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Carrier Frequently Asked Questions in 2013

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The following questions have been received by the Idaho Department of Insurance regarding the Idaho Health Insurance Exchange and SHOP (Idaho Exchange), the filing process, Qualified Health Plan standards, and other related topics. The answers are intended to offer guidance on current issues based on the DOI’s current understanding of applicable federal and state law requirements. If you have any concerns regarding the accuracy of any of the guidance, please contact Wes Trexler at the DOI by phone at 208-334-4315 or email. The DOI will continue to release additional information and revise these responses as needed.

1. What is the Idaho exchange user fee?   Read >>

2. What fee should carriers use in QHP filings prior to the Idaho Exchange Board setting the exchange user fee?   Read >>

3. What are the names of the rating areas so that we can input them in our rating template? The bulletin identifies how the areas are defined but will there be a standard naming convention that will be used by all the carriers?   Read >>

4. What is the minimum number of medical plans that a carrier may offer through the Idaho Exchange?   Read >>

5. Will the Notice of the Ten (10)-Day Right to Examine a Policy requirement be applicable to the QHPs?   Read >>

6. Must the SERFF filing of the policies, Outlines of Coverage (OOCs) and/or Summaries of Benefits and Coverage (SBCs) be “filed” before we can associate the filings in the binder or can the policies just be in submitted and in the review at the DOI process when we create the binder?   Read >>

7. Will the DOI be using the FFE standards to determine network adequacy?   Read >>

8. the state has a question regarding a deficiency, will this be handled like an objection in SERFF?   Read >>

9. We have been advised in CCIIO meetings the Medical Loss Ratio & Uniform Rate Review Template (URRT) will need to be sent to HIOS as well as SERFF. Are you aware of additional templates that will also need to be submitted to SERFF?   Read >>

10. Has a date been set for the filing of dental products for 2014?   Read >>

11. Rate filings must be filed through SERFF by May 31. What is the timeline for forms such as our contracts or certificates?   Read >>

12. Have you established a filing deadline for non-exchange products?   Read >>

13. For Individual, will there be opportunities to change rates after they are filed? Once we have submitted our products and rates, can we drop them? What is the cutoff date?   Read >>

14. For Small Employer, the ACA and regulation (45 CFR § 155.705(b)(6)(i)) allows for rates to be changed on a quarterly, monthly, or annual basis. What will the filing timeline be for quarterly changes?   Read >>

15. Do rate manuals need to be included with the QHP filings?   Read >>

16. Since Idaho does not have a rule or law on minimum participation and has allowed the carriers to make their own participation rules in the past, is Idaho going to continue to allow this procedure in 2014 or are carriers going to be required to follow the exchange minimum?   Read >>

17. Regarding the SHOP in Idaho, is the DOI going to limit options?   Read >>

18. Is the no rider/endorsement requirement also applicable for plans outside the exchange?   Read >>

19. When, at what stage of the filing process in SERFF, do filings become public?   Read >>

20. Below are some of the areas where it appears the requirements of Rule 30 (IDAPA 20.18.01.30) could require richer benefits than are required under the benchmark plan. Please clarify if the benchmark plan limits apply to individual plans (preempting Rule 30) or if Rule 30 still applies to individual plans, with the restrictions shown in the table? [TABLE OMITTED]   Read >>

21. Will there be specific questions that we should ask prospective members?   Read >>

22. Will short term policies be limited to transitional membership only?   Read >>

23. Per Bulletin 13-02, the state allows SHOP rating on a per member basis. Does this also extend to premium billing as well, or do premium rates have to be billed at the subscriber level? If subscriber-level billing is required, can premium rates be billed separately for different levels of dependent coverage (e.g., Employee Only, Employee & Child, Employee & Spouse, Employee & Family) or must they be billed for employee only coverage versus employee plus family coverage (i.e., 2-tier rating)?   Read >>

24. Does Bulletin 13-01 apply to stand-alone dental plans?   Read >>

25. Is minor variability allowed for something like contact information?   Read >>

26. Is Idaho going to require having coverage for Non-Emergency Care When Traveling outside the U.S.?   Read >>

27. Does ACA say that individual plans will all be based on calendar year accumulators (for deductibles/OOP maxes) and small group will be based on plan year accumulators? Does the same apply to dental plans?   Read >>

28. What is the Idaho benchmark plan supplement covering pediatric oral care?   Read >>

29. Which of the HHS requirements noted in the Final Rule dated 2/25/13 that apply to FFE and state-partnerships also apply to pediatric dental in the Exchange?   Read >>

30. Must the stand-alone dental plan have unlimited coverage?   Read >>

31. What is the maximum out of pocket for stand-alone dental plans?   Read >>

32. Are two stand-alone dental plans required at the 70% and 85% AV level?   Read >>

33. Will medically necessary orthodontia be required as an EHB?   Read >>

34. Is there a 24 month waiting period for orthodontia?   Read >>

35. Would adult dental be considered an optional rider for the medical carriers and a stand-alone policy for dental carriers? Will it be allowed to be offered in the Exchange?   Read >>

36. In the DOI’s Q&A dated 5/3/13, question #24, it states that the DOI “expects current dental plans that cover pediatric dental to be discontinued and replaced with an ACA compliant (i.e. Idaho benchmark plan) pediatric dental plan, in compliance with Bulletin 13-01.”
An alternative would be for the DOI to require that any new dental plans sold in 2014 to individuals or groups with less than 50 employees “carve out” the pediatric dental plan and allow those individuals and groups to purchase the new pediatric dental plan (benchmark plan) which will be unique from the adult dental plan. Any current policies for individual and/or group policies with less than 50 employees would be required to “carve out” the pediatric dental plan at their next renewal date in compliance with DOI Bulletin 13-01.
  Read >>

