OHIC 2016 Form Filing Instructions Individual and Small Group

Transcription

1 OHIC 2016 Form Filing Instructions Individual and Small Group A. General Instructions 1. The following are Form Filing Instructions for the State of Rhode Island Office of the Health Insurance Commissioner s (OHIC) 2016 individual and small employer group form review process for commercial health insurance issuers in Rhode Island for the CY 2016 policy period. Note that OHIC will issue a separate set of Rate Filing Instructions for CY These Form instructions apply to filings for the individual market effective January 1, 2016 and continuing through December 31, 2016 and the small group market issued during calendar year 2016, and effective on or after January 1, Instructions relating to Affordable Care Act market rules (e.g. the size of entities considered a small group, and the manner of counting small group employees) will be included within separate Rate Filing Instructions. 3. The 2016 form filings shall also include the 15% Discount Plan required by the Rate Approval Conditions applicable to 2014 and 2015 plans. This Affordable Health Plan filing shall include all related plan forms as described below. 4. Form filings shall be submitted in two phases. Standard forms due April 1, 2015 are defined as those that include Certificates of Coverage, Group Policies, Schedule of Benefit and other benefit documents listing Essential Health Benefits, Benchmark Plan, Rhode Island Benefit Mandates, benefit exclusions and standard benefit provisions set forth in applicable federal and state health insurance regulations but do not require benefit design cost shares. As the second phase of the form filing process, Plan Design documents due May 1, 2015 are defined as the schedules of benefit and plan documents that include specific consumer cost shares and network design. Plan Design documents shall include but are not limited to the following: Schedule of Benefits for Medical/Surgical, Dental, Vision, and RX. Additional Document Filing Schedule Instructions are set forth in Para. F, below. This form filing schedule does not apply to stand-alone dental and vision plans, and stand-alone EHB-compliant pediatric dental and vision plans. These stand-alone plans will be subject to separate filing instructions. 5. The documents and information below shall be submitted only in the specific System for Electronic Rate and Form Filing (SERFF) sections noted unless otherwise requested by OHIC, and according to the timelines noted in Section D and F herein. 6. Only one form filing for each market, Individual and Small Group, shall be filed. 7. Form filings must be separate from rate filings Each SERFF Item in the form filings must be designated as Off or On/Off Exchange only, as noted below. All Qualified Health Plans offered through the HealthSource RI must be available outside of the Exchange as noted in Item B (2) below. SERFF Tracking numbers associated with each form filing must be identified in the SERFF General Information Tab according to item B (3) instructions below. 1

2 8. These form filing instructions are issued pursuant to OHIC Regulation 17 5 and will be posted on SERFF. B. General Information Tab 1. Product Name must be identified as Small Group Medical or Individual Medical. Separate filings will be required for Small and Individual SERFF filings. Under the General Information Tab, the line titled Include Exchange Intentions must be accurately completed. Issuers shall identify if the submission contains On/Off or Off (only) plans in this tab under line titled Filing Description and in the appropriate column of the OHIC Crosswalk. Form filings will be reviewed according to how this question is answered. 2. No issuer shall submit an On Exchange only SERFF filing. With the approval of the Commissioner, an issuer may not be required to market plans Off the Exchange. Plans being filed as On/Off the Exchange but not intended to be marketed Off the Exchange must be identified in this SERFF sections under line titled Filing Description and in the appropriate column of the OHIC Crosswalk document. 3. Associated rate SERFF Tracking numbers must be submitted in line titled Corresponding Filing Tracking Number as a Post Submission Update when associated Rates Filings are subsequently submitted on May 1, Pediatric Dental Filing Requirements (embedded benefits). a. Each Small Group and Individual plan filing is required to include plans with and without embedded pediatric dental. This will be reflected in both the COCs filed (variable language) as well as the building of the plan evidenced on the Crosswalk. b. Small Group plan filings intending to be marketed on the Rhode Island s Health Benefit Exchange (HSRI) are not allowed to embed pediatric dental coverage in its medical plan. c. For the Individual Market, all medical plan filings intending to be marketed on HSRI, it is up to the Issuer to embed or exclude pediatric dental. d. A plan offered outside the Exchange must cover the pediatric services covered by the EHB Benchmark Plan, except that a Plan offered outside of the Exchange shall not cover the pediatric dental services coved by the EHB-Benchmark Plan if the Issuer determines, after reasonable inquiry, that the small group policyholder is covered under a dental insurance plan that covers the pediatric dental services covered by the EHB-Benchmark Plan. 5. Other filing instruction requirements. a. Acupuncture. In accordance with R.I. Gen. Laws , each health insurer must offer an option rider with coverage of acupuncture services. An acupuncture rider may be offered as a separate rider, or may be offered as a covered service in one or more distinct plans. Each distinct plan need not be filed with and without acupuncture services. b. Cancellations and terminations. i The plan must state that the enrollee may terminate coverage upon no greater than 14 days notice to the issuer or the Exchange. ii For QHP s only, the plan must state that the issuer is permitted to terminate coverage if: The enrollee is no longer eligible for coverage through the Exchange; Payment of premiums cease (after appropriate grace periods); The enrollee s covered is rescinded for a non-prohibited reason. The Qualified Health Plan is terminated or decertified; or 2

