Overview of Health Insurance Exchanges

Overview of Health Insurance Exchanges
April 29, 2021
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
Vanessa C. Forsberg
virtual marketplaces in which consumers and smal business owners and employees can
Analyst in Health Care
shop for and purchase private health insurance coverage and, where applicable, be
Financing
connected to public health insurance 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 general y includes operating a web portal that
al ows 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 cal center.
Exchanges also are responsible for several administrative functions, including certifying the plans that wil be
offered in their marketplaces.
The ACA general y 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 smal 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.
Individuals and smal 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, smal businesses may enroll at any time during the
year. There are plans available in al individual exchanges, and about 12 mil ion people obtained health insurance
through the individual exchanges during the 2021 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 2021.
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
. Smal 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 $1.8 bil ion on the operation of exchanges in FY2020, and it projected
$1.2 bil ion in spending for FY2021. 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., consumer outreach and assistance programs,
including 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. The report also includes information about policy changes enacted under the American
Rescue Plan Act of 2021 (ARPA; P.L. 117-2), as wel as administrative policy changes made in response to the
Coronavirus Disease 2019 (COVID-19) pandemic and related economic recession.
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Contents
Introduction ................................................................................................................... 1
Overview ....................................................................................................................... 2
Types and Administration of Exchanges ........................................................................ 2
Individual and SHOP Exchanges ............................................................................ 2
State-Based and Federal y Facilitated Exchanges ...................................................... 3
Exchange Administration....................................................................................... 5
Qualified Health Plans................................................................................................ 6
Individual Exchanges ...................................................................................................... 7
Eligibility and Enrollment ........................................................................................... 7
Interaction with Medicaid, CHIP, and Medicare ........................................................ 8
Open and Special Enrollment Periods ...................................................................... 8
Special Enrollment Periods and COVID-19 ............................................................ 10
Enrollment Estimates .......................................................................................... 11
Premiums and Cost Sharing ...................................................................................... 13
Premium Tax Credits and Cost-Sharing Reductions ................................................. 14
Insurer Participation................................................................................................. 17
SHOP Exchanges .......................................................................................................... 19
Eligibility and Enrollment ......................................................................................... 19
Enrollment Periods ............................................................................................. 20
Online Enrollment versus Direct Enrollment........................................................... 21
Enrollment Estimates .......................................................................................... 22
Congressional Member and Staff Enrollment via the D.C. SHOP Exchange ................ 23
Premiums and Cost Sharing ...................................................................................... 23
Smal Business Health Care Tax Credit .................................................................. 23
Insurer Participation................................................................................................. 24
Exchange Enrollment Assistance ..................................................................................... 25
Navigators and Other Exchange-Based Enrollment Assistance........................................ 25
Brokers, Agents, and Other Third-Party Assistance Entities ............................................ 26
Exchange Spending and Funding ..................................................................................... 27
Initial Grants for Exchange Planning and Establishment ................................................ 27
Ongoing Federal Spending on Exchange Operation....................................................... 27

Funding Sources for Federal Exchange Spending ......................................................... 28
User Fees Collected from Participating Insurers ...................................................... 28
Other Federal Funding Sources............................................................................. 30
State Financing of the Exchanges ............................................................................... 30
American Rescue Plan Act Grants for Exchange Modernization...................................... 30


Figures
Figure 1. Individual and SHOP Exchange Types by State, Plan Year 2021................................ 5
Figure 2. Plan Year 2021 Insurer Participation in the Individual Exchanges, by County............ 18
Figure 3. Federal User Fee for Insurers Participating in Specified Types of Individual
Exchanges, by Plan Year.............................................................................................. 29

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Figure C-1. Centers for Medicare & Medicaid Services “Health Insurance Exchanges
Transparency Table,” FY2021 ...................................................................................... 39

Tables
Table 1. Open Enrollment Periods for Individual Exchanges on the Federal Platform, by
Plan Year .................................................................................................................... 9
Table 2. Nationwide Individual Exchange Enrollment Estimates, by Plan Year ....................... 12
Table 3. Annual Out-of-Pocket Limits, by Plan Year ........................................................... 14
Table 4. Data on Premiums, Advance Premium Tax Credits, and Cost-Sharing Reductions
Nationwide, by Plan Year ............................................................................................ 16

Table A-1. Exchange Types and Key Details by State, Plan Year 2021 ................................... 32
Table B-1. Types of Plans Offered Through the Exchanges .................................................. 36
Table C-1. CMS Federal Exchange Funding Sources for Specified Fiscal Years ...................... 40
Table D-1. HHS “Notice of Benefit and Payment Parameters,” Final Rule by Year .................. 41

Appendixes
Appendix A. Exchange Information by State ..................................................................... 31
Appendix B. Types of Plans Offered Through the Exchanges ............................................... 36
Appendix C. Exchange Spending and Funding Details from CMS Budget Justifications .......... 38
Appendix D. Additional Resources .................................................................................. 41

Contacts
Author Information ....................................................................................................... 43


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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 smal 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 smal 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 smal
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 smal 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 smal business exchanges discuss eligibility and enrollment, plan
costs and financial assistance available to eligible consumers and smal 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 has been updated
to include information about policy changes enacted under the American Rescue Plan Act of 2021
(ARPA; P.L. 117-2), as wel as administrative policy changes made in 2021 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, as are small businesses and
sm all em ployers.
2 For example, about 12 million people obtained health insurance through the individual exchanges during the 2021
open enrollment period (for coverage beginning January 2021). T his figure is approximatel y 3.6% of the U.S.
population of about 331 million people. See Table 2 regarding exchange enrollment estimates and sources. T he U.S.
population estimate is as of April 2020, per the 2020 Census results: https://www.census.gov/.

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Overview
Types and Administration of Exchanges
Individual and SHOP Exchanges
The ACA required health insurance exchanges to be established in al states and the District of
Columbia.3 In general, the health insurance exchanges began operating in October 2013 to al ow
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 individual (also cal ed non-group)
and smal -group segments of the private health insurance market, respectively.5 In an individual
exchange, eligible consumers can compare and purchase non-group insurance for themselves and
their families and can apply for premium tax credits and cost-sharing reductions (PTCs and
CSRs; see “Premium Tax Credits and Cost-Sharing Reductions”). In a SHOP exchange, smal
businesses can compare and purchase smal -group insurance and can apply for smal business
health insurance tax credits (see “Smal Business Health Care Tax Credit”); in addition,
employees of smal businesses can enroll in plans offered by their employers on a SHOP
exchange.
Each exchange covers a whole state.6 Within a given 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 smal businesses may obtain coverage within their state’s individual or
SHOP exchange, respectively, or they may shop in the individual or smal -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 stil are privately operated websites
that al ow the comparison and purchase of coverage sold by different insurers, broadly similar in
concept to the ACA exchanges.8

3 T he 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 T he term individual exchange is used for purposes of this report. It is not defined in exchange-related statute or
regulations.
5 T he private health insurance market includes both the group market (largely made up of employer-sponsored
insurance) and the individual m arket (which includes plans directly purchased from an insurer). T he group market is
divided into small- and large-group market segments; a sm all 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 T here 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 2021.
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 Requirem ents to
Selected Health Coverage Arrangem ents
.
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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 federal y
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
al ows 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 overal counts of FFEs, which is the model this report general y follows.10
In rulemaking finalized January 19, 2021 (the 2022 Notice of Benefit and Payment Parameters, or
“Payment Notice”11), HHS and the Department of the Treasury established new “direct
enrollment” variations of the exchange types: FFE-DE, SBE-DE, and SBE-FP-DE.12 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 stil 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
wil be 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, and as such,
may be reconsidered by the Biden Administration.13

9 See Centers for Medicare & Medicaid Services (CMS) Center for Consumer Information and Insurance Oversight
(CCIIO), “ General Guidance 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 T his report focuses on the three types of exchanges that are commonly discussed in CMS resources, but other entities
may also track states with variations of state partnership FFEs. For example, the Kaiser Family Foundation (KFF) notes
FFEs in which the state conducts plan management activities at “ State Health Insurance Marketplace T ypes, 202 1,” at
https://www.kff.org/health-reform/state-indicator/state-health-insurance-marketplace-types/.
11 See 2022 Payment Notice, starting page 6143, regarding information in this p aragraph. T he 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. See Table D-1 for Payment Notice citations.
12 For additional discussion of direct enrollment, see “ Online Enrollment versus Direct Enrollment” in the SHOP
section of this report.
13 See Office of Management and Budget, “Memorandum for the Heads of Executive Departments and Agencies,”
86 Federal Register 7424, January 28, 2021.
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For PY2021, 30 states have FFEs, 15 states have SBEs, and 6 states have SBE-FPs.14 A few states
have changed approaches one or more times (e.g., initial y 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 general y in the direction of less federal
involvement. As of the publication of this report, at least five states are transitioning or
considering transitions for PY2022 or beyond.15
SHOP exchanges may be federal y facilitated (FF-SHOP) or state-based (SB-SHOP).16 For
PY2021, there are 32 FF-SHOPs and 18 SB-SHOPs. However, in more than half of these states,
no insurers are offering medical plans in the SHOP exchange, meaning there is effectively no
SHOP exchange there.17 One state is exempted from operating a SHOP exchange.18 For the 2021
plan year, most states’ individual and SHOP exchanges are administered in the same way (i.e.,
both state-based or both federal y facilitated). However, a handful of states have different
approaches for their individual and SHOP exchanges. Some resources refer to this as a bifurcated
approach.
See Figure 1 for individual and SHOP exchange types by state in PY2021, and see Table A-1 for
additional information, including on state transitions to different exchange types.

14 See Table A-1 for details and citations for this paragraph. In tallies throughout this report, the District of Columbia is
counted as a state.
15 One of these states, Georgia, received approval through the Section 1332 state innovation waiver process shift to it s
own Georgia Access Model, essentially a direct enrollment approach, beginning in PY2023. T his 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
more information.
16 As of June 2018, states can 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. For more information, see “ Online Enrollment versus Direct Enrollment
in the SHOP section of this report.
17 See “Insurer Participation” in the SHOP Exchanges section of this report for more information.
18 Hawaii received a Section 1332 waiver exempting it from operating a SHOP exchange.
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Overview of Health Insurance Exchanges

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

Sources: Congressional Research Service (CRS) il ustration. See data sources in Table A-1.
Notes: SHOP = smal business health options program; IT = information technology. Counts of “states” include
the District of Columbia. In the individual exchanges, plan year is general y that calendar year, but group coverage
plan years, including in the SHOP exchanges, may start at any time during a calendar year. See “Types and
Administration of Exchanges”
in this report regarding individual and SHOP exchanges, and federal and state
administration of exchanges.
In more than half of states, no insurers are offering medical plans in the SHOP exchange, meaning there is
effectively no SHOP exchange there. These states have a circle symbol in the SHOP Exchange map above. See
“Insurer Participation” in the SHOP Exchanges section of this report for more information.
Hawai 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 federal y facilitated, exchanges are required by law to fulfil 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.19
A primary function of the exchanges is to provide a way for consumers and smal businesses to
compare and purchase health plan options offered by participating insurers.20 This general y
includes operating a web portal that al ows 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 wil be offered in their marketplaces.21 This includes annual y 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
structure, provider network, premiums, marketing practices, and quality improvement activities,

19 See “Qualified Health Plans” in this report.
20 42 U.S.C. §18031(b)(1)(A).
21 42 U.S.C. §18031(d)(4).
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to ensure compliance with applicable federal and state standards.22 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).23 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.24 Covering the EHB package means covering 10 broad categories of benefits and
services, complying with limits on consumer cost sharing on the EHB, and meeting certain
generosity requirements (in terms of actuarial value).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 plans; a QHP offered through a
SHOP exchange must comply with state and federal requirements applicable to smal -group
market plans. For example, the requirement to cover the EHB applies to individual and smal -
group plans both in and out of the exchanges.
There are additional requirements that apply only to QHPs sold in the exchanges. For example, an
insurer wanting to sel QHPs in an exchange must offer at least one silver-level and one gold-
level plan in al of the areas in which the insurer offers coverage within that exchange. In
addition, QHPs must meet network adequacy standards, including maintaining provider networks
that are “sufficient in number and types of providers” and include “essential community
providers.”27
A QHP is the only type of comprehensive health plan an exchange may offer, but QHPs may be
offered outside of exchanges, as wel . Besides standard QHPs, other types of plans may be
available in a given exchange, including child-only plans, catastrophic plans, consumer operated
and oriented plans (CO-OPs), and multi-state plans (MSPs). Technical y, these are also QHPs.

