2013-04 Process for Filing Amendments to Forms to Comply with ACA
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South Carolina
Department of Insurance
Capitol Center
1201 Main Street, Suite 1000
Columbia, South Carolina 29201
Mailing Address:
P.O. Box 100105, Columbia, S.C. 29202-3105
Telephone: (803) 737-6160
BULLETIN NUMBER 2013-04
NIKKI R. HALEY
Governor
RAYMOND G. FARMER
Director
TO:
All Insurers Licensed to Transact Accident and Health Insurance Business within
the State of South Carolina and All South Carolina Licensed Health Maintenance
Organizations (collectively "Health Insurance Issuers" or "Issuers")
FROM:
Raymond G. Farmer
/.?J G F,
Director of Insurance
. } "..
r
'
SUBJECT:
Process for Filing Amendments to Forms to Comply with the 2014 Market
Reform Requirements of the Patient Protection and Affordable Care Act (ACA)
DATE:
April29, 2013
I.
BACKGROUND AND PURPOSE
The purpose of this Bulletin is to inform all licensed Issuers of the procedures for filing
amendments to existing policy forms, including grandfathered coverage, or new policy forms to
comply with the 2014 Market Reforms and any additional filing requirements related to the
Patient Protection and Affordable Care Act (ACA) requirements. South Carolina Department of
Insurance (Department) Bulletin 2010-04 informed all licensed Issuers of the procedures for
filing amendments to comply with the Immediate Market Reforms. This Bulletin supplements
the filing requirements set forth in Bulletin 20 I 0-04.
THIS BULLETIN REFLECTS REGULATORY AND FILING REQUIREMENTS
BASED UPON THE FEDERAL GUIDANCE THAT HAS BEEN ISSUED FOR
COMPLIANCE WITH THE ACA TO DATE. THIS BULLETIN
1\>tAY
BE
SUPPLEPtfENTED OR MODIFIED IN THE FUTURE TO REFLECT ADDITIONAL
REQUIREMENTS OR GUIDANCE AS IT BECOMES AVAILABLE.
1
iate Market Reforms. This Bulletin supplements
the filing requirements set forth in Bulletin 20 I 0-04.
THIS BULLETIN REFLECTS REGULATORY AND FILING REQUIREMENTS
BASED UPON THE FEDERAL GUIDANCE THAT HAS BEEN ISSUED FOR
COMPLIANCE WITH THE ACA TO DATE. THIS BULLETIN
1\>tAY
BE
SUPPLEPtfENTED OR MODIFIED IN THE FUTURE TO REFLECT ADDITIONAL
REQUIREMENTS OR GUIDANCE AS IT BECOMES AVAILABLE.
1
II.
ACA REQUIREMENTS
Listed below are the market reforms with which issuers must comply.
A. Immediate Market Reforms
The following health insurance market reforms became effective six months after the enactment
of ACA and are often referred to as the "Immediate Market Reforms:"
I. No lifetime benefit limits on dollar value of benefits (PHSA §2711);
2. Restricted annual limits on certain benefits as determined by United States Department of
Health and Human Services (HHS) (PHSA §2711);
3. Rescissions prohibited (except for fraud or intentional misrepresentation) (PHSA §2712);
4. Benefits for preventive services required, with no cost-sharing (PHSA §2713);
5. Coverage of dependent children up to age 26 (PHSA §2714);
6. Pre-existing condition exclusions prohibited for children up to age 19 (PHSA §2704);
7. Prohibition of discrimination based upon salary (PHSA §2716) ;
8. Internal and external appeals process for enrollees (PHSA §2719);
9. Access to primary care provider, including pediatricians (PHSA §2719A);
10. Access to OB/GYNs (PHSA §2719A); and
11. Coverage for emergency services at in-network cost-sharing level; no prior authorization
requirements (PHSA §2719A).
B
ge 19 (PHSA §2704);
7. Prohibition of discrimination based upon salary (PHSA §2716) ;
8. Internal and external appeals process for enrollees (PHSA §2719);
9. Access to primary care provider, including pediatricians (PHSA §2719A);
10. Access to OB/GYNs (PHSA §2719A); and
11. Coverage for emergency services at in-network cost-sharing level; no prior authorization
requirements (PHSA §2719A).
B. 2014 Market Reforms
The following health insurance market reforms become effective January 1, 2014, and are often
referred to as the "2014 Market Reforms."
1) No preexisting condition exclusions (PHSA §2704);
2) Fair health insurance premiums (premiums may only vary by age, tobacco use,
geographic rating area, and whether coverage is individual or family) (PHSA §270 1 );
3) Guaranteed availability of coverage (PHSA §2702);
4) Guaranteed renewability of coverage (with certain exceptions) (PHSA §2703);
5) Prohibitions on discrimination against individual participants and beneficiaries based on
health status (PHSA §2705);
6) Prohibitions on discrimination against providers operating within the scope of their
practice and individuals or employers based upon receipt of subsidy or providing
information to investigators (PHSA §2706);
7) Inclusion of Essential Health Benefits (EHB), including compliance with cost-sharing
limitations, deductibles, and actuarial value standards (PHSA §2707) (PPACA § 1302) ;
8) Prohibition on imposing annual limits on the dollar value of EHBs (PHSA §2711);
9) Prohibition on excessive waiting periods (PHSA §2708); and
1 0) Coverage for individuals participating in approved clinical trials for certain conditions
(PHSA §2709).
2
efits (EHB), including compliance with cost-sharing
limitations, deductibles, and actuarial value standards (PHSA §2707) (PPACA § 1302) ;
8) Prohibition on imposing annual limits on the dollar value of EHBs (PHSA §2711);
9) Prohibition on excessive waiting periods (PHSA §2708); and
1 0) Coverage for individuals participating in approved clinical trials for certain conditions
(PHSA §2709).
2
C. Other ACA requirements
1) Summary of benefits and coverage (PHSA §2715)
The ACA creates a separate summary benefit disclosure requirement. PHSA 2715 requires
group health plans and insurers to provide each enrollee with a 4-page double-sided Summary of
Benefits and Coverage (EBC) and a uniform glossary of terms. The filing requirements for the
SBC are set forth in Section III below.
2) Provision of Additional Information (PHSA§2715A)
All plans must submit to the Secretary of HHS and the Department and make available to the
public the following information in plain language:
•
Claims payment policies and practices;
•
Periodic financial disclosures;
•
Data on enrollment;
•
Data on disenrollment; and
•
Data on the number of claims that are denied.
Filing requirements for this information are set forth below.
D. Grandfathered Coverage
1. Overview
Grandfathered plans are those group health plans or health insurance coverage that do not need
to comply with certain ACA coverage mandates if the plan had at least one individual enrolled as
of March 23, 2010. In order to maintain status as a grandfathered health plan, a plan must: a)
include a statement in any plan material that the plan is a grandfathered plan within the meaning
of Section 1251 of the ACA and b) maintain records necessary to substantiate the terms of the
plan if effective as of March 23, 2010, and verify its status as a grandfathered plan for as long as
the plan maintains that it is entitled to grandfathered status. Grandfathered status extends to new
enrollees
e a statement in any plan material that the plan is a grandfathered plan within the meaning
of Section 1251 of the ACA and b) maintain records necessary to substantiate the terms of the
plan if effective as of March 23, 2010, and verify its status as a grandfathered plan for as long as
the plan maintains that it is entitled to grandfathered status. Grandfathered status extends to new
enrollees. Accordingly, additional family members may be enrolled in group and individual
policies and new employees and their families may enroll in group health plans. Group health
plans that are maintained pursuant to a collective bargaining agreement will remain
grandfathered until the last of the agreements governing the plan terminates.
