CMS-10433 Program Attestations

Federally-facilitated Marketplace Issuer Attestations:
Statement of Detailed Attestation Responses
Instructions:
Please review and respond Yes or No to each of the attestations below and sign the Statement of
Detailed Attestation Responses document. CMS may accept a No response, along with a justification
for any of these No responses, to any of the individual attestations identified. Please be sure to
reference the specific attestation in your justification discussion.

Program Attestations
General Issuer Attestations
1. Applicant attests that it will have a license by the end of the certification period and be in
good standing pursuant to 45 CFR 156.200(b)(4), and be authorized to offer each specific type of
insurance coverage offered in each state in which the issuer offers a QHP.

2. Applicant attests that it will not discriminate on the basis of race, color, national origin,
disability, age, sex, gender identity or sexual orientation, pursuant to 45 CFR 156.200(e).
3. Applicant attests that it will market its QHPs in accordance with all applicable state laws and
regulations and will not employ discriminatory marketing practices in accordance with 45 CFR
156.225.
4. Applicant attests that it will adhere to all non-renewal and decertification requirements, in
accordance with 45 CFR 156.290 and 156.810.
5. Applicant attests that it will adhere to requirements related to the segregation of funds for
abortion services consistent with 45 CFR 156.280 and all applicable guidance, as applicable.
6. Applicant attests that it will adhere to provisions addressing payment of federally-qualified
health centers in 45 CFR 156.235(e), if such providers are included in networks.
7. Applicant attests that it will adhere to the QHP participation requirement, pursuant to 45 CFR
156.200(g).

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Federally-facilitated Marketplace Issuer Attestations:
Statement of Detailed Attestation Responses
Compliance Plan
1. Applicant attests that it has a compliance plan that adheres to all applicable laws, regulations,
and guidance, that the compliance plan is ready for implementation, and that the applicant agrees
to reasonably adhere to the compliance plan provided. Any changes to the compliance plan will
be submitted to HHS for review.
Applicant will upload a copy of the applicant’s compliance plan, as applicable.
Organizational Chart Attestations
1. Applicant attests that it is providing its organizational chart and that it will inform HHS of any
significant changes to the organizational chart provided within 30 days of that change after the
submission of this application.
Applicant will upload a copy of the applicant’s organizational chart, as applicable.
Operational Attestations
1. Applicant attests that, in accordance with 45 CFR 156.330, it will notify HHS of a change in
ownership if one or more of its Federally-facilitated Exchange (FFE) QHPs undergoes a change
of ownership as recognized by the State in which the issuer offers the QHP, in a manner to be
specified by HHS. The applicant understands that in accordance with 156.330, the new owner
must adhere to all applicable statues and regulations
2. Applicant attests that it will comply with all QHP requirements, including technical
requirements related to the use of FFE plan management system, on an ongoing basis and
comply with Exchange systems, tools, processes, procedures, and requirements.

Benefit Design Attestations
1. Applicant attests that it will not employ benefit designs that have the effect of discouraging
the enrollment of individuals with significant health needs or preexisting conditions in QHPs in
accordance with 45 CFR 156.225.
2. Applicant attests that it will comply with all benefit design standards, federal regulations and
laws, and state laws regarding state mandated benefits for all services as applicable including:
preventive services, emergency services, and formulary drug list.

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Federally-facilitated Marketplace Issuer Attestations:
Statement of Detailed Attestation Responses
3. Applicant attests that it will abide by all cost-sharing limits, including that:
a. it will charge the same cost sharing rate (expressed as a copayment amount or coinsurance
rate) for emergency department services regardless of provider network status, and in
accordance with applicable cost sharing requirements under 45 CFR 156.130(g)(2);
b. it will make available enrollee cost sharing under an individual’s plan or coverage for a
specific item or service, consistent with 45 CFR 156.220; and
c. it will maintain appropriate systems to accurately calculate cost sharing amounts and
ensure compliance with deductible (if applicable) and cost sharing limits required under 45
CFR 156.130.
4. Applicant attests that it will follow all actuarial value requirements including 45 CFR 156.135
and 156.140, or 156.150 for stand-alone dental plans.
5. Applicant attests that it will offer through the Exchange a minimum of one QHP at the silver
coverage level and one QHP at the gold coverage level in accordance with 45 CFR 156.200(c),
or a minimum of one plan at either a high or low coverage level for issuers of stand-alone dental
plans.
6. Applicant attests that any catastrophic QHPs it offers will only enroll individuals under the
age of 30 or individuals deemed exempt from the individual mandate.
7. Applicant attests that its QHPs provide coverage for each of the 10 statutory categories of
essential health benefits (EHB) in accordance with applicable federal law and regulations,
including that
a. its QHPs provide benefits and limitation on coverage that are substantially equal to those
covered by the EHB benchmark plan pursuant to 45 CFR 156.115(a)(1);
b. it complies with the requirements of 45 CFR 146.136 with regard to mental health and
substance use disorder services, including behavioral services;
c. it provides coverage for preventive services described in 45 CFR 147.130;

