Key Changes for PY2023

The changes outlined below are not exhaustive and do not include changes to QHP Application templates or specific data entry requirements. Issuers should refer to the Published Guidance and Regulations webpage and review the most updated version of the QHP Issuer Application Instructions on the QHP certification website. 

Network Adequacy Review and Justification

CMS will conduct Network Adequacy reviews for all FFE issuers, including issuers in states performing plan management functions that do not elect to perform their own reviews. All FFE issuers and issuers in states performing plan management functions are required to complete and submit the IndividualProviders (NA) and FacilityProviders (NA) tabs within the ECP/Network Adequacy Template. Per the HHS Notice of Payment and Benefit Parameters for 2023, CMS will review issuers’ network adequacy data, and release review results in the PM Community for issuers in FFE states and states performing plan management functions that do not elect to perform their own reviews. Issuers with any required Network Adequacy corrections will receive a partially pre-populated Network Adequacy Justification Form via the PM Community that they will be required to complete and upload via the PM Community. Refer to the ECP and Network Adequacy webpage for more information.

ECP Justification Form

For issuers needing to submit an ECP Justification Form, CMS will only accept the official ECP Justification Form as an Excel document. CMS will no longer accept individually customized supplemental response forms as a substitute for the official form. Issuers with any required ECP corrections will receive a partially pre-populated ECP Justification Form via the PM Community that they will be required to complete and upload via the PM Community. Refer to the ECP and Network Adequacy webpage for more information.

Standardized Plan Option Review

The requirement to offer standardized plans is being reinstated. Per the HHS Notice of Payment and Benefit Parameters for 2023, issuers offering QHPs in FFEs, states performing plan management functions, and SBE-FPs will be required to offer standardized options at every product type, metal level, and throughout every service area that they offer non-standardized options in PY2023. Applicable issuers will be required to complete and submit the corresponding standardized option fields within the Plans & Benefits Template. CMS will review issuers’ standardized plans and release review results in the PM Community. Refer to the Plans and Benefits webpage for more information.

Formulary Directory Submission

Issuers should submit their Formulary Directories in the HIOS SSM (in addition to their Formulary URLs) for all URL IDs. CMS reviews formularies to ensure that they contain accurate issuer marketing information for consumers and that there are no inaccuracies when compared to data within an issuer’s submitted QHP Application. CMS will review issuers’ Formulary Directories and release review results in the PM Community. Refer to the URLs webpage for more information.

SBC Form Submission

Issuers should submit their SBC Forms in the HIOS SSM (in addition to their SBC URLs) for all plans they intend to offer on the Exchange. CMS will review SBCs to ensure that they contain accurate information for consumers and that there are no inaccuracies when compared to data within an issuer’s submitted QHP Application, and release review results in the PM Community. Refer to the URLs webpage for more information.

Machine-Readable Data Submission and Review Results

Issuers will submit their machine-readable index URLs in the SSM, along with other plan documentation URLs. Issuers will no longer be able to submit their machine-readable index URLs in the MR Index URL Submission Portal. Refer to the URLs webpage or the Machine-Readable Data webpage for more information.

Transparency in Coverage URL Submission

Issuers are no longer required to submit a Transparency in Coverage Template before submitting a Transparency in Coverage URL. Once the SSM is open, issuers can submit Transparency in Coverage URLs with or without the template. Refer to the URLs webpage or the Transparency in Coverage webpage for more information.

Interoperability Attestation and Justification Form

The Interoperability Attestation and Justification Form will be embedded in the HIOS SSM as a web-based form that issuers complete directly in HIOS. In the form, issuers applying to offer QHPs in FFE states or states performing plan management functions will attest to meeting requirements and include the URLs for API documentation and enrollee resources. Issuers will no longer be able to upload a form as a supporting document in the Program Attestations Section of the Issuer Module or SERFF. Refer to the Interoperability webpage for more information.

URR Template Submission

Issuers are now able to submit the URR Template directly in SERFF; a rate filing that is filed through SERFF and automatically uploaded to the URR Module of HIOS will be considered filed with CMS. This new transfer method will not apply to states that do not have an effective rate review program and states that do not have access to SERFF. Those issuers will continue to submit rate filings directly into HIOS. States that can access SERFF, and states with an effective rate review program, are required to file the PY 23 Rate Filing Justification in the new URRT Tab of SERFF; this includes issuers in states that do not perform plan management functions and otherwise submit QHP Application data in HIOS. Refer to the Unified Rate Review webpage or the Submission Systems webpage for more information.

Service Area Data Change Requests

CMS has removed the requirement to submit a service area DCR prior to the final submission deadline. Issuers may make changes to their plan’s service area after the initial submission deadline without first submitting a DCR for CMS authorization. After the final submission deadline, a DCR is required for any change to QHP data, including service area. Refer to the Data Change Windows webpage for more information.