CMS and states share responsibilities for overseeing QHPs offered through the exchanges. Specifically, CMS is responsible for establishing minimum QHP certification standards that all QHPs must meet in order to participate in any exchange. Federal regulations require that all exchanges have procedures to certify QHPs annually to ensure compliance with federal requirements. To be certified as a QHP, a plan must meet certain minimum federal requirements, including those related to, for example, the coverage of certain benefits and limits on cost- sharing. In FFE states, CMS is responsible for overseeing compliance with these requirements; in states operating SBEs, the states are responsible for ensuring that plans comply. CMS is responsible for conducting oversight and monitoring of QHPs offered on the FFE, and also requires all SBEs to develop an oversight and monitoring program. In addition to meeting federal exchange-specific requirements, QHP issuers must also abide by state-specific insurance regulations that apply to all issuers offering health insurance products, as states are the primary regulators of health insurance. Specifically, all QHPs, whether offered on the FFE or SBE, must be offered by a health insurance issuer that is licensed and in good standing to offer insurance coverage in each state in which it offers QHPs. As a result, QHP issuers are subject to oversight by the states in which they offer QHPs. As part of this oversight, state departments of insurance manage complaint hotlines where enrollees can notify agencies of concerns related to any health insurance plan sold in that state, including QHPs offered on the FFE or an SBE. All exchanges are required to carry out certain consumer assistance functions. Specifically, CMS requires exchanges to operate a toll-free call center and website to address the needs of consumers and enrollees requesting assistance and to conduct outreach and educational activities. For example, CMS operates a Marketplace Call Center to assist the needs of consumers in states that utilize the FFE. In addition, all exchanges are required to have a “navigator” program to carry out public education activities, help consumers select a QHP, and offer QHP enrollees with assistance after their enrollment, among other things. CMS awards grants to organizations to serve as navigators for the FFE. All exchanges may also implement other “assister” programs that perform many of the same or similar functions as navigators. Navigators and other assisters are collectively referred to as “assisters.” Individuals purchasing coverage through the exchanges may be eligible to receive financial assistance to offset the cost of such coverage, and, according to CMS, over three-fourths of QHP enrollees obtain at least one form of such assistance. Eligibility for financial assistance is based on income and provided in the form of premium tax credits and cost-sharing subsidies. One form of assistance is the premium tax credit, which is generally available to income-eligible individuals who do not have access to health insurance that meets certain standards. The credit is designed to reduce an eligible individual’s cost of purchasing health insurance through the exchange and can be paid to an enrollee’s issuer in advance to reduce the enrollee’s monthly premium costs. The amount of the premium tax credit varies and is designed to provide larger credit amounts to those with lower incomes. QHP enrollees who qualify for and opt to receive advance payments of the premium tax credit based on their income and family size at the time of application must attest that they will file a federal tax return for the applicable plan year. Such enrollees must reconcile on their federal tax return the amount of advance payments received based on their actual reported income and family size for the year. Enrollees who qualify for premium tax credits may also be eligible to receive cost- sharing reduction assistance to help offset QHP enrollees’ out-of-pocket expenses, including by lowering their deductibles, coinsurance and co- payments. Available data from the five national surveys we identified through our literature review show that most QHP enrollees were satisfied overall with the plans they obtained through the exchanges. QHP enrollees have also expressed satisfaction, to varying degrees, with specific aspects of their plans, including their coverage, their choice of providers, and plan affordability, according to five national surveys we reviewed. QHP enrollees who obtained their coverage through the exchanges have reported overall satisfaction with their plans from 2014 through 2016, according to national surveys that we reviewed. Specifically, 65 percent or more of QHP enrollees surveyed expressed overall satisfaction with their plans in 2014 through 2016, according to three national surveys that asked this question of enrollees. (See table 1.) The overall satisfaction level of QHP enrollees was somewhat lower than or similar to those who were enrolled in employer-sponsored health insurance in 2015 and 2016. Specifically, one national survey reported that 86 percent of QHP enrollees were satisfied or somewhat satisfied