Version 1 4 2019 Qx480049004AP Application Instructions Optional Program AttestationsInstructionsx3A003B The following attestation is optional CMS strongly encourages all applicants including those s ID: 891888
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1 State Partnership Exchange Issuer Progra
State Partnership Exchange Issuer Program Attestation Response Form Version 1 4 2019 Q�P Application Instructions Optional Program AttestationsInstructions� The following attestation is optional. CMS strongly encourages all applicants, including those submitting only medical Q�Ps, only SADPs, or both to respond �Yesâ and upload a compliance plan and the compliance plan cover sheet in the Issuer Module. Applicants may also respond �Noâ and submit a justification below. Applicant is submitting a compliance plan that adheres to all applicable laws, regulations, and guidance, that the compliance plan is ready for implementation, and that the applicant agrees to reasonably adhere to the compliance plan provided. The applicant agrees to submit in advance any changes to the compliance plan to ��S for review. Applicant will upload a copy of the applicantâs compliance plan. If Yes, upload a copy of the applicantâs compliance plan. See the Instructions Manual for further information. YesSignature Date ________________________________ _________________________ Printed Name Title/Position Justification for the Optional Program Attestation Provide a justification you responded to the Optional Program Attestation. State Partnership Exchange Issuer Program Attestation Response Form Version 1 3 2019 Q�P Application Instructions Attestations Required of Medical Q�P Issuers OInstructions� The following attestations apply to all medical Q�Ps �not SADPs) that an issuer is submitting for certification for the next plan year. Applicants applying to offer medical Q�Ps on the FFEs are required to respond �Yesâ to the following attestations with regard to those medical Q�Ps. All applicants not applying to offer medical Q�Ps should select Aâ �not applicable). Applicant agrees to adhere to all applicable requirements in 45 CFR Parts 146,147,155, and 156, including those related to the segregation of funds for abortion services. YesAttestations Required of SADP Issuers OnlyInstructions� The following attestations apply to all SADPs that an issuer is submitting for certification for the next plan year. Only applicants who wish to offer certified SADPs are required to respond �Yesâ to the following attestations. All applicants not offering certified SADPs should select Aâ �not applicable). Applicant agrees to adhere to all of the certification standards and operational requirements applicable to applicant in 45 CFR Parts 155 and 156. Yes State Partnership Exchange Issuer Program Attestation Response Form Version 1 2 2019 Q�P Application Instructions Does the applicant use a provider network? Upload an ECP/NA template if you respond Yes to this question. Yes State Partnership Exchange Issuer Program Attestation Response Form Version 1 1 2019 Q�P Application Instructions Contents Attestations Required of Both Medical Q�P and SADP Issuers ...................................................Attestations Required of Medical Q�P Issuers Only .....................................................................Attestations Required of SADP Issuers Only .................................................................................Optional Program Attestations ........................................................................Justification for the Optional Program Attestation .........................................................................Attestations Required of Both Medical Q�P and SADP Issuers Instructions� The following attestations apply to all Q�Ps and SADPs that an issuer is submitting for certification for the next plan year. All issuers who wish to offer either certified Q�Ps or SADPs on the FFEs are required to respond �Yesâ to the following attestations. Applicant agrees t
