draft issuer letter

8/12/2019 Draft Issuer Letter

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2015 Letter to Issuers in the Federally-facilitated

Marketplace (FFM)

1

Date: February 4, 2014

From: Center for Consumer Information and Insurance Oversight, Centers for Medicare

& Medicaid Services

Title: Draft 2015 Letter to Issuers in the Federally-facilitated Marketplaces

The Centers for Medicare & Medicaid Services (CMS) is releasing this draft Letter to Issuers in

the Federally-facilitated Marketplaces (Letter). This Letter provides issuers seeking to offer

Qualified Health Plans (QHPs), including stand-alone dental plans (SADPs), in a Federally-

facilitated Marketplace (FFM) and/or Federally-facilitated Small Business Health Options

Program (FF-SHOP), with operational and technical guidance to help them successfullyparticipate in the Marketplaces. Unless otherwise specified, references to the Marketplaces or

FFMs include the FF-SHOP.

As indicated in previous guidance, states that are performing plan management functions in an

FFM have some flexibility in assessing compliance with certification standards and adjusting

processes. Throughout this Letter, we identify the areas in which states performing plan

management functions in an FFM have flexibility to follow an approach different from that

articulated in this guidance. We note that the policies articulated in this Letter apply to QHP

issuers starting in the 2015 certification year and beyond, until or unless they are superseded by

subsequent guidance or regulations. In the future, CMS intends to issue similar letters and otherguidance to provide operational updates to QHP issuers, but we do not intend to issue these

letters on more than an annual basis.

CMS has previously published regulations and guidance on market-wide and QHP certification

standards, eligibility and enrollment procedures, and other Marketplace-related topics in several

phases. Additional requirements may be included in upcoming regulations. These regulations

are set out in 45 C.F.R. Subtitle A, Subchapter B as well as in Federal Register issuances. Issuers

are advised to consult these materials in conjunction with the Letter to ensure full compliance

with the requirements of the Patient Protection and Affordable Care Act and Health Care and

Education Reconciliation Act of 2010 (together referred to as the Affordable Care Act), asimplemented. These and other regulatory and guidance materials are available at

http://cciio.cms.gov/resources/regulations/index.html.Unless otherwise indicated, regulatory

references herein are to Title 45 of the Code of Federal Regulations. QHP issuers in FFMs may

also be subject to other requirements for the 2015 certification year, as made in future

rulemaking.
http://cciio.cms.gov/resources/regulations/index.htmlhttp://cciio.cms.gov/resources/regulations/index.htmlhttp://cciio.cms.gov/resources/regulations/index.html


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Comments

We welcome comments on this proposed guidance, but note that to the extent that this guidance

merely summarizes policies proposed through other rulemaking processes that have not yet been

finalized, such as the rulemaking process for the HHS Notice of Benefit and Payment Parameters

for 2015 (2015 Payment Notice),1issuers have already had or will have an opportunity to

comment on those underlying policies through these ongoing rulemaking processes. Therefore,

CMS is not soliciting any additional comments on the substance of the underlying policies

proposed in unfinalized rulemakings through the comment process for this Letter. Please send

comments on other aspects of this Letter to [email protected] by February 25. 2014.

Comments will be most helpful if commenters organize them by subsections of this document.

1Patient Protection and Affordable Care Act; HHS Notice of Benefit and Payment Parameters for 2015; Proposed

Rule, 78 Federal Register 72322 (December 2, 2013).


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TABLE OF CONTENTS

Chapter 1: Certification Process and Standards for Qualified Health Plans ........................................... 6Section 1. FFM QHP Application and Certification Process ................................................................... 7

i. Registration and QHP Application ............................................................................................... 9

ii. Issuer Data Collection and Coordination with States ................................................................. 10

iii. FFM review of QHP Applications .............................................................................................. 11

iv. Plan Preview for FFM Issuers ..................................................................................................... 12

Section 2. QHP Certification Process in a State Performing Plan Management Functions in an FFM . 12

i. QHP Application and State Review Process ............................................................................... 13

ii. Plan Preview ............................................................................................................................... 14

Section 3. Review of Rates .................................................................................................................... 14

i. Consideration of Rate Increases .................................................................................................. 15

ii. Review of QHP Rates ................................................................................................................. 15

Section 4. OPM Certification of Multi-State Plans ................................................................................ 16

Section 5. Certification of Consumer Operated and Oriented Plans (CO-OPs) ..................................... 17

Chapter 2. Qualified Health Plan and Stand-alone Dental Plan Certification Standards ........................... 17

Section 1. Licensure and Good Standing ................................................................................................ 17

Section 2. Service Area ........................................................................................................................... 17

Section 3. Network Adequacy ................................................................................................................ 19

Section 4. Essential Community Providers ............................................................................................. 20

i. Evaluation of Network Adequacy with respect to ECP .................................................................. 20

ii. Requirements for Payment of Federally Qualified Health Centers................................................. 27

Section 5. Accreditation .......................................................................................................................... 27

Section 6. Patient Safety Standards for QHP Issuers .............................................................................. 29

Section 7. QHP and SADP Agreements ................................................................................................. 30

Chapter 3. Qualified Health Plan and Stand-alone Dental Plan Design .................................................... 30

Section 1. Discriminatory Benefit Design: 2015 Approach .................................................................... 30

i. EHB Discriminatory Benefit Design .......................................................................................... 30

ii. QHP Discriminatory Benefit Design .......................................................................................... 31

Section 2. Prescription Drugs ................................................................................................................. 32


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Section 3. Supporting Informed Consumer Choice ................................................................................ 33

Section 4. Stand-alone Dental Plans: 2015 Approach .......................................................................... 35

i. Stand-alone Dental Plan Rates .................................................................................................... 35

ii. Intent to Apply ............................................................................................................................ 36

Section 5. Cost Sharing Reduction Plan Variation Reviews .................................................................. 36

Section 6. Calculation of Cost-Sharing Reduction Advance Payments ................................................. 37

Section 7. Coverage of Primary Care: 2015 Approach ........................................................................... 38

Chapter 4. Qualified Health Plan Performance and Oversight .................................................................. 38

Section 1. Account Management: 2015 Issues ...................................................................................... 38

Section 2. QHP Issuer Compliance Monitoring Program ...................................................................... 39

Section3. QHP Issuer Compliance Reviews ........................................................................................ 39Section 4. FFM Oversight of Agents/Brokers ........................................................................................ 40

Section 5. Monitoring of Marketing Activities ....................................................................................... 41

Chapter 5. Employee Choice and Premium Aggregation Services in FF-SHOPs ..................................... 41

Section 1. Overview ............................................................................................................................... 41

Section 2. Single Bill, Single Payment under Premium Aggregation ..................................................... 42

Section 3. FF-SHOP Enrollment and Payment Portals ........................................................................... 43

Section 4. Beginning Balances for Plan Years Beginning on and after January 1, 2015 ....................... 44

Section 5. Bank Accounts ....................................................................................................................... 44

Section 6. Initial Payments for New Group Coverage and Frequency of Issuer Payments .................... 44

Section 7. Enrollment and HIX 820 Transactions .................................................................................. 45

Section 8. Terminations for and Reinstatements after Non-payment of Premiums ................................ 45

Section 9. Premium Payment Reconciliations ........................................................................................ 45

Section 10. Agent and Broker Commissions and User Fees ................................................................... 45

Section 11. Customer Service for FF-SHOPs ......................................................................................... 46

Section 12. Premium Aggregation Technical Assistance ....................................................................... 46

Section 13. Minimum Participation Rates and Renewals during November 15-December 15 .............. 46

Chapter 6. Consumer Support and Related Issues ...................................................................................... 47

Section 1. Provider Directory.................................................................................................................. 47

Section 2. Complaints Tracking and Resolution .................................................................................... 47


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CHAPTER 1: CERTIFICATION PROCESS AND STANDARDS FOR QUALIFIED HEALTHPLANS

The Affordable Care Act and the applicable Marketplace regulations establish that health plans

must meet a number of standards to be certified as qualified health plans (QHPs). Several of

these standards apply generally to plans offered in the individual and small group markets

regardless of whether the plan is offered through or outside of the Marketplace; the remaining

standards are specific to QHPs seeking certification from the Marketplace. CMS expects that

states will enforce 2014 market reforms2; accordingly, CMS expects to rely on states reviews of

policy forms and rate filings for market reforms as part of its QHP certification process, provided

that such states review for compliance with standards that are consistent with federal regulatorystandards and complete such reviews in a manner consistent with operational timelines. Issuers

should follow state guidance regarding compliance with the processes and criteria for reviews

conducted by states.

