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QHP Certification State Toolkit

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QHP Certification State ToolkitQHP Certification State Toolkit Key Resources for States for Plan Year 2018
Contents Purpose of Toolkit ........................................................................................................................................ 2
PY2018 QHP Certification Overview ............................................................................................................ 3
QHP Application Data Collection ................................................................................................................. 6
Review Tools ................................................................................................................................................ 7
CCIIO Plan Management Community ........................................................................................................ 15
New for PY2018: Policy and Regulatory Updates ...................................................................................... 16
Appendix A: QHP Certification Review Roles by State Exchange Model .................................................. 18
Appendix B: Plan Year 2018 Exchange Types ............................................................................................ 26
2








For technical questions related to HIOS, contact XOSC Help Desk at 1-855-CMS-1515 (1-855- 267-1515) or [email protected]
For technical questions related to SERFF, contact the SERFF Plan Management Help Desk at [email protected]
For state-related questions, contact the Plan Management State Coordination (PMSC) mailbox at [email protected]
For Form Filing reviews in Direct-enforcement states, contact [email protected]
For Rate Review questions, contact [email protected]
For Oversight Group (OG) questions, contact your State Engagement Coordinators
For general CCIIO information, see the CCIIO FAQs and Fact Sheets
For key documents related to QHP Certification, see the QHP Certification Website
WHERE TO FIND HELP
Table 1. State Plan Management Overview
1 CMS enforces market-wide standards under the Affordable Care Act (ACA) for direct enforcement states (Missouri, Oklahoma, Texas, and Wyoming). CMS expects all other states to enforce these market-wide standards.
Federally-Facilitated Exchange (FFE) States
the FFE
Read General Information
CMS collects QHP Applications via HIOS
Review HIOS Manual
Review and confirm plan list Receive and Review Correction Notices
Review notices and reach out to CMS, as needed
Confirm Final List of Plans
Review and confirm plan list
Read General Information
Prepare for Reviews
Attend REGTAP tool trainings
Collect QHP Applications via SERFF
Review SERFF Manual
Review and confirm plan list Review Plans
Run review tools
Reach out to CMS Help Desk with questions as necessary at: [email protected]
Transfer Plans
Review Correction Notices
Confirm Final List of Plans
Review and confirm plan list
Read General Information
Prepare for Reviews
Attend REGTAP tool trainings
Review SERFF Manual
Review and confirm plan list Review Plans
Run review tools
Reach out to CMS Help Desk with questions as necessary at: [email protected]
Transfer Plans
Confirm Final List of Plans
Review and confirm plan list
Table 2 briefly lists reviews for PY2018 that CMS will rely on states to conduct. Appendix A of this document details the certification reviews and the primary reviewer for each by Exchange model. Table 3 provides the high-level QHP certification timeline for states to review in preparation for certification.
Table 2. Summary of QHP State Reviews for PY2018
FFE States that do not Perform Plan
Management Functions
SBE States Using the Federal Platform








