~Justification~~ FY2022-2024 in this table: HHS, CMS, Justification of Estimates for Appropriations Committees, Fiscal Year ~~2021~~~~, March 3, 2020, at~~
~~https://www.cms.gov/About-CMS/Agency-Information/PerformanceBudget/FY2021-CJ-Final.pdf. “Federal~~
~~Exchanges” table, page 195.~~
FY2018 column in table: HHS, CMS, ~~Justification of Estimates for Appropriations Committees, Fiscal Year 2020,~~
~~March 13, 2019, at https://www.cms.gov/files/document/fy2020-cms-congressional-justification-estimates-~~
~~appropriations-committees.pdf. “Federal Exchanges” table, page 178.~~
Notes: FY = fiscal year.
~~a. See source documents for description of Treasury Account categories.~~
~~b. The FY2019 Final and FY2020 Enacted amounts were estimates as of January 2020.~~
~~c. The FY2021 President’s budget amounts were the Administration’s proposals for FY2021.~~
~~d. Per communication with CMS, this row is inclusive of both FFE and SBE-FP federal user fees.~~
e 2024 (CMS Budget Justification FY2024), March 13, 2023. See “Federal Marketplace Programs” table, page 199. FY2021: CMS Budget Justification FY2023, May 6, 2022. See “Federal Marketplace Programs” table, page 199. FY2020: CMS Budget Justification FY2022, May 31, 2021. See “Federal Marketplaces” table, page 199. FY2019: CMS Budget Justification FY2021, March 3, 2020. See “Federal Exchanges” table, page 195. FY2018: CMS Budget Justification FY2020, March 13, 2019. See “Federal Exchanges” table, page 178. Notes: FY = fiscal year; CR = continuing resolution; PB = President’s Budget (proposed); FFE = federally facilitated exchange; N/A = not available. Actual spending for the proposed budget year depends on the availability of appropriations, among other factors. a. See source documents for description of Treasury Account categories. b. Per communication with CMS, this row is inclusive of both federally facilitated exchange and state-based exchange using the federal information technology platform federal user fees. c. Health Care Fraud and Abuse Control (HCFAC) “Mandatory Appropriation” was listed in the FY2020 table . Health Care Fraud and Abuse Control (HCFAC) “Mandatory Appropriation” was listed in the FY2020 table
that included that included ~~the~~these FY2018 amounts FY2018 amounts, but not in the FY2021 but not in the FY2021 ~~table that included the other amounts~~or subsequent Budget Justifications. The . The
FY2020 table also showed $5,000 in this row for “FY2019 Enacted,” but the FY2021 table did not show any FY2020 table also showed $5,000 in this row for “FY2019 Enacted,” but the FY2021 table did not show any
such amounts for “FY2019 Final.” Per the FY2020 table, “HCFAC mandatory Wedge funding is subject to such amounts for “FY2019 Final.” Per the FY2020 table, “HCFAC mandatory Wedge funding is subject to
an annual an annual ~~al ocation~~allocation process process by the Attorney Generalby the Attorney General and Secretary of Health and Human Services.” and Secretary of Health and Human Services.”
f.
d. Calculated by CRS. Calculated by CRS.
Congressional Research Service Congressional Research Service

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link to page 46 link to page 46 link to page 46 link to page 46 Overview of Health Insurance Exchanges

