The following questions have been received by the Idaho Department of Insurance
regarding the Idaho Health Insurance Exchange and SHOP (Idaho Exchange), the filing process, Qualified
Health Plan standards, and other related topics. The answers are intended to offer guidance on current
issues based on the DOI’s current understanding of applicable federal and state law requirements. If you
have any concerns regarding the accuracy of any of the guidance, please contact
Wes Trexler at the DOI by phone at 208-334-4315 or email. The
DOI will continue to release additional information and revise these responses as needed.
What is the Idaho exchange user fee?
(Revised 8/8/2013) The Idaho Health Insurance Exchange Board set the 2014 fee during the June 28, 2013 board meeting at 1.5% of premium.
What fee should carriers use in QHP filings prior to the Idaho Exchange Board setting the exchange user fee?
(5/3/2013) For filings made prior to the board’s decision, carriers should use what they reasonably expect for the exchange user fee. Once the fee is determined, and if different than that contained in the filing, the DOI will submit an objection to the filed exchange fee through SERFF, allowing carriers the opportunity to modify the templates and documents as needed to reflect only the change to the fee. If for whatever reason, modifications are not sufficient, the DOI will allow new filings after May 31, 2013 for the narrow purpose of fixing the exchange fee used in the rate development. Changes to the Unified Rate Review Template (URRT) or the actuarial memorandum will also need to be resubmitted through HIOS. Please be aware that all objections will need to be resolved with sufficient time for the DOI to complete its review and certification of QHPs by the DOI’s July 31, 2013 deadline.
What are the names of the rating areas so that we can input them in our rating template? The bulletin identifies how the areas are defined but will there be a standard naming convention that will be used by all the carriers?
What is the minimum number of medical plans that a carrier may offer through the Idaho Exchange?
(5/3/2013) A carrier must at a minimum offer a silver and gold plan in each market in which the carrier wishes to participate. Variant plans are required under Federal law for the Cost- Sharing Reductions for the Silver metal level and the two Indian variant plans for all metal levels.
Will the Notice of the Ten (10)-Day Right to Examine a Policy requirement be applicable to the QHPs?
(5/3/2013) Idaho Code and Rule 30 provisions will be applicable unless preempted by federal law. The notice of the ten-day right to examine a policy is not considered preempted.
Must the SERFF filing of the policies, Outlines of Coverage (OOCs) and/or Summaries of Benefits and Coverage (SBCs) be “filed” before we can associate the filings in the binder or can the policies just be in submitted and in the review at the DOI process when we create the binder?
(5/3/2013) The SERFF process involves first filing the materials and then associating the filings to the binder. The materials do not have to be accepted as filed prior to being associated with a binder. Additionally, all materials are not required to be filed simultaneously.
Will the DOI be using the FFE standards to determine network adequacy?
(5/3/2013) We plan on using network adequacy standards similar to the FFE standards.
If the state has a question regarding a deficiency, will this be handled like an objection in SERFF?
(5/3/2013) Yes, that is the current expectation. SERFF filing guidelines and procedures for QHP binders are the same as all other filings.
We have been advised in CCIIO meetings the Medical Loss Ratio & Uniform Rate Review Template (URRT) will need to be sent to HIOS as well as SERFF. Are you aware of additional templates that will also need to be submitted to SERFF?
(5/3/2013) The URRT and the actuarial memorandum must be filed with HIOS at the same time as the filing with SERFF.
Has a date been set for the filing of dental products for 2014?
(Revised 5/31/2013) The recommended QHP filing deadline for stand-alone dental plans that issuers would like “Exchange certified” has been extended to June 7, 2013. There is no set filing deadline for stand-alone dental plans that issuers are not seeking to have “Exchange certified.”
Rate filings must be filed through SERFF by May 31. What is the timeline for forms such as our contracts or certificates?
(5/3/2013) The May 31, 2013 “soft” filing deadline in the March 26, 2013 Notice to Carriers applies to contracts and certificates, as they are part of a complete SERFF binder filing.
Have you established a filing deadline for non-exchange products?
(5/3/2013) Non-exchange QHPs should also be filed by May 31, 2013. There is no established deadline for non-QHPs. However, please be aware that the single risk pool standard requires that all plan rates be based on the same URRT.
For Individual, will there be opportunities to change rates after they are filed? Once we have submitted our products and rates, can we drop them? What is the cutoff date?
(5/3/2013) Rates, forms, and templates can be modified through May 31, 2013. After that date, modifications that are not made at the request of the DOI may result in the modified plan/product being moved in priority behind non-modified plans/products. Carriers can withdraw QHP applications through July 31, 2013.
