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Home > Insurance Division > Health Insurance Programs > Plan Management
Qualified Health Plan Instructions for Plan Year 2021

New Jersey expects to operate a State Based Exchange (SBE) for the Open Enrollment Period beginning November 1, 2020, for plan year 2021 coverage, through the New Jersey Department of Banking and Insurance (Department). To support this goal, the Department will perform full plan management functions for Plan Year 2021, and expects to contract with carriers that intend to offer Qualified Health Plans (QHPs) through the SBE. Note that New Jersey is in the review and approval process with the U.S. Department of Health and Human Services regarding New Jersey’s transition to an SBE, and will continue to operate using the federal platform for a period of time, including the transfer of certain information from State Plan Management files to federal Plan Management files.  Accordingly, carriers may continue to receive messages through the federal Plan Management Community environment, and will need to be responsive to such messages until instructed otherwise.

Note:  There are no separate filing fees.

General Information and Resources

Only carriers (insurance companies, service corporations, and health maintenance organizations) licensed or authorized to offer a health insurance/coverage business in New Jersey may offer a QHP or Stand-alone Dental Plan (SADP) to individuals or small employers for delivery in New Jersey, whether through the SBE or outside of it.

New Carriers, and Carriers seeking to amend an existing Authorization.  A carrier that is not admitted in New Jersey, or admitted but not authorized, to offer health benefits plans, may apply for admission and/or authorization while also applying to offer QHPs and SADPs; required regulatory reviews will occur parallel to one another when necessary.  This is also the case for carriers authorized to operate in a limited service area that want to expand (or shrink) it, or carriers that want to establish a new network, etc.  Such carriers are cautioned, however, that there are no guarantees how long the various review processes may take, and carriers should not assume all required components will be completed in a timeframe adequate to permit the offer of plans during the designated open enrollment period for the immediately upcoming plan year.  Carriers should note:

  • If a carrier seeking to offer QHPs or SADPs through the SBE does not obtain all required approvals in a timely manner, the carrier will not be permitted to participate in the SBE, because, to participate in the SBE:
    • The carrier must be able to participate fully in the open enrollment period immediately preceding the upcoming calendar year; and
    • The carrier must be able to effectuate coverage as of January 1 of the calendar year immediately following the beginning of the open enrollment period; and
    • The carrier must commit to offering plans through the SBE for a full calendar year.

  • A carrier seeking to offer a QHP to small employers solely outside of the SBE is permitted to begin offering plans at any time during a calendar year. However, when a carrier is unable to offer its QHPs during the small employer annual open enrollment period (November 15 through December 15) designated for the calendar year in which the carrier wants to offer its QHPs, and the carrier elects to start offering its QHPs during that calendar year anyway, the carrier must offer its QHPs on a continuously guaranteed issue basis through the remainder of the calendar year. 

Terminology.  For purposes of these instructions and related information:

  • QHP is being used to refer to health benefits plans providing medical and health services (with or without a defined set of pediatric dental services embedded in the health benefits plan).  All standard health benefits plans (see below) are QHPs.  To become certified for offer through the SBE, both the carrier and QHP must meet certain requirements, and the carrier must enter into a contract with the Department to participate in the SBE.

  • SADP is being used to refer to dental only plans that include the defined set of pediatric dental services and that carriers intend to offer to individuals and/or employees of small employers that have enrolled in QHPs lacking coverage of pediatric dental services.  To become certified for offer through the SBE, both the carrier and the SADP must meet certain requirements, and the carrier must enter into a contract with the Department to participate in the SBE.

Standard Health Benefits Plans, the Benchmark Plan, Qualified Health Plans and Stand-Alone Dental Plans

New Jersey has had standard health benefits plans for its individual and small employer markets since the early 1990s, and carriers may offer only standard health benefits plans to individuals and small employers.  All of New Jersey’s standard health benefits plans are consistent with New Jersey’s Benchmark Plan required by the federal Affordable Care Act (ACA), including an option for embedded coverage of a defined set of pediatric dental services.  However, carriers may offer the defined set of pediatric dental services through SADPs as well.  CCIIO provides a link to New Jersey’s Benchmark Plan, and provides separate information about the defined set of pediatric dental benefits via https://www.cms.gov/CCIIO/Resources/Data-Resources/ehb.html.  (Scroll to access information about each state individually.)

Locating QHP Information:  Carriers that wish to offer a QHP, with or without pediatric dental services embedded in the plan, must issue the standard health benefits plans set forth in the Appendix Exhibits of N.J.A.C. 11:20 and N.J.A.C. 11:21, and as posted at:

The standard health benefits plans forms include variable text for the pediatric dental services.  Carriers also should refer to the “BMP Summary” at https://www.cms.gov/CCIIO/Resources/Data-Resources/ehb.html to obtain more specific information about the Prescription Drug EHB-Benchmark Plan Benefits by Category and Class.