In 2014, when insurers will be required to maintain a single risk pool for all of their individual
market policies in a state and a single risk pool for all of their small group market policies in a
state, grandfathered plans will not be required to be included in those single risk pools. Any state
law that attempts to require them to be included would be invalid. In addition, grandfathered
plans will not be included in the risk adjustment mechanism or the temporary risk corridor
program. While grandfathered plans will be required to make payments into the transitional
reinsurance program for the individual market that the bill establishes, they will not be eligible to
collect payments under the program.
3
require them to be included would be invalid. In addition, grandfathered
plans will not be included in the risk adjustment mechanism or the temporary risk corridor
program. While grandfathered plans will be required to make payments into the transitional
reinsurance program for the individual market that the bill establishes, they will not be eligible to
collect payments under the program.
3
2. Coverage Mandates for Grandfathered Plans
The ACA does specifically apply a number of provisions to grandfathered plans from which they
would otherwise be exempt. These provisions include:
•
Relating to excessive waiting periods (PHSA §2708);
•
Provisions of section PHSA §2711 relating to lifetime limits (but not those dealing with
annual limits);
•
Relating to rescissions (PHSA §2712);
•
Relating to extension of dependent coverage (PHSA §2714);
•
Uniform summary of benefits and coverage and standardized definitions (PHSA §2715);
and
•
Bringing down the cost of health care coverage (PHSA §2718).
Other provisions are applied only to group plans that are grandfathered. These provisions are:
•
Provisions of PHSA §2711 relating to annual limits;
•
Relating to pre-existing condition exclusions (PHSA §2704); and
•
Relating to coverage of adult children only if the adult child is not eligible for their own
employer-sponsored coverage (PHSA §2714).
3. Specific Coverage Exemptions for Grandfathered Plans
Grandfathered plans are exempt from all other provisions of subtitles A (immediate reforms) and
C (market reforms) for as long as they are able to maintain their grandfathered status
(PHSA §2704); and
•
Relating to coverage of adult children only if the adult child is not eligible for their own
employer-sponsored coverage (PHSA §2714).
3. Specific Coverage Exemptions for Grandfathered Plans
Grandfathered plans are exempt from all other provisions of subtitles A (immediate reforms) and
C (market reforms) for as long as they are able to maintain their grandfathered status. These
provisions include the following reforms that go into effect prior to 2014 including:
•
First-dollar coverage of preventive health benefits (PHSA §2713);
•
Provision of additional information (PHSA §2715A);
•
Prohibition of discrimination based upon salary (PHSA §2716);
•
Ensuring the quality of care (PHSA §2717);
•
Internal and external appeals (PHSA §2719);
•
Patient protections (PHSA §2719A);
•
Health insurance consumer information (PHSA §2793); and
•
Ensuring that patients get value for their dollars (PHSA §2794).
Grandfathered plans are also exempt from the market reforms that go into effect on January 1,
2014. These provisions include:
•
Fair health insurance premiums (PHSA §2701);
•
Guaranteed availability of coverage (PHSA §2702);
•
Guaranteed renewability of coverage (PHSA §2703);
•
Prohibition on discrimination based upon health status (PHSA §2705); and
•
Nondiscrimination in health care (PHSA §2706).
4
4. Ways to Lose Grandfathered Status
A plan can lose its grandfathered status
2014. These provisions include:
•
Fair health insurance premiums (PHSA §2701);
•
Guaranteed availability of coverage (PHSA §2702);
•
Guaranteed renewability of coverage (PHSA §2703);
•
Prohibition on discrimination based upon health status (PHSA §2705); and
•
Nondiscrimination in health care (PHSA §2706).
4
4. Ways to Lose Grandfathered Status
A plan can lose its grandfathered status. There are a number of ways a grandfathered health plan
may lose its grandfathered status:
•
Through business restructuring (i.e., merger, acquisition, or similar restructuring to cover
new individuals under the plan); or
• If the grandfathered plan:
o
Eliminates of all or substantially all benefits to diagnose or a condition;
o
Increases the cost-sharing percentage (e.g., coinsurance) from what it was on
March 23, 2010;
o
Increases the deductible or out-of-pocket limit (based on a certain formula);
o
Decreases the employer's contribution by more than 5% over what it was on
March 23, 2010; and
o Adopts an annual dollar limit that is lower than the annual dollar limit in effect on
March 23, 2010, based on certain rules.
Insurers must be able to document and justify any claim to grand fathered status. Questions about
grandfathered status may be directed to the contact person referenced infra. The filings
requirements for grandfathered plans and non-grandfathered plans are detailed in the sections
that follow.
III.
REQUIREMENTS APPLICABLE TO FILINGS
All filings made to comply with the 2014 Market Reforms must also comply with the
requirements of Bulletin 2003-13. Pursuant to Bulletin 2011-09, all filing must be made via the
System for Electronic Rate and Form Filings (SERFF). South Carolina is using SERFF Plan
Management for inside and outside health insurance exchange plans. All templates submitted
should include all plans in the market, regardless of context inside or outside of the health
insurance exchange
ith the
requirements of Bulletin 2003-13. Pursuant to Bulletin 2011-09, all filing must be made via the
System for Electronic Rate and Form Filings (SERFF). South Carolina is using SERFF Plan
Management for inside and outside health insurance exchange plans. All templates submitted
should include all plans in the market, regardless of context inside or outside of the health
insurance exchange. No more than one binder should be submitted per market - one individual
and one Small Business Health Insurance Options Program (SHOP). Qualified Health Plans
(QHP) must submit applications in HIOS as well as SERFF.
In addition, the following information must be included with the filing:
A. Grandfathered Policy Forms
Health Insurance Issuers may file amendments to grandfathered policy forms solely to
incorporate the required 2014 market reforms. The following additional information should be
provided:
1) Filing Description;
2) ACA Uniform Compliance Summary (See Appendix A);
3) ACA Certification of Compliance, which indicates that the only amendments that have
been made are amendments necessary to incorporate the 2014 market reforms (See
Appendix B-1);
5
4) If rates are impacted, rates must be submitted for prior approval in accordance with
Bulletin 2013-01, which may be accessed at:
http://doi.sc.gov/Documents/Bulletins/20 13/Rate%20Filing%20Procedures.pdf; and
5) A copy of the SBC required by PHSA §2715, a certification that the document complies
with the requirements of PHSA §2715, and any related regulatory guidance must be
provided within 30 days of the submission of the filing. The filing must also include a
certification that the SBC has been provided to all policyholders and enrollees as required
PHSA §2715 and any related regulatory guidance. The certification must be submitted
annually by July 1st of each year thereafter.
B
s
with the requirements of PHSA §2715, and any related regulatory guidance must be
provided within 30 days of the submission of the filing. The filing must also include a
certification that the SBC has been provided to all policyholders and enrollees as required
PHSA §2715 and any related regulatory guidance. The certification must be submitted
annually by July 1st of each year thereafter.
B. Non-Grandfathered Policy Forms Amendments
Health Insurance Issuers may file amendments to existing policy forms solely to incorporate the
required 2014 market reforms. The following additional information should be provided:
1) Filing Description;
2) ACA Uniform Compliance Summary (See Appendix A);
3) ACA Certification of Compliance, which indicates that the only amendments that have
been made are amendments necessary to incorporate the 2014 market reforms (See
Appendix B-1 );
4) If rates are impacted, rates must be submitted for prior approval in accordance with
Bulletin 2013-01, which may be accessed at:
http://doi.sc.gov/Documents/Bulletins/20 13/Rate%20Filing%20Procedures.pdf; and
5) A copy of the SBC required by PHSA §2715, a certification that the document complies
with the requirements of PHSA §2715, and any related regulatory guidance must be
provided within 30 days of the submission of the filing. The filing must also include a
certification that the SBC has been provided to all policyholders and enrollees as required
PHSA §2715 and any related regulatory guidance. The certification must be submitted
annually by July 1st of each year thereafter.
