QHP 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
Additional State Roles in QHP Certification ............................................................................................... 10
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
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PURPOSE OF TOOLKIT The Plan Year (PY) 2018 Qualified Health Plan (QHP) Certification State Toolkit is a series of consolidated resources states may use throughout the QHP certification process. This toolkit consolidates important information such as states’ roles and responsibilities throughout the QHP certification process, key dates and reminders, submission trainings and manuals for the System for Electronic Rate and Form Filing (SERFF) and Health Insurance Oversight System (HIOS), and more resources states can use to assist with plan management functions on the Health Insurance Exchanges. This toolkit is a supplemental resource and is not intended to replace official guidance or instructions. In future years, CMS intends to continue providing greater flexibility to states involved in the QHP certification process, and intends to make more and updated tools available to assist in that process.
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
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PY2018 QHP CERTIFICATION OVERVIEW States performing plan management functions in the Federally-facilitated Exchange (FFE) and State-based Exchanges using the federal platform (SBE-FPs) conduct certification reviews for issuers applying for QHP certification in their state.1 Table 1 gives an overview of state plan management activities.
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
States Performing Plan Management Functions in
the FFE
State-Based Exchange Using the Federal Platform (SBE-FP)
Read General Information
Review Guidance and Regulations
Review Application/ Template Updates
Attend the Monthly State Open Q&A Webinar Series
CMS collects QHP Applications via HIOS
Review HIOS Manual
Watch SERFF trainings Confirm Initial List of Plans
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
Review Guidance and Regulations
Review Application/ Template Updates
Attend the Monthly State Open Q&A Webinar Series
Prepare for Reviews
Review state review responsibilities
Review tool summaries and functionality
Attend REGTAP tool trainings
Review Plan Year (PY) 2018 Required Supporting Documents
Collect QHP Applications via SERFF
Review SERFF Manual
Watch SERFF trainings Confirm Initial List of Plans
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
Coordinate transfer with CMS and SERFF, if needed
Review Correction Notices
Review notices and reach out to CMS, if needed
Confirm Final List of Plans
Review and confirm plan list
Read General Information
Review Guidance and Regulations
Review Application/Template Updates
Attend the Monthly State Open Q&A Webinar Series
Prepare for Reviews
Review state review responsibilities
Review tool summaries and functionality
Attend REGTAP tool trainings
Review Plan Year (PY) 2018 Required Supporting Documents
Collect QHP Applications via SERFF and/or State System
Review SERFF Manual
Watch SERFF trainings Confirm Initial List of Plans
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
Coordinate transfer with CMS and SERFF, if needed
Confirm Final List of Plans
Review and confirm plan list
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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
FFE States that Perform Plan Management Functions
SBE States Using the Federal Platform
Licensure and Good Standing
Network Adequacy
Program Attestations
Organization Charts/Compliance Plans
Accreditation
Licensure and Good Standing
Service Area
Network Adequacy
Essential Community Providers
Silver/Gold Review
Quality Improvement Strategy
Non-Discrimination – Cost Sharing
Prescription Drug Non-Discrimination – Clinical Appropriateness
Prescription Drug Non-Discrimination – Formulary Outlier
Meaningful Difference
Cost Sharing Reduction Plan Variation
Simple Choice Plan Data Integrity Review
Stand-alone Dental Plan (SADP) – EHB Supporting Documentation and Justification
SADP – Annual Limitation on Cost Sharing
SADP – EHB Benchmark
SADP – Actuarial Value Supporting Documentation and Justification
Plan ID Crosswalk
Data Integrity
Administrative
Program Attestations
Organization Charts/Compliance Plans
Accreditation
Licensure and Good Standing
Service Area
Network Adequacy
Essential Community Providers
Silver/Gold Review
Quality Rating System
Quality Improvement Strategy
Non-Discrimination – Cost Sharing
Prescription Drug Non-Discrimination – Clinical Appropriateness
Prescription Drug Non-Discrimination – Formulary Outlier
Meaningful Difference
Cost Sharing Reduction Plan Variation
Simple Choice Plan Data Integrity Review
SADP – EHB Supporting Documentation and Justification
SADP – Annual Limitation on Cost Sharing
SADP – EHB Benchmark
SADP – Actuarial Value Supporting Documentation and Justification
Plan ID Crosswalk
Data Integrity
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Figure 1. QHP Certification Summary Timeline
Table 3. QHP Certification Timeline
Activity Dates
QHP Application Submission and Review Process
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
States Send CMS Final Plan Recommendations Wed, 9/27/2017
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
Open Enrollment Wed, 11/1/2017 – Fri, 12/15/2017
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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
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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)
Identifies critical data errors within and acrosstemplates.
