CMS-10433 QHP Certification Instrument Screenshots

Appendix L. QHP Certification Instrument Screenshots
Figure 1: Administrative Data Template
No changes to this template included in this PRA package.
Administrative Data

The QHP Application requires sub mission of certain administrative data that will b e utilized for operational purposes. This information includes identifying information and contact information.

Go to cell B1 for instructions

Some of this information will b e pre-populated b ased on the information you have previously entered in HIOS.

Validate

All fields marked with an asterik ( * ) are required. Depending on the Proposed Exchange Market Coverage selected, certain additional fields may b e required.
On validation, missing or incorrect data is highlighted.

Finalize

To validate the template, use the Validate b utton or press Ctrl + Shift + V. To finalize the template, press the finalize b utton or press Ctrl + Shift + F.
Issuer ID:*

Proposed Exchange Market Coverage:*

Issuer State:*

Current Sales Market:*

1. Administrative Data
Company Legal Name:*

Issuer Legal Name:*

Issuer Marketing Name:*

Associated Health Plan ID:

TIN:*

NAIC Company Code:

NAIC Group Code:

Address:*

Address 2 (optional):

City:*

State:*

Zip Code:*

Address:*

Address 2 (optional):

City:*

State:*

Zip Code:*

Last Name:

E-mail Address:

Phone Number:

Phone Extension:

First Name:

Last Name:

E-mail Address:

Phone Number:

Phone Extension:

First Name:*

Last Name:*

E-mail Address:*

Phone Number:*

Phone Extension:

First Name:*

Last Name:*

E-mail Address:*

Phone Number:*

Phone Extension:

Customer Service Phone Extension:

Customer Service Toll Free:

Customer Service TTY:

Customer Service URL:

Customer Service Phone:

Customer Service Phone Extension:

Customer Service Toll Free:

Customer Service TTY:

Customer Service URL:

Contact Type

First Name

Last Name

Phone Number

Extension

2. Company Address

3. Issuer Address

4. Select Your Primary Contact:*

5. Issuer Individual Market Contact
First Name:

6. Issuer SHOP (Small Group) Contact

7. CEO

8. CFO

9. Customer Service - Individual Market
Customer Service Phone:

10. Customer Service - SHOP (Small Group)

11. Contacts
E-mail Address

Enrollment Contact
Online Enrollment Center Contact (Primary)
Online Enrollment Center Contact (Backup)
System Contact
Appeals/Grievances Contact
Customer Service Operations Contact
User Access Contact
Backup User Access Contact
Marketing Contact
Medical Director
Chief Dental Director
Pharmacy Benefit Manager

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Figure 2: Network Adequacy/Essential Community Provider Template: User Control Tab Screenshot
Fields highlighted bright green indicate a field that would be added under this PRA package.

Current Tabs

NA ECP Template

User Control & Details for Template
Issuer Information
Issuer ID:*
Source System:*
Market:*
Dental Only:*
State:*

Notes & Instructions
1. Enter all Issuer Information , then create a new
tab using the buttons below to enter data.

Delete Tab? If you would like to delete a provider
Number of Rows
Number of
tab please click 'Delete' for the corresponding tab.
per Tab
Validation Errors
WARNING!: Deleted tabs cannot be recovered.

IndividualECPs
Facilities&PharmaciesECPs
IndividualProviders1

9
7
2

0 Delete
0 Delete
0 Delete

Facilities&Pharmacies1

2

0 Delete

2. Ensure automatic calculation is turned on.
Formulas -> Caculation Options -> Automatic

Alternate ECP
Standard Issuer:*

Drop Down:
Yes
No

No. of Networks:*

7

3. Data can be entered manually or Copy & Pasted into each tab.
4. All fields in with an asterisk ( * ) are required
5. Validate data (using the "Validate" button
below) after entering in all information.

Actions
1.

Create New Provider Tab

Please enter all Issuer Information above before
creating a new tab

A. New Individual Provider Tab
Create Individual Tab
B. New Facility & Pharmacy Tab
Create Facility and Pharmacy Tab
2.

Import Network IDs

Exporting Data:
1. Data must pass all validation check s before
being exported. Any invalid entries will be
displayed in the 'Errors' and must be corrected.
2. Click "Create Documents" to export data
from all provider tabs.
3. When prompted, select the folder in which
you wish to save the files.

