filing guidance for plan year 2020 - washington state office ......2019/04/16 · rate filings...

Filing Guidance for Plan Year 2020 Division of Rates & Forms

Agenda

• Housekeeping• Important Information for PY2020• General Filing Instructions & Speed To Market documents• Rate Filings• Form Filings• Provider Network Submissions• SERFF Binder Filings• Next Steps• Questions?• Contact Information

April 16, 2019Filing Guidance for Plan Year 2020 2

Housekeeping

• The PowerPoint Deck will be posted on our website after the webinar. We will send out a link via GovDelivery.

• Remote attendees: please mute your phones!• How to ask questions:

• Remote: send questions through WebEx chat to Rocky Patterson

• In-person: raise hand – we will repeat your question for the remote audience

• If we do not answer your question today, send it to [email protected]


mailto:[email protected]

Important Information for Plan Year 2020Molly Nollette, Deputy Commissioner R&F


Important Dates for Plan Year 2020

May 23, 2019 is the filing deadline for PY2020:• Individual health plans• Small group health plans• Dental plans with the pediatric dental Essential

Health Benefit• Higher education student health plans for school

year 2019-2020

Please do not wait until the last minute to file.



For Exchange plans:September 5, 2019

• QHPs and QDPs approved by OIC by Sept 5th will be presented to Washington Health Benefit Exchange (WAHBE) Board for Certification as QHPs/QDPs

September 12, 2019:• WAHBE Board QHP/QDP Certification meeting

Please contact Christine Gibert at [email protected] for more information related to QHP/QDP Certification.




Open Enrollment for Plan Year 2020:• November 1, 2019

All PY2020 individual and small group rates must be in final status in HIOS by November 1, 2019.


Important Information for Plan Year 2020Qualified Health Plans & Qualified Dental Plans:• The WAHBE Board certifies both QHPs and QDPs for

PY2020, including QDPs offered off-Exchange.

Individual market QHPs must not include the pediatric dental essential health benefit. • The pediatric dental essential health benefit must be

offered in a stand-alone dental plan for QDP certification.

• A stand-alone QDP that offers the pediatric dental essential health benefit may be offered as a pediatric-only plan or as a family plan that includes adult dental benefits.


General Filing Instructions & Speed to Market documents


Molly Nollette

General Filing Instructions & Speed To Market documents

General Filing Instructions (GFIs) are required to be followed in order for OIC to accept a filing in SERFF.• Following GFIs does not mean that your filing will be

automatically approved.

Speed to Market documents (STMs) are tools, processes, and checklists. STMs are optional. Using STMs makes it easier for OIC to complete the review process, therefore speeding your filing to market.• Using an STM does not mean that your filing will be

automatically approved.


STM Checklists & Plan Year 2020We are all in this together.

• Please submit completed STM checklists with your PY2020 filings.• If you do not submit completed checklists with your PY2020 filings,

but you follow the GFIs, your filing will be accepted.• If you have included a completed checklist, we will begin review.• If you have not included a completed checklist, our first objection will

be to ask you for it.• We will work on filings with completed checklists first, and then turn to

filings without completed checklists as time permits.• Due to workload and deadlines, we must prioritize filings that can be

turned around quickly.

We value our partnership with you!


Rate FilingsLichiou Lee, Chief Actuary


Rate FilingsIndividual and Small Group Rate Filings• Per RCW 48.02.120(5) and 45 CFR §154.215, 154.225, 147.102, and

156.80, for all individual and small group health plan rate filings, carriers must submit HHS Unified Rate Review (URR) Rate Filing Justification Parts I, II, and III at the time of filing.

• Parts I, II, and III are not required for student health plan rate filings or dental only plans with the pediatric dental Essential Health Benefit.

• HHS has issued a new version of URR Template and Instructions for Plan Year 2020.

• All checklists are in STMs.


Family QDPs

For family dental plans marketed inside the Exchange, due to Exchange functionality restrictions, issuers must set one statewide rate per member per month (PMPM) for a child who qualifies to receive pediatric dental EHB, and one statewide rate PMPM for an adult.


Exchange User Fees for PY 2020

The Exchange plans to schedule a carrier meeting on the draft assessment the week of April 22, 2019, solicit feedback, and finalize the assessment by May 1, 2019.


