Last updated: November 2026
Qualified health plan (QHP) issuer certification readiness is the work a health insurer does before it applies to offer plans on an Exchange: testing its licensure, quality program, network, accreditation and contracts against the federal participation standards. The federal baseline is 45 CFR 156.200, which requires a certification issued or recognized by the Exchange for each plan the issuer offers there. Integral Healthcare Solutions (IHS) is a consulting firm that tests your documents against those standards and drafts what is missing for your leaders and counsel to approve.
What are the QHP issuer participation standards?
Paragraph (b) of 45 CFR 156.200 lists what a QHP issuer must do (summary of eCFR text opened November 5, 2026):
- Comply with the requirements of the subpart for each of its QHPs on an ongoing basis (b)(1).
- Comply with Exchange processes, procedures and requirements under subpart K of part 155 and, in the small group market, sections 155.705 and 155.706 (b)(2).
- Ensure that each QHP complies with benefit design standards as defined in section 156.20, which require essential health benefits, cost-sharing limits, and bronze, silver, gold or platinum coverage or a catastrophic plan (b)(3).
- Be licensed and in good standing to offer coverage in each State in which the issuer offers health insurance coverage (b)(4).
- Implement and report on a quality improvement strategy, disclose and report quality and outcomes information, and implement appropriate enrollee satisfaction surveys, under Affordable Care Act sections 1311(c)(1)(E), 1311(g), 1311(c)(1)(H), 1311(c)(1)(I), 1311(c)(3) and 1311(c)(4) (b)(5).
- Pay any applicable user fees assessed under section 156.50 (b)(6).
- Comply with the standards under 45 CFR part 153 (b)(7), which section 153.10 describes as standards for transitional reinsurance, temporary risk corridors and permanent risk adjustment programs.
Who needs it, and what triggers it?
Any health insurance issuer that offers or plans to offer a health plan in an Exchange needs a certification for it. Triggers:
- A first Marketplace application, or a move into a new State, which brings the licensure duty in (b)(4).
- Annual recertification: except for multi-State plans and CO-OP QHPs, an Exchange must establish a process that at minimum reviews the general certification criteria in section 155.1000(c), and notify the issuer of its recertification status. Section 155.1075(b) requires completion no later than 2 weeks before the open enrollment date at section 155.410(e)(2) of the applicable calendar year (section 155.1075).
- An accreditation date coming due under section 155.1045, or a change of delegated vendors.
Readiness planning should use the application instructions and dates for the issuer's State, Exchange and intended plan year.
How IHS helps
IHS assesses gaps against the applicable requirements, maps evidence, drafts missing program and compliance documents, and conducts mock and readiness reviews. Your leaders and counsel approve the documents; your clinicians approve any clinical content.
You supply licenses by State, plan designs, network data and contracts, delegation agreements, accreditation status and the Exchange's application instructions.
The limit: IHS does not file with an Exchange or CMS, does not enter data in a submission system and gives no legal advice. Maureen Plumstead leads NCQA accreditation work at IHS; any accrediting entity makes its own decisions.
What to have ready
Bring these six evidence sets, selected from 45 CFR text opened November 5, 2026.
- Plan designs: document benefit design standards and at least one silver and one gold QHP throughout each service area it offers through the Exchange, plus child-only coverage at each offered coverage level for individuals under 21 at the beginning of the plan year (156.200(b)(3), (c)).
- Accreditation records and release authorization: accreditation must reflect local QHP performance in the categories in 156.275(a). Authorize release of the most recent survey and any survey-related information HHS requires to the Exchange and HHS. Meet the applicable 155.1045 timeline and maintain accreditation while offering QHPs.
- Network evidence and directory: for network QHPs, document a network available to all enrollees, ECP compliance and enough providers, including mental health and substance use disorder specialists, for all services without unreasonable delay, consistent with PHS Act section 2702(c). For FFE issuers in States without a CMS-determined Effective Provider Access Review Program, time/distance standards apply from plan years beginning January 1, 2023, and appointment wait standards from January 1, 2025; under 156.230(a)(3) the FFE may grant an exception while CMS conducts provider access reviews, if it finds the plan serves qualified individuals' interests. Supply the directory to the Exchange for online publication under HHS guidance and to potential enrollees in hard copy on request; identify providers not accepting new patients. Under 156.230(b)(2), from plan years beginning January 1, 2016, publish an accurate, complete, current directory with patient-acceptance status, location, contact details, specialty, medical group and institutional affiliations, publicly accessible without an account or policy number and, with multiple networks, showing which plans and networks each provider is in.
- ECP participation and offers: for FFE network plans using the general standard, show HHS-specified minimum participation percentages across categories and within specified categories in each service area. Count colocated providers once and tiered-network providers only in the lowest cost-sharing tier. Offer contracts to all available Indian health care providers in the service area using federally required special terms, and at least one ECP in each of eight categories per service-area county where available and furnishing services covered by the plan type. Record offer status as required by 156.235(a)(3). Plans furnishing most covered professional services through employed physicians or one contracted medical group may use the alternative in (b), under (a)(5); under (d), paragraph (a) does not compel contracting with an ECP that rejects rates and provisions accepted by similarly situated providers.
- Delegation agreements: the issuer retains its own and delegates' compliance responsibilities under the Exchange-model-specific standards in 156.340(a). If those activities or obligations are delegated, agreements must state activities, reporting, remedies for unsatisfactory performance and legal compliance, and provide the Secretary/OIG and relevant Exchange authority the access specified in (b)(4)-(5) until 10 years from the agreement period's final date.