The following sections describe CMSs approach to reviewing plans against standards that

generally apply only to issuers seeking certification of QHPs from a Marketplace. The reviews

described in these sections will be conducted either by a state that is performing plan

management functions and making QHP certification recommendations to CMS, or by CMS as a

part of the process of certifying a QHP in the applicable FFM. Each section describes CMSs

planned approach to evaluating QHPs against a certification standard when the state is notperforming plan management functions. As noted in previously released guidance, states that are

performing QHP certification reviews have some flexibility in their application of QHP

certification standards, provided that the states application of each standard is consistent with

CMS regulations and guidance. Issuers seeking QHP certification in states that are performing

plan management functions should refer to state direction in addition to this guidance. State-

based Marketplaces will conduct their own reviews for QHP-specific standards.

2

States are the primary regulators of health insurers and are responsible for enforcing the market reform provisionsin title XXVII of the Public Health Service (PHS) Act both inside and outside the Marketplaces. Under 2723 and

2761 of the PHS Act and existing regulations, codified at 45 C.F.R. part 150, CMS is responsible for enforcing the

provisions of Parts A and B of title XXVII of the PHS Act in a state if a state notifies CMS that it has not enacted

legislation to enforce or that it is not otherwise enforcing one or more of the provisions, or if CMS determines that

the state is not substantially enforcing the requirements. As necessary, CMS will provide additional information on

enforcement.


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This Chapter provides an overview of the QHP certification process in FFMs, both when a state

is performing plan management functions as well as when the FFM is performing planmanagement functions. The QHP certification process for the FFM for the 2015 benefit year

maintains many aspects of the process carried out for 2014, including close coordination and

collaboration with states. The 2015 process also incorporates some adjusted review standards as

well as operational changes.

Similar to the QHP certification process in 2014, in 2015, states may choose to conduct reviews

of QHP Applications and provide recommendations to CMS on QHP certification

determinations. These states will evaluate health plans against QHP certification standards as

part of the states traditional regulatory role for the insurance industry and/or enforcement of

Title XXVII of the Public Health Service Act (PHS Act), or otherwise for state purposes. Basedon the states analysis and review, the state will recommend plans for QHP certification to CMS,

and CMS will decide whether to certify the plans as QHPs. Similarly, in states not conducting all

reviews or making QHP certification recommendations to CMS, CMS anticipates integrating

state regulatory activities that the states conduct into its decision-making for QHP certification in

the FFMs, provided that states make these determinations and provide information to CMS

consistent with federal standards and FFM timelines. These principles underlie the discussion in

this Letter about the QHP certification process.

CMS will review the states recommendations or findings to confirm that they are consistent

with federal regulatory standards, and will communicate to the state any concerns that wouldpreclude CMSs implementation of the states recommendations or findings according to the

process and timeline outlined below and in other guidance. CMS is responsible for the final QHP

certification decisions in each FFM state.

Section 1. FFM QHP Application and Certification Process

This section describes how CMS, as administrator of the FFMs, will conduct QHP certification

when CMS is performing the review and certification of QHPs, including stand-alone dental

plans (SADPs).

In accordance with 45 C.F.R. part 155 subpart K, CMS will review and approve or deny QHP

Applications from issuers that are applying to offer QHPs in an FFM. Table 1.1 presents a high-

level overview of key dates in the FFM QHP certification process. Each major component of the

process is described in greater detail in the subsections that follow.


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For certification of a plan as a QHP for the 2015 benefit year, issuers will be required to submit a

complete QHP Application, including for plans that were certified as QHPs for the 2014 benefityear. CMS will review QHP applications against all QHP certification standards for issuers that

are currently offering QHPs in the FFM as well as issuers that are applying for QHP certification

in the FFM for the first time. CMS also expects that states performing plan management

functions in an FFM will review QHP Applications from all issuers applying for certification of

a QHP for the 2015 benefit year.

For the 2014 certification cycle for the 2015 benefit year, CMS will allow issuers additional time

to view and modify their plan data, in the following manner:

Extended Plan Preview synchronized with data review.The Plan Preview process willtake place concurrent with the QHP Application submission and review process. Issuers

applying for QHP certification in states that are not performing plan management will be

able to view plan data in the Plan Preview environment concurrent with data submission

and correction. This ability will start slightly later for issuers in states performing plan

management. This change is designed to allow for maximum time to ensure the accuracy

of QHP data.

Ongoing data revision, with specified deadlines for review.After the close of the initialapplication submission window, issuers will be able to upload revised data templates on

an as-needed basis until the final data submission deadline. Revisions will appear in the

Plan Preview environment on a rolling basis for issuers in FFM states and at specific

points in time for issuers in states performing plan management. CMS reviews will occur

at pre-defined times during this window and will be based on the QHP data in the system

on certain dates.

Stand-alone dental plan QHP Application timeline synchronized with medicalsubmissions. Stand-alone and embedded dental plan data submission will follow the same

timeline as that of medical plans.


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Table 1.1 Key Dates: QHP Certification in an FFMNote: All dates are subject to change. The given dates are dependent upon whether the datesproposed in the 2015 Payment Notice are finalized as proposed.

Activity Dates

(Approximate)

QHP Application

Submission and

Review Process(Integrated Plan

Preview)

Initial FFM QHP Application Submission Window (Plan

Preview available during this time)

5/26/2014

6/27/2014

FFM Review of QHP Application Submissions as of Initial

Submission Deadline

6/30/2014

7/25/2014

1stCorrection Notice Sent 7/29/2014

Deadline for Submission of Revised QHP Data for Re-

review8/10/2014

FFM Reviews of Corrected QHP Application Submissions

Received as of August 10

8/11/2014

8/25/2014

2ndCorrection Notice Sent 8/26/2014

Deadline for Final Submission of QHP Application data 9/4/2014

FFM Completes Re-review of QHP Application Data; DataLocked Down

9/20/2014

QHP Agreement/

Final Certification

Certification Notices and QHP Agreements Sent to Issuers 10/14/2014

Issuers Return Signed QHP Agreements 10/17/2014

Open Enrollment 11/15/2014

i. Registration and QHP ApplicationTo offer QHPs in FFMs for the 2015 benefit year in states where CMS is performing both the

primary review and certification of QHPs, health insurance issuers will complete QHP

Applications electronically through the Health Insurance Oversight System (HIOS). Before

submitting an application, issuers must gain access to HIOS and request user roles (such as QHP

Issuer Submitter and QHP Issuer Validator), and obtain HIOS user IDs.


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We expect that between May 26 and June 27, 2014, issuers will access the QHP Application in

HIOS to submit all information necessary for certification of health plans and stand-alone dentalplans as QHPs. The QHP Application will collect both issuer-level information and plan-level

benefit and rate data, largely through standardized data templates. Applicants will also be

required to attest to their adherence to the regulations set forth in 45 C.F.R. parts 155 and 156,

and provide requested supporting documentation. Based on the requirement set forth in 45

C.F.R. 156.340 that QHP issuers maintain responsibility for the compliance of their delegated

and downstream entities, these attestations will also reflect that vendors and contractors of the

issuer will adhere to applicable requirements.

