2015 Health Plans Form Filings, Including Recommendations Regarding Qualified Health Plan Certification

1'1101110:: 1,S'.k'·' _.,,[.1;' / :.jL).:o1+1-12'1·10/ l\Lu l ax. (-Iti; ; ;·1 ~,,- S('curiu"" l'.1A. ('lib, 1, ,.'"')>-. I 1'1!'~T-dX:, l(1,,1 f 11·1':-.) I 1 "\",11 J .1.\ ([Ill> iii- qq" ;-;Iii I 1,.10'11,1Av«.. ) I"},·n.,\II "'lii1i \'/("['>11. \'/w,,' ('1 mt)':;'0' I .\\,11!: ('''I;'' :11\ :;", The following table includes information about the timeline for filing major medical health plans including: policy forms and templates, rates, provider network information, and the Qualified Health Plan (QHP) certification recommendationprocess. The Office of the Commissioner of Securities and Insurance, Montana State Auditor (CSI). is the marketplace plan manager for the State of Montana. The CSI will be performing the plan management functions required for insurers' participation in the federally facilitated marketplace (FFM), along with its regular function to approve forms and templates, network adequacy. and review rates for all health plans sold in Montana. Mygoal is to make health plan regulation as efficient and streamlined as possible for health insurers and thereby reduce costs and complications and to create a level playing field in Montana. This memorandum provides instructions for on- and off-exchange hearthplans. 2015 HEALTH PLAN FORM FILINGS, INCLUDING RECOMMENDATIONS REGARDING QUALIFIED HEALTH PLAN CERTIFICATION May7,2014 DATE: TO; Health Insurers Intending to Issue or RenewSmall Employer Group or Individual Major Medical Health Insurance in 2015 MONICA J. L1NOEE~'L4-/ . Commissioner of s~~Ja~nce Montana State Auditor FROM: ADVISORY MEMORANDUM QnlCL OL' n l[ Mo c 1·\\. \ S1A1L AlDllDR MONICA J. Ll:"\'DEEN CO:v1'vHSSJONER COMMISSIONER OF SECURITIES & INSURANCE REGARDING QUALIFIED HEALTH PLAN CERTIFICATION May7,2014 DATE: TO; Health Insurers Intending to Issue or RenewSmall Employer Group or Individual Major Medical Health Insurance in 2015 MONICA J. L1NOEE~'L4-/ . Commissioner of s~~Ja~nce Montana State Auditor FROM: ADVISORY MEMORANDUM QnlCL OL' n l[ Mo c 1·\\. \ S1A1L AlDllDR MONICA J. Ll:"\'DEEN CO:v1'vHSSJONER COMMISSIONER OF SECURITIES & INSURANCE Issuers that WILL PARTICIPATE in the Issuers that WILL NOT PARTICIPATE in the Exchanges (QHP issuers) Exchanges Timeline for Filing Timeline for Filing All major medical health insurers that wish Health insurers that do not intend to offer plans to issue QHP coverage inside the federally through the FFM, but will offer major medical facilitated marketplace must file with the CSI health plans in 2015 must file their forms and all their forms, including all required documents associated documents and their binders for policies, certificates, or membership containing all templates through State Electronic contracts; and their plan binders containing Rate and Form Filing System (SERFF) between all required templates for coverage that will June 30 and July 29, 2014. The rate filing be issued on January 1, 2015, or later window will also begin on June 30 and end between May 27 and June 10,2014, by on July 29,2014. All templates must be 5:00 P.M. MST. The filing window for rate included in the binder, except the administrative filings is also May 27 to June 10,2014, by data template. New templates must be filed 5:00 P.M. MST. Late filings will not be even if the policy form has not changed. The accepted. Policy forms may be filed prior to Unified Rate Review Template (URRT) must be May 27, but binders including templates used and placed in a separate rate filing. cannot be accepted prior to that date the administrative filings is also May 27 to June 10,2014, by data template. New templates must be filed 5:00 P.M. MST. Late filings will not be even if the policy form has not changed. The accepted. Policy forms may be filed prior to Unified Rate Review Template (URRT) must be May 27, but binders including templates used and placed in a separate rate filing. cannot be accepted prior to that date. FFM issuers must file all health plans to be All required information for network adequacy offered on and off of the exchange in the review must be filed according to the same individual and small employer group timelines listed above. market during this filing window. If a policy form that will be used in 2015 has no All required information for network changes from the approved form for 2014, the adequacy review must be filed according to issuer may file an attestation certifying that there the same timelines listed above. are no changes in the form. However, any changes to cost-sharing will trigger a new filing All Summary of Benefit and Coverage (SBC) for the Summary of Benefits and Coverage, and