Chapter XX Health Reform

Transcription

1 Chapter XX Health Reform Federal law defers enforcement of health reform to state insurance regulators. To help ensure strong consumer protections remain in place, state insurance regulators are developing new tools and methods for comprehensive oversight of the health insurance marketplace. Examination Standards States are developing examination standards for the immediate mandates of health reform. Since the immediate mandates are new to the marketplace and regulators, each examination standard includes introductory language setting forth the appropriate health reform provision title, citation, effective date, summary of the provision, background, and cross references to FAQs. The introductory language is followed by the examination standards for health reform mandate formatted for the NAIC s Market Regulation Handbook. Examination Checklist Once the examination standards are finalized, the standards will be placed into an examination checklist for use by state insurance regulators and health carriers. The examination checklist will serve as a uniform tool through which states and health carriers can measure compliance. Additional Data Collection As the examination standards and checklist are developed, additional data may need to be collected for monitoring and oversight of the marketplace. Collaboration Methodology The final component of state market conduct compliance tools for health reform is enhanced state collaboration which would provide consistent interpretation and review of the health reform standards National Association of Insurance Commissioners Page 1 of 11

2 MARKET CONDUCT EXAMINATION STANDARDS Health Reform Provisions Effective Provision Title Prohibitions on preexisting conditions exclusions for individuals under 19 years of age Health Reform Page Citation PHSA National Association of Insurance Commissioners Page 2 of 11

3 PROVISION TITLE: Prohibitions on preexisting conditions exclusions for individuals under 19 years of age CITATION: PHSA 1255 and 2704 (75 Fed Reg 37188, 45 CFR ) EFFECTIVE DATE: Plan/Policy years beginning September 23, 2010 PROVISION: Health reform prohibits health carriers from denying coverage; limiting benefits; or, denying benefits to a child younger than age 19 based upon a preexisting condition. Pursuant to the citation above and associated FAQs, the Department of Health and Human Services (HHS) indicates that states have the authority to establish one or more uniform open enrollment periods for children under the age of 19, but may not allow health carriers to selectively deny enrollment for children under the age of 19 with preexisting conditions while enrolling healthy children outside of the open enrollment period. Health carriers with an open enrollment period may not, during the rest of the year, medically underwrite and decline coverage to children with preexisting conditions while enrolling healthy children. Health carriers must either 1) enroll all children at all times throughout the year; or 2) enroll all children during the open enrollment and decline coverage to children outside of that period. BACKGROUND: Preexisting condition exclusion means a limitation or exclusion on benefits (including a denial of coverage) based on the fact that the condition was present before the effective date of coverage, (or if coverage is denied, the date of the denial) under a group health plan or group or individual health insurance coverage (or other coverage provided to federally eligible individuals pursuant to 45 CFR part 148), whether or not medical advice, diagnosis, care, or treatment was recommended or received before that day. A pre-existing condition exclusion includes any limitation or exclusion of benefits (including denial of coverage) applicable to an individual as a result of information relating to an individual s health status before the individual s effective date of coverage (or if coverage is denied, the date of the denial) (technical change from Carla Bailey (WA) on Aug. 6, 2013 and Tim Jost on Sept. 30, 2013 (in Sept. 5, 2013 NAIC Consumer Representatives comment letter) under a group health plan, or group or individual health insurance coverage (or other coverage provided to federally eligible individuals pursuant to 45 CFR part 148), such as a condition identified as a result of a pre-enrollment questionnaire or physical examination given to the individual, or review of medical records relating to the pre-enrollment period). FAQs: See HHS website for guidance National Association of Insurance Commissioners Page 3 of 11

4 NOTES: 2013 National Association of Insurance Commissioners Page 4 of 11

5 Standard 1 A health carrier may not deny coverage to applicants/proposed insureds under the age of 19 years pursuant to the provisions of any preexisting condition exclusion or preexisting condition limitation. Apply To: All group health products, (grandfathered and non-grandfathered products) for plan years Individual health products which are non-grandfathered products, for policy years Priority: Essential Documents to be Reviewed Health carrier underwriting policies and procedures related to eligibility and coverage for applicants/proposed insureds under the age of 19 with preexisting conditions Health carrier policyholder service policies and procedures related to eligibility and coverage for applicants/proposed insureds under the age of 19 with preexisting conditions Health carrier complaint handling policies and procedures related to eligibility and coverage for applicants/proposed insureds under the age of 19 with preexisting conditions Underwriting files Policyholder service files Complaint register/logs Health carrier complaint records (supporting documentation including but not limited to: records of inquiries, complaints, complainant correspondence and health carrier response) Applications for coverage and pre-enrollment questionnaires (Suggestion from Tim Jost on Sept. 30, 2013 (in Sept. 5, 2013 NAIC Consumer Representatives comment letter) Training materials Producer records Applicable state statutes, rules and regulations NAIC References 2013 National Association of Insurance Commissioners Page 5 of 11

