Fillable PPACA Uniform Compliance Summary (Montana Office of the Commissioner of Securities and Insurance, Montana State Auditor)

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PPACA Uniform Compliance Summary (Montana Office of the Commissioner of Securities and Insurance, Montana State Auditor)

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BROWSE MONTANA OFFICE OF THE COMMISSIONER OF SECURITIES AND INSURANCE, MONTANA STATE AUDITOR (MT) FORMS

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PPACA Uniform Compliance Summary
- 1 -
Please select the appropriate check box below to indicate which product is amended by this filing.
INDIVIDUAL HEALTH BENEFIT PLANS (Complete SECTION A only)
SMALL / LARGE GROUP HEALTH BENEFIT PLANS (Complete SECTION B only)
This form filing compliance summary is to be submitted with your [endorsement][contract] to comply with the immediate market reform
requirements of the Patient Protection and Affordable Care Act (PPACA). These PPACA requirements apply only to policies for health insurance
coverage referred to as “major medical” in the statute, which is comprehensive health coverage that includes PPO and HMO coverage. This form
includes the requirements for grandfathered (coverage in effect prior to March 23, 2010) and non-grandfathered plans, and relevant statutes. Refer to
the relevant statute to ensure compliance. Complete each item to confirm that diligent consideration has been given to each. (If submitting your filings
electronically, bookmark the provision(s) in the form(s) that satisfy the requirement and identify the page/paragraph on this form.)
*For all filings, include the Type of Insurance (TOI) in the first column.
Check box if this is a paper filing.
COMPANY INFORMATION
Company Name NAIC Number SERFF Tracking
Number(s) *if applicable
Form Number(s) of Policy
being endorsed
Rate Impact
Yes No
PPACA Uniform Compliance Summary
SECTION A – Individual Health Benefit Plans
TOI Category Statute Section Grandfathered
Non-
Grandfathered
2
Eliminate Pre-existing Condition Exclusions for Enrollees
Under Age 19
[Sections 2704 and 1255 of the
PHSA/Section 1201 of the PPACA]
N/A
Yes No
If no, please explain.
Explanation:
Page Number:
Eliminate Annual Dollar Limits on Essential Benefits
Except allows for “restricted” annual dollar limits for essential
benefits for plan years prior to January 1, 2014.
[Section 2711 of the PHSA/Section
1001 of the PPACA]
N/A
Yes No
If no, please explain.
Explanation:
Page Number:
Eliminate Lifetime Dollar Limits on Essential Benefits [Section 2711 of the PHSA/Section
1001 of the PPACA]
Yes No
If no, please explain.
Yes No
If no, please explain.
Explanation:
Page Number:
Prohibit Rescissions – Except for fraud or intentional
misrepresentation of material fact.
[Section 2712 of the PHSA/Section
1001 of PPACA]
Yes No
If no, please explain.
Yes No
If no, please explain
Explanation:
Page Number:
Reset Form
PPACA Uniform Compliance Summary
SECTION A – Individual Health Benefit Plans
TOI Category Statute Section Grandfathered
Non-
Grandfathered
3
Preventive Services – Requires coverage and prohibits the
imposition of cost-sharing for specified preventative services.
[Section 2713 of the PHSA/Section
1001 of the PPACA]
N/A
Yes No
If no, please explain.
Explanation:
Page Number:
Extends Dependent Coverage for Children Until age 26 – If
a policy offers dependent coverage, it must include dependent
coverage until age 26.
[Section 2714 of the PHSA/Section
1001 of the PPACA]
Yes No
If no, please explain.
Yes No
If no, please explain.
Explanation:
Page Number:
Appeals Process – Requires establishment of an internal
claims appeal process and external review process.
[Section 2719 of the PHSA/Section
1001 of the PPACA]
N/A
Yes No
If no, please explain.
Explanation:
Page Number:
Emergency Services – Requires plans that cover emergency
services to provide such coverage without the need for prior
authorization, regardless of the participating status of the
provider, and at the in-network cost-sharing level.
[Section 2719A of the PHSA/Section
10101 of the PPACA]
N/A
Yes No
If no, please explain.
Explanation:
Page Number:
PPACA Uniform Compliance Summary
SECTION A – Individual Health Benefit Plans
TOI Category Statute Section Grandfathered
Non-
Grandfathered
