{"text_format":"1","workbook":"xlsx","n_sheets":16,"sheets":["Instructions","Review Summary","Accreditation","Program Attestation","ECP","Category Class Drug Count","Formulary Outlier","Clinical Appropriateness","Benefit Cost Sharing","Non-Discrimination Cost Sharing","Service Area","Drop Down","MOOP Details","Tukey Outlier Overview","Non-Discrimination Guidance","Actuarial Value Guidance"],"not_rendered":{"charts":0,"images":1,"macros":1,"external_links":4,"defined_names":16,"comments":0,"pivot_tables":0},"unopened":[],"bounds":{"document_bytes":16777216,"sheet_cells":100000,"rows_first":2000,"rows_last":500,"rows_between":2000,"halvings":0,"cell_chars":16384,"cell_head_chars":4096},"cells_cut":0,"cells_raw":0,"read":"whole","date_system":"1900"}

{"sheet":"Instructions","index":0,"n_rows":18,"n_cols":3,"rows_kept":18,"cut":false,"hidden":false,"merged":[[17,2,17,3],[2,1,2,3],[11,1,13,1],[11,2,11,3],[12,2,12,3],[13,2,13,3],[14,2,14,3],[15,2,15,3],[8,1,8,3],[9,2,9,3],[10,2,10,3],[7,1,7,3],[1,1,1,3],[5,1,5,3],[3,1,3,3],[4,1,4,3],[16,2,16,3]]}
[]
[null,"Instructions for Using the Review Process Guide (2021 v1.1)"]
[null,"Use of tools by state regulators is optional. States may use any tools or parts of tools they believe will assist in their review process. These tools are methods for reviewing for compliance with specific standards. Any alternative state review methods must be consistent with federal standards, but need not be identical to the approach methods via these tools."]
[null,"Use of tools by issuers is optional. Issuers are encouraged to use these tools proactively before submitting their QHP applications and can also reference them when a state or federal regulator requests corrections after a review that relied on these tools. However, please note that issuers must respond to any deficiencies identified by a state or federal regulator even if an identified issue is different than the results obtained using these tools. "]
[null,"Use of these tools by CMS and states. CMS plans to use these tools in Federally-Facilitated Exchanges (FFEs) for those standards that are specific to certification of QHPs. This includes certification standards for Federally-facilitated Small Business Health Options Program (FF-SHOP). For more information on the FFE certification process and related standards, please see the \"2021 Letter to Issuers in the Federally-facilitated Exchanges” available on the CCIIO website under Regulations and Guidance.\n\nIssuers in states performing plan management functions may contact their state regulator to determine if one or more of these review tools will be part of their review processes. CMS will review and confirm the state's QHP certification recommendations and make final QHP certification decisions. CMS will work closely with states that are performing plan management functions to coordinate this process."]
[null,"In prior plan years, this tool was part of the Master Review Tool. To reduce the number of tabs within each tool, all of the review standards and sample review methodologies has been pulled out of the Master Review Tool and can now be found in this file, the Review Process Guide."]
[]
[null,"Tabs Within the Review Process Guide"]
[null,"There are a number of tabs in this workbook, the following explains how to use them."]
[null,"Tab","Use/Explanation"]
[null,"Review Summary","This tab keeps track of whether each plan has met each of the standards. This is not a comprehensive list of all review standards. The cells are empty, so you can enter notes, or \"Met\" or \"Not Met\" based on the results you found for each review area."]
[null,"Standard Review Tabs","These tabs (as listed on the Review Summary tab) contain proposed step by step validation steps for reviewing a specific standard. When a stand-alone tool is available to assist in the analysis, this is explained on the individual tabs. You may go through each of the tabs to determine if the standards have been met."]
[null,null,"The column headers on each tab will indicate the level of review. For example, the Accreditation review should be completed for each issuer, while the cost sharing review should be completed for each plan. After you indicate the result of the review on the standard review tabs, you can manually transfer the results into the \"Review Summary\" tab for each plan."]
[null,null,"For each standard, you can go through all of the steps and keep track of whether they have been met or not met, or make any necessary notes, and then make a final \"Met\" or \"Not Met\" designation for the review at the top of the tab. Keep in mind that not all steps may be relevant for every plan, for example some steps may apply only to silver plans, or only to plans within the Small Group Market. "]
[null,"MOOP Details","This tab contains a table explaining which MOOP fields should be compared with the threshold depending on the following plan attributes: if you're looking at the Individual or Family threshold, if there are multiple in network tiers, if the medical and drug MOOPs are integrated, and if there is an in network MOOP or if in network is \"Not Applicable\" because a combined in and out of network MOOP is being used instead."]
[null,"Tukey Outlier Overview","The Tukey Outlier Test is used to conduct the Non-Discrimination cost sharing outlier review (see \"Non-Discrimination\" tab for more information) and the Formulary Outlier review (see \"Formulary Outlier\" tab for more information). The Tukey Outlier Method is described in more detail on this tab."]
[null,"Non-Discrimination Guidance","The intent of this guidance is to clarify non-discrimination standards and provide examples of benefit design that are potentially discriminatory under the Affordable Care Act."]
[null,"Actuarial Value Guidance","The purpose of this guidance is to document the review of alternate AV calculation methods, and to outline the review of AV for both metal tier level plans and Cost Sharing Reduction (CSR) silver plan variations."]

{"sheet":"Review Summary","index":1,"n_rows":23,"n_cols":3,"rows_kept":23,"cut":false,"hidden":false,"merged":[[0,0,0,1],[22,0,22,1]]}
["Review Summary"]
[null,null,"Validation Results"]
[null,"HIOS Issuer ID:"]
[null,"Type of Plan:"]
[null,"Plan ID:"]
[null,"Plan Benefit Workbook Name, Benefits Package:"]
[null,"Formulary ID:"]
[null,"Network ID:"]
[null,"Service area ID:"]
["Section/Standard","Function of Review"]
["Accreditation","Ensure the issuer is accredited by NCQA or URAC, or is assumed to be working towards accreditation."]
["Program Attestation","Confirm submission of program attestations."]
["ECP","Ensure issuers have ECPs, where available, that meet the policy standards."]
["Category Class Drug Count","Ensure compliance with EHBs and check for discrimination by counting drugs in each USP category and class."]
["Non-Discrimination Formulary Outlier","Identifies plans with an unusually large number of drugs that require step therapy or prior authorization in 28 USP classes."]
["Non-Discrimination Clinical Appropriateness","Analyzes the availability of covered drugs associated with nine conditions as recommended in clinical guidelines, to ensure that issuers are offering a sufficient type and number of drugs."]
["Benefit Cost Sharing - MOOP","Check in-network out-of-pocket maximum costs for individual and family EHB coverage against the annual dollar limits."]
["Benefit Cost Sharing - CSR","Ensure the cost sharing plan variations meet all requirements."]
["Benefit Cost Sharing - Catastrophic Plans","Ensure catastrophic plans meet all requirements."]
["Non-Discrimination Cost Sharing","Perform an outlier analysis on selected benefits cost-sharing."]
["Service Area","Confirm that issuers include full counties or have a justifiable reason for partial counties."]
[]
["OVERALL PLAN VALIDATION"]

{"sheet":"Accreditation","index":2,"n_rows":14,"n_cols":6,"rows_kept":14,"cut":false,"hidden":false,"merged":[[0,0,0,4]]}
["Accreditation Review Process Steps"]
[null,null,null,null,null,"Validation Results"]
[null,null,null,null,"HIOS Issuer ID:"]
[null,null,null,null,"SELECT REVIEW RESULT:  "]
["Review","Review step","Review description and procedure","Step description","Source"]
[1,null,"If the issuer is new to the Exchange for 2021 then review if the issuer is accredited or working towards accreditation. "]
[1,"a",null,"Ensure the issuer is accredited by NCQA, URAC, or AAAHC. If yes, mark as \"Met.\" If no, move to review 2b. "]
[1,"b",null,"If the issuer is not accredited, advise the issuer that they need to be working towards accreditation. Issuers should be scheduling or plan to schedule an accreditation review with NCQA, URAC, or AAAHC. Mark as \"Met.\" "]
[2,null,"If the issuer was part of the Exchange last year, but this is not their 4th year of QHP certification, then review if the issuer is accredited."]
[2,"a",null,"If the issuer reports Marketplace/Exchange, Commercial or Medicaid accreditation, ensure that the issuer is accredited by NCQA, URAC, or AAAHC, and that the policies and procedures underlying their accreditation are the same as those for their QHP. If yes, mark as “Met.”"]
[2,"b",null,"If the issuer does not report Exchange/Marketplace, Commercial or Medicaid accreditation by NCQA, URAC or AAAHC, or reports some other kind of accreditation not listed here, then mark as \"Not Met.\""]
[3,null,"If the issuer is participating on the Exchange for the fourth year (or more) then review if the issuer meets year 4 requirements."]
[3,"a",null,"If the issuer is accredited by NCQA or URAC, ensure that the issuer reports Marketplace/Exchange accreditation. If yes, move to review 3b. If the issuer does not report Marketplace/Exchange accreditation, then mark as “Not Met.”"]
[3,"b",null,"If the issuer reports an acceptable accreditation status, mark as “Met”. Acceptable statuses for year 4 issuers are: AAAHC-Accredited; NCQA-Excellent, Commendable, Accredited, Provisional; URAC-Full, Conditional. If the issuer does not report an acceptable accreditation status, mark as “Not Met.” "]

{"sheet":"Program Attestation","index":3,"n_rows":18,"n_cols":6,"rows_kept":18,"cut":false,"hidden":false,"merged":[[0,0,0,4]]}
["Program Attestation Process Steps"]
[null,null,null,null,null,"Validation Results"]
[null,null,null,null,"HIOS Issuer ID:"]
[null,null,null,null,"SELECT REVIEW RESULT:  "]
["Review","Review step","Review description and procedure","Step description","Source"]
[1,null,"Verify QHP and SADP program attestations response.",null,"Attestation "]
[1,"a",null,"Verify the issuer responded to the QHP and SADP Program Attestations subsection. If the issuer responds “Yes,” it complies; go to the next review. If the issuer responds “No,” it does not comply; mark as “Not Met” and continue to the next review."]
[null,"b",null,"For “QHP” and “SADP” issuers, verify the issuer responded to the Network Adequacy/Essential Community Provider attestations required of both Medical QHP and SADP issuers. If the issuer responds “Yes” or “No,” it complies; continue to the next review. "]
[2,null,"Verify Medical QHP-only program attestations response.",null,"Attestation"]
[2,"a",null,"Using the issuer type information, determine how the issuer should respond. “QHP Only” and “Dual Issuers” issuers must attest “Yes” to this subsection. “SADP Only” issuers may attest “Yes,” “No,” or “N/A.”"]
[2,"b",null,"For “QHP Only” and “Dual Issuers” issuers, verify the issuer responded to the Medical QHP-only Program Attestations subsection. If the issuer responds “Yes,” it complies; go to next review. If the issuer responds “No,” it does not comply; mark as “Not Met” and continue to next review."]
[2,"c",null,"For “SADP Only” issuers, verify the issuer responded to the Medical QHP-only Program Attestations subsection. If the issuer responds “Yes,” “No,” or “N/A,” it complies; go to the next review."]
[3,null,"Verify SADP-only program attestations response.",null,"Attestation"]
[3,"a",null,"Using the issuer type information, determine how the issuer should respond. \"SADP Only” issuers and “Dual Issuers” issuers must attest “Yes” to this subsection. “QHP Only” issuers may attest “Yes,” “No,” or “N/A.”"]
[3,"b",null,"For “SADP Only” and “Dual Issuers” issuers, verify the issuer responded to the SADP-only Program Attestations subsection. If the issuer responds “Yes,” it complies; go to the next review. If the issuer responds “No,” it does not comply; mark as “Not Met” and continue to the next review."]
[3,"c",null,"For “QHP Only” issuers, verify the issuer responded to the SADP-only Program Attestations subsection. If the issuer responds “Yes,” “No,” or “N/A,” it complies; go to the next review."]
[4,null,"Verify optional program attestations response."," ","Attestation"]
[4,"a",null,"Verify the issuer responded to the Optional Program Attestations subsection. If the issuer responds “Yes,” it complies. Write notes where applicable, finalize the review, and end the Program Attestation review. If the issuer responds “No,” verify the issuer has submitted a justification form. If no justification form has been provided, mark as “Not Met”, write notes where applicable, finalize the review, and end the Program Attestation review."]

