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One Step Closer to Knowing - DOI Issues QHP Guidance

Under the Affordable Care Act, one of the new options for individuals and small businesses to buy health insurance for themselves and their employees in 2014 will be the Illinois health insurance exchange or "marketplace." On March 29, 2013, the Illinois Department of Insurance (DOI) issued guidance to Illinois insurers about the requirements for a plan to be certified as a Qualified Health Plan (QHP), which means that they meet all of the coverage and cost-sharing requirements of the Affordable Care Act and can be sold in the Illinois Marketplace. This brings us one step closer to knowing what the plans/process will look like beginning in 2014.

This guidance tells us that:

DOI, with the assistance of the Illinois Department of Public Health (DPH), will initially review the plans and then by July 31, 2013 recommend the plan for certification to the federal government agency (called "CCIIO") to formally certify the plan.
CCIIO will then be responsible for all contracting with the insurance plans and issuing the cost-sharing subsidies to people who enroll in the marketplace and purchase insurance.
DOI will conduct QHP oversight in 2014.
Insurance plans must provide information about cost-sharing. For example, in 2014, deductibles in the small group market may not exceed $2,000 for self-only coverage and $4,000 for family coverage.
All insurance plans must offer at least one plan at the Silver and Gold level of coverage and at least one child-only plan.
Catastrophic plans can be offered but only to individuals under the age of 30 or is exempt from the Shared Responsibility Payment by reason of lack of affordable coverage or hardship.
Rates must be the same for products sold inside and outside the Exchange
The plans' networks must have "sufficient geographic distribution of providers" and must include providers that specialize in mental health and substance abuse services. In addition, as part of network adequacy, the guidelines specifies that plans must have Essential Community Providers (ECPs) that serve predominantly low-income, medically underserved individuals. (ECPs include FQHCs, Ryan White Providers and hospitals, among other entities. More information is available in HHS guidance here.) QHP issuers that do not include at least 20 percent ECP participation in network in the plan service area must submit an additional narrative justification in their QHP application. HHS has a non-exhaustive list of Essential Community Providers here.
There are also requirements for health insurance plans to design their premium rates only on the basis on geographic location, tobacco use and age. Within these categories, the guidance sets parameters which limit the rates that can be charged based on ratios. For example, within the age category, insurers may not charge a (non-smoker) person who is 64 years old a rate that is more than 3 times as high as they charge a (non-smoker) person who is 21 years old.

Lastly, insurers must file rates for review with the DOI and must submit a justification for a rate increase. Beyond these guidelines, however, the state does not have the authority to directly approve or disapprove of the rates insurance companies will charge. Many consumer advocates have recommended that the state grant the Department of Insurance more authority to review & deny insurance rate increases, as they do in other states. State legislation (SB 2344) is currently pending to do so.

We'll report back in a few months to let you know additional progress on the QHP selection in Illinois in order to get ready for October 1, 2013 enrollment.

Stephani Becker & Stephanie Altman
Health & Disability Advocates
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