Carrier Frequently Asked Questions in 2014Show All Hide All
|The following questions have been received by the Idaho Department of Insurance
regarding the Qualified Health Plan (QHP) standards, the filing process and requirements, Your Health Idaho
(YHI) and market-wide policies, 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.
(5/15/2014) Yes. Please see the 2015 QHP Standards notice distributed April 21, 2014, available on the DOI website under Health Care Reform.
2. Due to SERFF binder functionality delays, will the DOI change the deadlines from what is presented in the 2015 QHP Standards document distributed April 21, 2014 by the Idaho DOI? Read >>
(6/27/2014) In addition to the changes below, the Carrier Plan Preview is expected to begin July 10, and YHI is contemplating moving the participation agreement deadline from October 10 to prior to September 1.
(5/15/2014) The 2015 QHP Standards notice stated that, “In the case that SERFF is not ready to accept binder filings by the May 9 or May 30 due dates specified above, carriers will still be expected to submit their forms and rates through standard (non-binder) filings. DOI will expect carriers to complete their application by submitting the remaining components in a binder within one week of the SERFF binder functionality becoming available.” The DOI has moved the May 9 filing date for new exchange participants back to align with the general filing date of May 30. The general filing date for standard forms and rates filings of May 30 is not changing. Due to the unknown status of the SERFF binder functionality, the DOI is specifying the binder filing date as June 13, which is two weeks after the standard filing date. At this time, none of the other dates referenced in the 2015 QHP Standards notice are changing.
3. Have you established a filing deadline for off-exchange plans for the 2015 plan year? Read >>
(5/15/2014) While there is no hard deadline for off-exchange plans, the DOI recommends carriers selling only off-exchange plans have the 2015 forms, rates, and federal templates filed no later than August 29, 2014. If a carrier filing on-exchange plans also wishes to sell some plans only off-exchange, the carrier must include all plans (on and off-exchange) together in one filing by May 30, 2014 (See question 2). Please note that if an individual plan is not available for purchase throughout the full open enrollment period as stipulated by 45 C.F.R § 147.104(b)(1)(ii), the carrier will not be able to limit enrollment outside of the open enrollment period and instead must enroll any individual who applies at any time during the following calendar year. Similarly, if a small group plan is not available for purchase during the full November 15 to December 15 annual enrollment period when minimum participation and contribution rates cannot be imposed, the carrier must not apply a minimum participation or minimum contribution rate to any small group applicant during the following calendar year.
4. Will the off-exchange open enrollment period for the 2015 calendar year coverage differ from the on-exchange open enrollment period of November 15, 2014 through February 15, 2015? Read >>
(5/15/2014) At this time, the DOI does not expect to expand or modify the off-exchange open enrollment period from the on-exchange open enrollment period.
5. What is the Idaho exchange user fee for the 2015 plan year? Read >>
(5/15/2014) The Idaho Health Insurance Exchange Board set the 2015 fee at the April 18, 2014 board meeting at 1.5% of premium.
6. Does Idaho require a health plan to embed the pediatric dental benefit when off the exchange, and what is considered reasonable assurance? Read >>
(5/15/2014) For questions regarding the pediatric dental care EHB and reasonable assurance, please see Idaho DOI Bulletin 14-02.
7. When can plans be added to either the individual or small group market? Read >>
(5/15/2014) Since the market-wide index rate development must reflect all plans in the single risk pool, all plans in the risk pool have to have their rates approved at the same time, regardless of YHI participation. Therefore, new plans must be submitted with all other plans within the same market at the same time the market-wide index rate is changed. 45 C.F.R. § 156.80(d)(3) states that carriers (selling inside or outside an Exchange) may adjust the individual market-wide index rate annually and the small group market-wide index rate quarterly. Because the QHP certification process occurs annually and in order to maintain parity between QHPs and non-QHPs, new plans will not be allowed as part of the quarterly adjustments in the small group market. The quarterly index rate adjustments should be limited to modifications of the small group market index rate and expected trend through the fourth quarter of the calendar year.