Provides immediate feedback about data,reducing issuer resubmissions.
Alerts issuers and state reviewers toirregularities in the template submissions.
Imports QHP and SADP data from mostapplication templates.
Conducts validation checks beyond thestandard HIOS and SERFF checks.
Looks across templates for consistency in keyfields.
Produces error reports that describe the errorand its location in the template.
Plans & Benefits Business Rules Network ID Prescription Drug Service Area Rates Table Unified Rate Review
Plan ID Crosswalk Tool Checks that the Plan ID Crosswalk Template has been completed accurately by ensuring that:
All counties in all FFE plans (including statesperforming plan management functions in anFFE) that were offered in 2017 are included inthe crosswalk;
The plans are crosswalked to valid 2018 plans;
The crosswalk reasons selected are consistentwith plan offerings; and
The crosswalk is compliant with the regulationin 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 CommunityProvider (ECP)/Network Adequacy (NA), andPrescription 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
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Review Tool Description Applicable Template(s)
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
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 chemicallydistinct drugs in each USPv6 category and classfor 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
Includes the tools to run two reviews, including:
Non-Discrimination Clinical AppropriatenessReview: Analyzes the availability of covereddrugs associated with nine conditions asrecommended in clinical guidelines, to ensurethat issuers are offering a sufficient type andnumber of drugs.Non-Discrimination Formulary Outlier Review:Identifies and flags as outliers those plans thathave unusually large numbers of drugs subjectto prior authorization and/or step therapyrequirements in 27 USP classes.
Prescription Drug
Master Review Tool with Plans & Benefits data is recommended to use this tool
Plan Preview Environment
Displays plans to issuers, similar to how PlanCompare displays plans to consumers onHealthCare.gov. FFE and SBE-FP state DOIs withHIOS State Reviewer access can use PlanPreview to preview the plan benefit displays forall participating issuers in their state.
Issuers are also strongly encouraged to usePlan Preview to verify the accuracy of theirplans’ display to consumers before finalizingplan data for the year.
A helpful resource is the Plan Preview UserGuide.
Plans & Benefits Service Area Business Rules Rates Templates
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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 Issuer 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 functionsshould review their plan lists and note any concerns they have about issuers and plans incertification 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-FPstates, 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 tosubmit 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 thisdecision. CMS will send communications outlining the process states should take to submitpertinent decisions. States and CMS work closely to ensure state and issuer concerns areaddressed 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 issuersor states submit the withdrawal notification form prior to agreement signing, or indicate in thefinal plan confirmation table that the plan should be withdrawn from certification and should notbe available on the Exchange.
2. After agreement signing (post-certification withdrawal): Applicable to instances in which an issueror state submits withdrawal notification after agreement signing. Post-certification withdrawalsrequire state approval. Please note that the process for plan withdrawal may vary if a withdrawalis 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.
Withdrawal Form:o
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.
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Table 6. Overview of Allowable Data Changes During the QHP Certification Cycle
Timeframe PY2018 Dates
Allowable Data Changes Data Change
Request Required?
During the initial application submission window
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)
Exchange Model Issuer Data Change
Request Form State Approval Documentation
Oversight Group Approval
Documentation
FFE
None
FFE-DE (Non-SADP) None
FFE-DE (SADP)
Approval or Deferral required+
*
*
+
None
States performing plan management functions
None None
Issuers are not required to provide CMS with state approval documentation, but do need state approval to make changes.Transferring plan data from SERFF to HIOS indicates state authorization.
