Overview of Health Insurance Exchanges

June 10, 2015 – March 17, 2023 R44065

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

In general, states must have two types of exchanges: an individual exchange and a small business

health options program (SHOP) exchange. Exchanges may be established either by the state
itself as a state-based exchange (SBE) or by the Secretary of Health and Human Services (HHS) as a federally facilitated
exchange (FFE). Some states have SBE-FPs: they have SBEs but use the federal information technology platform (FP),
including the federal exchange website www.HealthCare.gov.
A primary function of the exchanges is to facilitate enrollment. This generally includes operating a web portal that allows for
the comparison and purchase of coverage; making determinations of eligibility for coverage and financial assistance; and
offering different forms of enrollment assistance, including Navigators and a call center. Exchanges also are responsible for
several administrative functions, including certifying the plans that will be offered in their marketplaces.
The ACA generally 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 and must meet
specified requirements, including covering the essential health benefits (EHB). QHPs sold in the individual 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 individual and small-group markets, respectively. Additional 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.
Consumers and small businesses must meet certain eligibility criteria to purchase coverage through the individual and SHOP
exchanges, respectively. There is an annual open enrollment period during which any eligible consumer may purchase
coverage via the individual exchanges; otherwise, consumers may purchase coverage only if they qualify for a special
enrollment period. In general, small businesses may enroll at any time during the year. There are plans available in all
individual exchanges, and about 16.3 million people obtained health insurance through the individual exchanges during the
2023 open enrollment period. Nationwide SHOP exchange enrollment estimates are not regularly released; in addition, there
are no SHOP exchange plans available in more than half of states in 2023, similar to 2022.
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 eligible for federal financial
assistance with premiums and OOP costs in the form of premium tax credits and cost-sharing reductions. Small businesses
that use the SHOP exchanges may be eligible for small business health insurance tax credits that assist with the cost of
providing health insurance coverage to employees.
The federal government spent an estimated $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. Much of the federal spending on the exchanges is funded by
user fees paid 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., their own Navigator programs).
This report provides an overview of key aspects of the health insurance exchanges, including types and administration of
exchanges, eligibility and enrollment, plan costs and financial assistance, insurer participation, and exchange financing. It
also includes information about policy changes enacted under the American Rescue Plan Act of 2021 (ARPA; P.L. 117-2)
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 Coronavirus Disease 2019 (COVID-19) pandemic and related economic
recession.

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Introduction
The Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended) required health
insurance exchanges (also known as marketplaces) to be established in every state. The ACA
exchanges are virtual marketplaces in which consumers and small businesses can shop for and
purchase private health insurance coverage and, where applicable, be connected to public health
insurance programs (e.g., Medicaid).1 Certain consumers and small employers are eligible for
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
intended to supplant the private market outside of the exchanges but rather to provide an
additional source of private health insurance coverage options.
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 small
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)
and (2) to certify, recertify, and otherwise monitor the plans that are offered in those
marketplaces.
Although a relatively small 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
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
coverage and costs, the roles of the public and private sectors in the provision of health coverage,
and more.
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.
Sections on the individual and small business exchanges discuss eligibility and enrollment, plan
costs and financial assistance available to eligible consumers and small businesses, insurer
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.
Appendixes offer further details, including exchange types by state.
The report includes information about policy changes enacted under the American Rescue Plan
Act of 2021 (ARPA; P.L. 117-2) 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 Coronavirus Disease 2019 (COVID-19) pandemic and related economic
recession.

1 In this report, the terms consumers and individuals generally are used interchangeably, 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 exchanges during the 2023
open enrollment period (November 1, 2022, through January 15, 2023, in most states). This figure is approximately
4.88% of the U.S. population of about 334.4 million people as of February 2023. See Table 1 regarding exchange
enrollment estimates and sources. The U.S. population estimate is 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/.
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Overview
Types and Administration of Exchanges
Individual and SHOP Exchanges
The ACA required health insurance exchanges to be established in all states and the District of
Columbia.3 In general, the health insurance exchanges began operating in October 2013 to allow
consumers to shop for health insurance plans that began as soon as January 1, 2014.
There are two types of exchanges—individual exchanges and small business health options
program (SHOP) exchanges.4 These exchanges are part of the nongroup and small-group
segments of the private health insurance market, respectively.5 In an individual exchange, eligible
consumers can compare and purchase nongroup insurance for themselves and their families and
can apply for premium tax credits and cost-sharing reductions (PTCs and CSRs) that are available
only through the exchanges (see “Premium Tax Credits and Cost-Sharing Reductions”).
In a SHOP exchange, small businesses can compare and purchase small-group insurance and can
apply for small business health insurance tax credits (see “Small Business Health Care Tax
Credit”); in addition, employees of small businesses can enroll in plans offered by their
employers on a SHOP exchange.
Each exchange covers a whole state.6 Within an 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 sold
within a given exchange may cover services offered by providers located in more than one state.
In general, consumers and small businesses may obtain coverage within their state’s individual or
SHOP exchange, respectively, or they may shop in the nongroup or small-group health insurance
markets outside of the exchanges, which existed prior to the ACA and continue to exist.7 Outside
of the ACA exchanges, consumers can purchase coverage through agents or brokers, or they can
purchase it directly from insurers. In addition, there were and still are privately operated websites
that allow the comparison and purchase of coverage sold by different insurers, broadly similar in
concept to the ACA exchanges.8

