Chapter 10: Instructions for the Plans & Benefits Application Section

Transcription

1 Chapter 10: Instructions for the Plans & Benefits Application Section Overview In this section, issuers supply information for each health plan, including plan identifiers, attributes, dates, geographic coverage, URLs, benefit information, and cost share variances, including cost-sharing reductions. In addition, issuers upload supporting documents. For more information on the SHOP Tying Provision, see the SHOP Tying Provision Supporting Documentation and Justification Template in Chapter 13. The Plans & Benefits template contains two types of sections (tabs). The first section is the Benefits Package, which includes high-level information regarding the plans, as well as a list of benefits with any quantitative limits or exclusions. All plans defined within a Benefits Package will share the same set of benefits and limits but may differ in cost sharing. The second section is the Cost Share Variances tab, which is created for each Benefits Package after the package has been completed. This tab allows you to provide Deductibles and Maximum Out of Pocket information for In/Out/Combined Networks, for both Individual and Family, as well as In/Out/Combined Network Copays and Coinsurances. This information must be provided for each plan. In addition, this tab allows issuers to create the cost-sharing reduction plan variations associated with each standard plan. Purpose This chapter guides you through completing the plans and benefits section of your QHP application. Plans & Benefits Data Requirements To complete this section, you need the following information: 1. HIOS generated Issuer ID 2. Tax Identification Number 3. HIOS generated Product ID for QHPs 4. HIOS generated Plan ID 5. Plan marketing name 6. Child-Only Plan ID 7. Plan type 8. Benefits packages and cost sharing information. Version

2 Application Instructions The Plans & Benefits section of the QHP Application uses an Excel template to collect plan and benefit information. Figure 10-1 identifies some key items to note when reading these instructions and completing the Plans & Benefits section. Figure Plans & Benefits Section Highlights The Plans & Benefits template and add-in file should be downloaded from HIOS. The Actuarial Value Calculator (AVC) should be downloaded from CCIIO s website ( You must save the Plans and Benefits Add-in file in the same folder as the Plans & Benefits template for the macros to run properly. To ensure proper functionality, download the latest add-in file and AVC and delete any older versions. The Network, Service Area, and Formulary templates must have already been completed with the Excel files and saved to your computer before filling out this template. If you are a registered HIOS user, your template may have certain fields that have already been populated. Pre-populated fields cannot be changed. To complete the Plans & Benefits section of the QHP Application, you must complete a Benefits Package for each separate benefits package you wish to offer and a row in an associated Cost Share Variances worksheet for each plan and variation you wish to offer. If you are a stand-alone dental plan issuer, refer to the stand-alone dental plan instructions. The elements described in these instructions are in the same order as in the template. In this document, data fields and section headings have been italicized, and data entries, buttons, and ribbon names have been bolded. In this document, all data fields used by the AVC are identified by a carrot (^) next to the field name. For more information on how data fields on Plans & Benefits template map to the AVC, refer to Chapter 11: Actuarial Value Calculator. In the Cost Share Variances tab, your answers to the fields Medical & Drug Deductibles Integrated?, Medical & Drug Maximum Out of Pocket Integrated?, and Multiple In Network Tiers? may result in some fields no longer being applicable and thus being grayed out on the template. When a cell is grayed out, it will be locked and you cannot edit it. If data were already entered into the cell before it was grayed out, the QHP Application system will not process these data. If you want to create additional benefits packages, click the Create New Benefits Package button on the menu bar under the Plans and Benefits ribbon. The HIOS Issuer ID, Issuer State, Market Coverage, Dental Only Plan, and TIN fields are autopopulated. Complete the rest of the template using the instructions above. Version

3 Template Instructions Complete the downloaded Plans & Benefits template using the instructions that follow to provide information on each health plan you wish to submit. The Plans and Benefits ribbon (Figure 10-2) is a tab across the top of the Excel file that contains various buttons that will be used to complete the template. It will appear in Excel when the Plans & Benefits add-in file has been opened. See Appendix A for information on the add-in file. Before using this template, you must enable macros in Microsoft Excel. Enable template macros using the Options button on the Security Warning toolbar, and select Enable this content. If macros are not enabled, you will have to reenter template information. If macros are not enabled prior to entering data, the template will not recognize your data and you will have to reenter it. Figure Plans and Benefits Ribbon and Plans & Benefits Template General Information This template section contains basic information about the issuer and the type of plans that will be in this benefits package. 1. HIOS Issuer ID (required). Enter the five-digit HIOS-generated issuer ID number. 2. Issuer State (required). Select the state in which you are licensed to offer this plan using the drop-down menu. 3. Market Coverage (required). Select the market coverage. Choose from the following: a. Individual if the plan is offered on the individual market b. SHOP (Small Group) if the plan is offered on the small group market. Note: The following certification requirement (45 CFR (g)) only applies if you or another issuer within your issuer group have more than a 20 percent share of the small group market in this state. An issuer group is defined under as all Version

4 entities treated under subsection (a) or (b) of section 52 of the Internal Revenue Code of 1986 as a member of the same controlled group of corporations as (or under common control with) a health insurance issuer, or issuers affiliated by the common use of a nationally licensed service mark. If you participate in this state s small group market, you must also participate in the state s SHOP. If you do not participate in the state s small group market, then another issuer in your issuer group must participate in the SHOP. 4. Dental Only Plan (required). Indicates whether the plan is a dental-only plan. Choose from the following: a. Yes if this is a dental-only package. If you are a stand-alone dental plan issuer, refer to the stand-alone dental plan instructions. b. No if this is not a dental-only package. NOTE: A revised version of the Plan and Benefits Template will be customized and made available for stand-alone dental plans. 5. TIN (required). Enter the issuer s nine-digit TIN. Plan Identifiers This template section has high-level data about each plan, including its ID and which network, service area, and formulary the plan will be using (Figure 10-3). Complete the following section for each standard plan you want to create for this benefits package. A standard plan is a QHP offered at the bronze, silver, gold, platinum, or catastrophic level of coverage, and a benefits package is a group of plans that cover the same set of benefits; each plan in a benefits package can have different cost sharing, which is defined in the Cost Share Variances tab. If you run out of empty rows for new plans, click the Add Plan button on the menu bar under the Plans and Benefits ribbon and a new row will appear for an additional plan. Each benefits package can have up to 50 plans. If you have more than 50 plans associated with the same benefit package, you will have to create a new benefit package with the identical plan structure. Figure Plan Identifiers Section 1. HIOS Plan ID (Standard Component) (required). Enter the 14-character HIOS-generated plan ID number. 2. Plan Marketing Name (required). Enter the plan marketing name. The plan name should be at the plan level. Version

5 3. HIOS Product ID (required). Enter the 10-character HIOS-generated product ID number. 4. HPID (optional). Enter the 10-digit National Health Plan Identifier. 5. Network ID (required). Click the Import Network IDs button on the menu bar under the Plans and Benefits ribbon and select the appropriate Excel file to import a list of values from the network template, and select one from the drop-down menu. (You must have completed the network template before importing the Network IDs.) 6. Service Area ID (required). Click the Import Service Area IDs button on the menu bar under the Plans and Benefits ribbon and select the appropriate Excel file to import a list of values from the service area template, and select one from the drop-down menu. (You must have completed the service area template before importing the Service Area IDs.) 7. Formulary ID (required). Click the Import Formulary IDs button on the menu bar under the Plans and Benefits ribbon and select the appropriate Excel file to import a list of values from the prescription drug template, and select one from the drop-down menu. (You must have completed the formulary template before importing the Formulary IDs.) Plan Attributes This template section includes more specific data for each plan, including its type, metal level, and other specific medical requirements. 1. New/Existing Plan? (required). Indicate whether this is a new or existing plan. Choose from the following: a. New if this is a new plan. A new plan is a set of benefits and cost sharing linked to a form filing that has been newly approved or is under review by a state and is being reported to the federal government for the first time. b. Existing if this plan currently has enrollment. 2. Plan Type (required). Select the plan type. Choose from the following: a. Indemnity b. PPO c. HMO d. POS e. EPO (exclusive provider organization). 3. Metal Level^ (required). Select the metal level of the plan based on its AV. A de minimis variation of +/-2 percentage points is used for standard plans, while +/-1 percentage point is used for silver plan CSR variations. Furthermore, the AV of a standard Silver plan and Version