3 The enrollee changes from one plan to another through an open or special enrollment period. iii The plan must state that if coverage is terminated, 30 days prior notice is required, and the notice must include the reason for termination. iv The Plan must state that a 31 day or monthly grace period is provided c. Rescissions. Rescission is a cancellation of coverage that has retroactive effect. The plan document must state that the issuer may not rescind the plan except in cases of fraud or intentional misrepresentation of material fact. The plan document must also state that coverage may not be contested 2 years after issuance of the plan for any reason. It includes a cancellation that voids benefits paid. Coverage may not be rescinded except with 30 days prior notice to each enrolled person who would be affected. d. Mental health and substance abuse parity. The Summary of Benefits and Coverage must state that it provides, and must provide coverage for parity in mental health and substance use disorder benefits, and must describe, through illustrations, FAQ s, or other consumer explanation how the plan provides for parity in connection with financial requirements, quantitative treatment limitations, prescription drug benefits, and non-quantitative treatment limitations. 6. All other sections must be completed and filled out according to SERFF filing rules. Incomplete or incorrect filing information in this Tab may necessitate a re-filing. C. Form Schedule Tab 1. Issuer shall add all Form Schedule documents noted in C 3 under the Form Schedule tab. Each of these documents shall be filed in redlined format (refer to C 9 herein) and clean copy or clean copy if no changes from previously approved form filing. 2. Item # a. Numerical beginning with #1 b. Use one item # for each distinct Form filed for approval e.g. for each distinct COC and each plan design according to COC, Group Policy and Schedule (Summary) of Benefit submission restrictions noted below. 3. Form Name Must be identified as follows: a. COC (for certificate of coverage or evidence of coverage documents) b. GP (for employer agreements and policy documents filed only as necessary for new agreements or updates to previously filed GP document) c. SOB (for medical schedule of benefits or medical summary of benefits documents) d. Dental (For dental SOB documents) e. Vision (For vision SOB documents) f. RX (For pharmacy SOB documents) 4. Form Number- Standard Documents (Due April 1, 2015) For each Standard document (form) name there shall be: a. A number sequencing to distinguish among filings with the same form name to avoid rereview of the same form. b. Filing in accordance with Section C10 of these filing instruction variable language requirement. c. For COC, GP, SOB, Dental, Vision, and RX and under Form Schedule Tab, place Base Form Name as follows (Example Attached): 3