3 The Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended) also gave the territories the option
of establishing exchanges, but none elected to do so, by the statutory deadline of October 1, 2013. See 42 U.S.C.
§18043.
4 The term individual exchange is used for purposes of this report. It is not defined in exchange-related statute or
regulations.
5 Broadly, private health insurance includes group plans (largely, employer-sponsored insurance) and nongroup plans
(i.e., plans that consumers purchase directly from insurers). The group market is divided into small- and large-group
market segments; a small group is typically defined as a group of up to 50 individuals (e.g., employees), and a large
group is typically defined as one with 51 or more individuals.
6 There is an option for states to coordinate in administering regional exchanges or for a single state to establish
subsidiary exchanges that serve geographically distinct areas (see 45 C.F.R. §155.410), but none have done so.
7 However, plans are not available in all small business health options program (SHOP) exchanges in 2023.
8 An example of a privately owned website that allows for comparison and purchase of coverage from different insurers
is ehealthinsurance.com. Note that some types of coverage sold outside of the federal and state exchanges, potentially
including 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 CRS Report R46003, Applicability of Federal Requirements to
Selected Health Coverage Arrangements.
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State-Based and Federally Facilitated Exchanges
A state can choose to establish its own state-based exchange (SBE). If a state opts not to
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
the exchange in the state as a federally facilitated exchange (FFE).
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 federally
facilitated information technology (IT) platform, or federal platform (FP) (i.e., HealthCare.gov).
There is also a variation on the FFE approach: a state may have a state partnership FFE, which
allows 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
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
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 separately, but rather
may be included in overall counts of FFEs, which is the model this report generally follows.
In rulemaking finalized January 19, 2021 (the 2022 Notice of Benefit and Payment Parameters, or
“Payment Notice”10), HHS and the Department of the Treasury established new “direct
enrollment” variations of the exchange types: FFE-DE, SBE-DE, and SBE-FP-DE. States 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, 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 would still have
to “make available a website listing basic [qualified health plan] QHP 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 would have
been 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 transition. 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/
Resources/Fact-Sheets-and-FAQs/Downloads/ffe-guidance-05-16-2012.pdf. Also see CMS, CCIIO, “Guidance on
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 “Navigators and Other
Exchange-Based Enrollment Assistance” in this report.
10 See 2022 Payment Notice, “Part 1,” starting page 6143, regarding information in this paragraph. The Notice of
Benefit and Payment Parameters, or Payment Notice, is an annually published rule that includes updates and policy
changes related to the exchanges and private health insurance. Because different parts of the Final 2022 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.
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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 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 from a fully state-based approach to an SBE-FP (i.e., transitioned toward more
federal involvement). Recent and ongoing transitions are generally in the direction of less federal
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 SHOP 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 PY2023, and see Table A-1 for
additional information, including on state transitions to different exchange types.

12 In tallies throughout this report, the District of Columbia is counted as a state.
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 to shift to its own
Georgia Access Model, essentially a direct enrollment exchange type, beginning in PY2023. 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 states to waive specified ACA provisions, including provisions related to the
establishment of health insurance exchanges and related activities, see CRS Report R44760, State Innovation Waivers:
Frequently Asked Questions. 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)
approach, except that the two states with that model at that time (Nevada and Kentucky) could maintain it. According
to CMS, those states no longer use that model. See “Enrollment Processes and Options” in the SHOP section of this
report for more information.
16 See “Insurer Participation” in the SHOP section of this report for more information.
17 Hawaii 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.
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Overview of Health Insurance Exchanges

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

Source: CRS il ustration. See data sources in Table A-1.
Notes: SHOP = small business health options program; IT = information technology. Counts of “states” include
the District of Columbia. In the individual exchanges, plan year is generally the calendar year, but group plan
years, including in the SHOP exchanges, may start at any time during a calendar year. See report “Overview”
regarding individual and SHOP exchanges, and federal and state administration of exchanges.
In about half of the states, no insurers are offering medical plans in the SHOP exchange, meaning there is
effectively no SHOP exchange there. See “Insurer Participation” in the SHOP section of this report for more
information. There are medical plans available in all individual exchanges.
Hawaii received a Section 1332 waiver exempting it from operating a SHOP exchange. For more information,
see CRS Report R44760, State Innovation Waivers: Frequently Asked Questions.
Exchange Administration
Whether state-based or federally facilitated, exchanges are required by law to fulfill certain
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
regarding the requirements for plans that may be sold through the exchanges.18
A primary function of the exchanges is to provide a way for consumers and small businesses to
compare and purchase health plan options offered by participating insurers.19 This generally
includes operating a web portal that allows for comparing and purchasing coverage, making
determinations of eligibility for coverage and financial assistance, and offering different forms of
enrollment assistance.
Exchanges also are responsible for several administrative functions, including certifying the plans
that will be offered in their marketplaces.20 This includes annually certifying or recertifying plans
to be sold in their exchanges as qualified health plans (QHPs, discussed below). QHP
certification involves a review of various factors, including the plan’s benefits, cost-sharing

