QHP and Dental Plan Invitation:
New – Posted 6/3/2013
Q. Could you provide additional guidance on the treatment cost calculator? Beyond the information offered in the invitation, would a link to the Fair Health cost calculator satisfy this requirement?
A. Use of a link to the Fair Health cost calculator would be sufficient to meet the treatment cost calculator requirement. Contact FAIR Health ifyou wish to set up a link in order to establish an appropriate licensing arrangement.
New – Posted 6/3/2013
Q. Section II.G.2(b)(2) of the Invitation requires the Applicants to use the logo and branding designated by the Department of Health on their marketing and outreach materials, as well as the Exchange website and toll-free telephone number. When can Applicants obtain this information?
A. The Department of Health is unable to provide a date certain when such information will be available for use by Applications. Accordingly, the Invitation is hereby amended to state that the Applicants mayuse the logo and branding designated by the Department of Health, and mayuse the Exchange website and toll-free telephone number, on their marketing and outreach materials. The Department of Health will provide such information to the Applicants as soon as it becomes available.
Posted 4/16/2013
This is to clarify the number of non-standard products that may be offered by Applicants. This clarification supersedes all prior instructions, including the January 31, 2013 Plan Invitation and previous Questions and Answers issued by the DOH.
Applicants may elect to offer:
(1) Same number of non-standard products at every metal level (e.g., 2 bronze, 2 silver, 2 gold, 2 platinum); or
(2) At least one and not more than 3 non-standard products at each metal level subject to the following:
(a) The number of non-standard products at any metal level may not exceed the number of non-standard products at any other metal level by more than one; and
(b) The number of non-standard bronze products may not exceed the number of non-standard products of at least one other metal level.
Permissible combinations under 2 above include:
1 bronze, 2 silver, 1 gold, 1 platinum
1 bronze, 1 silver, 2 gold, 1 platinum
1 bronze, 1 silver, 1 gold, 2 platinum
1 bronze, 2 silver, 1 gold, 2 platinum
2 bronze, 2 silver, 1 gold, 1 platinum
2 bronze, 2 silver, 2 gold, 1 platinum
3 bronze, 3 silver, 2 gold, 2 platinum
3 bronze, 3 silver, 3 gold, 2 platinum
3 bronze, 2 silver, 3 gold, 2 platinum
3 bronze, 2 silver, 3 gold, 3 platinum
We will permit the participation proposals to be modified only as a result of the above modification. To meet the above requirement, insurers can either remove non-standard products or submit additional non-standard products. We will be contacting each insurer directly by the end of the week to see how they would like to proceed. In the event, an insurer chooses to add non-standard products to conform to the above, DFS will permit the insurer to submit such additional Exchange non-standard products no later than May 15.
Posted 4/2/2013
Q. Has New York modified the deadlines for QHP and Dental Plans to submit the participation proposal, addenda, networks, and SERFF Plan Management templates?
A. The following modifications have been made.
- QHP and Dental Plan participation proposals and the supporting addenda are due on April 15th. Applicants will be able to revise proposals and addenda throughout the certification process as needed.
- Health Insurer Applicant and Dental Insurer Applicant SERFF form and rate filings are due on April 15. However, DFS is willing to entertain requests for extensions, and filings must be made no later than April 30.
- Health Insurer Applicant SERFF Plan Management Binder filings containing the CCIIO data templates are due April 30th.
- Provider network submissions are due on April 30th.
- Dental Plan Applicant SERFF Plan Management Binder filings containing the CCIIO data templates will be due after they are released, likely at the end of May.
However, we encourage Applicants to submit filings as early as possible, which will facilitate DFS and DOH review.
Posted 3/6/2013
Q. Given that the federal government updated the Actuarial Value (AV) Calculator last week, will the State be revising the standard benefits included in the Application? If so, when will plans receive updated guidance?
A. The Department of Financial Services is in the process of reviewing the standard benefits based on the revised AV Calculator. Updated guidance, if needed, will be available during the week of March 11th.
Posted 3/6/2013
Q: Given that final regulations were promulgated by CCIIO last week, will the DOH be extending the deadline for submission of questions?
A: Yes, the DOH will be extending the deadline for submission of questions from March 1, 2013 to March 29, 2013.
Posted 3/6/2013
Q: Section II.G.1.d of the Invitation references the Participation Form Submission Due Date. Is Attachment E - Participation Proposal of the Invitation the Participation Form that is due on April 5th?
A: Yes, Attachment E - Participation Proposal is the Participation Form that is due on April 5, 2013.
QHP and Dental Plan Proposal Submission:
Posted 5/7/2013
Q: Must all stand-alone dental QHPs offered within the Health Benefit Exchange include coverage of the pediatric essential health benefit?