8. Are small group composite premiums allowed at certain group sizes, as long as the total is equal to the allowable per-member rating at issue and renewal? Read >>
(7/15/2014) On July 8, CMS leadership approved the proposed small group composite premium method described below. The full proposal with additional details around the methodology is found here.
(6/27/2014) Idaho DOI has recommended an alternative composite premium development methodology to CMS, per the regulation referenced below. It is expected that the method will be accepted. The Idaho specific method is equivalent in total to the required per-member rating methodology. The total premium is allocated back to employees based on a four-tier structure with standard tier factors, assigning any allowable tobacco use load separately to the corresponding individual. If the Idaho-specific method is approved, carriers cannot use the federally defined method. The tiers and factors are as follows:
- Employee Only = 1.0
- Employee and Spouse = 2.0
- Employee and Child(ren) = 1.9
- Employee, Spouse, and Child(ren) = 2.9
9. Will YHI allow premium aggregation (employee choice) in the SHOP during 2015? Read >>
(5/15/2014) YHI will be implementing a manual process for SHOP enrollment for plan year 2015 and is not planning to implement employee choice in 2015. YHI will be conducting an on-going assessment of the SHOP marketplace in the coming months and will determine whether employee choice will be an offering in the future.
10. What requirements exist for brokers / producers who wish to participate in YHI? Read >>
(5/15/2014) Work is underway to transition the training and certification process from CMS to Your YHI for the 2015 open enrollment period. For the 2015 Open Enrollment period, all producers that would like to sell plans from the Exchange must complete YHI’s training and certification process – as the training will be Idaho specific and cover new material and systems not covered in the 2014 CMS training. YHI anticipates having on-line, self-paced training available in early September. Once the YHI specific training program is available, YHI and the DOI will communicate those details to the producer community. NOTE: Any producers not already certified through CMS to sell Exchange products who would like to be certified for the Special Enrollment Period (now through November 15, 2015) must complete the Federally Facilitated Marketplace (FFM) Training via The Medicare Learning Network. Producers will be required to take YHI’s training for sale of 2015 plans. A quick reference guide explaining that process can be found at http://www.cms.gov/CCIIO/Programs-and-Initiatives/Health-Insurance-Marketplaces/Downloads/agent-broker-reg-quick-reference.pdf. Any questions regarding YHI’s training and certification process can be directed to the YHI Consumer Connector Program at connect@YourHealthIdaho.org.
11. How do federal regulations change how Idaho carriers determine if an employer qualifies as a small group in 2015? Read >>
(5/15/2014) Idaho’s definition of a small employer and method of counting employees, found in Idaho Code section 41-4703(28), will continue to apply in 2015. As of January 1, 2016, the federal method of counting employees, provided by the IRS at 26 USC 4980H, will apply, and a small employer will be defined as those with not more than 100 employees, per 45 C.F.R. § 155.20.
12. Are rate manuals required to be included as part of a QHP rate filing? Read >>
(5/15/2014) Idaho requires individual and small group carriers maintain a rate manual at the place of business and file the rate manual with the DOI prior to use. The DOI will expect that carriers file rate manuals for the 2015 plan year as part of the rate filing associated with an on-exchange or off-exchange plan. The rate manual should specify all rating factors used in calculating a premium. This requirement also applies to stand-alone dental carriers seeking exchange certification.
13. Do carriers need to submit the federal rating business rules template in 2015? Read >>
(6/27/2014)Yes. While YHI will not be utilizing this template, QHP carriers are still expected to submit it by July 1, 2014. The rules and responses below should be used to complete the template. Carriers have the flexibility to add additional relationships to the response to the final business rule, as what is shown in the table is the minimum. These responses are to apply to on-exchange and off-exchange policies of QHPs and non-QHPs in both the individual and small group market. Please contact Wes Trexler with any questions about these responses.