18 See “Qualified Health Plans” in this report.
19 42 U.S.C. §18031(b)(1)(A).
20 42 U.S.C. §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.21 The QHP certification process
is to be completed each year in time for insurers to market their plans and premiums during the
exchanges’ annual open enrollment period (see “Open and Special Enrollment Periods”).
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
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 qualified health plans
(QHPs).22 A QHP is a plan offered by a state-licensed insurer that is certified to be sold in that
state’s exchange, covers the essential health benefits (EHB) package, and meets other specified
requirements.23 Covering the EHB package means covering 10 broad categories of benefits,
complying with limits on consumer cost sharing on the EHB, and meeting certain 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
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
state and federal requirements applicable to individual market (or nongroup market) plans; a QHP
offered through a SHOP exchange must comply with state and federal requirements applicable to
small-group market plans. For example, the requirement to cover the EHB applies to individual
and small-group plans both in and out of the exchanges.
There are additional requirements that apply only to QHPs sold in the exchanges.27 For example,
an insurer wanting to sell QHPs in an exchange must offer at least one silver-level and one gold-
level plan in all of the areas in which the insurer offers coverage within that exchange. In
addition, QHPs that use provider networks must meet network adequacy standards, including
maintaining provider networks 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, at https://www.cms.gov/CCIIO/Resources/Regulations-
and-Guidance/Downloads/Final-2023-Letter-to-Issuers.pdf. Hereinafter referred to as “CMS, 2023 Final Letter to
Issuers.”
22 42 U.S.C. §18031(d)(2)(B).
23 42 U.S.C. §18021(a)(1).
24 42 U.S.C. §18022.
25 See “Cost Sharing, Maximum Out-of-Pocket Limits, and Actuarial Value Levels” for more information.
26 For more information about federal requirements applicable to different types of plans, see CRS Report R45146,
Federal Requirements on Private Health Insurance Plans. This report also addresses states’ roles as the primary
regulators of health insurance.
27 See, for example, 42 U.S.C. §§18021, 18023, and 18031; and 45 C.F.R. §§156.200 et seq. Also see CMS, 2023 Final
Letter to Issuers.
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“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.
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
an exchange, it must meet applicable federal and state requirements, as discussed in this section
and the prior one on “Exchange Administration.” Insurer participation in the individual and
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.
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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,
consumers can be determined eligible for exchange financial assistance (see “Premium Tax
Credits and Cost-Sharing Reductions” in this report), as well as Medicaid and the State
Children’s Health Insurance Program (CHIP), as discussed below.36 The exchange website
displays all exchange plans available to a consumer, with estimates of the consumer’s costs,
including monthly premiums that reflect the application of any federal financial assistance for
which they are eligible.
In addition to using their exchange website, consumers can apply and enroll by phone, by mail, 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., through exchange Navigators or
through agents or brokers).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
or planned employment in a state, and other circumstances. See 45 C.F.R. §155.305.
34 U.S. citizens and U.S. nationals are eligible for coverage through the exchanges. Lawfully present immigrants are
also eligible for coverage through the exchanges. Examples of lawfully present immigrants include those who have
qualified non-citizen immigration status without a waiting period, humanitarian statuses or circumstances, valid non-
immigrant visas, and legal status conferred by other laws. See 45 C.F.R. §155.305 and HealthCare.gov, “Coverage for
Lawfully Present Immigrants,” at https://www.healthcare.gov/immigrants/lawfully-present-immigrants/.
35 42 U.S.C. §18083, 45 C.F.R. §155.405.
36 Medicaid is a joint federal-state program that finances the delivery of primary and acute medical services, as well as
long-term services and supports, to a diverse low-income population, including children, pregnant women, adults,
individuals with disabilities, and people aged 65 and older. CHIP is a means-tested program that provides health
coverage to targeted low-income children and pregnant women in families that have annual income above Medicaid
eligibility levels but have no health insurance. The “applicable State health subsidy programs” also include the Basic
Health Program, which is operational 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.
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Interaction with Medicaid, CHIP, and Medicare
In conjunction with the streamlined application mentioned above, exchanges must have systems
for coordinating with the Medicaid and CHIP programs on eligibility determinations and
enrollment into those programs, for eligible consumers. These systems may vary by state.38
Consumers who are eligible for Medicaid or CHIP may choose to buy exchange coverage instead,
but they would not be eligible for financial assistance for exchange coverage (i.e., PTCs or cost-
sharing reductions).
There are some limitations on the sale of exchange plans to Medicare-eligible or Medicare-
enrolled individuals.39 In short, it is generally illegal to sell an individual exchange plan to
someone enrolled in or entitled to Medicare because it would duplicate coverage.
Open and Special Enrollment Periods
Consumers may enroll in coverage through the exchanges only during specified “open” and
“special” enrollment periods.
Open Enrollment Periods
Anyone eligible for exchange plan coverage may newly enroll (or make changes to existing
coverage) during an annual open enrollment period (OEP).40 The OEP typically takes place in fall
of the year preceding the plan year (PY; the calendar year in the individual exchanges) during
which the coverage is effective.
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, at https://www.cms.gov/files/document/ffeffshop-enrollment-manual-
2022.pdf. Hereinafter referred to as “CMS, FFE and FF-SHOP Enrollment Manual (2022).” Regarding SBE states,
also see Sara Rosenbaum et al., Streamlining Medicaid Enrollment: The Role of the Health Insurance Marketplaces
and the Impact of State Policies, Commonwealth Fund, March 30, 2016, at https://www.commonwealthfund.org/
publications/issue-briefs/2016/mar/streamlining-medicaid-enrollment-role-health-insurance.
39 Social Security Act §1882(d)(3)(A)(i). Medicare is a federal program that pays for covered health care services for
most people aged 65 and older and for certain permanently disabled individuals under the age of 65. The prohibition on
selling an individual exchange plan to someone enrolled in or entitled to Medicare does not apply to employment-based
coverage, including coverage sold in the SHOP exchanges. See CMS, “Medicare and the Marketplace,” updated
December 2021, at https://www.cms.gov/Medicare/Eligibility-and-Enrollment/Medicare-and-the-Marketplace/
Overview1.html. Also see Section 3.4.8 of CMS, FFE and FF-SHOP Enrollment Manual (2022). Information for
consumers is at Medicare.gov, “Medicare & the Marketplace,” at https://www.medicare.gov/about-us/medicare-the-
marketplace.
40 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
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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
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” section cites CMS, 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, at https://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/Updated-Federal-Standard-
Notices-for-coverage-beginning-in-the-2021-plan-year.pdf. There, see “Instructions for Attachment 2,” item 20.
45 For more information about plan renewal options and processes, including automatic renewals of enrollees in their
existing plans or in alternate plans if their existing ones will no longer be available, see Section 3.2 of CMS, FFE and
FF-SHOP Enrollment Manual (2022). Although this manual describes processes for HealthCare.gov states, SBEs also
have processes for automatic reenrollment.
46 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 minimum essential coverage
(MEC) that are identified in the Internal Revenue Code (IRC) Section 5000A and its implementing regulations.
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.
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 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 circumstances, 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 federal and state laws. SEPs for the individual exchanges may or may not apply to the
federal SHOP exchanges and/or to the nongroup market outside the exchanges.59
Eligibility 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.