{"sheet":"ECP","index":4,"n_rows":63,"n_cols":6,"rows_kept":63,"cut":false,"hidden":false,"merged":[[57,0,58,0],[57,1,58,1],[57,2,58,2],[57,4,58,4],[46,0,48,0],[46,1,48,1],[46,2,48,2],[46,4,48,4],[51,0,52,0],[51,1,52,1],[51,2,52,2],[51,4,52,4],[42,0,43,0],[42,1,43,1],[42,2,43,2],[42,4,43,4],[36,0,38,0],[36,1,38,1],[36,2,38,2],[36,4,38,4],[40,0,41,0],[40,1,41,1],[40,4,41,4],[40,2,41,2],[0,0,0,4],[2,0,2,4],[13,0,14,0],[13,1,14,1],[13,2,14,2],[13,4,14,4],[16,0,17,0],[16,2,17,2],[16,4,17,4],[16,1,17,1],[32,0,33,0],[32,1,33,1],[32,2,33,2],[32,4,33,4],[20,0,21,0],[20,1,21,1],[20,2,21,2],[20,4,21,4],[30,0,31,0],[30,1,31,1],[30,2,31,2],[30,4,31,4]]}
["Essential Community Providers (ECP) Review Process Steps"]
[]
["There is a separate tool available to assist in the ECP review. The following explains the steps followed in the tool."]
[null,null,null,null,null,"Validation Results"]
[null,null,null,null,"HIOS Issuer ID:"]
[null,null,null,null,"Plan ID:"]
[null,null,null,null,"Network ID:"]
[null,null,null,null,"Service area ID:"]
[null,null,null,null,"SELECT REVIEW RESULT:  "]
["Review","Review step","Review description and procedure","Step description","Source"]
[1,null,"Determine whether the issuer is a general standard issuer or an alternate standard issuer."]
[1,"a",null,"If the answer to “Is this an Alternate ECP Standard Issuer?” is No on the User Control tab of the ECP/NA Template, the issuer is a general ECP standard issuer.","ECP/NA Template"]
[1,"b",null,"If the answer to “Is this an Alternate ECP Standard Issuer?” is Yes on the User Control tab of the ECP/NA Template, the issuer is an alternate ECP standard issuer.","ECP/NA Template"]
[1,"c",null,"If the issuer submitted an ECP Write-In Worksheet, compare the answer to “Are you an alternate ECP standard issuer?” on the ECP Write-In Worksheet to the response provided in the ECP/NA Template. If the responses do not match, mark as “Not Met” and end the ECP review.","ECP Write-In Worksheet"]
[null,null,null,"If the responses are the same, proceed to review 2."]
[2,null,"Verify the issuer has identified ECPs for each of its networks."]
[2,"a",null,"If all entries in the ECP/NA Template are dummy values, confirm that the issuer has submitted an ECP supplemental response. Use the ECP Supplemental Response Reviewer Guide to evaluate the issuer’s ECP supplemental response.","ECP/NA Template, ECP Write-In Worksheet, and supporting document"]
[null,null,null,"If the justification satisfactorily addresses all elements of the supplemental response, mark as “Not Met”, add comments, and end the ECP review."]
[2,"c",null,"If all entries are dummy values and the justification does not satisfactorily address all elements of the supplemental response, mark as “Not Met”, add comments, and end the ECP review.","ECP/NA Template, ECP Write-In Worksheet, and supporting document"]
[2,"c",null,"If all entries are dummy values and no justification is provided, mark as “Not Met”, add comments, finalize the section, and end the ECP review.","ECP/NA Template, ECP Write-In Worksheet, and supporting document"]
[2,"d",null,"If ECPs are provided for some but not all networks, use the ECP Supplemental Response Reviewer Guide to verify the issuer has provided a justification (Supplemental Response Form) for the networks without ECPs.","ECP/NA Template, ECP Write-In Worksheet, and supporting document"]
[null,null,null,"If the justification satisfactorily addresses all supplemental response elements, mark as “Not Met”, add comments, and go to the next review."]
[2,"e",null,"If ECPs are provided for some but not all networks and the justification does not satisfactorily address all supplemental response elements, mark as “Not Met”, add comments, and go to the next review.","ECP/NA Template, ECP Write-In Worksheet, and supporting document"]
[2,"f",null,"If ECPs are provided for some but not all networks and no justification is provided, mark as “Not Met”, add comments, and go to the next review.","ECP/NA Template, ECP Write-In Worksheet, and supporting document"]
[3,null,"Perform checks for data submission errors."]
[3,"a",null,"Review the Service Area IDs and Network IDs in the Plans in the Analyzer data to confirm that the same combination is not used for both medical and dental plans. If the same Service Area ID and Network ID combination is used for both plan types, mark as “Not Met”, add comments, and end the ECP review.","Plans & Benefits Template"]
[3,"b",null,"Review the ECP/NA Template data to determine whether data integrity issues exist that would prevent completion of the ECP review. If data integrity issues exist and you cannot correct them, mark as “Not Met”, add comments, and end the ECP review.","ECP/NA Template and ECP Write-In Worksheet"]
[3,"c",null,"If no data integrity issues exist, then go to review 4, if the issuer is a general ECP standard issuer, or go to review 5, if the issuer is an alternate ECP standard issuer.","ECP/NA Template and ECP Write-In Worksheet"]
[3,"d",null,"If data integrity issues exist and you can correct them, clean up the data. Go to review 4, if the issuer is a general ECP standard issuer. Go to review 5, if the issuer is an alternate ECP standard issuer.","ECP/NA Template and ECP Write-In Worksheet"]
[4,null,"If the issuer is a general ECP standard issuer, determine whether it has met the threshold—20 percent of available ECPs—for all networks in all proposed service areas."]
[4,"a",null,"If you found no data integrity issues, run the ECP Individual Tool and record the ECP review results from the output. If the issuer meets the 20 percent ECP threshold for all network–service area combinations, add comments and go to review step 4e.","ECP Tool"]
[null,null,null,"If the issuer does not meet the 20 percent ECP threshold for all network–service area combinations, go to review step 4c."]
[4,"b",null,"If you found data integrity issues, clean up the data and run the ECP Individual Tool. If the issuer meets the 20 percent ECP threshold for all network–service area combinations, add comments and go to review step 4e.","ECP/NA Template, Plans in the Analyzer report, ECP Tool"]
[null,null,null,"If the issuer does not meet the ECP threshold for all network–service area combinations, go to review step 4c."]
[4,"c",null,"If the 20 percent threshold is met for some but not all issuer network–service area combinations, document the review results, write comments as needed, and go to review step 4e.","ECP Tool"]
[4,"d",null,"If the 20 percent threshold is not met for any issuer network-service area combinations, document the review results, add comments as needed, and go to review step 4e.","ECP Tool"]
[4,"e",null,"Check the ECP question. If the issuer met the 20 percent threshold and responds “Yes” to the ECP question, finalize the ECP section and end the ECP review."]
[null,null,null,"If the issuer met the 20 percent threshold and responds “No” to the ECP question, go to review 7."]
[null,null,null,"If the issuer did not meet the 20 percent threshold and responds “Yes” or “No,” go to review 6."]
[5,null,"If the issuer is an alternate standard issuer, determine whether the issuer has met the ECP threshold—20 percent of available ECPs—for all networks in all proposed service areas and has provider locations in HPSAs and low-income ZIP codes in all service areas."]
[5,"a",null,"If you found no data integrity issues in review 3, run the ECP Individual Tool and record the ECP review results from the output. If the issuer meets the 20 percent ECP threshold for all network–service area combinations, add comments as needed and go to step 5e.","ECP tool"]
[null,null,null,"If the issuer does not meet the 20 percent ECP threshold for all network–service area combinations, go to review step 5c."]
[5,"b",null,"If you found data integrity issues, clean up the ECP data and run the ECP Individual Tool. If the issuer meets the ECP threshold for all network–service area combinations, document the review results, add comments as needed, and go to review step 5e.","ECP/NA Template, ECP Write-In Worksheet, Plans in the Analyzer report, and ECP Tool"]
[null,null,null,"If the issuer does not meet the 20 percent ECP threshold for all network–service area combinations, add comments as needed and go to review step 5c."]
[5,"c",null,"If the 20 percent threshold is met for some but not all issuer network–service area combinations, record the review results, add comments as needed, and go to review step 5e.","ECP Tool"]
[5,"d",null,"If the 20 percent threshold is not met for any issuer network–service area combination, document the review results, add comments as needed, and go to review step 5e.","ECP Tool"]
[5,"e",null,"Check the ECP question. If the issuer met the 20 percent threshold and responds “Yes” to the ECP question, finalize the ECP section and end the ECP review."]
[null,null,null,"If the issuer met the 20 percent threshold and responds “No,” go to review 7."]
[null,null,null,"If the issuer did not meet the 20 percent threshold and responds “Yes” or “No” to the ECP question, go to review 6."]
[6,null,"Determine whether the ECP supplemental response is satisfactory for issuers not meeting the 20 percent threshold."]
[6,"a",null,"Review the issuer’s ECP Supplemental Response Form (justification).","Supporting documents"]
[6,"b",null,"Using the ECP Supplemental Response Reviewer Guide, document your findings from the review of the ECP Supplemental Response Form.","Supporting documents"]
[null,null,null,"If the issuer’s network(s) did not meet the 20 percent threshold, but the issuer’s ECP supplemental response satisfactorily addresses all supplemental response elements, mark as “Not Met”, add comments as needed, finalize the review, and end the ECP review."]
[6,"c",null,"If the issuer’s network(s) did not meet the 20 percent threshold and the issuer’s ECP supplemental response does not satisfactorily address all supplemental response elements, mark as “Not Met”, add comments, and end the ECP review.","Supporting documents"]
[6,"d",null,"If the issuer’s network(s) did not meet the 20 percent threshold and no justification is provided, mark as “Not Met”, add comments, and end the ECP review.","Supporting documents"]
[7,null,"For issuers meeting the 20 percent threshold that answered “No” to the ECP question, determine whether the ECP supplemental response is satisfactory."]
[7,"a",null,"Review the ECP Supplemental Response Form (justification).","Supporting documents"]
[7,"b",null,"Use the ECP Supplemental Response Reviewer Guide to evaluate and document the issuer’s ECP supplemental response.","Supporting documents"]
[null,null,null,"If the 20 percent threshold is met and the answer to the ECP question is “No,” and the justification satisfactorily addresses all supplemental response elements, end the ECP review."]
[7,"c",null,"If the 20 percent threshold is met and the answer to the ECP question is “No,” and the justification does not satisfactorily address all supplemental response elements, mark as “Not Met”, add comments, and end the ECP review.","Supporting documents"]
[7,"d",null,"If the 20 percent threshold is met and the answer to the ECP question is “No,” and no justification is provided, mark as “Not Met”, add comments, and end the ECP review.","Supporting documents"]
[7,"c",null,"If the 20 percent threshold is met and the answer to the ECP question is “Yes,” and the justification does not satisfactorily address all supplemental response elements, mark as \"Not Met\", add comments, and end the ECP Review.","Supporting documents"]
[7,"d",null,"If the 20 percent threshold is met and the answer to the ECP question is “Yes,” and no justification is provided, mark as \"Not Met\", add comments, and end the ECP Review.","Supporting documents"]

{"sheet":"Category Class Drug Count","index":5,"n_rows":31,"n_cols":6,"rows_kept":31,"cut":false,"hidden":false,"merged":[[27,0,29,0],[27,1,29,1],[27,2,29,2],[27,4,29,4],[21,0,25,0],[21,1,25,1],[21,2,25,2],[21,4,25,4],[19,0,20,0],[19,1,20,1],[19,2,20,2],[0,0,0,4],[2,0,2,4]]}
["Category Class Count Review Process Steps"]
[]
["There is a stand-alone tool available to assist in the category class count review. The following explains the steps followed in the tool."]
[null,null,null,null,null,"Validation Results"]
[null,null,null,null,"HIOS Issuer ID:"]
[null,null,null,null,"Formulary ID:"]
[null,null,null,null,"Drug list ID:"]
[null,null,null,null,"SELECT REVIEW RESULT:  "]
["Review","Review step","Review description and procedure","Step description","Source"]
[1,null,"Create a list of RXCUIs included in the drug list under review."]
[1,"a",null,"For each RXCUI, if the RXCUI has a Tier Level not equal to “NA” in the drug list under review, add the RXCUI to the list of RXCUIs for review.","RXCUI, Tier Level"]
[null,null,null,"RXCUIs with a Tier Level equal to “NA” are not included in the given drug list."]
[2,null,"Map RXCUIs to categories and classes by using the EHB Rx Crosswalk."]
[2,"a",null,"For each RXCUI being reviewed, if the RXCUI is included in the EHB Rx Crosswalk, map the RXCUI to one or more categories and classes. If the RXCUI is not included in the EHB Rx Crosswalk, ignore the RXCUI.","RXCUI, EHB Rx Crosswalk"]
[3,null,"Convert the RXCUIs to chemically distinct drug identifiers by using the EHB Rx Crosswalk."]
[3,"a",null,"For each RXCUI, if the RXCUI is included in the EHB Rx Crosswalk, map the RXCUI to a chemically distinct drug identifier. If the RXCUI is not included in the EHB Rx Crosswalk, ignore the RXCUI.","RXCUI, EHB Rx Crosswalk"]
[4,null,"Count the number of chemically distinct drugs in each category and class."]
[4,"a",null,"Count the number of unique chemically distinct drug identifiers in each category and class."]
[5,null,"Compare the number of chemically distinct drugs in each category and class with the number in the EHB benchmark."]
[5,"a",null,"For each category and class, compare the number of unique chemically distinct drug identifiers in the drug list with the number of chemically distinct drugs in the EHB benchmark."]
[null,null,null,"If the category does not have any classes, perform the comparison at the category level."]
[5,"b",null,"For each category and class, if the EHB benchmark is met, no further review is required.","EHB benchmark"]
[null,null,null,"For each category and class, if the count of the chemically distinct drug identifiers in the drug list is less than the greater of"]
[null,null,null,"     one drug or"]
[null,null,null,"     the number of chemically distinct drugs in the EHB benchmark in the given category and class,"]
[null,null,null,"flag the category and class in the drug list for further review."]
[6,null,"Examine justification documents for categories and classes requiring further review."]
[6,"a",null,"For each flagged category and class in each drug list needing further review, consider the following:","Justification documents"]
[null,null,null,"If the issuer submitted a Formulary Justification Template that includes one of the preapproved reasons for having an inadequate number of drugs in the given category and class, consider the category and class to have a valid justification and repeat this review step for the next flagged category and class."]
[null,null,null,"If the issuer’s Formulary Justification Template includes a reason other than one of those preapproved for having an inadequate number of drugs in the given category and class, or if the issuer submitted drug count justification documents other than the Formulary Justification Template, research the provided justifications to confirm their validity. This research should be performed by a pharmacist when appropriate."]
[6,"b",null,"If the issuer provided no valid justification for a flagged category and class in a drug list needing further review, flag all plans associated with the drug list as “Not Met”."]

{"sheet":"Formulary Outlier","index":6,"n_rows":42,"n_cols":6,"rows_kept":42,"cut":false,"hidden":false,"merged":[[28,0,30,0],[28,1,30,1],[28,2,30,2],[28,4,30,4],[39,0,40,0],[39,1,40,1],[39,2,40,2],[39,4,40,4],[24,0,27,0],[24,1,27,1],[24,2,27,2],[24,4,27,4],[0,0,0,4],[2,0,2,4],[11,0,12,0],[11,1,12,1],[11,2,12,2],[11,4,12,4]]}
["Formulary Outlier Process Steps"]
[]
["There is a stand-alone tool available to assist in the formulary outlier review. The following explains the steps followed in the tool."]
[null,null,null,null,null,"Validation Results"]
[null,null,null,null,"HIOS Issuer ID:"]
[null,null,null,null,"Formulary ID:"]
[null,null,null,null,"Drug list ID:"]
[null,null,null,null,"SELECT REVIEW RESULT:  "]
["Review","Review step","Review description and procedure","Step description","Source"]
[1,null,"For each drug list, create a list of RXCUIs  included in the drug classes being reviewed for formulary outlier non-discrimination."]
[1,"a",null,"For each RXCUI, if the RXCUI has a Tier Level not equal to “NA” in the drug list under review, add the RXCUI to the list of RXCUIs for potential review.","RXCUI, Tier Level"]
[1,"b",null,"If the RXCUI maps to the drug classes being reviewed, keep the RXCUI in the list of RXCUIs for review.","RXCUI"]
[null,null,null,"If the RXCUI does not map to the drug class being reviewed, remove the RXCUI from the list of RXCUIs for review."]
[2,null,"Convert the RXCUIs to chemically distinct drug identifiers."]
[null,null,null,"For each RXCUI being reviewed, map the RXCUI to a chemically distinct drug identifier by using the EHB Rx Crosswalk.","RXCUI, EHB Rx Crosswalk"]
[3,null,"For each drug list, count the number of chemically distinct drugs in the drug class being reviewed without a prior authorization or step therapy requirement."]
[3,"a",null,"For each chemically distinct drug identifier, determine whether any of the RXCUIs mapped to the chemically distinct drug identifier have either a prior authorization or step therapy requirement. If any of the RXCUIs mapped to the chemically distinct drug identifier have neither requirement, consider the chemically distinct drug identifier “unrestricted.”","RXCUI, Prior Authorization Required, Step Therapy Required"]
[3,"b",null,"Count the number of unique, unrestricted chemically distinct drug identifiers in each category and class.","RXCUI"]
[4,null,"Remove drugs lists that do not map to a plan.",null," "]
[4,"a",null,"Determine the drug lists that map to a plan. Map the formulary ID from the Prescription Drug template to the formulary IDs on the Plans & Benefits template. Exclude the drug lists that do not map to a plan in the steps that follow.","Formulary ID, State Code, Issuer ID, Plan ID"]
[5,null,"Remove drug lists that map to a suppressed or withdrawn plan."]
[5,"a",null,"Determine the drug lists that map to a plan. Map the formulary ID from the Prescription Drug template to the formulary IDs on the Plans & Benefits template. Exclude the drug lists that do not map to a plan in the steps that follow.","Formulary ID, State Code, Issuer ID, Plan ID"]
[5,"b",null,"Determine the plans that are suppressed and withdrawn. Map plans to suppression and withdrawn status. Exclude the drug lists that only map to a suppressed or withdrawn plan in the steps that follow.","Plan ID, Suppression Status, Withdrawn Status"]
[6,null,"For each drug list, cap the count of unrestricted chemically distinct drugs by the number of chemically distinct drugs in the EHB benchmark for the drug class being reviewed."]
[6,"a",null,"For the drug class being reviewed, if the number of chemically distinct drugs in the EHB benchmark is equal to 0, find the capped count of unrestricted drugs by taking the minimum of","EHB benchmark"]
[null,null,null,"¿ one, or"]
[null,null,null,"¿ the number of unrestricted grouping numbers."]
[null,null,null,"If not, skip this step."]
[6,"b",null,"If the capped count was determined in step a, skip this step. Otherwise, find the capped count of unrestricted drugs by taking the minimum of the number of","EHB benchmark"]
[null,null,null,"¿ chemically distinct drugs in the EHB benchmark in the drug class being reviewed, or"]
[null,null,null,"¿ unrestricted chemically distinct drug identifiers."]
[7,null,"If this is the initial outlier calculation, calculate the state-level lower outlier threshold of the count of unrestricted drugs in the drug class being reviewed."]
[7,"a",null,"Using the modified Tukey’s test method, calculate and store the state lower outlier threshold of the count of unrestricted drugs for each state."]
[8,null,"If this is the initial outlier calculation, calculate the national-level lower outlier threshold of the count of unrestricted drugs in the drug class being reviewed."]
[8,"a",null,"Using the modified Tukey’s test method, calculate and store the national lower outlier threshold of the count of unrestricted drugs."]
[9,null,"Determine whether each drug list is a formulary low outlier in the drug class being reviewed."]
[9,"a",null,"For each drug list, if the count of unrestricted drugs in the drug class being reviewed is less than the state-level lower outlier threshold, or the national lower outlier threshold, flag the drug list for further review."]
[10,null,"Examine justification documents for drug lists requiring further review."]
[10,"a",null,"If no justification accompanies the drug list, mark the drug list as “Not Met” for the drug class being reviewed."]
[10,"b",null,"If a justification accompanies the drug list, examine the clinical validity of the issuer’s drug list for the drug class being reviewed. In addition, for the drug class marked as \"Not Met\", assess the restrictions applied to all the drugs in the drug class and determine whether each drug is restricted, unrestricted, or not on formulary. Finally, identify how the drug list marked as \"Not Met\" differs from those marked as \"Met\" within the state."]
[null,null,null,"Provide a recommendation regarding whether the justification is acceptable or unacceptable. If the justification is unacceptable, mark the drug list as \"Not Met\" for the drug class being reviewed."]
[10,"c",null,"If the justification is found to be acceptable, assess the drug list to determine whether it meets the criteria referenced in the justification."]

