Filing Requirements For Individual and Small Employer Group Health Insurance Policies Subject to The Affordable Care Act (ACA)

BULLETIN HC-90 NOVEMBER 1,2012 TO: ALL INSURANCE COMPANIES, FRATERNAL BENEFIT SOCIETIES, HOSPITAL SERVICE CORPORATIONS, MEDICAL SERVICE CORPORATIONS AND HEALTH CARE CENTERS THAT DELIVER OR ISSUE INDIVIDUAL AND SMALL EMPLOYER GROUP HEALTH INSURANCE POLICIES IN CONNECTICUT RE: FILING REQUIREMENTS FOR INDIVIDUAL AND SMALL EMPLOYER GROUP HEALTH INSURANCE POLICIES SUBJECT TO THE AFFORDABLE CARE ACT The Connecticut Insurance Department (CID) anticipates a large volume of filings to be made for health insurance policies subject to the requirements of the Affordable Care Act (ACA) effective January 1,2014. These requirements pertain to filings for the Connecticut Health Insurance Exchange (HIX) as well as policies to be sold in the commercial market. All policy forms are subject to prior approval, but CID will provide some flexibility regarding the timing of health filings subject to this bulletin to facilitate the process and meet the needs of HIX. Essential Health Benefit Plans The State has selected the benchmark plan to set the essential health benefits for 2014 and 2015. The listing of coverages is provided as an appendix to this bulletin. All plans in the individual and small employer group markets both inside and outside of the exchange are required to provide coverage for the essential health benefits. A copy of the selected benchmark plan can be found on the Department website. Form Filings CID is requiring that complete contracts be filed for all individual and small group policies or certificates subject to this bulletin to be issued on or after January 1,2014 both in and out of HIX. To facilitate the plan management functions of HIX, a separate submission should be made for forms to be offered in the exchange, and the form number must include the prefix "HIX" for easy identification. The forms for the exchange must not contain any variable language. To ensure forms are approved prior to being filed with HIX, CID requests that filings of policies and certificates for plans to be offered in HIX be made in November 2012. Filings will be reviewed in the order received. Submissions of policies and certificates to be offered outside of HIX may be filed at a later date allowing no less than 3 months prior to the date marketing of the product will begin. If a form is to be issued outside of HIX that was submitted or approved for HIX, a red-lined version of the HIX form should be filed with a reference to the HIX filing including the state tracking number if available. The same form number excluding the prefix "HIX" should be used. Variable language is acceptable in the form filings for offerings outside of HIX provided all variability is thoroughly explained. Schedules of benefits can no longer be filed with variable language for products offered inside or outside of the exchange. Separate schedules of benefits must be filed for each unique offering and be assigned a unique form number that incorporates a prefix that identifies the metal tier. For uniformity, the prefixes should be B, S, G, and P for bronze, silver, gold and platinum levels. The specific cost sharing for that offering must be provided along with the Actuarial Value. The filing should include a certification by a member of the American Academy of Actuaries regarding the calculation of the actuarial values of the metal levels. Since the Center for Consumer Information and Insurance Oversight (CCIIO) has not yet published their calculator for determining the actuarial value of the essential health benefits, policy forms and certificates may be filed without the schedule of benefits so as not to delay the review and approval of these forms. The schedules of benefits may be filed at a later date with a target date not later than January, 2013. Rate Filings Rate filings should be made in accordance with Bulletin HC-81-2 and HC-88 if applicable. Generally, policy form and rate filings are not approved until both filings are complete. For the health insurance policies subject to this bulletin, CID will approve the form filings in advance of required rate filings for products to be made available on January 1,2014. In addition once a rate filing is submitted to CID, carriers may submit corresponding rates to the Exchange for set up and testing with notice that such rates are subject to approval by CID. In no circumstance can an unapproved rate be offered during an open enrollment period. QUESTIONS Please contact the Insurance Department Life and Health Division at cid.1h@ ct.gov with any questions. L~4..