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.
Common Review Results Guidance
The Common Review Results Guidance document (Coming soon!) compiles some of the most common review results issuers submitting QHP Applications have received in prior plan years. This document includes correction codes, correction language, and tips on resolving each identified review result that issuers may receive before or after they submit their QHP Applications. Issuers are encouraged to review this document throughout the QHP Application submission process.
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
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 |
|
|
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 |
|
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 |
|
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 |
|
Service
Area (Including Partial County) | FFE | Y | Y |
|
Silver/Gold | FFE | Y |
|
|
Standardized
Plan Options | FFE,
state performing plan management functions, SBE-FP | 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 |
|