{"sheet":"Clinical Appropriateness","index":7,"n_rows":27,"n_cols":6,"rows_kept":27,"cut":false,"hidden":false,"merged":[[24,0,25,0],[24,1,25,1],[24,2,25,2],[24,4,25,4],[0,0,0,4],[2,0,2,4],[11,0,12,0],[11,1,12,1],[11,2,12,2],[11,4,12,4]]}
["Clinical Appropriateness Review Process Steps"]
[]
["There is a stand-alone tool available to assist in the clinical appropriateness eview. The following explains the steps followed in the tool."]
[null,null,null,null,null,"Validation Results"]
[null,null,null,null,"HIOS Issuer ID:"]
[null,null,null,null,"Formulary ID:"]
[null,null,null,null,"Drug list ID:"]
[null,null,null,null,"SELECT REVIEW RESULT:  "]
["Review","Review step","Review description and procedure","Step description","Source"]
[1,null,"For each drug list, create a list of RXCUIs included in the drug classes being reviewed for clinical appropriateness."]
[1,"a",null,"For each RXCUI, if the RXCUI has a Tier Level not equal to “NA” in the drug list under review, add the RXCUI to the list of RXCUIs for potential review.","RXCUI, Tier Level"]
[1,"b",null,"If the RXCUI maps to the drug classes being reviewed, keep the RXCUI in the list of RXCUIs for review.","RXCUI"]
[null,null,null,"If the RXCUI does not map to the drug classes being reviewed, remove the RXCUI from the list of RXCUIs for review."]
[2,null,"Convert the RXCUIs to clinically distinct drug identifiers."]
[2,"a",null,"For each RXCUI being reviewed, map the RXCUI to a clinically distinct drug identifier by using the Clinical Appropriateness drug list.","RXCUI"]
[3,null,"For each drug list, count the number of clinically distinct drugs in the drug class being reviewed."]
[3,"a",null,"Count the number of unique clinically distinct drugs in each of the drug classes being reviewed. This is the covered drug count.","RXCUI, Prior Authorization Required, Step Therapy Required"]
[4,null,"For each drug list, count the number of clinically distinct drugs in the drug class being reviewed without a prior authorization or step therapy requirement."]
[4,"a",null,"For each clinically distinct drug identifier, determine whether any of the RXCUIs mapped to the clinically distinct drug identifier have either a prior authorization or step therapy requirement. If any of the RXCUIs mapped to the clinically distinct drug identifier have neither requirement, consider the clinically distinct drug identifier “unrestricted.”","RXCUI, Prior Authorization Required, Step Therapy Required"]
[4,"b",null,"Count the number of unique, unrestricted clinically distinct drug identifiers in each category and class. This is the unrestricted drug count.","RXCUI"]
[5,null,"Determine whether a drug list’s count of drugs is less than the clinically appropriate threshold."]
[5,"a",null,"For each drug list, if the drug count, or unrestricted drug count, in the drug class being reviewed is less than the clinically appropriate threshold flag the drug list for further review."]
[6,null,"Examine justification documents for drug lists requiring further review."]
[6,"a",null,"If no justification accompanies the drug list, flag the drug list as “Not Met” for the drug class being reviewed."]
[6,"b",null,"If a justification accompanies the drug list, examine the clinical validity of the issuer’s drug list for the drug class being reviewed. Finally, identify how the drug list with issuer differs from those without issues within the state."]
[null,null,null,"Provide a recommendation regarding whether the justification is acceptable or unacceptable. If the justification is unacceptable, flag the drug list as being \"Not Met\" for the drug class being reviewed."]
[6,"c",null,"If the justification is found to be acceptable, assess the drug list to determine whether it meets the criteria referenced in the justification."]

{"sheet":"Benefit Cost Sharing","index":8,"n_rows":85,"n_cols":6,"rows_kept":85,"cut":false,"hidden":false,"merged":[[70,2,72,2],[70,4,72,4],[70,0,72,0],[70,1,72,1],[0,0,0,4],[29,0,29,4],[61,0,61,4],[2,0,2,4],[10,0,10,4],[12,0,13,0],[12,1,13,1],[12,2,13,2],[12,3,13,3]]}
["Benefit Cost Sharing Review Process Steps"]
[]
["There is a stand-alone tool available to assist in the cost sharing reviews. The following explains the steps followed in the tool."]
[null,null,null,null,null,"Validation Results"]
[null,null,null,null,"HIOS Issuer ID:"]
[null,null,null,null,"Plan ID:"]
[null,null,null,null,"SELECT MOOP REVIEW RESULT:  "]
[null,null,null,null,"SELECT COST SHARING REDUCTION (CSR) REVIEW RESULT:  "]
[null,null,null,null,"SELECT CATASTROPHIC PLAN REVIEW RESULT:  "]
["Review","Review step","Review description and procedure","Step description","Source"]
["Perform the Maximum Out of Pocket (MOOP) Review for all plans."]
[1,null,"Determine the appropriate MOOP to compare with the annual dollar limitation specified in regulation."]
[1,"a",null,"Use MOOP Details tab to determine the appropriate MOOP to compare with the annual dollar limitation specified in regulation. The limit for QHPs is expected to be $8,550 for individuals and $17,100 for family.","Multiple In Network Tiers?"]
[null,null,null,null,"Medical & Drug Maximum Out of Pocket Integrated? Dental Only Plan; refer to MOOP Details"]
[1,"b",null,"If an issuer enters “Not Applicable” for all the relevant MOOPs, mark as \"Not Met.\" If an issuer enters “Not Applicable” for all family MOOPs, proceed to the next review. Otherwise, go to review 3."]
[2,null,"If family MOOP values are all “Not Applicable,” check the Business Rules Template to see whether the plan is intended to be offered to individuals only, not to families.",null,"Business Rules Template: Product ID, Plan ID (Standard Component), “What relationships between primary and dependent are allowed, and is the dependent required to live in the same household as the primary subscriber?”"]
[2,"a",null,"If the given Plan ID and Product ID do not exist in the Business Rules Template, use the default Issuer Rule (the row where both the Plan ID and the Product ID are blank)."]
[2,"b",null,"If the given Plan ID does not exist in the Business Rules Template, the given Product ID exists in the template, and the “What relationships between primary and dependent are allowed, and is the dependent required to live in the same household as the primary subscriber?” field is blank for the given Product ID, use the default Issuer Rule."]
[2,"c",null,"If the given Plan ID does not exist in the Business Rules Template, the given Product ID exists in the template, and the “What relationships between primary and dependent are allowed, and is the dependent required to live in the same household as the primary subscriber?” field is not blank for the given Product ID, use the Product Rule."]
[2,"d",null,"If the given Plan ID exists in the Business Rules Template and the “What relationships between primary and dependent are allowed, and is the dependent required to live in the same household as the primary subscriber?” field is not blank for the given Plan ID, use the Plan Rule."]
[2,"e",null,"If the given Plan ID and Product ID exist in the Business Rules Template and the “What relationships between primary and dependent are allowed, and is the dependent required to live in the same household as the primary subscriber?” field is blank for both the given Plan ID and Product ID, use the default Issuer Rule."]
[2,"f",null,"If the given Plan ID and Product ID exist in the Business Rules Template and the “What relationships between primary and dependent are allowed, and is the dependent required to live in the same household as the primary subscriber?” field is blank for the given Plan ID, but not blank for the Product ID, use the Product Rule."]
[2,"g",null,"For the relevant rule, if “What relationships between primary and dependent are allowed, and is the dependent required to live in the same household as the primary subscriber?” is equal to “Self, Yes” or “Self, No,” proceed to the next review to compare the individual MOOP. Otherwise, mark as \"Not Met\"."]
[3,null,"Compare the appropriate MOOP with the annual dollar limitation specified in regulation."]
[3,"a",null,"For QHPs, the threshold is determined in regulation and is expected to be $8,150 for an individual and $16,300 for a family. Compare the Individual MOOP and Per Person Family MOOP to the individual limit and the Per Group Family MOOP to the family limit."]
[3,"b",null,"If the appropriate MOOP is at or below the threshold, the analysis is complete and the plan passes the MOOP cost-sharing review. If the appropriate MOOP is above the threshold, proceed to the next review."]
[4,null,"Check justifications."]
[4,"a",null,"If the MOOP is above the threshold and no justification is submitted, mark as \"Not Met.\""]
[4,"b",null,"If the MOOP is above the threshold and an appropriate justification is submitted, the plan has passed the MOOP review. Mark as \"Met.\""]
["Perform the Cost Sharing Reduction Plan Variation Review for all metal plans in the Individual Market."]
[1,null,"Determine whether all required plan variations have been created for the individual market plans."]
[1,"a",null,"For each silver plan, check for associated 73% AV, 87% AV, and 94% AV variations. If a silver plan variation is missing, mark as \"Not Met.\"","Market Coverage, HIOS Plan ID (Stand Component + Variant), Metal Level, CSR Variation Type"]
[1,"b",null,"For all metal level plans (except catastrophic), check for two variations: a zero cost-sharing plan variation and a limited cost-sharing plan variation. If a variation is missing, mark as \"Not Met.\"","Market Coverage, HIOS Plan ID (Stand Component + Variant), Metal Level, CSR Variation Type"]
[2,null,"Determine whether the appropriate MOOP is at or below the threshold."]
[2,"a",null,"For the 73% AV silver plan variation, the MOOP must be less than or equal to $6,800 for an individual or $13,600 for a family. Compare the Individual MOOP and Per Person Family MOOP to the individual limit and the Per Group Family MOOP to the family limit. If the appropriate MOOP exceeds the threshold, mark as \"Not Met.\"","CSR Variation Type, MOOP Fields"]
[2,"b",null,"For the 87% and 94% AV silver plan variations, the MOOP must be less than or equal to $2,8500 for an individual or $5,700 for a family. Compare the Individual MOOP and Per Person Family MOOP to the individual limit and the Per Group Family MOOP to the family limit. If the appropriate MOOP exceeds the threshold, mark as \"Not Met.\"","CSR Variation Type, MOOP Field"]
[2,"c",null,"For the zero cost-sharing plan variation, all in-network EHB MOOP values must be $0. The out-of-network and combined in/out EHB MOOP values should be $0, but they also may be “Not Applicable” if the associated standard plan is “Not Applicable.” If any MOOP is not $0 (or “Not Applicable”), mark as \"Not Met.\"","CSR Variation Type, MOOP Fields"]
[2,"d",null,"For the limited cost-sharing plan variation, the MOOP must be the same as the associated standard plan’s MOOP. If any MOOP differs from the standard plan, mark as \"Not Met.\"","CSR Variation Type, MOOP Fields"]
[3,null,"Determine whether the cost sharing for benefits in the zero cost-sharing and limited cost-sharing plan variations are in accordance with HHS guidance.",null," "]
[3,"a",null,"For the zero cost-sharing plan variation, if EHB is “Yes” and the EHB Variance Reason is not “Not EHB,” or if EHB is blank and the EHB Variance Reason is “Additional EHB Benefit” or “Other Law/Regulation,” the benefit cost-sharing values must all be $0, 0%, or No Charge for both in and out of network. The out-of-network coinsurance may also be 100% if the standard plan is 100%. If any cost-sharing value is not 0 (or 100%), mark as \"Not Met.\"","EHB, CSR Variation Type, Default Copayment In Network, Default Coinsurance In Network, Copayment In Network (Tier 1), Copayment In Network (Tier 2), Copayment Out of Network, Coinsurance In Network (Tier 1), Coinsurance In Network (Tier 2), Coinsurance Out of Network"]
[3,"b",null,"For the zero cost-sharing plan variation, if EHB is blank and the EHB Variance Reason is not “Additional EHB Benefit” or “Other Law/Regulation,” or if EHB is “Yes” and EHB Variance Reason is “Not EHB,” the benefit cost sharing must follow successive cost sharing with the associated limited plan variation. If successive cost sharing is not followed, amark as \"Not Met.\"","EHB, EHB Variance Reason, HIOS Plan ID (Standard Component + Variant), CSR Variation Type, Default Copayment In Network, Default Coinsurance In Network, Copayment In Network (Tier 1), Copayment In Network (Tier 2), Copayment Out of Network, Coinsurance In Network (Tier 1), Coinsurance In Network (Tier 2), Coinsurance Out of Network"]
[3,"c",null,"For the zero cost-sharing plan variation, if EHB is blank and the EHB Variance Reason is not “Additional EHB Benefit” or “Other Law/Regulation,” or if EHB is “Yes” and EHB Variance Reason is “Not EHB” and Level of Coverage is “Silver,” the benefit cost sharing must follow successive cost sharing with the associated 94% AV plan variation. If successive cost sharing is not followed, mark as \"Not Met.\"","EHB, EHB Variance Reason, Level of Coverage, HIOS Plan ID (Standard Component + Variant), CSR Variation Type, Default Copayment In Network, Default Coinsurance In Network, Copayment In Network (Tier 1), Copayment In Network (Tier 2), Copayment Out of Network, Coinsurance In Network (Tier 1), Coinsurance In Network (Tier 2), Coinsurance Out of Network"]
[3,"d",null,"For the limited cost-sharing plan variation, if EHB is “Yes” and the EHB Variance Reason is not “Not EHB,” or if EHB is blank and the EHB Variance Reason is “Additional EHB Benefit” or “Other Law/Regulation,” benefit cost-sharing values must be the same as the associated standard plan’s value. If any cost-sharing values differ, mark as \"Not Met.\"","EHB, EHB Variance Reason, HIOS Plan ID (Standard Component + Variant CSR Variation Type, Default Copayment In Network, Default Coinsurance In Network, Copayment In Network (Tier 1), Copayment In Network (Tier 2), Copayment Out of Network, Coinsurance In Network (Tier 1), Coinsurance In Network (Tier 2), Coinsurance Out of Network"]
[3,"e",null,"For the limited cost-sharing plan variation, if EHB is “Yes” and the EHB Variance Reason is “Not EHB,” or if EHB is blank and the EHB Variance Reason is not “Additional EHB Benefit” or “Other Law/Regulation,” benefit cost-sharing values must follow successive cost sharing with the associated standard plan’s value. If successive cost sharing is not followed, mark as \"Not Met.\"","EHB, EHB Variance Reason, HIOS Plan ID (Standard Component + Variant CSR Variation Type, Default Copayment In Network, Default Coinsurance In Network, Copayment In Network (Tier 1), Copayment In Network (Tier 2), Copayment Out of Network, Coinsurance In Network (Tier 1), Coinsurance In Network (Tier 2), Coinsurance Out of Network"]
[4,null,"Determine whether the deductibles for the zero cost-sharing and limited cost-sharing plan variations are in accordance with HHS guidance.",null," "]
[4,"a",null,"For the zero cost-sharing plan variations, all in-network deductible values must be $0. The out-of-network and combined in/out deductible values should be $0, but they also may be “Not Applicable” if the associated standard plan is “Not Applicable.” If any deductible value is not $0 (or “Not Applicable”), mark as \"Not Met.\"","CSR Variation Type, HIOS Plan ID (Stand Component + Variant), Medical Deductible (all values), Drug EHB Deductible (all values), Combined Medical and Drug Deductible (all values)"]
[4,"b",null,"For the limited cost-sharing plan variation, all deductible values must be the same as the associated standard plan’s value. If deductible values differ, mark as \"Not Met.\"","CSR Variation Type, HIOS Plan ID (Stand Component + Variant), Medical Deductible (all values), Drug EHB Deductible (all values), Combined Medical and Drug Deductible (all values)"]
[5,null,"Determine whether plan variations have the required tier utilization."]
[5,"a",null,"All plan variations (73%, 87%, and 94% AV silver plan variations and zero cost-sharing and limited cost-sharing plan variations) must have the same first and second tier utilization as the associated standard plan. If either the first or second tier utilization differs, mark as \"Not Met.\"","HIOS Plan ID (Standard Component + Variant), Metal Level, CSR Variation Type, 1st Tier Utilization, 2nd Tier Utilization"]
[6,null,"Determine whether the AVs for all plan variations are in accordance with HHS guidance."]
[6,"a",null,"If the plan has a unique design, the issuer AV is evaluated. If the plan does not have a unique plan design, the AV calculator output number is evaluated.","Unique Plan Design? HIOS Plan ID (Standard Component), HIOS Plan ID (Standard Component and Variant)"]
[6,"b",null,"The 73% AV silver plan variation’s AV must be between 72% and 74%. If the AV is outside the allowed range, mark as \"Not Met.\"","Unique Plan Design? HIOS Plan ID (Standard Component), HIOS Plan ID (Standard Component and Variant), Metal Level, CSR Variation Type, AV calculator output number"]
[6,"c",null,"The 73% AV silver plan variation’s AV must be at least 2 percentage points different from the associated standard silver plan’s actual AV. If the AV is within 2 percentage points of the associated standard silver plan, mark as \"Not Met.\"","Unique Plan Design? HIOS Plan ID (Standard Component), HIOS Plan ID (Standard Component and Variant), HIOS Plan ID (Standard Component + Variant), CSR Variation Type, Metal Level, AV calculator output number"]
[6,"d",null,"The 87% AV silver plan variation’s AV must be between 86% and 88%. If the AV is outside the allowed range, mark as \"Not Met.\"","Unique Plan Design? HIOS Plan ID (Standard Component), HIOS Plan ID (Standard Component and Variant), Metal Level, CSR Variation Type, AV calculator output number"]
[6,"e",null,"The 94% AV silver plan variation’s AV must be between 93% and 95%. If the AV is outside the allowed range, mark as \"Not Met.\"","Unique Plan Design? HIOS Plan ID (Standard Component), HIOS Plan ID (Standard Component and Variant), Metal Level, AV calculator output number"]
[6,"f",null,"The zero cost-sharing plan variation’s AV must be 100%. If the AV is not 100%, mark as \"Not Met.\"","Unique Plan Design? HIOS Plan ID (Standard Component), HIOS Plan ID (Standard Component and Variant), CSR Variation Type, AV calculator output number"]
[6,"g",null,"The limited cost-sharing plan variation’s AV must be greater than or equal to the associated standard plan’s AV. If the AV is not greater than or equal to the associated standard plan, mark as \"Not Met.\"","Unique Plan Design? HIOS Plan ID (Standard Component), HIOS Plan ID (Standard Component and Variant), HIOS Plan ID (Standard Component + Variant), CSR Variation Type, AV calculator output number"]
[7,null,"Determine whether for related silver plan variations, successive cost sharing is followed, meaning benefit cost sharing decreases or stays the same as the AVs increase."]
[7,"a",null,"The EHB MOOP values for the 94% AV variation must be less than or equal to the EHB MOOP values for the 87% AV variation, which must be less than or equal to the EHB MOOP values for the 73% AV variation, which must be less than or equal to the standard silver plan. If the AV variations and appropriate EHB MOOPs do not adhere to the relationship described above, mark as \"Not Met.\"","HIOS Plan ID (Standard Component + Variant), Metal Level, CSR Variation Type, MOOPs"]
[7,"b",null,"The EHB deductible values for the 94% AV variation must be less than or equal to the EHB deductible values for the 87% AV variation, which must be less than or equal to the EHB deductible values for the 73% AV variation, which must be less than or equal to the EHB deductible values for the standard silver plan. If the AV variations and appropriate EHB deductible do not adhere to the relationship described above, mark as \"Not Met.\"","HIOS Plan ID (Standard Component + Variant), Metal Level CSR Variation Type"]
[7,"c",null,"The copay and coinsurance values for all benefits for the 94% AV variation must be less than or equal to the values for the 87% AV variation, which must be less than or equal to the values for the 73% AV variation, which must be less than or equal to the values for the standard silver plan. If the AV variations and copayment and coinsurance values for covered benefits do not adhere to the relationship described above, mark as \"Not Met.\"","HIOS Plan ID (Standard Component), Is this Benefit Covered? HIOS Plan ID (Standard Component + Variant), CSR Variation Type, Reference, Copayment In Network (Tier 1), Copayment In Network (Tier 2), Copayment Out of Network, Coinsurance In Network (Tier 1), Coinsurance In Network (Tier 2), Coinsurance Out of Network"]
["Perform the Catastrophic Plan Review for all plans with a metal level of Catastrophic"]
[1,null,"Confirm that the catastrophic plan is offered only in the individual market."]
[1,"a",null,"If the Market Coverage is “SHOP (Small Group),” mark as \"Not Met.\"","Market Coverage"]
[2,null,"Ensure that the catastrophic plan does not have multiple in-network tiers."]
[2,"a",null,"If Multiple In Network Tiers? is “Yes,” mark as \"Not Met.\"","Multiple In Network Tiers?"]
[3,null,"Ensure that medical and drug deductibles and MOOPs are integrated."]
[3,"a",null,"If Medical & Drug Maximum Out of Pocket Integrated? is “No,” mark as \"Not Met.\"","Medical & Drug Maximum Out of Pocket Integrated?"]
[3,"b",null,"If Medical & Drug Deductibles Integrated? is “No,” mark as \"Not Met.\"","Medical & Drug Deductibles Integrated?"]
[4,null,"Check the in-network copay and coinsurance values."]
[4,"a",null,"Perform this check for each benefit, excluding “Primary Care to Treat Illness or Injury,” if EHB is “Yes” and EHB Variance Reason is not “Above EHB,” or if EHB is blank and EHB Variance Reason is “Additional EHB Benefit” or “Other Law/Regulation.”","EHB, EHB Variance Reason, In Network (Tier 1) Copay, In Network (Tier 1) Coinsurance"]
[null,null,null,"All In Network (Tier 1) Copay and In Network (Tier 1) Coinsurance values must be equal to “$0,” “0%,” “No Charge,” “$0 after deductible,” “0% after deductible,” “No Charge after deductible,” “$0 per day,” or “$0 per stay.” If the values of In Network (Tier 1) Copay or In Network (Tier 1) Coinsurance do not equal any of those, mark as \"Not Met.\""]
[null,null,null,"The combination of copay and coinsurance data entry for the benefit must indicate that the consumer does not have any out-of-pocket charges after meeting the deductible. This data entry would result in “No Charge After Deductible” being displayed for In Network on Plan Compare."]
[5,null,"Check that cost sharing is subject to deductible."]
[5,"a",null,"For each benefit, excluding “Primary Care to Treat Illness or Injury” and “Preventive care/screening/ immunization,” if EHB = “Yes” and EHB Variance Reason is not \"Not EHB,” or if EHB Variance Reason is “Additional EHB Benefit” or “Other Law/Regulation,” In Network (Tier 1) Copay or In Network (Tier 1) Coinsurance cost sharing must include “after deductible.” If not, mark as \"Not Met.\"","EHB, Is This Benefit Covered? EHB Variance Reason, In Network (Tier 1) Copay, In Network (Tier 1) Coinsurance"]
[5,"b",null,"If the benefit is “Preventive care/screening/immunization,” In Network (Tier 1) Copay and In Network (Tier 1) Coinsurance must be equal to “$0,” “0%,” or “No Charge.” If it is equal to any other value, mark as \"Not Met.\"","EHB Variance Reason, In Network (Tier 1) Copay, In Network (Tier 1) Coinsurance"]
[6,null,"Check MOOPs and deductibles against the annual limitations on cost sharing."]
[6,"a",null,"If Maximum Out of Pocket for Medical & Drug EHB Benefits (Total) In Network Individual is not equal to the annual dollar limitation specified by the 2021 Payment Notice or “Not Applicable,” mark as \"Not Met.\"","Maximum Out of Pocket for Medical & Drug EHB Benefits (Total) In Network Individual"]
[6,"b",null,"If Maximum Out of Pocket for Medical & Drug EHB Benefits (Total) In Network Individual is “Not Applicable,” Maximum Out of Pocket for Medical & Drug EHB Benefits (Total) Combined In/Out of Network Individual must be equal to the annual dollar limitation specified by the 2021 Payment Notice. If it is not, mark as \"Not Met.\"","Maximum Out of Pocket for Medical & Drug EHB Benefits (Total) In Network Individual, Maximum Out of Pocket for Medical & Drug EHB Benefits (Total) Combined In/Out of Network Individual"]
[6,"c",null,"If Maximum Out of Pocket for Medical & Drug EHB Benefits (Total) In Network Individual has a value other than “Not Applicable,” Maximum Out of Pocket for Medical & Drug EHB Benefits (Total) Combined In/Out of Network Individual must be equal to or greater than the value specified by the 2021 Payment Notice. If it is not, mark as \"Not Met.\"","Maximum Out of Pocket for Medical and Drug EHB Benefits (Total) In Network Individual, Maximum Out of Pocket for Medical & Drug EHB Benefits (Total) Combined In/Out of Network Individual"]
[6,"d",null,"If Maximum Out of Pocket for Medical & Drug EHB Benefits (Total) Out of Network Individual is not equal to or greater than the annual dollar limitation specified by the 2021 Payment Notice, mark as \"Not Met.\"","Maximum Out of Pocket for Medical & Drug EHB Benefits (Total) Out of Network Individual"]
[6,"e",null,"If Combined Medical & Drug EHB Deductible In Network Individual is not equal to the annual dollar limitation specified by the 2021 Payment Notice or “Not Applicable,” mark as \"Not Met.\"","Combined Medical & Drug EHB Deductible In Network Individual"]
[6,"f",null,"If Combined Medical & Drug EHB Deductible In Network Individual is “Not Applicable,” Combined Medical & Drug EHB Deductible Combined In/Out of Network Individual must be equal to the annual dollar limitation specified by the 2021 Payment Notice. If it is not, mark as \"Not Met.\"","Combined Medical & Drug EHB Deductible In Network Individual, Combined Medical & Drug EHB Deductible Combined In/Out of Network Individual"]
[6,"g",null,"If Combined Medical & Drug EHB Deductible In Network Individual has a value other than “Not Applicable,” Maximum Out of Pocket for Medical & Drug EHB Benefits (Total) Combined In/Out of Network Individual must be equal to or greater than the annual dollar limitation specified by the 2021 Payment Notice. If it is not, mark as \"Not Met.\"","Combined Medical & Drug EHB Deductible In Network Individual, Combined Medical & Drug EHB Deductible Combined In/Out of Network Individual"]
[6,"h",null,"If Combined Medical & Drug EHB Deductible Out of Network Individual is not equal to or greater than the annual dollar limitation specified by the 2021 Payment Notice, mark as \"Not Met.\"","Combined Medical & Drug EHB Deductible Out of Network Individual"]