For Small Employer, the ACA and regulation (45 CFR § 155.705(b)(6)(i)) allows for rates to be changed on a quarterly or annual basis. What will the filing timeline be for quarterly changes?
(1/4/2019) The Federal URR instructions have requires carriers submit quarterly adjustments at least 105 days before the requested effective date. Therefore, for example a Q2 small group rate adjustments must be submitted through SERFF no later than December 15. The carrier should submit a rate filing supporting the Index Rate shift and request to update the applicable SERFF binder with a new URR, rate table template, and memorandum.
(5/3/2013) Regarding the 2014 calendar year, the DOI recommends that carriers file quarterly trend adjustments with the initial submission, including each set of quarterly rates on separate sheets of the Rate Template. At this time, it is unclear if the Idaho SHOP will be prepared to accept additional adjustments to rates effective during the 2014 calendar year, beyond expected quarterly trend.
Do rate manuals need to be included with the QHP filings?
(5/3/2013) Idaho Code requires a rate manual be filed with the DOI prior to use. The DOI will consider a complete QHP filing, which includes all requested templates, to have met this requirement.
Since Idaho does not have a rule or law on minimum participation and has allowed the carriers to make their own participation rules in the past, is Idaho going to continue to allow this procedure in 2014 or are carriers going to be required to follow the exchange minimum?
(Revised 5/31/2013) The Idaho Exchange Board has the authority to set a minimum participation requirement for the Idaho SHOP. The Board has set the minimum participation requirement at 70% for small employers who wish to enroll through the SHOP. Carriers can continue setting their own reasonable participation requirements outside the Exchange. Pursuant to 45 C.F.R. § 147.104, small employers who meet the applicable participation requirement can purchase health insurance coverage at any point during the year. Small employers who do not meet the participation requirement must be allowed to purchase coverage during an annual enrollment period from November 15 to December 15. These enrollment periods apply market-wide.
Regarding the SHOP in Idaho, is the DOI going to limit options?
(5/3/2013) The DOI does not plan to limit options on the SHOP, outside of the finite departmental resources explained in the March 26, 2013 Notice to Carriers.
Is the no rider/endorsement requirement also applicable for plans outside the exchange?
(Revised 1/22/2015) Optional riders are not permissible on on-exchange or off-exchange health plans. Mandatory riders are allowed as long as the benefits are considered part of the plan in rating.
(Revised 5/17/2013) Optional Non-EHB riders with corresponding additional premium will be permitted outside the exchange. Plans offered in and out of the exchange must charge the same premium prior to any optional riders. Off-exchange only plans can include mandatory riders. Mandatory riders must be considered part of the policy when completing the filing templates.
When, at what stage of the filing process in SERFF, do filings become public?
(Revised 5/17/2013) Per Idaho Code § 9-340D(1), the DOI generally considers records as proprietary or “trade secret” any rates or rating information that is flagged as confidential within a filing. While such a designation by a company does not necessarily conclusively resolve the question, it does assist the DOI and has been referenced in Bulletin 95-2. Due to the significant market changes, form filings that issuers designate as confidential will be considered as such to the extent authorized by applicable law by the DOI at least through the date the corresponding QHP is certified. We have no information regarding public access to information filed through HIOS.
Below are some of the areas where it appears the requirements of Rule 30 (IDAPA 20.18.01.30) could require richer benefits than are required under the benchmark plan. Please clarify if the benchmark plan limits apply to individual plans (preempting Rule 30) or if Rule 30 still applies to individual plans, with the restrictions shown in the table? [TABLE OMITTED]
(Revised 5/17/2013) The general preemption guideline is that a state law is preempted by the ACA only where complying with it would result in non-compliance with the federal act or regulation. IDAPA 18.01.30.018.04 prohibits dollar limits except for a specified list of benefits. ACA as implemented through 45 C.F.R § 147.126(a)(2) prohibits dollar limits on EHB. Visit limits on EHB are not precluded under Rule 30 or ACA.
Will there be specific questions that we should ask prospective members?
(5/3/2013) Yes. Please see the federal application for preliminary guidance. The Idaho Exchange Board may decide to provide additional guidance with the Exchange application.
Will short term policies be limited to transitional membership only?
(5/3/2013) Correct. There is no change in the intended use of short term policies.
Per Bulletin 13-02, the state allows SHOP rating on a per member basis. Does this also extend to premium billing as well, or do premium rates have to be billed at the subscriber level? If subscriber-level billing is required, can premium rates be billed separately for different levels of dependent coverage (e.g., Employee Only, Employee & Child, Employee & Spouse, Employee & Family) or must they be billed for employee only coverage versus employee plus family coverage (i.e., 2-tier rating)?
