CMS-2U2-25-001_REV1_Final.pdf

Notice of Funding Opportunity

Application due January 15, 2025

EHB-Benchmark Plan Modernization Grant for States with a Federally Facilitated Exchange Opportunity number: CMS-2U2-25-001

Contents Before you begin 3

Step 1: Review the Opportunity 4

Basic information 5

Eligibility 7

Program description 9

Step 2: Get Ready to Apply 18

Get registered 19

Step 3: Prepare Your Application 20

Application contents and format 21

Step 4: Learn About Review and Award 30

Application review 31

Award notices 37

Step 5: Submit Your Application 38

Application submission and deadlines 39

Step 6: Learn What Happens After Award 42

Post-award requirements and administration 43

Contacts and Support 47

Endnotes 49

Contents 2

Before you begin If you believe you are a good candidate for this funding opportunity, secure your SAM.gov and Grants.gov registrations now. If you are already registered, make sure your registrations are active and up-to-date.

SAM.gov registration (this can take several weeks)

You must have an active account with SAM.gov. This includes having a Unique

Entity Identifier (UEI).

See Step 2: Get Ready to Apply

Grants.gov registration (this can take several days)

You must have an active Grants.gov registration. Doing so requires a Login.gov registration as well.

See Step 2: Get Ready to Apply

Apply by the application due date

Applications are due by 11:59 p.m. Eastern Time on January 15, 2025.

To help you find what you need, this NOFO uses internal links. In Adobe

Reader, you can go back to where you were by pressing Alt + Left Arrow

(Windows) or Command + Left Arrow (Mac) on your keyboard.

Before you begin 3 https://sam.gov/ https://grants.gov/

Jump to a step

1. Review 2. Get Ready 3. Prepare 4. Learn 5. Submit 6. Award Contacts

Step 1:

Review the Opportunity

In this step

Basic information 5

Eligibility 7

Program description 9

Basic information Centers for Medicare and Medicaid Services (CMS)

Center for Consumer Information and Insurance Oversight

Helping states improve their essential health benefits.

Have questions?

See Contacts and

Support.

Key facts

Opportunity name: EHB-

Benchmark Plan

Modernization Grant for

States with a Federally

Facilitated Exchange

Opportunity number:

CMS-2U2-25-001

Announcement version:

New

Federal assistance listing: 93.679

Key dates

Application deadline:

January 15, 2025

Optional letter of intent deadline: December 16, Expected award date:

March 14, 2025

Expected earliest start date: March 14, 2025.

See other submissions for other time frames that may apply to this

NOFO.

Summary We know it can be challenging for states to fund the work necessary to improve the Essential Health Benefits (EHB). Improving EHB typically involves:

• Comprehensively reviewing EHB-benchmark plans.

• Seeking public feedback on the coverage of EHB in the state.

• Submitting an application to CMS to change the EHB in the state.

We understand that, due in part to these challenges, that there are many states that have not considered updating their EHB-benchmark plans. These states include 24 of the 28 states expected to have a Federally Facilitated

Exchange (FFE) as of January 1, 2026.

As a result, the covered benefits in the Qualified Health Plans (QHPs) offered through the Exchanges in these states may not reflect recent changes in medical evidence, scientific advancement, and clinical care guidelines.

Additionally, people enrolled in these QHPs may have trouble accessing EHB because of cost, claims denials, utilization management, discriminatory benefit design, or other factors.

We want to lessen these challenges through the EHB-Benchmark Plan

Modernization Grant for States with a Federally Facilitated Exchange (FFE

EHB Mod Grant). This new grant program will fund states with an FFE for a variety of activities related to the review of EHB-benchmark plans. The goal is to help applicants modernize and change their EHB-benchmark plans under

45 CFR 156.111.

1. Review 2. Get Ready 3. Prepare 4. Learn 5. Submit 6. Award Contacts

Step 1: Review the Opportunity 5 https://www.ecfr.gov/current/title-45/section-156.111

Funding details Type: Grant

Expected total funding for the program: $10,500,000, subject to availability of funds.

Expected total awards: Up to 28.

Funding range per applicant for the period of performance:

• $250,000 base award per applicant.

• An additional $125,000 award for each applicant that decides to establish an advisory board as part of their project.

Total award amounts may increase depending on the number of eligible applications received.

We will provide funding in full for the three-year period of performance.

Step 1: Review the Opportunity 6

Eligibility Eligible applicants Government organizations You are eligible for funding under this funding opportunity if you meet all of the following criteria:

• You are a state government’s executive branch agency.

• You regulate the non-grandfathered[1] individual and small group health insurance markets in the state, even if any of the following are true:

• The state does not have statutory authority to enforce the EHB requirements.

• The state is not otherwise enforcing the EHB requirements, or CMS has determined that the state is not substantially enforcing the EHB requirements.

• Your state must have an FFE as of January 1, 2026. The states expected to have an FFE as of January 1, 2026 are: AL, AK, AZ, DE, FL, HI, IN, IA, KS, LA, MI, MS, MO, MT, NE, NH, NC, ND, OH, OK, SC, SD, TN, TX, UT, WV, WI, and WY[2]

Eligibility limitations You are ineligible for funding under this funding opportunity if your state currently has a State-Based Exchange (SBE), including a State-based

Exchange on the Federal Platform (SBE-FP) or an FFE that is anticipated to transition to an SBE as of January 1, 2026.

