Payer Guidelines for a Qualiﬁed - Nalashaa Health · Thejesh Kumar C. is a Solutions Consultant with 13 years of experience in US Healthcare across diﬀerent functional areas

Payer Guidelines

for a Qualified Health Plan

Payer Guidelines

for a Qualified Health Plan

Thejesh Kumar C. is a Solutions Consultant with 13 years of experience in US Healthcare across different functional areas. Apart from being a certified RCM, AHM, PAHM, CMS and AHIP professional, he also has vast experience in Claim benefit management, ANSI X12 transactions, HL7, Medicare & Medicaid solutions, Enrolment and other key areas.

Thejesh Kumar C

What is QHP?QHPs offer the same core set of benefits, including preventive services, mental health and substance abuse services, emergen-cy services, prescription drugs and hospitalization. Some plans include benefits beyond the core set.

QHPs are categorized and labeled by a standard coverage level to help consumers compare plans. The four standard coverage levels which are also known as metallic tiers are:

Platinum: the plan must cover 90% of expected costs for the average individual

Gold: the plan must cover 80% of expected costs for the average individual

Silver: the plan must cover 70% of expected costs for the average individual

Bronze: the plan must cover 60% of expected costs for the average individual

There are also catastrophic plans. Catastrophic plans have high deductibles and offer less coverage than the metal level plans. Premium tax credits could not be used with these plans. Consumers must be under 30 or meet other criteria to be eligible to purchase a catastrophic plan.

As defined in the Afford-able Care Act (ACA), a QHP is an insurance plan certi-fied by the Health Insur-ance Marketplace. It pro-vides Essential Health Benefits (EHBs), follows established limits on cost sharing, and meets other requirements outlined in the application process.

Monthly Cost

Cost whenyou get Care

Good option if you...

Platinum Gold Silver Bronze

$$$$ $$$ $$ $

$ $$ $$$ $$$$

Plan to use alot of medical care services

Want to save on the monthly premi-um, while keeping your out-of-pocket costs low

Need to balance your monthly cost with your out-of-pocket costs

Don,t plan on needing a lot of medical care services

Source: https://www.peoplekeep.com/blog/faq-what-is-a-quali-fied-health-plan-qhp

1 Copyright © 2018 Nalashaa

SHOP and the effect of Payer QHP on SHOPSmall Business Health Option Program (SHOP) is a health insurance exchange place that assists people to buy health insurance plans. SHOP QHPs would not be required to follow guidance from previous years if the 2019 payment notice proposed rule is finalized. Depending on the outcome of the proposed rule, the CMS would offer guidance as required.

The CMS has stated that issuers applying for certification of plans as QHPs, offered through federally facilitated SHOPs, should review the 2019 payment notice proposed rule and the final rule when it is promulgated.

What Makes a Plan a Quali-fied Health Plan?For a plan to be availed on the marketplace it must be certified as a Qualified Health Plan, for which it must meet certain requirements including:

Providing at least ten essential benefits, such as preventive services, drugs, lab services, pediatric services etc.

Follows established limits on cost sharing (like deductibles, copayments, and out-of-pocket maximum amounts and provide minimum actuarial value).

Meets all other minimum standards outlined by the Affordable Care Act.

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Guidelines for QHP: Mandatory Health BenefitsA qualified health plan must offer a certain number of mandatory benefits, as explained in the graphic below. Since Obamacare has been in place, most people had to have a qualified health plan with minimum essential benefits, or else face a fine.

What Should youWhat Should you

KNOWKNOW MajorMedical Plans

QualifiedHealthPlans

CatastrophicPlans

Gap(short-Term)Plans

Usualy within 45 days




about these different types of products?

When can coverage start?

Will I be subject to a taxpenalty in 2019?

Can I buy it on a state exchange?

Can may application bedeclined for pre-existing conditions?