C. New Policy Forms
Health Insurance Issuers may submit new policy forms to comply with the 2014 market reforms.
The policy forms must incorporate the Immediate Market Reforms and the 2014 Market Reforms
and any additional South Carolina requirements
s as required
PHSA §2715 and any related regulatory guidance. The certification must be submitted
annually by July 1st of each year thereafter.
C. New Policy Forms
Health Insurance Issuers may submit new policy forms to comply with the 2014 market reforms.
The policy forms must incorporate the Immediate Market Reforms and the 2014 Market Reforms
and any additional South Carolina requirements. The following additional information should be
provided:
1) Filing Description;
2) ACA Uniform Compliance Summary (See Appendix A);
3) ACA Certification of Compliance, which indicates that the policy form complies with
applicable requirements of the ACA (See Appendix B-2);
6
4) Rates for new policy forms must be submitted for prior approval in accordance with
Bulletin 2013-01, which may be accessed at:
http://doi.sc.gov/Documents/Bulletins/20 l3/Rate%20Filing%20Procedures.P...<!f; and
5) A copy of the SBC required by PHSA §2715, a certification that the document complies
with the requirements of PHSA §2715, and any related regulatory guidance must be
provided within 30 days of the submission of the filing. The filing must also include an
initial certification that the SBC will be provided to all policyholders and enrollees as
required. The certification must be submitted annually by July 1st of each year thereafter
indicating that the SBC has been provided to all policyholders and enrollees as required
PHSA §2715 and any related regulatory guidance.
D. Additional Filing Requirements Applicable to All Filings
1) The Issuer must include a certification that the information required by PHSA §2715A
has been made available to the public and a method for the Department to access the
information or a copy of the information
t the SBC has been provided to all policyholders and enrollees as required
PHSA §2715 and any related regulatory guidance.
D. Additional Filing Requirements Applicable to All Filings
1) The Issuer must include a certification that the information required by PHSA §2715A
has been made available to the public and a method for the Department to access the
information or a copy of the information.
2) For any network plan that either requires enrollees to use or creates incentives, including
financial incentives, for enrollees to use the plan's participating provider network, the
issuer must include a certification that it has reviewed our Network Adequacy Procedures
found in Appendix C and that the network for the plan meets these standards.
3) Health Insurance Issuers must clearly indicate the method for supplementing habilitative
services and the benefits provided in the filings submitted.
4) If actuarial substitutions are included in the filing, the information described in Appendix
D must be submitted to the Department as part of filing.
5) Each filing must include a demonstration of the calculation of the actuarial value (A V),
together with a certification from a credentialed actuary that the plan has been accurately
entered into the AV calculator and that the metal level assigned accurately reflects the
results of the A V calculator.
6) To the extent that an Issuer has not complied with a South Carolina law or regulation due
to a conflict with the ACA and a belief that the South Carolina requirement prevents the
application of the federal law and is therefore preempted, the Issuer must clearly
document the provision that has not been complied with and the reason the Issuer
believes the requirement to be preempted in making the certification required in
Appendix B.
IV.
ADDITIONAL REGULATORY GUIDANCE
Additional regulatory guidance related to EHBs, AV, EHB Substitutions, Cost Sharing
Reductions, Fair Premiums, Pediatric and Adult Dental and Vision Plans is found in Appendix
D.
7
document the provision that has not been complied with and the reason the Issuer
believes the requirement to be preempted in making the certification required in
Appendix B.
IV.
ADDITIONAL REGULATORY GUIDANCE
Additional regulatory guidance related to EHBs, AV, EHB Substitutions, Cost Sharing
Reductions, Fair Premiums, Pediatric and Adult Dental and Vision Plans is found in Appendix
D.
7
V.
QUESTIONS
Any questions about the contents of this Bulletin should be directed to the attention of: Loraine
Ingram, Compliance Analyst, at 803-737-6097, or Tina Brown. Supervisor, Life, Accident and
Health Forms & Rates, Program Area, at 803-737-6162.
8
Please select the appropriate check box below to indicate which product is amended by this filing.
INDIVIDUAL HEALTH BENEFIT PLANS (Complete SECTION A only)
SMALL / LARGE GROUP HEALTH BENEFIT PLANS (Complete SECTION B only)
-1-
Rate Impact
Form Number(s) of Policy being
endorsed
SERFF Tracking Number(s)
*if applicable
NAIC Number
ACA Uniform Compliance Summary
This form filing compliance summary is to be submitted with your [endorsement][contract] to comply with the market reform requirements of the Affordable
Care Act (ACA). These ACA requirements apply only to policies for health insurance coverage referred to as “major medical” in the statute, which is
comprehensive health coverage that includes PPO and HMO coverage. This form includes the requirements for grandfathered (coverage in effect prior to March
23, 2010) and non-grandfathered plans, and relevant statutes. Refer to the relevant statute to ensure compliance. Complete each item to confirm that diligent
consideration has been given to each. (If submitting your filings electronically, bookmark the provision(s) in the form(s) that satisfy the requirement and identify
the page/paragraph on this form.)
COMPANY INFORMATION
(Revised to include all reforms)
Company Name
O Yes O No
Appendix A
statutes. Refer to the relevant statute to ensure compliance. Complete each item to confirm that diligent
consideration has been given to each. (If submitting your filings electronically, bookmark the provision(s) in the form(s) that satisfy the requirement and identify
the page/paragraph on this form.)
COMPANY INFORMATION
(Revised to include all reforms)
Company Name
O Yes O No
Appendix A
-2-
Category
ACA Uniform Compliance Summary
Non -Grandfathered
Grandfathered
Reference
Description
SECTION A – Individual Health Benefit Plans
Lifetime Limits
O Yes O No
If no, please explain.
O Yes O No
If no, please explain.
Explanation:
Page Number:
Recissions
Annual Limits
N/A
O Yes O No
If no, please explain.
Explanation:
Page Number:
Explanation:
Page Number:
N/A
O Yes O No
If no, please explain.
Pre Existing
Conditions
Eliminate Pre-existing Condition Exclusions
§ 2704
Eliminate Annual Dollar Limits on Essential Health Benefits
§ 2711
§ 2711
Eliminate Lifetime Dollar Limits on Essential Health Benefits
§ 2712
Prohibit Rescissions – Except for fraud or intentional misrepresentation of material
fact.
O Yes O No
If no, please explain.
O Yes O No
If no, please explain.
Explanation:
Page Number:
-3-
Preventive Care
N/A
O Yes O No
If no, please explain.
Explanation:
Page Number:
Dependent
Coverage
O Yes O No
If no, please explain.
O Yes O No
If no, please explain.
Explanation:
Page Number:
ACA Uniform Compliance Summary
SECTION A – Individual Health Benefit Plans
Category
Grandfathered
Non -Grandfathered
Description
Internal Appeals
N/A
O Yes O No
If no, please explain.
Explanation:
Page Number:
Extenal Review
N/A
O Yes O No
If no, please explain.
Explanation:
Page Number:
§ 2712
Preventive Services – Requires coverage and prohibits the imposition of cost-
sharing for specified preventative services
dual Health Benefit Plans
Category
Grandfathered
Non -Grandfathered
Description
Internal Appeals
N/A
O Yes O No
If no, please explain.
Explanation:
Page Number:
Extenal Review
N/A
O Yes O No
If no, please explain.
Explanation:
Page Number:
§ 2712
Preventive Services – Requires coverage and prohibits the imposition of cost-
sharing for specified preventative services.
§ 2714
Extends Dependent Coverage for Children Until age 26 – If a policy offers
dependent coverage, it must include dependent coverage until age 26.
