1

COHBE Qualified Plan Certification

2

SB-200 Requirements

• CRS 10-22-104 The exchange shall not duplicate or replace the duties of the commissioner established in section 10-1-108, including rate approval, except as directed by the federal act. The exchange shall foster a competitive marketplace for insurance and shall not solicit bids or engage in the active purchasing of insurance.

• CRS 10-22-106(1)– (i) Consider the unique needs of rural Coloradans as they pertain to access,

affordability, and choice in purchasing health insurance;– (j) Consider the affordability and cost in the context of quality care and

increased access to purchasing health insurance; and– (k) Investigate requirements, develop options, and determine waivers, if

appropriate, to ensure that the best interests of Coloradans are protected.

3

Marketplace Rules

4

Plan Management

• Certification, recertification, decertification– Regulatory requirements– Accreditation standards

• Business Relationship– Data exchange standards– Customer service standards

• Exchange will develop objective plan management standards and communicate those standards to carriers before certification.

5

Exchange Partners

• Exchange will work with Division of Insurance, Department of Public Health and Environment, and Department of Health Care Policy and Financing to minimize QHP burdens

6

Certification Requirement Activities

Accreditation Licensure Requirements

Complaint Data Marketing Requirements

Claim Payment Disclosures MLR requirements

Discriminatory Benefit Design Review Network Adequacy

Essential Benefit Validation Out-of-Network Disclosure Requirements

Essential Community Health Providers QHP Quality Measures

Financial Disclosures Provider Directory

Formulary Requirements Solvency Requirement

Accreditation Marketing Requirements

Complaint Data MLR requirements

Claim Payment Disclosures Network Adequacy

Discriminatory Benefit Design Review Out-of-Network Disclosure Requirements

Essential Benefit Validation Plan Differentiation

Essential Community Health Providers Provider Directory

Financial Disclosures QHP Quality Measures

Formulary Requirements Rate Review

Licensure Requirements Solvency Requirement

7

State, Federal, or UX Guidance

Accreditation (Fed) MLR Requirements (Fed)

Complaint Data (State) Network Adequacy (State)

Claim Payment Disclosures (State) Out-of-Network Disclosure Requirements (State)

Financial Disclosures (State) Provider Directory (UX)

Formulary Requirements (UX) Rate Review (State)

Licensure Requirements (State) Solvency Requirement (State)

8

New Processes

Some Existing Processes

Essential Community Providers QHP Quality Measures

Marketing Requirements

Completely New Processes

Discriminatory Benefit Design Essential Benefit Validation

Plan Differentiation

9

Decertification

• The Exchange will only decertify an issuer during the year if the issuer is not able to meet responsibilities (loses licensure, insolvency, or inadequate network, etc.) – The Exchange will work to move members to a new

QHP in an efficient manner• An issuer who fails to meet necessary business

partnership levels will not be recertified but members will continue to be enrolled in the QHP

10

Recertification

• The Exchange will develop an annual recertification process

• The recertification will allow the Exchange board to change the baseline certification processes in future years