For Issuers Offering Qualified Dental Plans
in the Washington Health Benefit Exchange
Issuers intending to offer Qualified Dental Plans in 2020 on Washington Healthplanfinder, the Exchange’s online marketplace, are
required to sign and submit a Participation Agreement to the Washington Health Benefit Exchange (WAHBE) by August 1, 2019, as
detailed in the 2020 QDP Guidance for Participation.
The Participation Agreement consists of four categories of materials that must be provided to WAHBE:
1. Attestations (Completed by signing and returning this form to WAHBE. A separate completed and signed State-
based Exchange Issuer Attestations Form, required by CMS, must also be submitted to the Office of the Insurance
2. Electronic Data Interchange Trading Partner Agreement (Required only from issuers offering plans for the first time in
the Exchange. Must be completed, signed, and returned to WAHBE by August 1, 2019.)
3. Marketing brochures (Maximum of two brochures per plan (one English and one Spanish), to be submitted in final
form no later than September 5, 2019.)
4. Issuers of Qualified Dental Plans offered through the Exchange will provide enrollment, payment, and disenrollment
data in a manner and frequency specified by the Exchange as necessary to support Exchange operations including but
not limited to:
(a) Eligibility, enrollment, or disenrollment processes.
(b) Reports or provision of information required by the U.S. Department of Health and Human Services, Internal
Revenue Service, or the Washington State Legislature.
(c) Estimation or collection of assessments or fees specified in RCW 43.71.080.
All of the above materials must be provided to WAHBE no later than the dates specified above for an issuer to have the opportunity
to participate in Washington Healthplanfinder. A new Participation Agreement will be required annually as part of the recertification
By signing this Participation Agreement, you, the Issuer, attest that you will follow the terms for participation in Washington
Healthplanfinder as described in the Guidance for Participation and the accompanying Enrollment Payment and Process Guide.
By signing this Participation Agreement, you, the Issuer, acknowledge that your participation in and plans offered through
Washington Healthplanfinder are subject to federal and state law, and you agree to comply with applicable law which will include
accepting payments on behalf of individuals as required under 45 CFR § 156.1240 and in accordance with the sponsorship policy
established under RCW 43.71.030 and the Exchange Premium Sponsorship Program.
This Participation Agreement is an amendment to the Guidance for Participation and incorporates, by reference, the terms and
requirements for participation in Washington Healthplanfinder.
Issuer Name_________________________________________________ Date_________________________________
Signature of Issuer’s Authorized Representative________________________________________________________________