outline of coverage documents must be outline of coverage and schedule of benefits filed at the same time as the policy form. documents. See the CSI bulletin on SBC's and Outlines of Coverage on the CSI website: All Summary of Benefit and Coverage (SBC) and www.csi.mt.gov. outline of coverage documents must be filed at the same time as the policy form. See the CSI Small employer group and individual bulletin on SBC's and Outlines of Coverage on health plans must be submitted in the CSI website: www.csi.mt.gov. separate filings and binders. Correspondence related to the binder must Small employer group and individual health be attached to the binder filing. plans must be submitted in separate filings and binders. Correspondence related to the All rate, form, and binder filings must be fully binder must be attached to the binder filing. approved by close of business (5:00 P.M. MST) on August 7,2014 t.gov. separate filings and binders. Correspondence related to the binder must Small employer group and individual health be attached to the binder filing. plans must be submitted in separate filings and binders. Correspondence related to the All rate, form, and binder filings must be fully binder must be attached to the binder filing. approved by close of business (5:00 P.M. MST) on August 7,2014. No exceptions will All rate, form and binder filings must be fully be permitted. approved by close of business (5:00 P.M. MST) on September 30,2014. Advisory Memorandum May7,2014 Page 2 QHP Certification Other deadlines related to off-exchange forms filed by non-QHP issuers CSI will conduct the preliminary review for QHP certification and make a QHP Certification does not apply to issuers that recommendation to the FFM. It is not will not sell plans on the exchange. necessary to file forms in the federal Health Insurance Oversight System (HIOS). Any off-exchange rate, form, binder and network filings submitted by non-QHP issuers for new products must be filed and approved no later Guidance in the FFM's Letter to Issuers than November 14, 2014. New health plans may not be marketed or offered for sale until all parts All exchange filers should carefully review of the review and approval process are the Letter to Issuers (LOI) that is posted on complete. Issuers that do not meet that deadline the CMS website. That document contains will be subject to "open enrollment" all year long. detailed guidance regarding QHP Renewal health plan filings must be completely certification, as well as other important approved by September 30 in order to meet the federal guidance for health plans in general. 60 notice requirement in Montana law. Except as noted here, the CSI will review health plans that will be sold on the FFM according to the guidance issued in that Guidance in the FFM's Letter to Issuers letter rding QHP Renewal health plan filings must be completely certification, as well as other important approved by September 30 in order to meet the federal guidance for health plans in general. 60 notice requirement in Montana law. Except as noted here, the CSI will review health plans that will be sold on the FFM according to the guidance issued in that Guidance in the FFM's Letter to Issuers letter. Throughout this process, the CSI continues to seek voluntary compliance with All filers should carefully review the Letter to the minimum requirements of federal law Issuers (LOI) that is posted on the CMS website. that are legally applicable to issuers in That document contains important federal Montana. If voluntary compliance is not guidance for health plans in general. The CSI achieved, the CSI will notify CMS for follow seeks to promote a level playing field to the up and enforcement. greatest extent possible at all times. The process for meeting FFM expectations The CSI is seeking voluntary compliance with regarding QHP accreditation, benefit design, the minimum requirements of federal law that review for non-discrimination and are legally applicable to health plan issuers in meaningful difference, annual maximum out- Montana. If voluntary compliance is not of-pocket and other topics is outlined in the achieved, the CSI will notify CMS for follow up issuer letter. Non-discrimination attestations and enforcement. from insurers must be submitted to the CSI through State Electronic Rate and Form All health plans will be reviewed for possible Filing System (SERFF). discriminatory benefit design. Montana does not have any state specific Montana does not have any state specific benefit benefit mandates that go beyond the mandates that go beyond the essential health essential health benefit categories. benefit categories Advisory Memorandum May 7,2014 Page 3 ugh State