Comment and Response document

Appendix N. QHP Certification 60-Day Comment Summary Responses to Paperwork Reduction Act Notice
Published August 3, 2015
Initial Plan Data Collection to Support QHP Certification (CMS-10433)
Comment Type

Comment Summary

Application
process

Recommends that CMS provide issuers
with the opportunity to review (but not
necessarily edit) the QHP Application in
HIOS at any point
Objects to several data points due to
concern that burden is excessive.

Burden

Burden

Burden

Concern that CMS is creating unnecessary
burden on issuers through the state
certification form and that CMS should
collect information directly from state
insurance departments.
Objects to burden created based on data
elements for off-Marketplaces plans for
Risk Adjustment, Reinsurance, and
Payment Operations.

QHP Certification 60-Day Comment Summary Responses

Template
Area
N/A

Response

N/A

CMS believes that burden estimates accurately reflect the time it
takes for an issuer to complete the activities noted in this
package and bases its estimates on experience from the
certification process for 2014-2016.
The reference to the state certification has been removed. A
certification form is not required.

N/A

N/A

We will continue to consider the technical feasibility of allowing
issuers to review the QHP Application in HIOS at any point but do
not believe this will be feasible for 2017 plans.

With regards to Appendix D Plan Data Elements, these data
elements are essential to the calculation of plan liability risk
scores and risk adjustment transfers. These data elements are
required of all Affordable Care Act-compliant, non-grandfathered
individual and small group market plans, on and off the
Exchange. These plans are considered risk adjustment covered
plans under the Affordable Care Act’s permanent risk adjustment
program. We note that plan types such as grandfathered plans
and Medicaid plans are not subject to the risk adjustment
program and therefore, not subject to this data collection.

1

Comment Type

Comment Summary

Data collected

Recommends that CMS include issuer
logos on the FFM.

Data collected

Data collected

Data collected

Data collected

Data collected

Template
Area
N/A

Response

Recommends that CMS have the data
integrity tool provide more detailed error
information and align the validation checks
within the DIT tool and the HIOS portal.

N/A

This comment is out of scope to this PRA package, as the data
integrity tool does not involve a collection of information and is
therefore not part of this information collection.

Suggests that CMS revisit the fields in the
Administrative Data Template against
what is also provided by issuers in the
HIOS Marketplace Issuer Data Fields in
HIOS Plan Finder to avoid duplication.
Suggests that CMS allow for additional
flexibility for issuers to set age
requirements for grandchildren and
dependents of minor dependents and
categorization of domestic partners and
other partnership situations.
Supports creating a new field in the
essential community provider (ECP) issuer
application template to document the
number of DMDs and DDSs authorized by
the state to independently treat and
prescribe within a facility.
Recommends that CMS allow issuers to
write in ECP providers that are missing
from CMS’ list.

Administrative CMS continues to work towards streamlining the QHP application
Data
process, including the administrative data collection.
Template

QHP Certification 60-Day Comment Summary Responses

We will continue to consider the technical feasibility of including
issuer logos.

Business Rules
Template

We will consider the technical feasibility of allowing issuers to
define additional business rules in future years. While we are not
changing the allowed business rules for plan year 2017, we will
seek issuer feedback as to which changes and additions would be
most useful before making changes in the future.

Essential
Community
Provider
Template

We are modifying this data field in the ECP template to collect
the number of practitioners with whom the issuer has contracted
among the available practitioners reported by the facility via the
ECP petition and as reflected on the ECP list.

Essential
Community
Provider
Template

This comment is out of scope to this PRA package, as the
template does not include a write-in feature. Any changes to the
current ECP policy itself would not be through the PRA process,
which is limited to collections of information.

2

Comment Type

Comment Summary

Data collected

Recommends that CMS rely on data
provided in the ECP Provider Petition to
capture the number of contracted MDs,
DOs, PAs, and NPs rather than adding a
new field to the ECP Template.
Recommends that 340B participation and
HPSA fields also be reflected on the ECP
List and that the ECP Review Tool is
updated when the ECP List is updated.
ECP Template and ECP Tool should have
formulas updated to accommodate for
multiple rows if name or National Provider
Identifier (NPI) is the same for multiple
locations of the same provider on the ECP
list. Instructions should also be updated
accordingly to provide issuers with clear
guidance on how to address duplicate
providers with multiple addresses but a
single NPI.
Where CMS proposes adding new data
elements, provide additional detail
regarding how the data will be used for
QHP certification and/or public display.