Issuers seeking to offer QHPs must also submit the Unified Rate Review Template (URRT) to

CMS via HIOS according to the same timeline. Issuers not seeking to offer any QHPs shouldconsult with state regulators and CMS regarding their rate review obligations. Consistent with

the approach in 2014, issuers do not need to submit URRTs for SADPs.

ii. Issuer Data Collection and Coordination with StatesCMS expects that states will review potential QHPs for compliance with all requirements under

state law, as well as with market-wide standards established by the Affordable Care Act.

Specifically, CMS expects states to review potential QHPs for compliance with essential health

benefits (EHB) and actuarial value (AV) standards, among others.3CMS expects that state

regulators may request access to QHP data templates to facilitate review of potential QHPs.Issuers that wish to prohibit CMS from sharing QHP Application and oversight information with

the relevant state department of insurance must do so by notifying CMS via email at

[email protected] to the QHP Application submission deadline. In

this case, the issuer may need to share this information directly with the state in addition to

sharing it with CMS.

We expect that states will establish the timeline, communication process, and resubmission

window for any reviews conducted under state authority. Issuers should comply with any state-

specific guidelines for review and resubmission related to state-reviewed standards. CMS notes

3We note that, because SADP issuers are only required under federal law to adhere to pediatric dental essential

health benefits requirements for SADPs offered through a Marketplace, CMS does not have the same expectation of

state review for SADPs offered through the Marketplace if such standards are otherwise not applied under state law.

Accordingly, CMS plans to review SADPs for compliance with applicable Affordable Care Act standards.
mailto:[email protected]:[email protected]:[email protected]


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that issuers may be required to submit data to state regulators in addition to that required for

QHP certification through the FFM, if required by a state, and must comply with any requests forresubmissions from the state or from CMS in order to be certified. CMS will coordinate with

states to ensure that any state-specific review guidelines and procedures are consistent with

applicable federal law and operational deadlines. In addition, CMS will conduct outreach to all

state departments of insurance at the end of the QHP certification cycle to confirm that all

potential QHPs meet applicable state and federal standards, and are approved for sale in the

Marketplace.

iii. FFM review of QHP ApplicationsIssuers applying for QHP certification in the FFM will submit complete and accurate QHPApplications into HIOS by approximately June 27, 2014. Plans for which QHP applications are

received after this date and plans for which significant changes to the initial submission are

submitted after this date without CMS approval may not be considered for certification.

CMS expects to review FFM QHP Applications in two rounds; one between June 30 and July 25,

and a second between August 11 and August 25. Following each review period, CMS will send

applicants notices summarizing any need for correction identified during CMSs review. Issuers

will be able to upload revised QHP data templates and make other necessary changes to QHP

Applications in response to CMSs feedback until September 4. Issuers will also be able to make

changes based on state feedback and make other minor corrections to their applications, withstate approval,on the same timeline. CMS also intends to implement a petition process to receive

requests from issuers and review additional requested changes that are particularly significant

during this time, such as changes to service area. Requests to make these more substantial

changes must be reviewed and approved by CMS and the state prior to submission of an update

to the QHP Application. CMS intends to release further guidance on this process.

As stated previously, all final QHP data must be submitted by September 4, 2014. After this date,

issuers will not be allowed to make further changes to QHP data unless necessary to correct data

errors or align QHPs with products and plans as approved by the state. All such changes must be

pre-approved by CMS and the state. CMS expects to review final QHP data, verify and confirmstate approval, and inform issuers of its final certification determinations by October 14, 2014.

CMS will work with FFM states to ensure that state approvals are completed in early October.


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iv. Plan Preview for FFM IssuersAs mentioned above, this year the Plan Preview process will take place concurrent with the QHP

Application submission and review process. Issuers applying for QHP certification in FFMs in

states that are not performing plan management will be able to view plan data in the Plan

Preview environment concurrent with data submission and correction. This new approach will

allow issuers to identify and correct data submission errors before the QHP Application data

submission deadline. CMS will not provide a prescribed Plan Preview data change request period

at the end of the QHP certification process.

Section 2. QHP Certification Process in a State Performing Plan Management Functions in

an FFM

This section describes how states performing plan management functions in an FFM will

conduct QHP certification. Issuers applying in states where CMS is performing all QHP

Application review and QHP certification should refer to Section 1 above.

In an FFM state where the state is performing plan management functions, issuers will work

directly with the state to submit all QHP issuer application data in accordance with state

guidance.4FFM states performing review of QHP Applications will likely utilize the System for

Electronic Rate and Form Filing (SERFF) system to collect QHP Applications from issuers. The

state will review QHP Applications for compliance with the standards described in this guidanceand will provide a certification recommendation for each proposed plan to CMS. CMS will

coordinate the Plan Preview process, review and confirm the states QHP certification

recommendations, make final QHP certification decisions, and load certified QHP plans on the

Marketplace website. CMS will work closely with states that are performing plan management

functions to coordinate this process.

As indicated in Table 1.2, the QHP certification process in FFM states where the state is

performing plan management functions will align with the process for issuers for which CMS is

performing the review. Each major component of the process is described in greater detail in the

subsections that follow.

4CMS will work with states performing plan management functions in an FFM to ensure that such guidance is

consistent with federal regulatory standards and operational timelines.


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Table 1.2 Key Dates: QHP Certification in FFM States Where the State is Performing Plan

Management FunctionsNote: All dates are subject to change. The given dates are dependent upon whether the dates

proposed in the 2015 Payment Notice are finalized as proposed.

Activity Dates (Approximate)

QHP ApplicationSubmission and

Review Process

(Integrated Plan

Preview)

Issuers Submit Plan Data to States, States Review Varied

1stSERFF Data Transfer Deadline 8/10/2014

Plan Preview Available 8/12/2014

FFM Reviews Plan Data 8/11/2014-8/25/2014

FFM Notifies States of any Needed Corrections to QHP

Data8/26/2014

Last date for Issuers to Resubmit Plan Data into SERFF 9/4/2014

2ndSERFF Data Transfer 9/5/2014-9/10/2014

FFM Completes Re-review of Plan Data and State

Recommendations9/20/2014

QHP Agreement/FinalCertification

Certification Notices and QHP Agreements Sent toIssuers

10/14/2014

Issuers Return Signed QHP Agreements 10/17/2014

Open Enrollment 11/15/2014

i. QHP Application and State Review ProcessAn issuers HIOS issuer ID will be used to link the state and federal records for a given issuer or

QHP. Therefore, like an issuer applying in HIOS, an issuer applying to a state via SERFF mustaccess HIOS and obtain the necessary identification numbers and user roles.

Issuers in states performing plan management functions in an FFM are to submit QHP

Applications, typically in SERFF, according to the timeline set by each state. Each state will

define the relevant submission window as well as dates and processes for corrections and


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resubmissions. Issuers seeking to offer QHPs must submit the URRT to the state, and to CMS

via HIOS, on the same timeline as the submission of the QHP Application. Issuers that areapplying for QHP certification in states performing plan management functions in an FFM

should not submit QHP Applications into HIOS.

CMS will provide two defined SERFF transfer windows in order to better coordinate the flow of

QHP data from states performing plan management functions in an FFM. The first SERFF

transfer will take place by August 10, 2014 and will constitute an initial transfer by each state.

QHP data in this transfer do not need to be final, and the plans included in the transfer do not

need to be in final, approved status. CMS believes that this earlier opportunity will improve the

QHP certification process by allowing issuers more time for Plan Preview. CMS will review the

plan data in the initial transfer, and will notify States of any needed corrections. States will workwith issuers to revise their submissions according to CMS and state feedback.