Meaningful Difference
Simple Choice Plan Data Integrity Review







SADP – Annual Limitation on Cost Sharing
SADP – EHB Benchmark
Plan ID Crosswalk



Meaningful Difference





SADP – EHB Benchmark


Table 3. QHP Certification Timeline
Activity Dates
Initial QHP Application Submission Window Wed, 5/10/2017 – Wed, 6/21/2017
CMS Reviews Initial QHP Applications as of 6/21/17 Thu, 6/22/2017 – Tue, 7/25/2017
CMS Sends First Correction Notice Tue, 8/1/2017 – Wed, 8/2/2017
Deadline for Service Area Petition Fri, 8/4/2017
Final deadline for issuer changes to QHP Application Wed, 8/16/2017
CMS reviews Final QHP submissions as of 8/16/17 Thu, 8/17/2017 – Mon, 9/11/2017
CMS sends Final Correction Notice to issuers with Agreements for signature and plan lists for confirmation
Thu, 9/14/2017 – Fri, 9/15/2017
QHP Agreement, Plan Confirmation, and Final Certification
Issuers send signed Agreements, confirmed plan lists, and final Plan Crosswalks to CMS
Sat, 9/16/2017 – Wed, 9/27/2017
CMS Sends Certification Notices with countersigned Agreements and final plan lists to issuers
Wed, 10/11/2017 – Thu, 10/12/2017
Limited data correction window: Outreach to Issuers with CMS or state identified data errors; issuers submit corrections; CMS reviews and finalizes data for Open Enrollment
Fri, 9/15/2017 – Sat, 10/7/2017
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QHP APPLICATION DATA COLLECTION There are two different systems issuers use to submit QHP Application data: the Health Information Oversight System, or HIOS, and the System for Electronic Rate and Form Filing, or SERFF. The system that issuers use depends on their state’s Exchange model type. States can review their issuers’ data within the corresponding system with the appropriate login credentials. The State Plan Management Systems table provides more detail on the systems states are using for QHP Application and plan data review.
Health Information Oversight System (HIOS) stores QHP Application data from issuers and SERFF, and CMS collects this material through HIOS. State users can register for the State Reviewer role in HIOS to review this data. For more information on how to obtain access to HIOS, refer to the HIOS User Manual or the HIOS Quick Reference Guide. Questions related to HIOS should be directed to the Exchange Operations Support Center (XOSC) at 1- 855-267-1515 or [email protected]
HIOS
System for Electronic Rate and Form Filing (SERFF) is used to collect QHP Application data. States performing plan management functions and SBE-FP states (as applicable) collect QHP Application data through SERFF, and then transfer this data from SERFF to HIOS for CMS review. States performing plan management functions and SBE-FP states must transfer their QHP Applications from SERFF to HIOS. The SERFF data transfer deadline aligns with the HIOS QHP Application submission deadlines. State transfers should include all plans submitted to the state for certification, including SADPs and off-Exchange sales. States can transfer through SERFF multiple times, and are strongly encouraged to transfer their plans early to avoid transmission delays. However, SBE-FPs should not transfer off-Exchange SADPs. For more information, refer to the SERFF State Manual and User Manual Appendix, or SERFF Plan Management Training.
Questions related to SERFF functionality should be directed to the SERFF Plan Management Help Desk at 816-783-8990 or [email protected]
SERFF
REVIEW TOOLS CMS also provides tools for issuers and states to review QHP Application data. States can download the review tools from the QHP Certification website. Table 4 provides summaries of the publicly available review tools.
Table 4. Tools for States’ QHP Certification Reviews
Review Tool Description Applicable Template(s)
Data Integrity Tool (DIT)




Conducts validation checks beyond the standard HIOS and SERFF checks.
Looks across templates for consistency in key fields.
Produces error reports that describe the error and its location in the template.
Plans & Benefits Business Rules Network ID Prescription Drug Service Area Rates Table Unified Rate Review




All counties in all FFE plans (including states performing plan management functions in an FFE) that were offered in 2017 are included in the crosswalk;
The plans are crosswalked to valid 2018 plans;
The crosswalk reasons selected are consistent with plan offerings; and
The crosswalk is compliant with the regulation in 45 C.F.R. 155.335(j).
Plans & Benefits Service Area Plan ID Crosswalk
Master Review Tool


Aggregates data from the Plans & Benefits, Service Area, and Essential Community Provider (ECP)/Network Adequacy (NA), and Prescription Drug Templates.
Serves as a data input file to the other stand- alone tools.
Checks plans for silver/gold plan compliance.
Plans & Benefits Service Area ECP/NA Prescription Drug





Calculates the total number of ECPs an issuer has in each plan's network and compares this to the number of available ECPs in that service area.
Checks whether the percentage of the plan's networked ECPs is equal to or greater than the ECP threshold (as defined by federal or state regulators) to demonstrate satisfaction of the ECP inclusion standard set forth in 45 C.F.R. 156.235.
Plans & Benefits Service Area ECP/NA Master Review Tool is required to use this tool
SADP Essential Community Providers (ECP) Tool
Calculates the total number of ECPs an issuer has in each plan's network and compares this to the number of available ECPs in that service area.
Checks whether the percentage of the plan's networked ECPs is equal to or greater than the ECP threshold (as defined by federal or state regulators) to demonstrate satisfaction of the ECP inclusion standard set forth in 45 C.F.R. 156.235.
Plans & Benefits Service Area ECP/NA Master Review Tool is required to use this tool
Meaningful Difference Tool
Performs the "Supporting Informed Consumer Choice" review as discussed in regulation and the 2018 Letter to Issuers.
Compares all plans an issuer offers to check whether there are multiple plans in the same county that would appear virtually identical to a consumer.
Plans & Benefits Service Area Prescription Drug Master Review Tool is required to use this tool
Non-Discrimination Tool
Performs an outlier analysis for "QHP Discriminatory Benefit Design" as discussed in the 2018 Letter to Issuers.
Reviews all plans within the state, goes through a group of pre-determined benefits and determines if any plan has a significantly higher copay or coinsurance for those benefits, which could potentially mean that the coverage is discriminatory.
Plans & Benefits Master Review Tool is required to use this tool
Cost Sharing Tool Runs four different checks (when they are applicable to the plan) for cost sharing standards. This includes: Maximum Out of Pocket (MOOP) Review, Cost Sharing Reduction (CSR) Plan Variation Review, Simple Choice Plan Design Review, and Catastrophic Plan Review.
Plans & Benefits Service Area Prescription Drug Master Review Tool is required to use this tool
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Review Tool Description Applicable Template(s)
Category & Class Drug Count Tool
Compares the count of unique chemically distinct drugs in each USPv6 category and class for each drug list against a state’s benchmark.
Prescription Drug
Master Review Tool with Plans & Benefits data is recommended to use this tool
Formulary Review Suite



