On November 10, the Centers for Medicare and Medicaid Services (CMS) at the Department of Health and Human Services (HHS) released its Draft 2018 Letter to Issuers in the Federally Facilitated Marketplace (FFM). CMS releases a letter each year to insurers that offer coverage through the FFM or through state-based marketplaces that use the Healthcare.gov platform (SBM-FP) laying out the ground rules for qualified health plan (QHP) and standalone dental plan (SADP) coverage for the following year. The letter is usually released each spring at about the time that HHS releases its final benefit and payment parameters rule (the “payment rule”). A draft of the letter is usually issued late in the preceding year.
This year the letter and the payment rule will be released early, both because of the change of administrations and because there are relatively few changes from the 2017 payment notice and letter. The draft letter, therefore, is being issued in early November with a brief comment period ending December 1, 2016 and a final letter due late in 2016 or very early in 2017. Given that president-elect Donald Trump and the Republicans in control of both houses of Congress are committed to repealing the Affordable Care Act (ACA), the release of a draft letter two days after the election might seem a bit whimsical. But until Congress actually acts, CMS has no option but to proceed as though life will go on as normal.
The FFM has been in existence for three years now and has settled into a routine. The pace of development and change of regulations has slowed considerably. The draft 2018 payment rule therefore, is shorter than the payment rules of previous years, and the 2018 draft letter resembles very closely the 2017 letter. Only a few sections of the letter-notably those that deal with the SHOP exchange, network adequacy, and the SBM-FPs-contain material that is significantly different from the 2017 letter. These sections closely track changes in the 2018 proposed payment rule.
Application of the Draft Letter
The draft letter applies to insurers that offer qualified health plans (QHPs) and standalone dental plans (SADPs) through the FFM, SBM-FPs and the federally facilitated SHOP exchange. It applies (although with some differences) in all states that use the Healthcar.gov platform, including states in which the federal government enforces the Affordable Care Act directly; states in which the state enforces general ACA provisions but the federal government performs all marketplace functions; plan-management FFM states in which the state performs plan management functions and makes plan certification recommendations to CMS; and states in which the state-based marketplace uses the FFM platform for eligibility and enrollment functions.
In states other than direct enforcement states, CMS relies on state review of policy forms and rate filings for determining compliance with market-wide standards. States with effective rate review programs also bear primary responsibility for reviewing rates, while states with plan management authority must make timely recommendations as to QHP certification. In direct enforcement states (Texas, Oklahoma, Missouri, and Wyoming), insurers must submit their rates and forms to CMS for review.
States performing QHP certification reviews may exercise reasonable flexibility in their application of CMS' QHP certification guidelines as long as their application of each standard is consistent with CMS regulations and guidance. CMS will work with the states to ensure that QHPs meet federal and state certification standards. Multistate plan insurers must also be approved by the Office of Personnel Management. The FFM only offers QHPs and SADPs and will not display ancillary insurance products or plans that are not QHPs.
Qualified Health Plan Certification and Rate Filing Calendar
Together with the draft letter, CMS released its Proposed Key Dates Calendar for 2017. QHP insurers must submit QHP applications and rate filings for 2018 certification between April 5 and May 3, 2017. Applications will not be accepted after this date. CMS begins an exchange of correction notices and revised data with insurers on June 12.
QHP insurers will be able to view plan data in the Plan Preview environment to identify and correct submission errors. After May 3, insurers may not add new plans or change plans from off-marketplace to on-and-off marketplace. They must petition CMS to change service areas, but can make other changes before the final submission deadline. Final submission of all QHP data and permitted changes are due to CMS on August 21. After this date, insurers are only permitted to make limited data corrections requested by CMS or a state. Insurers will send a QHP certification agreement and Privacy and Security Agreement, with senior officer acknowledgement, between September 12 and 15 and CMS will send a countersigned agreement and certification notice between September 21 and 22.
Insurers seeking to offer QHPs or SADPs in the FFM must submit their application through the federal Health Insurance Oversight System (HIOS). In plan management states, QHP applications are submitted through the National Association of Insurance Commissioners (NAIC) System for Electronic Rate and Form Filing (SERFF) system. The plan management states will transfer the data submitted by insurers to CMS.
