Filing Guidance for Individual and Small Employer Health and Dental Plans in Nebraska

NEBRASKA Good Life. Great Opportunity. DEPARTMENT OF INSURANCE [LOGO] Pete Ricketts, Governor # COVER SHEET CB-130 (Amended) April 20, 2021 ## BULLETIN ### SUBJECT: FILING GUIDANCE FOR INDIVIDUAL AND SMALL EMPLOYER MAJOR MEDICAL PLANS AND STAND-ALONE DENTAL PLANS IN NEBRASKA This guidance document is advisory in nature but is binding on an agency until amended by such agency. A guidance document does not include internal procedural documents that only affect the internal operations of the agency and does not impose additional requirements or penalties on regulated parties or include confidential information or rules and regulations made in accordance with the Administrative Procedure Act. If you believe that this guidance document imposes additional requirements or penalties on regulated parties, you may request a review of the document. Contents of CB-130 (Amended) follow on next page. Eric Dunning, Director Department of Insurance 1135 M Street, Suite 300 PO Box 82089 Lincoln, Nebraska 68501-2089 OFFICE 402-471-2201 FAX 402-471-4610 www.doi.nebraska.gov NEBRASKA Good Life. Great Opportunity. DEPARTMENT OF INSURANCE  April 20, 2021 CB-130 (Amended) Pete Ricketts, Governor ## BULLETIN ### SUBJECT: FILING GUIDANCE FOR INDIVIDUAL AND SMALL EMPLOYER MAJOR MEDICAL PLANS AND STAND-ALONE DENTAL PLANS IN NEBRASKA This amended bulletin provides guidance for filers of individual, small group and stand-alone dental plans (SADP), offered on and off the Federal Facilitated Marketplace, that wish to issue or renew plans in Plan Year 2022. Pursuant to the implementation of the Affordable Care Act (ACA), the federal government mandated rules for the rating and review of health insurance and stand-alone dental policies. The following information outlines the Nebraska Department of Insurance (Department) filing process and rating requirements allowed under ACA and subsequent regulations issued by the federal government. As in previous years, the Department will engage in "marketplace plan management." The following dates and corresponding actions relate to plan year 2022. All dates may be subject to change, the Department will attempt to promptly post any revisions when they occur. The published table of key dates from CCIIO is available at https://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/Final-Key-Dates-Table-for-CY2021.pdf. Qualified Health Plan (QHP) certification requires all templates. Please see https://www.qhpcertification.cms.gov/s/QHP for more information. The Department encourages all issuers to ensure that key staff receive CMS training and review QHP requirements to avoid delays and resubmissions due to missing or incorrect templates. Please do not submit documents in SERFF that include a comma in their name. Documents are not recognized or searchable in SERFF if they include a comma. | Date | Action | | --- | --- | | April 22, 2021 | First day that initial QHP Application submissions will be accepted. | 1 of 8 Eric Dunning, Director Department of Insurance 1135 M Street, Suite 300 PO Box 82089 Lincoln, Nebraska 68501-2089 OFFICE 402-471-2201 FAX 402-471-4610 www.doi.nebraska.gov | Date | Action | | --- | --- | | June 2, 2021 | Last day that issuers are allowed to submit their plan binder(s), templates and forms to the Department. This includes all QHP and Non-QHP Major Medical Plans in the Individual or Small Employer Marketplace, whether ON-Marketplace or OFF-Marketplace. Issuers must have HIOS and Carrier ID numbers. This includes SADP plans ON-Marketplace, and certified OFF-Marketplace. These SADPs must also submit rate filings by this date. OFF-Marketplace only non-certified SADPs are not subject to the ACA, and not subject to this Bulletin. For Major Medical Plans the Rate Filings, Rate Table Template (RTT) and Unified Rate Review Template (URRT) are NOT required to be included as part of this initial submission. See subsequent dates for when these are required to be provided. | | June 16, 2021 | Final day for NDOI to submit QHP plans to CMS. | | June 30, 2021 | **Deadline for all issuers providing major medical coverage that includes a QHP in the Single Risk Pool Market (ON-Marketplace Individual or Small Group) to submit SERFF rate filings and Rate Table Templates (RTTs).** Issuers must include the RTT in their SERFF binder. Issuers should submit the URRT via HIOS, and also in the SERFF rate filing and binder. The URR Module consists of the Part I URRT, the Part II Rate Filing Justification (RFJ) if applicable, and the Part III Actuarial Memorandum. Please note: while rates and forms are not made public by NDOI until final approval, federal law and CMS activities can preempt Nebraska's approach. Public exposure of some rate information is expected to occur on July 30, 2021, as discussed below. | | July 14, 2021 | **Deadline for all issuers providing Single Risk Pool major medical coverage that does not include a QHP to submit SERFF rate filings and rate table templates. This pertains to Individual and Small Group Issuers offering plans that are all strictly OFF-Marketplace.