1 Presentation to Enroll Virginia Navigators September 9, 2016Thomas S. Bridenstine, MPS Managed Care Ombudsman Julie S. Blauvelt Policy Advisor and Plan Management Administrator
2 Presentation OverviewThe State Corporation Commission Plan Management Functions Rate Review Process 2017 Applications/Plans Approved Consumer Services – Complaints Office of the Managed Care Ombudsman – Appeals Independent External Review
3 The State Corporation CommissionThe State Corporation Commission Virginia Constitution created the State Corporation Commission (SCC) 3 Commissioners appointed for 6 year terms by the General Assembly Organized as an independent state regulatory agency Separate department of government Own legislative, administrative and judicial powers SCC powers are delineated by state constitution and state law SCC decisions can only be appealed to the Supreme Court of Virginia Operational funds do not come from the General Fund
4 SCC Regulatory OversightSCC Regulatory Oversight Began operations in 1903 Regulated railroads, telegraph companies, later telephone companies SCC jurisdiction includes: State-chartered financial institutions – banks, credit unions Insurance companies and agents Life and health insurance and property and casualty insurance Securities Public utilities – telephone, electric, natural gas, water Retail Franchising Railroads Central filing office for corporations, partnerships, and LLCs
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6 Bureau of Insurance (BOI)The BOI licenses, regulates, reviews policy forms and rates for filing and/or approval, investigates and examines insurance companies, agencies and agents on behalf of the citizens of the Commonwealth of Virginia. The BOI also registers, examines and investigates (title) real estate settlement agents and agencies. BOI ensures regulated companies follow applicable laws in Title 38.2 of the Code of Virginia
7 SCC to perform plan management functions for FFM2013 Legislation Enacted SCC to perform plan management functions for FFM Virginia Department of Health to assist in plan management functions SCC authority to review and approve Health Insurance premium rates in Individual and Small Group markets Revised Virginia’s laws to conform to most ACA health insurance laws at the time
8 Plan Management Virginia evaluates applications for qualified health plans and recommends certification, decertification, and recertification to CMS
9 Plan Management Review, Monitoring and Oversight DutiesBureau of Insurance Department of Health Licensed and in Good Standing Accreditation Requirements and Timeline Plans and Benefits (variations for cost-sharing reductions) Network Adequacy Essential Health Benefits Essential Community Providers Actuarial Value Standards Service Area Rates (new and increases) Program Attestations Meaningful Difference Marketing
10 QHP/SADP Review/Approval ProcessCarrier submissions through SERFF (binders include templates, and form/rate filings) CMS validates templates and provides electronic tools to assist in review BOI and VDH correspond with carriers through SERFF Recommendations and Data Transfer of QHPs and SADPs to CMS through SERFF
11 Rate Review Premium Rates applicable to health benefit plans in the individual and small group markets in Virginia are subject to review and approval: §§ and – identifies forms and rates subject to the Commission’s review and approval § – defines and describes plan management Rules Governing Filing of Rates for Individual and Group Accident and Sickness Insurance – 14 VAC et. seq. – establishes specific standards applicable to both initial rates and premium rate changes All carriers planning on participating in the individual and small group markets present rate information to the Commission each year
12 Rating Rules Rates in Individual and Small Group Markets may only vary from plan-to-plan and person-to-person by: Individual vs. family coverage (3 oldest children <21) Rating Area (12 in Virginia) Age (3:1) Tobacco use (1.5:1) Rates may only change annually, except for changes to: Family Member requested coverage change Member moves to another geographic location
13 Rate Filings – Individual and Small Group Health Insurance PlansRate Sheets Rate Review Requirements Checklist URRT – Part I Actuarial Memorandum – Part III Actuarial Value Calculator Screen Shots Rate Revisions Template – Form 130A Trend Analysis Details – Form 130B Virginia Rate Template Health Insurance Rate Request Summary – Part 1 and Summary Life & Health Actuarial Memorandum
14 Major Rate Change Drivers – 2017Medical claim trend, including provider unit costs and increased utilization Population morbidity Reinsurance program elimination Changes in provider contracts and networks Maintain compliance with Actuarial Value Changes in program richness Changes in administrative costs Risk Adjustment payments or receipts
15 Overview * Off-Exchange Rates not final Market 2015 2016 2017No. of Carriers Avg. Rate Change Individual On-Exchange 9 +8.4% 11 +11.0% +19.5% Individual Off-Exchange 6 +13.7% 5 +12.1% 3 +17.5%* Small Group On-Exchange +4.4% +3.3% +8.6% Small Group Off-Exchange 18 +6.6% 13 +5.6% +11.8%* * Off-Exchange Rates not final
16 Planned Changes for 2017 Aetna Health Inc. (HMO) to replace Aetna Life Insurance Company (PPO) (Roanoke/SWVA, Williamsburg/Tidewater, Northern Neck, Bedford) and Coventry Health Care of Virginia, Inc. (POS) (Richmond, Charlottesville, Danville areas) on FFM Optima Health Plan (HMO) will no longer service entire state on FFM; only plans to serve (Williamsburg/ Tidewater, Lynchburg, Roanoke, Winchester, and Harrisonburg areas) UnitedHealthcare of the Mid-Atlantic, Inc. (HMO) will leave Clarke, Frederick, Orange, Shenandoah, and Warren counties and Winchester on FFM Cigna Health and Life Insurance Company (EPO) plans to enter FFM in Richmond and Northern Virginia areas