Insurers seeking to offer QHPs in states without an effective rate review program must submit a Unified Rate Review Template (URRT) to the FFM by May 3, 2017. In states with effective rate review programs, insurers must submit proposed rate filings for non-grandfathered individual and small group coverage (QHP and non QHP) to the state by a date set by the state, but no later than June 1, 2017. Insurers offering QHPs must in any event submit their QHP rate tables with their QHP application materials by May 3, 2017, even if the URRT is due later.
CMS will post proposed rate filings on June 30, 2017 and states must post proposed rate filings subject to their review no later than this date. Insurers must finalize rate filings that contain QHPs by August 21, 2017 and all rate filings involving only non-QHPs by October 6, 2017. Final rate information for single risk pool coverage will be posted on November 1, 2017.
Insurers that seek recertification of 2017 plans for 2018 must submit a crosswalk of their 2017 and 2018 QHPs and SADPs to help the FFM passively reenroll 2017 QHP enrollees into similar plans if they do not return to the marketplace to actively reenroll for 2018.
Standardized Plans
The FFM will again in 2018 allow QHP insurers to offer standardized or “simple option” plans. These plans have standardized in-network deductibles, cost-sharing limits, and copayments and coinsurance amounts for a key set of essential health benefits, as well as four tiers of drug benefits. The proposed 2018 payment rule offers three sets of standardized options, at least one of which complies with each state's cost-sharing requirements. Each set of standardized options includes a plan at the bronze, silver, and gold levels, as well as options for each silver cost-sharing reduction level. A standardized bronze option is also offered that is health savings account (HAS) compatible. Insurers can choose to offer one or more of the standardized plans, although they must offer all standardized silver plan cost-sharing variations if they offer a silver plan.
Insurers may offer more than one standardized plan at a level of coverage if the plans are meaningfully different. Insurers might, for example, offer additional standardized plans with extra benefits or with varying networks or other features. The 2018 standardized options are different from the 2017 options, so insurers should not assume that 2017 standardized options should automatically be crosswalked into the 2018 standardized options.
QHP Certification Requirements
To be qualified for certification, QHPs must be licensed and in good standing - that is, without outstanding state sanctions. QHPs must have a service area that covers at least a county, or group of counties, unless the FFM concludes that a smaller service area is necessary, nondiscriminatory, and in the best interest of marketplace enrollees. Service areas must be established without regard to racial, ethnic, language, or health-status related considerations. QHPs must offer both silver and gold coverage throughout the entire service area in which they offer coverage.
Network Adequacy
In 2018, CMS will, for the second year, evaluate whether QHPs reach a general network adequacy standard of “reasonable access” using numerical standards. It will apply time and distance standards focusing on hospital systems, dental (if applicable), endocrinology, infectious diseases, oncology medical/surgical, oncology radiation/radiology, mental health, primary care, rheumatology, hospitals, and outpatient dialysis. The draft letter includes a table of maximum time and distance standards. For example, in a large urban area at least 90 percent of enrollees in a plan should be able to reach a hospital in 10 miles or twenty minutes; in a rural area in 60 miles or 75 minutes. Insurers that cannot meet these standards because of local circumstances may submit a justification explaining how they nonetheless meet the reasonable access standard.
The draft letter further addresses provider transitions. Insurers must give regular patients at least 30 days' notice of termination of provider. Where 30 days' notice is not possible, notice should be given as soon as practicable. Insurers should work with providers to obtain lists of their patients or use claims data to identify patients of particular providers. Insurers should notify enrollees of other comparable network providers accessible to the patient. CMS will defer to states that have similar or more protective standards.
A patient must be allowed to continue treatment by providers terminated without cause for up to 90 days or until the course of treatment is complete if 1) the patient is in active treatment for life-threatening or serious acute conditions, or in her second or third trimester of pregnancy or postpartum, and 2) a treating physician attests that discontinuance of treatment by the provider would worsen the condition or interfere with the anticipated outcome. Insurers are only required to pay network rates for terminated providers under these circumstances, leaving open the possibility that providers will balance bill.
CMS is implementing for the first time for 2018 a provision to address balance billing, albeit a very weak provision. Under the provisions of the draft letter, and the proposed 2018 payment notice, QHP insurers must notify enrollees at least 48 hours before the provision of a service at an in-network facility (or, if longer, at the time the insurer would typically respond to a prior authorization request) that the enrollee might receive a service from an out-of-network ancillary provider who might balance bill and whose charges are not subject to the in-network cost sharing limit. If the insurer fails to give timely notice, and the enrollee is charged for out-of-network cost sharing by the ancillary provider, the insurer must count the cost-sharing against the enrollee's annual out-of-pocket limit.