Appendix D. Additional Resources
HHS “Notice of Benefit and Payment Parameters” ~~(Payment~~
~~Notices), Final Rule~~ by Year
The “Notice of Benefit and Payment Parameters,” also The “Notice of Benefit and Payment Parameters,” also ~~cal ed~~called the “Payment Notice,” is a rule the “Payment Notice,” is a rule
published published ~~annual y~~annually by the Department of Health and Human Services (HHS). It addresses the by the Department of Health and Human Services (HHS). It addresses the
exchanges and certain other private health insurance topics. It includes annual updatesexchanges and certain other private health insurance topics. It includes annual updates, such as such as
changes to insurer user fee amounts, and policy changeschanges to insurer user fee amounts, and policy changes, such as modified eligibility such as modified eligibility
requirements for the Navigator program.requirements for the Navigator program.
The rule is titled according to the upcoming plan year that it addresses. For example, the 2021 The rule is titled according to the upcoming plan year that it addresses. For example, the 2021
Payment Notice was finalized in May 2020, with changes applicable to the 2021 plan year (which Payment Notice was finalized in May 2020, with changes applicable to the 2021 plan year (which
~~is general y~~is generally the calendar year). the calendar year).
Final and proposed Payment Notices can Final and proposed Payment Notices can also be found by searching “Notice of Benefit and Payment be found by searching “Notice of Benefit and Payment
Parameters” at www.federalregister.gov.Parameters” at www.federalregister.gov.
Table D-1. HHS “Notice of Benefit and Payment Parameters,” Final Rule by Year
For Plan
Publication
Year
Title ~~and Link~~
Citation
Date
~~2022~~2023 Patient Protection
~~Patient Protection~~ and Affordable Care Act; HHS Notice of Benefit and 87 Federal May 6, 2022 Payment Parameters for 2023 Register 27208 2022, Patient Protection and Affordable Care Act; Updating Payment 86 Federal September “Part 3”a Parameters, Section 1332 Waiver Implementing Regulations, and Register 53412 27, 2021 Improving Health Insurance Markets for 2022 and Beyond 2022, Patient Protection and Affordable Care Act; HHS Notice of Benefit and 86 Federal May 5, 2021 “Part 2”a Payment Parameters for 2022 and Pharmacy Benefit Manager Standards Register 24140 2022, Patient Protection and Affordable Care Act; HHS Notice of Benefit and 86 Federal January 19, “Part 1”a Payment Parameters for 2022; Updates to State Innovation Waiver Register 6138 2021 (Section 1332 Waiver) Implementing Regulations 2021 Patient Protection and Affordable Care Act; HHS Notice of Benefit and 85 Federal May 14, 2020 Payment Parameters for 2021; Notice Requirement for Non-Federal Register 29164 Governmental Plans 2020 Patient Protection and Affordable Care Act; HHS Notice of Benefit and 84 Federal April 25, Payment Parameters for 2020 Register 17454 2019 2019 Patient Protection and Affordable Care Act; HHS Notice of Benefit and 83 Federal April 17, Payment Parameters for 2019 Register 16930 2018 2018 Patient Protection and Affordable Care Act; HHS Notice of Benefit and 81 Federal December Payment Parameters for 2018, Amendments to Special Enrol ment Register 94058 22, 2016 Periods and the Consumer Operated and Oriented Plan Program 2017 Patient Protection and Affordable Care Act; HHS Notice of Benefit and 81 Federal March 8, Payment Parameters for 2017 Register 12203 2016 2016 Patient Protection and Affordable Care Act; HHS Notice of Benefit and ~~Care Act; HHS Notice~~ 86 Federal
~~January 19,~~
~~of Benefit and Payment Parameters for 2022; Updates to~~
Register 6138
~~2021~~
~~State Innovation Waiver (Section 1332 Waiver)~~
~~Implementing Regulations~~ a
~~https://www.federalregister.gov/documents/2021/01/19/2021-~~
~~01175/patient-protection-and-affordable-care-act-hhs-notice-of-~~
~~benefit-and-payment-parameters-for-2022~~
~~2021~~
~~Patient Protection and Affordable Care Act; HHS Notice 85 Federal~~
~~May 14, 2020~~
~~of Benefit and Payment Parameters for 2021; Notice~~
Register 29164
~~Requirement for Non-Federal Governmental Plans~~
~~https://www.federalregister.gov/documents/2020/05/14/2020-~~
~~10045/patient-protection-and-affordable-care-act-hhs-notice-of-~~
~~benefit-and-payment-parameters-for-2021~~
~~2020~~
~~Patient Protection and Affordable Care Act; HHS Notice 84 Federal~~
~~April 25, 2019~~
~~of Benefit and Payment Parameters for 2020~~
Register 17454
~~https://www.federalregister.gov/documents/2019/04/25/2019-~~
~~08017/patient-protection-and-affordable-care-act-hhs-notice-of-~~
~~benefit-and-payment-parameters-for-2020~~
~~2019~~
~~Patient Protection and Affordable Care Act; HHS Notice 83 Federal~~
~~April 17, 2018~~
~~of Benefit and Payment Parameters for 2019~~
Register 16930
~~https://www.federalregister.gov/documents/2018/04/17/2018-~~
~~07355/patient-protection-and-affordable-care-act-hhs-notice-of-~~
~~benefit-and-payment-parameters-for-2019~~
~~2018~~
Patient Protection and Affordable Care Act; HHS Notice 81 Federal
~~December 22,~~
~~of Benefit and Payment Parameters for 2018,~~
Register 94058
~~2016~~
~~Amendments to Special Enrollment Periods and the~~
~~Consumer Operated and Oriented Plan Program~~
~~https://www.federalregister.gov/documents/2016/12/22/2016-~~
~~30433/patient-protection-and-affordable-care-act-hhs-notice-of-~~
~~benefit-and-payment-parameters-for-2018~~
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~~link to page 17~~ ~~Overview of Health Insurance Exchanges~~