Import Network IDs
3.

Validate Data

Validate information entered into all tabs.
Warning : Depending on data size, validation may
take several minutes.

Validate
4.

Create Supporting Documents

Perform data validation & export data to text files

Create Documents
5.

4. All files will be saved as tab delimited
text files.
Warning : Files larger than 50mb cannot be
uploaded to HIOS/SERFF. Please ensure that each
exported text file is less than 50mb. On average,
tabs with less than 300,000 records should be ok ay.

Validation Status
Incomplete

Delete an Exisiting Tab?

Refer to Column P on this tab if you would like to
delete an existing tab

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Figure 3: Network Adequacy/Essential Community Provider Template: Select ECPs Tab Screenshot
Fields highlighted bright green indicate a field that would be added under this PRA package.
Tab 2: Select ECPs
Row
Organization
Site Name
Number
Name

National
Provider
Identifier

ECP
Category

Number of
authorized
MDs, DOs,
PAs, NPs

Number of
authorized Site Street Site Street
Site
Site City
DMDs and Address 1 Address 2
State
DDSs

Site Zip
Site
Org Street Org Street
Org Zip
Org
Org City Org State
Code County Address 1 Address 2
Code County

POC 1
Name

POC 1
POC 1 POC 1
Phone
Title Phone #
Ext

POC 1
Email

URL 1

POC 2
Name

POC 2
POC 2 POC 2
Phone
Title Phone #
Ext

POC 2
Email

URL 2

Figure 4: Network Adequacy/Essential Community Provider Template: Select ECPs Tab Screenshot
Fields highlighted bright green indicate a field that would be added under this PRA package.
Tab 3: Individual ECPs
Note: The fields in this worksheet will be pre-populated with information pulled from the ECP list, as well as additional fields that the Issuer will need to complete. If the issuer is an “Alternate ECP Standard Issuer” they will be
responsible for manually completing all information.
National
Provider
Number
(NPI)*

Provider First Name
ECP
Street
Street
City State* County Zip Provider Network
Middle
Last Name Suffix of Physician / Specialty Type Provider
Number of
Number of
Name of Provider*
*
IDs*
Initial
of Provider* Provider Non-Physician*
(area of
Name* Category* Address* Address 2
*
*
Type*
Contracted MDs, Contracted DMDs
Prefix
of Provider
medicine)*
DOs, PAs, and NPs*
and DDSs*

Figure 5: Network Adequacy/Essential Community Provider Template: Facility ECPs Tab Screenshot
Fields highlighted bright green indicate a field that would be added under this PRA package.

Tab 4: Facility ECPs
Note: The fields in this worksheet will be pre-populated with information pulled from the ECP list, as well as additional fields that the Issuer will need to complete. If the issuer is an “Alternate ECP Standard Issuer” they will be
responsible for manually completing all information.
National Provider
Number (NPI)*

Facility
Name*

Facility Type*

Provider Name*

ECP Category*

Street
Address*

Street
Address 2

City*

State* County*

Zip*

Network IDs*

Number of Contracted Number of Contracted
MDs, DOs, PAs, and NPs*
DMDs and DDSs*

Figure 6: Network Adequacy/Essential Community Provider Template: Individual Providers Tab Screenshot
Fields highlighted bright green indicate a field that would be added under this PRA package.
Tab 5: Individual Providers
National Provider
Number (NPI)*

Provider Tier

Provider Cost
Sharing

QHP Certification Instrument Screenshots

First Name
of Provider*

Middle Initial of
Provider

Last Name
of Provider*

Suffix of
Provider

Physician /
NonPhysician*

Specialty Type Street Address*
(area of
medicine)*

Street Address 2

Figure 7: Network Adequacy/Essential Community Provider Template: Facilities & Pharmacies Tab Screenshot
Fields highlighted bright green indicate a field that would be added under this PRA package.
3

City*

State*

County*

Zip*

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Network
IDs*

Tab 6: Facilities and Pharmacies
National Provider
Number (NPI)*

Facility Tier

Facility Cost
Sharing

Facility Name*

Facility Type*

Street Address*

Street
Address 2

State*

City*

County*

Zip*

Figure 8: URAC Template
No changes to this template included in this PRA package.