|Business Rule||Recommended Carrier Response|
|How are rates for contracts covering two or more enrollees calculated?||A different rate (specifically for parties of two or more) for each enrollee is added together.|
|What is the maximum number of under age (under 21) dependents used to quote a two parent family?||3 or more|
|What is the maximum number of under age (under 21) dependents used to quote a single parent family?||3 or more|
|What is the maximum number of children used to quote a children-only contract?||3 or more|
|Is there a maximum age for a dependent?||Yes, 25 (through first month of 26th birthday), excepting wards.|
|Are domestic partners treated the same as secondary subscribers?||No|
|Are same-sex partners treated the same as secondary subscribers?||No|
|How is age determined for rating and initial eligibility purposes?||Age on effective date.|
|How is tobacco status determined for subscribers and dependents?||“Not Applicable” or “6 months” are both acceptable, aligning with the carrier’s rates.|
|What relationships between primary and dependent are allowed, and is the dependent required to live in the same household as the primary subscriber?||Spouse, No; Adopted Child, No; Ward, No; Stepson or Stepdaughter, No; Self, No; Child, No; Other Relationship, No|
YHI will be utilizing additional relationships in certain circumstances. QHP carriers should be prepared to accept “Court Appointed Guardian” in cases where the primary applicant has legal guardianship of a non-child dependent (grandchild, nephew, etc.), and QHP carriers will need to accept “Brother or Sister” when an application is for a children-only policy where all are allowable dependents of the policy’s responsible party.
14. Do carriers need to submit the federal network adequacy template in 2015? Read >>
(5/15/2014) Yes. The DOI is requesting carriers submit the network adequacy template by July 1, 2014. While the DOI will not be using this template for QHP review purposes, the DOI will be using the template data to inform future decisions regarding network adequacy standards.
15. Are there recommended changes to the default add-in EHB information provided in the federal plans and benefits template? Read >>
(5/16/2014) Yes. CMS has released "Revised Benchmark Spreadsheets" which carriers should rely on when correcting the EHBs auto-populated within the federal plans and benefits template. The individual market EHBs are available here, and the small group market EHBs are available here.
16. Are enrollees of the Idaho Individual High Risk Pool plans eligible for a special enrollment period upon reaching the maximum lifetime benefit per carrier, allowing the individual to enroll in 2014 ACA-compliant health plan? Read >>
(5/15/2014) No. Reaching the maximum lifetime benefit does not meet the criteria for a special enrollment period. The Idaho Individual High Risk Pool has existing procedures to allow enrollees to migrate to another carrier upon reaching the maximum benefit. Carriers should continue to follow those procedures, which will allow the enrollee unbroken access to coverage.
17. Are the Idaho Individual High Risk Pool plans considered minimum essential coverage? Read >>
(6/27/2014) Currently, yes. However, per federal guidance Idaho Individual High Risk Pool plans will not satisfy the minimum essential coverage requirement starting with plan years that begin January 1, 2015 or later. Accordingly, the expiration of HRP coverage as minimum essential coverage will effect a special enrollment period at that point in 2015. Individuals should be notified of such and encouraged to enroll in ACA compliant plans in order to maintain minimum essential coverage and avoid the potential tax penalty.
18. What templates are required for on-exchange plans and what templates are required for off-exchange only plans? Read >>
(6/27/2014) Regarding QHPs and SADPs that are seeking certification (for on or off-exchange sale), please see the DOI’s QHP Binder Filing Instructions.
For off-exchange only medical plans, the following templates and corresponding supporting documentation are required: Plans and Benefit Template, Prescription Drug Template, Network Template, Service Area Template, Rate Data Template, Business Rules Template, Unified Rate Review Template. The following templates are optional (not required) for off-exchange only medical plans: Administrative Template, ECP Template, Accreditation Template, Network Adequacy Template, Network Access Cover Sheet, Idaho Specific Attestations.
For SADPs not seeking certification, no binders or templates are needed.
19. Can adults purchase a stand-alone dental plan on YHI? Read >>
(6/27/2014) No. At least for the 2015 plan year, YHI will not sell coverage through a stand-alone dental plan to individuals age 19 or greater. YHI will offer stand-alone dental plans for purchase that provide coverage to individuals under age 19. YHI will be conducting an assessment to determine anticipated future functionality regarding stand-alone dental plans including covering adults. Plans with adult benefits can still be exchange-certified, and adult coverage can be purchased outside of YHI.