22 42 U.S.C. §18031(c)(1); 42 U.S.C. §18031(e). For more information, see, for example, CMS, CCIIO, “ Final 2021
Lett er to Issuers in the Federally Facilitated Exchanges,” May 7, 2020, at https://www.cms.gov/CCIIO/Resources/
Regulations-and-Guidance/Downloads/Final-2021-Letter-to-Issuers-in-the-Federally-facilitated-Marketplaces.pdf.
Hereinafter referred to as “CMS 2021 Letter to Issuers.”
23 42 U.S.C. §18031(d)(2)(B).
24 42 U.S.C. §18021(a)(1).
25 42 U.S.C. §18022. For brief explanation of actuarial value (AV) and cost -sharing limits, see “ Premiums and Cost
Sharing”
in this report. For more information on the essential health benefits, cost-sharing limits, and AV requirements,
see CRS Report R45146, Federal Requirem ents on Private Health Insurance Plans.
26 For more information about federal requirements applicable to different types of plans, see CRS Report R45146,
Federal Requirem ents on Private Health Insurance Plans. T his 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 the CMS 2021
Letter to Issuers. Network adequacy standards are at 45 C.F.R. §156.200. T he requirement regarding silver and gold
plans is discussed in “ Premiums and Cost Sharing” in this report.
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Stand-alone dental plans (SADPs) are the only non-QHPs offered in the exchanges. See Table B-
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.
Individual Exchanges
Eligibility and Enrollment
Consumers may purchase health insurance plans for themselves and their families in their state’s
individual exchange. Consumers may enroll as long as they (1) meet state residency
requirements;28 (2) are not incarcerated, except individuals in custody pending the disposition of
charges; and (3) are U.S. citizens, U.S. nationals, or “lawfully present” residents.29
Undocumented individuals are prohibited from purchasing coverage through the exchanges, even
if they were to pay the entire premium without financial assistance.
Consumers can use their state’s exchange website (HealthCare.gov or a state-run site) to apply for
coverage and financial assistance and to compare and enroll in plans. The ACA requires
exchanges to provide a “single, streamlined form” that consumers can use to apply for “al
applicable State health subsidy programs within the State.”30 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 wel as Medicaid and the State
Children’s Health Insurance Program (CHIP), as discussed below.31 The exchange website
displays al 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, or
in person, as available by state. Enrollment assistance is available for those who want it (e.g.,
through exchange Navigators or through agents or brokers; see “Exchange Enrollment
Assistance” in this report).

28 State residency may be established through a variety of means, including actual or planned residence in a state, actual
or planned employment in a state, and other circumstances. See 45 C.F.R. §155.305.
29 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/.
30 42 U.S.C. §18083, 45 C.F.R. §155.405.
31 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. T he “applicable State health subsidy programs” also include the Basic
Health Program, which is operational in two states: Minnesota and New York.
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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.32
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.33 In short, it is general y il egal to sel an individual exchange plan to
someone enrolled in Medicare because it would duplicate coverage.
Open and Special Enrollment Periods
Consumers may enroll in coverage through the exchanges only during specified enrollment
periods.
Anyone eligible for exchange plan coverage may enroll during an annual open enrollment period
(OEP).34 The OEP typical y takes place in fal of the year preceding the plan year (PY; the
calendar year in the individual exchanges) during which the coverage is effective. The OEP for
PY2021 coverage was November 1, 2020, to December 15, 2020, for FFE and SBE-FP states.
States with SBEs may extend their OEPs, and many do. See Table 1, including table notes, for
details.
Before and during an OEP, consumers already enrolled in coverage through an exchange should
receive notification from the exchange and from their insurer about the opportunity to make any
updates to their application data and/or coverage choices. Insurers must notify consumers of
changes to their plans such as premiums, benefit coverage, or provider networks (such changes
general y cannot be made during a plan year, only in preparation for, and as applicable to, a new

32 45 C.F.R. Part 155, Subpart D, including §155.302. Regarding FFE and SBE-FP states, also see “Medicaid & CHIP
Eligibility” in Section 2.1 of CMS, FFE and FF-SHOP Enrollment Manual, June 26, 2018, at https://www.cms.gov/
CCIIO/Programs-and-Initiatives/Health-Insurance-Marketplaces/General-Resources-Items/FFM-and-FF-SHOP-
Enrollment -Manual. Information for consumers is at Medicare.gov, “ Medicare & the Marketplace,” at
https://www.medicare.gov/about -us/medicare-the-marketplace. Hereinafter referred to as CMS, FFE and FF-SHOP
Enrollm ent Manual
. Regarding SBE states, also see Sara Rosenbaum et al., Stream lining Medicaid Enrollm ent: The
Role of the Health Insurance Marketplaces and the Im pact of State Policies
, Commonwealth Fund, March 30, 2016, at
https://www.commonwealthfund.org/publications/issue-briefs/2016/mar/streamlining-medicaid-enrollment -role-health-
insurance.
33 Medicare is a federal health insurance 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. T he prohibition on selling an individual
exchange plan to someone enrolled in Medicare does not apply to employment -based coverage, including coverage
sold in the SHOP exchanges. See CMS, “ Medicare and the Marketplace,” updated December 2019, at
https://www.cms.gov/Medicare/Eligibility-and-Enrollment/Medicare-and-the-Marketplace/Overview1.html. Also see
Section 2.6.8 of CMS, FFE and FF-SHOP Enrollm ent Manual, June 26, 2018, at https://www.cms.gov/CCIIO/
Programs-and-Initiatives/Health-Insurance-Marketplaces/General-Resources-Items/FFM-and-FF-SHOP-Enrollment -
Manual. Information for consumers is at Medicare.gov, “ Medicare & the Marketplace,” at https://www.medicare.gov/
about-us/medicare-the-marketplace. CMS, FFE and FF-SHOP Enrollm ent Manual.
34 45 C.F.R. §155.410.
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plan year).35 If an existing exchange plan enrollee does not take any action during the OEP, they
general y wil be automatical y reenrolled in the same plan for the upcoming plan year.36
Table 1. Open Enrollment Periods for Individual Exchanges on the Federal Platform,
by Plan Year

Plan Year

2014
2015
2016
2017
2018
2019
2020
2021
Oct. 1,
Nov. 15,
Nov. 1,
Nov. 1,
Nov. 1,
Nov. 1,
Nov. 1,
Nov. 1,
HealthCare.
2013-
2014-
2015-
2016-
2017-
2018-
2019-
2020-
gov OEP
Mar. 31,
Feb. 15,
Jan. 31,
Jan. 31,
Dec. 15,
Dec. 15,
Dec. 15,
Dec. 15,
2014
2015
2016
2017
2017
2018
2019
2020
Source: CRS analysis of Department of Health and Human Services (HHS) reports on enrol ment during annual
open enrol ment periods. See the “Pre-effectuated Enrol ment Data” section of CRS Report R46638, Health
Insurance Exchanges: Sources for Statistics
for reports by year.
Notes: FFE = federal y facilitated exchange; OEP = open enrol ment period; PY = plan year; SBE = state-based
exchange; SBE-FP = state-based exchange using the federal information technology platform; SEP = special
enrol ment period. See “State-Based and Federal y Facilitated Exchanges” in this report for more information.
The HealthCare.gov OEP applies to FFE and SBE-FP states. In some years, there also have been federal OEP
extensions or SEPs for broadly applicable situations, such as the SEP during PY2021 due to the COVID-19
pandemic. See “Open and Special Enrol ment Periods” in this report for more information.
The OEPs of SBEs may be longer in a given year. For PY2021, 13 of 15 SBEs extended their OEPs. See CMS,
“2021 Marketplace Open Enrol ment Period Public Use Files” at https://www.cms.gov/research-statistics-data-
systems/marketplace-products/2021-marketplace-open-enrol ment-period-public-use-files.
Consumers also may be al owed to enroll for coverage in an exchange if they qualify for a special
enrollment period
(SEP). General y, consumers qualify for SEPs due to a change in personal
circumstances—for example, a change in marital status or number of dependents—or loss of
qualifying coverage.37 HHS also may choose to offer SEPs or extend an OEP for some or al

35 See Section 2.6 of CMS, FFE and FF-SHOP Enrollment Manual; the “Reenrollment Communications to Enrollees”
section cites CMS guidance: Updated Federal Standard Renewal and Product Discontinuation Notices, September
2016, at https://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/Final-Updated-Federal-
Standard-Renewal-and-Product -Discontinuation-Notices-090216.pdf. T here, see “ Instructions for Attachment 2.”
36 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 2.6 of CMS, FFE and
FF-SHOP Enrollm ent Manual
. Although this manual describes processes for HealthCare.gov states, SBEs also have
processes for automatic reenrollment.
37 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. Most types of comprehensive coverage
are considered MEC, including public coverage (e.g., Medicaid, Medicare), as well as private insurance (e.g.,
employer-sponsored insurance and non-group insurance). For other types of coverage losses t hat can trigger an
exchange special enrollment period (SEP), see 45 C.F.R. §155.420. Also see 45 C.F.R. §147.104 regarding SEPs
applicable to the individual and group markets overall.
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consumers due to broadly applicable circumstances.38 Subject to statutory requirements, HHS
may make changes to SEPs.39
Federal SEPs apply to FFEs, SBE-FPs and general y to SBEs, but SBEs have flexibility regarding
implementation of some SEPs. SBEs also may create their own SEPs, subject to applicable
federal and state laws. Federal SEPs for the individual exchanges may or may not apply to the
federal SHOP exchanges and/or to the individual market outside the exchanges.40
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.
Special Enrollment Periods and COVID-19
COVID-19 pandemic and related economic recession, there have been questions about SEPs to
al ow consumers to enroll in coverage via the exchanges.
In response to COVID-19, most SBEs created SEPs to al ow individuals to purchase coverage.
These SEPs general y were open in spring 2020, with varied timing and durations. Some were
extended one or more times. In general, these SEPs were available to any uninsured individuals
eligible for exchange coverage.41
In 2020, HHS did not announce a COVID-related federal SEP for al uninsured individuals to
enroll in coverage in FFEs and SBE-FPs. However, an existing SEP al ows individuals to enroll if
they lose their job-based coverage or other qualifying coverage. A June 2020 Centers for
Medicare & Medicaid Services (CMS) report on exchange enrollment during the pandemic
further stated that “any consumers who qualified for a SEP but missed the deadline as a result of
the COVID-19 pandemic—for example, if they were sick with COVID-19 or were caring for
someone who was sick with COVID-19—may also be eligible for another SEP.”42 This is similar
to federal SEPs announced in relation to prior disasters. In addition, at least as of the second half
of 2020, the federal exchange website HealthCare.gov indicated that losing qualifying coverage
since the start of 2020 could qualify someone for an SEP, as opposed to the standard eligibility
criterion of losing qualifying coverage in the prior 60 days.43