Typically

01

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04


The Patient Protection and Affordable Care Act (PPACA) and applicable regulations assert that health plans, including SADPs, must meet a number of standards in order to be certified as a QHP. Several of these are market-wide standards that apply to plans offered in the individual and small group markets both inside and outside of the exchanges. The remaining standards are specific to health plans seeking QHP certification from the exchanges.

This process applies to:

States performing plan management functions and making QHP certification recommendations to the CMS

States where the CMS is performing all the plan management functions and certifying QHPs while the state is enforcing the market-wide standards under the PPACA

Direct enforcement states where the CMS is performing plan management functions and enforcing market-wide standards under the PPACA.

All payers submitting QHPs have to obtain Health Insur-ance Oversight System (HIOS) product and plan IDs for their plans, to enable administrators to efficiently catalog a payer’s QHP.

Issuers may have their QHP application denied if they fail to meet the deadlines mentioned below:

QHP certification Guidelines for Payers

Certification process

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Initial QHP application submis-sion window

5/9/18 - 6/20/18

Initial QHP application deadline6/20/18

Initial deadline for QHP applica-tion Rates Table Template

7/25/18

CMS reviews initial QHP applica-tions as of 6/20/18

6/21/18 - 8/3/18

CMS releases first correction notice

8/8/18 - 8/9/18

Service area petition deadline8/13/18

Final deadline for issuers to change QHP application8/22/18

CMS reviews final QHP applica-tions as of 8/22/18

8/23/18-9/10/18

CMS posts QHP agreements and plan lists9/17/18

CMS sends final correction notice to issuers9/17/18

Limited data correction window9/20/18-9/21/18

State sends CMS final plan recommendations

9/25/18

Issuers send signed agreements, confirmed plan lists, and final plan crosswalks to CMS

9/17/18-9/25/18

CMS sends certification notice to issuers

10/4/18-10/5/18

Open enrollment begins11/1/18


QHP AccreditationSeveral QHP accreditation measures remain unchanged from previous years, such as a plan’s licensure, network adequacy, quality reporting, prescription drug benefits, and discriminatory bene-fit reviews. The CMS will also continue to perform data integrity reviews of certain plan data relating to the plan display on HealthCare.gov, such as annual re-enrollment.

If an issuer is entering its initial year of QHP certifi-cation, it must schedule (or plan to schedule) a review with a recognized accrediting entity (i.e., AAAHC, NCQA, or URAC). An issuer is not required to be accredited in its initial years of QHP certifica-tion.

Any information provided on accredited products must be, for the same legal entity, in the same state of QHP application submission.

If an issuer is entering into a QHP participation, it must be accredited in the Marketplace market and with one of the following status:

AAAHC: Accredited NCQA: Excellent, Commendable, Accredited, or Provisional URAC: Full or Conditional

If an issuer is accredited by AAAHC, it must e-mail its accreditation data to the CMS

Business RulesAll issuers must provide a series of questions and answers that define the business rules used to calculate rates and determine consumer eligibility for a plan. This information, in conjunction with a plan’s rates, is used in the calculation of the premiums for each enrollment group.

All issuers are required to provide the following data on their health plans:

Plan identifiers

Plan attributes

URLs

Covered benefits and their limits

Cost-sharing information

Prescription drugs

Issuers cannot use or implement any benefit designs that have the effect of discriminating against individuals on the basis of age, expected length of life, present or predicted disability, quality of life, or other health conditions. The CMS uses the data collected in this portion of the QHP application to review compliance for non-discrimination standards.

Plans and Benefits


Essential Community Providers/Net-work Adequacy

In the ECP/Network Adequacy section, issuers will need to demonstrate that they meet the requirements of having a network of contracted in-network providers to provide reason-able access to all the covered services and a sufficient number and geographic distribution of ECPs, as well as collect provider data in each network associated with a QHP.

The health carrier’s network, including how the use of telemedicine or telehealth or other technology may be used to meet the network access standards, if applicable.

The health carrier’s procedures for making and authoriz-ing referrals within and outside its network, if applicable.

