Bulletin2010-04 Process for Filing Amendments to Forms to Comply with the Immediate Market Reform...

To: From: South Carolina Department of Insurance Capitol Center 1201 Main Street, Suite 1000 Columbia, South Carolina 29201 Mailing Address: P 0 Box 100105, Columbia, S.C. 29202-31 05 Telephone: (803) 737-6160 BULLETIN 2010-04 MARK SANFORD Governor SCOTT H. RICHARDSON Director of Insurance All Licensed Life, Accident & Health Insurers and Health Maintenance Organizations in the State of South Carolina Scott H. Richardson, CPC~.h? Director ~K:-- Subject: Process for Filing Amendments to Forms to Comply with the Immediate Market Reform Requirements of the Patient Protection and Affordable Care Act (PPACA) Date: Junel6, 2010 I. Purpose The purpose of this Bulletin is to inform all licensed life, accident & health insurers and health maintenance organizations of the procedures for tiling amendments to policy forms to comply with the immediate market reform requirements of the Patient Protection and Affordable Care Act (PPACA). II. Immediate Market Reforms The Patient Protection and Affordable Care Act was signed into law on March 23, 2010. Amendments to the PPACA were included in the Health Care and Education Reconciliation Act of2010, which was enacted on March 30,2010 (these two Acts are collectively refened to as the "PPACA"). The following health insurance market reforms become effective for plan years beginning on or after six months after the enactment of PP ACA and are often referred to as the ''Immediate Market Reforms." l. No lifetime limits on dollar value of benefits: 2. Restricted annual limits on dollar value of certain benefits as defined by HI-IS; 3. Rescissions prohibited (except for fraud or intentional misrepresentation); 4. Coverage of dependent children up to age 26; 5. Pre-existing condition exclusion prohibited for children up to age 19; 6. Internal and external appeals process for enrollees; 7. Benefits for preventive services required, '-Vi th no cost-sharing; 8. Prohibition of discrimination based upon salary; 9. Access to pediatricians: 10. Access to OB/GYNs: and at no III. Requirements Applicable to Filings All t11 to with the immediate market requirements of PPACA must also comply with the requirements of Bulletin 2003-13. In addition, the following information must be included with the filing: SERFF Submissions: 1 . Filing Description PPACA Uniform Compliance Summary, interactive PDF in SERFF; 3. PPACA Certification. see attached link: 4. If rates are impacted, rates must be submitted for prior approval in accordance with Bulletin 2003-13. Filings containing rate changes cannot be submitted as priority PPACA filings. PAPER Submissions: 1. Description to be included on the cover letter. The filing description must clearly state that the filing has been made to comply with the immediate market reform requirements PPACA. In addition, filing description must state vvhether or not been made to the fom1 and filing: see attached link: 4. Ill. Questions: PPACA Uniform Compliance Summary - 1 - Please select the appropriate check box below to indicate which product is amended by this filing. INDIVIDUAL HEALTH BENEFIT PLANS (Complete SECTION A only) SMALL / LARGE GROUP HEALTH BENEFIT PLANS (Complete SECTION B only) This form filing compliance summary is to be submitted with your [endorsement][contract] to comply with the immediate market reform requirements of the Patient Protection and Affordable Care Act (PPACA). These PPACA requirements apply only to policies for health insurance coverage referred to as “major medical” in the statute, which is comprehensive health coverage that includes PPO and HMO coverage. This form includes the requirements for grandfathered (coverage in effect prior to March 23, 2010) and non-grandfathered plans, and relevant statutes. Refer to the relevant statute to ensure compliance. Complete each item to confirm that diligent consideration has been given to each. (If submitting your filings electronically, bookmark the provision(s) in the form(s) that satisfy the requirement and identify the page/paragraph on this form.) *For all filings, include the Type of Insurance (TOI) in the first column. Check box if this is a paper filing. COMPANY INFORMATION Company Name NAIC Number SERFF Tracking Number(s) *if applicable Form Number(s) of Policy being endorsed Rate Impact Yes No PPACA Uniform Compliance Summary SECTION A – Individual Health Benefit Plans TOI Category Statute Section Grandfathered Non- Grandfathered 2 Eliminate Pre-existing Condition Exclusions for Enrollees Under