Service Area

Issuers must identify the proposed service areas that will be associated with their QHPs, by state and by county. In most cases, HHS will only approve service areas covering full counties. In instances when the issuer proposes a service area that will cover only part of a county, the service area must also indicate associated zip codes. All issuers are required to submit service area information as part of their QHP Application.

Key Changes for PY21:
  • No changes for the 2021 QHP Application.

Tips for the Service Area Section

  • An issuer may not change its service area after the initial submission deadline unless it submits a data change request to do so and makes this change only during the timeframe specified by CMS. This includes issuers submitting through National Association of Insurance Commissioners’ (NAIC’s) System for Electronic Rate and Form Filing (SERFF), even if the issuer is responding to an error issued by the state. See the Service Area Data Change Request Process in the Review Periods, Revision Process, and Certification section for more information.
  • Dual-product issuers (issuers offering QHPs and SADPs) must create two different service area IDs for use with the two plan types, regardless of whether the service area is intended to serve both QHPs and dental plans.
  • Dual-product issuers must use the word “dental” in the service area name for their dental service area to distinguish the QHP service area from the dental service area.
  • Excel template file names must be all lowercase and cannot contain spaces. For example, “servicearea_data” is a valid template file name, but “ServiceArea_data” and “service area data” are not valid template file names.
  • Name the partial county justification, if applicable, using the following naming convention: [HIOS Issuer ID]_[State]_service_area_partial_county, for example, “12345_AZ_service_area_partial_county.”
  • When deciding how to establish service areas, consider existing health care delivery markets in the states in which the issuer is applying to offer plans. If people in a rural county generally travel a long distance to see a health care provider or dentist and the distance is consistent with practices permitted by the state, it may not be necessary to have a contracted provider in all parts of the rural county. In these cases, issuers may want to consider establishing a service area for the entire state, giving members in the more rural part of the county the option to see providers in other ZIP codes. Alternatively, an issuer may elect to exclude an entire county from its service area if no providers are available in the excluded ZIP codes.
  • A service area can be associated with multiple plans. For example, an issuer has five plans and four service areas. The first plan has a service area (SA001) that covers the entire state. The second and third plans have a service area (SA002) that covers counties A and B. The fourth plan has a service area (SA003) that covers counties C and D. The fifth plan has a service area (SA004) that covers counties A, B, C, and D.
  • A QHP or SADP must always be associated with a single service area ID and with a single network ID, but networks and service areas may be used for multiple QHPs or SADPs. The issuer creates one template for all service areas and identifies each service area with a unique service area ID. The issuer also completes the Network ID Template and creates a unique network ID for each network. When the issuer completes the Plans & Benefits Template, it maps each plan to a specific service area ID and network ID as entered in the Service Area and Network ID Templates. Service area IDs and network IDs may both be used for multiple plans and do not have to correspond one-to-one (for example, an issuer may have a single state-wide network, identified with a network ID, assigned to all of its plans but have two service area IDs, each made up of half the state and each assigned to a different plan).
  • The Exchange does not require an issuer’s service area to cover a complete rating area. However, issuers are also bound by state service area requirements, so carefully review the state guidance on this topic to ensure the proposed service areas comply with state requirements. Multiple rating areas are allowed within a service area as specified by the state. Separate service area IDs are not required even if a service area is made up of multiple rating areas.
  • Issuers in states that perform plan management functions and file through SERFF are strongly encouraged to submit a Microsoft Excel version of their Service Area Template.
Application Resources

Service Area Data Change Request

For information about submitting a service area data change request, including the requisite documentation, please refer to the data change windows page.

HPSA Zip Code Listing

HHS periodically designates health professional shortage areas (HPSAs). Areas must fulfill 3 criteria to receive HPSA designation:
  1. The geographic area involved must be rational for the delivery of health services
  2. A specified population-to-practitioner ratio representing shortage must be exceeded within the area
  3. Resources in contiguous areas must be shown to be overutilized, excessively distant, or otherwise inaccessible
The latest list of HPSA zip codes is provided below.