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Serff Uniform Compliance (Commonwealth of Massachusetts)

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DEVAL L. PATRICK GREGORY BIALECKI
GOVERNOR SECRETARY OF HOUSING AND
ECONOMIC DEVELOPMENT
TIMOTHY P. MURRAY BARBARA ANTHONY
LIEUTENANT GOVERNOR UNDERSECRETARY OF CONSUMER AFFAIRS
AND BUSINESS REGULATION
JOSEPH G. MURPHY
COMMISSIONER OF INSURANCE
Filing Guidance Notice 2010-D
Bureau of Managed Care
TO: Commercial Health Insurers, Blue Cross and Blue Shield of Massachusetts, Inc.
(BCBSMA), Health Maintenance Organizations (HMOs)
FROM: Nancy Schwartz, Director, Bureau of Managed Care
DATE: June 9, 2010
RE: SERFF PPACA Uniform Compliance Form
The purpose of this notice is to provide guidance for health carriers about
the PPACA Uniform
Compliance Summary. This form was designed to be submitted with all SERFF filings for forms
that have requirements under the federal Patient Protection and Affordable Care Act (PPACA).
NAIC and SERFF staff developed the PPACA Uniform Compliance Summary to help carriers
address the immediate market reform requirements of the PPACA. This form is in interactive PDF
format and has been added to the Submission Requirements for all TOIs identified as PPACA. The
PPACA Uniform Compliance Summary is intended to be used in all states, so that multiple-state
filers will use the same form for all of the states in which they file.
Carriers will note that the SERFF General Instructions for Massachusetts has been modified to
include information about the PPACA Uniform Compliance Summary and the document has been
added to the SERRFF Submission Requirements for each TOI that has PPACA requirements.
SERFF will also provide documentation in SERFF's Online Help shortly after the release.
As of June 10, 2010, all SERFF filings for the TOIs and sub-TOIs identified should include a
completed PPACA Uniform Compliance Summary. Please note that if a filing is submitted without
this document in addition to any or all of the required checklists, an objection letter will be sent
advising that the checklists must be submitted before any other review is completed.
If you have any questions, please contact Nancy Schwartz at (617) 521-7347.
COMMONWEALTH OF MASSACHUSETTS
Office of Consumer Affairs and Business Regulation
DIVISION OF INSURANCE
1000 Washington Street, Suite 810 • Boston, MA 02118-6200
(617) 521-7794 • FAX (617) 521-7758
http://www.mass.gov/doi
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, 2010, 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:
PPACA ELIGIBLE TOI's AND SUB-TOI's
PPACA ELIGIBLE TOI's AND SUB-TOI's
T
yp
e of Insuranc
e
Sub-T
yp
e of Insurance
H04 Health - Blanket Accident/Sickness H04.000 Health - Blanket Accident/Sickness
H04.001 Student
H06 Health - Conversion H06.000 Health - Conversion
H12 Health - Excess/Stop Loss H12.001 Accident & Sickness
H12.002 Managed Care
H12.004 Self-Funded Health Plan
H15G Group Health - Hospital/Surgical/Medical Expense H15G.001 Any Size Group
H15G.002 Large Group Only
H15G.003 Small Group Only
H15I Individual Health - Hospital/Surgical/Medical Expense H15I.001 Health - Hospital/Surgical/Medical Expense
H16G Group Health - Major Medical H16G.001A Any Size Group - PPO
H16G.001B Any Size Group - POS
H16G.001C Any Size Group - Other
H16G.002A Large Group Only - PPO
H16G.002B Large Group Only - POS
H16G.002C Large Group Only - Other
H16G.003A Small Group Only - PPO
H16G.003B Small Group Only - PPO Basic
H16G.003C Small Group Only - PPO Standard
H16G.003D Small Group Only - POS
H16G.003E Small Group Only - POS Basic
H16G.003F Small Group Only - POS Standard
H16G.003G Small Group Only - Other
H16G.004 Short Term
H16I Individual Health - Major Medical H16I.005A Individual - Preferred Provider (PPO)
H16I.005B Individual - Point-of-Service (POS)
H16I.005C Individual - Other
H16I.004 Short Term
H21 Health - Other H21.000 Health - Other
HOrg02G Group Health Organizations - Health Maintenance (HMO) HOrg02G.001 Conversion
HOrg02G.002A Any Size Group - PPO
HOrg02G.002B Any Size Group - POS
HOrg02G.002C Any Size Group - HMO
HOrg02G.002D Any Size Group - Other
HOrg02G.003A Large Group Only - PPO
HOrg02G.003B Large Group Only - POS
HOrg02G.003C Large Group Only - HMO
HOrg02G.003D Large Group Only - Other
HOrg02G.004A Small Group Only - PPO Basic
HOrg02G.004B Small Group Only - PPO Standard
HOrg02G.004C Small Group Only - POS Basic
HOrg02G.004D Small Group Only - POS Standard
HOrg02G.004E Small Group Only - Other
HOrg02G.004F Small Group Only - HMO
HOrg02I Individual Health Organizations - Health Maintenance (HMO) HOrg02I.005A Individual - Preferred Provider (PPO)
HOrg02I.005B Individual - Point-of-Service (POS)
HOrg02I.005C Individual - Other
HOrg02I.005D Individual - HMO
HOrg03 Health - Other HOrg03.000 Health - Other
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Serff Uniform Compliance (Commonwealth of Massachusetts)

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Completed 26 July 2020

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