17 2017 QHP Applications Company Product Type Individual SHOPAetna Health Inc. HMO CareFirst BlueChoice, Inc. HMO/POS Cigna Health and Life Insurance Company EPO Group Hospitalization and Medical Services, Inc. PPO HealthKeepers, Inc. Innovation Health Insurance Company Innovation Health Plan, Inc. Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. Optima Health Plan Piedmont Community HealthCare HMO, Inc. Piedmont Community HealthCare, Inc. UnitedHealthcare of the Mid-Atlantic, Inc. Totals 11 5
18 Consumer Services - Complaints Office of Managed Care Ombudsman - Appeals
19 Consumer Services Section (CSS)Serves as a general resource for consumers and interested parties Educates consumers on insurance products Provides personalized assistance to consumers that want to file a complaint against their insurer The complaint must be written and signed by the insured CSS writes to the insurer and the insurer must respond in writing Informs consumer of the result of the investigation Investigates complaint and related issues, initiate corrective action when regulatory violations are found May take disciplinary action against the insurer, or refer to another section in the Bureau of Insurance for disposition
20 Complaints Typically involves administrative denialsIncludes coverage termination, premium payments, coordination of benefits, administrative/contractual denials, denials not supported by policy provisions Examples: Insured did not fully understand the policy Insured paid the premium but insurer states it was not received Individual has trouble affording the out-of-pocket costs Insurer incorrectly terminated the coverage Individual has a HMO but requires out-of-network services Delay in insurer receiving identification card Insurer started new plan but experienced problems with continuity of care/Rx drugs Dysfunctional communications between the insurer and Marketplace Rate increase
21 Office of the Managed Care OmbudsmanOffice of the Managed Care Ombudsman Serves as a general resource for consumers and interested parties, to include providers Provides personalized assistance to consumers requesting to appeal a denial Navigate the process Protect appeal rights Formally assist the individual in filing an appeal Contact the insurer, help resolve disputed issues Review decisions
22 Appeals Typically involves denials based on medical necessity, or investigational/experimental denials Common appeals include, prescription drugs, imaging tests (CT Scans, PET Scans, MRIs) laboratory tests, hospital admissions, hospital length of stay, mental health care, and substance/alcohol abuse treatment Includes both outpatient and inpatient treatment and services May include denial for out-of-network care Examples: Prescription drug denied as not medically necessary CT/PET scan denied for a cancer patient IVIG infusion denied for neurology patient Dental insurance denied crowns Insurer did not approve certain inpatient treatment for a substance abuse patient
23 Independent External ReviewVirginia law regarding External Review applies to all fully- insured health benefit plans Process described in coverage documents Covered persons or an authorized representative may request an Independent External Review of certain adverse determinations by insurers Persons are notified of their right by the insurer Requests are made to the Bureau’s External Review Section No fee; no minimum dollar amount of claims If determined eligible, the Bureau administers the review by randomly selecting a contracted Independent Review Organization (IRO) Insurer or plan pays for cost of IRO review The insurer and covered person may submit material for the IRO’s consideration The IRO issues a determination that is binding on the parties
24 Eligibility for Independent External ReviewMust exhaust internal appeals, includes not receiving a timely determination and filing an expedited appeal Must be covered by a fully-insured Virginia policy, or a self-insured ERISA plan that elected to use Virginia’s External Review process Must receive a denial, reduction or termination of a covered service on the basis that it is not medically necessary, does not meet requirements for appropriateness, health care setting, level of care or effectiveness, or is experimental/investigational Bureau must receive request within 120 days of person receiving notice of right to External Review
25 Independent External Review TimelineAppeal must be filed with the Bureau within 120 days of the date enrollee receives notice of right to independent external review 5 business days to submit additional information to IRO IRO must inform insurer and enrollee of final decision within 45 days (timeframes for experimental denial reasons slightly different) Expedited review for urgent care claims Decision from IRO within 72 hours
26 Statistics July 1, 2015 – June 30, 2016 Consumer Services Complaints353 Marketplace-related complaints Managed Care Ombudsman Appeals 624 Inquiries 131 Appeals Independent External Reviews 171 Eligible External Reviews Closed 44% Overturned July 1, 2015 – June 30, 2016
27 SCC Bureau of InsuranceContact Information Presenters SCC Bureau of Insurance State Corporation Commission Bureau of Insurance Life & Health Division Mailing address: Street address: P.O. Box E. Main St. Richmond VA Richmond VA 23219 Fax: (804) TDD/Voice: (804) External Review: Fax: (804) Thomas S. Bridenstine, MPS Managed Care Ombudsman (804) or Julie S. Blauvelt Policy Advisor and Plan Management Administrator (804)
28 Knowledge Is Your Best Policy… 8/2016