Age 19 [Sections 2704 and 1255 of the PHSA/Section 1201 of the PPACA] N/A Yes No If no, please explain. Explanation: Page Number: Eliminate Annual Dollar Limits on Essential Benefits Except allows for “restricted” annual dollar limits for essential benefits for plan years prior to January 1, 2014. [Section 2711 of the PHSA/Section 1001 of the PPACA] N/A Yes No If no, please explain. Explanation: Page Number: Eliminate Lifetime Dollar Limits on Essential Benefits [Section 2711 of the PHSA/Section 1001 of the PPACA] Yes No If no, please explain. Yes No If no, please explain. Explanation: Page Number: Prohibit Rescissions – Except for fraud or intentional misrepresentation of material fact. [Section 2712 of the PHSA/Section 1001 of PPACA] Yes No If no, please explain. Yes No If no, please explain Explanation: Page Number: Reset Form PPACA Uniform Compliance Summary SECTION A – Individual Health Benefit Plans TOI Category Statute Section Grandfathered Non- Grandfathered 3 Preventive Services – Requires coverage and prohibits the imposition of cost-sharing for specified preventative services. [Section 2713 of the PHSA/Section 1001 of the PPACA] N/A Yes No If no, please explain. Explanation: Page Number: Extends Dependent Coverage for Children Until age 26 – If a policy offers dependent coverage, it must include dependent coverage until age 26. [Section 2714 of the PHSA/Section 1001 of the PPACA] Yes No If no, please explain. Yes No If no, please explain. Explanation: Page Number: Appeals Process – Requires establishment of an internal claims appeal process and external review process. [Section 2719 of the PHSA/Section 1001 of the PPACA] N/A Yes No If no, please explain. Explanation: Page Number: Emergency Services – Requires plans that cover emergency services to provide such coverage without the need for prior authorization, regardless of the participating status of the provider, and at the in-network cost-sharing level. [Section 2719A of the PHSA/Section 10101 of the PPACA] N/A Yes No If no, please explain. Explanation: Page Number: PPACA Uniform Compliance Summary SECTION A – Individual Health Benefit Plans TOI Category Statute Section Grandfathered Non- Grandfathered 4 Access to Pediatricians – Mandates that if designation of a PCP for a child is required, the person be permitted to designate a physician who specialized in pediatrics as the child’s PCP if the provider is in-network. [Section 2719A of the PHSA/Section 10101 of the PPACA] N/A Yes No If no, please explain. Explanation: Page Number: Access to OB/GYNs – Prohibits authorization or referral requirements for obstetrical or gynecological care provided by in-network providers who specialize in obstetrics or gynecology. [Section 2719A of the PHSA/Section 10101 of the PPACA] N/A Yes No If no, please explain. Explanation: Page Number: PPACA Uniform Compliance Summary SECTION B – Group Health Benefit Plans (Small and Large) TOI Category Statute Section Grandfathered Non- Grandfathered 5 Eliminate Pre-existing Condition Exclusions for Enrollees Under Age 19 [Sections 2704 of the PHSA/Section 1201 of the PPACA] Yes No If no, please explain. Yes No If no, please explain. Explanation: Page Number: Eliminate Annual Dollar Limits on Essential Benefits – Except allows for “restricted” annual dollar limits for essential benefits for plan years prior to January 1, 2014. [Section 2711 of the PHSA/Section 1001 of the PPACA] Yes No If no, please explain. Yes No If no, please explain. Explanation: Page Number: Eliminate Lifetime Dollar Limits on Essential Benefits [Section 2711 of the PHSA/Section 1001 of the PPACA] Yes No If no, please explain. Yes No If no, please explain. Explanation: Page Number: Prohibit Rescissions – Except for fraud or intentional misrepresentation of material fact. [Section 2712 of the PHSA/Section 1001 of PPACA] Yes No If no, please explain. Yes No If no, please explain. Explanation: Page Number: Reset Form PPACA Uniform Compliance Summary SECTION B – Group Health Benefit Plans (Small and Large) Non- TOI Category Statute Section Grandfathered Grandfathered 6 ◊ For plan years beginning before January 1, 2010, grandfathered group plans are not required to extend coverage to a child until the age of 26 if such child is eligible to enroll in another employee-sponsored plan Preventive Services – Requires coverage and prohibits the imposition of cost-sharing for specified preventative services [Section 2713 of the PHSA/Section 1001 of the PPACA] N/A Yes No If no, please explain. Explanation: Page Number: Extends Dependent Coverage for Children Until age 26 – If a policy offers dependent coverage, it must include dependent coverage until age 26. ◊ [Section 2714 of the PHSA/Section 1001 of the PPACA] Yes◊ No If no, please explain. Yes No If no, please explain. Explanation: Page Number: Appeals Process – Requires establishment of an internal claims appeal process and external review process. [Section 2719 of the PHSA/Section 1001 of the PPACA] N/A Yes No If no, please explain. Explanation: Page Number: PPACA Uniform Compliance Summary SECTION B – Group Health Benefit Plans (Small and Large) TOI Category Statute Section Grandfathered Non- Grandfathered 7 Emergency Services – Requires plans that cover emergency services to provide such coverage without the need for prior authorization, regardless of the participating status of the provider, and at the in-network cost-sharing level. [Section 2719A of the PHSA/Section 10101 of the PPACA] N/A Yes No If no, please explain. Explanation: Page Number: Access to Pediatricians – Mandates that if designation of a PCP for a child is required, the person be permitted to designate a physician who specialized in pediatrics as the child’s PCP if the provider is in-network. [Section 2719A of the PHSA/Section 10101 of the PPACA] N/A Yes No If no, please explain. Explanation: Page Number: Access to OB/GYNs – Prohibits authorization or referral requirements for obstetrical or gynecological care provided by in-network providers who specialize in obstetrics or gynecology. [Section 2719A of the PHSA/Section 10101 of the PPACA] N/A Yes No If no, please explain. Explanation: Page Number: PPACA CERTIFICATION CERTIFICATION OF COMPLIANCE WITH IMMEDIATE MARKET REFORMS OF PPACA I, THE UNDERSIGNED OFFICER OF _____ (Name of Entity) HAVE REVIEWED OR SUPERVISED THE REVIEW OF THE POLICY FORMS, ENDORSEMENTS OR AMENDMENTS CONTAINED IN THIS FILING AND HEREBY CERTIFY TO THE BEST OF MY KNOWLEDGE AND BELIEF THAT THEY ARE IN COMPLIANCE WITH THE PROVISIONS OF THE PATIENT PROTECTION AND AFFORDABLE CARE ACT WHICH BECOME EFFECTIVE 6 MONTHS AFTER ENACTMENT (“IMMEDATE MARKET REFORMS”) AND ANY APPLICABLE STATUTES, REGULATIONS AND BULLETINS OF THE STATE OF SOUTH CAROLINA. I FURTHER CERTIFY THAT THE FORMS WILL BE REVISED AND/OR DISCONTINUED AS APPROPRIATE IN THE EVENT OF FUTURE CHANGES IN APPLICABLE STATE OR FEDERAL STATUTES, REGULATIONS OR BULLETINS. (Signature of Officer*) (Title of Officer*) (Printed Name of Officer*) (Date) * If the individual signing the certification is other than the president, vice president, assistant vice president, corporate secretary, assistant corporate secretary, CEO, CFO, COO, General Counsel, or an actuary that is also a corporate officer, documentation must be included that shows that this individual has been appointed as an officer of the organization by the Board of Directors. FAQ Patient Protection and Affordable Care Act (PPACA) 1. If a company already complies with a PPACA requirement, do they have to file anything with the Department of Insurance? Yes, please review the filing requirements listed in Bulletin 2010-04. The Uniform Compliance Summary provides for each category, including a description and page number. This, along with the Certification will confirm compliance. 2. What plans are considered grandfathered? Plans that were in effect as of March 23, 2010 and have maintained their grandfathered status per regulation are considered grandfathered. 3. What immediate health insurance reforms affect grandfathered plans for form filing requirements? Individual Individual lifetime dollar limits on essential benefits Prohibition of rescissions Dependent coverage for children until age 26 Small/Large Group Eliminate annual dollar limits on essential benefits Eliminate lifetime dollar limits on essential benefits Prohibition of rescissions Dependent coverage for children until age 26 Eliminate pre-existing condition exclusions for enrollees under age 19 4. How should the changes to the grandfathered plans be submitted to the Department? The changes should be made as amendments to the original product as specified in Bulletin 2010-04. 5. What are the plans effective March 24 through September 22, 2010 considered; grandfathered or non-grandfathered? Non-grandfathered 6. What reforms affect the plans in effect March 24, 2010 through September 22, 2010? All Immediate Market Reforms as specified in Bulletin 2010-04 that are required of all non- grandfathered plans apply to these. 7. Can the changes to the non-grandfathered plans be made via amendment or does a new product have to be filed? A new product must be filed because a single product number cannot offer different coverages. A ‘me-too’ filing may be made with a new form # and the appropriate amendments. 