You may submit only one application under this NOFO.

In your attachments, you must submit eligibility documentation including:

• A letter stating that the state is not receiving other federal grants for the same activities.

• A maintenance of effort certification.

Step 1: Review the Opportunity 7

Completeness and responsiveness criteria We will review your application to make sure it meets the requirements found in eligibility, applications contents and format, and application submission and deadlines.

We won’t consider an application that:

• Is from an organization that doesn’t meet all eligibility criteria.

• Is submitted after the deadline.

• Is not submitted through Grants.gov.

• Does not address the program requirements.

The Division of Grants Director or Deputy Director may choose to continue the review process for an ineligible application if it is in the best interests of the government to meet the objectives of the program.

Cost sharing This program has no cost-sharing requirement. If you choose to include cost-sharing funds, we will not consider it during review. However, we will hold you accountable for any funds you add, including requirements for grant reporting.

1. Review 2. Get Ready 3. Prepare 4. Learn 5. Submit 6. Award Contacts

Step 1: Review the Opportunity 8 https://grants.gov/

Program description Purpose The purpose of this funding opportunity is to provide funding to eligible states with an FFE to review and potentially change their EHB-benchmark plans because of:

• Enrollees experiencing difficulties in accessing needed services.

• Changes in medical evidence or scientific advancement

• Changes in the health needs of their populations.

• Other clinical considerations as authorized by the Affordable Care Act

(ACA).

Background Section 1301(a)(1)(B) of the ACA directs all QHP issuers to cover the EHB package described in section 1302(a) of the ACA.

The EHB package includes:

• Coverage of the services described in section 1302(b) of the ACA.

• Adherence to the cost-sharing limits described in section 1302(c) of the

ACA

• Meeting the actuarial value levels established in section 1302(d) of the

ACA.

Section 2707(a) of the PHS Act, which is effective for plan or policy years beginning on or after January 1, 2014, extends the requirement to cover the

EHB package to non-grandfathered individual and small group health insurance coverage, whether that coverage is offered through an Exchange.

Section 1302(b) of the ACA requires the Secretary of HHS to define the EHB and make sure that the EHB:

• Includes at least the following general categories and the items and services covered within the categories:

◦ Ambulatory patient services.

◦ Emergency services.

◦ Hospitalization.

◦ Maternity and newborn care.

◦ Mental health and substance use disorder services.

1. Review 2. Get Ready 3. Prepare 4. Learn 5. Submit 6. Award Contacts

Step 1: Review the Opportunity 9 https://www.congress.gov/111/plaws/publ148/PLAW-111publ148.pdf https://www.congress.gov/bill/111th-congress/house-bill/3590

◦ Including behavioral health treatment.

◦ Prescription drugs.

◦ Rehabilitative and habilitative services and devices.

◦ Laboratory services.

◦ Preventive and wellness services and chronic disease management.

◦ Pediatric services, including oral and vision care.

• Is equal in scope to the benefits provided under a typical employer plan.

• Reflect an appropriate balance among the categories, so that benefits are not unduly weighted toward any category.

• Does not make coverage decisions, determine reimbursement rates, establish incentive programs, or design benefits in ways that discriminate against individuals because of their age, disability, or expected length of life.

• Takes into account the health care needs of diverse populations, including women, children, persons with disabilities, and other groups.

• Makes sure that individuals are not denied essential health benefits on the basis of their age, expected length of life, present or predicted disability, degree of medical dependency, or quality of life.

• Is periodically reviewed and updated to address any gaps in access to coverage, changes in medical evidence, or scientific advancement.

CMS defined the EHB using a benchmark-based approach in the February 25, 2013 Federal Register (78 FR 12834) (EHB Rule).

Under this approach, a health plan provides the EHB if it provides, among other things:

• Benefits that are substantially equal to the EHB-benchmark plan including covered benefits.

• Limitations on coverage (including coverage of benefit amount, duration, and scope) that are substantially equal to the EHB-benchmark plan.

• Prescription drug benefits that meet the requirements of 45 CFR 156.122.

Thus, a state’s EHB-benchmark plan serves as a reference plan for benefits defined as EHB in the state.

States play an integral role in determining what benefits are included in EHB-benchmark plans. For plan years beginning on or after January 1, 2020, states select or change an EHB-benchmark plan by meeting the requirements at 45

CFR 156.111, which include certain actuarial analysis and confirmations that

1. Review 2. Get Ready 3. Prepare 4. Learn 5. Submit 6. Award Contacts

Step 1: Review the Opportunity 10 https://www.govinfo.gov/app/details/FR-2013-02-25/2013-04084#:~:text=related%20to%20accreditation.-,Summary,as%20the%20Affordable%20Care%20Act.

https://www.ecfr.gov/current/title-45/section-156.122 the state’s selected EHB-benchmark plan meets the scope of benefits requirements at § 156.111(b)(2).

CMS recently revised the requirements at § 156.111 in the April 15, 2024

Federal Register (89 FR 26218) (2025 Payment Notice), to make this process easier to understand and to undertake, with the ultimate goal of promoting more frequent EHB-benchmark plan changes to expand coverage. Twelve states, including only four states with an FFE (Alaska, Michigan, North Dakota, and South Dakota), have used 156.111 to add or expand coverage for certain benefits to EHB-benchmark plans since 2020.[3]

Program requirements and expectations At a minimum, you must use grant funds to perform the following activities.