Non-Discrimination Clinical Appropriateness Review: Analyzes the availability of covered drugs associated with nine conditions as recommended in clinical guidelines, to ensure that issuers are offering a sufficient type and number of drugs. Non-Discrimination Formulary Outlier Review: Identifies and flags as outliers those plans that have unusually large numbers of drugs subject to prior authorization and/or step therapy requirements in 27 USP classes.
Prescription Drug
Master Review Tool with Plans & Benefits data is recommended to use this tool
Plan Preview Environment


Issuers are also strongly encouraged to use Plan Preview to verify the accuracy of their plans’ display to consumers before finalizing plan data for the year.
A helpful resource is the Plan Preview User Guide.
Plans & Benefits Service Area Business Rules Rates Templates
ADDITIONAL STATE ROLES IN QHP CERTIFICATION
QHP Notices CMS sends several formal notices to issuers and states during the QHP certification process. All states will
receive notices, regardless of their Exchange model. See Table 5 for a notices timeline, an overview of
notices, and the state and issuer role in each.
Table 5. Overview of QHP Notices
Notice Date Sent to FFE and
SBE-FP States State Response
Requested
Initial Plan Confirmation June 30 Yes. Return State Plan Confirmation Table to CMS.
Yes. Return Issuer Plan Table to CMS.
First Plan ID Crosswalk August 1 Yes, State Authorization is required.
No. Make changes and resubmit Plan ID Crosswalk Template, if applicable.
First Correction Notice/Data Integrity
August 1 No. However, states performing plan management functions and SBE-FPs should retransfer corrected data through SERFF.
No. Make corrections to QHP Application, if applicable.
Final Plan Confirmation List
September 12 Yes. Return State Plan Confirmation Table to CMS.
No.
Final Correction Notice September 14 No. However, states performing plan management functions and SBE-FPs should retransfer corrected data through SERFF.
Yes. Reply to final correction notice and indicate whether issuer will make the required changes.
Plan ID Crosswalk Validation
September 22 No. Yes. Validate CMS has correct template on file, or make changes and resubmit Plan ID Crosswalk Template.
Certification October 11 Yes. Return State Plan Confirmation Table to CMS.
Yes. Return Plan Confirmation Table and QHP Agreement to CMS, if applicable.
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Plan Confirmation For PY2018, states and issuers will have two opportunities to confirm the plans submitted and approved for certification. Shortly after the close of the initial and final data submission windows, all FFEs, SBE-FPs, and states performing plan management functions with an active QHP Application will receive plan confirmation notices.
What do states need to do? SBE-FP, FFE, and FFE states performing plan management functions should review their plan lists and note any concerns they have about issuers and plans in certification reviews.
Plan ID Crosswalk and Alternate Enrollment The Plan ID Crosswalk Template crosswalks PY2017 QHP standard component ID and service area
combinations (e.g., Plan ID and county combinations) to a PY2018 QHP Plan ID. This data will facilitate
834 enrollment transactions from CMS to the issuer for those enrollees in the individual market who have
not actively selected a different QHP during open enrollment. These instructions apply to QHP and SADP
issuers that offered individual market QHPs on the Exchange during PY2017.
Issuers are expected to submit evidence from the state, such as an email confirmation, that the issuer is authorized to submit its Plan ID Crosswalk.
What do states need to do? Issuers submitting Plan ID Crosswalk templates in FFE states, SBE-FP states, and states performing plan management functions should submit evidence from the state, such as a state authorization form or an email confirmation, that the issuer is authorized to submit its Plan ID Crosswalk Template. States can return authorization forms directly to issuers.2
Additionally, 45 CFR 155.335(j)(3) authorizes Exchanges to determine alternate enrollments for enrollees in QHPs where the issuer will have no Exchange enrollment option for the upcoming plan year, unless otherwise directed by the state. In the FFEs, FFE states performing plan management functions, and the SBE-FPs, this activity will apply to all QHP enrollees where the issuer no longer has a QHP available through the Exchange for the upcoming plan year with a service area that covers the enrollee’s location. This activity will not apply to SADPs or Small Business Health Options Program (SHOP) plans.
If the enrollee's current QHP is not available through the Exchange, and no QHPs from the original issuer are available for auto re-enrollment in the Exchange that cover a service area that includes the enrollee’s location, and no direction is provided by the state, CMS, if feasible, will determine an alternate enrollment for affected enrollees. CMS will determine an alternate enrollment in another QHP available through the Exchange with a service area that covers the enrollee’s location, taking into account the issuer’s ability to absorb new enrollment and the lowest premium plan. This is done to help maintain coverage through the Exchange for affected enrollees who fail to return to the Exchange to make their own plan selection by December 15. Unless otherwise directed by the state, the Exchange directs such selections.
