2017 Form and Rate Filing Requirements for Stand-Alone Dental Plans

STATE OF MICHIGAN DEPARTMENT OF INSURANCE AND FINANCIAL SERVICES Bulletin 2016-09-1NS In the matter of 2017 Form and Rate Filing Requirements for Stand-Alone Dental Plans / Issued and entered this // day of March 2016 by Patrick M. McPharlin Director Information in this bulletin is subject to change as federal guidance is finalized. Issuers are strongly urged to routinely check the Department of Insurance and Financial Services (DIFS) website and the System for Electronic Rate and Form Filing (SERFF) State Messages for updates. SECTION 1: CERTIFICATION AND RECERTIFICATION FILING REQUIREMENTS FOR STAND-ALONE DENTAL PLANS (SADPs) ON AND OFF THE MARKETPLACE General Information and Timelines DIFS will continue to perform Plan Management functions for the 2017 plan year. Plan Management functions are part of DIFS' regulatory role for products offered on and off the Marketplace. Issuers will work directly with DIFS to submit all Stand- Alone Dental Plans (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). New Plans and Recertification of SADPs For the 2017 plan year, DIFS' process for certification and recertification of a SADP is consistent with the process used in prior plan years. Plans applying for recertification will be required to submit much of the same information as in prior years. Plans seeking certification for the first time should review the pertinent federal and state guidance. The omission of any particular federal or state requirement from this bulletin should not be construed to mean that compliance with those requirements is not necessary. For guidance, issuers are urged to refer to the 2017 Letter to Issuers in the Federally-Facilitated Marketplace ("Letter"). lans seeking certification for the first time should review the pertinent federal and state guidance. The omission of any particular federal or state requirement from this bulletin should not be construed to mean that compliance with those requirements is not necessary. For guidance, issuers are urged to refer to the 2017 Letter to Issuers in the Federally-Facilitated Marketplace ("Letter"). Timeline for SADP Submissions SADP submissions will follow this timeline. This timeline differs from the Medical Plans Timeline. Activity Dates SADP Michigan Filing Deadline 4/11/2016 Application Submission and DIFS 1st Transfer of Plan Data to CMS 5/11/2016 Review Process CMS Reviews Plan Data; Sends 5/12/2016 to Correction Notices 6/16/2016 DIFS 2nd Transfer of Plan Data to 6/30/2016 CMS CMS Reviews Plan Data; Sends 2nd 7/01/2016 to Set of Correction Notices 8/09/2016 DIFS Final Transfer to CMS 8/23/2016 Final CMS Review of Revised QHP 8/24/2016 to Application Submissions Received as 9/09/2016 of August 23 SADP Certification Notices Sent to Issuers; 9/15/2016 to Agreements Signed by Issuers; Agreement/Final 10/04/2016 Validation Confirming Final Plan List Certification Open Enrollment 11/01/2016 to 1/31/2017 *AII dates based on CMS functions are subject to change 2017 SADP Filing Requirements SADP issuers must submit the required Templates and run the 2017 QHP Application Tools and Data Integrity Tool as outlined in Exhibit 1. Please note: onlyone Business Rules Template needs to be completed. The one template will include both individual and small group plans. However, the Business Rules Template must be submitted in both the individual and small group SERFF filings and binders. Stand-Alone Dental Checklist Requirements (Revised for 2017) For the 2017 filing year, DIFSdeveloped SADP-specific forms, rates, and network adequacy checklists iness Rules Template needs to be completed. The one template will include both individual and small group plans. However, the Business Rules Template must be submitted in both the individual and small group SERFF filings and binders. Stand-Alone Dental Checklist Requirements (Revised for 2017) For the 2017 filing year, DIFSdeveloped SADP-specific forms, rates, and network adequacy checklists. Each SADPfiling must include completed forms FIS 2304 (SADP Rates Checklist), FIS2305 (SADP Forms Checklist), and FIS2314 (SADP Network Adequacy Checklist) and be filed as shown in Exhibit 1. Revisions to Previously-Approved SADPs: Red-Lined Versions Issuers making revisions to previously-approved SADP forms must provide red- lined versions. Red-lined versions should be filed under the Forms Schedule tab of the SERFF Rate/Form filing. File Naming Certain items under the Supporting Documentation