Accreditation FAQs

Q1: Which accrediting entities are recognized by Centers for Medicare & Medicaid Services (CMS)?
  • The three CMS-recognized accrediting entities are: the Accreditation Association for Ambulatory Health Care (AAAHC), the National Committee for Quality Assurance (NCQA), and URAC.
Q2: When are issuers offering coverage in the Federally-facilitated Exchange (FFE) required to be accredited?
  • 45 CFR 155.1045(b) establishes the timeline by which QHP issuers offering coverage in the FFE must be accredited. Issuers have two separate accreditation requirements that begin prior to entering their second and fourth year of QHP Certification, respectively.
    Issuers must begin the accreditation process as early as possible to meet the accreditation standards required for QHP Certification.
    First Year Issuers 
    Issuers applying for QHP Certification for the first time are not required to be accredited.
    If an issuer does not have an existing commercial, Medicaid, or Exchange health plan accreditation granted by a recognized Accrediting Entity (AE) in each state in which the issuer is applying for certification, the issuer must schedule a review of its QHP policies and procedures with a recognized AE as soon as possible in order to be accredited no later than 90 days prior to Open Enrollment the following year.
    Second Year Issuers & Beyond
    QHP issuers applying for their second year of certification must be accredited by a recognized AE on the policies and procedures applicable to its commercial, Medicaid, or Exchange health plans granted by a recognized AE for each state in which the issuer is offering Exchange coverage. The deadline for obtaining accreditation is no later than 90 days prior to Open Enrollment, i.e., August 4.
    The issuer is considered accredited if its commercial, Medicaid, or Exchange plans have one of the following acceptable Accreditation statuses:

    • NCQA – Accredited, Provisional, or Interim status
    • URAC – Full, Conditional, or Provisional status
    • AAAHC – Accredited status

CMS will only consider an issuer accredited if its accreditation is completed by the deadline. CMS will not consider an issuer accredited if the accreditation review is scheduled or in progress. The issuer must maintain accreditation in future years to remain eligible for QHP Certification.

Fourth Year Issuers & Beyond

Issuers entering their fourth year of QHP certification must have an Exchange health plan accreditation status from one of the following AEs no later than 90 days prior to Open Enrollment: 
    • NCQA – Exchange accreditation and Accredited, or Provisional status
    • URAC – Exchange accreditation and Full or Conditional status
    • AAAHC - Accredited status

CMS will only consider an issuer accredited if its accreditation is completed by the deadline. CMS will not consider an issuer accredited if the accreditation review is scheduled or in progress. The issuer must maintain their Exchange accreditation status for future years to be eligible for QHP Certification.

Example: Accreditation Timeline for New PY24 QHP Issuers

Participation Year

Calendar Year

Plan/Review Year

Accreditation Requirement

First Year

2023

2024

Contact AE as soon as possible to schedule a review.

Accreditation is required 90 days prior to Open Enrollment of second year of participation, i.e., August 4, 2024

Second Year (or Later)

2024 and onwards

2025 and onwards

•  Issuer must be accredited by a recognized AE to be eligible for QHP Certification.

• Accreditation is required 90 days prior to Open Enrollment for PY25 (August 4, 2024)

• Issuer is considered accredited if commercial, Medicaid, or Exchange accredited with acceptable Accreditation status:

NCQA – Accredited, Provisional, or Interim status

URAC – Full, Conditional, or Provisional status

AAAHC – Accredited status

Fourth Year (or Later)

2026

2027

•  Issuer must be Exchange accredited by a recognized AE to be eligible for QHP Certification.

•  Accreditation is required 90 days prior to fourth year of participation's Open Enrollment for PY27 (i.e., August 4, 2026)

• Acceptable Accreditation status:

NCQA – Exchange accreditation and Accredited, or Provisional status

URAC – Exchange accreditation and Full or Conditional status

AAAHC - Accredited status


Q3: What if an issuer leaves the Marketplace, but returns to apply for QHP certification in the future?
  • If a QHP certified issuer participates in the Marketplace, exits, then returns to the Marketplace it will be held to the second-year accreditation standard.
Q4: What if the issuer crosswalks enrollees to a new HIOS ID?
  • CMS reviews issuers that crosswalk enrollees to a new HIOS Issuer ID for accreditation based on their cumulative years of certification.
    For example, Issuer A has been on the Marketplace for 3 consecutive years, and is now crosswalking all of their plans to Issuer B, which is in its first year on the Marketplace. For QHP Certification purposes, Issuer B would be considered a fourth-year issuer and must meet the accreditation requirements for issuers in their fourth or later year of participation.
    Issuers must ensure that the receiving HIOS Issuer ID issuer is appropriately accredited.