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Federally-facilitated Marketplace Issuer Attestations:
Statement of Detailed Attestation Responses
d. it complies with EHB requirements with respect to prescription drug coverage pursuant to
45 CFR 156.122;
e. any benefits substituted in designing QHP plan benefits are actuarially equivalent to those
offered by the EHB benchmark plan and are in the same EHB category pursuant to 45 CFR
156.115(b);
f. with regard to EHB, it does not discriminate in its benefit design based on age, expected
length of life, present or predicted disability, degree of medical dependency, quality of life or
other health conditions, in accordance with 45 CFR 156.125;
g. its QHPs' benefits reflect an appropriate balance among the EHB categories, so that
benefits are not unduly weighted toward any category pursuant to 45 CFR 156.110(e); its
QHPs include all applicable state required benefits; and
h.with the exception of the EHB category of coverage for pediatric services, its QHPs do not
exclude an enrollee from coverage in an EHB category.

Stand-Alone Dental Attestations
1. Applicant attests that all stand-alone dental plans that it offers will comply with all benefit
design standards and federal regulations and laws unique to stand-alone dental plans in 45 CFR
155.1065 and 156.150, including that:
a. the out-of-pocket maximum for its stand-alone dental plan complies with the regulatory
standard in 45 CFR 156.150 for out of pocket maximum;
b. it offers the pediatric dental EHB;
c. it does not include annual and lifetime dollar limits on the pediatric dental EHB.
2. Applicant attests that any stand-alone dental plans it offers are limited scope dental plans.
3. Applicant attests that any stand-alone dental plans it offers will adhere to the standards set
forth by HHS for the administration of advance payments of the premium tax credit, including 45
CFR 155.340(e) and (f).

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Federally-facilitated Marketplace Issuer Attestations:
Statement of Detailed Attestation Responses
4. Applicant attests that it either offers no stand-alone dental plans or attests to all of the above.

Rate Attestations
1. Applicant attests that it will comply with all rate requirements as applicable, including that it
will:
a. charge the same rates for each QHP of the issuer without regard to whether the plan is
offered through an Exchange or whether the plan is offered directly from the issuer or
through an agent;
b. set rates for an entire benefit year, or for the SHOP, for an entire plan year, and submit the
rate and benefit information to the Exchange as required in 45 CFR 156.210;
c. submit to the Exchange a justification for a rate increase prior to the implementation of an
increase;
d. prominently post rate increase justifications on its Web site pursuant to 45 CFR 155.1020;
e. adhere to all applicable rating area variation requirements pursuant to 45 CFR 156.255 for
QHPs;
f. comply with federal rating requirements or the state’s Affordable Care Act compliant
rating requirements, as applicable.

Enrollment Attestations
1. Applicant attests that it will meet the individual market requirement to:
a. enroll a qualified individual during the initial and subsequent annual open enrollment
periods and abide by the effective dates of coverage pursuant to 45 CFR 156.260;
b. make available, at a minimum, special enrollment periods established by the Exchange
and abide by the effective dates of coverage determined by the Exchange pursuant to 45 CFR
156.260.
2. Applicant attests that it will enable enrollees to make enrollment changes during open and
special enrollment periods for which they are eligible.
3. Applicant attests that it will only terminate coverage as permitted by the Exchange and
applicable State or Federal law, including pursuant to 45 CFR 156.270, including that:
a. the applicant will abide by the termination of coverage effective dates requirements;
b. the applicant will maintain termination records in accordance with Exchange requirements;

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Federally-facilitated Marketplace Issuer Attestations:
Statement of Detailed Attestation Responses
c. the applicant will provide the enrollee with a notice of termination of coverage, consistent
with the effective date required by applicable regulations, if terminating an enrollee’s
coverage for any reason. Notices must include an explanation of the reason for the
termination. When applicable, the applicant will include in the notice an explanation of the
enrollee’s right to appeal;
d. the applicant will establish a standard policy for the termination of coverage of enrollees
due to nonpayment of premium, provision of fraudulent application information or abuse of
his or her benefit cards.
4. Applicant attests that it will provide enrollees with required documentation including: an
enrollment information package, effective dates of coverage, summary of benefits and coverage,
evidence of coverage, provider directories, enrollment/disenrollment notices, coverage denials,
ID cards, and any notices as required by State or Federal law.
5. Applicant attests that it will adhere to enrollment information collection and transmission
requirements and will:
a. accept enrollment information in an electronic format from the Exchange that is consistent
with requirements;
b. reconcile enrollment files with the Exchange no less than once a month;
c. acknowledge receipt of enrollment information in accordance with Exchange standards
and;
d. timely, accurately and thoroughly process enrollment transactions and submit electronic
834 confirmation files to the Exchange to confirm the enrollee’s portion of the premium has
been paid and coverage has been effectuated.
6. Applicant attests that if applicant utilizes Application Programming Interface (API) provided
by the Exchange, the applicant will:
a. direct individuals to the Exchange in order to initiate the eligibility process;
b. enroll an individual only after receiving confirmation from the Exchange that the
eligibility process is complete and the individual has been determined eligible for enrollment
in a QHP, in accordance with the standards.
7. Applicant attests that the Issuer will follow the premium payment process requirements
established by the Exchange in accordance with 45 CFR 156.265(d) and 156.1240.

