Qualified Health Plan Requirements

May 2, 2013 Bulletin 198 QUALIFIED HEALTH PLAN REQUIREMENTS This Bulletin is directed to all insurers writing accident and health insurance policies, as defined by IC 27-8-28-9, in the non grandfathered individual and small group market; health maintenance organizations, as defined by IC 27-13-1-19; risk retention groups, as defined by IC 27-7-10-11; reciprocals, as provided by IC 27-6-6-1; fratemal benefit societies, as provided by IC 27-11-1-0.3; rating organizations, associations, and all other entities making accident and health product filings subject to the Patient Protection and Affordable Care Act (ACA). The purpose of this Bulletin is to provide guidance on Indiana's rnles regarding Essential Health Benefits (EHBs). Substitution of EHBs 45 CFR §156.115(b) permits a State to limit or prohibit EHB substitutions, The Depmiment hereby prohibits EHB substitutions for plan years effective on or after January I, 2014. The Depmiment will reassess this rule for subsequent plan years. However, this EHB substitution prohibition is not applicable to prescription drug benefits coverage. 45 CFR §156.122 requires a plan to cover at least the greater of (i) one drug in every United States Pharmacopeia (USP) category and class; or (ii) the same number ofprescription drugs in each category and class as the EHB-benchmm·k plan. By meeting either ofthe prescription drug benefit requirements, the health plan satisfies this EHB provision, and is not considered a prohibited substitution. Permissible Benefit Limits Generally, limits on the dollar amount of benefits are prohibited by ACA. However, the three benefits listed below, as part ofthe State's EHB benchmark plan, will maintain their dollm limit quantity and do not have to be converted to actuarially equivalent treatment or service limits as paii of 45 CFR §147.126. Health plans are pennitted to maintain these limits as pmi of their plan's benefit design and satisfy EHB requirements. Benefit Limit Quantity Dental Services for Accidental Injury and Other Related Medical Services $3,000 Human Organ and Tissue Transplant Services- Transportation and Lodging $10,000 Human Organ and Tissue Transplant Services- Unrelated Donor Search $30,000 Questions regarding this Bulletin should be directed to Erin Mathies, Deputy Commissioner of Insurance Policy, at (317) 234-7732 and emathies@idoi.in.gov or compliance@idoi.in. gov. ertson, Insurance Commissioner 2