qhp issuer workshop part ii - arkansas...plan management updates meaningful difference • the...

of 56 /56
QHP Issuer Workshop Part II QHP Application and Review Process Overview, Part II April 15, 2014 www.pcghealth.com

Author: others

Post on 06-Jun-2020

0 views

Category:

Documents


0 download

Embed Size (px)

TRANSCRIPT

  • QHP Issuer Workshop Part II

    QHP Application and Review Process Overview, Part II

    April 15, 2014

    www.pcghealth.com

  • Schedule and Logistics

    QHP Advisory Committee 2

    Meeting Information

    The meeting will be available in Webex. To join the meeting,

    click here and enter meeting password ARQHP. The phone

    number to for the voice conference is:

    Call-in toll-free number (US/Canada): 1-877-668-4493

    Access code: 766 660 437

    Proposed Schedule

    • 1:30pm – Start meeting

    • 2:45pm – 15 Minute Break

    • 3:00pm - Resume

    • 4:15pm – Wrap up

    https://pcgus.webex.com/pcgus/j.php?MTID=ma1d730574c3d5a6d6f31b0ce602f30c7

  • Agenda

    QHP Advisory Committee 3

    • Introductions

    • Plan Management Updates

    • AR 2015 QHP Filing and Certification Requirements

    • Review of QHP Bulletin

    • Recertification

    • Uniform Modification Allowances

    • Essential Health Benefits; new considerations

    • Quality Improvement Initiatives

    • Plan Variations

    • Rate Filing

    • CMS Review Tools

    • Questions?

  • Plan Management Updates

    QHP Bulletin

    • The QHP Bulletin was released on Monday, April 14

    2015 Final Letter to Issuers

    • The 2015 final letter to issuers was released by CCIIO on

    March 14 and summarizes plan year 2015 QHP

    certification requirements

    • The letter can be found here

    Network Adequacy Rule

    • The AID Network Adequacy rule is expected to be

    published within the week (by April 22nd)

    QHP Advisory Committee4

    http://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/2015-final-issuer-letter-3-14-2014.pdf

  • Plan Management Updates

    • 2014 QHP Application and Certification Timeline – Part I

    *AID is requesting that all plan changes be completed by August 6th

    to allow time for transmission to HIOS

    QHP Advisory Committee5

    2014 Key Dates Description

    May 1st – June 15th QHP Applications must be submitted to AID by

    June 15th

    June 16th – August 8th * AID QHP review period

    August 11th–August 25th FFM Reviews Plan Data

    August 26thFFM Notifies States of any Needed Corrections

    to QHP Data

    September 4th Last day for issuers to resubmit plan data

    September 5th – September

    10th2nd SERFF Data Transfer

  • Plan Management Updates

    • 2014 QHP Application and Certification Timeline – Part II

    QHP Advisory Committee6

    2014 Key Dates Description

    September 22nd FFM Completes Re-review of Plan Data and

    State Recommendations

    September 24th– October 6th Limited Data Correction Window

    October 14th– November 3rd

    Certification Notices and QHP Agreements

    Sent to Issuers, Agreements Signed, QHP Data

    Finalized

    November 15th Open Enrollment Begins

  • Plan Management Updates

    • Outstanding technical and policy updates that could

    impact the timelines:

    • Release of 2015 Plan Management Templates (CMS)

    • Completion of updated SERFF validation services (expected by

    late May)

    • Final AID and Health Care Independence Program (“HCIP”,

    a.k.a. “Private Option”) QHP certification criteria and details on

    cost-sharing variations (expected by May 1)

    • Changes to the proposed market standards for 2015 and beyond

    (CMS)

    QHP Advisory Committee7

  • Plan Management Updates

    Meaningful Difference

    • The review process or meaningful difference in plans was

    expanded for 2015 and changed slightly from the proposed rule.

    • Plans will be segmented by plan type, metal level and

    overlapping counties/service areas and then evaluated for

    differences in network, formulary, deductibles, MOOP, covered

    benefits, HSAs, and availability for children (premiums was taken

    out as a criteria)

    • Plans are expected to differ in at least one of these areas.

