Agenda - Arkansas · 2014. 2. 14. · Option program 2015 Draft Letter to Issuers: ... Summary of Benefits and Coverage (SBC): • SBCs are required to be submitted for plan year

PCG Health 2/13/2014

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QHP Issuer Workshop Part I

QHP Application and Review Process Overview, Part I

February 14, 2014

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Agenda

QHP Advisory Committee 2

• Introductions

• Plan Management Updates

• AR 2014 QHP Filing and Certification Requirements

• Filing and QHP Certification Requirements

• Licensure

• Attestations

• New Schedule of Benefits Naming Conventions

• Essential Health Benefits; Coverage and Limitations

• Drug Formularies

• Network Adequacy Requirements

• Essential Community Providers

• Provider Directories

• Questions?


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Schedule and Logistics

QHP Advisory Committee 3

Meeting Information:

The meeting will be available in Webex. To join the meeting,

click here and enter meeting password ARQHP. The phone

number to for the voice conference is:

Call-in toll-free number (US/Canada): 1-877-668-4493

Access code:768 574 435

Proposed Schedule:

• 8:00am – Start meeting

• 9:15am – 15 Minute Break

• 9:30am - Resume

• 10:45am – Wrap up

Plan Management Updates

QHP Bulletin:

• The QHP Bulletin is pending decisions related to Private

Option program

2015 Draft Letter to Issuers:

• The 2015 draft letter to issuers was released by CCIIO and

summarizes plan year 2015 QHP certification requirements

• The letter can be found here.

QHP Advisory Committee4

https://pcgus.webex.com/pcgus/j.php?MTID=m404241b5e3338610ad8d29b73425f8c2

http://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/draft-issuer-letter-2-4-2014.pdf


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• 2014 QHP Application and Certification Timeline*:


2014 Key Dates Description

March 25th

Issuers submit planned service areas to AID;

Stand Alone Dental plans submit intent to

participate with planned service areas

April 1st – May 30th QHP Applications must be submitted to AID by

May 30th

June 1st – August 10th AID QHP Review Period

August 15th Accreditation of policies and procedures due

August 12th – September

10thRolling Plan Preview Period

September 10th Last day for issuers to resubmit plan data

October 17th Expected QHP Certification Agreement Date

November 15th Open Enrollment Begins

* Subject to change

Filing and QHP Certification Requirements

Accreditation Timeline:

• First year of AR Marketplace participation: Issuers must

schedule an accreditation review

• Second year of participation: Issuers must receive

accreditation on QHP Issuer policies and procedures

(plans certified in the first year of participation must have

their policies and procedures accredited by time of

recertification)

• Prior to the QHP Issuer’s fourth year of QHP Issuer

certification and in every subsequent year of certification, a

QHP Issuer must be accredited in accordance with 45

CFR 156.275.



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Meaningful Difference:

• The proposed review process for meaningful difference in plans

was expanded for 2015.

• Plans will be segmented by plan type, metal level and

overlapping counties/service areas and then evaluated for

differences in network, formulary, deductibles, MOOP, covered

benefits, premiums, HSAs, and availability for children.

• Plans are expected to differ in at least two of these areas.

7


Small Business Health Insurance Options Program

(SHOP):

• Employee choice (premium aggregation) was delayed in 2014

but will be effective in 2015; employers can offer one QHP or can

offer a choice of all QHPs offered at a single level of coverage

(bronze, silver, gold)

• For stand alone dental, employers can offer choice of all SADPs

offered or a single SADP

• CCIIO has indicated that SHOP participation requires at least two

silver and at least two gold plans.

• Additional clarifications are outlined in the draft letter to issuers

8


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Calculation of Cost-Sharing Reduction Payments:

• The process for estimation of cost-sharing reduction payments

was simplified for 2015: the product of actuarial value percentage

and plan premium will be used to calculate monthly advanced

payments instead of estimated payments by issuer.

9


Summary of Benefits and Coverage (SBC):

• SBCs are required to be submitted for plan year 2015.

SBCs illustrate benefits and coverage for common

conditions chosen by HHS: Routine maintenance of well-

controlled type 2 diabetes and having a baby (normal

delivery).

• SBCs for plan variations are not required, but are

encouraged.

45 CFR 147.200

10


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Additional updates:

• CCIIO has indicated that plans offered on the exchange must be

mirrored off the exchange in both benefit package and rating

(regardless of benefits offered, last year this was only a requirement

for plans that offered all ten EHBs, including pediatric dental).

• CCIIO has indicated that riders will not be allowed in the

Marketplace. In order to comply with AR Mandated Benefit

Offerings, mandated offerings will be required to be incorporated in

QHPs. Specific guidelines on meeting this requirement are

forthcoming.



QHP Application Process:

• QHP applications will be filed through SERFF

• Rate and form filings must both be submitted by the QHP

application deadline (see timelines).

• Process will be similar to 2014 QHP certification

• AID sent recommended changes to CCIIO regarding the

Plan and Benefit Add-in file such as:

• Grouping well child and well baby care with preventive services

• Clarifying EHB status of benefits such as “nutritional counseling” and

“infertility treatment” (EHBs only for diabetes management and in

vitro fertilization)

• Correcting EHB classifications such as with habilitation and Infertility



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QHP Application Process:

• Arkansas Health Plan Submission Requirements

(Attachment C) lists required templates, forms, and

documents required for application

• Please plan to attend the CCIIO workshop on April 7th and

8th:

“…This one-and-a-half day event will provide critical hands-on

training on the new QHP templates and QHP application

review tools…”



Recertification:

• All plans must be recertified annually to continue to offer

plans in the FFM

• If plans have changed significantly since the last plan year,

they may be certified as new QHPs (CCIIO is working on

guidance for recertification of plans)

• If an issuer is not seeking recertification of a plan sold in the

Marketplace, AID requests timely notice and fulfillment of all

coverage and reporting obligations



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Filing for Actuarial Rate Review:

• The process will be similar to last year; issuers submit the

actuarial memorandum and rates will be reviewed for all

QHPs (except SADPs)

• An additional standardized data template may be

requested to supplement the actuarial memorandum

(format and content TBD and can be reviewed in Part II)

• Carriers need to ensure that actuaries are available for

questions and discussions during the QHP review period

and can respond within 48 hours

• A new URRT was recently sent to AID and will be made

available

Complete filing instructions will be posted in SERFF



Marketing Materials:

• Marketing materials must be fined before they are used,

but do not have to be filed by the QHP deadline.

• Marketing materials will be reviewed for compliance with

state and federal standards; issuers may be asked to

modify or correct marketing materials



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Marketing Materials (continued):

• CCIIO requests that marketing materials and press

releases for QHPs include the following language (after

certification):

• “[Insert plan’s legal or marketing name] is a Qualified Health Plan

issuer in the [Health Insurance Marketplace]…” and;

• “[Insert plan’s legal or marketing name] does not discriminate on the

basis of basis of race, color, national origin, disability, age, sex,

gender identity, sexual orientation, or health status in the

administration of the plan, including enrollment and benefit

determinations.”

• Additional state guidelines are under consideration



Requirements Specific to Stand Alone Dental Plans

(SADPs):

• Stand-alone and embedded dental plan data submission

will follow the same timeline as that of medical plans.

Intent to apply is due March 25th.

• Rates submitted for SADPs will continue to be submitted

as “estimated” or “guaranteed”, but CMS has proposed to

make information available to consumers regarding

differences in estimated rates and actual premiums.



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Licensure and Solvency

Licensure and Solvency Review:

• An insurer must hold an Arkansas Certificate of Authority “C of A”

granting it authority to write Accident & Health insurance or to

operate as a Health Maintenance Organization. AID’s Finance

Division will certify whether or not the health plan applicant is

properly licensed in our state.

• Simultaneous QHP and licensure applications are allowed;

however, a QHP Issuer may not be certified for participation in the

Marketplace until state licensure has been established. All

licensure activities must be completed by August 10, 2014.


