| Carrier Application/Certification form

Instructions: This form is required for all Qualified Health Plan (QHP) and Stand-Alone Dental Plan (SADP) applications.

Application Details Section

Applicant Issuer's Legal Name*

NAIC Number*

Date Maryland Licensure Received*

Expiration Date of Maryland License*

Federal Employer Identification Number*

HIOS Issuer Identification Number*

Address*

Street Address City State ZIP Code

Submitter’s Contact Name*

Submitter’s Title*

Submitter’s Contact Phone*

Do you have a TPA for processing enrollment?*

Yes
No

Do you have a TPA for processing claims?*

Yes
No

If you're using a TPA, please mention the TPA Name

Carrier/Issuer’s address for consumer’s payment submissions*

Street Address City State ZIP Code

Issuer's point of contact and contact information for template error resolution*

Include name, email address and phone number.

Attestations Section

I hereby certify to the Maryland Health Benefit Exchange (MHBE) that the below organization (doing business as (d/b/a) is*

MHBE Issuer’s Attestations

Statement of Attestation Responses Instructions: Please review and affirm each of the attestations below and complete and sign and date the Statement of Detailed Attestation Responses document.

Licensed or Authorized to Operate in Maryland Attestation*

I hereby affirm and attest that Carrier(mentioned in Carrier/Issuer’s Legal Name) is Licensed in the State of Maryland as a risk bearing entity, or Authorized to operate as a risk bearing entity in the state of Maryland, and in good standing with the Maryland Insurance Administration.

Accreditation Attestation

I hereby affirm and attest that Carrier (mentioned in Carrier Details) is an Accredited Issuer through below mentioned entity and rating

Accreditation Entity

Accreditation Rating

Carrier Business Agreement Attestation*

I hereby affirm and attest that there is an active and binding Carrier Business Agreement in place with the Maryland Health Benefit Exchange ensuring compliance with MHBE policies and State and Federal regulations.

Non-Exchange Entity Agreement Attestation*

I hereby affirm and attests that there is an active and binding Non-Exchange Entity Agreement in place with the Maryland Health Benefit Exchange that assures compliance with the ACA privacy and security rules.

Network Adequacy Attestation*

I hereby affirm and attest that the issuer satisfies all applicable Network Adequacy requirements promulgated in COMAR 31.10.44, and will complete all requirements under the transition to full implementation of the rule.

Provider Directory Attestation*

I hereby affirm and attest that the issuer will 1) submit provider directory data to MHBE every fourteen days in the form and manner established by MHBE, 2) ensure that the submitted data is accurate, complete, and current under 45 CFR 156.230(b), and 3) comply with 45 CFR 156.230(b) to make available on the issuer’s website, in a manner determined by the issuer, provider directory information that is accessible without requiring the public to first login.

List of Subcontractors Attestation*

I hereby affirm and attest that a list containing any material subcontractor (relevant to Exchange specific functions and the administrator of service to Exchange population) is current and filed with MHBE

Marketing and Benefit Design of QHPs*

I hereby affirm and attest that in accordance with 45 CFR §156.225, the issuer 1) complies with any applicable laws and regulations regarding marketing by health insurance issuers; and, 2) does not employ marketing practices or benefit designs that have the effect of discouraging the enrollment of individuals with significant health needs in QHPs

Final Attestation*

I hereby affirm and attest that in order to offer Quality Health Plans they must meet all the requirements and standards detailed in the Annual Issuer Letter.

Organization Name*

Attestation Contact Name*

Contact Phone Number*

Contact Email*

Date of Submission

Carrier Application/Certification form

Application Details Section

Attestations Section

MHBE Issuer’s Attestations

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