QHP Issuer Workshop Part II

Transcription

1 QHP Issuer Workshop Part II QHP Application and Review Process Overview, Part II April 15,

2 Schedule and Logistics Meeting Information The meeting will be available in Webex. To join the meeting, click here and enter meeting password ARQHP. The phone number to for the voice conference is: Call-in toll-free number (US/Canada): Access code: Proposed Schedule 1:30pm Start meeting 2:45pm 15 Minute Break 3:00pm - Resume 4:15pm Wrap up 2

3 Agenda Introductions Plan Management Updates AR 2015 QHP Filing and Certification Requirements Review of QHP Bulletin Recertification Uniform Modification Allowances Essential Health Benefits; new considerations Quality Improvement Initiatives Plan Variations Rate Filing CMS Review Tools Questions? 3

4 Plan Management Updates QHP Bulletin The QHP Bulletin was released on Monday, April Final Letter to Issuers The 2015 final letter to issuers was released by CCIIO on March 14 and summarizes plan year 2015 QHP certification requirements The letter can be found here Network Adequacy Rule The AID Network Adequacy rule is expected to be published within the week (by April 22 nd ) 4

5 Plan Management Updates 2014 QHP Application and Certification Timeline Part I 2014 Key Dates Description May 1st June 15th QHP Applications must be submitted to AID by June 15th June 16th August 8th * AID QHP review period August 11th August 25th FFM Reviews Plan Data August 26th FFM Notifies States of any Needed Corrections to QHP Data September 4th September 5th September 10th Last day for issuers to resubmit plan data 2 nd SERFF Data Transfer * AID is requesting that all plan changes be completed by August 6 th to allow time for transmission to HIOS 5

6 Plan Management Updates 2014 QHP Application and Certification Timeline Part II 2014 Key Dates Description September 22nd FFM Completes Re-review of Plan Data and State Recommendations September 24th October 6th Limited Data Correction Window October 14th November 3rd November 15th Certification Notices and QHP Agreements Sent to Issuers, Agreements Signed, QHP Data Finalized Open Enrollment Begins 6

7 Plan Management Updates Outstanding technical and policy updates that could impact the timelines: Release of 2015 Plan Management Templates (CMS) Completion of updated SERFF validation services (expected by late May) Final AID and Health Care Independence Program ( HCIP, a.k.a. Private Option ) QHP certification criteria and details on cost-sharing variations (expected by May 1) Changes to the proposed market standards for 2015 and beyond (CMS) 7

8 Plan Management Updates Meaningful Difference The review process or meaningful difference in plans was expanded for 2015 and changed slightly from the proposed rule. Plans will be segmented by plan type, metal level and overlapping counties/service areas and then evaluated for differences in network, formulary, deductibles, MOOP, covered benefits, HSAs, and availability for children (premiums was taken out as a criteria) Plans are expected to differ in at least one of these areas. 8

9 Plan Management Updates Summary of Benefits and Coverage (SBC) SBCs are required to be submitted for plan year SBCs illustrate benefits and coverage for common conditions chosen by HHS: Routine maintenance of wellcontrolled type 2 diabetes and having a baby (normal delivery) SBCs for plan variations are not required, but are encouraged. SOBs must be accurate and match policy and SOB s information. 9

10 Plan Management Updates 2015 Plan requirements Riders are not permitted to be offered in conjunction with Marketplace plans, even if the riders are for non- EHB benefits In addition to federal requirements that at least one silver and at least one gold plan are offered in the individual market, QHPs in the Arkansas individual market are required to include at least one silver-level plan that contains only the EHBs included in the state base-benchmark plan 10

11 Filing and QHP Certification Requirements QHP Application Process QHP applications will be filed through SERFF Rate and form filings must both be submitted by the QHP application deadline (see timelines) Individual and small group plans that are only outside the marketplace are not required to have submitted applications by the June 15 deadline SAD issuers should submit both inside and outside marketplace plans (that will be certified as a supplement to EHB) SERFF will conduct Issuer trainings April 22-May 21 11