Individual Health Plan STM Tools


• Rate GFIs: Washington State SERFF Health and Disability Rate Filing General Instructions

• Start here, points to appropriate STM guidance and tools.• STM Guidance: STM – Rates – Health – Individual and Small Group

document• Points to supporting STM Tools

• Supporting STM Tools:• Checklist - Rates - 2020 Individual Nongrandfathered Health Plans• Checklist - RF - 2020 Individual Medical Uniform Product Modification

JustificationUseful information in the UPMJ Instructions (first tab of this Excel file) related to product, plan, renewal product, renewal plan, and illustrative examples.• Certification - Rates - 2020 Ind Mental Health and Substance Use Disorder

Financial Reqs• Format - Rates - 2020 Individual Nongrandfathered Health Plan Rate

Schedule• Format - Rates - WAC 284-43-6660 Summary Duplicate

Small Group Health Plan STM Tools



• Start here, points to appropriate STM guidance and tools• STM Guidance: STM – Rates – Health – Individual and Small Group

document• Points to supporting STM Tools

• Supporting STM Tools:• Checklist - Rates - 2020 Small Group Nongrandfathered Health Plans• Checklist - RF - 2020 Small Group Medical Uniform Product Modification

JustificationUseful information in the UPMJ Instructions (first tab of this Excel file) related to product, plan, renewal product, renewal plan, and illustrative examples.• Certification - Rates - 2020 Sm Grp Market Mental Health and Substance

Use Disorder Financial Reqs• Format - Rates - 2020 Small Group Nongrandfathered Health Plan Rate

Schedule• Format - Rates - WAC 284-43-6660 Summary Duplicate

Stand Alone Pediatric Dental Plan STM Tools



• Start here, points to appropriate STM guidance and tools

• STM Guidance: STM - Rates - SAPD - Individual and Small Group

• Points to supporting STM Tools• Supporting STM Tools: Checklist - Rates - 2020

EHB Dental Rate Filing

Student Health Plan STM Tools


• Rate GFIs: Washington State SERFF Life and Disability Rate and Form Filing General Instructions

• Start here, points to appropriate STM guidance and tools

• STM Guidance: STM - Rates - Student Health Plans

• Points to supporting STM Tools• Supporting STM Tools: Checklist - Rates - 2019-

2020 School Year Higher Education Student Health Plan

Cost-Sharing Reductions (CSRs) • For issuers participating in the PY2020 Exchange individual market, the

direction for silver-loading to reflect federal government not funding the 2020 CSRs is the same as that of PY2019 rate filings.

• On April 5, 2019, the Centers for Medicare & Medicaid Services (CMS) released an FAQ on 2018 Benefit Year Cost-sharing Reduction (CSR) Reconciliation. The OIC expects all issuers who participated in the 2018 individual market to submit the 2018 CSR report to CMS by the due date set by CMS.

• How to report the 2018 CSRs in the 2020 rate filing URRT Worksheet 2 Experience Period?

• Unless issuers actually receive the payments related to the 2018 CSRs from federal government, the 2018 CSRs reported in the 2020 rate filing URRT Worksheet 2 Experience Period should be reported as zero.


Form FilingsAndrea Philhower, Manager Health Forms Compliance


Definitions of “Product” and “Plan”Product (same benefits and provider network type)

• discrete package of health coverage benefits

• use a particular provider network type (HMO, PPO, EPO, POS or indemnity)

• within a service area.

• Differences in the scope of benefits (such as limits on the frequency of treatment, number of visits, days of coverage, or other similar limits on the amount, scope or duration of treatment) mean different products.

• Differences in the amount of payment for a service owed by the consumer (differences in “cost-sharing structure”) do not mean different products.

• A product can be modified in some ways, yet remain the same product. (“Uniform Modification”: 45 CFR §146.152(f ), §147.106(e), or §148.122(g)).

Plan (same product, different cost-sharing structure, actual provider network, and/or service area)• The pairing of a set of benefits (product) and a particular cost-sharing structure, provider network, and

service area.

• The combination of all service areas of the plans offered within a product constitutes the service area of the product.


Definitions of “Product” and “Plan”

Resources on Product vs. Plan

• Pg. 1 of the Uniform Product Modification Justificationform

• CMS Qualified Health Plan (QHP) Series XII Slides, “Federal Definitions for Health Insurance Products and Plans” is available dated 02/07/2019

• Careful – the 2016 slides on CMS.gov are no longer correct

• Copy of slides available on RegTAP or upon request

• 45 CFR §144.103April 16, 2019Filing Guidance for Plan Year 2020 23

Structure of Form Filing ReviewsPreliminary Review

• “Products” and “Plans” correctly sorted and same number in rates, forms, and binder?

