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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 3 – May 31, 2013
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 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 10, 16, 24, 27, 46, and 47 from prior Q&A releases have been revised as shown below.
- Has a date been set for the filing of dental products for 2014?
A. (Revised 5/31/2013) The recommended QHP filing deadline for stand-alone dental plans that issuers would like “Exchange certified” has been extended to June 7, 2013. There is no set filing deadline for stand-alone dental plans that issuers are not seeking to have “Exchange certified.”
- 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?
A. (Revised 5/31/2013) The Idaho Exchange Board has the authority to set a minimum participation requirement for the Idaho SHOP. The Board has set the minimum participation requirement at 70% for small employers who wish to enroll through the SHOP. Carriers can continue setting their own reasonable participation requirements outside the Exchange. Pursuant to 45 C.F.R. § 147.104, small employers who meet the applicable participation requirement can purchase health insurance coverage at any point during the year. Small employers who do not meet the participation requirement must be allowed to purchase coverage during an annual enrollment period from November 15 to December 15. These enrollment periods apply market-wide.
- Does Bulletin 13-01 apply to stand-alone dental plans?
A. (Revised 5/31/2013) Stand-alone dental plans and vision plans are considered exempted benefits, and are therefore not subject to most ACA reforms. Plans currently being sold do not need to be modified or discontinued. Stand-alone dental plans that issuers wish to sell as “Exchange certified” must be filed through SERFF as new plans and meet all applicable requirements such as covering pediatric oral benefits without annual or lifetime limits, meeting a specific actuarial value, and having a reasonable out-of-pocket maximum (see Q&A #31).
- 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?
A. (Revised 8/8/2013) In the individual market, deductibles and maximums must accumulate on a calendar year basis. In the small group market, federal regulations do not provide guidance, so deductibles and maximums can continue to accumulate on a calendar year or renewal year basis. “Exchange certified” stand‐alone dental plans have the same accumulator requirements as medical QHPs.
- How is preventive care defined in reference to the pediatric oral EHB for the purpose of applying
the requirement of no cost-sharing?
A. (Revised 5/31/2013) The specific preventive care services that are required to be covered with no cost sharing are not tied to the state’s EHB benchmark, but instead to the certain preventive services as required by 45 C.F.R. § 147.130. For more information on preventive services that must be covered without cost sharing under the requirements of the Affordable Care Act, please see http://www.healthcare.gov/news/factsheets/2010/07/preventive-services-list.html.
- To comply with the essential health benefits for pediatric dental, must the issuer offer a child-only
plan on the SHOP?
A. (Revised 5/31/2013) Offering a child-only option is a requirement under section 2707(c) of the Affordable Care Act for enrollees under the age of 21, or in the case of the SHOP, employees under the age of 21. This age aligns with the rating restriction for medical plans to apply the same age factor in developing the premium for all individuals under the age of 21. The pediatric dental EHB coverage only pertains to individuals under the age of 19. If an “Exchange certified" stand-alone dental plan is offered that covers only the pediatric dental EHB, it could be priced for individuals age 19 and older at no cost.
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.