§ 2719
Internal Appeals Process –Must offer an internal claims and appeals process that complies with law in
effect on March 23, 2010, meet the requirements of Section 2719(a)(1) of the Pubic Health Service Act
as added by Title I, Subtitle A, Section 1001(4) of the Patient Protection and Affordable Care Act, and
must update the claims and appeals processes in accordance with standards established by the
Secretary of Health and Human Services.
§ 2719
External Review – Must comply with state law if state external review procedures at a minimum include
the consumer protections set forth in the Uniform External Review Model Act promulgated by the
National Association of Insurance Commissioners (“NAIC Uniform Model Act”). If the state has not
established an external review process that at a minimum includes the consumer protections set forth in
the NAIC Uniform Model Act, then must comply with the minimum standards established by the
Secretary of Health and Human Services.
Reference
n the Uniform External Review Model Act promulgated by the
National Association of Insurance Commissioners (“NAIC Uniform Model Act”). If the state has not
established an external review process that at a minimum includes the consumer protections set forth in
the NAIC Uniform Model Act, then must comply with the minimum standards established by the
Secretary of Health and Human Services.
Reference
-4-
ACA Uniform Compliance Summary
SECTION A – Individual Health Benefit Plans
Category
Grandfathered
Non -Grandfathered
N/A
O Yes O No
If no, please explain.
Explanation:
Page Number:
Primary Care
Providers
N/A
O Yes O No
If no, please explain.
Explanation:
Page Number:
Emergency
Services
N/A
O Yes O No
If no, please explain.
Explanation:
Page Number:
Gynecological
and Obstetric
Services
§ 2719A
Access to Pediatricians – Mandates that if designation of a PCP for a child is
required, the person be permitted to designate a physician who specialized in
pediatrics as the child’s PCP if the provider is in-network.
§ 2719A
Access to OB/GYNs – Prohibits authorization or referral requirements for
obstetrical or gynecological care provided by in-network providers who specialize
in obstetrics or gynecology.
§ 2719A
Emergency Services – Requires plans that cover emergency services to provide
such coverage without the need for prior authorization, regardless of the
participating status of the provider, and at the in-network cost-sharing level.
Description
Reference
or referral requirements for
obstetrical or gynecological care provided by in-network providers who specialize
in obstetrics or gynecology.
§ 2719A
Emergency Services – Requires plans that cover emergency services to provide
such coverage without the need for prior authorization, regardless of the
participating status of the provider, and at the in-network cost-sharing level.
Description
Reference
-5-
Summary of
Benefits and
Coverage
O Yes O No
If no, please explain.
O Yes O No
If no, please explain.
Explanation:
Page Number:
ACA Uniform Compliance Summary
SECTION A – Individual Health Benefit Plans
Category
Grandfathered
Non -Grandfathered
N/A
O Yes O No
If no, please explain.
Explanation:
Page Number:
O Yes O No
If no, please explain.
O Yes O No
If no, please explain.
Explanation:
Page Number:
§ 2715
Summary of Benefits and Coverage and Uniform Glossary of terms/standardized
definitions
§ 2701
Restrictions on Health Insurance Premiums - premiums may only vary by age,
tobacco, geographic rating area and whether coverage is individual or family)
Guaranteed
Availability of
Coverage
N/A
O Yes O No
If no, please explain.
Explanation:
Page Number:
Restrictions on
Health Insurance
Premiums
Excessive Waiting
Periods
§ 2708
Relating to Excessive Waiting Periods
§ 2702
Guaranteed availability of coverage
Description
Reference
s may only vary by age,
tobacco, geographic rating area and whether coverage is individual or family)
Guaranteed
Availability of
Coverage
N/A
O Yes O No
If no, please explain.
Explanation:
Page Number:
Restrictions on
Health Insurance
Premiums
Excessive Waiting
Periods
§ 2708
Relating to Excessive Waiting Periods
§ 2702
Guaranteed availability of coverage
Description
Reference
-6-
Guaranteed
Renewability of
Coverage
N/A
O Yes O No
If no, please explain.
Explanation:
Page Number:
Prohibitions on
Discrimination
against
individuals and
beneficiaries
N/A
O Yes O No
If no, please explain.
Explanation:
Page Number:
Essential Health
Benefits
N/A
O Yes O No
If no, please explain.
Explanation:
Page Number:
Prohibitions on
Discrimination
against providers
N/A
O Yes O No
If no, please explain.
Explanation:
Page Number:
Prohibitions on discrimination against providers operating within scope of practice
and individuals or employers based upon receipt of subsidy or providing
information to investigators
Inclusion of Essential Health Benefits (EHB), including compliance with cost-sharing
limitations, deductibles and actuarial value standards
§ 2703
Guaranteed renewability of coverage (with certain exceptions)
§ 2705
Prohibitions on discrimination against individual participants and beneficiaries
based on health status
§ 2705
§ 2707 (PPACA §1302)
ACA Uniform Compliance Summary
SECTION A – Individual Health Benefit Plans
Category
Description
Reference
Grandfathered
Non -Grandfathered
ations, deductibles and actuarial value standards
§ 2703
Guaranteed renewability of coverage (with certain exceptions)
§ 2705
Prohibitions on discrimination against individual participants and beneficiaries
based on health status
§ 2705
§ 2707 (PPACA §1302)
ACA Uniform Compliance Summary
SECTION A – Individual Health Benefit Plans
Category
Description
Reference
Grandfathered
Non -Grandfathered
-7-
Provision for
Additional
Information
N/A
O Yes O No
If no, please explain.
Explanation:
Page Number:
§ 2715A
Clinical Trials
N/A
O Yes O No
If no, please explain.
Explanation:
Page Number:
Provision of Additional Information
§ 2709
Coverage for individuals participating in approved clinical trials for certain
conditions
Non -Grandfathered
ACA Uniform Compliance Summary
SECTION A – Individual Health Benefit Plans
Category
Description
Reference
Grandfathered
-8-
Category
Grandfathered
Non -Grandfathered
Annual Limits
O Yes O No
If no, please explain.
O Yes O No
If no, please explain.
Explanation:
Page Number:
Pre Existing
Conditions
O Yes O No
If no, please explain.
O Yes O No
If no, please explain.
Explanation:
Page Number:
Recissions
O Yes O No
If no, please explain.
O Yes O No
If no, please explain.
Explanation:
Page Number:
Lifetime Limits
O Yes O No
If no, please explain.
O Yes O No
If no, please explain.
Explanation:
Page Number:
ACA Uniform Compliance Summary
SECTION B – Group Health Benefit Plans (Small and Large)
Description
Reference
Eliminate Pre-existing Condition Exclusions
§ 2704
Eliminate Annual Dollar Limits on Essential Health Benefits
§ 2711
Eliminate Lifetime Dollar Limits on Essential Health Benefits
§ 2711
Prohibit Rescissions – Except for fraud or intentional misrepresentation of material
fact.
§ 2712
er:
ACA Uniform Compliance Summary
SECTION B – Group Health Benefit Plans (Small and Large)
Description
Reference
Eliminate Pre-existing Condition Exclusions
§ 2704
Eliminate Annual Dollar Limits on Essential Health Benefits
§ 2711
Eliminate Lifetime Dollar Limits on Essential Health Benefits
§ 2711
Prohibit Rescissions – Except for fraud or intentional misrepresentation of material
fact.
§ 2712
-9-
Preventive Care
N/A
O Yes O No
If no, please explain.
Explanation:
Page Number:
ACA Uniform Compliance Summary
SECTION B – Group Health Benefit Plans (Small and Large)
Category
Grandfathered
Non -Grandfathered
Extenal Review
N/A
O Yes O No
If no, please explain.
Explanation:
Page Number:
Dependent
Coverage
O Yes O No
If no, please explain.
O Yes O No
If no, please explain.
Explanation:
Page Number:
Internal Appeals
N/A
O Yes O No
If no, please explain.
