ADEA State Update

HHS Releases Letter to Issuers on Federally-facilitated and State Partnership Exchanges

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On April 5, the U.S. Department of Health and Human Services (HHS) released a letter to issuers on federally-facilitated and state partnership exchanges. The letter primarily provides issuers seeking to offer Qualified Health Plans (QHPs) in federally-facilitated and state partnership exchanges with operational guidance. Specifically, the letter provides operational guidance related to stand-alone dental plans. According to the letter issued by HHS, the following applies to stand-alone dental plans seeking certification as a QHP:

  • Prohibition on Annual and Lifetime Dollar Limits

The pediatric dental essential health benefit (EHB) offered by stand-alone dental plans certified to be offered in the exchanges must be offered without annual and lifetime limits.

  • Annual Limits on Cost-Sharing

Stand-alone dental plans certified to be offered inside an exchange will be required to demonstrate to the exchange that they have a reasonable annual limitation on cost-sharing in place. The exchange is responsible for determining “reasonableness.” There are separate specific dollar limits that apply to cost-sharing for comprehensive medical QHPs. For the 2014 coverage year in the federally-facilitated exchange (FFE), the Centers for Medicare & Medicaid Services (CMS) interprets “reasonable” as it relates to stand-alone dental plans to mean any annual limit on cost-sharing that is at or below $700 for a plan with one child enrollee, or $1,400 for a plan with two or more child enrollees.

  • Certification of Stand-Alone Dental Plans

Stand-alone dental plans must meet applicable certification standards related to EHBs, maximum out-of-pocket limits, network adequacy, and marketing.

  • Displaying Stand-alone Dental Plan Rates 

The exchanges are required to collect and display premium rate information for all QHPs, including stand-alone dental plans, in a standardized and comparable way. CMS will also display comparable rate information as well as calculate the advance payment of the premium tax credit for stand-alone dental plans using the pediatric dental EHB premium allocation. Stand-alone dental plans must indicate to consumers whether they are guaranteeing the information displayed in the rate table or reserving the option to charge additional premium amounts.

  • Separately Offering and Pricing Stand-Alone Dental Plans

Each exchange may require, as a condition of certification, comprehensive medical QHPs to offer and price the pediatric dental EHB (if covered) separately, if doing so would be in the best interest of consumers.

For the 2014 coverage year, CMS will not require comprehensive medical QHP issuers that provide pediatric dental coverage to offer and price the pediatric dental EHB separately from the rest of the plan in connection with certification by an FFE.

  • Data Collected Through the Stand-Alone Dental Plan Voluntary Reporting Program

CMS created a voluntary reporting program to determine in which exchanges dental issuers were likely to offer stand-alone dental plans. The data indicate that a stand-alone dental plan is expected to be offered in each state in which a FFE and a state partnership exchange will be operating. As a result, QHP issuers participating in FFEs and state partnership exchanges can expect to have the option to omit the pediatric dental EHB because stand-alone dental plans will be offered in those exchanges.

Duggan Dental