20. Will YHI display in the shopping experience stand-alone dental plans designated as either “Allows Child-Only” or “Allows Adult and Child-Only” within the plans and benefits template? Read >>
(6/27/2014) YHI will make available both “Allows Child-Only” dental plans and “Allows Adult and Child-Only” plans for selection after an applicant purchases a medical QHP, and at least one individual on the application is under age 19. However, if a family is applying for coverage on YHI, the dental application will include coverage for only the family members under age 19. This functionality may be expanded in the future to include offering dental coverage for adults. The DOI and YHI will work with carriers to ensure that in cases when there are multiple plans from a single carrier that have identical pediatric benefits, only one of those plans will be made available through YHI. The other plans can still be exchange-certified and purchased directly from carriers outside of YHI.
21. Regarding stand-alone dental plans, will YHI allow the “household” composite rating tiers (Individual, Couple, Couple and Children, Family, etc.) or only the per member rating by age? Read >>
(6/27/2014) The DOI recommends that stand-alone dental plans utilize the per member build-up using age rating in order to improve consistency among dental carriers. Because YHI will only be quoting stand-alone dental plans for individual under age 19, carriers must not use the household tier rating methodology for stand-alone dental plans in the individual market that will be sold through YHI. Carriers can utilize household tier rating on plans in the small group market and in the individual market if not offered through YHI. In the future, if stand-alone dental plans with adult benefits are displayed in YHI, both per member rating and household tier rating will be supported in the individual market, although the DOI recommendation to rate using the per member build-up will remain.
22. Regarding stand-alone dental plans, will YHI distinguish between “guaranteed” and “estimated” rates? Read >>
(6/27/2014) No. YHI’s solution will not distinguish between a plan that is defined to have guaranteed rates (the premium for the plan will always match what YHI displays during shopping) or estimated rates (the premium can vary from what YHI displays during shopping). Therefore, in order to minimize confusion and avoid misleading consumers purchasing a dental plan, YHI requires that, at least for 2015, dental carriers develop guaranteed rates for child-only policies.
23. Is the Carrier Acknowledgement & Consent to Publishing of Rate Information and Determination form required for stand-alone dental plans wishing to be exchange-certified? Read >>
(6/27/2014) No. That form is only needed for medical plans.
24. Since accreditation is not a requirement of stand-alone dental plans, how should a SADP demonstrate network adequacy? Read >>
(6/27/2014) Stand-alone dental carriers should demonstrate network adequacy by submitting with their binder the Network Adequacy Cover Sheet and an accompanying Network Access Plan which demonstrates that each SADP meets 45 C.F.R. 156.230(a)(2) as it applies to SADPs. The following sections of the Cover Sheet apply to SADPs: standards for network composition (excluding references to mental health and substance abuse providers), ongoing monitoring process, plan for addressing needs of special populations, member communication methods, and continuity of care plan (in the event of provider contract termination or corporate insolvency).
25. On September 12, 2014, CMS released “Revised Bulletin #10 on Grace Periods Related to Terminations for Non-Payment of Premiums and Enrollment through the Federally-facilitated Marketplace across Benefit Years.” The bulletin specifically applies to Federally-facilitated Marketplaces, and therefore is not directly applicable to Idaho. How does the DOI interpret the regulations regarding a grace period that crosses benefit years? Read >>
(11/12/2014) The CMS bulletin treats the specific case of an enrollee either passively or actively renewing his/her policy into the identical plan (or the applicable replacement plan if the same plan is not available) differently from the case of an enrollee choosing a different plan at renewal. The bulletin requires that the three-month grace period applicable to QHPs with APTC span benefit years, as long as the enrollee does not actively choose a different plan. In this case (renewing into the same plan), carriers are permitted to apply any payments received as part of a renewal to the outstanding debt. If the enrollee does not become current on payments by the end of the three-month grace period, the carrier can terminate the policy for non-payment in accordance with the policy language. If instead the enrollee chooses a different plan, the carrier would treat the reenrollment as a new enrollment – not applying any payments to the outstanding debt for the prior benefit year.