Licensure and Solvency

Licensure and Solvency Review:

• If an insurer is not licensed in the state of Arkansas, they may

apply for a C of A by submitting an Uniform Certificate of Authority

Application “UCAA”. The UCAA application, fees, Arkansas

contact information and detailed instructions can be found on the

following website: http://www.naic.org/industry_ucaa.htm

• Arkansas has a standard goal of processing all applications within

a 90 day time frame from the day of receipt of a complete

application

• The Finance Division will certify whether or not the health plan is

compliant with statutory financial requirements, as required by

Arkansas laws and regulations.


https://owa.pcgus.com/owa/redir.aspx?C=3doHduhZLUC_bp-Ar8scqTymzjh-_NAIlafhUa6mRc80gVu9xjfbDEIcohpnqFIA0RATkYbOyO8.&URL=http%3a%2f%2fwww.naic.org%2findustry_ucaa.htm



Attestations

Attestations forms:

• Only the federal attestation form will be required (this form has

not yet been released for plan year 2015 but will be included in

issuer filing instructions)

• Additional attestations may be requested

Attestation subjects include:

• Child-only plans

• Essential Health Benefit (EHB) standards

• EHB Formulary Standards

• Marketing standards

• Actuarial Value standards

• Plan Variation Standards

• Collection of Medicare quality information from hospitals



Naming Conventions:

Naming conventions will be required for plan schedules of

benefits:

• Schedules should be named in the following way:

Sch- + [-Component Plan ID-] + [Variation ID]

For example: Sch-15234AR0070003-01





Associated Schedule Items:

• QHP forms and associated documentation should be

attached to the binder through SERFF Plan Management

functionality. All applicable forms must be attached to the

correct plans in the binder.



Service Areas:


• AR has seven service areas. QHPs are required to cover all counties

in any geographic region included in the plan service area. The

premium rating areas are aligned with these service areas.



Essential Health Benefits

Overview:

Beginning in 2014, the Affordable Care Act required non-grand

fathered health plans to cover essential health benefits (EHB),

and HHS defines EHB based on state-specific EHB-benchmark

plans. AID chose these benchmark plans:

• Medical-BCBS Health Advantage POS

• Mental Health and Substance Use Disorder-QCA FEHBP

• Pediatric Vision-CHIP (AR Kids B)

• Pediatric Dental-CHIP (AR Kids B)

Benefit Checklist:

• Reference AR Essential Health Benefits Guidelines for an

overview of EHBs and required coverage (Attachment D).


Essential Health Benefits: Clarifications

ALL benefits included in the benchmark plans and outlined in the EHB

summary must be covered, including the benefits below:


Ambulatory Patient

ServicesEmergency Services Hospitalization

• Home Health-

Minimum 50 visits per

member per contract

year

• Standby Physicians

• After-Hours Care or

Urgent Care Center

• Observation

Services

• Transfer to In-

Network Hospital

• Outpatient Hospital

Services-must cover

services at an

Outpatient Radiation

Therapy Center

• Skilled Nursing

Facility- Minimum of

60 days per member

per contract year

http://hbe.arkansas.gov/FFE/Plan/BCBS-POS-SmGrp.pdf

http://hbe.arkansas.gov/FFE/Plan/QC-Federal-EHBP.pdf

http://hbe.arkansas.gov/FFE/Plan/PediatricVision.pdf

http://hbe.arkansas.gov/FFE/Plan/PediatricDental.pdf





Maternity and

Newborn CarePreventive Services

Pediatric Dental and

Vision

• Certified Nurse

Midwives

• Genetic Testing to

determine presence

of existing anomaly

or disease

• US Preventive

Services Task Force

A and B Rated

Benefits- must cover

at 100%

• See Attachment E

• Removable

Prosthetic Services

• Oral and

Maxillofacial

Services- must cover

Nitrous

oxide/analgesia N20

• Surgical evaluation

• Vision Therapy

Developmental

Testing

• Orthoptic and

Pleoptic Training

• Sensorimotor Exam


• Tobacco Cessation (a preventive service):

• USPSTF includes tobacco cessation as a Level A preventive service.

This includes “Tobacco use counseling and interventions” for both non-

pregnant adults and pregnant women.

• Click here for clinical summary of the USPSTF recommendation

for tobacco cessation (Attachment F)


Non-pregnant adultsThe USPSTF recommends that clinicians ask all adults

about tobacco use and provide tobacco cessation

interventions for those who use tobacco products.

Pregnant womenThe USPSTF recommends that clinicians ask all pregnant

women about tobacco use and provide augmented,

pregnancy-tailored counseling to those who smoke

http://www.uspreventiveservicestaskforce.org/uspstf09/tobacco/tobaccosum2.htm




• Tobacco Cessation (a preventive service):


Suggested Tobacco Cessation Language

“We cover tobacco cessation treatments. Covered counseling sessions include

proactive telephone counseling, group counseling and individual counseling for

tobacco cessation. Benefits are payable for up to two attempts per person per

calendar year, with up to four counseling sessions of at least 30 minutes each

per attempt. In addition, we cover over-the-counter (with a physician’s

prescription) and prescription smoking cessation drugs approved by the FDA,

including nicotine gum, nicotine patch, nicotine lozenge, nicotine nasal spray

and nicotine inhaler, bupropion and varenicline. The quantity of drugs

reimbursed will be subject to recommended courses of treatment. You may

obtain tobacco cessation drugs through … Pharmacy [A and B]. You may

access counseling and medication treatments without any cost-sharing.”

Essential Health Benefits: Cost Sharing

Maximum Out of Pocket Limits*:

• Note that OON Emergency Services can count towards in-

network MOOP

* Based on Proposed 2015 Proposed Benefit and Payment Parameters


Medical Dental

Individual $6,750 $300

Family $13,500 $400



Essential Health Benefits: Cost Sharing

Annual and Lifetime Dollar Limits:

• Not permitted in-network or out-of-network on EHBs

• Are allowed on non-EHBs in-network and out-of-network

• Annual or lifetime dollar limits are allowed if there is no visit or

utilization limit (i.e. an air ambulance visit can have a reasonable

dollar limit if the number of air transports is not limited)

Balanced Billing:

• Allowed for out-of-network services (with the exception of private

option plans)


Drug Formularies

Overview:

• Health plans must cover at least the greater of (1) one drug in

every USP category and class or (2) the same number of

prescription drugs in each USP category and class as the state’s

EHB -benchmark plan (See Attachment I for benchmark

formulary)

• All covered drugs, including medical drugs, should be submitted

in the drug formulary template

Updates for plan year 2015:

• CMS is proposing to modify the drug formulary template to allow

designation of “medical” drug covered under medical benefits or

“preventive” drug covered at no cost sharing.

• CMS is considering additional guidelines related to discriminatory

outlier analysis for drug coverage, as well as continuity of care




Network Adequacy requirements: Overview

Overview:

• QHPs must comply with state and federal network adequacy

guidelines.

• CCIIO has proposed that issuers submit a provider list that

includes all in network providers and facilities, focusing most

closely on hospital systems, mental health providers, oncology

providers, and primary care providers.

• PMAC and AID have developed AR Network Adequacy guidelines

which will be formalized in an AID rule; additionally, a draft

requirements checklist can be found in Attachment G.


Network Adequacy requirements:

AR Network Adequacy Submission Requirements Overview:

• Proof of Accreditation (if applicable)

• GeoAccess Maps

• Network Access Statistics

• Network Access Justification (if applicable)




Essential Community Providers

Overview:

• Essential community providers (ECPs) include providers that

serve predominantly low-income and medically underserved

individuals as described in 340B of the PHS Act and section

1927(c)(1)(D)(i)(IV) of the Social Security Act (SSA). ECP

requirements also apply to SADPs.

CCIIO 2015 Plan Year Proposed Requirements:

• Issuers are required to contract with 30% of available ECPs in the

QHP service area.

• CCIIO has outlined additional methods to meet ECP

requirements in the letter to issuers

• ECP list available here; Additional list for dental providers at

ECPs available here.



CCIIO 2015 Plan Year Proposed Requirements (continued):

• For Indian health providers and/or providers on CMS’ non-

exhaustive ECP list, issuers would contract with the corporate

entity named on the CMS list for that provider to be counted as an

ECP.

• Individual practitioners having the same address as another ECP on the CMS

list would not be counted as ECPs for purposes of meeting this standard.


http://cciio.cms.gov/programs/exchanges/qhp.html.

https://data.cms.gov/dataset/List-of-Essential-Community-Providers-ECPs-that-Pr/nwve-k4qu




Additional AID requirements:

• Arkansas Network Adequacy guidelines include the following

additional requirements related to ECPs:

• All ECPs in the provider network must be submitted in the FFM ECP template

and categorized according to CMS standards

• School-based providers must be included in the ‘Other’ category in FFM ECP

template

• A separate list of school-based providers must be submitted with address, zip

code, and county. (Excel or delimited format preferred); and

• At least one QHP includes one FQHC or RHC in each of the seven state

service areas


Provider Directories

Updated Federal Requirements for 2015 Plan Year (draft):

• QHP provider directories must be available online and indicate

the following:

• Location

• Contact information

• Specialty

• Medical group and any institutional affiliations

• Whether the provider is accepting new patients

• The URL provided to the Marketplace as part of the QHP

Application should link directly to the directory, such that

consumers do not have to log on, enter a policy number, or

navigate to directory





Updated Federal Requirements for 2015 Plan Year:

• CMS encourages issuers to include:

• Languages spoken

• Provider credentials

• Whether the provider is an Indian health provider



Updated AID Requirements for 2015 Plan Year:

• Online provider directory must be available in Spanish

• The directory search must include the ability to filter by FQHC,

Ryan White Provider, Family Planning Provider, Indian Provider,

Hospital, and Other ECP Provider

• Part-time or full-time availability is shown for each provider

• After-hours availability indicator is shown for each provider

• Participation in PCMH is indicated for each provider




Topics for Issuer Workshop Part II

• Additional clarifications from CCIIO

• Plan variations and cost sharing

• Private Option considerations

• Additional EHB requirements not covered today


Questions?