Data collected

Data collected

Template
Area
Essential
Community
Provider
Template

Response

Essential
Community
Provider
Template
Essential
Community
Provider
Template

This comment is out of scope to this PRA package, which does
not involve the ECP list.

N/A

We are adding this new data field to the ECP template to capture
the number of practitioners with whom an issuer has contracted,
as opposed to the number of practitioners that the provider has
indicated are available at its facility via the ECP petition.

We plan to embed the HHS ECP List within the ECP template, so
that issuers will electronically select ECPs from the ECP List and
the provider data will auto-populate the issuer’s template and
eliminate the complexities associated with issuers manually
entering providers with multiple addresses and a single NPI.

Network adequacy template – We are proposing adding a field to
collect tiering information. We believe this information is
necessary to help us better understand how the network is
structured and how reasonable access is being provided.
ECP template – We are proposing to collect the number of
contracted practitioners at each facility. We believe this
information will allow CMS to have more complete data on the
provider participation within an issuer’s provider network.
Plans & Benefits template – New data fields to capture mental
health, substance abuse, and specialist cost sharing are intended
to ensure that the template can accommodate potential changes

QHP Certification 60-Day Comment Summary Responses

3

Comment Type

Data collected
Data collected

Data collected

Data collected

Comment Summary

Template
Area

Recommends that the Network URL be
moved from the Network Template to the
Plans & Benefits Template.
Requests confirmation that a Plan Type of
“Indemnity” entered into the Plans &
Benefits Template will not result in those
fields being required in the Network
Template
Does not support the addition of tier and
cost-sharing information. Recommends
that if CMS collects this information, CMS
add a place for issuers to provide a
description of their plan network and how
enrollees can access benefits.

Network
Template

Recommends adding provider type listing
for additional categories of behavioral
health and substance abuse providers.

Network
Adequacy
Template

QHP Certification 60-Day Comment Summary Responses

Network
Template

Network
Adequacy
Template

4

Response
to the AV Calculator in the future. Information about the plans’
AV calculation is collected during QHP certification and is a
requirement established at 45 CFR 156.135 and 156.140. These
data may also be used by CMS to display more detailed cost
sharing information to consumers in the future.
Plans & Benefits template – The new data field, “Plan design
type” would allow issuers to indicate whether each plan has a
particular cost sharing design. A number of State-based
Marketplaces require issuers to offer uniform plan designs at
various metal levels. Adding this data element will assist states in
reviewing plans.
This URL was put in this specific template for administrative
reasons. We will take this recommendation into consideration
for the future.
Indemnity plans are not required to fill out the network adequacy
provider template.

It important for CMS to understand how issuers structure plans
and provide benefits in accordance with the requirement to
provide reasonable access to all covered services. In order to
understand this, we are requesting tier information as part of
network provider data that we collect. Issuers provide additional
information about benefit design in other areas of the QHP
application.
We believe this is adequately addressed under the category of
mental health.

Comment Type

Comment Summary

Data collected

Recommends not creating a new data field
to capture the Essential Health Benefit
category for each service listed (“EHB
Category”).

Data collected

Unclear on the distinction between new
data fields to capture limitations for
essential health benefits (“Visit Limits”)
and existing fields (“Quantitative Limit on
Service” and “Quantity Limit Information”)
Recommends that including benefit
information for “Off-Exchange” only plans
within the same template remains
optional

Data collected

Data collected

Notes need for organizations to modify
design systems to capture elements from a
different template location if the “AV Calc.
Additional Benefit Design” is moved

Data collected

Recommends that “Other, specify” be
included in the drop down list for “Limit
Unit”

Data collected

Requests clarification for “Which benefits
begin cost sharing after set of visits?” and
“Which benefits begin
deductible/coinsurance after set copays?”
including whether these are free-form
fields or drop down menus. Recommends
rewording the question, “Which benefits

QHP Certification 60-Day Comment Summary Responses

Template
Area
Plans and
Benefits
Template –
Benefits
Package tab
Plans and
Benefits
Template –
Benefits
Package tab
Plans and
Benefits
Template –
Benefits
Package tab
Plans and
Benefits
Template –
Benefits
Package tab
Plans and
Benefits
Template –
Benefits
Package tab
Plans and
Benefits
Template –
Benefits
Package tab

5

Response
The data fields are necessary in order to evaluate mental health
parity in accordance with regulations.