** Issuers must include the RTT in their SERFF binder. Issuers should submit the URRT via HIOS, and also in the SERFF rate filing and binder. The URR Module consists of the Part I URRT, the Part II Rate Filing Justification (RFJ) if applicable, and the Part III Actuarial Memorandum. | 2 of 8 | Date | Action | | --- | --- | | July 21, 2021 | Final day for NDOI to submit all proposed rates to CMS for both QHP and Non-QHP plans, ON and OFF Marketplace. Rate data will be refreshed in the HIOS URR module by 2:00 p.m. on July 21, 2021. These rates will be posted for consumer review on July 30, 2021. Note that there will be opportunities during the QHP certification process for issuers to update, correct, or change the QHP Rate Table Template (as may be necessary). | | July 30, 2021 | CMS intends to publish proposed rate changes for comment. Nebraska will use the federal website for state publication purposes. Public access will be via a link to the rate information at: https://ratereview.healthcare.gov. | | August 18, 2021 | Final CMS deadline for issuer changes to QHP application. This includes all Individual and Small Employer Major Medical ON-Marketplace plans. Note that CMS requires all rate filings that contain a QHP be finalized in the HIOS URR module by 3:00 p.m. EDT on August 18, 2021. | | August 11-25, 2021 | Issuers complete final plan confirmation, and submit final Plan ID Crosswalk Templates, in the PM Community. | | September 14, 2021 | CMS sends issuers QHP Certification Agreements. | | September 22, 2021 | Deadline for Issuers to return signed Certification Agreements and Final Plan Crosswalks to CMS. States send CMS final plan recommendations. | | October 1, 2021 | Final date for NDOI to close all Non-QHP only rate filings. Note that all issuers must finalize all rate filings that only contain non-QHPs in the HIOS URR module by 3:00 p.m. EDT on October 15, 2021. | | November 1, 2021 | The target date for NDOI to release all ACA SERFF rate filings to be publicly viewable. Material within the filing that has been accepted as being "Trade Secret" is kept confidential and not publicly viewable. | | November 1, 2021 | Open enrollment begins. Final rates are published by CMS. | 3 of 8 | Date | Action | | --- | --- | | December 15, 2021 | Deadline to submit 2nd Quarter 2022 rate adjustments, with rate filings and binders in SERFF for Small Group On- and Off-Exchange plans. Also, URRTs must be submitted in HIOS by this date. | | February 15, 2022 | Deadline for 2nd Quarter 2022 Small Group rate filings to be completed with final RTTs submitted to CMS, URRTs submitted in HIOS. | | March 15, 2022 | Deadline to submit 3rd Quarter 2022 rate adjustments, with rate filings and binders in SERFF for Small Group On- and Off-Exchange plans. Also, URRTs must be submitted in HIOS by this date. | | May 15, 2022 | Deadline for 3rd Quarter 2022 Small Group rate filings to be completed with final RTTs submitted to CMS, URRTs submitted in HIOS. | | June 15, 2022 | Deadline to submit 4th Quarter 2022 rate adjustments, with rate filings and binders in SERFF for Small Group On- and Off-Exchange plans. Also, URRTs must be submitted in HIOS by this date. | | August 15, 2022 | Deadline for 4th Quarter 2022 Small Group rate filings to be completed with final RTTs submitted to CMS, URRTs submitted in HIOS. | **IMPORTANT:** The following form and rate filing requirements are offered to clarify the process. The sequence in which the information is shown is not indicative of the level of importance. 1. The issuer's plans must be certified in order to participate in the Marketplace. Nebraska's benchmark plan, as determined by the United States Department of Health and Human Services, is the BlueCross BlueShield of Nebraska BluePridePlus, Option 102 Gold. 2. Both ON-Marketplace and OFF-Marketplace plans must be submitted in SERFF Plan Management. The General Instructions for Nebraska in SERFF provide checklists and trade secret protection guidance. - All filings are required to be in Binders (including OFF-Marketplace only Health Plans) when entered in SERFF. - Individual and Small Group filings must be submitted under separate SERFF tracking numbers. - The Binder(s) will include forms, rates (the RTT) and other templates for Individual plans and a separate binder for Small Employer plans. Nebraska's statutory definition of small employer group size is 2 to 50. 4 of 8 - For major medical plans the final Rate Table Template ("RTT") and Uniform Rate Review Template ("URRT") must be submitted by July 1, 2021 for QHPs, and by July 15, 2021 for non-QHPs. For SADPs the RTT should be submitted with the binder by the June 2, 2021 deadline. 3. All ACA compliant filings should include the 2022 Health Insurance Form Review Checklist, redline versions showing changes from previously approved forms, the Nebraska Filing Form, URRT, Actuarial Memorandum (unredacted and redacted versions), templates, SBC for each plan variation (no variability allowed), Readability Certification, Accreditation Certificate, attestations, any Justifications, copy of the Provider Network, and cover letter information. Each product submitted can only be filed in one SERFF filing, with its corresponding SBCs and any application documents in that same SERFF filing. You must run the Federal tools before submitting each template. Templates must include an .xls version. 