CMS requires either state approval documentation or documentation that the state declines to review the data change request.
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Make sure to allow ample time to use the review tools.
States using SERFF should transfer plans into HIOS early in case issuesarise.
Search the QHP certification website for answers to questions beforecontacting the CMS Help Desk.
Attend state and issuer webinars to ask questions about the QHPcertification process and learn about operational guidance (see REGTAPfor more information and registration).
APPLICATION
TIPS
QHP Certification Website
CCIIO Website
QHP Application Instructions
In some instances, issuers operating in states performing plan management functions and SBE-FP states must submit supporting documents along with their QHP Applications. The PY2018Required Supporting Documents are intended for informational purposes so that statesperforming plan management functions and SBE-FP states know which documents issuers cansubmit with their applications.
Final PY2018 Letter to Issuers (LTI) in the Federally-facilitated Exchange with Addendum
Final PY2018 HHS Notice of Benefit and Payment Parameters
Market Stabilization Final Rule
Guidance to States on Review of QHP Certification Standards in the FFEs for PY2018
State Regulator Webinar Series on QHP Certification
State Plan Management Systems and Submission Deadline for 2018
The State Exchange Resource Virtual Information System (SERVIS) is a user-friendly, state-facing
web portal that provides technical assistance resources related to the Exchange
implementation. States use SERVIS to directly request TA from CCIIO, access CCIIO-approved
content, and view customized information including upcoming events and new resources.
SERVIS can be accessed by going to the CMS Enterprise Portal.
RESOURCES & KEY GUIDANCE
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CCIIO PLAN MANAGEMENT COMMUNITY For PY2018, CMS is piloting the CCIIO Plan Management (PM) Community, hosted in Salesforce.
Salesforce is a cloud-based software tool that helps manage stakeholder relationships. The CCIIO PM
Community is designed to improve communication and coordination between CMS, issuers, and states
about QHP certification. Rollout of the PM Community coincided with the opening of the QHP submission
window in early May 2017.
State regulators and issuers are the anticipated users for the CCIIO PM Community. State users will log in
to access profiles for each issuer ID and Plan ID in their state. Pilot participants will use the CCIIO PM
Community for a limited number of tasks in the QHP certification process. Examples of state roles include:
Managing state contacts;
Viewing issuer contacts for pilot participants with the state;
Viewing issuer and plan-level data for all issuers and plans in the state;
Completing plan confirmation;
Completing the QHP Withdrawal Form, if applicable;
Communicating directly with CMS on non-policy issues via Salesforce’s Chatter function; and
Accessing notices, including correction notices, from CMS.
Additional details on the PM Community:
Users will access the system via a login page on the QHP certification website.
The homepage of the PM Community will contain updates from CMS.
Users will view key components of the PM Community as shown below in Figure 2.
Figure 2. PM Community Features for States
State participants will be asked for regular feedback on user experience to assist CCIIO in improving the
system. States should email questions regarding the CCIIO PM Community to
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NEW FOR PY2018: POLICY AND REGULATORY UPDATES Market Stabilization Final Rule
Special Enrollment Period Pre-Enrollment Verification: The rule expands pre-enrollmentverification of eligibility to all individuals who newly enroll through special enrollment periods inExchanges using the HealthCare.gov platform. This change will help make sure that specialenrollment periods are available to all who are eligible for them, but will require individuals tosubmit supporting documentation, a common practice in the employer health insurance market.This will help place downward pressure on premiums, curb abuses, and encourage year-roundenrollment.
Guaranteed Availability: The rule addresses potential abuses by allowing an issuer to collect past-due premiums for coverage in the prior 12 months, before enrolling a consumer in new coveragewith the same issuer or any other issuer within the same controlled group. This will incentivizeconsumers to avoid coverage lapses.
Determining the Level of Coverage: The rule makes adjustments to the de minimis range used fordetermining the level of coverage by providing greater flexibility to issuers to provide patientswith more coverage options.
