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District of ColumbiaQHP Application Bulletin - Version 1.0, October 26, 2012Backup User Access Contact - Name and Contact InformationMarketing Contact - Name and Contact InformationChief Medical Officer/Medical Director - Name and ContactInformationPharmacy/Formulary Contact - Name and Contact InformationPayment Contact - Name and Contact InformationGovernment Relations - Contact Name and Contact InformationHIPAA Security Officer - Name and Contact InformationHIPAA Privacy Officer - Name and Contact InformationFinancial Reporting Contact - Name and Contact InformationComplaints Tracking Contact - Name and Contact InformationQuality Contact - Name and Contact InformationAPTC/CSR Contact - Name and Contact InformationRisk Corridors - Name and Contact InformationCompliance Officer - Name and Contact InformationIndividual Market Contact - Name and Contact InformationSmall Group Contact - Name and Contact InformationRate and Benefit Contact - Name and Contact InformationRisk Adjustment Contact - Name and Contact InformationReinsurance Contact - Name and Contact InformationQuality Contact - Name and Contact hBothBothBothBothBothBothBothBothBothBothDistrict of Columbia Dental RequirementsContact information and attestation language will also be required for the dental application.The application or attached instructions will contain clear directions that the point of contact identifiedshould be the person with primary responsibility for and authority over the carrier’s QHP(s) in the DCExchange.7

District of ColumbiaQHP Application Bulletin - Version 1.0, October 26, 20123- Licensure and Financial ConditionThis information will be Carrier-specific and will only need to be submitted once, per carrier, for allrelated initial QHP application submissions.ACA RequirementsA QHP issuer must be licensed and in good standing to offer health insurance coverage in each state inwhich the issuer offers health insurance coverage (45 CFR Part 156.200(b)(4)).District of Columbia QHP Requirements The application will request licensure and financial condition information.QHPs will be required to attest to language similar to, “We certify that we are licensed to sellhealth insurance in the District of Columbia, and are in good standing, and will maintain goodstanding and appropriate solvency levels consistent with the addition of this new business.”Necessary information may include:o Licensure Supporting Documentation: Supporting documentation to demonstratecurrent licensure and authority. May include license and/or certificate(s) of authority.o Seeking Licensure Narrative: Free text narrative describing additional licenses and/orauthority needed to offer proposed plans described in application, if applicable.o Expected Date of Licensure/Authorization: Date by which the applicant expects to haveobtained necessary licenses and/or authority, if applicable.o Solvency Supporting Documentation: Supporting documentation to demonstratecurrent compliance with State financial solvency requirements.o Solvency Justification Narrative: Free Text narrative providing justification for why theissuer does not meet State solvency requirements and/or does not project a positive networth for the calendar year in which it is currently applying to offer QHPs, if applicable.o State Corrective Action Narrative: Free text narrative providing explanation related tocurrent State corrective action, if applicable.o Financial Solvency Good Standing Documentation: Supporting documentation todemonstrate that applicant is not currently under corrective action by State related tonon-compliance with financial solvency requirements.District of Columbia Dental RequirementsThe dental application will also require an attestation and licensure and financial condition information.8

District of ColumbiaQHP Application Bulletin - Version 1.0, October 26, 20124- Quality Information (Accreditation)This information will be Carrier-specific and will only need to be submitted once, per carrier, for allrelated initial QHP application submissions.ACA RequirementsTo be certified, a plan shall at a minimum (i) be accredited with respect to local performance on clinicalquality measures such as the Healthcare Effectiveness Data and Information Set, patient experienceratings on a standardized Consumer Assessment of Healthcare Providers and Systems survey, as well asconsumer access, utilization management, quality assurance, provider credentialing, complaints andappeals, network adequacy and access, and patient information programs by any entity recognized bythe Secretary for the accreditation of health insurance issuers or plans (so long as any such entity hastransparent and rigorous methodological and scoring criteria), or (ii) receive such accreditation within aperiod established by the Exchange for such accreditation that is applicable to all qualified health plans.(Section 1311 (c)(1)(D) of the ACA)District of Columbia QHP Requirements The District of Columbia will accept all HHS accrediting entities (i.e., NCQA or URAC), as long asthey cover the basic ACA requirements.Accreditation must cover the carrier’s District of Columbia operations.There will be a one-year grace period for compliance for plans that are not accredited at thetime of application. For QHPs within the grace period, an attestation that the plan has appliedfor accreditation and an updated application status will be required.Required data elements may include:o Accreditation Organization Identification Number (Org ID)/Application Numbero Name of Accrediting Entityo Market Type (Commercial or Medicaid) Health care coverage that a health care entity is already providing in the large,small or individual commercial markets or in the Medicaid market.o Accrediting Product (if applicable) (HMO/POS/PPO) An organization may have accreditation at the product levelo Accreditation Sub ID (if applicable) A unique identifier that an accrediting entity assigns to each product withineach existing line of business that is offered by a health care organization.o Authorized Release of Accreditation Survey Indicator of whether applicant authorized release of accreditation survey by theaccrediting entity to the Exchange and HHS. This authorization is required.District of Columbia Dental RequirementsThis information will not be required for the dental application.Because of the reliance the D.C. HBX Authority will be placing on accreditation, additional qualityinformation will be required of plans in the grace period that have not yet obtained their accreditation.9