• Metal Level requirements met? • Electronic Review Tool Results submitted with Binder filing? • Redlines attached for any “Revised” forms?• Are the HIOS IDs correct?• Is there at least one renewal product to prevent market

withdrawal?Substantive Review

• Begins when Preliminary Objections are Resolved• Using applicable Analyst Checklist


Structure of Form Filing ReviewsReview of Plans in Groups

Priority: Student Health Plans, then Plans for Sale on the Exchange, then Outside plans

• Sometimes Individual and Small Group filings from the same carrier can be reviewed together;

depends on whether they’re similar enough

• A carrier’s On- and Off-Exchange filings in the same market will usually be reviewed together

You designate the “Primary Product” in each Market

• The most complex

We Review the Primary Product Beginning to End

• Objections on Primary Product

• Objections on other Products only re: Differences

When All Objections Resolved in Primary Product Filing, We Ask You to Conform All the Other

Product Filings

• Make all changes consistent with the changes made to the Primary Product filing


OIC Review TeamsEvery carrier’s Individual and Small Group filings are reviewed by a team of 4 reviewers

– Actuary, Forms Analyst, Network Analyst, and Binder Analyst (who is an Actuarial

Analyst).

• Internal emails and meetings about a carrier’s filings must include the entire team

SCRUM – weekly status meetings of entire Rates and Forms Healthcare team

• Each team member reports status of their review; full SCRUM can be followed by team

meetings as needed

“Binder meetings” – meetings of team reviewing a particular carrier’s filings (meetings

are sometimes split between markets as needed)

• First binder meeting is scheduled to occur when the first set of substantive rate and

forms objections has been sent and responses received

• After first binder meeting, objections synchronized so rate, form, and binder objections

(which include Network objections) all go out same dayApril 16, 2019Filing Guidance for Plan Year 2020 26

Timelines for Objection Responses• You may see shorter response times than you do for

filings without a deadline

• Forms:• Preliminary and First Substantive Objection Letters – 5

days• Second Objection Letter – 3 days• Subsequent Objection Letters – 2 days

• You may request an extension of the respond by date. We will grant reasonable extension requests. If we have a concern, we may communicate with you about whether we can get to done before the deadline.


New for 2020Required GFIs vs. Optional Speed to Market Tools and Processes• New structure, changes in wording – no new requirements

• Clearly identifies what is necessary to get your filing in the door and

what you can do to help your filing get reviewed as quickly as possible

• GFIs get your filing in the door

• No new GFIs

• STM tools and processes get your filing reviewed

• None of the STM tools or processes are new

• Based upon most common and time-consuming review difficulties, and most

common objections


New for 2020Required GFIs vs. Optional Speed to Market Tools and Processes

• GFIs for filing Student Health Plans are now located in the Life and Disability Rates and FormsGeneral Filing Instructions.

• STM Guide Includes Guidelines for Identifying Administrative vs. Non-Administrative Variability


New for 2020Required GFIs vs. Optional Speed to Market Tools and Processes

Tools: Checklists, Certifications, Preferred Format for “Statement of Variability”

Processes: Associating previously-approved forms, Correctly numbering Tables of Contents, Facilitating review with other filings (redlines and identifying “chassis”)


New for 2020STM Tools for Individual and Small Group FilingsChecklists for Forms:• Individual Forms Analyst Checklists (Disability Company, HCSC, HMO) – for

major medical plans• Small Group Forms Analyst Checklists (Disability Company, HCSC, HMO) –

for major medical plans• Individual Stand-Alone Dental with Pediatric EHB Forms Analyst Checklists

(Disability company, HCSC)• Small Group Stand-Alone Dental with Pediatric EHBs Forms Analyst

Checklists• All Filers Individual Embedded Pediatric Dental with EHBs Forms Analyst

Checklists• All Filers Small Group Embedded Pediatric Dental with EHBs Forms Analyst

Checklist• 2019-2020 School Year Higher Education Student Health Plan Forms

Analyst ChecklistApril 16, 2019Filing Guidance for Plan Year 2020 31

New for 2020

STM Processes for Individual and Small Group Filings

• Include a Snapshot document in your Binder• Identify a primary product for review• Use Section III of the STM Guide to ensure you include only

administrative variability• Include correct page numbers in the Table of Contents


#1 Thing You Can Do to Speed Up ReviewMAKE SURE YOUR RATE FILING, FORM FILING, NETWORK

FILINGS, and BINDER MATCH.