You may engage contractors such as actuarial, health policy, or clinical firms to help with all or some of these activities, under your guidance and direction.

You must do all of the following:

1. Undertake a comprehensive review of the state’s current EHB-benchmark plan and consider potential changes based on your review.

At a minimum, you must:

• Identify whether enrollees are having trouble accessing the benefits in the state’s EHB-benchmark plan for reasons of cost, claims denials, utilization management, discriminatory benefit design, or other factors.

You may fulfill this analysis through statistically valid consumer surveys, engaging in outreach with interested parties such as consumer groups, and reviewing data on issuer claim denials, utilization management, or consumer complaints related to consumers enrolled in the FFE.

• Ensure health equity. To ensure that EHB-benchmark plans are designed to further health equity[4] initiatives and address health care disparities, your analysis must address how the state’s EHB-benchmark plan could be updated to better meet the needs of people:

◦ With lower incomes.

◦ Of all ages, including children and older adults.

◦ With disabilities or who have a greater risk of developing serious health issues.

◦ Of color.

◦ Who identify as LGBTQIA+.

1. Review 2. Get Ready 3. Prepare 4. Learn 5. Submit 6. Award Contacts

Step 1: Review the Opportunity 11 https://www.ecfr.gov/current/title-45/section-156.111 https://www.federalregister.gov/documents/2024/04/15/2024-07274/patient-protection-and-affordable-care-act-hhs-notice-of-benefit-and-payment-parameters-for-2025

◦ In rural communities.

◦ Who have limited English proficiency.

◦ Who have been historically underserved, marginalized, and adversely affected by persistent poverty and inequality.

• Identify areas where the state’s EHB-benchmark plan could be updated to account for changes in medical evidence, scientific advancement, and clinical care guidelines. This may involve consulting or contracting with one or more clinical experts to analyze the state’s EHB-benchmark plan.

For example, states could do one or more of the following:

◦ Consider whether benefit visit and other limits are clinically based and meet the needs of a diverse population, or whether they are arbitrary.

◦ Look at current EHB-benchmark coverage for particular conditions or scenarios, such as HIV, diabetes, infertility, chronic kidney disease, or developmental disabilities, and compare that coverage to generally accepted clinical guidelines.

◦ Examine whether coverage prevents access to medical advancements such as new radiology and laboratory methods, cost-effective yet newer advancements such as silver diamine fluoride, or newer treatment modalities such as doula care and peer recovery support services.

• Identify areas where the state’s EHB-benchmark plan could be updated to account for national and/or state healthcare concerns.

◦ You must examine your EHB-benchmark plan for how it may account for nationwide health care concerns (such as the opioid epidemic or addressing mental health concerns).

◦ You must also examine your EHB-benchmark plan for how it accounts for concerns that may be specific to the state (such as diabetes, obesity, or maternal health outcomes).

◦ You must identify at least five areas where your EHB-benchmark plan may need to be modified or updated to account for a national healthcare concern, a state healthcare concern, or both.

• Perform a regional comparison analysis. You must assess how the state’s

EHB-benchmark plan’s benefits compare to at least three other state

EHB-benchmark plans in a nearby geographic region. This assessment must include whether there are differences in the scope of EHB (such as maternity and newborn care), benefits not covered as EHB for which there

Step 1: Review the Opportunity 12 is a public health need or expectation of coverage (such as durable medical equipment), or other deficiencies.

• Ensure the state’s EHB-benchmark plan is clear and unambiguous. You must perform a comprehensive review of its EHB-benchmark plan to determine whether it is sufficiently clear which benefits are covered and the scope of benefits. If the plan is ambiguous in any way, you must consider how to make it clearer.

2. Submit a Section 508-compliant report to CMS for publication and publish the same report on a public state website.

The report must reflect the findings of your comprehensive review of your current EHB-benchmark plan, as described in the previous requirements.

3. For applicants that decide to submit pursuant to the process at

156.111(b)(2)(ii) before the end of the period of performance: Submit such an application to CMS by May 6, 2026, for effectiveness in plan year 2028, or by

May 5, 2027, for effectiveness in plan year 2029.

We encourage you to submit an application to update your EHB-benchmark plan after the end of the award period, but the grant will not be extended to provide you with support. We urge you to apply to update your EHB-benchmark plans as a result of completing the requirements of this grant, but this application is not required.

States that decide to submit an EHB-benchmark plan submission before the end of the period of performance may use grant funds to conduct the required actuarial analysis to demonstrate that the state’s new EHB-benchmark plan complies with the typicality regulatory requirements at 156.111(b)(2).[5]

You do not have to include your EHB-benchmark plan application in the report described in program requirement #2.

4. For applicants that decide to seek additional grant funds for an advisory board to advise the state: Applicants that create advisory boards may not require the advisory board to be responsible for completing other program requirements. At a minimum, a state’s advisory board must:

• Include patients and patient representatives on the advisory board.

• Ensure the participation or perspective of persons:

◦ With lower incomes.

◦ Of all ages, including children and older adults.

◦ With disabilities or who have a greater risk of developing serious health issues.

Step 1: Review the Opportunity 13

◦ Of color.

◦ Who identify as LGBTQIA+.

◦ In rural communities.