This provision does not apply to balance billing as such-billing for the difference between the provider's charge and the amount the insurer is willing to pay. The insurer is not responsible for balance bills (although they may not be legally enforceable against the consumer). Consumers in some states will receive greater protection from state law.
The draft letter describes CMS's development of a network breadth label to guide shoppers on healthcare.gov, which is being beta tested in four states for 2017. This measure will focus on adult primary care, pediatric primary care, and hospitals, with either separate classifications as to each or a composite classification. The classifications will be calculated by comparing the total number of providers available in each of the classifications in a plan's network in a county to the total number of that classification of providers available in all QHPs in a county. This number is called the Provider Participation Rate, or PPR. All networks within a standard deviation of the median PPR calculated nationally will be labeled as standard. Networks with a PPR more than a standard deviation above the national mean will be labeled “broad” and those with a PPR more than a standard deviation below the national mean will be labeled “narrow.” An alternative approach, explained at length in the letter, may be used to identify integrated delivery systems.
Finally, CMS is considering implementing a program for 2018 for assessing consumer access to higher-cost specialist providers. CMS recognizes that limiting access to such providers may discourage enrollment of individuals with significant health needs. CMS is considering monitoring consumer access within QHPs to cardiology, endocrinology, gynecology (OB/GYN), infectious diseases, nephrology, neurology, oncology, ophthalmology, pediatrics, psychiatry, pulmonology and rheumatology specialists as well as access to general acute hospitals, outpatient dialysis, and cancer treatment centers facility types; the agency would compare access in each QHP to that provided by other QHPs in its service area.
Essential Community Providers
The draft letter contains a lengthy section addressing coverage of essential community providers (ECP) - providers that serve low-income and medically underserved individuals. In general, insurers must have contracts with 30 percent of available ECPs in their service area as identified on a list maintained by CMS based on petitions from ECP providers, offer contracts in good faith to all Indian health providers in their service area, and offer contracts in good faith to at least one ECP in each of six categories of ECPs (family planning providers, federally qualified health centers, hospitals, Indian health care providers, Ryan White providers, and “other” ECPs). For 2018, multiple ECPs located at a single address will only count as one ECP for calculating the 30 percent ratio. Further provisions on contracting with Indian health providers are included later in the letter.
Insurers that do not meet the 30 percent standard may submit a narrative justification explaining how they adequately meet the needs of their low-income and medically underserved enrollees and how they intend to increase ECP participation in the future. The draft letter describes in detail the information the narrative justification must include.
The letter describes in detail alternative ECP standards that must be met by plans that provide services through employed or contracted medical groups or hospitals, such as staff model HMOs. It also specifies that a SADP must offer good faith provider contracts to at least 30 percent of the dental ECPs and to all available Indian dental health care providers in its service area. Unlike QHPs, SADPs need merely offer, not actually conclude, a contract with 30 percent of ECPs. As with health insurers, a SADP unable to satisfy the 30 percent requirement may offer a narrative justification meeting specified standards.
QHPs must pay federally qualified health centers Medicaid rates or a negotiated rate that is at least equal to the rates generally paid by the QHP insurer.
Accreditation and Quality Requirements
QHP insurers in their fourth year of FFM participation in 2018 must be accredited based on local performance of their QHPs with respect to nine specific criteria. Insurers in their second and third year of FFM participation must at least be accredited for their commercial or Medicaid products, while insurers in their first year must have at least scheduled or planned to schedule an accreditation review. The letter lists accreditation categories that are acceptable, including “provisional” or “conditional” accreditation.
QHP insurers must verify that hospitals with more than 50 beds with which the insurer contracts have implemented a person-centered discharge program and use a patient safety evaluation system, including a contract with a patient safety organization or an alternative approach described in the draft letter. CMS has recently released guidance on this requirement.
QHP insurers must continue to collect and submit validated clinical quality measure data. They must also contract with HHS-approved QHP enrollee survey vendors to collect and submit enrollee survey data on their behalf. CMS is using quality and satisfaction survey data to calculate star ratings by product type (e.g. EPO, HMO, POS, and PPO). For the first time for the 2017 open enrollment period, ratings are being displayed on the marketplace website using a five-star scale in two states. QHP insurers may use their star ratings in their plan year marketing materials in a manner specified by CMS. Further information on the quality rating system is available here and here.