12 Filing and QHP Certification Requirements CMS Onsite Training QHP Certification Onsite Technical Assistance Session for Issuers April at CMS in Baltimore The purpose of this session is to provide the Issuers and other entities with information needed for successful QHP certification Register by Thursday, April 17 12

13 Filing and QHP Certification Requirements Recertification The CMS 2015 Final Letter to Issuers indicates that the recertification process will largely resemble the initial certification process and that all application materials must be re-submitted A recertified plan can keep the same plan and HIOS ID, and enrollees will remain enrolled into the new benefit year Plans that issuers are proposing to recertify will remain in effect into the new benefit year unless the enrollee terminates their policy Applications for recertification should include a redlined version of the plan forms and a written justification for any changes to cost-sharing and covered benefits (A template for submission of plan change justifications will be posted in SERFF) 13

14 Filing and QHP Certification Requirements Uniform Modification Plans with uniform modifications are allowed to be renewed and recertified if the change is pursuant to Federal or state law, such as increasing annual limitations on cost-sharing as a result of the application of the premium adjustment percentage. 14

15 Filing and QHP Certification Requirements Uniform Modification If changes are made to the plan that not due to Federal and state law, then they may still meet the uniform modification criteria if the plan: Is offered by the same health insurance issuer and is the same product type (i.e. PPO or HMO); Covers a majority of the same counties in its service area; Maintains the same cost-sharing structure, except for actuarial adjustments that are a result of cost and utilization of medical care or in order to maintain the same A/V level of coverage; and Provides the same covered benefits, unless changes to benefits impact the rates only ± 2%. 15

16 Filing and QHP Certification Requirements Uniform Modification FAQs Q1: Do changes to plans such as inclusion of mandatory benefits like TMJ and hearing aids, changes to a plan to meet the EHB-only silver plan requirement, changes to HCIP cost-sharing requirements, and removal of riders count as a uniform modifications? A1: These changes are pursuant to changes in federal and state law and guidance and are considered uniform modifications Q2: Will changes to non-ehb benefits violate uniform modification criteria? A2: If the changes to non-ehbs affect the plan index rate by more than 2%, it will not be considered a uniform modification. 16

17 Filing and QHP Certification Requirements Uniform Modification FAQs Q3: To what extent is a change to MOOP allowed and it still be considered pursuant to federal law (due to annual increase in MOOP in the 2015 benefit and payment parameters)? A3: CMS has recently indicated that in order to qualify as a uniform modification, the change must be pursuant (required) by law, so a change in plan MOOP due to annual increase in the maximum allowable MOOP levels would not be considered a uniform modification. AID is submitting comments on the proposed market standards and will indicate this suggested clarification in the final rule. 17

18 Filing and QHP Certification Requirements Certification Standards Applicable to Stand-alone Dental Plans Certification Standard Applies (* denotes modified standard) Essential Health Benefits* Actuarial Value* Certification Standard Does Not Apply Accreditation Annual Limits on Cost Sharing* Network Adequacy Licensure Inclusion of ECPs Cost-sharing Reduction Plan Variations Unified Rate Review Template Marketing Service Area Meaningful Difference Non-discrimination 18

19 Filing and QHP Certification Requirements Associated Schedule Items QHP forms and associated documentation should be attached to the binder through SERFF Plan Management functionality. All applicable forms must be attached to the correct plans in the binder. The SERFF instructions for associated schedule items can be found here. 19

20 Essential Health Benefits The QHP Issuer must offer coverage that is substantially equal to the coverage offered by the state s base benchmark plan and attest that plans are in compliance with all EHB standards. Benefits and coverage requirements for the AR Benchmark Plan can be found in the QHP Checklist and AR Essential Health Benefits Guidelines (see Attachment D). 20