4. All SADP filers must complete the Pediatric Dental Checklist. 5. All Small Group or Individual Health Plan issuers must make available an off-exchange plan to mirror each on-exchange plan submitted. 6. A separate Summary of Benefits and Coverage must be submitted for each plan, and must be filed in the same SERFF product filing as the coverage document that the SBC describes. Similarly, any applications filed in SERFF must be filed in the same product filing as the coverage document for which the application will be used. Please see https://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/Downloads/FAQs-Part-41.pdf for a description of the most recent changes to the SBC coverage examples calculator, the guide and narratives for coverage examples, instructions for completing the SBC template, and the SBC template and associated materials. 7. In general, the ACA requirements for Individual and Small Group cannot be added by endorsement, matrix inserts, variables or amendment rider. - Policy forms must meet state requirements, as well as the 2017 ACA benchmark essential health benefits, metal levels, PPACA, and community rating requirements. State benchmark plans are listed on the CMS website at https://www.cms.gov/CCIIO/Resources/Data-Resources/ehb#ehb. - Plans must be guaranteed issue and guaranteed renewable, with no pre-existing condition limitations. NDOI allows only limited form variability. - Each metal level of Platinum (90% AV), Gold (80% AV), Silver (70% AV), or Bronze (60% AV) should have a separate non-variable schedule with a unique form number. - Please note that each FFM issuer must offer a Silver plan statewide and a Gold plan statewide. The Platinum and Bronze levels are optional. 8. Issuers must provide documentation verifying that all plans have adequate networks in place, including demonstrating geographical saturation, and providing a signed attestation confirming network adequacy. For plans submitting a narrow or closed 5 of 8 network product, please denote to the reviewer the product name, location of the narrow network for the product, and provider information for the narrow network, and include MAPS or illustrations. 9. Individual Catastrophic plans are for under age 30 and are optional. 10. Issuers will maintain a single statewide risk pool for each of their non-grandfathered individual and small group markets. 11. Rating territories are limited to no greater than four in the state, determined by three-digit zip codes for the Small Employer market, and determined by Counties for the Individual market. 12. No application shall contain health questions, although questions determining tobacco use, age and gender, may be asked. 13. No Binders will be accepted after June 2, 2021, with the exception of small group quarterly rate filing adjustment requests, rates and forms may only be filed once per year. 14. MHPAEA compliance review will incorporate the Self-Compliance Tool at https://www.dol.gov/sites/dolgov/files/EBSA/laws-and-regulations/laws/mental-health-parity/self-compliance-tool.pdf. Filers are specifically directed to the Self-Compliance Tool, Section B, Financial Requirements and Quantitative Treatment Limitations, which describes six classifications of benefits. "Any financial requirement or quantitative treatment limitation that applies to mental health/substance use disorder benefits within a particular classification cannot be more restrictive than the predominant requirement or limitation that applies to substantially all medical/surgical benefits within the same classification. See 29 CFR 2590.712(c)(2)." If parity concerns are flagged during review, a SERFF objection describing the potential violation will be transmitted, and the filer will have an opportunity to re-evaluate the provision and either make a plan correction or explain to the Department the reason the provision does not violate MHPAEA. A completed Self-Compliance Tool, or a completed FR/QTL table from Chapter 24B of the Market Regulation Handbook, can demonstrate MHPAEA compliance. Filers may find it efficient to complete this table during pre-filing compliance checks, to avoid delays during review of filed plans. 15. Requests for trade secret protection should be submitted using the trade secret request template found in the Attachments list at the bottom of Nebraska's General Instructions in SERFF. All information is considered Public unless a valid Trade Secret request has been properly submitted within the rate filing. 