    8

  • Plan Management Updates

    Summary of Benefits and Coverage (SBC)

    • SBCs are required to be submitted for plan year 2015.

    SBCs illustrate benefits and coverage for common

    conditions chosen by HHS: Routine maintenance of well-

    controlled type 2 diabetes and having a baby (normal

    delivery)

    • SBCs for plan variations are not required, but are

    encouraged. SOBs must be accurate and match policy and

    SOB’s information.

    9

  • Plan Management Updates

    2015 Plan requirements

    • Riders are not permitted to be offered in conjunction

    with Marketplace plans, even if the riders are for non-

    EHB benefits

    • In addition to federal requirements that at least one

    silver and at least one gold plan are offered in the

    individual market, QHPs in the Arkansas individual

    market are required to include at least one silver-level

    plan that contains only the EHBs included in the state

    base-benchmark plan

    QHP Advisory Committee10

  • Filing and QHP Certification Requirements

    QHP Application Process

    • QHP applications will be filed through SERFF

    • Rate and form filings must both be submitted by the QHP

    application deadline (see timelines)

    • Individual and small group plans that are only outside the

    marketplace are not required to have submitted

    applications by the June 15 deadline

    • SAD issuers should submit both inside and outside

    marketplace plans (that will be certified as a supplement to

    EHB)

    • SERFF will conduct Issuer trainings April 22-May 21

    QHP Advisory Committee11

  • Filing and QHP Certification Requirements

    CMS Onsite Training

    • QHP Certification Onsite Technical Assistance Session for

    Issuers April 22-23 at CMS in Baltimore

    • The purpose of this session is to provide the Issuers and

    other entities with information needed for successful QHP

    certification

    • Register by Thursday, April 17

    QHP Advisory Committee12

  • Filing and QHP Certification Requirements

    Recertification

    • The CMS 2015 Final Letter to Issuers indicates that the

    recertification process will largely resemble the initial

    certification process and that all application materials must be

    re-submitted

    • A recertified plan can keep the same plan and HIOS ID, and

    enrollees will remain enrolled into the new benefit year

    • Plans that issuers are proposing to recertify will remain in

    effect into the new benefit year unless the enrollee terminates

    their policy

    • Applications for recertification should include a redlined

    version of the plan forms and a written justification for any

    changes to cost-sharing and covered benefits (A template for

    submission of plan change justifications will be posted in

    SERFF)

    QHP Advisory Committee13

  • Filing and QHP Certification Requirements

    Uniform Modification

    • Plans with “uniform modifications” are allowed to be renewed and

    recertified if the change is pursuant to Federal or state law, such as

    increasing annual limitations on cost-sharing as a result of the

    application of the premium adjustment percentage.

    QHP Advisory Committee14

  • Filing and QHP Certification Requirements

    Uniform Modification

    • If changes are made to the plan that not due to Federal and

    state law, then they may still meet the uniform modification

    criteria if the plan:

    • Is offered by the same health insurance issuer and is the same

    product type (i.e. PPO or HMO);

    • Covers a majority of the same counties in its service area;

    • Maintains the same cost-sharing structure, except for actuarial

    adjustments that are a result of cost and utilization of medical

    care or in order to maintain the same A/V level of coverage; and

    • Provides the same covered benefits, unless changes to benefits

    impact the rates only ± 2%.

    QHP Advisory Committee15

  • Filing and QHP Certification Requirements

    Uniform Modification – FAQs

    Q1: Do changes to plans such as inclusion of mandatory benefits

    like TMJ and hearing aids, changes to a plan to meet the EHB-only

    silver plan requirement, changes to HCIP cost-sharing

    requirements, and removal of riders count as a uniform

    modifications?

    A1: These changes are pursuant to changes in federal and state

    law and guidance and are considered uniform modifications

    Q2: Will changes to non-EHB benefits violate uniform modification

    criteria?