URAC Template

All fields with an asterisk ( * ) are required. To validate the template, use the Validate button or Ctrl + Shift + V. To finalize the template, use the Finalize button or Ctrl + Shift + F.
The information for the accredited products must be for the same legal entity as is submitting the QHP application.

Validate

Please follow the instructions provided in the Accreditation Chapter (Chapter 5) of the QHP Application Instructions Manual closely and carefully.
The Department of Health and Human Services (HHS) will verify the information that you have provided about your existing accreditation with NCQA, URAC, or both.

Finalize

Only data that can be verified will be displayed on the website.
HIOS Issuer ID*

URAC Application Number*
Required:
Enter the 9-10 alphanumeric URAC Application Number

Market Type*

Accreditation Status*

Expiration Date*

Required:
Select the Market Type from list

Required:
Select the Accreditation Status
from list

Required:
Enter a future date in mm/dd/yyyy
format

Figure 9: NCQA Template
No changes to this template included in this PRA package.

NCQA Template

All fields with an asterisk ( * ) are required. To validate the template, use the Validate button or Ctrl + Shift + V. To finalize the template, use the Finalize button or Ctrl + Shift + F.

Go to cell B1 for instructions

The information for the accredited products must be for the same legal entity as is submitting the QHP application.

Validate

Please follow the instructions provided in the Accreditation Chapter (Chapter 5) of the QHP Application Instructions Manual closely and carefully.
The Department of Health and Human Services (HHS) will verify the information that you have provided about your existing accreditation with NCQA, URAC, or both.

Finalize

Only data that can be verified will be displayed on the website.
It is only necessary to enter one accreditation entry per product/mark et type, using the product with the largest number of covered lives.
HIOS Issuer ID*

NCQA Org ID*

Market Type*

NCQA Sub ID

Product Type*

Product ID*

Accreditation Status*

Expiration Date*

Required:
Enter the 2-5-digit NCQA Org ID number

Required:
Select the Market Type from list

Required if Market is NOT
Exchange:
Enter the 2-5-digit NCQA Sub ID number

Required:
Select the Product Type from list

Required:
Enter the 10-character Product ID

Required:
Select the Accreditation Status from list

Required:
Enter a future date in mm/dd/yyyy format

Figure 10: AAAHC Template
No changes to this template included in this PRA package.
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AAAHC Template

All fields with an asterisk ( * ) are required. To validate the template, use the Validate button or Ctrl + Shift + V.
Please reference Chapter 5 of the QHP Instructions for instructions on completing this template

Validate

HIOS Issuer ID*
AAAHC Org ID*
Required:
Enter the 3 to 6 digit AAAHC Org ID

Market Type*

Accreditation Status*

Expiration Date*

Required:
Select the Market Type from list

Required:
Select the Accreditation Status
from list

Required:
Enter a date after 05/27/2014 in
mm/dd/yyyy format

Figure 11: Plans & Benefits Template — Benefits Package Tab – Plan Identifiers
Fields highlighted green indicate a field that would be added under this PRA package.

Plans & Benefits Template

To use this template, please review the user guide and instructions. All

HIOS Issuer ID*

You will need to save the latest version of the add-in file (PlansBenefits

Issuer State*

To create the cost share variance work sheet and enter the cost sharing

Market Coverage*

To create additional Benefits Pack age work sheets, use the Create New

Dental Only Plan*

To populate the benefits on the Benefits Pack age work sheet with your

TIN*
Multi-State Plan
Benchmark Used

Plan Identifiers
HIOS Plan ID*
(Standard Com ponent)

Plan Marketing Name*

HIOS Product
ID*

HPID

Network ID*

Service Area
ID*

Formulary ID*

Figure 12: Plans & Benefits Template – Benefits Package – Plan Attributes
Fields highlighted green indicate a field that would be added under this PRA package.