~~For Plan~~
~~Publication~~
~~Year~~
~~Title and Link~~
~~Citation~~
~~Date~~
~~2017~~
Patient Protection and Affordable Care Act; HHS Notice 81 Federal
~~March 8, 2016~~
~~of Benefit and Payment Parameters for 2017~~
Register 12203
~~https://www.federalregister.gov/documents/2016/03/08/2016-~~
~~04439/patient-protection-and-affordable-care-act-hhs-notice-of-~~
~~benefit-and-payment-parameters-for-2017~~
~~2016~~
~~Patient Protection and Affordable Care Act; HHS Notice 80 Federal~~
~~February 27,~~
~~of Benefit and Payment~~ 80 Federal February 27, Payment Parameters for 2016
Register 10749 10749
~~2015~~
~~https://www.federalregister.gov/documents/2015/02/27/2015-~~
~~03751/patient-protection-and-affordable-care-act-hhs-notice-of-~~
~~benefit-and-payment-parameters-for-2016~~
~~2015~~
~~Patient Protection~~ 2015 2015 Patient Protection and Affordable Care Act; HHS Notice of Benefit and 79 79 Federal
March 11, March 11,
~~of Benefit and Payment~~ Payment Parameters for 2015
Register 13743 13743
~~2014~~
~~https://www.federalregister.gov/documents/2014/03/11/2014-~~
~~05052/patient-protection-and-affordable-care-act-hhs-notice-of-~~
~~benefit-and-payment-parameters-for-2015.~~ 2014 2014 Patient Protection
~~2014~~
~~Patient Protection~~ and Affordable Care Act; HHS Notice of Benefit and 78 78 Federal
March 11, March 11,
~~of Benefit and Payment~~ Payment Parameters for 2014
Register 1540915409
~~2013~~
~~https://www.federalregister.gov/documents/2013/03/11/2013-~~
~~04902/patient-protection-and-affordable-care-act-hhs-notice-of-~~
~~benefit-and-payment-parameters-for-2014~~
Source: United States Federal Register at https://www.federalregister.gov/.
2013 Source: United States Federal Register at https://www.federalregister.gov/. Congressional Research Service 41 Overview of Health Insurance Exchanges Notes: There have been other rulesThere have been other rules and agency guidance relevant to the exchanges and private health and agency guidance relevant to the exchanges and private health
insurance. This table is meant to be a compilation of only this type of annual rule. insurance. This table is meant to be a compilation of only this type of annual rule.
a. The 2022 Payment Notice final rulea. The 2022 Payment Notice final rule ~~was published but not in effect before the presidential transition. As~~
~~such, it may be reconsidered by the Biden Administration. See Office of Management and Budget,~~
~~“Memorandum for the Heads of Executive Departments and Agencies,” 86 Federal Register 7424, January 28,~~
~~2021. In addition, the final rule published January 19, 2021, did not address al the topics discussed in the~~
~~November proposed rule, including topics subject to annual updating, like the out-of-pocket maximum for~~
~~2022 (see “Premiums and Cost Sharing” in this report). The final rule stated on page 6139 that HHS~~
~~“intend[s] to address the other topics and proposed policies outlined in the proposed 2022 Payment Notice~~
~~in future rulemaking, taking into account comments received on those proposals,” and on page 6141 that~~
~~“HHS determined that it was appropriate to address in this final rule only those policies in the proposed~~
~~2022 Payment Notice that were most important to advancing the policy goals of reducing fiscal and~~
~~regulatory burdens across related program areas and providing stakeholders with greater flexibility.”~~
, here noted as “Part 1,” was published by the Trump Administration, but did not take effect before the presidential transition. The Biden Administration subsequently published two more Final 2022 Payment Notices, repealing some of what had been published in Part 1, and addressing some topics not included in Part 1. In this report and elsewhere, the informal references “Part 1,” “Part 2,” and “Part 3,” are used to distinguish these three final rules. Other Federal Resources
Selected resources are available at the following links. Selected resources are available at the following links.
 Center for Consumer Information and Insurance Oversight (CCIIO) FAQs,  Center for Consumer Information and Insurance Oversight (CCIIO) FAQs,
letters, and other resources related to the exchanges (also see pages linked to the letters, and other resources related to the exchanges (also see pages linked to the
left side of the webpage): https://www.cms.gov/CCIIO/Programs-and-Initiatives/left side of the webpage): https://www.cms.gov/CCIIO/Programs-and-Initiatives/
Health-Insurance-MarketplacesHealth-Insurance-Marketplaces
 CRS compilation of HHS resources on exchange enrollment  CRS compilation of HHS resources on exchange enrollment: and other exchange data: CRS Report CRS Report
R46638, R46638, Health Insurance Exchanges: Sources for Statistics

~~Congressional Research Service~~

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~~Overview of Health Insurance Exchanges~~

Author Information

Vanessa C. Forsberg Vanessa C. Forsberg

Analyst in Health Care Financing Analyst in Health Care Financing

~~Acknowledgments~~
~~Noah Isserman, Analyst in Health Care Financing, and Kate Costin, Research Librarian, provided~~
~~significant review of the content and tables in this report, respectively .~~

Disclaimer
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