CMS-10433 Accreditation Attestations

Accreditation Attestation for Accredited Issuers:
The QHP applicant attests that, if in their second or third year of participation on the Exchange, its
application includes:
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Accreditation by a HHS-recognized accrediting entity on the policies and procedures that are
applicable to its Exchange products; or
Commercial or Medicaid accreditation granted by a HHS-recognized accrediting entity for the
same state in which the issuer is offering Exchange coverage and the administrative policies and
procedures underlying that accreditation are the same or similar to the administrative policies
and procedures used in connection with the QHP.

The QHP applicant attests that their application includes accreditation in compliance with the timeline
established in 45 C.F.R. 155.1045(b).
The QHP applicant understands and acknowledges that the Exchange Internet web site may display that
a QHP applicant is accredited if that applicant is accredited on its commercial, Medicaid, or Exchange
product lines by one of the HHS-recognized accrediting entities. The QHP applicant understands and
acknowledges that the Exchange Internet web site may display a QHP applicant as “Not yet accredited”
if the applicant does not provide accreditation information that can be verified with a recognized
accrediting entity, or does not have any products that the applicable accrediting entity considers to be
accredited (e.g., an applicant will be displayed as “Not yet accredited” if the accreditation review is
“scheduled” or “in process”).

Signature:
Issuer ID:

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Printed Name:

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Title of Issuer Representative:

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Signature:

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Date:

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