    A2: If the changes to non-EHBs affect the plan index rate by more

    than 2%, it will not be considered a uniform modification.

    QHP Advisory Committee16

  • Filing and QHP Certification Requirements

    Uniform Modification – FAQs

    Q3: To what extent is a change to MOOP allowed and it still be

    considered pursuant to federal law (due to annual increase in

    MOOP in the 2015 benefit and payment parameters)?

    A3: CMS has recently indicated that in order to qualify as a uniform

    modification, the change must be pursuant (required) by law, so a

    change in plan MOOP due to annual increase in the maximum

    allowable MOOP levels would not be considered a uniform

    modification. AID is submitting comments on the proposed market

    standards and will indicate this suggested clarification in the final

    rule.

    QHP Advisory Committee17

  • Filing and QHP Certification Requirements

    Certification Standards Applicable to Stand-alone Dental

    Plans

    QHP Advisory Committee18

    Certification Standard Applies (* denotes modified standard)

    Certification Standard Does Not Apply

    Essential Health Benefits*

    Actuarial Value* Accreditation

    Annual Limits on

    Cost Sharing*

    Licensure Cost-sharing Reduction Plan Variations

    Network

    Adequacy

    Inclusion of ECPs Unified Rate Review Template

    Marketing Service Area Meaningful Difference

    Non-discrimination

  • Filing and QHP Certification Requirements

    Associated Schedule Items

    • QHP forms and associated documentation should be

    attached to the binder through SERFF Plan Management

    functionality. All applicable forms must be attached to the

    correct plans in the binder.

    • The SERFF instructions for associated schedule items can

    be found here.

    QHP Advisory Committee19

    https://login.serff.com/Appendix II.pdf

  • Essential Health Benefits

    • The QHP Issuer must offer coverage that is substantially equal to

    the coverage offered by the state’s base benchmark plan and

    attest that plans are in compliance with all EHB standards.

    • Benefits and coverage requirements for the AR Benchmark Plan

    can be found in the QHP Checklist and AR Essential Health

    Benefits Guidelines (see Attachment D).

    QHP Advisory Committee20

  • Essential Health Benefits

    Mental Health Parity

    • MHPAEA requires that treatment limitations (whether quantitative or non-

    quantitative) for MHSA benefits are no more restrictive than the

    predominant requirements or limitations applied to substantially all

    medical/surgical benefits.

    Mental Health Benchmark Requirements

    • The AR benchmark coverage for mental health is based on the

    QualChoice federal employee benefits health plan. However, the non-

    quantitative treatment limitations in the mental health and substance

    abuse benchmark plan may not meet the MHPAEA; issuers must ensure

    that the quantitative and non-quantitative treatment limitations in MHSA

    coverage comply with MHPAEA requirements.

    • For example, the benchmark plan states that all services require

    preauthorization and an approved treatment plan, and this would not be

    permitted under MHPAEA unless the same limitation applies to substantially

    all medical and surgical benefits in the benefit category.

    QHP Advisory Committee21

  • Essential Health Benefits

    Mental Health Parity and AR Network Adequacy Standards

    • Network adequacy- Mental Health, Behavioral Health and

    Substance Abuse access standard was previously 45 minutes or

    45 miles. Due to updates in the mental health parity rule and

    confirmation from CCIIO, the standard has been changed to 30

    minutes or 30 miles. It is understood that in some areas of the

    state, there are not sufficient providers to meet this standard.

    QHP Advisory Committee22

  • Essential Health Benefits

    Prescription Drugs

    • CMS noted in the letter to issuers that the agency intends to

    review plans that are outliers based on an unusually large

    number of drugs subject to prior authorization and/or step therapy

    requirements in a particular category and class.

    • CMS also expects the URL link to direct consumers to an up-to-

    date formulary where they can view the covered drugs, including

    tiering, that are specific to a given QHP.

