Health Insurance Marketplace Plan Management

New Hampshire Insurance Department

Health Insurance Marketplace Plan

Management

2020 Health Plan Filing Process

April 10, 2019

Agenda (Contents)

New Hampshire Insurance Department | April 10, 2019

Part 1: Policy Discussion Slide

Federal Key Dates for QHP Certification 4

NHID QHP Timeline 5

QHP Guidance and Tools 6

QHP Carrier Assignments 7

QHP Weekly Calls 8

Federal Review Tools 9

Issuer Evaluation of QHP Application 10

Applicability of Federal Review Tools 11

Issuer Evaluation of QHP Application 12

Cost Sharing 13-14

Balanced Billing Protections 15

Prescription Drugs 16-20

Stand-Alone Dental 21

Auto Enrollment Notices 22

Agenda (Contents)


Part 2: Network Adequacy Slide

Network Adequacy Hospital Coverage 24

Network Adequacy for Plan Year 2019 25

Network Adequacy Reminders 26

Part 3: SERFF and Filing Submittal Slide

Advertising 28-29

Summary of Benefits and Coverage 30

SERFF Online Portal 31-32

Filing 33-35

Binder 36-39

Helpful Filing Tips 40-42

NHID Contacts 43

Appendix Slide

Appendix I: Federal Key Dates for QHP Certification 45

Appendix II: Federal Rate Review Timeline 46

Appendix III: Standards and Tools Applicable to SADPs 47

Federal Key Dates for QHP Certification


• Initial application submission / transfer deadline to CMS: June 19, 2019

• Final submission / transfer deadline: August 21, 2019

• Open enrollment: November 1, 2019 through December 15, 2019

See Appendices I and II for full CMS QHP Certification and Rate Review timelines

NHID QHP Timeline DRAFT


QHP Guidance and Tools

The Department understands the complexity of the QHP Certification process and, as such, the Department has guidance and tools to assist issuers during the QHP submission and review process.

CMS Tools/Guidance include:• SERFF Industry User Manual • New QHP Application Website

NHID Tools/Guidance include:• 2020 QHP Certification Issuer Bulletin• QHP Filing Checklists (Individual, Small Group Medical Plans & Individual/Small Group

Stand-Alone Dental Plans) • Master list of SERFF form and binder documents needed for QHP submission


All NHID tools/guidance will be available on the Department website

QHP Carrier Assignments


Issuers will have an assigned review team much like previous years, and all questions or concerns will be triaged through their review team. Your review team lead will facilitate the carrier calls and ensure appropriate NHID staff are available to respond to questions.

Ingrid Marsh – Harvard, [email protected]

Gail Matson – Delta Dental, Anthem SADP, MetLife Dental, Celtic (Ambetter)[email protected]

David Schechtman – Anthem/Matthew Thornton Health Plans, Tufts [email protected]

QHP Weekly Calls

Much like previous review periods, issuers will have the opportunity to check-in with the compliance team and other members of the QHP review team by phone on a weekly basis. The NHID will announce a standing time when they will be available for calls.

• Issuers must schedule a specific time within that block in advance.

• Issuers must submit questions in writing 24 hours in advance of their scheduled conference call. NHID will do their best to have responses prepared in advance of the weekly call.

• These calls will begin the week of April 22nd.• The Department will post significant updates that arise from questions and

responses that pertain to all issuers*


*The Department will not distribute questions / responses containing carrier specific information, product design, rate, or other proprietary information.

Federal Review Tools


Additional guidance on the review tool can be found at the new

Qualified Health Plan Website: Information and Guidance

Each year CMS releases review tools templates, required documentation, and instructions along with training materials in order to ensure accurate completion of all require QHP application sections.

Application Sections• Data Integrity Tool (DIT)• Master Review Tool• Cost Sharing Tool• Essential Community Providers (ECP)

Tool• Stand-alone Dental Plan (SADP) ECP

Tool• Non-Discrimination Tool• Formulary Review Suite Tool

• Plan Crosswalk Validation Tool• Drug Count Tool (Updated

February 28, 2019)• EHB Rx Crosswalk (Updated

February 28, 2019)• Rx Norm Data File (Updated

February 28, 2019)• EHB Rx Crosswalk

Methodology (Updated February 28, 2019)

CMS 2020 Application and Review Tools Coming Soon!

