Marketplace Components FAQ
- Are there a maximum number of plans a carrier may offer on the Marketplace?
No. Issuers may submit as many plans as it wants to offer; however, plans will be reviewed for meaningful difference using the CMS QHP review tools. Meaningful difference will be assessed by placing the plans into subgroups based on plan type, metal level, and overlapping counties/service areas. Each subgroup will be reviewed to determine if there is difference among plans on at least one of the following criteria:
- Different network;
- Different formulary;
- $50 or more difference in both individual and family in-network deductibles;
- $100 or more difference in both individual and family in-network maximum out of pocket requirements; and
- Difference in covered EHB.
- Does Michigan have insight on the meaningful difference calculation?
As outlined in the previous question, standards have been established for assessing the differences in plan variations. DIFS will use the review tools created by CMS to evaluate meaningful difference.
- How often are carriers permitted to put new plans or new pricing on the Marketplace?
Carriers may file new plans and pricing for the Marketplace on an annual basis. Each year a filing window will be established during which new plans and pricing may be filed, along with required binders. New plans filed within the filing window will have a January 1 effective date for the subsequent year.
- Does every policyholder have to move to a January renewal due to open enrollment requirements?
DIFS will allow individuals with non-calendar year plans to transition to a calendar year plan in 2014. These policies will be effective through 12/31/14, at which time they will be converted to a calendar year plan effective 1/1/15. This pattern is consistent with individuals who, as a result of a qualifying event, enter the individual market mid-year. Individuals will be issued a policy that runs through December 31 of that year and will subsequently be converted to a calendar year plan.
- What method will be used to electronically transmit enrollment, premium payment and payment of subsidies?
The 2015 Letter to Issuers does not provide additional guidance on the transmission or enrollments, premium payments, or the payment of subsidies. Michigan will continue to rely on the guidance provided in Section 4, pages 38 through 40, of HHS's2014 Letter to Issuers on Federally-facilitated and State Partnership Marketplaces as required under 45 CFR 155.270. Please review the letter for more detailed information. Another source for FFM enrollment policy and guidance can be found in the FFM Enrollment Operational Policy & Guidance, dated October 3, 2013.
- What is the deadline to complete the accreditation process for QHP issuers that are not currently accredited?
- During certification for an issuer's initial year of QHP certification (for example, in 2013 for the 2014 coverage year), an issuer without existing accreditation granted by a recognized accrediting entity for the same state in which the issuer is applying to offer coverage must have scheduled or plan to schedule a review of QHP policies and procedures of the applying QHP issuer with a recognized accrediting entity.
- Prior to an issuer's second year and third year of QHP certification (for example, in 2014 for the 2015 coverage year, and 2015 for the 2016 coverage year), an issuer must be accredited by a recognized accrediting entity on the policies and procedures that are applicable to their Marketplace products, or an issuer must have commercial or Medicaid health plan accreditation granted by a recognized accrediting entity for the same state in which the issuer is offering Marketplace coverage and the administrative policies and procedures underlying that accreditation must be the same or similar to the administrative policies and procedures used in connection with the QHP.
- Prior to the issuer's fourth year of QHP certification and in every subsequent year of certification (for example, in 2016 for the 2017 coverage year and forward), an issuer must be accredited.
For additional information, please review Chapter 2, Section 5 of the 2015 Letter to Issuers in the Federally-facilitated Marketplace (FFM).
- What kind of proof must we require for an individual who is requesting a special enrollment? Do we take them at their word or do they have to show us something?