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).
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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
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Enrollment Estimates
Annual individual exchange enrollment estimates to date are shown in 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.
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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 is the number of unique individuals who have been determined eligible to enrol in
an exchange plan and have selected a plan but may or may not have submitted the first premium payment.
Final pre-effectuated enrol ment estimates typically are released fol owing an OEP and include any broadly
applicable OEP extensions or longer state-based exchange (SBE) OEPs. For these data sources by year, see
the “Pre-effectuated Enrol ment Data” section of the report mentioned above. For example, the 2021
estimate is from CMS, Health Insurance Exchanges 2021 Open Enrollment Report, April 2021.
b. Effectuated enrollment is the number of unique individuals who have been determined eligible to enrol in an
exchange plan, have selected a plan, and have submitted the first premium payment for an exchange plan.
HHS generally releases effectuated enrol ment estimates for a point in time early in the plan year and may
release additional point-in-time estimates 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, the 2020 estimate is
from CMS, Early 2020 Effectuated Enrollment Snapshot, July 2020.
c. See table note (b) regarding effectuated enrol ment and point-in-time estimates. Average estimates reflect
an average over a specified time period, in this case one month. For PY2014 and PY2015, quarterly point-in-
time estimates were released, including those shown. Average monthly enrol ment data were not provided
for those years. For PYs 2016 and on, average monthly enrol ment data are provided. Although point-in-
time and average monthly estimates are not the same, they are provided here to show late-year enrol ment
estimates across all plan years. Data sources by year are in the “Point-in-Time Effectuated Enrol ment Data”
and “Average Monthly Effectuated Enrolment Data” sections of the report mentioned above (e.g., the 2018
estimate is from the end of the report CMS, Early 2019 Effectuated Enrollment Snapshot, August 2019).
Premiums, Cost Sharing, and Subsidies
Typically, enrollees of private health insurance plans (in or out of the exchanges) pay premiums to
obtain coverage. They also are generally responsible for out-of-pocket (OOP) costs, or cost
sharing, as they use benefits.
Premiums
Premiums are set by insurers and are based on their expected medical claims costs (i.e., the
payments they expect to make to health care providers for covered health benefits for a given
group of enrollees), 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
exchanges. For example, insurers cannot vary premiums based on health status.66 In addition,
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.67 If consumers do not pay their
premiums, insurers may terminate their coverage, subject to applicable federal and state
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).
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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. 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
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. There are no grandfathered plans sold through the exchanges,
but they may be available off the exchanges. For more information, see CRS Report R46003, Applicability of Federal
Requirements to Selected Health Coverage Arrangements, as well as HHS, “Grandfathered Health Insurance Plans,” at
https://www.healthcare.gov/health-care-law-protections/grandfathered-plans/.
73 42 U.S.C. §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).
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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 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. Annual Payment Notices are cited in Table D-1.
Notes: Once an enrol ee’s cost sharing (including deductibles, coinsurance, and co-payments) meet the plan’s
OOP limit in a plan year, the insurer generally wil pay 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.
Premium Tax Credits and Cost-Sharing Reductions
Consumers purchasing coverage through the individual exchanges may be eligible to receive
financial assistance that effectively reduces their cost of that coverage. Eligibility for such
assistance is based primarily on income, and assistance is provided in the form of premium tax
credits (PTCs) and cost-sharing reductions (CSRs).77
As temporarily enhanced (see text box), the PTC generally is available to consumers with
household incomes above 100% of the federal poverty level (FPL) and who do not have access to
public coverage (e.g., Medicaid) or employment-based coverage that meets certain standards.
Some exceptions apply. The credit is designed to reduce an eligible 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 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 second-lowest-cost silver plan (SLCSP) in a consumer’s local area,
consumers may apply the credit to any bronze- or higher-metal level plan available 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.
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Individuals who receive PTCs also may be eligible for subsidies that reduce cost-sharing
expenses.78 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 eligible individual’s exchange plan.
Second, the insurer must effectively raise the AV of the eligible individual’s plan, for example by
reducing other cost-sharing requirements in addition to the lowered OOP cap. Among other
eligibility requirements, CSRs generally are available 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
level plan, CSRs are applicable 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 provisions of the American Rescue Plan Act of 2021 (ARPA; P.L. 117-2) temporarily expanded eligibility
for and the amount of the premium tax credit (PTC) and cost-sharing reductions (CSRs) for certain individuals.
For example, 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, Health Insurance 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 summarizes nationwide data on premiums, advance premium tax credit (APTC) 79, and
CSRs by year, as available in relevant HHS reports on effectuated enrollment.80 The average
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 individual chooses and/or the factors by
which an insurer is able to vary premiums. 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 cost-sharing
subsidies to their enrollees. However, the ACA did not appropriate funds for such payments. In October 2017, the
Trump Administration halted these payments, effective immediately, until Congress appropriates funds. Insurers still
must provide the subsidies to eligible consumers, but insurers are not reimbursed. See HHS, “Payments to Issuers for
Cost-Sharing Reductions,” October 12, 2017, at https://www.hhs.gov/sites/default/files/csr-payment-memo.pdf.
79 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
automatically reduce monthly premiums by the credit amount. This option is called the advance premium tax credit, or
APTC. Consumers may instead claim the full credit amount of the PTC when filing their taxes, even if they have little
or no federal income tax liability.
80 In the reports cited in Table 3, 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 be available on demographics and/or metal
levels of plans. For more information, see CRS Report R46638, Health Insurance Exchanges: Sources for Statistics.
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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Table 3. Data on Premiums, Advance Premium Tax Credits, and Cost-Sharing
Reductions Nationwide, by Plan Year
(based on effectuated enrollment in all individual exchanges)

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
$276
$272
$291 $373.06 $519.89 $514.01 $491.53 $485.67 $508.26
per monthf
Percentage of
enrol ees
86%
85%
85%
84%
87%
87%
86%
86%
90%
receiving APTCg
Percentage of
enrol ees
58%
57%
57%
57%
53%
52%
50%
48%
49%
receiving CSRh
Data as of
Dec.
Mar.
Mar.
PY
Feb.
Feb.
Feb.
Feb.
Feb.
2014
2015
2016
2017
2018
2019
2020
2021
2022
Source: CRS analysis based on Department of Health and Human Services (HHS) reports of individual exchange
enrol ment in private health insurance plans, as specified in table notes and cited at CRS Report R46638, Health
Insurance Exchanges: Sources for Statistics in the “Point-in-Time Effectuated Enrol ment Data” section. 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 financial assistance that effectively reduce premiums and cost sharing, respectively, for
eligible consumers obtaining coverage in the individual exchanges. The average premium and APTC amounts
shown above may obscure wide variations in actual amounts per consumer, depending on the metal level plan an
individual chooses and/or the factors by which an insurer is able to vary premiums (see “Premiums, Cost Sharing,
and Subsidies” in this report). In addition, the APTC data in the table are not necessarily final, 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.
a. Relevant data for PY2014 are available only as of December 2014. These numbers are provided to allow for
approximate comparison within the table. Average premium amounts were not provided in this or the
fol owing year’s report. See March 31, 2015 Effectuated Enrollment Snapshot, June 2015.
b. Average premium amounts for PY2015 and PY2016 were not provided in those years’ or the fol owing
years’ reports. See March 31, 2015 Effectuated Enrollment Snapshot, June 2015 and March 31, 2016
Effectuated 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.