tab in the Rate/Form filing and/or the Binder filing must adhere to a standard naming convention as follows: lssuerName_MIFormDescription_Version#. The purpose of this naming convention is to track new versions as they are updated on the system. It is important to start with Version 1 and use the same Issuer Name and Form Description in the file name each time. Items that are required to have a standard naming convention are: DIFS SADP Forms Checklist; DIFS SADP Rates Checklist; DIFS SADP Network Adequacy Checklist; Ml Network Data Template; Rates Table Template; Actuarial Memorandum; Justifications and Attestations; Summary of Benefits and Coverage; Any document that is amended from its original version that is not automatically versioned through SERFF. SERFF Filings All filings submitted via SERFF (on and/or off the Marketplace) are considered to be public immediately upon being filed in SERFF. All federal and Michigan-specific templates must be filed in the Rate/Form filing and in the Binder in Excel (xml and xlsm) formats. Do not submit templates in PDF amended from its original version that is not automatically versioned through SERFF. SERFF Filings All filings submitted via SERFF (on and/or off the Marketplace) are considered to be public immediately upon being filed in SERFF. All federal and Michigan-specific templates must be filed in the Rate/Form filing and in the Binder in Excel (xml and xlsm) formats. Do not submit templates in PDF. Product Withdrawal and Uniform Modification SADPs are subject to product withdrawal/uniform modification rules. For the 2017 filing year, DIFS requires that the Michigan Uniform Modification Justification form (FIS 2316) be submitted as shown on Exhibit 1. Licensure and Good Standing DIFS will review the licensure status of all issuers filing SADPs. Actuarial Value (AV) Requirements All individual and small group SADPs offered on- and off- Marketplace must have an actuarial value of 70% (low) or 85% (high) with a de minimis variation of +/- 2 percentage points. All SADP issuers must include a certification by a member of the American Academy of Actuaries of the plan's actuarial value. Annual Limit on Cost-Sharing The 2017 out-of-pocket maximums for Marketplace-certified SADPs are $350 for one covered child and $700 for two or more covered children. Service Area With regard to plans on the Marketplace, CMS requires that any partial service areas (geographic areas smaller than a county) offered on the Marketplace be established without regard to racial, ethnic, language, or health status related factors. Issuers with partial service areas must submit a partial service area justification in the supporting documentation tab of the binder. Issuers should refer to the CMS Service Area Partial County Justification Instructions regarding acceptable reasons for partial service areas. Partial service area requests will be reviewed on a case-by-case basis , language, or health status related factors. Issuers with partial service areas must submit a partial service area justification in the supporting documentation tab of the binder. Issuers should refer to the CMS Service Area Partial County Justification Instructions regarding acceptable reasons for partial service areas. Partial service area requests will be reviewed on a case-by-case basis. Issuers of on-Marketplace SADP plans are urged to refer to the "Letter." Network Adequacy DIFS will collect network detail on the Michigan Network Data Template. The Michigan Network Data Template is required for stand-alone dental networks, and is available with accompanying instructions in SERFF. Please review the Michigan Network Adequacy Guidance for network adequacy standards. For consideration of any service area, the issuer must demonstrate that it has dental providers located within the boundaries of the county. Additionally, the issuer must demonstrate that at a minimum, there are endodontic, oral surgery, and periodontics dental specialists in each of the metropolitan service areas it is requesting approval for. All network adequacy reviews are also subject to CMS oversight. Essential Community Providers Issuers of on-Marketplace plans should refer to the "Letter" for current Essential Community Provider requirements. SECTION 2: CONTRACT REQUIREMENTS Readability Submitted forms must comply with the following readability standards found under MCL 500.2236(3): 1. Each form entered in 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 dards found under MCL 500.2236(3): 