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PCG Health 2/13/2014
www.pcghealth.com 1
QHP Issuer Workshop Part I
QHP Application and Review Process Overview, Part I
February 14, 2014
www.pcghealth.com
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?
PCG Health 2/13/2014
www.pcghealth.com 2
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
PCG Health 2/13/2014
www.pcghealth.com 3
Plan Management Updates
• 2014 QHP Application and Certification Timeline*:
QHP Advisory Committee5
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.
QHP Advisory Committee6
PCG Health 2/13/2014
www.pcghealth.com 4
Plan Management Updates
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
Plan Management Updates
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
PCG Health 2/13/2014
www.pcghealth.com 5
Plan Management Updates
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
Plan Management Updates
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
PCG Health 2/13/2014
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Plan Management Updates
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 Advisory Committee11
Filing and QHP Certification Requirements
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
QHP Advisory Committee12
PCG Health 2/13/2014
www.pcghealth.com 7
Filing and QHP Certification Requirements
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…”
QHP Advisory Committee13
Filing and QHP Certification Requirements
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
QHP Advisory Committee14
PCG Health 2/13/2014
www.pcghealth.com 8
Filing and QHP Certification Requirements
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
QHP Advisory Committee15
Filing and QHP Certification Requirements
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
QHP Advisory Committee16
PCG Health 2/13/2014
www.pcghealth.com 9
Filing and QHP Certification Requirements
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
QHP Advisory Committee17
Filing and QHP Certification Requirements
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.
QHP Advisory Committee18
PCG Health 2/13/2014
www.pcghealth.com 10
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.
QHP Advisory Committee19
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.
QHP Advisory Committee20
PCG Health 2/13/2014
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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
QHP Advisory Committee21
Filing and QHP Certification Requirements
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
QHP Advisory Committee22
PCG Health 2/13/2014
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Filing and QHP Certification Requirements
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.
QHP Advisory Committee23
Filing and QHP Certification Requirements
Service Areas:
QHP Advisory Committee24
• 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.
PCG Health 2/13/2014
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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).
QHP Advisory Committee25
Essential Health Benefits: Clarifications
ALL benefits included in the benchmark plans and outlined in the EHB
summary must be covered, including the benefits below:
QHP Advisory Committee26
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
PCG Health 2/13/2014
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Essential Health Benefits: Clarifications
QHP Advisory Committee27
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
Essential Health Benefits: Clarifications
• 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)
QHP Advisory Committee28
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
PCG Health 2/13/2014
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Essential Health Benefits: Clarifications
• Tobacco Cessation (a preventive service):
QHP Advisory Committee29
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
QHP Advisory Committee30
Medical Dental
Individual $6,750 $300
Family $13,500 $400
PCG Health 2/13/2014
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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)
QHP Advisory Committee31
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
QHP Advisory Committee32
PCG Health 2/13/2014
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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.
QHP Advisory Committee33
Network Adequacy requirements:
AR Network Adequacy Submission Requirements Overview:
• Proof of Accreditation (if applicable)
• GeoAccess Maps
• Network Access Statistics
• Network Access Justification (if applicable)
QHP Advisory Committee34
PCG Health 2/13/2014
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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.
QHP Advisory Committee35
Essential Community Providers
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.
QHP Advisory Committee36
PCG Health 2/13/2014
www.pcghealth.com 19
Essential Community Providers
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
QHP Advisory Committee37
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
QHP Advisory Committee38
PCG Health 2/13/2014
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Provider Directories
Updated Federal Requirements for 2015 Plan Year:
• CMS encourages issuers to include:
• Languages spoken
• Provider credentials
• Whether the provider is an Indian health provider
QHP Advisory Committee39
Provider Directories
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
QHP Advisory Committee40
PCG Health 2/13/2014
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Topics for Issuer Workshop Part II
• Additional clarifications from CCIIO
• Plan variations and cost sharing
• Private Option considerations
• Additional EHB requirements not covered today
QHP Advisory Committee41
Questions?
QHP Advisory Committee42
PCG Health 2/13/2014
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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”.
QHP Advisory Committee43
44
Public Consulting Group, Inc.
