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C.L. "BUTCH" OTTER
DEPARTMENT OF INSURANCE
700 West State Street, 3rd Floor
P.O. Box 83720
Boise, Idaho 83720-0043
WILLIAM W. DEAL
Idaho Carrier Questions and Answers, Part 2 – May 17, 2013
The following additional 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 or email at 208-334-4315 or firstname.lastname@example.org. The DOI will continue to release additional information and revise these responses as needed.
The answers to questions 18, 19, 20, 25, and 26 from the May 3, 2013 Q&A (which was posted and distributed May 6, 2013) have been revised as shown below. The remaining questions are new.
- Is the no rider/endorsement requirement also applicable for plans outside the exchange?
A. (Revised 5/17/2013) Optional Non-EHB riders with corresponding additional premium will be permitted outside the exchange. Plans offered in and out of the exchange must charge the same premium prior to any optional riders. Off-exchange only plans can include mandatory riders. Mandatory riders must be considered part of the policy when completing the filing templates.
- When, at what stage of the filing process in SERFF, do filings become public?
A. (Revised 5/17/2013) Per Idaho Code § 9-340D(1), the DOI generally considers records as proprietary or “trade secret” any rates or rating information that is flagged as confidential within a filing. While such a designation by a company does not necessarily conclusively resolve the question, it does assist the DOI and has been referenced in Bulletin 95-2. Due to the significant market changes, form filings that issuers designate as confidential will be considered as such to the extent authorized by applicable law by the DOI at least through the date the corresponding QHP is certified. We have no information regarding public access to information filed through HIOS.
- 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]
A. (Revised 5/17/2013) The general preemption guideline is that a state law is preempted by the ACA only where complying with it would result in non-compliance with the federal act or regulation. IDAPA 18.01.30.018.04 prohibits dollar limits except for a specified list of benefits. ACA as implemented through 45 C.F.R § 147.126(a)(2) prohibits dollar limits on EHB. Visit limits on EHB are not precluded under Rule 30 or ACA.
- Is minor variability allowed for something like contact information?
A. (Revised 5/17/2013) Individual filings can continue to include benefit variables such as deductibles and coinsurance or contact information. However, optional benefits such as dependent age or dental cannot use variable language.
- Is Idaho going to require having coverage for Non-Emergency Care When Traveling outside the U.S.?
A. (Revised 5/17/2013) This particular benefit has been re-categorized as a network issue rather than an essential health benefit. If not covered, an issuer should choose “Not Covered" in the template and use the EHB Variance Reason "Other Law/Regulation."
- What is the Idaho benchmark plan supplement covering pediatric oral care?
A. Per Appendix B of the Essential Health Benefits Final Rule published February 25, 2013, in Federal Register Vol. 78 No. 37, the supplement benchmark plan for FEDVIP is the MetLife Federal Dental Plan-High. The 2012 plan benefit brochure for that plan can be found at http://www.opm.gov/insure/health/planinfo/2012/brochures/MetLife.pdf.
- 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?
A. Under 45 C.F.R. § 155.1065(a)(2), the pediatric dental EHB offered by stand-alone dental plans certified to be offered in the Exchanges must be offered without annual and lifetime limits. Under 45 C.F.R. § 156.150(a), rather than meeting the specific dollar limits that apply to cost sharing for comprehensive medical QHPs, stand-alone dental plans certified to be offered inside an Exchange will be required to demonstrate to the Exchange (FFE or otherwise) that they have a reasonable annual limitation on cost-sharing in place. The EHB/Accreditation final rule also clarified that the Exchange is responsible for determining the level for “reasonable.” As stated in 45 C.F.R. § 155.1065, issuers of stand-alone dental plans and stand-alone dental plans must meet QHP certification standards, except for any certification requirement that cannot be met because the plan only covers dental benefits.
The insurance market reform provisions generally do not apply, including guaranteed availability, renewability of coverage, medical loss ratio standards, and rating standards.
- Must the stand-alone dental plan have unlimited coverage?
A. Under 45 C.F.R. § 155.1065(a)(2), the pediatric dental EHB offered by stand-alone dental plans certified to be offered in the Exchanges must be offered without annual and lifetime limits.
- What is the maximum out of pocket for stand-alone dental plans?
A. Under 45 C.F.R. § 156.150(a), rather than meeting the specific dollar limits that apply to cost sharing for comprehensive medical QHPs, stand-alone dental plans certified to be offered inside an Exchange will be required to demonstrate to the Exchange (FFE or otherwise) that they have a reasonable annual limitation on cost-sharing in place. The EHB/Accreditation final rule also clarified that the Exchange is responsible for determining the level for “reasonable.” In fulfilling the plan management role for the Idaho Exchange, the DOI will find a maximum out of pocket limit of up to $1,000 per person reasonable for stand-alone dental plans.
- Are two stand-alone dental plans required at the 70% and 85% AV level?
A. No. Per 45 C.F.R. § 156.150(b), a stand-alone dental plan must meet either a low level (70%) or high level (85%) of coverage. There is no requirement for an issuer to offer both levels.
- Will medically necessary orthodontia be required as an EHB?
A. Medically necessary orthodontia is part of the supplemented Idaho benchmark plan, and therefore part of the essential health benefits, making it a required coverage.
- Is there a 24 month waiting period for orthodontia?
A. A 24 month waiting period for orthodontia is permissible.
- 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?
A. Adult dental is a permitted optional rider outside the Exchange. Riders are not permitted in the Exchange on either medical or stand-alone dental plans (see Q18). Adult dental coverage is permitted as an additional benefit on the Exchange provided it is embedded with the other benefits.
- 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.
A. The DOI would find it acceptable for the pediatric benefit to be carved out from current plans. The carved-out pediatric benefit would need to be offered as a new pediatric dental plan that meets EHB standards.