(5/3/2013) As stated in Bulletin 13-02, small group premiums can be, but will not be required to be based on average enrollee amounts. Per the final market rules, this means that issuers are permitted to develop the premium on a per-member basis or use average enrollee amounts. Average enrollee amount premiums are permitted as long as the total is equal to the per-member build up premium total. Average enrollee amounts can be set using multiple tiers (including more than two), as long as the tier factors are standardized and are applied consistently.
Does Bulletin 13-01 apply to stand-alone dental plans?
(Revised 5/31/2013) Stand-alone dental plans and vision plans are considered exempted benefits, and are therefore not subject to most ACA reforms. Plans currently being sold do not need to be modified or discontinued. Stand-alone dental plans that issuers wish to sell as “Exchange certified” must be filed through SERFF as new plans and meet all applicable requirements such as covering pediatric oral benefits without annual or lifetime limits, meeting a specific actuarial value, and having a reasonable out-of-pocket maximum (see Q&A #31).
Is minor variability allowed for something like contact information?
(Revised 5/17/2013) Individual filings can continue to include benefit variables such as deductibles and coinsurance or contact information. However, optional benefits such as dependent age or dental cannot use variable language.
Is Idaho going to require having coverage for Non-Emergency Care When Traveling outside the U.S.?
(Revised 5/17/2013) This particular benefit has been re-categorized as a network issue rather than an essential health benefit. If not covered, an issuer should choose “Not Covered" in the template and use the EHB Variance Reason "Other Law/Regulation."
Does ACA say that individual plans will all be based on calendar year accumulators (for deductibles/OOP maxes) and small group will be based on plan year accumulators? Does the same apply to dental plans?
(Revised 8/8/2013) In the individual market, deductibles and maximums must accumulate on a calendar year basis. In the small group market, federal regulations do not provide guidance, so deductibles and maximums can continue to accumulate on a calendar year or renewal year basis. “Exchange certified” stand-alone dental plans have the same accumulator requirements as medical QHPs.
What is the Idaho benchmark plan supplement covering pediatric oral care?
(5/17/2013) Per Appendix B of the Essential Health Benefits Final Rule published February 25, 2013, in Federal Register Vol. 78 No. 37, the supplement benchmark plan for FEDVIP is the MetLife Federal Dental Plan-High. The 2012 plan benefit brochure for that plan can be found at http://www.opm.gov/insure/health/planinfo/2012/brochures/MetLife.pdf
Which of the HHS requirements noted in the Final Rule dated 2/25/13 that apply to FFE and state-partnerships also apply to pediatric dental in the Exchange?
(5/17/2013) Under 45 C.F.R. § 155.1065(a)(2), the pediatric dental EHB offered by stand-alone dental plans certified to be offered in the Exchanges must be offered without annual and lifetime limits. Under 45 C.F.R. § 156.150(a), rather than meeting the specific dollar limits that apply to cost sharing for comprehensive medical QHPs, stand-alone dental plans certified to be offered inside an Exchange will be required to demonstrate to the Exchange (FFE or otherwise) that they have a reasonable annual limitation on cost-sharing in place. The EHB/Accreditation final rule also clarified that the Exchange is responsible for determining the level for “reasonable.” As stated in 45 C.F.R. § 155.1065, issuers of stand-alone dental plans and stand-alone dental plans must meet QHP certification standards, except for any certification requirement that cannot be met because the plan only covers dental benefits.
The insurance market reform provisions generally do not apply, including guaranteed availability, renewability of coverage, medical loss ratio standards, and rating standards.
Must the stand-alone dental plan have unlimited coverage?
(5/17/2013) Under 45 C.F.R. § 155.1065(a)(2), the pediatric dental EHB offered by stand-alone dental plans certified to be offered in the Exchanges must be offered without annual and lifetime limits.
What is the maximum out of pocket for stand-alone dental plans?
(5/17/2013) Under 45 C.F.R. § 156.150(a), rather than meeting the specific dollar limits that apply to cost sharing for comprehensive medical QHPs, stand-alone dental plans certified to be offered inside an Exchange will be required to demonstrate to the Exchange (FFE or otherwise) that they have a reasonable annual limitation on cost-sharing in place. The EHB/Accreditation final rule also clarified that the Exchange is responsible for determining the level for “reasonable.” In fulfilling the plan management role for the Idaho Exchange, the DOI will find a maximum out of pocket limit of up to $1,000 per person reasonable for stand-alone dental plans.
Are two stand-alone dental plans required at the 70% and 85% AV level?
