QHP certification is the annual process by which the Centers for Medicare and Medicaid Services or a state-based marketplace verifies that a health insurance plan meets ACA minimum standards before it can be listed and sold through the Marketplace. A plan that passes certification is a Qualified Health Plan. A plan that does not pass is not listed on HealthCare.gov or an equivalent SBM portal for that plan year.
Certification is not an endorsement. CMS does not rank certified plans or recommend one over another. Passing certification means the plan clears four regulatory thresholds: essential health benefits coverage, metal tier actuarial value, network adequacy, and accreditation. Everything beyond that floor, including network breadth, premium, cost-sharing, and formulary quality, is a plan-level variable that brokers and households evaluate independently.
Key Takeaways
- A Qualified Health Plan is a plan certified by a Marketplace as meeting ACA minimum standards under 45 CFR Part 156. Certification is required for a plan to be sold through HealthCare.gov or a state-based marketplace.
- QHP certification verifies four main areas: essential health benefits coverage, metal tier actuarial value thresholds, network adequacy standards, and health plan accreditation.
- Certification does not guarantee a plan covers a client's specific providers, hospitals, or medications. Brokers must independently verify network and formulary adequacy for each household.
- CMS publishes the FFM QHP certification timeline annually. Plans that miss the application deadline are not listed on HealthCare.gov for that plan year, regardless of how competitive their rates are.
- State-based marketplace certification requirements often exceed CMS minimums. A plan offered in an FFM state may not qualify in a state like California or New York without meeting additional SBM standards.
The four pillars of QHP certification
The regulatory authority for QHP certification sits primarily in , which CMS updates annually through the Notice of Benefit and Payment Parameters. The four certification pillars each have specific standards with de minimis ranges and exceptions that change from plan year to plan year.
| Requirement | Standard | Regulatory source |
|---|---|---|
| Essential Health Benefits | Must cover all 10 EHB categories including ambulatory care, emergency services, hospitalization, maternity, mental health, prescriptions, rehabilitation, lab services, preventive care, and pediatric services | 42 U.S.C. § 18022; 45 CFR § 156.110 |
| Metal tier actuarial value | Bronze 60% (±2%), Silver 70% (±2%), Gold 80% (±2%), Catastrophic 60% (for eligible enrollees only). Plus-or-minus 2% de minimis variation allowed. | 45 CFR § 156.140 |
| Network adequacy | Sufficient choice of providers in each specialty so that services are available without unreasonable delay. CMS uses time-and-distance standards by county and specialty type. | 45 CFR § 156.230 |
| Accreditation | Must be accredited by NCQA, URAC, or AAAHC within specified timeframe. New issuers may receive a provisional certification for the first plan year. | 45 CFR § 156.275 |
| Quality rating | Must report quality data to CMS annually. Plans participating in QRS receive a 1 to 5 star rating displayed on HealthCare.gov. | 45 CFR § 156.1120 |
| Non-discrimination | Must not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, or sexual orientation in benefit design or administration. | 42 U.S.C. § 18116; 45 CFR Part 92 |
Regulatory citations current as of plan year 2026. CMS updates QHP certification standards annually in the Notice of Benefit and Payment Parameters.
Essential health benefits: what the categories cover
The 10 essential health benefit categories are defined by federal statute but implemented through state-specific benchmark plans. Each state selects an EHB benchmark, which sets the specific benefit level for that category within that state. A QHP must cover at least the benefits in the state's benchmark for each category.
The practical effect is that EHB coverage varies by state. A QHP in Texas covers the Texas EHB benchmark. A QHP in New York covers New York's benchmark, which includes benefits Texas does not mandate. Brokers who move clients across state lines or who quote plans in multiple states need to understand that two Bronze plans certified in different states are not equivalent products, even if they hit the same actuarial value.
One EHB nuance that comes up frequently: mental health parity. The Mental Health Parity and Addiction Equity Act requires that mental health and substance use disorder benefits be no more restrictive than medical and surgical benefits. QHP certification verifies parity compliance, but the practical test is plan-level. Brokers with clients who use behavioral health services should check prior authorization requirements and in-network provider availability separately from the certification status.
Metal tiers and actuarial value thresholds
Metal tier certification is one of the more mechanically precise parts of QHP review. CMS uses an actuarial value calculator to verify that a plan's cost-sharing structure produces an actuarial value within a de minimis range of the target: plus or minus 2 percentage points for standard metal tiers.
Actuarial value is a population-level measure. A Silver plan with 70 percent actuarial value is expected to pay 70 percent of covered medical expenses for a standard population. It does not mean a specific client will pay 30 percent of their claims. A client who uses no services pays nothing. A client with a complex chronic condition may pay more than 30 percent of their actual claims if services exceed the out-of-pocket maximum or fall outside the benefit structure.
The cost-sharing reduction tiers on Silver plans add a complexity layer. A household with income between 100 and 150 percent FPL enrolled in a Silver plan receives the 94 percent AV CSR variant. The underlying plan remains Silver-certified, but the effective benefit design is materially different from what a higher-income Silver enrollee receives. Certification covers the standard Silver product. The CSR variants are administered by CMS separately.
Network adequacy: what certification checks and what it misses
CMS assesses network adequacy using time-and-distance standards published in the annual QHP certification guidance. The standards specify maximum drive times and distances for specific provider types, differentiated by county designation: urban, suburban, rural, and large rural. A plan with a network that meets the time-distance thresholds in every county where it is offered passes the network adequacy screen.