2 o adhere to all of the certification sta
o adhere to all of the certification standards and operational requirements applicable to applicant in 45 CFR Parts 153, 155, and 156.YesNetwork Adequacy/Essential Community Provider AttestationsDoes the applicant meet the General ECP Standard or the Alternate ECP Standard �as defined in the Annual Letter to Issuers)? In order to meet the General ECP Standard, the applicant has� �1) contracted with at least 20 percent of available ECPs in each planâs service area to participate in the planâs provider network; 2) offered contracts in good faith to all available Indian health care providers in the planâs service area for the respective Q�P certification plan year; and 3) offered contracts in good faith to at least one ECP in each ECP category in each county in the service area for the respective Q�P certification plan year, where an ECP in that category is available �not applicable to SADP applicants). In order to meet the Alternate ECP standard, the applicant has� �1) contracted with at least 20 percent of available ECPs in each planâs service area to participate in the planâs provider network; and �2) offered all of the categories of services provided by entities in each of the ECP categories in each county in the planâs servicarea as outlined in the general ECP standard, or otherwise offered a contract to at least one ECP outside of the issuerâs integrated delivery system per ECP category in each county in the planâs service area �not applicable to SADP applicants). Upload an ECP supplemental response justification if you respond to this question. Yes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³ V ´ D Q G X S O R D G D F R P S O L D Q F H S O D Q D Q G W K H F R P S O L D Q F H S O D Q F R Y H U V K H H W L Q W K H , V V X H U 0 R G X O H $ S S O L F D Q W V P D \ D O V R U H V S R Q G ³ 1 R ´ D Q G V X E P L W D M X V W L I L F D W L R Q E H O R Z $ S S O L F D Q W L V V X E P L W W L Q J D F R P S O L D Q F H S O D Q W K D W D G K H U H V W R D O O D S S O L F D E O H O D Z V U H J X O D W L R Q V D Q G J X L G D Q F H W K D W W K H F R P S O L D Q F H S O D Q L V U H D G \ I R U L P S O H P H Q W D W L R Q D Q G W K D W W K H D S S O L F D Q W D J U H H V W R U H D V R Q D E O \ D G K H U H W R W K H F R P S O L D Q F H S O D Q S U R Y L G H G 7 K H D S S O L F D Q W D J U H H V W R V X E P L W L Q D G Y D Q F H D Q \ F K D Q J H V W R W K H F R P S O L D Q F H S O D Q W R + + 6 I R U U H Y L H Z $ S S O L F D Q W Z L O O X S O R D G D F R S \ R I W K H D S S O L F D Q W ¶ V F R P S O L D Q F H S O D Q , I V X S O R D G D F R S \ R I W K H D S S O L F D Q W ¶ V F R P S O L D Q F H S O D Q 6 H H W K H , Q V W U X F W L R Q V 0 D Q X D O I R U I X U W K H U L Q I R U P D W L R Q V 6 L J Q D W X U H ' D W H B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B 3 U L Q W H G 1 D P H 7 L W O H 3 R V L W L R Q - X V W L I L F D W L R Q I R U W K H 2 S W L R Q D O 3 U R J U D P $ W W H V W D W L R Q 3 U R Y L G H D M X V W L I L F D W L R Q \ R X U H V S R Q G H G W R W K H 2 S W L R Q D O 3 U R J U D
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P $ W W H V W D W L R Q 6 W D W H 3 D U W Q H U V K L S ( [ F K D Q J H , V V X H U 3 U R J U D P $ W W H V W D W L R Q 5 H V S R Q V H ) R U P 9 H U V L R Q 4 + 3 $ S S O L F D W L R Q , Q V W U X F W L R Q V $ W W H V W D W L R Q V 5 H T X L U H G R I 0 H G L F D O 4 + 3 , V V X H U V 2 , Q V W U X F W L R Q V 7 K H I R O O R Z L Q J D W W H V W D W L R Q V D S S O \ W R D O O P H G L F D O 4 + 3 V Q R W 6 $ ' 3 V \f W K D W D Q L V V X H U L V V X E P L W W L Q J I R U F H U W L I L F D W L R Q I R U W K H Q H [ W S O D Q \ H D U $ S S O L F D Q W