Explanation:
Page Number:
◊ For plan years beginning before January 1, 2014, grandfathered group plans are not required to extend coverage to a child until the age of 26 if such child is eligible to enroll in
another employee-sponsored plan
Description
Reference
Extends Dependent Coverage for Children Until age 26 – If a policy offers
dependent coverage, it must include dependent coverage until age 26.
§ 2714
Internal Appeals Process –Must offer an internal claims and appeals process that complies with law in
effect on March 23, 2010, meet the requirements of Section 2719(a)(1) of the Pubic Health Service Act
as added by Title I, Subtitle A, Section 1001(4) of the Patient Protection and Affordable Care Act, and
must update the claims and appeals processes in accordance with standards established by the
S
f H
l h
d H
S
i
§ 2719
External Review – Must comply with state law if state external review procedures at a minimum include
the consumer protections set forth in the Uniform External Review Model Act promulgated by the
National Association of Insurance Commissioners (“NAIC Uniform Model A
Care Act, and
must update the claims and appeals processes in accordance with standards established by the
S
f H
l h
d H
S
i
§ 2719
External Review – Must comply with state law if state external review procedures at a minimum include
the consumer protections set forth in the Uniform External Review Model Act promulgated by the
National Association of Insurance Commissioners (“NAIC Uniform Model Act”). If the state has not
established an external review process that at a minimum includes the consumer protections set forth in
h NAIC U if
M d l A
h
l
i h h
i i
d
d
bli h d b
h
§ 2719
Preventive Services – Requires coverage and prohibits the imposition of cost-
sharing for specified preventative services.
§ 2712
-10-
Page Number:
Emergency
Services
N/A
O Yes O No
If no, please explain.
Explanation:
Page Number:
ACA Uniform Compliance Summary
SECTION B – Group Health Benefit Plans (Small and Large)
Category
Grandfathered
Non -Grandfathered
Description
Reference
Gynecological
and Obstetric
Services
N/A
O Yes O No
If no, please explain.
Explanation:
Page Number:
Primary Care
Providers
N/A
O Yes O No
If no, please explain.
Explanation:
Access to OB/GYNs – Prohibits authorization or referral requirements for
obstetrical or gynecological care provided by in-network providers who specialize
in obstetrics or gynecology.
§ 2719A
Emergency Services – Requires plans that cover emergency services to provide
such coverage without the need for prior authorization, regardless of the
participating status of the provider, and at the in-network cost-sharing level.
§ 2719A
Access to Pediatricians – Mandates that if designation of a PCP for a child is
required, the person be permitted to designate a physician who specialized in
pediatrics as the child’s PCP if the provider is in-network.
§ 2719A
Excessive Waiting
Periods
Relating to Excessive Waiting Periods
§ 2708
Explanation:
Page Number:
N/A
O Yes O No
If no, please explain.
-sharing level.
§ 2719A
Access to Pediatricians – Mandates that if designation of a PCP for a child is
required, the person be permitted to designate a physician who specialized in
pediatrics as the child’s PCP if the provider is in-network.
§ 2719A
Excessive Waiting
Periods
Relating to Excessive Waiting Periods
§ 2708
Explanation:
Page Number:
N/A
O Yes O No
If no, please explain.
-11-
Excessive Waiting
Periods
Relating to Excessive Waiting Periods
§ 2708
O Yes O No
If no, please explain.
O Yes O No
If no, please explain.
Explanation:
Page Number:
ACA Uniform Compliance Summary
SECTION B – Group Health Benefit Plans (Small and Large)
Category
Summary of
Benefits and
Coverage
O Yes O No
If no, please explain.
O Yes O No
If no, please explain.
Explanation:
Page Number:
Summary of Benefits and Coverage and Uniform Glossary of terms/standardized
definitions
§ 2715
Grandfathered
Non -Grandfathered
Restrictions on
Health Insurance
Premiums
N/A
O Yes O No
If no, please explain.
Explanation:
Page Number:
Guaranteed
Availability of
Coverage
N/A
O Yes O No
If no, please explain.
Explanation:
Page Number:
Restrictions on Health Insurance Premiums - premiums may only vary by age,
tobacco, geographic rating area and whether coverage is individual or family)
§ 2701
Guaranteed availability of coverage
§ 2702
Description
Reference
o
If no, please explain.
Explanation:
Page Number:
Guaranteed
Availability of
Coverage
N/A
O Yes O No
If no, please explain.
Explanation:
Page Number:
Restrictions on Health Insurance Premiums - premiums may only vary by age,
tobacco, geographic rating area and whether coverage is individual or family)
§ 2701
Guaranteed availability of coverage
§ 2702
Description
Reference
-12-
Prohibitions on discrimination against providers operating within scope of practice
and individuals or employers based upon receipt of subsidy or providing
information to investigators
§ 2705
Inclusion of Essential Health Benefits (EHB), including compliance with cost-sharing
limitations, deductibles and actuarial value standards
§ 2707 (PPACA §1302)
Guaranteed
Renewability of
Coverage
N/A
O Yes O No
If no, please explain.
Explanation:
Page Number:
Prohibitions on
Discrimination
against
individuals and
beneficiaries
N/A
O Yes O No
If no, please explain.
Explanation:
Page Number:
Guaranteed renewability of coverage (with certain exceptions)
§ 2703
Prohibitions on discrimination against individual participants and beneficiaries
based on health status
§ 2705
ACA Uniform Compliance Summary
SECTION B – Group Health Benefit Plans (Small and Large)
Category
Description
Reference
Grandfathered
Non -Grandfathered
Prohibitions on
Discrimination
against providers
N/A
O Yes O No
If no, please explain.
Explanation:
Page Number:
Essential Health
Benefits
N/A
O Yes O No
If no, please explain.
Explanation:
Page Number:
us
§ 2705
ACA Uniform Compliance Summary
SECTION B – Group Health Benefit Plans (Small and Large)
Category
Description
Reference
Grandfathered
Non -Grandfathered
Prohibitions on
Discrimination
against providers
N/A
O Yes O No
If no, please explain.
Explanation:
Page Number:
Essential Health
Benefits
N/A
O Yes O No
If no, please explain.
Explanation:
Page Number:
-13-
Clinical Trials
N/A
O Yes O No
If no, please explain.
Explanation:
Page Number:
Provision for
Additional
Information
N/A
O Yes O No
If no, please explain.
Explanation:
Page Number:
Coverage for individuals participating in approved clinical trials for certain
conditions
§ 2709
Provision of Additional Information
§ 2715A
Category
Description
Reference
Grandfathered
Non -Grandfathered
ACA Uniform Compliance Summary
SECTION B – Group Health Benefit Plans (Small and Large)
Appendix B-1
ACA CERTIFICATION- AMENDMENTS TO POLICY
CERTIFICATION OF COMPLIANCE WITH ACA
I, THE UNDERSIGNED OFFICER OF - -------------
(Name of Entity)
HAVE REVIEWED OR SUPERVISED THE REVIEW OF THE POLICY
FORMS, ENDORSEMENTS, OR AMENDMENTS CONTAINED IN THIS
FILING AND HEREBY CERTIFY TO THE BEST OF MY KNOWLEDGE AND
BELIEF THAT THEY ARE IN COMPLIANCE WITH THE PROVISIONS OF
THE PATIENT PROTECTION AND AFFORDABLE CARE ACT, INCLUDING
ANY INTERIM OR FINAL RULES, AS
APPLICABLE, AND ANY
APPLICABLE STATUTES, REGULATIONS, AND BULLETINS OF THE
STATE OF SOUTH CAROLINA. I FURTHER CERTIFY THAT THE ONLY
AMENDMENTS MADE TO THE POLICY ARE THOSE NECESSARY TO
INCOPORATE THE 2014 MARKET REFORMS AND THE FORMS WILL BE
REVISED AND/OR DISCONTINUED AS APPROPRIATE IN THE EVENT OF
FUTURE CHANGES IN APPLICABLE STATE OR FEDERAL STATUTES,
REGULATIONS, OR BULLETINS
RULES, AS
APPLICABLE, AND ANY
APPLICABLE STATUTES, REGULATIONS, AND BULLETINS OF THE
STATE OF SOUTH CAROLINA. I FURTHER CERTIFY THAT THE ONLY
AMENDMENTS MADE TO THE POLICY ARE THOSE NECESSARY TO
INCOPORATE THE 2014 MARKET REFORMS AND THE FORMS WILL BE
REVISED AND/OR DISCONTINUED AS APPROPRIATE IN THE EVENT OF
FUTURE CHANGES IN APPLICABLE STATE OR FEDERAL STATUTES,
REGULATIONS, OR BULLETINS.