Attachment Index

Documents mentioned in this presentation:

A. 2015 Draft Letter to Issuers

B. SERFF Filing Instructions (Will be found on SERFF)

C. Arkansas Health Plan Submission Requirements

D. AR Essential Health Benefits Guidelines

E. USPSTF preventive health benefits guide

F. USPSTF Tobacco Cessation Recommendations

G. Draft Network Adequacy Checklist

H. State benchmark plans

I. Benchmark drug formulary

J. New URRT and Instructions

K. Uniform Certificate of Authority Application “UCAA”.


44

Public Consulting Group, Inc.

148 State Street, Tenth Floor, Boston, Massachusetts 02109

(617) 426-2026, www.publicconsultinggroup.com

http://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=2&cad=rja&ved=0CDAQFjAB&url=http%3A%2F%2Fwww.cms.gov%2FCCIIO%2FResources%2FRegulations-and-Guidance%2FDownloads%2Fdraft-issuer-letter-2-4-2014.pdf&ei=Tyr9UtrNIMqiyAGy7oGIBQ&usg=AFQjCNGZBkcsUo13SygQgcDt7yFsDYBs4A&sig2=Q7hePgp8Q3IQrVP650hv1A&bvm=bv.61190604,d.aWc

http://www.uspreventiveservicestaskforce.org/uspstf/uspsabrecs.htm

http://www.uspreventiveservicestaskforce.org/uspstf09/tobacco/tobaccosum2.htm

http://www.naic.org/industry_ucaa.htm

MedicalStand Alone

Dental (Pediatric)

Medical (Non-

Grandfathered)

SADP

(Non-EHB)*

Program Attestation Form

Federal Attestation Form; Includes

Justification Form form if required, such as if

issuer responds "No" to any attestation

Required Required Not Required Not Required

Compliance Plan

Includes compliance plan and organizational

chart evaluation questions and review

criteria


Administrative General Company and Contact Information Required Required Required Required

Essential Community Providers List of ECPs included in the provider network Required Required Not Required Not Required

List of School-Based ProvidersList of school-based providers covered in-

networkRequired

Required (if

applicable)Not Required Not Required

Actuarial Value Calculator

CMS Tool that validates A/V Requirements

for medical plans (with the exception of

unique benefit design plans)

Required Not Required Recommended Not Required

Plan/ Benefit Data CMS Plan and benefit information template Required Required Required Required

Plan/Benefit Add In CMS Plan and benefit add-in template Required Required Required Required

Service Area CMS Plan service area template Required Required Not Required Not Required

Network CMS Network Template Required Required Not Required Not Required

Prescription Drug Formulary CMS Formulary Information Template Required Not Required Required Not Required

Rate Data CMS Rating Tables Template Required Required Required Required

Business RulesCMS Template for Supporting business rules-

defines rates and helps determine eligibilityRequired Required Required Required

AccreditationCMS Template to indicate NCQA or URAC

accreditation statusRequired Not Required Not Required Not Required

Unified Rate Review Form Rate Review Template developed by HHS Required Not Required Required Not Required

Part II Consumer Justification

Narrative

Justification narrative for rate increases

(that exceed 10% threshold)If applicable Not Required If applicable Not Required

Part III Actuarial MemorandumRate filing documentation to support QHP

rates and all rate increasesIf applicable Not Required If applicable Not Required

SADP Disclosure of Attribution and

Allocation Methods

Stand Alone Dental form to indicate

attribution and allocation methods if plan

also includes adult dental coverage

Not Required If applicable Not Required Not Required

SADP Actuarial Value FormStand Alone Dental Actuarial Value

Justification formNot Required Required Not Required Required

PPACA Uniform Compliance

Summary

Summary of compliance with PPACA health

insurance marketplace reformsRequired Required Required Required

Gen

eral

Req

uir

emen

ts

|

DRAFT Arkansas Health Plan Submission RequirementsPlan Year 2015

FFM Plan (including plans also offered

outside the FFM)Plans Offered Only Outside of the FFM

DescriptionForm or Template

Templates, Forms, and Other Certifications Required for Plans Offered In the Federally-Facilitated Marketplace (FFM) and

Outside Market

Page 1 AR Health Plan Submission Requirements Last Revised 2/13/2014

MedicalStand Alone

Dental (Pediatric)

Medical (Non-

Grandfathered)

SADP

(Non-EHB)*

Gen

eral

Req

uir

emen

ts

|




Unique Actuarial Value Plan

Justification Form

Form that is required if A/V calculator

cannot be used due to unique plan design.

Must be certified by an actuary.

Required for unique

plan designNot Required

Required for unique

plan designNot Required

EHB Benefit Subtitution Form

Actuarial verification that benefit

substitution is "substantially equivalent" to

base benchmark plan

Required for EHB

substitution

Required for EHB

substitution

Required for EHB

substitution

Required for EHB

substitution

Drug Formulary Inadequate

Category/ Class Count Supporting

Documentation and Justification

Justification form required if formulary does

not meet category / class count standardsIf applicable Not required If applicable Not required

SHOP Tying Provision FormVerification of compliance with SHOP Tying

provision

Required for

individual market

Required for

individual marketNot Required Not Required

Essential Community Provider

Supplemental Response Form

Required by some issuers if ECP standards

to not meet "Safe Harbor" or Alternative

ECP standards

If applicable If applicable Not Required Not Required

Federal Access Plan Cover Sheet*NOT Required for Arkansas filings. See AR

Network Access Plan BelowNot Required Not Required Not Required Not Required

Service Area Partial County

Justification

Required if service area covers any partial

county service areaIf applicable If applicable Not Required Not Required

Limited Cost Sharing Plan

Variation— Estimated Advance

Payment Supporting


Certifies that an issuer has followed the CMS

standards for developing limited cost

sharing CSR advance payment estimates

Required Not Required Not Required Not Required

Discrimination - Cost Sharing

Outlier Justification

http://www.serff.com/documents/plan_ma

nagement_data_instructions_ch13d.pdfIf requested If requested Not Required Not Required

Marketing Language JustificationMay be required if marketing language is

identified as discriminatoryIf requested If requested Not Required Not Required

Discrimination Drug Utilization

Management Outlier Justification

May be required if drug utilization design is

determined to be an outlier; issuers may

submit justification with filing if the plan is

unique or it is anticipated to be identified as

an outlier

If requested Not Required Not Required Not Required

Meaningful Difference JustificationMay be required if plans are not determined

to be meaningfully different.If requested If requested Not Required Not Required

Cost Sharing—Supporting


for Exceeding Annual Limitation on

Small Group Deductibles

Certifies that plans meet the reasonableness

exception for exceeding

annual limitation on small group deductibles

If applicable Not Required If applicable Not Required




Out of Pocket Expenses ("Nesting"

Justification")

Justification for possible plan design where

the drug and/or medical out of pocket

maximums count towards each other but

exceed total required maximum.

If applicable Not Required If applicable Not Required




Small Group Out of Pocket

Maximums (Multiple

Small group plans are required to submit

this justification plan if total MOOP is

exceeded due to non-integrated plans

If applicable If applicable If applicable If applicable

Sup

ple

men

tal J

ust

ific

atio

n F

orm

s

|


http://www.serff.com/documents/plan_management_data_instructions_ch13d.pdf

http://www.serff.com/documents/plan_management_data_instructions_ch13d.pdf

MedicalStand Alone

Dental (Pediatric)

Medical (Non-

Grandfathered)

SADP

(Non-EHB)*

Gen

eral

Req

uir

emen

ts

|




Network Access Plan

Access plan requirement published in AID

network adequacy rule (for non-accredited

issuers only)


GeoAccess Maps and Access

StatisticsSee AID Network adequacy rule Required Required Required Required

List of School-Based ProvidersList of school-based providers covered in-

networkRequired

Required (if

applicable)Not Required Not Required

QHP Certification Checklist QHP Certification checklist found on SERFF Recommended Recommended Not Required Not Required

Actuarial Spreadsheet

Additional actuarial spreadsheet may be

requested to supplement the actuarial

memorandum

Required Not Required Not Required Not Required

Ark

ansa

s-Sp

ecif

ic

Re

qu

irem

ents

* Note that Stand Alone Dental plans intended to be utilized outside the

Marketplace only for use to supplement medical plans such that the medical

plans must comply with federal requirement of offering all 10 EHBs outside the

Marketplace as required under the Public Health Services Act must follow the

Marketplace certification filing process and must include all submissions

required under "FFM Plan" Requirements.


