Marketplace Plan Management Compliance Reviews (MPMCR)

CMS, and specifically, the Centers for Consumer Information and Insurance Oversight (CCIIO), is broadly responsible for the Marketplace, or Exchange, implementation. CCIIO has promulgated regulations for the establishment and practices of Exchanges in the District of Columbia, States, as well as for the various programs associated with the Exchanges. Section 1311 of the Affordable Care Act (ACA) sets minimum standards for the Exchange covering key areas of consumer protection. The Division of Issuer Compliance & Monitoring (DICM) is a division within CCIIO's Marketplace Plan Management Group (MPMG). CMS is charged with oversight of issuers offering qualified health plans (QHP issuers) in the FFEs. Each QHP issuer offers more than one QHP; therefore, the total number of issuers in each FFE will always be less than the total number of all QHPs offered in that FFE. The Compliance Reviews conducted under this procurement will be reviews of QHP issuers and direct-enrollment entities in the FFEs. FFE Compliance Reviews are not intended to replace the functions of State Departments of Insurance (DOI), and this contract will focus only on Marketplace-specific requirements. Compliance Reviews are one of the primary means for CMS to ensure and document QHP issuers' and direct-enrollment entity compliance with PPACA and FFE requirements. Compliance Reviews are necessary to identify irregularities, to validate self-reported data, and to ensure that CMS is managing the FFE programs effectively. The Compliance Reviews performed for this contract will have some similarities to other audits of major medical insurers but will primarily assess QHP issuers' and direct-enrollment entity compliance with FFE certification criteria and other operational standards.