at https://www.cms.gov/CCIIO/Resources/Data-Resources/QHP-Choice-Premiums. Hereinafter referred to as “CMS,
QHP Choice, PY2023.” Also see KFF, “Average Marketplace Premiums by Metal Tier, 2018-2023,” not dated, at
https://www.kff.org/health-reform/state-indicator/average-marketplace-premiums-by-metal-tier/; and KFF, “Cost-
Sharing for Plans Offered in the Federal Marketplace, 2014-2023,” February 2023, at https://www.kff.org/slideshow/
cost-sharing-for-plans-offered-in-the-federal-marketplace/.
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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 required to participate
in the 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
county in all states. However, there 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
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, “Last ‘bare’ county in the U.S. scores ACA exchange coverage,” Modern
Healthcare, August 24, 2017, at https://www.modernhealthcare.com/article/20170824/NEWS/170829941/last-bare-
county-in-the-u-s-scores-aca-exchange-coverage.
83 CMS, QHP Choice, PY2023.
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Figure 2. Plan Year 2023 Insurer Participation in the Individual Exchanges, by County

Source: Centers for Medicare & Medicaid Services (CMS), Center for Consumer Information and Insurance
Oversight (CCIIO), “County by County Plan Year 2023 Insurer Participation in Health Insurance Exchanges,”
published October 31, 2022, at https://www.cms.gov/CCIIO/Programs-and-Initiatives/Health-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. In January 2019, the Government Accountability
Office (GAO) released a report on insurer participation and related issues in the individual
exchanges.84 The report provided background on 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, reinsurance, and risk adjustment—
meant to mitigate insurers’ financial risk in the individual and small-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
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 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
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
Protection and Affordable Care Act; Establishment of Exchanges and Qualified Health Plans; Exchange Standards for
Employers,” March 27, 2012, 77 Federal Register 18309, page 18399.
93 For purposes of SHOP eligibility, the definition of full-time employee is at 45 C.F.R. §155.20.
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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
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.98 Then,
employees review their employer’s plan option(s) and enroll if they choose. The process of
comparing and enrolling in coverage depends partially on a state’s SHOP exchange type:
 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
compare plan options on HealthCare.gov, but they need to work directly with a
SHOP-registered agent, broker, or insurer to purchase coverage.99 This is called
direct enrollment, and it has been the only option in such states since plan years
beginning in 2018.100 Previously, employers and employees could purchase
coverage on HealthCare.gov or via direct enrollment.