The health carrier’s process for monitoring and assuring the sufficiency of the network on an ongoing basis to meet the health care needs of populations that enroll in network plans

The factors used by the health carrier to build its provider network, including a description of the network and criteria used to select [and/or tier] providers.

The health carrier’s proposed plan for providing continui-ty of care in the event of contract termination between the health carrier and any of its participating providers.

The health carrier’s system for ensuring the coordination and continuity of care.

2019 Payment Notice Proposed Rule

Health insurance companies operating through the exchanges have found themselves serving a more expensive consumer base than the Obama administration initially predicted. Insurers are taking on more health care costs than in prior years while receiving fewer premiums from healthier populations.

The proposed payment rule sets forth payment parameters and provisions related to the risk adjustment and risk adjustment data validation programs, cost-sharing parameters and cost sharing reductions and user fees for Federally-facilitated Exchanges and State-based Exchanges on the federal platform. It proposes changes that would enhance the role of

states as related to essential health benefits (EHB) and quali-fied health plan (QHP) certification. It would provide states with additional flexibility in the operation and establishment of Exchanges, comprising the Small Business Health Options Program (SHOP) Exchanges. It includes proposed changes to standards related to Exchanges, the required functions of SHOPs, actuarial value for stand-alone dental plans, the rate review program, the medical loss ratio program, eligibility and enrollment, exemptions, and other relat

State Licensure

In the State Licensure section, issuers must indicate their licensure status and provide documentation that shows they satisfy licensure requirements for the applicable QHP markets, service areas, and products.

Issuers must provide licensure documentation for all the products and service areas in which it intends to offer a QHP. This requirement applies to all the licensed issuers, including any affiliated or other issuers underwriting the dental benefits that the QHP proposes to offer.

Issuers must submit one form of licensure documenta-tion (state license, COA, certificate of compliance, or the equivalent).

If the issuer is not yet licensed and therefore unable to provide licensure documentation during the initial appli-cation submission, the issuer must submit evidence of licensure during the QHP application resubmission window.


Issuers should submit their templates and supporting documentation and justifications for all plans to be certi-fied as part of their QHP Application which will be reviewied to check for compliance with market-wide standards and other regulations.

Quality Improvement

All issuers offering QHPs through the Marketplaces that meet the Quality Improvement Strategy (QIS) participation criteria must comply with the QIS requirements as a condition of certification and participation in the Marketplaces.

Quality Rating

The Quality Rating System (QRS) rates QHPs based on the relative quality and price, and requires the display of QHP quality ratings on Marketplace websites to assist in consumer selection of plans. QHP issuers are required to submit quality rating information as a condition of certification and participa-tion in the Federally Facilitated Marketplace (FFM).

The CMS will calculate the quality performance ratings for QHPs offered through all the Marketplaces, regardless of the Marketplace model. The CMS will apply the QRS rating meth-odology to the validated QRS clinical measure data and a subset of the QHP Enrollee Survey validated response data (QRS survey measures) to produce quality ratings on a 5-star rating scale.

Rates

Issuers must enter the rates for each subscriber type offered within the parameters of the premium rate they charge for each type of enrollee. These rates are based on the variables such as rate effective date, rate expiration date, age, rating area ID etc. These rates, in conjunction with the data from the Business Rules Template, are used to calculate premiums for each enrollment group.

Service Area

Issuers must identify the proposed service areas that will be associated with their QHPs, by state and by county. In most cases, the HHS will only approve service areas covering full counties. In instances where the issuer proposes a service area that will cover only a part of a county, the service area must also indicate associated zip codes. All issuers are required to submit service area information as part of their QHP application.


CMS provides issuers with a number of review tools to check their plans for errors in the QHP application that would result in correction notices following submission. Issuers should run each of the below tools, as applicable to their issuer type (e.g. SADP/QHP) before uploading materials to HIOS or SERFF to identify and rectify data errors. Given the limited review cycle, it is critical that issuers use the tools to ensure that all the data submitted is error-free, so that their plans will be reviewed for certifi-cation on time. Below is the descrtption of a few tool’s functionalities.