with their current health plan in 2015, compared to 93 percent of employer-sponsored health insurance enrollees. The survey did not specifically report the reason for the difference in satisfaction levels. The same survey in 2016 reported that overall plan satisfaction among QHP enrollees was equivalent to those with employer-sponsored health insurance, although other national surveys that we reviewed reported that QHP enrollees were, for example, less satisfied with their choice of providers or less likely to report ease in affording their premiums, compared to those with employer-sponsored insurance. Two of the national surveys we reviewed examined QHP re-enrollment, which can provide additional context for QHP enrollees’ overall satisfaction with their plans. Specifically, one national survey found that 77 percent of adult QHP enrollees that re-enrolled in the same plan for 2016 reported satisfaction with their QHP. Another national survey of QHP enrollees reported that, in 2015, most—82 percent—of those re- enrolling selected a plan with the same insurance company and about half stayed with the same plan. Stakeholders we interviewed and other literature we reviewed also provided additional context for QHP enrollees’ overall satisfaction with their plans based on QHP re-enrollment and a stable volume of consumer complaints regarding health insurance. For example, while many factors, including financial incentives, may affect an enrollee’s decision to re-enroll in a plan, officials from one exchange office we interviewed told us that they consider plan re-enrollment as one important measure of QHP enrollee satisfaction because enrollees have the capacity to change QHPs annually. In addition, a statewide survey of Vermont QHP enrollees found that 9 percent of QHP enrollees renewing their coverage in 2015 switched plans, with 80 percent of renewing QHP enrollees reporting that their plan fit their needs very or somewhat well. Although the remaining four selected states in our review had not directly measured QHP enrollee satisfaction, officials from all of these states’ departments of insurance told us that QHP enrollees in their states have not reported significant problems that are unique to QHPs. In addition, department of insurance officials from two of these selected states told us that the volume of complaints they received for all health plans had not increased since health insurance became available through the exchanges in 2014. QHP enrollees who obtained their coverage through the exchanges have rated their health insurance coverage positively and generally expressed satisfaction with their choice of providers, according to national surveys we reviewed. Specifically, two national surveys reported that approximately 70 percent of QHP enrollees rated their health insurance coverage as good, very good, or excellent in 2016. QHP enrollees have also generally reported satisfaction with their choice of providers, according to four national surveys we reviewed. For example, one national survey reported that 74 percent of QHP enrollees noted satisfaction with their choice of primary care doctor in 2016, and a smaller portion of enrollees—59 percent—noted satisfaction with their choice of specialists. Two other national surveys reported that more than 75 percent of QHP enrollees surveyed were satisfied with the doctors included under their plan. The fourth national survey reported levels of dissatisfaction, stating that 14 percent of QHP enrollees reported dissatisfaction with their choice of doctors and other providers. (See table 2.) In addition to reporting satisfaction with their choice of providers, most QHP enrollees surveyed had used their health insurance coverage in 2015 or 2016, according to four national surveys that reported this information. For example, one national survey reported that about two- thirds of QHP enrollees reported using their plans to access care or purchase medication. Three national surveys found that over half of QHP enrollees reported having a regular or routine check-up. Another national survey reported that 62 percent of QHP enrollees who needed to see a specialist could do so within 2 weeks or less. Satisfaction with plan affordability among QHP enrollees who obtained their coverage through the exchanges was lower than for satisfaction with plans overall and for coverage and access. Nevertheless, about half or more of QHP enrollees surveyed reported satisfaction with their plan’s affordability, according to the five national surveys that we reviewed. For example, two national surveys reported that about half or more of QHP enrollees found it easy to afford their plan’s premium costs. One national survey found that 45 percent of QHP enrollees reported high levels of confidence in their ability to obtain affordable care. Another national survey reported rates of dissatisfaction, with 25 percent of QHP enrollees reporting being very or somewhat dissatisfied with the premiums they paid for their plans. Finally, one national survey reported that approximately 60 percent of QHP enrollees were satisfied with various plan costs in 2016, such as annual deductibles and copayment amounts. (See table 3).