148 State Street, Tenth Floor, Boston, Massachusetts 02109
(617) 426-2026, www.publicconsultinggroup.com
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
Required Required Not Required Not Required
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
|
FFM Plan (including plans also offered
outside the FFM)Plans Offered Only Outside of the FFM
DescriptionForm or Template
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
Documentation and Justification
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
Documentation and Justification
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
Cost Sharing—Supporting
Documentation and Justification
for Exceeding Annual Limitation on
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
Cost Sharing—Supporting
Documentation and Justification
for Exceeding Annual Limitation on
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
|
Page 2 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
|
FFM Plan (including plans also offered
outside the FFM)Plans Offered Only Outside of the FFM
DescriptionForm or Template
Network Access Plan
Access plan requirement published in AID
network adequacy rule (for non-accredited
issuers only)
Required Required Not Required Not Required
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.
Page 3 AR Health Plan Submission Requirements Last Revised 2/13/2014
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
BenefitBenchmark Plan or AR
StatuteLimitations Coverage Definition or Policy Language
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
BenefitBenchmark Plan or AR
StatuteLimitations Coverage Definition or Policy Language
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
BenefitBenchmark Plan or AR
StatuteLimitations Coverage Definition or Policy Language
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
BenefitBenchmark Plan or AR
StatuteLimitations Coverage Definition or Policy Language
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
BenefitBenchmark Plan or AR
StatuteLimitations Coverage Definition or Policy Language
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
BenefitBenchmark Plan or AR
StatuteLimitations Coverage Definition or Policy Language
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
BenefitBenchmark Plan or AR
StatuteLimitations Coverage Definition or Policy Language
Testing and Evaluation BCBS POS Page 27 minimum 15 hours per member per year.
BenefitBenchmark Plan or AR
StatuteLimitations Coverage Definition or Policy Language
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.
BenefitBenchmark Plan or AR
StatuteLimitations Coverage Definition or Policy Language
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
BenefitBenchmark Plan or AR
StatuteLimitations Coverage Definition or Policy Language
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
BenefitBenchmark Plan or AR
StatuteLimitations Coverage Definition or Policy Language
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
BenefitBenchmark Plan or AR
StatuteLimitations Coverage Definition or Policy Language
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
BenefitBenchmark Plan or AR
StatuteLimitations Coverage Definition or Policy Language
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
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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)
P a g e | 2 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
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;
Number of members and percentage of total members within 30 mile or 30 minute radius* of each
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
General/Family Practitioners or Internal Medicine
Family Practitioners and Pediatricians
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;
Number of members and percentage of total members within 60 mile or 60 minute radius* of each
specialty 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
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;
P a g e | 3 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
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 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
Essential Community Providers:
Number of members and percentage of total members within 30 mile or 30 minute radius* of each
essential community provider type below for entire state;
Number of members and percentage of total members within 30 mile or 30 minute radius* of each
essential community provider type 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
FQHC Ryan White Provider Family Planning Provider Indian Provider Hospital Other ECP (Including School-Based Providers)
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
P a g e | 4 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
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...
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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
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)
P a g e | 2 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
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;
Number of members and percentage of total members within 30 mile or 30 minute radius* of each
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
General/Family Practitioners or Internal Medicine
Family Practitioners and Pediatricians
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;
Number of members and percentage of total members within 60 mile or 60 minute radius* of each
specialty 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
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;
P a g e | 3 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
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 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
Essential Community Providers:
Number of members and percentage of total members within 30 mile or 30 minute radius* of each
essential community provider type below for entire state;
Number of members and percentage of total members within 30 mile or 30 minute radius* of each
essential community provider type 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
FQHC Ryan White Provider Family Planning Provider Indian Provider Hospital Other ECP (Including School-Based Providers)
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
P a g e | 4 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
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
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (SEX HORMONES/MODIFIERS)
ANDROGENS 4
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (SEX HORMONES/MODIFIERS)
ESTROGENS 6
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (SEX HORMONES/MODIFIERS)
PROGESTINS 4
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (SEX HORMONES/MODIFIERS)
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