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INSURANCE DEPARTMENT

Affordable Care Act; Guidance for Compliance Submissions; Notice 2014-04

[44 Pa.B. 1846]
[Saturday, March 22, 2014]

 The Affordable Care Act—that is, Patient Protection and Affordable Care Act (Pub. L. No. 111-148) and the Health Care and Education Reconciliation Act of 2010 (Pub. L. No. 111-152), collectively and as amended—along with regulations and subregulatory guidance issued pursuant thereto (collectively, the ACA), sets forth market reform requirements for plan years beginning on or after January 1, 2015, for, inter alia, individual and small group health insurance policies that provide ''major medical'' coverage, which is comprehensive health coverage, including PPO and HMO coverage. The ACA also sets forth requirements for a plan to be a qualified health plan (QHP), so that the plan may be certified for offering on an exchange. Finally, the ACA contains several provisions that will impact rate development.

 The Insurance Department (Department) provides the following guidance to insurance entities seeking to demonstrate compliance with the ACA relative to new or modified policy forms offered, issued or renewed in this Commonwealth. This guidance applies to new policy forms, as well as to policy forms for which an insurance entity (insurer) is not seeking to make any changes other than as necessary to make the policy form comply with the ACA. Further, it applies to any plan an insurer anticipates may be certified as a QHP.

 If an insurer is required under the act of December 22, 2011 (P. L. 614, No. 134) to file a policy form or policy form modification with the Department for prior approval, it should file the form in SERFF and is requested to submit a ''Compliance Checklist and Certification'' as described as follows to assist the Department in its review. If an insurer is intending to use after January 1, 2015, a form not required to be filed, that is, a ''product'' as contemplated by the ACA, the Department requests that the form be submitted in SERFF in conjunction with any rate filing. For any form not required to be filed, the Commonwealth will accept as evidence of satisfying the ACA market reform requirements a ''Compliance Checklist and Certification,'' with the Market Reform portion of the Compliance Checklist filled out and the Certification executed by an authorized representative of the insurer. In each case, it is suggested that the Compliance Checklist and Certification be substantially identical to the ''Compliance Checklist and Certification'' as Attachment A. Attachment A is also available on the Department's web site at www.insurance.pa.gov. File a form with each policy form or policy form modification being submitted.

 If an insurer is anticipating that any form/product along with its associated plans may be certified as a QHP and offered on an exchange, the Commonwealth will accept as evidence of satisfying the ACA QHP requirements a Compliance Checklist and Certification, with both the Market Reform and the QHP portions of the Compliance Checklist filled out and the Certification executed by an authorized representative of the insurer, where the Compliance Checklist and Certification is substantially identical to the ''Compliance Checklist and Certification'' following as Attachment A. Attachment A is also available on the Department's web site. File a Compliance Checklist and Certification with each form/product and its associated plans being submitted. In addition to any Federally-facilitated exchange filing requirement (that is, HIOS), also include the QHP Application Templates in the SERFF filing, as instructed in SERFF.

 Further, with respect to the ACA rating requirements, including those amending the Public Health Service Act (PHSA) (42 U.S.C.A. §§ 201—300mm-61) and as further explained in Federal regulations, the Department requests that an actuarial memorandum be submitted as part of a rate filing for a product or plan subject to the ACA. In that actuarial memorandum, submitters are requested to:

 • State the anticipated loss ratio (see ACA § 1001, PHSA § 2718, noting also compliance with 31 Pa. Code § 89.83(b) (relating to rates)).

 • State the actuarial level of coverage (see ACA § 1302(d)).

 • State the insurer's intention regarding whether the product or plan will be offered on or off the Federal Marketplace.

 • Specify compliance with the rating requirements in the ACA, that is, use of no rating factors other than: (i) age (premium band ratio not exceeding 3:1 and Federally approved standard age curve); (ii) tobacco use (premium band ratio not exceeding 1.5:1); (iii) family size (as specified in Federal regulation); and (iv) geography (State rating regions as Federally approved, listed in Attachment B and also shown in map form on the Department's web site) (see ACA § 1201, PHSA § 2701).