6 the AV of the associated 73 percent silver plan CSR variation must differ by at least 2 percentage points. Choose from the following: a. Bronze AV of 60 percent b. Gold AV of 70 percent c. Silver AV of 80 percent d. Platinum AV of 90 percent e. Catastrophic offered to certain qualified individuals; it does not meet a specific AV but must comply with the maximum out of pocket (MOOP) limit. See the Catastrophic section at the end of this chapter for further catastrophic plan requirements. 4. Unique Plan Design? (required). Indicate whether the plan design is unique, meaning it cannot use the standard AV calculator (AVC). For example, the following types of plan designs could be considered unique for purposes of determining AV: Example 1. A plan with coinsurance rates that increase with out-of-pocket spending, such as a plan design with 10 percent coinsurance for the first $1,000 in consumer spending after the deductible, 20 percent coinsurance for the next $1,000 in consumer spending, and 40 percent coinsurance up to a $6,400 MOOP. This plan design would be considered unique because the current AVC can only accommodate a single coinsurance rate for each benefit. Example 2. A plan with a multi-tiered provider or hospital network with substantial amounts of utilization expected in tiers other than the two lowest-priced tiers. This plan design would be considered unique because the current AVC does not take into account utilization beyond the second network tier when AV is computed. Choose from the following: a. Yes if the plan design is unique for purposes of calculating AV. If Yes is selected, upload the Unique Plan Design Supporting Documentation and Justification. See Chapter 13 for a suggested format. The actuarial certification is a signed and dated certification that a member of the American Academy of Actuaries performed the calculation, which complies with all applicable federal and state laws and actuarial standards of practice. b. No if the plan design is not unique. 5. QHP/Non-QHP (required). Indicate whether the plan is offered on the Exchange, off the Exchange, or both. Choose from the following: a. On Exchange if the plan will be offered on the Exchange Version

7 b. Off Exchange if the plan will be offered off the Exchange. FFE is not currently collecting off Exchange plans. c. Both if the plan will be offered both on and off the Exchange. 6. Notice Required for Pregnancy (required). Indicate whether a notice is required for pregnancy, i.e., indicate whether or not the plan has to be notified (by member or doctor) before pregnancy benefits are covered. Choose from the following: a. Yes if a notice is required b. No if a notice is not required. 7. Is a Referral Required for a Specialist? (required). Indicate whether a referral is required to see a specialist. Choose from the following: a. Yes if a referral is required to see a specialist b. No if a referral is not required to see a specialist. 8. Specialist(s) Requiring a Referral (required if Yes is entered for Is a Referral Required for Specialist?). Enter the types of specialists that require a referral. 9. Plan Level Exclusions (optional). Enter any plan exclusions. 10. Limited Cost Sharing Plan Variation Estimated Advance Payment (optional). Estimate of the per member per month dollar value of the cost-sharing reductions to be provided over the benefit year under the limited cost sharing plan variation associated with this standard plan. See the discussion in 45 CFR (a)(2) for more details on how to calculate this estimate. 11. HSA-Eligible (required). Indicate whether the plan meets all of the requirements to be a health savings account (HSA) eligible plan. Choose from the following: a. Yes if the plan meets all of the HSA requirements b. No if the plan does not meet all of the HSA requirements. 12. HSA/HRA Employer Contribution^ (required for Small Group only). Indicate whether the employer contributes to an HSA/health reimbursement arrangement (HRA). Choose from the following: a. Yes if the plan has an HSA/HRA employer contribution b. No if the plan does not have an HSA/HRA employer contribution. 13. HSA/HRA Employer Contribution Amount^ (required if Yes is entered for HSA/HRA Employer Contribution). Enter a numerical value representing the employer contribution Version

8 amount to HSA/HRA. The template will not permit an individual market plan to enter an HSA/HRA contribution amount. 14. Child-Only Offering (required). Indicate whether the plan will also be offered at a child-only rate or will have a corresponding child-only plan; one option must be selected consistent with the requirements at 45 CFR This does not apply if the plan s coverage level is catastrophic. Choose from the following: a. Allows Adult and Child-Only if the plan allows adult enrollment and will also be offered at a child-only rate b. Allows Adult-Only if the plan does not allow child-only enrollment c. Allows Child-Only if the plan is a child-only plan. 15. Child Only Plan ID (required if Allows Adult-Only is entered for Child-Only Offering). Enter the corresponding 14-character Plan ID if this plan does not allow child-only enrollment. The entered Plan ID must correspond to a plan in which Child Only Offering is equal to Allows Adult and Child-Only or Allows Child-Only. The corresponding plan must have the same Level of Coverage as the plan for which you are entering data. 16. Wellness Program Offered (required). Indicate whether the plan offers wellness programs according to Section 2705 of the Public Health Service Act. Choose from the following: a. Yes if the plan offers a wellness program in accordance with Section 2705 of the Public Health Service Act b. No if the plan does not offer a wellness program in accordance with Section 2705 of the Public Health Service Act. 17. Disease Management Programs Offered (optional). Indicate whether the plan offers disease management programs. Choose one or more of the following: a. Asthma b. Heart Disease c. Depression d. Diabetes e. High Blood Pressure & High Cholesterol f. Low Back Pain g. Pain Management h. Pregnancy. Version

9 Stand-Alone Dental Only This template section contains fields that have additional input data that are only relevant for stand-alone dental plans. NOTE: A revised version of the Plans & Benefits Template will be customized and made available for stand-alone dental plans. Stand-alone dental plans should wait to complete the Plans & Benefits Template until this version is available. 1. EHB Apportionment for Pediatric Dental (required if Yes is entered for Dental Only Plan). Enter the dollar amount of the expected premium allocated for the Pediatric Dental EHB. This amount will be used in calculations for advance payments of the premium tax credit. This amount may not be changed after certification, even if the rate is estimated. 2. Guaranteed vs. Estimated Rate (required if Yes is entered for Dental Only Plan). Select if this plan offers guaranteed or estimated rates. a. Guaranteed Rate if the plan offers a guaranteed rate b. Estimated Rate if the plan offers an estimated rate. This indicates whether the rate for this stand-alone dental plan is a guaranteed rate or an estimated rate. Estimated rates will require enrollees to contact the issuer to determine a final rate. Signifying a guaranteed rate means that the issuer agrees to only charge the rate reported. AV Calculator Additional Benefit Design This template section contains optional fields, which may be filled out to be used as inputs in the AVC. 1. Maximum Coinsurance for Specialty Drugs^ (optional). Indicates whether there is a limit on the amount of coinsurance on specialty prescription drugs by capping the maximum coinsurance payment on specialty drugs at a set amount. Enter the maximum coinsurance payments allowed for specialty prescription drugs. If no maximum coinsurance, leave the field blank. 2. Maximum Number of Days for Charging an Inpatient Copay?^ (optional). Indicates whether there is a limit on the number of days on which a patient can be charged a copay for an inpatient stay, if inpatient copays are charged per day. Enter the maximum number of days allowed (1-10). If this option does not apply, leave the field blank. 3. Begin Primary Care Cost-Sharing After a Set Number of Visits?^ (optional). Indicates whether primary care cost sharing begins after a certain number of fully covered visits have occurred. Enter the maximum number of visits allowed (1-10). If this option does not apply, leave the field blank. 4. Begin Primary Care Deductible/Coinsurance After a Set Number of Copays?^ (optional). Indicates whether primary care visits are subject to the deductible and coinsurance rates only after a certain number of primary care visits with copay have occurred. Enter the Version

