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Plan Management - Qualified Health Plan Instructions for Plan Year 2020

Filing Date:  Carriers must submit binders for MEDICAL and DENTAL products intended to be offered as Qualified Health Plans on the Marketplace and through the SHOP for Plan Year 2020 no later than June 5, 2019. (Note: Form submissions for SADPs are due by July 1, 2019; use the 2020 rate-filing link below for rate-filing deadlines).

General Instructions/Resources

The New Jersey Department of Banking and Insurance, in coordination with the Individual Health Coverage Program and the Small Employer Health Benefits Program, performs Plan Management functions on behalf of the Federally Facilitated Marketplace (Marketplace) in New Jersey.  Accordingly, carriers must submit information to the Department through SERFF, instead of HIOS (except for the Unified Rate Review Template, which must be submitted in both HIOS and SERFF, and the Administrative Template, which must be submitted in HIOS).  Take note:

  • Carriers may only offer Qualified Health Plans (QHPs) in New Jersey’s individual and small employer markets.
  • All carriers that intend to offer a QHP or stand-alone pediatric dental (SADP) plan in the individual market, whether inside and outside of the Marketplace, or only outside of the Marketplace, must submit plan information as identified below.
  • All carriers that intend to offer a QHP through the Marketplace’s SHOP to small employers, or SADPs to small employers, must submit plan information as identified below.

State Essential Health Benefits (EHBs) and Mandates
CMS provides a link to New Jersey’s Benchmark Plan, which includes all EHBs and applicable New Jersey mandates.  In addition, the link provides information about pediatric dental benefits separately.  See: https://www.cms.gov/CCIIO/Resources/Data-Resources/ehb.html. For best use, note:

  • scroll to access information for each state individually
  • select 2017-2020 EHB Benchmark Plan Information for New Jersey
  • the BMP Summary includes the Prescription Drug EHB-Benchmark Plan Benefits by Category and Class
  • carriers offering SADPs should review both the BMP Summary and the NJ-CHIP files

Cover Letter
Carriers must submit a cover letter for each binder submitted.  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
    • The metal level and the specific AV for each plan if available when submitted (SADPs should include the AV only, when available)
    • Indication of whether the plan will be offered inside/outside of the Marketplace, or outside the Marketplace only

Completion of Federal Templates and Supporting Documents
With few exceptions, templates, forms and instructions for completing the templates and forms, as well as instructions for submitting certain required information that does not have a specified template or form, are available at http://www.qhpcertification.cms.gov/s/Home.  Note:

  • Carriers should always download the version of a template or form specific to the plan year for which the information is being submitted
  • Carriers should complete CMS templates and forms in accordance with CMS’ instructions, including document naming conventions when specified
  • Carriers should use the Data Integrity Tool
  • Carriers may combine some submissions in the Supporting Documentation tab in the SERFF binder (for example, the organizational chart could be within the compliance plan), but must explain it in the appropriate section for the requirement (in this instance, the section regarding the organizational chart)
  • Carriers must mark as N/A any supporting documentation not submitted by the carrier because the supporting documentation is not necessitated by the federal instructions given the carrier’s circumstances
  • Carriers must submit a compliance plan
  • The Department may require submission of supporting documentation omitted by the carrier, or other information if, upon review, the Department believes additional documentation is necessary or otherwise appropriate

Carriers must follow the deadlines established for SERFF submissions for items that must be submitted in SERFF.  The SERFF deadlines are earlier than the HIOS deadlines.

Filing Fees
There are no filing fees.

 
Medical Health Benefits Plan Requirements

New Jersey has had standard health benefits plans for its individual and small employer markets since the early 1990s.  All New Jersey’s standard health benefits plans are consistent with the New Jersey benchmark plan.  Carriers that offer a standard health benefits plan inside the Marketplace must offer the same standard health benefits plan outside of the Marketplace.  However, carriers may offer standard health benefits plans outside of the Marketplace that they do not offer inside the Marketplace.  Whether offering inside the Marketplace or outside the Marketplace, carriers issuing health benefits plans to individual consumers or small employers in New Jersey must issue the standard health benefits plans as posted at:

Carriers must submit the documents indicated in the chart via SERFF, using the Plan Management section and the tabs within the Plan Management section, as indicated.  Generally, documents required for binders containing plans that will be offered inside and outside of the Marketplace are also required for binders containing plans that will be offered only outside of the Marketplace.  Required documentation is indicated by checkmarks, but some items need only be submitted based upon whether certain conditions occur as established by the federal instructions.  Note:

  • The NJ Benefit Design Template is an attachment in the instructions in SERFF, as well as on the Supporting Documentation Tab in the SERFF NJ Plan Management Section.
  • Regarding rate filings:  rate filings typically are due after the plan filings; carriers must associate the rate filing submissions with the plan submissions upon submission of the rate filing.  For medical plans, the associated schedule must include the URRTs, AV screenshots, and the Actuarial Memorandum (Part III).  Carriers are not required to associate the Rate Chart or Part II for the binder.
 
Stand-alone Pediatric Dental Plan (SAPD) Requirements

Carriers offering SADPs to individual consumers or small employers to satisfy Essential Health Benefits with respect to pediatric dental benefits must:

  • Submit a policy form that contains language for the coverage of pediatric dental benefits that is identical to the policy form language set forth in Exhibit A in the Appendix to N.J.A.C. 11:20, or, in the event the carrier chooses to use alternative language, submit a cross-walk document that shows each element required for the pediatric dental benefit set forth in Exhibit A and the specific location of the corresponding text in the carrier’s policy form;
  • Include in the policy form submitted a statement that pediatric dental benefits are provided for all covered persons through at least the end of the month in which the covered person turns 19, consistent with 45 C.F.R. 156.115, regardless of the covered person’s enrollment status; and
  • Include in the policy form submitted only such frequency limits, limitations, or exclusions as permitted for the pediatric dental benefit set forth in Exhibit A of the Appendix to N.J.A.C. 11:20.

Under no circumstance may the carrier deny coverage under the SADP because of preexisting conditions, nor shall there be any language in the policy form or related materials that suggests that preexisting conditions are considered with respect to the provision of pediatric dental benefits.

In addition to submission of the policy form in SERFF, the carrier shall submit the documentation shown in the chart using the Plan Management Section, and Plan Management tabs as indicated (applicable to all SADPs with the pediatric dental benefit offered to individual consumers and small employers).  Note:

  • Regarding rate filings:  rate filings typically are due later than the plan filings; carriers must associate the rate filing submissions with the plan submissions upon submission of the rate filing.  For SADPs, the associated schedule must include the Actuarial Memorandum.                    
 
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New Jersey Department of Banking and Insurance