Insurers with non-child-only QHP products covering more than 500 enrollees that have offered marketplace coverage for at least two consecutive years must implement a quality improvement strategy (QIS) complying with CMS guidelines. They can either implement a new QIS or provide an update on an existing QIS. Technical guidance for the QIS for 2018 will be available no later than January of 2017. A QIS offers incentives to providers or enrollees to improve health care quality or outcomes. State Based Marketplaces (SBMs) as well as the FFM must ensure insurer compliance with QIS requirements. In plan management states, the QIS will be reviewed by both the state and the FFM.
Rate Review
QHPs must submit justifications for rate increases to CMS. CMS does not intend to duplicate rate reviews carried out by states under state law and will integrate state rate review into its certification process. Information supporting all proposed QHP rate increases will be posted on the CMS rate filing website, omitting trade secrets and confidential commercial or financial information.
Discriminatory Benefit Design
The draft letter contains provisions regarding discriminatory essential health benefit (EHB) and QHP benefit designs. Non-grandfathered health plans in the individual and small group market may not discriminate in the provision of essential health benefits (EHB) on the basis of age, expected length of life, present or predicted disability, degree of medical dependency, quality of life, or other health condition. Age limits may be considered discriminatory if they are applied to EHB services found to be clinically effective at all ages. Discrimination requirements should not be circumvented by labeling a benefit clinically appropriate for adults as a pediatric service. Drug formulary exclusions and/or tier structures can also be discriminatory. Enforcement of the non-discrimination requirement with respect to EHB is largely the responsibility of state regulators, although civil rights laws that apply are also enforced by the Office of Civil Rights of HHS.
CMS will assess compliance of QHPs with nondiscrimination requirements. It will conduct cost-sharing outlier analysis of QHPs to identify outliers based on QHP benefits and cost sharing and analyze plans and benefits information to identify discriminatory features or wording. It will continue to review QHPs to identify outliers based on estimated out-of-pocket costs associated with standard treatment regimens based on nationally recognized clinical guidelines. For 2018, this outlier analysis will address bipolar disorder, diabetes, Hepatitis C, HIV, multiple sclerosis, opioid dependence, rheumatoid arthritis, and schizophrenia. CMS may identify a benefit design as discriminatory even if it is does not appear to be an outlier.
Drug Formularies
QHP formularies must meet EHB standards, which is to say they must cover the greater of one drug in every USP category and class and the same number of drugs in each category and class as the state's EHB benchmark plan. As of 2017 they must cover Naloxone as an opioid reversal agent.
CMS will perform several reviews of drug formularies. First, CMS will perform an outlier analysis comparing plan formularies to formularies at both the state and national level to ensure that QHPs meet outlier threshold levels. QHPs that subject an unusually high number of drugs in a class or category to prior authorization or step therapy would be identified as outliers. For 2018, CMS will be adding review of Antivirals/Anti-cytomegalovirus (CMV) Agents, Antivirals/Anti-hepatitis B (HBV) Agents, Antivirals/Anti-hepatitis C (HCV) Agents, Antivirals/Antiherpetic Agents, and Antiemetics/Emetogenic Therapy Adjuncts to the drugs on which it focused outlier analysis in 2017.
Second, CMS will review each QHP's drug coverage to ensure the availability of drugs recommended by nationally recognized clinical guidelines. In some cases it will evaluate whether drugs are available without step therapy or prior authorization. This drug review will include, but not be limited to, drugs used to treat bipolar disorder, breast cancer, diabetes, hepatitis C, HIV, multiple sclerosis, prostate cancer, rheumatoid arthritis, and schizophrenia.
Finally, it will review formularies to identify “adverse tiering” in which drugs to treat certain chronic, high-cost conditions are assigned consistently to high cost-sharing tiers. It will focus here on drugs used to treat diabetes, Hepatitis C, HIV, multiple sclerosis, opioid dependence, and rheumatoid arthritis.