(5/17/2013) No. Per 45 C.F.R. § 156.150(b), a stand-alone dental plan must meet either a low level (70%) or high level (85%) of coverage. There is no requirement for an issuer to offer both levels.
Will medically necessary orthodontia be required as an EHB?
(5/17/2013) Medically necessary orthodontia is part of the supplemented Idaho benchmark plan, and therefore part of the essential health benefits, making it a required coverage.
Is there a 24 month waiting period for orthodontia?
(5/17/2013) A 24 month waiting period for orthodontia is permissible.
Would adult dental be considered an optional rider for the medical carriers and a stand-alone policy for dental carriers? Will it be allowed to be offered in the Exchange?
(5/17/2013) Adult dental is a permitted optional rider outside the Exchange. Riders are not permitted in the Exchange on either medical or stand-alone dental plans (see Q18). Adult dental coverage is permitted as an additional benefit on the Exchange provided it is embedded with the other benefits.
In the DOI’s Q&A dated 5/3/13, question #24, it states that the DOI “expects current dental plans that cover pediatric dental to be discontinued and replaced with an ACA compliant (i.e. Idaho benchmark plan) pediatric dental plan, in compliance with Bulletin 13-01.”
An alternative would be for the DOI to require that any new dental plans sold in 2014 to individuals or groups with less than 50 employees “carve out” the pediatric dental plan and allow those individuals and groups to purchase the new pediatric dental plan (benchmark plan) which will be unique from the adult dental plan. Any current policies for individual and/or group policies with less than 50 employees would be required to “carve out” the pediatric dental plan at their next renewal date in compliance with DOI Bulletin 13-01.
(5/17/2013) The DOI would find it acceptable for the pediatric benefit to be carved out from current plans. The carved-out pediatric benefit would need to be offered as a new pediatric dental plan that meets EHB standards.
Do all of the SHOP dental plans need to be age rated since the pediatric benefit only applies to children up to age 19? Apparently, SERRF requires age rating and not tiered rating. Is this correct? Note, this is related to DOI’s Q&A dated 5/3/13, question #23.
(5/17/2013) The ACA market rules regarding rating standards do not apply to dental plans; therefore, it is not required that SHOP dental plans be age rated. It is correct that the federal rate template used by SERFF does not allow rating structures that do not meet the ACA rating standards. Question #23 applies to plans that are subject to the market reform rating rules, which stand-alone dental plans are not.
Must stand-alone dental plans offer rate manuals, DOI’s Q&A dated 5/3/13, question #15? If rate manuals must be provided, please specify what should be included and if this would be considered proprietary.
(5/17/2013) If stand-alone dental plans can provide accurate and complete rate manual details through the use of the requested templates, then the templates should be used to meet that requirement. Since stand-alone dental plans are exempted from several market reforms, the templates will likely not provide accurate rating details, and therefore the DOI would expect that a complete rate manual be included with stand-alone dental plan filings.
Does the DOI consider stand-alone dental plans to be QHPs?
(5/17/2013) As stated in 45 C.F.R. § 155.1065, issuers of stand-alone dental plans and stand-alone dental plans must meet QHP certification standards, except for any certification requirement that cannot be met because the plan only covers dental benefits. We generally consider stand-alone dental plans to be a type of QHP.
Will childless adults be required to purchase pediatric dental in the Exchange?
(5/17/2013) No. The Exchange must offer the full set of essential health benefits, including pediatric dental. The pediatric dental can be embedded or stand-alone. The Exchange cannot require an applicant to purchase a stand-alone dental plan if a QHP chooses to not embed the pediatric dental benefit.
Will medical carriers be required to price embedded pediatric dental benefits separately in and out of the Exchange for comparison purposes?
(5/17/2013) No. The DOI will not be requiring the pediatric dental coverage to be embedded in QHPs or to be offered only as stand-alone dental plans separate from a medical QHP, and we will not be requiring separate pricing of embedded dental benefits. All QHPs must meet all applicable rating standards, regardless of the inclusion or exclusion of dental benefits. The rating criteria applicable to QHPs with embedded pediatric dental are sufficiently distinct from the rating criteria for stand-alone dental plans that direct comparisons are of limited usefulness.
Will the Exchange provide information about the dentists contracted with the medical or dental carrier?
(5/17/2013) According to 45 C.F.R. § 156.230(b), a QHP issuer must make its provider directory for a QHP available to the Exchange for publication online in accordance with guidance from the Exchange and to potential enrollees in hard copy upon request. In the provider directory, a QHP issuer must identify providers that are not accepting new patients.
Does Idaho require a health plan to embed the pediatric dental benefit when off the Exchange?