38 For example, in 2014, the Department of Health and Human Services (HHS) established an SEP due to technical
problems submitting insurance applications through the federal information technology platform (i.e., HealthCare.gov).
In 2015, HHS established an SEP around tax season for individuals who had not enrolled in 2015 cov erage and were
subject to the 2014 individual mandate penalty. For 2018 coverage, HHS established an SEP for consumers in states
that were affected by the 2017 hurricanes or other severe weather events. See, for example, HHS, HealthCare.gov,
“Special Enrollment Periods for Complex Issues,” at https://www.healthcare.gov/sep-list/.
39 Statutory requirements for exchange SEPs are at 42 U.S.C. §18031(c)(6). Multiple examples and discussion of
administrative changes made to SEPs are in the HHS final rule, “ Patient Protection and Affordable Care Act; Market
Stabilization,” 82 Federal Register 18346, April 18, 2017, at https://www.federalregister.gov/documents/2017/04/18/
2017-07712/patient-protection-and-affordable-care-act-market-stabilization. T he background of this rule also provides
information on prior administrative actions related to SEPs.
40 For more information about SEPs, see Section 5 of CMS, FFE and FF-SHOP Enrollment Manual.
41 T he National Association of Insurance Commissioners (NAIC) has been tracking various state-level actions related
to COVID-19 and insurance, including SEPs announced by SBEs. See NAIC, “ Coronavirus Resource Center,” “ Life
and Health” spreadsheet, at https://content.naic.org/naic_coronavirus_info.htm.
42 T his report was initially published in June 2020 and then reissued in November 2020 with corrected data. CMS,
Special Trends Report: Enrollm ent Data and Coverage Options for Consum ers During the COVID-19 Public Health
Em ergency,
November 2020, at https://www.cms.gov/CCIIO/Resources/Forms-Reports-and-Other-Resources/
Downloads/SEP-Report -Nov-2020.pdf.
43 HealthCare.gov page on SEPs, at https://www.healthcare.gov/coverage-outside-open-enrollment/special-enrollment-
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On January 28, 2021, HHS (via CMS) announced a new COVID-19-related SEP, in effect
February 15-May 15, 2021, to al ow al exchange-eligible consumers to newly enroll or update
their enrollment in an exchange plan.44 This SEP was subsequently extended to August 15,
2021.45 This SEP is available in al states using the HealthCare.gov enrollment platform (FFEs
and SBE-FPs); states with SBEs are “strongly encouraged” by CMS to take similar action.
Per the initial announcement, CMS wil spend $50 mil ion to conduct a consumer outreach
campaign to promote the SEP. CMS later announced $2.3 mil ion in funding newly available to
existing Navigator grantees (consumer outreach entities) in FFE states, to assist with SEP
outreach and enrollment efforts.46
For information about other coverage options following loss of job-based coverage, see CRS In
Focus IF11523, Health Insurance Options Following Loss of Employment.
Enrollment Estimates
Annual individual exchange enrollment estimates to date are shown in Table 2. Given the
exchange eligibility determination process, as wel as the different time frames of OEPs and
SEPs, CMS releases data on exchange enrollment in stages. Pre-effectuated enrollment is the
number of unique individuals who have been determined eligible to enroll in an exchange plan
and have selected a plan. These individuals may or may not have submitted the first premium
payment. In general, cumulative and final pre-effectuated enrollment estimates are released
during and soon after an annual open enrollment period.
Subsequently, effectuated enrollment is the number of unique individuals who have been
determined eligible to enroll in an exchange plan, have selected a plan, and have submitted the
first premium payment for an exchange plan. Effectuated enrollment estimates general y are
point-in-time and may change over the coverage year. For example, due to changes in life
circumstances, an individual may disenroll (e.g., if later offered coverage through an employer),
or enroll (e.g., given eligibility for an SEP) in an exchange plan, outside of an OEP.
CMS also releases average effectuated enrollment estimates over specified time periods (e.g.,
over the first half of an enrollment year or monthly for the previous enrollment year). See the
“Enrollment Statistics” section of CRS Report R46638, Health Insurance Exchanges: Sources for
Statistics, for HHS reports and resources detailing different enrollment estimates by year.

period/.
44 CMS, “2021 Special Enrollment Period in response to the COVID-19 Emergency,” January 28, 2021, at
https://www.cms.gov/newsroom/fact-sheets/2021-special-enrollment -period-response-covid-19-emergency.
45 CMS, “Extended Access Opportunity to Enroll in More Affordable Coverage T hrough HealthCare.gov,” March 23,
2021, at https://www.cms.gov/newsroom/fact-sheets/extended-access-opportunity-enroll-more-affordable-coverage-
through-healthcaregov.
46 CMS, “ CMS Announces Additional Navigator Funding to Support Marketplace Special Enrollment Period,” March
1, 2021, at https://www.cms.gov/newsroom/press-releases/cms-announces-additional-navigator-funding-support -
marketplace-special-enrollment-period. For more information about the Navigators, see “ Navigators and Other
Exchange-Based Enrollment Assistance”
in this report .
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Table 2. Nationwide Individual Exchange Enrollment Estimates, by Plan Year

Plan Year
Nationwide
Enrollment
Estimate
Type
2014
2015
2016
2017
2018
2019
2020
2021
Pre-
effectuated,a
8.0M
11.7M
12.7M
12.2M
11.8M
11.4M
11.4M
12.0M
final for PY
OEP
Effectuated,
early in the
Early
2014
10.2M,
11.1M,
10.3M,
10.6M,
10.6M,
10.7M,
Data
plan year
estimate
Mar.
Mar.
Feb.
Feb.
Feb.
Feb.
expected
(point-in-time
not
2015
2016
2017
2018
2019
2020
summer
as of date
found
2021
shown)b
Effectuated,
late in the plan
year (point-in-
6.3M,
8.8M,
9.1M,
8.9M,
9.2M,
9.1M,
Data
Data
time or
Dec.
Dec.
Dec.
Dec.
Dec.
Dec.
expected
expected
average for
2014
2015
2016
2017
2018
2019
summer
summer
month
2021
2022
shown)c
Source: CRS analysis based on Department of Health and Human Services (HHS) reports of individual exchange
enrol ment. Data sources are in CRS Report R46638, Health Insurance Exchanges: Sources for Statistics, in report
sections specified in table notes below.
Notes: FFE = federal y facilitated exchange; OEP = open enrol ment period; PY = plan year; SBE = state-based
exchange; SBE-FP = state-based exchange using the federal information technology platform. See “Open and
Special Enrol ment Periods”
and “State-Based and Federal y Facilitated Exchanges” in this report.
a. Pre-effectuated enrol ment is the number of unique individuals who have been 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 typical y are released fol owing an OEP and include any broadly
applicable OEP extensions or longer 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 Enrol ment Report, April 2021.
b. Effectuated enrol ment 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 ex change plan.
HHS general y 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 Enrol ment 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 al 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. For example,
the 2018 estimate is from the end of the report CMS, Early 2019 Effectuated Enrol ment Snapshot, August
2019.
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Premiums and Cost Sharing
Typical y, enrollees of private health insurance plans (in or out of the exchanges) pay monthly
premiums. They also are general y responsible for out-of-pocket (OOP) costs, or cost sharing, as
they use services. In general, cost sharing includes deductibles, coinsurance, and co-payments, up
to an annual maximum amount of OOP spending.47
Premiums are set by health insurance issuers and are based on their expected medical claims costs
(i.e., the payments they expect to make for covered health benefits for a given group of enrollees,
or a given risk pool), 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.48 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.49 If consumers do not pay their
premiums, insurers may terminate their coverage, subject to applicable federal and state
requirements.50
In addition to setting premiums, insurers set cost-sharing levels, or the share of the costs of
covered benefits (or medical claims) for which the insurer and enrollee wil be responsible. Most
health plans sold through the exchanges (and non-grandfathered plans sold in the individual and
smal -group markets off-exchange51) are subject to minimum actuarial value (AV) standards and
accordingly, are given a precious metal designation (platinum, gold, silver, or bronze).52 AV is a
summary measure of a plan’s generosity in terms of cost sharing, estimated for a standard
population.53 Actuarial values by metal level are platinum (AV of 90%), gold (80%), silver (70%),
and bronze (60%). For example, for a silver plan, the insurer expects to cover approximately 70%
of cost sharing for the plan’s enrollees overal . The higher the AV percentage, the lower the cost
sharing, on average, for the plan population. However, plans with higher AV also may have
higher premiums, on average, to cover their increased share of their enrollees’ medical claims

47 A deductible is the amount an insured consumer pays for covered health care services before coverage begins (with
exceptions). Coinsurance is the share of costs, figured in percentage form, an insured consumer pays for a covered
health service. A co-paym ent is the fixed dollar amount an insured consumer pays for a covered health service. Once an
insured consumer’s out-of-pocket spending has met an out-of-pocket limit or maximum in a plan year, the insurer will
generally pay 100% of covered costs for the remainder of the plan year.
48 See CRS Report R45146, Federal Requirements on Private Health Insurance Plans, for more information about this
and other requirements related to setting premiums.
49 See “Exchange Administration” in this report.
50 See 45 C.F.R. §156.270 regarding insurer termination of enrollee coverage, including for nonpayment of premiums.
It also addresses the “grace period” of three consecutive months of premium nonpayment for enrollees who receive a
premium tax credit (discussed in the “ Premium T ax Credits and Cost -Sharing Reductions” section of this report ).
51 Grandfathered plans are individual or group plans in which at least one individual was 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. T here 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
Requirem ents to Selected Health Coverage Arrangem ents
, as well as HHS, “ Grandfathered Health Insurance P lans,” at
https://www.healthcare.gov/health-care-law-protections/grandfathered-plans/.
52 42 U.S.C. §18022(d).
53 Actuarial value (AV) is expressed as the percentage of medical expenses estimated to be paid by the insurer for a
standard population and set of allowed charges. It is not a measure of plan generosity for an enrolled individual or
family, nor is it a measure of premiums or benefits packages. AV calculations are required to apply only to the plan’s
covered essential health benefits (EHB) that are furnished by an in-network provider, unless otherwise addressed in
federal or state law.
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costs (assuming other factors affecting premiums remain the same, such as administrative
expenses). The AV standards, and the related metal levels, are meant, in part, to help consumers in
comparing the value of plans.
With the exception of “catastrophic” plans and stand-alone dental plans (see Table B-1), plans
must have at least 60% AV to be sold in the exchanges. Insurers sel ing a given plan in an
exchange must offer at least a silver and gold version of the plan throughout each service area in
which the insurers offer coverage.54
Annual OOP limits also apply to al health plans sold in the exchanges (and to al non-
grandfathered individual and group plans sold outside the exchanges).55 These limits are updated
each year through HHS rulemaking (see Table 3). Plans may set their OOP limits lower than
these maximums.
Additional data on premiums and cost sharing are in Table 4 at the end of the following section.
Table 3. Annual Out-of-Pocket Limits, by Plan Year
(Federal y set maximums; insurers may set lower out-of-pocket limits)
Plan Year

2014
2015
2016
2017
2018
2019
2020
2021
Self-only coverage
$6,350
$6,600
$6,850
$7,150
$7,350
$7,900
$8,150
$8,550
Coverage other
$12,700
$13,200
$13,700
$14,300
$14,700
$15,800
$16,300
$17,100
than self-only
Percentage increase
N/A
4%
4%
4%
3%
7%
3%
5%
over prior year
Source: CRS analysis of relevant federal rulemaking. These amounts are updated each year through an HHS rule
cal ed the Notice of Benefit and Payment Parameters, also known as the Payment Notice. For example, the
PY2021 rates were finalized in the 2021 Payment Notice, p. 29229. PY2022 OOP limits are not set, as of the
date of this report. Unlike in past years, HHS published a partial final Payment Notice for PY2022 in which HHS
stated its intention to publish the remainder, including the PY2022 OOP limits, at a later date. Annual Payment
Notices are cited in Table D-1.
Notes: PY = plan year. Out-of-pocket (OOP) limits are related to an insured consumer’s cost sharing, or OOP
spending (including deductibles, coinsurance, and co-payments; see “Premiums and Cost Sharing” in this report
for more information). Once this OOP spending meets the plan’s OOP limit or maximum in a plan year, the
insurer general y wil pay 100% of covered costs for the remainder of the plan year. An individual enrol ed in a
plan by themselves has self-only coverage. An individual enrol ed in a plan with a spouse and/or dependents has
coverage other than self-only, or family coverage.
Premium Tax Credits and Cost-Sharing Reductions
Consumers purchasing coverage through the individual exchanges may be eligible to receive
financial assistance that effectively reduces their cost of that coverage. Eligibility for such
assistance is based primarily on income and provided in the form of premium tax credits (PTCs)
and cost-sharing reductions (CSRs).56