District of ColumbiaQHP Application Bulletin - Version 1.0, October 26, 20125- Quality Information (Quality Reporting)This information will be Carrier-specific and will only need to be submitted once, per carrier, for allrelated initial QHP application submissions.ACA RequirementsThe Secretary shall, by regulation, establish criteria for the certification of health plans as qualifiedhealth plans. Such criteria shall require that, to be certified, a plan shall, at a minimum, (H) provide information to enrollees and prospective enrollees, and to each Exchange in which theplan is offered, on any quality measures for health plan performance endorsed under section399JJ of the Public Health Services Act, as applicable, and (I) report to the Secretary at least annually andin such manner as the Secretary shall require, pediatric quality reporting measures consistent with thepediatric quality reporting measures established under section 1139A of the Social Security Act. (Section1311(c)(1)(H)&(I))QHP issuers must disclose and report on: Health care quality and outcomes measures Implement and report on Quality Improvement Strategy(s) consistent with 1311(g) Enrollee satisfaction surveys consistent with section 1311(c)(4) (covered later in thePerformance Information section) (45 CFR Part 156.200(b)(5))Note: Specific measures related to health care quality and outcomes have not been further defined byHHS.District of Columbia QHP Requirements Carriers will be required to report District of Columbia-specific quality information to satisfy DCquality reporting requirements. Specific guidance on District of Columbia quality reportingrequirements will be provided in the future.District of Columbia Dental RequirementsQuality reporting will not be required for the current dental application. Dental-specific qualitymeasures may be promulgated by the District of Columbia for future plan years.In an effort to ensure equal comparison of data between QHPs and to minimize administrative burden tothe Exchange, health care quality and outcome measures should be reported in a consistent format asdefined by HHS or the District of Columbia.10

District of ColumbiaQHP Application Bulletin - Version 1.0, October 26, 20126- Quality Information (Quality Strategy)This information will be Carrier-specific and will only need to be submitted once, per carrier, for allrelated initial QHP application submissions.ACA RequirementsQHP issuers must implement and report on quality improvement strategy or strategies consistent with1311(g)(1) of the ACA (45 CFR Part 156.200(b)(5). Note: This is the same citation as for the previousrequirement, #1, as it is one of the three quality requirements listed.)(g) REWARDING QUALITY THROUGH MARKET-BASED INCENTIVES:(1) STRATEGY DESCRIBED – A strategy described in this paragraph is a payment structure that providesincreased reimbursement or other incentives for:(A) Improving health outcomes through the implementation of activities that shall includequality reporting, effective case management, care coordination, chronic disease management,medication and care compliance initiatives, including through the use of the medical homemodel, for treatment or services under the plan or coverage.(B) the implementation of activities to prevent hospital readmissions through a comprehensiveprogram for hospital discharge that includes patient-centered education and counseling,comprehensive discharge planning, and post discharge reinforcement by an appropriate healthcare professional.(C) the implementation of activities to improve patient safety and reduce medical errorsthrough the appropriate use of best clinical practices, evidence based medicine, and healthinformation technology under the plan or coverage;(D) the implementation of wellness and health promotion activities; and(E) [as added by section 10104(g)] the implementation of activities to reduce health and healthcare disparities, including through the use of language services, community outreach, andcultural competency trainings.(2) The Secretary, in consultation with experts in health care quality and stakeholders, shall developguidelines concerning the matters described in paragraph (1). (Section 1311 (g) of the ACA)District of Columbia QHP Requirements Quality improvement information will not be requested in the application from accreditedcarriers, but an attestation that addresses the required elements from this section will beincluded.Accreditation status for carriers will meet the quality strategy requirements if the accreditationadequately covers all required elements of the quality strategy requirements, including theguidelines to be developed by HHS.For carriers that have not been accredited, this requirement will apply and a written qualityimprovement strategy must be submitted.District of Columbia Dental Requirements11

District of ColumbiaQHP Application Bulletin - Version 1.0, October 26, 2012The attestation of a quality strategy will not be required for the dental application.12

District of ColumbiaQHP Application Bulletin - Version 1.0, October 26, 20127- Quality Information (Pharmacy Utilization Management Program)This information will be Carrier-specific and will only need to be submitted once per carrier for all relatedinitial QHP application submissions.ACA RequirementsA QHP issuer must provide to HHS the following information: The percentage of all prescriptions that were provided under the QHP through retail pharmaciescompared to mail order pharmacies, and the percentage of prescriptions for which a genericdrug was available and dispensed compared to all drugs dispensed, broken down by pharmacytype, (Section 156.295(a)(1)) The aggregate amount, and the type of rebates, discounts or price concessions (Section156.295(a)(2)) The aggregate amount of the difference between the amount the QHP issuer pays its contractedPBM and the amounts that the PBM pays retail pharmacies, and mail order pharmacies, and thetotal number of prescriptions that were dispensed (Section 156.295(a)(3))District of Columbia QHP RequirementsThe District of Columbia will have no requirements above and beyond ACA Pharmacy UtilizationManagement Program requirements.District of Columbia Dental RequirementsPharmacy utilization management program quality information will not be required for the dentalapplication.13

