Review Tools

CMS provides issuers a number of review tools to check their plans for errors within the QHP Application that would result in corrections following submission. Issuers are encouraged to use these tools to identify and correct data errors before uploading materials to HIOS or SERFF. At a minimum, issuers should refer to the Data Integrity Tool (DIT) and its supporting documents, but all QHP Application Review Tools can help prevent issues with application data.

The available review tools for plan year 2021 are below.

Review Tool Instructional Videos

CMS also provides a series of instructional videos on the QHP Application Review Tools, which are intended to help issuers and states use the review tools to check QHP Application data. Videos on the following topics have been updated for plan year 2021, and are available at the links below.

QHP Application Review Tools Overview

The QHP Application Review Tools Overview below provides a high-level description of each tool’s functionality.

Data Integrity Tool

This tool identifies critical data errors within and across templates. Provides immediate feedback about data, reducing issuer resubmissions. Alerts issuers and state reviewers to irregularities in the template submissions. Imports QHP and SADP data from most application templates. Conducts validation checks beyond the standard HIOS and SERFF checks. Looks across templates for consistency in key fields. Produces error reports that describe the error and its location in the template.

CMS recommends this tool be used first, to ensure the accuracy of data prior to importing this data into the other tools.

Key Updates for PY21:

  • Accommodates new 2021 data
  • Incorporates 2021 MOOP limits set by the final 2021 Payment Notice
  • Ensures family Deductible and MOOP values adhere to the correct format
  • Ensures Rating Areas found in the Rates Table Template are associated to counties in the Service Areas listed in the Plans & Benefits Template
  • Ensures that there are no duplicate ZIP codes in the Service Area Template
  • Ensures consistency between the Plan Variant Marketing Name and other fields in the Plans & Benefits Template
  • Ensures consistency between the Medical/Dental plan indicator in the Plans & Benefits Template and the Business Rule Template

Master Review Tool   

Aggregates data from the Plans & Benefits, Service Area, Essential Community Provider (ECP)/Network Adequacy (NA), and Prescription Drug Templates and serves as a data input file to the other stand-alone tools.

Many tools require the import of a populated Master Review Tool in order to run, so CMS recommends this tool be used second, after the Data Integrity Tool has been run.

Key Updates for PY21:

  • Accommodates new 2021 data

Review Process Guide

Provides model step-by-step processes that state regulators could follow to review QHP Applications for compliance with specific PPACA standards. This includes descriptions of the backend functionality in the other automated review tools.

This tool is optional, but is a good reference for users to see the steps taking place in each of the standalone tools. This tool is also helpful in completing reviews that cannot be automated.

Key Updates for PY21:

  • Updated to incorporate any changes to PY2021 reviews

Plan ID Crosswalk Tool

Checks that the Plan ID Crosswalk Template has been completed accurately, by ensuring that all counties in all FFE plans that were offered in 2020 are included in the crosswalk, the plans are crosswalked to valid 2021 plans, the crosswalk reasons selected are consistent with plan offerings, and that the crosswalk is compliant with the regulation in 45 CFR 155.335(j).

Key Updates for PY21:

  • Accommodates new 2021 templates

Essential Community Providers (ECP) Tool

Calculates the total number of ECPs an issuer has in each plan's network and compares this to the number of available ECPs in that service area. This tool will check whether the percentage of the plan's networked ECPs is equal to or greater than the ECP threshold (as defined by federal or state regulators) to demonstrate satisfaction of the ECP inclusion standard set forth in 45 CFR 156.235.

Key Updates for PY21:

  • Accommodates new 2021 templates
  • Updated with 2021 ECP list

SADP Essential Community Providers (ECP) Tool

Calculates the total number of ECPs an issuer has in each plan's network and compares this to the number of available ECPs in that service area. This tool will check whether the percentage of the plan's networked ECPs is equal to or greater than the ECP threshold (as defined by federal or state regulators) to demonstrate satisfaction of the ECP inclusion standard set forth in 45 CFR 156.235.

Key Updates for PY21:

  • Accommodates new 2021 templates
  • Updated with 2021 ECP list

Non-Discrimination Cost Sharing Review Tool

Performs an outlier analysis for "QHP Discriminatory Benefit Design" per 45 CFR 156.225 which prohibits QHPs from employing market practices or benefit designs that have the effect of discouraging the enrollment of individuals with significant health needs. It looks at all plans within the state, goes through a group of pre-determined benefits, and determines if any plan has a significantly higher copay or coinsurance for those benefits, which could potentially mean that the coverage is discriminatory.

Key Updates for PY21:

  • Accommodates new 2021 templates
  • Tool title was changed from “Non-Discrimination Benefit Review Tool” to “Non-Discrimination Cost Sharing Review Tool”

Cost Sharing Tool

Runs 4 different checks (when they are applicable to the plan) for cost sharing standards. This includes: Maximum Out of Pocket (MOOP) Review, Cost Sharing Reduction (CSR) Plan Variation Review, Catastrophic Plan Review, and Expanded Bronze Plan Review.

Key Updates for PY21:

  • Accommodates new 2021 templates
  • Incorporates 2021 MOOP limits set by the final 2021 Payment Notice

Category & Class Drug Count Tool

Compares the count of unique chemically distinct drugs in each USPv7.0 category and class for each drug list with the benchmark.

Key Updates for PY21:

  • Accommodates new 2021 templates
  • EHB-Rx Crosswalk has been updated using USPv7.0 Model Guidelines
  • EHB-Rx Crosswalk has been updated using the December 2, 2019 monthly release of RxNorm
  • RxNorm Drug Name Extract has been updated using the December 2, 2019 monthly release of RxNorm

Formulary Review Suite

Aggregate tool that performs both the Non-Discrimination Formulary Outlier Review and the Non-Discrimination Clinical Appropriateness Review.

Non-Discrimination Formulary Outlier Review

Identifies and flags as outliers those plans that have unusually large numbers of drugs subject to prior authorization and/or step therapy requirements in 28 USP classes.

Key Updates for PY21:

  • Accommodates new 2021 templates
  • Drug lists and categories and classes have been updated using USPv7.0 Model Guidelines

Non-Discrimination Clinical Appropriateness Review

Analyzes the availability of covered drugs associated with ten conditions as recommended in clinical guidelines, to ensure that issuers are offering a sufficient type and number of drugs.

Key Updates for PY21:

  • Accommodates new 2021 templates