21 Essential Health Benefits Mental Health Parity MHPAEA requires that treatment limitations (whether quantitative or nonquantitative) for MHSA benefits are no more restrictive than the predominant requirements or limitations applied to substantially all medical/surgical benefits. Mental Health Benchmark Requirements The AR benchmark coverage for mental health is based on the QualChoice federal employee benefits health plan. However, the nonquantitative treatment limitations in the mental health and substance abuse benchmark plan may not meet the MHPAEA; issuers must ensure that the quantitative and non-quantitative treatment limitations in MHSA coverage comply with MHPAEA requirements. For example, the benchmark plan states that all services require preauthorization and an approved treatment plan, and this would not be permitted under MHPAEA unless the same limitation applies to substantially all medical and surgical benefits in the benefit category. 21

22 Essential Health Benefits Mental Health Parity and AR Network Adequacy Standards Network adequacy- Mental Health, Behavioral Health and Substance Abuse access standard was previously 45 minutes or 45 miles. Due to updates in the mental health parity rule and confirmation from CCIIO, the standard has been changed to 30 minutes or 30 miles. It is understood that in some areas of the state, there are not sufficient providers to meet this standard. 22

23 Essential Health Benefits Prescription Drugs CMS noted in the letter to issuers that the agency intends to review plans that are outliers based on an unusually large number of drugs subject to prior authorization and/or step therapy requirements in a particular category and class. CMS also expects the URL link to direct consumers to an up-todate formulary where they can view the covered drugs, including tiering, that are specific to a given QHP. The URL provided to the Marketplace as part of the QHP Application should link directly to the formulary, such that consumers do not have to log on, enter a policy number or otherwise navigate the issuer s website before locating it. If an issuer has multiple formularies, it should be clear to consumers which formulary applies to which QHP(s). 23

24 Essential Health Benefits Arkansas Habilitative Services Definition of Habilitative Services Habilitative services are services provided in order for a person to attain and maintain a skill or function that was never learned or acquired and is due to a disabling condition Coverage of Habilitative Services Subject to permissible terms, conditions, exclusions and limitations, health benefit plans, when required to provide essential health benefits, shall provide coverage for physical, occupational and speech therapies, developmental services and durable medical equipment for developmental delay, developmental disability, developmental speech or language disorder, developmental coordination disorder and mixed developmental disorder. 24

25 Essential Health Benefits Arkansas Habilitative Services Establishing Parity QHPs must offer habilitative services at parity with rehabilitative services. Because developmental services are generally less expensive and required on a long-term basis, the department has determined that parity must be established through the use of unit equivalency. All medical QHPs must include developmental services with unit limits at an acceptable level of parity with Outpatient and Inpatient Rehabilitation for the 2015 plan year policies. The minimum acceptable limits are included in the table below: Outpatient Rehabilitation (OT, PT, ST) 30 visits (1 visit = 1 unit = 1 hour or less) Habilitative Services (OT, PT, ST) 30 visits (1 visit = 1 unit = 1hour or less) Habilitative Developmental Services N/A Inpatient 60 days N/A 180 units (1 unit = 1 hour) 25

26 Essential Health Benefits Mandated Offerings as EHBs Due to Arkansas statutory language and the CCIIO requirement that riders are not allowed with any filing, TMJ and Hearing Aids will be considered Mandated Benefits and must be embedded in all QHPs, unless the plan is an HMO not subject to the AR mandatory hearing aid offering requirement (Bulletin 7-A 2009) In-vitro Fertilization In-vitro is a mandated AR benefit so must be embedded in all QHPs (except HMOs) even though it is not included in the state benchmark plan 26

27 Essential Health Benefits New AR-Mandated Benefits AR mandated benefits enacted after December 2011 are considered in addition to EHB and must be excluded from the silver EHB-only plan and excluded from premium allocated towards EHBs in the actuarial memorandum. Act 1226 of 2013 enacted a new mandated benefit for Craniofacial surgery. These additional laws were enacted in 2013 and apply to existing mandated benefits: Act 1259 of 2013: Mammography reimbursements Act 342 of 2013: Physical therapists must be paid the same as general practice doctors Act 464 of 2013: Must have review process for excluded services that are experimental Act 1233 of 2013: Revised coverage for orthotics 27