(3/11/2015) Please see DOI Bulletin No. 14-02 for policies effective 1/1/2015 or later.
(5/17/2013) Issuers have the option but are not required to embed the pediatric dental EHB in QHPs or off-exchange plans. For off-exchange plans that do not embed the pediatric dental EHB, the issuer must have a procedure for becoming “reasonably assured” that policy holders obtain pediatric dental coverage through an “Exchange certified” stand-alone dental plan.
Will the DOI allow the following language to be used to meet the “reasonably assured” requirement for policies sold outside the Idaho Exchange that do not embed pediatric dental? The following language has been recommended by the Wisconsin & Iowa Insurance Commissioners:
“This policy does not include pediatric dental services as required under the federal Patient Protection and Affordable Care Act. This coverage is available in the market and can be purchased as a stand-alone product. Please contact your carrier, your insurance agent, or the if you wish to purchase pediatric dental coverage or a stand-alone dental services product.”
(3/11/2015) Please see DOI Bulletin No. 14-02 on disclaimer language for policies effective 1/1/2015 or later.
(5/17/2013) Issuers have the responsibility to be “reasonably assured” that an individual has obtained pediatric dental coverage through an Exchange-certified stand-alone dental plan. Issuers will need to decide how they fulfill that responsibility in order to be found compliant with EHB requirements. The Idaho DOI would accept the above language.
How does a stand-alone dental plan off-exchange obtain the status of “Exchange certified”?
(3/11/2015) Please see section 21 of the Your Health Idaho 2016 Qualified health Plan Standards.
(5/17/2013) An off-exchange only stand-alone dental plan can be “Exchange certified” by submitting through SERFF all the requirements for on-exchange QHPs, while indicating that the plan is off-exchange only. It will go through the same process as an on-exchange product, and it has the same filing deadlines as on-exchange products.
How is preventive care defined in reference to the pediatric oral EHB for the purpose of applying the requirement of no cost-sharing?
(Revised 5/31/2013) The specific preventive care services that are required to be covered with no cost sharing are not tied to the state’s EHB benchmark, but instead to the certain preventive services as required by 45 C.F.R. § 147.130. For more information on preventive services that must be covered without cost sharing under the requirements of the Affordable Care Act, please see http://www.healthcare.gov/news/factsheets/2010/07/preventive-services-list.html.
To comply with the essential health benefits for pediatric dental, must the issuer offer a child-only plan on the SHOP?
(Revised 5/31/2013) Offering a child-only option is a requirement under section 2707(c) of the Affordable Care Act for enrollees under the age of 21, or in the case of the SHOP, employees under the age of 21. This age aligns with the rating restriction for medical plans to apply the same age factor in developing the premium for all individuals under the age of 21. The pediatric dental EHB coverage only pertains to individuals under the age of 19. If an “Exchange certified" stand-alone dental plan is offered that covers only the pediatric dental EHB, it could be priced for individuals age 19 and older at no cost.
Can a carrier offer coverage outside of the Exchange if it does not also offer a plan through the Exchange?
What is the filing deadline for off-exchange only, non-QHPs?
(Revised 8/8/2013) Due to the considerable changes to plan requirements and limitations, the DOI is unable to provide assurance that the review and acceptance of filings will be fully completed by October 1 if a filing is submitted after August 31. Therefore, DOI strongly suggests that rates and forms for new ACA-compliant plans to be sold only off-exchange be filed with the DOI no later than August 31.
In accordance with federal regulation and guidance, non-QHPs must be filed at the same time as QHPs. Please see CMS FAQ released April 18, 2013, question 50 and CMS FAQ released April 24, 2013, question 29 for additional details.
Please note that if an individual plan is not available for purchase throughout the full open enrollment period as stipulated by 45 C.F.R § 147.104(b)(1)(ii), the carrier will not be able to limit enrollment outside of the open enrollment period and instead must enroll any individual who applies at any time during the following calendar year.
Similarly, if a small group plan is not available for purchase during the full November 15 to December 15 annual enrollment period when minimum participation and contribution rates cannot be imposed, the carrier must not apply a minimum participation or minimum contribution rate to any small group applicant during the following calendar year.
For Idaho, it appears that QHPs and off-exchange plans should be filed through SERFF. Are there any requirements to also file with the Health Insurance Oversight System (HIOS) or the Rate and Benefits Information System (RBIS)?
(5/17/2013) We understand there are federal filing requirements for on and off-exchange plans. Questions regarding what information issuers need to file should be confirmed with CCIIO.
Are issuers permitted to offer shorter or longer than 12 month policies in the individual or small group markets?