District of ColumbiaQHP Application Bulletin - Version 1.0, October 26, 20128- Quality Information (Quality Rating Data)This information will be Carrier-specific and will only need to be submitted once, per carrier, for allrelated initial QHP application submissions.ACA RequirementsThe Secretary shall develop a rating system that would rate qualified health plans offered through anExchange in each benefits level on the basis of the relative quality and price. The Exchange shall includethe quality rating in the information provided to individuals and employers through the Internet portalestablished under paragraph (4) (Section 1311(c)(3) of the ACA).District of Columbia QHP RequirementsQuality rating information will be requested in the application.District of Columbia Dental RequirementsQuality rating information will not be required for the dental application unless required by HHS or theDistrict of Columbia.DISB will request the quality rating data from the carriers that will be necessary to provide, implementand maintain the quality rating system developed by HHS. Reporting of quality data will be in a singleform and format (to be determined).14

District of ColumbiaQHP Application Bulletin - Version 1.0, October 26, 2012Section 3: Potential QHP-specific Application Requirements1- Basic QHP DataThis information will be QHP-specific and will need to be included for each QHP in the carrier'ssubmission.ACA RequirementsThis information is not required by the ACA for QHP certification.District of Columbia QHP RequirementsRequired data elements may include:Element NameBank Account IDBank Name and AddressBank Account NumberABA Routing NumberHIOS Product IDH.S.A.-Eligible?Child-Only OfferingPlan Type (Network design)Stand-Alone Dental Plan TypeProduct IDProduct NamePlan Effective DatePlan Expiration DateAdministrative Fees (e.g., monthly fees)Issuer Fee ConditionsPrimary Care Physician RequiredNetwork IDNetwork NameNetwork Provider List URLDistrict of Columbia Dental RequirementsThe dental application will also require basic plan data.15

District of ColumbiaQHP Application Bulletin - Version 1.0, October 26, 20122- Plan Benefit DesignThis information will be QHP-specific and will need to be included for each QHP in the carrier'ssubmission.ACA RequirementsA QHP issuer must submit rate and benefit information to the Exchange pursuant to 45 CFR Part155.1020 (45 CFR Part 156.210(b)).Benefit and rate information:The Exchange must receive the following information, at least annually, from QHP issuers for each QHPin a form and manner to be specified by HHS: Rates Covered benefits Cost-sharing requirements (45 CFR Part 155.1020(3)(c))District of Columbia QHP Requirements QHPs must complete an actuarial certification of benefit level (i.e., that the plan is actuarialequivalent to the metal level proposed) and include plan benefit design information. Under the approach described in the HHS Essential Health Benefits Bulletin, a plan couldsubstitute coverage of services within each of the ten statutory categories, so long assubstitutions were actuarially equivalent, based on standards set forth in CHIP regulations at 42CFR 457.431, and provided that substitutions would not violate other statutory provisions. The detailed contract should also be included in the certification application. The plan must outline health benefit data and identify plan benefits which must meet or exceedthe benefits of the benchmark plan.1o DC has selected the CareFirst BluePreferred Option 1 Plan as the Benchmark Plan.1Pursuant to the District’s EHB submission, further federal guidance may impact final benefit design and benefitlimits.16

District of ColumbiaQHP Application Bulletin - Version 1.0, October 26, 2012CareFirst BluePreferred Option 1 Plan Benefits:17

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District of ColumbiaQHP Application Bulletin - Version 1.0, October 26, 2012 Carriers must identify benefit cost sharing – cost-sharing tiers that permit different cost-sharingamounts for a set of providers or services (cost-sharing data are applicable to specific benefits,though not all cost-sharing factors are applicable to all benefits).o Plans will need to identify the applicability of cost-sharing characteristics that canpotentially be applied to each of the specific health benefits that carriers will need toidentify.o Possible cost-sharing characteristics are included in the below table:CharacteristicCovered?Tier (Y/N)?Number of tiersTier nameCoinsurance (in network)Coinsurance (out of network)Copayment (in network)Copayment (out of network)Description of CharacteristicIs this benefit covered, not covered,available as rider?Do you have cost-sharing tiers?Enter the number of cost-sharing tiersEnter the name of the cost-sharing tierIf an in-network coinsurance is charged,enter the percentage here. If nocoinsurance is charged, leave blank.If an out of network coinsurance is charged,enter the percentage

Insurance Subcommittee The proceeding bulletin is meant to inform District of Columbia health insurance carriers and other interested stakeholders of the anticipated requirements for the submission and certification of qualified health plans (QHPs) to the District of Columbia Health Benefits Exchange (DC HBX) for the 2014 plan year.