Transparency in Coverage Reporting by QHP Issuers

Under section 1311(e)(3) of the Patient Protection and Affordable Care Act, as implemented by regulations at 45 CFR 155.1040(a) and 156.220, health insurance issuers seeking certification of a health plan as a qualified health plan (QHP) must make accurate and timely disclosures of certain information to the appropriate Health Insurance Marketplace (also known as Exchange), the Secretary of HHS, and the state insurance commissioner, and make it available to the public. Section 2715A of the PHS Act, as added by the Patient Protection and Affordable Care Act, extends the transparency reporting provisions under section 1311(e)(3) to non-grandfathered group health plans and health insurance issuers offering group or individual coverage, except that a plan or coverage not offered through an Exchange shall only be required to submit such information to the Secretary of HHS and state insurance commissioner, and make the information public.

Key Changes for PY21:
  • The Transparency in Coverage Template will be submitted in the Benefits and Service Area Module of HIOS. Issuers who submit via SERFF will submit their Transparency in Coverage Template in their SERFF binders.
  • Issuers must include all plan IDs that are present in their QHP Application (including off-Exchange SADPs and medical QHPs) in the Transparency in Coverage Template.
  • The Claims Payment Policies and Other Information URL will be collected in the Supplemental Submission Module (SSM).
  • Issuers who submit via HIOS will need to submit their Transparency in Coverage Template into the Benefits & Service Area Module before submitting the Transparency URL via the SSM.
  • For issuers who submit via SERFF, states will need to transfer submissions into HIOS before issuers will be able to access the SSM and submit Transparency in Coverage URL information.
  • Transparency URLs must be active at the time of template submission. Specific dates can be found on Timeline webpage.

Tips for the Transparency in Coverage Section

  • Issuers applying to offer QHPs for PY2021 that did not offer QHPs in 2019 must still submit a Transparency Coverage Template. 
  • Required data elements are identified by an asterisk (*) next to the field name. If a field is not required and does not apply to your organization, enter “N/A.”
  • Complete the template for each unique HIOS Issuer ID.
  • Use only the tabs provided in the Transparency Template and do not add additional tabs, rows, or columns. Separate templates should be submitted for each unique HIOS Issuer ID.
  • Enter all Plan Level data in the Plan Level Data tab. One plan ID should be captured in each row. Each plan ID listed should be distinct 14-character IDs. 
  • Check the template(s) for completeness and data validity prior to submission by clicking the “Validate” button on the issuer level data tab. 
  • Once the template is completed, HIOS issuers must upload the template to the Benefits and Service Area Module of HIOS by the required deadline.
  • Issuers submitting via SERFF should submit one identical template with all plan IDs in each of their submission binders. 
  • States who transfer data to CMS via SERFF will need to transfer issuer data before the issuer will be able to access the SSM in HIOS and submit the Claims Payment Policies and Other Information URL. 

Application Resources