- 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.
A. The ACA market rules regarding rating standards do not apply to dental plans; therefore, it is not required that SHOP dental plans be age rated. It is correct that the federal rate template used by SERFF does not allow rating structures that do not meet the ACA rating standards. Question #23 applies to plans that are subject to the market reform rating rules, which stand-alone dental plans are not.
- 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.
A. If stand-alone dental plans can provide accurate and complete rate manual details through the use of the requested templates, then the templates should be used to meet that requirement. Since stand-alone dental plans are exempted from several market reforms, the templates will likely not provide accurate rating details, and therefore the DOI would expect that a complete rate manual be included with stand-alone dental plan filings.
- Does the DOI consider stand-alone dental plans to be QHPs?
A. As stated in 45 C.F.R. § 155.1065, issuers of stand-alone dental plans and stand-alone dental plans must meet QHP certification standards, except for any certification requirement that cannot be met because the plan only covers dental benefits. We generally consider stand-alone dental plans to be a type of QHP.
- Will childless adults be required to purchase pediatric dental in the Exchange?
A. No. The Exchange must offer the full set of essential health benefits, including pediatric dental. The pediatric dental can be embedded or stand-alone. The Exchange cannot require an applicant to purchase a stand-alone dental plan if a QHP chooses to not embed the pediatric dental benefit.
- Will medical carriers be required to price embedded pediatric dental benefits separately in and
out of the Exchange for comparison purposes?
A. No. The DOI will not be requiring the pediatric dental coverage to be embedded in QHPs or to be offered only as stand-alone dental plans separate from a medical QHP, and we will not be requiring separate pricing of embedded dental benefits. All QHPs must meet all applicable rating standards, regardless of the inclusion or exclusion of dental benefits. The rating criteria applicable to QHPs with embedded pediatric dental are sufficiently distinct from the rating criteria for stand-alone dental plans that direct comparisons are of limited usefulness.
- Will the Exchange provide information about the dentists contracted with the medical or dental carrier?
A. According to 45 C.F.R. § 156.230(b), a QHP issuer must make its provider directory for a QHP available to the Exchange for publication online in accordance with guidance from the Exchange and to potential enrollees in hard copy upon request. In the provider directory, a QHP issuer must identify providers that are not accepting new patients.
- Does Idaho require a health plan to embed the pediatric dental benefit when off the Exchange?
A. Issuers have the option but are not required to embed the pediatric dental EHB in QHPs or off-exchange plans. For off-exchange plans that do not embed the pediatric dental EHB, the issuer must have a procedure for becoming “reasonably assured” that policy holders obtain pediatric dental coverage through an “Exchange certified” stand-alone dental plan.
- 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 [Idaho Health Insurance Exchange] if you wish to purchase pediatric dental coverage or a stand-alone dental services product.”
A. Issuers have the responsibility to be “reasonably assured” that an individual has obtained pediatric dental coverage through an Exchange-certified stand-alone dental plan. Issuers will need to decide how they fulfill that responsibility in order to be found compliant with EHB requirements. The Idaho DOI would accept the above language.
- How does a stand-alone dental plan off-exchange obtain the status of “Exchange certified”?
A. An off-exchange only stand-alone dental plan can be “Exchange certified” by submitting through SERFF all the requirements for on-exchange QHPs, while indicating that the plan is off-exchange only. It will go through the same process as an on-exchange product, and it has the same filing deadlines as on-exchange products.
- Can a carrier offer coverage outside of the Exchange if it does not also offer a plan through the Exchange?
- What is the filing deadline for off‐exchange only, non‐QHPs?
A. (Revised 8/8/2013) Due to the considerable changes to plan requirements and limitations, the DOI is unable to provide assurance that the review and acceptance of filings will be fully completed by October 1 if a filing is submitted after August 31. Therefore, DOI strongly suggests that rates and forms for new ACA‐compliant plans to be sold only off‐exchange be filed with the DOI no later than August 31.
In accordance with federal regulation and guidance, non‐QHPs must be filed at the same time as QHPs. Please see CMS FAQ released April 18, 2013, question 50 and CMS FAQ released April 24, 2013, question 29 for additional details.
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.
- 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)?
A. We understand there are federal filing requirements for on and off-exchange plans. Questions regarding what information issuers need to file should be confirmed with CCIIO.
- Are issuers permitted to offer shorter or longer than 12 month policies in the individual or small group markets?
A. Nonshort-term comprehensive medical policies in Idaho have generally been offered with a rating period of 12 months. All policies must conform to the rating period specified in the policy forms and the corresponding rate manual. Federal regulations implementing the ACA define plan years and policy years as 12 month periods (45 C.F.R. § 144.103). Therefore, health plan filings in either the individual or small group markets that use policy periods or plan periods that are greater or fewer than 12 months will not be accepted.
- Can issuers offer off-cycle renewals to policy holders?
A. Offering policy holders the opportunity to renew prior to the policy renewal date is not specifically prohibited by the Idaho Code. However, issuers should be attentive to potential unfair discrimination (Idaho Code § 41-1313) or other possible violations of law that such a practice may generate if not undertaken with sufficient care. Any off-cycle renewal offer must be offered to all policy holders within a given market (individual or small group). Risk loads must not be adjusted from the current policy period, while case characteristics may be updated. The renewal offer must clearly communicate that coverage will continue at the current premium rate through the standard renewal date if no action is taken, and it must include language similar to the model renewal notice language found in the CMS notice released April 30, 2013.
About the Department of Insurance
The Idaho Department of Insurance has been regulating the business of insurance in Idaho since 1901. The mission of the Department is to equitably, effectively and efficiently administer the Idaho Insurance Code and the International Fire Code. For more information, visit www.doi.idaho.gov.