    • The URL provided to the Marketplace as part of the QHP

    Application should link directly to the formulary, such that

    consumers do not have to log on, enter a policy number or

    otherwise navigate the issuer’s website before locating it. If an

    issuer has multiple formularies, it should be clear to consumers

    which formulary applies to which QHP(s).

    QHP Advisory Committee23

  • Essential Health Benefits

    Arkansas Habilitative Services

    Definition of Habilitative Services

    • Habilitative services are services provided in order for a person to

    attain and maintain a skill or function that was never learned or

    acquired and is due to a disabling condition

    Coverage of Habilitative Services

    • Subject to permissible terms, conditions, exclusions and limitations, health

    benefit plans, when required to provide essential health benefits, shall provide

    coverage for physical, occupational and speech therapies, developmental

    services and durable medical equipment for developmental delay,

    developmental disability, developmental speech or language disorder,

    developmental coordination disorder and mixed developmental disorder.

    QHP Advisory Committee24

  • Essential Health Benefits

    Arkansas Habilitative Services

    Establishing Parity

    • QHPs must offer habilitative services at parity with rehabilitative services.

    Because developmental services are generally less expensive and required

    on a long-term basis, the department has determined that parity must be

    established through the use of unit equivalency. All medical QHPs must

    include developmental services with unit limits at an acceptable level of parity

    with Outpatient and Inpatient Rehabilitation for the 2015 plan year policies.

    The minimum acceptable limits are included in the table below:

    QHP Advisory Committee25

    Rehabilitation

    (OT, PT, ST)

    Habilitative Services

    (OT, PT, ST)

    Habilitative

    Developmental

    Services

    Outpatient

    30 visits

    (1 visit = 1 unit = 1

    hour or less)

    30 visits

    (1 visit = 1 unit = 1hour or

    less)

    N/A

    Inpatient 60 days N/A 180 units (1 unit = 1 hour)

  • Essential Health Benefits

    Mandated Offerings as EHBs

    • Due to Arkansas statutory language and the CCIIO requirement that

    riders are not allowed with any filing, TMJ and Hearing Aids will be

    considered Mandated Benefits and must be embedded in all QHPs,

    unless the plan is an HMO not subject to the AR mandatory hearing aid

    offering requirement (Bulletin 7-A 2009)

    In-vitro Fertilization

    • In-vitro is a mandated AR benefit so must be embedded in all QHPs

    (except HMOs) even though it is not included in the state benchmark

    plan

    QHP Advisory Committee26

  • Essential Health Benefits

    New AR-Mandated Benefits

    • AR mandated benefits enacted after December 2011 are

    considered in addition to EHB and must be excluded from the

    silver EHB-only plan and excluded from premium allocated

    towards EHBs in the actuarial memorandum. Act 1226 of 2013

    enacted a new mandated benefit for Craniofacial surgery.

    • These additional laws were enacted in 2013 and apply to existing

    mandated benefits:

    • Act 1259 of 2013: Mammography reimbursements

    • Act 342 of 2013: Physical therapists must be paid the same as

    general practice doctors

    • Act 464 of 2013: Must have review process for excluded services

    that are experimental

    • Act 1233 of 2013: Revised coverage for orthotics

    QHP Advisory Committee27

  • Essential Health Benefits: Cost Sharing

    Maximum Out of Pocket Limits*

    • Note that OON Emergency Services can count towards in-

    network MOOP

    * Based on Final 2015 Benefit and Payment Parameters

    QHP Advisory Committee28

    Medical Dental

    Individual $6,600 $350

    Family $13,200 $700

  • QHP Quality Requirements

    Three Quality Goals:

    • #1 - Inform Plan Certification – Includes QHP certification

    standards, issuer quality improvement practices, and safety

    • #2 - Provide Information to Consumers for Plan Selection –

    Includes quality rating system and enrollee satisfaction surveys

    • #3 - Monitor Plan Quality - Oversight and monitoring to include

    complaints and appeals data, disenrollment information, and denied

    claims

    QHP Advisory Committee29

  • QHP Quality RequirementsGoal #1 - Inform Plan Certification – Includes QHP certification standards, issuer quality improvement practices, and safety

