With respect to insured women, evidence-informed preventive care and screenings provided for in comprehensive guidelines supported by the HRSA.

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1 Summary of PPACA-Related Changes to Chapter 20 Conducting the Health Examination of the Market Regulation Handbook Adopted by the Market Conduct Examination Standards (D) Working Group on Dec. 18, 2012 PPACA-related amendments were adopted by the NAIC membership to the Model Language for Lifetime and Annual Limits (#930-C), Model Language for Preventive Services (#930-D) and Model Language for Prohibition on Preexisting Condition Exclusions for Individuals under the Age of 19 (#930-E) to reflect the provisions of section 2719 of the Public Health Service Act (PHSA) of the federal Patient Protection and Affordable Care Act (ACA) and the interim final regulations published in the Federal Register. In each of the following subject areas, language was added to Chapter 20 Conducting the Health Examination of the Market Regulation Handbook to reflect new PPACA-related health carrier requirements: Claims Requirements - Preventive Services The health carrier must establish written claims handling policy/procedures regarding compliance with PPACA-related restrictions on the assessment of cost-sharing upon insureds for preventive items and services as set forth in the Model Language for Preventive Services (#930-D). The health carrier s system of PPACA-related oversight must be reasonably designed to: Detect improper assessment of cost-sharing upon insureds for preventive items and services; Identify exceptions found; Set forth recommended next steps; and Provide for appropriate corrective action/adjustments to be performed by the health carrier on the insured s policy deductibles, copayments, coinsurance and other cost sharing mechanisms in a timely and accurate manner. The health carrier must properly apply deductibles, co-payments, coinsurance and other methods of cost-sharing on preventive items and services as provided for in Model #930-D. The health carrier must not improperly impose any cost-sharing requirements, such as a copayment, coinsurance or deductible with respect to all of the following items or services: Evidence-based items or services that have in effect a rating of A or B in the recommendations of the United States Preventive Services Task Force (USPSTF) as of September 23, 2010 with respect to the insured; Immunizations for routine use in children, adolescents and adult insureds that have in effect a recommendation from the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC) with respect to the individual involved. A recommendation from the ACIP of the CDC is considered in effect after it has been adopted by the Director of the CDC, and a recommendation is considered to be for routine use if it is listed on the Immunization Schedules of the CDC; With respect to infants, children and adolescent insureds, evidence-informed preventive care, and screenings provided for in comprehensive guidelines supported by the Health Resources and Services Administration (HRSA); and With respect to insured women, evidence-informed preventive care and screenings provided for in comprehensive guidelines supported by the HRSA. The health carrier must not improperly impose any cost-sharing requirements with respect to an office visit if a preventive item or service is not billed separately or is not tracked as individual 2012 National Association of Insurance Commissioners Page 1 of 7

2 encounter data separately from the office visit and the primary purpose of the insured s office visit is the delivery of the item or service. Claims Requirements Lifetime and Annual Limits The health carrier must establish written claims handling policy/procedures regarding compliance with PPACA-related restrictions on establishing annual/lifetime limits on the dollar amount of essential health benefits for any individual, as set forth in the Model Language for Lifetime and Annual Limits (#930-C). The health carrier s system of PPACA-related oversight must be reasonably designed to: Detect improper application of annual/lifetime limits on the dollar amount of essential health benefits for any individual; Identify exceptions found; Set forth recommended next steps; and Provide for appropriate corrective action/adjustments to be performed by the health carrier regarding incorrectly applied annual/lifetime limits, in a timely and accurate manner. The health carrier must properly apply annual/lifetime limits on the dollar amount of essential health benefits for any individual, as provided for in Model #930-C. The health carrier must not improperly establish a lifetime limit on the dollar amount of essential health benefits for any individual. Verify that the health carrier does not establish an annual limit on the dollar amount of essential health benefits for any individual, with the following exceptions: Health flexible spending arrangements (FSA), as defined in section 106(a)(2)(i) of the Internal Revenue Code; Medical savings accounts (MSA), as defined in section 220 of the Internal Revenue Code; and Health savings accounts (HSA), as defined in section 223 of the Internal Revenue Code. The health carrier must have taken into account only essential health benefits, in determining whether an individual has received benefits that meet or exceed the allowable limits. Claims Requirements Prohibition on Preexisting Condition Exclusions for Individuals under the Age of 19 The health carrier must establish written claims handling policy/procedures regarding compliance with PPACA-related restrictions on limitations or exclusions of coverage via the health carrier s issuance of preexisting condition exclusions on any individual under the age of 19, under an individual health insurance health benefit plan, as set forth in the Model Language for Prohibition on Preexisting Condition Exclusions for Individuals under the Age of 19 (Model #930-E). The health carrier s system of PPACA-related oversight must be reasonably designed to Detect improper application of limitations or exclusions of coverage, via the health carrier s issuance of preexisting condition exclusions, on any individual under the age of 19; Identify exceptions found; Set forth recommended next steps; and Provide for appropriate corrective action/adjustments to be performed by the health carrier in a timely manner regarding the improper application of limitations or exclusions of coverage, via the health carrier s issuance of any preexisting exclusion on any individual under the age of National Association of Insurance Commissioners Page 2 of 7