1

Attachment D

BenefitBenchmark Plan or AR

StatuteLimitations Coverage Definition or Policy Language

Primary care physician visits BCBS POS Page 11

Specialist office visit BCBS POS Page 12

Services and procedures provided in

the Specialist office other than

consultation and evaluation

BCBS POS Page 12

Outpatient Services BCBS POS Page 13

Surgical Services - Outpatient BCBS POS Page 12

Ambulatory Surgical Center Services BCBS POS Page 13

Outpatient Diagnostics BCBS POS Page 14

Advanced Diagnostic Imaging BCBS POS Page 14

Outpatient Physical Therapy BCBS POS Page 15 Minimum of 30 days per member per contract year.

Outpatient Occupational Therapy BCBS POS Page 15 Minimum of 30 days per member per contract year.

Home Health BCBS POS Page 18 Minimum of 50 visits per member per contract year.

Hospice Care for individuals with life

expectancy of less than 6 monthsBCBS POS Page 19

Qualified Assistant Surgeon Services BCBS POS Page 12

Standby Physicians BCBS POS Page 12



Emergency Care Services BCBS POS Page 16 has to have same cost sharing OON as in network

After-hours clinic or urgent care

centerBCBS POS Page 16

Observation services BCBS POS Page 16

Transfer to in-network hospital BCBS POS Page 16

Ambulance Services BCBS POS Page 18

Ground and water ambulance covered at a minimum

cost of $1,000 per trip; Air ambulance services

minimum of 1 trip per contract year

Arkansas Essential Health Benefits Guidelines

Ambulatory Patient Services

Emergency Services

2



Hospital Services BCBS POS Page 12

Physician Hospital Visits BCBS POS Page 13

Inpatient Services BCBS POS Page 13

Outpatient Hospital Services BCBS POS Page 13must include services provided in an Outpatient

Radiation Therapy Center

Hospital services in connection with

Dental TreatmentBCBS POS Page 13

benchmark plan: services in connection with

treatment for a complex dental condition provided to:

1) Person under 7 who is determined by 2 dentists to

require the dental treatment without delay; 2) Person

with a diagnosis of serious mental or physical

condition; or 3) Person certified by his PCP to have a

significant behavioral problem.

Surgical Services - Inpatient BCBS POS Page 12

Inpatient Physical Therapy BCBS POS Page 15 Minimum of 60 days per member per contract year.

Inpatient Occupational Therapy BCBS POS Page 15 Minimum of 60 days per member per contract year.

Skilled Nursing Facility Services BCBS POS Page 18

Minimum of 60 days per member per contract year.

Must be admitted within at least 7 days of release

from hospital. Custodial care is not an EHB.

Organ Transplant Services BCBS POS Page 21



Certified nurse midwives BCBS POS Page 14

benchmark plan: Coverage is only provided for

services provided by a certified nurse

midwife who has a collaborative agreement with a

Physician who is within immediate proximity to the

Hospital utilized by the certified nurse midwife, in case

there is need for assistance during the delivery.

Newborn care in the hospitalBCBS POS Page 14 §23-

79-129 & Bulletin 1-84

Hospital stay for a newborn child of at least 48 hours

following a vaginal delivery or at 96 hours following a

cesarean section. Out of Network newborn coverage

has to be at least $2,000 per member for all services

(for first 90 days of birth).

Hospitalization

Maternity and Newborn Care

3

In vitro fertilization

BCBS POS Page 33 (not

covered in benchmark

plan) 23-85-137, 23-86-

118 & Rule 1

In vitro is not covered in the benchmark plan but it is a

mandated benefit so it has to be covered. A dollar

limit is not allowed but a service limit that is

actuarially similar to the $15,000 established in Rule 1

is allowed (1 cycle equivalent)

Genetic testing to determine

presence of existing anomaly or

disease

BCBS POS Page 15

benchmark plan: Covered if (a) is the only way to

diagnose the disease or condition, (b) has been

scientifically proven to improve outcomes when used

to direct treatment, and (c) will affect the individual’s

treatment plan.Prenatal and Newborn Testing BCBS POS Page 27

Maternity and Obstetrics, including

pre and post natal careBCBS POS Page 14

Routine Prenatal Care includes minimum of one

routine ultrasound



Professional Services(by licensed

practitioners acting within the scope

of their license)

QCA HMO Page 45

Marriage and family counseling must be covered if

provided for treatment of a disorder defined in the

most recent edition of the Diagnostic and Statstical

Manual of Mental Disorders of the American

Psychiatric Association

"we cover professional services by licensed professional

mental health and substance abuse practitioners when

acting within the scope of their license, such as

psychiatrists, psychologists, clinical social workers, licensed

professional counselors, or marriage and family therapists."

Diagnosis and treatment services QCA HMO Page 46 Must include services listed in benchmark→

Diagnosis and treatment of psychiatric conditions,

mental illness, or mental disorders. Services include:

• Diagnostic evaluation

• Crisis intervention and stabilization for acute

episodes

• Medication evaluation and management

(pharmocotherapy)

• Psychological and neuropsychological testing

necessary to determine the appropriate psychiatric

treatment

• Treatment and counseling (including individual or

group therapy visits)

• Diagnosis and treatment of alcoholism and drug

abuse, including detoxification, treatment and

counseling

• Professional charges for intensive outpatient

treatment in a provider's office or other

professional setting

Diagnostics QCA HMO Page 45

Inpatient hospital or other covered

facilityQCA HMO Page 46

benchmark plan: Room and board, such as semiprivate

or intensive accomodations, general nursing care,

meals and special diets, and other hospital services

Mental Health and Substance Use Disorders, Including Behavioral Health Treatment

4

Outpatient hospital or other covered

facilityQCA HMO Page 46

benchmark plan: Services in approved treatment

programs, such as partial hospitalization, half-way

house, residential treatment, full-day hospitalization,

or facility based intensive outpatient treatment



Prescription Drugs:

Plan covers at least the greater of:

(1) One drug in every category and

class; or (2) the same number of

drugs in each category and class as

the EHB-benchmark plan



Rehabilitative Physical,

Occupational, and Speech TherapiesBCBS POS Page 15, 28

Outpatient (including chiropractors): Minimum 30

aggregate visits per member per contract year.

Cardiac Rehabilitation: minimum 36 visits per member

per contract year).

Neurologic rehabilitation: minimum 60 days per

member per lifetime.

Habilitative Physical, Occupational,

and Speech TherapiesBCBS POS Page 15, 28

Outpatient (including chiropractors): Minimum 30

aggregate visits per member per contract year.

Cardiac Rehabilitation: minimum 36 visits per member

per contract year).

Neurologic rehabilitation: minimum 60 days per

member per lifetime.

Developmental services BCBS POS Page 15 TBD

Durable Medical Equipment BCBS POS Page 17 at least 90-day supply per purchase.

Prosthetic and Orthotic DevicesBCBS POS Page 17, 23-99-

417

Replaced no less frequently than once per 3-year

period except when necessary due to growth or end of

the device's useful life.

Cochlear and other implantable

devices for hearing, but not hearing

aids

BCBS POS Page 17

must be covered: 1. Cochlear implants actuarially

similar to $35,000 lifetime limit. 2. at least one

auditory brain stem implant per lifetime for an

individual twelve years of age and older with a

diagnosis of Neurofibromatosis Type II (NF2) who has

undergone or is undergoing removal of bilateral

acoustic tumors 3. implantable osseointegrated

hearing aid for patients with single-sided deafness

Medical supplies BCBS POS Page 17 31-day supply per month

Rehabilitative and Habilitative Services and Devices

Prescription Drugs

5



Testing and Evaluation BCBS POS Page 27 minimum 15 hours per member per year.



