QHP Application Review Results

Throughout the QHP Application validation and submission process, CMS releases review results to issuers to communicate validation errors and warnings as well as required corrections that issuers need to make to their applications.

CMS’s review results are categorized as pre-submission review results, or validation results, and post-submission review results, or required corrections. 

Pre-Submission Review Results:

Issuers receive pre-submission review results by validating application data in the Plan Validation Workspace, interacting with SERFF Validate & Transform, or by cross validating application data in either the Plan Validation Workspace or the MPMS Module. There are two types of pre-submission review results:
  • Validation Errors: These identify data integrity and other data errors present in issuers’ applications. Issuers are required to correct all validation errors prior to submitting an application. 
  • Validation Warnings: These identify potential issues present in issuers’ applications, including those related to data integrity or the submission of supporting documents and justifications. 
Post-Submission Review Results:

Issuers receive post-submission review results after CMS receives one or more components of an issuer’s QHP Application and reviews that data for compliance with one or more federal standards. Once CMS completes these reviews, these results are shared in either the MPMS Module or the PM Community; these review results reflect required corrections to issuers’ applications. 
  • For required corrections released before the final QHP Application submission deadline: Issuers should make needed corrections to their applications and submit their updated data to CMS as soon as possible, but by no later than the deadlines specified in the QHP Data Submission and Certification Timeline bulletin. For some review areas, CMS will re-review data resubmitted and release additional review results prior to the final deadline.
  • For required corrections released after the final QHP Application submission deadline: Issuers should review the corrections and follow instructions from CMS to make corrections and submit updated data, if needed. 
Note: Individual application groupings will be locked (i.e., not able to be edited) while CMS conducts reviews on the submitted data. After CMS’s review of all sections within a given group is complete, the application grouping will display a status of Corrections Required or No Action Required, depending on whether required corrections were identified as part of CMS’s reviews. Issuers will receive review results as CMS completes reviews for each application section, but issuers will not be able to make edits to any sections within a group until CMS completes reviews for all sections within that group.

Please be advised that CMS’s review is limited to compliance with QHP/SADP certification standards and does not constitute or imply a determination of the QHP Application’s compliance with requirements under state law. Issuers should consult with the applicable state(s) (and CMS in states that do not enforce market-wide requirements) regarding the requirements and processes for any rate or product reviews.

Ensure You Receive Communications from CMS Regarding Your QHP Application

To ensure receipt of communications regarding QHP certification, issuers should manage their contacts within the Organizations tab of the PM Community. For more information on maintaining contacts for your organization, visit the Register for Updates webpage. Please note: Notifications regarding review results’ availability in the MPMS Module will be sent to all points of contact with a PM Issuer Submitter role for a given issuer ID.

Review Results by Exchange Type & System

This table indicates which review areas issuers in each state Exchange type can expect to receive review results for, and the system in which they will receive these results. Issuers and states will also receive email notifications when one or more reviews have been completed and results have been made available. Issuers and states can also refer to the Review Role by State Exchange Model (Updated 9/5/2023) for more information on each review, including guidance on whether CMS or the state is primarily responsible for reviewing applicable QHP Application data to ensure its compliance with certification standards.

Review Area

Affected Exchange Models



Validation Results in MPMS Module

Required Corrections in MPMS Module

Required Corrections in PM Community

Accreditation

FFE

Y

Y


Administrative

FFE, state performing plan management functions, SBE-FP

Y



Adverse Tiering

FFE



Y

Cost Sharing Reduction (CSR) - Plan Variation

FFE, state performing plan management functions

Y



Data Integrity

FFE, state performing plan management functions, SBE-FP

 Y*



 Y*

Dental Maximum Out of Pocket (MOOP)

FFE

Y



Essential Community Providers

FFE



Y

Interoperability

FFE, state performing plan management functions

Y

Y


Machine-Readable Index URLs

FFE, state performing plan management functions, SBE-FP

Y

Y

Y

Network Adequacy

FFE, state performing plan management functions

Y


Y

Network Breadth

Issuers in states participating in the Network Breadth Pilot (TN, TX)



Y

Non-Discrimination (Clinical Appropriateness)

FFE, state performing plan management functions

Y

Y

Y**

Non-Discrimination (Cost-Sharing)

FFE



Y

Non-Discrimination (Formulary Outlier)

FFE, state performing plan management functions



Y

Non-Discrimination (Treatment Protocol Calculator)

FFE



Y

Plan ID Crosswalk

FFE, state performing plan management functions, SBE-FP



Y

Plan Marketing Name

FFE, state performing plan management functions, SBE-FP



Y 

Program Attestations

FFE

Y



Quality Improvement Strategy (QIS)

FFE, state performing plan management functions



Y

Quality Rating Strategy (QRS)

FFE, state performing plan management functions



Y

SADP EHB Benchmark

FFE

Y

Y

Y

Service Area (Including Partial County)

FFE

Y

Y


Silver/Gold

FFE

Y



Standardized Plan Options

FFE, state performing plan management functions, SBE-FP

Y*


Y*

Transparency in Coverage

FFE, state performing plan management functions, SBE-FP

Y

Y


URL

FFE, state performing plan management functions, SBE-FP

Y


Y


*Some Data Integrity and Standardized Plan Options review results are shared via the PM Community on a rolling basis, in addition to the validations that issuers may receive via the MPMS Module or in SERFF Validate & Transform.
**Required corrections for Non-Discrimination (Clinical Appropriateness) are shared in the PM Community only for issuers in states performing plan management functions.