    Areas with current federal guidelines:

    • Accreditation

    • Patient Safety (may be more in the future)

    Areas pending guidelines:

    • Submission of Plan Performance

    • Pediatric quality reporting measure

    • Quality improvement strategy

    While there is not yet federal guidance in some of these areas, QHP issuers are

    required to participate in the AR Payment Improvement Initiative as a current

    QHP certification standard, including the AR Patient-Centered Medical Home

    Model in alignment with Medicaid PCMH standards.QHP Advisory Committee

    30

  • QHP Quality RequirementsGoal #2 - Provide Information to Consumers for Plan Selection

    Areas with current federal guidelines:

    • Proposed Quality Rating System Guidelines

    • Proposed Enrollee Satisfaction Surveys

    AID gathered input from stakeholders via the PMAC quality

    subgroup and submitted comments on the initial QRS proposed rule.

    Additional details regarding the rating methodologies were published

    recently and can be found here (CMS Health Insurance Marketplace

    Quality Initiatives website).

    QHP Advisory Committee31

    https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityInitiativesGenInfo/Health-Insurance-Marketplace-Quality-Initiatives.html

  • QHP Quality RequirementsGoal #3 - Monitor Plan Quality

    Areas with current federal guidelines:

    • Review of complaints and appeals as part of Accreditation requirements

    Areas pending guidelines:

    • Submission of disenrollment information and denied claims

    AID conducts quarterly audits of Qualified Health Plans and quality

    components will be included in the audits. QHP issuers are required

    to submit requested data to AID in the oversight and monitoring

    process.

    QHP Advisory Committee32

  • Additional Updates

    Third Party Payment of QHP Premiums

    • CMS has published an interim final rule in 45 CFR §156.1250

    regarding acceptance of certain third party payments. Issuers are

    required to accept premiums from Ryan White HIV/AIDS

    programs, Indian tribal organizations, and State and federal

    government programs (such as the HCIP program)

    QHP Advisory Committee33

  • Additional Updates

    AID Bulletin 8-2013 regarding Marketing Standards

    • QHP Issuers are prohibited from using a design of a program, entity

    name, webpage, or internet solicitation intended to look like

    Healthcare.gov, ARHealthconnector.org or Access Arkansas; nor shall a

    person or entity create any name, logo, symbol, or web address of any

    kind which is similar enough to mislead a consumer to believe it is a

    direct pathway for purchase of qualified health plans offered in

    Healthcare.gov, ARHealthconnector.org or Access Arkansas.

    • QHP Marketing materials must be submitted to AID prior to use.

    QHP Advisory Committee34

  • Z L

    73 = 73% A/V Silver Variation

    87 = 87% A/V Silver Variation

    94 = 94% A/V Silver Variation

    L= Limited Cost Sharing Variation

    Z= Zero Cost Sharing Variation35

    Z = Zero Cost Sharing Variation

    L = Limited Cost Sharing Variation

    CatastrophicStandard

    Bronze

    Standard

    Silver

    Standard

    Gold

    Z L Z L Z L

    8773 9494

    What about HCIP? Standard Platinum

    Plan Variations

    Z

  • Catastrophic and Standard Plans

    The Catastrophic Plan:

    • Has an actuarial value of < 60%

    • Is not required to have a Zero or Limited Cost Sharing Variation

    The “Standard” Plans:

    • Have actuarial values of 60%, 70%, and 80%, and 90% for

    Bronze, Silver, and Gold and Platinum, respectively.

    • Must include at least one Silver and one Gold plan for each

    issuer.

    36

  • Zero Cost Sharing Variation

    The Zero Cost Sharing Variation:

    • Is required for the Bronze, Silver, and Gold Plans

    • Is for the purpose of removing all cost sharing for EHB

    services for Indians up to 300% FPL.

    • Must have zero cost sharing for both in and out of network

    services.