54 45 C.F.R. §156.200(c)(1).
55 Like AV calculations, the annual out -of-pocket limit is only required to apply to the plan’s covered EHB that are
furnished by an in-network provider, unless otherwise addressed in federal or state law.
56 For more information about these forms of consumer financial assistance, including applicable eligibility criteria and
illustrative examples, see CRS Report R44425, Health Insurance Prem ium Tax Credit and Cost-Sharing Reductions.
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The PTC general y is available to consumers with household incomes between 100% and 400%
of the federal poverty level (FPL), with some exceptions, and who do not have access to public
coverage (e.g., Medicaid) or employment-based coverage that meets certain standards. 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 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.
Individuals who receive PTCs also may be eligible for subsidies that reduce cost-sharing
expenses.57 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 actuarial value of the eligible individual’s plan, for
example by reducing other cost-sharing requirements beyond the lowered OOP cap. Among other
eligibility requirements, CSRs general y 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
Several provisions of the American Rescue Plan Act of 2021 (ARPA; P.L. 117-2) temporarily expand eligibility for
and the amount of the premium tax credit (PTC) and cost-sharing reductions (CSRs) for certain individuals. For
example, ARPA expands eligibility for the PTC in tax years 2021 and 2022 by eliminating the phaseout for
households with annual incomes above 400% the federal poverty level. For more information about this and other
temporary changes regarding the PTC and CSRs, see CRS Report R44425, Health Insurance Premium Tax Credit and
Cost-Sharing Reductions
.
For information about another ARPA provision relevant to the exchanges, see “American Rescue Plan Act Grants
for Exchange Modernization”
in this report. For information about other health provisions in ARPA, see CRS
Report R46777, American Rescue Plan Act of 2021 (P.L. 117-2): Private Health Insurance, Medicaid, CHIP, and Medicare
Provisions
.
Table 4 summarizes nationwide data on premiums, advance premium tax credit (APTC) 58, and
CSRs by year, as available in relevant HHS reports on effectuated enrollment.59 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, discussed below.60 Premium and cost-sharing data on

57 T he 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
T rump Administration halted these payments, effective immediately, until Congress appropriates funds. I nsurers 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.
58 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. T his option is called the advance premium tax credit, or
APT C. Consumers may instead claim the full credit amount of the PT C when filing their taxes, even if they have little
or no federal income tax liability.
59 In the reports cited in Table 4, 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.
60 In addition, the APT C data in the table are not necessarily final, because when an individual receiving an APT C files
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al plans offered in the exchanges, as opposed to such data for plans selected, also are available,
including for PY2021.61
Table 4. Data on Premiums, Advance Premium Tax Credits, and Cost-Sharing
Reductions Nationwide, by Plan Year
(Data based on ef ectuated enrol ment in al individual exchanges)
Plan Year

2014a
2015b
2016b
2017c
2018d
2019e
2020f
Average total
N/A
N/A
N/A
$470.52
$597.20
$594.17
$576.16
premium per
monthg
Average APTC
$276
$272
$291
$373.06
$519.89
$514.01
$491.53
per monthh
Percentage of
86%
85%
85%
84%
87%
87%
86%
enrol ees
receiving APTCi
Percentage of
58%
57%
57%
57%
53%
52%
50%
enrol ees
receiving CSRj
Data as of
Dec. 2014
Mar. 2015
Mar. 2016
PY2017
Feb. 2018
Feb. 2019
Feb. 2020
Sources: CRS analysis based on specified Department of Health and Human Services (HHS) reports of
individual exchange enrol ment in private health insurance plans. Titles and publication dates of sources by year
are listed below. These sources are ful y cited in CRS Report R46638, Health Insurance Exchanges: Sources for
Statistics
, in the “Point-in-Time Effectuated Enrol ment Data” section of the report.
Notes: APTC = Advance premium tax credit; CSR = Cost-sharing reduction; PY = Plan year. These 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 and Cost Sharing” 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 al ow 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 Enrol ment 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 Enrol ment Snapshot, June 2015 and March 31, 2016
Effectuated Enrol ment Snapshot
, June 2016, respectively.

his or her tax return for a given year, the total amount of advance payments he or she received in that tax year is
reconciled with the amount he or she should have received based on the individual’s actual income over the course of
the tax year.
61 For example, an October 2020 CMS report discusses premiums and cost sharing on plans offered in HealthCare.gov
exchanges (FFEs and SBE-FPs) in PY2021: CMS, CCIIO, Plan Year 2021 Qualified Health Plan Choice and
Prem ium s in HealthCare.gov States,
October 2020, at https://www.cms.gov/CCIIO/Resources/Data-Resources/QHP-
Choice-Premiums. Also see KFF, Average Marketplace Premiums by Metal T ier, 2018 -2021, 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, 2014-2021, at https://www.kff.org/slideshow/cost -sharing-for-plans-offered-in-the-federal-
marketplace/.
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c. The June 2017 report provided average APTC data but not average premium data for February 2017.
However, the July 2018 report provided average monthly premium and APTC data for the 2017 plan year
(total amounts for the year, divided by the total number of member months). The data in this column, from
the July 2018 report, are provided to al ow for approximate comparison, but they are average monthly
estimates for the year rather than the average estimates for a given month as shown in this table for other
years. See 2017 Effectuated Enrol ment Snapshot, June 2017 and Early 2018 Effectuated Enrol ment Snapshot,
July 2018.
d. See Early 2018 Effectuated Enrol ment Snapshot, July 2018.
e. See Early 2019 Effectuated Enrol ment Snapshot, August 2019.
f.
See Early 2020 Effectuated Enrol ment Snapshot, July 2020.
g. This definition, or a non-substantive variation of it, appears in one or more reports: “Average total premium
per month is the total premium (including APTC and any premium paid by the policyholder) for the month,
divided by the number of individuals who had an active policy for the month.”
h. This definition, or a non-substantive variation of it, appears in one or more reports: “Average APTC per
month is the total amount of APTC for the month for al individuals who received APTC, divided by the
number of individuals who received APTC.”
i.
This definition, or a non-substantive variation of it, appears in one or more reports: “APTC enrol ment is
the total number of individuals who had an active policy in February 2017, who paid their premium (thus
becoming effectuated), and who received an APTC subsidy.”
j.
This definition, or a non-substantive variation of it, appears in one or more reports: “CSR enrol ment is the
total number of individuals who had an active policy in February 2017, who paid their premium (thus
effectuating their coverage), and received CSRs.”
Insurer Participation
As stated earlier (see “Qualified Health Plans”), insurers are not required to participate in the
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 al states. See Figure 2 for projected insurer participation in PY2021.62 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 PY2018.63

62 As of April 22, 2021, this map of projected insurer participation for PY2021 is the most current one on the CCIIO
website. In addition, insurer participation maps for PYs 2018 to 2020 are at https://www.cms.gov/CCIIO/Programs-
and-Initiatives/Health-Insurance-Marketplaces/Health-Insurance-Exchange-Coverage-Maps.html. A Kaiser Family
Foundation analysis of insurer participation from 2014 to 2020 is discussed later in this section.
63 See, for example, T eichert, Erica, “Last ‘bare’ county in the U.S. scores ACA exchange coverage,” Modern
Healthcare, August 24, 2017, at https://www.modernhealthcare.com/article/20170824/NEWS/170829941/last-bare-
county-in-the-u-s-scores-aca-exchange-coverage.
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Figure 2. Plan Year 2021 Insurer Participation in the Individual Exchanges, by County
(CMS map of projected participation as of October 2, 2020)

Source: CMS, CCIIO, “County by County Plan Year 2021 Projected Insurer Participation in Health Insurance
Exchanges,” published October 16, 2020 at https://www.cms.gov/CCIIO/Programs-and-Initiatives/Health-
Insurance-Marketplaces/Health-Insurance-Exchange-Coverage-Maps. This page also has insurer participation
maps for PYs 2018 to 2020.
Notes: CCIIO = Center for Consumer Information and Insurance Oversight; CMS = Centers for Medicare &
Medicaid Services; PY = plan year. As of April 22, 2021, this map of projected insurer participation for PY2021 is
the most current one on the CCIIO website.
CMS notes on map: “Values may not add to 100% due to rounding. Federal y Facilitated Exchange (FFE) data
reflected on this map are point in time as of 10/02/2020. State-Based Exchange (SBE) data are preliminary and
self-reported from the Exchanges to CMS. These data are point in time as of 10/09/2020 for CO, CT, DC, ID,
MA, MD, MN, NV, RI, VT, and WA, and 08/30/2020 for NJ and PA. County-level information for the fol owing
SBE states (CA and NY) is representative of PY2020 participation as PY2021 participation has not yet been
provided by the Exchanges to CMS.”
An insurer might choose to begin, continue, or stop offering coverage in a state or locality, on
and/or off an exchange, for various reasons. Fundamental y, insurers make decisions based on
their assessment of their risk, or likelihood and potential magnitude of loss. Individuals differ in
their health insurance risk based on their health status, with sicker individuals considered high
risk and expected to have greater health care costs than healthier individuals (i.e., low-risk
individuals). Other factors that may affect insurers’ risk assessments and decisionmaking
regarding market participation include federal and state policies, provider and insurer market
competition, and consumer behavior, as wel as the potential for uncertainty regarding any of
these factors (e.g., the potential for unexpected federal or state policy changes affecting insurers).
In January 2019, the Government Accountability Office (GAO) released a report on insurer
participation and related issues in the individual exchanges.64 The report provided background on
a range of potential contributing factors, including the federal requirements imposed by the ACA
on plans sold in the individual market, including the exchanges65; the consumer financial

64 Government Accountability Office (GAO), Health Insurance Exchanges: Claims Costs and Federal and State
Policies Drove Issuer Participation, Prem ium s, and Plan Design
, January 2019, at https://www.gao.gov/products/
GAO-19-215.
65 Several provisions of the ACA, such as guaranteed issue of health insurance, generally have increased higher-risk
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assistance available only in the exchanges66; the three ACA programs—risk corridors,
reinsurance, and risk adjustment—meant to mitigate insurers’ financial risk in the individual and
smal -group markets, including in the exchanges67; federal policy changes in the years since the
enactment of the ACA68; and state-level requirements. These and other factors, such as the health
of the populations enrolling in exchange plans, had varying impacts on claims costs (the costs
insurers pay for their enrollees’ health benefits), which in turn impacted insurer participation, as
wel as insurers’ decisions about premium amounts and plan designs (e.g., covered benefits, cost
sharing, and provider networks).
Insurer participation general y increased in PY2021 over PY2020. According to an October 2020
CMS report (on FFE and SBE-FP states only),
Out of the 36 PY21 HealthCare.gov states, 16 states have more QHP issuers participating
in PY21 than PY20, and 27 states have counties with more QHP issuers in PY21 than PY20
due to new issuers entering and existing issuers expanding service areas. Only one state
(Delaware) has a single QHP issuer in PY21, compared to two states in PY20.69
A November 2020 Kaiser Family Foundation analysis of insurer participation in al states’
individual exchanges from 2014 to 2021 also indicates such participation is rising for the third
consecutive year and “there wil be an average of 5.0 insurers per state in 2021, up from a low of
3.5 in 2018 but stil below the peak of 6.0 in 2015.”70
SHOP Exchanges
Eligibility and Enrollment
Certain smal businesses are eligible to use the SHOP exchanges. For purposes of SHOP
eligibility, a smal business, or small employer, is general y an employer with not more than 50