Meaningful Difference
CMS will continue to review plans to ensure that they are “meaningfully different” to support consumer choice. CMS will first group together plans that are of the same plan type, child-only-plan offering status, metal level, and service area. Within these groups, CMS will consider plans meaningfully different only if they have:
- Or do not have an integrated medical and drug maximum-out-of pocket limit;
- Or do not have an integrated medical and drug deductible;
- Multiple-in-network provider tiers instead of one;
- $500 or more difference in maximum out-of-pocket limits;
- $250 or more difference in deductibles;
- A different provider network with a different network ID;
- Differences in additional benefits that display on the healthcare.gov website, such as acupuncture or bariatric surgery; or
- Differences in drug list IDs.
If a plan is flagged as not meaningfully different, an insurer must modify it or provide a justification to CMS.
Third-Party Payments and Cost-Sharing Reductions
The draft letter notes that insurers offering QHPs or SADPs are required under the 2017 proposed payment rule to accept third-party payments for premiums or cost sharing from federal or state government programs, including Ryan White HIV/AIDs programs and from their grantees or sub-grantees. The letter does not address other third party premium payment arrangements.
QHP must offer plans meeting the standard reduced cost-sharing variations for low-income enrollees. The draft letter contains guidelines to ensure that reduced cost-sharing plans meet the prescribed actuarial value and maximum out-of-pocket limits, and that they under no circumstances provide less generous coverage than higher cost-sharing plan variations. It also describes the 2018 data integrity tool that plans must use and data integrity reviews CMS will conduct.
Decision Support Tools
For the 2018 open enrollment period, CMS will offer again on the FFM the marketplace the provider lookup, formulary lookup, and out-of-pocket cost comparison consumer support tools that it premiered in 2015. The draft letter sets out the requirements that QHP insurers must meet to make their provider network directories and drug formularies accessible to consumers.
QHP and SADP provider directories and QHP formularies must be provided in the FFM in machine-readable form to facilitate the provision of data for the lookup tools. Provider directories must be updated at least monthly. Provider directories and formulary drug lists must be viewable on an insurer's website without a consumer having to create or access an account or enter a policy number. QHP insurers must also provide the inputs necessary for the out-of-pocket cost calculator. QHP insurers are also required to meet transparency reporting requirements which will be made available for 2018 in late spring. They will largely mirror 2017 requirements.
Standalone Dental Plans
Standalone dental plans are only required to meet a subset of the requirements that apply to QHPs and their application requirements are truncated accordingly. The draft letter identifies the requirements that they must meet. It also references the payment letter's provisions on SADP annual cost-sharing limit updates, which remain $350 for one child and $700 for two or more children. Finally, it clarifies that, although marketplace enrollment in SADPs is limited to marketplace open or special enrollment periods, SADPs may enroll individuals off-marketplace outside of these periods.
Compliance Issues, Including Agent and Broker Oversight
The draft letter contains a substantial chapter dealing with oversight of QHPs and agents and brokers. Each insurer participating in the FFM will be assigned an account manager to serve as its point of contact with CMS. CMS will continue to monitor compliance of QHP insurers with program requirements and expects them to monitor their own compliance. CMS will conduct risk-based and targeted compliance reviews, which may be desk or on-site reviews, and coordinate with state regulatory authorities.
QHP insurers are responsible for ensuring compliance with regulatory requirements by their downstream and delegated entities, including agents and brokers. In particular they must confirm that affiliated agents and brokers are licensed and comply with training and registration requirements.
To assist consumers in the FFMs and FF-SHOP, agents and brokers must sign general and privacy and security agreements with the FFMs. Web brokers must sign web broker agreements. CMS can terminate these agreements for sufficiently serious noncompliance or material breach. CMS will maintain a list of agents and brokers whose agreements and registration have been suspended or terminated by CMS.
The 2017 payment rule described the authority of CMS to suspend or terminate broker participation for various cause. If CMS reasonably suspects that an agent or broker may have engaged in fraud or abusive conduct that may result in imminent or ongoing consumer harm using personally identifiable information of FFM applicants or enrollees, or in connection with an FFM enrollment, CMS may impose an immediate 90-day suspension. If a state or federal agency determines that an agent or broker has engaged in such conduct, CMS may immediately terminate the agent or broker's FFM agreements. States, of course, retain primary disciplinary authority over agents and brokers, but CMS will notify states of disciplinary action it takes.
The draft letter describes the responsibilities of web brokers, including their responsibility to differentially display standardized plans. It briefly mentions the enhanced direct enrollment path, described in greater detail in the 2018 payment notice. It also references enhanced direct enrollment consumer protections and CMS oversight.