A: Yes. According to 45 CFR 155.1065(a)(2), stand-alone dental plans certified to be offered within the Health Benefit Exchange must cover at least the pediatric dental essential health benefit. Accordingly, the Invitation is amended to require the following for stand-alone dental plans:
- One standard pediatric dental plan that includes only pediatric dental benefits; the standard pediatric dental plan must include the pediatric dental benefits set forth in Attachment A, Essential Health Benefits, and may include additional benefits. The standard pediatric dental plan may be offered at either 85% actuarial value or 70% actuarial value, but not both.
- Up to 2 additional non-standard dental plans in each county of the service area; the non-standard dental plans can consist of either another pediatric dental plan at a different AV level and/or another dental product that includes the required pediatric dental benefits. Such non-standard products can be offered at various rating tiers (ie, individual, couple, parent/child(ren), couple/child(ren)) and can include adult benefits. The non-standard products must include the pediatric dental benefits set forth in Attachment A, Essential Health Benefits.
Given the above change, stand alone dental carriers may resubmit their Participation Proposals only to conform to the above guidance and will have until May 15, 2013 to make such modifications. If a modification is needed to the Participation Proposal, submit the entire revised Participation Proposal and Addendums 4 and 5 to . Please be sure the Addendums are sent in Excel.
Posted 5/7/2013
Q. The most recent amendment to the Notice of Benefit and Payment Parameters provides an exception for State Based exchanges regarding requiring issuers to develop plan variations for all QHPs offered on the Exchange (regardless of metal level) for applicants that are American Indians (AI) or Alaska Natives (AN). Will New York require Health Insurer Applicants to offer zero cost share products for eligible AI/AN customers at each metal level?
A. Yes, all Health Insurer Applicants must offer a zero cost share product for eligible AI/ANs at each metal level.
Posted 5/7/2013
Q. Are we correct in assuming that we can add out-of-network benefits to the Standard Plans, and those plans will still be considered “Standard”?
A. Yes, out-of-network benefits may be a component of Standard Plans.
Posted 5/7/2013
Q. Are we understanding correctly that if benefits (such as adult dental) are added to the standard plans, the plan would then be considered “non-standard”, even if the cost sharing for all identified, covered benefits remains the same, or would that be classified as a “standard” plan? Does the answer change depending upon whether or not the added benefit is part of an EHB category?
A. Per Section II.D.1.c of the Invitation, the standard product offered by Health Insurer Applicants must include the same benefits and visit limits as delineated in Attachment A and the same cost-sharing limitations delineated in Attachment B. This requirement applies to the Individual Exchange and the SHOP Exchange. Therefore, adding benefits to the Essential Health Benefits would create a Non-Standard product. Applicants can choose to offer benefits such as the adult dental benefit in non-standard plans.
Posted 5/7/2013
Q. Attachment B of the Participation Proposal has a line item for Pediatric Dental Services and states: 50% cost sharing for Bronze, 0% cost sharing for catastrophic and 0% cost sharing on sharing variation less than or equal to 300% FPL. Can you please clarify how we are supposed to interpret this with regards to Stand-alone dental plans?
A. The most recent version of Attachment B states: “Note: The pediatric dental cost sharing indicated is when pediatric dental is included as part of the standard design medical QHP plan. A stand-alone pediatric dental planwill have its own deductible and cost sharing arrangements and associated premium.”
Revised – Posted 4/3/2013
Q. Which specific federal templates will be required to be submitted with the proposal in April?
What specific Riders are Applicants required to file with Exchange products for Individual and SHOP products, Standard and Non-Standard products, and Catastrophic and Child only products?
A. The following plan management templates will be required upon the April 30th Submission:
- Administrative Template
- Plan/Benefit Template
- Prescription Drug Template
- Network Template
- Service Area Template
- Rate Data Templates
- Uniform Rate Review Template
- Business Rules Template
These templates can be found on the SERFF website:
These templates must be submitted in the QHP filing in SERFF. DFS is in the process of finalizing instructions on how to complete the templates, and the instructions will be posted to this DFS website:
Posted 4/1/2013
Q: Will the new regulations regarding guarantee issue have an impact on the Minimum Participation requirement set forth in Section II.D.4.c of the Invitation?
A: Yes. By way of this answer we are amending the Invitation to remove Section 11.D.4.c. Minimum Participation is no longer required.
Posted 4/1/2013
Q. NYS has stated that Applicants will submit their Network through the HPN process. Does that mean that Applicants do not need to fill out the Federal Network template? The Plan Data template has a dependency on the Network template (per import) so it will need to be filled out from that perspective. Additionally there is a required field for a network URL. What is that URL? Where do Applicants get it?