◦ Who have limited English proficiency.

◦ Who have been historically underserved, marginalized, and adversely affected by persistent poverty and inequality.

◦ Be subject to a public notice and comment process to address updates and full public transparency on advisory board proceedings and materials.

• Be subject to disclosure and conflict of interest protocols.

Funding policies and limitations Limitations We do not allow the following costs:

• Pre-award costs.

• Meeting matching requirements for any other federal funds or local entities.

• Services, equipment, or supports that are the legal responsibility of another party under federal, state, or tribal law, such as vocational rehabilitation or education services, or under any civil rights laws, such as modifying a workplace or providing accommodations that are obligations under law.

• Goods or services not allocable to the project.

• Supplanting existing state, local, tribal, or private funding of infrastructure or services, such as staff salaries, etc.

• Construction.

• Capital expenditures for improvements to land, buildings, or equipment that materially increase their value or useful life as a direct cost, except with our prior written approval.

• The cost of independent research and development, including their proportionate share of indirect costs (see 45 CFR 75.476).

• Funds related to any activity designed to influence the enactment of legislation, appropriations, regulation, administrative action, or executive order.

• Certain telecommunications and video surveillance equipment (see 2 CFR

200.216).

1. Review 2. Get Ready 3. Prepare 4. Learn 5. Submit 6. Award Contacts

Step 1: Review the Opportunity 14 https://www.ecfr.gov/current/title-45/section-75.476 https://www.ecfr.gov/current/title-2/subtitle-A/chapter-II/part-200/subpart-C/section-200.216 https://www.ecfr.gov/current/title-2/subtitle-A/chapter-II/part-200/subpart-C/section-200.216

• Meals, unless in limited circumstances such as:

◦ Subjects and patients under study.

◦ Where specifically approved as part of the project or program activity, such as in programs providing children’s services.

◦ As part of a per diem or subsistence allowance provided in conjunction with allowable travel.

• Costs that supplant funds for any other Notice of Funding Opportunity or

Financial Assistance Program. You cannot use grant funds for the same grant activities for which you receive other federal grant dollars (for example, grant activities performed under the Expanding Access to

Women’s Health Grant). If you receive other federal grant dollars for these grant activities, you must explain in your budget narrative how other federal grant dollars are not used to perform grant activities performed under this grant.

• Other than for normal and recognized executive-legislative relationships or participation by an agency or officer of a state, local, or tribal government in policymaking and administrative processes within the executive branch of that government, funding awarded under this NOFO may not be used for:

◦ Paying the salary or expenses of any grant recipient, or agent acting for such recipient, related to any activity designed to influence the enactment of legislation, appropriations, regulation, administrative action, or executive order proposed or pending before the Congress or any state government, state legislature, or local legislature or legislative body.

◦ Lobbying, but awardees can lobby at their own expense if they can segregate federal funds from other financial resources used for lobbying.

Program-specific limitations You must also follow these program-specific funding limitations:

• Funds requested in your budget must be derived from the approximate enrollment size of the off-Exchange market relative to the on-Exchange market in the states eligible to apply for this grant.

• You cannot use grant funds to account for a percentage of program requirements that impact enrollees in off-Exchange plans in the non-grandfathered individual and small group markets.

Step 1: Review the Opportunity 15

• On average, total enrollment in the FFEs accounts for approximately 80% of total enrollment in non-grandfathered individual and small group health insurance coverage in states with an FFE.

◦ You are responsible for the remaining percentage of costs to perform program requirements. You must explain in your budget narrative how you plan to account for this proportion of costs to ensure that user fees funds are not used to impact non-grandfathered individual and small group health insurance coverage in the off-Exchange market in your state.

◦ Specifically address how these costs will not be funded by user fees.

◦ State employee salary hours (such as an actuary) may be used as non-federal share if grants funds are not supplanted.

◦ Include the date of your most recently approved cost allocation plan.

Indirect costs Indirect costs are those for a common or joint purpose across more than one project and that cannot be easily separated by project.

To charge indirect costs you can select one of two methods:

Method 1 – Approved rate. You currently have an indirect cost rate or cost allocation plan approved by your cognizant federal agency.

Method 2 – De minimis rate. Per 2 CFR 200.414(f), if you have never received a negotiated indirect cost rate, you may elect to charge a de minimis rate. If you are awaiting approval of an indirect cost proposal you may also use the de minimis rate. If you choose this method, costs included in the indirect cost pool must not be charged as direct costs.

This rate is 15% of modified total direct costs (MTDC). See 2 CFR 200.1 for the definition of MTDC. You can use this rate indefinitely.

Salary rate limitation The salary rate limitation in the current appropriations act applies to this program. As of January 2024, the salary rate limitation is $221,900. We will update this limitation in future years.

1. Review 2. Get Ready 3. Prepare 4. Learn 5. Submit 6. Award Contacts

Step 1: Review the Opportunity 16 https://www.ecfr.gov/current/title-2/section-200.414 https://www.ecfr.gov/current/title-2/part-200#p-200.1(Modified%20Total%20Direct%20Cost%20(MTDC))

Program income Program income is money earned as a result of your award-supported project activities. You must use any program income you generate from awarded funds for approved project-related activities. Find more about program income at 45 CFR 75.307.