    • Is not offered in SHOP.

    • Is used in the HCIP for individuals 0-100% FPL in plan

    year 2014. Out of network cost sharing is not allowed in

    the HCIP.37

  • Limited Cost Sharing Variation

    The Limited Cost Sharing Variation:

    • Is required for the Bronze, Silver, and Gold Plans

    • Is for the purpose of removing cost sharing for EHB

    services furnished by Indian Providers for Indians

    regardless of income (over 300% FPL since below 300%

    FPL will be covered by the Zero Cost Sharing variation).

    • Looks just like the corresponding Bronze, Silver, and Gold

    standard plan in the templates.

    • Is not offered in SHOP.

    38

  • Silver Plan Variations Part I

    The Silver Plan Variations:

    • Reduce cost sharing and MOOP amounts for

    individuals up to 250% FPL.

    • Must first increase actuarial value by reducing

    MOOP, then increase actuarial value by reducing

    cost sharing (copays and coinsurance).

    • Are allowed to have out of network cost sharing.

    • Must have equivalent non-EHB cost-sharing to

    the corresponding standard silver plan.

    • Are not offered in SHOP.

    39

    73 = 73% A/V Silver Variation

    87 = 87% A/V Silver Variation

    94 = 94% A/V Silver Variation

  • Silver Plan Variations Part II

    The Silver Plan Variations are determined

    according to income. Lower income individuals

    qualify for higher cost sharing reduction plans

    with higher A/V.

    40

    73 = 73% A/V Silver Variation

    87 = 87% A/V Silver Variation

    94 = 94% A/V Silver Variation

    (a.k.a. “High Silver”)

    94%87%

    73%150% FPL200% FPL

    250% FPL

  • Silver Plan Variations Part III - MOOP

    The Maximum Out of Pocket (MOOP) amounts

    are required to be reduced for silver plan

    variations. CCIIO may change these reduction

    amount requirements over time.

    41

    73 = 73% A/V Silver Variation

    87 = 87% A/V Silver Variation

    94 = 94% A/V Silver Variation

    (a.k.a. “High Silver”)

    94%87%

    73%150% FPL200% FPL

    250% FPL

    The MOOP allowance for the standard silver

    plan is $6,600 (2015). The MOOP reduced

    allowances for 2015 are shown above

    (tentative).

    $2244$3300

    $3300

  • HCIP Variations Part I

    • HCIP uses Silver plan variations only.

    • For plan year 2014, the plans used for

    HCIP include the Zero Cost Sharing plan

    and the 94% High Silver plan.

    • The Zero Cost Sharing plan is not allowed

    to have Out of Network cost sharing.

    • The 94% High Silver Plan is given

    specific cost sharing requirements (

    Appendix E in the plan year 2015 QHP

    Bulletin).

    • The 94% high silver plan is allowed to

    have OON cost sharing and was not

    modified for the HCIP.

    42

    73 = 73% A/V Silver Variation

    87 = 87% A/V Silver Variation

    94 = 94% A/V Silver Variation

    Z = Zero Cost Sharing Variation

    L = Limited Cost Sharing Variation

  • HCIP Variations Part II

    • The variations that apply to HCIP are shown

    below. The Actuarial Value is shown below

    each of the “steps” and the applicable income

    level by percent FPL is shown above each of

    the steps. The silver plan variation with a 94%

    A/V is shared between the HCIP program and

    FFM.

    43

    73 = 73% A/V Silver Variation

    87 = 87% A/V Silver Variation

    94 = 94% A/V Silver Variation

    Z = Zero Cost Sharing Variation

    L = Limited Cost Sharing Variation

    100%94%

    87%73%

    151-200%

    201-250% FPL

    0-100% FPL

    Zero Cost Sharing Plan (Z2)

    HCIP FFM

    94% Actuarial Value Plan

  • HCIP Variations Part III

    Issuers submit separate benefit summaries

    for plan variations, including HCIP variations.

