Pennsylvania Health Insurance Enforcement and Consumer Protections Grant Award

Cycle I Grant Application Summary

Pennsylvania Grantee: Pennsylvania Department of Insurance

Award Date: October 31, 2016

Total Award: $1,486,251.36

Baseline Award: $476,998

Selected Market Reforms Amount: $600,000

Workload Award Amount: $409,253.36

• Section 2707 - The Pennsylvania Department of Insurance will enhance its ability to review formularies, including analyzing previously approved formularies to identify trends or areas of potential discrimination to inform future reviews. Pennsylvania will also develop standard operating procedures and tools for form reviewers to use when reviewing formularies.

• Section 2713 - The Pennsylvania Department of Insurance will develop standardized policy form language for Affordable Care Act (ACA)-compliant health insurance plans, for use starting in the 2019 plan year in the individual and small group markets. This will ensure that policy documents include appropriate, clear descriptions of preventive services. Pennsylvania will conduct a comprehensive review of preventive health service coverage language in prior years’ forms, identify any potentially non-compliant or unclear language, and conduct staff training for ensuring forms appropriately reference preventive health services. This effort will inform the development of standard forms and will ensure that form review staff are fully trained in the requirements of coverage of preventive health services.

• Section 2718 - The Pennsylvania Department of Insurance will analyze the development of, and assess the feasibility of, integrating substantive testing of health insurance issuers’ Medical Loss Ratio (MLR) Annual Reports, in accordance with the Agreed Upon Procedures developed with the National Association of Insurance Commissioners (NAIC), into Pennsylvania’s regular financial exams of health insurance issuers subject to Section 2718. The Department of Insurance will conduct a comparative review of its issuers’ MLR reports in order to identify trends within the market and assist with potential future determinations regarding the appropriateness of items reported.

• Section 2726 - The Pennsylvania Department of Insurance will use review forms and the Qualified Health Plan (QHP) parity tool to ensure compliance with provisions related to quantitative and non-quantitative treatment limits. The Pennsylvania Department of Insurance will create internal checklists for the form reviewers to use and external templates and associated guidance for health insurance issuers to submit in order to demonstrate compliance when submitting plans for review. Pennsylvania will train form reviewers on the use of the checklists and review of the templates, and will provide training for consumer services staff on analysis of parity complaints. Finally, the Pennsylvania Department of Insurance will develop an online tool for issuers to use to submit templates or other data related to the Mental Health Parity and Addiction Equity Act (MHPAEA).