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
SEPs for the individual exchanges].”
98 A business with locations or employees in multiple states has options for offering SHOP coverage to all its eligible
employees. See 45 C.F.R. §155.710 and HealthCare.gov, “SHOP Coverage for Multiple Locations and Businesses,” at
https://www.healthcare.gov/small-businesses/provide-shop-coverage/business-in-more-than-one-state/.
99 HealthCare.gov, “Overview of SHOP: Health insurance for small businesses,” at https://www.healthcare.gov/small-
businesses/choose-and-enroll/shop-marketplace-overview/.
100 HHS finalized this change in the 2019 Payment Notice (page 16996), citing generally low employer participation in
the SHOP exchanges and decreasing insurer participation (both discussed elsewhere in the SHOP section of this
report). HHS also confirmed in the 2019 Payment Notice that because of these reductions in federal SHOP web portal
functionality, state-based SHOP exchanges would no longer be able to use the federal IT platform. In other words,
HHS eliminated the SB-FP-SHOP option (discussed in “State-Based and Federally Facilitated Exchanges”). The two
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 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 directly
with an agent, broker, or insurer to obtain coverage in the 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 exchange enrollment data, SHOP exchange enrollment data are not released
annually. However, CMS estimated that there were approximately 27,000 small employers and
233,000 employees using the SHOP exchanges across the country in January 2017.105 CMS
previously estimated 10,700 active small employers and 85,000 employees in the SHOP
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
in prior years may not be consistently available. However, a 2019 GAO report indicates that in 2015-2017, there was at
least one insurer participating in each of the 46 of 51 states for which it had such data for all three of those years. See
Table 7 in GAO, Private Health Insurance: 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 “GAO
Enrollment Report, March 2019.”
105 This estimate excludes Hawaii, as Hawaii’s SHOP exchange was no longer operational in 2017 due to the state’s
receipt of a 1332 waiver. See CMS, CCIIO, “SHOP Marketplace Enrollment as of January 2017,” May 15, 2017, at
https://www.cms.gov/CCIIO/Resources/Data-Resources/Downloads/SHOP-Marketplace-Enrollment-Data.pdf.
106 This estimate excludes Vermont and Idaho; these states had not reported 2015 enrollment data to CMS. See CMS,
“Update on SHOP Marketplaces for Small Businesses,” July 2, 2015, archived at http://wayback.archive-it.org/2744/
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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 generally are required to obtain their health
insurance through the exchanges in order to receive a government contribution (i.e., their
employer’s contribution) for their coverage.108 As implemented, they purchase coverage through
the District of Columbia’s SHOP exchange. Congressional offices are not eligible for the small
business tax credit (discussed below), and congressional Members and staff obtaining coverage
through the SHOP are not eligible for the PTC and CSRs that are available to individuals who
enroll in coverage offered on the individual exchanges (see “Premium Tax Credits and Cost-
Sharing Reductions”).
Premiums and Cost Sharing
The information earlier in this report on premiums and cost sharing in the individual exchanges,
including certain federal requirements that apply to premiums and cost sharing (e.g., AV levels),
generally applies in the SHOP exchanges, as well. See CRS Report R45146, Federal
Requirements on Private Health Insurance Plans for other requirements applicable to the
nongroup and small-group markets, on and off the exchanges.
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
for part of their employees’ premiums.
CRS is not aware of HHS or other organizations’ reports on premium or cost-sharing data
specific to the SHOP exchanges.
Small Business Health Care Tax Credit
Certain small businesses are eligible for the small business health care tax credit (SBTC).109 In
general, this credit is available only to 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 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. This is also
true for the Congressional Members and staff who obtain coverage through the SHOP. Certain congressional staff may
not be required to obtain their coverage through the SHOP, and may be able to otherwise obtain coverage through
FEHB. See Office of Personnel Management, “Members of Congress and Designated Staff – General,” at
https://www.opm.gov/healthcare-insurance/changes-in-health-coverage/changes-in-health-coverage-faqs/.
109 See 26 U.S.C. §45R for eligibility for the Small Business Health Care Tax Credit (SBTC) and credit amount details
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(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).
In states with no insurers offering plans through the SHOP exchange, certain eligible employers
still 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 the next year, they may
receive their second consecutive year’s credit with a plan purchased off-exchange.112
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
available to employers that have 10 or fewer FTE employees who have average taxable wages of
$30,700 or less (in 2023).113 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
times the limit for the full credit.114
Employees who enroll in a SHOP plan do not receive this tax credit, nor are they eligible for the
financial assistance available to certain consumers who purchase coverage on the individual
exchanges (see “Premium Tax Credits and Cost-Sharing Reductions”).
The IRS has published information on the number of SBTCs filed in tax years 2010-2016.115 For
2016, the IRS indicates that 6,952 employers claimed the SBTC.116
Insurer Participation
As stated above, as of PY2023, there are no insurers offering SHOP medical plans in about half
of states. Some of the factors affecting insurer participation in the individual exchanges (see
“Insurer Participation” in the Individual Exchanges section above) also may affect insurer
participation in the SHOP exchanges. For example, just as in the nongroup market, there were
new federal requirements imposed by the ACA on plans sold in the 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 https://www.irs.gov/statistics/soi-tax-stats-affordable-care-act-aca-statistics-
credit-for-small-employer-health-insurance-premiums.
116 Ibid. See excel file, “Small Business Health Care Tax Credits Filed in Tax Years 2010–2016,” linked on this
webpage.
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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
SHOP exchanges, such as delays in setting up online enrollment capabilities when the SHOPs
were being established and the limited duration and administrative complexity of the small
business tax credit.118
Exchange Enrollment Assistance
Navigators and Other Exchange-Based Enrollment Assistance
Federal statute and regulations require exchanges to carry out certain consumer outreach and
assistance functions. These functions generally include in-person and other forms of outreach and
assistance.119
Each exchange must have a Navigator program.120 Navigators are entities whose employees
and/or volunteers
 conduct public outreach and education activities about the exchanges and QHPs;
 provide impartial information to consumers (including small employers and their
employees) about their insurance options;
 help consumers access individual and SHOP exchange coverage, exchange
financial assistance, and/or public program coverage (e.g., Medicaid or CHIP) if
they qualify;
 refer consumers to any applicable consumer assistance programs as needed, such
as state agencies that assist consumers with questions or complaints about their
plans; and
 comply with other Navigator requirements, as specified.
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.”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; 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 Plans To Effectively End The SHOP Exchange,” Health Affairs Blog, May 15, 2017,
at https://www.healthaffairs.org/do/10.1377/hblog20170515.060112/full/.
119 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. §155.225.
120 Ibid. Specifically, for the requirement to implement Navigator programs, see 45 C.F.R. §155.210.
121 45 C.F.R. §155.210(c)(1)(iii).
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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
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.
Exchanges also must have a Certified Application Counselor (CAC) program.125 CAC staff
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
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
Navigators do. CACs are not exchange-funded in FFE states and are not required to be exchange-
funded in other states.
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
them enroll in coverage. Neither Navigators nor CACs may be health insurers or take
compensation for selling health policies from insurers or consumers.126
Besides facilitating the above assistance programs, exchanges must provide for the operation of a
call center and maintain a website (e.g., HealthCare.gov) that meets certain informational
requirements.127 Exchanges also provide consumer information and outreach via mail, radio or
television ads, and/or other methods. Overall, exchanges’ consumer outreach efforts and materials
must meet certain standards regarding accessibility for individuals with disabilities or with
limited English proficiency.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.
126 45 C.F.R. §155.215.
127 45 C.F.R. §155.205.
128 45 C.F.R. §155.205.
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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
providing information and access to all plans that would be available to a consumer via the
exchange website.131 Unlike the exchange websites and exchange Navigators and other assistors,
however, these entities may also assist consumers with enrolling in plans that are not available on
the exchanges.
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
plans, the SHOP exchange websites direct consumers to these third party assisters, who can help
them enroll in SHOP plans and/or small-group plans available off-exchange.132
Exchange Spending and Funding
Initial Grants for Exchange Planning and Establishment
The ACA provided an indefinite (i.e., unspecified) appropriation for HHS grants to states to
support the planning and establishment of exchanges.133 For each fiscal year (FY) between
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
January 1, 2015, and exchanges were expected to be self-sustaining beginning in 2015.134
Ongoing Federal Spending on Exchange Operation
The federal government spent an estimated $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 numbers as 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 Report R43066, Federal Funding for Health Insurance Exchanges (last updated in October 2014) for more
information about these planning and establishment grants.
135 CMS, Justification of Estimates for Appropriations Committees, Fiscal Year 2024, March 13, 2023, at
https://www.cms.gov/files/document/cms-fy-2024-congressional-justification-estimates-appropriations-
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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
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
a permanent appropriation through the tax code.137 These tax credit costs are beyond the scope of
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
participating health insurance plans.138
To raise funds for the exchanges it administers and/or provides a web platform, HHS assesses a
monthly fee on each health insurance issuer that 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 to fund only federal activities or functions specific to the FFE
and SBE-FP exchanges; the user fees cannot fund federal activities that serve all exchanges
(including SBEs).139 The fees are lower for insurers in SBE-FP 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. 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 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

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
of CMS activities conducted on behalf of certain versus all exchanges at CMS Budget Justification, FY2024, pages
200-201.
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Overview of Health Insurance Exchanges

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 is the stated percentage of the value of monthly premiums collected by insurer on exchange plans)

Source: CRS analysis of annual “Payment Notice” federal rules cited in Table D-1, as well as Internal Revenue
Service, “Rev. Proc. 2013-25,” May 2, 2013, at http://www.irs.gov/pub/irs-drop/rp-13-25.pdf.
Notes: FFE = federally facilitated exchange; SBE-FP = state-based exchange using the federal information
technology (IT) platform. See “Types and Administration of Exchanges” for discussion of 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.
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Overview of Health Insurance Exchanges