A. Applicants will be required to submit their network through the HPN process. However, the Plan Benefits Template submitted through SERFF is dependent on the Network and Service Area templates being completed, and therefore Applicants must submit all the required templates including the Network Template submitted through SERFF. The URL in the Network Template only requires a link to the Applicant’s provider directory that the Exchange may use on the Exchange web site.
Posted 4/1/2013
Q. Section III.C.6.a of the Invitation indicates that the factor for Single + Child(ren) is 1.70 and the factor for Single + Spouse + Child(ren) is 2.85. Is there the potential for viewing this as charging more for children if they are attached to a couple versus a single parent?
A. The single + children rate is for coverage of one parent with one or more children. This factor includes an assumed number of children per family where only one parent is covered. The single +spouse + children rate is for coverage of two parents with one or more children. This factor includes an assumed number of children per family. Based upon a review of premium rate filings, it is appropriate to assume a higher number of children will be covered when spousal coverage is issued. For a family with husband and wife and 3 children, where the husband covers the 3 children and the wife is covered by her own group plan, the rate for the husband would be single + child(ren).
Posted 4/1/2013
Q. Do Attachment E and addendums 1 and 3 need to include details on the 3 CSR plans and the Native American Plans?
A. No. The cost-share reduction plans and the Native American plans are variations of products that will be filed, and Health Insurer Applicants do not need to include this information on Attachment E and Addendums 1 and 3.
Posted 4/1/2013
Q. Does an Exchange Broker compensation schedule have to be filed with the rates and forms?
A. Yes. A broker compensation schedule must be filed with premium rates consistent with all policies.
Posted 4/1/2013
Q. Can Applicants offer products with rates that differentiate whether a broker is involved in the sale of the product or not? For example, for each unique metal level plan sold, can an Applicant file two sets of premium rates; one with the broker compensation built in to the rates for groups that use brokers and a lower rate that doesn't include a broker load for groups that don't use a broker? Can the Applicant create unique products that are marketed through brokers vs. those that aren't with the broker compensation only included in those products available to be sold through abroker?
A. At this time, state laws and regulations do not permit differentiation of premium based upon whether a broker is used or not.
Posted 4/1/2013
Q. With reference to Section III.C.6.b of the Invitation, the language for child-only policies says, “Separate policy forms must be created and provided to enrollees of child-only products.” What is the separate policy form being cited? Wouldn’t the policy form be the same form as the Standard Product policy form for the Individual Exchange on each metal level? Is this referring to the separate rate filing form?
A. Model contract language and filing instructions are currently being drafted which will address this question. These types of policies will have a distinct filing number and form number. The benefits of the Child Only policies will be the same as the standard products for the Individual Exchange. However, the eligibility and termination sections of the policy forms will differ.
Posted 4/1/2013
Q. In the list of requested URLs in the Participation Proposal, please describe what DOH is referring to for both “Product Descriptions (if applicable)” and for “Summary(ies) of Benefits.” We are interpreting these as marketing descriptions/materials and SBCs respectively. Is this correct?
A. The URL linking to a product description would be a link to a webpage with information about the product that might include information such as an overview of covered services and cost sharing, premium information, provider network information, and more. It could also be a link to an online marketing brochure. The URL for the Summary of Benefits would be a link to the Summary of Benefits and Coverage required by the ACA.
Posted 4/1/2013
Q. Given the lengthy timeline for trademark review required for product naming (which will not be complete for many plans by the 4/15 filing deadline), will Applicants be allowed to submit “placeholder” names for Exchange products, and then update those names prior to the Exchange going live for enrollment?
A. Final product names may be provided to the DOH after the April filing deadlines and prior to September when testing of information on the Exchange portal will commence.
Posted 4/1/2013
Q. Is a wholly owned subsidiary company, such as a pharmacy benefits administrator, considered a separate service entity for purposes of Section 2 of Attachment E?
A. Yes, a subsidiary company should be considered a separate entity.
Posted 4/1/2013
Q. Should the actuarial value (“AV”) associated with a particular plan always be based on a single policy and not a family policy?
A. The AV Calculator standard population and claims data were developed using claims data that did not include any family cost-sharing information. Applicants offering plans with deductibles and/or out of pocket maximum costs that accumulate at the family rather than the individual level have several options depending on the specifics of the family plan. In the case of a plan with a deductible and/or out-of-pocket maximum that accumulates first at the individual level and in addition at the family level, the plan enters the individual deductible and out-of-pocket maximum into the AV Calculator to determine AV. If deductible and out-of-pocket maximum accrues only at the family level and not at the individual level, the issuer may either include the family deductible and out-of-pocket maximum into that actuarial value calculator or, if the issuer believes that the family plan cost-sharing features of the plan’s cost-sharing features will make a material difference in the AV produced by the calculator, the issuer may use one of the §156.135(b) exceptions described above to calculate AV and include plan-specific data on how the family-specific cost sharing is adjusted.