Existing fields that address limits on services may allow for drop
down options such as “Care Plan required on or after ##
visits”/“Approval required on or after ## visits”/“Limited to ##
visits per plan year,” etc.
For QHP certification by CMS, cost sharing information is required
of the issuer for Off-Exchange, including Off-Exchange dental
plans, in order to validate and finalize the information.
We update the AV Calculator annually and the AV Calculator for
the given benefit year must be used. We also anticipate
remapping the inputs between the AV Calculator and Plans and
Benefits Template when these features are moved.
While we appreciate the comment, this is not a change the
template can accommodate at this time.

As these features would map to the AV Calculator, the options to
select would align with the AV Calculator options and would only
be available for a limited set of benefits thereby eliminating any
potential for inconsistencies. These inputs would not be
freeform, and we intend to provide clarification on this mapping
in the QHP application instructions.

Comment Type

Data collected

Comment Summary
begin deductible/coinsurance after set of
copays?” to clarify and eliminate
potentially inconsistent responses
between this question and the question,
““Begin primary care cost-sharing after a
set number of visits?” Recommends
moving these fields to the Cost Share
Variance Tab.
Recommends that the Plan Marketing
Name field be an editable field once
populated when the cost share tab is
created

Data collected

Recommends that the new field indicating
whether each plan has a particular cost
sharing design be optional or allows
issuers to indicate “not applicable”

Data collected

Recommends not including the field
referring to Care Plan Limit. Requests
more information on the “Care Plan Limit”
column including how and when the field
will be used, whether it is limited to
specific benefits, drop down options,
definitions, and instructions
Recommends creating a separate entry for
“Mental Health Office Visits” and
“Substance Abuse Office Visits” in the
Outpatient office visits sub-classifications
and deleting “Mental/Behavioral Health
Outpatient Services,” “Substance Abuse
Disorder Outpatient Services,” and

Data collected

QHP Certification 60-Day Comment Summary Responses

Template
Area

Response

Plans and
Benefits
Template –
Benefits
Package tab
Plans and
Benefits
Template –
Benefits
Package tab
Plans and
Benefits
Template –
Benefits
Package tab
Care Plan
Limit
Plans and
Benefits
Template –
Benefits
Package tab
Mental health

We plan to make Plan Marketing Name editable on the Cost
Sharing Variance tab for plan year 2017.

6

The “Plan design type” field will either be optional or allow
issuers to indicate that the field is “not applicable” for a
particular plan. We intend to provide further instructions on the
field will accompany the release of the 2017 Plans & Benefits
Template.
Without Care Plan Limit, the Plans & Benefits Template cannot be
used to auto-populate an effective MHPAEA outlier tool that
addresses non-quantitative limitations.

We devised these categories based on categorization permitted
under mental health parity regulations.

Comment Type

Comment Summary
“Mental Health Parity”

Data collected

Data collected

Data collected

Recommends removing all proposed data
elements related to mental health parity
reviews. Requests additional information
regarding the proposed data fields to
support mental health parity reviews,
including clear definitions and examples
and explanations of the overlap with
existing mental health categories.
Recommends that the new data fields
“Which benefits begin cost sharing after
set number of visits” and “Which benefits
begin deductible/coinsurance after set
number of copays” apply to any
combination of primary care, specialist,
and mental health/substance use visits.
Recommends that the AV Calculator
provide issuers the option to respond
separately for mental health/substance
use facilities and office visit categories

QHP Certification 60-Day Comment Summary Responses

Template
Area

Response

Plans and
Benefits
Template –
Benefits
Package tab
Mental health

We appreciate the recommendation; however, we are including
these elements so that states can use them as part of a future
mental health parity tool to determine compliance. We intend to
provide further instruction in the future.