(Signature of Officer*)
(Title of Officer*)
(Printed Name of Officer*)
(Date)
* If the individual signing the certification is other than the presidellt, vice president, assistant
vice president, corporate secretary, assistant corporate secretary, CEO, CFO, COO, General
Counsel, or an actuary that is also a corporate officer, documentation must be included that
shows that this individual lzas been appoimed as an officer of the organization by the Board of
Directors.
10
Appendix B-2
ACA CERTIFICATION- NEW POLICY FORMS
CERTIFICATION OF COMPLIANCE WITH ACA
I. THE UNDERSIGNED OFFICER OF ---~----------
(Name of Entity)
HAVE REVIEWED OR SUPERVISED THE REVIEW OF THE POLICY
FORMS, ENDORSEMENTS, OR AMENDMENTS CONTAINED IN THIS
FILING AND HEREBY CERTIFY TO THE BEST OF MY KNOWLEDGE AND
BELIEF THAT THEY ARE IN COMPLIANCE WITH THE PROVISIONS OF
THE PATIENT PROTECTION AND AFFORDABLE CARE ACT, INCLUDING
ANY INTERIM OR FINAL RULES, AS
APPLICABLE, AND ANY
APPLICABLE STATUTES, REGULATIONS, AND BULLETINS OF THE
STATE OF SOUTH CAROLINA. I FURTHER CERTIFY THAT THE FORMS
WILL BE REVISED AND/OR DISCONTINUED AS APPROPRIATE IN THE
EVENT OF FUTURE CHANGES IN APPLICABLE STATE OR FEDERAL
STATUTES, REGULATIONS, OR BULLETINS
ITH THE PROVISIONS OF
THE PATIENT PROTECTION AND AFFORDABLE CARE ACT, INCLUDING
ANY INTERIM OR FINAL RULES, AS
APPLICABLE, AND ANY
APPLICABLE STATUTES, REGULATIONS, AND BULLETINS OF THE
STATE OF SOUTH CAROLINA. I FURTHER CERTIFY THAT THE FORMS
WILL BE REVISED AND/OR DISCONTINUED AS APPROPRIATE IN THE
EVENT OF FUTURE CHANGES IN APPLICABLE STATE OR FEDERAL
STATUTES, REGULATIONS, OR BULLETINS.
(Signature of Officer*)
(Title of Officer*)
(Printed Name of Officer*)
(Date)
* If the individual signing the certification is other than the president, vice presidem, assistant
vice president, corporate secretary, assistant corporate secretary, CEO, CFO, COO, General
Counsel, or an acfllary that is also a corporate officer, documelllation must be included that
shows that this individual has been appointed as an officer of the organization by the Board of
Directors.
1 I
Appendix C
NETWORK ADEQUACY STANDARDS
General:
This section sets out the general requirements for developing and maintaining an adequate
network of providers to ensure access to appropriate care. The requirements are developed
pursuant to authority set forth in S.C. Code Ann. § 38-3-110(1), §38-33-40 (B), 38-71-1750
and 25A S.C. Code Ann. Reg. 69-22.
Health insurance coverage, health insurance issuer ("issuer"), health maintenance organization
(HMO) and network plan are as defined in 38-71-840. For avoidance of doubt, a network plan
includes any plan that either requires enrollees to use or creates incentives, including financial
incentives, for enrollees to use the plan's participating provider network.
1.
The issuer must have a network of providers, including primary care physicians, hospitals
and specialists. The network of providers must meet any additional standards set forth in
§ 1311 (c)(l) of the ACA as further defined in 45 CFR Section 156.230.
2.
There must be a network within a reasonable distance of each geographical area to be
served. An area is a county
ating provider network.
1.
The issuer must have a network of providers, including primary care physicians, hospitals
and specialists. The network of providers must meet any additional standards set forth in
§ 1311 (c)(l) of the ACA as further defined in 45 CFR Section 156.230.
2.
There must be a network within a reasonable distance of each geographical area to be
served. An area is a county. The issuer of a network plan shall establish and maintain
adequate arrangements to ensure reasonable proximity of participating providers to the
business and personal residence of enrollees.
3.
Where the rural nature of a county makes it impossible to build an adequate network, the
issuer must contract with a sufficient number of providers to represent the general health
care access patterns within that county.
4.
Out of network providers may be used to supplement the network but not ordinarily to
meet the minimum requirements, unless providers are unavailable (rural area).
5.
Issuers must maintain a complete file on each provider, including members of a practice
group (may be kept at a PPO or similar group administrator). The file must include an
original, signed hold harmless agreement, an original provider agreement (may refer to
master contract between group and HMO), and the original or copies of all credentialing
material, even where credentialing is delegated. Group administrators may sign for the
group as permitted by law, including hold harmless and participation agreement.
6.
A network plan must disclose in writing, using the plain and ordinary meaning of words
so as reasonably to ensure comprehension by the insured or member, and make available
to an insured or a member at the time of enrollment:
• services or benefits under the plan, including limitations on services;
• rules regarding copayments, prior authorization, and review requirements that
apply to the benefits plan of the insured or member;
12
sing the plain and ordinary meaning of words
so as reasonably to ensure comprehension by the insured or member, and make available
to an insured or a member at the time of enrollment:
• services or benefits under the plan, including limitations on services;
• rules regarding copayments, prior authorization, and review requirements that
apply to the benefits plan of the insured or member;
12
• potential financial liability for the insured or member to pay for a portion of
services received from an out-of-network provider;
• financial obligations of the insured or member for items and services both in and
out of the network;
• the number, mix, and distribution of network providers and a current list of
network providers upon request from an insured or a member;
• the rights and responsibilities of an insured or a member, including an
explanation of any appeals process for the denial of care or services under the plan;
and
• the existence of any limitations on the choice of providers by an insured or a
member.
7.
The burden of network sufficiency shall lie with the Issuer. The Issuer shall demonstrate
the adequacy of the providers in its network plan by providing supporting documentation
and a certification as described in Appendix A upon initial approval of the network plan
and annually thereafter.
8.
Specific guidelines as set forth below:
PROVIDER NETWORK ADEQUACY GUIDELINES
I.
The Department will continue to license HMO and review the adequacy of networks
for network plans by county.
2.
The Department will continue to approve HMOs for initial marketing and actual
enrollment after reviewing the completed provider networks (executed contracts) by
county.
3.
Networks may include providers outside the area to be served.
4.
Issuers shall contract with providers in each county to be served, and not rely solely
on radius standards.
5
f networks
for network plans by county.
2.
The Department will continue to approve HMOs for initial marketing and actual
enrollment after reviewing the completed provider networks (executed contracts) by
county.
3.
Networks may include providers outside the area to be served.
4.
Issuers shall contract with providers in each county to be served, and not rely solely
on radius standards.
5.
The Department reserves the right to withdraw approval of any network plan if based
on actual practice, it becomes apparent that a network does not meet community
standards of care.
6.