37. Do all of the SHOP dental plans need to be age rated since the pediatric benefit only applies to children up to age 19? Apparently, SERRF requires age rating and not tiered rating. Is this correct? Note, this is related to DOI’s Q&A dated 5/3/13, question #23.   Read >>

38. Must stand-alone dental plans offer rate manuals, DOI’s Q&A dated 5/3/13, question #15? If rate manuals must be provided, please specify what should be included and if this would be considered proprietary.   Read >>

39. Does the DOI consider stand-alone dental plans to be QHPs?   Read >>

40. Will childless adults be required to purchase pediatric dental in the Exchange?   Read >>

41. Will medical carriers be required to price embedded pediatric dental benefits separately in and out of the Exchange for comparison purposes?   Read >>

42. Will the Exchange provide information about the dentists contracted with the medical or dental carrier?   Read >>

43. Does Idaho require a health plan to embed the pediatric dental benefit when off the Exchange?   Read >>

44. Will the DOI allow the following language to be used to meet the “reasonably assured” requirement for policies sold outside the Idaho Exchange that do not embed pediatric dental? The following language has been recommended by the Wisconsin & Iowa Insurance Commissioners:
“This policy does not include pediatric dental services as required under the federal Patient Protection and Affordable Care Act. This coverage is available in the market and can be purchased as a stand-alone product. Please contact your carrier, your insurance agent, or the if you wish to purchase pediatric dental coverage or a stand-alone dental services product.”
  Read >>

45. How does a stand-alone dental plan off-exchange obtain the status of “Exchange certified”?   Read >>

46. How is preventive care defined in reference to the pediatric oral EHB for the purpose of applying the requirement of no cost-sharing?   Read >>

47. To comply with the essential health benefits for pediatric dental, must the issuer offer a child-only plan on the SHOP?   Read >>

48. Can a carrier offer coverage outside of the Exchange if it does not also offer a plan through the Exchange?   Read >>

49. What is the filing deadline for off-exchange only, non-QHPs?   Read >>

50. For Idaho, it appears that QHPs and off-exchange plans should be filed through SERFF. Are there any requirements to also file with the Health Insurance Oversight System (HIOS) or the Rate and Benefits Information System (RBIS)?   Read >>

51. Are issuers permitted to offer shorter or longer than 12 month policies in the individual or small group markets?   Read >>

52. Can issuers offer off-cycle renewals to policy holders?   Read >>

53. When can plans be added to either the individual or small group market?   Read >>

54. When is the Plan Preview for plans that are participating in the Idaho Exchange?   Read >>

55. Under what circumstances can a small group plan exceed the annual deductible limit of $2,000 for an individual or $4,000 for a family specified in 45 C.F.R. § 156.130(b)?   Read >>

56. Are conversion plans required after January 1, 2014, even with guaranteed-issue in the individual market? If conversion will still need to be offered, will it have to conform to all ACA requirements for other non-grandfathered plans, i.e., EHB’s, metal plan level, etc.?   Read >>

57. Is small group composite rating allowed at certain group sizes, as long as the total is equal to the allowable per-member rating at issue and renewal   Read >>

58. Is there an updated version of the Idaho Small Employer Application that conforms to the requirements of the ACA (i.e., removal of health status questions, etc.)?   Read >>

59. What requirements exist for brokers / producers who wish to participate in the Idaho Exchange?   Read >>

60. How will carriers be notified if a producer is certified to sell through the Exchange?   Read >>

61. For the transition of non-grandfathered off-exchange moving to EHB medical coverage, can a carrier automatically enroll an individual or group onto an Exchange-certified stand-alone dental plan to ensure compliance, if the carrier can’t obtain a definitive response from the member or group that they have purchased an Exchange-certified stand-alone dental plan?   Read >>

62. For off-exchange shoppers wanting to purchase medical coverage, how should carriers enroll an individual or group onto a QHP pediatric product?   Read >>

63. If a family drops a dependent eligible for the pediatric dental benefit and the carrier cannot become reasonably assured that the dependent has an Exchange-certified standalone dental plan through another carrier, will the medical policy also need to be terminated for the entire family or just the dependent?   Read >>

64. If an off-exchange member/group does not provide the evidence requested by the medical carrier to be reasonably assured that they have an Exchange-certified standalone dental plan, will the medical carrier that is not providing the pediatric dental EHB be forced to terminate the member/group as non-compliant?   Read >>

65. How often does a carrier have to track or certify compliance with covering the pediatric dental EHB?   Read >>

66. Will groups that purchase on the Idaho SHOP be able to make multiple plan options available to their employees? Does the same apply for stand-alone dental plans available on the Idaho SHOP?   Read >>

67. How do new federal regulations and the exchange change how Idaho carriers determine if an employer qualifies as a small group in 2014?   Read >>

68. While Idaho insurance code section 41-4708(3)(f)(i) requires insurers to offer to cover dependents, are small groups required to provide coverage to spouses and children dependents of employees?   Read >>

69. What Idaho and federal regulatory requirements apply to large groups regarding coverage of spouses and children dependents?   Read >>

70. Since the market reforms include guaranteed availability, must an individual health carrier continue to actively market or offer the Idaho Individual High Risk Pool plans?   Read >>

71. While federal regulations do not provide a special enrollment period upon the expiration of a short-term health insurance policy since it is not deemed Minimum Essential Coverage, should carriers allow individuals to transfer to a full EHB compliant health plan at that time?   Read >>

72. At what time and under what conditions should an individual or small group health policy be re-rated after a change in primary address?   Read >>

73. Must employers provide notice to their employees concerning the Exchange and their new coverage options?   Read >>


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