6 Model Language for Prohibition on Preexisting Condition Exclusions for Individuals under the Age of 19 (#930-E) Review Procedures and Criteria Review health carrier underwriting, policyholder service and complaint handling policies and procedures for provisions addressing applicants/proposed insureds under 19 years of age to verify that the health carrier has adequate and appropriate policies and procedures in place to ensure that coverage is not denied to applicants/proposed insureds under the age of 19 on the basis of a preexisting condition. Such review should include examination of applications for coverage and pre-enrollment questionnaires. (Suggestion from Tim Jost on Sept. 30, 2013 (in Sept. 5, 2013 NAIC Consumer Representatives comment letter) Verify that the health carrier does not limit or exclude coverage under an individual or group health insurance benefit plan for an individual under the age of 19 via the health carrier s issuance of a preexisting condition exclusion on that individual. Review health carrier underwriting files/records for denials of coverage for applicants/proposed insureds under 19 years of age on the basis of a preexisting condition. Review health carrier policyholder service files to identify inquiries regarding coverage denials for applicants/proposed insureds under 19 years of age on the basis of a preexisting condition. Review health carrier complaint register/logs and complaint records to identify complaints relating to coverage denials for applicants/proposed insureds under the age of 19, on the basis of a preexisting condition. Review health carrier enrollment policies and procedures to verify that the health carrier has adequate and appropriate policies and procedures in place regarding applications for coverage for individuals under 19 years of age, to include provisions addressing open enrollments and renewals. Where a health carrier offers individual health insurance coverage that only covers individuals under age 19, verify that the health carrier offers such coverage continuously throughout the year, or during one or more open enrollment periods as set forth in applicable state statutes, rules and regulations. If the applicable state has established one or more open enrollment periods for individuals under the age of 19, verify that the insurance carrier does not selectively deny enrollment to individuals under the age of 19 with preexisting conditions while enrolling health (Technical change from Reva VandeVoorde (NE) on Oct. 18, 2013) children outside of the open enrollment period. Verify that, during an open enrollment period, a health carrier does 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. Verify that the coverage offered by the health carrier is effective for those applying during an open enrollment period on the same basis as any applicant qualifying for coverage on an underwritten basis National Association of Insurance Commissioners Page 6 of 11

7 Verify that the health carrier: Provides 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 Provides 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. Review health carrier training materials to verify that information provided therein is complete and accurate with regard to limitations and restrictions regarding the issuance of preexisting condition exclusions limitations on individuals under the age of 19. Review producer records to verify that information provided by producers to applicants/proposed insureds is complete and accurate with regard to limitations and restrictions regarding the issuance of preexisting condition exclusions limitations on individuals under the age of 19. Note: Examiners need to be aware that the language of this standard is based upon NAIC adopted model language, which is based upon federal health care law. With regard to conflict of state and federal law, examiners may need to review and base examinations upon applicable state law, especially where state law goes beyond health reform requirements set forth in federal law National Association of Insurance Commissioners Page 7 of 11

8 Standard 2 A health carrier may not deny benefits under a policy to any insured under the age of 19 pursuant to the provisions of any preexisting condition exclusion or other preexisting condition limitation. Apply To: All group health products, (grandfathered and non-grandfathered products) for plan years Individual health products which are non-grandfathered products, for policy years Priority: Essential Documents to be Reviewed Health carrier policyholder service policies and procedures related to eligibility and coverage for insureds under the age of 19 with preexisting conditions Health carrier complaint handling policies and procedures related to eligibility and coverage for insureds under the age of 19 with preexisting conditions Health carrier claims handling and grievance policies and procedures related to denial of benefits to insureds under the age of 19 with preexisting conditions Policyholder service files, including claim denial letters and explanation of benefit forms (Suggestion from Tim Jost on Sept. 30, 2013 (in Sept. 5, 2013 NAIC Consumer Representatives comment letter) Complaint register/logs Health carrier complaint records (supporting documentation including but not limited to: complaint files, complainant correspondence and health carrier response) Claim and grievance procedures register/logs Claims and grievance procedures histories regarding individuals under the age of 19 Claims and grievances regarding individuals under the age of 19 Producer records Applicable state statutes, rules and regulations NAIC References 2013 National Association of Insurance Commissioners Page 8 of 11