 • Specify compliance with the single risk pool per market (individual or small group) requirement (see ACA § 1312).

 Additional information may be found in the general instructions in SERFF.

 Finally, while certain forms and rates referenced in this notice are subject to review and approval by the Department prior to use, the Department reminds filing entities that those forms and rates (and all forms and rates used in this Commonwealth) remain subject to, and must comply in all respects with, the Commonwealth's insurance laws and regulations and the Department retains its ability to take after-use enforcement action and seek any available remedy for noncompliant forms or rates. An insurer will be responsible for assuring that all of its insureds are provided the full benefits provided by the ACA.

 Questions regarding this notice may be directed to Peter Camacci, Director, Bureau of Life, Accident and Health Insurance, Insurance Department, 1311 Strawberry Square, Harrisburg, PA 17120, (717) 787-0762, pcamacci@state.pa.us.

MICHAEL F. CONSEDINE, 
Insurance Commissioner

Attachment A

Compliance Checklist and Certification

 If an entity (the ''Company'') submits a form filing to the Commonwealth, or intends to use after January 1, 2014 a form not required to be filed, that is, a ''product'' as contemplated by the ACA, where that form/product is intended to comply with the market reform requirements or the market reform and qualified health plan requirements of the Affordable Care Act (ACA), the Commonwealth will accept as demonstrating compliance with those requirements a compliance checklist and certification submitted with your contract/ endorsement via SERFF as a Form Schedule document, substantially identical to this Compliance Checklist and Certification. These ACA requirements apply only to policies for health insurance coverage referred to as ''major medical'' in the statute, which is comprehensive health coverage, including PPO and HMO coverage. This checklist identifies the requirements for small group and individual plans, and, where specified, for grandfathered plans (coverage in effect prior to March 23, 2010). Refer to the relevant statute and any applicable regulations to ensure compliance. Complete each item applicable to your product category to confirm that diligent consideration has been given to each statutory requirement as to each plan encompassed by the identified form/product. Additionally, complete the QHP Requirements portion of this checklist for any policy form/product intended to be offered as a qualified health plan.

 Bookmark the provision(s) in the form(s) that satisfy the requirement OR identify the page/paragraph where this provision appears in the form by use of the last column in the checklist below.

Company Name:
NAIC Number:
SERFF Tracking Number(s):
Type of Insurance (TOI):
Product Category:
  __ Individual
  __ Grandfathered Individual
  __ Small Group
  __ Grandfathered Small Group
Form Number(s) of Policy Being Submitted/Endorsed:

Certification

 I hereby certify that the above-referenced policy form submission and related rate filing, required to be in compliance with the requirements of the Patient Protection and Affordable Care Act, P. L. 111-148, 124 Stat. 119, and the Health Care and Education Reconciliation Act of 2010, P. L. 111-152, 124 Stat. 1051, together and as modified referred to as the ACA, has been drafted or modified to be in compliance with the ACA and the regulations promulgated thereunder.

 I am aware that accident and health rates and forms may be disapproved, or otherwise give rise to remedies or sanctions, if they fail to comply with applicable law or regulations. See, e.g., 40 P. S. § 3801.304(b); 40 P. S. § 1171.5(a)(5)(prohibiting knowingly filing a false statement of material fact with a supervisory or public official).

 I hereby warrant that I have full, complete and final authority to attest to the representations of the Company as set forth herein, and do hereby attest that the representations set forth in this Compliance Checklist and Certification Form are true, correct and complete.

______  _________________
Date      Name and Title of Authorized Represent-
          ative of the Company

Compliance Checklist

 Please confirm, by checking the appropriate box, the compliance status of the above referenced form(s) with each specified ACA requirement.