28 Essential Health Benefits: Cost Sharing Maximum Out of Pocket Limits * Medical Dental Individual $6,600 $350 Family $13,200 $700 Note that OON Emergency Services can count towards innetwork MOOP * Based on Final 2015 Benefit and Payment Parameters 28

29 QHP Quality Requirements Three Quality Goals: #1 - Inform Plan Certification Includes QHP certification standards, issuer quality improvement practices, and safety #2 - Provide Information to Consumers for Plan Selection Includes quality rating system and enrollee satisfaction surveys #3 - Monitor Plan Quality - Oversight and monitoring to include complaints and appeals data, disenrollment information, and denied claims 29

30 QHP Quality Requirements Goal #1 - Inform Plan Certification Includes QHP certification standards, issuer quality improvement practices, and safety Areas with current federal guidelines: Accreditation Patient Safety (may be more in the future) Areas pending guidelines: Submission of Plan Performance Pediatric quality reporting measure Quality improvement strategy While there is not yet federal guidance in some of these areas, QHP issuers are required to participate in the AR Payment Improvement Initiative as a current QHP certification standard, including the AR Patient-Centered Medical Home Model in alignment with Medicaid PCMH standards. 30

31 QHP Quality Requirements Goal #2 - Provide Information to Consumers for Plan Selection Areas with current federal guidelines: Proposed Quality Rating System Guidelines Proposed Enrollee Satisfaction Surveys AID gathered input from stakeholders via the PMAC quality subgroup and submitted comments on the initial QRS proposed rule. Additional details regarding the rating methodologies were published recently and can be found here (CMS Health Insurance Marketplace Quality Initiatives website). 31

32 QHP Quality Requirements Goal #3 - Monitor Plan Quality Areas with current federal guidelines: Review of complaints and appeals as part of Accreditation requirements Areas pending guidelines: Submission of disenrollment information and denied claims AID conducts quarterly audits of Qualified Health Plans and quality components will be included in the audits. QHP issuers are required to submit requested data to AID in the oversight and monitoring process. 32

33 Additional Updates Third Party Payment of QHP Premiums CMS has published an interim final rule in 45 CFR regarding acceptance of certain third party payments. Issuers are required to accept premiums from Ryan White HIV/AIDS programs, Indian tribal organizations, and State and federal government programs (such as the HCIP program) 33

34 Additional Updates AID Bulletin regarding Marketing Standards QHP Issuers are prohibited from using a design of a program, entity name, webpage, or internet solicitation intended to look like Healthcare.gov, ARHealthconnector.org or Access Arkansas; nor shall a person or entity create any name, logo, symbol, or web address of any kind which is similar enough to mislead a consumer to believe it is a direct pathway for purchase of qualified health plans offered in Healthcare.gov, ARHealthconnector.org or Access Arkansas. QHP Marketing materials must be submitted to AID prior to use. 34

35 Plan Variations Z = Zero Cost Sharing Variation L = Limited Cost Sharing Variation What about HCIP? Catastrophic Standard Bronze Standard Silver Standard Gold Standard Platinum Z L Z L Z L Z L = 73% A/V Silver Variation 87 = 87% A/V Silver Variation 94 = 94% A/V Silver Variation L= Limited Cost Sharing Variation Z= Zero Cost Sharing Variation 35

36 Catastrophic and Standard Plans The Catastrophic Plan: Has an actuarial value of < 60% Is not required to have a Zero or Limited Cost Sharing Variation The Standard Plans: Have actuarial values of 60%, 70%, and 80%, and 90% for Bronze, Silver, and Gold and Platinum, respectively. Must include at least one Silver and one Gold plan for each issuer. 36

37 Zero Cost Sharing Variation The Zero Cost Sharing Variation: Is required for the Bronze, Silver, and Gold Plans Is for the purpose of removing all cost sharing for EHB services for Indians up to 300% FPL. Must have zero cost sharing for both in and out of network services. Is not offered in SHOP. Is used in the HCIP for individuals 0-100% FPL in plan year Out of network cost sharing is not allowed in the HCIP. 37