Locating SADP Information:  Because the standard health benefits plans contain the required benefits and language to comply with New Jersey’s selected benchmark pediatric dental coverage, the Department recommends that carriers wishing to offer an SADP with the ACA-compliant pediatric dental coverage look to the relevant variable text in the standard health benefits plans at:

Alternatively, carriers may refer to https://www.cms.gov/CCIIO/Resources/Data-Resources/ehb.html, paying particular attention to New Jersey’s BMP Summary and NJ-CHIP files.   

General offer requirement:  Carriers that offer a QHP through the SBE must also offer the standard health benefits plan outside of the SBE.  Carriers may offer a standard health benefits plan solely outside of the SBE, but the standard health benefits plan still must meet the requirements applicable to a QHP, with a few exceptions.  This is true whether coverage is being offered to individuals or small employers.

Similarly, carriers that offer an SADP through the SBE must also offer the SADP outside of the SBE; however, carriers may offer an SADP solely outside of the SBE.  Carriers offering SADPs must structure their plans so that a child may be covered by the SADP without regard whether a parent or guardian is also covered under the SADP.  This is true whether coverage is being offered to individuals or small employers, and whether coverage is being offered through the SBE or not.  

 
The Basics of Submission and Market Participation

Who must submit information:  All carriers that intend to offer a standard health benefits plan in the individual or small employer market during Plan Year 2021 must submit plan management information, whether or not the standard health benefits plan will be offered through the SBE.  Similarly, carriers that intend to offer an SADP in the individual or small employer market during Plan Year 2021 must submit plan management information, whether the SADP will be offered through the SBE, or not.  Carriers offering standard health benefits plans solely outside of the SBE must submit most, but not all, of the information required to be submitted by carriers that are seeking certified QHP status for their standard health benefits plans. All carriers offering SADPs must submit specified documentation, regardless of whether the plan will be offered through the SBE or SHOP.

What must be submitted:  Except as indicated otherwise, carriers will complete and submit the templates developed by the Center for Consumer Information and Insurance Oversight (CCIIO) for the Federally Facilitated Exchange for Plan Year 2021, as well as supporting documentation, using the instructions prepared by CCIIO for its templates and supporting documentation.  Carriers should see https://www.qhpcertification.cms.gov/s/QHP.  Carriers should also be mindful of CCIIO’s 2021 Letter to Issuers in the Federally-facilitated Exchanges.  There are some additional documents/submissions required for QHPs and SADPs.  In addition, there are a few special instructions for use of a couple of the CCIIO templates.  More details are provided below, and a chart of the documentation is provided for easier reference.

When must items be submitted:   The following dates apply:

Submission Deadline Overview Chart Deadline System
2020 QHP Enrollee survey data * HIOS & SERFF
2020 QRS Clinical Data * HIOS & SERFF
Initial Binder components deadline (not including the Rates Table Template, rate filing,Transparency in Coverage data) June 5, 2020 SERFF
Transparency in Coverage data (NJ-initial) June 17, 2020 SERFF
Rates Table Templates July 22, 2020 SERFF
Rate Filing June 19, 2020 SERFF
Transparency in Coverage data (for CMS initial) Aug. 19, 2020 SERFF
Issuer URL Template (final) Aug. 19, 2020 SERFF
Transparency in Coverage data resubmission Sept. 10, 2020 SERFF

*On April 18, 2020, CMS issued guidance stating it would not enforce submission of this data (or Quality Improvement Strategy programs) because of the challenges it represents to healthcare providers and the safety issues that may result to all involved in the data collection process.  Likewise, New Jersey will not be enforcing submission of these reports. See https://www.cms.gov/files/document/covid-qrs-and-marketplace-quality-initiatives-memo-final.pdf.

Where/How must carriers submit the information.  Carriers must submit all documents through SERFF.  Most documents must be submitted through the Plan Binder section of SERFF.  A few documents must be submitted through SERFF either as part of the process for rate filings (applicable to all QHPs and SADPs), or form filings (applicable only to SADPs).  However, carriers must associate documents from the rate filings and/or the form filings with the relevant plan binders using the Associate Schedule Tab of the Plan Binder section of SERFF.

Some information must also be submitted to CCIIO through HIOS, as noted in the Submission Deadline Overview Chart.  HIOS is composed of several different modules, including a Benefits and Service Area Module and SSM.  Carriers should refer to https://www.qhpcertification.cms.gov/s/QHP for more information.  

 
Documentation (the Application)

The Documents to be Submitted chart identifies which documents must be submitted for which types of plans.  A majority of the templates and forms to be used are available through CCIIO, but some additional instructions are provided below. 