Special enrollment periods (SEPs) are required under 45 CFR 155.420. The proof of SEP eligibility depends on the cause of the SEP. The Marketplace must allow qualified individuals and enrollees to enroll in or change from one QHP to another as a result of the following triggering events:
- A qualified individual or dependent loses minimum essential coverage;
- A qualified individual gains a dependent or becomes a dependent through marriage, birth, adoption or placement for adoption;
- An individual, who was not previously a citizen, national, or lawfully present individual gains such status;
- A qualified individual's enrollment or non-enrollment in a QHP is unintentional, inadvertent, or erroneous and is the result of the error, misrepresentation, or inaction of an officer, employee, or agent of the Marketplace or HHS, or its instrumentalities as evaluated and determined by the Marketplace. In such cases, the Marketplace may take such action as may be necessary to correct or eliminate the effects of such error, misrepresentation, or inaction;
- An enrollee adequately demonstrates to the Marketplace that the QHP in which he or she is enrolled substantially violated a material provision of its contract in relation to the enrollee;
- An individual is determined newly eligible or newly ineligible for advance payments of the premium tax credit or has a change in eligibility for cost-sharing reductions, regardless of whether such individual is already enrolled in a QHP. The Marketplace must permit individuals whose existing coverage through an eligible employer-sponsored plan will no longer be affordable or provide minimum value for his or her employer's upcoming plan year to access this special enrollment period prior to the end of his or her coverage through such eligible employer-sponsored plan;
- A qualified individual or enrollee gains access to new QHPs as a result of a permanent move;
- An Indian, as defined by section 4 of the Indian Health Care Improvement Act, may enroll in a QHP or change from one QHP to another one time per month; and
- A qualified individual or enrollee demonstrates to the Marketplace, in accordance with guidelines issued by HHS, that the individual meets other exceptional circumstances as the Marketplace may provide;
- Loss of minimum essential coverage.
- Loss of minimum essential coverage includes those circumstances described in 26 CFR 54.9801-6(a)(3)(i) through (iii).
- Loss of coverage does not include termination or loss due to: 1) Failure to pay premiums on a timely basis, including COBRA premiums prior to expiration of COBRA coverage, or 2) Situations allowing for a rescission as specified in 45 CFR 147.128.
- Will HMOs still have to provide one open-enrollment period annually?
Yes, the open enrollment period will either be an open enrollment for an individual plan to be offered on or off the Marketplace. If an HMO off the Marketplace decides to limit enrollment to open and specific enrollment periods, the enrollment period must mirror the enrollment period on the Marketplace.
Subsection E, 45 CFR 155.410 and 155.420 explains enrollment in QHPs, a link in provided for your reference: 45 CFR 155.410. For individual QHPs offered through the Marketplace, issuers, including HMOs, must adhere to the initial and annual open enrollment periods as required under 45 CFR 155.410. The initial open enrollment period begins October 1, 2013, and extends through March 31, 2014. For benefit years beginning on or after January 1, 2015, the annual open enrollment period begins October 15 and extends through December 7 of the preceding calendar year. 45 CFR 155.420(d) provides nine events that would trigger eligibility for qualified individuals to enroll in QHPs during a special enrollment period outside of the established annual open enrollment period.
- Does the ACA's, three-month grace period requirement for consumers receiving premium tax credits supersede the state's prompt pay law?
The federal regulation supersedes state law in the above scenario. States can maintain their laws if it does not interfere with the implementation of federal law. In this case, the federal grace period requirement supersedes the state prompt pay law.
- What options is Michigan considering to address adverse selection in the individual market?
Michigan has not taken action specifically related to curtailing adverse selection.
- At what point in the issuer agreement process can an issuer decide which of its certified products will be offered through the Marketplace?
Signing the issuer agreements with CMS will commit the issuer to the Marketplace for those selected products. Up to the time of signing, the issuer can decide whether it wants to market its plans on the Marketplace. The issuer must have indicated, at the time of filing, that the plan was for both on and off the Marketplace.
- Are all certified products required to be offered on the Marketplace?
No, an issuer may decide prior to signing the agreement whether they want to market the plan on the Marketplace. All pediatric dental plans are Marketplace-certified, regardless of the sales market.
- What application form and enrollment process will Michigan use for Marketplace enrollments?
As an FFM state, Michigan will follow the federal guidelines on application and enrollments in the FFM. Please review the document below for further information.
FFM Enrollment Operational Policy & Guidance.
The answers provided are not meant to be a substitute for legal advice.