Statutory authority Section 1311(d)(5)(A) of the ACA allows an Exchange to charge user fees to issuers of QHPs, “to support [the Exchange’s] operations.” CMS, as operator of the FFE in 28 states that have not elected to establish their own State-based

Exchange, assesses user fees to issuers that offer QHPs on an FFE. In addition, section 1311(e)(1)(B) of the ACA also requires an Exchange to ensure that health plans available through the Exchange are in the interests of qualified individuals and qualified employers in the state.

1. Review 2. Get Ready 3. Prepare 4. Learn 5. Submit 6. Award Contacts

Step 1: Review the Opportunity 17 https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-A/part-75/subpart-D/subject-group-ECFR911e5e1a30bfbcb/section-75.307

Step 2:

Get Ready to Apply

In this step

Get registered 19

Get registered SAM.gov You must have an active account with SAM.gov. This includes having a Unique

Entity Identifier. SAM.gov registration can take several weeks. Begin that process today.

To register, go to SAM.gov Entity Registration and select Get Started. From the same page, you can also select the Entity Registration Checklist for the information you will need to register.

When you register or update your SAM.gov registration, you must agree to the financial assistance general certifications and representations. You must agree to those for grants specifically, as opposed to contracts, because the two sets of agreements are different. You will have to maintain your registration throughout the life of any award.

Grants.gov You must also have an active account with Grants.gov.

You can see step-by-step instructions at the Grants.gov Quick Start Guide for

Applicants.

Need help? See Contacts and Support.

Find the application package The application package has all the forms you need to apply. You can find it online. Go to Grants Search at Grants.gov and search for opportunity number

CMS-2U2-25-001.

1. Review 2. Get Ready 3. Prepare 4. Learn 5. Submit 6. Award Contacts

Step 2: Get Ready to Apply 19 https://sam.gov/content/entity-registration https://www.hhs.gov/sites/default/files/financial-assistance-general-certification-representations.pdf http://grants.gov/applicants/applicant-registration https://www.grants.gov/quick-start-guide/applicants https://www.grants.gov/quick-start-guide/applicants https://www.grants.gov/search-grants

Step 3:

Prepare Your Application

Application contents and format 21

Application contents and format Applications include five main components. The following sections include guidance and instructions on the required format for each.

You can find all referenced forms within the funding opportunity’s application package on Grants.gov.

Make sure you include each of these:

Component Submission format

Project abstract Use the Project Abstract Summary form.

Project narrative Use the Project Narrative Attachment form.

Budget narrative Use the Budget Narrative Attachment form.

Attachments Insert each in the Other Attachments form.

Other required forms Upload using each required form.

See requirements for other submissions.

Your organization’s authorized organizational representative (AOR) must certify and submit your application.

We will provide instructions on document formats in the following sections.

See completeness and responsiveness criteria to understand what may disqualify your application from consideration.

Project abstract Limit to one page. May be single spaced but follow other formatting requirements listed for the project narrative.

Write a one-page summary of your proposed project including the purpose and outcomes. Do not include any proprietary or confidential information. We will use this document for information sharing and public information requests if you get an award.

1. Review 2. Get Ready 3. Prepare 4. Learn 5. Submit 6. Award Contacts

Step 3: Prepare Your Application 21

Include:

• The name of your state.

• Project goals.

• Total budget amount.

• A description of how you will use the funds.

Project narrative

Required format for project narrative

Page limit: 15, excluding attachments

File name: Project Narrative

Format: PDF (Do not compress or encrypt)

Size: 12-point font or bigger

Footnotes and text in graphics may be 10-point.

Spacing for project abstract, tables, and footnotes: Single-spaced

Spacing for main content: Double-spaced

Margins: 1-inch

Page size: 8.5 x 11

Include consecutive page numbers throughout.

The project narrative is the most important part of your application and should clearly describe your proposed project. You must address the proposed goals, measurable objectives, and milestones in accordance with the instructions in the following sections.

See the merit review criteria to understand how reviewers will assess and score your project narrative.

Your project narrative should include the following four sections:

• Capabilities

• Proposed activities

• Project goals

• Work plan and timeline

Step 3: Prepare Your Application 22

1. Capabilities Why are you qualified to review and assess the items and services covered or not covered as EHB in your state?

To demonstrate your eligibility, describe how you meet both of the following criteria:

• Be an executive branch agency of a state government that regulates the non-grandfathered individual and small group health insurance market in the state.

• Plan to have a Federally Facilitated Exchange for years beginning on or after January 1, 2026.

• To demonstrate your capability, describe your procedural requirements to review and update EHBs, which may include coordination with your state legislature as well as certain public engagement requirements.

2. Proposed activities What are you going to do?

Describe your proposed project and how you will carry out all the program requirements. Explain how you will do all of the following:

• Identify whether enrollees are having trouble accessing the benefits in your EHB-benchmark plan for reasons of cost, claims denials, utilization management, discriminatory benefit design, or other factors.

• Identify areas where your EHB-benchmark plan could be updated to account for changes in medical evidence, scientific advancement, and clinical care guidelines.

• Identify areas where your EHB-benchmark plan could be updated to account for national and/or state healthcare concerns.

• Perform a regional comparison analysis.

• Ensure the state’s EHB-benchmark plan is clear and unambiguous.

• Submit a Section 508-compliant report to CMS for publication and publish the same report on a public state website. The report should reflect your findings in undertaking a comprehensive review of the state’s current EHB-benchmark plan within three years of the grant award.