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 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.
American Rescue Plan Act Grants for Exchange Modernization
Section 2801 of the ARPA provided for new grants to be awarded to health insurance exchanges
“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 all applicable
requirements.” The HHS Secretary was authorized to determine specified aspects of the grant
funding application process. Eligibility for these grants was limited to SBEs and SBE-FPs. The
legislation specified that FFEs were not eligible through its reference to exchanges established
under 42 U.S.C. Section 18041(c).
For this grant program, $20 million was appropriated for FY2021, out of Treasury funds not
otherwise appropriated. The funding was 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 “Premium Tax Credits and Cost-Sharing Reductions” regarding other ARPA provisions
relevant to the exchanges and the plans sold in them.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 Report R46777, American Rescue Plan Act of
2021 (P.L. 117-2): Private Health Insurance, Medicaid, CHIP, and Medicare 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
administration are state-based exchanges (SBEs), federally facilitated exchanges (FFEs), and
state-based exchanges using a federal platform (SBE-FPs). For plan year (PY) 2023, there are 30
FFEs, 18 SBEs, and 3 SBE-FPs.
A few states have changed approaches one or more times (e.g., initially 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 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 involvement). Recent and ongoing transitions generally are in the direction of less federal
involvement.
SHOP exchanges may be federally facilitated (FF-SHOP) or state-based (SB-SHOP).145 For
PY2023, there are 30 FF-SHOPs and 20 SB-SHOPs. One state (Hawaii) is exempted from
operating a SHOP exchange. However, in about half of all states, no insurers are offering medical
plans in the SHOP exchange, meaning there is effectively no SHOP exchange there.
For PY2023, most states’ individual and SHOP exchanges are administered in the same way (i.e.,
both state-based or both federally facilitated). However, a few states have different approaches for
their individual and SHOP exchanges. Some resources refer to this as a bifurcated approach.
Table A-1 shows individual exchange types by state, with information on past changes in
individual exchange types and changes underway. It also shows SHOP exchange types by state
and provides details on SHOP plan availability and enrollment method.
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,
except that the two states with that model at that time (Nevada and Kentucky) could maintain it. According to CMS,
those states no longer use that model.
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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)
Delaware
HealthCare.gov
FFEi
FF-SHOP, but no medical plansd
District of
DC Health Link
SBE
SB-SHOP
Columbia
Florida
HealthCare.gov
FFE
FF-SHOP, but no medical plansd
Georgia
HealthCare.gov
FFE j
FF-SHOP, DE onlyc
Hawaii
HealthCare.gov
FFE 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
FF-SHOP, but no medical plansd
Missouri
HealthCare.gov
FFE
FF-SHOP, but no medical plansd
Montana
HealthCare.gov
FFEi
FF-SHOP, DE onlyc
Nebraska
HealthCare.gov
FFEi
FF-SHOP, but no medical plansd
Nevada
Nevada Health Link
SBE as of PY20 (initially SBE, then
SB-SHOP, but no medical plansf
SBE-FP as of PY15)e
New
HealthCare.gov
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
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
FF-SHOP, but no medical plansd
Carolina
North Dakota
HealthCare.gov
FFE
FF-SHOP, but no medical plansd
Ohio
HealthCare.gov
FFEi
FF-SHOP, DE onlyc
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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)
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 at Centers for Medicare & Medicaid Services (CMS),
Center 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/. States with
no medical 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 all areas.
c. All FF-SHOPs (that offer plans) use a direct enrollment approach only, meaning HealthCare.gov
does not offer online SHOP plan enrol ment but instead instructs users to connect with agents or brokers
to enrol in plans through the state’s SHOP exchange. See 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.
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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, however.) Some state exchange websites suggest that small businesses contact
agents, brokers, and/or insurers directly to learn about other coverage options. See links in table.
g. For the purposes of SHOP exchange participation, states may define small employers (or small businesses) as
employers that have not more than 50 or not more than 100 employees. 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 enrollment approach only: They do not offer online
enrol ment but instead instruct users to connect with agents, brokers, insurers, or assistors – or to submit
a paper application to the exchange—to enrol in plans through the state’s SHOP exchange. See links in
table.
i.
In some FFE states, the federal government performs all exchange administration functions, but in these FFE
states, the state partners with the federal government to perform some plan management functions. See
footnotes cited in the resource at table note (a).
j.
Georgia initially received approval through the Section 1332 state innovation waiver process to shift to its
own “Georgia Access Model,” essentially a direct enrol ment approach, beginning in PY2023. However, this
component of the waiver was later suspended for PY2023. The 1332 process allows states to waive
specified ACA provisions, including provisions related to the establishment of health insurance exchanges
and related activities. See CRS Report R44760, State Innovation Waivers: Frequently Asked Questions, for
background on 1332 waivers and for more information about Georgia’s waiver. 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 exchange, initially for PYs 2017-2021
then extended through PY2026. This is related to the state’s pre-existing program and requirements related
to employment-based coverage. See the report cited in table note (j) for more information.
l.
Regarding Virginia’s ongoing transition to a state-based exchange, see https://scc.virginia.gov/pages/Health-
Benefit-Exchange-(6).
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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
(QHPs).146 See “Qualified Health Plans” in this report regarding QHP certification requirements.
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, there may be other types of plans
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 all also QHPs.
Stand-alone dental plans (SADPs) are the only non-QHPs offered in the exchanges.
Table B-1. Types of Plans Offered Through the Exchanges
PTC and
Can Be Offered
CSR
Outside

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

146 42 U.S.C. §18031(d)(2)(B).
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Notes: 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
or affordability exemptions through the exchange. 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
solvency loans for eligible nonprofit organizations applying to become a CO-OP. The majority of products
offered by a CO-OP must be QHPs sold in the nongroup and small-group markets, including through
exchanges. CMS initially awarded loans to 24 CO-OPs, but one of those 24 was dropped from the program
prior to offering health plans. See CRS Report R44414, Consumer Operated and Oriented Plan (CO-OP)
Program: Frequently Asked Questions. Among the remaining 23 CO-OPs, it 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
or were in 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
Maine: Community Health Options: https://www.healthoptions.org/
Idaho, Montana, and Wyoming: Mountain Health CO-OP: https://www.mountainhealth.coop/ and
Wisconsin: Common Ground Healthcare Cooperative: https://www.commongroundhealthcare.org.
c. The ACA directs ACA directs the federal Office of Personnel Management (OPM) to contract with private
insurers in each state to offer at least two QHPs under the MSP program. The term multi-state plan is meant
to indicate that this program extends across the states, not that the plans themselves are necessarily
interstate. There are not currently any multi-state plans available.