• Same number of products and plans• Same cost sharing amounts in binder and forms

• Including whether before and after deductible• Same network name(s) in network filings and forms• Same benefits and cost sharing in rates and forms

We strongly suggest that you do a matching review before submitting your filing to ensure that your forms, rates, networks,

and binder all contain the same information.

This is by far our most common objection, and most time-consuming!


#1 Thing You Can Do to Save Your Sanity

CALL US WHEN YOU HAVE A QUESTION.• Unclear about a filing instruction?• Question about an item on a checklist?• Confused by an objection?• Not sure what to do in response to an objection?• Question not addressed in the GFIs or other

resources?CALL US – Analysts are standing by busy but willing to

take your call

Your company has an assigned Analyst. To learn who your assigned Analyst is, look in your SERFF filing.


Provider Network SubmissionsJennifer Kreitler, Manager Network Access


Network Date TimelineNetwork Access Portal is open and ready for upload

• Network Access reports must be submitted by May 23rdOn the Form, Rate, and Binder approval date

• Network must demonstrate it will support services guaranteed in the health benefit plan

November 1, 2019• Notification to OIC is required the network may have an access gap on

January 1, 2020• Submit an Alternative Access Delivery Request for approval

December 31, 2019 through December 31, 2020• Is your Alternative Access Delivery Request still needed?• Is your Alternative Access Delivery Request approved?• Are you monitoring your network throughout the plan year?


Identify the Network Name

The Network Name must be clearly and consistently identified

• What must match?• Provider Agreement and Compensation Exhibits• Provider Directory• Health benefit plan documents• Provider Network Form A• Access Plan and Geonetwork reports• Binder - Network Template


New Network Questions?

Is it too late to develop a new network?• It depends.

We currently have 3 approved Networks and are planning on leveraging previously approved provider agreements to develop a 4th new network. Is this allowed?

• It depends.How do we generate geonetwork reports with zero enrollment?

• Rate filing• Justified number


PY2020 requirements• WAC 284-170-230(3) and (4) - Network maintenance and monitoring

standards for health benefit plans and stand-alone dental plan offered through the exchange or of a stand-alone dental plan offered outside the exchange for the purpose of providing the essential health benefit category of pediatric oral benefits.

• Know the reporting timelines!

• Example of maintenance and monitoring requirements• The baseline enrollment will start with the numbers used to generate the network

access reports• Projected enrollment = 20,000• February 1, 2020 enrollment = 40,000• Trigger in WAC is +\- 25% enrollment• February 1, 2020 enrollment = 50% enrollment change• Required notice to OIC that carrier has met trigger• 10 days to make determination whether an Alternative Access Delivery Request must

be filed for approval.


SERFF Binder FilingsRocky Patterson


Binder Filing Changes

We do not have the final CMS templates, tools, and instructions.

This information is based on what we have to date.


Information related to the CMS templates

• Templates and instructions• Located at

https://www.qhpcertification.cms.gov/s/Application%20Materials.

• Ensure you are using the current version of the templates.

• Draft instructions for PY2020 were just released yesterday by CMS. You should complete the templates according to the final instructions.

• Find webinars and walkthroughs on REGTAP (https://www.regtap.info/).


https://www.qhpcertification.cms.gov/s/Application%20Materials

https://www.regtap.info/

Binder Filing GFIs

GFI Name: Washington State SERFF Health and Disability Binder Filing General Instructions

• Found on our website and SERFF• Explains how to setup your binder filing and points to

helpful Speed to Market Tools (STMs)• We do not expect significant changes from last years

instructions


Binder Filing STMs

Document Name

Description

Exhibit A Identifies what CMS templates are required in each type of binder filing.

Exhibit B Instructions to explain how to correcting populate the EssentialHealth Benefit (EHB) information in the Plans and Benefits template (PBT).

Exhibit C Visual map of instructions in Exhibit B.• Shows PBT after EHBs are populated by add-in file.• Shows PBT after add-in file data is corrected based on the

instructions in Exhibit B.


Binder Filing STMs: Snapshot Template


WA Template used to summarize a carrier’s market portfolio.