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Federally-facilitated Marketplace Issuer Attestations:
Statement of Detailed Attestation Responses
8. Applicant attests that it will provide a grace period of at least three consecutive months if an
enrollee receiving advance payments of the premium tax credit has previously paid in full at least
one month’s premium. If an enrollee exhausts the grace period without submitting payment in
full of outstanding premium due, the applicant will terminate the enrollee’s coverage effective at
the end of first month of the payment grace period.
9. Applicant attests that it will provide the enrollee with notice of payment delinquency if an
enrollee is delinquent on premium payment.
10. Applicant attests that it will develop, operate and maintain viable systems, processes,
procedures, and communication protocols for:
a. the timely, accurate and valid enrollment and termination of enrollees’ coverage within the
exchange;
b. the prompt resolution of urgent issues affecting enrollees, such as changes in enrollment
and discrepancies identified during reconciliation.
11. Applicant attests that it will accept the total premium breakdown as determined by the
Exchange and as specified in the electronic enrollment transmission. This includes:
a. the total premium amount which is based on rate attestations submitted by the applicant;
for stand-alone dental plans, this applies for rates submitted as guaranteed rates.
b. the advanced payment of the premium tax credit amount;
c. any other payment amounts as depicted on the enrollment transmission.
12. Applicant attests that it will accept the advance cost sharing reduction amount as determined
by the Exchange and as specified in the electronic enrollment transmission as applicable.
13. Applicant attests that it will approve the use of the following information for display on the
FFE Web site for consumer education purposes: information on rates and premiums; information
on benefits; the provider network URL(s) provided in this application; the URL(s) for the
summary of benefits and coverage provided in this application; the URL(s) for payment provided
by this application; information on whether the issuer is a Medicaid managed care organization;
and quality information, as applicable, derived from the accreditation survey, including
accreditation status and Consumer Assessment of Healthcare Providers and Systems (CAHPS)
data.

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Federally-facilitated Marketplace Issuer Attestations:
Statement of Detailed Attestation Responses
Financial Management Attestations
1. Applicant attests that it will adhere to the risk corridor standards and requirements set by HHS
as applicable.
2. Applicant attests that it will adhere to the standards set forth by HHS for the administration of
advance payments of the premium tax credit and cost sharing reductions, including the
provisions at 45 CFR 156.410, 156.425, 156.430, 156.440, 156.460, and 156.470.
3. Applicant attests that it will submit to HHS the applicable plan variations that adhere to the
standards set forth by HHS at 45 CFR 156.420, as applicable.
4. Applicant attests that it will pay all user fees in accordance with 45 CFR 156.200(b)(6).
5. Applicant attests that it will reduce premiums on behalf of eligible individuals if the Exchange
notifies the QHP Issuer that it will receive an advance payment of the premium tax credit on
behalf of that individual pursuant to pursuant to 45 CFR 156.460.
6. Applicant attests that it will adhere to the data standards and reporting for the CSR
reconciliation process, pursuant to 45 CFR 156.430(c) for QHPs.
7. The following applies to applicants participating in the risk adjustment and reinsurance
programs inside and/or outside of the Exchange. Applicant attests that it will:
a. adhere to the risk adjustment standards and requirements set by HHS in the annual HHS
notice of benefit and payment parameters (45 CFR Subparts G and H);
b. remit charges to HHS under the circumstances described in 45 CFR 153.610.

SHOP Attestations
1. Applicant attests that it either offers no SHOP plans, or that it will adhere to the SHOP issuer
requirements set by HHS in 45 CFR 156.285.

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Federally-facilitated Marketplace Issuer Attestations:
Statement of Detailed Attestation Responses
Reporting Requirements and Transparency Attestations
1. Applicant attests that it will provide to the Exchange the following information in the manner
identified by HHS, as applicable: claims payment policies and practices; periodic financial
disclosures; data on enrollment; data on disenrollment; data on the number of claims that are
denied; data on rating practices; information on cost sharing and payments with respect to any
out of network coverage; and information on enrollee rights under title I of the Affordable Care
Act.
2. Applicant attests that it will comply with the specific quality disclosure, reporting, and
implementation requirements of 45 CFR 156.200(b)(5) and 156.1110.
3. Applicant attests that, consistent with 45 CFR 156.230, it will make available to enrollees, and
maintain accessible and operational links to, a current accurate provider network directory.
4. Applicant attests that, consistent with 45 CFR 147.200(a)(2)(i)(K), it will make available to
enrollees, and maintain accessible and operational links to, current and accurate information on
the prescription drugs covered under its plan formulary.

Attestation Justification

X
Signature

Date

Printed Name

Title/Position

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