9 Model Language for Prohibition on Preexisting Condition Exclusions for Individuals under the Age of 19 (#930-E) Review Procedures and Criteria Review health carrier, policyholder service, complaint handling, grievance procedures and claims policies and procedures for provisions addressing insureds under 19 years of age to verify that a health carrier has adequate and appropriate policies and procedures in place to ensure that coverage is not denied to insureds under the age of 19 on the basis of a preexisting condition. Verify that the health carrier does not limit or exclude coverage under an individual or group health insurance benefit plan for an individual under the age of 19 via the health carrier s issuance of a preexisting condition exclusion on that individual. Review health carrier policyholder service files/records for inquiries regarding denial of benefits to insureds under 19 years of age on the basis of a preexisting condition. Review health carrier complaint register/logs and complaint records to identify complaints relating to denial of benefits to insureds under the age of 19 on the basis of a preexisting condition. Review health carrier claims and formal and informal grievances to identify occurrences of denial of benefits to insureds under 19 years of age on the basis of a preexisting condition. Review complaint records of formal and informal grievances, as well as records of appeals of adverse utilization review determinations, to verify that, when a health carrier has improperly applied limitations or exclusions of coverage through the issuance of a preexisting condition exclusion on any individual under the age of 19, the health carrier has taken appropriate corrective action/adjustments regarding the removal of the limitations/exclusions in a timely and accurate manner. Ascertain if the health carrier error could have been the result of some systemic issue (e.g. programingprogramming (technical change from Tim Jost on Sept. 30, 2013 (in Sept. 5, 2013 NAIC Consumer Representatives comment letter) or processing error). If so, determine if the health carrier has implemented any corrective actions including remediation and interest payments. The examiner should include this information in the examination report. If it appears financial harm occurred to consumers and the health carrier did not provide remediation, the examiner should make a recommendation for remediation to all affected consumers in the examination report. Verify that the health carrier maintains proper documentation for all correspondence supporting corrective action provided to the insured, including website notifications. Review health carrier training materials to verify that information provided therein is complete and accurate with regard to limitations and restrictions regarding the issuance of preexisting condition exclusions limitations on individuals under the age of National Association of Insurance Commissioners Page 9 of 11

10 Review producer records to verify that information provided by producers to insureds and claimants is complete and accurate with regard to limitations and restrictions regarding the issuance of preexisting condition exclusions limitations on individuals under the age of 19. Note: Examiners need to be aware that the language of the standard is based upon NAIC adopted model language, which is based upon federal health care law. With regard to conflict of state and federal law, examiners may need to review and base examinations upon applicable state law, especially where state law goes beyond health reform requirements set forth in federal law National Association of Insurance Commissioners Page 10 of 11

11 Standard 3 Policy language, enrollment materials and marketing and sales materials may not directly or indirectly indicate that individuals under the age of 19 with a preexisting condition cannot enroll in coverage or receive benefits under a group health or individual health insurance policy. Apply To: All group health products, (grandfathered and non-grandfathered products) for plan years Individual health products which are non-grandfathered products, for policy years Priority: Essential Documents to be Reviewed Forms approvals (policy language, enrollment materials and advertising materials), as required under applicable state statutes, rules and regulations Samples of policies, enrollment materials and advertising materials Producer records Applicable state statutes, rules and regulations NAIC References Model Language for Prohibition on Preexisting Condition Exclusions for Individuals under the Age of 19 (#930-E) Review Procedures and Criteria Review the health carrier s filed policy forms and endorsements for preexisting conditions exclusions and preexisting conditions coverage limitations applicable to individuals under the age of 19. Review the health carrier s enrollment materials, marketing and sales materials and other information disseminated to applicants/proposed insureds, insureds and claimants to verify that complete and accurate information is provided about the limitations and restrictions regarding the issuance of preexisting condition exclusions limitations on individuals under the age of 19. Review producer records to verify that information provided by producers to applicants/proposed insureds, insureds and claimants is complete and accurate with regard to limitations and restrictions regarding the issuance of preexisting condition exclusions limitations on individuals under the age of 19. Note: Examiners need to be aware that the language of the standard is based upon NAIC adopted model language, which is based upon federal health care law. With regard to conflict of state and federal law, examiners may need to review and base examinations upon applicable state law, especially where state law goes beyond health reform requirements set forth in federal law National Association of Insurance Commissioners Page 11 of 11