Plans and
Benefits
Template –
Benefits
Package tab
Mental health

The fields will allow the issuer to specify any combination of
primary care, specialist, and mental health/substance use limits.

Plans and
Benefits
Template –
Benefits
Package tab
Mental health

This comment is out of scope to this PRA package. CMS intends
to provide a comment period to the draft AV Calculator at a
separate time.

7

Comment Type

Comment Summary

Data collected

Recommends that CMS only collect cost
share and limitation data for office visits,
outpatient services, and emergency
services for mental health, substance use,
and behavioral health in one tab

Data collected

Suggests adding a Mental Health and
Substance Abuse Outpatient Other
category

Data collected

Recommends not collecting “Plan design
type” benefit field. Recommends making
the field optional. Requests more
information regarding the definition of the
“plan design type” field in relation to “plan
type.”

Data collected

Requests that the new data field to
capture cost share variant level
information for the plan marketing name
be optional and recommends ensuring
that the number of characters in this field
do not exceed the standard in place for
EDI. Supports proposed change to capture
cost share variant level information for
plan marketing name and recommends

QHP Certification 60-Day Comment Summary Responses

Template
Area
Plans and
Benefits
Template –
Benefits
Package tab
Mental health
Plans and
Benefits
Template –
Benefits
Package tab
Mental health
Plans and
Benefits
Template –
Benefits
Package tab
Plan Design
Type

Plans and
Benefits
Template –
Cost Share
Variances tab

8

Response
Technical limitations related to the Plans & Benefits Template
preclude capturing cost sharing variance information on the same
worksheet. We continue to evaluate ways to streamline
information collection.
Mental health parity regulations allow mental health and
substance use disorder outpatient office visits to be divided
between outpatient office visits and all other outpatient visits;
those categories are currently in the template.
CMS believes it is important to collect this field. In particular,
states that operate their own Marketplace may wish to use this
field. The “Plan design type” field will either be optional or allow
issuers to indicate that the field is “not applicable” for a
particular plan. We intend for further instructions on the field to
accompany the release of the 2017 Plans & Benefits Template.
The current “plan type” field is a required field that allows issuers
to define the product network type of a plan (HMO, POS, PPO,
EPO, indemnity). The proposed “plan design type” field will allow
issuers to indicate that a plan has a pre-defined cost sharing
design.
CMS intends to make the new data field for capturing cost share
variant level information for the plan marketing name an optional
field and also ensure that the number characters in this field do
not exceed the standard in place for EDI. CMS also intends to
auto-populate and allow edits based on the plan marketing name
for the standard plan.

Comment Type

Comment Summary
continuing to auto-populate and allow
edits based on the plan marketing name
for the standard plan.

Data collected

Data collected

Recommends adding the options of “per
day” and “per stay” (with and without
deductible) for other services that can be
obtained while an inpatient is in the
hospital
Suggests that CMS add fields so that
minimum and maximum values for
Employer’s Contribution to HRAs/HSAs are
captured

Data collected

Recommends updating the AV Calculator
to allow for more flexibility in how co-pays
can occur, including vision or dental visit
co-pays.

Data collected

Recommends that the AV Calculator
include Speech Therapy and Occupational
and Physical Therapy categories

Data collected

Opposes moving the AV Calc. Additional
Benefit Design to the Cost Sharing
Variance tab

QHP Certification 60-Day Comment Summary Responses

Template
Area

Response

Plans and
Benefits
Template –
Cost Share
Variances tab
Plans and
Benefits
Template –
Cost Share
Variances tab
Plans and
Benefits
Template –
Cost Share
Variances tab
AV Calculator
Plans and
Benefits
Template –
Cost Share
Variances tab
AV Calculator
Plans and
Benefits
Template –
Cost Share

The implementation of this recommendation would compromise
the current logic used to calculate cost-sharing and its relation to
AVC.