10 maximum number of visits allowed (1-10). If this option does not apply, leave the field blank. Plan Dates This template section contains fields for the effective date and expiration date for each plan. 1. Plan Effective Date (required). Enter the effective date of the plan using the mm/dd/yyyy format. (It must be January 1 for individual market and SHOP.) 2. Plan Expiration Date (optional). Enter the date that a plan becomes closed and no longer accepts new enrollments using the mm/dd/yyyy format. (It must be December 31 for individual market.) Geographic Coverage This template section contains fields detailing what kinds of coverage will be offered in additional geographic locations. 1. Out of Country Coverage (required). Indicate whether care obtained outside the country is covered under the plan. Choose from the following: a. Yes if the plan covers care obtained out of the country b. No if the plan does not cover care obtained out of the country. 2. Out of Country Coverage Description (required if Yes is entered for Out of Country Coverage). Enter a short description of the care obtained outside the country that is covered under the plan. 3. Out of Service Area Coverage (required). Indicate whether care obtained outside the service area is covered under the plan. Choose from the following: a. Yes if the plan covers care obtained outside the plan service area b. No if the plan does not cover care obtained outside the plan service area. 4. Out of Service Area Coverage Description (required if Yes is entered for Out of Service Area Coverage). Enter a short description of the care obtained outside the service area that is covered under the plan. 5. National Network (required). Indicate whether a national network is available. Choose from the following: a. Yes if a national network is available b. No if a national network is not available. Version

11 URLs This template section contains fields for optional URLs for applicable websites. 1. URL for Summary of Benefits & Coverage (optional). Enter the website location for the summary of benefits and coverage (SBC). While this is identified as optional, issuers will be required to submit it prior to open enrollment. 2. URL for Enrollment Payment (optional). Enter the website location for enrollment payment information. 3. Plan Brochure (optional). Enter the website location for the plan brochure. Benefit Information This template section is for indicating whether each benefit is an EHB or has a state mandate. After the information above is completed, click the Refresh EHB Data button on the menu bar under the Plans and Benefits ribbon. If you have a multistate plan using an alternate benchmark, click Yes to the pop-up. Otherwise click No. Scroll down the worksheet to the Benefit Information and General Information sections (Figure 10-4). The following fields may auto-populate: EHB State Mandate Is this Benefit Covered? Quantitative Limit on Service Limit Quantity Limit Unit Minimum Stay Explanation. Version

12 Figure Benefit Information and General Sections If you click the Refresh EHB Data button after filling out the Benefit Information, General Information, or Deductible and Out of Pocket Exceptions sections, the default values will return and all inputs, including any added benefits, will be deleted. 1. EHB (required). This field will be auto-populated for all benefits listed in the template according to the state EHB benchmark. Users cannot edit this field. 2. State Mandate (required). This field will be auto-populated if a particular state and market has a state mandate for that benefit for at least one type of plan. For example, in the small group market, there may be a state mandate that applies only to a PPO with more than five enrollees. To determine whether this benefit needs to be covered, you should refer to the list of state mandates ( for your state. Users cannot edit this field. To add a benefit that is not on the template, click the Add Benefit button on the menu bar under the Plans and Benefits ribbon. a. Look through the drop-down menu to see whether the benefit already exists, and select it if it does. If it is not on this menu, click the Custom button and type in the name of the benefit. The benefit name may not be identical to any other benefit s name. b. A row for this benefit will then appear below the last row in the Benefit Information section. c. If a benefit is mistakenly added, it cannot be deleted, but you may do one of the following: i. You may select Not Covered under the Is this Benefit Covered? column (described below) to work around this, or Version

13 ii. You may click the Refresh EHB Data button on the menu bar under the Plans and Benefits ribbon. This will delete the added benefit, but you will also lose any other data you have entered in the Benefit Information, General Information, or Deductible and Out of Pocket Exceptions sections. d. If the benefit added is not an EHB found in the state s benchmark, and the benefit is not being used to substitute an EHB found in the state s benchmark, select Above EHB as the EHB Variance Reason. e. If the benefit added is not an EHB found in the state s benchmark, and the benefit is being used to substitute an EHB found in the state s benchmark, select Additional EHB Benefit as the EHB Variance Reason. f. If the benefit added is a state mandate enacted after December 2011, select Above EHB as the EHB Variance Reason. g. A benefits package should not have multiple benefits with identical names. In the event of multiple cost-sharing schemas for a given benefit based on multiple limits, choose the cost sharing type that is applicable for the limits in Limit Quantity and Limit Unit for each of the network types. See number 4 below for instructions on handling multiple limits. General Information This template section contains fields that give further information about each benefit in the benefits package, such as whether it is covered, if there are any limits on the benefit, and any applicable exclusions or explanations. 1. Is this Benefit Covered? (required). This field will be auto-populated for benefits identified in the template as Covered for an EHB or a State Mandate. If this data element is changed to Not Covered for an EHB then you must substitute another benefit or combination of benefits in its place and provide the EHB-Substituted Benefit (Actuarial Equivalent) Supporting Documentation and Justification document to support the actuarial equivalence of the substitution (Reference the EHB Variance Reason data field in number 8 below, and see Chapter 13 for more details). If a benefit is Not Covered, the rest of the fields for this benefit may be left blank. Choose from the following options: a. Covered if this benefit is covered by the plan. A benefit is considered covered if the issuer covers the cost of the benefit listed in a policy either through first-dollar coverage or in combination with a cost-sharing mechanism (for example, copays, coinsurance, or deductibles). b. Not Covered if this benefit is not covered by the plan. A benefit is considered not covered if the subscriber is required to pay the full cost of the services with no effect on deductible and MOOP limits. c. If a benefit is changed to Not Covered for a State Mandate that is not applicable to the benefits package, choose the appropriate EHB Variance Reason from the list in number 8 below. Version

14 d. If a benefit is changed to Not Covered due to a law or regulation, such as Adult Dental, or Long Term Custodial Nursing Home Care, choose the appropriate EHB Variance Reason from the list in number 8 below. 2. Quantitative Limit on Service? (required if Covered is entered for Is this Benefit Covered?). This field is auto-populated for benefits identified in the template as EHBs. If this data element is changed, you must provide an EHB variance reason and associated supporting documents. For any benefits not identified as EHBs, choose from the following: a. Yes if this benefit has quantitative limits b. No if this benefit does not have quantitative limits. 3. Limit Quantity (required if Yes is entered for Quantitative Limit on Service?). This field is auto-populated for benefits in the template identified as EHBs. If this data element is changed, you must provide an EHB Variance Reason. For any benefits not identified as EHBs, enter a numerical value showing the quantitative limits placed on this benefit. (For example, if you have a limit of two specialist visits per year, enter 2 here.) 4. Limit Unit (required if Yes is entered for Quantitative Limit on Service?). This field is auto-populated for benefits in the template identified as EHBs. If this data element is changed, you must select the EHB Variance Reason Substantially Equal. For any benefits not identified as EHBs, using the drop-down menus, enter the units being restricted per interval to show the quantitative limits you place on this benefit. (For example, if you have a limit of two specialist visits per year, enter Visits per year here.) Choose from the following: a. Hours per week b. Hours per month c. Hours per year d. Days per week e. Days per month f. Days per year g. Months per year h. Visits per week i. Visits per month j. Visits per year k. Lifetime visits Version

15 l. Treatments per week m. Treatments per month n. Lifetime treatments o. Lifetime admissions p. Procedures per week q. Procedures per month r. Procedures per year s. Lifetime procedures t. Dollar per year u. Dollar per visit v. Days per admission w. Procedures per episode x. If a benefit has limit units that do not align with the list above, the limit will not be auto-populated in Limit Unit, but will auto-populate in the Explanation column (for example, one hearing aid per ear every 48 months for subscribers up to age 18). y. If a benefit has quantitative limits that span several types of services, those limits will not be auto-populated. Refer to the EHB Benchmarks posted on the CCIIO website ( The message Quantitative limit units apply, see EHB benchmark will appear in the Explanation column (for example, Outpatient Rehabilitation Services 30 combined visits for physical therapy, speech therapy, and occupational therapy for habilitative and rehabilitative services). z. If a benefit has multiple limit units, those limits will not be auto-populated. Put the limit quantity and limit unit that should be displayed on the plan compare function of the FFE website in these columns and put all other quantitative limits in the explanation (for example, Substance Abuse Disorder Inpatient Services 90 days per year in limit quantity and limit unit columns; two treatments per year in the explanation). aa. The message, Quantitative limit units apply, see EHB benchmark, may appear in the explanation column for a benefit that does not have quantitative limits in the Benefits and Limits section in the EHB Benchmark posting on the CCIIO website ( This message appears because certain benefits, identified in the Other Benefits section of the EHB Benchmark Version