Network Adequacy: The final rule takes an important step in reaffirming the traditional role ofstates to serve their populations. In the review of QHPs, CMS will defer to the states’ reviews instates with the authority and means to assess issuer network adequacy. States are bestpositioned to ensure their residents have access to high quality care networks.
Essential Community Providers: The final rule reduces the essential community provider (ECP)threshold for issuers in FFEs from 30 to 20 percent of the available ECPs in an issuer’s service areato participate in the plan’s network and continues the ECP write-in process toward satisfaction ofthe ECP inclusion standard set forth in 45 C.F.R. 156.235
QHP Certification Calendar: In the rule, CMS announced its intention to release a revised timelinefor the QHP certification and rate review process for PY 2018. The revised timeline will provideissuers with additional time to implement proposed changes that are finalized prior to the 2018coverage year. These changes will give issuers flexibility to incorporate benefit changes andmaximize the number of coverage options available to patients.
Open Enrollment Period: The final rule shortens the upcoming annual open enrollment period forthe individual market. For the 2018 coverage year, the open enrollment period will be fromNovember 1, 2017, through December 15, 2017. This change will align the Exchanges with theEmployer-Sponsored Insurance Market and Medicare, and help lower prices for Americans byreducing adverse selection.
Guidance to States on Review of QHP Certification Standards in the FFE for Plan
Years 2018 and Later Licensure, Good Standing, Network Adequacy: CMS will rely on states to determine whetherissuers meet QHP certification standards for licensure, good standing, and network adequacy (instates that CMS has determined to have an adequate review process), regardless of whether thestate is otherwise performing plan management activities on the FFE.
Review Clarifications for States Performing Plan Management Functions: In states that performplan management functions on the FFE, CMS will rely on state reviews and processes for servicearea and prescription drug formulary outliers and cost sharing outliers.
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Final HHS Notice of Payment & Benefit Parameters for 2018
o
o
Standardized Options (“Simple Choice Plans”): The 2018 Payment Notice established three sets ofsix standardized options. One of the sets is applicable for each state that uses the federalplatform, depending on that state’s requirements. Issuers may choose to offer Simple ChoicePlans, i.e., plans with cost-sharing amounts that align with the set applicable for the state. Referto the 2018 Payment Notice for more information on your state.
Cost Sharing: In 2018, QHP issuers must count cost sharing paid by an enrollee for any essentialhealth benefits (EHBs) provided out-of-network at an in-network setting towards in-network out-of-pocket limits in certain circumstances.
QHP issuers also must notify enrollees of the possibility of out-of-network balance billingat least 48 hours in advance (or longer in some cases).The annual limitation on cost sharing is $7,350 for self only coverage, and $14,700 forfamilies.
Web-Brokers: In PY2018, web-brokers that use the direct enrollment pathway must differentiallydisplay all standardized options, and be consistent with HHS’s approach for display onHealthCare.gov. If web-brokers’ websites deviate from HealthCare.gov’s display approach, theymust receive approval from HHS.
New Requirements for SBE-FPs: While SBE-FPs are primarily responsible to enforce QHPrequirements in their states, CMS has the authority to review and suppress plans in states thatfall out of compliance with program requirements.
Summary of Benefits and Coverage: Summaries of Benefits and Coverage (SBCs) are required toshow whether the QHP will cover certain women’s health services in cases where federal fundingis unavailable. Additionally, QHP issuers must ensure SBCs that accurately reflect each costsharing plan variation are available, and must provide an appropriate SBC for a plan variationwithin seven business days after receiving notice that an enrollee has been assigned to a newplan variation.
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APPENDIX A: QHP CERTIFICATION REVIEW ROLES BY STATE
EXCHANGE MODEL Table 8 below lists reviews for PY2018 that CMS and states will conduct to ensure issuers applying to offer QHPs through FFEs and SBE-FPs meet and maintain applicable certification standards. State regulators should refer to this review table in preparation for PY2018 QHP certification. CMS remains the ultimate certifying entity for all states in the FFE.