8. What are the filing requirements for the prohibition of discrimination based on salary since it is not included on the Uniform Compliance Summary? The same filing requirements as the other reforms must be adhered to. The category can be manually filled in. It applies to non-grandfathered group health plans. 9. What are the filing requirements with regard to the internal and external review processes? Internal claims appeal process: Grandfathered plans – No filing required. Non-grandfathered plans – all plans – new product must incorporate Department of Labor’s claims and appeals procedures. External review: Non-grandfathered plans – all plans – must meet current state law requirements. (Department has until 7/1/2011 to adopt most recent model act at which time plans must comply with the new model act). 10. How will the rates be treated for the PPACA filings? The current rating statutes apply. However, it is important to note that the new Medical Loss Ratio standards become effective January 1, 2011. These new standards must be reflected in new rate filings. Also, the Department of Health and Human Services is establishing guidelines to define ‘unreasonable’ rate increases. Additional filing requirements may be required when the new regulations are developed. FAQ Patient Protection and Affordable Care Act (PPACA) 1. If a company already complies with a PPACA requirement, do they have to file anything with the Department of Insurance? Yes, please review the filing requirements listed in Bulletin 2010-04. The Uniform Compliance Summary provides for each category, including a description and page number. This, along with the Certification will confirm compliance. 2. What plans are considered grandfathered? Plans that were in effect as of March 23, 2010 and have maintained their grandfathered status per regulation are considered grandfathered. 3. What immediate health insurance reforms affect grandfathered plans for form filing requirements? Individual Individual lifetime dollar limits on essential benefits Prohibition of rescissions Dependent coverage for children until age 26 Small/Large Group Eliminate annual dollar limits on essential benefits Eliminate lifetime dollar limits on essential benefits Prohibition of rescissions Dependent coverage for children until age 26 Eliminate pre-existing condition exclusions for enrollees under age 19 4. How should the changes to the grandfathered plans be submitted to the Department? The changes should be made as amendments to the original product as specified in Bulletin 2010-04. 5. What are the plans effective March 24 through September 22, 2010 considered; grandfathered or non-grandfathered? Non-grandfathered 6. What reforms affect the plans in effect March 24, 2010 through September 22, 2010? All Immediate Market Reforms as specified in Bulletin 2010-04 that are required of all non- grandfathered plans apply to these. 7. Can the changes to the non-grandfathered plans be made via amendment or does a new product have to be filed? A new product must be filed because a single product number cannot offer different coverages. A ‘me-too’ filing may be made with a new form # and the appropriate amendments. 8. What are the filing requirements for the prohibition of discrimination based on salary since it is not included on the Uniform Compliance Summary? The same filing requirements as the other reforms must be adhered to. The category can be manually filled in. It applies to non-grandfathered group health plans. 9. What are the filing requirements with regard to the internal and external review processes? Internal claims appeal process: Grandfathered plans – No filing required. Non-grandfathered plans – all plans – new product must incorporate Department of Labor’s claims and appeals procedures. External review: Non-grandfathered plans – all plans – must meet current state law requirements. (Department has until 7/1/2011 to adopt most recent model act at which time plans must comply with the new model act). 10. How will the rates be treated for the PPACA filings? The current rating statutes apply. However, it is important to note that the new Medical Loss Ratio standards become effective January 1, 2011. These new standards must be reflected in new rate filings. Also, the Department of Health and Human Services is establishing guidelines to define ‘unreasonable’ rate increases. Additional filing requirements may be required when the new regulations are developed.