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l fields with an asterisk ( * ) are required
sAddIn.xlam) on your machine.
g amounts for both individual and SHOP (small group) mark ets, use the Create Cost Share Variances macro.
w Benefits Pack age macro.
State EHB Standards, use the Refresh EHB macro.

Plan Attributes
New/Existing
Plan?*

Plan Type*

Level of Coverage*

Unique Plan Design?*

QHP/Non-QHP*

Notice Required
for Pregnancy*

Is a Referral
Required for
Specialist?*

Specialist(s)
Requiring a Referral

Plan Level Exclusions

Limited Cost
Sharing Plan
Variation - Est
Advanced
Payment

Does this plan
offer Composite
Rating?*

Child-Only Offering*

Child Only Plan Tobacco Wellness Disease Management
ID
Program Offered*
Programs Offered

EHB Percent of Total
Premium*

Plan Design Type

Figure 13: Plans & Benefits Template – Benefits Package – Stand Alone Dental Only, Plan Dates and Geographic Coverage
Fields highlighted red indicate a field that is moving from the Benefits Package tab to the Cost Share Variance tab.

Stand Alone Dental Only
EHB Apportionment for
Pediatric Dental

Guaranteed vs.
Estimated Rate

AV Calculator Additional Benefit Design
Maximum
Coinsurance for
Specialty Drugs

Maximum Number of
Days for Charging an
Inpatient Copay?

Begin Primary Care
Begin Primary Care
Deductible/
Cost-Sharing After a
Coinsurance After a Set
Set Number of Visits?
Number of Copays?

Plan Dates
Plan Effective
Date*

Plan Expiration
Date

Plan Level URLs

Geographic Coverage
Out of Country
Out of Country
Coverage*
Coverage Description

Out of Service
Out of Service Area
Area
Coverage Description
Coverage*

National
Network*

URL for Enrollment Payment

Figure 14: Plans & Benefit Template – Benefits Package – Benefits Information
Fields highlighted green indicate a field that would be added under this PRA package.

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Benefit Information
Benefits

EHB
(Autopopulated)

General Information
EHB (Issuer)

EHB Category

State-Required
Benefit

Is this Benefit
Covered?

Quantitative Limit on Service

Limit Quantity

Limit Unit

Quantitative Limit
Units Apply see EHB
Benchmark

Deductible and Out of Pocket Exceptions
Care Plan Limit?

Number of Visits
before Care Plan
Limit applies

Exclusions

Benefit Explanation

EHB Variance
Reason

Subject to
Deductible
(Tier 1)

Subject to
Deductible
(Tier 2)

Excluded from Excluded from
In Network
Out of Network
MOOP
MOOP

Primary Care Visit to Treat an Injury or Illness
Mental Health and Substance Use Disorder Office Visit
All Other Mental Health/Substance Use Outpatient Visits
Specialist Visit
Other Practitioner Office Visit (Nurse, Physician Assistant)
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Outpatient Surgery Physician/Surgical Services
Hospice Services
Non-Emergency Care When Traveling Outside the U.S.
Routine Dental Services (Adult)
Infertility Treatment
Long-Term/Custodial Nursing Home Care
Private-Duty Nursing
Routine Eye Exam (Adult)
Urgent Care Centers or Facilities
Home Health Care Services
Emergency Room Services
Mental Health Emergency Services
Emergency Transportation/Ambulance
Inpatient Hospital Services (e.g., Hospital Stay)
Inpatient Physician and Surgical Services
Bariatric Surgery
Cosmetic Surgery
Skilled Nursing Facility
Prenatal and Postnatal Care
Delivery and All Inpatient Services for Maternity Care
Mental/ Behavioral Health Outpatient Services
Mental/ Behavioral Health Inpatient Services
Substance Abuse Disorder Outpatient Services
Substance Abuse Disorder Inpatient Services
Generic Drugs
Preferred Brand Drugs
Non-Preferred Brand Drugs
Specialty Drugs
Outpatient Rehabilitation Services
Habilitation Services
Chiropractic Care
Durable Medical Equipment
Hearing Aids
Imaging (CT/PET Scans, MRIs)
Preventive Care/Screening/Immunization
Routine Foot Care
Acupuncture
Weight Loss Programs
Routine Eye Exam for Children
Eye Glasses for Children
Dental Check-Up for Children
Rehabilitative Speech Therapy
Rehabilitative Occupational and Rehabilitative Physical Therapy
Well Baby Visits and Care
Laboratory Outpatient and Professional Services
X-rays and Diagnostic Imaging
Basic Dental Care – Child
Orthodontia – Child
Major Dental Care – Child
Basic Dental Care – Adult
Orthodontia – Adult
Major Dental Care – Adult
Abortion for Which Public Funding is Prohibited
Transplant
Accidental Dental
Dialysis
Allergy Treatment
Chemotherapy
Radiation
Diabetes Education
Prosthetic Devices
Infusion Therapy
Treatment for Temporomandibular Joint Disorders
Nutritional Counseling
Reconstructive Surgery
Additional State-Required Benefits