4 Line 1: SG for Small Group, I for Individual followed by form name, # sequencing, calendar year of implementation, ending with the Issuer abbreviation. Line 2: Add term Standard to indicate that this is part of the Standard form submission in order to distinguish from subsequent final plan design form filing. d. Standard benefit coverage forms shall include Essential Health Benefits, Benchmark Plan benefits, RI State Benefit Mandates, and evidence of compliance with standard provisions set forth in applicable federal and state health insurance regulations but do not require benefit design cost shares and out of pocket maximums. Benefit design cost shares and out-of-pocket maximums may be filed as a variable (either left blank or with a $ range), at the option of the filer. Actual benefit design cost shares and OOP maximums must be filed with plans filed May 1, Form Number - Final Plan Design Schedules of Benefits (Due May 1, 2015) These benefit schedule forms are to be added to the initial April 1, 2015 SERFF Standard form filing as follows. a. Plan design schedules of benefits (Medical, Dental, Rx, and Vision) are to follow the last form Item Number under the Form Filing Tab. b. Plan design schedules of benefits (Medical, Dental, RX, and Vision) may only be embedded in a COC with the prior approval of the Commissioner. c. Plan design schedules of benefits (Medical, Dental, RX, and Vision) must include any and all cost shares associated with a plan design being filed for approval and associated with a corresponding filed rate. d. Plan design schedules of benefits (Medical, Dental, RX, and Vision) combined with Standard documents previously filed must be inclusive of all final plan design components, and must demonstrate compliance with all state and federal benefit coverage and health insurance form requirements. e. For Plan Design SOB (Medical, Dental, Vision, and RX) and under Form Schedule Tab, place Form Name as follows (Example Attached) (i) Line 1: SG for Small Group, I for Individual followed by Plan, # sequencing, letter sequencing (a=with pedi dental with abortion, b=without pedi dental with abortion, c=with pedi dental without abortion, d=without pedi dental without abortion) calendar year of implementation, ending with the Issuer abbreviation. (ii) Line 2: Add term Design to indicate that this is part of the Plan Design form submission in order to distinguish from subsequent final plan design form filing. f. As noted in the OHIC Plan Crosswalk instructions below, each listed plan design shall have a corresponding rate as well as associated rates with and without pediatric dental. The OHIC Plan Crosswalk will display an a and b for each OHIC plan design number. g. At least one plan variation for individual market plan designs offered on/off the Exchange at each metal tier level at which the carrier is offering a plan or plans, shall exclude coverage for abortion services as defined by federal law. h. If the issuer proposes different rates for plan designs with the plan variation in letter (g) above or for the religious exemption variable language in the small group market in its COC for the purpose of excluding coverage for abortion services as defined by federal law, each listed plan design (SOB) shall include rates associated with, and needed to make the exclusion (a separate SOB for each version of the variable.) i. If the issuer does not propose different rates for plan designs with the religious exemption variable language in the small group market in its COC, an additional SOB is not required to represent each version of the COC variable. 4

5 6. Form Type a. COC use CER for Certificate b. GP use POL for Policy, Contract, Fraternal Certificate SOB, Dental, Vision, and RX use SCH for Schedule 7. Readability Score Each form filed must be assigned a readability score in this section of the Form Tab as required by Regulation Attachmentsa. For each item #, the attachments shall be identified as marketed by the issuer. b. The OHIC Plan Crosswalk shall be completed for EACH plan design listed by the issuer in this section of the Form Tab to account for these attachments; see instructions below. 9. Prior to formal disposition and approval of a form filing, changes can be made to filed forms according to the timeline noted in Section F and as follows: a. Initially filed form may be withdrawn by issuer and identified in Form Schedule tab as Previously Filed. Replacement forms may not be added to the end of the form section rather added as part of original Item number appearing adjacent to withdrawn filing. b. Replacement forms may then be submitted and new submission date noted under the form filing date titled Submitted. c. Redlined documents must be submitted to identify changes in replacement forms as well as a clean copy in each respective tab noted above. d. Redlined and clean copies shall be filed under the same Item # and as attachments. These documents should not be filed in the Supporting Documentation tab. 10. Each Distinct GP and COC, and SOB due April 1, 2015 shall include the following variable language when applicable. These topics shall constitute the only variable language permitted: a. Domestic partnership b. To allow for federal ACA exemptions or religious accommodations c. Grace Periods (Required to accommodate HSRI variations, e.g. contact information, grace periods, eligibility) d. Contact #s and issuer addresses e. Cost shares (copays, co-insurance, deductibles) f. Dental (Pediatric) g. Vision (Pediatric) h. Pharmacy i. Other categories as approved by OHIC 11. All other Form Schedule SERFF filing rules apply to Form Schedule Tab if not in conflict with the above. D. Supporting Documentation Tab 1. The following required Form Filing documents shall be placed in this tab unless otherwise requested by OHIC. These documents and templates will either be posted on SERFF, or posted on OHIC s website. a. OHIC benefit Template (Due April 1, 2015) b. OHIC Plan Crosswalk (Due May 1, 2015) 5