Issuer Evaluation of QHP Application


• Issuers must submit attestations that all CMS QHP tools have been run and errors resolved prior to submission of data templates.

• If issuers receive an “unmet” when running a tool but believe they are still compliant, they must add an “explanations” column for their justification on the Excel tool’s results tab.

• Both the attestation form and excel spreadsheet must be uploaded to the Supporting Documents tab in SERFF.

• One NHID staff member will be responsible for running the tools for 2020, and thus issuers are urged to complete templates with the utmost accuracy to cut down on objections

Review Tools Requirement

Applicability of Federal Review Tools


Medical and Dental qualified health plans are subject to different standards for Marketplace Certification, and thus certain QHP review tools (which measure compliance with these standards) apply to certain plan types.

Tool Name Qualified Health Plan Qualified Dental PlanData Integrity Tool ✓ ✓

Plan ID Crosswalk Tool ✓ ✓

Master Review Tool ✓ ✓

Essential Community Providers Tool ✓

SADP Essential Community Providers Tool ✓

Non-Discrimination Tool ✓

Cost Sharing Tool ✓ ✓

Formulary Review Suite ✓

Non-Discrimination Formulary Outlier ✓

Non-Discrimination Clinical Appropriateness ✓

TOTAL 10 5

Issuer Evaluation of QHP Application


Matching Policy Forms and the Plan and Benefits Template• Data on the Plan and Benefits Template must: (1) be accurate; and (2) match the

policy forms.• Issuers must indicate in the Plan and Benefits Template whether a benefit has

any limits, and any applicable exclusions or benefit explanations.

• Issuers must update plan forms when updating the Plan and Benefits Template and vice versa.

• Discrepancies will significantly slow down the review process and possibly cause issuers to not be certified in 2020.

FORMS TEMPLATES

Cost Sharing


Awaiting IRS Guidance on HSA Limits

Category2019 2020 Draft CS

Self-Only Other than Self-Only Self-Only Other than

Self-Only

Maximum Annual Limit on Cost Sharing $7,900 $15,800 $8,200 $16,400Reduced Annual Limit on Cost Sharing for Individuals between 100% and 150% of the Federal Poverty Level (FPL)

$2,600 $5,200 $2,700 $5,400

Reduced Annual Limit on Cost Sharing for Individuals between 150% and 200% of the FPL

$2,600 $5,200 $2,700 $5,400

Reduced Annual Limit on Cost Sharing for Individuals between 200% and 250% of the FPL

$6,300 $12,600 $6,550 $13,100

Cost Sharing for Out-of-Network Services


Issuers must count cost sharing paid for an EHB provided by an out-of-network, ancillary provider at an in-network facility toward the in-network MOOP unless the issuer provides written notice by the longer of:

• When the issuer would typically respond to a prior authorization request; or

• 48 hours prior to the provision of the benefit.

For 2020, the Annual Notice of Consumer Rights and Access to Out-of-Network Services the annual notice must be filed under Supporting Documents in the QHP submission for all QHPs and SADPs. This annual notice must be sent to policyholders in the individual, small and large group at the time of issuance of a new policy or at the renewal of a policy.

Issuers must provide a statement to the Department outlining how they are complying with this requirement.

Balanced Billing Protections


The Department is tasked with enforcement of RSA 329:31-b, Prohibition on Balance Billing; Payment for Reasonable Value of Services

Providers of anesthesiology, radiology, emergency medicine, or pathology services are prohibited from billing consumers covered by managed care plans for fees or amounts other than copayments, deductibles, or coinsurance*, if the service is performed in a hospital or ambulatory surgical center that is in the patient’s health insurance plan provider network. • This prohibition applies whether or not the health care provider is contracted

with the patient’s insurance carrier.

*The Department may be called in to determine what a commercially reasonable fee is if the carrier and provider cannot resolve the issue. Issuers and providers are instructed to make best efforts to resolve the dispute prior to seeking the Department’s assistance to do so.