V D S S O \ L Q J W R R I I H U P H G L F D O 4 + 3 V R Q W K H ) ) ( V D U H U H T X L U H G W R U H V S R Q G ³ H V ´ W R W K H I R O O R Z L Q J D W W H V W D W L R Q V Z L W K U H J D U G W R W K R V H P H G L F D O 4 + 3 V $ O O D S S O L F D Q W V Q R W D S S O \ L Q J W R R I I H U P H G L F D O 4 + 3 V V K R X O G V H O H F W $ ´ Q R W D S S O L F D E O H \f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³ H V ´ W R W K H I R O O R Z L Q J D W W H V W D W L R Q V $ O O D S S O L F D Q W V Q R W R I I H U L Q J F H U W L I L H G 6 $ ' 3 V V K R X O G V H O H F W $ ´ Q R W D S S O L F D E O H \f $ S S O L F D Q W D J U H H V W R D G K H U H W R D O O R I W K H F H U W L I L F D W L R Q V W D Q G D U G V D Q G R S H U D W L R Q D O U H T X L U H P H Q W V D S S O L F D E O H W R D S S O L F D Q W L Q & ) 5 3 D U W V D Q G V 6 W D W H 3 D U W Q H U V K L S ( [ F K D Q J H , V V X H U 3 U R J U D P $ W W H V W D W L R Q 5 H V S R Q V H ) R U P 9 H U V L R Q 4 + 3 $ S S O L F D W L R Q , Q V W U X F W L R Q V ' R H V W K H D S S O L F D Q W X V H D S U R Y L G H U Q H W Z R U N " 8 S O R D G D Q ( & 3 1 $ W H P S O D W H L I \ R X U H V S R Q G V W R W K L V T X H V W L R Q V 6 W D W H 3 D U W Q H U V K L S ( [ F K D Q J H , V V X H U 3 U R J U D P $ W W H V W D W L R Q 5 H V S R Q V H ) R U P 9 H U V L R Q 4 + 3 $ S S O L F D W L R Q , Q V W U X F W L R Q V & R Q W H Q W V $ W W H V W D W L R Q V 5 H T X L U H G R I % R W K 0 H G L F D O 4 + 3 D Q G 6 $ ' 3 , V V X H U V $ W W H V W D W L R Q V 5 H T X L U H G R I 0 H G L F D O 4 + 3 , V V X H U V 2 Q O \ $ W W H V W D W L R Q V 5 H T X L U H G R I 6 $ ' 3 , V V X H U V 2 Q O \ 2 S W L R Q D O 3 U R J U D P $ W W H V W D W L R Q V -
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³ V ´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f " , Q R U G H U W R P H H W W K H * H Q H U D O ( & 3 6 W D Q G D U G W K H D S S O L F D Q W K D V \f F R Q W U D F W H G Z L W K D W O H D V W S H U F H Q W R I D Y D L O D E O H ( & 3 V L Q H D F K S O D Q ¶ V V H U Y L F H D U H D W R S D U W L F L S D W H L Q W K H S O D Q ¶ V S U R Y L G H U Q H W Z R U N \f R I I H U H G F R Q W U D F W V L Q J R R G I D L W K W R D O O D Y D L O D E O H , Q G L D Q K H D O W K F D U H S U R Y L G H U V L Q W K H S O D Q ¶ V V H U Y L F H D U H D I R U W K H U H V S H F W L Y H 4 + 3 F H U W L I L F D W L R Q S O D Q \ H D U D Q G \f R I I H U H G F R Q W U D F W V L Q J R R G I D L W K W R D W O H D V W R Q H ( & 3 L Q H D F K ( & 3 F D W H J R U \ L Q H D F K F R X Q W \ L Q W K H V H U Y L F H D U H D I R U W K H U H V S H F W L Y H 4 + 3 F H U W L I L F D W L R Q S O D Q \ H D U Z K H U H D Q ( & 3 L Q W K D W F D W H J R U \ L V D Y D L O D E O H Q R W D S S O L F D E O H W R 6 $ ' 3 D S S O L F D Q W V \f , Q R U G H U W R P H H W W K H $ O W H U Q D W H ( & 3 V W D Q G D U G W K H D S S O L F D Q W K D V \f F R Q W U D F W H G Z L W K D W O H D V W S H U F H Q W R I D Y D L O D E O H ( & 3 V L Q H D F K S O D Q ¶ V V H U Y L F H D U H D W R S D U W L F L S D W H L Q W K H S O D Q ¶ V S U R Y L G H U Q H W Z R U N D Q G \f R I I H U H G D O O R I W K H F D W H J R U L H V R I V H U Y L F H V S U R Y L G H G E \ H Q W L W L H V L Q H D F K R I W K H ( & 3 F D W H J R U L H V L Q H D F K F R X Q W \ L Q W K H S O D Q ¶ V V H U Y L F D U H D D V R X W O L Q H G L Q W K H J H Q H U D O ( & 3 V W D Q G D U G R U R W K H U Z L V H R I I H U H G D F R Q W U D F W W R D W O H D V W R Q H ( & 3 R X W V L G H R I W K H L V V X H U ¶ V L Q W H J U D W H G G H O L Y H U \ V \ V W H P S H U ( & 3 F D W H J R U \ L Q H D F K F R X Q W \ L Q W K H S O D Q ¶ V V H U Y L F H D U H D Q R W D S S O L F D E O H W R 6 $ ' 3 D S S O L F D Q W V \f 8 S O R D G D Q ( & 3 V X S S O H P H Q W D O U H V S R Q V H M X V W L I L F D W L R Q L I \ R X U H V S R Q G W R W K L V T X H V W L R Q