9

For the purposes of the AV calculation, the plan can only have
one employer contribution amount as the employer contribution
amount is being mapped to the AV Calculator and being taking
into account for the AV calculation.
This is out of scope to this PRA package. CMS intends to provide a
comment period to the draft AV Calculator at a separate time.

This is out of scope to this PRA package. CMS intends to provide a
comment period to the draft AV Calculator at a separate time.

The Plans & Benefits Template does not allow issuers to vary the
“Additional Benefit Design” options between silver plan variants.
Silver plans variances have different AVs and can vary cost
sharing for the Additional Benefit Design features. The purpose

Comment Type

Comment Summary

Template
Area
Variances tab
AV Calculator

Data collected

Suggests that the Plan & Benefits
Template be consistent with any upcoming
changes made to the AV Calculator

Data collected

Recommends eliminating additional new
data fields to capture SBC scenario or
making them optional for the first year.
Recommends eliminating existing fields to
capture the cost of having diabetes and
having a baby.

Plans and
Benefits
Template –
Cost Share
Variances tab
AV Calculator
Plans and
Benefits
Template –
Cost Share
Variances tab
SBC Scenario

Data collected

Supports the requirement to provide fill
quantity and fill limits, but not the addition
of pharmacy restrictions and over-thecounter requirements

Prescription
Drug
Template –
Formulary tab

Data collected

Requests that specific definitions of terms
related to the proposed “Quantity Limits
and “Fill Limits” fields be added

Prescription
Drug
Template –
Formulary tab

QHP Certification 60-Day Comment Summary Responses

10

Response
of this change would be to allow users the flexibility to vary these
features for silver plans in the template and could help ensure
that some users can use the integrated version of the AV
Calculator in the Plans & Benefits Template (instead of submitting
their plans as unique plan designs).
We will consider changes being made to the AV Calculator when
considering updates to the Plans & Benefits Template and will
continue to look ways to ensure more consistency between
templates.
QHP issuers are required to provide the Summary of Benefits and
Coverage (SBC) in a manner compliant with the standards set
forth in in 45 C.F.R. 147.200, which implements section 2715 of
the PHS Act, as added by the Affordable Care Act. Specifically,
issuers must fully comply with the requirements of 45 C.F.R.
147.200(a)(3), which requires issuers to “provide an SBC in the
form, and in accordance with the instructions for completing the
SBC, that are specified by the Secretary in guidance.”
Knowing if the dispensing of a drug is restricted to a particular
pharmacy would be beneficial to consumers. Similar to the
standard step therapy data currently collected, OTC step therapy
requires the step therapy to include the use of over-the-counter
equivalences first. Both limits are industry standards and
currently being collected for Medicare Part D submissions.
Quantity limits and fill limits are recognized terms used in the
pharmacy industry. Additional clarification language may be
added in the template guidelines and instructions.

Comment Type
Data collected

Data collected

Data collected

Data collected

Data collected

Data collected

Comment Summary

Template
Area
Requests clarification on what is
Prescription
considered a pharmacy restriction and
Drug
information on how proposed changes for Template –
1/1/2017 requiring access through physical Formulary tab
pharmacies may affect the use of this field
Supports moving the cost sharing
Prescription
information collected on the Formulary
Drug
Tiers tab to the Plans & Benefits
Template –
instrument, assuming that the issuer is
Formulary tab
able to select a cost share maximum in coinsurance plans that differs across the
Silver variant plans
Recommends also moving tiering and tier
Prescription
name descriptions and drug cost sharing
Drug
information to the Plans & Benefits
Template –
template.
Formulary tab
Requests clarification of CMS’ approach
Prescription
for inputting the number of tiers and
Drug
associated cost sharing and recommends
Template –
allowing issuers to input up to 7 tiers using Formulary tab
the current approach
2 commenters recommend moving away
Prescription
from categorical approach to tiering and
Drug
toward a numerical approach (“Tier 1,”
Template –
“Tier 2,” “Tier 3,” etc.)
Formulary tab
Recommends displaying specialty and non- Prescription
specialty drug copayments for each tier, or Drug
displaying the non-specialty drug
Template –
copayments for each tier
Formulary tab

QHP Certification 60-Day Comment Summary Responses

11

Response
Knowing if the dispensing of a drug is restricted to a particular
pharmacy would be beneficial to consumers. Currently, this data
will not be collected in the 2017 RX template, although this may
change.
We appreciate the recommendation; however technical
limitations related to the Plans and Benefits template prevent the
addition of cost share maximum data for coinsurances across
variant plans at this time.