16 Benefit template, may have quantitative limits, which may not apply to all services within the higher-level benefit category. 5. Minimum Stay (optional). This field will be auto-populated for benefits in the template identified as EHBs. If this data element is changed, you must provide an EHB variance reason and associated supporting documents, if applicable. For any benefits not identified as EHBs, enter a numerical value representing the minimum stay. a. If there is a minimum stay, list the minimum stay in hours for this benefit. b. If there is no minimum stay, leave this field blank. 6. Exclusions (optional). Enter any benefit level exclusions. a. If particular services or diagnoses are subject to exclusions (covered under some circumstances but not others), list those specific exclusions. b. If no services or diagnoses are excluded, leave this field blank. 7. Explanation (optional). Enter any explanations. 8. EHB Variance Reason (required if you changed any of the following fields: Is this Benefit Covered?, Limit Units, Limit Quantity, and Minimum Stay or if the benchmark has an unallowable limit or exclusion under the Affordable Care Act. (See the Guide to Reviewing Essential Health Benefits Benchmark Plans document on CCIIO website for more information). Select from the following EHB Variance Reasons if this benefit differs from your state s benchmark: a. Above EHB if this benefit is not an EHB benefit found in the state s benchmark. b. Substituted if this benefit or combination of benefits is in the state s benchmark and you are substituting a different benefit, the EHB Variance Reason for the original benefit should be Substituted. For an added benefit that is used for substitution, see the Additional EHB Benefit section. c. Substantially Equal if the limit unit or limit quantity associated with a benefit is changed. i. if the Limit Quantity for a benefit is now different from, but still substantially equal to, the benefit in the respective state EHB-benchmark ii. if the Limit Unit for a benefit is now different from, but still substantially equal to, the benefit in the respective state EHB-benchmark. For example, if the benchmark lists a limit of 40 Hours per Month, the plan defines a day as 8 hours and lists a limit of 5 Days per Month. d. Using Alternate Benchmark if you are using a multistate plan and therefore have an alternate benchmark. Version

17 e. Other Law/Regulation if another law or regulation overrides the benefit or quantitative limit in the state s benchmark. i. For example, if the benchmark includes adult dental services or adult vision services. ii. If a benefit is not in the state benchmark, but is a state mandate and the state mandate is not applicable to the benefits package, the EHB Variance Reason should be Other Law/Regulation and the benefit should be changed to Not Covered. f. Additional EHB Benefit if there is a benefit that is in the EHB benchmark but is not included in the auto-populated list by state or if the benefit is being substituted for an EHB. i. For example, the drug benefits may not be listed as covered in the auto-populated table when they actually are. In this case, change the benefit to Covered and choose this as the EHB Variance Reason. ii. If a benefit not in the state s benchmark is being used as a substitute for an EHB benefit that is in the state s benchmark, the EHB Variance Reason for this new benefit should be Additional EHB Benefit, and an attestation should be submitted indicating that the benefit or set of benefits is actuarially equivalent to the reference benefit in the state s EHB-benchmark plan. g. Dental Only Plan Available if a dental benefit is not covered because a dental only plan is available. Deductible and Out of Pocket Exceptions This template section is for indicating whether each benefit is subject to the deductible or excluded from the MOOP. All plans in a benefits package must have the same deductible MOOP structure. If the plans only have a combined (no in network) MOOP (or deductible), either all of the plans in a benefits package need to set their in network MOOP (or deductible) to a dollar value, or they all need to set their in network MOOP (or deductible) equal to Not Applicable and set their combined in/out network MOOP (or deductible) to a dollar value. Either all of the plans in a benefits package need to have multiple in network tiers, or they all need to use only one tier. All of the plans in a benefits package need to exclude the same benefits from the MOOP. All of the plans in a benefits package need to subject the same benefits to the deductible. Version

18 To create plans with a different deductible or MOOP structure, you must create a new benefits package and subsequently a new Cost Share Variances worksheet. If the plans only have a combined (no in network) MOOP, set Excluded from In Network MOOP equal to Excluded from Out of Network MOOP. If the plans only have a combined (no in network) Deductible, set Subject to Deductible [Tier 1] equal to Subject to Deductible [Tier 2.] If the plans do not have multiple in network tiers, set Subject to Deductible [Tier 2] equal to Subject to Deductible [Tier 1]. If Is this Benefit Covered? for a benefit is Not Covered, leave Subject to Deductible [Tier 1], Subject to Deductible [Tier 2], Excluded from In Network MOOP and Excluded from Out of Network MOOP blank. If the plans do not have an out-of-network MOOP, set Excluded from Out of Network MOOP equal to Yes. In this section you must complete the following fields: 1. Subject to Deductible [Tier 1] (required)^. Indicate whether the benefit is subject to a deductible in network tier 1. Choose from the following: a. Yes if the enrollee is required to pay a deductible for this benefit b. No if the enrollee is not required to pay a deductible for this benefit. 2. Subject to Deductible [Tier 2] (required)^. Indicate whether the benefit is subject to a deductible in network tier 2. Choose from the following: a. Yes if the enrollee is required to pay a deductible for this benefit b. No if the enrollee is not required to pay a deductible for this benefit. 3. Excluded from In Network MOOP (required). Indicate whether this benefit is excluded from the in-network MOOP. Only those benefits that are not part of the state EHB benchmark can be excluded from the in network MOOP. Choose from the following: a. Yes if this benefit is excluded from in network MOOP b. No if this benefit is not excluded from in network MOOP. 4. Excluded from Out of Network MOOP (required). Indicate whether this benefit is excluded from the out-of-network MOOP. Choose from the following: a. Yes if this benefit is excluded from the out-of-network MOOP Version

19 b. No if this benefit is not excluded from out-of-network MOOP. After the benefit-related information is completed, click the Create Cost Share Variances button on the menu bar under the Plans and Benefits ribbon (Figure 10-5). The Cost Share Variances tab is designed to collect more detailed cost sharing benefit design information for all plans and cost-sharing reduction plan variations submitted by the issuer. Figure Create Cost Share Variances Button Click OK after reading the warning (Figure 10-6) and make any necessary changes. Figure Warnings Pop-up Box The following questions will pop up regarding deductible subgroups. Deductible subgroups should be used to identify benefits or groupings of benefits that have their own deductibles. These deductible subgroups are not separate deductibles outside of any maximums allowed, and they still contribute to the overall MOOP and deductible limits. You are not required to have any deductible subgroups. 1. Do you have any deductible subgroups? a. Yes if the plan contains deductible subgroups b. No if the plan does not contain deductible subgroups. 2. How many deductible subgroups do you have? Enter the correct number, and click OK. 3. What is the name of this deductible subgroup? Enter the name of each subgroup, and click OK after each. You must use a different name for each subgroup. Version

20 A new worksheet, Cost Share Variances, will be created for each Benefits Package worksheet (Figure 10-7). Corresponding sheets will be labeled with the same number. For example, enter information on Cost Share Variances 2 for benefits on Benefits Package 2. The worksheet contains several auto-populated cells; verify that the information in each is accurate. Figure Cost Share Variances Worksheet Once the Cost Share Variances tab has been created, you can update it as follows: If you add a new plan on the benefits package tab, click the Update Cost Share Variances button on the menu bar under the Plans and Benefits ribbon. It will add the new plan to the Cost Share Variances worksheet. If you need to delete a plan on the benefits package tab, you will need to delete all data for that plan s row. If there are any plans below that row, you will need to cut these rows and paste them into the empty row, as illustrated in the example below. This is an important step because if the Update Cost Share Variances Plan is clicked when there is an empty row between plans, all plans below this blank row and their corresponding data will be deleted from the Cost Share Variances tab. Example: If you wish to delete Plan 2 (see Figure 10-8), follow the following steps and then click the Update Cost Share Variances Plan and Plan 2 will be removed from the Cost Share Variances tab. Version