Figure 15: Plans & Benefits Template – Cost Sharing Variances Tab – Plan Cost Sharing Attributes
Fields highlighted green indicate a field that would be added under this PRA package.

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AV Calculator Additional Benefit Design

Plan Cost Sharing Attributes

HIOS Plan ID*
(Standard Com ponent Plan Marketing Name*
+ Variant)

Level of
Coverage*

CSR Variation Type*

(Metal Level)

Issuer
Actuarial
Value

AV Calculator Medical & Drug
Output
Deductibles
Number*
Integrated?*

Medical & Drug
Maximum Out of
Pocket
Integrated?*

Multiple In
Network
Tiers?*

1st Tier
Utilization*

Maximum
Coinsurance
for Specialty
Drugs

2nd Tier
Utilization

Maximum
Which
Number of
Benefits
Number of Visits
Days for
Begin Costbefore Cost
Charging an Sharing After
Sharing Begins
Inpatient
a Set Number
Copay?
of Visits?

Which
Benefits
Begin
Deductible/
Coinsurance
After a Set
Number of
Copays?

Number of
Copays before
Deductible/Coins
urance Begins

Figure 16: Plans & Benefits Template – Cost Sharing Variances Tab – SBC Scenarios
Fields highlighted green indicate a field that would be added under this PRA package.
SBC Scenario

Having a Baby

Deductible

Copayment

Having Diabetes

Coinsurance

Limit

Deductible

Copayment

Simple Fractures

Coinsurance

Limit

Deductible

Copayment

Coinsurance

Limit

Figure 17: Plans & Benefits Template – Cost Sharing Variance Tab – MOOP
No changes to this template included in this PRA package.
Maximum Out of Pocket for Medical EHB Benefits
In Network

Individual

Family

In Network (Tier 2)

Individual

Family

Maximum Out of Pocket for Drug EHB Benefits

Out of Network

Individual

Family

Combined In/Out Network

Individual

Family

In Network

Individual

Family

In Network (Tier 2)

Individual

Family

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total)
Out of Network

Individual

Family

Combined In/Out Network

Individual

Family

In Network

Individual

Family

In Network (Tier 2)

Individual

Family

Out of Network

Individual

Family

Combined In/Out Network

Individual

Figure 18: Plans & Benefits Template – Cost Sharing Variance Tab – Deductible
No changes to this template included in this PRA package.
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Family

Medical EHB Deductible

Individual

Family

Drug EHB Deductible

In Network
(Tier 2)

In Network

Default
Coinsurance

Individual

Family

Out of Network

Default
Coinsurance

Individual

Combined In/Out Network

Family

Individual

Family

In Network

Individual

Combined Medical and Drug EHB Deductible

In Network (Tier 2)

Default
Coinsurance

Family

Individual

Default
Coinsurance

Family

Combined In/Out Network

Out of Network

Individual

Individual

Family

In Network

Individual

Family

Out of Network

In Network (Tier 2)

Default
Coinsurance

Family

Family

Individual

Default
Coinsurance

Individual

Combined In/Out Network

Family

Individual

Family

Figure 19: Plans & Benefits Template – Cost Sharing Variances Tab – HSA/HRA Detail, URLs
No changes to this template included in this PRA package.