The Review Area and Review Description columns detail each standard with which issuers must comply to achieve QHP certification. The Reference in PY2018 Letter to Issuers column directs states to existing guidance for states and issuers pertaining to this certification standard. The Applicability by Type of QHP column indicates whether the certification standard applies differentially to QHPs that are SADPs.
The Reviewer columns indicate the entity primarily responsible for reviewing QHP Application data to ensure its compliance with the applicable certification standard. If a state is the primary reviewer with CMS ratification, CMS intends to conduct a minimal review of the state’s results of QHP Application reviews, and communicate any outstanding deficiencies to issuers. If the state is the primary reviewer with no CMS ratification, CMS will accept QHP Application data as submitted by the state without additional review. If CMS is the primary reviewer, no state review is expected.
Finally, the table indicates whether an applicable review tool is available. Applicable review tools can be
found on the QHP certification website.
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Table 8. QHP Certification Review Roles by State Exchange Model
Review Area Review Description Reference in
PY2018 Letter to Issuers
Applicability by Type of
QHP
Reviewer: FFE states that
do not perform plan
management functions
Reviewer: States that
perform plan management functions in
the FFE
Reviewer: SBEs Using the
Federal Platform
Review Tool
1 Administrative The review ensures that issuers provide contact information (e.g., phone number, address, URL) which appears on HealthCare.gov for consumer use.
2014 LTI Page 45
All QHPs CMS CMS State (No CMS ratification)
No tool available.
2 Program Attestations
The review confirms that issuers agree to comply with FFE requirements and standards.
2018 LTI Page 9
All QHPs CMS State (No CMS ratification)
State (No CMS ratification)
No tool available.
3 Organization Charts/ Compliance Plans
The review examines compliance plans that issuers submit to ensure that appropriate processes are in place to maintain adherence with applicable regulations and guidelines, as well as to prevent fraud, waste, and abuse. The organizational chart review ensures that the Compliance Officer reports to the board of directors (or other senior governing body).
2018 LTI Page 55
All QHPs CMS State (No CMS ratification)
State (No CMS ratification)
No tool available.
4 Accreditation The review examines issuers’ existing accreditation to determine whether a QHP satisfies the accreditation requirements.
2018 LTI Page 35
Not applicable to SADPs
CMS State (No CMS ratification)
State (No CMS ratification)
No tool available.
5 Licensure and Good Standing
The review ensures issuers have provided documentation that shows they have satisfied licensure and good standing requirements for the proposed QHP markets, service areas, and products.
2018 LTI Page 21
All QHPs State (No CMS ratification)
State (No CMS ratification)
State (No CMS ratification)
No tool available.
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Review Area Review Description Reference in
PY2018 Letter to Issuers
Applicability by Type of
QHP
Reviewer: FFE states that
do not perform plan
management functions
Reviewer: States that
perform plan management functions in
the FFE
Reviewer: SBEs Using the
Federal Platform
Review Tool
6 Service Area The review confirms that issuers establish a service area that covers a minimum geographical area that is at least the entire geographic area of a county. If the issuer proposed a service area small than a full county, the review ensures issuers proposing to cover part of a county are doing so because partial county coverage is necessary, non-discriminatory, and in the best interest of potential enrollees.
2018 LTI Page 22
All QHPs CMS State (No CMS ratification)
State (No CMS ratification)
No tool available.
7 Network Adequacy4
The review assesses whether issuers meet standard of “reasonable access” to providers of covered services. In states that do not perform sufficient network adequacy reviews, CMS will review access plans for issuers without accreditation.
2018 LTI Page 23: Chapter 2, Section 3(i)
All QHPs State/CMS (No CMS ratification)
State/CMS (No CMS ratification)
State (No CMS ratification)
No tool available.
8 Essential Community Providers
The review determines whether the issuer’s provider networks are adequate with respect to inclusion of ECPs. ECPs include providers that serve predominantly low-income and medically underserved individuals. Inclusion of ECPs in issuer networks helps to ensure reasonable and timely access to a broad range of ECPs for enrollees in issuer service areas.
