Compliance
The QHP certification process leads into the start of Marketplace Open Enrollment on November 1, 2024. CMS continuously monitors issuers for potential compliance issues during the plan year.
Issuer Compliance Monitoring
CMS monitors QHP issuers participating in the Federally-facilitated Exchanges (FFEs) for ongoing compliance with certification requirements throughout the plan year. CMS evaluates issuer performance to determine whether making the issuer’s health plan(s) available is in the interest of qualified individuals and employers enrolling in coverage through the FFEs.
Compliance monitoring is based on several state and national data sources, including:
- Complaints data
- Issuer self-reporting of problems
- Issuer policies, procedures, and operations
- Network adequacy analysis
- Indicators of customer service and satisfaction
Issuer Compliance Reviews
CMS performs compliance reviews throughout the year to monitor issuer compliance with applicable Exchange-specific requirements and operational standards. Issuers may be notified of their plans' selection for these compliance reviews at any time during the year.
When appropriate, CMS will coordinate with state regulatory entities to conduct compliance reviews. When all compliance reviews for the year have been completed, CMS will share summary results with states and lessons learned with issuers. CMS will also make this information available to the public.
Compliance with Appointment Wait Time Standards
Starting in PY2025, CMS will assess medical QHP issuers participating in the FFEs for compliance with appointment wait time standards, as established in the HHS Notice of Benefit and Payment Parameters for 2023 Final Rule and detailed in the Final 2025 Letter to Issuers in the Federally-facilitated Exchanges. To demonstrate compliance with these standards, medical QHP issuers will be required to contract with a third-party entity to administer secret shopper surveys to an issuer’s primary care (routine) and behavioral health providers. These issuers will be required to report the results of the secret shopper surveys to CMS as part of QHP issuer compliance and monitoring activities. See the Appointment Wait Time Secret Shopper Technical Guidance for QHP Issuers in the FFEs for guidance on how issuers and third-party entities should conduct secret shopper surveys.