Electronic Rate and Form All health plans will be reviewed for possible Filing System (SERFF). discriminatory benefit design. Montana does not have any state specific Montana does not have any state specific benefit benefit mandates that go beyond the mandates that go beyond the essential health essential health benefit categories. benefit categories Advisory Memorandum May 7,2014 Page 3 • Individual market health plan rates, both on and off the exchange, must be guaranteed for the calendar year beginning January 1, 2015. No interim rate increases will be permitted. • Smoking rate ups are not allowed for anyone under the age of 21. This applies to policies sold both on and off the exchange. • Rates entered into the rate filing or plan binder by the issuer should have no more than 2 decimal points in order to avoid validation errors later in the review. • The rate plan information and R2D2 must be completed for all rate filings. Any correspondence related to information contained in the rating filing must be filed as part of the rate filing. • Pursuant to federal regulations, the URRT for individual and small employer group health plans must be completed and submitted to both eMS and the state insurance regulator in HIOS and SERFF, even if the state is an effective rate review state. • Geographic rating factor support must include documentation regarding how utilization was removed from the development of those geographic rating factors. All insurers operating in the individual and small employer group major medical market must submit the federal rate data templates (contained in the plan binder) and the URRT, even if they do not intend to sell in the FFM. A rate filing that contains the URRT and is separate from the form filing and the plan binder must be filed. Do not duplicate templates submitted in the plan binder in the rate filing. The URRT, the Part III Actuarial Memo, and all supporting documentation for the rate should be submitted in a separate SERFF rate filing the plan binder) and the URRT, even if they do not intend to sell in the FFM. A rate filing that contains the URRT and is separate from the form filing and the plan binder must be filed. Do not duplicate templates submitted in the plan binder in the rate filing. The URRT, the Part III Actuarial Memo, and all supporting documentation for the rate should be submitted in a separate SERFF rate filing. The URRT is not part of the plan binder. Other instructions related to the rate filing are as follows: Rate Review-Separate rate filing required. All major medical health insurance forms must be filed through SERFF, even if those health plans are offered only in the market outside the FFM. The data templates for benefits and rates (except the Administrative Data Template) must be completed for all individual and small employer group health plans, even if the plan is not seeking QHP certification. New templates for 2015 must be filed even if no changes were made to the underlying policy forms. These templates are only available through the SERFF system. General instructions to filers in Montana will be provided on Montana's state page in SERFF-including any updates to these instructions. Please check SERFF on a regular basis for important general information, as well as specific information about your company's filings. All filings must be submitted through the SERFF. Please check the SERFF website for information about SERFF trainings that are offered throughout the month of May. Attendance at this training is highly recommended for all filers. Use of SERFF Required GUIDANCE FOR ALL ISSUERS Advisory Memorandum May 7,2014 Page 4 nt general information, as well as specific information about your company's filings. All filings must be submitted through the SERFF. Please check the SERFF website for information about SERFF trainings that are offered throughout the month of May. Attendance at this training is highly recommended for all filers. Use of SERFF Required GUIDANCE FOR ALL ISSUERS Advisory Memorandum May 7,2014 Page 4 If an issuer is using different network for different health plans, all networks must be properly identified and submitted separately. Instructions on where to access the sample work sheets will be found on SERFF or you may contact CSI directly for that information. A complete list of every hospital and other medical facility (including stand-alone residential treatment centers) in a separate Excel spreadsheet must also be provided. The master list of providers and facilities used by the CSI to review networks for 2015 is available upon request. In order to assess compliance with state and federal network adequacy laws for PPO and "PPO type" health plans offered in 