Statutory Requirement ACA/PHSA
Section
Product Applicability Certification of
Compliance
Market Reforms
Elimination of Annual Limits ACA
§ 1001/PHSA
§ 2711
xx Group
xx Individual
xx Grandfathered Group
[  ] Yes
[  ]  No
Elimination of Lifetime Limits ACA
§ 1001/PHSA
§ 2711
xx Group
xx Individual
xx Grandfathered Group
xx Grandfathered Individual
[  ] Yes
[  ]  No
Prohibition of Rescission ACA
§ 1001/PHSA
§ 2712
xx Group
xx Individual
xx Grandfathered Group
xx Grandfathered Individual
[  ] Yes
[  ]  No
Preventive Health Services ACA
§ 1001/PHSA
§ 2713
xx Group
xx Individual
[  ] Yes
[  ]  No
Extension of Dependent Coverage ACA
§ 1001/PHSA
§ 2714
xx Group
xx Individual
xx Grandfathered Group
xx Grandfathered Individual
[  ] Yes
[  ]  No
Uniform Explanations of Coverage and Standardized Definitions ACA
§ 1001/PHSA
§ 2715
xx Group
xx Individual
xx Grandfathered Group
xx Grandfathered Individual
[  ] Yes
[  ]  No
Prohibition on Discrimination in Favor of Highly Compensated Individuals ACA
§ 1001/PHSA
§ 2716
xx Group
xx Individual
[  ] Yes
[  ]  No
Appeals Process ACA
§ 1001/PHSA
§ 2719
xx Group
xx Individual
[  ] Yes
[  ]  No
Patient Protections ACA
§ 1001/PHSA
§ 2719A
xx Group
xx Individual
[  ] Yes
[  ]  No
Prohibition of Pre-Existing Condition Exclusions ACA
§ 1201/PHSA
§ 2704
xx Group
xx Individual
xx Grandfathered Group
[  ] Yes
[  ]  No
Fair Premiums (limited rating factors) ACA
§ 1201/PHSA
§ 2701
xx Group
xx Individual
[  ] Yes
[  ]  No
Guaranteed Availability ACA
§ 1201/PHSA
§ 2702
xx Group
xx Individual
[  ] Yes
[  ]  No
Guaranteed Renewability ACA
§ 1201/PHSA
§ 2703
xx Group
xx Individual
[  ] Yes
[  ]  No
Prohibition on Discrimination Based on Health Status ACA
§ 1201/PHSA
§ 2705
xx Group
xx Individual
[  ] Yes
[  ]  No
Non-Discrimination in Health Care ACA
§ 1201/PHSA
§ 2706
xx Group
xx Individual
[  ] Yes
[  ]  No
Comprehensive Coverage ACA
§ 1201/PHSA
§ 2707
xx Group
xx Individual
[  ] Yes
[  ]  No
Prohibition on Excessive Waiting Periods ACA
§ 1201/PHSA
§ 2708
xx Group
xx Individual
xx Grandfathered Group
xx Grandfathered Individual
[  ] Yes
[  ]  No
Coverage for Participating in Approved Clinical Trials ACA
§ 1201/PHSA
§ 2709
xx Group
xx Individual
[  ] Yes
[  ]  No
Essential Health Benefits Package ACA
§ 1302
xx Group
xx Individual
[  ] Yes
[  ]  No
EHB Package—Pediatric ACA
§ 1302
xx Group
xx Individual
[  ] Yes
[  ]  No
EHB Package—Habilitative Services ACA
§ 1302
xx Group
xx Individual
[  ] Yes
[  ]  No
EHB Package—Prescription Drug Coverage ACA
§ 1302
xx Group
xx Individual
[  ] Yes
[  ]  No
Requirements Related to Cost-Sharing ACA
§ 1302
xx Group
xx Individual
[  ] Yes
[  ]  No
Actuarial Value/Metal Level ACA
§ 1302
xx Group
xx Individual
         [  ] Yes (included
in binder)
[  ]  No
Child-Only Plan ACA
§ 1302(f)
xx Group
xx Individual
[  ] Yes
[  ]  No
Special Rules Relating to Coverage of Abortion Services ACA
§ 1303
xx Group
xx Individual
[  ] Yes
[  ]  No
Mental Health Parity ACA
§ 1563/PHSA
§ 2726
xx Group
xx Individual
[  ] Yes
[  ]  No
Health Insurance Reform Regulatory Requirements for the Group Health Insurance Market 45 C.F.R.
Subtitle A
Subchapter B
Part 146
xx Group
xx Grandfathered Group
(as applicable)
[  ] Yes
[  ]  No
Health Insurance Reform Regulatory Requirements for the Group and Individual Health Insurance Markets 45 C.F.R.
Subtitle A
Subchapter B
Part 147
xx Group
xx Individual
xx Grandfathered Group (as applicable)
xx Grandfathered Individual (as applicable)
[  ] Yes
[  ]  No
Health Insurance Reform Regulatory Requirements for the Individual Health Insurance Market 45 C.F.R.
Subtitle A
Subchapter B
Part 148
xx Individual
xx Grandfathered Individual (as applicable)
[  ] Yes
[  ]  No
Health Insurance Reform Regulatory Requirements—Essential Health Benefits 45 C.F.R.
Subtitle A
Subchapter B
Part 156
Subpart B
xx Group
xx Individual
[  ] Yes
[  ]  No
QHP Requirements
Definition of Qualified Health Plan ACA
§ 1301
xx Group
xx Individual
[  ] Yes
[  ]  No
Marketing Requirements ACA
§ 1311(c)(1)
xx Group
xx Individual
[  ] Yes
[  ]  No
Network Adequacy Requirements ACA
§ 1311(c)(1)
xx Group
xx Individual
       [  ] Yes—Submitted
to Dept. of
Health directly
or via Excel
upload to
SERFF on:
______
[  ]  No
Essential Community Providers Requirement ACA
§ 1311(c)(1)
xx Group
xx Individual
[  ] Yes
[  ]  No
Accreditation Requirement ACA
§ 1311(c)(1)
xx Group
xx Individual
       [  ] Yes—
Accred. Body:
NCQA/URAC
Date of
Accred.: ____
[  ]  No
Quality Improvement Strategy ACA
§ 1311(c)(1)
xx Group
xx Individual
[  ] Yes
[  ]  No
Uniform Enrollment Form ACA
§ 1311(c)(1)
xx Group
xx Individual
[  ] Yes
[  ]  No
Standard Format for Health Benefit Options ACA
§ 1311(c)(1)
xx Group
xx Individual
[  ] Yes
[  ]  No
Quality Measures for Performance Information ACA
§ 1311(c)(1)
xx Group
xx Individual
[  ] Yes
[  ]  No
Pediatric Quality Reporting measures ACA
§ 1311(c)(1)
xx Group
xx Individual
[  ] Yes
[  ]  No
Mental Health Parity ACA
§ 1311(j)
xx Group
xx Individual
[  ] Yes
[  ]  No
Exchange Functions: Certification of Qualified Health Plan Regulations 45 C.F.R.
Subtitle A
Subchapter B
Part 155
Subpart K
xx Group
xx Individual
[  ] Yes
[  ]  No
Exchange Health Insurance Issuers Standards Regulations 45 C.F.R.
Subtitle A
Subchapter B
Part 156
xx Group
xx Individual
[  ] Yes
[  ]  No