21 Figure Deleting a Plan If you change any benefits package data about a specific plan that already exists, the data does not update when you click the Update Cost Share Variances button. If you need to update the information for an existing plan, you first need to delete that plan on the Benefits Package worksheet, as explained above, and then click the Update Cost Share Variances button on the menu bar under the Plans and Benefits ribbon. All previously entered information for this plan on the Cost Share Variances tab will be deleted. Reenter the plan and associated data on the Benefits Package tab and click the Update Cost Share Variances button. If you change whether a benefit is Covered on the Benefits Package tab, it will not update with the Update Cost Share Variances button. Instead you must delete the entire Cost Share Variances worksheet and then click the Create Cost Share Variances button on the menu bar under the Plans and Benefits ribbon and start again. Cost Sharing Reduction Information This template section has fields with basic information about each plan and cost-sharing reduction plan variation, such as its plan ID, marketing name, and metal level. It also asks questions about the medical and drug integration for deductibles and MOOP in order to determine the appropriate columns to fill out later in the template. Note: The Cost Share Variances tab is designed to collect more detailed cost sharing benefit design information for all plans and plan variations submitted by the user. 1. HIOS Plan ID [Standard Component + Variant] (required). The HIOS-generated number auto-populates for each cost share variation. a. For the individual market only each metal level plan (except for catastrophic) has two plan variations: one with zero cost sharing and one with limited cost sharing. b. In addition, in the individual market each silver plan has an additional three cost sharing variation plans created: a 73 percent AV plan, an 87 percent AV plan, and a 94 percent AV plan. 2. Plan Marketing Name (required). The name of the plan auto-populates for standard plans. 3. Metal Level^ (required). The coverage level for the plan auto-populates for standard plans. Version

22 4. CSR Variation Type^ (required). The plan variation type auto-populates. 5. Issuer Actuarial Value (required if Yes is entered for Unique Plan Design). Enter the issuer-calculated AV. This only applies to health plans that indicate they are a unique plan for AV purposes. 6. AV Calculator Output Number (required). Clicking the Check AV Calc button on the Plans and Benefits ribbon, and selecting the correct file, populates this field with the AV for all plans on this sheet with a non-unique plan design. (All cost-sharing information and benefits package information should be filled in first. See Chapter 11: Actuarial Value Calculator for more information.) Make sure that the AVs meet the following requirements. a. For all standard plans, the AV must be within 2 percentage points of the metal level AV. b. For the three cost-sharing reduction silver plan variations, the AV must be within 1 percentage point of the AV level. Within the AVC, the Desired Metal Tier is set to Silver for the 73 percent AV variation, Gold for the 87 percent AV variation, and Platinum for the 94 percent AV variation. c. For the 73 percent AV silver plan variation, the actual AV must be at least 2 percentage points different than the AV of the associated standard silver plan. (For example, if the standard silver plan has an AV of 71 percent, the 73 percent AV variation plan must have an AV between 73 percent and 74 percent). d. The zero cost sharing plan variation must have an AV of 100 percent. e. The limited cost sharing plan variation must have an AV that is the same as the associated standard plan s AV. Although this template does not reflect the costsharing reductions required for individuals assigned to the limited cost-sharing plan variation, QHP issuers must ensure that the limited cost-sharing plan variation has no cost sharing on any item or service that is an EHB furnished directly by the Indian Health Service, an Indian tribe, a tribal organization, or an urban Indian organization or through referral under contract health services, pursuant to 45 CFR (b)(2). These cost-sharing reductions are not represented in the Plans & Benefits template and are not included in the AV calculation. Issuers are encouraged to assess the AV of a given plan design by first using the standalone AVC. After completion of the Plans & Benefits Template, the AV obtained from the Template should be identical to the value obtained via the stand-alone AVC. If it is not, issuers should first ensure that they filled out this Template correctly per the instructions in this chapter. If issuers are still unable to obtain an AV from the Plans and Benefits Template that matches what they obtain via the stand-alone AVC, then they should designate that particular plan as a unique plan design using the Unique Plan Design? field of the Benefits Package worksheet. For this plan, the issuer should then complete the Issuer Actuarial Value data field with the value from the stand-alone AVC. The issuer should also upload a screen shot of the stand-alone AVC with that value as a Version

23 supporting document for each plan for which this situation occurs. They should indicate the HIOS Plan ID (Standard Component) in the Description field when uploading the screen shot as a supporting document in HIOS as well as indicating the HIOS Plan ID (Standard Component) in the file name of the screen shot. Please note that in this situation designating your plan as a unique plan design will not require submission of an actuarial certification and you will not be considered unique for review purposes. 7. Medical & Drug Deductibles Integrated?^ (required). Indicate whether the medical and drug deductible is integrated. An integrated deductible means that both medical and drug charges contribute to a total plan-level deductible. A separate deductible means medical and drug charges contribute to separate plan-level deductibles. Choose from the following: a. Yes if medical and drug deductible is integrated. If Yes is entered, you should not enter information in the following sections: Medical Deductible and Drug Benefits Deductible. b. No if medical and drug deductible is not integrated. If No is entered, you should not enter information in the following section: Combined Medical & Drug Deductible. 8. Medical & Drug Maximum Out of Pocket Integrated?^ (required). Indicate whether the medical and drug MOOP is integrated. An integrated MOOP means that both medical and drug charges contribute to a total plan level MOOP. A separate MOOP means medical and drug charges contribute to separate plan level MOOP values. Choose from the following: a. Yes if the medical and drug MOOP is integrated. If Yes is entered, you should not enter information in the following sections: Maximum Out of Pocket for EHB Benefits and Maximum Out of Pocket for Drug Benefits. b. No if the medical and drug deductible MOOP is not integrated. If No is entered, you should not enter information in the following section: Maximum Out of Pocket for EHB and Drug Benefits (Total). 9. Multiple In Network Tiers?^ (required): Indicate whether there are multiple in-network provider tiers. The value must be the same for all variations of a plan. Choose from the following: a. Yes if there are multiple in network provider tiers. Enter your Tier 1 information into In Network Family and In Network Individual. b. No if there are not multiple in network provider tiers. You should not enter information into In Network (Tier 2) Family and In Network (Tier 2) Individual st Tier Utilization^ (required). If the answer to Multiple In Network Tiers? is Yes, enter the 1st Tier Utilization as a percentage here. If the answer to Multiple In Network Tiers? is No, field will auto-populate to 100%. (Ensure all plan variations have the same tier utilization as the standard plan.) Version

24 11. 2nd Tier Utilization^ (required). If the answer to Multiple In Network Tiers? is Yes, enter the 2nd Tier Utilization as a percentage here. This cell may be grayed out based on answers to other data elements. If so, it is locked and cannot be edited. (Ensure all plan variations have the same tier utilization as the standard plan.) SBC Scenario This template section contains fields for basic information about two SBC scenarios. While these data fields are optional, issuers are advised that the FFE may be using certain data elements from the SBC in Plan Compare. If this issuer does not provide this information, then Plan Compare will show not available. Fill out the following data elements for both coverage examples (Having a Baby and Having Diabetes): 1. Deductible (optional). Enter the numerical value for the deductible. 2. Copayment (optional). Enter the numerical value for the copayment. 3. Coinsurance (optional). Enter the numerical value for the coinsurance. 4. Limit (optional). Enter the numerical value for the benefit limits or exclusion amount. MOOP and Deductible Requirements and Guidance The following contains requirements and guidance for the MOOP and deductible values when completing the MOOP and Deductible template sections described below: 1. When entering the MOOP and Deductible values, ensure the following limits are met: a. The standard plans MOOP values must be within the required limits. b. For the 73 percent AV silver plan variations, MOOP must be less than or equal to $5,200 for an individual or $10,400 for a family. c. For the 87 percent and 94 percent AV silver plan variations, MOOP must be less than or equal to $2,250 for an individual or $4,500 for a family. d. For the zero cost sharing plan variations, MOOP and deductible values must be $0. This will auto-populate and should not be changed. e. For the limited cost sharing plan variations, MOOP and deductible values must be the same as the associated standard plan s MOOP. This will auto-populate whenever a value is entered for a standard plan and should not be changed. 2. When multiple children are taking part in the child-only plans, this is captured in the family fields. 3. Some plans may have only combined in- or out-of-network deductibles or MOOPs, rather than separate in-network and out-of-network deductibles or MOOPs. Other plans may have a mixture of in-network, out-of-network, and combined in-network and Version