(5/17/2013, revised 10/2/2015) Nonshort-term comprehensive medical policies in Idaho have generally been offered with a rating period of 12 months. All policies must conform to the rating period specified in the policy forms and the corresponding rate manual. Federal regulations implementing the ACA define plan years and policy years as 12 month periods (45 C.F.R. § 144.103). Therefore, health plan filings in either the individual or small group markets that use policy periods or plan periods that are greater or fewer than 12 months will not be accepted.
Carriers may request a limited exception to this requirement for renewals of transitional, or grandmothered, plans. The carrier may be permitted to renew for a period greater than 12 months if this would result in a benefit to consumers: for example, an issuer renewing a transitional health plan as of October 1, 2016 for a 15 months period in order to align with the calendar year.
Can issuers offer off-cycle renewals to policy holders?
(5/17/2013) Offering policy holders the opportunity to renew prior to the policy renewal date is not specifically prohibited by the Idaho Code. However, issuers should be attentive to potential unfair discrimination (Idaho Code § 41-1313) or other possible violations of law that such a practice may generate if not undertaken with sufficient care. Any off-cycle renewal offer must be offered to all policy holders within a given market (individual or small group). Risk loads must not be adjusted from the current policy period, while case characteristics may be updated. The renewal offer must clearly communicate that coverage will continue at the current premium rate through the standard renewal date if no action is taken, and it must include language similar to the model renewal notice language found in the CMS notice released April 30, 2013.
When can plans be added to either the individual or small group market?
(8/8/2013) Since the market-wide index rate must reflect all plans in the single risk pool, all plans in the risk pool have to have their rates approved at the same time, both on and off the Exchange. Therefore new plans must be submitted with all other plans within the same market at the same time the market-wide index rate is changed. The proposed Program Integrity rule includes 45 C.F.R. § 156.80(d)(3), stating that carriers (selling inside or outside an Exchange) may adjust the individual market-wide index rate annually and the small group market-wide index rate quarterly. However, quarterly adjustments in the small group market are not available until after the HHS issues notification that the FFSHOP can process quarterly rate updates.
When is the Plan Preview for plans that are participating in the Idaho Exchange?
(8/8/2013) The Plan Preview for the Idaho Exchange extends from August 8 to August 23, 2013. During this period, the participating carriers can review a selection of their submitted carrier and plan data that will be displayed to consumers. Carriers can review the information through HIOS, and any requests for changes should be sent to the XOSC Help Desk by August 16, 2013, by email at CMS_FEPS@cms.hhs.gov or via phone at 1- 855-CMS-1515. Once the change is approved by the Idaho DOI, the carrier will make the change through SERFF.
Please see https://www.regtap.info/ann_view.php?id=22
for more details.
Under what circumstances can a small group plan exceed the annual deductible limit of $2,000 for an individual or $4,000 for a family specified in 45 C.F.R. § 156.130(b)?
(8/8/2013) According to 45 C.F.R. § 156.130(b)(3), “a health plan's annual deductible may exceed the annual deductible limit if that plan may not reasonably reach the actuarial value of a given level of coverage as defined in § 156.140 of this subpart without exceeding the annual deductible limit.” The Idaho DOI and CMS sub-regulatory guidance agree that bronze metal level plans cannot reasonably reach the actuarial value without exceeding the annual deductible limit, and therefore are exempt from this requirement. Silver, gold, and platinum plans must not exceed the limit.
Are conversion plans required after January 1, 2014, even with guaranteed-issue in the individual market? If conversion will still need to be offered, will it have to conform to all ACA requirements for other non-grandfathered plans, i.e., EHB’s, metal plan level, etc.?
(8/8/2013) Unless the DOI releases additional future guidance, conversion plans are no longer required. The purpose of a conversion plan is met through the ACA-compliant individual market plan options. Current conversion plans are permitted to discontinue consistent with Idaho DOI Bulletin 13-01. An EHB compliant replacement conversion plan is not required.
Is small group composite rating allowed at certain group sizes, as long as the total is equal to the allowable per-member rating at issue and renewal
(8/8/2013) At this time, it appears that federal regulations and Idaho code allow the carrier to determine the size at which composite rates are offered outside the Exchange. Additionally, it appears acceptable to modify the composite rates only at issue and renewal, as long as the total premium is equivalent to the allowed per-member rating at those times. Additional federal guidance is expected to address this more directly.
Is there an updated version of the Idaho Small Employer Application that conforms to the requirements of the ACA (i.e., removal of health status questions, etc.)?
(8/8/2013) The updated version is being worked on and will be posted to the Idaho DOI website when finalized and approved.