Review Tools

Data Integrity Tool

It identifies critical data errors within and across templates as well as provides immediate feedback about data, reducing issuer resubmissions. The tool also alerts issuers and state reviewers on irregularities in the template submissions. It imports QHP and SADP data from application templates and conducts validation checks beyond the standard HIOS and SERFF checks. By looking across templates for consistency in key fields, it produces error reports that describe the error and its location in the template.

P l a n ID Crosswalk Tool

It checks that the Plan ID Crosswalk Template has been completed accurate-ly, by ensuring that the counties in the FFM plans offered in 2017 are included in the crosswalk. It also ensures that the crosswalk reasons selected are consis-tent with plan offerings, and the cross-walk is compliant with the regulation.

Master Review Tool

Aggregates data from the plans & benefits, service area, and ECP/network adequacy, and prescription drug templates and serves as a data input file to other stand-alone tools.

Cost Sharing Tool

Runs five different checks (when they are applicable to the plan) for cost sharing standards. This includes Maximum Out-of-Pocket (MOOP) Review, Cost Sharing Reduction (CSR) Plan Variation Review, Simple Choice Plan Design Review, Expanded Bronze, and Catastrophic Plan Review.


Issuers must submit petitions for all the service area changes made after the initial submission deadline, and the final submission deadline. Issuers must submit a signed data change request form, justification for the change, and evidence of the state or the CMS approving the form filing.

Data Change Requests

Issuers are encouraged to use the QHP application checklist prior to submitting their application. The checklist is organized by HIOS module, and is inclusive of all the templates and supporting documentation that QHP and SADP issuers must complete and upload prior to application submission.

Submission Checklist

Application SubmissionHealth Insurance Oversight System (HIOS) - Issuers in FFM states should submit QHP appli-cation data to HIOS. Note that some states may also require data to be submitted to SERFF.

System for Electronic Rate and Form Filing (SERFF) - Issuers in the states performing plan management functions or State-based Marketplaces on the Federal Platform (SBM-FP) should submit QHP application data to SERFF.

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State’s submission break up for individual market & SHOP market

Individual &SHOP Market

Number of States

HIOS SERFF State system + HIOS State system + SERFF

17 28 1 5

Qualified Health Plan Issuers Stand-alone Dental plan Issuers

HIOS QHP Issuer ModuleComplete Program Attestations

Upload Compliance Plan

Upload Organizational Chart

Complete State Licensure Questions

Upload State License, COA, or Certificate of Compliance

Complete Good Standing Questions

Upload Good Standing Documentation

Upload Accreditation Template

Upload Accreditation Certificate

Upload Network Adequacy/ ECP Template

Complete Network Adequacy Attestation

Complete ECP Attestation

Upload ECP Supplemental Response Form

Upload ECP Write-in Worksheet

HIOS QHP Rating ModuleUpload Rates Table Template

Upload Business Rules Template

HIOS Unified Rate Review SystemUpload Unified Rate Review Template

HIOS QHP Benefits and Service Area ModuleUpload Plans and Benefits Template

Upload Network ID Template

Upload Service Area Template

Upload Prescription Drug Template

Upload Unique Plan Design Supporting Documentation

Upload Screenshot of Stand-alone AVC

Upload EHB-Substituted Benefit Supporting Documentation

Upload State Partnership Marketplace Issuer Program Attestation

Responses (required for SPM issuers only)

Upload Formulary Supporting Documentation

Upload Partial County Justification

HIOS Plan Finder ModuleComplete Marketplace General Information Administrative Data