{"sheet":"Non-Discrimination Cost Sharing","index":9,"n_rows":91,"n_cols":6,"rows_kept":91,"cut":false,"hidden":false,"merged":[[25,0,26,0],[36,0,38,0],[36,1,38,1],[36,2,38,2],[36,4,38,4],[29,0,30,0],[29,1,30,1],[29,4,30,4],[25,1,26,1],[25,2,26,2],[25,4,26,4],[27,0,28,0],[27,1,28,1],[27,2,28,2],[27,4,28,4],[31,4,32,4],[0,0,0,4],[10,0,18,0],[10,1,18,1],[10,2,18,2],[10,4,18,4],[8,0,8,4],[21,0,21,4],[23,0,24,0],[23,1,24,1],[23,2,24,2],[23,4,24,4],[31,1,32,1],[31,0,32,0],[39,0,42,0],[39,1,42,1],[39,2,42,2],[39,4,42,4],[49,0,50,0],[49,1,50,1],[49,2,50,2],[49,4,50,4],[51,0,54,0],[51,1,54,1],[51,2,54,2],[51,4,54,4],[66,0,67,0],[66,1,67,1],[66,2,67,2],[66,4,67,4],[68,4,69,4],[76,4,78,4],[79,0,80,0],[79,1,80,1],[79,2,80,2],[79,4,80,4],[76,0,78,0],[76,1,78,1],[76,2,78,2],[68,0,69,0],[68,1,69,1],[68,2,69,2]]}
["Discriminatory Cost Sharing Review Process Steps"]
[]
["There is a stand-alone tool available to assist in the non-discrimination review. The following explains the steps followed in the tool."]
[null,null,null,null,null,"Validation Results"]
[null,null,null,null,"HIOS Issuer ID:"]
[null,null,null,null,"Plan ID:"]
[null,null,null,null,"SELECT REVIEW RESULT:  "]
["Review","Review step","Review description and procedure","Step description","Source"]
["Perform the EHB Non-Discrimination Language Review Business Rules for all plans."]
[1,null,"Review Exclusions and Explanation (text field) for discriminatory language.",null,"Non-Discrimination Guidance"]
[1,"a",null,"Review that the Exclusions and Explanation fields do not contain limit information that contradicts information entered in the corresponding limit data elements:","Benefits 1-13: Exclusions, Explanation (text field), Limit Quantity, Limit Unit"]
[null,null,null,"¿ Limit Quantity"]
[null,null,null,"¿ Limit Unit."]
[null,null,null,"Also, review text for the following:"]
[null,null,null,"¿ Discriminatory language related to limits or exclusions"]
[null,null,null,"¿ Obvious policy violations"]
[null,null,null,"¿ Unlawful exclusions or limits."]
[null,null,null,"Pay special attention to the terms listed for EHB text review (see “Text Review Approach”). The list is not exhaustive; if any text in an Exclusions or Explanation field has one or more of the above characteristics, it may be discriminatory."]
[null,null,null,"EHB text review should focus on language related to limits or other restrictions to covered benefits. QHP text review should focus on language related to cost sharing."]
[1,"b",null,"If any discriminatory language was identified, check whether justification was submitted. "]
[1,"c",null,"If justification was not submitted or is insufficient based on policy criteria, mark as \"Not Met.\""]
["Perform the QHP Cost-Sharing and Language Non-Discrimination Review Business Rules for all plans."]
[1,null,"Determine whether the cost-sharing structure for each benefit for each plan is copayment, coinsurance, or both."]
[1,"a",null,"If benefit being checked uses a copay per day/stay (Inpatient Hospital Services, Mental/Behavioral Health Inpatient Services, and Substance Abuse Disorder Inpatient Services) use step 1b, otherwise use this step.\nCheck whether the plan has a copayment. The plan is considered to have a copayment if the copayment field contains any value not equal to “Not Applicable” and the coinsurance is 0. The specific fields to use for evaluation are below:\n","Copay In Network (Tier 1), Coinsurance In Network (Tier 1)"]
[null,null,null,"¿  If Copay In Network (Tier 1) is not empty and not equal to “Not Applicable” and Coinsurance In Network (Tier 1) is one of the following—empty, “No Charge,” “No Charge after deductible,” 0% “Coinsurance after deductible,” “Not Applicable,” or 0%—the plan is treated as having a copay. Treat “No Charge” and “No Charge after deductible” as $0 and include in the copay analysis. For all other entries, just extract the numeric value and treat them the same, regardless of wording. "]
[1,"b",null,"If benefit being checked does not use a copay per day/stay use step 1a, otherwise use this step.\nCheck whether the plan has a copayment. The plan is considered to have a copayment if the copayment field contains any value not equal to “Not Applicable” and the coinsurance is 0. The specific fields to use for evaluation are below:\n","Copay In Network (Tier 1), Coinsurance In Network (Tier 1)"]
[null,null,null,"¿  If Copay In Network (Tier 1) is not empty and not equal to “Not Applicable” and Coinsurance In Network (Tier 1) is one of the following—empty, “No Charge,” “No Charge after deductible,” 0% “Coinsurance after deductible,” “Not Applicable,” or 0%—the plan is treated as having a copay. Treat “No Charge” and “No Charge after deductible” as $0. This amount should be included in both the copay per day and copay per stay outlier threshold calculations; the plan itself should be evaluated against the per stay threshold. \n\nFor all other entries, extract the numeric value and treat them as either copay per day or copay per stay, depending on the text included in the field. If the copay text does not distinguish between per day or per stay —“Copay before deductible,” “Copay after deductible,” or “$X” —treat the plan as copay per stay."]
[1,"c",null,"Check whether the plan has coinsurance. The plan is considered as having coinsurance if the coinsurance field contains any value not equal to “Not Applicable” and copayment is equivalent to 0. Use the following fields:","Copay In Network (Tier 1), Coinsurance In Network (Tier 1)"]
[null,null,null,"¿ If Coinsurance In Network (Tier 1) is not empty and not equal to “Not Applicable” and Copay In Network (Tier 1) is one of the following—empty, “No Charge,” “No Charge after deductible,” $0, $0 “Copay after deductible,” “Not Applicable,” $0 “Copay before deductible,” “$0 Copay per Stay,” “$0 Copay per Stay after deductible,” “$0 Copay per Stay before deductible,” “$0 Copay per Day,” “$0 Copay per Day after deductible,” “$0 Copay per Day before deductible,”—the plan is treated as having coinsurance. Treat “No Charge” and “No Charge after deductible” as 0% and include it in the coinsurance analysis. For all other entries, extract the numeric value and treat them the same, regardless of wording. "]
[1,"d",null,"If benefit being checked uses a copay per day/stay (Inpatient Hospital Services, Mental/Behavioral Health Inpatient Services, and Substance Abuse Disorder Inpatient Services) use step 1e, otherwise use this step.\nUse this step if both copayment and coinsurance have a value not equivalent to 0 or “Not Applicable.” Use the following fields:\n","Copay In Network (Tier 1), Coinsurance In Network (Tier 1)"]
[null,null,null,"¿ If Copay In Network (Tier 1) has a value greater than 0 and not equal to “Not Applicable” for “Copay after deductible,” “Copay before deductible,” or “$X” and Coinsurance In Network (Tier 1) has a value greater than 0 and not equal to “Not Applicable” for “Coinsurance after deductible,” “Coinsurance before deductible,” or “X%,” assign the values to each copay and coinsurance and use the value in the corresponding analysis."]
[1,"e",null,"If benefit being checked does not use a copay per day/stay use step 1d, otherwise use this step.\nUse this step if both copayment and coinsurance have a value not equivalent to 0 or “Not Applicable.” Use the following fields:\n","Copay In Network (Tier 1), Coinsurance In Network (Tier 1)"]
[null,null,null,"¿ If Copay In Network (Tier 1) has a value greater than 0 and not equal to “Not Applicable” for “Copay after deductible,” “Copay before deductible,” “$X,” “Copay per Stay,” “Copay per Stay after deductible,” “Copay per Stay before deductible,” “Copay per Day,” “Copay per Day after deductible,” or “Copay per Day before deductible,” and Coinsurance In Network (Tier 1) has a value greater than 0 and not equal to “Not Applicable” for “Coinsurance after deductible,” “Coinsurance before deductible,” or “X%,” assign the values to each copay and coinsurance and use the value in the corresponding analysis.\n\nIf the copay text does not distinguish between per day or per stay —“Copay before deductible,” “Copay after deductible,” or “$X” —treat the plan as copay per stay.\n"]
[2,null,"Group plans by metal level."]
[2,"a",null,"Group plans by metal level for both the state and the national analyses. Only plans in the same metal level are compared for all cost-sharing review steps that follow.","Metal Level"]
[3,null,"If outlier thresholds need to be calculated and all initial submissions have been received for each benefit, group all plans with the same metal level that were determined to have a copay for that benefit and calculate the outlier thresholds at the national level. If outlier thresholds have already been calculated, proceed to the next review."]
[3,"a",null,"Analyze outliers for copay using the modified Tukey’s Test method, with","Copay In Network (Tier 1)"]
[null,null,null,"M = 1.5 for each cluster of plans with"]
[null,null,null,"N > = 5. If N < 5, return “No Result” for plans in that group."]
[3,"b",null,"Store the upper threshold for each benefit field/metal level combination that has"]
[null,null,null,"N > = 5."]
[null,null,null,"Inpatient Hospital Services, Mental/Behavioral Health Inpatient Services, and Substance Abuse Disorder Inpatient Services have to be handled differently from the other benefits."]
[null,null,null,"These three benefits have two separate copay outlier thresholds, one for “Copay per Stay” and one for “Copay per Day.” These two categories are too different to be compared with each other, so two separate thresholds are needed. Every other benefit needs only one copay threshold because all of the copays are similar and do not have the different designations of per day and per stay."]
[3,"c",null,"If any lower-value metal level has a threshold that is more stringent (lower) than a higher-value metal level for the same benefit, adjust the lower-value metal level’s threshold to be equal to the higher-value metal level’s threshold."]
[3,"d",null,"If any threshold is equal to 0, change to “No Result.”"]
[4,null,"Determine whether copay is an outlier at the national level for each benefit."]
[4,"a",null,"Compare Copay In Network (Tier 1) with the appropriate upper threshold stored from the initial outlier calculation.","Copay In Network (Tier 1)"]
[4,"b",null,"Flag all plans that have high outliers (above the upper threshold). If the threshold is “No Result,” the plan should receive “Not Applicable” because it cannot be tested."]
[5,null,"If outlier thresholds need to be calculated and all initial submissions have been received for each benefit, group all plans with the same metal level that were determined to have a copay for that benefit and calculate the outlier thresholds at the state level. If outlier thresholds have already been calculated, proceed to the next review."]
[5,"a",null,"Analyze outliers for copay by using the modified Tukey’s Test method with M = 1.5 for each cluster of plans with N > = 5. If","Copay In Network (Tier 1)"]
[null,null,null,"N < 5, return “No Result” for plans in that group."]
[5,"b",null,"Store the upper threshold for each benefit field/metal level combination that has"]
[null,null,null,"N > = 5."]
[null,null,null,"Inpatient Hospital Services, Mental/Behavioral Health Inpatient Services, and Substance Abuse Disorder Inpatient Services have to be handled differently from the other benefits. "]
[null,null,null,"These three benefits have two separate copay outlier thresholds, one for “Copay per Stay” and one for “Copay per Day.” These two categories are too different to be compared with each other, so two separate thresholds are needed. Every other benefit needs only one copay threshold because all of the copays are similar and do not have the different designations of per day and per stay."]
[5,"c",null,"If any lower-value metal level has a threshold that is more stringent (lower) than a higher-value metal level for the same benefit, adjust the lower-value metal level’s threshold to be equal to the higher-value metal level’s threshold.","Copay In Network (Tier 1)"]
[5,"d",null,"If any threshold is equal to 0, change to “No Result.”"]
[6,null,"Determine whether copay is an outlier at the state level for each benefit."]
[6,"a",null,"Compare Copay In Network (Tier 1) with the appropriate upper threshold stored from the initial outlier calculation.","Benefits 1–15: Copay In Network (Tier 1)"]
[6,"b",null,"Flag all plans that have high outliers (above the upper threshold). If the threshold is “No Result,” the plan should receive “Not Applicable” because it cannot be tested."]
[7,null,"Determine whether each plan is an outlier for the copay."]
[7,"a",null,"If a plan received a flag for a benefit copay at both the state and national levels, check whether the corresponding benefit is subject to the deductible."]
[7,"b",null,"A benefit is subject to the deductible if its copay and/or coinsurance fields contain the word “deductible.” For instance, if a plan’s Generic Drug copay is equal to “$10 before deductible,” then the Generic Drug benefit is subject to the deductible for that plan.","Copay In Network (Tier 1), Coinsurance In Network (Tier 1)"]
[7,"c",null,"If a benefit is not subject to the deductible (i.e., neither the copay nor coinsurance fields contain the word “deductible”), then the plan can be twice the corresponding outlier thresholds before it is marked as \"Not Met.\" If the benefit is still an outlier, check whether justification was submitted.","Copay In Network (Tier 1), Coinsurance In Network (Tier 1)"]
[7,"d",null,"If justification was not submitted or is insufficient based on policy criteria, the plan is marked as being an outlier for that benefit cost sharing. Plans that received a flag as outliers at both the state and national levels and that have no or insufficient justification are marked as \"Not Met.\""]
[8,null,"If outlier thresholds need to be calculated and all initial submissions have been received for each benefit, group all plans with the same metal level that were determined to have a coinsurance for that benefit and calculate the outlier thresholds at the national level. If outlier thresholds have already been calculated, proceed to the next review."]
[8,"a",null,"Analyze outliers for coinsurance using the modified Tukey’s Test method with M = 1.5 for each cluster of plans with N > = 5. If","Coinsurance In Network (Tier 1)"]
[null,null,null,"N < 5, return “No Result” for plans in that group."]
[8,"b",null,"Store the upper threshold for each benefit field/metal level combination that has"]
[null,null,null,"N > = 5."]
[8,"c",null,"If any lower-value metal level has a threshold that is more stringent (lower) than a higher-value metal level for the same benefit, adjust the lower-value metal level’s threshold to be equal to the higher-value metal level’s threshold."]
[8,"d",null,"If any threshold is equal to 0, change to “No Result.”"]
[9,null,"Determine whether each plan’s coinsurance is an outlier at the national level for each benefit."]
[9,"a",null,"Compare Coinsurance In Network (Tier 1) with the appropriate upper threshold stored from the initial outlier calculation.","Coinsurance In Network (Tier 1)"]
[9,"b",null,"Flag all plans that have high outliers (above the upper threshold). If the threshold is “No Result,” the plan should receive “Not Applicable” because it cannot be tested."]
[10,null,"If the outlier thresholds need to be calculated and all initial submissions have been received for each benefit, group all plans with the same metal level that were determined to have a coinsurance for that benefit and calculate the outlier thresholds at the state level. If outlier thresholds have already been calculated, proceed to the next review."]
[10,"a",null,"Analyze outliers for coinsurance by using the modified Tukey’s Test method with","Coinsurance In Network (Tier 1)"]
[null,null,null,"M = 1.5 for each cluster of plans with"]
[null,null,null,"N > = 5. If N < 5, return “No Result” for plans in that group."]
[10,"b",null,"Store the upper threshold for each benefit field/metal level combination that has"]
[null,null,null,"N > = 5."]
[10,"c",null,"If any lower-value metal level has a threshold that is more stringent (lower) than a higher-value metal level for the same benefit, adjust the lower-value metal level’s threshold to be equal to the higher-value metal level’s threshold."]
[10,"d",null,"If any threshold is equal to 0, change to “No Result.”"]
[11,null,"Determine whether coinsurance is an outlier at the state level for each benefit."]
[11,"a",null,"Compare Coinsurance In Network (Tier 1) with the appropriate upper threshold stored from the initial outlier calculation.","Copay In Network (Tier 1)"]
[11,"b",null,"Flag all plans that have high outliers (above the upper threshold). If the threshold is “No Result,” the plan should receive “Not Applicable” because it cannot be tested."]
[12,null,"Determine whether each plan is an outlier for coinsurance."]
[12,"a",null,"If a plan received a flag for a benefit coinsurance at the state and national levels, check whether the corresponding benefit is subject to the deductible."]
[12,"b",null,"A benefit is subject to the deductible if its copay and/or coinsurance fields contain the word “deductible.” For instance, if a plan’s generic drug copay is equal to “$10 before deductible,” then the generic drug benefit is subject to the deductible for that plan.","Benefits 1–15: Copay In Network (Tier 1), Coinsurance In Network (Tier 1)"]
[12,"c",null,"If a benefit is not subject to the deductible (i.e., neither the copay nor coinsurance fields contain the word “deductible”), then the coinsurance amount can be up to 90% before it is considered an outlier. If the benefit has still not passed the evaluation, check whether a justification was submitted.","Benefits 1–15: Copay In Network (Tier 1), Coinsurance In Network (Tier 1)"]
[12,"d",null,"If a justification was not submitted or is insufficient based on policy criteria, the plan is an outlier for that benefit cost sharing. Plans that received a flag at the state and national levels and have no justification or insufficient justification are \"Not Met.\""]