Cover Letter to Binder
Carriers must submit a cover letter for each binder submitted.  Carriers should place the Cover Letter on the Supporting Documents tab of the Plan Management domain in SERFF.  The cover letter must include:

  • the carrier’s name and HIOS ID
  • the SERFF tracking number for the binder
  • the names and email addresses for two contact people who are familiar with the filing and able to respond to questions
  • a table with the following:
    • Product and plan name(s)
    • HIOS ID for each plan (Standard Component ID)
    • Indication of whether the plan will be offered in the individual (IHC) or small employer (SEH) market
    • For QHPs, the metal level and the specific AV for each plan if available when submitted
    • For SADPs, the AV for each plan when available
    • Indication of whether the plan will be offered inside/outside of the Marketplace, or outside the Marketplace only

NJ Benefit Summary Table  
Carriers must submit the NJ Benefit Summary Table, with a worksheet completed for each QHP (plan, not product) the carrier wants to offer.  The NJ Benefit Summary Table is available as part of the SERFF Plan Management instructions.  Carriers should place the NJ Benefit Summary Table on the Supporting Documents tab of the Plan Management domain in SERFF.  Carriers do not need to submit this template for SADPs.

Administrative Information, including URLs
Carriers have been required to submit administrative information to CMS though HIOS, and should update that information as necessary to keep it current so long as the carrier is offering QHPs through the SBE, or offering SADPs. This may include updating URLs using the HIOS Supplemental Submission Module (SSM, part of the QHP Benefits and Service Area Module). Carriers should update URL information for plans to be offered on the Exchange through the SSM (carriers may be able to generate a prepopulated Issuer URL Template for Plan Year 2021), as appropriate, and append the downloaded file to the Supporting Documents tab of the Plan Management domain in SERFF for each QHP and SADP binder the carrier submits. Carriers may add information for plans offered solely off the Exchange, or submit a separate URL Template for off-Exchange plans (see: https://www.qhpcertification.cms.gov/s/Administrative). We request that carriers append the most current URL information on June 5 (which may be for PY2020), and additional updated versions as necessary for PY2021.Subsequent to transfer by the Department of carrier plan and benefits data to CMS, a carrier’s intended PY2021 Plan IDs should be recorded in the SSM, and carriers should update information accordingly, submitting a final, completed Issuer URL Template in SERFF (prepopulated by the SSM, if possible) no later than August 19, 2020.  CMS has specified a “live and active” date of September 23, 2020, with the exception of Transparency in Coverage-related URLs, which must be “live and active” no later than August 26, 2020.  The Department is requesting that all URLs be “live and active” by August 19.

Attestations
Carriers intending to offer a QHP through the SBE, or an SADP must submit a completed State Partnership Exchange Issuer Program Attestation Response Form. The completed form must be submitted for each QHP and SADP binder submitted in SERFF. Carriers must place the State Partnership Exchange Issuer Program Attestation Response Form and all other relevant attestations on the Supporting Documents tab of the Plan Management domain in SERFF.

Accreditation
If the carrier is offering QHPs in New Jersey for three or fewer consecutive years, the carrier may submit a certificate of accreditation, or evidence of a scheduled review with an HHS-recognized accrediting entity (URAC, NCQA, or possibly AAAHC).  If the carrier is offering QHPs for the fourth consecutive year in New Jersey, whether through or outside of the SBE, the carrier must submit a certificate of accreditation by one of the HHS-recognized accrediting entities in one of the following statuses:

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

Note that, if a carrier is unable to locate the NCQA certificate, it can use the NCQA ISS to obtain a copy of the survey results, and provide a print of the results screen. 

Transparency in Coverage Data
All carriers submitting plans to be sold through the Exchange, as well as SADPs that will be offered only outside of the Exchange, must submit the Transparency in Coverage template.  We are requesting that carriers submit an initial Transparency in Coverage template by June 17, 2020.  As suggested by CMS, to avoid overwrite issues, the templates submitted for each binder of each HIOS Issuer ID should be the same; that is, each template submitted should include all plan IDs intended to be offered by the carrier in PY2021.  We do not intend to transfer this submission, so it is not necessary for carriers to include any additional actual or dummy plan data in the template submitted June 17.  So that we can transfer the Transparency in Coverage Template timely to meet CMS’ submission deadline in August, carriers must submit completed Transparency in Coverage templates in SERFF no later than August 19, 2020.  Carriers must include actual issuer level and plan level data for the August submission unless the carriers were not offering plans on the Exchange in 2019, or a specific plan was not offered in PY2019, in which case, dummy data will be necessary, as specified in CMS’ instructions.  However, contrary to CMS’ suggestion, carrier’s cannot wait until the resubmission deadline to submit required data.  To comply with CMS’ resubmission deadline, we require carriers to submit their final, completed Transparency in Coverage Template no later than September 10, 2020.  