Plan Variant Level URLs

HSA/HRA Detail

HSA
Eligible *

HSA/HRA
Employer
Contribution

HSA/HRA Employer
Contribution Amount

URL for Summary of Benefits & Coverage

Plan Brochure

Figure 20: Plans & Benefits Template – Cost Sharing Variance Tab – Benefit Cost Sharing (New Mental Health Benefits)
Fields highlighted green indicate a field that would be added under this PRA package.
Primary Care Visit to Treat an Injury or Illness
Coinsurance

Copay

In Network (Tier 1)

In Network (Tier 2)

Mental Health and Substance Use Disorder Office Visit

Out of Network

In Network (Tier 1)

In Network (Tier 2)

Copay

Out of Network

In
Network
(Tier 1)

In
Network
(Tier 2)

Coinsurance

Out of
Network

In
Network
(Tier 1)

In
Network
(Tier 2)

Copay

Out of
Network

Specialist Visit

All Other Mental Health/Substance Use Outpatient Visits

In
Network
(Tier 1)

In
Network
(Tier 2)

Copay

Coinsurance

Out of
Network

In
Network
(Tier 1)

In
Network
(Tier 2)

Out of
Network

In Network (Tier 1)

In Network (Tier 2)

Coinsurance

Out of Network

In Network (Tier 1)

In Network (Tier 2)

Figure 21: Plans & Benefits Template – Cost Sharing Variance Tab – Benefit Cost Sharing (New Mental Health Benefits cont.)
Fields highlighted green indicate a field that would be added under this PRA package.

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Out of Network

Emergency Room Services
Copay

In Network (Tier 1)

Coinsurance

In Network (Tier 2)

Out of Network

In Network (Tier 1)

Emergency Transportation/Ambulance

Mental Health Emergency Services
Copay

In Network (Tier 2)

Out of Network

In Network (Tier 1)

In Network (Tier 2)

Copay

Coinsurance

Out of Network

In Network (Tier 1)

In Network (Tier 2)

Out of Network

In Network (Tier 1)

In Network (Tier 2)

Coinsurance

Out of Network

In Network (Tier 1)

In Network (Tier 2)

Out of Network

Figure 22: Prescription Drug Template – Formulary Tiers Tab
Fields highlighted red indicate fields to be removed and re-incorporated into the Plans & Benefits Template.
Prescription Drug Formulary Template

All fields with an asterisk ( * ) are required. To validate the template, press the Validate button or Ctrl + Shift + V. To finalize, press Finalize button or Ctrl + Shift + F.
Click the Create Formulary IDs button (or Ctrl + Shift + C) to create Formulary IDs.

Validate

After creating Formulary IDs, select the ID from the drop down in Column A and 7 tiers will automatically be popoulated.
Select how many tiers a formulary uses from Number of Tiers and unused rows (tiers) will be greyed out.

Finalize

Enter all RXCUIs on the Drug Lists sheet. To add more drug lists, click Add Drug List (Ctrl + Shift + A) and to delete the last drug list added press Delete Drug Lists (or Ctrl + Shift + D).

HIOS Issuer ID*
Issuer State*

Formulary ID*

Formulary URL*

Drug List ID*

Number of
Tiers*

Required:
Select the Formulary ID

Required:
Enter the Formulary URL

Required:
Select the Drug List ID
(from Drug Lists sheet)

Required:
Select the
number of Tiers

Drug Tier ID*

Drug Tier Type*

Required:
The template w ill populate a Drug
Tier ID 1-7

Required:
Select all the Drug Types included in this
tier

1 Month Out of
1 Month In
1 Month In Network
Network Retail
Network Retail
Retail Pharmacy
Pharmacy
Pharmacy
Copayment*
Benefit
Coinsurance*
Offered?*

Required: Enter a
copayment amount

Required:
Does this tier offer
Required: Enter a
1 Month Out of
coinsurance
Netw ork Mail Order
amount
Pharmacy
benefits?