What requirements exist for brokers / producers who wish to participate in the Idaho Exchange?
(8/8/2013) The Idaho Exchange’s proposed Consumer Connector Program (CCP) includes defined roles and requirements for producers who wish to participate in the Exchange. Once the CCP is finalized and approved by the Exchange Board, the Exchange will communicate the details to the producer community. The proposed CCP utilizes the producers as the recipient of referrals from those needing recommendations or additional guidance while accessing information on-line or through the call center, or while working with the community based In-Person Assisters. For the 2013 open enrollment period, the Idaho Exchange will not be adding additional requirements to the producer community beyond the federal requirements, but it will make the CCP Training available for their use.
How will carriers be notified if a producer is certified to sell through the Exchange?
For the transition of non-grandfathered off-exchange moving to EHB medical coverage, can a carrier automatically enroll an individual or group onto an Exchange-certified stand-alone dental plan to ensure compliance, if the carrier can’t obtain a definitive response from the member or group that they have purchased an Exchange-certified stand-alone dental plan?
(8/8/2013) Yes. Per federal guidelines, the carrier is responsible for becoming “reasonably assured” that policy holders obtain the full set of ten EHBs, and the carrier must include coverage for the pediatric dental EHB if that assurance is not obtained. According to the EHB final rule (78 FR 12834), the carrier could potentially be found non-compliant with EHB requirements if the carrier does not ensure full coverage of EHB.
For off-exchange shoppers wanting to purchase medical coverage, how should carriers enroll an individual or group onto a QHP pediatric product?
3/11/2015) Please see DOI Bulletin No. 14-02 for policies effective 1/1/2015 or later.
(8/8/2013) If a carrier does not embed the pediatric dental benefit in their off-exchange plan offerings, the carrier has the responsibility to offer the full EHB or be reasonably assured that an individual has obtained the pediatric dental EHB through an Exchange-certified stand-alone dental plan. As discussed in questions 43 and 44 of the May 17, 2013 Idaho Carrier Questions and Answers, Part 2, carriers must decide how they fulfill that responsibility in order to be found compliant with EHB requirements..
If a family drops a dependent eligible for the pediatric dental benefit and the carrier cannot become reasonably assured that the dependent has an Exchange-certified standalone dental plan through another carrier, will the medical policy also need to be terminated for the entire family or just the dependent?
(8/8/2013) The carrier should not permit a family to discontinue pediatric dental EHB coverage for a member without first obtaining reasonable assurance that an Exchange-certified standalone dental plan will replace the coverage.
If an off-exchange member/group does not provide the evidence requested by the medical carrier to be reasonably assured that they have an Exchange-certified standalone dental plan, will the medical carrier that is not providing the pediatric dental EHB be forced to terminate the member/group as non-compliant?
(8/8/2013) The medical carrier should offer only the full EHB to applicants if it is not reasonably assured that the pediatric dental EHB is being met through a separate Exchangecertified plan. Enrolling an applicant in a plan which lacks coverage of the pediatric dental EHB without reasonable assurance of other acceptable coverage would violate the EHB regulations.
How often does a carrier have to track or certify compliance with covering the pediatric dental EHB?
(8/8/2013) The carrier is responsible for designing procedures to achieve compliance with EHB requirements to offer full EHB or be reasonably assured that all EHB are covered, as described in the final EHB rule.
Will groups that purchase on the Idaho SHOP be able to make multiple plan options available to their employees? Does the same apply for stand-alone dental plans available on the Idaho SHOP?
(9/25/2013) For plan years that begin prior to January 1, 2015, the group purchasing through the SHOP will select only one medical and up to one stand-alone dental plan to which all members of the group will have access. For plan years beginning on or after January 1, 2015, Idaho SHOP is expected to offer employee choice and premium aggregation, which would allow groups to allow employees to select among a subset of the plans offered on the SHOP.
How do new federal regulations and the exchange change how Idaho carriers determine if an employer qualifies as a small group in 2014?
(9/25/2013, revised 7/21/2015 and 10/13/2015) For small groups not participating in the Small Business Health Options Program (SHOP), Idaho’s definition of a small employer as one employing at least two but no more than 50 employees,
and method of counting employees,
found in Idaho Code section 41-4703
(28), and method of counting employees section 41-4703
(13) will continue to apply
the federal method of counting employees, provided by the IRS at 26 USC 4980H, will apply, and small employers will be defined as those employing 1-100 employees. The method of counting employees described in Idaho Code section 41-4703(28) will continue to apply in 2014 and future years
For small groups participating in the SHOP, the federal method of counting employees, provided by the IRS at 26 USC 4980H, will apply as of January 1, 2014
; however, small employer size will continue to be capped at 50 until January 2016
While Idaho insurance code section 41-4708(3)(f)(i) requires insurers to offer to cover dependents, are small groups required to provide coverage to spouses and children dependents of employees?