38 Limited Cost Sharing Variation The Limited Cost Sharing Variation: Is required for the Bronze, Silver, and Gold Plans Is for the purpose of removing cost sharing for EHB services furnished by Indian Providers for Indians regardless of income (over 300% FPL since below 300% FPL will be covered by the Zero Cost Sharing variation). Looks just like the corresponding Bronze, Silver, and Gold standard plan in the templates. Is not offered in SHOP. 38

39 Silver Plan Variations Part I 73 = 73% A/V Silver Variation 87 = 87% A/V Silver Variation 94 = 94% A/V Silver Variation The Silver Plan Variations: Reduce cost sharing and MOOP amounts for individuals up to 250% FPL. Must first increase actuarial value by reducing MOOP, then increase actuarial value by reducing cost sharing (copays and coinsurance). Are allowed to have out of network cost sharing. Must have equivalent non-ehb cost-sharing to the corresponding standard silver plan. Are not offered in SHOP. 39

40 Silver Plan Variations Part II 73 = 73% A/V Silver Variation 87 = 87% A/V Silver Variation 94 = 94% A/V Silver Variation (a.k.a. High Silver ) The Silver Plan Variations are determined according to income. Lower income individuals qualify for higher cost sharing reduction plans with higher A/V. 250% FPL 200% FPL 150% FPL 73% 87% 94% 40

41 Silver Plan Variations Part III - MOOP 73 = 73% A/V Silver Variation 87 = 87% A/V Silver Variation 94 = 94% A/V Silver Variation (a.k.a. High Silver ) The Maximum Out of Pocket (MOOP) amounts are required to be reduced for silver plan variations. CCIIO may change these reduction amount requirements over time. 250% FPL 200% FPL 150% FPL 73% 87% 94% $2244 $3300 $3300 The MOOP allowance for the standard silver plan is $6,600 (2015). The MOOP reduced allowances for 2015 are shown above (tentative). 41

42 HCIP Variations Part I Z = Zero Cost Sharing Variation L = Limited Cost Sharing Variation 73 = 73% A/V Silver Variation 87 = 87% A/V Silver Variation 94 = 94% A/V Silver Variation HCIP uses Silver plan variations only. For plan year 2014, the plans used for HCIP include the Zero Cost Sharing plan and the 94% High Silver plan. The Zero Cost Sharing plan is not allowed to have Out of Network cost sharing. The 94% High Silver Plan is given specific cost sharing requirements ( Appendix E in the plan year 2015 QHP Bulletin). The 94% high silver plan is allowed to have OON cost sharing and was not modified for the HCIP. 42

43 HCIP Variations Part II The variations that apply to HCIP are shown below. The Actuarial Value is shown below each of the steps and the applicable income level by percent FPL is shown above each of the steps. The silver plan variation with a 94% A/V is shared between the HCIP program and FFM. Z = Zero Cost Sharing Variation L = Limited Cost Sharing Variation 73 = 73% A/V Silver Variation 87 = 87% A/V Silver Variation 94 = 94% A/V Silver Variation Zero Cost Sharing 94% Plan Actuarial (Z 2 ) Value Plan 0-100% FPL % 100% 94% 87% % FPL 73% HCIP FFM 43

44 HCIP Variations Part III Issuers submit separate benefit summaries for plan variations, including HCIP variations. The form requirements include: Z = Zero Cost Sharing Variation L = Limited Cost Sharing Variation 73 = 73% A/V Silver Variation 87 = 87% A/V Silver Variation 94 = 94% A/V Silver Variation Limited Cost Sharing Plan Variation HCIP Zero Cost Sharing Plan (matches the Marketplace plan other than potential differences in title) Zero Cost Sharing Plan for Indians up to 300% FPL 73% A/V Cost Sharing Variation 87% A/V Cost Sharing Variation 94% A/V Cost Sharing Variation

45 Plan Variation Naming Conventions Naming Conventions: Naming conventions will be required for plan schedules of benefits: Schedules should be named in the following way: Sch- + [-Component Plan ID-] + [Variation ID] For example: Sch-15234AR