individuals’ ability to purchase insurance and restricted insurers’ ability to deny or limit coverage to such individuals.
T he ACA created some new requirements and expanded some existing requirements, including by applying
requirements on the individual market that previously existed in one or more segments of the group market. See the
appendix of CRS Report R45146, Federal Requirem ents on Private Health Insurance Plans.
66 See “Premium T ax Credits and Cost -Sharing Reductions” in this report. One of the factors cited in the GAO report as
affecting insurers’ participation was “federal funding changes,” including the ending of federal payments for cost -
sharing reduction subsidies in October 2017.
67 Of the three ACA risk-mitigation programs—risk corridors, reinsurance, and risk adjustment —one was designed to
be permanent. T he risk corridors and reinsurance programs were in effect from 2014 to 2016; the risk adjustment
program also began in 2014 and is still in effect. It assesses charges on applicable private health insurance plans with
relatively healthier enrollees and uses collected charges to make payments to private health plans in the same state that
have relatively sicker enrollees. See “ Other Federal Funding Sources” in this report regarding the charges assessed on
insurers via the risk adjustment program. T he phaseouts of the other two programs are cited among “ federal funding
changes” affecting insurers’ participation decisions. For descriptions of all three programs and their different
approaches, see T able 1 in CRS Report R45334, The Patient Protection and Affordable Care Act’s (ACA’s) Risk
Adjustm ent Program : Frequently Asked Questions
.
68 See Figure 1 in the GAO report discussed in this section.
69 CMS, CCIIO, Plan Year 2021 Qualified Health Plan Choice and Premiums in HealthCare.gov States, October 2020,
at the webpage “Qualified Health Plan Choice and Premiums in HealthCare.gov States,” at https://www.cms.gov/
CCIIO/Resources/Data-Resources/QHP-Choice-Premiums. T he corresponding CMS report from October 2019, posted
on the same webpage, also showed increasing in surer participation for PY2020 over PY2019.
70 Rachel Fehr et al., “Insurer Participation on the ACA Marketplaces, 2014-2021,” Kaiser Family Foundation,
November 2020, at https://www.kff.org/private-insurance/issue-brief/insurer-participation-on-the-aca-marketplaces-
2014-2021/.
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employees.71 States also may define small employer as having not more than 100 employees–four
states do.72 As of 2017, al states have the option to al ow large employers to use SHOP
exchanges, as wel , but no states have done so.73
SHOP eligibility also depends on an employer having at least at least one common-law
employee
.74 This means, for example, that a person who is self-employed and who has no
employees would not be eligible for the SHOP exchange (although they could purchase c overage
in the individual exchange, if they meet the other eligibility requirements). In addition, per the
definition of common-law employee, neither the business owner nor their business partner(s) nor
their spouse or family members (even if involved in the business) count as an employee for
purposes of SHOP eligibility.
To participate in a SHOP exchange, a smal business must offer coverage to al of its full-time
employees, which, for purposes of SHOP eligibility, means those employees working 30 or more
hours per week on average.75 The business may, but is not required to, offer coverage to part-time
or other employees, and/or to the spouses and dependents of any employees offered coverage.76
Employees and their enrolling family members must meet the same citizenship and other
eligibility requirements that apply in the individual exchanges.
Enrollment Periods
Enrollment in a SHOP exchange is not limited to a specified OEP, except in certain
circumstances.77 Such circumstances aside, a SHOP exchange must allow employers to enroll any
time during a year, and the employer’s plan year must consist of the 12-month period beginning
with the employer’s effective date of coverage.78 Whereas plans sold in the individual exchanges
general y align with the calendar year, plans sold in the SHOP exchanges need not (thus, statutory
or regulatory provisions affecting the SHOP exchanges may refer to “plan years beginning in” a
given year).
There are SEPs for SHOP exchange coverage. Some of the SEPs for the SHOP exchanges are the
same as in the individual exchanges.79

71 For purposes of SHOP eligibility, the number of employees is determined using the “full-time equivalent” (FT E)
employees calculation method. See 45 C.F.R. §155.20, “ Small employer,” which references 26 U.S.C. §4980H. Also
see CRS Report R45455, The Affordable Care Act’s (ACA’s) Em ployer Shared Responsibility Provisions (ESRP) for
discussion of FT E calculations.
72 California, Colorado, New York, and Vermont are the only states that define small businesses as having 100 or fe wer
employees for the purpose of participation in the SHOP exchanges. See Table A-1.
73 42 U.S.C. §18032(f)(2)(B). No states have allowed large employers (as defined by the state) use of their SHOP
exchanges.
74 For discussion of the SHOP eligibility requirement to have at least one common -law employee, see HHS, “ 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.
75 For purposes of SHOP eligibility, the definition of full-time employee is at 45 C.F.R. §155.20.
76 45 C.F.R. §155.710(e).
77 It is possible for SHOP exchanges to establish minimum participation rates and minimum contribution rates.
Businesses that do not comply with established rates cannot be prohibited from obtaining coverage through SHOP
exchanges; rather, health insurance plans may limit the availability of coverage for any employer that does not meet an
allowed minimum participation or contribution rate to an annual enrollment period—November 15 through December
15 of each year.
78 45 C.F.R. §155.726(b).
79 45 C.F.R. §155.726(c). See also Section 3.4 of the CMS, FFE and FF-SHOP Enrollment Manual, which notes that
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Online Enrollment versus Direct Enrollment
For an employee to obtain coverage through a SHOP exchange, a SHOP-eligible employer must
select one or more plan options on the SHOP exchange for its employees to choose from.80 Then,
employees compare their employer’s plan options and enroll if they choose. The process of
comparing and enrolling in coverage depends partial y on the type of SHOP exchange a state has:
 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.81 This is cal ed
direct enrollment, and it has been the only option in such states since plan years
beginning in 2018.82 Previously, employers and employees could purchase
coverage on HealthCare.gov or via direct enrollment.
 States administering their own SB-SHOP websites initial y were al owed to use a
direct enrollment approach, due to early difficulties some states had in getting
their SHOP exchange websites online.83 As of April 2016, HHS indicated SB-
SHOPs would need to implement online portals in time for plan years beginning
in 2019.84 However, in the 2019 Payment Notice, when HHS transitioned
HealthCare.gov SHOP exchanges to direct enrollment (see previous bullet), HHS
also announced SB-SHOPs had the option of retaining or returning to a direct
enrollment approach or maintaining enrollment sites if they had created them. As
of September 2020, 6 of the 15 SB-SHOP states are using a direct enrollment
approach only.85
Besides exchange website enrollment versus direct enrollment options, a significant factor
affecting access to SHOP plans is whether any insurers are offering plans in that state’s SHOP

SHOP 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]. Specifically, SEPs described in 45 CFR §155.420(d)(1)(ii), (3), and (6) do not
apply in SHOPs.”
80 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/.
81 HealthCare.gov, “Overview of SHOP: Health insurance for small businesses,” at https://www.healthcare.gov/small-
businesses/choose-and-enroll/shop-marketplace-overview/.
82 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”). T he two
states that used this option at the time, Kentucky and Nevada, were allowed to continue doing so if desired, despite the
reduced functionality of HealthCare.gov for SHOP. However, they have since transitioned their SHOPs to other types
(see Table A-1). Citation for this rule is in Table D-1.
83 For iterations of guidance on this topic issued between 2014 and 2016 , see CMS, CCIIO, “Extension of State-Based
SHOP Direct Enrollment T ransition,” April 18, 2016, at https://www.cms.gov/CCIIO/Resources/Regulations-and-
Guidance/Downloads/1332-and-SHOP-Guidance-508-FINAL.PDF.
84 Ibid. In April 2016, CMS also outlined different options for those states to consider, including transitioning to the
federal IT platform (becoming an SB-FP-SHOP) or applying for an ACA Section 1332 waiver to obtain an exception to
the requirement to have a SHOP exchange at all. For more information about ACA Section 1332 waivers, see CRS
Report R44760, State Innovation Waivers: Frequently Asked Questions.
85 See Table A-1.
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exchange. For PY2021, there are no insurers offering medical plans in SHOP exchanges in more
than half of states.86 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 smal -group market off-
exchange.
Following is a summary of SHOP exchange plan availability and enrollment methods, by SHOP
exchange type, for PY2021. See Table A-1 for more information, including by state.
FF-SHOP, 32 states: al direct enrollment only, 9 with and 23 without SHOP plans.
SB-SHOP, 18 states: 7 states with plans and SHOP website enrollment option, 6 with
plans and direct enrollment only, and 5 with no SHOP plans.
No SHOP, 1 state: state received waiver al owing it not to have a SHOP.87
Enrollment Estimates
Unlike individual exchange enrollment data, SHOP exchange enrollment data are not released
annual y. However, CMS estimated that there were approximately 27,000 smal employers and
233,000 employees using the SHOP exchanges across the country in January 2017.88 CMS
previously estimated 10,700 active smal employers and 85,000 employees in the SHOP
exchanges as of May 2015.89
According to a 2019 GAO report that included 2016 SHOP exchange enrollment data for 46
states,
As a proportion of the overall small group market, SHOP exchanges in most states had
little enrollment—that is, typically less than 1 percent of the overall small group market ..
The District of Columbia, Rhode Island, and Vermont were the only states where the SHOP
exchange was more than 3 percent of the overall small group market. The District of
Columbia and Vermont require all small group plans to be purchased through the state’s
SHOP exchange.90
In addition, District of Columbia SHOP enrollment includes congressional Members and staff, as
discussed below.

86 T he number of states with no insurers offering plans in SHOP exchanges in 2021 is based on CRS analysis of the
2021 “Business Rules” public use file at CMS, “ Health Insurance Exchange Public Use Files (Exchange PUFs),” at
https://www.cms.gov/CCIIO/Resources/Data-Resources/marketplace-puf, as well as information available on
HealthCare.gov and state exchange websites. 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 o f 51 states for which it had such data for all three of those years. See
T able 7 in GAO, Private Health Insurance: Enrollm ent Rem ains Concentrated Am ong 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.”
87 See footnote 18. See Table A-1 for details and citations.
88 T his 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.
89 T his 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/
20170118124128/https:/blog.cms.gov/2015/07/.
90 See page 24 and Appendix III of the GAO Enrollment Report, March 2019 .
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Congressional Member and Staff Enrollment via the D.C. SHOP Exchange
Per the ACA, Members of Congress and their staff general y 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.91 As implemented, they purchase coverage through
the District of Columbia’s SHOP exchange. Congressional offices are not eligible for the smal
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 section earlier in this report on “Premiums and Cost Sharing” in the individual exchanges,
including certain federal requirements that apply to premiums and cost sharing, general y applies
in the SHOP exchanges, as wel . See CRS Report R45146, Federal Requirements on Private
Health Insurance Plans
for other requirements applicable to the individual and smal -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 reports on premium or cost-sharing data specific to the SHOP
exchanges.
Small Business Health Care Tax Credit
Certain smal businesses are eligible for the smal business health care tax credit (SBTC).92 In
general, this credit is available only to smal employers with 25 or fewer full-time-equivalent
(FTE) employees that purchase coverage through SHOP exchanges and contribute at least 50% of
premium costs for their full-time employees.93 (For the purpose of this tax credit, full-time
employees
are those who work an average of 40 hours per week, whereas for the purpose of
SHOP eligibility, full-time employees are those who work an average of 30 hours per week.94) The
intent of the credit is to assist smal employers with the cost of providing health insurance
coverage to employees. The credit is available to eligible smal businesses for two consecutive
tax years (beginning with the first year the smal employer purchases coverage through a SHOP
exchange).