    The form requirements include:

    • Limited Cost Sharing Plan Variation

    • HCIP Zero Cost Sharing Plan (matches the

    Marketplace plan other than potential

    differences in title)

    • Zero Cost Sharing Plan for Indians up to 300%

    FPL

    • 73% A/V Cost Sharing Variation

    • 87% A/V Cost Sharing Variation

    • 94% A/V Cost Sharing Variation

    73 = 73% A/V Silver Variation

    87 = 87% A/V Silver Variation

    94 = 94% A/V Silver Variation

    Z = Zero Cost Sharing Variation

    L = Limited Cost Sharing Variation

  • Plan Variation Naming Conventions

    Naming Conventions:

    Naming conventions will be required for plan schedules of

    benefits:

    Schedules should be named in the following way:

    Sch- + [-Component Plan ID-] + [Variation ID]

    For example: Sch-15234AR0070003-01

    QHP Advisory Committee45

  • Summary of Plan Variations

    46

    • Zero Cost Sharing Variation: removes all cost sharing for EHB

    services for Indians up to 300% FPL; must have zero cost sharing

    for both in and out of network services.

    • Limited Cost Sharing Variation: removes cost sharing for EHB

    services furnished by Indian Providers for Indians regardless of

    income.

    • Silver Plan Variations: 73%, 87%, 94%. Reduce cost sharing

    and MOOP amounts for individuals up to 250% FPL; are allowed

    to have out of network cost sharing.

    • Plans Used for HCIP:

    • Zero Cost Sharing

    • 94% Silver Variation

  • HCIP 94% A/V ("High-Silver") Cost Sharing

    QHP Advisory Committee47

    • The AID Bulletin includes the

    required HCIP cost-sharing

    options for high-silver 94%

    A/V plans.

    • Additional guidance with

    specific cost-sharing guidance

    is expected prior to May 1st.

    The guidelines are expected

    to align with benefits in the

    templates.

    • The cost-sharing

    requirements are similar to

    last year, with the exception of

    the removal of the emergency

    copay.

  • Rate Filing

    Filing for Actuarial Rate Review:

    • The process will be similar to last year; issuers submit the

    actuarial memorandum and rates will be reviewed for all

    QHPs (except SADPs)

    • Carriers need to ensure that actuaries are available for

    questions and discussions during the QHP review period

    and can respond within 48 hours

    QHP Advisory Committee48

  • Rate Filing

    Issuers must submit all required rate review documentation, including:

    QHP Advisory Committee49

    Part I - Unified Rate

    Review (URR) Template

    Rate Review Template developed by

    HHS. The updated template can be found

    here.

    Part II Consumer

    Justification Narrative-

    Justification information

    received for rate

    increase, if applicable.

    Justification narrative for rate increases

    (that exceed 10% threshold)

    Part III Actuarial

    Memorandum

    Rate filing documentation to support QHP

    rates and all rate increases. A

    supplemental actuarial variation

    spreadsheet form required for AR rate

    reviews can be found in Attachment L.

    http://www.serff.com/documents/plan_management_data_templates_unified.xlsm

  • Rate Filing

    Additional rate filing updates:

    • Rate increases over 10% are required to be filed in HIOS. CMS

    has indicated that rate increases must be filed and approved by

    the state in the HIOS system before the rates can be shown

    correctly on Healthcare.gov.

    • A field to indicate premium allocation towards EHBs has been

    added in the proposed benefits and cost-sharing template. This

    must be completed and must align with information in the

    actuarial memorandum.

    QHP Advisory Committee50

  • Review Tools

    • Issuers will have access to the QHP Application Review Tools this

    year and we recommend issuers take advantage of these tools

    for a smooth certification process

    • These tools are a method for reviewing against specific standards

    such as the 30% threshold for ECPs, annual limitation on cost

    sharing, catastrophic plan requirements, etc.