• For applicants that decide to submit an EHB-benchmark plan application before the end of the period of performance: Submit such an application to CMS by May 6, 2026, for effectiveness in plan year 2028 or by May 5, 2027, for effectiveness in plan year 2029.

Step 3: Prepare Your Application 23

• For applicants that decide to seek additional grant funds: Create an advisory board to advise the state in completing program requirements.

3. Project goals What do you expect to achieve?

The goal of the grant opportunity is to fund state review of EHB-benchmark plans for states with an FFE to:

• Describe what barriers you anticipate enrollees may be facing accessing the benefits in its EHB-benchmark plan for reasons of cost, claims denials, utilization management, discriminatory benefit design, or other factors. Take into account medical evidence, scientific advancement, and clinical care guidelines.

• Identify barriers inhibiting enrollees from accessing care.

• Ensure that EHB-benchmark plans account for medical and scientific advancements in care.

• Identify areas where the state’s EHB-benchmark plan may warrant modification or updates to account for national and/or state healthcare concerns. You must examine your EHB-benchmark plan for how it may account for nationwide health care concerns (such as the opioid epidemic or addressing mental health concerns) and for how it accounts for concerns that may be specific to their state (such as diabetes, obesity, or maternal health outcomes). identify at least five areas (distributed between the following at the state’s discretion) where your EHB-benchmark plan may need to be modified or updated to account for both of the following:

• Any national healthcare concerns.

• Any healthcare concerns unique to the state. Conduct a review of its EHB-benchmark plan to ensure it is sufficiently clear which benefits are covered and the scope of benefits, and if ambiguity exists, how it may be revised.

• Create and submit a section 508 compliant report to CMS for publication as well as your public state website. This report will include your findings in undertaking a comprehensive review of your current EHB-benchmark plan, as described.

Step 3: Prepare Your Application 24

4. Work plan and timeline What is your action plan to meet the project goals and carry out the program requirements?

Your work plan must outline specific milestones for your proposed project and state how you will, at a minimum, carry out all the program requirements.

These milestones must be articulated clearly, measurable, and appropriate for the period of performance. The milestones should include all of the following:

• When you anticipate you will be able to contract with or hire new staff or consultants such as actuaries, clinicians, and health policy experts, if applicable.

• When you expect to conduct research in line with the program requirements.

• If applicable: Which EHB-benchmark application period, you expect to update the EHB-benchmark plan during.

• If applicable: When you would create an advisory board and how often the advisory board would meet.

You will need to procure contractor assistance as soon as practicable after the grant award. The three-year period of performance is such that you should be able to procure support and complete all activities without the need for extending the period.

Budget narrative The budget narrative supports the information you provide in Standard Form

424-A. See other required forms. It includes added detail and justifies the costs you ask for. As you develop your budget, consider:

• If the costs are reasonable and consistent with your project’s purpose and activities.

• The restrictions on spending funds. See funding policies and limitations.

• HHS now uses the definitions for equipment and supplies in 2 CFR 200.1.

The new definitions change the threshold for equipment to the lesser of the recipient’s capitalization level or $10,000 and the threshold for supplies to below that amount.

To create your budget narrative, see detailed instructions and a template on our website.

1. Review 2. Get Ready 3. Prepare 4. Learn 5. Submit 6. Award Contacts

Step 3: Prepare Your Application 25 https://www.ecfr.gov/current/title-2/part-200#p-200.1(Equipment) https://www.ecfr.gov/current/title-2/part-200#p-200.1(Supplies) https://www.cms.gov/about-cms/work-us/grants-cooperative-agreements/how-apply-cms-grants/budget-and-budget-narrative

In your budget narrative, you will:

• Identify a PI/PD who will dedicate sufficient time and effort to manage and provide oversight of the grant program.

• Include a yearly breakdown of costs for each line item in your SF-424A.

• Describe the proposed costs for each activity or cost within the line item.

• Define the proportion of the requested funding designated for each activity.

• Justify the costs, including how you calculated them.

• Provide an overall estimated budget for the entire three-year period of performance, that is, the total costs across all three years.

• Explain how you separate costs and funding administered directly by you as the lead agency, from funding you subaward to other consortium members.

• Be clear about how costs link to each activity and the goals of this program.

• Explain in your budget narrative how you plan to account for this proportion of costs to ensure that user fees funds are not used to impact non-grandfathered individual and small group health insurance coverage in the off-Exchange market in your state. Applicants that seek additional funding to create an advisory board may not utilize the board to complete other program requirements. However, at a minimum, a state’s advisory board must:

To create your SF-424A and budget narrative, see detailed instructions in

CMS Guidance for Preparing a Budget Request and Narrative on our website.

See merit review criteria to understand how reviewers will assess and score your budget narrative.

1. Review 2. Get Ready 3. Prepare 4. Learn 5. Submit 6. Award Contacts

Step 3: Prepare Your Application 26 https://www.cms.gov/about-cms/work-us/grants-cooperative-agreements/how-apply-cms-grants/budget-and-budget-narrative

Required format for budget narrative

Page limit: 10

File name: Budget Narrative

File format: PDF (Do not compress or encrypt.)

Font size: 12-point or larger

Spacing: Single-spaced

Margins: 1-inch

Page size: 8.5 x 11

Include consecutive page numbers throughout.