91 Other federal employees may obtain coverage through the Federal Employees Health Benefits Program (FEHB).
Like many other employers, the federal government contributes to the cost of its employees’ premiums. T his 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/.
92 See 26 U.S.C. §45R for eligibility for the Small Business Health Care T ax Credit (SBT C) and credit amount details
described in this section.
93 See the SHOP “ Eligibility and Enrollment ” section of this report for discussion of full-time equivalent employees.
94 Regarding SHOP eligibility, see 26 U.S.C. §4980H, 26 CFR §54.4980H-1(a)(21), and 45 CFR §155.20. Regarding
the SBT C, see 26 U.S.C. §45R.
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In states with no insurers offering plans through the SHOP exchange (see discussion above),
certain eligible employers stil 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.95
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
$27,800 or less (in 2021).96 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.97
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
market (see “Premium Tax Credits and Cost-Sharing Reductions” above).
The IRS has published information on the number of SBTCs filed in tax years 2010-2016.98 For
2016, the IRS indicates that 6,952 employers claimed the SBTC.99
Insurer Participation
As stated above, as of PY2020, there are no insurers offering SHOP plans in more than half of
states.100
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 individual market, there were new federal
requirements imposed by the ACA on plans sold in the smal -group market (including the SHOP
exchanges), and insurers in the smal -group market were or are participating in risk-mitigation
programs.
There are also factors unique to the SHOP exchanges that may have affected insurer participation.
For example, in December 2016, effective January 2018, HHS removed a requirement that in
order to participate in a federal y facilitated individual exchange, an insurer with more than 20%
of the smal -group market in that state also would have to participate in that SHOP exchange. In
the rule, HHS acknowledged the elimination of this requirement likely would reduce insurer
participation, and thus employer and employee participation, in affected SHOP exchanges.101

95 Internal Revenue Service (IRS), Small Business Health Care Tax Credit Questions and Answers: Who Gets the Tax
Credit,
Question 6D, updated September 2020, at https://www.irs.gov/newsroom/small-business-health-care-tax-credit -
questions-and-answers-who-gets-the-tax-credit.
96 IRS, Rev. Proc. 2020-45, Section 3.11, at https://www.irs.gov/pub/irs-drop/rp-20-45.pdf, referring to 26 U.S.C.
§45R(d)(3)(B).
97 26 U.S.C. §45R(d)(1)(B).
98 IRS, SOI Tax Stats - Affordable Care Act (ACA) Statistics: Credit for Small Employer Health Insurance,
Premiums,” page updated Sept. 2020, at https://www.irs.gov/statistics/soi-tax-stats-affordable-care-act-aca-statistics-
credit-for-small-employer-health-insurance-premiums.
99 Ibid. See excel file, “ Small Business Health Care T ax Credits Filed in T ax Years 2010–2016,” linked on this
webpage.
100 See “Online Enrollment versus Direct Enrollment” in this report.
101 2018 Payment Notice, page 94144. Citation for this rule is at Table D-1.
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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 smal
business tax credit.102
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 general y include in-person and other forms of outreach and
assistance.103
Each exchange must have a Navigator program.104 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 smal 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; and refer consumers to any applicable consumer assistance programs as
needed, such as state agencies that assist consumers with questions or complaints about their
plans. Navigators also may, but are not federal y required to, provide other assistance, such as
information or referrals regarding reconciliation of consumers’ PTCs via their annual income tax
filing.105 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.”106
Navigators are funded by the exchanges, via grants (federal or state, depending on exchange type)
provided to qualifying organizations. Information on current and prior-year Navigator grantees in
FFE states is available on the CMS website.107 For FFE states, certain eligibility requirements
changed in 2018 and 2019. For example, Navigator entities are no longer required to maintain a
physical presence in their exchange service area.108 Also for FFE states, additional funding was

102 See GAO, 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. Also see Jost, T imothy, “ CMS Announces
Plans T o Effectively End T he SHOP Exchange,” Health Affairs Blog, May 15, 2017, at https://www.healthaffairs.org/
do/10.1377/hblog20170515.060112/full/.
103 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.
104 Ibid. Specifically, for the requirement to implement Navigator programs, see 45 C.F.R. §155.210.
105 Some functions that were previously required are now optional for federally funded Navigator grantees. See 45
C.F.R. §155.210(e)(9).
106 45 C.F.R. §155.210(c)(1)(iii).
107 For information on FFE Navigator grants, see CMS, “ In-Person Assistance in the Health Insurance Marketplaces,”
at https://www.cms.gov/CCIIO/Programs-and-Initiatives/Health-Insurance-Marketplaces/assistance. Per the list of
2020 grantees, there were no eligible applicants in FFE states South Carolina and Utah. CRS is not aware of a
compilation of information about Navigator grants in states that administer these programs (those with SBEs and SBE-
FPs).
108 T he eligibility requirement changes were made via the 2019 and 2020 Payment Notices (cited in Table D-1). T he
changes, and existing eligibility requirements, are summarized in the 2019 Navigator funding opportunity
announcement, Cooperative Agreem ent to Support Navigators in Federally Facilitated Exchanges, at
https://www.grants.gov/web/grants/search-grants.html?keywords=CA-NAV-19-001 (select “ archived” option under
“opportunity status”).
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made available for Navigator grantees in March 2021, for purposes of outreach and enrollment
efforts regarding the COVID-19 SEP.109
Exchanges also must have a Certified Application Counselor (CAC) program.110 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 sel ing health policies from insurers or consumers.111
Besides facilitating the above assistance programs, exchanges must provide for the operation of a
cal center and maintain a website (e.g., HealthCare.gov) that meets certain informational
requirements.112 Exchanges also provide consumer information and outreach via mail, radio or
television ads, and/or other methods.
Overal , exchanges’ consumer outreach efforts and materials must meet certain standards
regarding accessibility for individuals with disabilities or with limited English proficiency.113
Brokers, Agents, and Other Third-Party Assistance Entities
Pursuant to state law, exchanges also may certify insurance agents, brokers, and/or web-brokers
to help consumers obtain coverage through exchanges.114
 An agent or broker is “a person or entity licensed by the State as an agent, broker
or insurance producer.”115 They may be individuals or entities that sel plans for
different insurance companies, general y receiving a commission from those
companies for doing so; or they may be employees of an insurance company who
help people enroll in that company’s plans.
 A web-broker is an exchange-certified individual or group of agent(s) or
broker(s), or other business entity (including a “direct enrollment technology
provider”), “that develops and hosts a non-Exchange website that interfaces with
an Exchange to assist consumers with direct enrollment in qualified health plans
offered through the Exchange.”116 In other words, they offer privately owned and
operated websites that may be similar in concept to the ACA exchange websites,
in that they al ow for comparison of purchase of different plans.

109 See “Special Enrollment Periods and COVID-19” in this report.
110 For the requirement to implement certified application counselor programs, see 45 C.F.R. §155.225.
111 45 C.F.R. §155.215.
112 45 C.F.R. §155.205.
113 45 C.F.R. §155.205.
114 45 C.F.R. §155.220. Definitions of terms discussed in this section, and of other related terms such as direct
enrollm ent entity
, are at 45 C.F.R. §155.20.
115 Ibid.
116 Ibid. See 45 C.F.R. §155.20 for full definition of this term.
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If certified to sel exchange plans, any of these “third party” entities must follow rules about
providing information and access to al plans that would be available to a consumer on the actual
exchange website.117 Unlike the exchange websites and exchange assistors, however, they 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 smal -group plans available off-exchange.118
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.119 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 2015.120
Ongoing Federal Spending on Exchange Operation
The federal government spent an estimated $1.8 bil ion on operating the exchanges in FY2020,
and it projected $1.2 bil ion in spending for FY2021.121 See Figure C-1, which includes these
numbers as wel as estimated and prior year federal spending on the exchanges by activity (e.g.,
information technology, Navigator grants), in a table that is included by CMS in its annual budget
justification to Congress.
In general, this federal spending is specific to FFEs. For example, the federal government funds
the Navigator program only in states with FFEs. Some of the federal spending, particularly in
terms of information technology and the cal center, also is applicable to SBE-FPs, because these
state-based exchanges use the federal HealthCare.gov platform. CMS performs and funds some
functions for al exchanges, including SBEs, such as “verifying consumers’ eligibility data for
financial assistance through the Exchange or other health insurance programs, including Medicaid
and the Children’s Health Insurance Program (CHIP).”122

117 45 C.F.R. §155.220.
118 See “Eligibility and Enrollment ” in the SHOP section of this report for more information about SHOP exchange
enrollment options and plan availability.
119 42 U.S.C. §18031(a).
120 42 U.S.C. §18031(a)(4)(B) specifies that no grant shall be awarded under this subsection after January 1, 2015. See
CRS Report R43066, Federal Funding for Health Insurance Exchanges (last updated in October 2014) for more
information about these planning and establishment grants.
121 Department of Health and Human Services, Centers for Medicare & Medicaid Services, Justification of Estimates
for Appropriations Com m ittees, Fiscal Year 2021
, March 3, 2020, at https://www.cms.gov/About -CMS/Agency-
Information/PerformanceBudget/FY2021-CJ-Final.pdf. See “ Federal Exchanges” table and narrative, page 195 -200,
and “Health Insurance Exchange T ransparency Table,” page 241. T he HHS FY2020 spending estimate was as of
January 2020. Hereinafter referred to as “ CMS Budget Justification, FY 2021.”
122 Page 196 of the CMS Budget Justification, FY2021.
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The costs of the plans themselves are covered by enrollees’ premiums and in some cases are
subsidized by the federal government (i.e., via PTCs). The costs of the PTCs are financed through
a permanent appropriation through the tax code.123 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.124 To raise funds for the exchanges it administers and/or for
which it provides a web platform, HHS assesses a monthly fee on each health insurance issuer
that offers plans through an FFE or SBE-FP. The user fee amounts are al owed to fund only
federal activities or functions specific to these exchanges; the user fees cannot fund federal
activities that serve al exchanges (including SBEs).125 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.
The fee is a percentage of the value of the monthly premiums the insurer collects on exchange
plans in a given state, and HHS updates the percentage each year through rulemaking. See Figure
3.
User fees also have been 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 SB-FP-
SHOPs, due to the reduced functionality of the federal SHOP website also announced in that
rule.126

123 31 U.S.C. §1324(b).
124 42 U.S.C. §18031(d)(5)(A).
125 For further discussion, see 2020 Payment Notice (cited 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, FY2021, p. 196.
126 2019 Payment Notice (cited in Table D-1), page 17007. See “ Online Enrollment versus Direct Enrollment
regarding t he reduced functionality of federal SHOP websites.
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Overview of Health Insurance Exchanges

Figure 3. Federal User Fee for Insurers Participating in Specified Types of Individual
Exchanges, by Plan Year
(Fee is the stated percentage of the value of monthly premiums col ected by insurer on exchange plans)

Source: CRS analysis of annual “Payment Notice” federal rules cited in Table D-1, as wel 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 = federal y facilitated exchange. SBE = state-based exchange. SBE-FP = state-based exchange using
the federal information technology (IT) platform. See “Types and Administration of Exchanges” for discussion of
exchange types.
Although some SBE-FPs existed prior to plan year 2017, HHS did not begin assessing a user fee on insurers in
those states until then.
SBEs’ assessment of user fees, if any, varies, as discussed in this section of the report.

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

127 Based on CRS analysis of data provided in CMS Budget Justifications for FY2021 and FY2020 (see Table C-1).
Comparable data not found in prior years’ budget justifications.
128 Ibid.
129 CMS Budget Justification, FY2021, page 199.
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Other Federal Funding Sources
Besides the user fees collected from participating insurers, federal funding for the exchanges
(including for federal activities related to al exchanges, including SBEs) largely comes from
discretionary appropriations for program management and program integrity. There is also a risk-
adjustment user fee, related to the risk-mitigation program briefly mentioned earlier in this
report.130 There is currently no mandatory HHS appropriation for exchange activities.131 An
overview of recent and currently proposed funding sources is in Table C-1.
State Financing of the Exchanges
States with SBEs finance their own exchange administration. States with SBE-FPs also finance
the costs associated with the exchange functions they administer (whereas the federal user fee is
assessed on insurers in such states to finance federal y run functions such as the IT platform, as
discussed above). 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 provides 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 al applicable
requirements.” The HHS Secretary is authorized to determine specified aspects of the grant
funding application process. Eligibility for these grants is limited to SBEs and SBE-FPs. The
legislation specifies that FFEs are not eligible through its reference to exchanges established
under 42 U.S.C. Section 18041(c).
For this grant program, $20 mil ion is appropriated for FY2021, out of Treasury funds not
otherwise appropriated. The funding is to remain available until the end of FY2022.
See “Premium Tax Credits and Cost-Sharing Reductions” regarding other ARPA provisions
relevant to the exchanges and the plans sold in them.132

130 See “Insurer Participation” in the Individual Exchanges section of the report.
131 According to the “Federal Exchanges” table in the FY2020 CMS CJ, a portion of the mandatory Health Care Fraud
and Abuse Control (HCFAC) appropriation went to the exchanges in FY2018 and FY2019. However, that table in the
FY2021 CJ does not show this for FY2019. See Table C -1 for citations.
132 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 Provision s
.
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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), federal y facilitated exchanges (FFEs), and
state-based exchanges using a federal platform (SBE-FPs). For plan year (PY) 2021, there are 30
FFEs, 15 SBEs, and 6 SBE-FPs.
A few states have changed approaches one or more times (e.g., initial y 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 general y are in the direction of less federal
involvement. There were three changes for PY2015, one for PY2016, three for PY2017, none for
PY2018 or PY2019, three for PY2020, and four for PY2021. As of the publication of this report,
at least five states are known to be transitioning or considering transitions for PY2022 or beyond.
SHOP exchanges may be federal y facilitated (FF-SHOP) or state-based (SB-SHOP).133 For
PY2021, there are 32 FF-SHOPs and 18 SB-SHOPs. However, in more than half of 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 Exchanges section of this report for
more information. One state is exempted from operating a SHOP exchange.
For PY2021 plan, most states’ individual and SHOP exchanges are administered in the same way
(i.e., both state-based or both federal y facilitated). However, a handful of states have different
approaches for their individual and SHOP exchanges. Some resources refer to this as a bifurcated
approach.
Table A-1 shows individual exchange types by state, with information on past changes in
individual exchange types and changes underway or planned. It also shows SHOP exchange types
by state and provides details on SHOP plan availability and enrollment method.

