C.F.R. » Title 45 » SUBCHAPTER B—REQUIREMENTS RELATING TO HEALTH CARE ACCESS › PART 155—EXCHANGE ESTABLISHMENT STANDARDS AND OTHER RELATED STANDARDS UNDER THE AFFORDABLE CARE ACT › Subpart K—Exchange Functions: Certification of Qualified Health Plans

45 C.F.R. § 155.1000

Certification standards for QHPs

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(a) Definition. The following definition applies in this subpart:

Multi-State plan means a health plan that is offered in accordance with section 1334 of the Affordable Care Act.

(b) General requirement. The Exchange must offer only health plans which have in effect a certification issued or are recognized as plans deemed certified for participation in an Exchange as a QHP, unless specifically provided for otherwise.

(c) General certification criteria. The Exchange may certify a health plan as a QHP in the Exchange if—

(1) The health insurance issuer provides evidence during the certification process in § 155.1010 that it complies with the minimum certification requirements outlined in subpart C of part 156, as applicable; and

(2) The Exchange determines that making the health plan available is in the interest of the qualified individuals and qualified employers, except that the Exchange must not exclude a health plan—

(i) On the basis that such plan is a fee-for-service plan;

(ii) Through the imposition of premium price controls; or

(iii) On the basis that the health plan provides treatments necessary to prevent patients' deaths in circumstances the Exchange determines are inappropriate or too costly.

(d) Special rule for SHOP. Except when a QHP is decertified by the Exchange pursuant to § 155.1080, in a SHOP that certifies QHPs on a calendar-year basis, the certification shall remain in effect for the duration of any plan year beginning in the calendar year for which the QHP was certified, even if the plan year ends after the calendar year for which the QHP was certified.

(e) Denial of certification. The Exchange may deny certification to any plan that does not meet the general certification criteria under § 155.1000(c).

[77 FR 18467, Mar. 27, 2012, as amended at 80 FR 10870, Feb. 27, 2015; 90 FR 4541, Jan. 15, 2025]
Notes of Decisions
Cited in 6 cases (2 in the last 5 years), 2019–2022 · leading case: In Re Blue Cross & Blue Shield 2022 Individual & Small Grp. Mkt. Filing, 2022 VT 53 (Vt. 2022).
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In Re Blue Cross & Blue Shield 2022 Individual & Small Grp. Mkt. Filing, 2022 VT 53 (Vt. 2022). “§ 1806(a); see also 45 C.F.R. §§ 155.1000 , 155.1075. The DVHA cannot evaluate a plan until its applicable rate has been approved by the GMCB.”
Maine Cmty. Health Options v. United States (Fed. Cl. 2019). “, 45 C.F.R. §§ 155.1000 , .1010, 156.200; (2) submitting rate and benefit information before the open enrollment period for the applicable year, see, e.”
Cmty. Health Choice, Inc. v. United States (Fed. Cl. 2019). “, 45 C.F.R. §§ 155.1000 , .1010, 156.200; (2) submitting rate and benefit information before the open enrollment period for the applicable year, see, e.”
Common Ground Healthcare Coop. v. United States (Fed. Cl. 2019). “, 45 C.F.R. §§ 155.1000 , .1010, 156.200; and (2) submitting rate and benefit information before the open enrollment period for the applicable year, see, e.”
Maine Cmty. Health Options v. United States (Fed. Cl. 2019). “, 45 C.F.R. §§ 155.1000 , .1010, 156.200; (2) submitting rate and benefit information before the open enrollment period for the applicable year, see, e.”
Texas Med. Resources, LLP Texas Physician Resources, LLP & Pediatric Emergency Med. Grp., LLP v. Molina Healthcare of Texas, Inc. (Tex. App. 2021). “45 C.F.R. § 155.1000 ; INS. CODE §843.071.”
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