2014, health insurers must provide the CSI with a complete provider directory for the each health plan offered for sale in Montana. At this point in time, this information must be submitted in an Excel workbook. The following categories of health care providers must be submitted in separate Excel work sheets within the Excel workbook: physicians, advanced practice registered nurses, physician assistants, naturopaths, chiropractors, licensed clinical social workers, licensed clinical professional counselors, psychologists, and physical therapists. The location (city, state, and zip code), the Montana license number, the provider type and any identified specialty (if available) must also be included. Only providers that are actively practicing medicine may be included. NETWORK ADEQUACY The CSI will provide technical assistance to health plans through the form approval/QHP certification recommendation process, as it always has cal therapists. The location (city, state, and zip code), the Montana license number, the provider type and any identified specialty (if available) must also be included. Only providers that are actively practicing medicine may be included. NETWORK ADEQUACY The CSI will provide technical assistance to health plans through the form approval/QHP certification recommendation process, as it always has. All consumer complaints about insurers, including QHP issuers, will be handled by the CSI. Consumer complaints about insurers that are received by the FFM through its toll-free phone number, the FFM website, or in any other manner, will be forwarded to the CSI for resolution. The CSI will track complaints concerning QHP issuers and forward them to the FFM when requested. Technical Assistance for Issuers & Consumer Complaint Handling The geographic rating areas set for 2014 will remain the same in 2015. Geographic Rating Areas Rate justifications, as required by applicable federal regulations and contained in Part II of the URRT, must be submitted with the initial rate filing and for all subsequent rate increases, no matter how large or small the increase. The Part II rate justification is the consumer-friendly explanation/justification for the rate. Those rate justifications will be posted on a CSI website immediately after they are received for all health plans sold in Montana, both on and off the exchange. Rate increases for small employer group health plan rates, both on and off the exchange, may be submitted quarterly, but increases must be submitted 60 days in advance of use, as outlined in Mont. Code Ann. § 33-22-156. The CSI requests that those rate increases be submitted at least 30 days prior to the notice of rate increase delivery date. Advisory Memorandum May 7,2014 Page 5 off the exchange. Rate increases for small employer group health plan rates, both on and off the exchange, may be submitted quarterly, but increases must be submitted 60 days in advance of use, as outlined in Mont. Code Ann. § 33-22-156. The CSI requests that those rate increases be submitted at least 30 days prior to the notice of rate increase delivery date. Advisory Memorandum May 7,2014 Page 5 Eventhough healthcare co-ops are "deemed" certified, as described in LOI, the CSI will review co-op health plan forms in the same way as all other health insurers - all timelines and instructionscontained in this advisory memorandumapply equally to healthcare co-ops. HEALTHCARE CO-OPS and MULTI-STATE PLANS The Excel spreadsheets should be sent directly to David Dachs at ddachs@mt.gov. Further instructionsand any changes to the network adequacy review process will be posted on SERFF, or you may contact David Dachs directly. The ECP list includes county health departments that offer immunizations. In some counties, the county health department is the only medical provider that offers immunizations. If an issuer encounters difficulties when contracting with county health departments, please contact the CSI for further instructions. If a OHP issuer does not include all Indian health care providers in its networks, it must submit proof that a provider contract was offered to and refused by the Indian provider. If a OHP does not have all Indian Health Services (IHS) providers in its network by the time it files its provider lists in June 2014, it must include a statement outlining its attempts to contract with IHS providers. Health plans that are determined to have an "inadequate" network are subject to a 25 percent reimbursement differential. An explanation of the formula used by CSI to determine the 25 percent differential allowed under Mont. Code Ann. § 33-22-1706 is available upon request. All OHP issuers must include essential community providers (ECPs) in their