The following questions have been received by the Idaho Department of Insurance
regarding the Idaho Health Insurance Exchange and SHOP (Idaho Exchange), the filing process, Qualified
Health Plan standards, and other related topics. The answers are intended to offer guidance on current
issues based on the DOI’s current understanding of applicable federal and state law requirements. If you
have any concerns regarding the accuracy of any of the guidance, please contact
Wes Trexler at the DOI by phone at 208-334-4315 or email. The
DOI will continue to release additional information and revise these responses as needed.
Will the Idaho DOI continue to allow transitional or “grandmothered” plans in the individual and small group market for 2015, for 2016, and beyond?
(3/4/2015, revised 10/2/2015 and 5/10/2016) DOI will continue to allow the grandmothered option for non-grandfathered individual and small group plans through 12/31/2017. After that date, individual and small group non-grandfathered plans must comply with all of the ACA provisions for the small group and individual market, per federal guidance released by the Center for Medicare and Medicaid Services (CMS).
Mid-size group plans (51-100), currently considered part of the large group market, will be redefined as small group plans for plan years beginning on or after January 1, 2016. Are these mid-size groups eligible for the transitional or “grandmothered” option, and if so, may they retain their current benefit design?
(3/4/2015, revised 7/21/2015 and removed 10/13/2015)
Per DOI Bulletin No. 14-01, carriers have the option of extending non-grandfathered mid-size group policies through plan years beginning on or before October 1, 2016. However, the ACA provisions listed in the bulletin that are applicable to grandmothered small group plans will also be applicable to these mid-size groups upon their redefinition from the large to the small group market, and so some changes may still be needed. For plan years beginning after October 1, 2016, the small group protections apply to employers with up to 100 employees, as determined by the federal method of counting employees provided by the IRS at 26 USC 4980H. Small groups must be provided all those protections, therefore the carrier must migrate them to an applicable small group plan upon renewal after October 1, 2016. According to DOI’s 2013 Frequently Asked Questions, the federal method of counting employees, provided by the IRS at 26 USC 4980H will be used beginning January 1, 2016, replacing the method found in Idaho Code section 41-4703(28). Does this mean that current small employer groups must be recalculated using the federal method to determine whether they retain small group status?
(3/4/2015, removed 7/21/2015)
Idaho permits renewal of a small group plan when a small employer subsequently gains employees and exceeds the limit for a small employer. See IDAPA 18.01.69.015.04. Therefore, employer size need not be recalculated if the employer chooses to renew the plan. However, if the employer fails to renew and selects a new plan, employer size must be recalculated, and if the new plan year begins on or after January 1, 2016, the federal counting method must be used. This renewal right is separate from how the group is defined for other purposes, such as the employer shared responsibility tax. When a grandfathered mid-size group is redefined as a small group (for plan years beginning on or after January 1, 2016), will they lose grandfathered status?
(3/4/2015, removed 10/13/2015)
Per the ACA, a mid-size employer with a grandfathered health plan loses grandfathered status only when one or more of the six changes listed at 45 C.F.R § 147.140(g)(1)(i-vi) are made to the plan. Therefore, the employer’s plan will not lose grandfathered status solely due to the redefinition as a small group.
Two or more businesses may be affiliated (under control of a single entity, per Idaho Code section 41-4703(2)). In situations where each business has fewer than 50
(or 100 beginning 1/1/2016) employees, but the total number of employees exceeds 50 (or 100 beginning 1/1/2016), are the affiliated businesses considered one large employer? If so, may each employer be issued a separate policy?
(3/4/2015, revised 10/13/2015) The affiliated businesses are considered to be a large employer, but each company could be issued a separate policy. However, in cases where the total number of employees of the affiliated businesses is
less than 50 (or 100 beginning 1/1/2016)at least two but no more than 50, Idaho Code 41-4708(3)(f) requires any small group policy offered by an insurer to be offered to every employee of all the affiliated businesses.
Has DOI established a filing timeline for large groups?
(3/4/2015) No, DOI timeline for filings for large groups continues to be “prior to use.”
The final 2016 Benefit and Payment Parameters rule modified the 2016 open enrollment period to November 1, 2015 through January 31, 2016. Does this change any of the dates in the DOI’s February 3, 2015 QHP Standards timeline?
(3/4/2015) The anonymous browsing will begin October 1, 2015, and open enrollment begins November 1, 2015. There are no other changes at this time.
What date can a carrier begin marketing 2016 QHPs?