1. Each form entered in 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. Health care policies and certificates, dental policies and certificates, and certificates of coverage, 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 with font size not less than 10 point (an exception under MCL 500.2236(3) for policies of disability insurance as defined in section MCL 500.3400); font requirement found in MCL 500.3402. Dependent Coverage Essential Health Benefit (EHB) coverage for pediatric services are required for enrollees until at least the end of the month in which the enrollee turns 19 years of age. Guaranteed Renewability Although SADPs are considered excepted benefits, and therefore not subject to federal guaranteed renewability requirements, CMS will apply certain guaranteed renewability standards to SADPs. See page 19 of the "Letter." 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, PA 251 of 2000 (MCL 550.1901 to 550.1929). These procedures must be part of the policy and submitted for 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 Rate/Form filing. and adhere to the external review process under the patient's right to independent review act, PA 251 of 2000 (MCL 550.1901 to 550.1929). These procedures must be part of the policy and submitted for 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 Rate/Form filing. 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 or be identified as having a "high" or "low" value are those that have followed the certification process and have been approved and recommended for certification to CMS. Benefit Enhancement in Excess of EHB Issuers of SADPs may offer enhanced benefit and benefit payment arrangements in excess of EHB. These enhanced arrangements are limited to non-EHB pediatric oral benefits only. SECTION 3: RATING For the 2017 certification of SADPs, 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. SADP Michigan rate filings must include the following components: • Rate manual showing only Michigan-specific rates; • Sample rate calculation; • Michigan Rate Checklist for SADPs; • Actuarial Memorandum addressing items from the Michigan Rate Checklist, including but not limited to: • Description and exhibits showing the development of rates from the experience; • Methodology and assumptions used to calculate each plan's actuarial value ponents: • Rate manual showing only Michigan-specific rates; • Sample rate calculation; • Michigan Rate Checklist for SADPs; • Actuarial Memorandum addressing items from the Michigan Rate Checklist, including but not limited to: • Description and exhibits showing the development of rates from the experience; • Methodology and assumptions used to calculate each plan's actuarial value. • Derivation of the EHB Apportionment percentage for pediatric dental (individual plans only) Any questions regarding this bulletin should be directed to: Department of Insurance and Financial Services Office of Insurance Rates and Forms 530 West Allegan Street, 7th Floor P.O. Box 30220 Lansing, Michigan 48909-7720 Toll Free: (877) 999-6442 atrick M. McPharlin Director Exhibit 1 2017 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 Rate/Form Filing & Binder Business Rules – One per Issuer, include both Individual and Small Group on the same template Yes Rate/Form Filing & Binder Michigan Required Templates, Checklists and Forms MI Network Data Template Yes Binder only MI 2017 Stand-Alone Dental Forms Checklist Yes Rate/Form Filing & Binder MI 2017 Stand-Alone Dental Rates Checklist Yes Rate/Form Filing & Binder MI 2017 Stand-Alone Dental Network Adequacy Checklist Yes Binder Only Company Actuarial Memorandum Yes Rate/Form Filing & Binder MI Uniform Modification Justification Form Yes Rate/Form Filing & Binder Filing Deadline: 4/11/2016 NOTE: All required templates must be completed and if applicable, validated, before filing 7 Stand-Alone Dental Rates Checklist Yes Rate/Form Filing & Binder MI 2017 Stand-Alone Dental Network Adequacy Checklist Yes Binder Only Company Actuarial Memorandum Yes Rate/Form Filing & Binder MI Uniform Modification Justification Form Yes Rate/Form Filing & Binder Filing Deadline: 4/11/2016 NOTE: All required templates must be completed and if applicable, validated, before filing. Use of the 2017 QHP Application Tools and Data Integrity Tool is required for initial template and subsequent template submissions. All template revisions must be uploaded to the same location as originally filed (i.e., SERFF Rate/Form Filing, Binder, or BOTH).