Review Tools

CMS provides a number of review tools to facilitate review of issuers’ QHP Application data, and to assist in identifying errors that would require corrections. Note that issuers are required to use the Plan Validation Workspace to validate their QHP Application data; use of these tools do not replace the use of the Plan Validation Workspace. 

The available review tools for plan year 2024 are coming soon.

Review Tool Instructional Videos

CMS also provides a series of instructional videos on the QHP Application Review Tools, which are intended to help use the review tools to check QHP Application data. Videos for each review tool are 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

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

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.

Master Review Tool   

Aggregates data from the Plans & Benefits, Service Area, Essential Community Provider (ECP)/Network Adequacy, 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.

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 that take place in each of the standalone tools. This tool is also helpful in completing reviews that cannot be automated.

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 2023 are included in the crosswalk, the plans are crosswalked to valid 2024 plans, the crosswalk reasons selected are consistent with plan offerings, and the crosswalk is compliant with the regulation in 45 CFR 155.335(j).

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.

SADP Essential Community Providers (ECP) Tool

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

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. The tool can assess potentially discriminatory cost sharing design relative to the national thresholds as well. For CMS’s review, a plan will be considered deficient if it has been calculated as an outlier at both the state and national levels. Since this tool requires the aggregate data for all plans in a state, this tool is only recommended for use by states, rather than issuers.

Cost Sharing Tool

Runs five 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, Standardized Options Review, Catastrophic Plan Review, and Expanded Bronze Plan Review.

Category & Class Drug Count Tool

Compares the count of unique chemically distinct drugs in each United States Pharmacopeia (USP)v8.0 category and class for each drug list with the benchmark.

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 27 USP classes.

Non-Discrimination Clinical Appropriateness Review

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