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COHBE Qualified Plan Certification 1. SB-200 Requirements CRS 10-22-104 The exchange shall not duplicate or replace the duties of the commissioner established.

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Presentation on theme: "COHBE Qualified Plan Certification 1. SB-200 Requirements CRS 10-22-104 The exchange shall not duplicate or replace the duties of the commissioner established."— Presentation transcript:

1 COHBE Qualified Plan Certification 1

2 SB-200 Requirements CRS The exchange shall not duplicate or replace the duties of the commissioner established in section , including rate approval, except as directed by the federal act. The exchange shall foster a competitive marketplace for insurance and shall not solicit bids or engage in the active purchasing of insurance. CRS (1) – (i) Consider the unique needs of rural Coloradans as they pertain to access, affordability, and choice in purchasing health insurance; – (j) Consider the affordability and cost in the context of quality care and increased access to purchasing health insurance; and – (k) Investigate requirements, develop options, and determine waivers, if appropriate, to ensure that the best interests of Coloradans are protected. 2

3 Marketplace Rules 3

4 Plan Management Certification, recertification, decertification – Regulatory requirements – Accreditation standards Business Relationship – Data exchange standards – Customer service standards Exchange will develop objective plan management standards and communicate those standards to carriers before certification. 4

5 Exchange Partners Exchange will work with Division of Insurance, Department of Public Health and Environment, and Department of Health Care Policy and Financing to minimize QHP burdens 5

6 Certification Requirement Activities AccreditationLicensure Requirements Complaint DataMarketing Requirements Claim Payment DisclosuresMLR requirements Discriminatory Benefit Design ReviewNetwork Adequacy Essential Benefit ValidationOut-of-Network Disclosure Requirements Essential Community Health ProvidersQHP Quality Measures Financial DisclosuresProvider Directory Formulary RequirementsSolvency Requirement 6 AccreditationMarketing Requirements Complaint DataMLR requirements Claim Payment DisclosuresNetwork Adequacy Discriminatory Benefit Design ReviewOut-of-Network Disclosure Requirements Essential Benefit ValidationPlan Differentiation Essential Community Health ProvidersProvider Directory Financial DisclosuresQHP Quality Measures Formulary RequirementsRate Review Licensure RequirementsSolvency Requirement

7 State, Federal, or UX Guidance Accreditation (Fed)MLR Requirements (Fed) Complaint Data (State)Network Adequacy (State) Claim Payment Disclosures (State)Out-of-Network Disclosure Requirements (State) Financial Disclosures (State)Provider Directory (UX) Formulary Requirements (UX)Rate Review (State) Licensure Requirements (State)Solvency Requirement (State) 7

8 New Processes Some Existing Processes Essential Community ProvidersQHP Quality Measures Marketing Requirements Completely New Processes Discriminatory Benefit DesignEssential Benefit Validation Plan Differentiation 8

9 Decertification The Exchange will only decertify an issuer during the year if the issuer is not able to meet responsibilities (loses licensure, insolvency, or inadequate network, etc.) – The Exchange will work to move members to a new QHP in an efficient manner An issuer who fails to meet necessary business partnership levels will not be recertified but members will continue to be enrolled in the QHP 9

10 Recertification The Exchange will develop an annual recertification process The recertification will allow the Exchange board to change the baseline certification processes in future years 10


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