Issued by: Centers for Medicare & Medicaid Services (CMS)

Issue Date: March 23, 2016

Program Area: Enrollment and Eligibility (ENR)

Question: Section 5.5 of the EDGE Server Business Rules (ESBR) states: "Overlapping Coverage in a Federally-facilitated Marketplace (FFM) or State based Marketplace (SBM) Plan Individuals enrolled in a plan offered on the Marketplace, either FFM or SBM, cannot be enrolled in the same plan for the same period of time. Issuers who have received 834 transactions where an individual has overlapping coverage must resolve the discrepancy. Overlapping Coverage in an Off Marketplace Plan Individuals enrolled in plans offered outside of the Marketplace may be enrolled in the same plan for the same period of time. In such instances, issuers will need to create a separate enrollment period for the time of overlap and report the appropriate premiums charged for the non-overlapping and overlapping periods." What is the definition of an Off-Marketplace plan? Is this a non-Exchange plan? Is it anything other than Health Insurance Marketplace plan? Medicare? Medicaid? Commercial?

Answer: An "off-Exchange plan" or "off-Marketplace plan" refers to a health insurance policy that is not available for purchase within a Federal or state exchange (a government-run Marketplace of health insurance plans). It is purchased directly from the carrier or through an agent or broker. Both off and on-Exchange health plans in the individual and small group markets must satisfy Essential Health Benefits (EHB) coverage requirements and utilize one of the metal plan (Bronze, Silver, Gold and Platinum) designs for medical out-of-pocket (OOP) costs.

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