Case Management Communications

made by PCPBCBS POS Page 12

Preventive Health Services BCBS POS Page 12 insurer pays 100%

Routine immunizations BCBS POS Page 12 insurer pays 100%

US Preventive Services Task Force A

and B rated benefitsBCBS POS Page 12

insurer pays 100%; policy must contain "US Preventive

Services Task Force A or B rated benefits"; please

include this tobacco language →

suggested tobacco cessation language for plan year 2015:

We cover tobacco cessation treatments. Covered counseling

sessions include proactive telephone counseling, group

counseling and individual counseling for tobacco cessation.

Benefits are payable for up to two attempts per person per

calendar year, with up to four counseling sessions of at least

30 minutes each per attempt. In addition, we cover over-the-

counter (with a physician’s prescription) and prescription

smoking cessation drugs approved by the FDA, including

nicotine gum, nicotine patch, nicotine lozenge, nicotine

nasal spray and nicotine inhaler, bupropion and varenicline.

The quantity of drugs reimbursed will be subject to

recommended courses of treatment. You may obtain

tobacco cessation drugs through …

Pharmacy [A and B]. You may access counseling and

medication treatments without any cost-sharing.



Oral and Maxillofacial ServicesCHIP (AR Kids B) Section

11-8

must cover Nitrous oxide/analgesia N20 when used

with a surgical procedure or a procedure other than

examination, prophylaxis, fluoride, sealants and X-

rays.

ConsultationsCHIP (AR Kids B) Section II-

9

benchmark plan: limited to two per year. Extensions

of this benefit are available to recipients under the age

of 21 when the consultation is medically necessary.

Laboratory Services

Preventive and Wellness Services

Pediatric Dental (if applicable)

6

RadiographsCHIP (AR Kids B) Section II-

10

benchmark plan: Periapical X-rays must be taken to

substantiate the need for extractions and/or

restorations and endodontia. Periapical X-rays limited

to four per visit without a prior authorization. A

complete series of intraoral radiographs is allowable

for beneficiaries of all ages only once every five years.

Any limits may be exceeded based on medical

necessity for beneficiaries under age 21.

Children's Preventive ServicesCHIP (AR Kids B) Section II-

11

benchmark plan: Dental prophylazis and flouride each

covered once every 6 months for under 21. Dental

sealants covered once per lifetime for 1st and 2nd

permanent molars only for under 21.

Dental Sealants CHIP (AR Kids B) Section II-

12

Space maintainersCHIP (AR Kids B) Section II-

12

RestorationsCHIP (AR Kids B) Section II-

12

benchmark plan: amalgam restorations- no prior

authorization needed. 4 or more surface composite-

resin restoration requires prior authorization.

Crowns

CHIP (AR Kids B)Section II-

13

benchmark plan: cast crowns not covered for posterior

teeth. Chrome (prior auth on all permanent teeth),

anterior (under 14), procelain to metal (prior

authorization under 21)

EndodontiaCHIP (AR Kids B) Section II-

13

Peridontal ProceduresCHIP (AR Kids B) Section II-

14

Removable prosthetic services

CHIP (AR Kids B)Section II-

14

benchmark plan: Full and acrylic partial dentures are

covered for beneficiaries of all ages. Full dentures or

acrylic partial dentures may be approved for use

instead of fixed bridges.

Oral Surgery

CHIP (AR Kids B) Section II-

15

Professional visitsCHIP (AR Kids B) Section II-

17



Eye Exam CHIP (AR Kids B) vision benchmark plan: limit 1 per year

Eye wear CHIP (AR Kids B) vision benchmark plan: limit 1 per year

Lenses CHIP (AR Kids B) vision

Contact lenses CHIP (AR Kids B) vision benchmark plan: if medically necessary

Pediatric Vision

7

Eye prosthesis CHIP (AR Kids B) vision

Polishing services CHIP (AR Kids B) vision

Surgical evaluation CHIP (AR Kids B) vision

benchmark plan: Eyeglasses for children diagnosed as

having the following diagnoses must have a surgical

evaluation in

conjunction with supplying eyeglasses:

1. Ptosis (droopy lid)

2. Congenital cataracts

3. Exotropia or vertical tropia

4. Children between the ages of twelve (12) and

twenty-one (21) exhibiting exotropiaVision Therapy Developmental

TestingCHIP (AR Kids B) vision

ORTHOPTIC AND PLEOPTIC

TRAININGCHIP (AR Kids B) vision

SENSORIMOTOR EXAMINATION CHIP (AR Kids B) vision



Diabetes Management ServicesBCBS POS Page 18, §23-79-

601 et al. & Rule 70

New Interventions BCBS POS Page 9

All plans have to cover new interventions. Benchmark

plan: 1. New interventions that have scientific

evidence are covered

2. New interventions in the process of phase I, II, III

trials are NOT covered

3. New interventions with rare or remote scope are

covered

Clinical Trials PHSA Sec. 2709

Please add language similar to the following to be in

compliance with PHSA Sec. 2709: "Routine patient costs"

mut be paid when a covered person participates in a clinical

trial, that includes coverage typically provided outside of

clinical trials. If an in-network provider is participating in a

clinical trial, the issuer may require participation in the trial

through the participating provider if the provider will accept

the individual as a participant. An individual may participate

in an approved clinical trial conducted outside the state in

which the individual resides. "Qualified Individual" -eligible

to participate according to the trial protocol and referring

health care professional/medical information establishing

appropriateness. Phase I,II,III, or IV clinical trials are covered

and conducted in relation to the prevention, detection, or

treatment of cancer or other life-threatening disease or

condition.

Complications from Smallpox

vaccineBCBS POS Page 28

Miscellaneous

8

Chelation Therapy BCBS POS Page 28

benchmark plan: Covered for control of ventricular

arrhythmias or heart block associated with digitalis

toxicity, emergency treatment of hypercalcemia,

extreme conditions of metal toxicity, including

thalassemia intermedia with hemosiderosis, Wilson’s

disease (hepatolenticular degeneration), lead

poisoning and hemochromatosis

Contraceptive Devices BCBS POS Page 28

Dietary and Nutritonal Counseling

ServicesBCBS POS Page 28

benchmark plan: covered for dietary and nutritional

counseling services when provided in conjunction with

Diabetic Self-Management Training, for services

needed by Members in connection with cleft 29palate

management and for nutritional assessment programs

provided in and by a Hospital and approved by Health

Advantage.

Electrotherapy Stimulators BCBS POS Page 29

bench mark plan: coverage is provided for a

Transcutaneous Electrical Nerve Stimulator (TENS) to

treat chronic pain due to peripheral nerve injury when

that pain is unresponsive to medication.

Enteral Feedings BCBS POS Page 29

benchmark plan: covered when such feedings have

been approved and documented by an In-Network

Physician as being the Member’s sole source of

nutrition.

High Frequency Chest Wall

OscillatorsBCBS POS Page 29

benchmark plan: covered for Member’s age 17 or

older with cystic fibrosis, for one high frequency chest

wall oscillator during such Member’s lifetime.

Inotropic Agents for Congestive

Heart FailureBCBS POS Page 29

benchmark plan: where the patient is on a cardiac

transplant list at a hospital where there is an ongoing

cardiac transplantation program, the Plan will cover

infusion of inotropic agents.

Trans-telephonic Home Spirometry BCBS POS Page 29benchmark plan: covered for patients who have had a

lung transplant.

Vision Enhancement BCBS POS Page 29

benchmark plan: coverage provided for a procedure,

treatment, service, equipment or supply to correct a

refractive error of the eye is covered in two instances:

(1) if such refractive error results from traumatic

injury or corneal disease, infectious or non infectious,

and (2) the single acquisition of eyeglasses or contact

lenses within the first six months following cataract

surgery



Autism Spectrum Disorders §23-99-418

Mandated Benefits

9

Breast Reconstruction/Mastectomy §23-99-405

Children’s Preventative Health Care§23-79-141 et al. & Rule

45

Colorectal Cancer Screening §23-79-1201 et al.

Dental Anesthesia §23-86-121

Diabetic Supplies/Education§23-79-601 et al. & Rule

70Equity in Prescription Insurance &

Contraceptive Coverage§23-79-1101 et al.

Formula for PKU/Medical Foods &

Low Protein Modified Food Products§23-79-701 et al.

Gastric Pacemakers §23-99-419

In-Vitro Fertilization§23-85-137, §23-86-118 &

Rule 1*does not apply to HMOs

Loss or Impairment of Speech or

Hearing§23-79-130

Maternity & Newborn Coverage §23-99-404

Mental Health Parity §23-99-501 et al.