Prescription Drugs


Issuers must provide notice of mid-year formulary changes to:• Enrollees• CMS• The Department

Notice requirements include:• Federal-required notice of changes to brand name drug coverage when a

generic alternative becomes newly available (45 CFR 146.152, 147.106 and 148.122)

• Must be sent to all plan enrollees at least 60 days prior to the change• Must be sent to CMS annually

• State-required notice of formulary changes (RSA 420-J:7-b)• Must be sent to impacted enrollees 45 days prior to a deletion or tier

change; notice of all changes must be sent to all enrollees annually• Copies of notices must be submitted to the Department via SERFF

There is some – but not complete – overlap between federal and state notice requirements and each notice requirement has specific requirements relative to the content and recipients. Issuers should familiarize themselves with the details of the notice requirements listed above and ensure they comply with the most stringent requirements applicable to the given situation.

Prescription Drugs


Health plans must have a process to allow an enrollee to request and gain access to clinically appropriate drugs not otherwise covered by the health plan, including:

1. An internal review;• 48 hour timeline under NH law

2. An external review

3. The ability to expedite reviews.• 24 hour timeline

In the event that an exception request is granted, the excepted drug(s) are

treated as an EHB including counting any cost sharing towards the plan's annual limitation on cost sharing.

NHID moved to a Uniform Prior Authorization form. Issuers are not allowed to edit or require more information than included in the standard form, but may have a version with the carrier contact information prefilled on their websites.

As in past years, all carriers must accept and use the NH Standard Prior Authorization RX form: https://www.nh.gov/insurance/legal/documents/nhstandard-rx-pa-form.pdf

Prescription Drugs


Cost Sharing for Brand DrugsWhen a generic alternative to a brand prescription drug becomes newly available, the issuer may make a mid-year change to the formulary in order to add the generic drug to the formulary and to remove or change the tier of the brand drug, as outlined above. However, for consumers for whom the brand drug is medically necessary, the cost sharing for the brand drug must be no less favorable to the consumer mid-year than it was at the beginning of the policy year, regardless of any tier change made generally. .

Prescription Drugs


The following reviews will evaluate prescription drug coverage for compliance with applicable law:Clinical Guideline-Based Review of Prescription Drug Coverage• Analyzes the availability of drugs recommended by nationally recognized clinical guidelines

• Evaluates whether certain first-line therapies are available without step therapy or prior authorization

• Applicable medical conditions for 2020: • Opioid Use Disorder • Bipolar Disorder• Breast and Prostate Cancer• Diabetes• Hepatitis C• HIV• Multiple Sclerosis• Rheumatoid Arthritis• Schizophrenia

Beginning in 2020, issuers must a complete 2020 Formulary file with initial plan filings.

The 2020 Formulary excel file must include the National Drug Code (NDC) without the hyphens- the information collected will help NHID in the development of future policy.

The form should be filed in SERFF under the Supporting Documents tab, with a complete and final list of the drugs included in the plan for 2020 uploaded prior to the close of the certification period.

New for 2020

Prescription Drugs


Formulary Category/Class Count• Plans must cover the greater of:

• One drug in every USP category and class; or • The same number of drugs in each category and class as the EHB benchmark plan

• Naloxone is the only drug in the Anti-Addiction/ Substance Abuse Treatment Agents class.

Formulary Outlier Review• CMS will not conduct active certification reviews for formulary outliers for States that

perform plan management functions, and will instead defer to those State processes.

The Department joins CMS in encouraging issuers to cover all drugs used for Medication Assisted Treatment.

• Coverage must comply with EHB nondiscrimination requirements and MHPAEA parity requirements.

Stand-Alone Dental


• All Stand-Alone Dental Plan (SADP) issuers are bound by the same timeline as QHP issuers.

• SADPs shall be filed using the SERFF system.

• Stand-alone dental plans, as offerors of excepted benefits, are not subject to many of the requirements that are applicable to all QHP issuers. (see Appendix III)

2020 SADP MOOP

Numberof

ChildrenMOOP

1 Child $3502 or more $700

All issuers are reminded that if no issuer offers a stand-alone pediatric plan for plan year 2020, then all issuers must embed the benefit.