Email to [email protected] ID Crosswalk Template

Plan ID Crosswalk State Approval Form

HIOS QHP Issuer ModuleComplete Program Attestations

Upload Compliance Plan

Upload Organizational Chart

Complete State Licensure Questions

Upload State License, COA, or Certificate of Compliance

Complete Good Standing Questions

Upload Good Standing Documentation

Upload Network Adequacy/ ECP Template

Complete Network Adequacy Attestation

Complete ECP Attestation

Upload ECP Supplemental Response Form

Upload ECP Write-in Worksheet

HIOS QHP Rating ModuleUpload Rates Table Template

Upload Business Rules Template

HIOS Unified Rate Review SystemUpload Unified Rate Review Template

HIOS QHP Benefits and Service Area ModuleUpload Plans and Benefits Template

Upload Network ID Template

Upload Service Area Template

Upload Unique Plan Design Supporting Documentation

Upload EHB-Substituted Benefit Supporting Documentation

Upload State Partnership Marketplace Issuer Program Attestation Responses

(required for SPM issuers only)

SADP AV Supporting Documentation

SADP Description of EHB Allocation

Upload Partial County Justification

HIOS Plan Finder ModuleComplete Marketplace General Information Administrative Data

Email to [email protected] ID Crosswalk Template

Plan ID Crosswalk State Approval Form


Member Guidelines - QHP Exemptions How can we identify an exchange member?

Member ID cards will have “QHP” on them. However, some members with QHP on their cards may have bought their individual plans off-exchange.

Are the precertification, authorization and referral processes the same for exchange plans?

Yes, the processes are the same.

Are the payer ID and claim address the same for exchange plans?

Yes, the payer ID and claim address are the same.

Will online eligibility and benefits verification system tell providers if the patient is on a state exchange plan?

You will verify benefits or eligibility in the same way, regardless of from where the member bought the plan.

Do Physicians have to refer patients to other providers within an exchange?

A QHP typically offers unique networks. The networks are often smaller than other plans. Physicians should make sure the provider they are recommending is within the patient’s plan network. Remember, members pay more for out-of-network services. Some members have no out-of-net-work coverage except for emergencies.

If an exchange member with a subsidy stops paying the premium, how will health care professionals be reimbursed?

Individual members who have not paid their monthly premium are considered delinquent.

Healthcare professionals will be paid for services received during the first 30 days of delinquency.

The carrier is allowed to pend claims for services provided during the second and third months of the grace period.

If full payment is not received by the end of the third month, the member's coverage will be terminated. This action is retroactive to the end of the first month of the grace period. If coverage is terminat-ed, the payer will not pay any pended claims for months two or three.

Is Medicaid a Qualified Health Plan?

No, individuals who are eligible for Medicaid are not eligible for a premi-um tax credit or cost-sharing reduction. However, Members can buy a qualified health plan at full cost (through participating insurance compa-ny).

List of specific cases

Uninsured for less than 3 consecutive months of the year

Your lowest-priced coverage option is more than 8% of your household income

You don’t have to file a tax return because your income is under the IRS filing requirement ($10,000 if single, 20,000 for couples filing jointly)

Member of a federally recognized tribe or eligible for services through an Indian Health Services provider

Member of a recognized health care sharing ministry

Member of a recognized religious sect with religious objections to insurance, including social security and Medicare

You’re incarcerated, and not awaiting administering of charges against you

Not lawfully present in the United States

You may qualify for the Cancellation Hardship Exemption if you have received a cancellation notice due to your health plan not meeting minimum requirements

You may also qualify for a hardship exemption if your circumstances affect-ed your ability to purchase health cover-age


ConclusionThe process of certification of a QHP plan will have a huge impact on payer business. The processes involved like monitoring the quality and defining quality metrics, defining rates, designing plans, SHOPs and Exchange need a comprehensive strategy of solution. Business process, policy, and system change impacts need to be identified, assessed, planned, and ana-lyzed before going live. Nalashaa has great exposure in Health Insurance Exchange and creating benefits for health plans, which will help assist in smooth delivery of QHP related services.

If you would like to bounce off your thoughts on this, let’s have a conversation.

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Payer Guidelines for a Qualiﬁed - Nalashaa Health · Thejesh Kumar C. is a Solutions Consultant with 13 years of experience in US Healthcare across diﬀerent functional areas