2018 LTI Page 29
All QHPs CMS State (No CMS ratification)
State (No CMS ratification)
QHP ECP and SADP ECP Tools
4 State/CMS indicates in the Exchange Stabilization Final Rule that states will conduct the review when CMS determines that the state performs sufficient network adequacy reviews and CMS will conduct the review when it does not.
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Review Area Review Description Reference in
PY2018 Letter to Issuers
Applicability by Type of
QHP
Reviewer: FFE states that
do not perform plan
management functions
Reviewer: States that
perform plan management functions in
the FFE
Reviewer: SBEs Using the
Federal Platform
Review Tool
9 Silver/Gold This regulation requires that QHPs must be offered through the applicable Exchange at both the silver and gold coverage levels (as described in section 1302(d)(1) of the ACA) throughout each service area in which the issuer applying for certification offers coverage through the Exchange.
The FFEs will apply this certification standard by ensuring that both a silver and gold level QHP (and/or Multi-State Plan options) are offered throughout each individual and FF-SHOP service area in which the QHP issuer offers coverage. The certification standard under paragraph 156.200(c)(1) does not apply to SADPs.
An issuer could meet this standard by offering Multi-State Plan options certified by the Office of Personnel Management (OPM) as described in Chapter 1, Section 4, “OPM Certification of Multi-State Plan Options” above in both silver coverage and gold coverage levels throughout each service area in which it offers QHPs through an Exchange.
2018 LTI Page 23
Not applicable to SADPs
CMS State (No CMS ratification)
State (No CMS ratification)
Master Review Tool
10 Quality Rating System
The review ensures issuers have submitted their quality data and enrollee satisfaction survey results.
2018 LTI Page 37
Not applicable to SADPs
CMS CMS State (No CMS ratification)
No tool available.
11 Quality Improvement Strategy
The review examines issuer QIS submissions to ensure that issuers have appropriately completed the QIS Implementation Plan and Progress Report forms and assess whether they meet the QIS requirements as part of their QHP Applications.
2018 LTI Page 39
Not applicable to SADPs
CMS State (CMS ratification)
State (No CMS ratification)
Master Review Tool
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Review Area Review Description Reference in
PY2018 Letter to Issuers
Applicability by Type of
QHP
Reviewer: FFE states that
do not perform plan
management functions
Reviewer: States that
perform plan management functions in
the FFE
Reviewer: SBEs Using the
Federal Platform
Review Tool
12 Non-Discrimination – Cost Sharing
To ensure non-discrimination in QHP benefit design, CMS will perform an outlier analysis on QHP cost sharing (e.g., co-payments and co-insurance) as part of the QHP certification application process. QHPs identified as outliers may be given the opportunity to modify cost sharing for certain benefits if CMS determines that the cost sharing structure of the plan that was submitted for certification could have the effect of discouraging the enrollment of individuals with significant health needs.
CMS’s outlier analysis will compare benefit packages with comparable cost-sharing structures to identify cost-sharing outliers with respect to specific benefits.
2018 LTI Page 43
Not applicable to SADPs
CMS State (No CMS ratification)
State (No CMS ratification)
Non Discrimination Benefit Review Tool
13 Prescription Drug Non-Discrimination– Clinical Appropriateness
The review ensures that issuers offer sufficient numbers and types of drugs to effectively treat high cost and chronic medical conditions and do not restrict access by lack of coverage or inappropriate use of utilization management techniques. Drug lists are created using nationally ranked clinical guidelines.
2018 LTI Page 45
Not applicable to SADPs
CMS State (No CMS ratification)
State (No CMS ratification)
Formulary Review Suite
14 Prescription Drug Non-Discrimination – Formulary Outlier
The review focuses on utilization management measures that an issuer may use, and it identifies and flags outlier plans that have an unusually low number of drugs that are unrestricted—not subject to prior authorization or step therapy requirements—in particular United States Pharmacopeial Convention (USP) categories and classes.