3 Complaint Handling Requirements Preventive Services The health carrier must establish written complaint handling policy/procedures regarding compliance with PPACA-related restrictions on the assessment of cost-sharing upon insureds for preventive items and services as set forth in the Model Language for Preventive Services (#930- D). When improper assessment of cost-sharing upon insureds occurs, the health carrier must take the appropriate corrective action/adjustments on the insured s policy deductibles, copayments, coinsurance and other cost-sharing mechanisms in a timely and accurate manner. Complaint Handling Requirements Lifetime and Annual Limits The health carrier must establish written complaint handling policy/procedures regarding compliance with PPACA-related restrictions on establishing annual/lifetime limits on the dollar amount of essential health benefits for any individual, as set forth in the Model Language for Lifetime and Annual Limits (#930-C). When improper application of annual/lifetime limits on the dollar amount of essential health benefits upon an individual occurs, the health carrier must taken appropriate corrective action/adjustments a timely and accurate manner. Complaint Handling Requirements Prohibition on Preexisting Condition Exclusions for Individuals under the Age of 19 The health carrier must establish written complaint handling policy/procedures regarding compliance with PPACA-related restrictions on limitations or exclusions of coverage via the health carrier s issuance of preexisting condition exclusions on any individual under the age of 19, under an individual health insurance health benefit plan, as set forth in the Model Language for Prohibition on Preexisting Condition Exclusions for Individuals under the Age of 19 (Model #930-E). When a health carrier improperly applies limitations or exclusions of coverage through the issuance of a preexisting condition exclusion on any individual under the age of 19, the health carrier must take appropriate corrective action/adjustments regarding the removal of the limitations/exclusions in a timely and accurate manner. Grievance Procedures Requirements Preventive Services The health carrier must establish written grievance procedures policy/procedures regarding compliance with PPACA-related restrictions on the assessment of cost-sharing upon insureds for preventive items and services as set forth in the Model Language for Preventive Services (#930- D). When improper assessment of cost-sharing upon insureds occurs, the health carrier must take the appropriate corrective action/adjustments on the insured s policy deductibles, copayments, coinsurance and other cost-sharing mechanisms in a timely and accurate manner National Association of Insurance Commissioners Page 3 of 7

4 Grievance Procedures Requirements Lifetime and Annual Limits The health carrier must establish written grievance procedures policy/procedures regarding compliance with PPACA-related restrictions on establishing annual/lifetime limits on the dollar amount of essential health benefits for any individual, as set forth in the Model Language for Lifetime and Annual Limits (#930-C). When improper application of annual/lifetime limits on the dollar amount of essential health benefits upon an individual occurs, the health carrier must take appropriate corrective action/adjustments a timely and accurate manner. Grievance Procedures Requirements Prohibition on Preexisting Condition Exclusions for Individuals under the Age of 19 The health carrier must establish written grievance procedures policy/procedures regarding compliance with PPACA-related restrictions on limitations or exclusions of coverage via the health carrier s issuance of preexisting condition exclusions on any individual under the age of 19, under an individual health insurance health benefit plan, as set forth in the Model Language for Prohibition on Preexisting Condition Exclusions for Individuals under the Age of 19 (Model #930-E). When a health carrier improperly applies limitations or exclusions of coverage through the issuance of a preexisting condition exclusion on any individual under the age of 19, the health carrier must take appropriate corrective action/adjustments regarding the removal of the limitations/exclusions in a timely and accurate manner. Policyholder Services Requirements Preventive Services The health carrier must establish written policy/procedures regarding compliance with PPACArelated restrictions on the assessment of cost-sharing upon insureds for preventive items and services as set forth in the Model Language for Preventive Services (#930-D). The health carrier, at least annually at the beginning of each new plan year or policy year, whichever is applicable, must revise the preventive services covered under its health benefit plans pursuant to Section 3 of Model 930-D and that are consistent with the recommendations of the USPSTF, the ACIP of the CDC and the guidelines with respect to infants, children, adolescents and women evidence-based preventive care and screenings supported by the HRSA in effect at the time. The health carrier s marketing materials provided to insureds and prospective insureds must provide complete, accurate information about the restriction of cost-sharing methods the health carrier may impose on the insured for preventive items and services described in Section 3 of Model #930-D. Policyholder Services Requirements Lifetime and Annual Limits The health carrier must establish written policy/procedures regarding compliance with PPACArelated restrictions on establishing annual/lifetime limits on the dollar amount of essential health benefits for any individual, as set forth in the Model Language for Lifetime and Annual Limits (#930-C) National Association of Insurance Commissioners Page 4 of 7