The Department will make all issuers aware if a filing revision is required soon after the initial intake procedure is completed, so that issuers may revise and embed pediatric dental if necessary.

Auto Enrollment Notices


• Issuers must send all consumer notices and correspondence related to auto-enrollment to the Department for approval prior to dissemination.

• Notices can be sent to the attention of Diana Lavoie, and will reviewed in a timely manner but issuers should allow for the appropriate time needed to ensure they meet any notice requirement deadlines.

• Issuers should consult the following Department guidance from 2018 related to auto enrollment: https://www.nh.gov/insurance/consumers/documents/11-21-17-information-for-minuteman-members-extended-enrollment.pdf

Part 2: Network Adequacy

• Federal ECP Templates• New Hampshire Hospital Template• NHID Network Adequacy Template• Network Adequacy Reminders


New Hampshire Hospital Template

New Hampshire Hospital Template: Issuers must indicate which of the 26 Acute Care Hospitals in NH are in the proposed network.

• Issuers will indicate if the network contract with the hospital includes the full scope of services.

• The template will be posted on the 2020 QHP Plan Year page on the NHID website.


NHID Network Adequacy Template


Network Adequacy Reminders


Reminders: Provider information submitted must be representative of signed contracts in place and all data submitted must be accurate and current as of the date of filing.

Issuers must provide updates if changes made to the issuer network after submission:

• Impact compliance with network adequacy standards; or

• Result in the loss of a major inpatient or outpatient facility or large provider group.

Such changes must be:• Reported to the Department in writing

immediately; and• Updated in all applicable state and federal

templates via SERFF.

Part 3: SERFF and Filing Submittal

• Advertising• Summary of Benefits and Coverage• SERFF


Advertising materials for all plans submitted for certification must be filed with the Department in SERFF prior to use.• Neither marketing practices nor benefit designs may have the effect of discouraging the

enrollment of individuals with significant health needs.

• Advertising must also comply with Ins 2600.

• For 2020 QHP certification purposes, the NHID requires issuers to file advertisements “prior to use.”

• Advertising materials include webpages and social media posts.

• Requested Filing Mode should be Informational.

Advertising


• Issuers shall also submit an attestation in the supporting documentation tab of the binder in SERFF stating that all advertising materials are in compliance with applicable state and federal regulation.

• All issuers should be prepared to participate in a full review of all filed materials, and are reminded that advertisements are subject to a market conduct review if issues arise after use.

• The Department reserves the right to review all advertisements, whether submitted or not, in order to protect consumers in the event such advertising is determined to be misleading or inaccurate.

Advertising


Summary of Benefits and Coverage


Further details on requirements for SBCs and schedules can be found in the NHID filing checklists.

Summaries of Benefits and Coverage (SBCs) must include a web address that links directly to a copy of the individual coverage policy or group certificate of coverage.

• All URL links included on the SBC must link directly to the referenced information, such as the specific formulary for that SBC benefit package.

• QHP insurers are required to make SBCs available that accurately reflect each cost-sharing plan variation, and must include a separate URL linking to the SBC created for each plan variation as part of the QHP data submission.

• QHP SBCs must disclose whether or not the QHP pays for abortions for which federal funding is not available.

CMS SBC instructions and templates can be found here.

QHP Filing Submission - SERFF


QHP filings to be submitted through the NAIC System for Electronic Rate and Form Filing (SERFF)

Process from SERFF to plan visibility on the Marketplace:

BinderFilingOnline Portal



Binder

Filing

Online Portal

Online Portal• Issuers must have valid SERFF ID and adequate access to

submit Form/Rate filings to NHID• SERFF Plan Management Industry Manual found at• https://login.serff.com/Appendix%20II.pdf• NHID has “retaliatory” fee requirements, meaning that issuer’s

state of domicile determines whether the issuer submits a filing fee

SERFF• QHP filings to be submitted through the System for Electronic Rate and

Form Filing (SERFF)• SERFF components include Filings (form/rate) and Binders



Binder

Filing

Online Portal

SERFFFiling

• Filings are submitted through SERFF• Instructions to create a filing:

https://login.serff.com/Complete%20Industry%20Manual.pdf• Filings must be submitted as a “Form/Rate” Filing type