{"sheet":"Service Area","index":10,"n_rows":16,"n_cols":6,"rows_kept":16,"cut":false,"hidden":false,"merged":[[0,0,0,4]]}
["Service Area Review Process Steps"]
[null,null,null,null,null,"Validation Results"]
[null,null,null,null,"HIOS Issuer ID:"]
[null,null,null,null,"Service Area ID:"]
[null,null,null,null,"SELECT REVIEW RESULT:  "]
["Review","Review step","Review description and procedure","Step description","Source"]
[1,null,"Determine whether the Service Area ID is unique.",null,"Service Area Template"]
[1,"a",null,"Determine whether more than one row of service area information is provided. If no, go to review 2. If yes, go to the next step."]
[1,"b",null,"Determine whether the same Service Area ID is used for a service area that covers the entire state (“yes” response in column C) and for a service area that covers part of the state (“no” response in column C). If no, go to the next review. If yes, mark as \"Not Met,\" add comments where applicable, and go to the next review."]
[2,null,"Determine whether the Service Area ID is unique for medical and dental plans (dual issuers only).",null,"Service Area Template"]
[2,"a",null,"Determine whether the same Service Area ID is used for both a medical plan and a dental plan. If no, go to review 3. If yes, mark as \"Not Met,\" add comments where applicable, and go to the next review."]
[3,null,"Determine whether the service area includes a full or partial county.",null,"Service Area Template"]
[3,"a",null,"Check the Partial County column (E) in the Service Area Template. If “yes,” go to the next review. If “no,” add a general comment “no partial county,” finalize the section, and end the service area review."]
[4,null,"Determine whether the required partial county documents are uploaded.",null,"Service Area Supplemental Response and Evidence of State Approval"]
[4,"a",null,"Check whether the issuer uploaded the partial county supplemental response. If yes, proceed to the next step. If no, mark as \"Not Met,\" add comments where applicable, and go to the next step."]
[4,"b",null,"Check whether the issuer uploaded evidence of state approval. If yes, proceed to the next review. If no, mark as \"Not Met,\" add comments where applicable, and go to the next review."]