16. The NDOI will work with carriers and their rate submissions during the period of time allotted under this Bulletin and CMS guidelines. Insurers are encouraged to submit early and will be served on a first come, first served basis. ### HIOS Uniform Rate Review Module (URR) Filings: 17. For Individual and Small Employer major medical health plans Issuers are required to submit the following URR components in HIOS: 6 of 8 - Part 1 – Uniform Rate Review Template (URRT). - Part 2 – Rate Increase Justification. Is only provided if any plan within a product in the filing is receiving a rate increase of 15% or greater. - Part 3 – Actuarial Memorandum Un-redacted version, and optional Redacted version. # Minimum Required Contents of Nebraska ACA Major Medical Rate Filings: ACA Major Medical rate filings should contain at a minimum the following items: - A cover letter outlining the rate action being taken, comments on key plan changes. - An authorization letter if an outside organization will be submitting the rate filing on behalf of the issuer. - The Federal Uniform Rate Review (URR) Module, which includes the following: o Part 1 URRT; o Part 2 Rate Increase Justification (if applicable); o Part 3 Actuarial Memorandum; an un-redacted version must be submitted, and also a redacted version may be submitted. Note that Nebraska applies different requirements regarding items allowed to be Trade Secret than what is allowed to be redacted in the Federal Memorandum. - In the Part 1 URRT spreadsheet the Department requests that all issuers complete the "Current Enrollment" line on Worksheet 2, Section 2, using enrollment as of June 1, 2021. If enrollment as of this date is not yet available at time of filing, then indicate the most recent date that you did have available and used, but note that you will be requested to update the URRT during rate filing review when this enrollment data as of June 1, 2021 becomes available. - Also in the URRT spreadsheet issuers with 2020 ACA experience must enter this data into Worksheet 1, Section 1. The issuer's 2019 ACA experience should not be entered in Section 1 in an attempt to avoid using 2020 experience which was impacted by COVID-19. - Issuers may provide an alternate rate development for 2022 using experience other than their own ACA 2020 experience if they deem their 2020 experience to be less than 100% credible due to COVID-19 claims distortions or other factors. Alternative experience should be provided and documented elsewhere in the Actuarial Memorandum and entered as the projected Manual EHB Allowed Claims pmpm in Section 2. - A Rate Manual to be provided under the Rate / Rule Schedule tab containing at least the "Base Rates" and all rating factors that are applied to the Base Rates to determine any policyholder's rates (Age rating factors, Area rating factors, Benefit factors / AV Pricing factors). 7 of 8 o Base Rates are defined to be the calibrated Plan Adjusted Index Rates to which each allowable consumer level rating adjustment is applied to obtain the Consumer Adjusted Premium Rates. Consumer level rating adjustments are: Age factors, Geographic Area factors, Tobacco factors, Family Structure rating. • The Nebraska Rate Table Spreadsheet. o Note: this is not the RTT which is only expected to be included in the binder, and not in the rate filing. The RTT should NOT be used to replace the Rate Manual under the SERFF Rate / Rule Schedule tab. • Actuarial Value (AV) Calculation sheets for each plan, and an Actuarial Attestation that AVs were calculated using accepted methods. • A complete Actuarial Memorandum with development of rates including a projection calculation demonstrating how 2022 projected claims, premium and membership were developed, and illustrating how all trend and projection factors were applied to base experience. The Department will be posting a SERFF guideline on specific rate development support being requested for PY 2022 to be provided in the rate filing. o Note that the Federal URRT and its supporting Part III Actuarial Memorandum are not required to be the official rate development used to set rates. If the Un-redacted Part III Actuarial Memorandum completely describes the rate setting method with detailed support for how all base rates and rating adjustments were developed and applied, then this may be used to satisfy this requirement. • A Trade Secret request if the company will be requesting any documents to be kept confidential once the filing is released publicly. The Department has posted a Nebraska SERFF Rate Filing Guideline with instructions for requesting Trade Secret protection for any item. The process for requesting trade secret protection through SERFF is available online at https://doi.nebraska.gov/sites/doi.nebraska.gov/files/doc/tsp-lh-inc-fil-serff_0.pdf o The Department has also posted in SERFF a Trade Secret Request Template that should be followed when submitting requests for Trade Secret handling of filing material. The format indicated in this template must be followed. • The Standard Rate Filing Form Listing. • Completed SERFF information tabs as required by NDOI. Please direct any questions regarding the aforementioned information to Laura Arp, Administrator for the Life and Health Division at 402-471-2201 or at laura.arp@nebraska.gov. Eric Dunning Director 8 of 8