Idaho insurance code section 41-4708
(9/25/2013) Idaho code does not require small employers to provide coverage to spouses or dependents of employees, so small employers may provide coverage to employees only, or to no one. Federal regulations also do not impose a requirement for small employers to offer coverage. To participate in the SHOP, the small employer is required only to provide coverage to full time employees, and is not required to provide coverage to spouses or dependents.
What Idaho and federal regulatory requirements apply to large groups regarding coverage of spouses and children dependents?
(9/25/2013) Idaho regulations do not require large employers to offer coverage to employees, spouses or dependents. The new federal regulation requires large employers, as of January 1, 2015 (per IRS notice 2013-45), to offer coverage to full time employees and their dependents. If coverage is not provided, the large employer will be assessed a tax penalty as defined in IRS code 26 USC § 4980H
Since the market reforms include guaranteed availability, must an individual health carrier continue to actively market or offer the Idaho Individual High Risk Pool plans?
(9/25/2013) Individual health carriers will no longer be required to offer Individual High Risk Pool plans for new coverage beginning January 2014 since the eligibility requirements as provided in Idaho Code section 41-5510 cannot be met. Eligibility through subsections 41-5510(1)(a) and (c) can no longer be met beginning January 2014 due to the guaranteed availability provisions of the market reforms as found in 45 CFR 147.104. The Health Coverage Tax Credit program which is needed for eligibility to the High Risk Pool plans under subsection 41-5510(1)(d) expires December 2013, and therefore individuals will no longer be eligible for the pool through 41-5510(1)(d) after that date.
Idaho Code subsection 41-5510(1)(b) requires the carrier to offer a High Risk Pool plan if the carrier refuses to issue a “substantially similar” plan at a premium lower than the premium for a High Risk Pool plan. The Department has concluded that the non-grandfathered, EHB compliant plans that will be offered both in and outside the Idaho Exchange are not substantially similar to plans available through the High Risk Pool (they will contain richer benefits, have no annual or lifetime benefit caps, lower out of pocket maximums, etc.). Therefore carriers will not be obligated to offer a High Risk Pool plan under 41-5510(1)(b) for coverage years beginning January 1, 2014.
Individuals already enrolled in a High Risk Pool plan will have the option during the open enrollment period as well as upon renewal of the High Risk Pool plan to either remain in the High Risk Pool plan or to enroll in a new individual plan in or outside the Exchange.
While federal regulations do not provide a special enrollment period upon the expiration of a short-term health insurance policy since it is not deemed Minimum Essential Coverage, should carriers allow individuals to transfer to a full EHB compliant health plan at that time?
(9/25/2013) While under federal or state law there is not a mandatory special enrollment period upon the expiration of a short-term policy, a carrier is permitted to offer such an enrollment period if so desired. The DOI highly recommends that carriers advise all short-term policy holders prior to January 1, 2014, that a short-term health policy does not qualify as Minimum Essential Coverage, and therefore the policyholder may be subject to the individual mandate tax penalty unless an EHB compliant health plan is purchased during the open enrollment period.
At what time and under what conditions should an individual or small group health policy be re-rated after a change in primary address?
(9/25/2013) For plans issued in the individual Exchange or the SHOP, the premium charged to an individual who changes address to a new rating area but remains within the same service area will not change until renewal. For off-Exchange plans, the issuer has the option to change the premium rate of an individual who changes address to a new rating area but remains within the same service area at either the beginning of the next month after the move or upon renewal. If an individual moves outside the service area for the enrolled plan, a special enrollment period is triggered; the individual must select a new plan and pay the new premium upon enrollment.
Must employers provide notice to their employees concerning the Exchange and their new coverage options?
(9/25/2013) All employers were required per the Affordable Care Act to send each employee a notice by October 1 2013, stating whether the employer provided health coverage to the employee and informing the employee of the new Exchange marketplace, the potential eligibility for a tax credit, and that the purchase of coverage through the Exchange might end any employer contribution towards health insurance. Originally, a penalty was to be assessed for employers who failed to comply. However, the U.S. Department of Labor announced September 11, 2013, that there is no penalty for not sending the notices. Employers may still wish to send notices in order to avoid repeated inquiries from employees or Exchange assisters on whether health insurance is available. Official guidance on this including model notices can be found at Department of Labor’s Technical Release No. 2013-02
If your question is not answered above, please submit your question directly to the DOI.