Forms/Binders – May 12, 2019Initial Rates – May 12, 2019

Off-Exchange Only Issuers Filings Due-June 29, 2019 Final Rates – July 18, 2019



Binder

Filing

Online Portal

SERFF

Form Schedule Documents• Policy• Certificate• Outline of Coverage• ID Cards• Schedule of Benefits• Summary of Benefits and

Coverage• Application / Enrollment

Form

s

Components of a Form/Rate Filing



Binder

Filing

Online Portal

SERFF Components of a Form/Rate Filing

Supporting Documentation• NHID Issuer Checklist• Compliance Certification• (Applicable) NHID Filing Checklist• Certificate of Readability• Patient Bill of Rights• Summary Plan Description of

Continuation of Coverage rights• Managed Care Consumers Guide to

External Appeal• Actuarial Memorandum with Rates,

URRT, Redacted Actuarial Memorandum*

• NH Rate Filing Exhibit Template Version 6*

* All rate questions should be directed to David Sky.



Binder

Filing

Online Portal

SERFFBinder• Binders contain specific QHP content and hyperlinks data

from filings• Instructions on binders:

https://login.serff.com/Appendix%20II.pdf

Final Binders Transferred to FFM: August 21, 2019



Binder

Filing

Online Portal

SERFF Components of a QHP Binder

Associate Schedule Items• Issuer links documents from

form/rate filing• Forms and rates assigned to

specific plans within the binder

• Instructions for associating forms, rates and supporting documentation to the binder can be found in the Industry User Manual Plan Management Appendix starting on page 20. https://login.serff.com/Appendix%20II.pdf

QHP Templates• Plan and Benefits• Prescription Drug• Network Service Area• Essential Community

Providers/ Network Adequacy• Rate Data• Rating Business Rules



Binder

Filing

Online Portal

SERFF Components of a QHP Binder



Binder

Filing

Online Portal

SERFF

Supporting Documentation• Plan ID Crosswalk– Individual, SHOP (On- and

Off-Exchange)• Advertising Attestation • Unified Rate Review Template • Actuarial Memorandum • New Hampshire Hospital Template• NHID Network Adequacy Template• Quality Improvement Strategy• State Insurance License• Certificate of Compliance• All Vendor and 3rd Party Licenses • SPM Attestations, which includes the mental

health parity attestation• CMS Tools Attestation• Formulary File

Components of a QHP Binder

Helpful Filing Tips


State Licensure• In order to receive a recommendation for certification, issuers must provide proof that

they have applied for or renewed a license in NH for the coming year. • Licenses are renewed on June 15th of each year.

• State license must be provided for the correct company for the filing (HMO product must have HMO license, etc).

• Issuers must submit to the Department proof of licensure for all subcontractors or third party entities performing services on their behalf.

• CMS annually requires the submission of a "Certificate of Good Standing" (aka, NH "Certificate of Compliance“).

• Updated NH Licenses and Certificates of Good Standing must be attached to the binders.

Contact for NH company license, TPA licenses or a NH "Certificate of Compliance"Diane CyganFinancial Examinations DivisionNew Hampshire Insurance Department21 S. Fruit St, Suite 14Concord, NH 03301Email: [email protected]: 603-271-2528

Helpful Filing Tips


Bookmarking• One of the more common errors we see are forms that have been amended and re-

submitted without proper bookmarking. • ALL forms must be bookmarked to the Table of Contents or Index, per NHCAR

Part Ins 401.13(h). • All forms containing 3,000 or more words or printed on 3 or more pages shall

contain a table of contents or an index of the principal sections of the policy and shall be electronically bookmarked.

NHID Filing Check Lists• SADP – Individual and SHOP• Medical – Individual and SHOP• Issuers must submit the applicable checklist with filings.