The second SERFF transfer is planned to take place between September 5 and September 10,

2014. CMS will use the data transferred by September 10 to make final QHP certification

decisions based on state recommendations. Issuers will be able to view updated information in

Plan Preview after September 10. After this transfer, issuers will not be allowed to make any

further changes to QHP data unless necessary to correct data errors or align QHPs with products

and plans approved by the state. All such changes must be pre-approved by CMS and the state.

ii. Plan PreviewAs described in Section 1 above, CMS will offer Plan Preview concurrently with QHP

Application submission and review. For issuers in states performing plan management functions

in an FFM, this Plan Preview capability will begin after the state first transfers QHP data from

SERFF, which is planned to take place on August 10, 2014. Issuers in these states will be able to

review plan data after this date and make any necessary corrections in SERFF according to the

timeline established by the state. Changes will be reflected once the state re-transfers plan data

from SERFF to HIOS. Any changes that issuers need to make to the data they view in Plan

Preview during this time must be approved by the state.

Section 3. Review of Rates

This section addresses how CMS will work with states to review rate increases for QHPs when

certifying plans as QHPs for participation in the FFM. States performing plan management

functions in an FFM may use a similar approach. The approach for stand-alone dental plans is

discussed in Section 8.


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i. Consideration of Rate IncreasesRegulations at 45 C.F.R. 155.1020 require a Marketplace to consider all rate increases when

certifying plans as QHPs. For the 2015 benefit year, CMS will consider issuers data and

actuarial justifications provided in the Unified Rate Review Template (URRT), other information

submitted as part of a filing under an Effective Rate Review program and any recommendations

provided to CMS by the applicable state regulator about patterns or practices of excessive or

unjustified rate increases and whether or not particular issuers should be excluded from

participation in the Marketplace. In future years, CMS will also take into account other factors

such as rate growth inside and outside the Marketplace as required by the Affordable Care Act.

CMS does not plan to duplicate reviews that a state is already conducting to enforce state law,and will take into consideration reviews the agency has conducted on behalf of a state for those

states that do not have Effective Rate Review programs. CMS anticipates integrating state and

other CMS rate reviews into its QHP certification processes, provided that states provide

information to CMS consistent with federal standards and agreed-upon timelines.

For rate increases not being reviewed by a state under an Effective Rate Review program or

CMS on behalf of a state (for those states that do not have Effective Rate Review programs):

The QHP issuers justification for all rate increases will be captured in the submission ofPart I of the rate filing justification (URRT).

To ensure consumer transparency, issuers must publish information from Part I of the ratefiling justification by either: (1) posting a link on the issuers website to the

Marketplaces website (or HealthCare.gov), or (2) posting the information on the issuers

website.

ii. Review of QHP RatesRates that are too high or too low could have undesirable consequences for consumers. If rates

are too high, consumers may be overpaying for coverage. If rates are too low, consumers may

purchase a plan in which the pricing is not sustainable over time, potentially leading tosignificant rate increases in future years. Such increases could be disruptive to consumers who

remain in the plan and to consumers who switch to more effectively priced plans but experience

changes in prescription drug formularies or provider networks. In addition, QHP rates

specifically, the rate for the second lowest cost silver plan directly impact the value of

premium tax credits as well as other federal outlays.


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As detailed above, CMS does not plan to duplicate reviews that a state is already conducting as a

matter of state law. CMS intends to implement a process that, in collaboration with existing stateEffective Rate Review programs, will help ensure that QHP rates are reasonable and that,

accordingly, offering the QHP through the FFM would be in the interest of consumers.

Specifically, CMS will conduct an outlier analysis on QHP rates to identify rates that are

relatively high or low compared to other QHP rates in the same rating area.

CMS recognizes that the identification of a QHP rate as an outlier does not necessarily indicate

inappropriate rate development. CMS will notify the appropriate state entity of the results of its

outlier identification process and will consider the states assessment of the plans rates when

determining whether, based on its rates, certifying the QHP to be offered on the FFM would be

in the interest of consumers. .

Section 4. OPM Certification of Multi-State Plans

This section provides additional guidance for health insurance issuers seeking to offer multi-

State plans in FFMs and State-based Marketplaces (SBMs).

The U.S. Office of Personnel Management (OPM) is responsible for implementing the Multi-

State Plan Program (MSPP) as required under section 1334 of the Affordable Care Act. In

accordance with section 1334(d) of the Affordable Care Act, Multi-State Plans (MSPs) offered

by MSPP issuers under contract with OPM are deemed to be certified by a Marketplace.

OPM anticipates that the process for MSPs to participate in an FFM for the 2015 benefit year

will largely mirror that used for 2014. Issuers seeking to offer MSPs must apply to participate via

OPMs online application portal. OPM will evaluate issuer applications and determine which

issuers are qualified to become MSPP issuers. OPM works closely with states in reviewing

benefits and rates to achieve its goals of offering more choice for consumers and maintaining a

level playing field for all issuers within a state.

OPMs contract with each MSPP issuer identifies each MSP that the issuer will offer and in what

state it will be offered. Each MSP so identified is deemed to be certified by OPM to be offered

through the Marketplace(s) operating in those states. In addition, the MSPP contract sets forthperformance requirements for MSPP issuers.

For more information on requirements for MSPP issuers, including the application timeline and

process, issuers should visithttp://www.opm.gov/healthcare-insurance/multi-state-plan-

program/issuer/.
http://www.opm.gov/healthcare-insurance/multi-state-plan-program/issuer/http://www.opm.gov/healthcare-insurance/multi-state-plan-program/issuer/http://www.opm.gov/healthcare-insurance/multi-state-plan-program/issuer/http://www.opm.gov/healthcare-insurance/multi-state-plan-program/issuer/http://www.opm.gov/healthcare-insurance/multi-state-plan-program/issuer/http://www.opm.gov/healthcare-insurance/multi-state-plan-program/issuer/


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Section 5. Certification of Consumer Operated and Oriented Plans (CO-OPs)

Consistent with the statute and the process and policy applied for 2014, CO-OPs are expected to

apply for QHP certification using the same processes applied to other QHP issuers.

CHAPTER 2. QUALIFIED HEALTH PLAN AND STAND-ALONE DENTAL PLAN

CERTIFICATION STANDARDS

Section 1. Licensure and Good Standing

This section describes how CMS will conduct QHP certification and recertification. States

performing plan management functions in an FFM may use a similar approach.

Consistent with 45 C.F.R. 156.200(b)(4), each QHP issuer must be licensed and in good standing

in each state in which it applies to offer QHPs for the applicable market, product type, and

service area. CMS interprets the good standing requirement to mean that the issuer is in

compliance with all applicable state solvency requirements and is in good standing in the state in

relation to compliance with state laws and regulations. Applicable state licenses or certificates of

authority will need to be provided with the QHP Application as supporting documentation. In

addition, for the 2015 benefit year, CMS will require issuers to submit a State Certification

Form. The issuer will need to indicate on this form that it is licensed and in good standing in

each state in which it is applying to offer QHPs. The form must further include a certification

from the applicable state insurance regulator that the issuer is licensed and in good standing in

the state, including meeting state solvency requirements. Issuers applying for QHP certification

must be able to demonstrate state licensure by no later than the first resubmission period during

the QHP certification process, August 10, 2014.

In addition to requiring state certification of good standing, CMS will consider complaints and

other QHP issuer oversight findings that occur during the 2014 benefit year in its determination

of whether an issuers offering of a plan is in the interest of consumers. CMS will consult with

the applicable state on these findings.

Section 2. Service Area

This section describes how CMS will conduct QHP certification and recertification in an FFM.

States performing plan management functions in an FFM may use a similar approach.


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Consistent with regulations at 45 C.F.R. 155.1055(a), the Marketplace must ensure that each

service area of a QHP covers a minimum geographic area that is at least the entire geographicarea of a county, or a group of counties defined by the Marketplace, unless the Marketplace

determines that serving a smaller geographic area is necessary, nondiscriminatory, and in the

best interest of the qualified individuals and employers. The Marketplace must also ensure that

the service area of a QHP has been established without regard to racial, ethnic, language, or

health status-related factors as specified under section 2705(a) of the PHS Act, or other factors

that exclude specific high utilizing, high cost or medically-underserved populations.

For the 2015 benefit year, CMS will review requests for service areas that serve a geographic

area smaller than a county to ensure that each service area meets the above regulatory standards,

particularly with respect to ensuring that the establishment of this partial county service area isnot discriminatory.