{"sheet":"Drop Down","index":11,"n_rows":6,"n_cols":103,"rows_kept":6,"cut":false,"hidden":true,"merged":[]}
["Review Result (Row 8)","Does Issuer Meet the Requirement? Yes/No/NA (Column F)","Missing Information or Other Elements/Criterion\n• 1-19\n• 20 (Review Step: a)\n• 24 (Review Step: b) \n• 24a, 24f, 24k, 24p (Review Steps: d-f) \n• 28 \n• 29e, 29j, 29n, 29o, 29s, 29t (Review Step: h)","Part A: New, Discontinuing, or Continuing QIS Submission; Part B: Issuer Information; Part C: Data Sources Used for Goal Identification and Monitoring Progress; Part D: QIS Summary","1-19 (see column c)",null,"Part E: QIS Requirements","20 (Review Step: a)","20 (Review Step: b)",null,21,null,22,null,"23a (Review Step: a) ","23a (Review Step: b) ","23b (Review Step: c) ","23c (Review Step: d ","23d (Review Step: e) ",null,"24 (Review Step: a) (Goal 1)","24a (Review Step: a)  (Goal 1, Measure 1a)","24a (Review Step: b)  (Goal 1, Measure 1a)","24a (Review Step: c)  (Goal 1, Measure 1a)","24b (Review Step: g) (Goal 1, Measure 1a)","24c (Review Steps: h, i) (Goal 1, Measure 1a)","24d (Review Step: j) (Goal 1, Measure 1a)","24e (Review Step: k) (Goal 1, Measure 1a)",null,"24f (Review Step: a) (Goal 1, Measure 1b)","24f (Review Step: b) (Goal 1, Measure 1b)","24f (Review Step: c) (Goal 1, Measure 1b)","24g (Review Step: g) (Goal 1, Measure 1b)","24h (Review Steps: h, i) (Goal 1, Measure 1b)","24i (Review Step: j) (Goal 1, Measure 1b)","24j (Review Step: k) (Goal 1, Measure 1b)",null,"24 (Review Steps: a-b) (Goal 2)","24k (Review Step: a) (Goal 2, Measure 2a)","24k (Review Step: b) (Goal 2, Measure 2a)","24k (Review Step: c) (Goal 2, Measure 2a)","24l (Review Step: g) (Goal 2, Measure 2a)","24m (Review Steps: h, i) (Goal 2, Measure 2a)","24n (Review Step: j) (Goal 2, Measure 2a)","24o (Review Step: k) (Goal 2, Measure 2a)",null,"24p (Review Step: a) (Goal 2, Measure 2b)","24p (Review Step: b) (Goal 2, Measure 2b)","24p (Review Step: c) (Goal 2, Measure 2b)","24q (Review Step: g) (Goal 2, Measure 2b)","24r (Review Step: h, i) (Goal 2, Measure 2b)","24s (Review Step: j) (Goal 2, Measure 2b)","24t (Review Step: k) (Goal 2, Measure 2b)",null,"25a (Review Step: a) ","25b (Review Step: b) ",null,"26a (Review Step: a) ","26b (Review Step: b) ",null,"Part F: QIS Modification Summary ","27a (Review Step: a) ","27b (Review Step: b) ","27c (Review Step: c) ",null,"28 (see column c)",null,"Part G: Progress Report Summary","29 (Review Step: a) (Goal 1)","29a (Review Step: a) (Goal 1, Measure 1a)","29b (Review Step: b) (Goal 1, Measure 1a)","29c (Review Step: c) (Goal 1, Measure 1a)","29d (Review Steps: d, e) (Goal 1, Measure 1a)","29e (Review Steps: f, g) (Goal 1, Measure 1a)",null,"29f (Review Step: a) (Goal 1, Measure 1b)","29g (Review Step: b) (Goal 1, Measure 1b)","29h (Review Step: c) (Goal 1, Measure 1b)","29i (Review Steps: d, e) (Goal 1, Measure 1b)","29j (Review Steps: f, g) (Goal 1, Measure 1b)",null,"29 (Review Step: a) (Goal 2) ","29k (Review Step: a) (Goal 2, Measure 2a)","29l (Review Step: b) (Goal 2, Measure 2a)","29m (Review Step: c) (Goal 2, Measure 2a)","29n (Review Steps: d, e) (Goal 2, Measure 2a)","29o (Review Steps: f, g) (Goal 2, Measure 2a)",null,"29p (Review Step: a) (Goal 2, Measure 2b)","29q (Review Step: b) (Goal 2, Measure 2b)","29r (Review Step: c) (Goal 2, Measure 2b)","29s (Review Steps: d, e) (Goal 2, Measure 2b)","29t (Review Steps: f, g) (Goal 2, Measure 2b)",null,"30 (Review Step: a) ","30 (Review Step: b) ","30 (Review Step: c) ",null,"31a (Review Step: a) ","31b (Review Step: b) ",null,"32a (Review Step: a) ","32b (Review Step: b) "]
["Meets","Yes","Missing Information  ",null,"Missing Information  ",null,null,"Element 20: The market-based incentive does not meet the QIS requirements.","Element 20: Provider “in-kind incentive” sub-type is checked, but description is not provided.",null,"Element 21: The topic area(s) selected for this QIS do not align with evidence supplied for other elements/criteria.",null,"Element 22: The rationale description is not clear about how the QIS addresses the needs of the current QHP enrollee population(s).",null,"Criterion 23a: Activities that will be implemented to achieve identified goal(s) are not provided.","Criterion 23a: The modified activities (as noted in Criterion 27b) are not reflected in Criterion 23a. If there were no modifications to the activities, then Criterion 27b should be updated. ","Criterion 23b: Activities provided do not relate to the selected market-based incentive (see Element 20).","Criterion 23c: Activities provided do not relate to the topic area(s) selected (see Element 21).","Criterion 23d: Issuer checked “Not Applicable,” but does not meet the “Not Applicable” conditions. Issuer must provide a description since the QIS includes activities in Criteria 23a that address health and health care disparities.",null,"Element 24 (Goal 1): Goal 1 does not match Goal 1 provided in Element 19.","Criterion 24a (Measure 1a): Measure name does not align with numerator and/or denominator.","Criterion 24a (Measure 1a): The modified measure name (as noted in Criterion 27c) is not reflected in Criterion 24a. If there were no modifications to Measure 1a, then Criterion 27c should be updated.","Criterion 24a (Measure 1a): Narrative description of the numerator and denominator is not provided.","Criterion 24b (Measure 1a): Description does not explain how Measure 1a supports Goal 1.","Criterion 24c (Measure 1a): Numerator and denominator do not calculate to the rate provided in the Baseline Assessment.","Criterion 24d (Measure 1a): Performance period is not clear how it relates to the QIS goal(s).","Criterion 24e (Measure 1a): Numerical value performance target is not provided.",null,"Criterion 24f (Measure 1b): Measure name does not align with numerator and/or denominator.","Criterion 24f (Measure 1b): The modified measure name (as noted in Criterion 27c) is not reflected in Criterion 24f. If there were no modifications to Measure 1b, then Criterion 27c should be updated. ","Criterion 24f (Measure 1b): Narrative description of the numerator and denominator is not provided.","Criterion 24g (Measure 1b): Description does not explain how Measure 1b supports Goal 1.","Criterion 24h (Measure 1b): Numerator and denominator do not calculate to the rate provided in the Baseline Assessment.","Criterion 24i (Measure 1b): Performance period is not clear how it relates to the QIS goal(s).","Criterion 24j (Measure 1b): Numerical value performance target is not provided.",null,"Element 24 (Goal 2): Goal 2 does not match Goal 2 provided in Element 19.","Criterion 24k (Measure 2a): Measure name does not align with numerator and/or denominator.","Criterion 24k (Measure 2a): The modified measure name (as noted in Criterion 27c) is not reflected in Criterion 24k. If there were no modifications to Measure 2a, then Criterion 27c should be updated.","Criterion 24k (Measure 2a): Narrative description of the numerator and denominator is not provided.","Criterion 24l (Measure 2a): Description does not explain how Measure 2a supports Goal 2.","Criterion 24m (Measure 2a): Numerator and denominator do not calculate to the rate provided in the Baseline Assessment.","Criterion 24n (Measure 2a): Performance period is not clear how it relates to the QIS goal(s).","Criterion 24o (Measure 2a): Numerical value performance target is not provided.",null,"Criterion 24p (Measure 2b): Measure name does not align with numerator and/or denominator.","Criterion 24p (Measure 2b): The modified measure name (as noted in Criterion 27c) is not reflected in Criterion 24p. If there were no modifications to Measure 2b, then Criterion 27c should be updated.","Criterion 24p (Measure 2b): Narrative description of the numerator and denominator is not provided.","Criterion 24q (Measure 2b): Description does not explain how Measure 2b supports Goal 2.","Criterion 24r (Measure 2b): Numerator and denominator do not calculate to the rate provided in the Baseline Assessment.","Criterion 24s (Measure 2b): Performance period is not clear how it relates to the QIS goal(s).","Criterion 24t (Measure 2b): Numerical value performance target is not provided.",null,"Criterion 25a: QIS Initiation/Start date invalid (date must be January 2020, or earlier, for continued QIS submissions and January 2021 for new QIS submissions, or earlier).","Criterion 25b: Milestone(s) are not related to activities described in Element 23.",null,"Criterion 26a: Barriers are not aligned with QIS.","Criterion 26b: Mitigation activities are not aligned with barriers provided in Criterion 26a.",null,null,"Criterion 27a: Issuer indicated that Goal 1 and/or Goal 2 were modified from the prior year’s QIS submission but did not describe modifications to goal(s). ","Criterion 27b: Issuer indicated that activities were modified from the prior year’s QIS submission but did not describe modifications to activities.  ","Criterion 27c: Issuer indicated that measures and/or associated performance targets were modified from the prior year’s QIS submission but did not describe modifications to measures or associated performance targets. ",null,"Missing information",null,null,"Element 29 (Goal 1): Goal 1 does not match what was indicated in Elements 19 and 24. If the issuer did not modify Goal 1 in Criterion 27a, Goal 1 should match in Elements 19, 24, and 29. ","Criterion 29a (Measure 1a): Performance period is not clear how it relates to the QIS goal(s).","Criterion 29b (Measure 1a): Performance period is not clear how it relates to the QIS goal(s).","Criterion 29c (Measure 1a): Measure name does not align with numerator and/or denominator.","Criterion 29d (Measure 1a): Numerator and denominator do not calculate to the rate provided.","Criterion 29e (Measure 1a): Numerator and denominator do not calculate to the rate provided.",null,"Criterion 29f (Measure 1b): Performance period is not clear how it relates to the QIS goal(s).","Criterion 29g (Measure 1b): Performance period is not clear how it relates to the QIS goal(s).","Criterion 29h (Measure 1b): Measure name does not align with numerator and/or denominator.","Criterion 29i (Measure 1b): Numerator and denominator do not calculate to the rate provided.","Criterion 29j (Measure 1b): Numerator and denominator do not calculate to the rate provided.",null,"Element 29 (Goal 2): Goal 2 does not match what was indicated in Elements 19 and 24. If the issuer did not modify Goal 2 in Criterion 27a, Goal 2 should match in Elements 19, 24, and 29.","Criterion 29k (Measure 2a): Performance period is not clear how it relates to the QIS goal(s).","Criterion 29l (Measure 2a): Performance period is not clear how it relates to the QIS goal(s).","Criterion 29m (Measure 2a): Measure name does not align with numerator and/or denominator.","Criterion 29n (Measure 2a): Numerator and denominator do not calculate to the rate provided.","Criterion 29o (Measure 2a): Numerator and denominator do not calculate to the rate provided.",null,"Criterion 29p (Measure 2b): Performance period is not clear how it relates to the QIS goal(s).","Criterion 29q (Measure 2b): Performance period is not clear how it relates to the QIS goal(s).","Criterion 29r (Measure 2b): Measure name does not align with numerator and/or denominator.","Criterion 29s (Measure 2b): Numerator and denominator do not calculate to the rate provided.","Criterion 29t (Measure 2b): Numerator and denominator do not calculate to the rate provided.",null,"Element 30: Explanation of why progress was or was not made toward the performance target(s) documented in Element 24 is not provided.","Criterion 30b: Issuer did not indicate whether the information provided here affects the decision to modify the QIS. ","Criterion 30c: Issuer did not indicate which elements and/or criteria were  updated based on PCA Notices. ",null,"Criterion 31a: Issuer checked “Yes,” that barriers were encountered, but did not accurately describe the barriers. ","Criterion 31b: Issuer checked “Yes,” that they encountered problems meeting timelines, but did not accurately describe the problems in meeting timelines.",null,"Criterion 32a: Mitigation activities are not aligned with barriers provided in Criterion 31a.","Criterion 32b: Mitigation activities are not aligned with problems meeting timelines provided in Criterion 31b."]
["Does Not Meet","No","Other",null,"Other",null,null,"Missing Information","Element 20: Provider “other” sub-type is checked, but description is not provided.",null,"Missing Information",null,"Element 22: The rationale description does not define the current QHP enrollee population(s).",null,"Criterion 23a: The activities provided do not align with identified goal(s).",null,"Criterion 23b: Description of how the activities relate to the market-based incentive does not match the activities listed in Criterion 23a.","Criterion 23c: Description of how the activities relate to the topic area(s) does not match the activities listed in Criterion 23a.","Criterion 23d: The description that the issuer provided did not adequately describe how it will address health and health care disparities.",null,"Element 24 (Goal 1): Relationship of Goal 1 to the selected topic area(s) is not clear.","Missing Information",null,"Criterion 24a (Measure 1a): Narrative description of the numerator is not provided.","Criterion 24b (Measure 1a): Description of how Measure 1a supports tracking of performance is not related to Goal 1.","Criterion 24c (Measure 1a): It is unclear how the value(s) provided relate(s) to the Baseline Assessment/Calculated Rate.  ","Criterion 24d (Measure 1a): Baseline performance period should start prior to implementation of the QIS.","Criterion 24e (Measure 1a): It is unclear how the performance target provided relates to the Baseline Assessment.",null,"Missing Information",null,"Criterion 24f (Measure 1b): Narrative description of the numerator is not provided.","Criterion 24g (Measure 1b): Description of how Measure 1b supports tracking of performance is not related to Goal 1.","Criterion 24h (Measure 1b): It is unclear how the value(s) provided relate(s) to the Baseline Assessment/Calculated Rate. ","Criterion 24i (Measure 1b): Baseline performance period should start prior to implementation of the QIS.","Criterion 24j (Measure 1b): It is unclear how the performance target provided relates to the Baseline Assessment.",null,"Element 24 (Goal 2): Relationship of Goal 2 to selected topic area(s) is not clear.","Missing Information",null,"Criterion 24k (Measure 2a): Narrative description of the numerator is not provided.","Criterion 24l (Measure 2a): Description of how Measure 2a supports tracking of performance is not related to Goal 2.","Criterion 24m (Measure 2a): It is unclear how the value(s) provided relate(s) to the Baseline Assessment/Calculated Rate.","Criterion 24n (Measure 2a): Baseline performance period should start prior to implementation of the QIS.","Criterion 24o (Measure 2a): It is unclear how the performance target provided relates to the Baseline Assessment.",null,"Missing Information",null,"Criterion 24p (Measure 2b): Narrative description of the numerator is not provided.","Criterion 24q (Measure 2b): Description of how Measure 2b supports tracking of performance is not related to Goal 2.","Criterion 24r (Measure 2b): It is unclear how the value(s) provided relate(s) to the Baseline Assessment/Calculated Rate. ","Criterion 24s (Measure 2b): Baseline performance period should start prior to implementation of the QIS.","Criterion 24t (Measure 2b): It is unclear how the performance target provided relates to the Baseline Assessment.",null,"Missing Information","Missing Information",null,"Criterion 26a: No barriers were listed but issuer did not describe how they assessed risk.","Missing Information",null,null,"Criterion 27a: Issuer indicated that Goal 1 and/or Goal 2 were modified from the prior year’s QIS submission but did not provide a rationale for the modifications.","Criterion 27b: Issuer indicated that activities were modified from the prior year’s QIS submission but did not provide a rationale for the modifications.","Criterion 27c: Issuer indicated that measures and/or associated performance targets were modified from the prior year’s QIS submission but did not provide a rationale for the modifications.",null,"Other",null,null,"Element 29 (Goal 1): Relationship of Goal 1 to the selected topic area(s) (Element 21) is not clear.","Criterion 29a (Measure 1a): Baseline performance period does not match what was indicated in Criterion 24d. If the issuer did not modify Measure 1a in Criterion 27c, Measure 1a baseline performance periods should match in Criterion 29a and Criterion 24d.","Criterion 29b (Measure 1a): Issuer indicated the same timeframe for their Baseline (Criterion 29a) and Progress Report (Criterion 29b) performance periods. ","Criterion 29c (Measure 1a): Measure 1a name does not match what was indicated in Criterion 24a. If the issuer did not modify Measure 1a in Criterion 27c, Measure 1a name should match in Criterion 29c and Criterion 24a.","Criterion 29d (Measure 1a): It is unclear how the value(s) provided relate(s) to the Baseline Assessment/Calculated Rate. ","Criterion 29e (Measure 1a): It is unclear how the value(s) provided relate(s) to the Baseline Assessment/Calculated Rate. ",null,"Criterion 29f (Measure 1b): Baseline performance period does not match what was indicated in Criterion 24i. If the issuer did not modify Measure 1b in Criterion 27c, Measure 1b baseline performance period should match in Criterion 29f and Criterion 24i.","Criterion 29g (Measure 1b): Issuer indicated the same timeframe for their Baseline (Criterion 29f) and Progress Report (Criterion 29g) performance periods. ","Criterion 29h (Measure 1b): Measure 1b name does not match what was indicated in Criterion 24f. If the issuer did not modify Measure 1b in Criterion 27c, Measure 1b name should match in Criterion 29h and Criterion 24f.","Criterion 29i (Measure 1b): It is unclear how the value(s) provided relate(s) to the Baseline Assessment/Calculated Rate. ","Criterion 29j (Measure 1b): It is unclear how the value(s) provided relate(s) to the Baseline Assessment/Calculated Rate. ",null,"Element 29 (Goal 2): Relationship of Goal 2 to the selected topic area(s) is not clear.","Criterion 29k (Measure 2a): Baseline performance period does not match what was indicated in Criterion 24n. If the issuer did not modify Measure 2a in Criterion 27c, Measure 2a baseline performance period should match in Criterion 29k and Criterion 24n.","Criterion 29l (Measure 2a): Issuer indicated the same timeframe for their Baseline (Criterion 29k) and Progress Report (Criterion 29l) performance periods. ","Criterion 29m (Measure 2a): Measure 2a name does not match what was indicated in Criterion 24k. If the issuer did not modify Measure 2a in Criterion 27c, Measure 2a name should match in Criterion 29m and Criterion 24k.","Criterion 29n (Measure 2a): It is unclear how the value(s) provided relate(s) to the Baseline Assessment/Calculated Rate. ","Criterion 29o (Measure 2a): It is unclear how the value(s) provided relate(s) to the Baseline Assessment/Calculated Rate. ",null,"Criterion 29p (Measure 2b): Baseline performance period does not match what was indicated in Criterion 24s. If the issuer did not modify Measure 2b in Criterion 27c, Measure 2b baseline performance periods should match in Criterion 24s and Criterion 29p.","Criterion 29q (Measure 2b): Issuer indicated the same timeframe for their Baseline (Criterion 29a) and Progress Report (Criterion 29q) performance periods. ","Criterion 29r (Measure 2b): Measure 2b name does not match what was indicated in Criterion 24p. If the issuer did not modify Measure 2b in Criterion 27c, Measure 2b name should match in Criterion 29r and Criterion 24p. ","Criterion 29s (Measure 2b): It is unclear how the value(s) provided relate(s) to the Baseline Assessment/Calculated Rate. ","Criterion 29t (Measure 2b): It is unclear how the value(s) provided relate(s) to the Baseline Assessment/Calculated Rate. ",null,"Element 30: Explanation of why progress was or was not made toward the performance target(s) documented in Element 24 does not include a description of activities that led to the outcome. ","Missing Information","Criterion 30c: Issuer did not describe the changes made to elements and/or criteria they were instructed to address based on PCA Notices. ",null,"Criterion 31a: Barriers are not aligned with the QIS.","Missing Information",null,"Criterion 32a: Mitigation activities are not provided for each of the barriers identified. ","Missing Information"]
["Interim Meets","NA",null,null,null,null,null,null,"Element 20: Enrollee “other” sub-type is checked, but description is not provided.",null,null,null,"Missing Information",null,null,null,"Missing Information","Missing Information","Missing Information",null,"Element 24 (Goal 1): Relationship of Goal 1 to the identified measure(s) is not clear.",null,null,"Criterion 24a (Measure 1a): Narrative description of the denominator is not provided.","Criterion 24b (Measure 1a): Description of how the measure supports tracking of performance does not match measure listed in Criterion 24a.","Criterion 24c (Measure 1a): Baseline assessment results should measure an issuer’s performance prior to implementation of the QIS.","Missing Information","Criterion 24e (Measure 1a): It is unclear what the numerical value performance target represents (e.g., percentage, count, ratio, proportion).",null,null,null,"Criterion 24f (Measure 1b): Narrative description of the denominator is not provided.","Criterion 24g (Measure 1b): Description of how the measure supports tracking of performance does not match measure listed in Criterion 24f.","Criterion 24h (Measure 1b): Baseline assessment results should measure an issuer’s performance  prior to implementation of the QIS.","Missing Information","Criterion 24j (Measure 1b): It is unclear what the numerical value performance target represents (e.g., percentage, count, ratio, proportion).",null,"Element 24 (Goal 2): Relationship of Goal 2 to identified measure(s) is not clear.",null,null,"Criterion 24k (Measure 2a): Narrative description of the denominator is not provided.","Criterion 24l (Measure 2a): Description of how the measure supports tracking of performance does not match measure listed in Criterion 24k.","Criterion 24m (Measure 2a): Baseline assessment results should measure an issuer’s performance prior to implementation of the QIS.","Missing Information","Criterion 24o (Measure 2a): It is unclear what the numerical value performance target represents (e.g., percentage, count, ratio, proportion).",null,null,null,"Criterion 24p (Measure 2b): Narrative description of the denominator is not provided.","Criterion 24q (Measure 2b): Description of how the measure supports tracking of performance does not match measure listed in Criterion 24p.","Criterion 24r (Measure 2b): Baseline assessment results should measure an issuer’s performance prior to implementation of the QIS.","Missing Information","Criterion 24t (Measure 2b): It is unclear what the numerical value performance target represents (e.g., percentage, count, ratio, proportion).",null,null,null,null,"Missing Information",null,null,null,"Missing Information","Missing Information","Missing Information",null,null,null,null,"Element 29 (Goal 1): Relationship of Goal 1 to the identified measure(s) is not clear.","Missing Information","Missing Information","Missing Information","Criterion 29d (Measure 1a): Baseline results do not match what was indicated in Criterion 24c. If the issuer did not modify Measure 1a in Criterion 27c, Measure 1a baseline results should match in Criterion 29d and Criterion 24c.","Criterion 29e (Measure 1a): It is unclear how the value(s) provided relate(s) to the follow-up results.",null,"Missing Information","Missing Information","Missing Information","Criterion 29i (Measure 1b): Baseline results do not match what was indicated in Criterion 24h. If the issuer did not modify Measure 1b in Criterion 27c, Measure 1b baseline results should match in Criterion 29i and Criterion 24h.","Criterion 29j (Measure 1b): It is unclear how the value(s) provided relate(s) to the follow-up results.",null,"Element 29 (Goal 2): Relationship of Goal 2 to the identified measure(s) is not clear.","Missing Information","Missing Information","Missing Information","Criterion 29n (Measure 2a): Baseline results do not match what was indicated in Criterion 24m. If the issuer did not modify Measure 2a in Criterion 27c, Measure 2a baseline results should match in Criterion 29n  and Criterion 24m.","Criterion 29o (Measure 2a): It is unclear how the value(s) provided relate(s) to the follow-up results.",null,"Missing Information","Missing Information","Missing Information","Criterion 29s (Measure 2b): Baseline results do not match what was indicated in Criterion 24r. If the issuer did not modify Measure 2b in Criterion 27c, Measure 2b baseline results should match in Criterion 29s and Criterion 24r. ","Criterion 29t (Measure 2b): It is unclear how the value(s) provided relate(s) to the follow-up results.",null,"Element 30: Issuer did not indicate whether the information provided here affects the decision to modify or change the QIS (Part F: QIS Modification Summary).","Other","Missing Information",null,"Missing Information",null,null,"Missing Information"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Element 24 (Goal 1): The modified Goal 1 (as noted in Criterion 27a) is not provided in Element 24. If there were no modifications to Goal 1, then Criterion 27a should be updated. ",null,null,"Criterion 24a (Measure 1a): Numerator and/or denominator does not align with Measure 1a name.","Missing Information","Missing Information",null,"Criterion 24e (Measure 1a): The modified Performance Target (as noted in Criterion 27c) is not provided in Criterion 24e. If there were no modifications to Measure 1a, then Criterion 27c should be updated.",null,null,null,"Criterion 24f (Measure 1b): Numerator and/or denominator does not align with Measure 1b name.","Missing Information","Missing Information",null,"Criterion 24j (Measure 1b): The modified Performance Target (as noted in Criterion 27c) is not provided in Criterion 24j. If there were no modifications to Measure 1b, then Criterion 27c should be updated.",null,"Element 24 (Goal 2): The modified Goal 2 (as noted in Criterion 27a) is not provided in Element 24. If there were no modifications to Goal 2, then Criterion 27a should be updated.",null,null,"Criterion 24k (Measure 2a): Numerator and/or denominator does not align with Measure 2a name.","Missing Information","Missing Information",null,"Criterion 24o (Measure 2a): The modified Performance Target (as noted in Criterion 27c) is not provided in Criterion 24o. If there were no modifications to Measure 2a, then Criterion 27c should be updated.",null,null,null,"Criterion 24p (Measure 2b): Numerator and/or denominator does not align with Measure 2b name.","Missing Information","Missing Information",null,"Criterion 24t (Measure 2b): The modified Performance Target (as noted in Criterion 27c) is not provided in Criterion 24t. If there were no modifications to Measure 2b, then Criterion 27c should be updated.",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Missing information",null,null,null,"Criterion 29d (Measure 1a): Issuer indicated the same baseline results (Criterion 29d) and follow-up results (Criterion 29e).","Criterion 29e (Measure 1a): Numerator and denominator do not calculate to the rate provided.",null,null,null,null,"Criterion 29i (Measure 1b): Issuer indicated the same baseline results (Criterion 29i) and follow-up results (Criterion 29j).","Missing information",null,"Element 29 (Goal 2): Goal 2 does not match what was indicated in Elements 19 and 24. If the issuer did not modify Goal 2 in Criterion 27a, Goal 2 should match in Elements 19, 24, and 29.",null,null,null,"Criterion 29n (Measure 2a): Issuer indicated the same baseline results (Criterion 29n) and follow-up results (Criterion 29o).","Missing information",null,null,null,null,"Criterion 29s (Measure 2b): Issuer indicated the same baseline results (Criterion 29s) and follow-up results (Criterion 29t).","Missing information",null,null,null,"Other"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Missing Information",null,null,"Criterion 24a (Measure 1a): Relationship of Measure 1a to Goal 1 is not clear.",null,null,null,null,null,null,null,"Criterion 24f (Measure 1b): Relationship of Measure 1b to Goal 1 is not clear.",null,null,null,null,null,"Missing Information",null,null,"Criterion 24k (Measure 2a): Relationship of Measure 2a to Goal 2 is not clear.",null,null,null,null,null,null,null,"Criterion 24p (Measure 2b): Relationship of Measure 2b to Goal 2 is not clear.",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Missing information","Missing information",null,null,null,null,"Missing information",null,null,"Missing information",null,null,null,"Missing information",null,null,null,null,null,"Missing information"]