What do states need to do? States that wish to direct this activity must notify CMS of this decision. CMS will send communications outlining the process states should take to submit pertinent decisions. States and CMS work closely to ensure state and issuer concerns are addressed throughout the alternate enrollment process.
2 Use of this form is optional, and a state may choose to develop its own form or method to document state authorization. If a state develops its own form, CMS requests that the state send a copy to CMS at [email protected] with the subject line “Plan ID Crosswalk Template – [STATE NAME] State Authorization Format.”
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Plan Withdrawal In this context, plan withdrawal refers to withdrawing a plan from certification (or consideration of
certification) as a QHP to be offered through an Exchange. This is distinct from (but sometimes a
consequence of) discontinuing a product or withdrawing completely from the market—the individual
market or small group market both inside and outside of the Exchange—in a state. There are two distinct
phases in the certification cycle that impact the plan withdrawal process:
1. During certification reviews (pre-certification withdrawal): Applicable to instances in which issuers or states submit the withdrawal notification form prior to agreement signing, or indicate in the final plan confirmation table that the plan should be withdrawn from certification and should not be available on the Exchange.
2. After agreement signing (post-certification withdrawal): Applicable to instances in which an issuer or state submits withdrawal notification after agreement signing. Post-certification withdrawals require state approval. Please note that the process for plan withdrawal may vary if a withdrawal is requested after open enrollment and if the plan has active enrollees. This is very rare.
To withdraw a plan from QHP certification consideration, an issuer or state should submit a plan
withdrawal form to CMS. After certification agreements are signed, states must approve or deny all plan
withdrawal requests.
o
Issuers and states can find withdrawal forms on the QHP website here. Issuers and states can submit the withdrawal form to the CMS Help Desk.
Data Changes & Data Change Windows The process for making changes to QHP data, including the state’s role in approving data change requests from issuers, varies depending on the timing of the request within the QHP certification cycle. Table 6 provides an overview of the acceptable data changes depending on the timing of the change request (i.e., during and after the initial application submission window, after the final submission deadline). Following QHP certification, there are multiple opportunities for issuers to update their QHP data throughout the plan year during data change windows (DCWs). To make changes during a scheduled DCW, issuers must submit data change request documentation to their state and/or CMS for approval, according to the Exchange model in which impacted plans are offered. Table 7 denotes which data change request documents need to be submitted to CMS prior to a DCW by Exchange model.3
What do states need to do? States performing plan management functions and SBE-FP states will
receive notices from CMS informing them of all data change requests submitted by issuers in
their state at the conclusion of planned data change windows. States will also receive notices
informing them of unapproved and critical data corrections made by issuers that may impact
their plan display on HealthCare.gov. States have the opportunity to respond to the data changes
made and request further communication from CMS regarding changes.
3 SBE-FP states coordinate and approve data change requests according to state guidelines and are not required to notify CMS of
expected changes. The state must notify NAIC to allow for SERFF transfers.
Table 6. Overview of Allowable Data Changes During the QHP Certification Cycle
Timeframe PY2018 Dates
Request Required?
May 10 – June 21, 2017
Issuers may make any changes to their data without CMS or state authorization, including adding or removing plans or changing plan type.
Data change request NOT required
After the initial application submission window
June 22 – August 16, 2017
Service Area Petition Deadline: August 4
Issuers may request to change their service area, but may not add plans or change plan type. To make a service area change request, issuers must submit a service area petition, and obtain state and CMS approval by August 4. Issuers must submit plan withdrawal forms to remove plans. For all other changes, issuers are not required to submit data change petitions or state authorization forms to CMS.
Data change request required for service area changes only
After the final application submission deadline
After August 16, 2017
No data changes are allowed between final submission and certification. Issuers will have a final opportunity to withdraw plans during the plan confirmation process. CMS may allow issuers to make critical post-certification data corrections in order to correct data display errors on HealthCare.gov and align QHP plan display with products and plans approved by the state. Post-certification data corrections require data change requests as well as approvals from the state and CMS. Allowable changes will occur during periodic, scheduled DCWs.
Data change request required
Table 7. Data Change Request Approval Process by Exchange Model
(Post-QHP Certification)
Oversight Group Approval
None None
Issuers are not required to provide CMS with state approval documentation, but do need state approval to make changes. Transferring plan data…

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