What the screen does not capture: actual provider availability within those parameters. A county may have three in-network primary care physicians within the time-distance threshold, each accepting no new patients. The plan passes network adequacy certification. A client enrolling in that plan finds zero available appointments. This gap between certified adequacy and functional availability is a persistent problem in rural and lower-income urban markets.
Brokers who write significant volume in rural counties or markets with known provider shortages should check carrier provider directories independently of certification status. The plan finder's network display shows which plans include specific providers, but a current provider directory confirmation from the carrier directly is more reliable for clients who need a specific specialist or hospital.
FFM vs. SBM certification: parallel processes with different rules
Brokers who write in multiple states face a certification landscape that splits in two. States using HealthCare.gov (Federally Facilitated Marketplace states) use the CMS certification process. The 21 states with state-based marketplaces run their own certification programs with their own timelines, standards, and portals.
| Area | FFM standard (HealthCare.gov) | SBM note |
|---|---|---|
| Certification authority | CMS / HHS certifies plans on HealthCare.gov | State agency (e.g., Covered California, NY State of Health) certifies plans for their marketplace. Different application, different timeline. |
| Network adequacy | CMS time-and-distance standards by specialty. Varies by county and urban/rural classification. | Many SBMs impose stricter standards. California requires provider directory accuracy reporting that exceeds CMS minimums. |
| Rate review | HHS conducts rate review for states without an approved rate review program. | SBM states with their own rate review programs (e.g., New York, Maryland) review rates independently before certification. |
| Essential health benefits benchmark | States select an EHB benchmark plan. Benchmark varies by state. | SBMs may supplement CMS EHB requirements. A plan meeting the FFM EHB benchmark may still need to add benefits to satisfy an SBM state's benchmark. |
SBM certification requirements vary by state and are updated annually by each state exchange authority. Verify current standards with each SBM directly.
The 1332 state innovation waiver framework adds another dimension. States with active 1332 waivers may have modified EHB requirements, adjusted subsidy structures, or alternative coverage mechanisms that affect which plans qualify on their marketplaces and at what benefit level. Brokers working in waiver states like Idaho, Alaska, or Georgia need to understand how the waiver modifies standard QHP rules before advising clients.
What certification does not tell brokers
QHP certification answers a narrow question: does this plan meet regulatory minimums? It does not answer the questions that matter for a specific household: Is the client's primary care physician in-network? Does the formulary cover the client's maintenance medications at a tier the client can afford? Is the deductible structure compatible with how the client uses healthcare?
The gap between certified and suitable is where broker value lives. Any plan finder can surface certified plans. The broker's job is to filter certified options by the client's actual healthcare utilization pattern, financial situation, and provider preferences. Certification status is the first filter, not the last.
The broker compliance calendar tracks the QHP certification timeline for each plan year alongside FFM recertification and carrier appointment deadlines, so the full regulatory calendar for each year is in one place.
QHP certification FAQ
Broker questions about Qualified Health Plan certification standards and what they mean in practice.
What does QHP certification actually verify?
QHP certification verifies that a health plan meets four main standards before it can be sold through a Marketplace: it covers all 10 essential health benefit categories, it hits the actuarial value threshold for its metal tier, it meets network adequacy standards in the counties where it is offered, and it is accredited by an approved accreditation body. Certification is a regulatory floor. It confirms the plan meets ACA minimums. It does not indicate the plan is a good fit for any particular household, and it does not guarantee broad networks or low cost-sharing.
Can a plan be sold off-Marketplace without QHP certification?
Yes. QHP certification is required only for plans sold through HealthCare.gov or a state-based marketplace. Individual plans sold outside the Marketplace do not require QHP certification and are not eligible for APTC or CSR subsidies. Some insurers offer both certified and uncertified plan variants. The certified version meets ACA standards and is eligible for subsidies. The uncertified off-Marketplace version may differ in benefit design. Brokers quoting off-Marketplace plans should verify ACA compliance separately.
How often does CMS update QHP certification standards?
CMS publishes updated QHP certification standards in the annual Notice of Benefit and Payment Parameters, typically released in the first quarter of each year. The NBPP covers changes to EHB requirements, actuarial value de minimis ranges, network adequacy rules, and quality rating methodology. Material changes in the NBPP can affect which plans qualify for the following plan year and at what metal tier. Brokers who want to understand why a carrier dropped a plan or changed its metal tier should check the most recent NBPP.
Does QHP certification mean a plan's network is adequate for my client?
No. QHP certification confirms the plan meets CMS time-and-distance standards in the counties where it is offered, which means a sufficient number of providers are available within a specified drive time or mileage. It does not confirm that a specific hospital, primary care physician, or specialist is in-network. Brokers must independently verify network adequacy for each household by checking the carrier's provider directory and, where relevant, the formulary for any maintenance medications the household depends on.
What happens when a QHP fails recertification?
A plan that does not meet CMS certification requirements for the upcoming plan year is decertified and cannot be offered on the Marketplace for that year. Enrollees in a decertified plan receive a notice from CMS and are given the opportunity to select a new plan during a special enrollment period. If they do not actively select a plan, CMS may auto-enroll them in a comparable plan if one is available. Brokers with clients in a decertified plan should proactively reach out to help with the transition rather than waiting for the client to receive the CMS notice.