• Updated checklists for 2020 will be posted to http://www.nh.gov/insurance/lah/

Helpful Filing Tips


SERFF, QHP Templates, Supporting Documentation• In SERFF, select the applicable Type of Insurance (TOI) that relates to the plans

submitted (HMO, PPO, POS); otherwise the filing will be rejected.• When associating schedule items in the binder, the Standard Component ID must be

entered exactly as generated by HIOS.• Both On- and Off-Exchange plans must be contained in a binder and be submitted

through SERFF.• Advertisements must be submitted within its own SERFF filing (Filing Type:

Advertisement).• Remember to set your SERFF message settings to accept binder notifications.• Changes to forms may require changes to binders and vice versa.• Please use the Note to Reviewer feature through SERFF for specific questions

regarding filings.• Please pay particular attention to your HSA plans. IRS guidelines for qualified HDHP

plans must be followed in both the form filings as well as the binder templates.

Activity Date

Initial application submission / transfer deadline to CMS June 19, 2019(submissions can begin April 25th )

Initial CMS review June 20th – Aug 2rd

First correction notices August 9th

Final submission / transfer deadline August 21st

CMS review of revised submissions August 21st – September 9th

CMS sends Final Correction Notice to issuers, with Agreements for signature and plan lists for confirmation September 16th

State deadlines for final plan recommendations from plan management partnership states September 24th

Issuers send signed agreements, confirmed plan lists, and final Plan Crosswalks to CMS September 16th – September 24th

Limited data correction window: Outreach to issuers with CMS or state identified data errors; issuers submit corrections; CMS reviews and finalizes data for Open Enrollment

September 19th – September 20th

CMS certification notices October 3rd – October 4th

Open enrollment November 1, 2019 – December 15, 2019

Appendix I: Federal Key Dates for QHP Certification


Appendix II: Federal Rate Review Timeline


Activity Date

Submission deadline for issuers in a state without an Effective Rate Review Program to submit proposed rate filing justifications for single risk pool coverage into the URR module of HIOS.

June 3rd

Submission deadline for issuers in a state with an Effective Rate Review Program to submit proposed rate filing justifications for single risk pool coverage into the URR module of HIOS.

July 24th

Target date on which CMS will post preliminary rate changes. August 1st

Deadline for all rate filing justifications for single risk pool coverage that includes a QHP to be in a final status in the URR system. August 21st

Deadline for all rate filing justifications for single risk pool coverage that includes only non-QHPs to be in a final status in the URR system. October 15th

Target date on which CMS will post all final rate changes. November 1st

Appendix III: Standards and Tools Applicable to SADPs


Standard or Tool Applies (* denotes modified standard)

Essential Health Benefits* Actuarial Value* Annual Limits on Cost Sharing* LicensureNetwork Adequacy Inclusion of ECPs Non-discrimination Service Area Acceptance of Third Party Premium and Cost-sharing Payments Data Integrity Tool

Rates submission* Machine Readable* (SADPs must comply with provider directory standards but not drug formulary standards)

Transparency in Coverage Reporting

SADP issuers applying for “Off-Exchange Certified” designations must comply with all standards applicable to on-Marketplace plans.

Standard or Tool Does Not ApplyAccreditation Patient SafetyQuality Reporting and Quality Improvement Strategy Standardized OptionsPrescription Drugs Out-of-Pocket Cost Comparison ToolCost Sharing Reductions

New Hampshire Insurance Department Contacts


Contact NHID Division Email

John R. Elias Executive Office [email protected]

Alexander Feldvebel Executive Office [email protected]

Jennifer Patterson L&H Director [email protected]

Tyler Brennan Health Policy [email protected]

David Sky LAH Actuarial [email protected]

Diana Lavoie Compliance Administrator [email protected]

Ingrid Marsh Compliance Examiner [email protected]

David Schechtman Compliance Examiner [email protected]

Debra LaCross Compliance Examiner [email protected]

Gail Matson Compliance Examiner [email protected]

Keith Nyhan Consumer Services [email protected]

Alain Couture Operations/Health Reform [email protected]

Thank You

Contact Information

New Hampshire Insurance Department21 South Fruit Street, Suite #14Concord, NH [email protected]: (603) 271-2261Fax: (603) 271-1406TTY/TDD: 1 (800) 735-2964

www.nh.gov/insurance

Please join us on April 18th for the interactive webinar Open House from 2:00PM to 3:00PM ET. Submit questions in advance to Diana Lavoie.New Hampshire Insurance Department | April 10, 2019

Health Insurance Marketplace Plan Management

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