networks s attempts to contract with IHS providers. Health plans that are determined to have an "inadequate" network are subject to a 25 percent reimbursement differential. An explanation of the formula used by CSI to determine the 25 percent differential allowed under Mont. Code Ann. § 33-22-1706 is available upon request. All OHP issuers must include essential community providers (ECPs) in their networks. ECPs are defined in federal law as those providers that serve low-income and medically underserved individuals. The list of ECPs published by CMS for Montana is incomplete. The complete list is posted on the CSI website. I have determined that the federal network adequacy standard that requires only 30 percent of all ECPs to be "in network" is not adequate for Montana. OHP issuers should strive to meet a standard that includes at least 80 percent of all ECPs on CSI's published list. If a health plan is unable to meet that standard, CSI will review the adequacy of the ECP network and make a determination on a case-by-case basis. Plans that are defined under Chapter 31 as "HMO" plans must seek a network adequacy determination through the Montana Department of Public Health and Human Services. However, because of requirements related to federal OHP certification, OHP issuers who are filing HMO health plans must also submit these provider lists to CSI, as well as the network template form, even though network work adequacy is governed for HMO products under Mont. Code Ann., Title 33, Chapter 36. That information will be kept on file for OHP HMO products for certification and enforcement purposes. Health plans seeking qualified health plan (OHP) certification must submit the necessary network provider lists as outlined in the "Timeline" section above, but no later than June 10,2014. All other health plans must submit the information at the same time that the 2015 binder is filed, but no later than July 29, 2014 be kept on file for OHP HMO products for certification and enforcement purposes. Health plans seeking qualified health plan (OHP) certification must submit the necessary network provider lists as outlined in the "Timeline" section above, but no later than June 10,2014. All other health plans must submit the information at the same time that the 2015 binder is filed, but no later than July 29, 2014. Provider information must still be supplied for all "PPO type" products, even if there are no other changes in the policy forms in 2015. Advisory Memorandum May 7,2014 Page 6 Before and after that call, if you have questions that cannot be answered through the SERFF process, please contact Rosann Grandy, Forms Bureau Chief, or Christina Goe, General Counsel, at (406) 444-2040 or rgrandy@mt.gov or cgoe@mt.gov. ALL-FILER CONFERENCECALL/MEETING May 20,2014 1:30 PM MST Dial-In Number: (712) 432-1212 Meeting 10: 236-818-235 There will be an all-filer conference call/meeting on May 20, 2014, at 1:30 P.M. MST. You may attend the meeting in person at the CSI offices in Helena or call the following phone number to join the conference call. This will be your opportunity to ask questions about this process. CONCLUSION QDP forms, rates and binders must be filed separately from QHP filings. Dental rates may use geographic rating factors; however, the geographic rating areas used must be the same as those identified for health plans. Dental binders/filings should include all Q DPs sold on and off the exchange. Qualified Stand-alone dental plans (QDPs) must file their rates, forms, plan binders and network lists according to the same timelines and instructions that apply to all QHP issuers. Montana's PPO network adequacy law applies to dental and vision plans. The benefits template will be modified for dental plans as described in 2015 FFM letter to issuers. Each QDP issuer must specify whether or not the rates contained in the templates are guaranteed to consumers or will be subject to change (underwriting) ording to the same timelines and instructions that apply to all QHP issuers. Montana's PPO network adequacy law applies to dental and vision plans. The benefits template will be modified for dental plans as described in 2015 FFM letter to issuers. Each QDP issuer must specify whether or not the rates contained in the templates are guaranteed to consumers or will be subject to change (underwriting). STAND-ALONE DENTAL PLANS Similarly, the CSI will review multi-state plans (MSPs) under contract with the Office of Personnel Management (OPM) according the same instructions and timelines outlined in this memorandum. MSP insurers will be notified by CSI if there is an alteration in these instructions that applies to them. Advisory Memorandum May 7,2014 Page 7