- Other compliance evidence: document applicable Exchange/State participation conditions for each QHP, QHP nondiscrimination under the full definition in 156.200(e), equal broker compensation for FFE QHPs and similar plans outside the FFE in the same State, and the certification attestation covering all operational requirements in part 156 subparts D, E, H, K, L and M.
Bring this list to the free introductory call.
How it compares
Sections 156.50 and 156.340(a) treat these arrangements differently (eCFR text opened November 5, 2026).
| Model | User fee (156.50) | Delegated and downstream entity standards (156.340(a)) |
|---|---|---|
| Federally-facilitated Exchange | A monthly user fee to HHS: the annual-notice rate for the benefit year times the monthly premium for each policy enrolled through that Exchange (156.50(c)(1)). | Paragraph (a)(2): the issuer remains responsible for delegates' and downstream entities' compliance with part 156 subpart C for each QHP on an ongoing basis; part 155 subparts H and K; and, in the small group market, sections 155.705 and 155.706 where applicable to the Exchange type. Section 155.220 applies to QHP enrollment assistance; sections 156.705 and 156.715 govern records and compliance reviews where applicable to the Exchange type. |
| State-based Exchange on the Federal platform | For functions covered by the Federal platform agreement, participating issuers pay HHS in its specified timeframe and manner, using the applicable benefit-year SBE-FP monthly rate in the annual HHS notice multiplied by each policy's monthly premium for enrollment through the SBE-FP, unless the State Exchange and HHS agree on another collection mechanism (156.50(c)(2)). | Paragraph (a)(2), as above. |
| State-based Exchange that does not use the Federal platform | Any user fee payments or other charges the State-based Exchange assesses under section 155.160 (156.50(b)). | Paragraph (a)(1): part 156 subpart C for each QHP on an ongoing basis; part 155 subparts H and K; and, in the small group market, sections 155.705 and 155.706, unless the standard is specifically applicable to a Federally-facilitated Exchange or FF-SHOP. |
Some standards, such as the time and distance standards in section 156.230(a)(2), apply only in a Federally-facilitated Exchange.
What it costs
Section 156.50(c)(1) sets the Federally-facilitated Exchange user fee as the monthly rate in the annual HHS notice of benefit and payment parameters for the benefit year, multiplied by the monthly premium charged for each policy under the plan where enrollment is through that Exchange. A State-based Exchange may assess its own under section 155.160. We did not open the annual notice, so this page states no rate.
IHS scopes each engagement after a free introductory call.
What this is not
- It is not legal advice. IHS is a consulting firm, and your counsel reviews every filing.
- It is not a guarantee that an Exchange will certify any plan. IHS does not file with an Exchange or CMS for you.
- It is not a reading of every Subpart C section, or of the risk adjustment sections of part 153.
Frequently asked questions
What does 45 CFR 156.200 require of a QHP issuer?
An issuer must have an effective certification issued or recognized by the Exchange for every plan it offers there. Section 156.200(b) sets issuer duties; the participation-standards section above identifies them. Paragraphs (c)-(f) and (h) add offering, State, nondiscrimination, broker-compensation and operational requirements.
What does a certification issued or recognized by the Exchange mean?
Under section 155.1010(a), Exchanges establish certification procedures consistent with section 155.1000(c) and monitor ongoing compliance. Under 155.1010(b), they must recognize qualifying OPM-certified multi-State plans and CO-OP QHPs deemed certified under section 156.520(e).
Must a QHP issuer offer silver and gold plans?
Yes, with conditions. Section 156.200(c) requires at least one silver and at least one gold QHP throughout each service area in which the issuer offers coverage through the Exchange, and a child-only plan at the same level of coverage as any QHP offered through the Exchange to individuals who, as of the beginning of the plan year, have not attained the age of 21.
Does a QHP issuer need accreditation?
Accreditation must meet section 156.275, continue while QHPs are offered, and follow section 155.1045's timing; OPM sets the period for multi-State plans. In an FFE, during initial-year certification, issuers without recognized commercial, Medicaid or Exchange accreditation for the same State must have scheduled or plan to schedule a review of their QHP policies and procedures. Before years two and three, issuers need recognized accreditation of Exchange-product policies and procedures, or recognized commercial or Medicaid accreditation for the same State with the same or similar administrative policies and procedures. Before year four and every subsequent year, accreditation must satisfy section 156.275.
What network standards apply?
Section 156.230 sets network access and directory requirements, with qualifications summarized in the checklist above. Under (a)(2)(ii), an FFE applicant in a State without a CMS-determined Effective Provider Access Review Program that misses the specified standards must submit a justification explaining adequate service and how the network will improve toward compliance before the plan year, plus supporting information the FFE requests.
Who sets user fees?
Under section 156.50(c)(1), an FFE participating issuer pays HHS monthly, in HHS's required timeframe and manner, using the applicable benefit-year rate in the annual HHS notice multiplied by each policy's monthly premium where enrollment is through the FFE. Verify current fees with HHS and your Exchange.
What happens if certification is denied?
An issuer denied FFE certification after submitting a complete application may request reconsideration. Under section 155.1090(a)(2), the written request must be submitted to HHS in its specified form and manner within 7 calendar days of the written denial notice's date, include all supporting documentation the issuer wishes to provide, and show by clear and convincing evidence that HHS's determination under section 155.1000(c) was erroneous.
What does IHS draft, and does it guarantee certification?
IHS drafts the gap assessment, quality improvement strategy, compliance procedures and readiness checklist for you and your counsel to approve. You submit the application. Readiness work does not guarantee certification; the Exchange decides.