• Describes all the products, plans, and lists all corresponding SERFF tracking numbers of the carriers market.

• Complete one snapshot for each market (Individual Medical, Small Group Medical, Individual SAPD, Small Group SAPD).

• This document is crucial, needed to tie your filings together

Unique Plan DesignUnique plan design?• Do the benefits and cost-sharing in the form filing fit into

the PBT without any transformations or translations?• Does the PBT allow you to accurately represent the benefits

and cost-sharing stated in the form filing?• Does the PBT and AV Calculator (AVC) calculate an accurate

actuarial value based on the entries in the PBT?• If you answer “No” to any of the above questions, you likely

have a unique plan design.• Unique plan designs require additionally documentation and

actuarial support. • If this is your first year offering unique plan designs or if you are

offering a new type of unique plan design (not offered in previous years), you should call us before you file to avoid unnecessary delays in the review process.


Unique Plan Design and STMs• Unique plan designs require additionally documentation

and actuarial support.• Rate filing requirements for unique plan designs are located in

the rate filing checklists referenced in the rate filing section.• Binder filings with unique plan designs require the carrier to

complete a Unique Plan Design Benefit Crosswalk when the benefits in the PBT are not consistent with the form filing.

• Common unique plan design:• More than 2 in-network benefit tiers.• More than 4 prescription drug tiers per in-network benefits tier.• Upfront visits that apply to benefit categories other than primary

care.• When a plan design includes a service that is not subject to

deductible, has no copay but does have coinsurance.


Electronic Review Tools

Don’t Forget there is a User Guide available to help you with these Tools

• 2020 version of the Drug Count Tool is final

• Several tool were released in draft yesterday. We will review them and update User Guide and Binder GFI when they are finalized


Electronic Review Tools

Data Integrity Tool (DIT)• Don’t forget to run the DIT on your templates.

• You must run the DIT, fix or explain any errors, and submit the results in your binder filing in SERFF.

• The PY2020 DIT works for both on and off exchange plans. All binder filings should include DIT results on the supporting docs tab.


Filing Consistency

Most objections are related to inconsistency in the form, rate, network, and binder filings!• Make sure the benefits in the form match the binder

filing.• Make sure the benefits in the rate filing match the

binder filing.• Make sure the network is consistent across all filings.• If there are changes in a filing during the review

process, make sure the changes are carried over to all the other filings!


Next Steps


Molly Nollette

Next Steps

May 23, 2019 is the filing deadline for py2020.• Please do not wait for the last minute to file.

We strongly encourage higher education student health plans be filed early. We would like to get the first round of objections out prior to May 23rd in order to get these products approved for use in summer for college students who need coverage for the 2019-2020 school year.


Next Steps

SERFF Binder General Filing Instructions will be published as soon as CMS releases all templates, tools, guides, and instructions.

New email address: [email protected]• Email sent to old email address will be received.




Questions?

Questions?

Molly NolletteDeputy Commissioner, Rates & Forms [email protected]

Connect with us!• Facebook: https://www.facebook.com/WSOIC• Twitter: https://twitter.com/WA_OIC• www.insurance.wa.gov



https://www.facebook.com/WSOIC

https://twitter.com/WA_OIC

http://www.insurance.wa.gov/

Additional Contact Information

Lichiou Lee, Chief [email protected]

Andrea Philhower, Health Forms Compliance [email protected]

Jennifer Kreitler, Network Access and Small Pharmacy Reimbursement Appeals [email protected]





Appendix: Resources

External Source Description AddressCMS Templates and Instructions https://www.qhpcertification.cms.gov/s/

Application%20MaterialsCMS Templates presentations and trainings


Draft GFIs and STM (Location as of 4/12)

https://www.insurance.wa.gov/gfi-revision-project

Analyst Checklists https://www.insurance.wa.gov/Checklists-health-coverage-analysts

Electronic Formulary Review Tools User Manual

https://www.insurance.wa.gov/sites/default/files/documents/electronic-formulary-review-tools-py19.pdf


https://www.qhpcertification.cms.gov/s/Application%20Materials


https://www.insurance.wa.gov/gfi-revision-project

https://www.insurance.wa.gov/Checklists-health-coverage-analysts

https://www.insurance.wa.gov/sites/default/files/documents/electronic-formulary-review-tools-py19.pdf

filing guidance for plan year 2020 - washington state office ......2019/04/16 · rate filings...

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