Presentation on theme: "Plan Management Update April 30, 2014 1. 2 Qualified Health Plan Requirements in 2015 Access Health CT (AHCT) released a Qualified Health Plan (QHP) Issuer."— Presentation transcript:
Plan Management Update April 30, 2014 1
2 Qualified Health Plan Requirements in 2015 Access Health CT (AHCT) released a Qualified Health Plan (QHP) Issuer Solicitation (2015 Solicitation) on March 17, 2014 – New Issuers or Issuers that wish to extend their participation to a new market (Individual or Small Group) were required to submit a Non- Binding Notice of Intent (NOI) – QHP Issuers that are currently participating in the AHCT Marketplace received a 2 year Issuer certification – QHP certification is performed on an annual basis, therefore, currently participating Issuers plans will have to meet pertinent 2015 certification requirements in order to be certified as QHPs
3 Change in the Requirements Some changes in QHP certification requirements were substantial, including: Network Adequacy Plan Options Prescription Drug Formulary Pediatric Dental Benefits
4 Network Adequacy Requirements AHCT proposes to change the substantially similar requirement requirement for Issuers provider networks for standard plans to a more comprehensive requirement in 2015. Issuers networks for all plans will need to adhere to AHCTs reasonable access standards which AHCT is currently developing and will propose to the Board at a later date. AHCT is not proposing to change the QHP Issuer contracting standards with Essential Community Providers for 2015 which the Board had previously approved.
5 Network Adequacy - continued 2014 Requirement: AHCT requires an Issuers provider network for standard plans to be substantially similar to the provider network available to the Issuers largest plan (representing a similar product) offered outside of the Marketplace. AHCT determines whether an Issuer meets the substantially similar requirement, by applying the following criteria:
6 Network Adequacy - continued Proposed 2015 Requirement: An Issuers provider network for the Standard Plan designs must include at least 85% of those unique providers and unique entities that are in the Issuers network for its largest plan (representing a similar product) that is marketed, sold and has active enrollees outside of the Marketplace (the benchmark plan.) – If an Issuer has an affiliated company that is active outside of the Marketplace, but in the State of Connecticut, AHCT will look to the larger of the Issuers network for its largest plan or the network of the Issuers affiliated companys largest plan (representing a similar product) that is marketed, sold and has active enrollees outside of the Marketplace, but in the State of Connecticut, as the benchmark plan.
7 Plan Options - QHPs AHCT proposes: Adding a Health Savings Account (HSA) compatible Standard Bronze Plan that Issuers must offer in 2015; and Expanding the previous limit on the number of non- standard Plans an Issuer may offer in the Marketplace from two (2014 limit) to three. – The proposal applies to both the Individual and Small Group markets
8 Plan Options – QHPs - continued 2014 Requirements: QHP Issuers must offer at least one Standard Gold Plan, one Standard Silver Plan, and one Standard Bronze Plan. QHP Issuers may offer: – One Standard Platinum Plan and up to two Non-Standard Platinum Plans – Two Gold Non-Standard Gold Plans – Two Silver Non-Standard Silver Plans – Two Bronze Non-Standard Plans If an Issuer decides to offer a non-standard Platinum plan, the Issuer must also offer the Standard Platinum Plan.
9 Plan Options – QHPs - continued Proposed 2015 Requirements: An Issuer must submit at least one Standard Gold Plan, one Standard Silver Plan, and two Standard Bronze Plans (one Standard Bronze Plan and one Standard HSA compatible Bronze Plan). QHP Issuers may offer a catastrophic coverage plan in the Individual market as well as any of the following options (in the Individual and Small Group markets) – One Standard Platinum Plan and up to two Non-Standard Platinum Plans – Up to three Non-Standard Gold Plans – Up to three Non-Standard Silver Plans with the corresponding cost- sharing reduction plans – Up to three Non-Standard Bronze Plans
10 Prescription Drug Formulary 2014 Requirement: QHP Issuers were required to meet the standards set forth in 45 C.F.R. 156.122 which provides that in order for a health plan to comply with the requirement to provide Essential Health Benefits (EHB), health plan must cover at least the greater of: – (i) One drug in every United States Pharmacopeia (USP) category and class or – (ii) The same number of prescription drugs in each category and class as the EHB-benchmark plan.
11 Prescription Drug Formulary - continued Proposed 2015 Requirement: An Issuer will be required to provide a prescription drug formulary in accord with the greater of either 45 C.F.R. 156.122 or equal in number and type to the formulary in the Issuers plan with the highest enrollment (representing a similar product) offered outside of the Marketplace.
12 Stand-Alone Dental Options Proposed 2015 Requirements: A Stand-Alone Dental Plan (SADP) Issuer will be required to offer a Standard High Option Plan A SADP Issuer may also offer up to three Non-Standard Plans (High and/or Low Option) AHCT was unable to develop a Standard Low Option Plan due to federal regulations reducing the annual limit on cost sharing – This difficulty was acknowledged by the Department of Human Health Services and confirmed by AHCTs actuarial consultant
13 Pediatric Dental Benefits 2014 Requirement: AHCTs Standard Plan designs embed pediatric dental benefits Proposed 2015 Requirement: To mandate inclusion of embedded pediatric dental benefits in AHCTs Standard Plan designs, and To recognize the QHP Issuers choice whether to embed or not embed the pediatric dental benefits in the Non- Standard Plans