In the QHP Application process, CMS considers the service area of a plan to be the county or set

of counties (or partial counties) that is covered by that particular plan. Any change to the list of

counties associated with a particular plan is considered a change in the service area, even if the

issuer offers other plans or products in the counties (or partial counties) in question. For the 2015

benefit year, QHP issuers will not be allowed to change their service area after their initial data

submission except via petition to CMS. Petitions for service area changes must follow a CMS-

prescribed format that will be detailed in future guidance and will only be allowed with State

approval. Changes to service areas will only be approved under very limited circumstances, suchas:

To address limitations in provider contracting: issuers will need to provide substantialdocumentation of their contracting efforts in the geographic areas dropped, including

lists of providers with whom the issuer attempted to contract and the contracts offered.

Expansions at the request of the state and/or CMS to address an unmet consumer need. To address a data error in the issuers initial Service Area Template submission: issuers

will need to provide significant evidence documenting the error, including evidence in

other parts of the QHP Application indicating an intent to cover a different area and/or a

mismatch with the service area in the issuers form filing.

Any additional circumstances would be severely limited and determined on a case by case basis

and only based on state approval and significant evidence of necessity and the best interest of the

consumer. CMS will not allow changes to service area after the final data submission date.


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Section 3. Network Adequacy



Pursuant to 45 C.F.R. 156.230(a)(2), an issuer of a QHP that has a provider network must

maintain a network that is sufficient in number and types of providers, including providers that

specialize in mental health and substance use disorder services, to assure that all services will be

accessible to enrollees without unreasonable delay. All issuers applying for QHP certification

will need to attest that they meet this standard as part of the certification/recertification process.

For the 2015 benefit year, issuers will be required to submit a provider list that includes all in-

network providers and facilities for all plans for which a QHP certification application issubmitted. Unlike the certification process for benefit year 2014, CMS will no longer utilize

issuer accreditation status, identify states with review processes at least as stringent as those

identified in 45 C.F.R. 156.230(a), or collect network access plans as part of its evaluation of

plans network adequacy. Rather, CMS will review the collected provider list to evaluate

provider networks using a reasonable access review standard, and will identify networks that

fail to provide access without unreasonable delay as required by 45 C.F.R. 156.230(a)(2). In

order to determine whether an issuer meets the reasonable access standard, CMS will focus

most closely on those areas which have historically raised network adequacy concerns. These

areas may include the following:

Hospital systems, Mental health providers, Oncology providers, and Primary care providers.

If CMS determines that an issuers network is inadequate under the reasonable access review

standard, CMS will notify the issuer of the identified problem area(s) and will consider the

issuers response in assessing whether the issuer has met the regulatory requirement and prior to

making the certification or recertification determination. CMS will share information and

analysis and coordinate with states which are conducting network adequacy reviews. Additional

technical guidance regarding the collection method for a plans provider list will be provided as

part of the certification/recertification instructions.

CMS also intends to use information learned during the network adequacy review process to

assist in its articulation of time and distance or other standards for FFM QHP networks that CMS


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intends to reflect in future rulemaking. We welcome comments on this proposal. CMS will share

its network adequacy findings with states and will incorporate state input into its networkadequacy review process. CMS is further considering appropriate formats for collection of this

data which would enable creation of a search engine function for consumers to search for

particular providers and provider types.

Section 4. Essential Community Providers

This section describes how CMS plans to conduct QHP certification and recertification. States

performing plan management functions in an FFM may use a similar approach. This section also

discusses payment requirements for services provided by Federally Qualified Health Centers

(FQHCs).

Essential community providers (ECPs) include providers that serve predominantly low-income

and medically underserved individuals, and specifically include providers described in section

340B of the PHS Act and section 1927(c)(1)(D)(i)(IV) of the Social Security Act (SSA). At 45

C.F.R. 156.235, CMS establishes requirements for inclusion of ECPs in QHP provider networks

and provides an alternate standard for issuers that provide a majority of covered services through

physicians employed by the issuer or a single contracted medical group.

i. Evaluation of Network Adequacy with respect to ECPBecause the number and types of ECPs available vary significantly by location, CMS intends topropose in rulemaking an approach to evaluating QHP Applications for sufficient inclusion of

ECPs for the 2015 benefit year. Specifically, CMS intends to propose in rulemaking the

sufficiency standard found at 45 C.F.R. 156.235 as being met by the ECP standard described

below.

ECP Standard: We intend to propose in rulemaking that an application for QHP certification

adhere to a general ECP inclusion standard in order to meet the regulatory standard established at

45 C.F.R. 156.235(a) without further documentation. If finalized, we intend for certification year

2015 to utilize a general ECP standard whereby the application would first have to demonstrate

that at least 30 percent of available ECPs in each plans service area participate in the providernetwork. We also intend to propose that, in addition to achieving a level of 30 percent

participation of available ECPs, the issuer would have to offer contracts in good faith prior to the

benefit year to:


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All available Indian health providers in the service area, using the model QHPAddendum

5

for Indian health providers developed by CMS; and At least one ECP in each ECP category (see Table 2.1) in each county in the service area,

where an ECP in that category is available.

As part of the issuers QHP application, we intend to propose that the issuer list the offers that it

has extended to all available Indian health providers and at least one ECP in each ECP category

in each county in the service area. To be offered in good faith, a contract should offer terms that

a willing, similarly-situated, non-ECP provider would accept or has accepted. We would expect

issuers to be able to provide verification of such offers if CMS chooses to verify the offers.

We anticipate that that all issuers will be held to the ECP standard for the 2015 benefit year, andintend to propose that there be no minimum expectation standard option as was available for the

2014 certification year. Instead, under our intended proposal, if an issuers application does not

satisfy the 30 percent ECP standard described above, the issuer would be required to include as

part of its application a satisfactory narrative justification describing how the issuers provider

network(s), as currently designed, provides an adequate level of service for low-income and

medically underserved enrollees and how the issuer plans to increase ECP participation in the

issuers provider network(s) in future years, as necessary.

In other words, under our intended proposal, an issuer that would have met only the 2014

minimum expectation standard option if the option had been extended for the 2015 benefit year

will still be considered for QHP certification for the 2015 benefit year, contingent on the issuers

satisfactory narrative justification described above. As only one issuer submitted a justification

for the 2014 benefit year as a means to satisfy the 20 percent ECP standard, we anticipate that

our intended proposal of this 30 percent ECP standard for the 2015 benefit year will be a feasible

standard for issuers to satisfy.

At a minimum, such narrative justification would include the following:

Number of contracts offered to ECPs for the 2015 benefit year; Number of additional contracts issuer expects to offer for the 2015 benefit year and the

timeframe of those planned negotiations;

5The model QHP Addendum for Indian health providers is available athttp://www.cms.gov/cciio/programs-and-

initiatives/health-insurance-marketplaces/qhp.html.
http://www.cms.gov/cciio/programs-and-initiatives/health-insurance-marketplaces/qhp.htmlhttp://www.cms.gov/cciio/programs-and-initiatives/health-insurance-marketplaces/qhp.htmlhttp://www.cms.gov/cciio/programs-and-initiatives/health-insurance-marketplaces/qhp.htmlhttp://www.cms.gov/cciio/programs-and-initiatives/health-insurance-marketplaces/qhp.htmlhttp://www.cms.gov/cciio/programs-and-initiatives/health-insurance-marketplaces/qhp.htmlhttp://www.cms.gov/cciio/programs-and-initiatives/health-insurance-marketplaces/qhp.html


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Names of the ECP hospitals and FQHCs to which the issuer has offered contracts, but anagreement with the providers has not yet been reached; and

Contingency plans for how, absent participation of the available ECP providers, the planwill be able to provide adequate care to enrollees who might otherwise be cared for by

relevant ECP providers. For example, if available Hemophilia Treatment Centers, Ryan

White Program Providers or Indian health providers are missing from the network(s), the

Application must explain how its target populations will be served.

