Fillable QHP/SADP Carrier Attestation Form (Oregon)

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QHP/SADP Carrier Attestation Form (Oregon)

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The QHP/SADP Carrier Attestation Form (Oregon) form is 7 pages long and contains:

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440-5186 (12/20/COM)
1
QHP/SADP
Carrier Attestation Form
Instructions
For each attestation below, carrier will check “yes,” or “no.” Please explain each “no” answer.
If desired, documents may be uploaded in lieu of a written explanation. Include the document title in the explanation text
field. Clearly label each document to indicate the corresponding question.
Carrier must respond to all attestations.
Carrier Agrees to Work Collaboratively with the Marketplace in Key Areas
1. Carrier will perform the following functions related to the Oregon Health Insurance Marketplace and the Centers for
Medicare and Medicaid Services:
• Consumer dispute resolution
• Plan data submission and display
• System integration with the Federally Facilitated Marketplace
• Member communications regarding exchange issues and instructions
❏ Yes ❏ No
If you checked “no,” explain below (1,000 character limit):
Federal Minimum Certification Requirements
As a condition of participation in the exchange, health insurance carriers must agree to comply with the federal
minimum certification requirements. These requirements are taken from the Patient Protection and Affordable Care Act
(ACA) and the related federal regulations promulgated by the United States Department of Health and Human Services
(HHS) in 45 CFR, Parts 155 and 156. This section highlights some of the major requirements. It is not intended to be
a complete list of federal certification requirements.
Licensure and Solvency
2. Carrier will be licensed and in good standing to offer health or dental insurance coverage or both in Oregon.
❏ Yes ❏ No
If you checked “no,” explain below (1,000 character limit):
2
Marketing
3. Carrier and its officials, employees, agents, and representatives will (a) comply with any applicable state laws and
regulations regarding marketing by health insurance carriers; and (b) not employ marketing practices or benefit designs
that will have the effect of discouraging the enrollment of individuals with significant health needs in Qualified Health
Plans (QHPs) or Stand Alone Dental Plans (SADPs).
❏ Yes ❏ No
If you checked “no,” explain below (1,000 character limit):
Accreditation
4. Carrier will receive exchang
e accreditation by URAC, the National Committee for Quality Assurance, or the
Accreditation Association for Ambulatory Health Care, Inc. by July 15, 2022. The carrier will provide the Oregon
Health Insurance Marketplace with its initial and subsequent accreditation certificates. Dental carriers, select NA.
❏ Yes ❏ No ❏ NA
If you checked “no,” explain below (1,000 character limit):
Quality Improvement Strategies, Quality Reporting, and Enrollee Satisfaction
5. Carrier will implement and report on a quality improvement strategy or strategies consistent with the standards of 45
CFR §156.1130, participate in the quality rating system as required by 45 CFR §156.1120, and implement appropriate
enrollee satisfaction surveys as outlined in 45 CFR §156.1125. Dental carriers, select NA.
❏ Yes ❏ No ❏ NA
If you checked “no,” explain below (1,000 character limit):
3
Fees and Assessments
6. Carrier will pay administrative charges to the Oregon Health Insurance Marketplace under Oregon Administrative Rules
Chapter 945, Division 30.
❏ Yes ❏ No
If you checked “no,” explain below (1,000 character limit):
Plan Offerings
7. Carrier will offer through the Oregon Health Insurance Marketplace at least one standardized QHP in the Bronze, Silver, and
Gold coverage levels. Dental carriers, select NA.
❏ Yes ❏ No ❏ NA
If you checked “no,” explain below (1,000 character limit):
8. Child-only plans. Carrier will include rates for ages 0-20 on all plans to accommodate the ACA’s child-only
plan requirement.
❏ Yes ❏ No
If you checked “no,” explain below (1,000 character limit):
4
Cost-Sharing Reductions
9. The ACA (§1402) requires carriers to reduce the cost-sharing levels in Silver-level QHPs sold to individuals with
household incomes less than 250 percent of the federal poverty level. Carrier will offer cost-sharing reductions
plans as required by §156.420 and then by reducing other forms of cost sharing. Dental carriers, select NA.
❏ Yes ❏ No ❏ NA
If you checked “no,” explain below (1,000 character limit):
Enrollment Management
The carrier will:
10. Enroll a qualified individual who is determined to be eligible by the Federally Facilitated Marketplace (FFM) for the
plan for which the qualified individual has applied during the annual open enrollment periods described in §155.410(b)
and (f), and abide by the effective dates of coverage established by the Oregon Health Insurance Marketplace, the
Federally Facilitated Marketplace (FFM), and state and federal law.
❏ Yes ❏ No
If you checked “no,” explain below (1,000 character limit):
5
11. Enroll a qualified individual who is determined to be eligible by the Federally Facilitated Marketplace (FFM) for the plan
for which the qualified individual has applied during a special enrollment periods described in §155.420(d) and abide by
the effective dates of coverage established by the Oregon Health Insurance Marketplace, the FFM, and state and
federal law.
❏ Yes ❏ No
If you checked “no,” explain below (1,000 character limit):
Risk Adjustment
12. Carrier will comply with the requirements of the federal risk adjustment program. Dental carriers, select NA.
❏ Yes ❏ No ❏ NA
If you checked “no,” explain below (1,000 character limit):
Small Employer Product Line Standards
Enrollment Timeline and Process
Carriers offering a small employer plan through the exchange will:
13. Provide new enrollees with an enrollment packet. ❏ Yes ❏ No
If you checked “no,” explain below (1,000 character limit):
6
14. Report on SHOP enrollment as requested. ❏ Yes ❏ No
If you checked “no,” explain below (1,000 character limit):
15. Enroll all qualified employees consistent with the plan year of the applicable employer. ❏ Yes ❏ No
If you checked “no,” explain below (1,000 character limit):
Network Adequacy
Carrier will ensure that the provider network of each of its plans is available to all enrollees and meets the
following standards:
16. Includes essential community providers in accordance with §156.235. ❏ Yes ❏ No
If you checked “no,” explain below (1,000 character limit):
7
17. Maintains a network that is sufficient in number and types of providers to ensure that all services will be accessible
without unreasonable delay.
❏ Yes ❏ No
If you checked “no,” explain below (1,000 character limit):
18. Is consistent with the network adequacy provisions of 45 CFR§156.230, ORS 743.B.505 and OAR 836-053-0300 to
836-053-0350.
❏ Yes ❏ No
If you checked “no,” explain below (1,000 character limit):
Submission Information
Carriers must submit the attestation and questionnaire responses via email to katie.m.button@oregon.gov no later than 5
p.m. PST on
February 5, 2021
. Please make sure the email subject line reads: [CARRIER NAME] RFA Submission.
The attestation must be complete and include complete responses. Fax, regular mail, and physical deliveries will
NOT be accepted. You will receive an email confirming your submission.
By submitting this attestation, I certify that the information contained herein is true and correct to the best of my knowledge.
Name and title of the person submitting this attestation:
For: Date:
(Company name)
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QHPSADP Carrier Attestation Form (Oregon)

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Completed 28 January 2021

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