Off-Label Drug Use §23-79-147

Prostate Cancer Screening §23-79-1301

Orthotic & Prosthetic Devices or

Services§23-99-417



Alcohol and Drug Dependency §23-79-139

Hospice §23-86-120

Mental Disorders §23-86-113

Mammogram §23-79-140

Out-Patient Service §23-86-108(5)

Psychological Examiners §23-79-142

TMJ (Musculoskeletal Disorders of

Face, Neck or Head)§23-79-150

Hearing Aids §23-79-1401 et al.

Mandated Offerings

P a g e | 1 D r a f t A R N e t w o r k A d e q u a c y C h e c k l i s t 2 / 1 4 / 2 0 1 4

DRAFT Arkansas Network Adequacy Standards Checklist Refer to AID Network Adequacy rule (pending) for QHP network adequacy guidelines. This checklist is a

summary of the guidelines that will be provided in the rule and is not intended to replace or modify anything in

the rule.

ACCREDITED ISSUERS ONLY

Proof of Accreditation (full accreditation or accreditation of network access policies and procedures)

NON-ACCREDITED ISSUERS ONLY

Network Access Policies and Procedures for Non-Accredited Carriers (additional guidelines will be included in the AID network adequacy rule).

ACCREDITED AND NON-ACCREDITED ISSUERS

A. GeoAccess Maps

Geo-Access maps should visually show the location of providers and the applicable drive time or mile radius

around those providers. Categories should be differentiated by separate

Primary Care Maps (30 mile or 30 minute radius*)

General/Family Practitioners or Internal Medicine

Family Practitioners and Pediatricians

Specialty Care Provider Maps (60 mile or 60 minute radius*)

Hospitals** Home Health Agencies Cardiologists Oncologists Obstetricians Pulmonologists

Endocrinologists Skilled Nursing Facilities Rheumatologists Opthalmologists Urologists Psychiatric and State Licensed Clinical Psychologist

Mental Health / Behavioral Health / Substance Abuse Provider Maps (45 mile or 45 minute radius*)

Psychiatric and State Licensed Clinical Psychologist Other (submit document outlining provider or facility types included)


Essential Community Providers (30 mile or 30 minute radius*)

FQHC Ryan White Provider Family Planning Provider Indian Provider Hospital Other ECP (Including School-Based Providers)

B. Performance Metrics

Primary Care:

Number of members and percentage of total members within 30 mile or 30 minute radius* of each

Primary Care provider below for entire state;


Primary Care provider below for each county;

The average distance to first, second, and third closest provider for each provider type below for

entire state;

The average distance to first, second, and third closest provider for each provider type below for each county



Specialty Care: Number of members and percentage of total members within 60 mile or 60 minute radius* of each

specialty care provider below for entire state;


specialty care provider below for each county;


entire state;

The average distance to first, second, and third closest provider for each provider type below for each

county

Hospitals** Home Health Agencies Cardiologists

Oncologists Obstetricians Pulmonologists

Endocrinologists Skilled Nursing Facilities Rheumatologists Opthalmologists Urologists

Psychiatric and State Licensed Clinical Psychologist

Mental Health / Behavioral Health / Substance Abuse: Number of members and percentage of total members within 45 mile or 45 minute radius* of each

mental health / behavioral health / substance abuse provider type below for entire state;



mental health / behavioral health / substance abuse provider type below for each county


entire state;


county

Essential Community Providers:


essential community provider type below for entire state;


essential community provider type below for each county


entire state;



C. Essential Community Providers (ECPs) All ECPs in the provider network are submitted in the FFM ECP template and categorized

according to CMS standards

School-based providers are included in the ‘Other’ category in FFM ECP template

Separate list of school-based providers submitted with address, zip code, and county. (Excel or

delimited format preferred)

At least one QHP includes one FQHC or RHC in each of the seven state service areas

D. Provider Directories Online Provider Directory available (URL submitted through network template in SERFF)

Online provider directory is available in Spanish

The directory search includes the ability to filter by FQHC, Ryan White Provider, Family Planning

Provider, Indian Provider, Hospital, and Other ECP Provider

Part-time or full-time availability shown for each provider

After-hours availability indicator for each provider

Participation in PCMH indicated for each provider

Additional Federal Requirements:

Directory indicates:

Location

Contact information

Specialty


Medical group and any institutional affiliations

Whether the provider is accepting new patients

*If carriers currently assess networks with more stringent internal network requirements (i.e. PCP available within 15 minutes or 15 miles), then maps and metrics should demonstrate these standards ** Hospitals types should be categorized according to hospital licensure type in Arkansas.

USPSTF Home Resource Links E-mail Updates

You Are Here: U.S. Preventive Services Task Force > Topic Index > Counseling: Tobacco Use > Clinical Summary

Counseling and Interventions to Prevent TobaccoUse and Tobacco-Caused Disease in Adults andPregnant WomenClinical Summary of U.S. Preventive Services Task ForceRecommendation

This document is a summary of the 2009 recommendation of the U.S. Preventive Services Task Force (USPSTF) oncounseling and interventions to prevent tobacco use and tobacco-caused disease in adults and pregnant women. Thissummary is intended for use by primary care clinicians.

Select for copyright and source information.

Population Adults Age ≥18 Years Pregnant Women of Any Age

Recommendation Ask about tobacco use.Provide tobacco cessation interventions

to those who use tobacco products.

Ask about tobacco use.Provide augmented pregnancy-tailored

counseling for women who smoke.

Grade: A Grade: A

CounselingThe "5-A" framework provides a useful counseling strategy:

Ask about tobacco use.1.Advise to quit through clear personalized messages.2.Assess willingness to quit.3.Assist to quit.4.Arrange follow-up and support.5.

Intensity of counseling matters: brief one-time counseling works; however, longersessions or multiple sessions are more effective.

Telephone counseling "quit lines" also improve cessation rates.

PharmacotherapyCombination therapy with counselingand medications is more effective thaneither component alone. FDA-approvedpharmacotherapy includes nicotinereplacement therapy, sustained-releasebupropion, and varenicline.

The USPSTF found inadequateevidence to evaluate the safety orefficacy of pharmacotherapy duringpregnancy.

ImplementationSuccessful implementation strategies for primary care practice include:

Instituting a tobacco user identification system.Promoting clinician intervention through education, resources, and feedback.Dedicating staff to provide treatment, and assessing the delivery of treatment instaff performance evaluations.

U.S. Preventive Services

Task Force

Counseling and Interventions to Prevent Tobacco Use and Tobacco-Ca... http://www.uspreventiveservicestaskforce.org/uspstf09/tobacco/tobacc...

1 of 2 2/13/2014 2:58 PM

Privacy Policy Terms of Use Accessibility Freedom of Information Act Web Site Disclaimers Contact Us

USPSTF Program Office 540 Gaither Road, Rockville, MD 20850

RelevantRecommendationsfrom the USPSTF

Recommendations on other behavioral counseling topics are available athttp://www.uspreventiveservicestaskforce.org.

Note: FDA = U.S. Food and Drug Administration; USPSTF = U.S. Preventive Services Task Force.

For a summary of the evidence systematically reviewed in making these recommendations, the full recommendationstatement, and supporting documents, please go to http://www.uspreventiveservicestaskforce.org.

Disclaimer: Recommendations made by the USPSTF are independent of the U.S. government. They should not beconstrued as an official position of the Agency for Healthcare Research and Quality or the U.S. Department of Health andHuman Services.

Return to Contents

Copyright and Source Information

This document is in the public domain within the United States.

Requests for linking or to incorporate content in electronic resources should be sent via the USPSTF contact form.

AHRQ Publication No. 09-05131-EF-2Current as of April 2009

Internet Citation:

U.S. Preventive Services Task Force. Counseling and Interventions to Prevent Tobacco Use and Tobacco-Caused Disease in Adults and Pregnant Women:Clinical Summary. AHRQ Publication No. 09-05131-EF-2, April 2009. http://www.uspreventiveservicestaskforce.org/uspstf09/tobacco/tobaccosum2.htm

Counseling and Interventions to Prevent Tobacco Use and Tobacco-Ca... http://www.uspreventiveservicestaskforce.org/uspstf09/tobacco/tobacc...

2 of 2 2/13/2014 2:58 PM


DRAFT Arkansas Network Adequacy Standards Checklist Refer to AID Network Adequacy rule (pending) for QHP network adequacy guidelines. This checklist is a

summary of the guidelines that will be provided in the rule and is not intended to replace or modify anything in

the rule.

ACCREDITED ISSUERS ONLY

Proof of Accreditation (full accreditation or accreditation of network access policies and procedures)

NON-ACCREDITED ISSUERS ONLY

Network Access Policies and Procedures for Non-Accredited Carriers (additional guidelines will be included in the AID network adequacy rule).