Examples:

Issuer A proposes a service area in which 80 ECPs are available. Issuer As networkincludes 35 ECPs, and Issuer A attests that it has offered good faith contracts to

available Indian health providers and one ECP in each major ECP category per county,

where an ECP in that category is available. Under our intended proposal, issuer A would

meet the ECP standard; no additional documentation would be required.

Issuer B also proposes a service area in which 80 ECPs are available. Issuer Bs networkincludes 20 ECPs, which would not satisfy the 30 percent ECP standard. Issuer B

provides a narrative justification that includes the following:

o Explanation for why its network includes only 20 ECPs and how it will ensure servicefor low-income and medically underserved enrollees;

o Attestation that the issuer has satisfied the good faith contracting requirement withrespect to offering contracts to Indian health providers and one ECP in each major

ECP category per county, where an ECP in that category is available;

o Number of contracts offered to ECPs for the 2015 benefit year;o Number of additional contracts issuer expects to offer for the 2015 benefit year and

the timeframe of those planned negotiations;

o Names of the hospitals and FQHCs to which the issuer has offered contracts, but theproviders have not yet accepted; and

o A description of how care will be provided to specific populations (e.g., AmericanIndians/Alaska Natives, persons with HIV, persons with hemophilia, etc.) that would

otherwise be served by ECPs that are missing in the service area.

Under our intended proposal, issuer B would be considered for QHP certification, despite

not satisfying the 30 percent ECP standard, based on the quantity of contracts being

offered and the quality of the justification offered for not yet meeting the standard. CMS


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would take into account factors and circumstances identified in the ECP Supplemental

Response Form,

6

along with an explanation of how the issuer will provide access to low-income and underserved populations. Additionally, justifications that include verification

of contracts offered in good faith, that include terms that a willing, similarly-situated,

non-ECP provider would accept or has accepted, would be considered toward satisfaction

of the ECP standard.

To assist issuers in identifying these providers, CMS published a non-exhaustive list of available

ECPs based on data maintained by CMS and other federal agencies, which issuers may use to

calculate their satisfaction of the 30 percent ECP standard. This non-exhaustive list is available

at:http://cciio.cms.gov/programs/exchanges/qhp.html.For Indian health providers and/or

providers on CMS non-exhaustive ECP list, issuers would contract with the corporate entitynamed on the CMS list for that provider to be counted as an ECP. Individual practitioners having

the same address as another ECP on the CMS list would not be counted as ECPs for purposes of

meeting this standard.

Issuers will indicate which ECPs are included in their provider network(s) by populating a

template as part of the QHP Application. CMS will provide detailed instructions to support

issuers in completing the template. Issuers that submit a narrative justification will do so as part

of the issuer application for QHP certification.

Issuers will be permitted to write in ECPs not on the CMS-developed list for consideration as

part of CMSs certification review, conditioned on the issuer satisfying the ECP write-in criteria

provided below. Under our intended proposal, allowable write-ins will count toward the

satisfaction of the 30 percent ECP standard and will count toward the denominator of available

ECPs for the issuer writing in the additional ECPs. CMS intends to credit the issuer with only

one ECP write-in per street address. Examples of allowable write-ins include any providers that

are currently eligible to participate in 340B programs but that are not included on the CMS-

developed list, or not-for-profit or state-owned providers that would be entities described in

section 340B but do not receive federal funding under the relevant section of law referred to in

section 340B. Such providers include not-for-profit or governmental family planning service

sites that do not receive a grant under Title X of the PHS Act.

6More information on the supplemental response can be found on the CCIIO website at:

http://www.cms.gov/cciio/programs-and-initiatives/health-insurance-marketplaces/qhp.html.
http://cciio.cms.gov/programs/exchanges/qhp.htmlhttp://www.cms.gov/cciio/programs-and-initiatives/health-insurance-marketplaces/qhp.htmlhttp://www.cms.gov/cciio/programs-and-initiatives/health-insurance-marketplaces/qhp.htmlhttp://www.cms.gov/cciio/programs-and-initiatives/health-insurance-marketplaces/qhp.htmlhttp://cciio.cms.gov/programs/exchanges/qhp.html


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Table 2.1: ECP Categories and Types in FFMs

Major ECP Category ECP Provider Types

Federally Qualified Health

Center (FQHC)

FQHC and FQHC Look-Alike Clinics, Outpatient health

programs/facilities operated by Indian tribes, tribal

organizations, programs operated by Urban Indian

Organizations

Ryan White Providers Ryan White HIV/AIDS Providers

Family Planning Provider Title X Family Planning Clinics and Title X Look-Alike

Family Planning Clinics

Indian Health Providers Indian tribes, Tribal and Urban Indian Organization Providers

Hospitals Disproportionate Share Hospital (DSH) and DSH-eligible

Hospitals, Childrens Hospitals, Rural Referral Centers, Sole

Community Hospitals, Free-standing Cancer Centers, Critical

Access Hospitals

Other ECP Providers STD Clinics, TB Clinics, Hemophilia Treatment Centers,

Black Lung Clinics, and other entities that serve

predominantly low-income, medically underserved

individuals.

To write in a provider not on the CMS-developed ECP list, an issuer would do the following for

each write-in to be considered an ECP:

Provide National Provider Identifier (NPI) number, if provider has an NPI number; Indicate whether the provider is a nonprofit provider entity; List the providers zip code reflecting provider location within a Medically Underserved

Area (MUA) and/or Health Professional Shortage Area (HPSA), or otherwise low-income, medically underserved area;

Provide the providers address (PO Box not sufficient, and only one ECP will be countedper address); and

Attest that the provider is a nonprofit entity operating in an MUA/HPSA or provide awritten justification describing how the provider otherwise meets the regulatorydefinition of an ECP. CMS will provide a format for submission of this write-injustification with the QHP Application.


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Examples:

Issuer C proposes a service area in which 80 ECPs are included on the CMS-developedECP list. Issuer Cs network includes 30 ECPs 23 of which the issuer selects from the

CMS-developed ECP list, and 7 of which the issuer writes in. Issuer C satisfactorily

submits all the required ECP write-in criteria for each ECP write-in. Issuer Cs

satisfaction of the 30 percent ECP standard would be calculated by dividing 30 by 87, as

the 7 approved ECP write-ins are counted toward the denominator of available ECPs in

the issuers service area (totaling 87). Issuer C would satisfies the 30 percent ECP

standard under the intended proposal.

Issuer D also proposes a service area in which 80 ECPs are included on the CMS-developed ECP list. Issuer Ds network includes 25 ECPs 5 of which the issuer selectsfrom the CMS-developed ECP list, and 20 of which the issuer writes in. Issuer D

satisfactorily submits all the required ECP write-in criteria for each ECP write-in. Under

the intended proposal, issuer Ds satisfaction of the 30 percent ECP standard is calculated

by dividing 25 by 100 (as the 20 approved ECP write-ins are counted toward the

denominator of available ECPs in the issuers service area , totaling 100). Since issuer

Ds network demonstrates only 25 percent participation of available ECPs in the issuers

service area, Issuer D would not satisfy the 30 percent ECP standard.

Note that CMS may conduct targeted audits of issuers that satisfy the ECP standard by virtue ofwriting in a significant number of their ECPs.

Issuers that qualify for the alternate ECP standard articulated in 45 C.F.R. 156.235(a)(2) and (b)7

must have a sufficient number and geographic distribution of employed providers and hospital

facilities, or providers of its contracted medical group and hospital facilities to ensure reasonable

and timely access for low-income, medically underserved individuals in the QHPs service area,

in accordance with the Marketplaces network adequacy standards. CMS interprets this standard

as being met if the issuer complies with the standard described above, based on employed or

contracted providers located in or contiguous to Health Professional Shortage Areas (HPSA)8

and 5-digit zip codes in which 30 percent or more of the population falls below 200 percent of

7To qualify for the alternate standard, an issuer must provide a majority of covered professional services through

physicians employed by the issuer or through a single contracted medical group.

