440-5186 (12/20/COM)
1
QHP/SADP
Carrier Attestation Form
For each attestation below, carrier will check “yes,” or “no.” Please explain each “no” answer.
If desired, documents may be uploaded in lieu of a written explanation. Include the document title in the explanation text
field. Clearly label each document to indicate the corresponding question.
Carrier must respond to all attestations.
Carrier Agrees to Work Collaboratively with the Marketplace in Key Areas
1. Carrier will perform the following functions related to the Oregon Health Insurance Marketplace and the Centers for
Medicare and Medicaid Services:
• Consumer dispute resolution
• Plan data submission and display
• System integration with the Federally Facilitated Marketplace
• Member communications regarding exchange issues and instructions
❏ Yes ❏ No
If you checked “no,” explain below (1,000 character limit):
Federal Minimum Certification Requirements
As a condition of participation in the exchange, health insurance carriers must agree to comply with the federal
minimum certification requirements. These requirements are taken from the Patient Protection and Affordable Care Act
(ACA) and the related federal regulations promulgated by the United States Department of Health and Human Services
(HHS) in 45 CFR, Parts 155 and 156. This section highlights some of the major requirements. It is not intended to be
a complete list of federal certification requirements.
Licensure and Solvency
2. Carrier will be licensed and in good standing to offer health or dental insurance coverage or both in Oregon.
❏ Yes ❏ No
If you checked “no,” explain below (1,000 character limit):