ACCREDITED AND NON-ACCREDITED ISSUERS

A. GeoAccess Maps

Geo-Access maps should visually show the location of providers and the applicable drive time or mile radius

around those providers. Categories should be differentiated by separate

Primary Care Maps (30 mile or 30 minute radius*)



Specialty Care Provider Maps (60 mile or 60 minute radius*)

Hospitals** Home Health Agencies Cardiologists Oncologists Obstetricians Pulmonologists

Endocrinologists Skilled Nursing Facilities Rheumatologists Opthalmologists Urologists Psychiatric and State Licensed Clinical Psychologist

Mental Health / Behavioral Health / Substance Abuse Provider Maps (45 mile or 45 minute radius*)

Psychiatric and State Licensed Clinical Psychologist Other (submit document outlining provider or facility types included)


Essential Community Providers (30 mile or 30 minute radius*)


B. Performance Metrics

Primary Care:


Primary Care provider below for entire state;


Primary Care provider below for each county;


entire state;




Specialty Care: Number of members and percentage of total members within 60 mile or 60 minute radius* of each

specialty care provider below for entire state;


specialty care provider below for each county;


entire state;


county

Hospitals** Home Health Agencies Cardiologists

Oncologists Obstetricians Pulmonologists

Endocrinologists Skilled Nursing Facilities Rheumatologists Opthalmologists Urologists

Psychiatric and State Licensed Clinical Psychologist

Mental Health / Behavioral Health / Substance Abuse: Number of members and percentage of total members within 45 mile or 45 minute radius* of each

mental health / behavioral health / substance abuse provider type below for entire state;



mental health / behavioral health / substance abuse provider type below for each county


entire state;


county

Essential Community Providers:


essential community provider type below for entire state;


essential community provider type below for each county


entire state;



C. Essential Community Providers (ECPs) All ECPs in the provider network are submitted in the FFM ECP template and categorized

according to CMS standards

School-based providers are included in the ‘Other’ category in FFM ECP template

Separate list of school-based providers submitted with address, zip code, and county. (Excel or

delimited format preferred)

At least one QHP includes one FQHC or RHC in each of the seven state service areas

D. Provider Directories Online Provider Directory available (URL submitted through network template in SERFF)

Online provider directory is available in Spanish

The directory search includes the ability to filter by FQHC, Ryan White Provider, Family Planning

Provider, Indian Provider, Hospital, and Other ECP Provider

Part-time or full-time availability shown for each provider

After-hours availability indicator for each provider

Participation in PCMH indicated for each provider

Additional Federal Requirements:

Directory indicates:

Location

Contact information

Specialty


Medical group and any institutional affiliations

Whether the provider is accepting new patients

*If carriers currently assess networks with more stringent internal network requirements (i.e. PCP available within 15 minutes or 15 miles), then maps and metrics should demonstrate these standards ** Hospitals types should be categorized according to hospital licensure type in Arkansas.

PRESCRIPTION DRUG EHB-BENCHMARK PLAN BENEFITS BY CATEGORY AND CLASS

Arkansas—6

CATEGORY CLASS SUBMISSION COUNT ANALGESICS NONSTEROIDAL ANTI-INFLAMMATORY DRUGS 20 ANALGESICS OPIOID ANALGESICS, LONG-ACTING 5 ANALGESICS OPIOID ANALGESICS, SHORT-ACTING 9 ANESTHETICS LOCAL ANESTHETICS 2 ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS ALCOHOL DETERRENTS/ANTI-CRAVING 2 ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS OPIOID ANTAGONISTS 3 ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS SMOKING CESSATION AGENTS 2 ANTI-INFLAMMATORY AGENTS GLUCOCORTICOIDS 1 ANTI-INFLAMMATORY AGENTS NONSTEROIDAL ANTI-INFLAMMATORY DRUGS 20 ANTIBACTERIALS AMINOGLYCOSIDES 6 ANTIBACTERIALS ANTIBACTERIALS, OTHER 17 ANTIBACTERIALS BETA-LACTAM, CEPHALOSPORINS 16 ANTIBACTERIALS BETA-LACTAM, OTHER 5 ANTIBACTERIALS BETA-LACTAM, PENICILLINS 10 ANTIBACTERIALS MACROLIDES 4 ANTIBACTERIALS QUINOLONES 8 ANTIBACTERIALS SULFONAMIDES 4 ANTIBACTERIALS TETRACYCLINES 4 ANTICONVULSANTS ANTICONVULSANTS, OTHER 1 ANTICONVULSANTS CALCIUM CHANNEL MODIFYING AGENTS 4 ANTICONVULSANTS GAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENTS 5 ANTICONVULSANTS GLUTAMATE REDUCING AGENTS 3 ANTICONVULSANTS SODIUM CHANNEL AGENTS 7 ANTIDEMENTIA AGENTS ANTIDEMENTIA AGENTS, OTHER 1 ANTIDEMENTIA AGENTS CHOLINESTERASE INHIBITORS 3 ANTIDEMENTIA AGENTS N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONIST 1 ANTIDEPRESSANTS ANTIDEPRESSANTS, OTHER 7 ANTIDEPRESSANTS MONOAMINE OXIDASE INHIBITORS 4 ANTIDEPRESSANTS SEROTONIN/NOREPINEPHRINE REUPTAKE INHIBITORS 8 ANTIDEPRESSANTS TRICYCLICS 9 ANTIEMETICS ANTIEMETICS, OTHER 10 ANTIEMETICS EMETOGENIC THERAPY ADJUNCTS 7 ANTIFUNGALS NO USP CLASS 22 ANTIGOUT AGENTS NO USP CLASS 5 ANTIMIGRAINE AGENTS ERGOT ALKALOIDS 2

Arkansas—7

CATEGORY CLASS SUBMISSION COUNTANTIMIGRAINE AGENTS PROPHYLACTIC 4 ANTIMIGRAINE AGENTS SEROTONIN (5-HT) 1B/1D RECEPTOR AGONISTS 7 ANTIMYASTHENIC AGENTS PARASYMPATHOMIMETICS 3 ANTIMYCOBACTERIALS ANTIMYCOBACTERIALS, OTHER 2 ANTIMYCOBACTERIALS ANTITUBERCULARS 8 ANTINEOPLASTICS ALKYLATING AGENTS 6 ANTINEOPLASTICS ANTIANGIOGENIC AGENTS 2 ANTINEOPLASTICS ANTIESTROGENS/MODIFIERS 3 ANTINEOPLASTICS ANTIMETABOLITES 2 ANTINEOPLASTICS ANTINEOPLASTICS, OTHER 3 ANTINEOPLASTICS AROMATASE INHIBITORS, 3RD GENERATION 3 ANTINEOPLASTICS ENZYME INHIBITORS 3 ANTINEOPLASTICS MOLECULAR TARGET INHIBITORS 12 ANTINEOPLASTICS MONOCLONAL ANTIBODIES 3 ANTINEOPLASTICS RETINOIDS 2 ANTIPARASITICS ANTHELMINTICS 3 ANTIPARASITICS ANTIPROTOZOALS 11 ANTIPARASITICS PEDICULICIDES/SCABICIDES 5 ANTIPARKINSON AGENTS ANTICHOLINERGICS 3 ANTIPARKINSON AGENTS ANTIPARKINSON AGENTS, OTHER 3 ANTIPARKINSON AGENTS DOPAMINE AGONISTS 4 ANTIPARKINSON AGENTS DOPAMINE PRECURSORS/L-AMINO ACID DECARBOXYLASE INHIBITORS 2 ANTIPARKINSON AGENTS MONOAMINE OXIDASE B (MAO-B) INHIBITORS 2 ANTIPSYCHOTICS 1ST GENERATION/TYPICAL 10 ANTIPSYCHOTICS 2ND GENERATION/ATYPICAL 9 ANTIPSYCHOTICS TREATMENT-RESISTANT 1 ANTISPASTICITY AGENTS NO USP CLASS 5 ANTIVIRALS ANTI-CYTOMEGALOVIRUS (CMV) AGENTS 2 ANTIVIRALS ANTI-HIV AGENTS, NON-NUCLEOSIDE REVERSE TRANSCRIPTASE

INHIBITORS 5 ANTIVIRALS ANTI-HIV AGENTS, NUCLEOSIDE AND NUCLEOTIDE REVERSE

TRANSCRIPTASE INHIBITORS 11 ANTIVIRALS ANTI-HIV AGENTS, OTHER 3 ANTIVIRALS ANTI-HIV AGENTS, PROTEASE INHIBITORS 9 ANTIVIRALS ANTI-INFLUENZA AGENTS 4 ANTIVIRALS ANTIHEPATITIS AGENTS 12 ANTIVIRALS ANTIHERPETIC AGENTS 5 ANXIOLYTICS ANXIOLYTICS, OTHER 4