1 Month Out of
Network Retail
Pharmacy
Copayment*

Required if Offered:
Enter a copayment
amount

1 Month Out of
Network Retail
Pharmacy
Coinsurance*

3 Month In
Network Mail
Order
Pharmacy
Benefit
Offered?*

3 Month In
3 Month Out of 3 Month Out of
3 Month In Network
3 Month Out of
Network Mail
Network Mail Network Mail
Mail Order
Network Mail Order
Order
Order
Order
Pharmacy
Pharmacy Benefit
Pharmacy
Pharmacy
Pharmacy
Coinsurance*
Offered?*
Copayment*
Copayment* Coinsurance*

Required:
Does this tier offer
Required if
Required if
3 Month In Netw ork
Offered: Enter a
Offered: Enter a
Mail Order
coinsurance amount
copayment amount
Pharmacy
benefits?

Required if Offered:
Enter a coinsurance
amount

Required:
Required if
Does this tier offer 3
Offered: Enter a
Month Out of Netw ork Mail
copayment amount
Order benefits?

Figure 23: Prescription Drug Template – Drug Lists Tab
Fields highlighted green indicate a field that would be added under this PRA package.
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Required if
Offered: Enter a
coinsurance
amount

Drug Lists

All fields with an asterisk (*) are required. To validate the template, press the Validate button or Ctrl + Shift + V. To finalize, press Finalize button or Ctrl + Shift + F.
Click the Create Formulary IDs button (or Ctrl + Shift + C) to create Formulary IDs.

Add Drug List
Remove Drug List

After creating Formulary IDs, select the ID from the drop down in Column A and 7 tiers will automatically be popoulated.
Select how many tiers a formulary uses from Number of Tiers and unused rows (tiers) will be greyed out.
Enter all RXCUIs on the Drug Lists sheet. To add more drug lists, click Add Drug List (Ctrl + Shift + A) and to delete the last drug list added press Delete Drug Lists (or Ctrl + Shift + D).

Drug List ID 1
RXCUI*

Tier Level*

Prior Authorization
Required

Step Therapy
Required

Quantity Limits

Fill Limits

Pharmacy Restrictions

Over-the Counter Step
Therapy Protocol

Required:
Enter the RXCUI

Required:
Select the Tier this drug is in, or select NA if
this drug is not a part of this Drug List

Required if Tier Level is
not NA:
Select "Yes" if Prior
Authorization is Required

Required if Tier Level is
not NA:
Select "Yes" if Step Therapy
is Required

Required if Tier Level is
not NA:
Select "Yes" if Coverage
features Quantity Limits.

Required if Tier Level is
not NA:
Select "Yes" if Coverage
features Fill Limits.

Required if Tier Level is
not NA:
Select "Yes" if Coverage
features Pharmacy
Restrictions.

Required if Tier Level is
not NA:
Select "Yes" if Coverage
features OTC Step Therapy
Protocols.

Figure 24: Service Area Template
No changes to this template included in this PRA package.

Service Area

All fields with an asterisk ( * ) are required

Go to cell B1 for instructions

To validate, press the Validate button or Ctrl + Shift + V. To finalize, press the Finalize button or Ctrl + Shift + F

Validate

Click Create Service Area IDs button (or Ctrl + Shift + S) to create service area ids based on your state
Service Area IDs will populate in the drop-down box in Service Area ID column

Finalize

For each row, enter one County for that Service Area ID (unless the Service Area covers entire state)
HIOS Issuer ID:*
Issuer State:*
Create Service Area IDs
Service Area ID*

Service Area Name*

State*

County Name

Required:
Enter the Service Area ID

Required:
Enter the Service Area Name

Required:
Does this Service Area
cover the entire state?

Required if State is "No":
Select the County - FIPS this Service
Area covers

Partial County

Service Area Zip Code(s)

Required if State is "No":
Required if Partial County is "Yes":
Does this Service Area include a partial Enter the zip codes in this county that are
county?
covered by this Service Area

Partial County Justification
Required if Partial County is "Yes":
Enter a Justification of w hy all of the zip
codes are not included in this service area.

Figure 25: Network ID Template
No changes to this template included in this PRA package.