Other Documents Specified by CCIIO (Some Special Instructions)
All other required forms and templates are available through CCIIO’s websites.  All can be accessed through https://www.qhpcertification.cms.gov/s/QHP, although carriers will find more information regarding quality reporting at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityInitiativesGenInfo/ACA-MQI/ACA-MQI-Landing-Page.  Please note:

  • SADP AV.  The federal cost-sharing limits for SADPs remain at $350 for one child, and $700 for two or more children for Plan Year 2021.  Carriers may offer SADPs without complying with any specific actuarial value; however, carriers must certify the actuarial value of the SADP, including submission of the AV Supporting Documentation and Justification Form.

  • Summary of Benefits & Coverage.  CCIIO released updates to the Summary of Benefits and Coverage forms (SBCs) for Plan Year 2021, as well as to the coverage examples calculator, guide and narratives, and the Uniform Glossary.  In general, carriers should use the updated SBC forms and instructions set forth by CCIIO, and should evaluate whether to use the updated calculator for estimating out-of-pocket costs for the SBC coverage examples.  However:

    • On the SBC, in the last sentence of the section Your Right to Continue Coverage, carriers should insert www.getcovered.nj.gov instead of www.HealthCare.gov, and should use the following phone number: 1-877-962-8448.
    • With respect to plans other than SADPs, carriers are reminded that all plans must comply with P.L. 2019, c. 361 (amendments to New Jersey’s contraceptive coverage requirement), and at least one of one plan must comply with P.L. 2019, c. 472 (amendments limiting cost-sharing for prescription drugs), and these changes may need to be reflected appropriately in the SBC, for example, when providing information in the section If you need drugs to treat your illness or condition, or explaining preventive services.   Careful explanations will be important particularly when/if combined with a High Deductible Health Plan (HDHP), because:
        • Some contraceptive services required to be covered may be outside of the definition of preventive services as recommended by federal law
        • Both P.L. 2019, c. 361 and P.L. 2019, c. 472 limit carriers to the application of the lowest HDHP deductible possible (for PY2021: $1400 for self-only coverage; $2800 for family) with respect to the provision of coverage for prescription drugs and/or contraceptives.
    • In addition, note that P.L. 2019, c. 472 may have an impact on the SBC example for management of diabetes.
             
           
  • Business Rules. Carriers offering QHPs must not select “sponsored dependents,”  “collateral dependents,” or “other relative” as a coverage category on the Business Rules/Rating Business Rules template because the terms, as used by CCIIO, are inconsistent with the definition of dependent in the standard health benefits plans.  In addition, although the standard individual health benefits plans would allow grandchildren, siblings, nephews, and nieces as eligible dependents, it is conditioned upon such individuals being in the same household and dependent upon the primary insured person.  While CCIIO’s form would allows for a selection of coverage for these classes of people when not in the household, carriers should not make that selection.  Also, an ex-spouse is never eligible for coverage under a primary insured’s individual health benefits plan.

  • QHP Enrollee Survey Data and QRS Clinical Data.  The Department of Banking and Insurance is not requiring submission of this information because CMS has determined not to require submission of this data this year.  Carriers should follow the requirements set forth at CCIIO’s QHP Certification website (https://www.qhpcertification.cms.gov/s/Quality%20Rating), and Marketplace Quality Initiative website (https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityInitiativesGenInfo/ACA-MQI/ACA-MQI-Landing-Page).
         

Rate Filings
Carriers must submit rate filings.  Additional instructions are provided on the Department of Banking and Insurance website.  The CCIIO-generated URRT must be included as part of the rate filing for QHPs.  All three parts of the rate filing must be associated with the binders to which the rate filing applies, using the Associate Schedule tab of the Plan Management domain of SERFF.

Form Filings
Carriers offering SADPs must file forms with the Department, or submit a letter indicating that a previously approved form remains in use without change in SERFF (not the SERFF Plan Management domain).  Carriers must associate both forms and letters with the SADP binders to which the form/letter applies, using the Associate Schedule tab of the Plan Management domain of SERFF.   

Plan ID Crosswalk.  The requirement to submit a Plan ID crosswalk applies to carriers offering QHPs as well as to carriers offering SADPs when offering through the SBE.  Carriers must crosswalk all prior year Plan IDs to a Plan Year 2021 Plan ID, taking into consideration the hierarchy set forth at 45 C.F.R. 155.335 to help expedite the auto-reenrollment process. 

Withdrawal of a plan.  Although a carrier may not remove a plan from its templates, carriers may seek to withdraw a plan, or change its SBE-status using the Plan Withdrawal Notification Form, submitted in the SERFF Plan Management domain.  (Carriers are reminded that withdrawal of a plan is not the equivalent of a withdrawal from the market, nor a plan option withdrawal, and that specific market withdrawal rules apply to such actions.)

 
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