2018 LTI Page 45
Not applicable to SADPs
CMS State (No CMS ratification)
State (No CMS ratification)
Formulary Review Suite
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Review Area Review Description Reference in
PY2018 Letter to Issuers
Applicability by Type of
QHP
Reviewer: FFE states that
do not perform plan
management functions
Reviewer: States that
perform plan management functions in
the FFE
Reviewer: SBEs Using the
Federal Platform
Review Tool
15 Meaningful Difference
The review ensures a reasonable consumer could determine a meaningful difference between an issuer's plan offerings within the same service area and metal level, with exceptions for areas with limited plan availability or issuers with a recent merger or acquisition.
2018 LTI Page 46
Not applicable to SADPs
CMS State (No CMS ratification)
State (No CMS ratification)
Meaningful Difference Tool
16 Cost-sharing Reduction Plan Variation
The review ensures that all plans on the Exchange offer cost sharing reduction plan variations that meet the standards for QHP certification. The required plan variations are the limited and zero cost sharing plan variations, and three silver plan variations. The limited and zero cost sharing variations are available to American Indians/Alaska Natives, and the silver plan variations are available to consumers under 250 percent of the federal poverty level. All plan variations reduce cost sharing for the consumer.
2018 LTI Page 47
Not applicable to SADPs
CMS State (CMS ratifies)
State (No CMS ratification)
Cost-Sharing Tool
17 Simple Choice Plan Data Integrity Review
This data integrity review ensures that all plans that indicate they are following a simple choice plan design have the cost sharing values associated with the regulatory guidance on simple choice plans of that level of coverage in that state.
2018 LTI Page 20
All QHPs CMS State (CMS ratifies)
State (No CMS ratification)
Cost-Sharing Tool
18 SADP – EHB Supporting Documentation and Justification
The review examines supporting documentation submitted by issuers who have changed their EHBs, by substitution, and verifies that the new benefit is actuarially equivalent to the original EHB and meets the standards of the EHB and the ACA.
2018 LTI Page 52
SADPs only CMS State (No CMS ratification)
State (No CMS ratification)
No tool available.
19 SADP – Annual Limitation on Cost-Sharing
The review ensures that the maximum out of pocket amount for all dental plans is within the required limit.
2018 LTI Page 52
SADPs only CMS State (No CMS ratification)
State (No CMS ratification)
Cost-Sharing Tool
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Review Area Review Description Reference in
PY2018 Letter to Issuers
Applicability by Type of
QHP
Reviewer: FFE states that
do not perform plan
management functions
Reviewer: States that
perform plan management functions in
the FFE
Reviewer: SBEs Using the
Federal Platform
Review Tool
20 SADP – EHB Benchmark
The review consists of comparing an issuer-submitted benefit package with the benefits covered by the applicable EHB benchmark plan (state and federal benchmarks). The compliance review for additional benefits not EHB, and for associated attestations, consists of additional checks of these benefits to ensure they comply with applicable standards defined in the ACA.
2018 LTI Page 52
SADPs only CMS State (No CMS ratification)
State (No CMS ratification)
No tool available.
21 SADP – Actuarial Value Supporting Documentation and Justification
The review examines documents submitted by issuers who have changed their EHBs by substitution and are required to submit the proper supporting documentation verifying that the new benefit is actuarially equivalent to the original EHB and meets the standards of the EHB and ACA.
2018 LTI Page 52
SADPs only CMS State (No CMS ratification)
State (No CMS ratification)
No tool available.
22 Plan ID Crosswalk: General Crosswalk Requirements
The Plan ID Crosswalk review for general crosswalk requirements includes cases in the individual market where an issuer renews coverage, consistent with the guaranteed renewability standards under 45 CFR 147.106(e) and 155.335(j)(1). This review also includes cases in the individual market where an issuer non-renews or discontinues coverage, or continues the product but no longer serves one or more enrollees, consistent with §147.106(c) and 155.335 (j)(2), and selects a plan under a different product offered by the issuer for those enrollees who do not make another plan selection. In all cases, issuers must comply with applicable federal and state law.