4
Access to Pediatricians – Mandates that if designation of a
PCP for a child is required, the person be permitted to designate
a physician who specialized in pediatrics as the child’s PCP if
the provider is in-network.
[Section 2719A of the PHSA/Section
10101 of the PPACA]
N/A
Yes No
If no, please explain.
Explanation:
Page Number:
Access to OB/GYNs – Prohibits authorization or referral
requirements for obstetrical or gynecological care provided by
in-network providers who specialize in obstetrics or
gynecology.
[Section 2719A of the PHSA/Section
10101 of the PPACA]
N/A
Yes No
If no, please explain.
Explanation:
Page Number:
PPACA Uniform Compliance Summary
SECTION B – Group Health Benefit Plans (Small and Large)
TOI Category Statute Section Grandfathered
Non-
Grandfathered
5
Eliminate Pre-existing Condition Exclusions for Enrollees
Under Age 19
[Sections 2704 of the PHSA/Section
1201 of the PPACA]
Yes No
If no, please explain.
Yes No
If no, please explain.
Explanation:
Page Number:
Eliminate Annual Dollar Limits on Essential Benefits –
Except allows for “restricted” annual dollar limits for essential
benefits for plan years prior to January 1, 2014.
[Section 2711 of the PHSA/Section
1001 of the PPACA]
Yes No
If no, please explain.
Yes No
If no, please explain.
Explanation:
Page Number:
Eliminate Lifetime Dollar Limits on Essential Benefits [Section 2711 of the PHSA/Section
1001 of the PPACA]
Yes No
If no, please explain.
Yes No
If no, please explain.
Explanation:
Page Number:
Prohibit Rescissions – Except for fraud or intentional
misrepresentation of material fact.
[Section 2712 of the PHSA/Section
1001 of PPACA]
Yes No
If no, please explain.
Yes No
If no, please explain.
Explanation:
Page Number:
Reset Form
PPACA Uniform Compliance Summary
SECTION B – Group Health Benefit Plans (Small and Large)
Non-
TOI Category Statute Section Grandfathered
Grandfathered
6
◊ For plan years beginning before January 1, 2014, grandfathered group plans are not required to extend coverage to a child until the age of 26 if such child is
eligible to enroll in another employee-sponsored plan
Preventive Services – Requires coverage and prohibits the
imposition of cost-sharing for specified preventative services
[Section 2713 of the PHSA/Section
1001 of the PPACA]
N/A
Yes No
If no, please explain.
Explanation:
Page Number:
Extends Dependent Coverage for Children Until age 26 – If
a policy offers dependent coverage, it must include dependent
coverage until age 26. ◊
[Section 2714 of the PHSA/Section
1001 of the PPACA]
Yes
◊
No
If no, please explain.
Yes No
If no, please explain.
Explanation:
Page Number:
Appeals Process – Requires establishment of an internal
claims appeal process and external review process.
[Section 2719 of the PHSA/Section
1001 of the PPACA]
N/A
Yes No
If no, please explain.
Explanation:
Page Number:
PPACA Uniform Compliance Summary
SECTION B – Group Health Benefit Plans (Small and Large)
TOI Category Statute Section Grandfathered
Non-
Grandfathered
7
Emergency Services – Requires plans that cover emergency
services to provide such coverage without the need for prior
authorization, regardless of the participating status of the
provider, and at the in-network cost-sharing level.
[Section 2719A of the PHSA/Section
10101 of the PPACA]
N/A
Yes No
If no, please explain.
Explanation:
Page Number:
Access to Pediatricians – Mandates that if designation of a
PCP for a child is required, the person be permitted to
designate a physician who specialized in pediatrics as the
child’s PCP if the provider is in-network.
[Section 2719A of the PHSA/Section
10101 of the PPACA]
N/A
Yes No
If no, please explain.
Explanation:
Page Number:
Access to OB/GYNs – Prohibits authorization or referral
requirements for obstetrical or gynecological care provided by
in-network providers who specialize in obstetrics or
gynecology.
[Section 2719A of the PHSA/Section
10101 of the PPACA]
N/A
Yes No
If no, please explain.
Explanation:
Page Number:
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PPACA Uniform Compliance Summary (Montana Office of the Commissioner of Securities and Insurance, Montana State Auditor)

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Completed 20 July 2020

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