5 For plan or policy years beginning prior to January 1, 2014, for any individual, the health carrier must establish, for its health benefit plans, the following minimum annual limits on the dollar amount of benefits that are essential health benefits: $750,000, for a plan or policy year beginning on or after September 22, 2010, but before September 23, 2011; $1,250,000, for a plan or policy year beginning on or after September 22, 2011, but before September 23, 2012; and $2,000,000, for a plan or policy year beginning on or after September 22, 2012, but before January 1, When a health benefit plan receives a waiver from the HHS, the health carrier must notify prospective applicants, affected policyholders and the commissioner in each state where prospective applicants and any affected insured are known to reside. When an applicable HHS waiver expires or is otherwise no longer in effect, the health carrier must notify affected policyholders and the commissioner in each state where any affected insured is known to reside. With regard to reinstatement of coverage, the health carrier must reinstate coverage for any individual: Whose coverage or benefits under a health benefit plan ended by reason of reaching a lifetime limit on the dollar value of all benefits for the individual; and Who becomes eligible, or is required to become eligible, for benefits not subject to a lifetime limit on the dollar value of all benefits under the health benefit plan: For group health insurance coverage, on the first day of the first plan year beginning on or after September 23, 2010; or For individual health insurance coverage, on the first day of the first policy year beginning on or after September 23, With regard to reinstatement of coverage, if an individual is eligible for benefits or is required to become eligible for benefits under the health benefit plan, the health carrier must provide the individual with written notice that: The lifetime limit on the dollar value of all benefits no longer applies; and The individual, if still covered under the plan, is again eligible to receive benefits under the plan. If an individual is not enrolled in the health benefit plan, or if an enrolled individual is eligible for, but not enrolled in any benefit package under a health benefit plan, the health carrier must provide an individual with an opportunity of at least 30 days to enroll in the health benefit plan. The health carrier must provide applicable notices and an enrollment opportunity beginning not later than: For group health insurance coverage, the first day of the first plan year beginning on or after September 23, 2010; or For individual health insurance coverage, the first day of the first policy year beginning on or after September 23, The health carrier must provide the notices as follows: For group health insurance coverage, to an employee on behalf of the employee s dependent; 2012 National Association of Insurance Commissioners Page 5 of 7

6 For individual health insurance coverage, to the primary subscriber on behalf of the primary subscriber s dependent; For group health insurance coverage, the notices may be included with other enrollment materials that a health benefit plan distributes to employees, provided the statement is prominently displayed on the notice; For group health insurance coverage, if a notice is provided to an individual, a health carrier s requirement to provide the notice with respect to that individual is satisfied. For any individual, who is eligible for benefits or who is required to become eligible for benefits under the health benefit plan, that enrolls in a health benefit plan, coverage provided by the health carrier under the plan must take effect not later than: For group health insurance coverage, the first day of the first plan year beginning on or after September 23, 2010; or For individual health insurance coverage, the first day of the first policy year beginning on or after September 23, With regard to reinstatement of coverage, the health carrier must: Offer the individual all of the benefit packages available to similarly situated individuals who did not lose coverage under the plan by reason of reaching a lifetime limit on the dollar value of all benefits; and Not require the individual to pay more for coverage than similarly situated individuals who did not lose coverage by reason of reaching a lifetime limit on the dollar value of all benefits. The health carrier s marketing materials provided to insureds and prospective insureds must provide complete, accurate information about lifetime and annual limits. Policyholder Services Requirements Prohibition on Preexisting Condition Exclusions for Individuals under the Age of 19 The health carrier must establish written policy/procedures regarding compliance with PPACArelated restrictions on limitations or exclusions of coverage via the health carrier s issuance of preexisting condition exclusions on any individual under the age of 19, under an individual health insurance health benefit plan, as set forth in the Model Language for Prohibition on Preexisting Condition Exclusions for Individuals under the Age of 19 (Model #930-E). Under an individual health insurance health benefit plan, the health carrier must not limit or exclude coverage via the health carrier s issuance of a preexisting condition exclusion on any individual under the age of 19, as provided for in Model #930-E. Where a health carrier offers individual health insurance coverage that only covers individuals under age 19, the health carrier must offer such coverage continuously throughout the year, or during one or more open enrollment periods as set forth in applicable state statutes, rules and regulations. During an open enrollment period, a health carrier must not deny or unreasonably delay the issuance of a policy, refuse to issue a policy or issue a policy with any preexisting condition exclusion rider or endorsement to an applicant or insured who is under the age of 19 on the basis of a preexisting condition National Association of Insurance Commissioners Page 6 of 7

7 The coverage offered by the health carrier is to be effective for those applying during an open enrollment period on the same basis as any applicant qualifying for coverage on an underwritten basis. The health carrier must provide: Prior prominent public notice on its Internet website and written notice of the open enrollment rights for individuals under the age of 19 to each of its policyholders at least 90 days before any open enrollment period; and Information as to how an individual eligible for the open enrollment right may apply for coverage with the health carrier during an open enrollment period. The health carrier must not limit or exclude coverage under a group health insurance health benefit plan for an individual under the age of 19 via the health carrier s issuance of a preexisting condition exclusion on that individual. The health carrier s marketing materials provided to insureds and prospective insureds must provide complete, accurate information about the limitations and restrictions regarding the issuance of preexisting condition exclusions limitations on individuals under the age of National Association of Insurance Commissioners Page 7 of 7