QHP Certification Instrument Screenshots

11

10/26/15

Network Template

All fields with an asterisk ( * ) are required.

Go to cell B1 for instructions

To validate the template, press Validate button or Ctrl + Shift + V. To finalize, press Finalize button or Ctrl + Shift + F.

Validate

Click Create Network IDs button (or Ctrl + Shift + N) to create network ids based on your state.
Network IDs will populate in the drop-down box in Network ID column.

Finalize

Use each Network ID only once.
HIOS Issuer ID*
Issuer State*

Network Name*

Network ID*

Network URL*

Required:
Enter the Netw ork Name

Required:
Select the Netw ork ID

Required:
Enter the Netw ork URL

Figure 26: Rates Table Template
No changes to this template included in this PRA package.
Rates Table Template

To validate press Validate button or Ctrl + Shift + V. To finalize, press Finalize button or Ctrl + Shift + F.

Go to cell B1 for instructions

If you are a community rating state, select Family Option under Age and fill in all columns.

Validate

If you are not community rating state, select 0-20 under Age and provide an Individual Rate for every age band.
If Tobacco is Tobacco User/Non-Tobacco User, you must give a rate for Tobacco Use and Non-Tobacco Use.

Finalize

To add a new sheet, press the Add Sheet button, or Ctrl + Shift + S. All plans must have the same dates on a sheet.
HIOS Issuer ID*
Federal TIN*
Rate Effective Date*
Rate Expiration Date*

Add Sheet
Plan ID*

Rating Area ID*

Required:
Enter the 14-character Plan ID

Required:
Select the Rating Area ID

QHP Certification Instrument Screenshots

Tobacco*

Age*

Individual Rate*

Required:
Required:
Select if Tobacco use of
Required:
Enter the rate of an Individual
subscriber is used to determine if Select the age of a subscriber
Non-Tobacco or No Preference
a person is eligible for a rate from
eligible for the rate
enrollee on a plan
a plan

Couple *

Primary Subscriber and Primary Subscriber and
One Dependent*
Two Dependents*

Required:
Enter the rate of a couple
based on the pairing of a
primary enrollee and a
secondary subscriber (e.g.
husband and spouse)

Required:
Required:
Enter rate of a family based on
Enter the rate of a family
a single parent w ith one
based on a single parent w ith
dependent
tw o dependents

Figure 27: Business Rules Template
No changes to this template included in this PRA package.
12

Family Tier
Primary Subscriber and
Three or More
Dependents*

Couple and One
Dependent*

Couple and Two
Dependents*

Couple and Three or
More Dependents*

Required:
Required:
Required:
Required:
Enter the rate of a family
Enter the rate of a family
Enter the rate of a family based Enter the rate of a family based
on a couple w ith one
based on a couple w ith three
based on a single parent w ith
on a couple w ith tw o
dependent
or more dependents
three or more dependents
dependents

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Business Rules Template

To validate the template, press Validate button or Ctrl + Shift + V. To finalize the template, press Finalize button or Ctrl + Shift + F.

Go to cell C1 for instructions

Enter the Issuer Rule on the first row (no Product ID or Plan ID).

Validate

For each Product rule, enter only the Product ID and the business rules that differ from the Issuer Rule.
For each Plan rule, enter only the Plan ID and the business rules that differ from the Product or Issuer Rule

Finalize

HIOS Issuer ID*
TIN*

Product ID

Plan ID
(Standard Component)

What are the
What are the maximum
maximum number
How are rates for
What are the maximum Are domestic partners Are same-sex partners
How is tobacco status
number of under age
How is age determined
of under age
contracts covering two or
number of children
treated the same as
treated the same as
determined for
Is there a maximum
(under 21) dependents
for rating and eligibility
(under 21)
used to quote a
subscribers and
secondary
secondary
more enrollees
age for a dependent?
purposes?
used to quote a two parent dependents used to
children-only contract?
dependents?
subscribers?
subscribers?
calculated?
family?
quote a single
parent family?

QHP Certification Instrument Screenshots

13

What relationships between
primary and dependent are
allowed, and is the dependent
required to live in the same
household as the primary
subscriber?

10/26/15