-t. Thomas B. Leonardi Insurance Commissioner 2014-2015 Essential Health Benefits in Connecticut SERVICE I LIMIT I Outpatient Services pCP Office Visits (non-preventive) Specialist Office Visits Outpatient Surgery Physician/Surgical Services Outpatient Facility Fee (e.g., Ambulatory Surgery Center) Home Health Care Services 100 visits/yea r Emergency Services Emergency Room Emergency Transportation/Ambulance per state mandate' Walk-in/Urgent Care Centers Hospitalization Inpatient Hospital (Facility & Provider Services) Skilled Nursing/Rehabilitation Facility 90 days/year Hospice life expectancy of 6 months or less Residential Treatment Facilities Mental Health and Substance Use Disorder Services Mental/Nervous and Substance Abuse Services Same as any other illness Rehabilitative and Habilitatlve Services and Devices Outpatient Rehabilitation Services (PT/OT/ST) 40 visits(combined)/year Cardiac Rehabilitation Chiropractic Visits 20 visits/year Durable Medical Equipment Prosthetics Ostomy Appliances and Supplies per state mandate' Diabetic Equipment and Supplies Wound care supplies per state mandate' Disposable Medical Supplies Hearing Aids for children under 12; l/every 24 months Surgically Implanted Hearing Devices Wigs per state mandate' Birth to Three per state mandate' Prescription Drugs Laboratory and Imaging Services Laboratory services Non-advanced radiology Advanced imaging (includes MRI, PET, CAT, nuclear cardiology) Preventive and Wellness Services and Chronic Disease ages 22-49 every 1-3 years and age SOl/year as recommended by physician Preventive Services Adult Physical Exam Based USPSTF A and B Recommendations Prenatal and Postnatal Care Infant/Pediatric Physical Exam In accordance with national guidelines Routine Immunizations In accordance with national guidelines Routine Gynecological Exam l/year Screening for gestational diabetes in pregnant women between 24 and 28 weeks of gestation and at first prenatal visit for high risk of diabetes Women aged 30+; l/every 3 years Counseling for Sexually Transmitted Infections Human Papillomavirus Testing For women l/year Counseling and Screening for HIV For women l/year Contraceptive Methods and Counseling For women Breastfeeding Support, Supplies and Counseling For women Screening and Counseling for Interpersonal and Domestic For women l/year Violence Preventive Lab Services Complete blood count & urinalysis once/year Baseline Routine Mammography 1 between ages 35-39 ; l/year age 40+ Adult Routine Vision Exam l/year Routine Cancer Screenings In accordance with national guidelines *Since PPACA prohibits annual dollar limits, any dollar limits in state mandates no longer apply 1 of 3 2014-2015 Essential Health Benefits in Connecticut SERVICE LIMIT Blood lead screening and risk assessment per state mandate" Bone density 1/every 23 months Pediatric Hearing Screening under age 19 as part of physical Other Services Craniofacial Disorders per state mandate" Oral Surgery for Treatment of Tumors, Cysts, Injuries, Treatments of Fractures Including TMJ and TMD TMJ for demonstrable joint disease only Dental Anesthesia per state mandate" Reconstructive Surgery To correct serious disfigurement or deformity resulting from illness or injury, surgical removal of tumor, or treatment of leukemia; For correction of congenital anomaly restoring physical or mechanical function Maternity Mastectomy per state mandate" Breast Reconstructive Surgery after Mastectomy Including on Non-diseased Breast to Produce a Symmetrical Appearance per state mandate" Breast prosthetics per state mandate" Breast Implant Removal per state mandate" Autism Coverage per state mandate" Clinical Trials per state mandate" Solid Organ and Bone Marrow Transplants Medically Necessary Donor Expenses and Tests Transportation, Lodging and Meal Expense for Transplants up to $10,000 per episode (initial evaluation until sooner of discharge or cleared to return home) Lyme Disease Treatment per state mandate" Allergy Testing Up to $315 every 2 years Diabetes Education per state mandate" Sterilization Casts and Dressings Renal Dialysis Sleep Studies 1 complete study/lifetime Pain Management per state mandate" Neuropsychological Testing per state mandate" Accidental Ingestion of a Controlled Drug per state mandate" Diseases and Abnormalities of the Eye Annual retina exams for members with glaucoma or diabetic retinopathy Corneal Pachymetry 1 complete test/lifetime Infertility per state ma ndate" Genetic Testing For members who have or are suspected of having a clinical genetic disorder Specialized Formula per state mandate" Nutritional Counseling 2 Visits/yea r Enteral or Intravenous Nutritional Therapy Modified Food Products for Inherited Metabolic Disease per state mandate" Pediatric Vision Care Routine Eye Exam 1 exam/year Lenses 1 pair/year Frames 1 frame/year Contact lenses 1 fitting and set of lenses/year Pediatric Oral Care Exams 1 every 6 months Bitewings 1 time/year Other X-rays Sealants On premolar and molar teeth Fluoride treatments including topical therapeutic fluoride varnish application For clients with moderate to high risk of dental decay *Since PPACA prohibits annual dollar limits, any dollar limits in state mandates no longer apply 2 of 3 2014-2015 Essential Health Benefits in Connecticut SERVICE LIMIT Access for Baby Care Early Dental Examination and Fluoride Varnish where an oral health screen, oral health education and fluoride varnish are applied to children's teeth during well child examinations up to 4 years of age Dental Orthodontia (under age of 19) Replacement Retainer Limited to one time per lifetime Amalgam and Composite Restorations (Fillings) Fixed Prosthodontics: Crowns, In lays and Onlays Recement Bridges, Crowns Inlays & Space Maintainers Removable Prosthodontics: Full or Partial Dentures Repair, Relining and Rebasing Dentures Intermediate Endodontic Services Major Endodontic Services: Root Canal Treatment, Retreatment of root canal therapy; apicoectomy; apexification Oral Surgery: Surgical Extraction, including impacted teeth Non-surgical Extraction Periodontal Surgery and Services Space Maintainers General Anesthesia and Sedation Miscellaneous Adjunctive Procedures *Since PPACA prohibits annual dollar limits, any dollar limits in state mandates no longer apply 3 of 3