The Department reserves the right to determine a network to be inadequate where the
standards have been met at a minimum, but the network does not appear to be
reasonable based on community practices, or the complaints are sufficient in number
and severity to warrant an adverse determination.
7.
Issuers should document good faith efforts to contract with providers where they feel
there are unreasonable barriers to entry.
13
8.
Issuers should document why certain providers do not meet its own standards for
quality, including lack of accreditation, inability to meet National Committee for
Quality Assurance standards, etc.
9.
Each Issuer must file an access plan with the filing for initial approval of the network
plan, showing the provider network, and by February 1st of each year thereafter, that
shows how it was determined that provider network meets the network adequacy
requirements set forth in this Network Adequacy Standard. These guidelines and the
"Managed Care Plan Network Adequacy Model Act" should also be used for
reference. The access plan should include a description of the network, referral
procedures, ongoing monitoring, and any reasonable criteria used by the Issuer to
determine
network
adequacy.
The
access
plan
should
be
stamped,
"CONFIDENTIAL." Radius maps must be included in the access plan. Use of
"GeoAccess" or something similar is encouraged
dequacy Model Act" should also be used for
reference. The access plan should include a description of the network, referral
procedures, ongoing monitoring, and any reasonable criteria used by the Issuer to
determine
network
adequacy.
The
access
plan
should
be
stamped,
"CONFIDENTIAL." Radius maps must be included in the access plan. Use of
"GeoAccess" or something similar is encouraged. The initial access plan should be
accompanied by a certification by an officer of the Issuer that the requirements set
forth in this Network Adequacy Standard have been met. After the first submission,
the Issuer may certify annually that there have been no substantive changes in the
network, and attach a current provider directory (in lieu of a complete description
analysis). This letter must come from an officer of the company and specify the
addition or loss of any hospital providers.
I 0.
Approval of a provider network will not, in and of itself, constitute proof of actual
provider network adequacy in the event of a complaint.
II.
There should be at least one primary care physician (PCP) per 2000 members
accessible within a 30-mile radius for 95% of the population of the area to be served.
If a radius map cannot demonstrate this, the Issuer may state that it generally meets
this requirement, and how this was determined. An exception may be made for an
Issuer serving only the Medicaid program, HHS allows a standard of one PCP per
2500 members.
12.
There should be a contracted hospital within the county, or within a 30-mile radius of
95% of the population of the area to be served where none exists in the county. The
Issuer must have a contractual arrangement with a tertiary care facility within a
reasonable travel distance.
13.
The Issuer must contract with an adequate number and type of specialists within a 50-
mile radius of 95% of the population in the area to be served. The mileage standards
do not apply to subspecialists
of the population of the area to be served where none exists in the county. The
Issuer must have a contractual arrangement with a tertiary care facility within a
reasonable travel distance.
13.
The Issuer must contract with an adequate number and type of specialists within a 50-
mile radius of 95% of the population in the area to be served. The mileage standards
do not apply to subspecialists. For subspecialists, the HMO should describe how it
will assure access to subspecialists, as necessary.
14.
There should be at least one OB-GYN within a 30-mile radius for 95% of the
population of the area to be served.
15.
There should be at least one pharmacy within a 20-mile radius of all enrollees.
14
NETWORK ADEQUACY CERTIFICATION
CERTIFICATION OF COMPLIANCE WITH NETWORK ADEQUACY
I, THE UNDERSIGNED OFFICER OF __________________________________________________
(Name of Entity)
CERTIFY THAT I HAVE REVIEWED THE NETWORK ADEQUACY PROCEDURES FOUND
IN APPENDIX C AS OUTLINED IN SC BULLETIN 2013-04 AND THAT OUR NETWORK
FOR THE PLAN MEETS THESE STANDARDS.
_______________________________
____________________________________
(Signature of Officer*)
(Title of Officer*)
_______________________________
____________________________________
(Printed Name of Officer*)
(Date)
* If the individual signing the certification is other than the president, vice president, assistant
vice president, corporate secretary, assistant corporate secretary, CEO, CFO, COO, General
Counsel, or an actuary that is also a corporate officer, documentation must be included that
shows that this individual has been appointed as an officer of the organization by the Board of
Directors.
* If the individual signing the certification is other than the president, vice president, assistant
vice president, corporate secretary, assistant corporate secretary, CEO, CFO, COO, General
Counsel, or an actuary that is also a corporate officer, documentation must be included that
shows that this individual has been appointed as an officer of the organization by the Board of
Directors.
Appendix D
Regulatory Guidance for Filing Products to Comply with Essential Health Benefits (EHBs)
The ACA requires that all carriers offering coverage for non-grandfathered, individual and small
group plans, both inside and outside a Health Insurance Exchange (Exchange), provide coverage
for EHBs. Carriers must include items and services within the following 10 benefit categories as
part of their plan design to comply with the EHB requirement:
•
Ambulatory Patient Services;
•
Emergency Services;
•
Hospitalization;
•
Maternity and Newborn Care;
•
Mental Health and Substance Use Disorder Services, Including Behavioral Health
Treatment;
•
Prescription Drugs;
•
Rehabilitative and Habilitative Services and Devices;
•
Laboratory Services;
•
Preventive and Wellness Services and Chronic Disease Management; and
•
Pediatric Services, including Oral and Vision Care.
The default benchmark plan is the largest small group plan by enrollment in the state. The plan
will constitute the EHBs for the non-grandfathered, individual, and small group market for
calendar years 2014 and 2015. The default benchmark plan for South Carolina is Blue Cross and
Blue Shield of South Carolina Business Blue Complete PPO. Pediatric oral and vision have been
supplemented by the Federal Employee Dental and Vision Insurance Program (FEDVIP).
Habilitative services were not included in the benchmark and must be supplemented in
accordance with the procedures outlined in the final market rules, 45 CFR 156.115 (a) (5)
rk plan for South Carolina is Blue Cross and
Blue Shield of South Carolina Business Blue Complete PPO. Pediatric oral and vision have been
supplemented by the Federal Employee Dental and Vision Insurance Program (FEDVIP).
Habilitative services were not included in the benchmark and must be supplemented in
accordance with the procedures outlined in the final market rules, 45 CFR 156.115 (a) (5).
Health Insurance Issuers must clearly indicate the method for supplementing habilitative services
and the benefits provided in the filings submitted.
Actuarial Guidelines
The following provides actuarial guidelines related to EHB Substitutions, AV, Cost Sharing
Reductions, and Fair Premiums:
I) EHB Substitutions
Certain provisions may be adopted by the Department to allow carriers to make actuarially
equivalent substitutions for their plans within each of the 10 EHB categories specified except for
prescription drug benefits. At this time, the Department has elected to allow for actuarial
substitutions. If actuarial substitutions are included in the filing, the following data must be
submitted to the Department as part of filing requirements to review substitution options:
15
•
Attach a demonstration/explanation of equivalent value in each category to the Actuarial
Memorandum in SERFF and include the following:
o
Provide an explanation of actuarial methodology following Actuarial Standards of
Practice (ASOP);
o
Use a standardized plan population; and
o
Determine equivalence regardless of cost-sharing.
•
Provide A V both before and after substitution including how benefits were defined and
entered into the AV calculator.
•
Include attestation certifying data used to derive substitution is accurate and follows
ASOP.
II) Actuarial Value
Carriers must supply A V for plans both inside and outside the Federally-Facilitated Exchange
(FFE) for consumer plan comparison purposes and to properly evaluate plans as part of the
actuarial review
ion including how benefits were defined and
entered into the AV calculator.
•
Include attestation certifying data used to derive substitution is accurate and follows
ASOP.
II) Actuarial Value
Carriers must supply A V for plans both inside and outside the Federally-Facilitated Exchange
(FFE) for consumer plan comparison purposes and to properly evaluate plans as part of the
actuarial review.