Attachment B

Pennsylvania Geographic Rating Areas (Individual and Small Group Markets)

(listing counties alphabetically in each ''Federal System'' Rating Area ID)

Rating Area 1—Clarion, Crawford, Erie, Forest, McKean, Mercer, Venango, Warren

Rating Area 2—Cameron, Elk, Potter

Rating Area 3—Bradford, Carbon, Clinton, Lackawanna, Luzerne, Lycoming, Monroe, Pike, Sullivan, Susquehanna, Tioga, Wayne, Wyoming

Rating Area 4—Allegheny, Armstrong, Beaver, Butler, Fayette, Greene, Indiana, Lawrence, Washington, Westmoreland

Rating Area 5—Bedford, Blair, Cambria, Clearfield, Huntingdon, Jefferson, Somerset

Rating Area 6—Centre, Columbia, Lehigh, Mifflin, Montour, Northampton, Northumberland, Schuylkill, Snyder, Union

Rating Area 7—Adams, Berks, Lancaster, York

Rating Area 8—Bucks, Chester, Delaware, Montgomery, Philadelphia

Rating Area 9—Cumberland, Dauphin, Franklin, Fulton, Juniata, Lebanon, Perry

[Pa.B. Doc. No. 14-615. Filed for public inspection March 21, 2014, 9:00 a.m.]



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