25 out-of-network deductibles or MOOPs. When defining deductibles and MOOPs, you must adhere to the following guidelines: a. If the plan does not have multiple in-network tiers, the following applies: i. If the In Network field is equal to a dollar value ($X), the Combined In/Out of Network field can be either a dollar value or Not Applicable. ii. If the In Network field is Not Applicable, the Combined In/Out of Network field must be equal to a dollar value. iii. If the Out of Network field has no restrictions; it can be either a dollar value or Not Applicable. b. If the plan has multiple in network tiers, the following applies: i. If the In Network and In Network (Tier 2) fields are equal to dollar values, the Combined In/Out of Network field can be either a dollar value or Not Applicable. ii. If the In Network field is Not Applicable, the In Network (Tier 2) field must be Not Applicable and the Combined In/Out of Network field must be equal to a dollar value. iii. If the In Network (Tier 2) field is Not Applicable, the In Network field must be Not Applicable and the Combined In/Out of Network field must be equal to a dollar value. iv. The Out of Network field has no restrictions; it can be either a dollar value or Not Applicable. c. To represent a plan with no in-network deductible, enter $0 in the relevant In Network or In Network Tier 2 fields (Medical EHB, Drug EHB, or Combined Medical & Drug EHB). Entering Not Applicable in the In Network deductible fields implies that in-network service costs accumulate toward the Combined In/Out of Network deductible. If the In Network and Combined In/Out of Network deductible fields are equal to Not Applicable, the template will return an error when calculating the plan s AV. 4. If any of your MOOP exceeds the annual dollar limitation specified by the Internal Revenue Service (IRS) for high-deductible health plans and your medical and drug MOOPs are not integrated, you may submit a justification (see Chapter 13 for a suggested format) if your benefits are nested. By nesting, we are referring to a possible plan design where the drug and/or medical MOOPs count towards each other. For example, a plan with a $6,000 MOOP for medical and a $1,000 MOOP for drugs would likely exceed the allowable limit since the sum of the two is $7,000, however, if the drug costs count toward the medical MOOP (i.e., nested), then the total out of pocket exposure for a consumer would really be $6,000 rather than $7,000.If your plan design has Version

26 nested MOOPs, then please submit a justification so that an evaluation can be made as to whether the plan meets the requirements for the annual dollar limitation. 5. If any of your small group plan MOOPs are not integrated, total MOOP is calculated by adding together the Medical EHB MOOP and Drug EHB MOOP. If the total MOOP exceeds the annual dollar limitation specified by the Internal Revenue Service (IRS) for high-deductible health plans, you will need to submit this justification document certifying that your plan design uses more than one administrator in order to satisfy the requirements related to the annual limitation on cost sharing. See the Affordable Care Act Implementation FAQs - Set 12 ( for more information). Maximum Out of Pocket for Medical EHB Benefits This is the next section in the template after the SBC Scenario section and its layout is shown in Figure Figure Maximum Out Of Pocket Fields This template section is for inputting MOOP values for medical EHB benefits and is required only if No is entered for Medical & Drug Maximum Out of Pocket Integrated? This section may be grayed out based on answers to other data elements. If so, it is locked and cannot be edited. If MOOPs are not integrated, enter the In Network Individual Maximum Out of Pocket and In Network Family Maximum Out of Pocket for EHBs dollar amount. (It must be blank if Yes is entered for Medical & Drug Maximum Out of Pocket Integrated?) Using the drop-down menus, enter the appropriate values for the Individual and Family MOOP for EHB benefits in the following areas on the template: 1. In Network Individual^. If MOOPs are not integrated, enter the In Network Individual Maximum Out of Pocket for EHBs dollar amount. 2. In Network Family. If MOOPs are not integrated, enter the In Network Family Maximum Out of Pocket for EHBs dollar amount. 3. In Network (Tier 2) Individual^. If MOOPs are not integrated and you have multiple in-network tiers, enter the In Network (Tier 2) Individual Maximum Out of Pocket for EHBs dollar amount. 4. In Network (Tier 2) Family. If the MOOPs are not integrated and you have multiple in-network tiers, enter the In Network (Tier 2) Family Maximum Out of Pocket for EHBs dollar amount. Version

27 5. Out of Network Individual. If MOOPs are not integrated, enter the Out of Network Individual Maximum Out of Pocket for EHBs dollar amount. 6. Out of Network Family. If MOOPs are not integrated, enter the Out of Network Family Maximum Out of Pocket for EHBs dollar amount. 7. Combined In/Out Network Individual^. If MOOPs are not integrated, enter the Combined In/Out of Network Individual Maximum Out of Pocket for EHBs dollar amount. 8. Combined In/Out Network Family. If MOOPs are not integrated, enter the Combined In/Out of Network Family Maximum Out of Pocket for EHBs dollar amount. Maximum Out of Pocket for Drug EHB Benefits This template section is for inputting MOOP values for drug EHB benefits and is required only if No is entered for Medical & Drug Maximum Out of Pocket Integrated? This section may be grayed out based on answers to other data elements. If so, it is locked and cannot be edited. If MOOPs are not integrated, enter the In Network Individual Maximum Out of Pocket for Drug Benefits dollar amount and the Family Maximum Out of Pocket for Drug Benefits dollar amount. (It must be blank if Yes is entered for Medical & Drug Maximum Out of Pocket Integrated?) Using the drop-down menus, enter the appropriate values for the Individual and Family MOOP for drug benefits. 1. In Network Individual^. If MOOPs are not integrated, enter the In Network Individual Maximum Out of Pocket for Drug Benefits dollar amount. 2. In Network Family. If MOOPs are not integrated, enter the In Network Family Maximum Out of Pocket for Drug Benefits dollar amount. 3. In Network (Tier 2) Individual^. If MOOPs are not integrated and you have multiple in-network tiers, enter the In Network (Tier 2) Individual Maximum Out of Pocket for Drug Benefits dollar amount. (If you only have multiple tiers for medical EHB benefits and not drug EHB benefits, this value should be the same as the Tier 1 value in the In Network-Individual field.) 4. In Network (Tier 2) Family. If the MOOPs are not integrated and you have multiple in-network tiers, enter the In Network (Tier 2) Family Maximum Out of Pocket for Drug Benefits dollar amount. (If you only have multiple tiers for medical EHB benefits and not drug EHB benefits, this value should be the same as the Tier 1 value in the In Network-Family field.) 5. Out of Network Individual. If MOOPs are not integrated, enter the Out of Network Individual Maximum Out of Pocket for Drug Benefits dollar amount. 6. Out of Network Family. If MOOPs are not integrated, enter the Out of Network Family Maximum Out of Pocket for Drug Benefits dollar amount. Version