Arkansas—8

CATEGORY CLASS SUBMISSION COUNTANXIOLYTICS SSRIS/SNRIS (SELECTIVE SEROTONIN REUPTAKE INHIBITORS/SEROTONIN

AND NOREPINEPHRINE REUPTAKE INHIBITORS) 5 BIPOLAR AGENTS BIPOLAR AGENTS, OTHER 6 BIPOLAR AGENTS MOOD STABILIZERS 4 BLOOD GLUCOSE REGULATORS ANTIDIABETIC AGENTS 21 BLOOD GLUCOSE REGULATORS GLYCEMIC AGENTS 2 BLOOD GLUCOSE REGULATORS INSULINS 10 BLOOD PRODUCTS/MODIFIERS/VOLUME EXPANDERS ANTICOAGULANTS 7 BLOOD PRODUCTS/MODIFIERS/VOLUME EXPANDERS BLOOD FORMATION MODIFIERS 8 BLOOD PRODUCTS/MODIFIERS/VOLUME EXPANDERS COAGULANTS 0 BLOOD PRODUCTS/MODIFIERS/VOLUME EXPANDERS PLATELET MODIFYING AGENTS 8 CARDIOVASCULAR AGENTS ALPHA-ADRENERGIC AGONISTS 5 CARDIOVASCULAR AGENTS ALPHA-ADRENERGIC BLOCKING AGENTS 4 CARDIOVASCULAR AGENTS ANGIOTENSIN II RECEPTOR ANTAGONISTS 8 CARDIOVASCULAR AGENTS ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITORS 10 CARDIOVASCULAR AGENTS ANTIARRHYTHMICS 9 CARDIOVASCULAR AGENTS BETA-ADRENERGIC BLOCKING AGENTS 13 CARDIOVASCULAR AGENTS CALCIUM CHANNEL BLOCKING AGENTS 9 CARDIOVASCULAR AGENTS CARDIOVASCULAR AGENTS, OTHER 4 CARDIOVASCULAR AGENTS DIURETICS, CARBONIC ANHYDRASE INHIBITORS 2 CARDIOVASCULAR AGENTS DIURETICS, LOOP 4 CARDIOVASCULAR AGENTS DIURETICS, POTASSIUM-SPARING 4 CARDIOVASCULAR AGENTS DIURETICS, THIAZIDE 6 CARDIOVASCULAR AGENTS DYSLIPIDEMICS, FIBRIC ACID DERIVATIVES 2 CARDIOVASCULAR AGENTS DYSLIPIDEMICS, HMG COA REDUCTASE INHIBITORS 7 CARDIOVASCULAR AGENTS DYSLIPIDEMICS, OTHER 6 CARDIOVASCULAR AGENTS VASODILATORS, DIRECT-ACTING ARTERIAL 3 CARDIOVASCULAR AGENTS VASODILATORS, DIRECT-ACTING ARTERIAL/VENOUS 3 CENTRAL NERVOUS SYSTEM AGENTS ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS,

AMPHETAMINES 4 CENTRAL NERVOUS SYSTEM AGENTS ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, NON-

AMPHETAMINES 4 CENTRAL NERVOUS SYSTEM AGENTS CENTRAL NERVOUS SYSTEM AGENTS, OTHER 3 CENTRAL NERVOUS SYSTEM AGENTS FIBROMYALGIA AGENTS 3 CENTRAL NERVOUS SYSTEM AGENTS MULTIPLE SCLEROSIS AGENTS 7 DENTAL AND ORAL AGENTS NO USP CLASS 7 DERMATOLOGICAL AGENTS NO USP CLASS 31 ENZYME REPLACEMENT/MODIFIERS NO USP CLASS 13 GASTROINTESTINAL AGENTS ANTISPASMODICS, GASTROINTESTINAL 6

Arkansas—9

CATEGORY CLASS SUBMISSION COUNTGASTROINTESTINAL AGENTS GASTROINTESTINAL AGENTS, OTHER 6 GASTROINTESTINAL AGENTS HISTAMINE2 (H2) RECEPTOR ANTAGONISTS 4 GASTROINTESTINAL AGENTS IRRITABLE BOWEL SYNDROME AGENTS 2 GASTROINTESTINAL AGENTS LAXATIVES 3 GASTROINTESTINAL AGENTS PROTECTANTS 2 GASTROINTESTINAL AGENTS PROTON PUMP INHIBITORS 4 GENITOURINARY AGENTS ANTISPASMODICS, URINARY 6 GENITOURINARY AGENTS BENIGN PROSTATIC HYPERTROPHY AGENTS 8 GENITOURINARY AGENTS GENITOURINARY AGENTS, OTHER 3 GENITOURINARY AGENTS PHOSPHATE BINDERS 3 HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (ADRENAL)

GLUCOCORTICOIDS/MINERALOCORTICOIDS23

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (PITUITARY)

NO USP CLASS 4

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (PROSTAGLANDINS)

NO USP CLASS 1

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (SEX HORMONES/MODIFIERS)

ANABOLIC STEROIDS 2


ANDROGENS 4


ESTROGENS 6


PROGESTINS 4


SELECTIVE ESTROGEN RECEPTOR MODIFYING AGENTS 1

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (THYROID)

NO USP CLASS 3

HORMONAL AGENTS, SUPPRESSANT (ADRENAL) NO USP CLASS 1 HORMONAL AGENTS, SUPPRESSANT (PARATHYROID) NO USP CLASS 1 HORMONAL AGENTS, SUPPRESSANT (PITUITARY) NO USP CLASS 8 HORMONAL AGENTS, SUPPRESSANT (SEX HORMONES/MODIFIERS) ANTIANDROGENS 5 HORMONAL AGENTS, SUPPRESSANT (THYROID) ANTITHYROID AGENTS 2 IMMUNOLOGICAL AGENTS IMMUNE SUPPRESSANTS 20 IMMUNOLOGICAL AGENTS IMMUNIZING AGENTS, PASSIVE 3 IMMUNOLOGICAL AGENTS IMMUNOMODULATORS 10 INFLAMMATORY BOWEL DISEASE AGENTS AMINOSALICYLATES 3 INFLAMMATORY BOWEL DISEASE AGENTS GLUCOCORTICOIDS 5 INFLAMMATORY BOWEL DISEASE AGENTS SULFONAMIDES 1

Arkansas—10

CATEGORY CLASS SUBMISSION COUNTMETABOLIC BONE DISEASE AGENTS NO USP CLASS 14 OPHTHALMIC AGENTS OPHTHALMIC PROSTAGLANDIN AND PROSTAMIDE ANALOGS 3 OPHTHALMIC AGENTS OPHTHALMIC AGENTS, OTHER 4 OPHTHALMIC AGENTS OPHTHALMIC ANTI-ALLERGY AGENTS 8 OPHTHALMIC AGENTS OPHTHALMIC ANTI-INFLAMMATORIES 11 OPHTHALMIC AGENTS OPHTHALMIC ANTIGLAUCOMA AGENTS 13 OTIC AGENTS NO USP CLASS 6 RESPIRATORY TRACT AGENTS ANTI-INFLAMMATORIES, INHALED CORTICOSTEROIDS 6 RESPIRATORY TRACT AGENTS ANTIHISTAMINES 11 RESPIRATORY TRACT AGENTS ANTILEUKOTRIENES 3 RESPIRATORY TRACT AGENTS BRONCHODILATORS, ANTICHOLINERGIC 2 RESPIRATORY TRACT AGENTS BRONCHODILATORS, PHOSPHODIESTERASE INHIBITORS (XANTHINES) 3 RESPIRATORY TRACT AGENTS BRONCHODILATORS, SYMPATHOMIMETIC 9 RESPIRATORY TRACT AGENTS MAST CELL STABILIZERS 1 RESPIRATORY TRACT AGENTS PULMONARY ANTIHYPERTENSIVES 6 RESPIRATORY TRACT AGENTS RESPIRATORY TRACT AGENTS, OTHER 5 SKELETAL MUSCLE RELAXANTS NO USP CLASS 6 SLEEP DISORDER AGENTS GABA RECEPTOR MODULATORS 3 SLEEP DISORDER AGENTS SLEEP DISORDERS, OTHER 4 THERAPEUTIC NUTRIENTS/MINERALS/ELECTROLYTES ELECTROLYTE/MINERAL MODIFIERS 5 THERAPEUTIC NUTRIENTS/MINERALS/ELECTROLYTES ELECTROLYTE/MINERAL REPLACEMENT 9