(3/4/2015) In Idaho, a carrier can market their plans once the plan is filed. Due to the new process for a plan to be certified by Your Health Idaho as a QHP, carriers should wait until after August 28 (which is the expected date of certification by the Your Health Idaho Board of Directors) to state in marketing or other material that a specific plan is a QHP or that it will be available through Your Health Idaho.
Are there any Essential Health Benefit corrections needed for the 2016 QHP templates?
(3/4/2015) No, the 2016 plans and benefits template accurately reflects the Idaho benchmark plan. Please let DOI know if you have any specific concerns.
Regarding rate development, how should the age calibration and the age curve be applied to the plan adjusted index rate?
(3/4/2015) As explained in the Part III Actuarial Memorandum Instructions, each plan adjusted index rate should be calibrated using “weighted average age,” which means the average age curve factor weighted on projected enrollment by age for the risk pool. This factor does not need to correspond a whole number age on the age curve. After calibrating the plan adjusted index rate for geography as described in the Part III instructions, applying this age calibration and a specific rating area factor will result in the age 21 non-tobacco consumer adjusted premium rate for that rating area. This age 21 premium should be rounded to the nearest penny, and then the standard age curve factors should be applied to the rounded age 21 premium to set the premium for all other ages (also rounded to the nearest penny).
Regarding rate development, can consumer adjusted premium rates by rounded to the nearest dollar or some other rounding other than nearest penny?
(3/4/2015) In the case of a system limitation, it is acceptable to round the final consumer adjusted premium rates to the nearest dollar. However, rounding to the nearest dollar should only happen after calculating all consumer adjusted premium rates, rounded to the nearest penny. Carriers should confirm premiums rounded to the dollar do not exceed the 3:1 rating band restriction.
Can a carrier apply an open enrollment period that is broader than the federally mandated open enrollment period?
(3/4/2015) Yes, for enrollment outside of the exchange, a carrier can decide to provide an open enrollment window that is longer than the federally mandated period, as long as the carrier still complies with all the individual market provisions of the PHS Act. Therefore, the carrier must not advertise or offer the extended open enrollment period in a manner that discriminates among individuals based on a pre-existing medical condition or health status.
The 2016 Benefit and Payment Parameters clarified that the self-only maximum out-of-pocket applies even for policies that are not self-only. Does this apply for High Deductible Health Plans as well as PPO plans?
(3/4/2015) Yes, it does. All ACA-compliant plans, including HSA-compatible plans, must not exceed the self-only federal limit for the maximum out-of-pocket costs for each individual receiving coverage. This applies even for family policies, which must include the self-only maximum out-of-pocket limit for each individual and a separate family maximum out-of-pocket limit that does not exceed federal limit for family coverage.
In order to exclude pediatric dental coverage from a QHP, as explained in Idaho DOI Bulletin 14-02, there must be at least one Exchange-certified stand-alone dental plan available in the market. Is this the case for 2016 plans?
(3/4/2015) Based on the notices of intent received to date, DOI expects there to be at least one certified stand-alone dental plan in both the individual and the small group markets. Therefore, QHPs can choose to exclude pediatric dental coverage from those plans. As explained in Bulletin 14-02, medical plans that are not sold through Your Health Idaho (non-QHPs) must embed pediatric dental coverage.
Regarding the Plans and Benefits template, what expectations does the DOI have around SBC and Plan Brochure URLs?
(3/4/2015) SBC and Plan Brochure URLs must point directly to a PDF that includes the benefits and cost sharing provisions that apply to the referring plan variation. Plan brochures can include the details for more than one plan, as long as the specific plan variation is also clearly represented.
What method of counting employees will be used for the purpose of determining whether a group is defined as a small employer group?
(7/21/2015, revised 10/13/2015) For the purpose of determining participation in the small group market, the federal method of counting employees (45 C.F.R § 144.103) includes all employees, full or part time. Employees are counted by averaging the number of employees on business days during the previous year. However, states have the option of considering only certain “eligible” employees, in which part time employees are not counted.
Idaho Code 41-4703 defines an “eligible” employee as one who works 30 or more hours during a normal work week (unless, by agreement between the employer and the carrier, employees who work between 20 and 30 hours per week are included).
The Idaho DOI will continue to follow the state method of counting employees
after January 1, 2016.
Note that under the ACA, the FTE method of counting employees is used for other purposes, such as determining whether an employer is an applicable large employer and thus subject to the employer shared responsibility mandate, and determining eligibility for the small business tax credit.
If your question is not answered above, please submit your question directly to the DOI.