28 7. Combined In/Out of Network Individual^. If MOOPs are not integrated, enter the Combined In/Out of Network Individual Maximum Out of Pocket for Drug Benefits dollar amount. 8. Combined In/Out of Network Family. If MOOPs are not integrated, enter the Combined In/Out of Network Family Maximum Out of Pocket for Drug Benefits dollar amount. Maximum Out of Pocket for Medical and Drug EHB Benefits (Total) This template section is for inputting MOOP values for medical and drug EHB benefits and is required only if Yes is entered for Medical & Drug Maximum Out of Pocket Integrated? This section may be grayed out based on answers to other data elements. If so, it is locked and cannot be edited. If MOOPs are integrated, enter the In Network Individual Maximum Out of Pocket for Total dollar amount and the In Network Family Maximum Out of Pocket for Total dollar amount. (It must be blank if No is entered for Medical & Drug Maximum Out of Pocket Integrated?) Using the drop-down menus, enter the appropriate values for the Individual and Family Total MOOP for drug benefits. 1. In Network Individual^. If MOOPs are integrated, enter the In Network Individual Maximum Out of Pocket for Total dollar amount. 2. In Network Family. If MOOPs are integrated, enter the In Network Family Maximum Out of Pocket for Total dollar amount. 3. In Network (Tier 2) Individual^. If MOOPs are integrated and you have multiple in-network tiers, enter the In Network (Tier 2) Individual Maximum Out of Pocket for Total dollar amount. 4. In Network (Tier 2) Family. If the MOOPs are integrated and you have multiple in-network tiers, enter the In Network (Tier 2) Family Maximum Out of Pocket for Total dollar amount. 5. Out of Network Individual. If MOOPs are integrated, enter the Out of Network Individual Maximum Out of Pocket for Total dollar amount. 6. Out of Network Family. If MOOPs are integrated, enter the Out of Network Family Maximum Out of Pocket for Total dollar amount. 7. Combined In/Out Network Individual^. If MOOPs are integrated, enter the Combined In/Out of Network Individual Maximum Out of Pocket for Total dollar amount. 8. Combined In/Out Network Family. If MOOPs are integrated, enter the Combined In/Out of Network Family Maximum Out of Pocket for Total dollar amount. Medical EHB Deductible This template section is for inputting deductible values for medical EHB benefits and is required only if No is entered for Medical & Drug Deductibles Out of Pocket Integrated? This section may be grayed out based on answers to other data elements. If so, it is locked and cannot be edited. If deductibles are not integrated, enter the In Network Individual Medical Deductible Version

29 dollar amount and the Family Medical Deductible dollar amount. (It must be blank if Yes is entered for Medical & Drug Deductibles Out of Pocket Integrated?) Using the drop-down menus, enter the appropriate values for the Individual and Family medical deductible data elements in the following areas on the template: 1. In Network Individual^. If deductibles are not integrated, enter the In Network Individual Medical Deductible dollar amount. 2. In Network Family. If deductibles are not integrated, enter the In Network Family Medical Deductible dollar amount. 3. In Network-Default Coinsurance^. If deductibles are not integrated, enter the numerical value for the in network coinsurance. Note: If deductibles are not integrated, this is a required field for the actuarial value (AV) calculation for those plans using the AV Calculator. 4. In Network (Tier 2) Individual^. If deductibles are not integrated and you have multiple in-network tiers, enter the In Network (Tier 2) Individual Medical Deductible dollar amount. 5. In Network (Tier 2) Family. If deductibles are not integrated and you have multiple in-network tiers, enter the In Network (Tier 2) Family Medical Deductible dollar amount. 6. In Network (Tier 2) Default Coinsurance^. If deductibles are not integrated, enter the numerical value for the in-network coinsurance. 7. Out of Network Individual. If deductibles are not integrated, enter the Out of Network Individual Medical Deductible dollar amount. 8. Out of Network Family. If deductibles are not integrated, enter the Out of Network Family Medical Deductible dollar amount. 9. Combined In/Out Network Individual^. If deductibles are not integrated, enter the Combined In/Out of Network Individual Medical Deductible dollar amount. 10. Combined In/Out Network Family. If deductibles are not integrated, enter the Combined In/Out of Network Family Medical Deductible dollar amount. Drug EHB Deductible This template section is for inputting deductible values for drug EHB benefits and is required only if No is entered for Medical & Drug Deductibles Out of Pocket Integrated? This section may be grayed out based on answers to other data elements. If so, it is locked and cannot be edited. If deductibles are not integrated, enter the In Network Individual Drug Deductible dollar amount and the Family Drug Deductible dollar amount. (It must be blank if Yes is entered for Medical & Drug Deductibles Out of Pocket Integrated?) Using the drop-down menus, enter the Version

30 appropriate values for the Individual and Family drug deductible data elements in the following areas on the template: 1. In Network Individual^. If deductibles are not integrated, enter the In Network Individual Drug Deductible dollar amount. 2. In Network Family. If deductibles are not integrated, enter the In Network Family Drug Deductible dollar amount. 3. In Network-Default Coinsurance^. If deductibles are not integrated, enter the numerical value for the in-network coinsurance. 4. In Network (Tier 2) Individual^. If deductibles are not integrated and you have multiple In Network Tiers, enter the In Network (Tier 2) Individual Drug Deductible dollar amount. (If you only have multiple tiers for medical EHB benefits and not drug EHB benefits, this value should be the same as the Tier 1 value in the In Network-Individual field.) 5. In Network (Tier 2) Family. If deductibles are not integrated and you have multiple In Network Tiers, enter the In Network (Tier 2) Family Drug Deductible dollar amount. (If you only have multiple tiers for medical EHB benefits and not drug EHB benefits, this value should be the same as the Tier 1 value in the In Network-Family field.) 6. In Network (Tier 2)-Default Coinsurance^. If deductibles are not integrated, enter the numerical value for the in-network coinsurance. (If you only have multiple tiers for medical EHB benefits and not drug EHB benefits, this value should be the same as the Tier 1 value in the In Network-Default Coinsurance field.) 7. Out of Network Individual. If deductibles are not integrated, enter the Out of Network Individual Drug Deductible dollar amount. 8. Out of Network Family. If deductibles are not integrated, enter the Out of Network Family Drug Deductible dollar amount. 9. Combined In/Out Network Individual^. If deductibles are not integrated, enter the Combined In/Out of Network Individual Drug Deductible dollar amount. 10. Combined In/Out Network Family. If deductibles are not integrated, enter the Combined In/Out of Network Family Drug Deductible dollar amount. Combined Medical & Drug EHB Deductible This template section is for inputting deductible values for combined medical and drug EHB benefits and is required only if Yes is entered for Medical & Drug Deductibles Out of Pocket Integrated? This section may be grayed out based on answers to other data elements. If so, it is locked and cannot be edited. If deductibles are integrated, enter the In Network Individual Medical Deductible dollar amount and the Family Medical Deductible dollar amount. (It must be blank if No is entered for Medical & Drug Deductibles Out of Pocket Integrated?) Using the Version

31 drop-down menus, enter the appropriate values for the Individual and Family combined medical and drug deductible data elements in the following areas on the template: 1. In Network Individual^. If deductibles are integrated, enter the In Network Individual Combined Medical and Drug Deductible dollar amount. 2. In Network Family. If deductibles are integrated, enter the In Network Family Combined Medical and Drug Deductible dollar amount. 3. In Network-Default Coinsurance^. If deductibles are integrated, enter the numerical value for the in-network coinsurance. Note: If deductibles are integrated, this is a required field for the actuarial value (AV) calculation for those plans using the AV Calculator. 4. In Network (Tier 2) Individual^. If deductibles are integrated and you have multiple In Network Tiers, enter the In Network (Tier 2) Individual Combined Medical and Drug Deductible dollar amount. 5. In Network (Tier 2) Family. If deductibles are integrated and you have multiple In Network Tiers, enter the In Network (Tier 2) Family Combined Medical and Drug Deductible dollar amount. 6. In Network (Tier 2)-Default Coinsurance^. If deductibles are integrated, enter the numerical value for the in-network coinsurance. 7. Out of Network Individual. If deductibles are integrated, enter the Out of Network Individual Combined Medical and Drug Deductible dollar amount. 8. Out of Network Family. If deductibles are integrated, enter the Out of Network Family Combined Medical and Drug Deductible dollar amount. 9. Combined In/Out Network Individual^. If deductibles are integrated, enter the Combined In/Out of Network Individual Combined Medical and Drug Deductible dollar amount. 10. Combined In/Out Network Family. If deductibles are integrated, enter the Combined In/Out of Network Family Combined Medical and Drug Deductible dollar amount. Other Deductible Users will be required to complete this template section if they have deductible subgroups; the user can add an unlimited number and name them. Enter the appropriate values for the Individual and Family data elements in the following areas on the template. (These values are not separate deductibles outside of any maximums allowed, and they still contribute to the MOOP and deductible limits.) 1. In Network Individual. If deductibles are not integrated, enter the In Network Individual Other Deductible dollar amount. 2. In Network Family. If deductibles are not integrated, enter the In Network Family Other Deductible dollar amount. Version

