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

STATE OF CONNECTICUT INSURANCE DEPARTMENT BULLETIN HC-90-14 MARCH 10,2014 TO: ALL INSURANCE COMPANIES, FRATERNAL BENEFIT SOCIETIES, HOSPITAL SERVICE CORPORATIONS, MEDICAL SERVICE CORPORATIONS AJ~D 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 (ACA) These requirements pertain to filings for policies sold through the Connecticut Health Insurance Exchange, doing business as Access Health CT (AHCT), as well as to filings for policies sold outside of the exchange. The requirements are for plan years beginning January 1,2015. Essential Health Benefit Plans The State has selected the benchmark plan to set the essential health benefits for 2014 and 2015. The listing of benefits 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 cm is requiring that complete contracts be filed for the initial filing of all fully ACA compliant individual and small group policies or certificates issued on or after January 1, 2014 both in and out of ABCT. Subsequent changes to approved policies or certificates may be filed as endorsements or amendatory riders. Where appropriate, a red-lined version should be part of the filing submission. The cover letter should clearly indicate the types of changes being made. To ensure forms are approved prior to being filed with AHCT, CID requests that filings ofpolicies, certificates, amendments or schedules of benefits for plans offered by carriers participating in AHCT be made no later than April 30 in any calendar year. The cover letter should clearly indicate which plans are to be offered on the exchange. Such carriers are no longer required to make a separate filing for the plans offered off exchange. Carriers that participate in the exchange must make all exchange plans available outside of the exchange at the same premium rate, benefits, network and administrative expense levels in accordance with section 2702 of the ACA. These plans are not required to be actively marketed, but must be made available if requested. Submissions ofpolicies, certificates, amendments or schedules ofbenefits to be offered by carriers that do not participate in AHCT may be filed at a later date allowing no less than 3 months prior to the date marketing of the plan will begin. Any plans that are not approved prior to open enrollment are subject www.ct.gov/cid P.O. Box 816 • Hartford, CT 06142-0816 An Equal Opportunity Employer to a continual open enrollment period. Although priority may be provided for exchange filings to meet the required deadlines, filings will otherwise be reviewed in the order received. All form filings including schedules of benefits may be filed with variable language for plans offered both inside and outside of the exchange. A detailed explanation of variability must be included as part ofthe filing submission. Since the Uniform Rate Review Template (URRT) included with the rate filing must detail specific plan options and provide the demonstration of adherence to the appropriate actuarial values, the form filing no longer needs to provide any certification or demonstration of compliance with the various metal tiers. The form filing should, however, contain a cross reference to the HIOS identifier included in the URRT, so the form filing can be matched up to the rate filings. Rate Filings Rate filings should be made in accordance with Bulletin HC-81-14 and HC-88 if applicable. For carriers that are participating in AHCT, the rate filings should be submitted no later than April 30 of each calendar year. Generally, policy form and rate filings are not approved until the review of both submissions is complete. Conditional approval may be provided for one subject to the approval of both submissions. In no circumstance can an unapproved rate or plan be offered during an open enrollment period. Connecticut has reported to the Centers for Medicare and Medicaid Services that the state will conform to all requirements of 45 CFR §147.102 regarding allowable rating factors with the exception of geographic rating areas. Connecticut requested and was approved to establish 8 rating areas by county for both the individual and small group markets. Age factors should be in accordance with the uniform age rating curve established by HHS. Gender rating will no longer be permitted. Rating for family must be in conformance with the final rule cited above. The family rate is the sum of the rates for policyholder/employee, spouse, children aged 21 or older, and the rates for the three oldest children under age 21. In addition, for small employer rating, industry and group size will no longer be permitted case characteristics. Tobacco use is permissible in the individual market and may be applied at a plan level. Premiums in the individual market may reflect differentials in network costs if a carrier offers plans with different networks. Similarly, differentials in administrative costs other than exchange user fees may be reflected at a plan level in the individual market. Since tobacco use, administrative expense differentials and network cost differentials are not allowed case characteristics under Conn. Gen. Statute §38a-567, these rating factors are not applicable in the small employer market. Questions Please contact the Insurance Department Life and Health Division at cid.lh@ ct.gov with any questions. Thomas B. Leonardi Insurance Commissioner 2014-2015 Essential Health Benefits in Connecticut OUTPATIENT SERVICES LIMIT 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/year EMERGENCY SERVICES LIMIT Emergency Room Emergency Transportation/Ambulance per state mandate* Walk-in/Urgent Care Centers HOSPITALIZATION LIMIT 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/SUBSTANCE USE DISORDER SERVICES LIMIT Mental/Nervous & Substance Abuse services Same as any other illness REHABILITATIVE/HABILITATIVE SERVICES & DEVICES LIMIT 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: 1/every 24 months Surgically Implanted Hearing Devices Wigs per state mandate* Birth to Three per state mandate* Prescription Drugs LABORATORY AND IMAGING SERVICES LIMIT Laboratory Services Non-advanced radiology Advanced imaging (includes MRI, PET, CAT, nuclear cardiology) PREVENTIVE & WELLNESS SERVICES & CHRONIC DISEASES LIMIT Adult Physical Exam Ages 22-49 every 1-3 years, age 50 1/year as recommended by physician Preventive Services 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 1/year Screening for gestational diabetes In pregnant women between 24 & 28 weeks of gestation and at first prenatal visit for high risk of diabetes Human Papillomavirus Testing Women aged 30+; 1/every 3 years Counseling for Sexually Transmitted Infections For women 1/year Counseling and Screening for HIV For women 1/year Contraceptive Methods and Counseling For women Breastfeeding Support, Supplies and Counseling For women Screening/Counseling for interpersonal & domestic violence For women 1/year Preventive Lab Services Complete blood count & urinalysis 1/year Baseline Routine Mammography 1 between ages 35-39, 1/year age 40+ Adult Routine Vision Exam 1/year Routine Cancer Screenings In accordance with national guidelines Blood lead screening & risk assessment per state mandate* Bone density 1/every 23 months Pediatric Hearing Screening Under age 19 as part of physical OTHER SERVICES LIMIT Craniofacial Disorders per state mandate* Oral Surgery for Treatment of Tumors, Cysts, Injuries, Treatments of Fractures Including TMJ & 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 expenses 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 mandate* Genetic testing For members who have or are suspected of having a clinical genetic disorder Specialized formula per state mandate* Nutritional counseling 2 visits/year Enteral or intravenous nutritional therapy Modified food products for inherited metabolic disease per state mandate* PEDIATRIC VISION CARE LIMIT 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 LIMIT 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 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 exams 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, inlays and onlays Recement bridges, Crowns, inlays and 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 (* Any dollar limits in state mandates no longer apply because PPACA prohibits annual dollar limits)