Alternatively, the three-month grace period can be allowed to span benefit years in all cases of continuous coverage. In this approach, the carrier would treat enrollees renewing into either the same or a different plan as renewals rather than new enrollments. As such, any payments made by the enrollee may be applied to the outstanding debt for the prior benefit year, and if the enrollee does not become current on payments by the end of the three-month grace period, the carrier can terminate the policy for non-payment in accordance with the policy language.
The DOI finds either approach acceptable, provided that the carrier communicates the policy to the enrollees and applies it consistently.
26. Are there Idaho standards regarding the acceptance of incomplete binder payments to effectuate coverage? Read >>
(11/12/2014) No. Each carrier should have a standard practice regarding incomplete payments of the initial premium. This could be a percentage or dollar threshold, and the threshold should be applied consistently.
27. Regarding renewing coverage, are there situations in which the carrier could require a new binder payment prior to processing the renewal? Read >>
(11/12/2014) In the case of an enrollee either passively or actively renewing his/her policy into the identical plan or the applicable replacement plan if the same plan is no longer an option, the carrier should not require a binder payment to continue coverage. Instead, the carrier should apply the contractual grace period for non-APTC coverage. The three-month grace period that applies to policies with APTC does not apply until the first month of a benefit year is paid, so it would not apply to the January payment of a renewal if the enrollee was current through the end of December.
In other cases, such as an enrollee actively renewing the policy into a different plan, the carrier should define and apply a consistent policy of either requiring or not requiring a binder payment to begin the coverage for the new benefit year.
28. Idaho’s small employer Basic, Standard, and Catastrophic plans, as described in IDAPA 18.01.70, do not qualify as grandfathered plans, and the plans do not meet ACA requirements to be sold as non-grandfathered coverage after January 1, 2014. Therefore, what options do carriers have regarding these plans mandated by Idaho Code § 41-4708? Read >>
(11/12/2014) The DOI has determined that the ACA requires that these mandated plans either be modified by carriers to adopt the grandfathered plan consumer protections or be discontinued following the discontinuation requirements of Idaho Code § 41-4707(1)(g).
29. How does the DOI interpret and intend to enforce the new requirements for fixed indemnity plans in the individual market, as described in the Market Standards final rule, published May 27, 2014? Read >>
(11/12/2014) Beginning January 1, 2015, fixed indemnity plans in the individual market may be sold only to individuals who attest in their application for coverage that they have other health coverage that meets the definition of minimum essential coverage under the ACA. The following additional requirements also apply:
- There must be no coordination between benefits that are provided in the fixed indemnity plan and excluded in another health plan;
- Benefits must be paid in a fixed dollar amount per period of hospitalization, illness or service without regard to the actual expense; and
- The Department requires that the plan display the following language in at least 14 point type on the face page of the policy and on the application materials: “THIS IS A SUPPLEMENT TO HEALTH INSURANCE AND IS NOT A SUBSTITUTE FOR MAJOR MEDICAL COVERAGE. LACK OF MAJOR MEDICAL COVERAGE (OR OTHER MINIMUM ESSENTIAL COVERAGE) MAY RESULT IN AN ADDITIONAL PAYMENT WITH YOUR TAXES.”
30. Do group health plans that do not include in-patient hospitalization services meet minimum value requirements if the plan provides at least a 60% value, as determined using the Minimum Value Calculator? Read >>
(11/12/2014) No. On November 4, 2014, the IRS issued Notice 2014-69. This notice states that health plans which fail to provide in-patient hospitalization services and/or physician services do not satisfy the minimum value requirement. Employers will not be subject to IRS penalties for offering coverage in such a plan if the plan year begins on or before March 1, 2015. However, employees who are offered coverage in an employer plan that does not include in-patient hospitalization services and/or physician services will be eligible to enroll in an individual plan with APTC regardless of when the plan year begins.
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