We appreciate the recommendation but we do not believe it is
technologically feasible at this time. Additionally, we believe it is
functional in the current location.
We appreciate the recommendation of allowing issuers to input
up to seven tiers in the Plans and Benefits template. We will
consider the technical feasibility of this change for future years.
CMS continues to work towards streamlining the QHP application
process, including the labeling of drug tiers.
Although the current PRA package does not include changes to
display specialty and non-specialty drug copayments for each
tier, we will consider these options for future years.

Comment Type

Comment Summary

Data collected

Recommends that CMS organize the Plans
& Benefits tab to use the same drug types
that are used in the Prescription Drug
Template, or that CMS uses the data in the
Prescription Drug Template to populate
healthcare.gov
Recommends not adopting the proposed
changes for capturing quantity limits, fill
limits, and pharmacy restrictions for each
RxCUI as well as OTC step therapy
protocols

Data collected

Data collected

Data collected

Data collected

Data collected

Requests clarification on whether the
“Over-the-Counter Step Therapy Protocol”
field would apply only to step therapy
programs where all agents in the step
protocol are over-the-counter
Requests confirmation of whether the
parameters for the “Over-the-Counter
Step Therapy Protocol” field will take into
account that many QHPs use a P&T
committee to approve the clinically
appropriate use of a step therapy program
Requests clarification regarding how OTC
Step Therapy is distinct from the existing
step therapy data element
Requests confirmation on whether the
description of how to complete the Rate

QHP Certification 60-Day Comment Summary Responses

Template
Area
Prescription
Drug
Template –
Formulary tab

Response

Prescription
Drug
Template –
Formulary tab
OTC

Fill limits and quantity limits data will be useful to consumers
when choosing a plan. Knowing if the dispensing of a drug is
restricted to a particular pharmacy would be beneficial to
consumers. Similar to the standard step therapy data currently
collected, OTC step therapy requirements extend the step
therapy to over-the-counter equivalences of the drugs. Both
limits are industry standards and currently being collected for
Medicare Part D submissions.
OTC Step Therapy only applies to drugs that require the use of an
OTC drug first. The current Step Therapy data pertains to other
prescription drugs.

Prescription
Drug
Template –
Formulary tab
OTC
Prescription
Drug
Template –
Formulary tab
OTC
Prescription
Drug
Template –
Formulary tab
OTC
Rate Table
Template
12

We will consider the technical feasibility of allowing the Plans and
Benefits template to capture the drug type data that are used in
the Prescription Drug Template and populating healthcare.gov
with data from the Prescription Drug Template in future years.

Issuers are required to adhere to the P&T Committee standards
in determining the appropriate use of step therapy restrictions.
Similar to the standard step therapy data currently collected, OTC
step therapy requires that the step therapy include the use of
over-the-counter equivalences first. This data is currently being
collected for Medicare Part D application submissions.
The OTC Step Therapy restriction only applies to the requirement
of the use of an over the counter drug first. The current Step
Therapy requirement pertains to other prescription drugs.
CMS is not proposing any changes to the Rate Table in this PRA
package. The explanatory text on row 13 of the Rates Table

Comment Type

Comment Summary
Table (Row 13) will be removed.

Data collected - Suggest that CMS provide additional
Instructions
information at the beginning of the QHP
application process regarding what is
considered discriminatory.
Timeline
Recommends that final PRA package be
released as soon as possible.

QHP Certification 60-Day Comment Summary Responses

Template
Area

Response

N/A

This comment is out of scope to this PRA package. CMS provided
information regarding potentially discriminatory benefit design in
the 2016 Payment Notice.

N/A

CMS will work to finalize the PRA package as soon as possible.

13

Template was inadvertently removed in the previous version of
the PRA package and has been restored in the current version.