46 Summary of Plan Variations Zero Cost Sharing Variation: removes all cost sharing for EHB services for Indians up to 300% FPL; must have zero cost sharing for both in and out of network services. Limited Cost Sharing Variation: removes cost sharing for EHB services furnished by Indian Providers for Indians regardless of income. Silver Plan Variations: 73%, 87%, 94%. Reduce cost sharing and MOOP amounts for individuals up to 250% FPL; are allowed to have out of network cost sharing. Plans Used for HCIP: Zero Cost Sharing 94% Silver Variation 46

47 HCIP 94% A/V ("High-Silver") Cost Sharing The AID Bulletin includes the required HCIP cost-sharing options for high-silver 94% A/V plans. Additional guidance with specific cost-sharing guidance is expected prior to May 1 st. The guidelines are expected to align with benefits in the templates. The cost-sharing requirements are similar to last year, with the exception of the removal of the emergency copay. 47

48 Rate Filing Filing for Actuarial Rate Review: The process will be similar to last year; issuers submit the actuarial memorandum and rates will be reviewed for all QHPs (except SADPs) Carriers need to ensure that actuaries are available for questions and discussions during the QHP review period and can respond within 48 hours 48

49 Rate Filing Issuers must submit all required rate review documentation, including: Part I - Unified Rate Review (URR) Template Part II Consumer Justification Narrative- Justification information received for rate increase, if applicable. Part III Actuarial Memorandum Rate Review Template developed by HHS. The updated template can be found here. Justification narrative for rate increases (that exceed 10% threshold) Rate filing documentation to support QHP rates and all rate increases. A supplemental actuarial variation spreadsheet form required for AR rate reviews can be found in Attachment L. 49

50 Rate Filing Additional rate filing updates: Rate increases over 10% are required to be filed in HIOS. CMS has indicated that rate increases must be filed and approved by the state in the HIOS system before the rates can be shown correctly on Healthcare.gov. A field to indicate premium allocation towards EHBs has been added in the proposed benefits and cost-sharing template. This must be completed and must align with information in the actuarial memorandum. 50

51 Review Tools Issuers will have access to the QHP Application Review Tools this year and we recommend issuers take advantage of these tools for a smooth certification process These tools are a method for reviewing against specific standards such as the 30% threshold for ECPs, annual limitation on cost sharing, catastrophic plan requirements, etc. The Data Integrity Tool (DIT) is specifically designed for issuers to (1) provide a method for issuers to check that the data contained in their templates is in the correct format; and (2) provide issuers with feedback immediately and reduce resubmissions 51

52 Overview of QHP Application Review Tools Select Market Reform Standards Actuarial Value Annual limitation on Cost Sharing (i.e. EHB out-of-pocket maximum) Catastrophic Plan Requirements EHB Discriminatory Benefit Design Formulary-USP Category Class Count Non-discrimination Formulary Outlier Non-discrimination Formulary Clinical Appropriateness Marketplace-Specific Standards Accreditation Cost Sharing Reduction Plan Variation Requirements Essential Community Providers Meaningful Difference Program Attestation Service Area SHOP tying provision Non-discrimination Cost Sharing Outlier 52

53 Questions? 53

54 Attachment Index A Final Letter to Issuers B. SERFF Filing Instructions C. Arkansas Health Plan Submission Requirements D. QHP Checklist and AR Essential Health Benefits Guidelines E. USPSTF preventive health benefits guide F. USPSTF Tobacco Cessation Recommendations G. Network Adequacy Checklist H. State benchmark plans Medical-BCBS Health Advantage POS Mental Health and Substance Use Disorder-QCA FEHBP Pediatric Vision-CHIP (AR Kids B) Pediatric Dental-CHIP (AR Kids B) I. Benchmark drug formulary 54

55 Attachment Index continued J. URRT and Instructions K. Uniform Certificate of Authority Application UCAA. L. AR Actuarial Memorandum Form M. Uniform Modification Recertification Form N. AID QHP Bulletin

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