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The Center for Consumer Information & Insurance Oversight

 

Qualified Health Plans

The 2016 Qualified Health Plan (QHP) Application is available to issuers applying for certification to participate in the Federally-facilitated Marketplaces. Click on the links below to access detailed application instructions, templates, justifications and supporting documents, and tools for issuers. Please read the application instructions carefully before beginning the application process.

Qualified Health Plan Application Instructions, Templates and Materials

A complete set of instructions for the Plan Year 2016 QHP Application is now available. Access instructions, templates, and supporting document by clicking on the links below. Application materials are organized by application area in the table below.

To access the video instructions using Internet Explorer, please download the video, save it to you desktop and open using “Windows Media Player”. All other internet browsers should open the videos when selected.

Application Area

Instructions

Template

Justifications/
Supporting Documents

General

QHP Instructions Introduction
QHP Instructions Table of Contents
QHP Application Abbreviations

QHP Instructions Revision History
QHP Instructions Revision History
Stand-Alone Dental Plans
Template Field Crosswalk

Video Session 1 – Introduction

Video Session 2 – Template Overview

Video Session 14 – Closing

Not applicable Justifications Overview
Administrative

Administrative

Video Session 3 – Administrative Template

Administrative Template (v5.04) Not Applicable
Attestations Program Attestations

No template – respond to attestations in HIOS Issuer Module

If applicable, upload Statement of Detailed Attestation Responses in HIOS Benefits and Service Area Module  or in SERFF

Compliance Plan and Organizational Chart Cover Sheet


Statement of Detailed Attestation Responses

SPM Statement of Detailed Attestation Responses

Licensure State Licensure No template – upload attestations in HIOS Issuer Module Not Applicable
Good Standing Good Standing No template – upload attestations in HIOS Issuer Module Not Applicable
Accreditation

Accreditation

Video Session 4 – Accreditation NCQA Template

Video Session 5 – Accreditation URAC Template

NCQA Template (v5.0)
URAC Template (v5.02)
AAAHC Template (v1.0)
Not applicable
       
SHOP Tying SHOP Tying No template – upload attestations in HIOS Benefits and Service Area Module SHOP Tying Provision
Network Adequacy

Network Adequacy
Network ID

Video Session 7 – Network ID Template

Video Session 9 – Network Adequacy Template

Network ID Template(v5.0)
Network Adequacy Template (v1.1)
Not applicable
Essential Community Providers

Essential Community Provider

Video Session 8 – Essential Community Providers Template

ECP Template (v5.06) Supplementary Response: Inclusion of Essential Community Providers
Service Area

Service Area

Video Session 6 – Service Area Template

Service Area Template.(v5.02) Supplemental Response: Partial County Explanation
Plans & Benefits

Plans & Benefits

Video Session 11 – Plans and Benefits Template:
11.1: Intro to P&B
11.2: Benefits Package Worksheet
11.3: Cost Share Variance Worksheet
11.4: Closing P&B

Plans & Benefits Template (v5.12)
Plans & Benefits Add-In (v5.17)

EHB Substituted Benefit Justification

Discrimination- Cost Sharing Outlier

Discrimination- Language

Meaningful Difference

SADP Actuarial Value

SADP – Description of EHB Allocation

Prescription Drugs

Prescription Drug

Video Session 10 – Prescription Drug Template

Prescription Drug Template (v5.06)

Formulary- Inadequate Category-Class Count

Discrimination – Formulary Outlier Review

Discrimination – Formulary Clinical Appropriateness

Discrimination - Formulary Treatment Protocol

Rates

Rating Data

Video Session 13 – Rates Template

Rates Template (v5.05) Not applicable
Business Rules

Issuer Business Rules

Video Session 12 – Business Rules Template

Business Rules Template (v5.07) Not applicable
Unified Rate Review Unified Rate Review Template Instructions Unified Rate Review Template (v2.0.4) Not applicable
Plan Crosswalk Plan ID Crosswalk Template Instructions Plan Crosswalk Template (v2.0.3) State Authorization Form
General Reference Not applicable   Not applicable

 


Qualified Health Plan Application Tools

A series of automated data review tools are available to issuers to check templates for data errors prior to submitting to CMS for review. Issuers are encouraged to use these tools to identify and correct data errors prior to uploading materials to HIOS or SERFF.

Other Qualified Health Plan Application Resources