2023 Form and Rate Filing Requirements for Stand-Alone Dental Plans ______________________________________

- 1 - STATE OF MICHIGAN DEPARTMENT OF INSURANCE AND FINANCIAL SERVICES Bulletin 2022-11-INS In the matter of: 2023 Form and Rate Filing Requirements for Stand-Alone Dental Plans ______________________________________/ Issued and entered this 22nd day of March 2022 by Anita G. Fox Director SECTION 1: CERTIFICATION AND RECERTIFICATION FILING REQUIREMENTS FOR STAND-ALONE DENTAL PLANS (SADPs) ON- AND OFF-MARKETPLACE General Information DIFS will continue to perform Plan Management functions for Plan Year 2023 (PY23). Plan Management functions are part of DIFS’ regulatory role for products offered on- and off-Marketplace. Issuers will work directly with DIFS to submit all Stand-Alone Dental Plan (SADP) application data in accordance with federal and state guidelines. SERFF will be used by issuers to transmit information to DIFS, and DIFS will use SERFF to transmit information to the Centers for Medicare & Medicaid Services (CMS). Issuers will again be required by CMS to be registered for the CCIIO Plan Management Community. This platform will be utilized to issue all notices, including corrections and notification notices. New Plans and Recertification of SADPs For PY23, DIFS’ process for certification and recertification of a SADP is consistent with the process used in prior plan years. Issuers submitting previously approved plans for recertification will be required to submit much of the same information as for prior plan years. Issuers submitting plans for certification for the first time should review the pertinent federal and state guidance. The omission of any federal or state requirement from this Bulletin should not be construed to mean that compliance with those requirements is not necessary. For additional guidance, issuers are urged to refer to the 2023 Draft Letter to Issuers (Draft Letter). - 2 - Timeline for SADP Submissions Activity Dates SADP Application Submission and Review Process Michigan Filing Deadline 5/11/22 DIFS’ 1st transfer of plan data to CMS; Transparency in Coverage and Plan ID Crosswalk Templates submission deadline 6/15/22 CMS reviews and posts initial SADP application results in PM Community 6/16/22 to 7/15/22 DIFS’ 2nd transfer of plan data to CMS 7/20/22 Final Review DIFS’ final transfer of plan data to CMS 8/17/22 CMS reviews and posts final SADP applications results in PM Community 8/18/22 to 9/12/22 SADP Agreement/ Final Certification CMS sends Certification Notices 9/13/22 Limited data correction window and last date to withdraw plans 9/15/22 to 9/16/22 CMS posts SADP agreements; Issuers send signed agreements; States confirm final SADP recommendations 10/4/22 to 10/5/22 Open Enrollment 11/1/22 to 12/15/22 - 3 - PY23 SADP Filing Requirements A complete submission includes the SERFF Form/Rate Filing and Binder, with all required validated templates and associated items, as outlined in Exhibit 1. Issuers are required to run the PY23 QHP Application Review Tools including the Data Integrity Tool for the initial and any subsequent template submissions. All template revisions made during DIFS’ review must be uploaded to the same locations as originally filed i.e., filing, Binder, or both. See Exhibit 1. Note: only one Business Rules Template and Transparency in Coverage Template needs to be completed. Each template must include both individual and small group plans and be submitted in the SERFF Binder, regardless of Marketplace participation. PY23 SADP Checklist Requirements Checklists that must be completed and filed as shown in Exhibit 1 are: • Checklist for Individual and Small Group SADP – Forms (FIS 2305) • Checklist for Individual and Small Group SADP – Rates (FIS 2304); and • Checklist for Individual and Small Group SADP – Network Adequacy (FIS 2314) Revisions to Previously Approved SADP Forms: Red-Lined Versions Issuers revising previously approved SADP forms must provide red-lined versions, as well as clean versions. The red-lined and clean versions should both be filed under the Forms Schedule tab of the SERFF Form/Rate filing under the same document number. Note: forms not being revised must still be submitted. Forms must be SADP-specific. Forms must not include variable bracketed fields for use interchangeably with non-SADP forms. File Naming Certain items under the Supporting Documentation tab in the Form/Rate filing and/or the Binder filing must adhere to a standard naming convention as follows: IssuerName_MIFormDescription_Version#. The purpose of adherence to a standard naming convention is to have the ability to track new versions as they are updated. It is important to start with Version 1 and use the same issuer name and form description in the file name each time. In addition, all review tools must be run each time a template is revised. - 4 - Items that are required to have a standard naming convention are: • DIFS SADP Forms Checklist; • DIFS SADP Rates Checklist; • DIFS SADP Network Adequacy Checklist; • Michigan Network Data Template; • Rates Table Template; • Actuarial Memorandum; • MI Uniform Modification Justification Form; • Justifications and Attestations; and • Any document that