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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
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,
produces a performance budget, also called a budget justification. Actual spending for the
proposed budget year depends on the availability of appropriations, among other factors.
However, the narratives and tables in each year’s budget document are also useful in
understanding prior-year spending.
Provisions in annual appropriations acts require CMS to provide, in its budget justification for
each fiscal year, “cost information” that “details the uses of all funds used by the Centers for
Medicare & Medicaid Services specifically 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
year]” for the categories shown in Table C-1.147 Each budget justification also includes narrative
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
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 Health Care Fraud and Abuse Control account, among other sources. Table
C-2 displays federal exchange spending according to these funding sources.
See “Exchange Spending and Funding” in this report for more information. Find current and
prior-year CMS budget justifications at CMS, “Performance and Budget,” at
https://www.cms.gov/About-CMS/Agency-Information/PerformanceBudget.

147 See, for example, the Consolidated Appropriations Act, 2023 (), Division H, Title II, Sec. 220.
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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 $2,307,565
Source: Department of Health and Human Services (HHS), Centers for Medicare & Medicaid Services (CMS),
Justification of Estimates for Appropriations Committees, Fiscal Year 2024, March 13, 2022, at https://www.cms.gov/
files/document/cms-fy-2024-congressional-justification-estimates-appropriations-committees.pdf. See “Health
Insurance Marketplaces Transparency Table,” pages 237-238, including for these data for FYs 2010-2017 and for
CMS notes on these data. Discussion of spending categories is at “Federal Marketplace Programs” table and
narrative, pages 199-204.
Notes: FY = fiscal year; CR = continuing resolution; PB = President’s Budget (proposed). Note that actual
spending for the proposed budget year depends on the availability of appropriations, among other factors.
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Table C-2. CMS Federal Exchange Funding Sources, Recent Years
($ in thousands)
FY2018
FY2019
FY2020
FY2021
FY2022
FY2023
FY2024
Treasury Accounta
Actual
Final
Final
Final
Final
Enacted
PB
Program Management
$1,944,190 $1,636,111 $1,618,091 $1,939,603 $2,066,898 $2,343,586 $2,263,744
Discretionary
Appropriation
$618,164
$263,895
$261,226
$142,455
$143,977
$147,729
$165,122
Program Operations (non-
add)
$580,886
$229,384
$226,035
$119,520
$119,685
$121,000
$137,003
Federal Administration
(non-add)
$37,278
$34,511
$35,191
$22,936
$24,292
$26,729
$28,119
Offsetting Col ections
$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 User Fee
(non-add)
$32,112
$47,435
$24,820
$46,778
$46,350
$57,504
$59,064
Other
$21,746
$20,323
$21,097
$21,120
$22,966
$32,272
$37,822
Health Care Fraud and
Abuse Control
$4,629
$19,256
$47,684
$24,143
$18,446
$39,398
$43,821
Discretionary
Appropriation
$0
$19,256
$47,684
$24,143
$18,446
$39,398
$43,821
Mandatory
Appropriationc
$4,629
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 User Fee Amounts
as a Percentage of
65.3%
78.8%
78.7%
88.1%
88.9%
88.4%
86.7%
Program Level Funding
Sourcesd
Sources: Unless otherwise specified, compiled by CRS from 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 were not found in prior years’ budget justifications.
FY2022-2024 in this table: HHS, CMS, Justification of Estimates for Appropriations Committees, Fiscal Year 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
that included these FY2018 amounts but not in the FY2021 or subsequent Budget Justifications. The 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 an
annual allocation process by the Attorney General and Secretary of Health and Human Services.”
d. Calculated by CRS.
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Appendix D. Additional Resources
HHS “Notice of Benefit and Payment Parameters” by Year
The “Notice of Benefit and Payment Parameters,” also called the “Payment Notice,” is a rule
published annually by the Department of Health and Human Services (HHS). It addresses the
exchanges and certain other private health insurance topics. It includes annual updates such as
changes to insurer user fee amounts, and policy changes such as modified eligibility requirements
for the Navigator program. 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 is generally the calendar year).
Final and proposed Payment Notices can also be found by searching “Notice of Benefit and
Payment Parameters” at www.federalregister.gov.
Table D-1. HHS “Notice of Benefit and Payment Parameters,” Final Rule by Year
For Plan
Publication
Year
Title
Citation
Date
2023
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 80 Federal
February 27,
Payment Parameters for 2016
Register 10749 2015
2015
Patient Protection and Affordable Care Act; HHS Notice of Benefit and 79 Federal
March 11,
Payment Parameters for 2015
Register 13743 2014
2014
Patient Protection and Affordable Care Act; HHS Notice of Benefit and 78 Federal
March 11,
Payment Parameters for 2014
Register 15409 2013
Source: United States Federal Register at https://www.federalregister.gov/.
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Notes: There have been other rules 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.
a. The 2022 Payment Notice final rule, 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.
 Center for Consumer Information and Insurance Oversight (CCIIO) FAQs,
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/Health-Insurance-Marketplaces
 CRS compilation of HHS resources on exchange enrollment and other
exchange data: CRS Report R46638, Health Insurance Exchanges: Sources for
Statistics

Author Information

Vanessa C. Forsberg

Analyst in Health Care Financing

Disclaimer
This document was prepared by the Congressional Research Service (CRS). CRS serves as nonpartisan
shared staff to congressional committees and Members of Congress. It operates solely at the behest of and
under the direction of Congress. Information in a CRS Report should not be relied upon for purposes other
than public understanding of information that has been provided by CRS to Members of Congress in
connection with CRS’s institutional role. CRS Reports, as a work of the United States Government, are not
subject to copyright protection in the United States. Any CRS Report may be reproduced and distributed in
its entirety without permission from CRS. However, as a CRS Report may include copyrighted images or
material from a third party, you may need to obtain the permission of the copyright holder if you wish to
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