8More information on Health Professional Shortage Areas is available at:http://bhpr.hrsa.gov/shortage/.
http://bhpr.hrsa.gov/shortage/http://bhpr.hrsa.gov/shortage/http://bhpr.hrsa.gov/shortage/http://bhpr.hrsa.gov/shortage/


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the federal poverty level (FPL). For example, if an issuers service area includes 50 available

ECPs, the issuer would need 15 providers (30 percent of 50) in the service area that are also in orcontiguous to a HPSA or low-income zip code to meet the threshold.

As with the general ECP standard, an application that does not demonstrate compliance with the

alternate ECP standard must include a narrative justification describing how the issuers provider

network(s) complies with the regulatory standard. In this context, an issuers explanation should

address how the issuer intends to ensure coverage in HPSAs or low-income zip codes in the

service area(s). The explanation should describe the extent to which the issuers provider sites

are accessible to, and have services that meet the needs of, specific underserved populations,

including:

Individuals with HIV/AIDS (including those with co-morbid behavioral healthconditions);

American Indians/Alaska Natives (AI/AN); and Low-income and underserved individuals seeking womens health and reproductive

health services.

Other specific populations served by ECPs in the service area.To the extent that issuers subject to the alternate ECP standard cannot meet the ECP standard,

CMS would plan to take into account factors and circumstances identified in the ECP

Supplemental Response Form,

9

along with an explanation of how the issuer will provide accessto low-income and underserved populations. Such issuers would also provide the following in

their narrative justification:

Number of contracts offered to contracted medical groups and hospital facilities thatserve low-income, medically underserved individuals in the QHPs service area for the

2015 benefit year;

Number of additional contracts the issuer expects to extend to medical groups andhospital facilities that serve low-income, medically underserved individuals in the QHPs

service area for the 2015 benefit year and the timeframe of those planned negotiations;

and

9More information on the supplemental response can be found on the CCIIO website at:

http://cciio.cms.gov/programs/Files/ecp_supplemental_response_Form_03_08_13.pdf.
http://cciio.cms.gov/programs/Files/ecp_supplemental_response_Form_03_08_13.pdfhttp://cciio.cms.gov/programs/Files/ecp_supplemental_response_Form_03_08_13.pdfhttp://cciio.cms.gov/programs/Files/ecp_supplemental_response_Form_03_08_13.pdf


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Names of providers to whom the issuer has offered contracts, but the providers have notyet accepted.

CMS is providing issuers with a database of zip codes listed as HPSAs or where more than 30

percent of the population falls below 200 percent of the FPL. The database is available at

http://www.cms.gov/cciio/programs-and-initiatives/health-insurance-marketplaces/qhp.html.

Issuers that qualify for the alternate standard would use the same data template as other issuers to

complete this section of the application.

CMS will continue to assess QHP provider networks, including ECPs, and may revise its

approach to reviewing for compliance with network adequacy and ECPs in later years.

ii. Requirements for Payment of Federally Qualified Health CentersWe reiterate the importance of issuers complying with 45 C.F.R. 156.235(e) regarding payment

of FQHCs. For covered services provided by an FQHC, QHP issuers must pay an amount that is

not less than the amount of payment that would have been paid to the center under section

1902(bb) of the SSA for such item or service, as specified in section 1302(g) of the Affordable

Care Act. Section 156.235(e) does allow the QHP issuer and FQHC to mutually agree upon

payment rates other than those that would have been paid to the center under section 1902(bb) of

the SSA, as long as such mutually agreed upon rates are at least equal to the generally applicable

payment rates of the issuer. We note that state law may define covered services for HMO plans

to be limited to those services provided by in-network providers. In such cases, this requirement

would not apply to non-emergent out-of-network services if provided by FQHCs. Otherwise, we

would expect issuers to pay FQHCs for covered services in accordance with section 1902(bb) of

the SSA. We encourage issuers and FQHCs, as well as other ECPs, to develop mutually

beneficial business relationships that promote effective care for medically underserved and

vulnerable populations. We intend to assess available data to understand the degree to which

such patients are cared for effectively and to inform our future regulatory approach.

Section 5. Accreditation



Requirements at 45 C.F.R. 155.1045(b) establish the timeline by which QHP issuers offering

coverage in an FFM must be accredited. CMS is continuing its phased approach to accreditation

for QHP issuers in FFMs. Prior to a QHP issuers second year of QHP certification, the QHP


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issuer must be accredited by a recognized accrediting entity on the policies and procedures that

are applicable to its Marketplace products, or a QHP issuer must have commercial or Medicaidhealth plan accreditation granted by a recognized accrediting entity for the same state in which

the issuer is offering Marketplace coverage and the administrative policies and procedures

underlying that accreditation must be the same or similar to the administrative policies and

procedures used in connection with the QHP. SADP issuers will not be reviewed for

accreditation status.

To meet the 2015 certification year requirement for QHP issuers entering their second year of

Marketplace participation, QHP issuers will be required to attest that the administrative policies

and procedures applicable to their Marketplace products have been reviewed and approved by a

recognized accrediting entity in compliance with 155.1045(b)(2). The timeline in 155.1045(b)will be applied by looking at the issuers accreditation status 90 days prior to open enrollment.

Issuers entering their initial year of QHP certification for the 2015 benefit year that do not have

an existing commercial, Medicaid, or Marketplace health plan accreditation granted by a

recognized accrediting entity for the same state in which the issuer is applying to offer coverage

must schedule or plan to schedule with a recognized accrediting entity a review of its QHP

policies and procedures. New QHP issuers may submit accreditation information for display if

they have existing accreditation. The requirements for first-year accreditation are described in

more detail in the 2014 Letter to Issuers.10

In addition to the attestation noted above, issuers will be asked to provide some information

about their accreditation status to determine if the standard in 155.1045(b) is met. This

information will be verified with the indicated accrediting entity. For certification in 2014 for the

2015 benefit year, the National Committee for Quality Assurance (NCQA), URAC, and the

Accreditation Association for Ambulatory Health Care (AAAHC) have been recognized by CMS

as accrediting entities for the purpose of QHP certification. The issuer will be asked for

information related to accreditation of their commercial, Medicaid, or Marketplace products.

Issuers will be considered accredited if the QHP issuer is accredited with the following status: by

AAAHC with Accredited, status; by NCQA with Excellent, Commendable, Accredited,

10Letter to Issuers on Federally-facilitated and State Partnership Exchanges, April 5, 2013,

http://www.cms.gov/CCIIO/Resources/Regulations-and-

Guidance/Downloads/2014_letter_to_issuers_04052013.pdf.
http://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/2014_letter_to_issuers_04052013.pdfhttp://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/2014_letter_to_issuers_04052013.pdfhttp://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/2014_letter_to_issuers_04052013.pdfhttp://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/2014_letter_to_issuers_04052013.pdfhttp://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/2014_letter_to_issuers_04052013.pdf


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and /or Interim status; or by URAC with Full, Provisional, and/ or Conditional, status.

An issuer will not be considered accredited if the accreditation review is scheduled or in process.

For the 2015 benefit year, the Marketplace website will display the accreditation status of a QHP

issuers HMO, PPO, POS, or EPO product if the issuer is accredited in the commercial,

Medicaid, or Marketplace markets by one of the currently recognized accrediting entities.

Accreditation will be displayed as one of the following, as applicable: Accredited by AAAHC,

Accredited by NCQA, Accredited by URAC, Accredited by AAAHC and NCQA,

Accredited by AAAHC and URAC, Accredited by NCQA and URAC, Accredited by

AAAHC, NCQA, and URAC. If the issuer does not have accreditation from a currently

recognized accrediting entity, neutral language such as Not yet accredited will be displayed.

Section 6. Patient Safety Standards for QHP Issuers

This section describes how CMS will review issuer compliance with the patient safety standards

for purposes of QHP certification and recertification if the proposed 2015 Payment Notice is

finalized as proposed. States performing plan management functions in an FFM may use a

similar approach.