is amended from its original version that is not automatically versioned through SERFF SERFF Filings All federal and Michigan-specific templates must be filed in Excel formats. Do not submit templates in PDF. Additionally, do not submit templates under the Supporting Documentation tab of the Binder, except for the Plan ID Crosswalk and Michigan Network Data Templates. Under Section 234 of the Michigan Insurance Code, MCL 500.234, the Director has the discretion to designate certain records to be nonpublic. Accordingly, issuers have the option to mark their filings as confidential upon submission. The filings will remain confidential until one day after the submission deadline at which time DIFS will make the filings public. Guaranteed Renewability Although SADPs are considered excepted benefits, and therefore not subject to federal guaranteed renewability requirements, CMS will apply the Plan ID Crosswalk Template to SADPs in order to support automatic re-enrollment for plans offered during PY23. Plan Withdrawal Plans may be withdrawn in accordance with the process in the Draft Letter. The final opportunity to withdraw plans will be during the plan confirmation process. Issuers opting to withdraw must submit the following in both the SERFF Form/Rate filing and Binder: 1. A completed CMS Plan Withdrawal form for plans offered either on-Marketplace or on- and off- Marketplace or a list of plans to be withdrawn for those offered off-Marketplace only; 2. A letter to the DIFS Director outlining the issuer’s intent and how it will comply with both state and federal guaranteed renewability and availability requirements; and 3. A copy of the proposed letter that will be sent to enrollees/consumers outlining the issuer’s intent and detailing all options available to the enrollee/consumer, including seeking coverage from a different issuer. This letter must not be sent to enrollees/consumers until approved by DIFS. Note: Do not make changes to templates. - 5 - Uniform Modification and Plan ID Crosswalk DIFS requires that the MI Uniform Modification Justification Form (FIS 2316) and Plan ID Crosswalk Template be submitted as shown on Exhibit 1. CMS requires that the Plan ID Crosswalk Template, together with authorization from DIFS, be submitted for SADPs in the individual market. The deadline for this submission is June 15, 2022. Licensure and Good Standing DIFS will review the licensure status of all issuers filing SADPs on- and/or off-Marketplace. Annual Limit on Cost-Sharing The PY23 out-of-pocket maximums for Marketplace-certified SADPs are $375 for one covered child and $750 for two or more covered children. Service Area DIFS does not permit service areas with partial counties for SADPs. Prior to DIFS’ first transfer of plan management data to CMS via SERFF on June 15, 2022, issuers should inform DIFS of any service area data change. After DIFS’ final transfer August 17, 2022, service area data may only be changed with DIFS’ approval and submission of a Data Change Request (DCR) to CMS, even if the change is directed by DIFS or CMS. The DCR must include an explanation and justification for the change(s), evidence of state approval, and the DCR Supplement. As CMS no longer requires the signed State Authorization of QHP Data Change Request form for Michigan issuers, state approval may be obtained through email and attached to the DCR in the PM Community. Examples of service area data changes: 1. Revising Service Area Template to: a. change any service area name or ID b. add or remove a service area c. add or remove a county/ies to a service area 2. Revising the Plans and Benefits Template (PBT) to: a. Change a Service Area ID b. Add or remove a Service Area ID 3. Any change to the list of counties associated with a particular plan Service Area Data Changes must be reflected on the Michigan Network Data Template, as applicable. For more information, see CMS’ data change windows page and the Data Change Request Instructions and Supporting Documents. - 6 - Network Adequacy New for PY23, DIFS will resume collecting the National Provider Identifier Number (NPI) on the Michigan Network Data Template. The network adequacy requirements, standards, and approach for review are unchanged from PY22. The Michigan Network Adequacy Guidance reflects network sufficiency requirements and standards. See also Network Data Template Instructions and Checklist for Individual and Small Group Stand-Alone Dental Plans - Network Adequacy (FIS 2314). Essential Community Providers The ECP requirements have changed to increase the ECP threshold from 20 to 35 percent of available ECPs in each plans service area. DIFS requires issuers to submit the results of the ECP Tool in the SERFF Binder under the Supporting Documentation tab. See CMS’ web page QHP Certification Application Materials for Application Instructions, ECP and Network Adequacy, and Review Tools. SECTION 2: CONTRACT REQUIREMENTS Readability Submitted forms must comply with the following readability standards found under MCL 500.2236(3): 1. Each form entered under the SERFF Forms Schedule tab shall include the form’s readability score. 