The ACA requires non-grandfathered individual and small group health insurance plans, except
for catastrophic plans, to fall within one of four "metal tiers .. as defined by the A V of the
benefits offered by the plan, relative to the full cost of the EHBs:
•
Platinum: 90% AV;
•
Gold: 80% A V;
•
Silver: 70% AV; and
•
Bronze: 60% A V.
Plans would be allowed a margin of +1- 2% of the required A V for each metal tier. At a
minimum, all Issuers selling coverage through the FFE must make available at least one plan in
the silver level and one plan in the gold level.
The ACA defines a catastrophic plan as a permissible benefit design offered to certain qualified
individuals. Catastrophic plans do not have to meet a specific AV, but must comply with the
maximum out-of-pocket limits.
The metallic levels of coverage that plans will be categorized by the ACA are not defined by
deductibles, copayments, or coinsurance. Instead, AVis used. For example, a plan with an AV
of 60% (bronze plan) means that for a standard population, the plan will pay 60% of their EHBs,
while the enrollees in it will pay 40% of the cost through some combination of deductibles,
copayments, and coinsurance. With a higher AV, the plan will have less patient cost-sharing
resulting in a higher premium amount on average for the insured. The percentage a plan pays for
any given enrollee will generally be different from the AV, which is an aggregated average in
terms of spending
Bs,
while the enrollees in it will pay 40% of the cost through some combination of deductibles,
copayments, and coinsurance. With a higher AV, the plan will have less patient cost-sharing
resulting in a higher premium amount on average for the insured. The percentage a plan pays for
any given enrollee will generally be different from the AV, which is an aggregated average in
terms of spending.
Section 1302( c )(2)(C) of the ACA directs that the limit on deductibles described in section
1302(c)(2)(A) for a health plan offered in the small group market be applied so as to not affect
16
the actuarial value of any health plan. Thus, a Health Insurance Issuer may make adjustments to
its deductible to maintain the specified A V for the applicable level of coverage. In so doing, a
plan may exceed the annual deductible limit if it cannot reasonably reach a given level of
coverage (metal tier) without doing so.
Each filing must include a demonstration of the calculation of the A V, together with a
certification from a credentialed actuary that the plan has been accurately entered into the A V
calculator and that the metal level assigned accurately reflects the results of the A V calculator.
III) Cost-Sharing Reductions
•
Ensure that the following cost sharing limits are maintained:
o
High-Deductible Health Plans (HDHP) for 2013- $6,250 Individual/ $12,500
Family.
The ACA outlines requirements for QHPs to provide reduced cost-sharing for individuals
purchasing coverage through the FFE with a household income below 250% of Federal Poverty
Level (FPL). Each silver level plan submitted to the FFE must be accompanied by three variants
providing AVs of 73%, 87% and 94%. These AVs would be provided in the same way that A Vs
for the metal tiers will be provided.
Cost-sharing must first be reduced by lowering the out-of-pocket limit to levels specified in
annual guidance that will be provided by HHS, and then by applying adjustments to other cost-
sharing factors
l plan submitted to the FFE must be accompanied by three variants
providing AVs of 73%, 87% and 94%. These AVs would be provided in the same way that A Vs
for the metal tiers will be provided.
Cost-sharing must first be reduced by lowering the out-of-pocket limit to levels specified in
annual guidance that will be provided by HHS, and then by applying adjustments to other cost-
sharing factors. Cost-sharing reductions exclude reductions in premiums, balance billing
amounts for non-network providers, and spending for non-covered services. The design of
reduced cost-sharing variants cannot violate prohibitions on discriminatory benefit design.
The ACA provides that QHPs covering an American Indian/Alaskan Native whose family
income is less than 300% of the FPL shall not be subject to any cost-sharing under the plan.
IV) Fair Premiums
The ACA requires non-grandfathered individual and small group health insurance plans to only
vary the rate charged for a particular plan or coverage by the following:
•
Age Rating Factors (Rate cannot vary by more than 3: 1.);
•
Geographic Rating Areas;
•
Tobacco Rating (Rate cannot vary by more than 1.5: 1.); and
•
Family Composition.
At this time, the Department is not electing to narrow the bands and ratios required by the ACA
nor merge the individual and small group markets. Geographic rating areas are specified by
county.
17
Section 1304 of ACA defines the small group market to include employers with 1-100
employees. Until 2016, states may elect to define it as employers with 1-50 employees. South
Carolina law currently defines small employers as employers with 1-50 employees. Thus, for
2014, "small employer" in South Carolina is defined as an employer with 1-50 employees.
Regulatory Guidance for Filing Pediatric/Adult Dental Products
It is anticipated that South Carolina may have five stand-alone dental plans offered on the FFE
elect to define it as employers with 1-50 employees. South
Carolina law currently defines small employers as employers with 1-50 employees. Thus, for
2014, "small employer" in South Carolina is defined as an employer with 1-50 employees.
Regulatory Guidance for Filing Pediatric/Adult Dental Products
It is anticipated that South Carolina may have five stand-alone dental plans offered on the FFE.
Since pediatric dental is one of the ten EHB categories, the Department assumes that the five
stand-alone dental plans will be offering pediatric dental coverage. As a result, if a carrier is
offering major medical products on the FFE, then they are not required to also offer pediatric
dental coverage. It is the carrier's choice if they still want to offer pediatric dental and also adult
dental on the FFE.
Carriers that are not participating on the FFE must offer pediatric dental coverage with their
major medical plan since pediatric dental is an EHB. Carriers that offer major medical, non-
grandfathered health insurance products in the individual and/or small group market must meet
EHB requirements whether or not participating on the FFE. Stand-alone adult dental plans will
continue to be offered off the FFE as a current option in the market and is not considered part of
the EHB requirements. However, an issuer may carve out pediatric dental from a plan if they
have assurance that the individual has purchased an FFE certified dental plan.
Grandfathered stand-alone pediatric and/or stand-alone adult (family) plans are excepted benefits
under HIPAA and are exempt from ACA market insurance reforms. However, the ACA requires
carriers offering dental coverage for the non-grandfathered, individual, and small group plans
inside the FFE to meet the same requirements as QHPs, as relevant. Further guidance is
anticipated as related to filing for dental plans
lone pediatric and/or stand-alone adult (family) plans are excepted benefits
under HIPAA and are exempt from ACA market insurance reforms. However, the ACA requires
carriers offering dental coverage for the non-grandfathered, individual, and small group plans
inside the FFE to meet the same requirements as QHPs, as relevant. Further guidance is
anticipated as related to filing for dental plans.
When filing for a pediatric and/or adult dental product whether on or off the FFE, please
consider that parts of the new filing instructions, checklists and/or requirements may not be
applicable and can be bypassed or noted as N/ A.
Regulatory Guidance for Filing Pediatric/ Adult Vision Products
Pediatric vision is one of the ten EHB categories. As stated above, carriers that offer major
medical, non-grandfathered health insurance products in the individual and/or small group
market must meet EHB requirements whether or not participating on the FFE. As a result,
carriers must include pediatric vision coverage as part of their major medical plan for both on
and off the FFE. Stand-alone pediatric vision plans will not be available on the FFE. Stand-alone
adult vision plans may be offered on the FFE. Stand-alone adult vision plans will continue to be
offered off the FFE as a current option in the market and is not considered part of the EHB
requirements.
When filing for a pediatric and/or adult vision product whether on or off the FFE, please
consider that parts of the new filing instructions, checklists and/or requirements may not be
18
applicable and can be bypassed or noted as N/ A. Pediatric dental and/or vision plans provide
coverage for individuals under the age of 19.
19
This is a copy of a public record, reproduced as it was published. It is not legal advice, and it may not be the version a court would rely on. Check the official source before you cite it.