32 3. In Network Tier 2 Individual. If deductibles are not integrated and you have multiple In Network Tiers, enter the In Network (Tier 2) Individual Other Deductible dollar amount. 4. In Network Tier 2 Family. If deductibles are not integrated and you have multiple In Network Tiers, enter the In Network (Tier 2) Family Other Deductible dollar amount. 5. Out of Network Individual. If deductibles are not integrated, enter the Out of Network Individual Other Deductible dollar amount. 6. Out of Network Family. If deductibles are not integrated, enter the Out of Network Family Other Deductible dollar amount. 7. Combined In/Out of Network Individual. If deductibles are not integrated, enter the Combined In/Out of Network Individual Other Deductible dollar amount. 8. Combined In/Out of Network Family. If deductibles are not integrated, enter the Combined In/Out of Network Family Other Deductible dollar amount. Covered Benefits This template section contains fields for copay and coinsurance values for all covered benefits. The covered benefits appear on the Cost Share Variances tab. Fill in information for each of the benefits, using the following guidance: If you have multiple in-network tiers, for any benefit category that does not have tiers, enter the same value for Tier 2 as you enter for Tier 1. If you have plans that do not have out-of-network benefits for a given category, enter $0 for the out-of-network copay fields and 100 percent for the out-of-network coinsurance fields. For further instructions on how to coordinate the prescription drug data entered in both the Plans & Benefits template and the Prescription Drug template, see the Suggested Coordination of Drug Data Between Templates section at the end of this chapter. For further instructions on how to fill out the copayment and coinsurance fields corresponding to the Actuarial Value Calculator, see Chapter 11: Actuarial Value Calculator. For the cost-sharing reduction silver plan variations, the copays and coinsurance values may not exceed the corresponding cost sharing required in the standard silver plan or any other silver plan variation thereof with a lower AV. See below for further detail. For all zero cost-sharing plan variations there should be $0 copays and 0% coinsurance for EHB covered services. See below for further detail. For all limited cost-sharing plan variations the copays and coinsurance values must be equal to the associated standard plan s values. This will auto-populate whenever a value is entered for a standard plan and should not be changed. See below for further detail. Version

33 The fields for each benefit are laid out as shown in Figure Figure Benefit Information Fill in the following information for each covered benefit on the benefits package sheet: 1. Copay In Network (Tier 1)^. If an in-network copayment is charged, enter the dollar amount here. If no copayment is charged, enter No Charge. Choose from the following: a. No Charge b. No Charge after deductible c. $X Copay d. $X Copay after deductible e. $X Copay before deductible. 2. Copay In Network (Tier 2)^. If you have multiple In Network Tiers and an in-network copayment is charged, enter the dollar amount here. If no copayment is charged, enter No Charge. This cell may be grayed out based on answers to other data elements. If so, it is locked and cannot be edited. Choose from the following: a. No Charge b. No Charge after deductible c. $X Copay d. $X Copay after deductible e. $X Copay before deductible. 3. Copay Out of Network. If an out-of-network copayment is charged, enter the amount here. If no copayment is charged, enter No Charge. Choose from the following: a. No Charge b. No Charge after deductible Version

34 c. $X Copay d. $X Copay after deductible e. $X Copay before deductible. 4. Inpatient Hospital Services (e.g. Hospital Stay) and Skilled Nursing Facility Copay In Network (Tier 1), Copay In Network (Tier 2), and Copay Out of Network. For Inpatient Hospital Services (e.g. Hospital Stay) and Skilled Nursing Facility only, define the copayment as charged per day or per stay. If no copayment is charged, enter $0 per Day. Choose from the following: a. $X Copay per Day b. $X Copay per Stay. Note: Any plain dollar values will be assumed to be per stay. 5. Coinsurance In Network (Tier 1)^. If an in-network coinsurance is charged, enter the percentage here. If no coinsurance is charged, enter No Charge, unless your plan has a tier 1 in-network copayment that the enrollee pays only until the deductible is met. In this case, enter 0%. Choose from the following: a. No Charge b. No Charge after deductible c. X% Coinsurance after deductible d. X%. 6. Coinsurance In Network (Tier 2)^. If you have multiple in-network tiers and an in-network coinsurance is charged, enter the percentage here. If no coinsurance is charged, enter No Charge, unless your plan has a tier 2 in-network copayment that the enrollee pays only until the deductible is met. In this case, enter 0%. This cell may be grayed out based on answers to other data elements. If so, it is locked and cannot be edited. Choose from the following: a. No Charge b. No Charge after deductible c. X% Coinsurance after deductible d. X%. 7. Coinsurance Out of Network. If an out-of-network coinsurance is charged, enter the percentage here. If no coinsurance is charged, enter No Charge, unless your plan has an Version

35 out-of-network copayment that the enrollee pays only until the deductible is met. In this case, enter 0%. Choose from the following: a. No Charge b. No Charge after deductible c. X% Coinsurance after deductible d. X%. 8. Verify that the covered benefit values for the plan variations are as follows: a. For the zero cost sharing plan variations, EHB cost-sharing values, for covered benefits, must all be 0, both in and out-of-network, and non-ehb cost-sharing values must be the same as the standard plan. If the QHP is a closed-panel HMO that does not cover services furnished by a provider outside of the network (i.e. cost sharing for services provided by an out-of-network provider is 100%), the spending, or cost sharing, for these non-covered services would not need to be eliminated for the zero cost sharing plan variation, and should be entered as it would be for non-covered out-of-network services under the corresponding standard plan. The cost-sharing values for all benefits for the zero cost sharing plan will auto-populate with $0 copays and 0% coinsurance, so for non-ehbs these values need to be updated to be the same as the values for the standard plan. (Note: Only applies to the individual market.) b. For the limited cost sharing variation plans, both EHB and non-ehb cost sharing values must be the same as the standard plan. (Note: Only applies to the individual market.) c. The three cost-sharing reduction silver plan variations follow the successive CSR rules, as follows: (Note: Only applies to the individual market.) i. The copay and coinsurance values for all EHBs for the 94 percent AV variation must be less than or equal to the values for the 87 percent AV variation, which must be less than or equal to the values for the 73 percent AV variation, which must be less than or equal to the values for the standard silver plan. ii. The copay and coinsurance values for non-ehbs must be the same as the values of the standard silver plan. iii. The default coinsurance values for the 94 percent AV variation must be less than or equal to the default coinsurance values for the 87 percent AV variation, which must be less than or equal to the default coinsurance values for the 73 percent AV variation, which must be less than or equal to the default coinsurance for the standard silver plan. Version

36 iv. The MOOP value for the 94 percent AV variation must be less than or equal to the MOOP value for the 87 percent AV variation, which must be less than or equal to the MOOP value for the 73 percent AV variation, which must be less than or equal to the MOOPS value for the standard silver plan. In addition, as discussed above, for the 73 percent AV silver plan variations, MOOP must be less than or equal to $5,200 for an individual or $10,400 for a family. For the 87 percent and 94 percent AV silver plan variations, MOOP must be less than or equal to $2,250 for an individual or $4,500 for a family. v. The deductible value for the 94 percent AV variation must be less than or equal to the deductible value for the 87 percent AV variation, which must be less than or equal to the deductible value for the 73 percent AV variation, which must be less than or equal to the deductible value for the standard silver plan. Once the entire template, including all Benefits Package and Cost Sharing Variances tabs, has been completed, click the Validate button on the menu bar under the Plans and Benefits ribbon. Review the errors (Figure 10-11), and click OK. Make the necessary changes. Figure Error Report Click the Finalize button on the menu bar under the Plans and Benefits ribbon (Figure 10-12), and save the validated template. Figure Finalize Button Version