133 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. For more information, see “ Online Enrollment versus Direct Enrollment” in the
“SHOP Exchanges” section of this report.
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Table A-1. Exchange Types and Key Details by State, Plan Year 2021
Individual Exchange Typea
SHOP Exchange Typeb
(and notes on exchange type
(with notes on plan availability and
State
Exchange Website
transitions, if applicable)
enrol ment options)
U.S. Totals

FFE: 30
FF-SHOP: 32 (23 have no plans;
SBE: 15
al are direct enrol ment only)
SBE-FP: 6
SB-SHOP: 18 (5 have no plans; 6
are direct enrol ment only)
(plans and online enrol ment available
in al counties, al states)
No SHOP: 1
Alabama
HealthCare.gov
FFE
FF-SHOP, via direct enrol mentc
Alaska
HealthCare.gov
FFE
FF-SHOP, but no medical plansd
Arizona
HealthCare.gov
FFE
FF-SHOP, but no medical plansd
Arkansas
Myarinsurance.com;
SBE-FP as of PY17
SB-SHOP, but no medical plansf
HealthCare.gov
(initial y FFE)e
California
Coveredca.com
SBE
SB-SHOP (up to 100 employees) g
Colorado
Connectforhealthco.com
SBE
SB-SHOP, via direct enrol menth
(up to 100 employees)g
Connecticut
Accesshealthct.com
SBE
SB-SHOP
Delaware
HealthCare.gov
FFEi
FF-SHOP, but no medical plansd
District of
DChealthlink.com
SBE
SB-SHOP
Columbia
Florida
HealthCare.gov
FFE
FF-SHOP, but no medical plansd
Georgia
HealthCare.gov
FFE (planning to replace exchange
FF-SHOP, via direct enrol mentc
with alternate approach as of PY23) j
Hawai
HealthCare.gov
FFE as of PY17 i (initial y SBE, then
No SHOP exchangek
SBE-FP for PY16)e
Idaho
Yourhealthidaho.org
SBE as of PY15
SB-SHOP, via direct enrol menth
(initial y SBE-FP)e
Il inois
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
Healthbenefitexchange.ky.
SBE-FP as of PY17 (initial y SBE)
FF-SHOP, but no medical plansd
gov; HealthCare.gov
Planning for SBE as of PY22e
Louisiana
HealthCare.gov
FFE
FF-SHOP, but no medical plansd
Maine
Enrol 207.com;
SBE-FP as of PY21 (initial y FFE)i
FF-SHOP, via direct enrol mentc
HealthCare.gov
Considering SBEe
Maryland
Marylandhealthconnection.
SBE
SB-SHOP, via direct enrol menth
gov
Massachusetts
Mahealthconnector.org
SBE
SB-SHOP
Michigan
HealthCare.gov
FFEi
FF-SHOP, but no medical plansd
Minnesota
Mnsure.org
SBE
SB-SHOP, but no medical plansf
Mississippi
HealthCare.gov
FFE
FF-SHOP, but no medical plansd
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Individual Exchange Typea
SHOP Exchange Typeb
(and notes on exchange type
(with notes on plan availability and
State
Exchange Website
transitions, if applicable)
enrol ment options)
Missouri
HealthCare.gov
FFE
FF-SHOP, but no medical plansd
Montana
HealthCare.gov
FFEi
FF-SHOP, via direct enrol mentc
Nebraska
HealthCare.gov
FFEi
FF-SHOP, but no medical plansd
Nevada
Nevadahealthlink.com
SBE as of PY20 (initial y SBE, then
SB-SHOP, but no medical plansf
SBE-FP as of PY15)e
New
HealthCare.gov
FFEi
FF-SHOP, via direct enrol mentc
Hampshire

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

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

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

Pennsylvania
Pennie.com
SBE as of PY21 (initial y FFE, then
SB-SHOP, but no medical plansf
SBE-FP as of PY20)e
Rhode Island
Healthsourceri.com
SBE
SB-SHOP
South
HealthCare.gov
FFE
FF-SHOP, but no medical plansd
Carolina
South Dakota
HealthCare.gov
FFEi
FF-SHOP, but no medical plansd
Tennessee
HealthCare.gov
FFE
FF-SHOP, but no medical plansd
Texas
HealthCare.gov
FFE
FF-SHOP, but no medical plansd
Utah
HealthCare.gov
FFEi
FF-SHOP, but no medical plansd
Vermont
Healthconnect.vermont.
SBE
SB-SHOP, via direct enrol menth
gov
(up to 100 employees)g
Virginia
Coverva.org/marketplace;
SBE-FP as of PY21 (initial y FFE i)
FF-SHOP, via direct enrol mentc
HealthCare.gov
Planning for SBE as of PY23e
Washington
Wahealthplanfinder.org
SBE
SB-SHOP, but no medical plansf
West Virginia
HealthCare.gov
FFEi
FF-SHOP, but no medical plansd
Wisconsin
HealthCare.gov
FFE
FF-SHOP, via direct enrol mentc
Wyoming
HealthCare.gov
FFE
FF-SHOP, via direct enrol mentc
Sources: Congressional Research Service (CRS) analysis of data at the sources indicated in notes section below.
Notes:
SHOP = Smal business health options program.
FFE and FF-SHOP = Federal y facilitated individual exchange; federal y facilitated SHOP exchange.
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SBE and SB-SHOP = State-based individual exchange; state-based SHOP exchange.
SBE-FP = State-based individual exchange using the federal information technology (IT) platform; state-based
SHOP exchange using the federal IT platform.
Counts of “states” include the District of Columbia. In the individual exchanges, “plan year” is general y that
calendar year, but group coverage plan years, including in the SHOP exchanges, may start at any time during a
calendar year. See report “Overview” for discussion of exchange types; see Figure 1 in this report for the 2021
exchange types by state in map form.
a. 2021 individual exchange types: SBEs and SBE-FPs are listed at Centers for Medicare & Medicaid
Services (CMS), Center for Consumer Information and Insurance Oversight (CCIIO), “State-based
Exchanges,” updated November 1, 2019, at https://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/
state-marketplaces. Remaining states have FFEs. Cross-referenced at Kaiser Family Foundation, “State
Health Insurance Marketplace Types, 2021,” at https://www.kff.org/health-reform/state-indicator/state-
health-insurance-marketplace-types/, and at state exchange websites as needed.
b. 2021 SHOP exchange types: HealthCare.gov, “Select your state,” at https://www.healthcare.gov/smal -
businesses/employers/, cross-referenced at state exchange websites or otherwise as needed. Kentucky and
Nevada both had SB-FP-SHOPs, but according to communication with CMS, their SHOP types are now as
shown in the table. States with no medical 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 al areas.
c. All FF-SHOPs are now using a direct enrollment approach only. They do not offer online
enrol ment but instead instruct users to connect with agents or brokers offering plans through the state’s
SHOP exchange. See “Online Enrol ment versus Direct Enrol ment” in this report for more information.
d. No insurers are currently offering medical plans in these FF-SHOPs. (Some may be offering dental
plans, however.) See CMS, Health Insurance Exchange Public Use Files, 2021: Business Rules PUF, at
https://www.cms.gov/CCIIO/Resources/Data-Resources/ma rketplace-puf. Contact report author for further
information.
e. While most states have maintained the same type of individual exchange they initial y opted for, some have
transitioned to different exchange types, or are planning to do so.
For transitions to date
2014 exchange types:
https://aspe.hhs.gov/pdf-report/addendum-health-insurance-marketplace-summary-
enrol ment-report
2015 exchange types:
FN 3 of https://www.cms.gov/newsroom/fact-sheets/march-31-2015-effectuated-
enrol ment-snapshot
2016 exchange types:
FN 3 of https://www.cms.gov/newsroom/fact-sheets/march-31-2016-effectuated-
enrol ment-snapshot
2017-2020 exchange types: State level public use files for each year, https://www.cms.gov/Research-
Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Marketplace-Products.
2021 and future transitions: See table note (a) regarding 2021 exchange types. Two CMS resources also
note PY2020 and PY2021 transitions, as referenced where relevant by state below: “CMS PY2021 QHP
report”
(CMS, CCIIO, Plan Year 2021 Qualified Health Plan Choice and Premiums in HealthCare.gov States,
October 2020, at https://www.cms.gov/CCIIO/Resources/Data-Resources/QHP-Choice-Premiums); and
“2020 CMS Navigator Recipients” (CMS, 2020 CMS Navigator Cooperative Agreement Recipients,
August 30, 2020, at https://www.cms.gov/CCIIO/Programs-and-Initiatives/Health-Insurance-Marketplaces/
assistance).
Kentucky:
https://kentucky.gov/Pages/Activity-stream.aspx?n=GovernorBeshear&prId=218
Maine:
https://www.maine.gov/dhhs/blog/maine-progresses-toward-state-based-health-insurance-
marketplace-2020-08-06. Also see 2020 CMS Navigator Recipients.
New Jersey: https://nj.gov/governor/news/news/562019/approved/20190322a.shtml. Also see CMS PY2021
QHP report.
New Mexico: https://www.bewel nm.com/Special-Enrol ment-(1)/partner-resources/State-Based-Exchange-
Transition.
Oregon:
https://healthcare.oregon.gov/marketplace/gov/Pages/tech-consumer-assistance.aspx.
Pennsylvania:
https://www.insurance.pa.gov/Coverage/Pages/State-Based-Exchange.aspx. Also see CMS
PY2021 QHP report.
Virginia: https://www.governor.virginia.gov/newsroom/all-releases/2020/august/headline-860017-en.html.
Also see 2020 CMS Navigator Recipients.
Also see
Sabrina Corlette et al., States Seek Greater Control, Cost-Savings by Converting to State-Based
Marketplaces
, Robert Wood Johnson Foundation, October 2019, at https://www.rwjf.org/en/library/
research/2019/10/states-seek-greater-control-cost-savings-by-converting-to-state-based-marketplaces.html.
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f.
No insurers are currently offering medical plans in these SB-SHOPs. (Some may be offering dental plans,
however.) The SHOP website suggests that smal businesses contact agents, brokers, and/or insurers
directly to learn about coverage options outside of the SHOP. See Arkansas: https://myarinsurance.com/
pages/manage-shop/
Minnesota: https://www.mnsure.org/employer-employees/index.jsp
Nevada: https://www.nevadahealthlink.com/overview/
Pennsylvania: Confirmed via state officials
Washington: Confirmed via state officials
g. For the purposes of SHOP exchange participation, states may define smal employers (or smal businesses) as
employers that have not more than 50 or not more than 100 employees. See SHOP “Eligibility and
Enrol ment”
in this report. Only four states use the threshold of 100. See
California: https://www.coveredca.com/forsmal business/eligible/
Colorado: https://connectforhealthco.com/get-started/options-for-smal -business-owners/, “Employer
application”
New York: https://nystateofhealth.ny.gov/employer
Vermont: https://info.healthconnect.vermont.gov/smal business_faq
h. These SB-SHOPs are using a direct enrollment approach only: They do not offer online
enrol ment but instead instruct users to connect with agents or brokers offering plans through the state’s
SHOP exchange. See
Colorado: https://connectforhealthco.com/get-started/options-for-smal -business-owners/
Idaho: https://www.yourhealthidaho.org/smal -business-insurance/
Maryland: https://mhcsmal biz.marylandhealthconnection.gov/anonymous-web/#/quote-engine/enrol
New York: https://nystateofhealth.ny.gov/employer
Oregon: https://healthcare.oregon.gov/marketplace/employers/Pages/employers.aspx
Vermont: https://info.healthconnect.vermont.gov/SB
i.
In some FFE states, the federal government performs al functions. But in these FFE states, the state
partners with the federal government to perform some functions. CMS data do not general y identify these
“partnership” variations, but the Kaiser Family Foundation tracks them at the site linked in table note (a).
j.
Georgia received approval through the Section 1332 state innovation waiver process to shift to its own
“Georgia Access Model,” essential y a direct enrol ment approach, beginning in PY2023. This 1332 process
al ows 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.
k. Hawai received a Section 1332 waiver exempting it from having SHOP exchange for PYs 2017-2021. This
was 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 about Hawai ’s waiver.
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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).134 See “Qualified Health Plans” in this report for requirements QHPs must meet to be
sold in the exchanges.
A QHP is the only type of comprehensive health plan an exchange may offer, but QHPs may be
offered outside of exchanges, as wel . 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). Technical y, these are al 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
Can Be
PTC and
Offered
CSR
Outside