The draft letter notes that agents and brokers must be paid the same compensation for the sale of QHPs in the marketplace as for similar plans outside the marketplace and describes how similarity of plans will be judged. CMS does not get involved in agent and broker compensation issues and is not taking any action to address the fact that many insurers are no longer paying brokers and agents commissions for QHP enrollments. CMS leaves to the states the question of whether brokers and agents can charge consumers directly for their services and how such charges should be disclosed. Of course, broker and agent charges to consumers are not covered by advance premium tax credits and can make coverage much less affordable for low-income consumers.
The draft letter describes how brokers and agents are identified for enrollments, including passive reenrollments. It suggests that insurers should withhold commissions from brokers and agents who fail to register or otherwise fail to comply with federal requirements. Finally, it describes the program under which HHS-approved vendors offer training to agents and brokers for assisting consumers on the FFM.
CMS has authority to monitor QHP marketing practices, including ensuring that QHP insurers do not discriminate based on race, color, national origin, disability, age, sex, gender identity, or sexual orientation. QHP insurers must comply with the recently issued section 1557 non-discrimination rules. Marketing materials and information provided by agents and brokers must also be accurate and not misleading. The use of the terms “exchange” or “marketplace” in websites must be avoided. Direct enrollment websites must not mislead consumers into believing they are visiting Healthcare.gov.
The 2018 proposed payment rule requires QHP insurers to make their QHPs available for enrollment for the full plan year for which the plan was certified unless a basis for suppression applies. QHPs who do not comply with this requirement are subject to civil penalties and can be excluded from the marketplace for up to two years.
The Federally Facilitated SHOP
The proposed 2018 payment rule changes and clarifies many of the rules governing federally facilitated SHOPs. In particular it modifies the process and timelines for enrolling newly qualified employees in SHOP coverage. The rule proposes reevaluating the requirement that insurers that are part of an insurer group with more than a 20 percent market share in a state's small group market must participate in the SHOP in order to sell QHPs in the individual FFP. The proposed payment rule also questions whether enrollment through a SHOP website continues to be necessary or whether alternative approaches to enrollment might work as well.
The draft letter raises these issues but also notes that until further notice, current SHOP enrollment functions remain in effect. It also describes the SHOP enrollment reconciliation process.
Consumer Support and Meaningful Access
The draft letter next deals with consumer support and related issues. It describes how “cases” involving consumer issues are handled in the FFM, as well as the responsibilities of QHP insurers for helping to resolve cases. Most cases involve enrollment, cancellation or termination, payment, application of premium tax credits and cost sharing reduction payments, and effective date issues. The letter notes that although cases usually involve specific identified consumers, CMS intends to address complaints that it receives about machine readable provider or formulary data on an anonymous basis as the identity of the complaint is not relevant to resolving these issues. It does not consider these issues to be “cases.”
The draft letter addresses in great detail meaningful access requirements for non-English speakers. Federal rules impose a number of different language access requirements on web brokers, marketplaces, and QHP insurers, including oral interpretation, document and website translation, and tagline requirements. Additional requirements apply to summaries of benefits and coverage and appeal documents. The section 1557 rule layers further requirements on those otherwise imposed by the QHP and marketplace rules.
Language access rules are described in detail in an earlier post. These rules may be amended by the 2018 payment rule. The language access requirements will not be described here.
QHP insurers are required to provide summaries of benefits and coverage (SBC) compliant with federal requirements. A new “2017 SBC” was finalized in 2016 and must be used by plans for the first open enrollment period that begins on or after April 1, 2017. It will thus apply for 2018 plans. SBCs must disclose whether or not the QHP pays for abortions for which federal funding is not available. QHP insurers are required to make SBCs available that accurately reflect each cost-sharing plan variation. Insurers must provide an appropriate SBC for a plan variation within seven days after receiving notice that a marketplace has assigned an enrollee to a new plan variation.
Finally, the letter concludes with sections addressing tribal relations and services and the responsibilities of state-based marketplaces using the FFM (SBM-FM) for certain functions. While the state-based marketplace retains primary responsibility for enforcing QHP requirements, the FFM can suppress plans in these states that do not comply with program requirements to ensure that consumers only have access to compliant plans. Requirements that apply to SBM-FMs were described at great length in the 2017 payment rule and are further developed in the proposed 2018 payment rule. They will not be explored further here.
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