{"sheet":"MOOP Details","index":12,"n_rows":29,"n_cols":6,"rows_kept":29,"cut":false,"hidden":false,"merged":[[4,1,4,5],[0,1,0,5],[0,7,0,11],[1,1,1,5],[2,1,2,5],[3,1,3,5],[5,1,5,5],[6,1,6,5],[9,1,10,1],[9,2,10,2],[9,3,10,3],[9,4,10,4],[9,7,10,7],[9,8,10,8],[9,9,10,9],[9,10,10,10],[12,1,13,1],[12,2,13,2],[12,3,13,3],[12,4,13,4],[12,7,13,7],[12,8,13,8],[12,9,13,9],[12,10,13,10],[15,1,16,1],[15,2,16,2],[15,3,16,3],[15,4,16,4],[15,7,16,7],[15,8,16,8],[15,9,16,9],[15,10,16,10],[18,9,19,9],[18,10,19,10],[18,8,19,8],[18,1,19,1],[18,2,19,2],[18,3,19,3],[18,4,19,4],[18,7,19,7]]}
[null,"Maximum Out of Pocket Details"]
[]
[null,"This table shows you which data elements to compare against the MOOP thresholds when doing the MOOP Review. Go through each column to find the row with the combination of the fields that apply to a particular plan, and then compare the data elements in column F to the threshold."]
[null,"The \"Integrated/separate (medical and drug)\" column indicates whether the medical and drug MOOP are integrated or separate."]
[null,"The \"Individual/family\" column indicates whether you're looking to compare the individual MOOP or the family MOOP."]
[null,"The \"Tier/no tier (in network)\" column indicates whether the plan has multiple in-network tiers (\"Tier\") or only one in netowrk tier (\"No Tier\")"]
[null,"The \"Combined in and out of network\" column indicates whether the plan is using the combined In and Out of Network MOOP, as indicated by \"Not Applicable\" being entered for the In Network MOOP fields (\"Yes\") or has separate In Network and Out of Network MOOPs (\"No\")."]
[]
[null,"Integrated/ separate (medical and drug)","Individual/ family","Tier/no tier (in network","Combined in and out of network","Data element to compare against thresholds"]
[null,"Integrated","Individual","Tier","No","Maximum Out of Pocket for Medical and Drug EHB Benefits (Total) In Network Individual"]
[null,null,null,null,null,"Maximum Out of Pocket for Medical and Drug EHB Benefits (Total) In Network (Tier 2) Individual"]
[null,"Integrated","Individual","No tier","No","Maximum Out of Pocket for Medical and Drug EHB Benefits (Total) In Network Individual"]
[null,"Integrated","Family","Tier","No","Maximum Out of Pocket for Medical and Drug EHB Benefits (Total) In Network Family"]
[null,null,null,null,null,"Maximum Out of Pocket for Medical and Drug EHB Benefits (Total) In Network (Tier 2) Family"]
[null,"Integrated","Family","No tier","No","Maximum Out of Pocket for Medical and Drug EHB Benefits (Total) In Network Family"]
[null,"Separate","Individual","Tier","No","Maximum Out of Pocket for Medical EHB Benefits for In Network Individual + Maximum Out of Pocket for Drug EHB Benefits for In Network Individual"]
[null,null,null,null,null,"Maximum Out of Pocket for Medical EHB Benefits for In Network (Tier 2) Individual + Maximum Out of Pocket for Drug EHB Benefits for In Network (Tier 2) Individual"]
[null,"Separate","Individual","No tier","No","Maximum Out of Pocket for Medical EHB Benefits for In Network Individual + Maximum Out of Pocket for Drug EHB Benefit In Network Individual"]
[null,"Separate","Family","Tier","No","Maximum Out of Pocket for Medical EHB Benefits for In Network Family + Maximum Out of Pocket for Drug EHB Benefits for In Network (Tier 2) Family"]
[null,null,null,null,null,"Maximum Out of Pocket for Medical EHB Benefits for In Network (Tier 2) Family + Maximum Out of Pocket for Drug EHB Benefits for In Network (Tier 2) Family"]
[null,"Separate","Family","No tier","No","Maximum Out of Pocket for Medical EHB Benefits for In Network Family + Maximum Out of Pocket for Drug EHB Benefits for In Network (Tier 2) Family"]
[null,"Integrated","Individual","Tier","Yes","Maximum Out of Pocket for Medical and Drug EHB Benefits (Total) Combined In/Out of Network Individual"]
[null,"Integrated","Individual","No tier","Yes","Maximum Out of Pocket for Medical and Drug EHB Benefits (Total) Combined In/Out of Network Individual"]
[null,"Integrated","Family","Tier","Yes","Maximum Out of Pocket for Medical and Drug EHB Benefits (Total) Combined In/Out of Network Family"]
[null,"Integrated","Family","No tier","Yes","Maximum Out of Pocket for Medical and Drug EHB Benefits (Total) Combined In/Out of Network Family"]
[null,"Separate","Individual","Tier","Yes","Maximum Out of Pocket for EHB Benefits for Combined In/Out of Network Individual + Maximum Out of Pocket for Drug EHB Benefits for Combined In/Out of Network Individual "]
[null,"Separate","Individual","No tier","Yes","Maximum Out of Pocket for EHB Benefits for Combined In/Out of Network Individual + Maximum Out of Pocket for Drug EHB Benefits for Combined In/Out of Network Individual "]
[null,"Separate","Family","Tier","Yes","Maximum Out of Pocket for EHB Benefits for Combined In/Out of Network Family + Maximum Out of Pocket for Drug EHB Benefits for Combined In/Out of Network Family"]
[null,"Separate","Family","No tier","Yes","Maximum Out of Pocket for EHB Benefits for Combined In/Out of Network Family + Maximum Out of Pocket for Drug EHB Benefits for Combined In/Out of Network Family"]

{"sheet":"Tukey Outlier Overview","index":13,"n_rows":12,"n_cols":2,"rows_kept":12,"cut":false,"hidden":false,"merged":[]}
[]
[null,"Non-Discrimination Review Outlier Methodology"]
[null,"The outlier test used for the Non-Discrimination Cost-Sharing Outlier and Non-Discrimination Formulary Outlier reviews is a modified version of Tukey’s Outlier Test1. Tukey’s Outlier Test (also known as Tukey’s Outlier Filter or Tukey’s Method) uses quartiles to determine the outliers in a given data set. It is a commonly utilized outlier test due to its ease of use and applicability to a variety of analyses. Tukey’s Outlier Test can be used regardless of data distribution, while most other outlier tests require advance knowledge or assumptions about the data distribution."]
[null,"To find outliers, the test first finds the interquartile range (IQR) of the data set: the middle 50 percent of the data set, or the 75th percentile (Q3) minus the 25th percentile (Q1). The IQR is then multiplied by a multiplier (M), subtracted from Q1, and added to Q3. The two most commonly used multiplier values are 1.5 and 2.0 (1.5 is the default value used in the tools). The two resulting values then set the bounds for what is considered an outlier. (Anything outside of the bounds is an outlier, and anything inside the bounds is not an outlier.) Expressed mathematically, the two bounds are calculated as follows:"]
[null,"IQR = Q3 – Q1."]
[null,"Lower Bound (LB) = Q1 – (M × IQR)."]
[null,"Upper Bound (UB) = Q3 + (M × IQR)."]
[null,"One flaw of using the IQR is the potential for a zero IQR if too many data points have the same value. A zero IQR makes it impossible to identify outliers using the method described above. Although the chances of this occurring are low, it does present a potential issue. The test used for the reviews modifies Tukey's Outlier Test so that if an IQR is initially equal to zero, Q1 will be multiplied by 0.75, and Q3 will be multiplied by 1.25. This will create a spread between Q1 and Q3 and make a non-zero IQR. The rest of the test will then be performed as described above."]
[null,"Another flaw of Tukey's Outlier Test is that there needs to be at least 5 data points in a data grouping to calculate outlier bounds. If there are 4 data points or less in a data grouping, none of the data points in that grouping can be evaluated."]
[null,"Any value below the LB is considered a “low outlier,” while any value above the UB is considered a “high outlier.” For the Non-Discrimination Cost-Sharing Outlier review, Tukey’s Outlier Test is used to identify high outliers in the cost sharing fields. For the Non-Discrimination Formulary Outlier review, Tukey’s Outlier Test is used to identify low outliers in the number of un-restricted drugs for various USP classes. The test is often displayed as a “box-and-whiskers plot,” as shown below."]
[]
[null,"[1] David Hoaglin, Frederick Mosteller, and John Tukey, eds., Understanding Robust and Exploratory Data Analysis (New York: John Wiley & Sons, 1983), p. 39, 54, 62, 223."]