    • The Data Integrity Tool (DIT) is specifically designed for issuers to

    (1) provide a method for issuers to check that the data contained

    in their templates is in the correct format; and (2) provide issuers

    with feedback immediately and reduce resubmissions

    QHP Advisory Committee51

  • Overview of QHP Application Review Tools

    Select Market Reform

    Standards

    Marketplace-Specific

    Standards

    • Actuarial Value

    • Annual limitation on

    Cost Sharing (i.e. EHB

    out-of-pocket

    maximum)

    • Catastrophic Plan

    Requirements

    • EHB Discriminatory

    Benefit Design

    • Formulary-USP

    Category Class Count

    • Non-discrimination

    Formulary Outlier

    • Non-discrimination

    Formulary Clinical

    Appropriateness

    • Accreditation

    • Cost Sharing Reduction

    Plan Variation

    Requirements

    • Essential Community

    Providers

    • Meaningful Difference

    • Program Attestation

    • Service Area

    • SHOP tying provision

    • Non-discrimination Cost

    Sharing Outlier

    QHP Advisory Committee52

  • Questions?

    QHP Advisory Committee53

  • Attachment Index

    A. 2015 Final Letter to Issuers

    B. SERFF Filing Instructions

    C. Arkansas Health Plan Submission Requirements

    D. QHP Checklist and AR Essential Health Benefits Guidelines

    E. USPSTF preventive health benefits guide

    F. USPSTF Tobacco Cessation Recommendations

    G. Network Adequacy Checklist

    H. State benchmark plans

    • Medical-BCBS Health Advantage POS

    • Mental Health and Substance Use Disorder-QCA FEHBP

    • Pediatric Vision-CHIP (AR Kids B)

    • Pediatric Dental-CHIP (AR Kids B)

    I. Benchmark drug formulary

    QHP Advisory Committee54

    http://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&cad=rja&uact=8&ved=0CCsQFjAA&url=http%3A%2F%2Fwww.cms.gov%2FCCIIO%2FResources%2FRegulations-and-Guidance%2FDownloads%2F2015-final-issuer-letter-3-14-2014.pdf&ei=SlZNU6eVJoiy8AHxpIAo&usg=AFQjCNE8XsYVg5NgN97s2MwB_OXnYCM1wQ&sig2=mpFSFHonxaGxmaXIQbNOsw&bvm=bv.64764171,d.b2Uhttp://www.uspreventiveservicestaskforce.org/uspstf/uspsabrecs.htmhttp://www.uspreventiveservicestaskforce.org/uspstf09/tobacco/tobaccosum2.htmhttp://hbe.arkansas.gov/FFE/Plan/BCBS-POS-SmGrp.pdfhttp://hbe.arkansas.gov/FFE/Plan/QC-Federal-EHBP.pdfhttp://hbe.arkansas.gov/FFE/Plan/PediatricVision.pdfhttp://hbe.arkansas.gov/FFE/Plan/PediatricDental.pdf

  • Attachment Index

    …continued

    J. URRT and Instructions

    K. Uniform Certificate of Authority Application “UCAA”.

    L. AR Actuarial Memorandum Form

    M. Uniform Modification Recertification Form

    N. AID QHP Bulletin 9-2014

    QHP Advisory Committee55

    http://www.serff.com/documents/plan_management_data_templates_unified.xlsmhttp://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&cad=rja&uact=8&ved=0CCsQFjAA&url=http://www.serff.com/documents/plan_management_data_templates_help_partI_unified_rate_review.pdf&ei=R09NU9LbE7O38gHCg4GwDQ&usg=AFQjCNE4nJLYZucE8Ozn3fVeVpcaeDAi0Q&sig2=oiVIIFqoOr8dq_N7T4MGQw&bvm=bv.64764171,d.b2Uhttp://www.naic.org/industry_ucaa.htmhttp://insurance.arkansas.gov/legal/Bulletins/9-2014.pdf

  • 56

    Public Consulting Group, Inc.

    148 State Street, Tenth Floor, Boston, Massachusetts 02109

    (617) 426-2026, www.publicconsultinggroup.com