Attachments You will upload attachments in Grants.gov using the Other Attachments Form.

Attachments do not count against application page limits.

Do not include additional attachments not requested in the NOFO. Reviewers will not review any attachments that are not listed here.

Indirect cost agreement If you include indirect costs in your budget using an approved rate or cost allocation plan, include a copy of your current agreement approved by your cognizant agency for indirect costs. If you use the de minimis rate, you do not need to submit this attachment. See CMS Guidance for Preparing a Budget

Request and Narrative.

Resume and job descriptions for key personnel For key personnel, such as the authorized organizational representative (AOR) and principal investigator/project director (PI/PD), attach resumes for positions that are filled. If a position isn’t filled, attach the job description with qualifications you plan to use for recruitment.

Business assessment of applicant organization Maximum 12 pages, single spaced.

CMS must assess your organization’s risk before we can make an award. This analysis includes your organization’s:

• Financial stability.

1. Review 2. Get Ready 3. Prepare 4. Learn 5. Submit 6. Award Contacts

Step 3: Prepare Your Application 27 http://www.grants.gov/ https://www.ecfr.gov/current/title-45/part-75#p-75.2(Cognizant%20agency%20for%20indirect%20costs) https://www.cms.gov/about-cms/work-us/grants-cooperative-agreements/how-apply-cms-grants/budget-and-budget-narrative https://www.cms.gov/about-cms/work-us/grants-cooperative-agreements/how-apply-cms-grants/budget-and-budget-narrative

• Quality of management systems.

• Internal controls.

• Ability to meet the management standards prescribed in 45 CFR Part 75.

For us to complete your assessment, you must review, answer, and attach the completed business assessment questions found on our website at Business

Assessment of Applicant Organization.

Organizational chart Submit an organizational chart clearly identifying the reporting relationships of key personnel assigned to implementing the grant.

Eligibility documentation You must submit both of the following:

• A letter attesting that the State is not receiving other federal grant dollars for the same activities for which it will receive (if awarded) EHB-

Benchmark Plan Modernization Grant for States with a Federally

Facilitated Exchange funds, signed by the head of the applicable State regulatory agency.

• A State certification of Maintenance of Effort verifying that the grant funds will not supplant existing State expenditures for related EHB-

Benchmark Plan Modernization, or related activities, signed by the head of the applicable State regulatory agency.

Other required forms You will need to complete four other required forms. Submit the following required forms through Grants.gov. You can find the forms in the NOFO application package or review them and their instructions at Grants.gov

Forms.

Forms Submission Requirement

Application for Federal Assistance (SF-424) With the application. See extra instructions.

Budget Information for Non-Construction

Programs (SF-424A)

With the application.

Disclosure of Lobbying Activities (SF-LLL) With the application.

Project/Performance Site Location(s) Form With the application.

1. Review 2. Get Ready 3. Prepare 4. Learn 5. Submit 6. Award Contacts

Step 3: Prepare Your Application 28 https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-A/part-75 https://www.cms.gov/files/document/business-assessment-template-revised.pdf https://www.cms.gov/files/document/business-assessment-template-revised.pdf https://www.grants.gov/forms https://www.grants.gov/forms

Extra instructions for SF-424: Official Application for Federal Assistance Special instructions include:

• To write your Descriptive Title of Applicant’s Project in Item 15, see

Writing a Strong Descriptive Title on our website.

• Check No to item 19c. State review under Executive Order 12372 does not apply .

• Your authorized organizational representative (AOR) must electronically sign this form. The AOR is the person who can make legally binding commitments for your organization. When the AOR authorizes an application, they agree to assume all award obligations.

1. Review 2. Get Ready 3. Prepare 4. Learn 5. Submit 6. Award Contacts

Step 3: Prepare Your Application 29 https://www.cms.gov/about-cms/work-us/grants-cooperative-agreements/how-apply-cms-grants#:~:text=Elements%20of%20a%20Strong%20Award%20Description https://www.ecfr.gov/current/title-24/subtitle-B/chapter-V/subchapter-C/part-570/subpart-K/section-570.612 https://www.cms.gov/about-cms/work-us/grants-cooperative-agreements/how-apply-cms-grants#:~:text=Authorized%20Organization%20Representative%20(AOR)

Step 4:

Learn About Review and Award

In this step

Application review 31

Award notices 37

Application review Initial review We review each application to make sure it meets basic requirements.

We will review your application to make sure that it meets both the completeness and responsiveness criteria. If your application does not meet these criteria, we will not move it to the merit review phase.

We will not review any pages that exceed the page limit.

Criterion Total number of points = 100

Project narrative sections 1, 2, and 3 60 points

Project narrative section 4 30 points

Budget narrative 10 points

Merit review A merit review panel reviews all applications that pass the initial completeness and responsiveness review. The members use the following criteria. For more information, see Review and Selection Process on our website.

1. Review 2. Get Ready 3. Prepare 4. Learn 5. Submit 6. Award Contacts

Step 4: Learn About Review and Award 31 https://www.cms.gov/about-cms/work-us/grants-cooperative-agreements/how-apply-cms-grants/merit-review

Criteria

Project narrative section 1

Capabilities: Why are you qualified to review and assess the items and services covered or not covered as EHB in your state?

Maximum points:

Describe the executive branch agency that will perform the activities under this funding opportunity.