6 c. Readability Certification (Due May 1, 2015). The Readability Certificate must be submitted with May 1, 2015 filing. d. Market Specific Form Compliance Attestation (Due May 1, 2015) e. Other Market Certification and form requests noted in SERFF (Due May 1, 2015) 2. OHIC Plan Crosswalk-See Attached Sample Document (Due May 1, 2015). a. Column A identifiers must include each SOB filed in the SERFF form filing tab. b. All COC, SOB, Dental, Vision, and Pharmacy forms filed should be represented at least once in this template. c. Each column B forward must include plan design version of this SOB to include the identification of a dental, vision, and pharmacy schedule. These schedules shall be identified as noted in the Form Number section of the SERFF Form Schedule Tab. d. All crosswalk columns, to include premium information, must be completed. 3. The OHIC Benefit Template shall be submitted in the Supporting Documentation Tab a. All cells must contain a response. N/A shall not be used to complete this template. If a benefit is not covered, NC shall be placed in each applicable cell. b. Benefit column A subcategory titled Pharmacy must differentiate among tiers of drugs noting generic, brand, specialty and any other pharmacy categories resulting in differing cost shares and benefit design. c. Preventive services include office visits, immunizations per CDC Advisory Committee on Immunizations, colorectal screenings/colonoscopy, all services/treatment not listed on this template but noted in U.S. Preventive Services Taskforce recommendations A & B and HRSA preventive guidelines. Preventive services required to be provided without cost shares are noted in red and corresponding coverage documents must reflect no cost shares for these listed preventive services. In the case of HSA plans, preventive services include only office visits, immunizations per CDC Advisory Committee on Immunizations, colorectal screenings/colonoscopy, and all services/treatment not listed on this template but noted in U.S. Preventive Services Taskforce recommendations A & B and HRSA preventive guidelines. HSA preventive services covered without cost sharing noted by * on the OHIC Benefit Template. d. Each cell corresponding to a benefit listing must identify the location of the specified benefit information by document name, section and sub-section. 4. The following documents must be filed in the Supporting Documentation - Exclusions, Substitutions, Deviations, and Conversions Tab. a. If the plan excludes a benefit or service covered in the R.I. Benchmark Selections, the filer must identify such benefit or services, and provide a written explanation for the exclusion. b. A plan may substitute a benefit or service for a benefit or service covered under the EHB Benchmark Plan only if: (1) the plan's substitute benefit or service is included within the same Essential Health Benefit category as the benefit or service covered under the EHB Benchmark Plan; (2) the substitute benefit or service and the substituted benefit or service are actuarially equivalent; and (3) the substitution is approved by the Commissioner. The filer must identify the substitution with a section or subsection reference, and must file an actuarial memorandum demonstrating that the substitution is actuarially equivalent. c. A plan may include a material deviation from a benefit or service for a benefit or service covered under the EHB-Benchmark Plan only if (1) the deviation is identified; (2) the 6