2018 LTI Page 18
All QHPs CMS State (CMS ratifies)
State (CMS ratifies)
Plan Crosswalk Validation Tool
25
Review Area Review Description Reference in
PY2018 Letter to Issuers
Applicability by Type of
QHP
Reviewer: FFE states that
do not perform plan
management functions
Reviewer: States that
perform plan management functions in
the FFE
Reviewer: SBEs Using the
Federal Platform
Review Tool
Plan ID Crosswalk: Alternate Enrollments
The Plan ID Crosswalk review for alternate enrollments includes cases in the individual market where an issuer non-renews or discontinues coverage consistent with 45 CFR 155.335(j)(3) and does not provide an enrollment option for affected enrollees for the upcoming plan year.
2018 LTI Page 19
Not applicable to SADPs
State unless State defers to CMS (CMS ratifies)
State unless State defers to CMS (CMS ratifies)
State unless State defers to CMS (CMS ratifies)
Plan Crosswalk Validation Tool
23 Rate Outlier Issuers with rates that are significantly lower than the rest of the rates in the Exchange may indicate issuers that are at risk for financial insolvency which could create market instability. These low rates are identified using an outlier analysis for plans in the same geographic region and metal level.
2018 LTI Page 41
Not applicable to SADPs
State rate
review process (No CMS ratification)
State rate
review process (No CMS ratification)
No tool available.
24 Data Integrity The review ensures that data submitted through an issuer’s QHP Application are in an appropriate format and structure. The review checks that the data conform to validations in the Health Insurance Oversight System (HIOS) and the System for Electronic Rate and Form Filing (SERFF), as well as requirements for correct template submission that are not found in HIOS or SERFF.
2018 LTI Page 49
All QHPs CMS State (CMS ratifies)
State (CMS ratifies)
Data Integrity Tool
State rate review process (No CMS ratification)
26
APPENDIX B: PLAN YEAR 2018 EXCHANGE TYPES Consumers and small businesses have access to Health Insurance Exchanges through the Patient Protection and Affordable Care Act (ACA). Consumers in every state and the District of Columbia are able to buy QHPs available through their states’ Exchange. States operate their own Exchanges (State-based Exchanges, or SBEs) or allow the Federal government to facilitate the Exchange in their state (Federally-facilitated Exchanges, or FFEs). Some states partner with the FFE to perform plan management functions, and some State-based Exchanges use the federal platform (SBE-FPs). This section of the toolkit describes the different Exchange types for plan management functions, and illustrates PY2018 Exchange types by state.
Table 9. Responsibilities by Exchange Type
Exchange Type Plan Management/
Platform Use Description/State Responsibilities
Federally-facilitated Exchange (FFE)
States not performing QHP management functions in the FFE
CMS performs all plan management functions, with the exception of QHP reviews for Licensure, Good Standing, and Network Adequacy in states with adequate review processes, which are performed by the state. CMS certifies QHPs while the state (except Direct Enforcement states) enforces market-wide standards5 under the ACA. Individuals and small businesses apply for health insurance coverage through HealthCare.gov. For direct enforcement states, CMS reviews rates and forms for compliance with ACA provisions when states that inform CMS that they do not have the authority to enforce or are not otherwise enforcing one or more provision themselves.
States performing plan management functions in the FFE
The state performs plan management functions and makes QHP certification recommendations to CMS. CMS is responsible for final certification decisions for QHPs based on the state’s recommendation. Individuals and small businesses apply for health insurance coverage through HealthCare.gov.
State-based Exchange (SBE)
SBEs using the Federal Platform
The state performs plan management functions and certifies QHPs. State uses HealthCare.gov and federal IT infrastructure for plan display, selection, and enrollment.
SBEs not using the Federal Platform
The state performs all Exchange functions for both the individual market and small business market (SHOP). Consumers and small employers and their employees in these states apply for and enroll in coverage through Exchange websites established and maintained by the states.
5 Market-wide standards include essential health benefits (EHBs) and actuarial value (AV) reviews.
27
Figure 3. QHP PY2018 Exchange Models Map