Summary
Eligible?
Exchanges?
Qualified
A plan that is offered by a state-licensed insurer that meets
Health Plan
specified requirements, is certified by an exchange, and covers
Yes
Yes
(QHP)
the essential health benefits (EHB) package.
QHP Variations
Child-Only
A plan in which only individuals under the age of 21 may enrol .
Health
If an insurer offers an al -ages QHP in an exchange, it also must
Yes
Yes
Insurance Plan
offer a child-only plan at the same actuarial level.
Catastrophic
A plan that provides the EHB and coverage for at least three
No
Yes
Plan
primary care visits; however, it does not meet the minimum
requirements related to coverage generosity (i.e., actuarial
value). Offered in individual but not smal business health
options program (SHOP) exchanges. Consumer eligibility
requirements apply. a
Consumer
Yes
Yes
Operated and
A plan sold by a nonprofit, member-run health insurance
Oriented Plan
company created via a Patient Protection and Affordable Care
(CO-OP)
Act (ACA; P.L. 111-148, as amended) program. b
Multi-state
A plan sold in the exchanges under contract with the federal
Yes
No
Plan (MSP)
Office of Personnel Management (OPM).c
Non-QHPs
Dental-Only
Coverage for dental care. May be offered either as a stand-alone
Plan
plan or in conjunction with a QHP, as long as it covers pediatric
Yes, in certain
Yes
dental benefits that meet relevant EHB requirements.
circumstances.
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. Dental-only 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).

134 42 U.S.C. §18031(d)(2)(B).
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Notes: PTC = premium tax credit. CSR = cost-sharing reduction.
a. Catastrophic plans are available only to individuals under the age of 30 and individuals who obtain hardship
or affordability exemptions from the ACA’s individual mandate to maintain minimum essential coverage or
pay a penalty. 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 non-group and smal -group markets, including through
exchanges. CMS initial y 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 appears that 3 remain
operational—meaning they are currently offering health plans and there is no indication that they wil stop
doing so in the future. The other 20 CO-OPs offered health plans at one time but have shut down or are in
various stages of shutting down. See
Maine: Community Health Options: https://www.healthoptions.org/
Idaho, Montana, and Wyoming: Mountain Health CO-OP: https://www.mountainhealth.coop/
Wisconsin: Common Ground Healthcare Cooperative: https://www.commongroundhealthcare.org
c. The ACA directs 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 cal ed 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 al funds used by the Centers for
Medicare & Medicaid Services specifical y 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 Figure C-1.135 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-1 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.

135 See, for example, the Further Consolidated Appropriations Act, 2020 (P.L. 116-94), Division A, T itle II, Sec. 220
and the Consolidated Appropriations Act, 2021 (P.L. 116-260), Division H, T itle II, Sec. 220.
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Figure C-1. Centers for Medicare & Medicaid Services “Health Insurance Exchanges Transparency Table,” FY2021
($ in thousands)

Source: Department of Health and Human Services, Centers for Medicare & Medicaid Services, Justification of Estimates for Appropriations Committees, Fiscal Year 2021,
March 3, 2020, at https://www.cms.gov/About-CMS/Agency-Information/PerformanceBudget/FY2021-CJ-Final.pdf. See “Health Insurance Exchanges Transparency Table,”
page 241. Discussion of spending categories is at “Federal Exchanges” table and narrative, page 195-200.
Notes: FY = fiscal year.

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Table C-1. CMS Federal Exchange Funding Sources for Specified Fiscal Years
($ in thousands)
FY2021
President’s
FY2021
Budget +/-
FY2018
FY2019
FY2020
President’s
FY 2020
Treasury Accounta
Actual
Finalb
Enactedb
Budgetc
Enacted
Program Management
$1,944,190
$1,636,111
$1,720,937
$1,171,728
($549,209)
Discretionary Appropriation
$618,164
$263,895
$296,533
$0
($296,533)
Program Operations (non-add)
$580,886
$229,384
$268,937
$0
($286,937)
Federal Administration (non-add)
$37,278
$34,511
$27,596
$0
($27,596)
Offsetting Col ections
$1,304,280
$1,351,893
$1,399,404
$1,171,728
($227,676)
Federal y facilitated Exchange User
$1,272,168
$1,304,458
$1,341,039
$1,120,199
($220,840)
Fee (non-add)d
Risk Adjustment User Fee (non-
add)

$32,112
$47,435
$58,365
$51,530
($6,836)
Other
$21,746
$20,323
$25,000
$0
($25,000)
Health Care Fraud and Abuse
Control

$4,629
$19,256
$63,918
$25,384
($38,534)
Discretionary Appropriation
$0
$19,256
$63,918
$25,384
($38,534)
Mandatory Appropriatione
$4,629
n/a
n/a
n/a
n/a
Total, Program Level
$1,948,818
$1,655,367
$1,784,855
$1,197,112
($587,743)

Exchange User Fee Amounts as
a Percentage of Program Level

65.3%
78.8%
75.1%
93.6%
n/a
Funding Sourcesf
Sources: Unless otherwise specified, data are compiled by CRS from the fol owing sources. Comparable data
not found in prior years’ budget justifications.
FY2019-FY2021 columns in table: Department of Health and Human Services, Centers for Medicare &
Medicaid Services, Justification of Estimates for Appropriations Committees, Fiscal Year 2021, March 3, 2020, at
https://www.cms.gov/About-CMS/Agency-Information/PerformanceBudget/FY2021-CJ-Final.pdf. “Federal
Exchanges” table, page 195.
FY2018 column in table: HHS, CMS, Justification of Estimates for Appropriations Committees, Fiscal Year 2020,
March 13, 2019, at https://www.cms.gov/files/document/fy2020-cms-congressional-justification-estimates-
appropriations-committees.pdf. “Federal Exchanges” table, page 178.
Notes: FY = fiscal year.
a. See source documents for description of Treasury Account categories.
b. The FY2019 Final and FY2020 Enacted amounts were estimates as of January 2020.
c. The FY2021 President’s budget amounts were the Administration’s proposals for FY2021.
d. Per communication with CMS, this row is inclusive of both FFE and SBE-FP federal user fees.
e. Health Care Fraud and Abuse Control (HCFAC) “Mandatory Appropriation” was listed in the FY2020 table
that included the FY2018 amounts, but not in the FY2021 table that included the other amounts. 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 al ocation process by the Attorney General and Secretary of Health and Human Services.”
f.
Calculated by CRS.
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Appendix D. Additional Resources
HHS “Notice of Benefit and Payment Parameters” (Payment
Notices), Final Rule by Year
The “Notice of Benefit and Payment Parameters,” also cal ed the “Payment Notice,” is a rule
published annual y 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 general y the calendar year).
Final and proposed Payment Notices can 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 and Link
Citation
Date
2022
Patient Protection and Affordable Care Act; HHS Notice 86 Federal
January 19,
of Benefit and Payment Parameters for 2022; Updates to
Register 6138
2021
State Innovation Waiver (Section 1332 Waiver)
Implementing Regulations
a
https://www.federalregister.gov/documents/2021/01/19/2021-
01175/patient-protection-and-affordable-care-act-hhs-notice-of-
benefit-and-payment-parameters-for-2022
2021
Patient Protection and Affordable Care Act; HHS Notice 85 Federal
May 14, 2020
of Benefit and Payment Parameters for 2021; Notice
Register 29164
Requirement for Non-Federal Governmental Plans
https://www.federalregister.gov/documents/2020/05/14/2020-
10045/patient-protection-and-affordable-care-act-hhs-notice-of-
benefit-and-payment-parameters-for-2021
2020
Patient Protection and Affordable Care Act; HHS Notice 84 Federal
April 25, 2019
of Benefit and Payment Parameters for 2020
Register 17454
https://www.federalregister.gov/documents/2019/04/25/2019-
08017/patient-protection-and-affordable-care-act-hhs-notice-of-
benefit-and-payment-parameters-for-2020
2019
Patient Protection and Affordable Care Act; HHS Notice 83 Federal
April 17, 2018
of Benefit and Payment Parameters for 2019
Register 16930
https://www.federalregister.gov/documents/2018/04/17/2018-
07355/patient-protection-and-affordable-care-act-hhs-notice-of-
benefit-and-payment-parameters-for-2019
2018
Patient Protection and Affordable Care Act; HHS Notice 81 Federal
December 22,
of Benefit and Payment Parameters for 2018,
Register 94058
2016
Amendments to Special Enrollment Periods and the
Consumer Operated and Oriented Plan Program
https://www.federalregister.gov/documents/2016/12/22/2016-
30433/patient-protection-and-affordable-care-act-hhs-notice-of-
benefit-and-payment-parameters-for-2018
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For Plan
Publication
Year
Title and Link
Citation
Date
2017
Patient Protection and Affordable Care Act; HHS Notice 81 Federal
March 8, 2016
of Benefit and Payment Parameters for 2017
Register 12203
https://www.federalregister.gov/documents/2016/03/08/2016-
04439/patient-protection-and-affordable-care-act-hhs-notice-of-
benefit-and-payment-parameters-for-2017
2016
Patient Protection and Affordable Care Act; HHS Notice 80 Federal
February 27,
of Benefit and Payment Parameters for 2016
Register 10749
2015
https://www.federalregister.gov/documents/2015/02/27/2015-
03751/patient-protection-and-affordable-care-act-hhs-notice-of-
benefit-and-payment-parameters-for-2016
2015
Patient Protection and Affordable Care Act; HHS Notice 79 Federal
March 11,
of Benefit and Payment Parameters for 2015
Register 13743
2014
https://www.federalregister.gov/documents/2014/03/11/2014-
05052/patient-protection-and-affordable-care-act-hhs-notice-of-
benefit-and-payment-parameters-for-2015.
2014
Patient Protection and Affordable Care Act; HHS Notice 78 Federal
March 11,
of Benefit and Payment Parameters for 2014
Register 15409
2013
https://www.federalregister.gov/documents/2013/03/11/2013-
04902/patient-protection-and-affordable-care-act-hhs-notice-of-
benefit-and-payment-parameters-for-2014
Source: United States Federal Register at https://www.federalregister.gov/.
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 was published but not in effect before the presidential transition. As
such, it may be reconsidered by the Biden Administration. See Office of Management and Budget,
“Memorandum for the Heads of Executive Departments and Agencies,” 86 Federal Register 7424, January 28,
2021. In addition, the final rule published January 19, 2021, did not address al the topics discussed in the
November proposed rule, including topics subject to annual updating, like the out-of-pocket maximum for
2022 (see “Premiums and Cost Sharing” in this report). The final rule stated on page 6139 that HHS
“intend[s] to address the other topics and proposed policies outlined in the proposed 2022 Payment Notice
in future rulemaking, taking into account comments received on those proposals,” and on page 6141 that
“HHS determined that it was appropriate to address in this final rule only those policies in the proposed
2022 Payment Notice that were most important to advancing the policy goals of reducing fiscal and
regulatory burdens across related program areas and providing stakeholders with greater flexibility.”
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: CRS Report
R46638, Health Insurance Exchanges: Sources for Statistics

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Author Information

Vanessa C. Forsberg

Analyst in Health Care Financing


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


Disclaimer
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 n ot 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
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Congressional Research Service
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