7 issuer files a memorandum demonstrating that the deviation is substantially equivalent to the EHB-Benchmark Plan; and (3) the deviation is approved by the Commissioner. The filer must identify the deviation with a section or subsection reference, and must file an actuarial memorandum demonstrating that the substitution is actuarially equivalent. d. If the specific benefits and services covered under the EHB-Benchmark Plan include annual or lifetime dollar limits on the coverage of any such benefit or service, the plan may propose an actuarially equivalent conversion of the dollar limit to a utilization limit, or some other quantitative or qualitative limit, subject to the Commissioner's approval. The filer must identify the proposed conversion with a section or subsection reference, and must file an actuarial memorandum demonstrating that the conversion is actuarially equivalent. 5. Medical necessity and external appeals. The following documents or explanations must be filed in the Supporting Documentation - Medical Necessity Tab. a. The filer must submit the standards, including the plan's medical necessity standard, applicable to prior approval, preauthorization, and utilization review procedures. b. The plan's definition of "medical necessity" must: (i) require coverage of health care services that are appropriate, in terms of type, amount, frequency, level, setting, and duration to the member s diagnosis or condition; (ii) Must be informed by generally accepted medical or scientific evidence and consistent with generally accepted practice parameters. c. The plan must explain to the enrollee how to obtain the clinical review criteria used to determine medical necessity in a particular situation. d. The Plan's definition of adverse benefit determination must be the definition used in 29 C.F.R The term also includes a rescission of coverage. e. In connection with external appeals, the plan must provide that: (i) the cost of an external appeal must be borne by the issuer; (ii) the claimant must not be charged a filing fee greater than $25; (iii) restrictions on the minimum dollar amount of a claim are not allowed; and (iv) the decision of the Independent Review Organization is binding on the issuer. f. The plan shall describe the process for an enrollee to request and receive coverage of clinically appropriate drugs not on the plan s formulary. The plan shall also describe the process for consumer access to information on formulary coverage. E. SERFF Communications: 1. A note to the filer shall be responded to as a note to reviewer. 2. An objection issued OHIC shall be responded to in the Objection Letter section under SERFF correspondence tab by the date noted by OHIC. Any request for an extension of the response date must be done in advance of that response date in a Note to Reviewer. F. Document Filing Schedule 1. April 1, 2015 the following shall be submitted on the traditional SERFF Filing Platform: a. Group Policy Standard language (updates to previously filed group agreements/policies must include redline and clean copy otherwise just a clean copy) b. COC w/ Standard Language c. Schedule of Benefit (Summary of Benefit) w/ Standard language d. OHIC Benefit Template 7

8 2. May 1, 2015 the following shall be submitted on the traditional SERFF Filing Platform: a. Plan specific (Benefit Plan Design forms) Schedule of Benefits document or specific benefits embedded as part of a plan specific COC to be ADDED to the corresponding April 1, 2015 SERFF Standard Form Filing. b. OHIC Plan Crosswalk c. Readability Certificate d. Market Specific Form Attestation 3. For QHP plans intended to be offered on the Exchange, filing shall include the following federal QHP templates on the traditional SERFF Filing Platform May 1, 2015 in the Supporting Documentation Tab: a. Essential Community Provider Template b. Prescription Drug Template c. 4. For QHP plans intended to be offered on the Exchange, RI plan-specific benefit and cost sharing data, in accordance with further HSRI instructions. 4. Form and rate filing changes or submissions are not allowed after May 15, 2015 unless requested by OHIC. 5. Due Post OHIC Approval of Form and Rate Filing: a. For all QHP plans intended to be offered on the Exchange, the issuer must file all Federal QHP Templates and Plan Management Binder documents on the SERFF Plan Management Filing Platform according to SERFF Plan Management filing instructions no later than 30 calendar days after OHIC formal approval unless otherwise requested by OHIC after consultation with HSRI. b. As necessary, updated RI plan-specific benefit and cost sharing data, in a form approved by HSRI, shall be filed with HSRI 14 days after OHIC approval. 8