4 points

Demonstrate how you will regulate the non-grandfathered individual and small group health insurance market in the state.

4 points

Describe your procedural requirements to review and update EHBs in your state, which may include coordination with your state legislature as well as certain public engagement requirements.

4 points

Describe your plan to have a Federally Facilitated Exchange for years beginning on or after January 1, 2026.

2 points

In your attachments, include an organizational chart clearly identifying the reporting relationships of key personnel assigned to implementing the grant.

4 points

In your attachments, include a resume or curriculum vitae for each individual identified as key personnel in the organizational chart. If key personnel have not yet been hired, provide a hiring strategy and job descriptions.

2 points

Step 4: Learn About Review and Award 32

Project narrative section 2

Proposed activities: What are you going to do?

Maximum points:

Identify whether enrollees are having trouble accessing the benefits in your EHB-benchmark plan for reasons of cost, claims denials, utilization management, discriminatory benefit design, or other factors.

4 points

Identify areas where your EHB-benchmark plan could be updated to account for changes in medical evidence, scientific advancement, and clinical care guidelines.

4 points

Identify areas where your EHB-benchmark plan could be updated to account for national and/or state healthcare concerns.

4 points

Perform a regional comparison analysis. 2 points

Ensure the state’s EHB-benchmark plan is clear and unambiguous. 2 points

Submit a Section 508-compliant report to CMS for publication and publish the same report on a public state website. The report should reflect your findings in undertaking a comprehensive review of the state’s current EHB-benchmark plan within three years of the grant award.

2 points

For applicants that decide to submit an EHB-benchmark plan application before the end of the period of performance: Submit such an application to CMS by May 6, 2026, for effectiveness in plan year 2028, or by May 5, 2027, for effectiveness in plan year 2029.

2 points

Step 4: Learn About Review and Award 33

Project narrative section 3

Project goals: What do you expect to achieve?

Maximum points:

Describe your project goals for carrying out the program requirements during the three-year period of performance:

Describe what barriers you anticipate enrollees may be facing accessing the benefits in its EHB-benchmark plan for reasons of cost, claims denials, utilization management, discriminatory benefit design, or other factors.

4 points

Ensure health equity. Identify populations that may be at-risk of health inequality and how the state’s EHB-benchmark plan may warrant modification to better meet the needs of people:

• With lower incomes.

• Of all ages, including children and older adults.

• With disabilities or who have a greater risk of developing serious health issues.

• Of color.

• Who identify as LGBTQIA+.

• In rural communities.

• Who have limited English proficiency.

• Who have been historically underserved, marginalized, and adversely affected by persistent poverty and inequality.

4 points

Identify areas where the state’s EHB-benchmark plan may warrant modification or updates to account for changes in medical evidence, scientific advancement, and clinical care guidelines. This may involve consulting or contracting with one or more clinical expert(s) to analyze the state’s EHB-benchmark plan, taking into account medical evidence, scientific advancement, and clinical care guidelines.

3 points

Identify areas where the state’s EHB-benchmark plan may warrant modification or updates to account for national and/or state healthcare concerns. You must examine your EHB-benchmark plan for how it may account for nationwide health care concerns

(such as the opioid epidemic or addressing mental health concerns) and for how it accounts for concerns that may be specific to their state (such as diabetes, obesity, or maternal health outcomes). You must identify at least five areas (distributed between the following at the state’s discretion) where a your EHB-benchmark plan may need to be modified or updated to account for both of the following:

• Any national healthcare concerns.

• Any healthcare concerns unique to the state.

3 points

Step 4: Learn About Review and Award 34

Project narrative section 3

Project goals: What do you expect to achieve?

Conduct a review of its EHB-benchmark plan to ensure it is sufficiently clear which benefits are covered and the scope of benefits, and if ambiguity exists, how it may be revised.

3 points

Create a Section 508-compliant report to CMS for publication and on a public state website that reflects your findings in undertaking a comprehensive review of your current EHB-benchmark plan, described above.

3 points

Project narrative section 4

Work plan and timeline: What is your action plan to meet the project goals and carry out the program requirements?

Maximum points:

Address all the components of your project goals. Your work plan must outline specific milestones for your proposed project and how you will, at a minimum, carry out each of the program requirements. These milestones must be articulated clearly, be measurable, and be appropriate for the period of performance.

14 points

Include a timeline of milestones for your proposed project and how you will, at a minimum, carry out all the program requirements. These milestones must be articulated clearly, be measurable, and be appropriate for the period of performance. The milestones should include:

When you anticipate you will be able to contract or hire with new staff or actuaries. 6 points

When you expect to conduct research, and which projects you plan to take on in line with the six program requirements.

10 points

Budget narrative Maximum points: 10

Provide a detailed budget that follows the instructions in the budget section for the period of performance.

6 points

Request funds that are reasonable based on the total available funding and that link each activity to the goals of this program.

2 points

Request funds that are reasonable based on proposed project goals. Identify any non-

CMS funding sources and the value of such funding and describe how the funding will be integrated into the project.

2 points

Step 4: Learn About Review and Award 35

Risk review Before making an award, we review the risk that you will not prudently manage federal funds. We need to make sure you’ve handled any past federal awards well and demonstrated sound business practices. We use SAM.gov

Responsibility/Qualification to check this history for all awards…