2. The readability score must be based on the Microsoft Word Flesch Reading Ease test and have a score of 45 or higher. Forms with a Microsoft Word Flesch Reading Ease score lower than 45 will not be approved by DIFS or transferred to CMS for certification. 3. Dental policies and certificates with more than 3,000 words printed on not more than three pages, or more than three pages of text regardless of the number of words, shall contain a table of contents. (This requirement does not apply to riders or endorsements.) 4. Be printed in font size not less than 10 point. Dependent Coverage Essential Health Benefit (EHB) coverage for pediatric services is required for enrollees until at least the end of the month in which the enrollee turns 19 years of age. Internal Formal Grievance and External Review Procedures SADPs offered by commercial issuers must offer a formal grievance procedure pursuant to MCL 500.2213 and adhere to the external review process under the Patient’s Right to Independent Review Act (PRIRA), PA 251 of 2000 (MCL 550.1901 to 550.1929). These procedures must be part of the policy and submitted for - 7 - approval with the SADP filing. If the issuer has DIFS-approved grievance and external review procedures, these must be filed under the Supporting Documentation tab of the SERFF Form/Rate filing. Complaint and Grievance Policy and Procedures must include information on DIFS’ Health Care Appeals – Request for External Review (FIS 0018) and contact information for DIFS including fax number, email address, and mailing address. Data Corrections After the Final Application Submission Deadline Issuers must request data correction changes and receive explicit direction and approval from CMS and DIFS. • Data change requests to CMS must be initiated in the PM Community, include an explanation and justification for each requested change, and evidence of DIFS’ approval. Issuers should work with DIFS to make any change • URL changes must be approved by DIFS (CMS authorization is not required) before making changes in the Supplemental Submission Module • Post-Certification Assessment(s) received from CMS require issuers to communicate to DIFS how errors or corrections were addressed Once SERFF Binders are closed, DIFS will only reopen the Binder for issuers to make data changes approved by CMS. Issuers must provide DIFS with evidence of CMS’ approval for each data change. Marketplace Certification All SADPs intended to be EHB-compliant must be Marketplace-certified, even if the plan will not be marketed on-Marketplace. The only SADPs that can be considered to provide EHB must have followed the certification process and have been approved and recommended for certification to CMS. SECTION 3: RATING DIFS will not accept more than one filing per market (individual or small group). Issuers that offer various types of offerings, such as on- and off-Marketplace or pediatric and adult, must submit all filings in the same Form/Rate filing. SADP issuers may submit more than one actuarial memorandum or format their actuarial memorandum to adequately address their entire filing. All SADP issuers must complete a separate Rates Table Template for individual and small group markets. For all plans other than the FF-SHOP plans, rates should be identified as either “guaranteed” or “estimated” in the Plans and Benefits Template and can either be individually age rated or family tier rated. For FF-SHOP plans, rates must be “guaranteed” and individually age rated. Per the Draft Notice of Benefit and Payment Parameters for 2023, issuers may offer pediatric dental EHBs at any actuarial value (AV). SADP issuers must, however, certify the AV of each SADP coverage. Exhibit 1 PY23 Stand-Alone Dental Filing Requirements Federal Required Templates Requires Submission via SERFF SERFF Location Essential Community Providers/Network Adequacy Yes Binder only Plans and Benefits Yes Binder only Service Area Yes Binder only Network ID Yes Binder only Rates Table Yes Form/Rate Filing & Binder Business Rules – One per Issuer, include both Individual and Small Group on the same template Yes Binder only Plan ID Crosswalk (Individual only)* Yes Binder only Transparency in Coverage – One per Issuer, include both Individual and Small Group on the same template Yes Binder only Michigan Required Supporting Documentation Michigan Network Data Template* Yes Binder only Checklist for Individual and Small Group Stand-Alone Dental Plans – Forms Yes Form/Rate Filing & Binder Checklist for Individual and Small Group Stand-Alone Dental Plans – Rates Yes Form/Rate Filing & Binder Checklist for Individual and Small Group Stand-Alone Dental Plans – Network Adequacy Yes Binder only Company Actuarial Memorandum Yes Form/Rate Filing & Binder MI Uniform Modification Justification Form Yes Form/Rate Filing & Binder Stand Alone Dental Plans – Description of EHB Yes Binder only Filing Deadline 5/11/2022 NOTE: All required templates must be completed and, if applicable, validated before uploading to SERFF. Use of the PY23 QHP Application Review Tools including the Data Integrity Tool is required for the initial template submission and any subsequent submission. * Except for the Plan ID Crosswalk and MI Network Data Templates, do not submit templates in Supporting Documentation in SERFF.