{"sheet":"Non-Discrimination Guidance","index":14,"n_rows":30,"n_cols":6,"rows_kept":30,"cut":false,"hidden":false,"merged":[[12,1,12,5],[0,1,0,5],[2,1,2,5],[3,1,3,5],[4,1,4,5],[5,1,5,5],[6,1,6,5],[7,1,7,5],[8,1,8,5],[9,1,9,5],[10,1,10,5],[11,1,11,5],[13,1,13,5],[14,1,14,5],[22,1,24,1],[22,2,23,2],[28,1,29,1]]}
[null,"Non-Discrimination in Benefit Design "]
[]
[null,"The intent of this guidance is to clarify non-discrimination standards and provide examples of benefit design that are potentially discriminatory under the Affordable Care Act. Ultimately, the regulator that reviews essential health benefits (EHB) and/or qualified health plan (QHP) non-discrimination will determine if a plan design is a discriminatory practice.  "]
[null,"The Affordable Care Act enacted standards that protect consumers from discrimination based on age, expected length of life, present or predicted disability, degree of medical dependency, quality of life, or health condition and prohibit issuers from designing benefits or marketing QHPs in a manner that would discourage individuals with significant health care needs from enrolling in QHPs. In addition, The Public Health Service Act (PHS) Section 2711, generally prohibits individual and group health plans from imposing lifetime or annual dollar limits on essential health benefits (listed below) offered under the plan or coverage.  Furthermore, with respect to plans that must provide coverage of the EHB package, issuers may not impose benefit-specific waiting periods, except in covering pediatric orthodontia, in which case any waiting periods must be reasonable pursuant to §156.125 and providing EHB.  It is also important to note that benefit designs must meet the Mental Health Parity and Addiction Equity Act (MHPAEA) requirements."]
[null,"The Essential Health Benefits:\n(1) ambulatory patient services; (2) emergency services;(3) hospitalization; (4) maternity and newborn care;(5) mental health and substance use disorder services including behavioral health treatment; (6) prescription drugs; (7) rehabilitative and habilitative services and devices;(8) laboratory services;(9) preventive and wellness services and chronic disease management; and (10) pediatric services, including oral and vision care."]
[null,"The Affordable Care Act and implementing regulations prohibit discrimination through the design of benefits, but also state that issuers should not be prevented from employing benefit designs that encourage efficient utilization and reasonable medical management techniques.  A number of benefit design features are utilized in the context of medical management, including but not limited to: "]
[null,"·         Exclusions"]
[null,"·         Cost-sharing"]
[null,"·         Medical necessity determinations"]
[null,"·         Drug formularies"]
[null,"·         Visit limits"]
[null,"·         Benefit substitution"]
[null,"·         Utilization management"]
[null,"Each of these features has the potential to be either discriminatory or an important element in a QHP’s quality and affordability, depending on how the feature is designed and administered.  CMS has identified examples of potentially discriminatory benefit design within each of these domains, as well as best practices for minimizing the discriminatory potential of these features (see Table 1). These examples are not definitively discriminatory.  As potential discrimination is assessed, issuers should consider the design of singular benefits in the context of the plan as a whole, taking into account all plan features, including maximum out of pocket (MOOP) limits. "]
[null,"Furthermore, issuers should note that EHB-benchmark plans are based on 2012 plan designs and do not necessarily reflect non-discrimination standards effective for plan years beginning on or after January 1, 2014.  When designing plans that are substantially equal to the EHB-benchmark plans, issuers should therefore ensure that benefit design also complies with the aforementioned non-discrimination requirements.  "]
[]
[null,"Examples of Potentially Discriminatory Benefit Design"]
[null,"Note. This is not an exhaustive list of examples of potentially discriminatory benefit designs.  "]
[null,"Domains","Example Benefit","Potentially Discriminatory Benefit Design Example","Reason Example Benefit Design is Potentially Discriminatory","Possible Method for Minimizing the Potential for Discrimination for the Example Provided"]
[null,"Exclusions","Transplant","Bone marrow transplants are excluded from transplant coverage, regardless of medical necessity","Excluding bone marrow transplants regardless of medical necessity may discriminate against individuals with specific conditions, including certain cancers and immune deficiency disorders, for which this procedure is a medically necessary treatment","Transplant coverage is dictated by medical evidence and consideration of patient history"]
[null,"Cost-Sharing","Emergency Room Services","Emergency room services with  significantly increasing cost-sharing burden as the number of visits increases","Increasing the cost-sharing burden with increasing emergency room visits may discriminate against individuals with certain medical conditions that reasonably necessitate more frequent emergency room usage (for example, but not limited to, asthma, sickle cell anemia, heart failure)","Emergency room services cost-sharing design that is not contingent on the frequency of service utilization "]
[null,"Medical Necessity Definitions","Speech Therapy","Medical necessity for rehabilitative speech therapy services that is defined with the use of restrictive phrases such as “recovery of lost function” or “restoration to previous levels of functioning” when habilitative speech therapy is not covered","Defining medical necessity for rehabilitative speech therapy with restrictive phrases may discriminate against individuals with health conditions that would benefit from this therapy in order to improve functionality that may have never been present (e.g. individuals with cerebral palsy) and/or to prevent further deterioration of function (e.g. multiple sclerosis)","Medical necessity for rehabilitative speech therapy services includes coverage for all conditions in which medical evidence supports the use of speech therapy services, regardless of whether this service is used to recover lost function, improve functionality that was never present, or to prevent further deterioration of function "]
[null,"Drug Formularies","Non-Preferred Brand/Specialty Drugs","Requiring consumers to receive  specialty medications particularly for certain medical conditions from mail-order pharmacies and not allowing the use of retail pharmacies  ","Eliminating access to certain specialty medications through retail pharmacies may discriminate against individuals with significant health care needs or with certain conditions, such as rheumatoid arthritis, who are eligible to receive discounts on those drugs through retail pharmacies ","Permitting consumers to use retail pharmacies when discounts are available and the cost-sharing is lower than the mail-order pharmacy option "]
[null,null,null,"Denying coverage for a single-tablet drug regimen or extended-release product that is customarily prescribed and is as effective as a multi-tablet regimen.","Without a medically appropriate reason for denial, this plan design effectively discriminates against, or discourages enrollment by, individuals who would benefit from such therapeutic options.","Allow drug regimen options for single tablet or extended-release products that benefit individuals with certain medical conditions when they are medically effective and appropriate."]
[null,null,"Non-Preferred Brand/Specialty Drugs","Placing expensive life-saving or life-prolonging drugs, for which there is no generic and/or less expensive comparable alternative treatment, in tiers with high consumer cost-sharing ","Placing high consumer cost-sharing on life-saving or life-prolonging drugs may discriminate against individuals with conditions such as HIV/AIDS for which these drugs are a necessary treatment    ","Structuring prescription drug cost-sharing design in manner that does not place disproportionate burden on individuals with specific conditions "]
[null,"Age Limits","Hearing Aids","Arbitrary age limit for hearing aids to those who are 6 years of age and younger","Age limits are discriminatory when applied to services that have been found clinically effective at all ages","Providing coverage for hearing aids based on medical necessity"]
[null,"Visit Limits","Outpatient Rehabilitation Services","The number of covered outpatient rehabilitation visits is limited without regard to best medical practices for a given condition","Limiting the number of covered outpatient rehabilitation visits without regard to medical necessity may discriminate against individuals conditions that require more rehabilitation services than are covered in order to fully regain function after certain conditions, such as stroke","The number of covered outpatient rehabilitation visits is determined by medical necessity and best medical practices"]
[null,"Benefit Substitution","Occupational Therapy","Occupational therapy substituted in order to offer more sessions of physical therapy","Removing occupational therapy may discriminate against individuals with certain conditions for which medical evidence supports the use of occupational therapy services as beneficial treatment","Benefit substitution that is actuarially equivalent to the benefit that is being replaced is within the same EHB benefit category, is not a prescription drug benefit, and does not result in effectively eliminating a benefit included in the EHB benchmark plan for a benefit applicable to a population with more favorable risk "]
[null,"Utilization Management","Non-Preferred Brand/ Specialty Drugs","Requiring prior authorization and/or step therapy for most or all drugs in drug classes such as anti-HIV protease inhibitors, and/or immune suppressants regardless of medical evidence","Requiring prior authorization and/or step therapy for most or all medications in a specific drug class may discriminate against individuals with conditions for which those drug classes are applicable, such as HIV or rheumatoid arthritis, and cause undue burden to receive necessary therapies","Using current medical evidence to establish clinically appropriate prior authorization, step therapy, or unrestricted coverage for drugs in a given drug class"]
[null,null,"Imaging (CT/PET Scans, MRIs)","Covering mammography alone and not covering breast MRIs in combination with mammography, for individuals who would benefit from breast cancer evaluation that incorporates an MRI","Denying coverage of diagnostic imaging without regard to medical evidence and necessity may discriminate against individuals who have either been previously diagnosed with or are more susceptible to developing breast cancer","Determining cancer diagnostic testing and treatment coverage based on current medical evidence and medical necessity"]

{"sheet":"Actuarial Value Guidance","index":15,"n_rows":49,"n_cols":3,"rows_kept":49,"cut":false,"hidden":false,"merged":[[5,1,5,2],[0,1,0,2],[1,1,1,2],[2,1,2,2],[3,1,3,2],[4,1,4,2],[24,1,24,2],[6,1,6,2],[9,1,9,2],[10,1,10,2],[11,1,11,2],[12,1,12,2],[16,1,16,2],[17,1,17,2],[18,1,18,2],[19,1,19,2],[21,1,21,2],[22,1,22,2],[39,1,39,2],[42,1,42,2],[46,1,46,2],[25,1,25,2],[26,1,26,2],[27,1,27,2],[30,1,30,2],[34,1,34,2],[35,1,35,2]]}
[null,"Actuarial Value Review Guidance"]
[]
[null,"Background"]
[null,"The purpose of this tab is to document the review of alternate AV calculation methods, and to outline the review of AV for both metal tier level plans and Cost Sharing Reduction (CSR) silver plan variations (i.e., plans with 73%, 87% and 94% AV) and does not include reviewing CSR silver plan variations for other cost sharing standards (see Benefit Cost Sharing tab)."]
[null,"Overview of Regulation on Calculating AV"]
[null,"45 CFR 156.135(a) requires that to calculate actuarial value (AV) to determine a level of coverage, issuers use the AV Calculator developed and made available by HHS for the given benefit year."]
[null,"45 CFR 156.135(b) allows an exception to the use of the AV Calculator if the health plan’s design is not compatible with the AV Calculator. In those cases, the issuer must use one of the two following methods to calculate AV:"]
[null,null,"(1) Estimate the fit of the plan designs into the parameters of the HHS AV Calculator and have an actuary who is a member of the American Academy of Actuaries (MAAA) certify that the plan design was fit appropriately in accordance with generally accepted actuarial principles and methodologies; or"]
[null,null,"(2) Use the AV Calculator to determine the AV for the plan provisions that fit within the HHS AV Calculator parameters and have an actuary who is a MAAA calculate and certify, in accordance with generally accepted actuarial principles and methodologies, appropriate adjustments to the AV identified by the calculator, for plan design features that deviate substantially from the parameters of the AV Calculator."]
[null,"In April of 2017, the Centers for Medicare and Medicaid Services (CMS) released a final rule, Patient Protection and Affordable Care Act; Market Stabilization that amends 45 CFR 156.140(c), which establishes the de minimis variation range for the level of coverage. Specifically, for plan years beginning on or after January 1, 2018, the allowable variation in the AV of a health plan that does not result in a material difference in the true dollar value of the health plan is -4 percentage points and +2 percentage points. The exception exists for bronze plans that either cover and pay for at least one major service, other than preventive services, before the deductible, or meet the requirements to be a high deductible health plan within the meaning of 26 U.S.C. 223(c)(2), in which case the allowable variation in AV for such plan is -4 percentage points and +5 percentage points. "]
[null,"Overview of Qualified Health Plan Certification Instructions"]
[null,"AV can be calculated in the Plans and Benefits Template (P&BT) using an integrated version of the AV Calculator. However, certain plans may not be able to match AVs between the P&BT and the AV Calculator due limitations in the template designs or a need to display different cost sharing in the P&BT. In those cases, the issuers may submit the plan as a unique plan design in the P&BT even though it does not meet one of the exceptions at § 156.135(b). The following are the instructions for those cases."]
[null,"For plans compatible with the AV Calculator whose AV obtained from the P&BT is not identical to the AV obtained from the stand-alone AV Calculator or otherwise have plan design features that cannot be mapped from the AV Calculator to the P&BT correctly, issuers are instructed to:"]
[null,null,"--Ensure the P&BT has been completed correctly and compare the AV Calculator screenshots to the P&BT AV Calculator screenshots."]
[null,null,"--If AVs obtained from the P&BT and the stand-alone AV Calculator are BOTH within the de minimis range, then submit with P&BT AV."]
[null,null,"--If the P&BT AV is outside de minimis range, then the issuer is instructed to designate the plan as unique and submit a screen shot of the stand-alone AV Calculator."]
[null,"For more information on the P&BT and its integration with the AV Calculator, please go to the CCIIO website (http://www.qhpcertification.cms.gov)."]
[null,"Overview of Related Requirements"]
[null,"For consistency throughout a State’s insurance market, HHS recommends that a State regulator’s AV review include a review of the AV of CSR plans. The procedures for reviewing AV for CSR silver plan variations are the same as those for standard metal level plans."]
[null,"However, CSR plans have additional cost sharing requirements that go beyond AV requirements (e.g., reduced annual limits on cost sharing) at 45 C.F.R. 156.420. To assist States, HHS has developed the Cost Sharing Tool, an optional resource for reviewing CSR silver plan variations for requirements other than AV. The Cost Sharing Tool, along with the other QHP Application Review Tools, is available to States at: http://www.qhpcertification.cms.gov."]
[]
[null,"Overview of Procedures"]
[null,"Steps 1 through 5 covers the review of plan designs that the issuer believes are not compatible with the HHS AV Calculator under 45 CFR § 156.135(b). \nStep 6 covers reviews of those plans submitted in the P&BT as “Unique Plan Design = Yes” but the issuer still used the AV Calculator and submitted a screenshot with their QHP application. \nStep 7 focuses on reviewing the data integrity between the Unified Rate Review Template and the P&BT.\nStep 8 describes how to review bronze plans that use the expanded de minimis range to comply with 45 CFR § 156.140(c).\nStep 9 records findings."]
[]
[null,"Steps of Review Procedures"]
[null,"1.     Review Part III Actuarial Memorandum and Certifications (and other related supporting documents) to determine if the issuer needs an exception to the requirement of calculating AV using the HHS AV Calculator for any plan.    "]
[null,"2.     If the issuer needs an exception to the requirement that they calculate AV using the HHS AV Calculator for a plan, verify that the issuer provided required actuarial certifications given by a MAAA as required under 45 CFR 156.135(b)(2) or 45 CFR 156.135(b)(3)."]
[null,"3.     Verify that one of the two allowed methods to calculate AV was used:"]
[null,null,"a.      45 CFR 156.135(b)(2) – estimate the fit of the plan design into to the parameters of the AV Calculator; or "]
[null,null,"b.     45 CFR 156.135(b)(3) – use the AV Calculator to determine the AV for the plan provisions that fit within the AV Calculator parameters and have an actuary calculate appropriate adjustments to the AV identified by the AV Calculator for plan design features that deviate substantially from the parameters of the AV Calculator."]
[null,"4.     Assess whether the AV value adjustment for each plan identified is:"]
[null,null,"a.     Made using generally accepted actuarial principles and methods;"]
[null,null,"b.     Supported; and "]
[null,null,"c.     Reasonable."]
[null,"5.     Assess whether additional review of assumptions and methods for the adjustments to the identified plan may be necessary and review as appropriate.      "]
[null,"6.     Review the AV Calculator screenshots for any plan designated in the P&BT as “Unique Plan Design = Yes” and not included in Part III Actuarial Memorandum and Certifications (and other related supporting documents) as needing an exception to the requirement that its AV be calculated using the HHS AV Calculator at 45 CFR § 156.135(b). "]
[null,null,"a.      Check that the AV in the screenshot matches the AV submitted in the \"Issuer Actuarial Value\" field in the  P&BT for this plan."]
[null,null,"b.     Check that the cost sharing parameters (e.g., deductible, out-of-pocket maximum, copay, coinsurance) in the screenshot matches the values entered into the P&BT for this plan."]
[null,null,"c.    Check that the issuer used the 2021 AV Calculator for its AV calculations. (The 2021 AV Calculator includes a label at the bottom of the \"AV Calculator\" tab stating “Final 2021 AV Calculator.”)"]
[null,"7.     Check for data integrity between the Unified Rate Review Template and the P&BT. The CMS Data Integrity Tool (DIT) can help states perform this check.   "]
[null,null,"a.      Check that the “Metal” field in the Unified Rate Review Template matches the “Level of Coverage” field in the P&BT for each plan.  "]
[null,null,"b.     Check that all plans listed in the P&BT are included in the Unified Rate Review Template."]
[null,"8.     Ensure that plans with “Expanded Bronze” level of coverage in the P&BT meet requirements to use the expanded de minimis range for bronze plans. To assist States in enforcing this requirement, we have added a review to the Cost Sharing Tool that is conducted based on the data submitted in the P&BT. The following is how to manually check: "]
[null,null,"a.      Check to see if any of the following services are coverage without applying the deductible: primary care visits (including 3 primary care visits before deductible), specialist visits, inpatient hospital services, generic drugs, preferred brand drugs, specialty drugs, or emergency room services. "]
[null,null,"b.      If yes, check the associated cost-sharing rate for that service to ensure that it does not require the enrollee to pay for more than 50 percent of the coinsurance (or the equivalent copay rate)."]
[null,null,"c.     If no, check to see if the plan selected “yes” for “HSA Eligible” in the P&BT or in plan documents and otherwise meets the requirements to be a high deductible plan within the meaning of 26 U.S.C.223(c)(2)."]
[null,"9.     Record findings "]
[null,null,"a.     If the plan passes all review steps 1-8, record finding that no regulatory issues were detected."]
[null,null,"b.     If the plan does not pass one or more of the review steps 1-8, record which standard was not satisfied."]