Beginning on January 1, QHP issuers are required to comply with patient safety standards and

may only contract with hospitals and health care providers that meet specified quality

improvement criteria. Proposed regulatory requirements at 156.1110 in the 2015 Payment

Notice outline how QHP issuers can demonstrate compliance with these standards, on a

transitional basis, for 2 years beginning January 1, 2015 or until further regulations are issued,

whichever is later. Specifically, the proposal requires QHP issuers that contract with a hospital

with greater than 50 beds to verify that the hospital, as defined in section 1861(e) of the SSA, is

Medicare-certified or has been issued a Medicaid-only CMS Certification Number (CCN) and is

subject to the Medicare Hospital Condition of Participation requirements for:

(1) A quality assessment and performance improvement program as specified in 42

C.F.R. 482.21; and

(2) Discharge planning as specified in 42 C.F.R. 482.43.

In addition, QHP issuers would be required to collect and maintain documentation of the CCNs

from their applicable network hospitals.

As part of the certification for the 2015 benefit year, we anticipate requiring QHP issuers to

demonstrate compliance with these patient safety standards as part of the QHP application with


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an attestation that they have collected and are maintaining the required documentation from their

network hospitals.

CMS has yet to finalize this proposed rule, and subsequently, the underlying regulation and this

accompanying requirement for the QHP application may change.

Section 7. QHP and SADP Agreements

Issuers offering QHPs or SADPs in an FFM, including FFMs in states performing plan

management functions, will be required to sign an agreement with CMS at the end of the

certification or recertification process, as applicable. We anticipate that the QHP Issuer

Agreement for the 2015 benefit year will be similar to the agreement signed by issuers for the

2014 benefit year. The agreement will cover all of the QHPs offered by a single issuer at the

HIOS Issuer ID level, and must be signed by an officer of the legal entity who has legal authority

to contractually bind the QHP or SADP legal entity. Of note, issuers should ensure that the legal

entity information listed in HIOS is identical to the legal entity information that will be used

when executing the agreement.

CHAPTER 3. QUALIFIED HEALTH PLAN AND STAND-ALONE DENTAL PLAN

DESIGN

Section 1. Discriminatory Benefit Design: 2015 Approach

This section addresses how CMS will review health plans applying to be QHPs in an FFM for

compliance with nondiscrimination standards. States performing plan management functions in

an FFM may use a similar approach.

i. EHB Discriminatory Benefit DesignNon-discrimination in benefit design with respect to EHB is a market-wide consumer protection

that applies inside and outside of Marketplaces. Accordingly, the enforcement of this standard is

largely conducted by states. CMS encourages states that are enforcing the Affordable Care Act to

consider a number of strategies for assessing compliance with this standard including, but not

limited to: analysis of information entered in the explanations and exclusions sections of the

QHP Plans and Benefits Template. CMS also intends to propose in future rulemaking a review of

prescription drugs based on clinical appropriateness that states may choose to implement.


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For purposes of QHP certification, CMS will assess compliance with this standard by collecting

an attestation that issuers QHPs will not discriminate against individuals on the basis of healthstatus, race, color, national origin disability, age, sex, gender identity or sexual orientation,

consistent with 45 C.F.R. 156.200(e). CMS will continue to assess compliance through issuer

monitoring and compliance reviews, including analysis of appeals and complaints, as set forth in

Chapter 4 and Chapter 6.

ii. QHP Discriminatory Benefit DesignIn addition to complying with EHB non-discrimination standards, QHPs must not employ market

practices or benefit designs that will have the effect of discouraging the enrollment of individuals

with significant health needs (see45 C.F.R. 156.225). To ensure non-discrimination in QHPbenefit 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.

CMSs outlier analysis will compare benefit packages with comparable cost-sharing structures to

identify cost-sharing outliers with respect to specific benefits, including but not limited to those

benefits listed below.

Inpatient hospital stays, Inpatient mental/behavioral health stays, Specialist visits, Emergency room visits, and Prescription drugs.

CMS also intends to review plans that are outliers based on an unusually large number of drugs

subject to prior authorization and/or step therapy requirements in a particular category and class.

We encourage states performing plan management functions in an FFM to implement this type

of review.

Also in reviewing a plans cost-sharing structure, CMS will analyze information contained in the

Plans and Benefits Template, including, but not limited to, the explanations and exclusions

sections, with the objective of identifying clearly discriminatory anomalies or wording.

Discriminatory cost-sharing language would typically involve reduction in the generosity of a

benefit in some manner for subsets of individuals other than based on clinically indicated


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common medical management practices. As in the case of cost-sharing outliers, where CMS

identifies a potentially discriminatory practice, CMS may offer issuers the opportunity to revisethe language in the explanations and exclusions portions of the Plans and Benefits Template

(or other section(s) as applicable) to address the potentially discriminatory practices.

Section 2. Prescription Drugs

Regulations at 45 C.F.R. 156.122 establish that a health plan that provides EHB must cover at

least the greater of (1) one drug in every United States Pharmacopeial Convention (USP)

category and class or (2) the same number of prescription drugs in each USP category and class

as the states EHB -benchmark plan. All plans seeking QHP certification must cover EHB and

comply with 156.122. CMS uses data collected in the Prescription Drug Template to reviewcompliance with this standard.

Based on the 2014 certification process and in response to stakeholder comments, CMS is

proposing in the Paperwork Reduction Act submission entitled Initial Plan Data Collection to

Support Qualified Health Plan (QHP) Certification and Other Financial Management and

Exchange Operations11(2015 QHP Information Collection) revisions to the prescription drug

benefit portion of the application process for 2015. Specifically, CMS is proposing the ability for

issuers to indicate whether a drug (identified through its RxNorm Concept Unique Identifier or

RxCUI12) is considered a medical drug covered under a plans medical benefit. CMS believes

that this revision will provide greater clarity with respect to how drugs are covered and paidwhile ensuring that medical benefit drugs are taken into account when evaluating potential QHPs

for compliance with 45 C.F.R. 156.122. We note that issuers will continue to be required to

submit their entire drug lists, including drugs covered either under the prescription drug or the

medical benefit, to the HIOS Count Service in order to test for compliance with the benchmark

drug counts. Under the similar proposal, issuers will have the option of identifying a drug as a

preventive drug covered at zero cost.

Detailed instructions related to these changes will be provided concurrently with the release of

the 2015 Prescription Drug Template.

11Agency Information Collection Activities: Proposed Collection; Comment Request, CMS-10433, 78 Federal

Register 65656 (Nov. 1, 2013).

12The RxNorm Concept Unique Identifier, or RxCUI, is a unique identifier associated with a drug concept and itsnormalized drug name. For a detailed definition of RxCUI, please refer to the National Library of Medicineswebsite at:http://www.nlm.nih.gov/research/umls/rxnorm/overview.html.
http://www.nlm.nih.gov/research/umls/rxnorm/overview.htmlhttp://www.nlm.nih.gov/research/umls/rxnorm/overview.htmlhttp://www.nlm.nih.gov/research/umls/rxnorm/overview.html


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As part of the QHP Application, issuers must provide a URL to their formularies and must also

provide information regarding formularies to consumers, pursuant to 45 C.F.R.147.200(a)(2)(i)(K). CMS expects the URL link to direct consumers to an up-to-date formulary

where they can view the covered drugs, including tiering and cost sharing, that are specific to a

given QHP. The URL provided to the Marketplace as part of the QHP Application should link

directly to the formulary, such that consumers do not have to log on, enter a policy number or

otherwise navigate the issuers website before locating it. If an issuer has multiple formularies, it

should be clear to consumers which directory applies to which QHP(s).

CMS also intends to propose through rulemaking that Marketplaces may require that issuers

temporarily cover non-formulary drugs, including drugs that are on the issuer's formulary but

require prior authorization

draft issuer letter

Documents